wmj31

UNITED STATES
vol. 57
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
G20438
Nr. 1, February 2011
• Medical Ethics and Personal vs. Public Conscience
• Tobacco-Free World in Twenty Years’Time!
• Czech Medical Chambers’ Experience to Make an Agreement
wmj 1 2011 5CS.indd I 21.02.2011 16:27:19
Cover picture from Korea
ii
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World Medical Association Officers, Chairpersons and Officials
Official Journal of the World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
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wmj 1 2011 5CS.indd Sec1:ii 21.02.2011 16:27:44
1
For over 60 Years the World Medical
Association has been the global platform
for medical ethics, physician affairs and
international medicine. It has been and is
being driven by the national medical asso-
ciations being the constituents of the or-
ganization. Outstanding physicians have
been and are until today its leaders. With
currently more than 90 nations in our
Association we are a truly global medical
voice representing more than 9  million
physicians worldwide.
Among the achievements of the World
Medical Association are landmark docu-
ments like the first International Code of
Medical Ethics (1948), the Declaration
of Geneva often referred to as the mod-
ern Hippocratic Oath (1949), or the most
famous of our declarations the Declaration of Helsinki – Ethi-
cal Principles for Medical Research Involving Human Subjects
(1964) – to mention just 3 out of more than 100 policies on medi-
cal ethics, human rights and socio-medical affairs. All of them are
living documents, up-to date, not trendy, but value- and reality-
based. They guide physicians all over the world in difficult ethical
situations, from the bedside at hospitals to the battlefields of this
world. Our policies have proven value and receive the highest re-
spect.
The World Medical Association is the voice of the physicians at
the international organization like the United Nations, the World
Health Organization, the International Labour Organization,
UNESCO and many others.
And although many physicians know WMA
policies and hopefully many more know the
WMA, only a few are aware that individual
physicians can be Associate Members of the
Association. With a very affordable rate the
membership in the WMA is not a matter of
money, but of engagement. Our Associate
Members stand for an independent medical
profession.Together we strive to achieve the
highest possible standards of medical care,
ethics, education and health-related human
rights for all people.
Associate Members have access to all work-
ing documents of the Association and
they are invited to voice their opinion on
our policy making either by writing or by
participating in the Association Members’
Meeting. The yearly Associate Members’
Meeting can even send its own policy proposals to the General As-
sembly for consideration. Membership benefits also include a sub-
scription to the World Medical Journal and significant discounts
on our registration fees for the WMA General Assembly and the
interim Council Session.
More information and the possibility to sign up can be found on
our website www.wma.net.
For the people of this world health is bridge to peace and a better living.
We are building it. Please join us.
Dr. Otmar Kloiber,
WMA Secretary General
Interested in Global Health? Join the World Medical
Association – Become an Associate Member
Otmar Kloiber
wmj 1 2011 5CS.indd 1 21.02.2011 16:27:45
2
Some time ago, New York Times colum-
nist Professor Stanley Fish (NY Times 12
April 2009) [1] wrote about “Conscience
vs. Conscience”, where he discussed the
conundrum about how people in general
and physicians in particular, under different
circumstances should or shouldn’t abide by
their own conscience.
The contending issue was that physicians
should not refuse treatment or procedures
basedontheirownpersonalmoralorreligious
grounds. Professor Fish argued that there
is such a thing as a collective “public con-
science”which should supersede that of one’s
personal conscience and value systems, no
matter how entrenched these may have been.
During the Bush administration, the culpa-
ble clause, called the Provider Refusal Rule,
allows health care providers to refuse to par-
ticipate in procedures they find objection-
able for moral or religious reasons.The main
bone of contention was of course regarding
freedom to choose abortion, pro-choice, or
conversely, pro-life.
In Fish’s article, he underscored an earlier
statement by Mike Leavitt, Bush’s Secre-
tary of Health and Human Services, who
had said that, “Doctors and other health
providers should not be forced to choose
between good professional standing and
violating their conscience.” The direction
of the Bush doctrine was of course to urge
the conservative right against unfettered
abortion on demand, which continues to
divide the American people.
Professor Fish reviewed the etymology of
“conscience” as ascribed to English phi-
losopher Thomas Hobbes. Here one of the
earliest definitions of conscience, referred to
those occasions “when two or more men know
of one and the same fact … which is as much
to know it together,” and where, violation of
conscience meant that knowing together,
men prefer their “secret thoughts” to what
has been publicly established.
Fish acknowledged that Hobbes understood
that many consider conscience to be the name
of the private arbiter of right and wrong.
But Hobbes regards this as a corrupted us-
age invented by those who wished to elevate
“their own …opinions”to the status of reliable
knowledge and try to do so by giving “their
opinions … that reverenced name of Conscience.”
Hobbes’s main argument is that if one can
prefer one’s own internal judgments to the
judgments of authorized external bodies
(legislatures, courts, professional associa-
tions), the result will be the undermining
of public order and the substitution of per-
sonal whim for general decorum: “… because
the Law is the public Conscience … in such di-
versity as there is of private Consciences, which
are but private opinions, the Commonwealth
must needs be distracted, and no man dare to
obey the Sovereign Power farther than it shall
seem good in his own eyes.”
Following his article, Fish was roundly
criticized for being half-right in his inter-
pretation of conflicting conscience, but in-
tellectual disagreement continues to divide
mostly implacable and partisan ethicists.
Nancy Berlinger in an ensuing Hastings
Center Report [2] has this to say: ‘Stanley
Fish… recognizes that defining “conscience”
more loosely  – as “moral intuition,” or those
“secret thoughts”… does not solve our contem-
porary problem. When medical professionals be-
lieve that they are being forced to do harm or are
prevented from doing good, the ethical solution
may not always be the conscience-clause remedy
of stepping away from troubling situations.’
Where does this leave the medical pro-
fessional when it comes to ethical under-
pinnings of doing what’s right or wrong?
Would our personal conscience suffice? Or,
should we subsume to the greater wisdom
of our collective professional voice (e.g.
national medical associations, professional
bodies, world medical association, medi-
cal councils, etc.), which through the long
arduous passage of time and historical ex-
periences, would have honed a burnished
if straitjacketed version of what’s generally
accepted as “ethically and publicly correct”?
Be that as it may, does this mean that the
medical professional would then have no
need to rely on his own personal conscience
and moral standing? No, but surely if these
are diametrically opposed to the greater
wisdom of peers, then one has to justify
one’s personal convictions all the more!
Again, this cannot be taken out of context
of the prevailing society and sociopolitical
situation. This becomes extremely relevant
in societies such as in Malaysia and other
quasi-democratic nations, where govern-
ments tend to be paternalistic, even ar-
rogant or worse [3]. The instruments and
institutions of power are often abused to
forcefully interpret laws or even medical
findings in a slanted manner, which severely
test the mettle and autonomy of physicians
under their charge.
David KL Quek
MALAYSIAMedical Ethics
Medical Ethics and Personal vs.
Public Conscience: a Malaysian Context
wmj 1 2011 5CS.indd 2 21.02.2011 16:27:48
3
Medical EthicsMALAYSIA
In certain authoritative or political circum-
stances, the medical professional is called
upon to exercise extreme judgment calls,
which can be sorely tested by either threats
from or fears of authority (e.g. police, su-
perior officers, military, even political pow-
ers) or worse, direct or indirect “rewards”for
passive compliance!
The 1st
century AD Hindu code, Charaka
Samhita [4], exhorts doctors to “endeavor
for the relief of patients with all thy heart
and soul; thou shall not desert or injure thy
patient for the sake of thy life or living”,
which have been restated in many codes
of professional conduct including our own.
Yet,these are often pushed to the backburn-
er, when conflicts of duties, arise.
Recent in Malaysia, public spats on medical
testimonials and reports have arguably cast
long shadows as to the so-called impartial-
ity, ethics or professionalism of some of our
medical colleagues [5]. Forensic pathologists
are facing some intense scrutiny of late,due to
questionable lapses, incoherent practices and
perhaps even perceived selective memories,
and slipshod standards of duty of care [6].
Other physicians making medical reports
are also put under the microscope for their
perceived biasness or slant of their reports,
one way or the other, until the truthfulness
of one vs. the other, appears difficult or im-
possible to discover [7]!
Such ambiguous if disingenuous medical
findings or reports cast a dismal if disap-
pointing view on our profession [8].While
some of these appear coerced, some might
conceivably be simply venal, just as if medi-
cal veracity can be made to sway according
to the purchasing power of the most damn-
ing and powerful!
Physicians must be reminded that for that
patient (deceased or detainee) under his/her
charge, there is frequently no other person
whose interests can be represented, except
from the physician’s unbiased assessment…
Sadly some of these dubious practices place
us at odds with the perceived wisdom and
conventions of some greater external collec-
tive conscience. These conventions although
seemingly unenforceable, have long been
articulated by world authorities such as the
World Medical Association and even the
United Nations Human Rights Commission.
The UN High Commission for Human
Rights Istanbul Protocol [9] is categorical in
stating that:
“Dilemmas arising from these dual obligations
are particularly acute for health professionals
working with the police, military, other securi-
ty services or in the prison system. The interests
of their employer and their non-medical col-
leagues may be in conflict with the best interests
of the detainee patients. Such health profes-
sionals with dual obligations, owe a primary
duty to the patient to promote that person’s best
interests and a general duty to society to ensure
that justice is done and violations of human
rights prevented. Whatever the circumstances
of their employment, all health professionals
owe a fundamental duty to care for the people
they are asked to examine or treat. They cannot
be obliged by contractual or other considerations
to compromise their professional independence.
They must make an unbiased assessment of the
patient’s health interests and act accordingly.”
Unfortunately, this protection by conven-
tion appears so remote to the lonely phy-
sician standing in the grips of perceived
authoritarian powers, whose influence are
imaginably all-powerful!
Seen in this context, society must exert its
moral imperative of the public good on a
universal basis, and demand the application
of such universal conventions, to protect the
hapless physician at the centre of such po-
litical or partisan storms, lest such pressure
lead to further erosion of already debilitated
institutions.
Similarly, the onus is on members of the
medical profession to remain steadfast to
the doctrine of public conscience and uni-
versal principles rather than personal ones,
when carrying out our duties, including
when making judgment or pronouncement
on some of our possibly errant colleagues.
Sectarian perceptions whether religious or
political, clearly must take a back seat, and
should not be allowed to color our thinking
or decision making.
Personal bias or experience or even con-
viction should yield to the more nuanced,
perhaps more balanced decision based on
strict interpretations of statutes, codes of
professional conduct, and perhaps legal
precedents.
The US Supreme Court [10] has ruled that
when the personal imperatives of one’s re-
ligion or morality lead to actions in viola-
tion of generally applicable laws – laws not
promulgated with the intention of affront-
ing anyone’s conscience – the violations will
not be allowed and will certainly not be cel-
ebrated; because: “To permit this would be to
make the professed doctrines of religious belief
superior to the law of the land, and in effect
to permit every citizen to become a law unto
himself.” Therefore,we must be quite clear to
dissect conscionably our dilemma of which
is the superior right.
Similarly, in the context of political or au-
thoritarian pressure, especially where dem-
ocratic institutions are weak, and where
risk to the individual may seem likely, it
behooves the professional to be reminded
about the World Medical Association’s Dec-
laration of Geneva [11], which is a modern
restatement of the Hippocratic values, as
well as to be cognizant of UN Conventions
such as the Istanbul Protocol. Doctors are
reminded that the health of their patients
is their primary consideration and that we
must devote ourselves to the service of hu-
manity with conscience and dignity.
We must learn and adhere to our historical
memories, that which are collectively ac-
knowledged as “correct” and first and fore-
wmj 1 2011 5CS.indd 3 21.02.2011 16:27:49
4
E-health AUSTRALIA
most for our patients’interests. Certainly, in
this context, every professional should not
let religious, political or sectarian reasons
from influencing our decision-making.
But does this mean that these are fixtures
which cannot or should not be modified
with the passage of time and perhaps move
in tandem with the “fashion” or faddism of
current perceptions or even societal move-
ment or direction?
Clearly this will depend on the circum-
stances and the human aspects of all pa-
tient-physician interactions. Although eth-
ics these days are not as immovable or as
permanently cast in stone, societal views do
evolve. Like sometimes shifting tides, ethi-
cal perceptions may very gradually ebb and
flow, but often with the anchored moorings
and underpinnings of moral public good
and greater and greater foundation of uni-
versal values.
So changes may occur, but again these must
be based on contextual interpretation which
should be carefully justified so that the
newer interpretation can withstand scrutiny
and/or rigorous re-examination, by an in-
creasingly knowledgeable public and also by
even more discerning generations of similar
professionals.
Thus, personal conscience and public con-
science must be employed together to shape
our moral compass when we are dealing
with ethics and medical professionalism. It
helps when we all undertake to reexamine
our own values and learn more and more as
to how these ethical dilemmas and ques-
tions are evolving in this day and age. We
must not be cowed into a mindset of conve-
nient way out or of callous expediency [12].
References
1. Fish S.Opinionator.Conscience vs.Conscience.
The New York Times. The Opinion pages. 12
April, 2009. http://opinionator.blogs.nytimes.
com/2009/04/12/conscience-vs-conscience.
2. Berlinger N. Conscience: We’re not donne yet.
Bioethics forum. The Hastings center report. 7
May 2009. http://www.thehastingscenter.org/
Bioethicsforum/Post.aspx?id=3404&blogid
=140.
3. Quek D.K.L. Unbiased treatment for all.
Malaysiakini,March23,2010.http://myhealth-
matters.blogspot.com/search?q=ethics+
conscience.
4. Roy P, Gupta H. Charaka Samhita. A scien-
tific synopsis. 2nd ed., Indian National Science
Academy, New Delhi, India, 1980.
5. Quek DKL. Kugan’s Autopsy Findings & In-
quiry: Unsettling Questions remain. Malaysia-
kini, April 8, 2009. http://myhealth-matters.
blogspot.com/2009/04/kugans-autopsy-find-
ings-inquiry.html.
6. Quek DKL. Ethics, medical confidentiality vs.
political pressures. Malaysiakini, July 31, 2008.
http://dq-liberte.blogspot.com/2008/07/eth-
ics-medical-confidentiality-vs.html
7. Chong D. Teoh family disappointed with Brit-
ish pathologist’s report. Malaysian Insider 26
April 2010. http://www.themalaysianinsider.
com/index.php/malaysia/61368-teoh-family-
disappointed-with-british-pathologists-report.
8. Quek DKL. Physicians must be more vigilant.
Malaysiakini,March 11,2009.http://myhealth-
matters.blogspot.com/2009/03/doctors-must-
be-vigilant-when-dealing.html.
9. Istanbul Protocol. Manual on the effective in-
vestigation and documentation of torture and
other cruel, inhuman or degrading treatment or
punishment. Office of the United Nations high
commissioner for human rights. United Na-
tions, Geneva, 1999.
10. Scalia J. Opinion of the Court. Supreme Court
of the United States; 494 U.S.872.Employment
Division, Department of Human Resources of
Oregon v. Smith. Certiorari to the Supreme
Court of Oregon No. 88–1213 Argued: Nov. 6,
1989; Decided: April 17, 1990.
11. WMA Declaration of Geneva. Revised 173rd
CouncilSession,Divonne-les-Bains,France,May
2006. https://www.wma.net/en/30publications/
10policies/g1/index.html.
12. Quek DKL. A New Malaysia still possible.
Malaysiakini, March 9, 2010. http://dq-liberte.
blogspot.com/2010/03/malaysiakini-new-malay-
sia-still.html.
Dr. David KL Quek, President,
Malaysian Medical Association
The promise of e-health has been on the
horizon for many years.
While the full potential of that promise is
yet to be delivered, it feels like we are just a
little bit closer to making e-health a reality.
The very fact that we are here today discuss-
ing the practical steps we need to develop
the personally controlled electronic health
record shows how close we really are.I would
like to acknowledge the efforts of Dr.Muke-
sh Haikerwal in pushing the e-health agen-
da. In his charming way, he has been tireless
and determined in bringing together all of
the relevant players over the last few years.
His involvement has had a significant im-
pact on the e-health agenda and its progress.
Clinicians Driving Change:
Supporting Patient Care
Speech at the E-health conference 2010, Melbourne, 30th November 2010
Steve Hambleton
wmj 1 2011 5CS.indd 4 21.02.2011 16:27:54
5
AUSTRALIA E-health
Doctors are excited about the prospect of
sharing patient information electronically
with each other and with other health care
providers to improve patient safety and the
quality of care we provide.
Many GPs now hold accurate and compre-
hensive information about their patients
that has been progressively built up over
more than a decade.
But at present the only way we can share it
is by printing it.Even then, it may or may
not be with the patient when he or she ar-
rives at the next doctor – and even then, at
best it is subject to transcription errors.
Today I am going to talk about what my
medical colleagues think must be done to
get the first stages of the electronic health
record up and running, and ensure that it is
done in a way that will best assist doctors in
caring for their patients.
We need to strike a balance between clini-
cal safety and consumer expectations in the
design and use of the electronic health re-
cord. To succeed, the e-health record must
be easy to use, support what doctors already
do, and not disturb time-honoured clinical
methods.We doctors talk to our patients,
take a history, perform a medical examina-
tion, assess supporting information, order
investigations if needed, then make a diag-
nosis for the patient and decide on a treat-
ment plan.
That is the hard part about what we do. It
takes years to learn and even longer to get
good at it. If doctors can rapidly access rel-
evant data via the electronic health record,it
will support this process. But irrelevant data
will get in the way.
During my consultations with my patients,
I find that most of them have a reasonable
understanding of their health circumstanc-
es – and they are usually very honest with
me about what’s going on with them. But
commonly – despite our best intentions –
doctors don’t always have all the clinical in-
formation that we need to provide the saf-
est, most clinically appropriate care.
This is where information obtained by other
health practitioners in relation to my pa-
tient during other episodes of health care
could ensure that I don’t miss the critical
issues that could impact on my treatment
decisions.
Here is a “live”example from one of my pa-
tients last week.John told me that he had
a number of times called an ambulance to
his home because he had severe abdominal
pain – RUQ 10/10.On the first two occa-
sions,his pain had gone by the time the am-
bulance arrived, and he was not transported.
He had a health summary from me with him
detailing his cardiac history,his diabetes,his
AAA, his past history of cholecystectomy.
He also had retained gallstones in the bile
duct after the above surgery and needed
an ERCP and sphincterotomy to solve the
problem.The next three times he was taken
to Royal Brisbane Hospital Emergency
Department where, once again, they were
in possession of his paper history. The pain
invariably went away within a few hours of
arriving at hospital.His diabetes and vascu-
lar disease were proving to be a distraction.
The CT Abdomen showed nothing more
than his AAA, and the US of the liver was
normal.This information trickled in to me
some days after his hospital visits.The first
discharge letter contained the blood results,
which showed a rise in his liver function
tests that were consistent with obstruction
of the bile duct.The second and third letters
from A&E did not include the above but,
when I asked for them to be faxed, it was
clear that on each occasion that there was
acute pain the liver enzymes rose.
For the non-doctors in the room, it was
clear evidence of bile duct obstruction.This
was enough evidence to convince another
gastroenterologist that he needed another
ERCP and, sure enough, there were two
more gallstones.There were five blood tests
on three different pathology computers. A
CT scan of the abdomen and an ultrasound
of the abdomen were also needed to make
the diagnosis.The patient had no way of
recalling the sort of detail that I needed to
make the diagnosis, or even of being sure
what tests had been done.
For example, the negative cardiac enzyme
tests were just as important. I was the only
one who had all of the information avail-
able. The diagnosis would have been made
much more quickly if we all had all the de-
tail in “real time”. It was time consuming
for me and inconvenient for the patient –
maybe even life threatening.
This is just one example where the sharing
of a patient’s information between health
care providers could make a real difference
to the quality, safety, and cost of the health
care that I could deliver.
At the most basic level, doctors should be
able to access from electronic health records
important information such as:
• pathology results;
• diagnostic imaging results;
• discharge summaries; and
• current medications and adverse events.
This is basic information, yet critical to pa-
tient care.
When I talk to doctors, and when I think
about my own practice, I am struck again
and again by what a difference it would
make – even in the case I have mentioned –
if we had an electronic health record.
The record could facilitate the sharing of
this most basic yet critical patient infor-
mation between treating doctors and other
health providers.
It would deliver a very loud bang for the
buck. Clearly, I am talking about a very
small but fundamental part of the much
grander plan for a personally controlled
electronic health record.
wmj 1 2011 5CS.indd 5 21.02.2011 16:27:55
6
AUSTRALIAE-health
Let’s start with the basics and get it up
and running. Let’s start with electronically
shared patient summary information that
cannot be altered by the patient, and which
is accessible to all doctors.
I am not suggesting that the personally
controlled aspects of the electronic health
record are not important. The point I am
making is that, if we are to get take-up of
the electronic health record by doctors, the
doctors need to be able to trust the reliabil-
ity and accuracy of the information the re-
cord contains so that they can act on it.
Most patients would recognise the need for
treating doctors to be confident about the
information that they have before them.
I can’t think of any of my patients who
would object to me being able to have ac-
cess to information about where they have
recently been hospitalised, or when they
needed to see another doctor. In fact, many
are surprised when I don’t have that kind
of information at my fingertips already.
How many patients have turned up at their
GP before the specialist’s letter or before
the discharge summary has arrived?In fact,
the Menzies-Nous Australian Health Sur-
vey published last week found that: “Most
people believed their doctor and all the people
treating them should have direct access to their
health record.”
The AMA has thought very hard about how
doctors will integrate the personally con-
trolled electronic health record into the way
they practise medicine. At the AMA, we
are talking about the sharing of summary
patient information electronically between
treating doctors.
We don’t talk about sharing all of our pa-
tient information  – just the key informa-
tion that other doctors need to provide safe,
quality patient care.And that is what we
do already – when I refer my patient to a
specialist, I don’t send their entire file. I just
send the key information that I think the
specialist needs.
The AMA supports the premise that the
sharing of accurate summary patient infor-
mation between treating doctors is critical
to the success of e-health.
This is information that sits beside a per-
sonally controlled record. It is essential that
this record contains reliable and relevant
medical information about individuals.
It is important that it aligns with clinical
workflows. It must integrate with existing
medical practice software.Otherwise we are
faced once again with the transcription er-
rors I spoke of earlier. It is also very impor-
tant that the personally controlled record
has appropriate security measures to protect
patient privacy.
We believe that if the system is to be truly
national and consistent, it must be governed
by a single national entity.
We believe governments must fund the sys-
tem and support its take-up with appropri-
ate incentives, education and training.
Progress in these areas would provide bene-
fits to patients through efficient and accurate
communication between GPs,other special-
ists, hospitals, and other health providers.
Over time, once the initial capability to
share the summary patient information
across healthcare settings is rolled out, there
is significantly more information that could
go on the summary.
It could include information such as pros-
theses, implants, ECGs, referrals, advance
care directives, health care plans, and team
care arrangements to name but a few.
Clearly, as the information on the record
starts to get more complex, patients will
inevitably and very reasonably want more
rules around who can access all that extra
information.
Privacy of and access to those parts of the
record will be very important.
This is also the point at which I think the
personally controlled aspect of the record
is very relevant. A personally controlled
record that patients would operate along-
side the summary information shared by
doctors could prove to be a great motivator
for many patients to become more involved
in their own health care. In my experience,
when my patients take responsibility for
their health and work with me, we usually
get the best outcomes. Most doctors don’t
like “Dr Google”and there are good reasons
for that. But it is undeniable that the advent
of the Internet has produced patients who
are more informed and perhaps a bit more
prepared when they come to see me.
I actually prefer it when patients with ongo-
ing health concerns take an active interest
in informing themselves about their con-
ditions and in actively engaging with me
about the steps they can take to manage
their condition better.
I think there are generational issues here
with some patients older than me who are
reluctant to use the web all that much.I find
that patients about my age are quite will-
ing to go after information and to inform
themselves.
Now there are young people who can’t
stop pulling down information. The chal-
lenge with them is to direct their gaze to
useful locations and to stop them getting
sidetracked. I think that the personally con-
trolled record will encourage and empower
patients to take more responsibility for as-
pects of their health care. The opportunity
to create their own record about how they
are managing their health will help patients
to keep track of their conditions and medi-
cal history. This should dovetail into home
monitoring for things like diabetes and
blood pressure.
This, in turn, will lead to patients being able
to truly engage with their health care pro-
vider to provide better management of their
health.
wmj 1 2011 5CS.indd 6 21.02.2011 16:27:57
7
AUSTRALIA E-health
However, we need to strike the right bal-
ance here between the health care provider’s
need to provide safe patient care and con-
sumer expectations about the role of the in-
formation they control in the record when
health care is delivered to them.
It is not realistic to expect that doctors will
turn to information put in the personally
controlled record by the patient as the de-
finitive source of information on which to
base clinical decisions. Doctors will always
take a history, do an examination, and
make an assessment and diagnosis putting
different weights on different types of in-
formation. We cannot just rely on what is
in the personally controlled record. Often,
diagnoses or previous conclusions need to
be challenged. Just like my patient I men-
tioned earlier. I have never ever seen a pa-
tient with retained gallstones after ERCP
and sphincterotomy, but that is what the
evidence said. To get it right we need all
the evidence though. Even now, doctors
have concerns that patients might be re-
luctant to share some information with
them. Patients may think that once in-
formation is on the record – somewhere,
sometime – that information might be ac-
cessed inappropriately. Patients are already
concerned about how treatment decisions
might affect them in other aspects of their
lives.
I recently saw a patient who wasn’t sure
whether he wanted to be prescribed anti-
depressant medication for fear that some-
how down the line it could “get out” and
affect his employment as a teacher. These
kinds of concerns will become even more
important to patients when diagnoses,
treatment decisions, and medications are
shared electronically.
So, if we look at a world where there is a
personally controlled electronic health re-
cord – where information may be in “The
Cloud” and therefore truly accessible – it is
entirely understandable that those concerns
for patients will intensify.
Unfortunately, if patients have the ability to
remove or “make private” facts that are part
of their summary information, they might
do so – for all kinds of reasons. And if they
choose to do so, then the record may be-
comes useless to a doctor because the doctor
could never rely on it.
For example, when prescribing medication,
if the anti-depressant was hidden, the real
possibility of a serious adverse medication
interaction could exist. If Tramadol is pre-
scribed, then it could precipitate a serotonin
syndrome if the patient was taking an SSRI
(Selective serotonin reuptake inhibitor).
Once the personally controlled record is
up and running, if there is just one serious
adverse medication event like this, then e-
health will not have delivered on its promise.
If the summary information was not avail-
able to the treating doctor, then the whole
venture will have failed.
Failed the patient. Failed the doctor. Failed
the health system.
The summary patient information needs to
be accessible to all doctors.
It should only be able to be changed by
doctors who understand the implication of
what is recorded – and this can certainly be
done in consultation with the patient.
Conversely, the addition of some informa-
tion into the electronic record by a patient
could also pose a clinical risk – if the doctor
were to rely upon it.
For instance, many patients believe they
have allergies to drugs, but they are simply
side effects. While they are important, they
do not have the same clinical impact. For
example, Augmentin nausea, muscle aches
with statins.
If we think about these examples, it is clear-
ly not true that the personally controlled
electronic health record will entirely remove
the need for patients to tell their history to
every new health professional they see. But
it will streamline it.
Doctors and other health providers who are
committed to safe, quality patient care will
need to have that conversation and practise
their craft, no matter what is in the record.
As I said earlier, it is essential that doctors
can rely on the summary information in-
cluding:
• pathology results;
• diagnostic imaging results;
• discharge summaries; and
• current medications and adverse events.
As we develop the personally controlled
electronic health record, we need to con-
sider that e-health in primary care will
drive most of the health system benefits.
Those benefits will be most apparent in
the acute care setting. Most of the costs,
however, will be incurred in the primary
care setting.
With this in mind, the Government must
invest in e-health at the primary care level
or the momentum will stall. The right ap-
proach, the right information, and the right
investment in e-health can deliver real ben-
efits to patient care and to the efficiency of
the health care system.
The AMA and the medical profession stand
ready to get behind e-health and make it
the reality that the Australian health system
needs.
Dr. Steve Hambleton, Australian
Medical Association, Vice President
wmj 1 2011 5CS.indd 7 21.02.2011 16:27:58
8
UNITED STATESMedical ethics
Lately I’ve been thinking about bridges.
One bridge in particular has been in my
mind: the so-called Bridge of No Return
between North and South Korea.
Here’s the story. More than 40 years ago,
as a young naval medical officer, I was part
of the team that examined crew members
of the USS Pueblo after they were released
from captivity in North Korea. The Pueblo,
a U.S. communications monitoring ship,
had been in international waters-legally  –
when it was surrounded and fired upon by a
North Korean warship.
One crewman was killed and 10 others were
wounded before Cmdr. Lloyd “Pete” Bucher
surrendered the ship. Had he not surren-
dered, the superior firepower of the North
Korean ships would have prevailed and many
more of his men would have been killed.
Bucher and his crew – 82 in all – were held
in captivity in North Korea for 11 long
months, during which time they were beat-
en, tortured, starved and humiliated on a
daily basis. When they were finally released,
they walked to freedom across that Bridge
of No Return.
Overall, the Pueblo’s commander and crew
were in pretty bad shape physically. All had
lost weight, and there were skin diseases,
jaundice, pneumonia, infections, contu-
sions, abrasions and broken bones. Despite
their ill health and having been tortured,
the Pueblo crew walked across that bridge
united,loyal and upbeat.None had been co-
opted by the North Koreans. They had not
turned on one another.
In their forced confession they had man-
aged to send a message of their own to the
American authorities. Their spirit could
have been destroyed, but it was not. Today,
the behavior of the Pueblo crew during that
captivity is held up as model of prisoner-of-
war resistance.
I have always felt privileged  – and sad-
dened – that I was on hand to meet these
men and their commander after they came
across that bridge and were brought to the
Balboa Naval Hospital in San Diego. It is
a time I shall never forget. And a time that
remains with me in lessons learned.
As a former naval medical officer, I am
keenly aware of how much my civilian
medical practice owes to military medicine.
Emergency and disaster medicine,in partic-
ular, are the offspring of battlefield medical
experience. So is public health.
Here are a few examples:
• During the Seminole Wars in the early
1800s, Army physicians discovered that
quinine was effective in treating people
with malaria
• Following the Spanish-American War
in 1898, military physician, Walter Reed,
headed a commission that proved the link
between yellow fever and mosquitoes
• The North African battlefields of World
War II were also a battleground that
proved the miracle of antibiotics
• During World War II, the work of Navy
Captain, Robert Phillips, broke new
ground in the treatment of cholera
Trauma and disaster medicine also have
military roots:
• Medical triage first took place on Napole-
on’s battlefields, offering a way to deal
with casualties and save lives in an orderly
way
• In the late 1940s, military physicians did
pioneering work in the treatment of burn
victims
• As a result of casualties in the Middle
Eastern conflicts we have seen new treat-
ments for amputees and advances in pros-
thetic technologies
• Out of Vietnam came an understanding
of the importance of the “golden hour”
and the need for early, even pre-hospital,
treatment. Our civilian EMT and mede-
vac systems are a direct result
• The Vietnam War and more recent mili-
tary conflicts in the Middle East taught
the value of a systems approach to han-
dling mass casualties  – a lesson civilian
medical teams applied after the 9/11 at-
tacks, the 2004 tsunami, Hurricane Ka-
trina and the earthquake that hit Haiti
early this year
• Today the military is a leader in telemedi-
cine, sending patient information from
the battlefield and receiving expert advice
back from around the world to physicians
who are on the front lines.This is technol-
ogy that ultimately may be as important
to a physician and patient in remote rural
areas as it is to those on the battlefield.
• All of this is a reminder of the impor-
tance of learning from one another, of
being united, of facing obstacles together.
That is my message for physicians today.
Cecil B. Wilson, MD, President,
American Medical Association
Humbled by Those Who Crossed
Bridge of No Return
Cecil B. Wilson
wmj 1 2011 5CS.indd 8 21.02.2011 16:27:59
9
Effective regulatory framework is the key
to delivery systems that create a well func-
tioning healthcare environment, this arti-
cle provides an analysis of the regulatory
framework of private health insurance as it
relates to the protection of beneficiaries and
the public within South Africa context. The
Council for Medical schemes (CMS) which
is the statutory body established in terms
of the Medical Schemes Act 131 of 1998 to
provide regulatory oversight to the medi-
cal schemes industry in a manner that is
complementary with national health policy.
Medical schemes that are regulated by the
CMS are insurance institutions that cover
medical expenses and provide health care
insurance in the private sector in South Af-
rica. Medical schemes reimburse their mem-
bers for actual expenditure on health. A
regulatory framework must protect the in-
terests of Beneficiaries, thus CMS contin-
ues to effectively engage on regulatory and
policy developments in the health and in-
surance industries to ensure that the rights
of South African Beneficiaries are protected
at all times.
Introduction
An effective regulatory framework is critical
to delivering system reform and to creating
a well-functioning healthcare market [13].
This paper presents such a framework with-
in the South African context; we give an
outline of goals that a regulation should ad-
dress. It is important to note that the South
Africa’s health system consists of a large
public sector and a smaller private sector.
The public sector is under-resourced and
over-used, while the private sector caters to
middle- and high-income earners who tend
to be members of medical schemes (16% of
the population in 2009,not significantly dif-
ferent to the 15% cover by medical schemes
in 2000). The demographic structure of
medical schemes implies a differently struc-
tured health system to that of the general
population. This is a worrying factor on the
resulting efficiency of the health system as a
whole, given the substantial resource alloca-
tion bias in favour of the medical scheme
market. In 1994, the National Depart-
ment of Health (DoH) allowed medical
schemes, which are primary to paying for
private health care, to be regulated [16].The
Medical Schemes Act 131 of 1998 gives
the Council for Medical Schemes (CMS)
power over medical schemes; the CMS
regulates not only medical schemes,but also
health insurance brokers, medical scheme
administrators and managed care organi-
sations [12]. It also imposes much stricter
controls upon medical schemes themselves
in terms of corporate governance, financial
and membership requirements, and provi-
sion of benefits.The Act states the functions
of the Council in a far more purposeful and
consumer-oriented terms, with a defined
focus on the protection of the interests of
medical scheme members.
To achieve its regulatory goals, the office
of the Registrar participates in the con-
sultative process which aims to demarcate
medical schemes from health insurance be-
cause it is the case that the encroachment
of risk-rated health insurance products into
the business of medical schemes results in
cream-skimming the young and healthy,
unfair discrimination against the old and
sickly, and a risk to the sustainability of
the medical schemes industry [7]. Another
critical element of regulating the private
health care sector is to, on an ongoing basis,
revise benefit and contribution structures
to protect community rating, which is the
principle that all beneficiaries on the same
benefit option pay the same contribution,
and that contributions may vary based only
on an individual’s income, number of de-
pendants, or both  [12]. The regulator of
medical schemes is in support of the initia-
tion of a proper consultative and research
process towards the development of a regu-
latory framework for collective bargaining
between healthcare providers and funders
(including the review of the National
Health Amendment Bill).
The Bill was published for comments in
2006 with the final comments at the end of
February in 2007. The new draft of the Bill
was submitted to the Minister of Health in
Monwabisi Gantsho Michael Mncedisi Willie
SOUTH AFRICA Healthcare insurance industry
The Regulatory Framework in the Healthcare
Insurance Industry:
In the Interest of Beneficiaries and Public
wmj 1 2011 5CS.indd 9 21.02.2011 16:28:00
10
Healthcare insurance industry SOUTH AFRICA
July 2007, and is awaiting discussion and
signature of the State President in Parlia-
ment.The Bill seeks to address among other
key topics the governance issues for medical
schemes, including the fit and proper status
of trustees.The Bill also seeks to change the
manner in which benefits are designed,so as
to improve transparency and further reduce
incentives for unfair discrimination.
Goals of regulation
The role of market regulation is to facilitate
the delivery of overarching policy objectives
through economic regulation and consumer
protection [13]. The objective of this arti-
cle is to assess the regulatory framework as
it relates to the protection of beneficiaries,
thus we focus on the following goals of reg-
ulations, the regulatory framework [3].
• Ensuring services (and goods) are safe
and of high quality.
• Ensuring fair access to services and
(where relevant) also ensure choice of
provision.
• Ensuring financial solvency of medical
schemes.
• Ensuring transparency and fairness in
the contractual relationship between the
medical scheme and beneficiary.
• Ensuring that health insurance packages
provide adequate financial protection.
• Managing key externalities and by-prod-
ucts of service provision.
• Governance of medical schemes.
Regulation in advanced
market economies
The regulatory framework of private health
care insurance industries is administered
by a government agency or agencies that
implement statutory requirements, usually
with the authority to establish administra-
tive rules and procedures [9]. This section
discuses the some of the regulated activities
within the health sector and core functions
of such regulating entities.
Licensing of medical schemes,
administrators, managed
care entities and brokers
A major reason for having regulation is to
protect regulated industries from instability
and lack of consumer confidence caused by
poor administration and trading systems.
Setting up minimum registration and ac-
creditation rules and regulations ensures the
efficient functioning of market mechanisms.
Establishing minimum standards and ac-
creditation rules reduces additional costs of
overhead spreads created by artificial mar-
ket signals that are driven by health insur-
ance administration functions. The Medi-
cal Scheme Act gives the CMS regulatory
powers over medical schemes,managed care
entities, brokers, and administrators. The
functions of the CMS are included in Sec-
tion 7 of the Act. For the purpose of this re-
port, the regulatory functions are expanded
using literature on regulatory theory  [7];
they are listed are as follows:
Supervising the conduct of registered in-
termediaries by the Council’s line and staff
functions, through the implementation of
rules-based bureaucratic style of carrying
out Council’s governance function:
• A managerial approach to the regulator’s
function of stewardship, controlling con-
duct by means of quantitative benchmarks
and/or qualitative scorecards, monitoring
observance to preset specification and
performance standards by registered in-
termediaries
• A collaborative governance approach
which allows for a joint learning process
in developing health insurance regulatory
policy by:
– configuring formal cooperative
interfaces between the regulator’s
internal operational line functions
and staff function (specialist ad-
visors) channels, for the benefit
of strengthening the responsive-
ness of benchmark or peer review
policy tools, economic incentives
and reducing market uncertainties
(market stability and institutional
sustainability);
– Increasing the scope of regulatory
transparency and democratizing
administrative justice processes by
making the Registrar’s Office and
market information more accessible
to medical scheme members
Policing registered institutions in terms
of their observance of rules for minimum
compliance and mandatory standards inter-
mediaries, such as the observance of:
• Rules of minimum compliance and ap-
proval requirements for the registration
of medical schemes and other institutions
within the regulator’s jurisdictional regu-
latory environment.
• Mandatory compliance standards.
• The regulatory function of: Legal en-
forcement of provisions emanating from
the Act and other forms of precedence,
such as behavioural incentives legitimat-
ed by enabling rules and guidance notices.
• The regulatory function of: Adjudicat-
ing over grievance applications made by
medical scheme enrolees.
• The regulatory function of: Educating
& Communication of the regulator’s fi-
duciary duty to medical scheme enrolees
and, the strengthening of the governance
function’s role of demonstrating account-
ability over regulated stakeholder and
medical scheme members.
• The regulatory function of: Sanctioning
the business of medical schemes and the
administration of health insurance busi-
ness functions.
• The regulatory function of: Observing
Fiduciary Obligations arising from Prin-
cipal-Agent market relationships by, gov-
erned schemes and other registered inter-
mediaries and,the Regulatory Body itself.
Solvency Regulation
Solvency regulation includes solvency mon-
itoring, capital requirements, other controls
on medical scheme behavior (for example,
wmj 1 2011 5CS.indd 10 21.02.2011 16:28:02
11
Healthcare insurance industrySOUTH AFRICA
investment regulations) and, in many cas-
es, establishment of beneficiary protection
schemes to pay specified claims against in-
solvent medical schemes  [9]. Beneficiaries
pay contributions towards medical schemes
for future health care spending and the fi-
nancial capacity for the scheme to respond
to claims/ pay for healthcare spending is de-
pendent on the schemes viability and finan-
cial soundness. It is of note that the claims
can potentially exceed the sum of the total
premiums/ contributions received and this
is critical to the viability of the scheme.
With solvency regulation, beneficiaries del-
egate responsibility for monitoring solvency
to regulators, as this is also the case in South
Africa. Regulatory monitoring might detect
medical scheme financial problems early
enough to prevent insolvency.In other cases,
monitoring can help regulators intervene
before the deficit between an insolvent med-
ical scheme’s assets and liabilities becomes
large. Some degree of regulatory restrictions
on medical scheme risk taking (for example,
investment limitations and capital require-
ments) could be efficient for this reason.
Solvency is measured in terms of Regulation
29 of the Act. The net assets, after deduct-
ing assets set aside for the specific purpose
of and unrealized non distributable reserves,
are also referred to as “Accumulated Funds”.
Regulation 29 prescribes the “Minimum ac-
cumulated funds” expressed as a percentage
of “Gross annual contributions”is referred to
as a solvency level.
The Medical Schemes Act requires schemes
to maintain a solvency of at least 25% [12].
In the same breath, a solvency level below
25% does not necessarily mean that the
scheme is experiencing financial difficulties.
Similarly, extremely high solvency levels are
not an indication that a scheme is in “per-
fect” financial position. Figure 1 shows the
number of schemes stratified by the (>25%)
and (≥25%) stratum. The phasing in of the
statutory solvency reserve requirements was
from 2000 to 2004, and upward trend in the
number of schemes in the ≥25% stratum
is seen until 2004, from 2005 a downward
trend is observed and the number of schemes
in ≥25% stratum declined significantly by
21% from 111 to 88 medical schemes. The
declining trend also correlates to the con-
solidation in the medical schemes environ-
ment. There were no significant declines in
<25% stratum from 2004 to 2009. Solvency ratio is one indicator used as a benchmark to measure the “financial health”of the scheme and a noteworthy feature of the ratio is that it triggers interventions on the financials of the medical scheme. Thus the regulator of medical schemes consistently monitors solvency levels of medical schemes together with other ratios,such as investment income, non-health expenditure, and membership profile. In ensuring the consumers’ willing- ness to pay contributions for private health insurance, effective regulation requires that schemes are financially sound such that they are able to reimburse their members for the actual expenditure on health. Benefit option packages, Scheme Rules, Pricing and Risk Selection Many governments significantly restrict private health insurance pricing and risk se- lection (underwriting), including imposing limits on rate differentials among different buyers, guaranteed-issue requirements, and guaranteed-renewability rules. Some gov- ernments require medical schemes to ob- tain prior regulatory approval of certain rate changes  [9]. In South Africa, the Council is mandated through the Medical Schemes Act 131 of 1998 [12] to approve all the rules before they are implemented by the schemes (s31).The Council also has to ensure that all proposed new benefit options, restructured options, and new schemes, are assessed fully for viability before they are registered in terms of section 33(2). The most important components of section 33 of the Act include the following. A medical scheme: • May apply for the registration of more than one benefit option. • Shall be self-supporting in terms of membership and financial performance. • Is financially sound. • Will not jeopardize the financial sound- ness of any existing benefit option within the medical scheme. Regulation 4 of the Act states that medi- cal scheme rules may provide members of dependants a right to participate in only one benefit option at a time. The referred regulation that scheme rules may provide that members may change options at the beginning of the month of January each year, and by giving written notice of at least three months before such a change is made. It is also stated that a medical scheme must not in its rules, or in any other manner, structure any benefit option in such a man- ner that creates a preferred dispensation for one or more specific groups of members or provides for the creation of ring-fenced net assets by means of such benefit option. The CMS also approves the amendments of rules to scheme rules and evaluate these in accordance to the required standards; these include mid-year contribution and benefit changes, new options, and the ef- ficiency discounted options for a number of schemes. Figure2illustratesstructuraldifferencesthat exist between open and restricted schemes in terms of benefit options. The 2009 data showed that 40% of restricted schemes, compared to the 3% of open schemes, con- sisted only of one benefit option. A similar distribution exists in schemes with two ben- efit options. However this trend is reversed on schemes with four or more benefit op- tions. There are many options in the open schemes environment and this is worrying as each represents a distinct package of ben- efits, thus members find it difficult to com- pare products to see which offers the best value for money. Also, as a general rule, the greater the number of benefit options, the greater the costs of providing these benefits. The CMS continues monitor the registra- tion of benefit options, ensuring that they wmj 1 2011 5CS.indd 11 21.02.2011 16:28:03 12 Healthcare insurance industry SOUTH AFRICA are self sustainable, affordable to enrollees, and, indeed, do offer value for money. Access to minimal level of care Many governments regulate most language by requiring certain contract provisions and prohibiting others. Some governments mandate minimum coverage provisions [9]. The concept of a minimum level of care is central to the facilitation and achievement of a more equitable and efficient qual- ity health care system in South Africa. The Prescribed Minimum Benefits (PMBs), as provided for by the Medical Schemes Act, have had the greatest importance. PMBs are minimum benefits which, by law, must be provided to all medical scheme mem- bers and include the provision of diagnosis, treatment and care costs for: • any emergency medical condition; • a range of conditions as specified in An- nexure A of the Regulations to the Medi- cal Schemes Act [12], subject to limita- tions specified in Annexure A; included in this list of conditions are chronic con- ditions. PMBs were introduced to avoid inci- dents where individuals lose their medical scheme cover in the event of serious illness and are put at serious financial risk due to unfunded utilization of medical services. They also aim to encourage improved ef- ficiency in the allocation of private and public health care resources. PMBs are not only legislated, but they are the envisaged platform for the national health insurance package, which defines the entitlement for any person contributing towards such in- surance. As a consequence, a package of PMBs with a focus on catastrophic care was developed as Annexure A in the Regu- lations to the new Act in 2000. In terms of the Regulations, the PMB package was to be reviewed every two years by the DoH. This review must involve the Council for Medical Schemes (CMS), stakeholders, provincial departments of health and con- sumer representatives. A review process of PMBs was begun by the Council for Medical Schemes in 2008 [4]. Comments from the stakeholders on the document were taken into account and publication of the third draft of the re- port in that process was published on the CMS webpage. This process was finalized in 2009/10 and the final draft regulation was submitted to the Minister of Health for consideration for possible publication in the government gazette for public comments. There are, however, challenges with the im- plementation of the Act and Regulations relating to PMBs. In this regard the CMS continues to engage with the provisions of PMB regulations, including the “payment in full” provisions contained in regulation 8 of the Medical Schemes Act. Market conduct and unfair trade practices Insurance regulators often enforce legisla- tion dealing with market conduct and unfair trade practices, such as provisions related to unfair claim settlement practices and po- tentially deceptive sales practices by medi- cal schemes and administrators [9]. The regulator of the medical schemes in South Africa actively participates in the consulta- tive process which aims to demarcate medi- cal schemes from health insurance. The of- fice of the Registrar is acutely aware that the encroachment of risk-rated health insur- ance products into the business of medical schemes results in cream-skimming, unfair discrimination,and a risk to the sustainabil- ity of the medical schemes industry. Effective regulation of medical schemes  – and the protection of beneficiaries – is criti- cally dependent on all entities and products being subjected to the rigorous oversight and strict protections are contained in the Medical Schemes Act. A serious threat is posed to the sustainability of medical scheme risk pools by the recent prolifera- tion of insurance products which seek to en- croach on the preserve of medical schemes. Thus, the CMS continues to participate in the demarcation work group established by National Treasury to draft regulations in support of certain amendments effected to the Long- and Short-Term Insurance Acts Figure 1. Industry solvency trends for all schemes (2000–2009) Source: [5] 119 112 111 109 111 108 102 97 92 88 30 30 31 26 22 21 22 25 22 22 0 20 40 60 80 100 120 140 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 year < 25% ≥25% Numberofschemes Figure 2. Distribution of benefit options across medical schemes (2009) Source: [21] wmj 1 2011 5CS.indd 12 21.02.2011 16:28:04 13 Healthcare insurance industrySOUTH AFRICA of 1998 by the Insurance Laws Amendment Act (Act 27 of 2008).The work group com- prises stakeholders from industry, govern- ment, and regulatory authorities, and has as its purpose consideration of the underlying principles required to inform the drafting of regulations to ensure that a clear delineation of products is achieved so that the purpose of the Medical Schemes Act is not under- mined. The differences between the Medi- cal Schemes and Insurance Products is out- lined in table 1. The Medical Schemes Act also states that it is not a good practice to market, adver- tise or in any other way promote a medi- cal scheme in a manner likely to create the impression that membership of such medi- cal scheme is conditional upon an applicant purchasing or participating in any product, benefit or service provided by a person other than the medical scheme. Thus, it is an of- fense to conduct practices that are not in line with the scheme rules, and the CMS secures adequate protection for beneficiaries by approving the manner in which medical schemes carry out business, including the products offered by medical schemes and schemes’ compliance with Section 21A. Information disclosure and consumer complaints Many governments make available con- sumer buying guides and other information about medical schemes contracts. In the United States, many jurisdictions provide contribution rate comparisons, and some publish counts of consumer complaints against medical schemes. Section 48 and 49 of the Medical Schemes Act provide that the Council has authority to resolve com- plaints between medical schemes and their members. This process requires that com- plaints to be made in writing to the Reg- istrar, who must then pass on the details of the complainant to the party that is subject to the complaint. The party against whom the complaint is made has 30 days in which to respond to the Registrar.The Registrar is required to resolve the dispute or submit it to Council, which is expected to take neces- sary steps to resolve the complaint. The fol- lowing are key problem areas in the medical schemes industry, according to an analysis of complaints data in 2010 [6]. • Intermediary behaviour and the func- tional dimensions of the registered en- tities were identified as one of the key problem areas that need to be addressed and monitored closely. • Lack of product quality and standardiza- tion is a policy problem is caused by exter- nal factors, related to capitalizing on op- portunities to take advantage of un-priced risk positions by market participants. • Fiduciary duties of intermediaries, duty to disclose and/or unilateral mistake vs. moral hazard and risk-selection are com- plaints are largely related to non-clinically related entitlements.Undesirable conduct is due to incomplete markets and char- acteristics of such markets creating bar- riers to accessing healthcare. These were identified as one of the biggest changes that threaten the systematic sustainability in the industry. • Conduct inducing market uncertainty is one of the contributing factors that relate to systematic sustainability in the indus- try.These complaints relate to the restruc- turing of financial & operating capital and contingencies impacting risk hazards in market environment. • Clinical treatment, formularies and pro- tocols were also identified as one of the key problem areas dealing with the sys- tematic sustainability in the medical schemes industry. Section 29(1) & An- nexure A of the regulation of the Medical Schemes Act 131 of 2008 is to be used as a base or control measure for clinical treatment, formularies and protocols re- lated types of complaints. The data analyzed by the CMS showed that social regulation, which also relates to Table 1. Differences between Medical Schemes and Insurance Products Source [16] Medical Schemes Insurance Products Medical Schemes Act 1998 Long Term Insurance Act 1998 and Short Term Insurance Act 1998 Governed by the Council for Medical Schemes Governed by the Financial Services Board May not refuse to admit prospective members Have the right to refuse to insure an individual on the grounds of carrying too high risk May not make profit Insures are listed companies which aim to make a profit for their shareholders Seek to match premiums and benefits paid over the period of a year Rely on underwriting and actuarial skills to predict future claims experience for given categories of insured persons over long-term Medical scheme reimburse members for the actual medical expenses Insurance companies pay policy holders a pre- agreed fixed rate in the event of a claim Can be paid directly to the provider of the service, a doctor or hospital Must be paid to the policy holder, not the provider of the service Registered medical schemes have to provide certain benefits and may not charge a member contributions based on your Insurance policies may refuse to sell a policy to an individual or may weight premiums according to perceived extra risk. Insurance companies are allowed to evaluate an individual’s life style and general state of health before selling a policy for ‘dread diseases cover/for example wmj 1 2011 5CS.indd 13 21.02.2011 16:28:06 14 Laws, Rules, and Norms & Conventions of Regulatory Institutions (456/469, 97.2%), is most dominant in the medical schemes en- vironment. Social Regulation [14] typically focuses on policy levers that enhance con- sumer welfare interventions within specific policy environments, thus the paternalistic and normative values of regulatory philoso- phy inform how regulators protect the inter- ests of consumers. There was a significantly a small number of complaints that relate to Economic Regulation – Institutional School (1/469, 0.2%) and Economic regulation  – neoclassical school (12/469, 2.6%). In keeping with the Act’s emphasis on complaints, in 2009, the Council embarked on a process of revamping the complaints system that captures complaints. This was to ensure an efficient and accessible, com- plaints processing system that will be an instrumental tool of health system policy analysis through strengthening the respon- siveness of policy levers to consumer needs and the advocacy of consumer interests. The Governance of Health Insurance The Medical Schemes Act imposes strict controls upon medical schemes themselves in terms of corporate governance in en- suring the protection of beneficiaries. The framework for medi- cal scheme corporate governance is derived from the common law, King II and the Medical Schemes Act of 1998. A ma- jor challenge facing all trustees, including medical aid trustees,is to act “with due care, diligence and the ut- most good faith”.Sec- tion 29 of the Act sets out certain minimum requirements to be contained in the rules of a medical scheme, with a view to protecting the interests of members and also providing a framework for good governance. In terms of section 24(2) of the Medical Schemes Act [12], no medical scheme shall be registered unless the Council is satisfied that members of the board of trustees and the principal officer of the proposed medical scheme are fit and proper persons to hold the office concerned. The statutory duties of the board of trustees of a medical scheme, however, derive pri- marily from the provisions of section 57 of the Act. These include: appointment of the principal officer; accountability for opera- tions of the scheme and resolutions passed by the board; ensuring that proper control systems are in place; communication to members on rights, benefits, contributions, and duties in terms of rules of the scheme; ensuring timely payment of contributions to the scheme; procuring professional in- demnity insurance and fidelity guarantee insurance; obtaining expert advice on legal, accounting, and business matters as re- quired; ensuring compliance with the Act; and protecting the confidentiality of mem- ber information. Ongoing governance fail- ures among medical schemes prompted the Council for Medical Schemes to undertake a project to review their governance prac- tices and to identify the key determinants of governance failures.The findings and rec- ommendations of the Council’s “Govern- ance Theme Project” were released in mid 2006, to recommend additional strategies to improve medical scheme governance and to mitigate the risk of governance failure. Out-of-pocket payments Out-of-pocket health expenditures rep- resent a significant burden on households globally. Most private health expenditure comprises out-of-pocket payments for health care, and this includes user fees or co-payments for insurance covered services, payments for health service not covered by the insurance and informal payments to providers. Private health expenditure ac- counted for 40% of total health spending in the EAC countries compared to the 27% in countries that are members of the Or- ganization for Economic Cooperation and Development (OECD). In Latvia, out-of- pocket expenditure for health care repre- sented 4.7% of household expenditure [20]. Health services funded by medical schemes only benefit the 15% of the population who were members of these schemes in 2000; this figured moved slightly to 16% in 2009. Medical schemes cover 16% of the popula- tion; this population uses the private sec- tor on an out-of-pocket basis for primary care but is almost entirely dependent on the public sector for hospital care [11]. The to- tal household expenditure in South Africa in 2007 was R148.5 billion. 19% of this was the out-of-pocket payments, which means that the spending over and above the medi- cal schemes contributions was R28 bil- lion [16].The figures presented in the figure 4 below show South Africa as the second lowest out-of-pocket expenditure with ref- erence to other countries. The Medical Schemes Act lays down the minimum benefits beneficiaries should re- ceive from their medical scheme; these are benefits that schemes must by law pay for in “full”. Earlier in 2009, a task team on the Healthcare insurance industry SOUTH AFRICA Figure 3. Nature of regulation classification Source: [6] Asapercentageoftheselctedsample(%) 97.2 0.2 2.6 0 20 40 60 80 100 120 Socila RegulaƟon-Lawas, Rules, Norms, & ConvenƟons of regulaƟon Economic regulaƟon- neoclassical School Economic RegulaƟon- InsƟtuƟonal School Nature of regulaƟon wmj 1 2011 5CS.indd 14 21.02.2011 16:28:07 15 PMBs was set up by the Registrar com- posed of the Council for Medical Schemes, medical schemes, healthcare providers and patient rights groups, who are working on clarifying how the PMBs are defined and (at the time of writing this article) this process was still in progress. The outcome of this process could result in schemes becoming liable for more healthcare costs; the success- ful implementation of PMB could possibly offer members the potential to save on out- of-pocket expenses and contribution costs. Contribution increases Increases in excess of the CPI create an af- fordability challenge for beneficiaries because medical scheme contributions comprise a larger proportion of household expenditure. When the pricing of benefit options in- creases it is often followed by a downward migration of beneficiaries to cheaper benefits options. Contribution increases are moni- tored by the CMS on annual basis to ensure the affordability of premiums by beneficiar- ies.The average increase in contributions per option is compared to a benchmark of CPIX + 3%. Options that reflect increases greater than this benchmark are requested to provide further justification for their increase.This is used as a guideline by the office to ensure that contribution increases are justified and fall within a reasonable range. The nominal increase in average risk con- tributions per average beneficiary (as per scheme financials) from 2006/2007 was 9.9% and the comparing figure for period 2009/2010 was 11.6% for the open schemes market, which was slightly higher than the restricted schemes. The average increase for restricted scheme in gross contribution per average beneficiary per month was 3.9% for 2006/7 and the comparing figure for 2009/10 was 11.6%. The contribution in- creases proposed by the schemes in 2009/10 were 15.7% (a deviation of 4.1% from the actual) for the open schemes and 12.7% for the restricted schemes (a deviation of 1, 1% from the actual). The considerable dif- ference between these estimated contribu- tion increases and the actual increase in the average contribution income of schemes indicates that some beneficiaries bought down from more comprehensive options to cheaper options, with the consequent dampening effect on contributions. This phenomenon is more pronounced in open schemes than the restricted schemes. The CMS vigorously investigates the contribu- tion increases and also monitors the afford- ability and access to healthcare within the medical schemes industry, which is done through the cost containing strategies. Non-healthcare costs and contribution increases Accredited entities, including medical schemes, administrators, brokers and man- aged care entities do not always act in the best interests of scheme members and the public at large. “Many schemes and admin- istrators attempt to influence brokers to Healthcare insurance industrySOUTH AFRICA PercentageofTotal 0 10 20 30 40 50 60 70 80 Out-of-pocket Private insurance Social sicurity General government South Africa VietnamColumbiaTaiwanMexicoSouth Korea ThailandJapan Figure 4. Out-of-pocket payments (Country comparisons) Sources: [22] Figure 5. Contribution rate changes (2001–2008) Source: [5] wmj 1 2011 5CS.indd 15 21.02.2011 16:28:08 16 advise clients to choose a particular scheme by bidding up broker commissions.This was what largely necessitated the regulated cap- ping of broker fees from 2004.However,the regulatory regime still has loopholes allow- ing conflicts of interest to exist by permitting schemes to pay the fees in respect of advice to members. The conflicts substantially re- duce the quality of advice in the market and permit schemes to avoid being wholly re- sponsive to members and beneficiaries”, [4]. Figure 6 illustrates the increase in broker fees relative to membership of schemes that pay brokers. Broker service fees have been rising sharply over the past few years,result- ing in rates of increase now far exceeding the increases in number of members. For those schemes that paid brokers, broker service fees PAMPM (per average mem- ber per month) increased by 169.6% since 2000 compared with an 81.6% net increase in the average number of members. The substantial increases in broker service fees are not proportional to the increase in new members in the medical schemes environ- ment [5], and this poses questions whether the brokers are indeed adding value to the medical schemes.The CMS has started ini- tiate consultative processes to propose the revision of the regulatory framework for the remuneration of healthcare brokers. Expanding coverage and health work force Regulated private insurance coupled with various social health insurance options and government subsidies represent the mid- dle-income country route toward build- ing a universal system. There has been a lot discussion about introducing National Health Insurance (NHI) in South Africa. “The first phase of the project will be rolled out in 2012, and will focus primarily on bringing services to areas with little or no access to quality healthcare and thereafter be extended to other areas of the country. Providing universal coverage for all South Africans, irrespective of whether they are employed or not should aim to ensure eq- uity and solidarity among the population through the pooling of risks and funds. The NHI calls for mandatory membership for all South Africans through mandatory contributions and social solidarity, it is up to the general public to continue with ad- ditional voluntary cover with the medical schemes after they have contributed to the NHI Fund”  [1]. Private health insurance plays a large and increasing role around the world and it is envisaged that even in South Africa the medical schemes could be an important component of achieving universal coverage. One possibility is envis- aged in which medical schemes continue to operate in an NHI setting and function as a supplementary cover; this is, of course, with reference to the international experi- ences and is also dependent on definition of the NHI package. A word of caution is to learn from the international experiences, so as to mitigate the shortcomings of es- tablishing such a fund and also to be aware of the different characteristics between countries. As South Africa prepares for the imple- mentation of the NHI, one of the key chal- lenges that needs to be addressed relates to the health work force. “There is a massive global shortage of health workers and these are most intensely in developing countries, the reasons for shortage in health workforce are multitude including underproduction, misdistribution of health workforce, health workforce exit and increase in demand of health care. Many countries in the world with acute shortage of health workforce face a lack of medical schools. For an in- stance, two thirds of sub-Saharan African countries have only one medical school and some have none” [17]. The number of nurses in South Africa, as estimated by the WHO, is 18000 and these professionals are serving a population of nearly 49 million. This translates to 3.8 per 1000 patients – significantly smaller than the 9.4 and 7.7 per 100 patients in the US and Canada respectively [16]. The national shortage of health care workers is critical to the imple- mentation of the NHI and key areas of at- tention for the initial roll-out of the NHI are being discussed.These include investing and rebuilding the country’s public health infrastructure, developing human resources programs to fill the national shortage of qualified health workers, and establish- ing a national health fund that would be ensconced in the Ministry of Health but operate autonomously. The CMS’ expertise and 10 years of experience can also play a vital role in making NHI Fund work effi- ciently. Healthcare insurance industry SOUTH AFRICA Figure 6. Broker fees and scheme membership Source [5] 230 289 354 581 704 848 903 980 1107 1125 1.3 1.5 1.8 1.9 1.9 2 2.1 2.2 2.2 2.3 0 200 400 600 800 1000 1200 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 0 0.5 1 1.5 2 2.5 Million(R) members(millions) Broker fees Average members wmj 1 2011 5CS.indd 16 21.02.2011 16:28:09 17 Healthcare insurance industrySOUTH AFRICA Conclusions The ultimate responsibility for the overall performance of a country’s health system lies with government,which,in turn,should involve all sectors of society, promoting the spirit of cooperation and partnerships among private and public health profes- sionals.A government has the responsibility for establishing the best and fairest health system possible with available resources and the oversight and regulation of private sec- tors, which must form part of the overall government response, must be high on the policy agenda. Regulation of private health insurance should not only provide oversight to private health insurance companies but it should also focus on encouraging demand for cov- erage and otherwise facilitating the entry and expansion of access to health care. This will then result in an environment where a greater proportion of the citizens of the country have access to good quality health- care. In the South African context, the pri- vate sector is critical to the implementation of the NHI fund, and policy makers need to confront the role that private health insur- ance will play. Regulatory approaches and policies can structure private health insur- ance markets in ways that mobilize resourc- es for health care, promote financial risk protection, protect consumers, and reduce inequities. Regulatory frameworks for pri- vate health insurance need to be structured in such a way that they regulate the sector appropriately so that it serves public goals of universal coverage and equity Effective regulation ensures the protection of beneficiaries and includes a critical re- sponsibility to ensure financial solvency of the schemes. This is achieved by establish- ing risk-based solvency and minimum capi- tal standards to mitigate risk for the insured population and employers.The rationale for an effective regulation framework should mandate disclosure requirements for poli- cies and costs requiring that their content is understandable to consumers and that the consumers are informed of their rights. Promoting equity involves ensuring access to health care by all income strata of the population, and minimizing risk skimming and adverse selection, which distort health insurance markets, and this is also a key policy goal for effective regulation. Govern- ment policy needs to provide a framework that result in coverage for a minimum level of essential services, irrespective of whether it is provided in the public or the private sectors. Given the existence of perverse in- centives in unregulated markets for health care, any regulation must pay careful atten- tion to the incentives generated. The use of mixed systems for covering and providing health care, combined with the correct ele- ments of choice, is the best approach to bal- ancing health care objectives with the need for operational efficiency. References 1. ANC Task Team NHI Proposal to NEC, 13 July 2009. Also available on www.health-e.org. za/news/article 2. Baldwin R, Cave, M. 1999. Understanding Regulation: Theory, Strategy and Practice, Ox- ford: Oxford University Press. 3. Bermuda Health Council (BHeC). 2010. En- hancing the Regulatory Framework for Health Insurers. Also available on www.bhec.bm 4. Council for Medical Schemes. 2008, CMS Press Release 3 Of 2008: Medical Schemes Cost Increases April 2010. Available on http:// www.medicalschemes.com. 5. Council for Medical Schemes. 2009, Annual Reports of the Registrar of Medical Schemes 2009/2010. Available on http://www.medicals- chemes.com 6. Council for Medical Schemes. Research and Monitoring Unit. 2010b. Key Complaints Ar- eas for Compliance Action, (unpublished re- port), 2010 7. Council for Medical Schemes. 2010a. CMS Press Release Template 2009: Regulator of Medical Schemes turns April 2010. Available on http://www.medicalschemes.com. 8. Georgetown University Health Policy Institute. 2004. “Summary of Key Consumer Protections in Individual Health Insurance Markets.” www. HealthInsurance.org. 9. Harrington, S.E. 2007. Facilitating and Safe- guarding Regulation in Advanced Market Economies,The World Bank. 10. King Committee on Corporate Governance. The King Report on Corporate Governance for South Africa. 2002. 11. McIntyre D, Thiede M, Nkosi M, Mutyam- bizi V, Castillo-Riquelme M, Gilson L, et al. A Critical Analysis of the Current South African Health System. Cape Town: Health Economics Unit, University of Cape Town and Centre for Health Policy, University of the Witwatersrand; 2007. 12 Medical Schemes Act, 1998 (Act No. 131 of 1998). Also available on www.doh.gov.za/docs/ bills/msr.pdf 13. Monitor, Independent Regulator of NHS Foundation Trust, “Developing an effective market Regulatory Framework in Healthcare”, 2010. Available on www.monitor-nhsft.gov.uk 14. Ogus; A. (2002). Regulatory Institutions and Structures. Annals of Public and Cooperative Economics, Vol. 73, Issue 4, pp. 627–648. 15. Pearmain, D. 2000. Impact of Changes to the Medical Schemes Act. South African Health Review 16. Still, L. 2008. Health Care in South Africa. Available on www.profile.co.za 17. V. Bhatt, S. Giri & S. Koirala: Health Work- force Shortage: A Global Crisis. The Internet Journal of World Health and Societal Politics. 2010 Volume 7 Number 1 18. Van den Heever, A. & Brijlal, V. 1997. Health care financing. South African Health Review, (8), 81–89. 19. Van Rensberg,H.C.J.2004.Health and Health- care in South Africa. First edition. Pretoria: Van Schaik Publishers. 20. Xu, K et al. (2009), Access to Health Care and the Fiancial Burden of Out-of-Pocket Health Payments in Latvia 21. Willie, MM & Nkomo, P. 2010. Intraclass cor- relation and multilevel modelling of contribu- tions data. First Global Symposium on Health Systems Research, 16–19 November 2010, Montreux, Switzerland 22. World health organisation (2004), Discussion paper number 3: Private health insurance: im- plications for developing countries Dr. Monwabisi Gantsho, Mr. Michael Mncedisi Willie Council for Medical Schemes, South Africa Email: m.gantsho@medicalschemes.com wmj 1 2011 5CS.indd 17 21.02.2011 16:28:11 18 On the threshold of the year 2011 I would like WMA to pay its attention to the dam- age caused by tobacco smoking and espe- cially to the disastrous consequences of smoking in the presence of infants, young children and pregnant women. Our task is to eliminate this malady forever. This year is favourable for its implementation as our friends in Monte Video have set as the main task for the General Assembly the recogni- tion of the extreme harmfulness of tobacco smoking. The Latvian Medical Association points out that our goal is not restriction of tobacco smoking but total elimination of this disaster. This is not an easily achievable goal as a long and persistent effort is re- quired here; however, it is possible to reach in a twenty-year period. From today’s point of view the most alarm- ing fact is that the Tobacco industry that has been continuously defeated in Europe, Australia and North America, has shifted its business to the Third World countries, increasing the number of smokers among children and young people, especially young girls.The Third World countries do not pos- sess enough resources to fight the Tobacco industry as they lack means to provide their population with food and drinking water and many of these countries suffer from high rate of unemployment. These hard conditions are still worsened by Tobacco stepping in and attracting the scarce re- sources. There is a principle that applies to a cer- tain group of countries in the world – the amount of finances spent on smoking equals that spent on healthcare as a whole.The old European countries have imposed high ex- cise duties and VATs on Tobacco, which re- directs a significant part of these taxes to the state budget. In the developing countries all money made on tobacco sales flows directly into the greedy arms of producers and mer- chants. Bread and water get exchanged for Tobacco. Even starving children smoke. So the Tobacco manufacturers kill people not only by means of nicotin, tar and carcino- gens but also economically. Today the World Medical Association has to undertake leadership in the campaign againstTobacco on a global scale.The World Medical Association cannot be bribed and its leaders will not take up any discussion or deal with the Tobacco industry. The World Medical Association has to use its authority and powers, the knowledge based on evidence and to declare world- wide: 1. Smoking in the presence of a child is vio- lence against a child. 2. Smoking in the presence of a pregnant woman is a crime against humanity. 3. What we can do is protect children and pregnant women worlwide from passive smoking within family, in public, in prmises, cars, hotels, hospitals, at sports events, train stations and anywhere else. 4. Those selling tobacco to young people and children and those involving children into smoking must be considered murderers. These four messages must become our slo- gan that we should bring to the WHO and governments of all countries thus obliging them to include these messages into their legislation and to declare smoking in the presence of children and pregnant women a crime to be prosecuted. Only WMA is able to act zealously and forcefully because there is no threat of friendly co-operation between it and the Tobacco industry.WMA should take the initiative of fighting the Tobacco industry in its hands, and espe- cially the tendency that forces children and young women in the developing countries to smoke. Almost all governments and politicians tend to be close to Tobacco manufacturing and merchandising companies, even receiv- ing direct or indirect support from them. Members of the World Medical Associa- tion are able to persuade their governments that flirting with the Tobacco industry is a dangerous game that puts the health and lives of their people at stake. Passive smoking is a significant cause of illnesses and deaths Environmental tobacco smoke (ETS) that is also called “second hand smoke” or “pas- sive smoking” is a widespread cause of ex- cessive morbidity and mortality worldwide, which results in significant costs paid by the whole world community. ETS is composed of more than 4.000 chemicals including more than 50 presently known carcinogens and a lot of toxic substances. The US Department of Health and Hu- man Services has classified ETS as human- generated carcinogen and toxic pollutant. Harm of tobacco LATVIA Pēteris Apinis Tobacco-Free World in Twenty Years’ Time! wmj 1 2011 5CS.indd 18 21.02.2011 16:28:12 19 Harm of tobaccoLATVIA It has been repeatedly proven that passive smoking causes serious damage to human health and life. Continuous passive smok- ing induces the same diseases that are pro- voked by active smoking including lung cancer, coronary heart disease and infantile diseases. A WHO survey states that non-smokers living together with smokers are by 20–30% more exposed to lung cancer. The risk of becoming ill with lung cancer is estimated as 12–19% for those working in a smoking environment. Passive smoking is connected with respiratory diseases and it causes exac- erbation of asthma,allergy and chronic lung disease that results in excluding from the social and working environment. Living together with a smoker increases the risk of cardiovascular diseases by 25–30%, while working in a smoking environment increases it by 15–18%. Besides, the con- nection between doses and the response is not a linear one. Passive smoking relates to heart diseases and the probability is about half of that resulted from 20 cigarettes a day. Even a small amount of tobacco smoke can have an immediate effect on blood clotting as well as a long-term influence on athero- sclerosis, which make the most significant heart disease factors. According to the European Respiratory Society, Cancer Research UK and Insti- tut National du Cancer, more than 79.000 adults in 25 member countries of the EU die annually from passive smoking. Home and work are the two main environments where tobacco smoke acts intensively and chronically. These estimations include deaths from heart diseases, stroke, lung cancer and dif- ferent respiratory diseases caused by passive smoking. These numbers do not include adult deaths caused by other conditions connected with ETS (such as pneumonia), early death or both serious acute and chron- ic diseases caused by passive smoking. “Second hand smoke” is particularly dangerous for young children and in- fants. Smoking in the presence of a child is an act of violence that threatens child’s health and life. Smoking in the presence of a pregnant woman is an act of vio- lence against her and the unborn child, consequently – a crime against the state “Second hand smoke” is particularly dan- gerous for young children and infants, it is related to sudden death, pneumonia, bron- chitis, asthma and respiratory symptoms as well as tympanitis. ETS can also result in decreased birth weight, prenatal death or premature birth. Smoking in the presence of a child can cause addiction that in turn makes the child an early smoker. Parents’ smoking becomes a kind of brand that is followed in the future life. After seeing a camel or brave horsemen in a prairie in their young years, people con- sider the image being a positive one in their adulthood. The WHO Framework Convention on Tobacco Control (FCTC) has recognized that there is scientific evidence of the fact that tobacco smoke causes death, diseases and disability. The convention obliges the member countries to prevent “second hand smoke” risks. According to FCCT article 8, every mem- ber is bound to “adopt and implement ef- fective legislative, executive, administrative and/or other measures, providing for pro- tection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and,as appropriate,other pub- lic places.” Smoking is an economic burden At the moment when country after coun- try has been stricken by the economic crisis, tobacco consumption imposes one of the heaviest burdens on the economy. However, politicians often pretend not seeing this threat. At first this burden includes the increased direct costs of health care determined by deseases caused by tobacco smoking. This burden is different in different countries, but in the EU it is considered that at least one quarter (24–32%) of health care costs are related to diseases caused directly by al- cohol and tobacco consumption. Another economic stroke coming from smoking is indirect costs, which occur be- cause smokers fall ill more often than non- smokers, they do not work and do not pro- duce any added value during these periods and thus they decrease the health and social budget. The same is also true for “passive smokers”. Their productivity is lower than that of non-smokers – oxygenation in the lungs becomes slower during smoking and smoker’s blood oxygen saturation decreases, which results in rapid tiredness and lack of attention. Smokers also tend to take breaks, so no work is being done during these pe- riods. One more aspect  – smoking quite often causes domestic, industrial and forest fires. Smoking while driving has been the reason for thousands of road accidents in the whole world. The policy of the Tobacco industry that supports tobacco manufacturing in the developing countries and a differenti- ated excise duty policy has facilitated turn- ing of the tobacco goods into a contraband that involves thousands of people traffick- ing tobacco produced in China, India, the Ukraine or Russia illegally into the EU or the USA. An essential task is to promote the stand- point that smoking is a calamity and it is “normal” not to smoke. One of the first tasks is to achieve the situation that medi- cal people do not smoke. Smoking by a physician is one of the most negative ex- amples possible. wmj 1 2011 5CS.indd 19 21.02.2011 16:28:13 20 Harm of tobacoo LATVIA Sixty years of fighting smoking. Sixty years of randomized research In this article I would like to give some in- sight into the history of fighting smoking and give evidence of the significant work done by doctors. In 1951 Austin Bradford Hill dis- covered that smoking causes lung cancer.For the time being it was a sensational discov- ery as after WW II most of male Europeans were smokers. During the war tobacco acted as a tranquillizer in entrenchments; even if it did not give relief, it kept one busy. It was not an easy task to prove this correlation because both healthy and unhealthy people used to smoke. So statistics was the only tool. The 1950’s were the time of paradigm shift in medicine because lung cancer came forward instead of tuberculosis. In England the number of lethal outcomes from lung cancer in 1950 exceeded those from tubercu- losis. In 1947 Austin Bradford Hill, Ernest Kennaway from St Bartholomew’s Hospital and Percy Stocks, chief government medical statistician, were asked to find out whether smoking could cause the shocking 15-fold increase in lung cancer deaths during the previous 25 years. They were accompanied by Dr Richard Doll. From April 1948 every suspected lung cancer case in 20 London hospitals was reported to Doll.In turn,a lady almoner was sent to interview a patient and two more patients from the control group – one with a stomach or colon cancer and the other one from any other therapy or surgery department.The research proved the correla- tion concerning smokers and non-smokers, as well as the number of cigarettes smoked a day. A control research was carried out outside London. The results were undoubt- able. At the same time similar results were obtained in the USA. However, this was not enough to persuade the world that smoking is harmful. Brad- ford Hill was looking for more evidence and he invented a new method of research. The previous method was a retrospective one, but to make it absolutely veritable, similar data had to be obtained in future perspective. So a large number of men and women were questioned, finding out about their habits, including smoking and they were observed for several years. So this prospective or cohort research gave the answer to the question why smokers die. Bradford Hill chose 60.000 physicians from the Medical Registry, who were reli- able for his research. There was no better way to promote this discovery than spread- ing it in the medical environment.The doc- tors passed the message about the harm of smoking over to their patients. In 1951 Bradford Hill sent a letter to the British Medical Journal, asking: “Do you smoke?” In the short period of two years, Bradford Hill got his response. Out of 40.000 re- spondents, 789 were dead, 36 of them of lung cancer.When the results were put into tables, a correlation between doses showed out. The more cigarettes were smoked, the more death cases occurred. Thus in 1951 Bradford Hill started the sta- tistical methods that are used by thousands of scientists and physicians in the whole world today. The randomized controlled re- search came as a substitute for clinical ob- servation. These findings of 1951 empowered physi- cians in the whole world to start the battle against tobacco. Smoking doctors disap- peared from packages, and some time lat- er – from posters that recommended ciga- rettes of a certain brand. Today at least in Latvia any advertising of tobacco is banned, and all legally sold packages have visible and serious warnings about the hazards of smoking – cancer, heart disease, impotency or at least bad teeth. In Northern Europe there is no smoking in clubs, bars and public places. In some countries no indoor smoking is allowed, because passive smoke is harmful not only for those standing next to the smoker but for smokers themselves as they are more exposed to cancer (and at the same time financial losses to the state health budget). A lot is achieved, still a lot is to be done. The Latvian Medical Association is pro- moting an anti-smoking legislation in Latvia and we are inviting the world to join us We are supplementing the Children’s Rights Defence Law with a thesis that no child must be exposed to tobacco smoke and nobody is allowed to smoke in the presence of a child, to ensure a smoke-free environment for children. The same law states that physical violence against a child is a conscious application of power when approaching a child or a situation when a child is exposed to harmful factors (air pollution, tobacco smoke, etc.). So smok- ing in the presence of a child, including an unborn one, is considered physical violence against a child and makes it suffer physi- cally. Latvian lawmakers today are forced to con- sider whether real imprisonment (5–15 days and work) should be imposed on those sell- ing cigarettes to minors or “kind uncles” buying those for minors. We propose that those who smoke in the presence of children and women should be naturally imprisoned. Let us join our forces in 2011 to protect children in the whole world against direct and indirect effects of tobacco smoking! References 1. Barnoya J, Glantz SA. Cardiovascular effects of secondhand smoke: nearly as large as smoking. Circulation. 2005 May 24;111(20):2684-98. Re- view. 2. Boldo E, Medina S, Oberg M, Puklová V, Mekel O. Health impact assessment of environmental tobacco smoke in European children: sudden in- fant death syndrome and asthma episodes.Public Health Rep. 2010 May-Jun;125(3):478-87. 3. Cardiovascular effects of secondhand smoke: nearly as large as smoking. Circulation. 2005; 111(20): 2684-2698 4. Commision of the European Communities. Gre- en paper: Towards a Europe free from Tobacco smoke: policy options at EU level. Available at: http://eur-lex.europa.eu/LexUriServ/site/en/ com/2007/com2007_0027en01.pdf. wmj 1 2011 5CS.indd 20 21.02.2011 16:28:14 21 Climate ChangeAUSTRALIA While many people and groups have ex- pressed disappointment with the outcomes or lack of outcomes from the Copenhagen climate talks, it remains undeniable that cli- mate change poses serious threats to human health globally. The world’s climate – our life-support sys- tem – is being altered in ways that are likely to pose significant direct and indirect chal- lenges to health. While climate change can be due to natu- ral forces or human activity, there is now substantial evidence to indicate that human activity – and specifically increased green- house gas emissions – is a key factor in the pace and extent of global temperature in- creases. Potential health impacts of climate change in Australia In Australia, consequences of climatic ex- tremes and changes to food and water supplies are predicted to have particular impacts on rural, regional, and some re- mote Indigenous communities, with some coastal communities facing relocation due to storms and flooding. Significant numbers of Australians are vul- nerable to severe storms and to increases in sea level. There is a consensus that the more vul- nerable members of the community – the elderly, the young and those whose health is already compromised – will be most af- fected by climate-related illnesses. Children’s exposure to climate change-re- lated exposures and social stresses has been highlighted as a particular concern. By 2056, there will also be a much higher proportion of Australians over the age of 65, as well as a rapid increase in the number of people aged 85 and over. By 2020, it is expected that Australian doc- tors and other health professionals will be seeing patients with illnesses and conditions related to both short-term and longer-term effects of climate change. 5. Doll R, Hill AB. Mortality in Relation to Smoking: Ten Years’ Observations of Bri- tish Doctors. Br Med J. 1964 June 6; 1(5396): 1460–1467. 6. Doll R,Hill AB. Smoking and carcinoma of the lung: preliminary report.Br Med J. 1950 Sep 30;2(4682):739-48. 7. Doll R, Hill AB. Study of the Aetiology of Carcinoma of the Lung. Br Med J. 1952 Dec 13;2(4797):1271-86. 8. Flouris AD. Acute health effects of passive smoking. Inflamm Allergy Drug Targets. 2009 Dec;8(5):319-20. 9. Gehrman CA, Hovell MF;Centre for Reviews and Dissemination. Protecting children from environmental tobacco smoke (ETS) exposure: a critical review. Cochrane Database of Ab- stracts of Reviews of Effects, 2003. 10. Glantz SA, Parmley WW. Even a little second- hand smoke is dangerous. JAMA. 2001 Jul 25; 286(4):462-3. 11. Hopkins DP, Briss PA, Ricard CJ, Husten CG, Carande-Kulis VG; Centre for Reviews and Dissemination. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Cochrane Da- tabase of Abstracts of Reviews of Effects , 2001. 12. Lin S, Fonteno S, Weng JH, Talbot P. Com- parison of the toxicity of smoke from con- ventional and harm reduction cigarettes using human embryonic stem cells.Toxicol Sci. 2010 Nov;118(1):202-12. 13. Oberg M, Jaakkola MS, Woodward A, Peruga A,Prüss-Ustün A.Worldwide burden of disease from exposure to second-hand smoke: a retro- spective analysis of data from 192 countries. Lancet. 2011 Jan 8;377(9760):139-46. 14. Prevalence and Incidence of Smoking.Available at:http://www.wrongdiagnosis.com/s/smoking/ prevalence.htm 15. Priest N,Roseby R,Waters E,Polnay A,Camp- bell R. Family and carer smoking control pro- grammes for reducing children’s exposure to environmental tobacco smoke. Cochrane Da- tabase of Systematic Reviews, 2008, October. 16. Reh DD, Lin SY, Clipp SL, Irani L, Alberg AJ, Navas-Acien A. Secondhand tobacco smoke exposure and chronic rhinosinusitis: a popula- tion-based case-control study.Am J Rhinol Al- lergy. 2009 Nov-Dec;23(6):562-7. 17. Wdowiak A, Wiktor H, Wdowiak L. Ma- ternal passive smoking during pregnancy and neonatal health. Ann Agric Environ Med. 2009 Dec;16(2):309-12. 18. Wipfli HL, Samet JM. Second-hand smoke’s worldwide disease toll.Lancet.2011 Jan 8;377(9760):101-2. 19. World Health Organization.WHO Report on the GlobalTobacco Epidemic,Implementing smoke-free environments. 2009 Pēteris Apinis, President, Latvian Medical Association Climate Change – a Serious Threat to Human Health Andrew Pesce wmj 1 2011 5CS.indd 21 21.02.2011 16:28:15 22 Climate Change AUSTRALIA Higher temperatures Heatwaves, especially in cities, can increase the rates of death and illness,primarily from heart and respiratory illnesses. Australia’s ageing population, increasing occurrence of chronic disease and co-mor- bidities and high levels of urbanisation all serve to increase susceptibility to the impact of heatwaves. If NSW were to experience a heatwave similar to one that occurred in Europe in 2003, calculations suggest that an extra 647 deaths would occur over a two-week period. Studies suggest that, over time, levels and patterns of airborne pollens and pollutants, which have significant effects on respiratory health, can be affected by higher tempera- tures and humidity resulting from climate change. While the links between ozone and atmo- spheric warming are complex,elevated levels of ambient ozone have been found to lead to more frequent asthma attacks and hospitali- sations and greater morbidity and mortality in patients with pre-existing pulmonary or cardiovascular disease. Investigations of the potential impact of climate change on ambi- ent ozone concentrations suggest that a con- tinuation of current trends over the next 10 years could result in asthma-related deaths rising by almost 20 per cent. Vector-borne diseases The potential for the resurgence of old dis- eases, the redistribution of others, and the emergence of new diseases have all been linked to altered climate and changing eco- logical balances. Changes in climate can significantly alter the ecology and epidemiology of viruses and their potential to cause outbreaks of human disease. The transmission of cer- tain arboviruses (transmitted to humans through mosquito bites) is particularly sus- ceptible to environmental conditions that enable breeding and survival – rainfall,tides, sea level, temperature, humidity and wind all play a part. Climate change is expected to particularly affect the spread of diseases such as malaria and dengue fever. The arboviruses of greatest concern in Australia are Ross River, Barmah Forest, Murray Valley encephalitis, Kunjin virus, dengue and Japanese encephalitis virus. The spread of other mosquito-borne diseas- es such as Chikungunya virus may also be affected, as there is evidence that the virus, previously thought to be limited to particu- lar species of mosquitoes, is capable of be- ing transmitted by species distributed more widely in Queensland and in other areas throughout Australia. It is believed that global warming will result in tropical conditions in Australia spreading south, as will disease vectors such as mos- quitoes. Food and water-borne diseases Heavy rain, flooding and increased temper- atures are factors that influence water-borne infections. As the temperature of the environment increases, the quality and the quantity of drinking water could decrease through drought. In Australia, there are already water restric- tions in many States for the first time in 20 years. It is expected that health disorders related to environmental and water contamination by bacteria, viruses, protozoa and parasites will increase as the quality of water de- creases. This contamination also occurs at the other extreme as heavy rainfall and run- off influence the transport of microbial and toxic agents from agricultural fields, human septic systems and toxic dumps. Warmer temperatures also encourage food- borne infections. The incidence of bacterial food-borne dis- eases (and amoebic diseases) increases dur- ing the summer months and is worse in the northern regions of Australia, due primarily to the increased bacterial replication where ambient temperatures are higher. If average temperatures continue to rise, rates of food-borne diseases are also pre- dicted to rise. However, actual health im- pacts will depend on factors such as food hygiene practices and contributions of dif- ferent pathogens. The combination of water shortages and lack of fresh food suggests the potential for significant harm to both the environment and human health in isolated Australian communities. Changes in the amount and distribution of wildlife, fish and vegetation could also have health consequences for people in remote Indigenous communities who follow a tra- ditional diet. Mental health Both extreme events and gradual climate- related changes, such as drought, may give rise to mental health problems, and these may continue for a significant period, and even be delayed. Populations exposed to climate-related ex- treme weather events or disasters experience social, physical and material conditions that adversely affect mental health. Post-trau- matic stress disorder,depression and anxiety may all result. Because of increasing num- wmj 1 2011 5CS.indd 22 21.02.2011 16:28:17 23 AUSTRALIA Climate Change bers of extreme weather events, the impact of natural disasters on mental health is a growing concern. Studies have found that mental health is- sues remain for a considerable time after the event and that, while post-disaster morbid- ity is likely to decline over time, the effects of exposure to the initial disaster and losses are likely to persist. A number of Australian studies have shown that bushfires increase psychological mor- bidity among individuals and communities experiencing loss. These effects can be chronic and delayed and may require ongoing intervention, al- though relatively few individuals develop serious long-term problems. Diagnosis of post-traumatic stress disorder requires a clinical evaluation of symptoms. Other mental health problems occurring in a post-disaster environment include depres- sion, bereavement complications, anxiety disorders, substance abuse and adjustment disorders. Three years after Hurricane Katrina in the USA, psychiatrists and other clinicians, hospitals,government and non-government agencies, schools and community groups were still working to help adults and chil- dren overcome persistent mental health problems. Studies have found that people recover from extreme events in different ways and that a range of support services across the whole of the community is required. People who had accessed the services of the ACT Bush- fire Recovery Centre after the 2003 Can- berra bushfires reported that, after the Re- covery Centre, doctors were the next most common source of help that they consulted. In addition to the impact of disaster events, coping with and moving away from longer-term effects of climate change may create mental health problems for some people. In Australia, drought has had a major im- pact on farm families and communities reli- ant on agricultural production. Levels of depression and suicide in rural Australia have been correlated with pro- longed drought, and there are concerns about the likelihood of mental health prob- lems continuing to increase, particularly among rural men. Many communities, including those famil- iar with drought, are likely to face the chal- lenges of longer-term climate change. Action Climate change is a real and serious prob- lem. The potential health effects are signifi- cant, and we need to take steps now to ad- dress them. In Australia, we need a national coordinated strategic approach to these health problems. The AMA advocates that a National Strategy for Health and Climate Change should be developed and imple- mented. That strategy should incorporate the fol- lowing: • localised disaster management plans for specific geographical regions that model potential adverse health outcomes in those areas and incorporate appropriate localised health and medical response measures, including for people who have been evacuated or relocated, temporarily or permanently, • strong and active communication link- ages between hospitals, major medical center and local weather forecasters and emergency response agencies (in at-risk locations) to maximize timely responses and efficient use of health resources in ex- treme weather events, • measures targeted to the needs of certain vulnerable population groups (older Aus- tralians, children, Indigenous communi- ties, members of remote communities), • measures to address health and medi- cal workforce needs in rural and remote communities, particularly in mental health services, • enhanced awareness among doctors and health professionals of the potential con- sequences on mental health of extreme weather events and disasters, • development of effective interventions to address mental health issues arising from extreme events, including those involv- ing mass casualties,and from longer-term changes, including drought, • programs to improve the education and awareness of health professionals about the links between health and climate change, and their understanding of the risks of new vector-borne diseases and their health impacts, • measures to prevent exotic disease vectors from becoming established in Australia and nationally coordinated surveillance for dangerous arboviruses, with public education programs promoting mosquito avoidance and measures to prevent mos- quito/arthropod breeding, and • preparedness to deal with the temporary and permanent dislocation of people due to climate-related physical events and economic conditions. Dr. Andrew Pesce, President, Australian Medical Association wmj 1 2011 5CS.indd 23 21.02.2011 16:28:18 24 More than 170 doctors from around the world gathered in Vancouver in mid-Octo- ber for a wide-ranging discussion about the pervasive and profound effects environmen- tal factors such as climate change can have on human health. The occasion was a scientific session orga- nized by the CMA as part of the World Medical Association’s (WMA) annual general assembly. WMA delegates, as well as many BC physicians who attended the meeting, were told how health issues re- lated to environmental change have become a policy focus for both the WMA and the CMA, thanks in part to the leadership of a CMA past president, Dr. Ruth Collins- Nakai. “Why on earth would we be interested in environment health?” asked Dr. Maura Ricketts, director of the CMA’s Office for Public Health, as the scientific session began. “Because our members are inte- rested.” She said members want and expect the CMA to take a strong advocacy stance with respect to issues such as climate change.Be- cause they are “extraordinarily well-trusted resources for information,” she added, phy- sicians can play a key role in making people aware of environmental issues and their im- pact on health. Dr. Alan Abelsohn, assistant professor of family medicine and community medicine at the University of Toronto, said survey data has shown that Canadians consider physicians – especially family physicians – to be the most credible source of informa- tion on the environment and health. The meeting began with a video greeting from federal Health Minister Leona Ag- lukkaq, who advised that every aspect of the environment can affect human health, and the discussions that followed supported her contention. The session’s keynote speaker,British Medi- cal Association President Sir Michael Mar- mot, provided an exhaustive global over- view of how social and economic inequities, as well as inequitable exposure to environ- mental risks, affect health. “If we put fairness at the heart of all de- cision-making, health would improve and health inequities would diminish,” said ser Marmot. He presented data which proved that com- munities and individuals at the lower end of the socioeconomic spectrum also face greater exposure to environment-related health risks. He was followed by several experts, many of whom work at Canadian centres, who cov- ered issues ranging from indoor air quality in developing nations to mercury toxicity. For instance, thermometers that contain mercury remain the largest source of that toxic element within health care settings. “The movement away from mercury ther- mometers has been global... and is certainly picking up steam,” said Dr. Peter Orris, chief of occupational and environmental medicine at the University of Illinois. He noted the number of thermometers broken in hospitals remains “quite extraordinary.” All presentations at the WMA meeting were recorded and will be made available on www.cma.ca Pat Rich, Canadian Medical Association World’s MDs Discuss Growing Health Threats Posed by Environment WMA news The World Medical Association has ap- pealed to the Mexican Government to restore order in the north Mexican city of Ciudad Juarez where physicians are being blackmailed, kidnapped and killed in drug related violence. Dr. Federico Marin, the President of the Mexican Medical Association, has urged the WMA to intervene to help the physi- cians in Jurarez. He told the WMA: “Due to the escalating violence and now the kidnapping of physicians, it has become impossible for the physicians in Juarez to provide medical care without threat to themselves. They have had to organise a work stoppage to bring attention to this issue.” Dr. Wonchat Subhachaturas, President of the WMA, strongly condemned the violence facing physicians. This year three medical workers have been killed and 11 kidnapped. He said: “Physicians have an ethical duty to care for their patients and governments have a duty to ensure that appropriate con- ditions exist to allow physicians to care for their patients. The situation in Jurarez ap- pears to be out of control, threatening phy- sicians and preventing them from carrying out their clinical work.” Physicians Urge Mexican Government to Restore Order in Juarez wmj 1 2011 5CS.indd 24 21.02.2011 16:28:20 25 The World Organization of Family Doctors (WONCA) is the global association of fam- ily doctors. Its familiar name “WONCA” is an acronym taken from the first letters of the first five words of the name used at the time of its formation: the World Organiza- tion of National Colleges, Academies, and Academic Associations of General Practi- tioners/Family Physicians. Beginning with 18 members in 1972, WONCA is now comprised of 122 member organizations in 102 countries that represent about 300 000 family doctors. Mission WONCA’s mission is to improve the quali- ty of life of the peoples of the world through defining and promoting its values, and by fostering high standards of care in general practice/family medicine by: • promoting personal, comprehensive and continuing care for the individual in the context of the family and the community; • encouraging and supporting the develop- ment of academic organizations of gen- eral practitioners/family physicians; • providing a forum for exchange of knowl- edge and information between Member Organizations and between general prac- titioners/family physicians; and • representing the policies and the edu- cational, research and service provision activities of general practitioners/family physicians to other world organizations and forums concerned with health and medical care. Governance afnd structure WONCA is governed by a World Council that meets once every three years in con- junction with the World Conference. Gov- ernance and oversight between meetings of the Council are provided by an Executive Committee,which consists of the President, President-Elect, Immediate Past President, 3 At-Large Members, 7 Regional Presi- dents, and the CEO, who serves ex officio without vote. Terms of office for the mem- bers of the Executive are for 3 years, except for the Immediate Past President (1 year) and the CEO (under contract). The Secre- tariat is located currently in Singapore; the current CEO is Dr. Alfred Loh. A regional structure has been created to facilitate the development of family medi- cine through increased interaction among neighboring member organizations within a region. The regions approximate the World Health Organization (WHO) regions: Af- rica, Asia-Pacific, Eastern Mediterranean, Europe, Iberoamericana (Latin America), North America, and South Asia. Many, but not all, of the regions convene an annual regional conference. A recent development has been the establishment of WONCA re- gional organizations for young family doc- tors, including the Vasco da Gama Move- ment (Europe), Rajakumar Movement (Asia-Pacific), NaFFDoNA (North Ameri- ca), and Waynakay (Latin America). Committees, Working Parties, Special Interest Groups Much of the policy development and ac- tivities of WONCA occur through its Committees, Working Parties, and Special Interest Groups, which typically consist of 5–15 family doctors selected from around the world who have a particular interest and expertise. The 7 Committees are By- laws, Finance, Membership, Nominating & Awards, Organizational Equity, Pub- lications & Communications, and World Conference. The 9 Working Parties in- clude Classification (WICC), Education, Ethics, Informatics, Rural Practice, Mental Health, Quality & Safety, Research, and Women and Family Medicine. There are 5 Special Interest Groups (SIGs): Com- plexity, Elderly Care, Environment, Pri- mary Care & Cancer Research, and Travel Medicine. World Organization of Family Doctors (WONCA) Regional and NMA news Richard G. Roberts “The fact that this week thousands of doc- tors and health workers in Ciudad Juarez went on a 24-hour strike in protest at the high number of threats and attacks they are subjected to shows how desperate the situa- tion has become.The government’s inability to curtail drug-cartel violence is unaccept- able.” Physicians in the city are calling for more soldiers and the Mexican federal police to bring the violence under control and the WMA and its national medical association members are urging the Mexican Govern- ment to listen to what physicians are saying. Nigel Duncan, WMA Public Relations Consultant wmj 1 2011 5CS.indd 25 21.02.2011 16:28:21 26 Regional and NMA news All around Europe the Member States are facing common challenges in terms of ensuring and maintaining an adequate health workforce to meet the changing and growing health needs of the EU citi- zens. Besides, the rapid changes in demo- graphic, the ageing population, the widen- ing health inequalities and the changing disease patterns place additional chal- lenges to the already stretched European health systems.  Therefore, adequate and sustainable EU Workforce for Health is crucial. Taking this into account, and as a follow-up of the Ministerial Conference, held in La Hulpe on 9–10 September 2010, and the Europe- an Parliament Written Declaration, signed by 182 MEPs, the European Federation of Nurses Associations (EFN) and the Euro- pean Public Health Alliance (EPHA) or- ganised a lunch debate on 27 October 2010, in the European Parliament. The debate, supported by five key MEPs – Oana Elena Antonescu (Romania, EPP), Jean Lambert (UK,Greens/EFA),Antonyia Parvanova (Bulgaria, ALDE), Marc Tara- bella (Belgium, S&D) and Marisa Matias (Portugal, GUE/NGL), analysed the extent of the EU Members states common chal- lenges and showed how the current practice of health professionals recruitment, mainly nurses and doctors, from some European countries and the developing world to fill gaps in the workforce in other areas of Eu- rope is unsustainable. Furthermore, speak- ers and participants pointed out a common and urgent need for policy makers to take action. The personal testimonies of a Latvian doctor (Mr. Peteris Apinis), a Polish nurse (Ms. Paulina Daczkowska), a Belgian nurse (Ms. Heidi Ceuppens), and a Bulgarian pa- tient (Ms. Evgeniya Adarska), made this concern clear by stressing that issues like recruitment and migration policies, work- ing and education conditions, attractive- ness of health professionals, and improve- ments in the recognition of qualifications, are essential for the health profession, and that the key EU solutions are undeniably: workforce planning, implementing recruit- ment and retention strategies, and develop a well-educated and motivated workforce for health. “Recruitment without retaining nurses and doctors is a waste of resources.” (Heidi Ceuppens, nurse). Myria Vassiliadou (EWL) chaired the fol- lowing discussions along the debate, high- lighting that it is always good to see the human the human face of the problems. During the political roundtable she brought EU Workforce for Health – Putting a Human Face to EU Policy-making EFN-EPHA Lunch Debate 27 October 2010 – European Parliament Collaboration with WHO and other world bodies WONCA has been involved in a number of WHO projects, including the Social Determinants on Health, WHO West- ern Pacific Region Patient at the Center of Care Initiative, Integrating Mental Health Services into Primary Health Care, GOLD – Global Initiative for Ob- structive Lung Disease, GARD – Global Alliance Against Chronic Respiratory Diseases, and the development of the third edition of International Classifica- tion in Primary Care (ICPC-3). A number of monographs, technical documents, and educational programs have resulted from this collaboration. WONCA participates in the annual World Health Assembly in Geneva. As the global voice for family doctors, WONCA is also involved with a number of other world organizations, including the World Medical Association and the Inter- national Federation of Medical Student As- sociations (IFMSA). Recently, WONCA and IFMSA have begun to collaborate to promote family medicine exchange experi- ences for medical students. The Future: Challenges and Opportunities In its 2008 World Health Report “Pri- mary Care: Now More Than Ever,” WHO concluded that the health systems of the world should be based on primary care. All 194 countries at the 2009 World Health Assembly approved a resolution advocating for countries to train sufficient numbers of primary care workers, includ- ing family physicians. Reliant on member organization dues and conference lev- ies, World WONCA operates on a very modest budget. To achieve all that is be- ing asked of family medicine, WONCA must develop a more robust governance structure and garner sufficient resources. WONCA’s challenge during the next de- cade is to grow from an academic club of national colleges to a global professional association. Richard G. Roberts, MD, JD President 2010–2013 World Organization of Family Doctors (WONCA) January 2011 wmj 1 2011 5CS.indd 26 21.02.2011 16:28:22 27 Regional and NMA news out for further discussions issues such as the mobility and the workforce, legal aspects, working and education conditions and fi- nancial crisis were addressed but from a different approach, taking into account and bearing in mind the ones that finally suffer from these challenges, patients and health- care professionals. Talking about recruitment and retention, the MEPs present agreed that several coun- tries are putting too much attention on the health professionals coming from third countries and the ones leaving their own countries are not looked enough. Therefore, it is extremely important to understand what makes the professionals stay or leave. So, this is not only about recruitment but also about retention policies. Furthermore, and as part of the strategy, we should not only focus on the new graduated health professionals but also at the existing and experienced workforce in keeping them motivated to stay in the nursing profession, as the difficult working conditions, mainly for women, and all the new demands of care provisions makes it harder to stay in the profession. As regards migration, the current trends are unsustainable, entailing shortages in several countries. “…due the economic situation in most countries, especially eastern European Member States, and due to the shortage of nurses in all national healthcare systems, member states fulfill these gaps by stealing nurses from each other…” (Paulina Dac- zkowska, nurse). “…Today, a widespread and unstop- pable trend has developed concerning the migration of medical doctors from poorer Eastern European countries to the “elder European world” especially to Great Britain, Germany, Scandinva- vian countries and France…” (Peteris Apinis, doctor). One of the main causes for nurses to leave is the extremely low salary and unpleas- ant working conditions they have in their own countries/settings. Excessive workload and lack of personnel in some shifts make nurses feel insecure and in need to find new possibilities for professional develop- ment. As well, the lack of recognition and the extreme low salaries make the nursing profession unattractive, losing potential new students to come into the nursing profession. Therefore, surrounded in the new increased demands of healthcare, more emphasis must be put towards recogni- tion of the nurses’ value within the society to knock the youth’s minds offering them successful opportunities for professional development. Furthermore, nurses who migrate to an- other country are not always working with the same tasks and responsibilities they usually perform in their home country. This situation often leads to a downgrad- ing of the nursing profession overall, and mainly to downgrading the individual as a person and a professional.This is where the human rights aspect comes into the equa- tion. Consequently, the migration of health professionals is an enriched process that should be done in a transparent and sound way. “…the process of obtaining the recogni- tion of the diploma and beginning to work and settling down in another country is everything but not easy. It involved me enormous and unacceptable administrative burdens, and long procedures before the final approval was achieved. It gave me many moments of stress, of insecurity and doubts, but I resisted…” (Paulina Dacz- kowska, nurse). As mentioned by MEP Marc Tarabella, in order to encounter that shortage of nurses, it is important to recognize the profession- als and to improve the mobility started with Bologna. We also need to harmonize the health systems all over Europe in or- der to improve the quality and safety of care. Only then, it will be possible to have an harmonized highly EU educated work- force guarantying a freedom of movement and a safe, updated and sensible process of professionals’ mobility, taking into account the need to update the minimum training requirements as set out in the Directive, the languages competences to provide safe care, and effective administrative process of mu- tual recognition. MEP Jean Lamberts took this opportu- nity to emphasize the need for a more dy- namic recognition process and boost the role of employers to deal with the language requirements. It is important to take into account both professionals: the ones being recruited from third countries and the ones leaving the country. In that sense, a need for recruitment policies is essential, as well as the link between the working conditions and the jeopardizing of the quality of care. Urgent actions are needed before the health workforce disappears. Therefore, recruit- ment and retention strategies are key to deal with the EU workforce challenges. MEP Oana Elena Antonescu also took this opportunity to mention the difficult situation Romania is living while seeing six thousand doctors and four thousand nurses leaving the country in the last two years to look for better working conditions. It is true that there are difficulties and differences be- tween regions but there is also a common shared problem regarding the shortage of qualified workforce. There is a need for an increase of the attractiveness of health pro- fessions. The EU needs human resources strategies to recruit health professionals, and to find strategies to retain them (im- proving working conditions), as well as data collection of health professionals. Participating in the meeting, Ms. Katja Neubauer (DG SANCO) pointed out that the consultations, with regard to the Green Paper on the EU Health Workforce, wmj 1 2011 5CS.indd 27 21.02.2011 16:28:23 28 Regional and NMA news made up till now show that people are very concerned by the shortage and that it is necessary to put this topic into the politi- cal agenda. The Council Conclusions are being discussed, and should be adopted in December 2010, and the Hungarian and the Polish Presidencies are very interested in this topic. Finally, it is important to look at the workforce planning in a broader way, taking into account what kind of workforce, how many, and with which skills, it will be needed in the future. As it is very difficult to recruit and maintain professionals, it is essential to look at new strategies (as, for example, what is done in Aalst Hospital – Belgium) and to make the link between Health Professional and Quality & Safety of care. DG Sanco hopes that in 2011 some concrete actions can be put forward. “…So together with 3 nurse colleagues, all of us working bed-side, we started a project: introducing nursing and promot- ing our profession to last year students of the secondary school, being 17 to 18 years old…”(Heidi Ceuppens, nurse). From Mr. Arnaud Senn (DG EMPL) per- spective, facing the needs of patients is one of the main issues to tackle future needs. As topics to go further in we need to highlight: the needs in long-term care,health inequali- ties and the pressure of health professionals. Regarding the current negotiations of the cross border directive, it is crucial to look at the consequences of patient and healthcare professionals’ mobility. Mr. François Decaillet (WHO Regional Office) stressed that the current challenge with the workforce for health is not only an EU problem but a global one, as shortage is a reality in every country around the world, especially in Africa, and emphasized the need for planning and implementation,next to the need for better coordination between all the countries, and for social innovation (as the project referred by Ms. Heidi Ceup- pens – Belgium). The EFN Secretary General, Paul de Raeve, encouraged the present MEPs to become champions in EU workforce for health, as in other initiatives such as the sharp injuries success story. The EU work- force for health needs to be treated at the highest political level. “…Every health system is unthinkable without nurses. The politicians should understand that …” (Evgeniya Adarska, patient). EPHA President, Mr. Archie Turnbull, concluded that with the bologna process, studies will be globally recognised, allow- ing guaranty and free movement of people. The question is “How to support the sec- tor and the need for thinking in a broader way?” “Today I know quite well that people with health problems seek support; seek someone who offers him hope; someone who will be nearby all the time; some- one who could give cosiness and security at the same time” (Evgeniya Adarska, patient). Listening to the 4 testimonies, the MEPs present were very clear on concrete actions and see an opportunity for the three EU Institutions: the Council, the Commission and the European Parliament, moving to- wards a European and innovative approach. Furthermore, synergies should be built be- tween the European Institutions and the Civil Society. MEP Antonyia Parvanova expressed that there are enough arguments to tackle this subject right now. Seen the future shortage of 500.000 nurses, we need to decide what to do at EU level (European Commission, European Parliament and Council). The current challenge of the workforce is an EU level problem, and it is time to start discus- sions on these deviations and how it could be done in a more legalised way. Coordina- tion and a legal framework to cope with the challenges of the EU workforce for health are urgently needed, next to a different ap- proach to human resources or employment perspectives towards solving the workforce issues. Finally,the MEPs considered taking further the following actions: Putting in place an EU monitoring and planning system to have comparable data available to map to EU health workforce, analysing how many and what kind of health professionals we will need in the fu- ture, and what type of policies need to be developed to respond to future needs. Investing in human capital by covering re- cruitment and retention strategies, evalu- ating income and working conditions and stimulate innovation and entrepreneurship. Within this context the social cohesion funds should be used for health. Establishing an EU Continuous Profes- sional Development Framework to main- tain a highly skilled and motivated work- force and to educate health professionals towards the new demands and types of care and train for the use of new tech- nologies. Taking a gender approach to EU workforce planning and valuing the increased partici- pation of women. EFN Report – November 2010 The European Federation of Nurses Associations (EFN) Email: efn@efn.be Website: www.efnweb.eu wmj 1 2011 5CS.indd 28 21.02.2011 16:28:24 29 Regional and NMA news The European Federation of Nurses As- sociations (EFN) was established in 1971, based on the nursing-education and free- movement Directives being drafted by the European Commission at that time. In 40 years, the EFN has grown to its present po- litical and professional maturity by becom- ing the one strong independent voice of the nursing profession at pan-European level, representing millions of nurses through the national nurses associations of 34 Member States. As such, EFN is a key partner in the design and re-engineering of the different health systems within the EU, all aimed at delivering high quality, safe and continuity of care to the population. As part of the origin of EFN, the EU Mu- tual Recognition of Professional Qualifica- tions (Dir2005/36/EC) is central in EFN lobby strategies towards the European Commission, the Council and the Euro- pean parliament.When re-designing health systems in the EU Member States (taking into account the re-activation of the “Lib- eralisation Act”) a highly educated health workforce, mainly focusing on nurses, mid- wives, doctors, pharmacists and dentists, remains the cornerstone for each legislative redesign. Therefore, the implementation of this Directive, alongside the “Acquis Com- munautaire” compliance process, was anal- ysed in 2010 by different stakeholders. For EFN, the conclusion represents the same nursing values and principles as advo- cated for by nurse leaders in the seventies. The Directive, which sets out the minimum education and training requirements for nursing education, substantially impacted the advancement of the nursing profes- sion and the status of nurses across Europe by positioning of nursing education in the Higher Education degree structure, within Universities and Colleges. The minimum education requirements have proven to be a valuable safeguard of quality and safety in healthcare, since they discourage govern- ments from downgrading nursing educa- tion as means to reduce costs. Nevertheless, updating the list of required subjects within nursing curricula is seen as an opportunity to consider topics such as patient safety, quality system thinking and e-Health as advancements in nursing edu- cation. One of the deliverables of the Eu- ropean Union Network for Patient Safety (EUNETPAS, 2010) – the guidelines for a curriculum on Patient Safety – in which a basic curricula framework for patient safety to be simultaneously taught to all healthcare professions, engaging patients in the design, could help facilitating the paradigm shift: creating a new generation of nurses, doctors and pharmacists. The review of the Directive is equally per- ceived by EFN as a unique opportunity to ascertain that “fitness to practice” remains a professional priority.This challenge is linked to the European Commission Agenda on “New Skills for New Jobs”,in which a highly skilled health workforce is prioritized at the same level as modernising labour markets and promoting work through new forms of flexibility and security. Interestingly, the EU health workforce became an essential driver in the EU health policy domain, with nurses – as the largest group of health pro- fessionals – playing a central role in pushing the paradigm shift further with the alliances concerned. For EFN, the Council Conclu- sions on the EU health workforce provide a good political framework for action to move from a “Green” to a “White” Paper on EU Workforce for Health  – an initiative that deserves and requires our attention. Skill mix,skill matching and extending roles and responsibilities for nurses is becoming a key component when re-designing existing health systems, for both the primary and hospital care system (“Nurses in Advanced Roles”, OECD, July 2010). Consequently, the establishment of an “EU Skills Pan- orama’ and Sectoral Skills” Councils opens a policy opportunity for the representative pan-European nurses organisation to re- spond to the societal demands for health systems and their outcomes. The concept of “Innovative Partnerships” is a step in the right direction to scale up “frontline initia- tives” into an EU added-value for citizens, patients and health professionals. The con- cept of the “link nurse”is a positive,innovate example, not only in relation to safety and quality,but in many other aspects of making health systems effective and efficient. E-health is a tool to decrease the increas- ing nurses’ workload, standardising activi- ties such as documentation, patient records, referrals and discharge, including the sur- rounding nursing activities such as planning homecare, e-prescribing of medication and wound care. Proper e-Health systems must help nurses to get rid of the excess of admin- istrative work providing them more time for direct patient contact.This is part of the management paradigm shift: bringing the nurse closer to the patient. The condition for success in shifting the paradigm is the Nurses Impact on the Health System Paradigm Shift Paul De Raeve wmj 1 2011 5CS.indd 29 21.02.2011 16:28:25 30 Regional and NMA news end-users’ engagement in the deployment of new innovative e-health solutions, which must be used as a tool to improve the infor- mation and communications processes,pro- mote the use of standards, indicators, inter- professional communication channels, and encourage continuous professional develop- ment.The paradigm shift includes therefore bringing upfront innovative “fieldwork” in patient empowerment, putting gender into the equation, embracing healthy years and quality of life, dignity and ability to self- management next to emphasising an inte- grated approach of service planning, organ- isation of care and financing. From a political perspective, a paradigm shift is only possible if the political insti- tutions themselves, governed by govern- ments, adapt their governance structure to move away from the old fashioned and well-known paradigms that are difficult to reform. Nevertheless, the policy paradigm shift is urgently needed, otherwise Mem- ber States will continue to produce Coun- cil Conclusions and WHO reports for the book shelves and avoid engaging concerned stakeholders collectively. Good governance in health systems implies implementing an effective stakeholder ap- proach, which goes far beyond online con- sultations and bilateral partnerships.The key principles for making the paradigm shift work is to empower transparency, engage a range of concerned stakeholders, build co- hesiveness, and make effectiveness measur- able to increase responsibility throughout the health system. But these principles re- quire trust and effective implementation. Therefore, EFN core business is to set the policy agenda pro-actively and design pipe- line EU legislation and not to lead EU proj- ects or work packages. As a successful EU legislative outcome, next to the Directive 36/2005/EC, the EU Directive on preven- tion from sharps injuries in the hospital and healthcare sector was adopted by the Euro- pean Council of Ministers on 11 May 2010. Every year huge numbers of nurses and their families face months of uncertainty and emo- tional anguish following a needlestick injury, not knowing if the accident will lead to a life- threatening infection. For many years EFN advocated for EU legislation ensuring that all healthcare workers (not only nurses) be adequately protected from needlestick and other medical sharps injuries. The legislative initiative was formally launched on World AIDS Day in 2004, when nurses infected by HIV and Hepatitis C due to a needle stick injury came to the European Parliament to request political at- tention and action. National requirements were failing to provide adequate protection and an EU added-value legislative initiative was needed.Such serious risks would be con- sidered unthinkable in other occupations, so why should nurses be exposed to life-threat- ening injuries every day when the majority of these can be avoided with better working practices, continuous professional develop- ment, and the use of readily available tech- nologies that incorporates needle protection? Although it has taken considerable politi- cal will and policy efforts, great progress has been made. The EU Directive on preven- tion from sharps injuries in the hospital and healthcare sector was published in the Offi- cial Journal of the European Union (OJEU) on 1 June 2010, the same day the European Biosafety Network,led by nurses,was estab- lished. The network has now the challenge making sure each EU Member State brings into force national legislation to implement the Directive by 11 May 2013 at the latest. To conclude, EU legislation is a top priority for EFN.Therefore, working towards devel- oping a strong policy advocacy strategy for nurses and nursing at the EU level is central to making the paradigm shift possible and consequently, to make progress in society. Therefore, EFN will remain focused on the following key policy priorities: education, workforce, quality, and safety. Rest assured that EFN will maintain its role as a strong advocate promoting a continuous and col- laborative dialogue among the EU policy- makers and the stakeholders involved in re-engineering health systems by putting a human face to EU policies. Paul De Raeve, RGN, MSc, MQA, Mphil/PhD Secretary General of the European Federation of Nurses Associations CZECH REPUBLIC Distinguished Colleagues, Dear Friends, al- low me to inform you briefly about the cam- paign “Thanks, We Are Leaving”, which is a legitimate expression of dissatisfaction of Czech doctors, and at the same time let me ask you for your help and support for my colleagues. Czech Doctors Trade Union, the largest and practically the only trade union or- ganisation of Czech doctors, announced in March last year a campaign “Thanks, We Are Leaving”, which is now reach- ing its culminating point. It´s essence are massive employment termination notices of hospital doctors in protest against poor working conditions, low wages and com- plete disruption of education system. The Czech Medical Chamber supports the campaign, because it is a completely legiti- Czech Medical Chamber Request for Support of Hospital Doctors wmj 1 2011 5CS.indd 30 21.02.2011 16:28:27 31 mate demand of the great majority of its members. Another reason for the support is that The Czech Medical Chamber as a supervisor of the high quality of medical care for the past several years is not able to guarantee this care to the citizens, due to the devastation of medical personnel in the Czech Republic.The necessary changes are not coming in spite of years-long debates and appeals to politicians, who are respon- sible for this situation and have the power to change it. For twenty years the Czech doctors waited in vain for dignified appreciation of their work. And for twenty years politicians were promising them to implement reforms, the results of which among others would be an improvement of professional and economic conditions of doctors. In reality, however, the situation of most hospital doctors wors- ened. Our health care is chronically underfunded as expenditures on health care represent only 7,0 –7,5% of GDP.Fair European level of the Czech health care and good access to health care for the voters (our patients) is secured by the politicians at the expense of doctors and other health care profession- als whose income remain low and working conditions poor. As the professional and working conditions are not improving in the Czech Republic, more and more of our colleagues are seeking emigration as solu- tion of their economic problems. Gradually, due to that comes to a personnel decompo- sition of hospital medical care in the Czech Republic. The gradual devastation of the hospital care due to the shortage of medi- cal personnel is the consequence of such a situation. The Labour Code and European Work- ing Time Directive (EWTD) are violated in most hospitals, and overworked doctors represent potential danger to patients. Re- ports on working hours are falsified and the number of doctors in the statistics is increased against the reality..... A qualified doctor must work monthly about fifty per- cent hours over time to obtain the average income of ca. CZK 45.000, – (about 1800 Euro). Such a salary is indicated in the statistics and it corresponds to less than double of the average income in the Czech Republic. The doctors demand an increase of their sal- ary for the basic working time to the level of 1,5–3 times higher than is the average salary income in the country, depending on their qualification and length of service. Such a salary level is quite common in countries to which the doctors from the Czech Republic are leaving. This requirement represents an increase in hourly wages of doctors from the current 100–200 CZK (about 4–8 EUR) to 200–400 CZK (about 8–16 EUR).The ful- filment of this demand requires only 3 bil- lion CZK per year, which is approximately only 1% of all the money spent in our health care. The aim of the action “Thanks, We Are Leaving” is not to drive the doctors into exile, but to improve their working condi- tions in Czech hospitals and in such a way to remove the reasons for their departure and the consequent personal devastation of Czech health care system. This is the main reason why Czech Medical Chamber fully supports the actions of doctor’s trade unions. Enclosed I am sending 13 reasons that lead Czech hospital doctors to procla- mation of the campaign “Thanks, We Are Leaving”and that was formulated by Czech Doctors Trade Union. These 13 reasons de- scribe the motives of doctors and the causes of the whole problem. In spite of the fact that employed doctors announced their intention to leave the hos- pitals in March 2010, political representa- tion did nothing to avert their decision. Up to the December 31 2010, 3850 doctors handed in their notices of leaving the em- ployment. Unless the government accepts their demands, then after the two month notice period these colleagues will not come to work on March 1, 2011. Doctors from the whole Czech Republic, from various hospitals and departments are involved. The notice of leaving the employment was handed in by the third of the total num- ber of 12.000 doctors working in hospitals. In some hospitals and in some regions the notice was handed in by more than 80% of doctors, but there are departments where the notice was handed in by all doctors. It is difficult to label the position of Czech government by something else than a haz- ardous play with the health and lives of citizens when instead of constructive ne- gotiations with doctors and search for a ra- tional solution, government concentrated on threatening doctors by declaring “emer- gency situation” which would allow to or- der the doctors to work similarly as is the case during natural catastrophes. Without doctors it is not possible to provide medi- cal care and there is nobody who can re- place doctors. For several weeks the Czech Medical Chamber has very actively negotiated with the representatives of all parliamentary political parties to find an acceptable so- lution to the current situation. Although the Czech health care is chronically un- derfunded, only 1% of the funds that flow into the Czech health care are sufficient to Regional and NMA news Milan Kubek CZECH REPUBLIC wmj 1 2011 5CS.indd 31 21.02.2011 16:28:28 32 meet the justified demands of hospital doc- tors. The money needed can be obtained by control of expenditures for the overpriced pharmaceuticals, by establishing an order in the completely chaotic investment policy, in the purchases of medical equipment and by reducing corruption.The Government of the Czech Republic has “the fight against corruption” as a main slogan, but in reality is rejecting all economic measures proposed by the Czech Medical Chamber and is try- ing to intimidate the protesting doctors. The Czech Medical Chamber would be happy to provide you on your request with additional and more detailed information on the largest protest campaign of doctors in the modern history of our country. The prestige and dignity of the whole medi- cal profession is involved in the ongoing struggle and therefore we cannot afford to lose this battle. The campaign “Thanks, We Are Leaving” proclaimed by the Czech Doctors Trade Union and supported by the Czech Medical Chamber represents a unique,and regretfully even an unrepeatable opportunity after 20 years of patiently but in vain waiting for a better professional and economic status of all doctors in the Czech Republic. Any defeat, however, would bring disastrous consequences for all doctors. Not only on behalf of the Czech Medical Chamber, but also on behalf of all doctors from the Czech Republic, I appeal to you for any kind of help, for any kind of state- ment of support and solidarity. 13 Reasons for the Exodus 1. Czech health care has been underfunded on a long-term basis. The share of GDP has oscil- lated around 7%, while the average in EU is 10%. From the monitored OECD countries,behind us are only Poland, Mexico and Korea. 2. The low pay contribution of the state for the state insurant that does not match the volume of funding that these “public patients” con- sume. Absence of commercial insurance. The government´s contribution for citizens without income is much lower than their real spending. 3. Large reserves in the internal functioning of the health care – the biggest item is the chaotic drug policy, where hundreds millions of Euros are wasted. 4. Strange economy in hospitals  – overpriced contracts (construction, purchase of equipment and medicine, etc.). Salaries of health care pro- fessionals are the only item for which commis- sion cannot be obtained. 5. Low salaries for doctors which do not corre- spond with the intensity of this profession, the necessary education and prestige. 6. Completely destructed system of education is one of the reasons for the departure of young doctors abroad. 7. Departure of doctors abroad due to better working conditions.The remaining doctors are burdened with more responsibilities than cor- respond to their qualification. More overtime work is needed. 8. The Labour Code is not observed, more over time is required from doctors and as a conse- quence of it potential medical errors, followed by legal proceedings may occur. 9. In 2013, the exemption from the European Di- rective on Overtime Work will no longer apply and hospitals will need more doctors. 10. Due to lack of staff, poor organisation and ir- rational use of funds, deterioration of patient care threatens, for which doctors do not want to take responsibility. 11. Unfulfilled promises of politicians  – since 1989, the doctors have been told that first the system must change and then their salaries will be improved. So far, this has not happened. 12. Health care became the object of an ideologi- cal war between political parties. The profound changes of the system require an agreement across all political parties, as it happens in other countries. 13. The Ministry of Health experience among all the ministries the most frequent changes of ministers, all of them with their own ideas how to change the system. There are constantly some elections taking place, whether they are regular or premature. Under such circumstanc- es, doctors have no guarantee that the necessary changes will take place. Dr. Milan Kubek President of the Czech Medical Chamber Dear Colleagues, Dear Friends, Allow me to express my gratitude for your support of the Czech doctors and the Czech Medical Chamber. It is my pleasure to announce that today an agreement was signed between doctors and the Czech Republic,represented by the Minister of Health. I believe that the “Thank You, We Are Leav- ing” protest campaign has come after 11 months to a close. Doctors that handed in their notices and were to leave their employment in hospitals on 1 March 2011, based on the above agreement will continue to work in hospitals. Agreement between the Ministry of Health and the Doctor’s Trade Unions Main agreement parameters: The base salaries of all employed physicians in all types of health care bed facilities and in the emergency medical service will increase from 1 March 2011 by 5 000,- CZK,  6 500,- CZK and 8 000,- CZK de- pending on their qualification.This increase represents a raise in base salaries by 21–36 percent. Regional and NMA news CZECH REPUBLIC Agreement between the Ministry of Health and the Doctor’s Trade Unions wmj 1 2011 5CS.indd 32 21.02.2011 16:28:29 33 Regional and NMA newsGEORGIA The issue of small countries’ development and their integration into the international society attracts more and more attention of the politicians and academic researchers in the modern world with the tendencies of globalization. Because of its geopolitical location, Geor- gia,differently from many other small coun- tries, faces specific challenges and threats. The events that developed in August 2008 had a great influence not only on Georgia’s positioning on the international level, but also on the processes developing inside the country. With the background of the world financial crisis, they pushed country’s eco- nomic, social, and political processes to a new phase. The state governance, besides the Conflict of August 2008,faced the great world finan- cial crisis that limited free finance attraction process, and consequently, the questions of state governance rationality and decrease in officials were highlighted in many countries and in Georgia, too. In September 2008, the world econo- my underwent difficulties. The wave of bankruptcy covered all the USA. The first to go bankrupt were the banks, and the investment crisis placed the world in front of big threats. The liquidity-mon- ey deficit occurred. The companies that were oriented on everyday credits ap- peared in a very bad situation. The Index of Dow Jones fell, other indexes under- went big attacks too, and the first time, after a long period, the USA entered the recession process. Additional increase by 10 percent, this time of the total salaries of doc- tors, will occur from 1.1.2012. The doctors’ incomes will be increased from 1.1.2013 so that the em- ployed doctors’ average pay would become 1,5–3 times higher than the average national salary (currently ca. 25 000,- CZK) and at the same time with a commitment to cutback the amount of overtime work to a maximum average of 8 hours per week. The government commits itself to work together with the representa- tives of doctors, including the Czech Medical Chamber and the Czech Doctor’s Trade Union, on the adjustment of the education system of doctors, on anti-corruption measures and on further reform changes in health care. CMC fully supported the struggle of hospital doctors for the im- provement of working conditions, the implementation of the neces- sary order and enforcement of the long overdue changes in medical care.CMC will continue to provide support to its members and will supervise the fulfilment of the agreement. Personally, I consider the result of this protest campaign as a colossal success of Czech doctors and hope that in the same way as the doctors also the political repre- sentation of the Czech Republic will fulfil all obligations stemming from this agreement. Allow me to thank you once again for your kind help and support. Yours faithfully, Dr. Milan Kubek President of the Czech Medical Chamber The Georgian Health Care System during the Conflict in August 2008 and World Crisis Presentation at the WMA conference on “Financial crisis and its implications for health care”, Riga, September 10-11th 2010 Tamar Lobzhanidze Kakhaber Jakeli Gia Lobzhanidze Zaza Khachiperadze wmj 1 2011 5CS.indd 33 21.02.2011 16:28:30 34 Regional and NMA news GEORGIA Soon the recession overtook Europe; the economy of Great Britain was facing seri- ous threats. As for Iceland, it almost totally went bankrupt. During this period and as a result of the situation that developed, the economy of Georgia was also damaged.The income in October 2008 decreased almost 2 times and its GDP reduced 1.9 times. According to the planned 2009 budget, the economic income was determined as 2%; however,the world economic crisis resulted in determining Georgia’s income as 4%.Budget- ary incomes decreased by 600 million GEL. In 2010 the increase in GDP was planned to reach 2%, inflation rate was determined as 6%, more than by 1% in comparison with the indicator in 2008. This crisis was very harmful to Georgian economy, but the country’s economy was not as sensitive to this crisis as many other countries’ economies proved to be because Georgia was not as much involved in the world economy. To be more precise, there were no securities on the USA Stock Ex- change, which saved Georgian financial as- sets. In fact, our economy was saved by iso- lation.The events of August 2008 were soon followed by economic recession. If, accord- ing to some sources, Georgia had increased its GDP by 9–10%, there was no indication of improvement in October. In 2009, the signs of large-scale job losses were noticed among employees. Social politics is an important part of Geor- gian economy. A large part of it is covered by health care and pension systems. The number of pensioners in Georgia reaches 1  million. According to the data of 2009, the problem of nation’s aging prevents the development of effective pension politics. The government accomplishes the issue of satisfying pensioners by a simple model-dis- tribution of the pension.The next necessary step to be done is to work out the strategy to direct pensioners’ access to the health care system and to getting the health care goods as it is done in other developed countries. The development of health care system and functions of strategic nature means system infrastructure rehabilitation through maxi- mum objectivity and foreign investment by the medical services of private market health insurance, and voluntary health in- surance stimulation. The health care system covers social and age groups with different mechanisms of financing (e.  g., refugees, 0–3 years old children, people over 60 years of age). The support to all kinds of medi- cal services increased by 6% from 2007 to 2008. The increase reached 3% in 2009, in comparison with 2008. Mostly the increase was determined by ambulance services and doctors’ visits. (Fig. 1.) In 2008 the hospitalization indicator (100.000 population) was increased by 11.2% in comparison with the indicators of 2007. And in 2009 the increase reached 1.2% in comparison with 2008.As for 2007, the increase reached 8.6%. (Fig. 2.) The attracted medical insurance premium increased by 72.4% in 2008, in comparison with 2007, and by 25% in 2009, in compari- son with 2008. Private money spending de- creased lightly. (Fig. 3.) The tendency of purchasing public and pri- vate sector medical services and supply has not decreased, on the contrary, according to some indicators, the tendency of growth is noticed. During the crisis the Georgian health system stability was achieved,first,by the strong support of the state for the medi- cal insurance, through which incurrence of population was managed. Secondly, financ- ing of the system and health care utilization was so small and minimal that the invested budgetary and private sources and the im- proved business environment maintained the system functioning. The effectiveness of the functioning of the Georgian health care system in the future will depend on the growth of the state share in health care costs (no more than 2% per year) and the basic improvement of the process administration. It is especially important to work out the 10-year health care system strategic and human resources development plans.That will be the basis for the education and health care system im- provement and affordability. Figure 1 Figure 2 Figure 3 Tamar Lobzhanidze, Assistant Professor of the University of Georgia Kakhaber Jakeli, Associate Professor of the University of Georgia Prof. Gia Lobzhanidze, Chairman of the Board of Directors of the Georgian Medical Association, Dr. Zaza Khachiperadze, Deputy Secretary of the Georgian Medical Association wmj 1 2011 5CS.indd 34 21.02.2011 16:28:32 35 The missions The College of Physicians is a legal entity of public law with civil personality and finan- cial authority. This is the highest medical professional authority. It ensures the main- tenance of the principles of morality, quality and dedication necessary for the practice of medicine. It also ensures compliance by all members with the professional duties and rules enacted by the code of ethics. It also ensures the defense of honor and traditions of the medical profession. It gives its opin- ion to the public authorities as regards leg- islation and medical regulations in General on all matters affecting public health and medical course. Organization The National Council The National Council includes: • The eight (8) elected members of sec- tion A (medical officers or public services contract,body teacher from the Faculty of Medicine). • The eight (8) members elected of section B (private doctors). • Three (3) members who are: - The dean of the faculty of medicine. - The director of public health. - The director of health of the armed forces. • A legal advisor (head judge). The office The office includes: • A President. • A Vice President, Secretary General. • Two members. The commissions There are five (5) commissions: • The commission of discipline and con- flicts. • The administrative and legal commission. • The commission of board qualification and specialization. • The social commission. • The cultural and scientific commission. The commission includes a President, a re- porter and members. The section councils The A section Council members include: The annual ZEVA Symposium provides a plat- form for exchange between physicians’ chambers from Central and Eastern European countries. During the symposium, representatives from EU and non-EU member states discuss common chal- lenges and share experiences in order to find ways to improve the working environment of physi- cians and the quality of healthcare in the interest of all patients. The central focus of the 17th ZEVA Symposium, which was held in Skopje, Macedonia, was pa- tient safety and quality in healthcare. After a fruitful discussion, the participating countries agreed on the: • Safety is the core element of quality in healthcare. • Physicians have an ethical and professional obligation to always strive for continuous quality improvement in healthcare and must ensure patient safety during all medi- cal decision making. • Physician self-regulation is based on the trust invested in the medical profession. Physicians’ chambers assume this respon- sibility and guarantee high standards of medical practice and the ethical provision of medical services by physicians. Patient safety and quality in healthcare are core ele- ments that drive the chambers’ decisions on policy, ethics, education and training. • By being competent advocates for patient safety, physicians prove their credibility in the political arena and to the public. Gov- ernments should recognize the crucial role of physicians and physicians’chambers in all matters relating to patient safety. • Patient safety incidents are often reported as errors by individual physicians. However, research has shown that nearly all incidents are actually a result of system failure and rarely errors by individuals. • Physicians should take a leading role in patient safety and be included in analyzing complex health information processes that lead to errors or create the potential for er- rors. • A Critical Incident Reporting System could be a valuable and effective physician-driven instrument. A blame free reporting culture is a precondition for this. • Most countries face similar challenges in improving patient safety. These primarily concern the provision of appropriate edu- cation and training, ensuring a safe work- ing environment, building and maintaining a suitable infrastructure, as well as guaran- teeing sufficient financial and human re- sources. • Patient safety and quality of care should take particularly high priority when consid- ering task shifting in the delivery of health services.The role of physicians as the health professionals with overall responsibility for diagnosis and treatment is crucial in this respect. • Physicians’ chambers should promote poli- cies on patient safety to all physicians in their country and support the development of appropriate post-graduate medical edu- cation. • Physicians’ chambers in the ZEVA region should continue to share experiences in the field of patient safety and foster more in- tense collaboration. • The physicians’ chambers in the ZEVA region fully endorse the World Medical Association’s “Declaration on Guidelines for Continuous Quality Improvement in Healthcare”and the WMA “Declaration on Patient Safety”. Regional and NMA newsSENEGAL The College of Physicians of Senegal Skopje Declaration on Patient Safety and Quality in Healthcare wmj 1 2011 5CS.indd 35 21.02.2011 16:28:33 36 Regional and NMA news DEMOCRATIC REP. of CONGO The National Medical Council has been created by order-law No. 68/070 of March 1, 1968, with the load and mission: defense, honor and the independence of the medical profession. It includes: • the National Council (CNOM) and its office; • the provincial Councils (COPROM) and their offices. The National Council sees: • To the respect and to the maintenance by all members of the principles of morality, integrity and devotion. • To the observance by all physicians of their professional duties and rules of the medical deontology. • To the defense of honor and the indepen- dence of the profession. • To the protection of the population’s health. The physician in the Democratic Republic of Congo is an actor and sanitary operator of a preeminent and important place that imposes on him permanent requirements of knowledge, ethics, morality, dignity, profes- sional independence and sharp sense of re- sponsibility.He dedicates his life to the cause of humanity and the patient remains his first worry. For it, it is necessary that he has the character of a perfect honest man. Honor, dignity, noble traditions must always come with it when he practices his profession. The Office of the National Council (CNOM) was elected at the 4th convention of the National Medical Council and took its functions on July 28, 2008 for five years. It is constituted by: The Office is the organ of daily manage- ment of the National Council and as such: Dr. Mbutuku: National President, Dr. Kaswa: National Vice-President, Dr. Sese: National Secretary, Dr. Ebondo: National Associate Secretary, Dr. Beya: National Treasurer. National Council and as such: • It elaborates the plan of action and the budget of the National Council. • It executes the decisions of the plenary assembly. • It manages the administrative and tech- nical staff, the plenary assembly of the National Council. • It coordinates the provincial Council activities. • It raises the yearly and multi-year reports submitted for the approval of the plenary assembly. • It initiates the internal and external au- dits for the improvement of its own man- agement. • It installs the Office elected from the per- manent Commissions of the CNOM and of the COPROM. The National President represents the Na- tional Council and all physicians of the country by the third in the acts of civil life. The National Vice-president helps him and replaces him in case of obstacles. He super- vises the general administration, notably the heritage, the bursary, the maintenance and the staff. The National Secretary is put in charge of the secretariat of the Council with a mission and load: • To look after the good holding and the updating of the Picture of the Council, of the cards of identity of the mem- bers and in general of all archives of the Council. • To conduct the correspondence of the Council that he signs together with the President. The National Associate Secretary helps the latter and replaces him in case of obstacles. The Treasurer looks after the good holding and the updating of the financial affairs and the books necessary for accounting. Dr. Kaswa, National Vice-President National Medical Council of the Democratic Republic of Congo • The eight (8) elected members. • Three (3) representatives of the Ministry of Guardianship. • A (1) representative of section B in sec- tion A. The section B Council members include: • The eight (8) elected members. • Two (2) representatives of the Ministry of Guardianship. • A (1) representative of section A in sec- tion B. Other agencies The national order of physicians in Senegal is a member of the national health research Ethics Board. This Committee has four (4) missions: • Review of research protocols in health in order to ensure the protection of per- sons that lend themselves to research and scientific quality of collection and data analysis research. • The issuance of ethical and scientific ad- vice to the Minister for Health with a view to authorization, suspension or pro- hibition of the pursuit of a search. • The supervision if there is place for health research. • The conduct and development of reflec- tion on the ethical and legal aspects aris- ing from the practice of health research. Conditions to practice medicine in Senegal • Having the Senegalese nationality. • Having the Senegalese diploma of doc- tor of medicine or an equivalent foreign degree recognized. • Being entered on the roll of the sections of the College of Physicians except for the medical doctors belonging to the ac- tive frame of the army medical service Senegalese and foreign military physi- cians serving as military assistance. Professeur M.L. SOW, Président de l’Ordre wmj 1 2011 5CS.indd 36 21.02.2011 16:28:34 37 Order of Physicians of Albania (OPA) Rr. Dibres. Poliklinika Nr.10, Kati 3 Tirana ALBANIA Dr. Din Abazaj, President Tel/Fax: (355) 4 2340 458 E-mail: albmedorder@albmail.com Website: www.umsh.org Col’legi de Metges C/Verge del Pilar 5, Edifici Plaza 4t. Despatx 11 500 Andorra La Vella ANDORRA Dr. Manuel González Belmonte, Presidente Tel: (376) 823 525 Fax: (376) 860 793 E-mail: coma@andorra.ad Website: www.col-legidemetges.ad Ordem dos Médicos de Angola (OMA) Rua Amilcar Cabral 151-153 Luanda ANGOLA Dr. Carlos Alberto Pinto de Sousa, President Tel. (244) 222 39 23 57 Fax (244) 222 39 16 31 E-mail: secretariatdormed@gmail.com Website: www.ordemmedicosangola.com Confederación Médica de la República Argentina Av. Belgrano 1235 Buenos Aires 1093 ARGENTINA Dr. Jorge C. Jañez, Presidente Tel/Fax: (54-11) 4381-1548 / 4384-5036 E-mail: comra@confederacionmedica.com.ar Website: www.comra.health.org.ar Australian Medical Association P.O. Box 6090 Kingston, ACT 2604 AUSTRALIA Dr. Andrew Pesce, President Tel: (61-2) 6270 5460 Fax: (61-2) 6270 5499 E-mail: ama@ama.com.au Website: www.ama.com.au Osterreichische Arztekammer (Austrian Medical Chamber) Weihburggasse 10-12 - P.O. Box 213 1010 Wien AUSTRIA Dr. Walter Dorner, President Tel: (43-1) 514 06 64 Fax: (43-1) 514 06 933 E-mail: international@aerztekammer.at m.reisinger@aerztekammer.at Website: www.aerztekammer.at Armenian Medical Association P.O. Box 143 Yerevan 375 010 REPUBLIC OF ARMENIA Dr. Parounak Zelvian President Tel. (3741) 53 58 68 Fax. (3741) 53 48 79 E-mail: info@armeda.am Website: www.armeda.am Azerbaijan Medical Association P.O. Box 16 AZE 1000, Baku REP OF Azerbaijan Dr. Nariman Safarli, President Tel.(99 450) 328 18 88 Fax. (99 412) 431 88 66 E-mail. info@azmed.az - azerma@hotmail.com Website: www.azmed.az Medical Association of the Bahamas P.O. Box N-3125 MAB House - 6th Terrace Centreville Nassau BAHAMAS Dr.Timothy Barrett, President Tel. (242) 328-1858 Fax. (242) 328-1857 E-mail: medassocbah@gmail.com Bangladesh Medical Association BMA Bhaban 5/2 Topkhana Road Dhaka 1000 BANGLADESH Prof. Mahmud Hasan, President Tel. (880) 2-9568714 / 9562527 Fax. (880) 2 9566060 / 9562527 E-mail: info@bma.org.bd Website: www.bma.org.bd Association Belge des Syndicats Médicaux Chaussée de Boondael 6, bte 4 1050 Bruxelles BELGIUM Dr. Roland Lemye, Président Tel: (32-2) 644 12 88 Fax: (32-2) 644 15 27 E-mail: absym.bvas@euronet.be Website: www.absym-bvas.be Colegio Médico de Bolivia Calle Ayacucho 630 Tarija BOLIVIA Dr. Fernando Arandia Castellanos, President Fax. (591) 4 666 3569 E-mail: colmedbol_tjo@hotmail.com Website: colegiomedicodebolivia.org.bo Associaçao Médica Brasileira R. Sao Carlos do Pinhal 324 - Bairro Bela Vista Sao Paulo SP - CEP 01333-903 BRAZIL Dr. José Luiz Gomes do Amaral, Presidente Tel. (55-11) 3178 6810 Fax. (55-11) 3178 6830 E-mail: presidente@amb.org.br Website: www.amb.org.br Bulgarian Medical Association 15, Acad. Ivan Geshov Blvd. 1431 Sofia BULGARIA Dr. Cvetan Raychinov, President Tel: (359-2) 954 11 81 Fax: (359-2) 954 11 86 E-mail: blsus@mail.bg Website: www.blsbg.com Canadian Medical Association P.O. Box 8650 1867 Alta Vista Drive Ottawa, Ontario K1G 3Y6 CANADA Dr. Jeffrey Turnbull, President Tel: (1-613) 731 8610 ext. 2236 Fax: (1-613) 731 1779 E-mail: karen.clark@cma.ca Website: www.cma.ca Ordem Dos Medicos du Cabo Verde (OMCV) Avenue OUA N° 6 - B.P. 421 Achada Santo António Ciadade de Praia-Cabo Verde CABO VERDE Dr Luis de Sousa Nobre Leite, President Tel. (238) 262 2503 Fax (238) 262 3099 E-mail: omecab@cvtelecom.cv Website: www.ordemdosmedicos.cv Colegio Médico de Chile Esmeralda 678 - Casilla 639 Santiago CHILE Dr. Pablo Rodríguez, Presidente Tel: (56-2) 4277800 Fax: (56-2) 6330940 / 6336732 E-mail: rdelcastillo@colegiomedico.cl Website: www.colegiomedico.cl Chinese Medical Association 42 Dongsi Xidajie Beijing 100710 CHINA Dr. CHEN Zhu, President Tel: (86-10) 8515 8136 Fax: (86-10) 8515 8551 E-mail: zhiliu@cma.org.cn Website: www.cma.org.cn Federación Médica Colombiana Carrera 7 N° 82-66, Oficinas 218/219 Santafé de Bogotá, D.E. COLOMBIA Dr. Sergio Isaza Villa, Presidente Tel./Fax: (57-1) 8050073 E-mail: federacionmedicacolombiana@enco- lombia.com Website: www.encolombia.com Conseil National de l’Ordre des Médecins du RDC B.P. 4922 Kinshasa - Gombe RÉPUBLIQUE DÉMOCRATIQUE DU CONGO Dr. Antoine Mbutuku Mbambili, Président Tel: (243-12) 24589 Fax: (243) 8846574 E-mail : cnomdrc@yahoo.fr Unión Médica Nacional Apartado 5920-1000 San José COSTA RICA Dr. Alexis Castillo Gutiérrez, Presidente Tel: (506) 290-5490 Fax: (506) 231 7373 E-mail: unmedica@racsa.co.cr Croatian Medical Association Subiceva 9 10000 Zagreb CROATIA Dr. Željko Metelko President Tel: (385-1) 46 93 300 Fax: (385-1) 46 55 066 E-mail: tajnistvo@hlz.hr Website: www.hlk.hr/default.asp Colegio Médico Cubano Libre P.O. Box 141016 Coral Gables, FL 33114-1016 UNITED STATES Dr. Enrique Huertas, Presidente 717 Ponce de Leon Boulevard Coral Gables, FL 33134 Tel: (1-305) 446 9902/445 1429 Fax: (1-305) 4459310 Cyprus Medical Association (CyMA) 14 Thasou Street 1087 Nicosia CYPRUS Dr. Andreas Demetriou, President Tel. (357) 22 33 16 87 Fax: (357) 22 31 69 37 E-mail: cyma@cytanet.com.cy WMA Directory of Constituent Members wmj 1 2011 5CS.indd 37 21.02.2011 16:28:35 38 Czech Medical Association Sokolská 31 - P.O. Box 88 120 26 Prague 2 CZECH REPUBLIC Prof. Jaroslav Blahos, President Tel: (420) 224 266 201-4 Fax: (420) 224 266 212 E-mail: czma@cls.cz - Website: www.cls.cz Danish Medical Association Kristianiagade 12, DK-2100 Copenhagen DENMARK Dr.Mads Koch Hansen, President Tel: (45) 35 44 85 00 Fax: (45) 35 44 85 05 E-mail: er@dadl.dk, cc: clr@dadl.dk Website: www.laeger.dk Egyptian Medical Association “Dar El Hekmah” 42, Kasr El-Eini Street Cairo EGYPT Prof. Ibrahim Badran Tel: (20-2) 3543406 E-mail : ganzory@tedata.net.eg Colegio Médico de El Salvador Final Pasaje N° 10 Colonia Miramonte San Salvador EL SALVADOR, C.A. Dr. Alcides Gómez Hernández, Presidente Tel: (503) 260-1111, 260-1112 Fax: (503) 260-0324 E-mail: comcolmed@telesal.net marnuca@ hotmail.com juntadirectiva@colegiomedico.org.sv Estonian Medical Association (EsMA) Pepleri 32 51010 Tartu ESTONIA Dr. Andrus Mäesalu, President Tel: (372) 7 420 429 Fax: (372) 7 420 429 E-mail: eal@arstideliit.ee Website: www.arstideliit.ee Ethiopian Medical Association P.O. Box 2179 Addis Ababa ETHIOPIA Dr. Fuad Temam, President Tel: (251-1) 158174 Fax: (251-1) 533742 E-mail: ema.emj@ethionet.et ema@eth.healthnet.org Fiji Medical Association 304 Wainamu Road G.P.O. Box 1116 Suva FIJI ISLANDS Dr. Ifereimi Waqainabete, President Tel. (679) 3315388 Fax. (679) 3315388 E-mail. fma@unwired.com.fj Finnish Medical Association P.O. Box 49 00501 Helsinki FINLAND Dr.Timo Kaukonen, President Tel: (358-9) 393 091 Fax: (358-9) 393 0794 E-mail: riikka.sorsa@fimnet.fi/ (fma@fimnet.fi) Website: www.medassoc.fi Association Médicale Française 180, Blvd. Haussmann 75389 Paris Cedex 08 FRANCE Dr. Elie Chow-Chine, President Tel: (33) 1 53 89 32 41 Fax. (33) 2 99 38 15 57 (Sylvie Deletoile - deletoile.sylvie@cn.medecin. fr) Website: www.assmed.fr Georgian Medical Association 7 Asatiani Street 0177 Tbilisi GEORGIA Prof. Gia Lobzhanidze, President Tel. (995 32) 398686 Fax. (995 32) 396751 / 398083 E-mail. georgianmedicalassociation@gmail.com Website: www.gma.ge Bundesärztekammer (German Medical Association) Herbert-Lewin-Platz 1 10623 Berlin GERMANY Prof. Jorg Dietrich Hoppe Tel: (49-30) 4004 56 360 Fax: (49-30) 4004 56 384 E-mail: rparsi@baek.de Website: www.baek.de Ghana Medical Association P.O. Box 1596 Accra GHANA Dr. Emmanuel Adom Winful, President Tel. (233-21) 670510 / 665458 Fax. (233-21) 670511 E-mail: gma@dslghana.com Website: www.ghanamedassn.org Association Médicale Haitienne 1ère Av. du Travail #33 - Bois Verna Port-au-Prince HAITI, W.I. Dr. Greta Roy, Présidente Tel. (509) 2244 - 32 Fax:(509) 2244 - 50 49 E-mail: secretariatamh@gmail.com amh@haitimedical.com Website: www.amhhaiti.net Hong Kong Medical Association, China Duke of Windsor Social Service Building 5th Floor 15 Hennessy Road HONG KONG Dr. Gabriel K. Choi, President Tel: (852) 2527-8285 Fax: (852) 2865-0943 E-mail: hkma@hkma.orgoui Website: www.hkma.org Association of Hungarian Medical Societies (MOTESZ) Nádor u. 36 - PO.Box 145 1051 Budapest HUNGARY Dr. István Kiss, President Tel: (36-1) 312 3807 - 312 0066 Fax: (36-1) 383-7918 E-mail: szalma.laura@motesz.hu Website: www.motesz.hu Icelandic Medical Association Hlidasmari 8 200 Kópavogur ICELAND Dr. Birna Jonsdottir, President Tel: (354) 864 0478 Fax: (354) 5 644106 E-mail: icemed@icemed.is Website: www.icemed.is Indian Medical Association Indraprastha Marg New Delhi 110 002 INDIA Dr. Vinay Agarwal, National President Tel: (91-11) 23370009/23378819/23378680 Fax: (91-11) 23379178/23379470 E-mail: imawmaga2009@gmail.com Website: www.imanational.com Indonesian Medical Association Ikatan Dokter Indonesia Jl. Samratulangi No. 29 Jakarta 10350 INDONESIA Dr. Prijo Sidipratomo, President Tel: (62-21) 3150679 / 3900277 Fax: (62-21) 390 0473 E-mail: pbidi@idola.net.id Website:www.idionline.org Irish Medical Organisation 10 Fitzwilliam Place Dublin 2 IRELAND Prof. Seán Tierney, President Tel: (353-1) 6767273 Fax: (353-1) 662758 E-mail: imo@imo.ie ccamilleri@imo.ie Website: www.imo.ie Israel Medical Association 2 Twin Towers, 35 Jabotinsky St. P.O. Box 3566, Ramat-Gan 52136 ISRAEL Dr. Leonid Eidelman, President Tel: (972-3) 610 0444 Fax: (972-3) 575 0704 E-mail michelle@ima.org.il Website: www.ima.org.il Ordre National des Médecins de la Côte d’Ivoire (ONMCI) Cocody Cité des Arts, Bât. U1, Esc.D, RdC, Porte n°1 BP 1584 Abidjan 01 IVORY COAST Dr. Aka Kroo Florent Pierre, President Tel. (225) 22 48 61 53 /22 44 30 78/ Tel. (225) 02 02 44 01 /08 14 55 80 Fax: (225) 22 44 30 78 E-mail: onmci@yahoo.fr Website: www.onmci.org Japan Medical Association 2-28-16 Honkomagome, Bunkyo-ku Tokyo 113-8621 JAPAN Dr. Y. Karasawa, President Tel: (81-3) 3946 2121/3942 6489 Fax: (81-3) 3946 6295 E-mail: jmaintl@po.med.or.jp Website: www.med.or.jp National Medical Association (NMA) of the Republic of Kazakhstan 117/1 Kazybek bi St., Almaty KAZAKHSTAN Dr. Aizhan Sadykova, President Tel. (7-327 2) 624301 / 2629292 Fax. (7-327 2) 623606 E-mail: doktor_sadykova@mail.ru Korean Medical Association 302-75 Ichon 1-dong, Yongsan-gu Seoul 140-721 REP. OF KOREA Dr. Man Ho Kyung, President Tel: (82-2) 794 2474 Fax: (82-2) 793 9190/795 1345 E-mail: intl@kma.org Website: www.kma.org wmj 1 2011 5CS.indd 38 21.02.2011 16:28:36 39 Kuwait Medical Association P.O. Box 1202 Safat 13013 KUWAIT Dr. Abdul-Aziz Al-Enezi, President Tel. (965) 5333278, 5317971 Fax. (965) 5333276 E-mail. kma@kma.org.kw / alzeabi@hotmail.com Latvian Physicians Association Skolas Str. 3 Riga 1010 LATVIA Dr. Peteris Apinis, President Tel: (371) 67287321 / 67220661 Fax: (371) 67220657 E-mail: lma@arstubiedriba.lv Website: www.arstubiedriba.lv Liechtensteinische Ärztekammer Postfach 52 9490 Vaduz LIECHTENSTEIN Dr. Remo Schneider, Secretary LAV Tel: (423) 231 1690 Fax. (423) 231 1691 E-mail: office@aerztekammer.li Website: www.aerzte-net.li Lithuanian Medical Association Liubarto Str. 2 2004 Vilnius LITHUANIA Dr. Liutauras Labanauskas, President Tel./Fax. (370-5) 2731400 E-mail: lgs@takas.lt Website: www.lgs.lt/ Association des Médecins et Médecins Dentistes du Grand- Duché de Luxembourg (AMMD) 29, rue de Vianden 2680 Luxembourg LUXEMBOURG Dr. Jean Uhrig, Président Tel: (352) 44 40 33 1 Fax: (352) 45 83 49 E-mail: secretariat@ammd.lu Website: www.ammd.lu Macedonian Medical Association Dame Gruev St. 3 P.O. Box 174 91000 Skopje MACEDONIA Prof. Dr. Jovan Tofoski, President Tel: (389-2) 3162 577/7027 9630 Fax: (389-91) 232577 E-mail: mld@unet.com.mk Website: www.mld.org.mk Society of Medical Doctors of Malawi (SMD) Post Dot Net, PO Box 387, Crossroads Lilongwe Malawi 30330 Lilongwe MALAWI Dr. Douglas Komani Lungu, President E-mail: dlungu@sdnp.org.mw Website : www.smdmalawi.org Malaysian Medical Association 4th Floor, MMA House 124 Jalan Pahang 53000 Kuala Lumpur MALAYSIA Dr. David K.L. Quek, President Tel: (60-3) 4041 1375 Fax: (60-3) 4041 8187 E-mail: info@mma.org.my / president@mma. org.my Website: www.mma.org.my Ordre National des Médecins du Mali (ONMM) Hôpital Gabriel Touré Cour du Service d’Hygiène BP E 674 Bamako MALI Prof. Alhousseïni AG Mohamed, President Tel. (223) 223 03 20/ 222 20 58/ E-mail: cnommali@gmail.com Website: www.keneya.net/cnommali.com Medical Association of Malta The Professional Centre Sliema Road, Gzira GZR 06 MALTA Dr. Steven Fava, President Tel: (356) 21312888 Fax: (356) 21331713 E-mail: martix@maltanet.net Website: www.mam.org.mt Colegio Medico de Mexico (CMM) Adolfo Prieto #812 Col.Del Valle D. Benito Juárez Mexico 03100 MEXICO Dr Federico Marin, Presidente Tel. 52 55 5543 8989 Fax. 52 55 5543 1422 E-mail: fenacome@gmail.com Website: www.colegiomedicodemexico.org Associação Médica de Moçambique (AMMo) Avenida Salvador Allende, n° 560 1° andar, Maputo MOCAMBIQUE Dr. Rosel Salomão, President E-mail: associacaomedicamz@gmail.com Medical Association of Namibia 403 Maerua Park - POB 3369 Windhoek NAMIBIA Dr. Reinhardt Sieberhagen, President Tel. (264) 61 22 4455 Fax. (264) 61 22 4826 E-mail: man.office@iway.na Nepal Medical Association Siddhi Sadan, Post Box 189 Exhibition Road Katmandu NEPAL Dr. Chop Lal Bhusal, President Tel. (977 1) 4225860, 4231825 Fax. (977 1) 4225300 E-mail. nma@healthnet.org.np Royal Dutch Medical Association P.O. Box 20051 3502 LB Utrecht NETHERLANDS Prof. A.C.Nieuwenhuijzen Kruseman, President Tel: (31-30) 282 38 28 Fax: (31-30) 282 33 18 E-mail: j.bouwman@fed.knmg.nl Website: www.knmg.nl www.artsennet.nl New Zealand Medical Association P.O. Box 156, 26 The Terrace Wellington 1 NEW ZEALAND Dr. Peter Foley, Chairman Tel: (64-4) 472 4741 Fax: (64-4) 471 0838 E-mail: lianne@nzma.org.nz Website: www.nzma.org.nz Nigerian Medical Association National Secretariat 8 Benghazi Street, Off Addis Ababa Crescent Wuse Zone 4, FCT, PO Box 8829 Wuse Abuja NIGERIA Dr. Prosper Ikechukwu Igboeli, President Tel: (234-1) 480 1569, 876 4238 Fax: (234-1) 493 6854 E-mail: info@nigeriannma.org Website: www.nigeriannma.org Norwegian Medical Association P.O.Box 1152 sentrum 0107 Oslo NORWAY Dr.Torunn Janbu, President Tel: (47) 23 10 90 00 Fax: (47) 23 10 90 10 E-mail: ellen.pettersen@legeforeningen.no Website: www.legeforeningen.no Asociación Médica Nacional de la República de Panamá Apartado Postal 2020 Panamá 1 PANAMA Dr. Rubèn Chavarria, Presidente Tel: (507) 263 7622 /263-7758 Fax: (507) 223 1462 Fax modem: (507) 223-5555 E-mail: amenalpa@cwpanama.net Colegio Médico del Perú Malecón Armendáriz N° 791 Miraflores Lima PERU Dr. Julio Castro Gómez, Presidente Tel: (51-1) 241 75 72 Fax: (51-1) 242 3917 E-mail: prensanacional@cmp.org.pe Website: www.cmp.org.pe Philippine Medical Association 2/F Administration Bldg. PMA Compound, North Avenue Quezon City 1105 PHILIPPINES Dr. Rey Melchor F. Santos, President Tel: (63-2) 929-63 66 Fax: (63-2) 929-69 51 E-mail: philmedas@yahoo.com Website: www.pma.com.ph Polish Chamber of Physicians and Dentists (Naczelna Izba Lekarska) 110 Jana Sobieskiego 00-764 Warsaw POLAND Dr. Konstanty Radziwill, President Tel. (48) 22 55 91 300/324 Fax: (48) 22 55 91 323 E-mail: sekretariat@hipokrates.org Website: www.nil.org.pl Ordem dos Médicos Av. Almirante Gago Coutinho, 151 1749-084 Lisbon PORTUGAL Dr. Pedro Nunes, President Tel: (351-21) 842 71 00/842 71 11 Fax: (351-21) 842 71 99 E-mail: intl@omcn.pt Website: www.ordemdosmedicos.pt Romanian Medical Association Str. Ionel Perlea, nr 10, Sect. 1, Bucarest ROMANIA Prof. Dr. C. Ionescu-Tirgoviste, President Tel: (40-21) 460 08 30 Fax: (40-21) 312 13 57 E-mail: amr@itcnet.ro Website: www.ong.ro/ong/amr/ wmj 1 2011 5CS.indd 39 21.02.2011 16:28:37 40 Russian Medical Society Udaltsova Street 85 119607 Moscow RUSSIA Dr. Mikhail Perelman, President Tel./Fax (7-495) 734-12-12 Tel. (7-495) 734-11-00/(7-495)734 11 00 E-mail. info@russmed.ru Website: www.russmed.ru/eng/who.htm Samoa Medical Association Tupua Tamasese Meaole Hospital Private Bag - National Health Services Apia SAMOA Dr. Viali Lameko, President Tel. (685) 778 5858 E-mail: viali1_lameko@yahoo.com Ordre National des Médecins du Sénégal (ONMS) Institut d’Hygiène Sociale (Polyclinique) BP 27115 Dakar SENEGAL Prof. Lamine Sow, President Tel. (221) 33 822 29 89 Fax: (221) 33 821 11 61 Website: www.ordremedecins.sn Lekarska Komora Srbije (LKS) Serbian Medical Chamber Kraljice Natalije 1-3 Belgrade SERBIA Dr.Tatjana Radosavljevic, General Manager E-mail: lekarskakomorasrbije@gmail.com Singapore Medical Association (SiMA) Alumni Medical Centre, Level 2 2 College Road Singapore 169850 Dr. Chong Yeh Woei, President Tel. (65) 6223 1264 Fax. (65) 6224 7827 E-mail. sma@sma.org.sg Website: www.sma.org.sg Slovak Medical Association Cukrova 3 813 22 Bratislava 1 SLOVAK REPUBLIC Prof. Peter Krištúfek, President Tel. (421) 5292 2020 Fax. (421) 5263 5611 E-mail: secretarysma@ba.telecom.sk Website: www.sls.sk Slovenian Medical Association Komenskega 4 61001 Ljubljana SLOVENIA Prof. Dr. Pavel Poredos, President Tel. (386-61) 323 469 Fax: (386-61) 301 955 Somali Medical Association 7 Corfe Close Hayes Middlesex UB4 0XE UNITED KINGDOM Dr. Abdirisak Dalmar Chairman E-mail: drdalmar@yahoo.co.uk The South African Medical Association P.O. Box 74789, Lynnwood Rydge 0040 Pretoria SOUTH AFRICA Dr. Norman Mabasa, President Tel: (27-12) 481 2036 Fax: (27-12) 481 2100 E-mail: EthelM@samedical.org Website: www.samedical.org Consejo de Médicos de España Plaza de las Cortes 11, 4a Madrid 28014 SPAIN Dr. Juan José Rodriguez-Sendin, Presidente Tel: (34-91) 431 77 80 Fax: (34-91) 431 96 20 E-mail: internacional@cgcom.es Website: www.cgcom.es Swedish Medical Association (Villagatan 5) P.O. Box 5610, Villagatan 5 SE - 114 86 Stockholm SWEDEN Dr. Eva Nilsson Bågenholm, President Tel: (46-8) 790 35 01 Fax: (46-8) 10 31 44 E-mail: info@slf.se Website: www.slf.se Fédération des Médecins Suisses (FMH) Elfenstrasse 18 - C.P. 170 3000 Berne 15 SWITZERLAND Dr. Jacques de Haller, Président Tel. (41-31) 359 11 11 Fax. (41-31) 359 11 12 E-mail: info@fmh.ch Website: www.fmh.ch Taiwan Medical Association 9F, No 29, Sec.1 An-Ho Road Taipei 10688 TAIWAN Dr. Ming-Been Lee, President Tel: (886-2) 2752-7286 Fax: (886-2) 2771-8392 E-mail: intl@tma.tw Website: www.tma.tw Medical Association of Thailand 2 Soi Soonvijai New Petchburi Road, Huaykwang Dist. Bangkok 10310 THAILAND Pol.Lt.Gen.Dr.Jongjate Aojanpong, President Tel: (66-2) 314 4333/318-8170 Fax: (66-2) 314 6305 E-mail: math@loxinfo.co.th Conseil National de l’Ordre des Médecins de Tunisie 16, rue de Touraine 1002 Tunis TUNISIA Dr.Taoufik Nacef, Président Tel: (216-71) 792 736/799 041 Fax: (216-71) 788 729 E-mail: cnom@planet.tn Turkish Medical Association GMK Bulvari Şehit Daniş Tunaligil Sok. N° 2 Kat 4 Maltepe 06570 Ankara TURKEY Dr Eris Bilaloglu, President Tel: (90-312) 231 31 79 Fax: (90-312) 231 19 52 E-mail: Ttb@ttb.org.tr Website: www.ttb.org.tr Uganda Medical Association Plot 8, 41-43 circular rd. P.O. Box 29874 Kampala UGANDA Dr. M. Mungherera, President Tel. +256 772 434 652 Fax. (256) 41 345 597 E-mail. mmungherera@yahoo.co.uk Ukrainian Medical Association (UkMA) 7 Eva Totstoho Street PO Box 13 Kyiv 01601 UKRAINE Dr. Oleg Musii, President Tel. (380) 50 355 24 25 Fax: (380) 44 501 23 66 E-mail: sfult@ukr.net Website: www.sfult.org.ua British Medical Association BMA House,Tavistock Square London WC1H 9JP UNITED KINGDOM Sir Michael Marmot, President Tel: (44-207) 387-4499 Fax: (44-207) 383-6400 Website: www.bma.org.uk American Medical Association 515 North State Street Chicago, Illinois 60654 UNITED STATES Cecil B Wilson, President Tel: (1-312) 464 5291 / 464 5040 Fax: (1-312) 464 5973 E.mail: ellen.waterman@ama-assn.org Website: www.ama-assn.org Sindicato Médico del Uruguay Bulevar Artigas 1515 CP 11200 Montevideo URUGUAY Dr. Jorge Lorenzo, Presidente Tel: (598-2) 401 47 01 Fax: (598-2) 409 16 03 E-mail: secretaria@smu.org.uy Associazione Medica del Vaticano 00120 Città del Vaticano VATICAN STATE Prof. Renato Buzzonetti, Président Tel: (39-06) 69879300 Fax: (39-06) 69883328 E-mail: servizi.sanitari@scv.va Federacion MedicaVenezolana Av. Orinoco con Avenida Perija Urbanizacion Las Mercedes Caracas 1060 CP VENEZUELA Dr. Douglas Leon Natera, Presidente Tel: (58) 2129935227/3527 Fax: (58) 2129932890/8139 Website: www.federacionmedicavenezolana.org Vietnam Medical Association (VGAMP) 68A Ba Trieu-Street Hoau Kiem District Hanoi VIETNAM Dr.Tran Huu Thang, Secretary General Tel: (84) 4 943 9323 Fax: (84) 4 943 9323 Zimbabwe Medical Association P.O. Box 3671 Harare ZIMBABWE Dr. Billy Rigawa, President Tel. (263-4) 791553 Fax. (263-4) 791561 E-mail: zima@zol.co.zw www.zima.org.zw wmj 1 2011 5CS.indd 40 21.02.2011 16:28:38 iii Regional and NMA newsLATVIA Latvian Medical Association together with Public Institute to arouse extra motivation in the minds of the population of Latvia to choose healthy foods and make “unhealthy ones” less available to the public. An extensive study has been performed to determine the main educational and motivational directions that should be in- troduced in Latvia. A special computer program for the diagnosis of the excess weight was developed. The program is able to determine the knowledge level concern- ing theoretical excess weight issues for each particular individual, impact of his or her practical actions onto weight fluctuations, as well as mark the psychological attitude of the individual towards the excess weight problem in general. The user of the program provides answers to 210 questions.In total 31 topics are covered: appetite, breakfast, diet and sports, fats, nu- trition, food shopping, sweets, salt, metabo- lism, and other. Participants received individual excess weight diagnostics free of charge, based on the answers they provided. Diagnostics included not only the above mentioned re- sults, but also individually tailored practical recommendations about what should be implemented in their daily routine so that they could control their weight successfully. More than 6000 participants applied for the study within two months. Comparing the number of the participants in the study with the number of inhabitants of Latvia, the proportion was as 800 000 people had been surveyed in the USA. The general level of knowledge about the weight reduction issues in Latvia is very good – on average 76% of all answers to the theoretical questions were correct. The situ- ation was different with the questions about practical actions; here the percentage of cor- rect answers reached only 40%. In order to make a comparison on what are the most sensitive topics from the point of view of knowledge and implementation of knowl- edge in everyday life, a term “voice of con- science ratio” was developed. It determines what proportion of the knowledge people possess they actually use in their daily rou- tine. People follow only 1/2 of what they know about excess weight issues. In the topics on shopping, appetite, consuption of healthy food respondents reval that they fol- low hardly 1/5 of the information they pos- sess. The study results prove that knowledge alone is not enough to make people live healthier lives. To persuade people to change their lifestyle, additional activities for motivation should be sought. Find full description of the study in English at page www.dietillustrated.com Initiative from Latvian Medical Association Knowledge and Habits EFMA in cooperation with the WHO have set up a joint workgroup on antimicrobial resistance. We would like to bring this im- portant issue to your attention and encour- age you to act to promote it to the doctors in your country. Antimicrobial resistance is continuing to in- crease throughout the world and has become a serious threat to public health. Approxi- mately 400.000 patients in Europe are annu- ally reported, to suffer from infections which are resistant to antibiotics. It is estimated that within the EU about 25.000 patients each year die from resistant infections. Such data shows that antibiotic resistance remains a public health problem across the European Region. Prudent use of antibiotics can help stop re- sistant bacteria from developing and help keep antibiotics effective for the use of future generations. We encourage you to make efforts at national level to reduce un- necessary antibiotic use. For more information on this topic, we suggest you look at the ECDC website: http://www.ecdc.europa.eu/en/eaad/pages/ home.aspx The ECDC has been working on the issue of antibiotic resistance and prepared vari- ous information documents in coordination with Antibiotics Awareness day. In prepa- ration for World Health Day, on the 7th April, which will be focused on antimicro- bial resistance, we suggest that you start to act in the following areas: • Increase awareness of the problem of An- ti-bacterial resistance • Promote publications in your medical journals on this issue • Organise press conferences in your region on World Health Day • Make contact with experts in the area and encourage the development of commit- tees to work in the areas of surveillance, promotion and protocol. I would appreciate it if you would please keep us informed of your actions. Leah Wapner Secretary General EFMA-WHO Antimicrobial Resistance wmj 1 2011 5CS.indd Sec2:iii 21.02.2011 16:28:39 iv Contents Interested in Global Health? Join the World Medical Association – Become an Associate Member . . . . . . . . . . . . . . 1 Medical Ethics and Personal vs. Public Conscience: a Malaysian Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Clinicians Driving Change: Supporting Patient Care . . . . . . . 3 Humbled by Those Who Crossed Bridge of No Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 The Regulatory Framework in the Healthcare Insurance Industry: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 In the Interest of Beneficiaries and Public . . . . . . . . . . . . . . . . 9 Tobacco-Free World in Twenty Years’Time! . . . . . . . . . . . . . . 18 Climate Change – a Serious Threat to Human Health . . . . . . 21 World’s MDs Discuss Growing Health Threats Posed by Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Physicians Urge Mexican Government to Restore Order in Juarez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 World Organization of Family Doctors (WONCA) . . . . . . . 25 EU Workforce for Health – Putting a Human Face to EU Policy-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Nurses Impact on the Health System Paradigm Shift . . . . . . . 29 Czech Medical Chamber Request for Support of Hospital Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Agreement between the Ministry of Health and the Doctor’s Trade Unions . . . . . . . . . . . . . . . . . . . . . . . . . 32 The Georgian Health Care System during the Conflict in August 2008 and World Crisis . . . . . . . . . . . . . . . . . . . . . . 33 Skopje Declaration on Patient Safety and Quality in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 The College of Physicians of Senegal . . . . . . . . . . . . . . . . . . . . 35 National Medical Council of the Democratic Republic of Congo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 WMA Directory of Constituent Members . . . . . . . . . . . . . . . 37 Initiative from Latvian Medical Association . . . . . . . . . . . . . . iii Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii wmj 1 2011 5CS.indd Sec2:iv 21.02.2011 16:28:40