wmj_1_2019_WEB

WMA General Assembly
vol. 65
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 1, May 2019
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The WMA Medical Ethics Conference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Customer Satisfaction and Medical Scheme Complaints in South Africa . . . . . . . . . . . . . . . . 4
Path to Universal Health Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Interview with Otmar Kloiber, Secretary General of the World Medical Association . . . . . . 13
Interview with Leonid Eidelman, President of the World Medical Association . . . . . . . . . . . 16
Report of the President on Presidential Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Interview with Miguel Roberto Jorge President-Elect of the World Medical
Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Interview with Ardis D. Hoven WMA Chairperson of Council American Medical
Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Interview with Frank Ulrich Montgomery Vice-Chairperson of Council of WMA . . . . . . . . 24
European Doctors Towards the European Elections 2019. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
10 Questions for SEEMF’s President, prof. Andrey Kehayov, MD . . . . . . . . . . . . . . . . . . . . . . 27
Georgian Medical Association Turns 30 years old . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Activities of the Belarusian Medical Association in the Modern Period . . . . . . . . . . . . . . . . . . 32
A Medical Voice Is Needed at the Human Rights Council in Geneva . . . . . . . . . . . . . . . . . . . . 33
Euthanasia and Physician-Assisted Suicide are Unethical Acts . . . . . . . . . . . . . . . . . . . . . . . . . 34
The Defensive Medicine isn’t the Best Way to Avoid Mistakes. . . . . . . . . . . . . . . . . . . . . . . . . . 37
CPME Position Paper on Defensive Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
WMA General Assembly
WMA General Assembly
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
The Latvian Medical Association, “Latvijas Ārstu biedrība”,
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Leonid EIDELMAN
WMA President
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Jung Yul PARK
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40 Cheongpa-ro,
Yongsan-gu
04373 Seoul
Korea, Rep.
Dr. Miguel Roberto JORGE
WMA President-Elect,
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Mari MICHINAGA
WMA Vice-Chairperson of Council
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,Tokyo
Japan
Dr. Osahon ENABULELE
WMA Chairperson of the Socio-
Medical Affairs Committee
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa
Crescent Wuse Zone 4, FCT,
PO Box 8829 Wuse
Abuja
Nigeria
Dr. Yoshitake YOKOKURA
WMA Immediate Past-President
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,
Tokyo, Japan
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
Indian Medical Association
Indraprastha Marg
110 002 New Delhi
India
Dr. Joseph HEYMAN
WMA Chairperson of the Associate
Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr Andreas RUDKJØBING
WMA Chairperson of the Medical
Ethics Committee
Danish Medical Association
Kristianiagade 12
2100 Copenhagen 0
Denmark
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
Editorial
Editorial
In recent years the documents, declarations and priority setting of
the World Medical Association have increasingly focused on the
future.The WMA policy is largely determined by its leaders – Presi-
dent, Council members and chairs, Secretary-General. The WMJ
also pursues this idea, and the Journal more and more often pub-
lishes articles that not only describes the current situation or reflects
current realities,but at the same time also seeks to predict the devel-
opment of global medicine – socio-medical affairs, environmental
health, social determinants, public health, universal coverage. The
forecast is needed for the WMA to act really as the world medical
leader.
Increasingly, we use the concepts of personalized medicine, preci-
sion medicine, stratified medicine, individualized medicine. Each
of them includes a slightly different set of concepts, but overall,
it is the way we see global health care and medicine moving. Per-
sonalized medicine is an adaptation of medical care to the indi-
vidual peculiarities of each patient. In fact, personalized medicine
is the reverse thinking for global business that dreams of selling
one contraceptive pill every day to every woman in the world, to
every elderly person one ibuprofen tablet in the morning and one
sleeping pill in the evening. The new thinking advocates that for
each person there are only definite drugs in appropriate doses that
help to maintain health, ensure quality of life, treat the disease and
extend survival.
The adjustment of treatment to patients has already been known
at the time of Hippocrates. A holistic approach to a patient is not
new either; by the way, various Eastern medical techniques largely
have sought to treat a patient holistically. However, in the current
understanding of personalized medicine, we can talk about the phe-
nomenon of the 21st
century as this approach to a particular patient
as a whole has expanded through the development of diagnostics
and information processing, which provides an understanding of
the molecular basis of the disease.The new diagnostic and informa-
tion processing techniques provide a clear evidence base to stratify
or group specific patients. Each person has a unique variation of the
human genome. The health of an individual is determined by this
genetic variation in combination with behaviour and environmental
impacts, although most of the differences in the genome do not
directly affect the individual’s health. Each person’s unique genetic
profile and unique molecule arrangements make them more sensi-
tive or less sensitive to individual diseases and chemicals (drugs).
However, globally, the ZIP Code affects human life expectancy
more than the genetic code. Social determinants continue to prove
convincingly that a wealthy person with a good education resid-
ing in a democratic country lives a considerably longer life than the
poor without education, but particularly when living in a country
without social guarantees. The World Medical Association today
faces two major challenges: universal coverage and the need to
provide available doctors assistance to every citizen of the planet,
rather than the assistance of poorly educated health professionals.
Our goal for the coming years will be focusing on how to combine
universal coverage for every citizen of the planet with personalized
medicine and the possibility of each individual person be treated for
a particular disease and diagnosed by applying genetic mapping. At
the same time, we uphold prescribing only appropriate medicines at
the appropriate dosage and duration. It will bring to the fore issues
relating to medical treatments, patients and relatives, ethics, data
security, science ethics, computerization and the big social networks
and Internet companies worming their way into medicine.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal
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2
Medical Ethics
The Icelandic Medical
Association (IcMA)
Laeknafelag Islands (The Icelandic Medical
Association, IcMA) was founded in 1918
by only 39 physicians. A local association
in the capital preceded it, but IcMA was
the first national association of doctors.The
membership slowly increased and the to-
tal number of active physicians is currently
around 1000 while the population has qua-
drupled from 90 000 to 360 000.Tradition-
ally, Icelandic physicians seek abroad for
specialisation and, therefore, have always
been in good contact with international
trends of the profession. The leaders of the
association followed closely the foundation
of WMA after World War II. A represen-
tative of IcMA was present at the prepara-
tory meeting in London in 1946 and two
representatives attended the first GA of
WMA in Paris in September 1947 ensuring
that IcMA became one of the 27 founding
members.Increasingly,the leaders of the as-
sociation have had an ambition to partici-
pate in the work of the WMA and to attend
its constituent meetings. Small work group
meetings of the WMA have been held in
Iceland, but four years ago, IcMA sought to
organize a General Assembly for the first
time, a request well received by the WMA
Council.
General Assembly in
Reykjavik, October 2018
The Assembly was organized in a tradition-
al manner with the exception of the science
day as discussed later. As the venue was in
the northernmost capital of the world, there
were some concerns regarding the weather.
Unsurprisingly, the weather changed more
than once a day as is customary in Iceland
at this time of the year and the delegates
experienced intermittently strong wind
with rain, strong and cold wind without
rain and calm and cool weather during the
four days of the Assembly. All of this was
forgotten when the northern lights became
visible at the night tour outside the capital.
As customary, the local hosts organized the
social events apart from the Assembly din-
ner. A tour was organized to Thingvellir,
where the oldest parliament in the world
was established in 930, functioning until
our times except for 45 years in the first
half of the 17th
century. The delegates and
guests walked through the area in a brisk
and cold wind and got hopefully an impres-
sion of what this was like in old times. The
tour ended by a dinner in a restaurant in a
Viking style.
In its ceremonial session, Dr. Gudni Johan-
nesson, President of Iceland, gave an ad-
dress that was very well received.
However, the Assembly will surely be re-
membered for the unexpected events
leading to the immediate termination of
membership of the Canadian Medical As-
sociation and subsequently of the Royal
Dutch Medical Association some weeks
later. These have been among the most ac-
tive members of the WMA for years and,
hopefully, this will be a time-limited deci-
sion.
The Medical Ethics Conference
The traditional science day was extended to
a two and a half day conference on medical
ethics.The idea was presented early and the
WMA Secretariat gave a very valuable sup-
port but it was informed of the idea as soon
as it came up.
The main purposes of the conference were
threefold:
• To allow delegates and WMA guests
to discuss more thoroughly the various
medical issues central to the associa-
tion.
• To involve in discussions those physi-
cians not familiar with the work of WMA
and thereby increase the visibility of the
association.
• To allow for the possibility for WMA
workgroups to present their work and to
get feedback from those interested but
not involved otherwise in the work.
It is fair to say that all of these aims were
reached and the presentations and discus-
sions facilitated the work on the various
issues. It is worth mentioning examples.
The Work Group on the revision on Ge-
netic Medicine had a fruitful open meeting
where several ideas were presented.This was
very helpful and has a positive effect on the
work. It was extremely gratifying for us in
the local association that the Medical Eth-
ics Committee subsequently proposed and
the Council agreed that even though the
The WMA Medical Ethics Conference
Reykjavik, Iceland, October 2018
Jon Snaedal
BACK TO CONTENTS
3
Medical Ethics
work on this policy was not finalized, it was
decided to name it “The Reykjavik Declara-
tion on Genetic Medicine”.
Another example is the session on the
central ethical policies for physicians, the
pledge of Declaration of Geneva (DoG) and
the International Code of Medical Ethics
(ICME).The former had been revised thor-
oughly a year earlier and has since been in-
creasingly visible for physicians, both those
active inside the WMA as well as others. It
was a moving moment when the pledge was
read out in at the Assembly session, first in
Icelandic by Guðrún Ása Björnsdóttir, the
chair of the Young Doctors Association in
Iceland, and subsequently, line by line and
simultaneously,in the three official languag-
es of the WMA by all delegates.
It was decided to start a revision process
of the ICME with an open consultation
method in the same manner as for other
major revisions in the last years.
The most heated debate was on end of life
issues, primarily on euthanasia, and phy-
sician-assisted suicide where the opinion
differs vastly. However, it must be kept in
mind that active end of life actions are only
allowed in very few countries represented in
the WMA and hardly any since the CMA
and RDMA withdrawal from the Associa-
tion.
Prominent professionals were invited to
give talks on some of the central issues.
Dr. Ruth Mcklin, Professor Emeritus in
Bioethics at the Albert Einstein College
in New York, gave her views on research
ethics with special consideration to the
Declaration of Helsinki. She argued for
some changes of the Declaration and these
will surely be considered during the next
revision most likely to take place some-
times in the coming decade. Dr. Bartha
Knoppers, Professor at McGill University
in Toronto, Canada, gave an overview of
the ethical challenges in genetic medicine
and so did also Kari Stefansson, the CEO
of the Reykjavik based research company
DeCode Genetics. Dr. Kristi Boyd from
Edinburgh, Scotland, gave a lecture on
palliative medicine and Baroness Ilora
Finley from the UK on ethical aspects on
physician-assisted suicide and euthanasia
for which she is a fierce opponent.
Many other issues were discussed in differ-
ent sessions such as “Hard Choices in Med-
icine”, Dual Loyalty of Physicians”, “Future
Challenges in Genetic Medicine”,“The Use
of Artificial Intelligence in Medical Care”,
“Health Care of Undocumented Immi-
grants”, “Ethical Use of Health Data” and
“Person Centered Medicine”. The scientific
committee organized all of these symposia
but in addition, the Nordic Bioethics Com-
mittee organized a symposium on “Prenatal
Testing” and the International Federation
of Pharmaceutical Physicians another one
on “Ethics in Education for Medicines De-
velopment”.
Addresses at the opening ceremony were
given by Mrs. Svandis Svavarsdottir, the
Minister of Health, and the President of
WMA Dr. Yokokura from Japan.
Generally, there is a great competition in
getting physicians to attend conferences,
at least those that do not have a long tra-
dition. The WMA has, however, a very
good name and is well connected to both
various National Member Association
and many different collaborators and that
helped. The attendance to the conference
was relatively good with 215 registered
participants when WMA meetings were
in session and 380 participants on the last
day when all the delegates were able to
attend.
The local organizers had meetings with
representatives from some of the NMAs
before the event and that was very help-
ful.The WMA Secretariat was very instru-
mental in realizing the event, both before
and during the days of the conference and
the local organisers are very grateful for
that.
In summary, these are the main take home
messages from the conference.
On the positive side:
• The content was generally very well re-
ceived and ethical issues are very suitable
for dialogues.
• Ethical issues central to the WMA were
well covered.
• An open session for a WMA work group
was well attended and many valuable
comments were presented.
• The work of WMA became more visible
to physicians that generally are not very
well aware of the work of the associa-
tion
On the negative side
• A part of the conference was parallel with
meetings of the WMA and this has been
criticised. To avoid this, the organizers
had discussed to hold the conference ei-
ther before the GA or right after but that
was found too risky for attendance.
• Most of the time, there were two and
even three parallel sessions and many
complained of the difficulty of choosing.
However, the central issues to physicians
are many and thus difficult to choose
which to leave out.
• The event faced a financial risk that had
to be carried by the local host.
Lessons to learn
• To organize a conference on core issues
of the WMA is definitely recommend-
able, as so many outside the organization
will learn about the important work of the
WMA.
• As the experience of an open WG meet-
ing was very good, this practice could be
used to a greater extent.
Jon Snaedal, Professor in Geriatric Medicine
President of the World Medical
Association 2007-2008
E-mail: jsn@mmedia.is
BACK TO CONTENTS
4
Social Medical Affairs
Introduction
Customer service is viewed as one of the
most fundamental concepts that deal with
customer loyalty and sustainability in busi-
ness. It is known that customers who are not
happy with the products offered to them are
likely to switch to products that meet their
needs or their expectations. Prior studies
have found that higher levels of dissatisfac-
tion with a company are associated with in-
creased brand switching behaviour and exit
intentions [18,7].Thus, customer service is a
necessary component for the success of most
businesses across all sectors, particularly in
health care. The health sector has typically
been slow or reluctant to adopt practices
that place a substantial effort into customer
satisfaction. There is, however, some empiri-
cal evidence that shows a growing interest in
focusing on patient and customer satisfaction
surveys [1,14].Studies [11,20,16] show that
industry leaders have been focusing their at-
tention on improving patient and customer
satisfaction through various initiatives.How-
ever,despite their many efforts and successes,
evidence shows that more work in this area is
still needed [12, 3, 13, 21].
A few entities assess medical scheme satis-
faction surveys in South Africa. These enti-
ties conduct surveys on an annual basis and
they do attempt to provide some insight.
However, various methodologies employed
have their own shortcomings. One of the
shortcomings is that the survey results are
not publicly available other than reported
at the aggregate level, thus the true level of
customer satisfaction is unknown.The other
limitation is that such surveys are mainly
conducted for commercial gain. There are
alsomethodological issues such as the sam-
ple size, the sample size used in some of the
customer satisfaction surveys might not be
representative of the medical schemes in-
dustry due to small sample size. A GTC
(formerly Grant Thornton Capital) study
admits that their annual medical scheme
survey does not necessarily provide a full
picture of medical schemes, as compared
with other similar types of surveys [8].
The medical schemes industry in South Af-
rica has been stagnant for the past ten years,
hovering at 16% of population covered by
medical schemes. Many social economic fac-
tors may have contributed to the slow growth
of the industry. One of the possible key fac-
tors that have not been explored in detail is
the effect of customer satisfaction and com-
plaints on the industry growth. The purpose
of the current article is the customer satis-
faction and complaints analysis pertaining
to medical scheme members. The objective
of the study is to depict both secondary data
sourced from various service providers as well
as primary complaints data that are collected
by the Council for Medical Schemes (CMS).
A strong correlation exists between cus-
tomer satisfaction, complaints and the value
the customer derives from the products they
purchase.Figure 1 below shows the key com-
ponents of customer satisfaction and the key
factors of perceived quality and customer
expectation and complaints [26, 27]. The
ACSI model uses survey data as input to the
cause-and-effect econometric model which
estimates customer satisfaction as the result
of the survey-measured inputs of expecta-
tions and perceptions of the quality services
offered. The ACSI model links satisfaction
with the survey-measured outcome of com-
plaints [26,27].Thus,if customer satisfaction
is not viewed as a function of perceived value,
perceived quality and customer expectation
as depicted in Figure 1, then there is a high
likelihood of these resulting in complaints.
Medical scheme members often complain
when a claim for services rendered is not
honoured or paid in full as expected. Mem-
bers often feel that they do not receive the
cover and the benefits they expect from
their medical scheme. A study [10] showed
that customer expectation has a significant
positive effect on the customer. Another
study revealed that service quality seems to
lead to positive word-of-mouth, and there-
fore the lessening of complaint [22]. There
is empirical evidence on the correlation be-
tween perceived value,perceived quality and
corporate image that have a significant pos-
itive influence on customer satisfaction [2].
There are investigations on how the sellers’
response to complaints affects complain-
ants’ satisfaction, perceptions of fairness,
etc. [23]. Furthermore, a study [24] found
that patients who register medical aid com-
plaints are four and a half times more likely
to voluntarily exit the Health Maintenance
Organization.
Other studies have also shown that there
is a statistically significant impact of the
Customer Satisfaction and Medical Scheme Complaints
in South Africa
Michael Mncedisi Willie
SOUTH AFRICA
BACK TO CONTENTS
5
Social Medical Affairs
overall dimensions of complaints handling
(service recovery, service quality, switching
cost, service failure, service guarantee, and
perceived value) on customer satisfaction
[25]. Thus, customer satisfaction goes be-
yond normal service delivery and further
taps into meeting the needs of the customer.
In many cases customer complaints arise
because their expectations or their needs are
not met by the service provider and that is
when the perceived value is not realised. A
study [17] discussed a framework focused
on a firm’s pre-emptive value offering (also
known as a customer value proposition).
Furthermore, [19] proposed a comprehen-
sive customer-value creation framework
that identifies four main types of value that
can be created by organisations:
• Functional/instrumental value: the at-
tributes of the product itself; the extent
to which a product is useful and fulfils a
customer’s desired goals.
• Experiential/hedonic value: the extent
to which a product creates appropriate
experiences, feelings, and emotions in the
customer.
• Symbolic/expressive value: the extent to
which customers attach or associate psy-
chological meaning to a product.
• Cost/sacrifice value: the cost or sacrifice
that would be associated with the use of
the product.
In terms of general business practices, com-
plaints might be a result of basic business
practices not being carried out as expected
by the member, and thus the product does
not meet the customer’s desired goals.Typi-
cally, a member of a medical aid scheme
expects a claim to be paid but, due to ad-
ministratively related issues, a claim is not
paid or a benefit is not paid in full. This is
not explained to the member. A rise in the
number of complaints is also due to admin-
istrative inefficiencies by third parties con-
tracted to the scheme, which ultimately af-
fect the members negatively. This is evident
in the two most complained about schemes
over the review period.
The Resolution Health Medical Scheme
and the Spectramed Medical Scheme are
open schemes that have reported the high-
est number of complaints. The schemes
have reported 2.6 and 4.4 complaints per
1000 beneficiaries respectively in 2017, and
this is considerably higher when compared
with other schemes. The trend has contin-
ued during the past three years.
The table below shows the number of mem-
bers and valid complaints about Spectramed
and Resolution between 2015 and 2017.
The schemes consistently reported more
complaints, and this possibly contributed to
a decline in the membership of more than
30% for both schemes.
The other contributing factor to the rise in
complaints is the complexity of the product
sold. The more complex the product is the
higher the risk of it not being fully under-
stood by the purchasers. During 2017 there
were 278 registered benefit options operat-
ing in 81 medical schemes, thus choosing a
benefit option became even more confusing
to customers. A study [9] depicts that the
number of benefit options available in the
medical scheme market creates a complex
environment impacting decision making.
Figure 1: ACSI Unique Benchmarking Model [28]
Source:ACSI Unique Benchmarking.The American Customer Satisfaction Index,the nation›s only cross-
industry measure of customer satisfaction, gives businesses science-based insights across the complete arc of
the customer experience.
Figure 2: Spectramed and Resolution Health Medical Schemes complaints related issues
Source: [4,5]
SOUTH AFRICA
BACK TO CONTENTS
6
It is not an easy task to accurately assess the
impact of customer satisfaction in health
care, particularly when medical scheme
beneficiaries view it with antipathy. Mem-
bers feel that there is nothing intrinsically
satisfying about spending money on medi-
cal risk mitigation [15]. They view it as a
must have, and there is no denying that in
the event of a major medical emergency,
medical aid membership is an absolute ne-
cessity.
Customer Satisfaction Scores
A number of customer satisfaction surveys
have been conducted. The recent data show
a declining trend in this regard. The South
African Customer Satisfaction Index (the
SA-csi) for Medical Schemes survey was
done on a sample of schemes, and shows
a declining trend in customer satisfaction
levels, which dropped from 74.2% in 2017
to 72.7% in 2018.The main factors contrib-
uting to the declining scores are increasing
premiums, shrinking benefits and lack of
value for money. A survey published by the
competition commissioner revealed that for
respondents whose family members were
not members of a medical scheme the rea-
sons for it were the following:
• no longer able to afford the contribu-
tions – 15%;
• no longer a dependant child and could
not afford it – 14%.
A survey conducted by one of the larg-
est restricted schemes in 2018 revealed
that affordability of the premiums, co-
payment, shrinking benefits or benefits
exhausting quickly were some of the fac-
tors contributing to lower customer sat-
isfaction scores. Table 2 below presents
the SA-csi customer satisfaction scores,
exposure, and demographic information
of the five schemes considered. The list of
schemes depicted in the table below ac-
counts for 65% of all schemes, 81% of all
open schemes and 46% overall, in terms of
beneficiaries in 2017.
Of the five large medical schemes surveyed,
only two had an improved index score. This
was an open scheme which had slightly
above 200 000 beneficiaries and a higher
solvency level, compared with the other five
schemes which rose from 72.6% last year to
75.1% this year. GEMS, which is the larg-
est restricted scheme (employer medical
scheme), also saw an increase in customer
satisfaction level, improving from 64.3% to
68.8% in 2017.The Discovery Health Med-
ical Scheme dropped from 74.8% to 73.1%,
while the Bonitas Medical Scheme – from
73.1% to 70.2% over the period.
The Momentum Health remained within the
range of 72.0%.Only one of the five schemes
is self-administered. Others are adminis-
tered by third party, which further discloses
the impact of the operating model upon the
types of services offered. Simplicity of prod-
ucts plays a role.Table 2 shows the number of
benefits offered by these schemes that offered
a range between 5 and 17 benefit options.
Survey Limitations
While the data give an insight into the cus-
tomer satisfaction survey, it is of importance
to note the following limitations: Only one
restricted scheme was considered, which
represents less than half of the restricted
schemes. There are also considerable differ-
ences in the scheme considered in terms of
demographics and the number of benefit
options offered, which is similar to the op-
erating model.
The other limitation of the survey is that it
considers a random sample of 1757 medical
aid members. A bigger sample size across
other scheme types could certainly improve
the findings of the study. The present num-
ber accounts for less than a percent (<1%
of the overall membership) of the overall
population coverage by medical schemes.
Table 1:
Membership and valid complaints data for Spectramed and Resolution Health
Medical Schemes
Category
Spectramed medical
scheme
Resolution health
medical scheme
Number of complaints
2017 81 70
2016 102 100
2015 167 123
Number of beneficiaries
2017 22,777 28,839
2016 27,599 37,546
2015 33,062 45,575
Table 2: Customer satisfaction scores for five selected medical schemes
Scheme Name
Scheme
Type
Beneficia-
ries
Number of
Options*
Solvency,
%
SA-csi Score,
% (2016)
Discovery health
medical scheme
Open 2,777,946 17 27.4 73.1 (74.8)
MEDIHELP Open 200,487 7 29.6 75.1 (72.6)
Momentum health Open 293,787 6 25.7 72.0 (72.2)
BONITAS Open 728,943 11 24.5 70.2 (73.1)
GEMS Restricted 1,807,538 5 15.2 68.8 (64.3)
Source: [15, 4, 5], * Excluded Efficiency Discount Options/Sub-options
Social Medical Affairs SOUTH AFRICA
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7
Complaints Trend Analysis
Table 4 below reveals the trend data of valid
complaints logged between 2015 and 2018,
the complaints ratio (valid complaints per
1000 beneficiaries) was slightly higher for
open schemes, compared with restricted
schemes. There was an increasing trend in
restricted schemes between 2015 and 2016;
however, a notable trend was noted in 2017
in both sectors.
There were more complaints in medical
schemes in 2017 compared with previous
years where an increase of more than 10%
was noted.
Over the period, the number of com-
plaints and complaint resolution time have
consistently increased. Open schemes
have reported more complaints than re-
stricted schemes. The data show an in-
creasing trend in the average complaint
resolution time within the range of two
to six months, in both open and restricted
schemes. It is seen that it took longer to
resolve complaints in 2017. This might be
attributed to the complexity of the com-
plaints received.
Types of Complaints Over
the Reviewed Period
The figure below presents a grouping of
complaints by the complaint type over the
period of three years. Complaints relating
to benefit payments accounted for a third
of the complaints, short payments – for just
under a quarter, pre-authorisations  – for
10%, and no-payments – for 9%.
Trends in complaint type
Figure 4 below reveals that the payment
of benefits accounted for ⅓ of complaints
in 2016 and 2017, and short payments –
for under a quarter of the complaints
and dropping to 24% of the complaints
in 2017. Complaints relating to pre-au-
thorisations were wthinin the range of 9
to 10%. Non-payments accounted for 8 to
9% of all complaints. A similar trend was
noted for complaints relating to customer
service.The data show that in 2015, short-
payment complaints had a large share;
however, this was improved in subsequent
years.
Median time to resolve
complaints by complaint
type
Figure 5 below shows the median time
to resolve complaints within the period
2015-2017 stratified by the complaint cat-
egory. Other types of complaints such as
Table 3: Demographic Information of SA-csi surveyed schemes
Scheme Name
Name of the admin-
istrator
Average
Age
Pensioner
ratio
No. of de-
pendents per
member
No of
Trustees
DHMS
Discovery Health
(Pty) Ltd
34.6 9.3 1.1 8
MEDIHELP Self-Administered 37 14.1 1.2 8
Momentum
health
MMI Health (Pty)
Ltd
32.8 8.1 0.9 8
BONITAS
Medscheme Hold-
ings (Pty) Ltd
33.3 8.3 1.2 11
GEMS
Metropolitan Health
Corporate (Pty) Ltd
30.5 6 1.6 11
Source: [4]
Table 4 Complaints ratio – Industry/100 beneficiaries
Year All Open Restricted
2017 0.47 0.50 0.43
2016 0.42 0.46 0.38
2015 0.42 0.47 0.36
Source: Author computations, extrapolated from the CMS reports [4,5,6]
Table 5: Median time to resolve complaints
Category
Number of Valid
Complaints
Median Time to resolve complaints
Days Months
Open
2017 2 500 169 6
2016 2 348 122 4
2015 2 353 91 3
Restricted
2017 1 690 143 5
2016 1 498 85 3
2015 1 400 63 2
Social Medical Affairs
SOUTH AFRICA
BACK TO CONTENTS
8
­
governance related complaints, late joiner
penalties and waiting periods were excluded
due to the smaller sample size within the
groups. In 2015, the median time to resolve
complaints ranged around three months and
this increased to six months in 2017.Notable
changes affected complaints related to non-
payment of claims, membership status, and
pre-authorisations that showed a significant
shift. Complaints related to payment of ben-
efits, contributions and medical savings ac-
counts increased from two to four months.
Discussion
The current report describes a decrease in
customer satisfaction scores, although the
sample used to assess these scores has its
own limitations. However, the data reveal
some valuable facts. One of the key findings
the surveys depict is declining of customer
satisfaction scores. The medical schemes
customer satisfaction score for a select list
of schemes surveyed in 2018 was less than
75%. This was substantially lower than that
measured in other financial service indus-
tries ranging from 77% to 79% for financial
services and life insurance industries, respec-
tively. Due to the complexity that exists in
the private health sector, the low customer
satisfaction scores might be an indication to
members’feeling about the quality of services
in medical schemes sector. One of the un-
derlying factors that drives the complexity is
information asymmetry, namely, the types of
products sold to members. There were over
270 benefit options that are also coupled
with complex rules and various treatment
protocols.There are, however, studies that do
not reflect the complexity of products offered
by medical schemes.A recent survey released
by the competition commissioner showed
that the 1 507 medical schemes surveyed
were about their knowledge of cost implica-
tions and benefits provided by the various
options across medical schemes.
The GTC annual survey conducted in 2017
depicted that consumers were unsure of
their own medical scheme details and ben-
efits they were entitled to [8]. Seventy-six
percent (76%) of respondents stated that
they made sure that they understood the
cost implications and the benefits of options
provided across a medical scheme before se-
lecting it. At the same time certain partici-
pants admitted that they had poor knowl-
edge of the cost and benefit implications
of the various medical scheme options. The
health market inquiry report published in
2018 made recommendations to standardise
benefit packages offered by medical schemes
to be able to allow members make better-
informed choices based on value-for-money.
In response to such challenges, the CMS
is currently working on the benefit op-
tions standardisation process, which will
ultimately assess the possible simplification
of benefit options and meeting members’
needs. Another aspect contributing to the
declining scores is the affordability of pre-
miums that have consistently risen above
the annual inflation rate and, as a result,
healthcare is becoming more unaffordable.
Payment of benefits
Short payment
Pre-authorisation
Non-payment
General customer service
Membership status
Medical Savings Account
Contributions
Waiting periods
Late joiner penalties
Benefit Option changes
Governance
Rejection of membership application
Broker conduct
0% 5% 10% 15% 20% 25% 30% 35%
Figure 3: Median time to resolve complaints by nature of the complaint, %
0
5
10
15
20
25
30
35
P
a
y
m
e
n
t
o
f
b
e
n
e
fi
t
s
S
h
o
r
t
p
a
y
m
e
n
t
P
r
e
–
a
u
t
h
o
r
i
s
a
t
i
o
n
N
o
n
–
p
a
y
m
e
n
t
G
e
n
e
r
a
l
c
u
s
t
o
m
e
r
…
M
e
m
b
e
r
s
h
i
p
s
t
a
t
u
s
M
e
d
i
c
a
l
S
a
v
i
n
g
s
…
C
o
n
t
r
i
b
u
t
i
o
n
s
W
a
i
t
i
n
g
p
e
r
i
o
d
s
L
a
t
e
j
o
i
n
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r
p
e
n
a
l
t
i
e
s
B
e
n
e
fi
t
O
p
t
i
o
n
…
G
o
v
e
r
n
a
n
c
e
R
e
j
e
c
t
i
o
n
o
f
…
B
r
o
k
e
r
c
o
n
d
u
c
t
B
e
n
e
fi
t
O
p
t
i
o
n
…
%
of
complaints
2015 2016 2017
Figure 4: Median time to resolve complaints by nature of complaint, trend data
Social Medical Affairs SOUTH AFRICA
BACK TO CONTENTS
9
Premiums between 2015 and 2017 have in-
creased within the range from 6% to 14%,
which is higher than inflation. A study
conducted by the GTC also revealed that
increase in medical aid premiums continues
to outstrip salary increase. Since 2010, the
CMS embarked on a process of a stringent
review of medical schemes [4].
The data presented in the current report
show a correlation between complaints
and loss of membership, as revealed by the
Resolution Medical Scheme and Spec-
tramed case studies. A noticeable trend
was the increase in valid complaints dur-
ing the period under review, and this trend
was evident in both open and restricted
schemes. One of the key features revealing
the increasing trend was complaints relat-
ing to the benefit payment that accounted
for more than a third of all valid complaints
in the review period. Coupled to this was
the median complaint resolution time that
increased twice between 2015 and 2017,
i.e. from three months to six months. This
might be the result of an increase in the
complexity of complaint types or the result
of increased operational inefficiencies in the
industry over the period. Industries, such
as the short-term industry, report a lower
resolution time with an average resolution
time of 131 days,which is equivalent to four
months.This shows the unique features and
complexity of the medical scheme industry.
Recommendations
The complexity of the medical schemes
industry with respect to the number of
products offered and the various operating
model used needs to be carefully consid-
ered when comparing customer satisfaction
scores. Considering methodological issues
such as smaller sample size and other key
features, e.g. the demographics, balance in
scheme types used in the survey, corporate
governance structures, third-party arrange-
ments, and the financial performance of the
scheme over time, could certainly add value
to annual customer satisfaction surveys.
The results presented, indeed, highlight the
complexity of the sector and the number
of components where a competing inter-
est may have possibly contributed to lower
satisfaction scores. One of the main issues
consistently evident in most of the com-
plaints relate to the effect of third parties
on complaints. There needs to be a clearer
separation of duties, responsibilities and ac-
countability between the scheme and con-
tracted parties.
The increase in the number of valid com-
plaints received by the regulator provides an
indication that the complaint department
needs to be properly resourced to be able to
impact positively on the turnaround times.
There is also a need to review the overall
complaint resolution time and this needs to
be consistent with the nature of complaints
and should reflect modern challenges that
the schemes are facing. The overall com-
plaints process needs to be aligned with the
regulatory tools in order to be more effective
and such a process should outline proactive
measures as opposed to a reactive approach
to complaint resolution. One of the key
recommendations in this regard is to invest
in data analytics as well as in research and
development to assist in developing mod-
els that will provide insight and ultimately
identify systematic issues that need urgent
attention from a regulatory perspective.
The current study revealed that more than
a half of the valid complaints are related to
the payment of benefits. In many cases the
scheme does not honour claims and pays only
up to a certain threshold. It is recommended
that medical schemes need to be proactive,
and they must effectively communicate to
members what benefits are covered. Fur-
thermore, in instances where a claim is not
covered in full, this should be communicated
to the members. Schemes are encouraged to
provide feedback to the members on benefits
paid.Training and member education on the
products offered by medical schemes could
go a long way towards changing the percep-
tion of medical schemes. The latter also ap-
plies to third parties who are contracted to a
scheme that,in its turn,affects the delivery of
service to the members.The operating model
of the scheme, particularly where third par-
ties are involved,needs to take accountability
for service failures.
References
1. Al-Abri R, Al-Balushi A. Patient satisfaction
survey as a tool towards quality improvement.
Oman Med J, 2014, 29 (1), 3–7.
2. Ali, Rizwan, Leifu, Gao, Rafiq, Muhammad
Yasir & Hassan, Mudassar. Role of Perceived
Value, Customer Expectation, Corporate Im-
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Satisfaction. The Journal of Applied Business
Research, 2015, 31 (4), 1425–1436.
3. Bleich S. How does satisfaction with the
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…
Months
Complaint category
2015 2017
Figure 5: Median time to resolve complaints by nature of complaint, trend data
Social Medical Affairs
SOUTH AFRICA
BACK TO CONTENTS
10
Annexure A1: Complaint Categories – descriptions
Complaint
category
Short description
Contribu-
tions
Complaints related to contributions/ premiums: These complaints relate to premium increases, incorrect contributions
raised to the member.
Payment of
benefits
Complaints related to payments of benefits: This is the largest category of complaints and has at least 19 subcategories,
the range of complaints transmit to payment on incorrect benefits, claims paid in error, sublimit on options, benefits
exhausted, incorrect information on accounts.
Short pay-
ment
Complaints where a scheme does not pay in full: This is where the claim in not paid in full due to incorrect diagnosis
ICD-10.
Non-pay-
ment
Complaints where a scheme does not pay a benefit: This is where the claim in not paid due to incorrect diagnosis ICD-
10.
Membership
status
Complaints related to the membership status: This category includes suspension and/or termination of membership.This
usually occurs when the membership status is terminated by the scheme due premiums not paid, material non-disclosure,
fraudulent conduct by the member.
Pre-authori-
sation
Complaints related to pre-authorisation: These types of complaints are the result of an authorization not granted by the
scheme due to benefits that are excluded, protocols, waiting periods, pending outstanding information and non-disclo-
sure.
Late joiner
penalties
These types of complaints are the result of late joiner penalties or waiting periods being imposed by a scheme to a
member. A “late joiner” refers to an applicant or an adult dependant of an applicant who, at the date of application for
membership or admission as a dependant, is 35 years of age or older and who was not a member of one or more medical
schemes as from a date preceding 1 April 2001,without a break in coverage exceeding 3 consecutive months since 1 april
2001. A waiting period is a time when a person cannot claim benefits as set out in the Medical Schemes Act. It aims to
protect current members of a medical scheme by ensuring that people do not just join a scheme, make a large claim and
then cancel their membership.
Waiting
periods
General cus-
tomer service
Complaints related to customer service: Complaints relating to the service offered, these types of complaints arise where
a brochure is not received by a member, schemes failure to provide feedback to the member, where the scheme sends
incorrect information to the member,
Medical Sav-
ings Account
(MSA)
Complaints related to medical savings account and would typically include a clawback of funds, refunds or received by
the member and self-payment gap. MSA is usually a percentage of their premiums that get put into a separate account,
from which certain benefits are paid, such as doctors’ visits and acute medication, etc.
Benefit Op-
tion changes
Complaints related to benefit option changes and typically instances where benefits are excluded or limited when a
member moves from one benefit option to another.
Rejection of
membership
application
Complaints related to membership application where a scheme depict that a dependant is not eligible or due to discrimi-
nation.
Broker con-
duct
Complaints due to the broker’s conduct, this may entail issues related to broker fees or incorrect advice by a broker.
Medical Schemes Act and Medical Schemes
Medical schemes are legal bodies registered in terms of the Medical Schemes Act for defraying medical expenses of its members.
There are two kinds of schemes – open and closed schemes. Any person can join an open scheme, but closed schemes are for specific
employer groups.
Social Medical Affairs SOUTH AFRICA
BACK TO CONTENTS
11
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8. GTC (formerly Grant Thornton Capital). The
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gtc.co.za, accessed February 2019.
9. Kaplan J. & Ranchod S. Analysing the structure
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in South Africa. In: South African Health Re-
view. Eds. Padarath A, King J, English R, 2015,
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tient Exp, 2017, 4 (4), 156–61, https://www.
ncbi.nlm.nih.gov/pmc/articles/PMC5734521,
accessed February 2019.
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tance of patient satisfaction measurement and
electronic surveys: methodology and potential
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satisfaction: an emerging health policy issue.Am
Acad Orthop Surg, 2013, 9, 29.
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Surg, 2010, 3, 151–155.
15. SAcsi–Consulta.South African Customer Satis-
faction Index (SAcsi) for medical schemes.Con-
sulta Pty Ltd. Central Park Building 1 Highveld
Techno Park, Cnr Witch Hazel Avenue & Es-
doring Street, Centurion, 0157, 2018, https://
consulta.co.za, accessed February 2019.
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shad M & Ahmad M.Factors Affecting Custom-
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with Open Source Software. Technology Inno-
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Case Management, 2002, 7, 194–200.
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Michael Mncedisi Willie,
General Manager Research & Monitoring,
Council for Medical Schemes, South Africa
E-mail: m.willie@medicalschemes.com
Annexure A2: Complaint categories and sub categories
Social Medical Affairs
SOUTH AFRICA
BACK TO CONTENTS
12
Regional Medical Affairs
Since time immemorial regardless of race,
regardless of era, health has been a primary
concern of human beings throughout his-
tory. Life expectancy that has kept on im-
proving in the past centuries serves as a
proof to this.
Governments from all over the world
started its interventions on health care,
first in Germany in 1883, with the Sick-
ness Insurance Law. Employers were re-
quired to provide injury and illness insur-
ance for their low-wage workers, and the
system was funded and administered by
employees and employers through “sick
funds”, which were drawn from deductions
in workers’wages and from employers’con-
tributions. This was later followed by the
United Kingdom, the National Insurance
Act 1911 provided coverage for primary
care (but not specialist or hospital care) for
wage earners, covering about one third of
the population. The Russian Empire es-
tablished a similar system in 1912. In New
Zealand, a universal health care system was
created in a series of steps, from 1939 to
1941.
Following World War II, universal health
care systems began to be set up around the
world. On July 5, 1948, the United King-
dom launched its universal National Health
Service. Universal health care was next in-
troduced in the Nordic countries of Swe-
den (1955), Iceland (1956), Norway (1956),
Denmark (1961), and Finland (1964). Uni-
versal health insurance was then introduced
in Asia in Japan (1961), and in Canada in
1962 to 1972.
As a result, life expectancy has kept on im-
proving in the past decades. By 2025, as
forecasted by the World Health Organiza-
tion, it will reach 73 years and it claims that
by then no country will have a life expec-
tancy of less than 50 years.
• 1955: 48 years
• 1995: 65 years
• 2025: 73 years
In February 2019, Margaret Chan, WHO
Director-General,described universal health-
care as a powerful tool to fight inequality.
According to the WHO, a lack of univer-
sal healthcare pushes 100 million people a
year below the poverty line because of pay-
ing for the services they need, while coun-
tries such as the United States and China
grapple with how to provide coverage to all
their citizens. “Universal health coverage is
one of the most powerful social equalizers
among all policy options. It is the ultimate
expression of fairness,” WHO’s Margaret
Chan said.
The path to implementing Universal Health
Care in the Philippines, having a high pov-
erty incidence with 25% of Filipinos earning
$5.21/day, is really tough. The 1987 Philip-
pine Constitution mandates that “Health
is a right of every Filipino citizen and the
State is duty-bound to ensure that all Filipi-
nos have equitable access to effective health
care services”. But with a $3,580 (2016) per
capita income inclusively implementing the
UHC makes it more challenging.
On February 20, 2019, President Duterte
signed the UHC Act into law. The newly-
signed law is groundbreaking as it replaces
the previous universal healthcare policies
into a definite, coherent government man-
date.The Universal Health Care Act expands
coverage from just hospitalization to preven-
tive, promotive, curative, and rehabilitative
healthcare services.The Act is commendable.
This Act is more inclusive because only 6 out
of 10 Filipinos have any form of PhilHealth
insurance. Based on the 2017 National De-
mographic and Health Survey and govern-
ment data, a little more than half (54.5%)
of all healthcare spending was financed by
households’ out-of-pocket payments.
There are just some limitations in the im-
plementation of the 2019 UHC Act. The
delivery of such healthcare services is also
severely constrained by the perennial short-
age of health human resources.
Doctors and nurses and caregivers and oth-
er healthcare professionals continue to leave
the country in droves (especially when va-
cancies suddenly crop up abroad),and with-
out enough of them, service delivery will
surely be compromised. Healthcare in the
Philippines suffers from a dire shortage of
human medical resources,especially doctors.
This makes the system run slower and less
efficiently. Only 30% of health profession-
als employed by the government address the
Path to Universal Health Coverage
“The usual reason given for not attempting to provide universal healthcare in a country is poverty.”
/Amartya Sen, Nobel Prize Laureate for Economics/
Jose P. Santiago
PHILIPPINES
BACK TO CONTENTS
13
WMA Health Policy
health needs of the majority. Healthcare in
the Philippines suffers because the remain-
ing 70% of health professionals work in the
more expensive privately-run sectors.
In 2016, under the Duterte Administra-
tion, the Philippines hopes to adopt the
Cuban health system but it needs to ad-
dress the shortage of doctors. The present
doctor-population ratio of 1:33,000 is a far
cry from the 1:1,000 in Cuba, majority of
whom are primary care physicians.
The Philippine Medical Association report-
ed that there are 140,000 licensed physicians
in the country, but only 80,000 are active in
the profession. A good number have actually
turned to nursing and work as nurses over-
seas. Only 2,300 doctors are produced annu-
ally. Only 30-40% passes the medical board
exam every year.It is common to residents in
far-flung villages of the Philippines never to
have seen a doctor from birth to death.
Another hurdle is the shortfall on its bud-
get. The 2019 General Appropriations Act
allocated only P217B ($4.14B) for the
implementation of UHC. The Universal
Health Care would require P257 billion this
year. It has a deficit of P40B ($765.40M).
This would limit the intended inclusivity of
the coverage of the 2019 UHC Act.
For many Filipinos, especially the poor, get-
ting sick is not an option. Each hour spent
in bed or in hospital is an hour not spent
earning money for one’s own family or one-
self. Moreover, serious illnesses continue to
push more Filipinos to poverty. This merely
affirms what the WHO said about Univer-
sal Health Care.
The challenge to implement the laudable
Universal Health Care of 2019 is how to
address its hurdles systemically. Govern-
ment, the health care industry and the third
sector should put their acts together to do
this.This would be a giant stride toward im-
proving the lives of the Filipinos in terms
of health and wellbeing. This is also aligned
with the vision that the Philippines will be
among the healthiest peoples in the South-
east Asia by the year 2022.
Jose P. Santiago, Jr., M.D.
President, Philippine
Medical Association
Apinis: Dr Kloiber, I would like to ask you
some questions about the Alma–Ata and the
Astana conferences on Primary Health Care.
The former took place forty years ago in Alma-
Ata, which at the time in 1978 was the capital
of the Kazakh Soviet Socialist Republic. The
latter conference took place last September in
Astana, the new capital of the now sovereign
country of Kazakhstan. At both conferences,
significant declarations on primary health care,
named after the cities in which the meetings
took place, were adopted.
At the time the first declaration, the Dec-
laration of Alma-Ata, was adopted I was
living in the Soviet Union and you in the
Federal Republic of Germany. There was
practically no exchange of information be-
tween our countries. In the Soviet Union
this Declaration was recognised as the most
important document on the subject globally.
What was the view of the Declaration in
Germany?
Kloiber: To be truthful, I didn‘t hear about
the Alma-Ata Declaration until I was active
in organized medicine. The reception of this
document in Germany was probably restrict-
ed to those who had a very specific interest in
primary care or international health. I would
not be able to say that the health commu-
nity in general really took notice of it. In our
defence: at that time Germany already had
a pretty well-established, high level primary
care system with fairly equitable access and
high performance. Certainly not perfect, but
pretty good on the global scale.
Apinis: This Declaration largely established
the principle that the point of entry into the
health care system is the family doctor. In the
Soviet Union they were called “precinct thera-
pists”. These specialists saw patients in large
outpatient clinics called “polyclinics”.These clin-
ics were built in cities throughout the USSR.
Other socialist countries and many develop-
ing countries followed this example. The real-
ity of the Declaration was that buildings were
erected, not that more family physicians were
educated.
Kloiber: We as physicians would, of course,
argue that each patient in primary care
should be seen by a primary care physician,
but not everybody interpreted the Alma-
Ata Declaration in this way. As you said:
some thought you could fulfil the pledge
of primary care – and that was the essence
of the Declaration  – by constructing new
buildings.Others thought bare-foot doctors
would be enough and, especially at WHO,
there was a move, at least by some, to see
nurses as “primary care providers”. They
The Astana Conference on Primary Health Care. Interview with
Otmar Kloiber, Secretary General of the World Medical Association
by WMJ Editor Peteris Apinis
BACK TO CONTENTS
14
thought that family physicians would be a
kind of luxury add-on.
And yes, you are right: in many places the
investment in educating and retaining phy-
sicians did not take place.
Apinis: So, the Alma-Ata Declaration did
not only bring about positive change, it had
negative aspects too. Did the Declaration of
Alma-Ata mean some poorer countries stopped
educating specialists and sought only doctors
with the lowest possible level of general medical
education?
Kloiber: Well there were reports from coun-
tries in Europe as well as in Africa that for
some time after Alma-Ata the education of
specialists was significantly reduced. In some
places this was a decision taken by the gov-
ernments themselves, in other places donors
told the countries to focus on primary care
physicians. At that time, this meant ending
education after the basic medical degree.
Apinis: The Declaration of Alma-Ata got very
special attention from the leaders of socialistic
Cuba. They started to train doctors in a very
short space of time and export these barely
trained people to countries in Africa and Latin
America.
Kloiber: There have been export pro-
grammes of Cuban doctors to African and
Latin American countries with very ques-
tionable methods and success. One new
programme started just last year in Kenya.
We see these programmes very critically for
various reasons. Most importantly: the Cu-
ban doctors are not subjected to the same
standards of checking of their qualifications
and abilities as everybody else, secondly,
they are not paid properly and the money
that the host countries pay goes to the Cu-
ban government. Finally, we have seen plac-
es where local physicians were pushed out
of their jobs, only to be replaced by Cuban
doctors.
Apinis:Could you mention other examples
where the Alma-Ata Declaration was trans-
lated inappropriately in practice?
Kloiber: After Alma-Ata, donors discussed
how to best fulfil the pledges of primary
care. In the end, UNICEF decided to go for
a very minimalist approach.The idea was to
save as many as possible children with the
funds they had. In my opinion, this did not
really lead to a sustainable development. In
many cases, I would be inclined to judge the
development that followed as a deteriora-
tion. Primary care is not a minimalist con-
cept. A good primary care structure should
be at the core of a comprehensive health
care system.There is no room for short cuts.
Apinis: Did the Alma-Ata Declaration
completely ignore the Social Determinants of
Health? Although the theory of social determi-
nants was not yet popular, medics already knew
that health was affected by social conditions.
Kloiber: No, I wouldn’t say that the Alma-
Ata Declaration ignored the Social Deter-
minants of Health. The Declaration itself is
not bad, it’s only that politicians and donors
did not live up to it.Although not expressed
verbatim, there is a strong sense of the So-
cial Determinants of Health in the docu-
ment. What many governments and donors
made out of the document was somehow
contrary to the intention: instead of build-
ing solid health care systems with quality
primary care systems at their core, they took
it as an excuse for minimalist approaches.
Apinis: Did the Alma Ata conference hinder
global medical and health care development in
the end? Did the financiers and politicians use
the resulting Declaration as an excuse not to
allocate enough funds to medicine and health-
care?
Kloiber: It is not a black and white picture.
Some countries understood the value of pri-
mary care. In the following years, solid evi-
dence was produced showing that proper pri-
mary care structures do significantly improve
the efficiency of a health care system. Other
countries, as I said, went the opposite way.
Apinis: Did the Alma Ata conference trigger
the global migration of doctors and medical
workers? In some poorer countries there are
very few health professionals left because most
of them have left for rich countries?
Kloiber:The Alma-Ata conference and Dec-
laration were certainly not the cause of the
brain drain from poorer to richer countries.
This migration existed before Alma-Ata.The
World Medical Association addressed brain-
drain in 1971 already, in a resolution which
demanded that richer countries educate
medical students from poorer countries, but
then send them back to their home countries
after receiving their degree. Germany, for in-
stance, did this and sent young doctors back
to their countries. After Alma-Ata, when
donors started to use minimalist approaches,
these young doctors wouldn’t find any op-
portunities for post-graduate education in
their home countries. Post-graduate educa-
tion was no longer supported because prima-
ry care was enough. These young physicians
finally left for other, richer countries, which
were happy to hire them.
Not the Alma-Ata Declaration, but rather
its misinterpretation aggravated the prob-
lem.
Otmar Kloiber
WMA Health Policy
BACK TO CONTENTS
15
Apinis: You took part in the Astana conference
marking the 40th
anniversary of the Alma-Ata
conference. Was there a sense of celebration?
Please describe the atmosphere at the Astana
conference in a few words.
Kloiber: Let me first pay a great compli-
ment to the government of Kazakhstan and
all the officials and volunteers who made
this a truly celebratory event. But it was not
just a big party: I had the impression from
our colleagues at the WHO that they took a
very serious approach to it.Ten years previ-
ously, the WHO carried out a critical analy-
sis of the developments after Alma-Ata in
the 2008 World Health Report “Primary
Care – now more than ever”.
The fact is that the WHO cannot realize
primary care itself, it is the role of the do-
nors to do that: governments, the global fi-
nancing mechanisms like the Global Fund,
GAVI, UNICEF and private relief founda-
tions, to name just a few.
Apinis: WHO documents state that universal
health coverage means that all people and com-
munities can use the promotive, preventive,
curative, rehabilitative and palliative health
services they need, of sufficient quality to be ef-
fective, while also ensuring that the use of these
services does not expose the user to financial
hardship.
Was the main discussion in Astana not around
this – primary care as a step towards universal
health coverage?
Kloiber: Yes, definitely. In contrast to the
past, the WHO has brought primary care
into the global picture of universal health
coverage. Primary care is not an end in it-
self, not a cheap substitute for real health
care. Primary care is an important invest-
ment in building a real and efficient health
care system. Maybe the most important
part, alongside action on the Social Deter-
minants of Health. It should certainly be
the first step, but it cannot be the last if uni-
versal health coverage is the aim.
Apinis: Please tell me, how do you understand
universal health coverage and the difference be-
tween how financiers and bankers understand
it?
Kloiber: I cannot tell you how bankers and
financiers define universal health coverage
(UHC). Personally, I go with the WHO
definition. In brief, “UHC means that all
individuals and communities receive the
health services they need without suffer-
ing financial hardship.” If I may take off
my physician hat for a moment and argue
from an economic perspective, I would de-
fine investment in universal health cover-
age as an important investment into the
most productive part of any service-based
economy. In other words: in most service-
based economies the health care sector is by
far the biggest part: highest turn-over, most
jobs, great return on investment.
Apinis: Isn’t it true that politicians, finan-
ciers and bankers would prefer a low-educated
health worker who is able to measure blood
pressure, detect blood sugar and cholesterol lev-
els, and dress a wound, over a universal or spe-
cialised doctor educated for ten or more years at
great expense?
Kloiber: Do you know of any politician, fi-
nancier or banker who would prefer to be
treated by a community health worker in-
stead of a physician? Those who think ahead,
those who care for their people, will accept
community health workers in their auxiliary
roles, but only in their auxiliary roles. We
may all sometimes have to accept second best
solutions where physicians are not available,
but in the end I hope everyone would agree
that all people who need to be seen by a phy-
sician should be seen by a physician.
Apinis: To what extent are global financial
custodians and donors nowadays interested in
replacing doctors with health workers, espe-
cially in poorer countries?
Kloiber: Unfortunately, we are seeing the
same tendencies as after Alma-Ata. Again,
there seems to be a strong appetite for quick
fixes. There is not enough focus on sustain-
able development and long-term planning.
Apinis: Will the lessons from the Astana con-
ference not become a new incentive for doctors
to migrate from poorer countries to wealthier
ones?
Kloiber: Again, like with the Alma-Ata
Declaration, the Astana Declaration is not
the problem. It is what we make out of it.
Apinis: Could the Astana conference not be-
come a reason for inequalities among doctors in
terms of work and pay, even though it stated
the exact opposite?
Kloiber:There are leaders who believe medi-
cine is a technical service, who believe a con-
trol and command approach is all they need.
Well, as George Santayana said: “Those who
cannot remember the past are condemned to
repeat it.”This is such a case.If we don’t learn
to build good workplaces in health care and
decent living conditions in poor countries,
the drama will just continue
Apinis: What are the main ideas and actions
of the World Medical Association for univer-
sal health coverage and the global development
of primary health care? What new ideas is the
WMA preparing for the WMA Conference
on Universal Health Coverage in Tokyo this
June?
Kloiber: For us, the biggest insight of the
last two decades has been that without tak-
ing action on the social and environmental
determinants of health, anything else will
only produce second rate results. To this
extent I think we are in perfect sync with
WHO: that universal health coverage is
the number one priority in health systems
policy. We will do what we can to convince
people, politicians, economists and our col-
leagues to go with us on this.
Apinis: Dr Kloiber, thank you very much for
your time.
WMA Health Policy
BACK TO CONTENTS
16
Apinis: Mr. Eidelman! Half of your presi-
dency period has elapsed. Time goes by very
fast. You have represented the WMA at vari-
ous global conferences and events. What do you
consider to be the most important part of your
global activities?
Eidelman: As Ppresident of the WMA,
I stated that I would like to devote my ten-
ure towards evaluating future challenges
faced by physicians throughout the world
as well as promoting preparedness. Dur-
ing the first half of my presidency, in order
to represent the WMA and fulfil my mis-
sion, I took an active part in the following
conferences and meetings: Global Confer-
ence on Primary Health Care (October
25-26, 2018) in Astana, Kazakhstan; Ja-
pan Medical Association Ceremony and
Medical Congress, (November 1, 2018) in
Tokyo, Japan; WHO GCM/NCD Gen-
eral Meeting (November 5, 2018) in Ge-
neva, Switzerland; Unveiling Ceremony of
the German Medical Profession Marking
the Withdrawal of the Medical Licenses
of Jewish German Doctors (hosted by the
National Association of Statutory Health
Insurance Physicians) (November 8, 2018)
in Berlin, Germany; CPME General As-
sembly (November 9-10, 2018) in Geneva,
Switzerland; Swedish Medical Association
Annual Meeting (November 21-22, 2018)
in Stockholm, Sweden; UNESCO Chair
in Bioethics 13th
World Conference (No-
vember 27–29, 2018) in Jerusalem, Israel;
Universal Health Care International Con-
ference (December 1, 2018) Taipei,Taiwan;
International Conclave on Zero Tolerance
To Violence Against Doctors and Hospi-
tals (February 8-9, 2019) in Mumbai, India;
Meeting at the American Medical Associa-
tion Headquarters (February 18-20, 2019)
in Chicago, Illinois, and 12th
Geneva Con-
ference on Person-Centered Medicine,Pro-
moting Wellbeing and Overcoming Burn-
out (March 25-27, 2019).
Apinis: You participated at the conference in
Astana (now Norsultan) which focused on the
issues of primary care and universal coverage
in order to provide medical treatment to ev-
ery citizen of our planet. This WHO conference
was dedicated to the 40th
anniversary of the
AlmaAta Declaration. When it was endorsed
you were still in Riga – the WHO meeting was
held in Riga in 1986 and was dedicated to the
10th
anniversary of the AlmaAta declaration.
What are your impressions of the Astana con-
ference?
Eidelman: The goal of the meeting was to
renew a commitment to primary health care
to achieve universal health coverage and the
Sustainable Development Goals which
is part of the UN agenda for 2030. The
Conference was co-hosted by the Govern-
ment of Kazakhstan, WHO and UNICEF.
This was the second meeting on Primary
Healthcare, the first one was held 40 years
prior in Almaty, Kazakhstan, during which
the Declaration of Alma-Ata was endorsed.
Strengthening of primary health care
(PHC) is essential for Universal Health
Coverage (UHC) which is one the major
theme of WMA, particularly promoted by
Dr. Yokokura during his presidency the last
year.The role of physicians is crucial in PHC
from education to prevention and acute and
chronic care. High quality, evidence-based
PHC provided by a trained team led by a
physician is probably the best foundation of
future medicine. However during the meet-
ing,it was noticeable that many participants
didn’t think the PHC model should have
the physician at the helm of leadership.The
conference focused on other health care
providers, traditional (nurses, pharmacists
and social workers) and new ones (com-
munity health workers and healthcare as-
sistants).
Apinis: Universal coverage is a global theme
nowadays. You have already discussed this in
Taiwan and we are looking forward to the
Tokyo conference. In June, the World Medi-
cal Association (WMA) in Tokyo is hosting
the conference HEALTH PROFESSIONAL
MEETING (H20) 2019  – THE ROAD
TO UNIVERSAL HEALTH COVERAGE.
Could you comment on the evolving discussions
on universal coverage in Taiwan and Tokyo
and on the upcoming Tokyo conference?
Eidelman: Yes, I attended the confer-
ence Universal Health Care International
Conference in Taipei. The International
Symposium on Universal Health Cover-
age featured an interesting array of panels
including presentations on disease pre-
vention, end-of-life care and quantity and
quality of UHC. I had the opportunity
to meet Dr. Shih-Chung Chen, Taiwan’s
Interview with Leonid Eidelman, President of the World Medical
Association by WMJ Editor Peteris Apinis
Leonid Eidelman
WMA Health Policy
BACK TO CONTENTS
17
Minister of Health. Dr. David Barbe,
Past President of the AMA, and I were
on a joint panel moderated by Dr. Otmar
Kloiber. Dr. Barbe presented on Ensuring
Access to Healthcare in the United States
and I presented on Medical Education in a
Post-modern Era. We had fruitful discus-
sions with Dr. Tai-Yuan Chiu, President
of the Taiwan Medical Association, about
how Taiwan achieved UHC in a relatively
short period of time. Until approximately
20 years ago, Taiwan had limited health
care accessibility.
In addition, I also participated at a very im-
portant event in Japan – the Japan Medical
Association Ceremony and Medical Con-
gress. The JMA is one of the most active
members of the WMA.The meeting mark-
ing the JMA’s 71st
anniversary was attended
by many international guests and stressed
the involvement of JMA and support to
NMAs in Asia and throughout the world.
During the meeting UHC was a topic of
discussion as well as the role of the JMA in
the international healthcare arena.
I’m sure,that the Tokyo Health Professional
meeting (H20) results will be ambitious and
courageous. I hope that we (WMA) will be
heard after the Tokyo meeting by politicians
and financiers gathering at the G20 sum-
mit.
Apinis: Aggression and violence against doc-
tors and medical professionals grow in the
world. A conference on the issue was held in
Mumbai, India. What did you learn at this
conference and what did you emphasize on
violence against doctors as the WMA Presi-
dent?
Eidelman: Violence against doctors has in-
creased significantly in India. To this end,
the Indian Medical Association and the
World Medical Association came together
on February 8-9 in Mumbai to discuss the
issue of increasing violence against doctors.
According to the IMA, nearly 72% of In-
dian doctors have suffered physical or verbal
abuse in their career. During his remarks,
Dr. Otmar Kloiber gave an international
perspective. The speakers described causes
of violence and ways to withstand it; they
urged all doctors to report all forms of vio-
lence, big or small.
I presented the statement of the WMA
on violence against physicians and stressed
that this kind of violence not only has de-
structive social effect but impairs a quality
of healthcare that is provided to innocent
patients as well. In addition, I emphasized a
role of physician burnout in this intolerable
phenomenon.
Apinis: We know you as a person who has al-
ways been interested in the future of medicine,
about the direction it will develop. Do you have
enough time to work on this?
Eidelman: On the subject – the future of
medicine – I attended an event in Chicago
that was very important and instructive –
the Meeting at the American Medical
Association Headquarters. This two-day
meeting organized by Ms. Robin Menes
focused on the future of medicine and
trends. We discussed augmented intel-
ligence, environmental intelligence, what
physicians want to know about technology,
healthcare economy and what is on the ho-
rizon. There were many discussions about
the importance of NMAs learning from
one another in order to ensure prepared-
ness for the future.
Apinis: In Tel Aviv you are currently pre-
paring one of the most interesting conferences
ever held by the World Medical Association
PHYSICIAN­2030: THE FUTURE IS
AROUND THE CORNER  – BE PRE-
PARED. Please could you tell me about the
ideas and objectives of this conference?
Eidelman: During the half year period,
I allocated a great deal of time preparing the
WMA and IMA “Physician 2030” meeting
which will be held in Herzliya, Israel, May
13-15. The conference will serve as a plat-
form for discussions in multiple areas and
dimensions of physician activity that is ex-
pected to be a subject of significant change
in the near future and which require special
preparations by physicians and the health-
care system.
World-renowned speakers: the Nobel prize
winner Yisrael Aumann, Kira Radinsky
from eBay, Daniel Kraft from the Singular-
ity University along with representatives of
NMAs from Africa, Europe, Asia, North
and Latin America will address the issues
of the validity of models and predictors in
health system, healthcare models and medi-
cal workplace in 2030, patient-physician re-
lationship,medical education-how it should
be changed and technology- where it can
take us.
I call upon NMAs to participate at this
unique conference and contribute their
knowledge, aspirations and experience in
order to understand the future, which is just
around the corner, and ultimately improve
our preparedness.
Apinis: One of the topics of modern medicine
is the burnout in doctors. You discussed this is-
sue and reported on it at the Geneva conference.
Eidelman: This year the International
College of Person-centered Medicine
(­
ICPCM) convened the 12th
Geneva Con-
ference on Person-centered Medicine Pro-
moting Wellbeing and Overcoming Burnout
dedicated to physician burnout that is one
of the most acute challenges of the con-
temporary medicine and endangers physi-
cians as well as the quality of healthcare.
Shortage of physicians that aggravates in
most countries of the world will have a
negative effect on physician wellbeing and
the society at large. Much research has
been conducted on the crisis of burnout,
its causes and manifestations. Currently,
there is a need for studying preventive and
treatment solutions. The WMA statement
on physician wellbeing was a part of my
presentation. The ICPCM has decided to
WMA Health Policy
BACK TO CONTENTS
18
organize meetings on physician burnout
and wellbeing every year.
Apinis: Each year you organise a global con-
ference on medical ethics, and you are one of the
keynote speakers. Please tell me about the con-
ference in Jerusalem?
Eidelman: Physicians and leading health
professionals from around the globe attend-
ed the UNESCO Chair at the 13th
World
Conference on Bioethics in Jerusalem, Isra-
el. I had the privilege of delivering remarks
on behalf of the WMA.
There were over 100 parallel sessions with
more than 1000 participants from over
70 countries including a sizable contingent
of WMA members: Dr. Otmar Kloiber,
Secretary General of the World Medical
Association, Dr. Yokokura, President of the
Japan Medical Association, Yuji Noto, in-
ternational relations of the JMA, Dr. Selma
Güngör, Board member of the Turkish
Medical Association, Dr. Jacques de Haller,
outgoing president of the CPME (Standing
Committee of European Doctors), Annabel
Seebohm, Secretary General of the CPME,
Sarada Das, Deputy Secretary General of
the CPME, Thomas Hedmark, policy ana-
lyst at the Swedish Medical Association,
Professor Ravi Wankhedkar, President of
the Indian Medical Association, Dr. R.N.
Tandon, honorary Secretary General of
the Indian Medical Association, Profes-
sor Thomas Linden, Board member at the
Swedish Medical Association and Jeppe
Berggreen Høj from the Danish Medical
Association.
Apinis: Time goes by too fast. The best medi-
cal texts and documents become outdated not
within decades, but by years. Don’t you think
about auditing, reviewing and updating any
of the WMA declarations of vital role?
Eidelman: The WMA declarations primar-
ily focus on medical ethics and are revised
every decade. Unlike the rapidly changing
medical advancements, the issues, outlined
in the declarations, focus on existential
rights and our moral obligations as physi-
cians. These are long term and don’t change
with the same speed. Moreover, NMA’s are
invited to submit statements to the WMA
annually concerning current medical dilem-
mas, technology and developments.
Apinis: We are currently going to the WMA
Council Session in Santiago, Chile. What are
your priorities at this meeting? What documents
do you consider to be the priority? What will we
achieve with our discussions in Santiago?
Eidelman: During the meeting there will
be elections for new leadership including
the Council chair and Treasurer, both key
positions. I look forward to joining my col-
leagues in reviewing the plethora of state-
ments and promoting the WMA mission to
serve humanity by endeavouring to achieve
the highest international standards in Med-
ical Education, Medical Science, Medical
Art and Medical Ethics, and Health Care
for all people in the world.
Report of the President on Presidential Activities
October 2018 – April 2019
As president of the WMA, I stated that
I would like to devote my tenure towards
evaluating future challenges faced by physi-
cians throughout the world as well as pro-
moting preparedness. During the first half
of my presidency, in order to represent the
WMA and fulfil my mission, I took an ac-
tive part in the following conferences and
meetings.
Global Conference on Primary
Health Care, October 25-26,
2018; Astana, Kazakhstan:
The goal of the meeting was to renew a
commitment to primary health care to
achieve universal health coverage and the
Sustainable Development Goals which
is part of the UN’s agenda for 2030. The
Conference was co-hosted by the Govern-
ment of Kazakhstan, WHO and UNICEF.
This was the second meeting on Primary
Healthcare, the first one was held 40 years
prior in Almaty, Kazakhstan during which
the Declaration of Alma-Ata was endorsed.
Strengthening of primary health care
(PHC) is essential for Universal Health
Coverage (UHC) which is one the major
theme of WMA, particularly promoted by
Dr. Yokokura during his presidency the last
year.The role of physicians is crucial in PHC
from education to prevention and acute and
chronic care. High quality, evidence-based
PHC provided by a trained team leaded by
a physician is probably the best foundation
of future medicine. However during the
meeting, it was noticeable that many partic-
ipants didn’t think the PHC model should
have the physician at the helm of leadership.
The conference focused on other health care
providers, traditional (nurses, pharmacists
and social workers) and new ones (com-
munity health workers and healthcare as-
sistants).
Japan Medical Association
Ceremony and Medical Congress,
November 1, 2018; Tokyo, Japan
The JMA is one of the most active mem-
bers of the WMA. The meeting marking
WMA Health Policy
BACK TO CONTENTS
19
the JMA’s 71st
anniversary was attended by
many international guests and stressed the
involvement of JMA and support to NMAs
in Asia and throughout the world. During
the meeting UHC was a topic of discussion
as well as the role of the JMA in the inter-
national healthcare arena.
WHO GCM/NCD General
Meeting, November 5, 2018;
Geneva, Switzerland
The General Meeting of the Global Co-
ordination Mechanism on the Prevention
and Control of Noncommunicable Dis-
eases (GCM/NCD) provided an opportu-
nity to increase coordination of activities
among participants which were comprised
of NGOs, the UN and Governments. The
prevalence of NCD is one of the leading
challenges physicians currently face and can
increase in the future. I had the privilege of
participating in a plenary entitled “Collec-
tive leadership: Multisectoral engagement
and policy coherence as key enablers of ac-
tion to address NCD and their underlying
determinants”.
Unveiling Ceremony of the
German Medical Profession
Marking the Withdrawal of the
Medical Licenses of Jewish German
Doctors (hosted by the National
Association of Statutory Health
Insurance Physicians), November
8, 2018; Berlin, Germany
On November 8, 2018, the eve of Kristall-
nacht, the National Association of Statuto-
ry Health Insurance Physicians in Germany
organized an unveiling ceremony marking
the withdrawal of the medical licenses of
Jewish German doctors 80 years ago.
My remarks concentrated on physician’s
moral responsibility and made mention of
the WMA’s Declaration of Geneva,recently
updated due to the immense contribution
of the German Medical Association, which
states that physicians must never use their
medical knowledge to violate human rights
and civil liberties, even under threat.
CPME General Assembly, November
9-10, 2018; Geneva, Switzerland
The Standing Committee of European
Doctors (CPME) General Assembly and
Working Groups meetings took place on
November 9-10 2018, in Geneva. During
the Assembly Prof. Dr Frank Ulrich Mont-
gomery was elected president. There were
an array of working groups focusing on diet,
nutrition and physical activity, e-health,
healthcare for refugees and undocumented
migrants, pharmaceuticals and professional
practice. One of the central themes of the
conference was Healthcare in Danger. I de-
livered a presentation about Healthcare in
Conflict Settings which featured key state-
ments of the WMA and position papers
developed by NMAs. I stressed the impor-
tance of the physician’s professional obliga-
tion to the patient and the highest ethical
standards.
Swedish Medical Association
Annual Meeting, November 21-
22, 2018; Stockholm, Sweden
The SMA designed a special program for
international guests. One of the day’s high-
lights was a meeting at the Swedish Agency
for Health Technology Assessment. There
was a fruitful discussion led by Sophie
Verkö, the agency’s president, on global
solutions enabling the implementation of
evidence into evidence-informed policies
and practices within healthcare. At my stay
in Stockholm, it was important to learn
about how Swedish physicians tackle with
language limitations and cultural differ-
ences while taking care of the large number
of refugees during the last years. Dr. Heidi
Stensmyren was re-elected president of the
SMA.
UNESCO Chair in Bioethics 13th
World Conference, November
27-29, 2018; Jerusalem, Israel
Physicians and leading health professionals
from around the globe attended this con-
ference. I had the privilege of delivering re-
marks on behalf of the WMA.
There were over 100 parallel sessions with
more than 1000 participants from over 70
countries including a sizable contingency
of WMA members: Dr. Otmar Kloiber,
secretary-general of the World Medical
Association, Dr. Yokokura, president of the
Japan Medical Association, Yuji Noto, in-
ternational relations of the JMA, Dr. Sel-
ma Güngör, board member of the Turkish
Medical Association, Dr. Jacques de Haller,
outgoing president of the CPME (The
Standing Committee of European Doc-
tors). Annabel Seebohm, secretary-general
of the CPME, Sarada Das, deputy secre-
tary-general of the CPME, Thomas Hed-
mark,policy analyst at the Swedish Medical
Association, Professor Ravi Wankhedkar,
President of the Indian Medical Associa-
tion, Dr. R.N. Tandon, honorary secretary-
general of the Indian Medical Association,
Professor Thomas Linden, a board mem-
ber at the Swedish Medical Association
and Jeppe Berggreen Høj from the Danish
Medical Association.
Universal Health Care International
Conference, December 1,
2018; Taipei, Taiwan
The International Symposium on Univer-
sal Health Coverage featured an interest-
ing array of panels including presentations
on disease prevention, end-of-life care and
quantity and quality of UHC. I had the op-
portunity to meet Dr. Shih-Chung Chen,
Taiwan’s health minister. Dr. David Barbe,
the past-president of the AMA, and I were
on a joint panel moderated by Dr. Otmar
Kloiber. Dr. Barbe presented on Ensuring
Access to Healthcare in the United States
WMA Health Policy
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20
Interview with Miguel Roberto Jorge President-Elect of the World
Medical Association by WMJ Editor Peteris Apinis
Apinis: Presidents of the World Medical
Association represent countries of the entire
world. ALL of them are highly qualified
specialists in different fields. Xavier Deau
is a family doctor, Sir Michael Marmot –
a scientist in social determinants, Ketan
Desai  – urologist, Yoshitake Yokokura  – a
surgeon, Leonid Eidelman  – an anesthe-
siologist. You are a psychiatrist. Perhaps it
is time for the World Medical Association
to look at health care from a position of a
psychiatrist.
Jorge: I am sure that the WMA does not
take into consideration the speciality of its
and I presented on Medical Education in a
Post-modern Era. We had fruitful discus-
sions with Dr. Tai-Yuan Chiu, president of
the Taiwan Medical Association,about how
Taiwan achieved UHC in a relatively short
period of time.Until approximately 20 years
ago, Taiwan had limited health care acces-
sibility.
International Conclave on Zero
Tolerance To Violence Against
Doctors and Hospitals, February
8-9, 2019; Mumbai, India
Violence against doctors has increased sig-
nificantly in India. To this end, The Indian
Medical Association and the World Medi-
cal Association came together to discuss the
issue of increasing violence against doctors.
According to the IMA, nearly 72% of In-
dian doctors have suffered physical or verbal
abuse in their career. During his remarks,
Dr. Otmar Kloiber gave an international
perspective. The speakers described causes
of violence and ways to withstand it, they
urged all doctors to report all forms of vio-
lence, big or small.
I presented the statement of the WMA
on violence against physicians and stressed
that this kind of violence not only has de-
structive social effect but impairs a quality
of healthcare that is provided to innocent
patients as well. In addition, I emphasized a
role of physician burnout in this intolerable
phenomenon.
Meeting at the American Medical
Association Headquarters, February
18-20, 2019; Chicago, Illinois
This two-day meeting organized by Ms.
Robin Menes focused on the future of med-
icine and trends. We discussed augmented
intelligence, environmental intelligence,
what physicians want to know about tech-
nology, healthcare economy and what is on
the horizon. There were many discussions
about the importance of NMAs learning
from one another in order to ensure pre-
paredness for the future.
12th
Geneva Conference on Person-
Centred Medicine, Promoting
Wellbeing and Overcoming
Burnout, March 25-27, 2019
This year conference of The International
College of Person-centred Medicine (ICP-
CM) was dedicated to physician burnout
which is one of the most acute challenges of
the contemporary medicine and endangers
physicians as well as a quality of health-
care. Shortage of physicians that aggravates
in most countries of the world will have a
negative effect on physician wellbeing and
the society at large. Much research has
been conducted on the crisis of burnout, its
causes and manifestations. Currently, there
is a need for studying preventive and treat-
ment solutions. The WMA statement on
physician wellbeing was a part of my pre-
sentation. The ICPCM has decided to or-
ganize meetings on physician burnout and
wellbeing every year.
During the reported half year period, I al-
located a great deal of time preparing the
WMA and IMA “Physician 2030” meeting
which will be held in Herzliya, Israel, May
13-15. The conference will serve as a plat-
form for discussions in multiple areas and
dimensions of physicians’activity that is ex-
pected to be a subject of significant change
in the near future and which require special
preparations by physicians and the health-
care system.
World-renowned speakers: Nobel prize
winner Israel Aumann, Kira Radinsky from
Ebay, Daniel Kraft from the Singular-
ity University along with representatives of
NMAs from Africa, Europe, Asia, North
and Latin America will address the issues
of the validity of models and predictors in
health system, healthcare models and medi-
cal workplace in 2030, patient-physician re-
lationship,medical education-how it should
be changed and technology- where it can
take us.
I call upon NMAs to participate in this
unique conference and contribute their
knowledge, aspirations and experience in
order to understand the future, which is just
around the corner, and ultimately improve
our preparedness.
Leonid Eidelman, President of the
World Medical Association
WMA Health Policy
BACK TO CONTENTS
21
members when electing them as officers of
the Association, including for the position
of President. But, considering the speciali-
ties of our Presidents and other officers in
the last few years, it is possible to recog-
nize the diversity represented in the WMA
Executive Committee. This adds value to
the business conduct by the Association
and – in times when mental health prob-
lems increase significantly in all regions
of the world and are very frequent among
patients in primary care services  – I be-
lieve that being a psychiatrist allows me to
emphasize the need of general physicians
to attend carefully to their patients’ overall
needs.
Apinis: You have worked for global psychia-
trist organizations, such as the World Federa-
tion of Mental Health, the World Psychiatric
Association, you have been a member of the
World Health Organization Panel of Experts
on Psychiatry, Mental Health and Substance
Abuse. You have a great knowledge and experi-
ence. What’s going on in mental health glob-
ally?
Jorge:There are many different aspects to be
considered but, briefly, we can say that the
most important problems related to mental
health identified in different regions of the
world involve a high prevalence of mental
disorders (around 30% of people experi-
ence a mental disorder during their lives).
Mental disorders are a major contributor
to people’s disability (around 22% of total
disabilities are due to mental disorders).
There is an important treatment gap (more
than 50% of people with mental disorders
do not receive treatment). Moreover, child
and adolescent mental health problems are
not considered enough by health care sys-
tems,and the flourishing urbanization (now
around 54% of the world population lives
in towns) is a risk factor for a considerable
part of population to develop mental health
problems.
Apinis: The world’s population is ageing. Isn’t
the main psychiatric problem the increasing
age related dementia? What is your vision of
the role, opportunities and development of psy-
chiatry in a situation where 20% of the world
population will be old people with different
age-related brain problems?
Jorge: The epidemiological transition in
the world population started some time
ago and, with the growing increase of the
representation of older people, it affects the
health sector. Cognitive impairment and
even dementia is just one of the problems
that physicians face when treating patients.
In the mental area, depression in the elderly
is also an important issue to be taken into
consideration. And, in general, comorbid
diseases and over medication are serious
problems sometimes neglected in everyday
practice.
Apinis: More than half of the people affected
by mental health burden have common mental
disorders such as major depression, generalized
anxiety disorder, and substance use disorders.
These patients are not well cared for in general.
Is it possible to treat these patients only by a
psychiatrist alone? Primary care professionals
are involved in this process, too. Psychiatry is
not a priority of big specialized hospitals only.
Could you comment on global transforma-
tions in psychiatry? How does the integration
of Common Mental Disorders treatment take
place in primary care?
Jorge: We do not have enough psychiatrists
to treat people with a mental illness. And
there are many mental illnesses that can be
treated by general practitioners, family doc-
tors and other medical specialists. I believe
it is not the nature of the mental illness, but
mainly its severity that requires specialized
care. The most common mental illnesses
are depression and anxiety disorders and
usually non-psychiatrists can efficiently
manage most of them if they are aware of
mental health problems and have received
appropriate training. Unfortunately, men-
tal health is not yet given enough attention
in medical school curricula and physicians
who are specialists in a particular area of
medicine usually do not pay any or enough
attention to other health areas of their pa-
tients.
Apinis: Could you comment on stigmatisa-
tion in psychiatry? In my opinion, in the whole
world stigma is attached not only to sick pa-
tients, but also to psychiatry in general. Adverse
effects of medical treatment are caused by a low
level of knowledge regarding mental illnesses
and prejudice and discrimination against peo-
ple with a mental illness.
Jorge: Stigma and discrimination against
patients with mental illnesses is just “the
tip of the iceberg”. There are lots of evi-
dence that stigma also reaches patient
families, psychiatrists, psychiatric services
(particularly hospitals), psychiatric treat-
ments (e.g., use of psychiatric medication,
electroconvulsive therapy), some particular
mental illnesses (e.g., drug dependence,
schizophrenia) and even the occurrence of
self stigma. The result is that people suffer-
ing from a mental illness are double penal-
ized – by the illness itself and by the stigma
against them.Early diagnosis and interven-
tion is of importance to improve response
and prognosis, but stigma is an important
factor of long delays in seeking for mental
health care.
Miguel Roberto Jorge
WMA Health Policy
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22
Apinis: Prevention of mental diseases is a
global challenge. Is it important to develop
Prevention of Child Mental Health as part
of Mental Disorders globally? It seems there
is a great stigmatisation in this area. What do
you think about the necessity to review WMA
documents to draw doctors’ attention to the pre-
vention of mental diseases, especially to mental
disorders in children?
Jorge: Prevention of mental disorders and
child and adolescent mental health are two
priorities of today. Some of the problems
identified in the mental health arena for
adults are even greater when considering
the situation among children and adoles-
cents. Research has shown that experiences
build brain architecture and toxic stress de-
rails healthy development. Mental health
problems affect 10 to 20% of children and
adolescents worldwide and there is a need
to propose well developed strategies to take
care of our future adults.
Apinis: As WMA President you agreed to pro-
mote solving the needs of each physician and the
world’s most vulnerable people, to represent a
strong voice of physicians from low and middle
income countries. Could you describe what’s go-
ing on in psychiatry and health care in general
in the countries of Latin America and the Ca-
ribbean Region?
Jorge: There are many studies showing that
the prevalence rates of mental disorders are
even higher in low and middle income coun-
tries such as those located in Latin America
and the Caribbean. Besides facing greater
prevalence, access to care is more difficult
and there is a scarcity of mental health ser-
vices and professionals, in addition to their
uneven distribution.The work conditions of
physicians represent a challenge for provid-
ing sometimes minimal care and, moreover,
a good quality medical care. In those coun-
tries, there are isles of excellence in terms of
the care provided to those who can pay by
themselves for good medical services. This
situation is not the same found in high in-
come countries but even there it is possible
to observe differences in services provided
to people in better or worse socio-economic
conditions.
Apinis: You come from São Paulo, a city
where eight times more people than in my
country live. Is overpopulation, the over-
crowding in cities a reason for increasing
mental health problems, too? What do you
think about mental health problems in the
world’s megalopolis?
Jorge: There are data from the United
Nations informing that the world had
28  megacities (those with more than
10 million inhabitants) in 2015.Many other
studies show that mental health problems
are more common in urban than in rural
areas, and there are many factors related to
urbanism that contribute to the difference.
One of the most important ones is trauma
experienced particularly through different
forms of violence when associated with sig-
nificant social inequalities and being part of
a minority group. Other factors that deserve
to be mentioned are a competitive environ-
ment and individual loneliness.
Apinis: There is mass migration in the world.
Travelling from one country to another, from
one continent to another usually causes over-
crowding, stress, depression, ignorance. What is
your view on how to take care of mental health
issues among refugees and migrants? But is it
a problem at all, maybe it is a myth created in
social networks?
There are some aspects related to be a refu-
gee and/or a migrant that can be a risk fac-
tor to develop mental illnesses such as to be
part of a minority group, to live in a diverse
cultural environment, to be deprived of
basic human needs (decent housing, food,
work, health care access) and to suffer stig-
ma and discrimination among other factors.
So, refugees and/or migrants are considered
a particularly vulnerable population to de-
velop mental illnesses and unfortunately
this is a reality in our world of fake news.
No myth concerning this fact.
Apinis: I promised to ask you not more than
ten questions. I know you’re not only a psy-
chiatrist, but also a psychotherapist. In which
direction does the world go: psychotherapy or
medical treatment?
Jorge: As my training as a medical student
and a psychiatrist was mostly between 1975
and 1986 in Brazil, at that time it was not
conceivable to separate those approaches.
Our patients, with a mental illness or any
other illnesses, need to be treated by physi-
cians that take into consideration the bio-
logic nature of their illnesses, their person-
ality characteristics and emotional impact of
the illness they present,and also their family
and social environment. We know that all
those aspects are of importance in plan-
ning, discussing different alternatives and
adopting treatments. Without an excellent
doctor-patient/family relationship no treat-
ment will work well enough. And I do not
think that be a medical doctor is just a mat-
ter of prescribing a medication even when
for some particular illness the medication
will be crucial to the desired outcome. That
is the way I work in my private practice and
what I will emphasize during my presidency
term.
WMA Health Policy
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23
Apinis: You have chaired the WMA Coun-
cil since 2015 and were the most influential
doctor in our global organization. You were
named one of Top 25 Women in Healthcare
of the World, in addition to its list of the 100
Most Influential People in Healthcare, and its
50 Most Influential Physician Executives and
Leaders. Whatever you do, it is accompanied
with smile and optimism. What makes you so
positive?
Hoven: I have had the opportunity over
many years to work with a variety of or-
ganizations and in doing so, I recognized
the value of a team and collaborative ef-
forts. As a leader when you recognize that
seated around the table are your partners
and colleagues, it makes being positive
and supportive so much easier. Building
trust and sharing values are equally im-
portant.
Apinis: In your time, the Council meetings
and the General Assembly have been held in
Oslo (Norway), Moscow (Russia), Buenos
Aires (Argentina), Taipei (Taiwan), Living-
stone (Zambia), Chicago (USA), Riga (Lat-
via), Reykjavik (Iceland). Very different cities,
different countries, different continents. Are the
WMA statements, settings and policies affected
by the continent and country we come together?
Hoven: Perhaps by a small amount, but
overall I would say that they represent all
who attend and are seated at the table. It
is the job of leadership to make sure that
all voices are heard, and that the minority
opinion is recognized and valued.
Apinis: Under your leadership, the Council
meetings and the General Assemblies became
shorter and more specific. The discussions were
more geared to working groups and commis-
sions. Consequently, at major events, people
worked quickly and constructively. Is that at
the basis of your leadership?
Hoven: I have tried throughout my years in
leadership to learn from mentors and un-
derstanding “best practices”. Small groups
are definitely better than large ones when
attempting to come to consensus and de-
termining a policy or statement for debate.
Apinis: The leaders of the national medical
associations are leaders because they are ambi-
tious, charismatic and energetic. At the WMA
Council meetings, the global leaders sit friendly
and in good humor at the table. How did you
make a team out of these brilliant leaders? Isn’t
it the way the conductor runs an all-star or-
chestra?
Hoven: Doing our work well at the Coun-
cil meetings and those of the General As-
sembly, requires all at the table to know that
what they say is important and respected.
No one’s voice should be diminished.I think
because of this, individuals feel more com-
fortable. By the way, a bit of humour goes a
long way in easing any tensions that might
develop around the table.
Apinis: Is it true that the chairperson of the
WMA Council has a key job on the phone or
at Internet conferences because all Board mem-
bers need to reconcile the nuances in documents
and strategies? How many hours a day did you
have to talk to world medical leaders?
Hoven: Yes, the role of Chair of Council
requires making important phone calls and
communicating on a regular basis with the
members of the Executive Committee and
any other groups as needed. I honestly have
not kept track of the time spent.
Apinis: The main issues of the Council are
nevertheless dealt with by the Committees.
Could you describe the leaders and performance
of the Medical Ethics Committee, Finance and
Planning Committee, Socio-Medical Affairs
Committee?
Hoven:(I am not quite sure about this ques-
tion). During my tenure as Chair, I  have
been very fortunate to have had elected
chairs of the committees who are commit-
ted to high quality work, strong leadership
skills, and the willingness to work on behalf
of WMA. As we have seen during recent
sessions, when the work of the Committee
is done well,it makes the work of the Coun-
cil so much easier and efficient.
Apinis: What are the main WMA documents
adopted under your leadership, and of which
are you proud to have adopted?
Hoven: I am going to have to go back and
review a lot of materials on this one. Several
Declarations in particular come to mind.
I will need to get back to you on this.
Interview with Ardis D. Hoven WMA Chairperson of Council
American Medical Association by WMJ Editor Peteris Apinis
Ardis D. Hoven
WMA Health Policy
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24
Apinis: Elections to the European Parliament
are approaching. The new Parliament will face
serious challenges in different areas, and we are
interested in issues related to public health, a
healthy environment, social determinants and
medicine, particularly in universal coverage
and access to medicine. How will CPME try
to ensure that these issues are always on the
agenda of the European Union?
Montgomery: Health in all policies is a
fundamental demand of CPME in the
work of the European Commission, the
EU Parliament and the Council of Member
States. We hope that the next Commission
will be more interested in the wellbeing of
citizens and good health than in industry
and commerce and we will constantly re-
mind the three large players of European
politics of their obligations and responsi-
bilities in these subjects.
Apinis: There is a lack of clarity in Europe on
the relationship between the United Kingdom
and the European Union after Brexit. Could
you comment on what the European Union
expects with restricting doctor mobility and, to
a large extent, narrowing of cooperation? Are
there opportunities to minimise Brexit’s nega-
tive impact on the health of European patients
and the work of medical professionals? Will
CPME make concrete proposals to the Euro-
pean Parliament on post-Brexit medical de-
velopment, including receiving of cross-border
medical services on the island of Ireland?
Montgomery: “British medicine is Europe-
an medicine” – This is the core message of
CPME on Brexit.At present nobody knows
what the exact results of Brexit will be but it
certainly demands changes in legislation on
both sides of the Channel. It is obvious that
we are fighting for maintaining free mobil-
ity of health care professionals. But there is
more to Brexit: Shortages of drugs both in
mainland Europe and the UK can be fore-
seen, liability questions arise when licenses
from the UK are no longer valid in Europe.
All this has to be dealt with and CPME is
prepared to take over responsibilities.
Interview with Frank Ulrich Montgomery Vice-Chairperson of
Council of WMA by WMJ Editor Peteris Apinis
Frank Ulrich Montgomery
Apinis: During these four years you had to
work with six WMA presidents: Xavier Deau
(France), Sir Michael Marmot (UK), Ketan
Desai (India), Yoshitake Yokokura (Japan),
Leonid Eidelman (Israel), Miguel R. Jorge
(Brasil). They all are great doctors. Could you
describe each of them and their contribution to
the world community of doctors?
Hoven: All of these gentlemen, during
their years of service have represented the
WMA well. Although they may have dif-
ferent styles of leadership, each one was
able to project their ideas and concerns gra-
ciously and knowledgably to those listen-
ing to them. I learned that they each have a
special side to them be it a sense of humour,
gentleness, charisma, or a passion in life and
health care that brought them to the WMA.
Apinis: Opportunities to familiarise them-
selves with culture, medicine and nature of dif-
ferent countries of the world, tours and parties
play an important role in all General Assem-
blies, Council meetings and conferences. What
do you remember most about our events?
Hoven: The opportunity to travel around
the world, and see amazing sites along with
having the opportunity to experience new
cultures, environments, and food has been
extraordinary. Perhaps what I have learned
the most, is that no matter where I have
travelled, the people of that country have
been wonderful and kind. Each country
has demonstrated great pride and we all
have been the recipients of graciousness and
kindness. I particularly am fond of learning
more about the culture and art of a country
and in my travels,I have learned a great deal.
It has been an extraordinary experience.
Apinis: The achievements and success of WMA
are also based on the precise and qualitative
work of the Secretary General and the Secre-
tariat. Could you comment on the role of the
Secretariat and your cooperation with the Sec-
retariat?
Hoven: Words cannot adequately express
my appreciation to Dr. Kloiber and the Sec-
retariat for all that they have accomplished
over the past four years. Guidance, encour-
agement and education have always been
plentiful and so valued. The WMA is very
fortunate to have individuals so committed
to the work of the WMA and working dili-
gently to make all of us look good!
WMA Health Policy
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25
Apinis: How could CPME at European level
influence vaccination attitudes, increase vac-
cine coverage, strengthen immunisation pro-
grammes while reducing unnecessary antibiotic
use in Europe and active action against anti-
microbial resistance?
Montgomery: Vaccination needs informa-
tion and awareness. It is sad that not only
the public but even European legislators are
badly informed on the values of vaccina-
tions. And AMR is another subject where
information is pivotal. Not only do we talk
to the other health care professions but
we also accompany campaigns by the G7-
States and the EU.
Apinis: How can we increase the safety of Eu-
ropean patient data while allowing these data
to be used for medical science and pharmaceuti-
cal development? What perspective do you see
in introducing personalized medicine that re-
lies heavily on patient genome data and large
amounts of data processing?
Montgomery: Though difficult to handle
on an individual level, the General Data
Protection Regulation (GDPR) guarantees
a high level of data-security. In the context
of co-creation of health, personalized medi-
cine relies on the information and consent
of patients and data processing must not
end up in “data mining”. CPME and its
Executive Council closely cover the devel-
opment in the European arena and keep
close watch not only on legislators but also
on member states – in the best interest of
patients and physicians.
Apinis: Globally, the main issue of the planet’s
future existence is climate control. The Europe-
an Parliament has done much to make Europe
significantly reduce greenhouse gas emissions.
We hope and believe that the next European
Parliament will be even more active in this
area. However, the turnout of Parliament is
influenced by stakeholders and in the field of
controlling and reducing climate change doc-
tors’ opinion has a very large role to play. What
will the CPME policy be, in cooperation with
the new EU leadership and Commissions, spe-
cifically in the field of climate control?
Montgomery: Climate control is an obliga-
tion of all citizens – not of physicians and
their organizations alone.Within this range
CPME takes part in international activities
to reduce greenhouse gases and enhance cli-
mate control.
Apinis: What are the main CPME priorities
concerning prevention? Can we achieve that
the provision that is already in force in some
European countries is incorporated in EU leg-
islation, namely that use of tobacco products
in the presence of children is violence against
children? And the fact that non-smokers have
a right to clean air and that right is always a
priority over a smoker’s right to smoke close to
others?
Montgomery: CPME stands for a strong
anti-smoking policy. We need a strict ban
on tobacco advertisements and we fight for
protection of children. It is absurd that in
some countries the taxes levied on tobacco
and alcohol by far exceed the investments in
prevention.
Apinis: How can we affect the European
Union to promote healthy living across Europe,
reduce alcohol consumption, take care of healthy
diets and increase sporting activities for every
European citizen?
Montgomery: Alcohol and food labelling
are important aspects of providing infor-
mation to citizens. But the “health in all
policies” strategy entails more than that.
Healthy living has to become part of all in-
dustrial relations, of city planning and the
development of industry.
Apinis: Education of future physicians is an
important topic for Europe. The Professional
Qualifications Directive (PQR) was a mile-
stone on the implementation of a common
training regime in Europe.What is the CPME
position on the PQR?
Montgomery: CPME has always been
heavily involved in all issues of basic profes-
sional training and specialization of physi-
cians. We are deeply concerned about the
introduction of new training schemes by
private institutions that have a clear finan-
cial interest. Medical training courses on an
IT basis are an important tool to achieve
basic knowledge but a medical training
course has to contain large quantities of
practical training. It has to be on a scientific
basis delivered by a university and it has to
contain at least 5500 training hours in five
years to comply with the PQR.
Apinis: Everyone talks of digitization. What
is the CPME position?
Montgomery: Digitization of medicine is
one of the most important topics of the fu-
ture. But it must be seen as a tool to assist
physicians and patients in the co-creation
process of health.We not only have to defend
the rights of patients but also of physicians to
data security and we have to fight data cor-
ruption. But we must also be open to new
technologies that are designed to help us!
WMA Health Policy
BACK TO CONTENTS
26
CPME Health Policy
The Standing Committee of Europe-
an Doctors (CPME) has launched its
Health Check 2019 ahead of the upcoming
European elections. The European doctors
call on EU decision-makers to: put health
high on the EU agenda, support skilled
doctors and safe conditions, enable healthy
living, invest in health security, foster trust
in the sharing of health data and guarantee
access to medicines.
Future of Health
The CPME Health Check 2019 puts
emphasis on the future of health. Although
the need to respect budgetary restraints is
recognised, it is equally important to as-
sess the impact that any budgetary plan
may have upon health policy. Health is an
essential element of the European social
model and contributes to social cohesion,
inclusive growth and nurtures a sound eco-
nomic environment which is a prerequisite
for investment.
The future newly-elected European Parlia-
ment and European Commission will have
the power to make concrete contributions
to the creation of a healthier European
Union and to keep health policy on the EU
agenda. Therefore, CPME considers it es-
sential that the political groups within the
European Parliament, national representa-
tives in EU Member States and the new
Commission commit to health priority on
their working agenda.
Skilled doctors, safe conditions
Ensuring the best possible conditions for
doctors’ education and professional prac-
tice remains a priority of CPME. There-
fore, the European medical community asks
that safe and attractive working conditions
for doctors be ensured across Europe, even
more so with Brexit changing the paradigm
of medical migration and education and
training. Brexit will bring many changes
within the EU membership and within
EU institutions. For the European medical
profession, the impact of Brexit on mobility
is a great concern. Doctor mobility in fact
takes many forms: students cross borders
to attend medical schools in other Member
States, junior doctors seek specialist train-
ing in another country, and professionals
take the chance to develop their capacities
by accepting posts abroad, be it temporary
or long-term. European doctors will there-
fore continue to advocate for a solution
that safeguards quality of care and a con-
tinued knowledge transfer in the profession
throughout Europe.
Invest in health security
The health status of the population faces
challenges which cannot be contained
without coordinated and systematic action,
often within a very short timeframe. This
is the case for the spread of antimicrobial
resistance (AMR) and vaccine hesitancy.
Therefore, European doctors ask for con-
stant efforts to tackle AMR and to increase
vaccination coverage. Resistance to antibi-
otics is progressing at a rapid pace and old,
vaccine-preventable diseases are reappear-
ing. Since these threats may cross national
borders, collaboration between Member
States and allocation of resources at Eu-
ropean level to raise awareness are crucial.
Policies must strengthen doctors and other
health professionals in playing an active role
in the fight against AMR and vaccine hesi-
tancy
CPME thanks you for your support of the
Health Check 2019 and the work of CPME
towards a safer and better Europe for all its
citizens.
Miriam Beatrice Vita D’Ambrosio
Communication and Project Officer
Standing Committee of European Doctors
European Doctors Towards the
European Elections 2019
Miriam Beatrice Vita D’Ambrosio
BACK TO CONTENTS
27
Regional Medical Affairs
Apinis: In 2019 the Southeast European
Medical Forum (SEEMF) organizes its Tenth
Anniversary International Medical Congress.
SEEMF’s congresses take place in different
Eastern European countries every year. This
year, the Congress will take place in Sofia, Bul-
garia. What are the main goals of the events?
What are the main topics of this year’s Con-
gress?
Kehayov: The main objectives of SEEMF
are to promote partnership between the
medical associations of the member coun-
tries; to discuss common problems in the
healthcare systems in the southeastern part
of the European continent; to exchange
experience in and develop common ap-
proaches towards all fields and activities
of the medical organizations; to promote
continuous medical education; to assist
its members in improving their medical
and managerial qualifications and skills;
to establish contacts and partnership with
other international medical organizations.
The scientific program of the Tenth An-
niversary Medical Congress of SEEMF is
comprised of variety of topics and will host
the attendance of leading lecturers, promi-
nent representatives of medical academia
with recognized academic and practical
competence.
• Aging of the population;
• Cardiovascular diseases and cardiovascular
surgery. Transplantations;
• Gastroenterology. Transplantations;
• Neurology, neurosurgery and psychiatry;
• Nephrology and urology. Transplanta-
tions;
• Sexual medicine and reproductive health;
• Orthopedics and traumatology. Calamity
medicine;
• Pharmacotherapy;
• VARIA.
We hope that during the round table dis-
cussion on the topic “Challenges in the
Healthcare Systems- 21st
Century. Values
and Principles” participants will have the
chance to share their views on and aspires
towards the present and the future of the
global healthcare. The Congress has al-
ready received the support of the Bulgar-
ian authorities and the World Medical
Association. The President of WMA- Dr.
Leonid Eidelman has already confirmed
his participation. As usual, the Con-
gress will apply for European Accredi-
tation Council for Continuous Medical
Education(EACCME) accreditation. The
social program of the event will be com-
prised of several tours- one around Sofia-
the capital of Bulgaria; to the Rila Monas-
tery- a historic Christian monument and a
visit to the Cultural Capital of Europe for
2019 – Plovdiv, the city with a thousand
year old history. I would like to use the op-
portunity to appeal to all the members of
the WMA and the readers of the World
Medicine Journal and cordially invite all of
you to attend the 10th
Anniversary Inter-
national Medical Congress of the SEEMF.
All information about the event  – regis-
tration and hotel accommodation is avail-
able on the website of the organization:
www.seemfcongress.com.
Apinis: At present, 18 countries (20 medical
organizations) are members of SEEMF’s so-
ciety – Albania, Azerbaijan, Belarus, Bosnia
and Herzegovina, the Medical Associations of
Bosnia and Herzegovina and Republika Srp-
ska, Bulgaria, the Czech Republic, Georgia,
Greece, Kazakhstan, Russia, Northern Mace-
donia and Montenegro, Slovenia, Ukraine,
Uzbekistan, Serbia, Moldova, Croatia, the
European Medical Student Organization.
Does SEEMF continue to extend? Do you
think that doctors from other countries will
join your organization?
Kehayov: Southeast European Medi-
cal Forum (SEEMF) was found in 2005
by the medical organizations of 4 Balkan
countries – Albania, Bulgaria, Greece and
the Republic of Northern Macedonia as an
association of doctors’ organizations from
Southeastern Europe- neighbouring coun-
tries with similar problems.Today, SEEMF
is one of the rapidly developing organiza-
tions that unites 20 medical associations.
Last year, during the Board Meeting held
amidst the Ninth International Medi-
cal Congress of SEEMF, we approved the
applications for membership from Rus-
sia, Croatia and Montenegro- our newest
member countries. As you can see every
year, the membership base of the organiza-
tion is enriched with new medical experi-
ence in the face of its new members. From
4 founders of the organization, we became
20. SEEMF is expanding naturally as a re-
sult of its mission and causes, which are also
part of the causes and missions of the world
medical organizations.
Apinis:Throughout the years, SEEMF’s Con-
gresses have been held in countries with politi-
cally unstable situations, an example of which
is the Congress in Odessa, Ukraine, at a time
when the military conflict in East Ukraine
10 Questions for SEEMF’s President,
prof. Andrey Kehayov, MD
Andrey Kehayov
BULGARIA
BACK TO CONTENTS
28
Regional Medical Affairs
took place. Does SEEMF thus show a political
standing?
Kehayov: SEEMF is an independent orga-
nization of physicians and is not under any
political ward. Our congresses are interdis-
ciplinary events. We are not only interested
in scientific and practical achievements in
medicine, but also in the organizational
structures of the healthcare systems of our
members. We outline the real labour mar-
ket; the problems of financial and human
resources and aim to provide guidance for
rational solutions. Before the institutions
that are involved in shaping the health
policies and before the society, we form
our unequivocal and prominent physicians’
position in order to find the adequate bal-
ance to change the system.These are the real
challenges of the time we live in. Through
brainstorming together,we raise our experts’
and specialists’ platforms and display them
before the various national and internation-
al institutions.
Apinis: The Board meetings of SEEMF are
often held on The Island of Kos, Greece, where
Hippocrates was born. Does this historical ref-
erence serve the philosophy of your organiza-
tion?
Kehayov: In accordance with SEEMF’s
Statute, SEEMF organizes at least two
board meetings annually.The board consists
of 30 individuals, most of whom are heads
of the medical associations of the member
states and prominent representatives of the
medical and academic society. The Board
meetings are held in different countries,
and this year for a second time we have de-
cided to hold our meeting in Kos, Greece –
The homeland of the “Father” of modern
medicine  – Hippocrates. The mission of
SEEMF, as an organization of physicians
from different countries, is to transform
moral-ethical behaviour and norms that
distinguish the medical profession from all
other professions as a leading one. Parallel
to the Board meeting, we have organized an
event with the title “International Confer-
ence on Medical Ethics and Moral. Oath of
Hippocrates – Symbol of Medicine”. Well-
known lecturers will present various moral
and ethical models, practices and standards
in medicine.
Apinis: Most of the countries, represented in
SEEMF, are former post-soviet or post-social-
ist states. Is it not the debate in your Congress
on the transition from socialistic medicine to
European medicine?
Kehayov: The discussions that participants
in SEEMF’s congresses hold are mainly
related to the socially significant diseases
and their prevention. However, the prima-
ry mission of the doctors and the medical
specialists is to take care of the health of
their patients and it has nothing in com-
mon with the country we come from or
live in. SEEMF’s congresses are multidis-
ciplinary universities and one of our main
goals is to improve participants’knowledge
and professional qualifications with the
latest theoretical and practical achieve-
ments of the global medicine. Implement-
ing the established European and global
medical standards and practices with a fo-
cus on what quality medical care really is,
we endeavour towards the improvement of
the healthcare systems in the countries of
the region.
Apinis: A regular topic during SEEMF’s
Congresses is the one about the migration of
doctors and medical professionals. Doctors tend
to go work in richer European countries and for
better wages.
Kehayov: The Migration of the medical
professionals in the European region has
been observed since the 1940s. After the
accession of Bulgaria to the EU, the most
active amongst the “migrants” became the
medical specialists with qualifications and
diplomas that are recognised by member
states of the EU.We witness a trend of gen-
eral migration – Bulgarian doctors migrate,
but specialists from other countries come to
Bulgaria.This process is two-sided.
Apinis: Medical tourism plays an increasingly
important role in EasternEurope. To what
extent are Bulgaria and the Balkan countries
updating medical tourism?
Kehayov: Due to its enormous natural
resources Bulgaria has posed a serious re-
quest to become one of the biggest health
centers in Europe. Using its endowments
and intellectual resources, as well as the
hundreds of mineral water springs, heal-
ing climate, organic farming and services
promoting a healthy lifestyle; cultural,
wine, seaside and mountain tourism Bul-
garia is turning into a competitive destina-
tion for a quality tourism. Bulgaria ranks
first in Europe according to the availability
and diversity of mineral water and spa re-
sorts. The Ministry of Tourism in Bulgaria
encourages development of medical and
health tourism and provides legislative
changes to adapt it in accordance with the
European standards and European market
requirements through implementation of
innovative practices and quality improving
strategies.
Apinis: SEEMF is a WMA associate member.
How would you describe the collaboration with
WMA?
Kehayov: The World Medical Associa-
tion is a constant supporter of the activi-
ties and the missions of SEEMF. SEEMF
shares strongly WMA’s goals, values ​​
and
standards. As President of SEEMF, I have
the honour and pleasure to participate in
the annual meetings of WMA- the Gen-
eral Assemblies and Council Sessions.
Many of the declarations and suggestions
proposed by our organization on differ-
ent issues, an example of which are the
ones on climate change and reduction of
emissions in the Mediterranean Sea, were
accepted by the WMA and noted by the
World Medical Journal. What greater rec-
ognition than the participation of several
WMA’s Presidents in the Congresses of
SEEMF? I would like to use the opportu-
nity to thank Dr. Otmar Kloiber – WMA
BULGARIA
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29
Regional Medical Affairs
Secretary General for his incredible moral
support and acknowledgment of SEEMF
throughout all the years.
Apinis: The next WMA General Assembly
will take place in one of SEEMF’s mem-
ber countries-Georgia. You organised one of
SEEMF’s congresses in Georgia with the aim
of investigating the extent to which Georgia is
prepared for very large medical congresses and
events. What is your impression of the Geor-
gian hospitality?
Kehayov: In 2016, in cooperation with the
Georgian Medical Association we con-
ducted the Seventh International Medical
Congress of SEEMF in Batumi, Georgia.
Georgia acquitted our expectations! The
President of the Georgian Medical Asso-
ciation – Prof. Gia Lobzhanidze, professor
in surgery at the University of Tbilisi – is
also one of the Vice President of SEEMF.
Thanks to his exceptional personal and or-
ganizational potential and with the active
support of the members of the Georgian
Medical Association,SEEMF’s Congress in
Georgia was a significant event with partic-
ipants from 20 countries. Georgia proved to
Europe and the World its scientific,medical
potential and incredible skills in conducting
large-scale international events. The gener-
ous Georgian hospitality combined with
the mixture of ancient cultural monuments
and wonderful nature turned the Congress
days into an impressive collection of shared
practices, thoughts and friendship.
Apinis: One of the subjects you teach as a pro-
fessor in a medical university in Bulgaria is
ethics. What are the challenges of medical ethics
in Bulgaria?
Kehayov: I am an Associated Professor in
the Medical University of Sofia, faculty of
Public health,”Health policy and manage-
ment Department”. As a former Presi-
dent of the Bulgarian Medical Association
(2009-2012), and as a member of the ethi-
cal Commission and university professor,
I worked and continue to work in the field
of medical ethics and moral. If we look at
the vision of ethics in public health, in our
country we witness the same problems that
effect the ethical values in most countries,
namely: with reference to availability, fair-
ness, timeliness and quality of healthcare.
If we take a look in particular at the chal-
lenges facing medical and clinical ethics,
I believe that the informed consent is es-
sential. The form, which the patients sign
expresses their “consent” only. In practice,
the process of communication that leads to
an informed consent, is missing, or is too
limited. The Autonomous model predicts
that the patient receives full and accessible
information about his disease, diagnostic
and therapeutic activities, as well as the
prognosis of his illness.This is not necessar-
ily the case in every situation,but is possible.
However,patients are increasingly informed
and empowered, seeking their rights, and
the physicians’ responsibility is to recog-
nize the necessity of the informed consent,
which is a legitimate mode to protect not
only the patient, but the physician as well.
Otherwise, we witness tension and growing
distrust towards the profession. The prob-
lems of patients with disabilities who need
additional care and more attention have also
become widely known. Of course, the issues
of confidentiality are also relevant; assisted
reproduction- especially against the back-
ground of the demographic crisis in which
our country currently is; donation and
transplantation; clinical trials and medical
tourism; ethical issues related to death, in-
cluding assisted suicide.
Georgian Medical Association
Turns 30 years old
The General Assembly (GA) will be held
in Tbilisi, Georgia, in October 2019. This
is one of the most strikingly original cities
in the world, founded in the 5th
century by
King Vakhtang I Gorgasali.
A legend tells us that once the King hunted
in the forests near Mtskheta, the first capital
of Georgia.After some time,he saw a pheas-
ant, shot and killed the bird. The King sent
his falcon to find the prey. The falcon flew
away, and after a while, the king lost sight of
him. In search of the birds, Vakhtang Gor-
gasali with his hunters came upon a spring
and saw that both the falcon and the pheas-
ant had got into its waters which turned out
to be hot.Amazed by this findVakhtang I de-
cided to found there a city realizing the great
advantages of the location.In addition to the
hot spring, the location had many important
other factors for building a city: a protected
position between the mountains, location on
a trade route, strategically favorable factors.
Thus, according to the legend, the city of
Tbilisi was founded. The word “tbili” trans-
lated from Georgian means “warm”.
GEORGIA
Gia Lobzhanidze
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30
Regional Medical Affairs
Historically, Tbilisi has been home to peo-
ple of multiple cultural, ethnic, and religious
backgrounds, though currently it is over-
whelmingly an Eastern Orthodox Chris-
tian country. Georgia is the educational and
transportation hub for the Caucasus region.
It has a unique cultural national heritage:
songs, dances, foods and wine. Wine has
been produced in the country over 8000
years. Georgia’s traditional winemaking
method of fermenting grapes in earthen-
ware, egg-shaped vessels “Qvevri” has been
added to the UNESCO World Heritage list.
For Georgians “the guest is a gift from god”.
Georgia is an enjoyable and spectacular
country. It is a country where many hospi-
table and generous people live. The word for
Georgian meal is supra, which is best trans-
lated as “feast”.
The Georgian language and alphabet are
included in the UNESCO’s Intangible
Cultural Heritage List and UNESCO ac-
knowledged Georgian polyphonic music as
“a masterpiece of the world’s cultural heri-
tage”.
Autumn is the velvet season in Georgia
when weather is still pleasant. Temperature
range is between 18-23°C (64-73°F).
The hotel Sheraton Grand Tbilisi Metechi
Palace will host the GA. There will be a
city tour for the accompanying persons on
24  october to old Tbilisi and the classi-
cal half-day tour for all the participants is
scheduled on 25 October to Mtskheta, one
of the oldest cities of Georgia, located ap-
proximately 20 kilometers (12 miles) north
of Tbilisi.
After the tour, dinner will be served in
Mtskheta. The guests will be able to taste
Georgian traditional cuisine.
Organizational Committee of Georgian
Medical Association from 1988 worked
with Rustaveli Association of Georgia.
From November of 1988, the mentioned
organizational committee separated from
Rustaveli Association and began indepen-
dent functioning. Committee unified as de-
served doctors,so pedagogues,scientists- so,
young apolitical generation.
Georgian Medical Association (GMA) was
officially founded on May 05, 1989 on the
first meeting, it is the first non-governmen-
tal professional organization in Georgia
which was registered in the Ministry of Jus-
tice of Georgia. GMA:
• From 1995 is the member of European
Forum of Medical Associations and
World Health Organization (EFMA/
WHO);
• From October 2002 is member of World
Medical Association (WMA)
• From 2011 is the member of South-East
European Medical Forum (SEEMF).
• From 2015 is the observer of European
Permanent Committee (CPME).
GMA unifies more than 90 professional as-
sociations acting in Georgia and cooperates
with multiple organizations and funds as
inside the country, so abroad.
Georgian Medical Association (GMA) is
an independent, professional union of doc-
tors founded for supporting professional
and personal needs of doctors working in
Georgia; it unifies doctors of all spheres of
medicine within the whole country; it is
voice of doctors-professionals and medi-
cal students before official health struc-
tures and administrations of the country,
it is interested in active participation of its
members in formation of issues of strategic
development and health policy of the coun-
try; it aims to active involvement of doc-
tors in protection of their civil, professional
and social – economical interests; supports
improvement of quality of medical aid of
population and improvement of health sys-
tem of the country.
Tasks of GMA are: supporting decentral-
ization of health system, protection of doc-
tors’rights,support of professional improve-
ment of doctors, popularization of scientific
achievements, illustration of ecological and
demographic problems, bio-medical ethics,
supporting young doctors, organization and
management of educational, scientific and
practical actions, licensing-accreditation of
doctors and medical institutions, constant
medical education and constant profes-
sional development (CME & CPD); close
relationships with legislative authorities and
lobbying of doctors interests.
GMA helps doctors and patients and in
order to achieve it supports union of doc-
tors to work in direction of social health and
most important professional issues.
What has been done
in recent period
Cooperation with Georgian Parliament:
Working on legislative changes (2001–
2008), working in scientific consultation
board of field professional associations at the
Parliament (2008–2012), working in scien-
tific – consultation board for prevention and
support of health (2017–2019), preparation
of some initiatives (2008; 2010; 2012);
Cooperation with the Ministry of Refu-
gees from the Occupied Territories of
Georgia, Labor, Health and Social Affairs
of Georgia
• Working in professional boards of the
Ministry of Labor, Health and Social Af-
fairs of Georgia (1999–2009);
• Health regulation sphere – preparation of
list of specialties (1999–2008); participa-
GEORGIA
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31
Regional Medical Affairs
tion in doctors’ and postgraduates quali-
fication exams (commission, members,
translators, operators) (2002–2013);
• Expertise of medical documentation
(2007–2010)
Other activities:
• Involvement of Tbilisi State Medical
University in international libraries net-
work (2000–2008);
Internal and international grants
• Together with organization OPM there
were arranged several workshops for
optimisation of calculation of human
resources in health sphere. 21 field asso-
ciation was actively participating in the
workshop (2000–2001);
• Assisting Georgian citizens in foreign
and Georgian clinics (Germany, Austria,
Switzerland) (from 1989 to present);
Sending members of Medical Associations
abroad for improvement of qualification
(from 1989 to present).
• By initiative of World Medical Associa-
tion joining of Georgian Medical Asso-
ciation to the project of rehabilitation of
torture victims “Istanbul Protocol”(2002)
and realization and implementation of
this project in Transcaucasia together
with Reabilitation Center of Torture Vic-
tims “Empathia” (from 2003 up to pres-
ent);
• In November 2008 in Georgian Parlia-
ment there was conducted a meeting
which was devoted to medical aspects of
August events;
• On October, 2008 there was created a
Fund for helping families of medical per-
sonnel damaged by war;
Exclusive contract with Georgian Airways
(from 2010 to present) (with discount on
flight tickets for GMA members).
• Together with foreign partners there
was concluded a contract with insurance
company “Ardi Group” and in 2011 there
was created “Georgian Insured Medic’s
Agency”,the basic functions of which are:
support of development of culture and
practice of professional liability insurance
in medical sphere, supporting protection
as of medics,so patients’rights; mediation
in disputes between medics and patients;
development of strategy and recommen-
dations of professional liability insurance
on the basis of got experience;
• Together with Ivane Javakhishvili Tbilisi
State University and Faculty of Medicine,
on July 09, 2014 there was executed Co-
operation Memorandum between Ivane
Javakhishvili Tbilisi State University and
Georgian Medical Association (GMA);
• In 1999, membership of students of
Medical Faculty of TSMU, and in 2010
membership of students of Medical Fac-
ulty of TSU in EMSA (European Medi-
cal Students Association);
• Celebrating annually with participation
of EMSA-TSU official days regulated by
World Health Organization (WHO);
• Organization of annual scientific work-
shops (autumn, spring) and school-sem-
inars (winter, summer) of students;
• Preparation of official Georgian trans-
lation of Geneva declaration of World
Medics Association and its update for
graduators of higher schools (oath text) –
Medical Faculty of Ivane Javakhishvili
Tbilisi State University, from 2010;
Editing activities
Translation and edition of “Medical Eth-
ics Manual” of World Medical Association;
together with 3 field professional associa-
tions preparation and edition of “Rules of
Professional Activity of Doctor”; together
with Medical Faculty of Tbilisi State Uni-
versity there was founded electronic scien-
tific magazine “ Translational and Clinical
Medicine – Georgian Medical Journal);
International forums in Georgia:
• April, 2015 Tbilisi – EFMA/WHO;
• September 2016 Batumi – SEEMF;
• September 2017 Tbilisi – First Meeting
of Georgian Surgeons;
• August 2018 Mestia – Congress of Geor-
gian Surgeons
Future plans:
• 2019–2021 – working on the project of
university clinic together with admin-
istration of TSU and Dean’s Office of
Medical Faculty;
• 2020–2021 – Conduction of workshops
of GMA Regional Organizations and
renewal registration of GMA members;
• 18–20 September, 2019, Batumi – “New
Approaches of Diagnostics and Treat-
ment”;
• 23–26 October 2019, Tbilisi – 70th
Gen-
eral Assembly of World Medics Associa-
tion (WMA).
Working on legislative initiatives
• Question of certification – recertification
(among them restoration of certificate);
• Postgraduate and continued medical edu-
cation;
• Protection of legal and social rights of
medical personnel.
Prof. Gia Lobzhanidze – Chairman
of Directors’ Board of GMA
MD/PhD Tinatin Supatashvili-
Deputy General Secretary of GMA
David Lobzhanidze – Deputy
General Secretary of GMA
Gvantsa Modebadze – Head
of Legal Office of GMA
GEORGIA
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32
The Belarusian Medical Association was
founded in 1992.As of January 2019,its ag-
gregate membership is about 25.0% of the
total number of medical practitioners.
The mission of the Belarusian Medical As-
sociation is to promote collaboration, coop-
eration and mutual understanding on the
basis of professional competence, profes-
sional ethics and deontology.
The Belarusian Medical Association is the
founder of the peer-reviewed research jour-
nal Medicine; it has its own website www:
beldoc.by, where colleagues can find inter-
esting and useful information, learn about
the activities of the association, ask ques-
tions and get knowledgeable assistance.The
Belarusian Medical Association established
the Ethics Commission chaired by Profes-
sor V. P. Krylov. It considers ethical issues in
the relationship between the colleagues and
administration of health care institutions.
Chairperson of the Belarusian Medical As-
sociation is a member of the Supreme At-
testation Commission of the Ministry of
Health of the Republic of Belarus for award-
ing qualification grades to health officials.
The Belarusian Medical Association has its
own regional and sectoral organizational
structures. Our activity is aimed at a broad
representation of the Belarusian medical
community, including its representation at
an international level. We have concluded
partnership and cooperation agreements
with international associations: the Lithua-
nian Medical Association, Latvian Medical
Association, Slovak Medical Chamber, and
the National Medical Chamber of Russia.
The Belarusian Medical Association is ad-
mitted as a Member of the Southeast Eu-
ropean Medical Forum (SEEMF), EFMA,
and WMA.
The Belarusian Medical Association is cur-
rently implementing a skills enhancement
and professional development program for
Belarusian medical specialists by organiz-
ing and financing their participation in in-
ternational academic programs and events.
In close cooperation with sponsors, we send
more than 250 medical specialists a year to
international symposia and conferences.This
makes it possible for our health profession-
als to adopt the best practices and introduce
them into the domestic public health as well
as to promote the achievements of the Be-
larusian medical school on the global stage.
Every year the Belarusian Medical Asso-
ciation organizes and sponsors conferences
and forums held in the Republic of Belarus
for medical specialists on diverse subject
matters, involving representatives of the
leading world schools.
The Belarusian Medical Association coor-
dinates the activities of public associations
operating in the health sector and holds
joint meetings with the heads of these as-
sociations to discuss issues related to coop-
eration with the Ministry of Health of the
Republic of Belarus.
In June 2018, a working meeting of the top
management of the Ministry of Health with
the chairpersons of medical public associa-
tions was held, during which they discussed
issues concerning the development of legal
protection of medical practitioners, improve-
ment of furnishing information about risks
and particular complications in the process
of providing medical treatment to patients.
The Ministry of Health welcomed a broad
participation of the medical community in
revisions of the clinical protocols for the di-
agnosis and treatment as well as participation
of members of public associations in the ac-
tivities of the Higher Attestation Commis-
sions of the Ministry of Health for awarding
qualification grades to health officials.Subse-
quent to the results of the meeting,a decision
on joint coordination of activities was made.
In 2018, the Belarusian Medical Associa-
tion established the award For Devotion to
Profession.The prize is awarded to the health
professionals who have made a significant
contribution to the development of Belaru-
sian medicine, the public health system of
the Republic of Belarus as well as to the de-
velopment of medical science. At its core,
this is recognition of the long-standing self-
less service and contribution made by the
awardees to preserve and promote life and
health in the Republic of Belarus.
The Belarusian Medical Association does
its best to strengthen the corporate soli-
darity, to protect the honor and dignity of
colleagues, to provide legal protection and
assistance in professional and occupational
training of specialists, to enhance the pres-
tige of people in white coats.
Dmitry Shevtsov, Chairperson of the
Belarusian Medical Association
Dmitry Shevtsov
Activities of the Belarusian Medical Association in the Modern Period
Regional Medical Affairs BELARUS
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33
The past few months of violence and blood-
shed in Sudan alone make a compelling ar-
gument that the international medical com-
munity should be more present in Geneva,
where the United Nations human rights
machinery is centered.
Since December 2018, more than 100 doc-
tors in Sudan have been arrested, and some
tortured, for their peaceful advocacy for
the independence of their profession and
the proper functioning of Sudan’s health
system. More than seven hospitals have
been invaded by security forces firing tear
gas into the buildings. Doctors have been
prevented from treating the sick and the
wounded, and at least one was shot dead as
he tried to treat an injured demonstrator.
The Sudan doctors’ union, along with other
professional groups, has been leading a civil
society movement to end one of the most
brutal military dictatorships in the world,
one in which the president and others in
his cabinet are wanted by the International
Criminal Court for genocide.Physicians for
Human Rights (PHR)’s April 2019 report
“Intimidation and Persecution: Sudan’s At-
tacks on Peaceful Protesters and Physicians”
detailed these violations.
And yet, the medical voice is rarely seen or
heard in the corridors of the Human Rights
Council in Geneva, where delegates from a
rotating roster of 47 governments elected
from each region of the world regularly sit
to review human rights reports, evaluate
information, and make public pronounce-
ments on violations,pressing for prevention,
protection, and promotion of human rights
globally.
Non-governmental organizations (NGOs)
like PHR that have consultative status with
the UN are able to address the Council at
its sessions. The messages are live-streamed
through UN media, so the reach can be sig-
nificant and preserved for the international
record.
Since the establishment of the Human
Rights Council in 2006, PHR has submit-
ted its reports to this body, spoken at the
open sessions of the Council, distributed
information to governmental delegates, and
participated in “side events”to provide med-
ical evidence of torture and sexual violence
and to highlight the devastating erosion of
protection of health facilities and personnel
guaranteed in the Geneva Conventions of
1949.
Following the Myanmar government’s 2017
campaign of extreme violence and persecu-
tion against the Rohingya Muslim minority,
PHR went to Geneva in September 2018
to present its medical evidence of atrocities
against the Rohingya collected during a se-
ries of population-based surveys and clini-
cal evaluation of survivors.
PHR and other NGOs also advocated for
the Council to launch an independent in-
vestigative body led by prominent experts to
investigate crimes against the Rohingya; the
mechanism was established in 2018. PHR
continues to press for the body’s operational
effectiveness as well as to advocate against
the ongoing crisis of displacement of Myan-
mar’s Rohingya and failures in accountabil-
ity for atrocities committed against them.
At the Human Rights Council’s March
2019 session, PHR was once more at the
table, delivering oral statements on the re-
lentless attacks on medical personnel and
facilities in the eight-year Syrian conflict
and also on the trauma faced by many
asylum seekers crossing the US-Mexico
border. “This is a human rights crisis that
is being treated as a security crisis,” PHR
Senior Researcher Tamaryn Nelson told
the Council, citing PHR’s documentation
of trauma among asylum seekers and call-
ing upon member states to press for an end
to U.S. policies that restrict the right to seek
asylum.
Dr. Craig Torres-Ness, an emergency medi-
cine physician at the USC Keck School of
Medicine and a member of PHR’s Asylum
Network, joined the PHR team in Geneva
to share his experiences of clinically evalu-
ating asylum seekers who bear the physical
and psychological scars of gang-related and
domestic violence. It was an extraordinary
platform for a medical professional who is
using his skills to advocate for human rights.
Another unique opportunity for human
rights organizations and civil society to be
heard at the Council is the Universal Peri-
odic Review process. Every year, the Coun-
cil reviews the human rights record of 42
countries. Governments, UN bodies, and
NGOs are able to submit information to
the UN Office of the High Commissioner
for Human Rights for the Council’s country
reviews.Issues relevant to medical organiza-
tions include: independence of the medical
Susannah Sirkin
A Medical Voice Is Needed at the Human Rights Council in Geneva
Medical Ethics
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34
Medical Ethics
and scientific communities and the right to
information about epidemics or outbreaks
of disease; persecution of health profession-
als for their independent medical or human
rights activities; attacks on health facilities
and personnel; medical evidence of torture
and sexual violence and their severe physi-
cal and psychological impacts; reproduc-
tive rights and health; collusion of health
professionals in human rights violations,
including torture and executions; overt ob-
struction of the right to health; discrimina-
tion within health systems; and much more.
PHR has submitted documentation to this
process on human rights violations in Bah-
rain, Myanmar, the United States and Zim-
babwe, among other countries.
Dozens of organizations worldwide regu-
larly send representatives to speak at Hu-
man Rights Council meetings on a range of
issues. But the credible and influential voice
of the medical community in these halls of
power is singularly underrepresented. PHR
has been opening a door to these opportu-
nities and welcomes company to develop a
more robust presence in Geneva as threats
against the independence of medical pro-
fessionals and the silencing of civil soci-
ety become ever more pervasive across the
globe.
Susannah Sirkin, Director of Policy,
Physicians for Human Rights
Ewan C Goligher Maria Cigolini Alana Cormier Sinéad Donnelly Catherine Ferrier Vladimir A. Gorsh-
kov-Cantacuzène
Sheila Rutledge
Harding
Mark Komrad Edmond Kyrillos Timothy Lau Rene Leiva Renata Leong Sephora Tang John Quinlan
Euthanasia and Physician-Assisted Suicide are Unethical Acts
The World Medical Association (WMA),
the voice of the international community
of physicians, has always firmly opposed
euthanasia and physician-assisted suicide
(E&PAS) and considered them unethi-
cal practices and contrary to the goals of
health care and the role of the physi-
cian [1]. In response to suggested changes
to WMA policy on this issue, an exten-
sive discussion took place among WMA
Associate Members. We, representing a
voice of many of those involved in this
discussion, contend that the WMA was
right to hold this position in the past and
must continue to maintain that E&PAS
are unethical.
The Central Issue Under Debate
is the Ethics of E&PAS
The question is whether it is ethical for
a doctor to intentionally cause a patient’s
death, even at his or her considered re-
quest. The fact that E&PAS has been
legalized in some jurisdictions and that
some member societies support these
practices has no bearing on the ethical
question. What is legal is not necessarily
ethical.The WMA already recognizes this
distinction, for example, by condemning
the participation of physicians in capital
punishment even in jurisdictions where
it is legal. The WMA should be consis-
tent in this principle also with respect to
E&PAS.
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35
Medical Ethics
E&PAS Fundamentally
Devalues the Patient
This devaluation is built into the very
logic of E&PAS. To claim that E&PAS
is compassionate is to suggest that a pa-
tient’s life is not worth living, that her
existence is no longer of any value. Since
the physician’s most basic tasks and con-
siderations are to ‘always bear in mind
the obligation to respect human life’ and
‘the health and well-being of the patient’
[2, 3], E&PAS must be opposed. E&PAS
distorts the notion of respect for the pa-
tient. On the one hand it claims to help
suffering persons, while on the other hand
it eliminates them. This is a profound in-
ternal contradiction; the ethical priority
is to respect the fundamental intrinsic
worth of the person as a whole.
E&PAS Puts Patients at
Risk
Patients are autonomous agents but are
not invulnerable to their need for affirma-
tion from others, including their physi-
cian. Amidst the overwhelming fears of
those who suffer (4, 5), a free autono-
mous decision to die is an illusion. Par-
ticular concern exists for those who may
feel their life has become a burden due
to changing perceptions of the dignity
and value of human life in all its differ-
ent stages and conditions, and an explicit
or implicit offer of E&PAS by a physi-
cian profoundly influences the patient’s
own thinking. The troubles of human
relationships within families, the pres-
ence of depression, and problems of abuse
and physician error in an already stressed
medical system, make muddy waters even
more turbulent [6]. Evidence shows that
societies cannot always defend the most
vulnerable from abuse if physicians be-
come life-takers instead of healers [1, 6].
The power of the therapeutic relationship
cannot be underestimated in the creation
of patient perceptions and choices.
E&PAS Totally Lacks
Evidence as ‘Medical
Treatment’
The consequences of E&PAS are unknown
as both physicians and patients have no
knowledge of what it is like to be dead. Ad-
vocates of E&PAS place blind faith in their
own assumptions about the nature of death
and whether or not there is an afterlife
when arguing that euthanasia is beneficial.
E&PAS is therefore a philosophical and
quasi-religious intervention, not a medical
intervention informed by science. Doctors
should not offer therapy when they have no
idea of its effects—to offer E&PAS is to
offer an experimental therapy without any
plans for follow-up assessment. Therefore,
key elements in any medical intervention
such as informed consent are simply not
possible without knowing what stands on
the other side of death. Rather than a stan-
dard medical discussion of alternatives based
on scientific data or clinical experience, the
discussion must leave the clinical domain
and enter the domain of speculation. This
is not an exercise in informed-consent.This
is not the accepted medical ethics of medi-
cal practice. All this is, in part, why E&PAS
cannot be a medical procedure.
These Weighty Moral
Considerations are Supported
by the Ethical Intuition of the
Global Medical Community
Only a small minority of physicians sup-
port E&PAS. The vast majority of doctors
around the world wish only to foster the
will to live and to cope with illness and suf-
fering, not to facilitate acts of suicide or to
create ambiguity around what constitutes a
medical treatment.We must remember that
the four regional WMA symposia demon-
strated that most doctors would never be
willing to participate in euthanasia. Even
the insistence of E&PAS proponents on (a)
using ambiguous language such as ‘Medical
Assistance in Dying’ to describe their prac-
tice and (b) avoiding mention of E&PAS
on death certificates suggests that they
share to some degree this fundamental ethi-
cal intuition about killing patients.
Acceptance of E&PAS
Undermines Boundaries
Between End-Of-Life Care
Practices That do not Intend
Death (palliative care,
withholding/withdrawing life-
sustaining therapy) and Those
that do Intend Death (E&PAS)
Confusion is created at a societal level about
what constitutes “medical treatment,” espe-
cially when language such as “medical assis-
tance in dying”or “voluntary assisted dying”
is used. This renders the reality of such acts
and their application unclear. As many pa-
tients share our conviction that deliberately
causing death is wrong, a misunderstanding
of the distinction between E&PAS and pal-
liative care may lead to rejection of palliative
care or insistence on futile life-sustaining
therapies. The availability of E&PAS also
distracts from the priority of providing so-
cial services and palliative care to those who
are sick and dying [7].
The WMA’s Code of Ethics
Strongly Influences Standards
for the Practice of Medicine
Around the World and
Neutrality on E&PAS by the
WMA Would be Interpreted
Globally as Tacit Approval
A change in the WMA statement would
imply a tacit endorsement of E&PAS and
render the WMA complicit with such prac-
tices [8, 9]. Neutrality by professional medi-
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36
cal organisations on E&PAS is perceived by
society, governments and the international
pro-euthanasia lobby as that organisation’s
acceptance of them as medical practice,
rather than as a response to a societal/po-
litical agenda.Those who seek international
approval to justify these practices will cre-
ate a silencing of the majority of the com-
munity, which has real medical, societal and
ethical concerns around E&PAS and their
effects on society internationally.
WMA policy on E&PAS reflects that
which is in place in hundreds of jurisdic-
tions with widely divergent legal and politi-
cal traditions. While it may be tempting to
placate some member societies so as to avoid
dissension, we must not destabilize medical
ethics around the world. We must continue
to characterize E&PAS as unethical even
if it conflicts with the demands of the state
or influential groups backed by the law. We
must not let imperfect law trump good
medical ethics. Undoubtedly many doctors
who perform E&PAS believe themselves
to be acting nobly; but it does not follow
that they should expect others to affirm
their views or not to oppose them; nor are
they wronged by existing WMA policy.Any
society that insists on transforming suicide
from a freedom to a right, should stand up
a different profession with the duty to fulfil
that new right, as killing does not belong in
the House of Medicine.
Neutrality on E&PAS
has Serious Consequences
for Physicians who
Refuse to Participate
In jurisdictions where E&PAS is legalized,
physicians who adhere to the long-standing
Hippocratic ethical tradition are suddenly
regarded as outliers, as conscientious objec-
tors to be tolerated and ultimately excluded
from the profession [10]. A neutral stance
by the WMA would compromise the po-
sition of the many medical practitioners
around the world who believe these prac-
tices to be unethical and not part of health
care. In some jurisdictions it is illegal not to
refer for these practices, creating a dystopic
situation where the doctor who practises
quality end-of-life care needs to conscien-
tiously object in order to do so, and may
be coerced to refer for E&PAS. Neutrality
from the WMA would promote the con-
travention of the rights and ethical practice
of these doctors, undermining their ethical
medical position at the behest of a societal
demand that can fluctuate with time.
In sum, the changes currently being de-
bated, arising from political, social, and
economic factors, have been rejected time
and again and most recently by the over-
whelming consensus of WMA regions. The
present debate represents a crucially im-
portant moment for the WMA that must
not be squandered. Given the influence of
the WMA and the profound moral issues
at stake, neutrality should not be an option.
The WMA policy must continue to stand
as a beacon of clarity to the world, bringing
comfort to patients and support to physi-
cians around the globe. The WMA should
not be coerced into promoting euthanasia
and assisted suicide by making its stance
neutral.
References
1. Leiva R, Friessen G, Lau T. Why Euthana-
sia is Unethical and Why We Should Name it
as Such. WMJ. 2018 Dec; 64 (4) pages 33-37.
[Cited 2019 Feb 05]. https://www.wma.net/wp-
content/uploads/2019/01/wmj_4_2018_WEB.
pdf
2. WMA INTERNATIONAL CODE OF
MEDICAL ETHICS.WMA [Internet] [cited
2019 Feb 05]. https://www.wma.net/policies-
post/wma-international-code-of-medical-
ethics
3. WMA DECLARATION OF GENEVA.
WMA [Internet] [cited 2019 Feb 05]. https://
www.wma.net/policies-post/wma-declaration-
of-geneva
4. Zaorsky NG et al. Suicide among cancer pa-
tients. Nat Commun. 2019 Jan 14;10 (1):207.
[cited 2019 Feb 05]. https://www.nature.com/
articles/s41467-018-08170-1
5. Rodríguez-Prat A et al. Understanding pa-
tients’ experiences of the wish to hasten
death: an updated and expanded systematic
review and meta-ethnography. BMJ Open.
2017 Sep 29;7(9):e016659. [Cited 2019 Feb
05].https://bmjopen.bmj.com/content/7/9/
e016659.long
6. Miller DG, Kim SYH. Euthanasia and physi-
cian-assisted suicide not meeting due care cri-
teria in the Netherlands: a qualitative review of
review committee judgements. BMJ Open. 2017
Oct 25;7(10):e017628. [cited 2019 Feb 05].htt-
ps://bmjopen.bmj.com/content/7/10/e017628.
long
7. The Canadian Society of Palliative Care Physi-
cians -KEY MESSAGES RE HASTENED
DEATH [Internet] [cited 2019 Feb 05].https://
www.cspcp.ca/wp-content/uploads/2015/10/
CSPCP-Key-Messages-FINAL.pdf
8. Sulmasy DP, Finlay I, Fitzgerald F, et al. Phy-
sician-assisted suicide: why neutrality by organ-
ized medicine is neither neutral nor appropriate.
J Gen Intern Med 2018; 33: 1394-1399.
9. Canadian Medical Association softens stand on
assisted suicide. Globe and Mail. AUGUST 19,
2014 [Internet] [cited 2019 Feb 05]. https://
www.theglobeandmail.com/news/national/ca-
nadian-medical-association-softens-stance-on-
assisted-suicide/article20129000/
10. Euthanasia in Canada: A Cautionary Tale.
WMJ 2018 Oct; 64 (3), p 17-23. [cited 2019
Feb 05].https://www.wma.net/wp-content/up-
loads/2018/10/WMJ_3_2018-1.pdf
(Institutional affiliations are provided for
identification purposes only and do not im-
ply endorsement by the institutions.)
Ewan C Goligher MD PhD
Assistant Professor
Interdepartmental Division of
Critical Care Medicine
University of Toronto
E-mail: ewangoligher@gmail.com
Dr Maria Cigolini
MBBS(Syd) FRACGP FAChPM
Grad.DiPallMed(Melb)
Clinical Director Palliative Medicine,
Royal Prince Alfred Hospital
Senior Clinical Lecturer,
University of Sydney
New South Wales, Australia
E-mail: Maria.Cigolini@health.nsw.gov.au
Medical Ethics
BACK TO CONTENTS
37
Alana Cormier MD CCFP
Family Physician, Twin Oaks
Memorial Hospital
Assistant Professor, Department of Family
Medicine, Faculty of Medicine, Dalhousie
University, Nova Scotia, Canada
E-mail: alana.cormier@dal.ca
Sinéad Donnelly MD, FRCPI,
FRACP, FAChPM
Consultant physician Internal
Medicine and Palliative Medicine,
Module convenor and Clinical lecturer
Palliative Medicine, University Otago,
Wellington, Aotearoa New Zealand
E-mail: Sinead.donnelly@ccdhb.org.nz
Catherine Ferrier, MD,
CCFP (COE), FCFP
Division of Geriatric Medicine,
McGill University Health Centre
Assistant Professor of Family
Medicine, McGill University
E-mail: catherine.t.ferrier@gmail.com
Vladimir A. Gorshkov-Cantacuzène,
BChE, MNeuroSci, MD,
DSc(med), TD, JCD
Director, Department of Clinical
Cardioneurology, American Institute
of Clinical Psychotherapists
E-mail: hypfoundation@gmail.com
Sheila Rutledge Harding, MD, MA, FRCPC
Hematologist, Saskatchewan Health Authority
Professor, College of Medicine,
University of Saskatchewan
Saskatoon SK Canada
E-mail: sheila.harding@me.com
Mark Komrad MD
Faculty of Psychiatry Johns Hopkins,
University of Maryland, Tulane
Ethics Committee, American
College of Psychiatrists
E-mail: Mkomrad@aol.com
Edmond Kyrillos, MD, CCFP, B. Eng.
(Mechanical), Lecturer, Department
of Family Medicine, Faculty of
Medicine, University of Ottawa
E-mail: edmond.kyrillos@usherbrooke.ca
Timothy Lau, MD, FRCPC
Distinguished Teacher, Associate
Professor, Faculty of Medicine,
Department of Psychiatry, Geriatrics,
Royal Ottawa Hospital.
E-mail: timlau@sympatico.ca
Rene Leiva, MD CM, CCFP (Care of
the Elderly/ Palliative Care); FCFP
Assistant Professor
Department of Family Medicine
Faculty of Medicine
University of Ottawa
E-mail: Rene.leiva@mail.mcgill.ca
Renata Leong
MDcM, MHSc, CCFP, FCFP
Assistant Professor, DFCM,
University of Toronto
E-mail: leongr@smh.ca
Sephora Tang, MD, FRCPC
Staff Psychiatrist, The Ottawa Hospital
Lecturer, Faculty of Medicine,
Department of Psychiatry
University of Ottawa
E-mail: sephora.md@gmail.com
John Quinlan MB.BS(Syd)
FAFRM MA(ethics)
E-mail: jpquinlan@bigpond.com
Defensive medical practice represents an
increasing concern in all over the world.
The practice of defensive medicine is main-
ly associated to the rising number of medi-
cal malpractice lawsuits. It negatively affect
the quality of care and waste the limited
resources in health sector. The economic
burden of defensive medicine on health
care systems should provide an essential
stimulus for a prompt review of this situ-
ation. Defensive medicine in simple words
is departing from normal medical practice
as a safeguard from litigation. The most
frequent daily practice of defensive medi-
cine is performing more unnecessary tests
and referring more patients to consultants
and hospitalization. Such behavior is an
ethically wrong and disagrees with deon-
tological duties of the doctor. Investigating
the prevalence of defensive medicine in a
number of international healthcare set-
tings, defensive medicine has been found
to be highly prevalent in many countries.
Majority of physicians across various spe-
cialties tends to adopt a defensive profes-
sional culture. Daiva Brogiene
Regional Medical Affairs
The Defensive Medicine isn’t the Best
Way to Avoid Mistakes
LITHUANIA
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38
The survey of 2440 physicians manifested
broad spread of the defensive medicine in
Lithuania. Results show that 86.3% of doc-
tors admitted that they refer their patients
to other specialists without any true need
and solely to protect themselves from po-
tential legal challenges. Moreover, 60.7% of
the consulted physicians admitted to hav-
ing performed unnecessary additional test
for the same reason. Also, 66.6% of the
physicians avoid ‘risky’ patients, which are
defined as those with a complicated or dan-
gerous disease, or those who are prepared
to challenge doctors’ decisions. In addition,
59.9% of the physicians consulted avoid us-
ing necessary, but risky procedures. Lastly,
40.3% of the physicians indicate that they
have prescribed or used unnecessary medi-
cines (Prevalence of defense medicine in
Lithuania. Liutauras Labanauskas, Viktoras
Justickis, Aistė Sivakovaitė. Health policy
and management, 2013).
We have to speak up about defensive medi-
cine, because it is a low-value care, which
has no benefit neither to the patient and nor
to the doctor. Defensive medicine brings
enormous prolongation of waiting time for
all patients. This causes great harm to pa-
tients who should receive the medical care
in a proper time, especcialy to the patients
who have the most serious diseases. But a
physician instead of doing his best to help
his patient is concentrated on defending
himself from any legal prosecution in the
case on unsuccessful treatment.
Doctors who prescribe unnecessary tests and
procedures out of fear of being sued waste a
lot of money each year. Defensive medicine
practice is difficult to precisely quantify. Low
value care – is a faulty and dangerous phe-
nomenon in the healthcare. International
projects analyze opportunities to eliminate
waste and lower value care. But the efforts
to rid the nation’s healthcare system of waste
and inefficiency faces a defensive medicine.
Clinical medicine has always been based
on patient – physician trust. Unfortunately,
this fundamental trust has been progres-
sively eroded by lack of patient face-time.
This is not a picture limited to one country,
for example Lithuania. If this relationship
is lost or diminished to unacceptable levels,
then defensive medicine is the logical con-
sequence. Time directly spent with patients
has been overtaken by time devoted to elec-
tronic health records and other documenta-
tion. It is necessary to reestablish the trust
between doctor and patient. Lithuanian
Medical Association demands the govern-
ment to normalize the worklowds of phy-
sicians and allowd them to spend the time
they need with their patients. A doctor who
sees patient’s distrust as an expression of his
hostility has no other option than to defend
and to use defensive medicine methods.
In keeping with the growing trend towards
considering healthcare as a consumer prod-
uct and patients as consumers, patients and
their families not infrequently demand ac-
cess to medical services that, in the consid-
ered opinion of physicians, are not appro-
priate. This problem is especially serious in
situations where resources are limited and
providing ‘futile’ or ‘nonbeneficial’ treat-
ments to some patients means that other
patients are left untreated. As a general rule
a patient should be involved in determining
futulity in his or her case. Overtreatment
with antibiotics is one example of defensive
medicine that endangers everyone. Con-
tinuing efforts must be made to educate the
public that information acquired from on-
line sources outside of an appropriate clini-
cal context is generally inappropriate.
There is no secret that a patient can sue
the doctor, betting on a chance to win a
big award. Such culture of litigation impact
both the medical and legal systems. The
laws and legal systems in each country, as
well as the social traditions and economic
conditions are different, but the fundamen-
tal principles of litigation culture are similar
for every country. So the adoption of no-
fault systems or other extra-judicial me-
diation are shown to be the most effective
strategies to reduce the number of litiga-
tions in courts, with consequent economic
savings. In countries where a no-fault sys-
tem or a system of conflict mediation is in
force, most of the litigations are disputed
out of the court of law. Lithuanian govern-
ment is also trying to solve this problem and
intend currently to enter the no-fault com-
pensation system without requiring a proof
of negligence. Lithuanian Medical Associa-
tion speaks up against the increasing crimi-
nalization or penal liability.
The physician who has personally been
named in a lawsuit becomes so called
‘second victom’. He/she commited an
error, and are consequently severely af-
fected in both their private life and subse-
quent practice. They suffer physically and
psycho-socially and try to overcome the
post-event emotional stress by obtaining
emotional support. Psychological support
obtained by these physicians in health care
institutions today is poor and inefficient.
There is a need for effective support to ‘sec-
ond victims’, because despite that they will
continue their defensive medicine in the
future. ‘Second victims’ may feel anxiety,
fear, guilt or anger and experience social
withdrawal, which may lead to depression.
Over the years, this situation may lead to
deterioration in his/her work and personal
life and, in rare circumstances, may lead to
pharmaceutical and even alcohol consump-
tion. It is no secret, there were the cases
when the physician have committed sui-
cide. But this support is not meant to dis-
rupt any correct medical investigation or to
stand for a doctor in any way, but rather to
allow him/her to focus on handling stress,
accepting the consequences of the mistake,
and finding out solutions to avoid similar
situations in the future, it means training
and learning from mistakes. Lithuanian
Medical Association openly and truly
provides the help to the colleagues which
need it. We hope that maintenance of high
standards in daily practice with continu-
ous training, clear communication and a
signed Patient’s Informed Consent Form
Regional Medical Affairs LITHUANIA
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39
CPME Position Paper on
Defensive Medicine
The Standing Committee of European Doctors (CPME) represents
national medical associations across Europe. We are committed to
contributing the medical profession’s point of view to EU and Eu-
ropean policy-making through pro-active cooperation on a wide
range of health and healthcare related issues [1].
Definition/ Background [2]
Defensive medicine has seen an increase in both prevalence and im-
pact over the past years.
The concept of ‘defensive medicine’ is subject to varying definitions
which broadly describe the practice of ordering medical tests,proce-
dures,or consultations which are not medically indicated or refusing
the treatment of certain patients in order to protect the responsible
physician from malpractice challenges.
Defensive medicine consists of two general behaviours. As Stud-
dert et al. set out, “[o]ne is assurance behaviour (sometimes called
“positive” defensive medicine), which involves supplying additional
services of marginal or no medical value with the aim of reducing
adverse outcomes, deterring patients from filing malpractice claims,
or persuading the legal system that the standard of care is met. The
other is avoidance behaviour (sometimes called “negative” defensive
medicine), which refers to physicians’ efforts to distance themselves
from sources of legal risk” [3].
THE Prevalence of Defensive Medicine
in Europe
A review of international scientific literature confirms that defen-
sive medicine is widespread and occurs in all diagnostic-therapeutic
areas, although some medical specialties are affected more often
than others. Various studies have looked at the situation at national
level, both within the EU and internationally [4–13].
Impact of Defensive Medicine
The adverse effects of defensive medicine affect healthcare systems
worldwide.
It is complicated to calculate or quantify the economic impact of de-
fensive medicine due to the many conflicting and overlapping fac-
tors [14–17]. Nevertheless it is expected that the cost of defensive
medicine is significant.
A culture of litigation impacts both the medical and legal systems
with damaging consequences to the patient-physician relationship
and the quality of healthcare services even though the national legal
frameworks for litigation differ.
Recommendations to Prevent and Reduce
the Practice of Defensive Medicine
There is no universal solution for all countries of how to reduce
this phenomenon due to cultural,economic and social differences in
the countries which create the different expectations of the patients,
different legal systems and legal procedures. However the common
essential directions may be put forward.
Recommendations for professionals
1. To ensure that healthcare responds appropriately to each indi-
vidual patient’s health needs.
2. To maintain high standards and evidence-based clinical guide-
lines in daily practice. Clinical guidelines require regular revision
to ensure they reflect the best available evidence, while allowing for
clinical independence to adequately respond to individual patients’
needs and choices.
3.To practice more valuable care for every patient through informed
choices and good conversation. With a patient engagement and
clear communication promote awareness about appropriate care,
unnecessary tests, treatments and procedures.
4. To support Continuous professional development (CPD) with
the objective of ensuring that professional practice is up-to-date.
Medical Affairs CPME
along with the appropriate documentation
of any procedure carried out may provide
professional safety.
So we are sure,the better care is the best de-
fense. The defensive medicine isn’t the best
way to avoid mistakes.
Dr. Daiva Brogiene
Vice-president CPME
Lithuanian Medical Association
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40
This will contribute to better patient outcomes, quality of care as
well as increasing the public’s confidence in the medical profession.
5.To maintain clear,well-documented and detailed medical records.
Appropriate documentation of all treatments and procedures con-
tributes to quality of care and patient safety.
Recommendations for policy-makers
6. To build a patient safety culture aimed at transparency, and
preventing and learning from errors. Appropriate open disclosure
policies can support both patients and doctors and should be ap-
propriately resourced. It has furthermore been established that the
disclosure of adverse events, which may include an apology to the
patient affected and their family, lowers the probability of litigation
against the doctor involved.
7. To engage in a debate with the public to contribute to improv-
ing media literacy on health information in particular in relation
to online sources. To inform the public about the consequences of
defensive medicine: reluctance to treat high risk patients, costs and
dangers if professionals continue to practice defensive medicine.
8.The medical community and administration of health institutions
need to be aware of the ‘second victim’phenomenon (or the clinical-
judicial syndrome) and ensure adequate psychosocial support to
both patients and doctors in the disclosure process.
9. To reduce fears of liability proceedings by reforming compensa-
tion mechanisms for medical malpractice. Mediation and adminis-
trative compensation systems all hold promise.
10. Further development of the liability system is necessary to en-
able a reform of tort law focused on balancing the ‘no blame prin-
ciple’ with the ‘accountability principle’. The use of extra-judicial
mediation and the adoption of no-fault systems have proven to be
effective approaches in reducing both defensive medicine and the
waste of resources it incurs.
11. Under-resourcing and under-staffing contribute to clinical error
and defensive medicine. Employers and funders have a duty of care
to ensure that clinical services are adequately resourced and staffed
to deal with appropriate workloads.
References
1. CPME is registered in the Transparency Register with the ID number
9276943405-41. More information about CPME’s activities can be found
on www.cpme.eu.
2. In 2016, CPME carried out a survey mapping the situation of defensive
medicine across Europe (CPME 2016/008 FINAL). Responses to the
CPME survey showed that a majority of National Medical Associations
support further CPME action concerning defensive medicine, in particular
to raise awareness about this problem. The impact of defensive medicine is
discussed in relation to several policy areas. There are CPME policies relat-
ing to the liability of doctors which also address the concept of defensive
medicine, in particular the CPME policy on the liability of service providers
adopted in 1991 (FR only) and the CPME Proposal for a directive on health
care liability adopted in 2000. Although discussions on doctors’liability were
raised both in the context of the Services Directive 2006/123/EC,the Cross-
Border Healthcare Directive 2011/24/EU and the Professional Qualifica-
tions Directive 2005/36/EC, there is currently no EU legislation on this is-
sue. Awareness of an increasingly defensive medical practice culture and its
negative implications has paved the way for a much-needed political focus,
like the ‘Choosing Wisely®’ campaign in the UK launched by the Academy
of Medical Royal Colleges. International projects analyse opportunities to
eliminate waste and lower value care (Netherlands, Alliance of University
Hospitals and Training centres – NFU programme), the European Collabo-
ration for Healthcare Optimization (ECHO).
3. Studdert DM, Mello MM, Sage WM, Des Roches CM, Peugh J, Zapert K,
et al. Defensive medicine among high-risk specialist physicians in a volatile
malpractice environment. JAMA. 2005;293:2609–17.
4. J Health Serv Res Policy. 2017 Jan, Prevalence and costs of defensive medi-
cine: a national survey of Italian physicians. Panella M, Rinaldi, Leigheb F,
Knesse S, Donnarumma C, Kul S,Vanhaecht K, Di Stanislao F.
5. Health Econ Policy Law. 2017 Jul;12(3):363-386. The determinants of de-
fensive medicine practices in Belgium. Vandersteegen T, Marneffe W, Cl-
eemput I, Vandijck D, Vereeck L.
6. J Eval Clin Pract. 2015 Apr;21(2):278-84. A national survey of defensive
medicine among orthopaedic surgeons, trauma surgeons and radiologists in
Austria: evaluation of prevalence and context. Osti M, Steyrer J.
7. Studdert DM, Mello MM, Sage WM, Des Roches CM, Peugh J, Zapert K,
et al. Defensive medicine among high-risk specialist physicians in a volatile
malpractice environment. JAMA. 2005;293:2609–17.
8. Hiyama T, Yoshihara M, Tanaka S, Urabe Y, Ikegami Y, Fukuhara T, et al.
Defensive medicine practices among gastroenterologists in Japan. World
J Gastroenterol. 2006;12:7671–5.
9. Bishop TF, Federman AD, Keyhani S. Physicians’ views on defensive medi-
cine: a national survey. Arch Intern Med. 2010;170:1081-1083.
10. Asher E, Greenberg-Dotan S, Halevy J, Glick S, Reuveni H (2012) Defen-
sive Medicine in Israel – A Nationwide Survey. PLoS ONE 7(8): e42613.
doi:10.1371/ journal.pone.0042613).
11. Cross-sectional survey on defensive practices and defensive behaviours
among Israeli psychiatristsI Reuveni, I Pelov, H Reuveni, O Bonne, and L
Canetti. BMJ Open. 2017; 7(3):
12. Prevalence of defense medicine in Lithuania. Liutauras Labanauskas, Vikto-
ras Justickis, Aistė Sivakovaitė . Health policy and management, 2013.
13. Asher E, Dvir S, Seidman DS, Greenberg-Dotan S, Kedem A, et al. (2013)
Defensive Medicine among Obstetricians and Gynecologists in Tertiary
Hospitals. PLoS ONE 8(3): e57108. doi:10.1371/journal.pone.0057108.
14. J Am Health Policy. 1994 Jul-Aug;4(4):7-15. How much does defensive
medicine cost? Rubin RJ, Mendelson DN.
15. Hermer LD, Brody H. Defensive medicine, cost containment, and reform.
J Gen Intern Med. 2010; 25:470-473.
16. Health Policy, 119 (2015) 367-374. Tom Vandersteegen and others. The
impact of no-fault compensation on health care expenditures: An empirical
study of OECD countries.
17. Reschovsky JD, Saiontz-Martinez CB. Malpractice claim fears and the costs
of treating medicare patients: a new approach to estimating the costs of de-
fensive medicine. Health Serv Res 2017.
Medical Affairs CPME
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IV
WMA General Assembly
WMA General Assembly
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