wmj_1_2020_WEB_layot

General Assembly Report
vol. 66
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 0049-8122
Nr. 1, January 2020
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Interview with Miguel Roberto Jorge, President of the World Medical Association
by WMJ Editor Peteris Apinis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Interview with Dr. RobertTwycross, DM Oxon, FRCP, FRCR, Emeritus Clinical Reader in
Palliative Medicine, Oxford University, Oxford, UK by WMJ Editor Peteris Apinis. . . . . . . . . 3
Interview with Mari Michinaga, Vice-Chairperson of Council of the World Medical
Association by WMJ Editor Peteris Apinis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Report on the Health Professional Meeting (H20) 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
The FCTC and Tobacco Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Hearing Screening in Traffic Police Personnel in Multiple Centers in India . . . . . . . . . . . . . . 13
Achieving Universal Health Coverage and Sustainable Development Goals:
The Global Fund’s contribution and my expectation for medical professionals,
national medical associations and World Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . 17
Short Overview of Developments in Azerbaijan Healthcare Policy and Legislation
During Last Decades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
The Welfare and Good Health of Patients is not Possible Without the Doctor:
Let’s Work Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Health Systems in Post Conflict; Case of Somaliland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
The Right to Health; What is the Role of the Doctor in Uganda?. . . . . . . . . . . . . . . . . . . . . . . . 28
Health Sector Reforms in Uganda, not yet Uhuru!. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Clean Indoor Air is Key to Asthma Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Interview – Survival: One Health, One Planet, One Future – Routledge, 1st
edition,
2019, by Daniele Dionisio PEAH – Policies for Equitable Access to Health . . . . . . . . . . . . . . 31
Digital Transformation In Healthcare – South African Context . . . . . . . . . . . . . . . . . . . . . . . . 34
Youth in the Health and Social Care Sector, challenges and opportunities. . . . . . . . . . . . . . . . 38
Memorandum of Tokyo on Universal Health Coverage and the Medical Profession. . . . . . . . iii
1
Editorial
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
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
Medicīnas apgāds, Ltd
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Miguel Roberto JORGE
WMA President,
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
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. David Barbe
WMA President-Elect,
American Medical Association
AMA Plaza, 330 N. Wabash, Suite
39300
60611-5885 Chicago, Illinois
United States
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. Leonid EIDELMAN
WMA Immediate Past-President
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
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
Editorial
A low dose of any chemical compound may be virtually harmless,
while its higher dose may cause diseases, but the highest dose may
turn into a deadly poison (there are exceptions – even the smallest
drop of hydrocyanic acid and some other chemicals used in warfare
is deadly). And too large a dose of a chemical compound is a global
poison for our planet. This idea has already been known since the
time of Hippocrates because the Greek word “pharmakon” means
either ‘medicine’ or ‘poison’ depending on the context. The father of
toxicology,Swiss doctor and alchemist Paracelsus (1493-1541),said,
“The dose makes it clear that a thing is not a poison.”
A swallowed tablet is medicine, but exaggerated dosing of medi-
cines mean poisoning. Discharge in Asian rivers of substances from
chemical plants manufacturing pharmaceutical raw material due to
insufficient wastewater treatment means an ocean poisoned with
biologically active substances. However, the raw materials of these
medicines are manufactured in Asia exactly because of their lower
cost and lower environmental standards there. The chemical indus-
try and pharmaceutical industry are often in the hands of one busi-
ness group.The chemical structure of some consumer chemicals and
pesticides is similar to that of synthetic female sex hormones, while
part of them – to modern antibiotics.These pesticides are ruthlessly
sprinkled on the fields of the globe. In the world, the production
of chemicals has doubled since 2000, and man depends on it more
than ever before.
It is similar with global warming – a hot day usually means switch-
ing on air conditioners on this planet. A heatwave means the deaths
of patients with chronic cardiovascular diseases. Global warming
means new infectious diseases, injuries
caused by catastrophic floods and hurricanes, psychosomatic dis-
eases. Global challenges can only be tackled by reducing environ-
mental poisoning with pesticides, fertilizers and consumer chemi-
cals, greenhouse gas emissions, deforestation, cleaning the ocean of
plastic and implementing other planet rescue programmes.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief
of the World Medical Journal
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2 3
Medical Ethics
WMA News
Jorge: Peteris, An initial suggestion: ask
someone to review the English language
in your questions. I believe they can be im-
proved. And I delete a phrase in your ques-
tion number 3 not because of the language
but because I do not think it was correct.
Apinis: You are a physician known world-
wide and a leader among psychiatrists.
Could you comment on whether doctors in
the world are burned out? Are doctors more
threatened by anxiety and depression than
other people? Is it true that doctors in cer-
tain professions (such as anesthesiologists
and psychiatrists) are more at risk of suicide
than people of other professions? How can
we help doctors in the world to feel appreci-
ated and reduce the risk of burnout?
Jorge: There are studies indicating a high
prevalence of burnout among physicians
worldwide even considering that burnout
is not equally distributed among them.
Providing medical care usually in difficult
circumstances exposes physicians to con-
tinuous stress at work and burnout is one of
the consequences of this kind of situation.
On regards of anxiety and depression, some
data suggest that physicians do not present
more depression than other people but the
rate of suicides among physicians is higher
than in the general population and, again,
the distribution of suicide rates among dif-
ferent medical specialties is not equal.In my
personal opinion, the best way for a physi-
cian to feel appreciation and reduce the risk
of burnout is to dedicate to build a good
relation with patients and share with them
the power to take decisions on treatment
alternatives.
Apinis: We see a new trend in world poli-
tics – doctors are undervalued. The global
trend is growing: doctors’ earnings are
declining against average earnings in the
country. Politicians and financiers, mean-
while, talk publicly that preparing doc-
tors is too expensive, that universal health
coverage should be cheaper to have health
specialists. How can we build the prestige
of our global profession and restore the re-
muneration?
Jorge: I can identify different situations in
your question. Nowadays, compared to past
times, medical doctors are given less value
and I believe the dehumanization of the
medical practice has contributed to this sit-
uation. Physicians not always have enough
time to dedicate themselves to build a good
physician-patient relationship that takes
the individuality of each patient in consid-
eration.And even when they have that time,
they are more prone to pay attention to lab
exams than to listen to the person they have
in front. I do not know if just earnings of
medical doctors are declining but I believe
the reasons for that are multiple and linked
to profound changes in the work market
everywhere in the globe. To prepare good
professionals, in any area of work, deserves
meaningful investments. And I do not be-
lieve that to prepare good primary care
physicians will cost less than to train a good
specialist. Any system of care, and particu-
larly those under the Universal Health Cov-
erage,requires good primary care physicians
as well as good specialists.
Apinis: In Tbilisi, the WMA accepted a
declaration on euthanasia. In this declara-
tion, the WMA condemned euthanasia and
assisted suicide. As physicians, they can’t
and don’t want to perform euthanasia or as-
sisted suicide. However, surveys show that
physicians as patients would like to shorten
their lives when they encounter major phys-
ical and mental health problems. These are
doctors as patients who are most likely to
refuse complicated and excessive treatment
if it can’t significantly prolong survival and
improve the quality of life. How would you
comment on a situation where a doctor, as a
patient, requires euthanasia or assisted sui-
cide?
Jorge: Indeed, the WMA took a very clear
position opposing physician assisted suicide
and euthanasia. We think that physicians
should not involve in such practices. We
want our patients to be sure that we value
their lives and that we are there to protect
and to help them even in very difficult situ-
ations. Physicians, when they become pa-
tients, are patients like any other person.
There is no different ethics for physicians
being patients. But the same is also true
as for any other person: we should abstain
from futile and undesired treatment, we
must respect a demand for ending treat-
ment and we have to give comfort and to
alleviate pain.
Apinis: Every doctor turns into a patient
sooner or later. Shouldn’t we be more open
to helping our sick colleagues? Shouldn’t
Apinis: The WMA adopted Declara-
tion on Euthanasia in October. In the
world, there is often sought interrelation
between the last weeks of life under the
care of a palliative medicine specialist and
the possibility of ending life through as-
sisted suicide or euthanasia. Could you
comment on this relationship from your
viewpoint?
Twycross: I am aware that in countries
where euthanasia and/or assisted suicide
(EAS) are legal options there are palliative
care services that have integrated EAS with
palliative care. However, for me, EAS and
palliative care are mutually exclusive phi-
losophies. Expecting doctors to switch from
one to the other is an expectation too far.
Further, palliative care specialists know that
almost all patients who begin by asking for
EAS change their mind when adequately
supported by palliative care. What of those
who do not? In my opinion, it is perfectly
consistent to argue that, ethically speaking,
EAS might be permissible in some extreme
cases but that it would be unwise to change
the law. As at present, it could be better to
allow hard cases to be taken care of by vari-
ous expedients than to introduce new leg-
islation that would inevitably become too
permissive as has happened, for example, in
both the Netherlands and Belgium.
However, if the law were to be changed,
there is no reason why doctors and nurs-
es should be involved. A separate service
staffed by registered individuals able to pre-
scribe or administer a single lethal overdose
for a patient who fulfilled the legal criteria
could be set up and monitored. Any EAS
law is likely to lead to a negative change
in the way that disability and dependency
are viewed by society generally – as increas-
ingly financially burdensome. Indeed, it is
for this reason that most disabled people
are strongly opposed to any liberalisation
of the law.
Apinis: Every doctor becomes a patient
sooner or later. We know that medical doc-
tors are more open to shorten their lives
when severe physical or mental health
problems arise. Does a doctor as a palliative
patient differ from other palliative patients
and how is it to work with a doctor as a pal-
liative patient?
Twycross: It is harder caring for medical
colleagues – it is too easy to become emo-
tionally over-involved  – but, in 30 years,
only one doctor-patient unwaveringly
wanted to pursue EAS. This was because of
existential distress, not for unrelieved physi-
cal symptoms. Indeed, despair is the com-
monest reason for a consistent desire for
EAS. Even in such cases, given adequate
Interview with Miguel Roberto Jorge, President of the
World Medical Association by WMJ Editor Peteris Apinis
Miguel Roberto Jorge
we find a global approach to assisting sick
doctors?
As said before, when physicians become
a patient, they act as any other patient.
So, medical doctors need to treat them as
any other patient, with courtesy, empathy,
compassion, and respect. There is not other
global approach than to treat well every pa-
tient we can have, being them physicians or
not. But the attending physician needs to
consider the possibility of facing colleagues
as more difficult patients to treat.
Apinis:World experience today shows that
these are doctors who most energetically
and honestly speak about the climate crisis
and pollution of the planet, protest against
burning of forests, against the reduction of
biodiversity on the planet.What are you go-
ing to do,as President of the World Medical
Association, in the fight for the well-being
of our planet?
Jorge: The World Medical Association
counts for many years with an Environ-
mental Caucus that meets yearly when
the WMA has its General Assembly. The
WMA has been producing a series of poli-
cies dealing with themes of interest to the
environment with recommendations to be
followed by physicians around the globe.
So, as the current WMA President, I will
continue to develop activities as the leaders
who came before me in highlighting the
importance of fighting against any situa-
tion that can decrease the world health
levels.
Interview with Dr. Robert Twycross, DM Oxon, FRCP, FRCR,
Emeritus Clinical Reader in Palliative Medicine, Oxford University,
Oxford, UK by WMJ Editor Peteris Apinis
Robert Twycross
BACK TO CONTENTS
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4 5
Medical Ethics Medical Ethics
support (including appropriate palliative
psychotherapy), there is often resolution.
The question remains: if EAS was permit-
ted, how long ought one to work for resolu-
tion before concluding that the distress is
definitely intractable?
Apinis:Three concepts – care,rehabilitation
and palliative care – are often mixed up [in
the whole world]. By care, we understand
long-term care services for patients whose
functioning restrictions have stabilized so
far that further improvement is unlikely to
occur. By rehabilitation, we understand a set
of measures to improve the functioning of
patients with at least six-month potential
survival, but by palliative care – individual
services for people with very poor treatment
forecasts and survival. Is there any tendency
for these different types of care to overlap?
Is there a place for rehabilitation in pallia-
tive care? Palliative care, in particular hos-
pice care,should be distinguished as the one
the provision of which must not be a source
of profit for the organisation concerned.
Twycross: All definitions of palliative care
have fluffy boundaries. Fifty years ago, it
was largely limited to comfort care at the
end of life. Since then the scope of palliative
care has expanded considerably, and prob-
ably can best be described as ‘care beyond
cure’. It is holistic (addressing physical,
psychological, social/family, and spiritual/
existential concerns); focused on quality of
life (but can be provided in tandem with
life-prolonging treatments); based on need
(not limited by diagnosis or prognosis); ap-
plicable across all age groups; and ideally
provided by a multidisciplinary healthcare
team. In other words: humane care for hu-
man beings, not mechanical care for human
machines.
However, to a certain extent, palliative care
tends to fill gaps in the provision for long-
term care. For example, in the UK in the
1980s and 1990s, many palliative care ser-
vices established lymphoedema clinics, car-
ing for those with congenital lymphoedema
as well as patients with cancer (cured or
end-stage). In Moldova, the Angelus Hos-
pice in Chisinau is the only service in the
country offering ostomy care; and, in Mos-
cow, long-term inpatient post-stroke and
long-term inpatient ventilation care have
been integrated into palliative care.
Rehabilitation – helping someone to achieve
their maximum potential in any of the do-
mains of personhood – is integral to pallia-
tive care. With the relief of pain and other
distressing symptoms, adequate sleep and
gentle encouragement, many palliative care
patients improve physically, sometimes dra-
matically. Of course, sooner or later, there
will come a time when physical improve-
ment is no longer possible. This is the time
when the challenge for many people is to
change from being a ‘human-doing’ to a
‘human-being’sustained within the embrace
of supportive loving relationships.
The norm worldwide is for palliative and
hospice care to be free of charge, typically
funded partly by government and partly
with charitable monies. In the USA two
thirds of hospices are ‘for profit’. This im-
mediately introduces a conflict of interest
with an inevitable focus on reducing costs
and maximizing profit for the shareholders
and owners rather than there being a single-
minded focus on quality of care. Ultimately,
this cannot be a good thing, and should
definitely be discouraged.
Apinis: Palliative care is not a priority in
many countries of the world, politicians
often forget about it. Universal health cov-
erage does not really provide for palliative
care either. However, the lifespan of people
extends and the role of palliative care is in-
creasing. How to make world politicians
and financiers be aware of the importance
of palliative care?
Twycross: At the recent High Level Meet-
ing at the United Nations, palliative care
was recognized as an essential component
of universal health coverage. However, for
palliative care to take root requires a com-
bination of a local charismatic champion
(often but not always a doctor) who can
inspire fellow healthcare professionals and
key supporters within civil society, together
with media publicity, and the enthusiastic
support of at least one celebrity and several
local and national politicians. Even so, there
may need to be an element of luck – being
in the right place at the right time in a com-
munity responsive to your message. Adopt-
ing a human rights approach can help but
is unlikely to be successful unless associated
with an appeal to the emotions.
In addition, palliative care will flourish only
if there is a combination of governmental
and philanthropic funding.This is true even
in the UK. For example, in middle England,
one particular comprehensive inpatient
and community-based palliative care ser-
vice costs £8 million per annum, but only
some £3 million is provided by the National
Health Service,leaving a deficit of £100,000
per week to be secured through fund-rais-
ing, donations, legacies, and grants. In the
County of Oxford (where I live) with a
population of about 700,000, the provision
of palliative care costs around £24 million
per annum, but statutory funding accounts
for only one third of this.
Apinis: Reducing pain in palliative care is
a very important aspect. [Isn’t it still that
doses of medicines are administered to pa-
tients with unbearable pain based on the ac-
cepted doses of medicines and bureaucratic
settings?] From your publications, I have
learned that, when used properly, morphine
and other powerful opioids are safe – safer
than non-steroidal drugs the prescrip-
tion of which goes unpunished. The use of
both types of painkillers is justified on the
grounds that the benefits of pain relief are
significantly greater than the risk of seri-
ous harmful effects. Clinical experience has
shown that cancer patients whose pain has
been relieved live longer than in case they
continued to be exhausted and demoralised
by severe pain. Could you comment on how
much we need painkillers in palliative treat-
ment?
Twycross: Medicinal availability of opi-
oids, particularly morphine, has been
championed for some 40 years by the
World Health Organization,among others.
National governments have a dual interna-
tional legal responsibility both to prevent
illicit use of opioid drugs and to ensure that
such drugs are readily available and easily
accessible for patients in whom other types
of analgesic are inadequate. Indeed, the
amount of morphine used per capita per
annum is used as an approximation of the
adequacy of palliative care provision. Thus,
in Georgia, if palliative care was available
to all who need it, the annual necessary
consumption of medicinal morphine is es-
timated to be 45 kg, but the actual amount
currently used is only 8kg. In fact, the pro-
portion of morphine that is used in low
and middle income countries is less than
10% of the world’s total (with about 85%
of the world’s population), compared with
over 90% in high income countries (with
about 15% of the world’s population). This
is a terrible injustice, and one which the
medical profession, actively supported by
the national and international Medical As-
sociations, must strive to correct.
However, changing overly restrictive laws is
only part of the answer: changing medical
and societal cultural attitudes to opioids is
equally necessary. For this, centres of ex-
cellence must establish and propagate best
practice, accepting responsibility for train-
ing the trainers to counter the many mis-
conceptions that abound around morphine
use. Rightly used, morphine is a remarkably
safe analgesic, and may well be safer than
traditional non-steroidal anti-inflammatory
drugs (also vitally important for cancer pain
management). Pain is an antagonist to the
respiratory depressant effect of morphine;
and psychological dependence (‘addic-
tion’) is rare when morphine is used within
the context of holistic ‘whole-person’ care.
Those who cannot accept this should visit
an established palliative care service and
meet some of the many patients who have
rehabilitated largely because of morphine.
6. There is an ongoing discussion about the
use of sedative drugs in palliative care.These
medicinal products should be administered
in accordance with ethical and pharmaco-
logical principles the same way other pa-
tients are treated in hospital for acute and
chronic diseases. What is the difference
between primary or palliative sedation and
sedation as a significant treatment for sec-
ondary symptoms? How to avoid sedation
to hasten death?
Twycross: my review Reflections on palliative
sedation was published in the on-line journal
Palliative Care: Research and Treatment ear-
lier this year, and I urge members of WMA
to share it with their colleagues [https://doi.
org/10.1177/1178224218823511]. First,
there is a problem with terminology which
means that the vast literature on the sub-
ject is often difficult to make sense of. The
original definition was too wide: it included
both intermittent as well as continuous
sedation in ‘imminently dying’ patients.
However, it did specifically exclude seda-
tion secondary to justifiable symptom man-
agement measures. I agree with you when
you say that sedative drugs should always
be administered in accordance with ethical
and pharmacological principles  – justified
by need and administered proportionately.
In my opinion, the term ‘palliative sedation’
should be dropped because of ambiguity in
its use, and discussion should focus specifi-
cally on continuous deep sedation (CDS)
until death in dying patients. CDS is clearly
ethically challenging because it ends a pa-
tient’s biographical (social) life and, if truly
deep (no response to noxious stimuli), will
shorten biological life because the nega-
tive impact on the brainstem will lead to
cardiorespiratory failure. Thus, CDS must
be viewed as an extra-ordinary ‘last resort’
measure, and should never be seen as the
default position for terminal distress. In ex-
treme circumstances, I imagine most doc-
tors would accept that it is ethically accept-
able to shorten survival by a few hours, or
maybe even by a few days. However, when
continuous sedation continues beyond this,
it is tantamount to ‘slow euthanasia’.
Regrettably, there is plenty of evidence that
the sedation is not always proportionate.
Further, in the Netherlands and Belgium
for example, CDS is sometimes used as a
proxy for EAS because it is more straight-
forward in terms of implementation, docu-
mentation, and external monitoring. In
France, CDS is now a legal right for termi-
nally ill patients should they request it on
the grounds of unbearable suffering,and the
activists who campaigned for this regard it
as substitute for EAS.
Apinis: What should the WMA and na-
tional medical associations do to teach their
doctors to improve their respective knowl-
edge, and their national politicians and fi-
nanciers that they should invest in hospice
and palliative care?
Twycross: Fortunately, palliative care does
now have greater global visibility than 30–
40 years ago.Every little helps; and hopeful-
ly the recent Scientific Session on palliative
care at the Annual Assembly of the WMA
will lead to several delegates from ‘palliative
care poor countries’ returning home deter-
mined to move things forward. Guidance is
available through such organizations as the
International Association for Hospice and
Palliative Care and the Worldwide Hospice
and Palliative Care Alliance, and regional
bodies such as the European Association
for Palliative Care.
E-mail: rob.twycross@spc.ox.ac.uk
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6 7
WMA Representatives
WMA Representatives
Apinis: Japan is among the top countries in
the world as to low infant mortality rate and
the highest average life expectancy. What is
the contribution of the Japan Medical As-
sociation in this area?
Michinaga: In Japan, maternal and child
health measures that seamlessly offer sup-
port from pregnancy to childcare based on
health checkups for expectant and nurs-
ing mothers and infants and Maternal and
Child Health Notebooks are well estab-
lished. This background leads to our glob-
ally high level of maternal and child health,
which further leads to low infant mortality
rate.
Recognizing the importance of the roles
of physicians and medical associations in
promoting the establishment of medi-
cal, health, and welfare environments for
the mother and child and supporting the
healthy mental/physical development of
children who will lead our next generations,
the Japan Medical Association (JMA) pro-
posed the JMA Declaration on Child Sup-
port concerning pregnancy, childbirth, and
childcare in May 2006.
The Declaration states the following:
• Support those who wish to become preg-
nant
• Enhance medical environment for safer
pregnancy and childbirth
• Ensure social environment for satisfying
(fulfilling, comfortable) pregnancy and
childbirth
• Enhance medical environment where
children can comfortably grow up
• Ensure social environment for childcare
• Enhance school health
• Support children with disabilities/diffi-
culties
• Advocate various measures for children
and child support to government officials
and others involved
It is worth noting that The Basic Law for
Child and Maternal Health and Child De-
velopment was enacted in December 2018
because of outreach activities by the JMA
and others.
The Basic Law clearly states that the na-
tional and local governments and other
organizations involved are responsible for
implementing necessary measures.
Under the public health insurance program
delivering Universal Health Coverage in
Japan, community planning is underway
wherein kakaritsuke physicians play the main
role. Its core is the collaboration of medical
and long-term care through the Commu-
nity-based Integrated Care System model;
moreover, efforts for prevention and healthy
living for local residents are underway.
Apinis:In Japan, the proportion of old peo-
ple is increasing. There is rising incidence
of chronic diseases. The role of preventive
medicine is growing in the Japanese health
care. Japan focuses on the extension of
healthy life expectancy. Please tell us about
the performance of the Japan Medical As-
sociation in this area.
Michinaga: The public health check-up
program in Japan is well established from
infancy to elderly, but the program is not
systematized. The JMA is proposing the
necessity of the systems as life-long health
services, In order to contribute to lifelong
health management for each individual citi-
zen, the data obtained from health check-
ups should be centralized and managed un-
der a strict privacy protection.
In addition, the Japan Health Conference
was launched in 2015, with the JMA Presi-
dent and Head of the Japan Chamber of
Commerce and Industry in joint represen-
tation roles.
The Conference is a place for leaders of the
business community, healthcare organiza-
tions, local governments, and others in-
volved to work together to extend healthy
life expectancy.
Apinis: You have done a lot to help the vic-
tims of the earthquake and nuclear disaster.
Could you describe the situation in these
areas at present?
Michinaga: In the Great East Japan Earth-
quake of March 2011, the JMA organized
the Japan Medical Association Team
(JMAT) – consisting of the members of all
prefectural medical associations, excluding
the four that suffered major damage – and
provided medical assistance in the affected
areas.
This experience has been applied further in
subsequent medical assistance activities in
Mari Michinaga
Interview with Mari Michinaga, Vice-Chairperson of Council of the
World Medical Association by WMJ Editor Peteris Apinis
major natural disasters, such as earthquakes,
major typhoons, and torrential rains.
The JMA is also planning various efforts
within the Confederation of Medical As-
sociations in Asia and Oceania (CMAAO)
region as the World Disaster Medicine
Platform plan, and an event to mark the
launch of the platform is scheduled for May
2020.
The JMA will be promoting the activity to
extend this plan to other WMA regions as
well.
Apinis: You have become the WMA Vice-
Chairperson of the Council. What are your
successes, reflections and conclusions?
Michinaga: In June 2019, the Health Pro-
fessional Meeting (H20) 2019, co-hosted
by the WMA and JMA, was held in To-
kyo, Japan. As the vice-chair of the WMA
Council, I served as a moderator for the
entire meeting and announced the adoption
of the Memorandum of Tokyo on Universal
Health Coverage and Medical Professions
with the Council chair. I also prepared its
report and submitted it to the WMJ.
In addition, the JMA and the International
College of Person-centered Medicine co-
hosted the 7th International Congress of
Person-Centered Medicine on the theme
“Work-Life Balance: Challenges and So-
lutions”, featuring physician burnout and
work style reforms (November 2019).
There, I chaired some sessions in which the
WMA president, council members, and
immediate past/former presidents partici-
pated.
Furthermore, at the CMAAO General As-
sembly in Goa in September 2019, I gave
a report on WMA meetings and related
events to CMAAO,which is positioned as a
WMA regional conference with the mem-
bership of 19 National Medical Associa-
tions in Asia-Oceania and to which I serve
as the Secretary General.
Apinis: You are the editor-in-chief of the
Japanese Medical Journal. What is dis-
cussed and advised by the Journal, and how
does it help in the work of Japanese doctors?
Michinaga: I should note that I am the As-
sociate Editor of the JMA Journal, not the
Editor-in-Chief. The JMA Journal accepts
a wide range of research papers in all fields
of medicine including clinical medicine,
basic medicine, and public health, as well
as the submission on heathcare policy and
opinions. Its purpose is to develop global
and broad perspectives and grow into a
widely shared journal in the international
community by collecting excellent study re-
sults from around the world.The JMA Jour-
nal is intended to serve as a powerful media
particularly for Japanese physicians and
medical researchers to speak out about their
achievements to the international commu-
nity. Its impact factor needs to be improved
to reach these goals.
The publication of this type of compre-
hensive English medical Journal is the first
challenge in Japan. The JMA Journal is ex-
pected to contribute to the enhancement of
medicine and the improvement of health-
care quality on a global scale by being read
and cited by many readers.
Apinis: Could you recommend good ar-
ticles of Japanese authors for the WMJ?
Michinaga: It seems to us that the WMJ
would merit to have in every number an ar-
ticle by some Japanese doctor presenting a
global view.
I recommend the following Japanese doc-
tors as authors for the WMJ:
• Dr.Shigeru Suganami,President,AMDA
(Association of Medical Doctors of Asia)
https://en.amda.or.jp/
• Dr.Masamine Jimba,Professor,Department
of Community and Global Health, Gradu-
ate School of Medicine, University of Tokyo
• Dr. Osamu Kunii, Head, Strategy, Invest-
ment and Impact Division (SIID)
• The Global Fund to Fight AIDS, Tuber-
culosis and Malaria
• Dr. Kenji Shibuya, Professor and Direc-
tor, University Institute for Population
Health, King’s College London
Apinis: We know that your special interest
is medical science. Could you tell us what
was essential in medical science in 2019 and
what to expect from 2020?
Michinaga: In December 2017, Japan’s
Prime Minister Shinzo Abe, with world
health leaders, supported the promotion
of universal health coverage (UHC) at the
UHC Forum 2017.
It grew into a global movement and led to
the Memorandum of Understanding be-
tween the WMA and the WHO in April
2018, establishing their collaboration on
UHC. In June 2019, the Health Profes-
sional Meeting (H20) 2019 was held as the
place to practice their cooperation.
At the G20 Osaka Summit and the Joint
Session of Finance and Health Ministers
(held at the end of the same month), the
importance of strengthening finance in
health to promote UHC and the shared
understanding for the need of sustainable
finance were expressed.
Last September, the United Nations High
Level Meeting on UHC was also held for
the first time, which raised the interest in
UHC promotion and led to concrete efforts
for its promotion among nations.
I believe that it was important that these
movements of UHC promotion and its ac-
celeration shifted from theory and moved
into practice.
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8 9
WMA Actualites
WMA Actualites
The Health Professional Meeting (H20)
2019 was held in Tokyo on June 13-14.The
theme of the meeting, jointly hosted by the
Japan Medical Association (JMA) and the
World Medical Association (WMA), was
the Road to Universal Health Coverage
(UHC).
In April 2018, JMA President Dr. Yoshita-
ke Yokokura, also the then President of the
WMA, concluded a memorandum of un-
derstanding (MOU) with WHO Director-
General Dr.Tedros Adhanom Ghebreyesus,
the purpose of which was to promote UHC
and emergency disaster preparedness. Thus,
the H20 meeting was organized as an op-
portunity to expound the implementation
of the MOU, focusing on the roles of physi-
cians and medical associations in promot-
ing UHC. Approximately 220 people from
38 countries, including eight countries from
the African region, were in attendance.
Opening ceremony
The opening ceremony took place in the
presence of Her Imperial Highness the
Crown Princess. At the opening of the
H20, Dr. Yoshitake Yokokura emphasized
the increasing importance of cross-border
unity among physicians worldwide, and ex-
pressed the desire to witness further UHC
progress under “beautiful harmony,” which
is the meaning of the new imperial era
Reiwa. The WMA President Dr. Leonid
Eidelman (the immediate past President
of the Israeli Medical Association) stated
that UHC promotion is a priority for the
achievement of the Sustainable Develop-
ment Goals, a global political objective, by
2030. He also called on the attendees to use
this meeting as an opportunity to debate
and discuss viable solutions for the further
promotion of UHC by strengthening co-
operation among the concerned parties in
each country.
Subsequently, Her Imperial Highness the
Crown Princess delivered a congratulatory
message. She referred to the high rates of
tuberculosis incidence and infant mortality
until the mid-twentieth century in Japan,
and to the fact that the Tuberculosis Con-
trol Law was enacted and the Mother and
Child Health Handbooks were introduced
in order to improve the situation. She ap-
preciated that the realization of Universal
Health Insurance in 1961 facilitated great
improvements in living conditions in Japan.
She also lauded the efforts of health pro-
fessionals in various organizations, includ-
ing the JMA, in supporting the health of
all Japanese people against the population
aging. In closing, she stated, “I wish that
your efforts will be fruitful in helping cre-
ate a world in which all people can enjoy a
healthy and happy life.”
Japanese Prime Minister Shinzo Abe stated
in his video message that the promotion of
UHC is an essential element of our society,
and appreciated that this meeting was be-
ing held in 2019, the year of the Japanese
Presidency of the G20 Osaka Summit. He
expressed his hopefulness regarding the
continued efforts of the concerned parties
toward the achievement of UHC.
Keynote addresses
The first keynote speech, titled Health In-
equities and Social Determinants of Health,
was delivered by Sir Michael Marmot, Pro-
fessor of Epidemiology, University College
London, Past President of the WMA. He
highlighted the fact that health is largely af-
fected by social situations, including wealth
gaps and poverty. He also pointed out that
it is imperative for health professionals to
take action to ensure that the global popula-
tion has access to better health. Health gaps
resulting from country-specific inequities in
healthcare constitute a social crisis impact-
ing much of the world. Thus, in addition to
the promotion of UHC, the following must
be ensured: (1) optimal childhood environ-
ment, (2) lifelong learning, (3) adequate
employment, (4) minimum income neces-
sary for maintaining an acceptable stan-
dard of living, and (5) disease prevention.
He called on all governments to act to aid
people in leading lives of dignity.
In the second speech, titled Toward UHC –
What We Need, Dr. Naoko Yamamoto,
Assistant Director-General, Universal
Health Coverage/Healthier Populations,
the WHO, pointed out that the realization
of UHC by 2030 would require the follow-
ing: (1) strong political leadership, (2) infu-
sion of funds into the field of healthcare, (3)
fostering of human resources, (4) primary
health care (PHC), and (5) development of
communities.Then,she enumerated the fol-
lowing expectations from medical associa-
tions: (1) participation in various fields be-
yond healthcare and advocacy and support
of activities placing a high value on human
health, (2) finding evidence, as well as effec-
tive policy formulation and implementation
based on the evidence collected, (3) playing
a role in cultivating human resources and
career path building, (4) improvement of
healthcare quality and promotion of peo-
ple-centered care, (5) contributing to fields
that require further research, education,
and practice, (6) taking action to manage
emerging infectious diseases and disasters,
and (7) cooperating and participating in
creating an environment where people have
basic knowledge of health and make efforts
to develop communities that promote and
foster healthy living.
Report on the Health Professional Meeting (H20) 2019
The Japan Medical Association
Session 1: Viewpoints on
How to Achieve UHC
According to the WHO, half of the world’s
population still lacks full coverage of essen-
tial health services, with about 100 million
people being pushed into extreme poverty
by having to pay for healthcare. In this ses-
sion, presentations were made from the
viewpoints of patients, international health
authorities, and medical associations.
From the perspective of a patient organiza-
tion, the International Alliance of Patients’
Organizations (IAPO), equitable and uni-
versal access to quality and affordable medi-
cations is indispensable. It was assured that
the IAPO is ready to work with the WMA
and its members to achieve UHC, placing
top priority on patient safety.
Medical professionals play a crucial role in
UHC.The expansion and transformation of
the health workforce is an investment an-
ticipated to pay a triple dividend: improved
health outcomes, enhanced global health
security, and economic growth through the
creation of employment opportunities. It is
necessary to ensure adequate public-sector
investment for education and employment
of health workers. It is anticipated that
medical associations will facilitate govern-
mental development and implementation
of robust national health plans and strate-
gies, and aid in the creation of resilient and
sustainable healthcare systems.
From the perspective of medical associa-
tions, advancing UHC requires addressing
the need for an adequate and well-trained
workforce, preventive care and health pro-
motion efforts, sustainable health financing
mechanisms, and strategic purchasing using
public funds. For example, to achieve UHC,
the Indian Medical Association provides
inputs into health governance and aids in
service delivery, particularly in fragile popu-
lations. It further advocated that to improve
health service delivery the deployment of
highly skilled health workers is crucial.
Session 2: Health
Security and UHC
Disasters and disease epidemics are major
threats to ongoing efforts to achieve UHC.
However, once attained, UHC can provide
a strong foundation for overcoming such
threats.This session addressed two major is-
sues: (1) the potential for controlling health
threats to contribute to achieving UHC, (2)
how UHC can be a key to overcoming vari-
ous devastating health threats.
Trust is important for responding to health
threats, such as natural disasters and dis-
ease epidemics, as it can build resilient
social systems bonding individuals, local
communities, and countries. It makes a
major contribution to overcoming dev-
astating health threats and, thereby, to
achieving UHC.
The international
community needs to
strengthen efforts to
support healthcare
systems in prepara-
tion for crises. UHC is
not possible until the
right to healthcare is
protected. It is neces-
sary to urge those re-
sponsible for inflicting
conflict and violence
to allow for neutral
and impartial treat-
ment of all victims. In
addition, amidst the
global health narrative
of achieving UHC,
doctors need to facili-
tate patient-centered
discussions. To pro-
mote UHC, healthcare
should be delivered
safely, and criminaliz-
ing medical colleagues
must be condemned
when they provide care
to patients.
In Thailand, UHC was successfully imple-
mented nationwide during the 2001-2002
period. This achievement is attributable to
the resilience of the health system, which
fostered the resilience of other essential
systems. The dynamics and interactions of
various groups and institutions within and
outside the health sector also reportedly
contributed to the marked effectiveness of
UHC and the resilience of the health sys-
tem.
Session 3: Political
Dimension of UHC/PHC
and Role of Medical
Professionals
UHC/PHC is more than simply a technical
challenge; its progress also depends on the
Yoshitake Yokokura, President of the World Medical
Association 2017–2018
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10 11
Tobacco Control
WMA Actualites
Introduction
Unanimously adopted by the World Health
Assembly in 2003, the Framework Conven-
tion on Tobacco Control (FCTC) is a land-
mark instrument due to its multifaceted
international legal approach [3; 20]. At that
point, the FCTC had been a decade in the
making. It seeks to address tobacco’s deadly
effect on public health,as it prematurely kills
between 5–6 million people each year [8]. It
may increase to killing more than 8 million
people per year by 2030 if current trends
continue, with 80% of premature deaths oc-
curring in low- and middle-income coun-
tries (LMICs) [9].
The FCTC uses six evidence-based strate-
gies, contained in the acronym MPOWER,
to reduce tobacco use [11]:
• Monitoring tobacco use and tobacco con-
trol policies
• Protecting people from dangers of to-
bacco smoke
• Offering help to quit tobacco
• Warning the public about the dangers of
tobacco
• Enforcing bans on tobacco advertising,
promotion, and sponsorship
• Raising tobacco taxes
The FCTC has contributed to an overall
decrease in smoking prevalence [6]. Nota-
bly, countries that have higher MPOWER
composite scores see a greater decrease in
current tobacco smoking [19].
Using the FCTC as a guiding document,
many countries, such as Spain and Kenya,
have created national coordination strate-
gies that adopt a multi-sectoral approach
to control tobacco [6; 9]. There has been
substantial progress in FCTC articles that
address the packaging of tobacco products,
protection from exposure to tobacco smoke,
public awareness and education, and the
reporting and exchange of information [6;
9]. There has been some progress in articles
that address regulations on taxes, advertis-
ing, sponsorship, illicit trade, and research
[6; 9]. While not as significant, there has
also been progress in articles that address
environmental protection, liability, and
economically viable alternatives for farmers
who grow tobacco [6; 9].
Successful implementation of the FCTC is
supported by a variety of factors. A crucial
element is a stable, effective political system
with a national tobacco control plan and the
capabilities to successfully enforce tobacco-
control policies [9; 15; 16]. Other beneficial
factors include having accountability across
stakeholders, including NGOs, and having
higher levels of FCTC implementation,
such as having mandated graphic warn-
ing labels (GWLs) on tobacco packaging
[10; 12].
There are also many factors that impede
FCTC adoption and implementation. The
global tobacco industry is a hugely impor-
tant obstructing factor, as will be discussed
later. Other factors include smoking-ac-
cepting cultures [23]; ineffective implemen-
tation of existing guidelines [9; 13]; illicit
trade [18]; lack of stakeholder involvement
[6; 9; 11]; lack of a multisectoral approach
[6; 17; 25]; and lack of sufficient resources,
capacity, and support, especially for LMICs
[6; 9; 14; 17]. In addition, not enough spe-
cial action has been made for vulnerable or
disadvantaged groups, such as youth, which
the tobacco industry targets [6].
Møller’s Memo
On June 28, 2019, Michael Møller, the out-
going director of the UN Office at Geneva,
raised skepticism against the tobacco-in-
dustry ban imposed by the FCTC by writ-
ing a memo directed to UN Secretary Gen-
eral António Guterres. In this memo, he
proposes that engaging the tobacco indus-
try in discussions may help better achieve
the 2030 SDGs for a “more nuanced ap-
proach”, since “businesses which are legiti-
mate enough to pay taxes to governments
should also be legitimate enough to partici-
pate in discussions concerning joint efforts
to minimize health risks and address other
problems of a common nature” (memo).
While this memo is worthy of consideration
as a “think piece” (foreign policy article), its
purpose as suggested by Møller’s chief of
staff, David Chikvaidze, is clear – the UN
should not engage the tobacco industry in
matters relating to tobacco control.
Evidence of TII
A substantial reason is the evident history
of persistent tobacco industry interference
(TII), which has been recognized as the
most important barrier against FCTC
implementation [2; 6]. Investigative re-
ports into TII have shown that the industry
views the WHO as an enemy and has paid
consultants to discredit key individuals and
the WHO, with a key strategy to “contain,
Ruth T. Lee
The FCTC and Tobacco Industry
political processes unique to the context of
each country and healthcare system. Medi-
cal professionals have a crucial role to play
in health policy. In this session, discussions
focused on the presentations of distin-
guished speakers from different angles such
as the national government, global health
academia, and national and world medical
associations.
In the case of Lebanon, it was shown that
the active involvement of medical pro-
fessionals contributed to conversion to
people-centered healthcare in the PHC
network. World health systems are chal-
lenged by population aging, chronic dis-
eases, an explosion of health technologies,
and globalization. System transformation
is required to ensure that no one is left
behind.
In the US, whether to continue with or re-
peal the Affordable Care Act (ACA, widely
referred to as “Obamacare”) is the major
subject in current debates on healthcare
reform. The new administration is eager to
repeal the ACA, which has led to concerns
regarding the erosion of patient protec-
tion. The American Medical Association
forms a broad alliance that aims to take the
necessary actions to protect the interests of
patients and their families. An appeal was
made for medical associations to engage
more actively in the ongoing debate on how
to deliver PHC.
To strengthen PHC, which is an essential
component of UHC, it is important to
achieve sustainable healthcare system fi-
nance, invest in efficient PHC, implement
performance evaluation and data collection
relevant to PHC, and strengthen partner-
ships among international health institu-
tions. It was also pointed out that the es-
tablishment of healthcare systems is the
most important element of social common
capital, ultimately serving as the foundation
of an affluent society.
Session 4: Shared
Responsibilities and Individual
Obligations toward UHC
In this session, Dr. Yoshitake Yokokura
made a speech on the steps necessary for
achieving UHC in Japan. In Japan, the pro-
vision of health insurance as an essential
part of UHC, in which all citizens are cov-
ered by insurance, was achieved in 1961. Dr.
Yokokura explained that until this achieve-
ment, there had been extensive discussions
among physicians, medical associations, and
governments about the medical practices of
physicians and healthcare expenditures, as
well as many other relevant factors. Given
that Japan is currently facing the challenge
of population aging, the national health in-
surance program must be firmly maintained
as the cornerstone of UHC. The JMA ex-
presses its views to the government based
on two criteria: does any policy contribute
to safe healthcare for the public and does
such a policy allow for UHC to be main-
tained through public health insurance? He
concluded by stating that with this in mind,
it is important for the JMA to continue
making proposals aimed at promoting and
maintaining the most appropriate health-
care system in which medical practitioners
can provide optimal level of care.
In the subsequent panel discussions among
representatives of the government, JMA,
WHO, and international organizations,
sharing the ongoing global UHC initiatives
and approaches, challenges and opportuni-
ties for achieving UHC, and a proposal of
solutions and actions for promoting UHC
were discussed, and various issues impeding
the achievement of UHC were highlighted.
These issues include shortage of human re-
sources in healthcare, regional issues such
as Ebola hemorrhagic fever, differences in
health insurance systems across countries,
and relationships with patients. In particu-
lar, the shortage of human resources was
shown to be related to the global shortage
of human resources involved in primary
care, concentration of human resources in
urban areas that are advantageous in terms
of pay and education, and the trend of med-
ical students from developing countries sent
to developed countries for educational pur-
poses not returning home. Thus, the prob-
lem is not only of absolute numbers but also
uneven distribution of resources. Further,
the importance of trusting relationships
between healthcare providers and receivers
was highlighted. Continuing efforts in each
country and unity among physicians across
countries were identified as essential for
solving a variety of problems and ultimately
achieving the aim of providing UHC.
Adoption of Memorandum
of Tokyo on UHC and the
Medical Profession
The H20 adopted the Memorandum of To-
kyo on UHC and the Medical Profession
that prescribed mainly (1) strengthening the
understanding and involvement of UHC
and primary care, (2) designing long-term
national policies aimed at achieving UHC,
and (3) defining the roles of physicians and
medical associations and formulating pro-
posals relevant to governmental policies and
to all aspects of society.
This memorandum calls on physicians and
their medical associations worldwide to
play a profound role in the advocacy for and
achievement of UHC. In addition, it ex-
presses hope that the G20 Summit will focus
on pursuing sustainable investments in the
healthcare systems of not only the G20 coun-
tries but also other economies where health-
care system investments are still insufficient.
Memorandum of Tokyo on Universal Health
Coverage and the Medical Profession
see on the cover p. iii
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12 13
Environmental Health
Tobacco Control
neutralize, and reorient WHO” (as quoted
in 10) away from tobacco control and other
NCDs.
The tobacco ‘big five’ – Philip Morris In-
ternational, British American Tobacco, Im-
perial Brands, Japan Tobacco International,
and China National Tobacco Company  –
has substantive economic power, with reve-
nues of one of these companies itself match-
ing the GDPs of countries like Morocco
and Ecuador [10]. Their economic leverage
and financial interests have caused them to
interfere with tobacco control by lobbying
governments and advocating for regulations
concerning looser advertising restrictions,
voluntary warning labels, and lower taxes
under a guise of ‘social responsibility’ for
the public interest [6; 12]. This is apparent
in the issue of illicit tobacco trade, which
has been used by tobacco industry – even
though research has shown that the major
multinational tobacco companies them-
selves have been involved in tobacco smug-
gling  – to prevent governments without
adequate financial capacity to pass stronger
tobacco control policies [18]. The industry
has been shown to fund surveys of dubi-
ous methodology that show associations
between tobacco control and large increases
in illicit trade – a finding inconsistent with
independent research [18]. Tobacco com-
panies also have a history of exaggerating
the number of job losses if tobacco control
measures are taken, especially on alternative
crops to reduce tobacco farming [40]. The
reality is that these measures cause no im-
mediate negative impact on tobacco farm-
ing or job losses in many countries [40].
The tobacco industry also tries to present it-
self as a partner to governments. One tactic,
demonstrated by a reported visit by a Turk-
ish ambassador to the Philip Morris Inter-
national Jordan headquarters, is one where
the industry advocates for a strategy on com-
bating illicit trade: reducing tobacco prices
[18]. Another tactic to present the industry
as a partner is by developing and market-
ing new product strategies of ‘reduced-risk
products’ like heated tobacco products and
e-cigarettes [16], which Møller references
in his memo as “highly advanced research
efforts to minimize the harmful effects of
their own products.” However, the research
is clear that these products are still harmful
to health [44].
A significant portion of TII is directed to-
wards warning labels on cigarette packag-
ing. A result, for example, is that between
1992 and 2012, sixteen countries made vol-
untary agreements with the tobacco indus-
try to put weak, text-only health warning
labels (HWLs) on cigarette packages [12].
Philip Morris in 1992 put English-language
HWLs on the sides of packages being sold
in 49 small, mostly African countries whose
native languages are not English  [12]. In
2008 in Vietnam, text-only health warnings
of “Smoking can cause lung cancer” and
“Smoking can cause COPD” covering 30%
of the cigarette package became the mini-
mum requirement after successful TII, con-
ducted against the MOH’s effort to push
through legislation requiring GWLs that
would cover 50% of the package [3].
A once-secret document of British Ameri-
can Tobacco revealed that the industry tries
to foster government relations and com-
munity involvement programs to maintain
looser regulations, especially in marketing,
with results like a proposed ad ban in Sierra
Leone removed from the Cabinet at the vot-
ing stage [15].In Botswana,the industry in-
directly advertises their products by printing
their tobacco product logos on clothing and
even school bags, effectively making chil-
dren “walking billboards” [15]. The tobacco
industry has also gone to court to challenge
tobacco control policies,with results like the
suspension of the public smoking ban set by
the Tobacco Control Act of 2007 in Kenya
[15]. Furthermore, the Dutch government
has held frequent consultations with the to-
bacco industry concerning current policies,
but there is no transparency and no minutes
of these meetings recorded in many cases
[24]. Ugandan policymakers have held se-
cret meetings with representatives of British
American Tobacco, and there is evidence of
bribery from British American Tobacco in
East Africa [16].
Conclusion
While Møller’s memo raises important
points regarding the tobacco industry, his-
tory overwhelmingly shows that there is no
place for the tobacco industry in discussions
of surrounding tobacco control. As private
corporations, tobacco companies are natu-
rally interested in financial profit and have
been shown to influence policies for their
self-interest. Engaging them in tobacco
control discussions will only be a slippery
slope, undermining the WHO and other
UN agencies’ goals of protecting human
health and environment and promoting
sustainable development. The industry has
tried to present itself as a partner, especially
through promoting smokeless alternatives.
But no matter what form it takes, tobacco
kills. If the goal truly is to achieve the high-
est attainable standard of health, then it is
plain that the tobacco industry cannot be
given a legitimate voice at the table.
References
Memo: https://assets.documentcloud.org/
documents/6188745/UN-Secretary-General-
Tobacco-Agenda.pdf
Foreign policy article: https://foreignpolicy.
com/2019/07/12/document-of-the-week-is-
the-u-n-revisiting-the-ban-on-big-tobacco/
1. https://www.reuters.com/investigates/special-
report/pmi-who-fctc/
2. http://www.who.int/fctc/cop/cop7/FCTC_
COP_7_4_EN.pdf
3. http://apps.who.int/iris/bitstream/han-
dle/10665/44244/9789241563925_eng.pdf;jses
sionid=84182F40181983FCD2648F5FCB099
B39?sequence=1
4. http://www.who.int/fctc/reporting/sum-
mary_2007_document_cop_2_6.pdf
5. http://apps.who.int/iris/bitstream/han-
dle/10665/147117/FCTC_COP6_15-en.
pdf?sequence=1&isAllowed=y
6. http://www.who.int/fctc/cop/cop7/FCTC_
COP_7_6_EN.pdf
7. http://www.who.int/fctc/reporting/2016_glob-
al_progress_report.pdf
8. https://academic.oup.com/eurpub/arti-
cle/26/1/1/2467458
9. https://tobaccocontrol.bmj.com/content/ear-
ly/2018/07/25/tobaccocontrol-2018-054374
10. https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC4884895/pdf/je-26-279.pdf
11. https://www.thelancet.com/journals/lancet/arti-
cle/PIIS0140-6736(13)62155-8/abstract
12. https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3795937/
13. https://bmcpublichealth.biomedcentral.com/
articles/10.1186/1471-2458-10-1
14. https://www.tobaccofreekids.org/assets/global/
pdfs/en/fctc_implementation_guide.pdf
15. https://www.ncbi.nlm.nih.gov/pub-
med/22163209
16. https://www.ncbi.nlm.nih.gov/pub-
med/28492203
17. https://www.ncbi.nlm.nih.gov/pub-
med/26876626
18. https://tobaccocontrol.bmj.com/con-
tent/23/4/279
19. https://www.thelancet.com/journals/lanpub/
article/PIIS2468-2667(17)30045-2/fulltext
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med/21243194
22. http://www.scielo.org.za/pdf/samj/v105n8/13.
pdf
23. https://www.ncbi.nlm.nih.gov/pub-
med/27087176
24. https://blogs.bmj.com/tc/2014/09/15/the-
netherlands-dutch-government-sued-over-
who-fctc-violations/
25. http://fctc.wpengine.com/wp-content/up-
loads/2015/02/FCTC_Shadow_Report_2014.
pdf
26. http://www.itcproject.org/node/70
27. https://tobaccocontrol.bmj.com/con-
tent/9/2/129.8
28. https://www.vox.com/2016/6/2/11818692/
plain-packaging-policy-us-australia
29. https://academic.oup.com/eurpub/arti-
cle/26/1/1/2467458
30. https://seatca.org/dmdocuments/SEATCA%20
WNTD%202013%20on%20TAPS_new.pdf
31. https://www.indonesia-investments.com/news/
todays-headlines/why-indonesia-doesn-t-rati-
fy-who-s-framework-convention-on-tobacco-
control/item6932?
32. http://www.academia.edu/17889167/
POLITICAL_ECONOMY_ANALY-
SIS_IN_NON-COMPLIANCE_INDONE-
SIA_TOWARDS_FRAMEWORK_CON-
VENTION_ON_TOBACCO_CONTROL
33. http://www.archive.healthycaribbean.org/publi-
cations/documents/reporte_cmct_ingles_1.pdf
34. https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2630219/
35. http://siteresources.worldbank.org/HEALTH-
NUTRITIONANDPOPULATION/Resourc-
es/281627-1095698140167/Aloui-Analysis_of-
whole.pdf
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article-view/feature-article-tobacco-control-in-
south-africa-the-fctc-and-lessons-from-other-
countries
37. https://escholarship.org/uc/item/09t535s7
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article?id=10.1371/journal.pmed.1001639
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com/articles/10.1186/s12992-015-0139-3
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cocontrol/28/Suppl_2/s113.full.pdf
44. https://www.cancer.net/navigating-cancer-care/
prevention-and-healthy-living/stopping-tobac-
co-use-after-cancer-diagnosis/health-risks-e-
cigarettes-smokeless-tobacco-and-waterpipes
Ruth T. Lee
Introduction
Noise pollution is regular exposure of
undesirable or hostile sounds at elevated
sound levels that can lead to adverse ef-
fects in humans or other living organisms.
According to WHO guidelines 2018 for
average noise exposure, the Guideline De-
velopment Group (GDG) strongly rec-
ommends reducing noise levels produced
by road traffic below 53 decibels (dB), as
road traffic noise above this level is asso-
ciated with adverse health effects. Noise
pollution is increasingly becoming a po-
tential hazard to health, physically and
psychologically, and affects the general
well-being of an individual [1]. It can dis-
turb sleep, cause cardiovascular and psy-
cho physiological effects, reduce perfor-
mance and provoke annoyance responses
and changes in social behavior [2]. The
Mehak Maheshwary
Hearing Screening in Traffic Police
Personnel in Multiple Centers in India
Sarika Verma
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14 15
Environmental Health
Environmental Health
first effects of exposure to excess noise are
typically an increase in the threshold of
hearing (threshold shift), which is defined
as a change in hearing thresholds of an
average 10 dB or more at 2000, 3000 and
4000  Hz in either ear (NIOSH, 1998).
Threshold shift is the precursor of noise
induced hearing loss (NIHL), the main
outcome of occupational noise. Because
hearing impairment is usually gradual, the
affected worker will not notice changes
in hearing ability until a large threshold
shift has occurred. Noise-induced hear-
ing impairment occurs predominantly at
higher frequencies (3000−6000 Hz), with
the largest effect at 4000 Hz. It is irrevers-
ible and increases in severity with contin-
ued exposure [3]. According to WHO,
disabled hearing loss is defined as “per-
manent unaided hearing threshold level
for the better ear of 41 dB hearing loss or
greater for the four frequencies 500, 1000,
2000 and 4000 kHz” [3]. In India, due to
urbanization and marked increase in ve-
hicular traffic in the past few years, there
has been an exponential rise in the levels
of noise pollution generated on road.Since
the traffic police personnel have continu-
ous and prolonged exposure to such high-
level of noise from these vehicles, they are
at a very high risk of developing NIHL. In
this study we aim to determine the effect
of noise pollution on the hearing of traffic
police personnel.
Materials and methods
On the occasion of International Noise
Awareness Day 2019,Indian Medical Asso-
ciation’s National Initiative for Safe Sound
(NISS) carried out a screening study to as-
sess hearing in traffic police personnel in
Gurugram, Agra, Nawashahar, Dibrugrah,
Guwahati,Panipat,Rewari and Karnal.This
cross-sectional study was done to screen the
traffic police personnel for hearing loss.
Screening was done using Pure Tone Audi-
ometry.The severity of NIHL was based on
the WHO grading.
Table 1: Grades of hearing according to
WHO
Grade of hearing Degree of hearing loss
Normal hearing
0–25 dB or loss (bet-
ter ear)
Mild impairment 26–40 dB (better ear)
Moderate im-
pairment
41–60 dB (better ear)
Severe impair-
ment
61–80 dB (better ear)
Profound impair-
ment
>80 dB (better ear)
The subjects have never used any form of
protective equipment to insulate their ears
from high traffic noise levels. Police person-
nel with pre-existing ear disease were ex-
cluded from the study.
Results
A total of 588 traffic police personnel were
screened across 8 cities in India using pure
tone audiometry. 266 (45.23%) had normal
hearing while 320 (54.42%) had some form
of sensorineural hearing loss.2 (0.34%) per-
sonnel had conductive hearing loss. Out of
the 320 police personnel who had hearing
loss, 175  (54.68%) had mild hearing loss,
91(28.43%) had moderate, 25 (7.81%) had
severe to profound and 29 (9.06%) had high
frequency dip at 4000 Hz.
Table 2: Results of screening showing per-
centage of police personnel with hearing
loss
Total number of police
personnel screened
588
Number of police person-
nel with normal hearing
(<25 dB)
266 45.23%
Number of police person-
nel with sensorineural
hearing loss
320 54.42%
Number of police person-
nel with conductive hear-
ing loss
2 0.34%
Discussion
Noise pollution has several detrimental ef-
fects on the human body,the most important
being hearing impairment. Noise-induced
hearing loss (NIHL) is the second most
common cause of sensorineural hearing loss
after age induced hearing loss or presbycu-
sis. Sustained exposure to loud noise is as-
sociated with damage to outer hair cells of
the cochlea in the inner ear.These hair cells
are responsible for conversion of sound en-
ergy to electrical signals transmitted to the
brain. The damage is irreversible. In gen-
eral, the amount of noise required to cause
permanent damage from chronic exposure
is anything equivalent to 10 years or more
at a level of 85 dB for more than 8 hours
175
55%
91
28%
25
8%
29
9%
Personnel with mild hearing loss
Personnel with moderate hearing loss
Personnel with severe to profoundhearing loss
Personnel with notch at 4000 Hz
Figure 1: Type of hearing loss in police personnel
a day [4,5]. The maximum hearing loss due
to noise exposure is 40 dB at low frequency
and 75 dB at high frequencies but when the
effects of presbycusis are added, the thresh-
olds may become greater [6,7].
Noise related hearing changes can be cat-
egorized into three groups: noise-induced
temporary threshold shift (NITTS), noise-
inducedpermanentthresholdshift(NIPTS)
and acute acoustic trauma. Initial exposure
to excessive sound level causes temporary
dullness of hearing (temporary threshold
shift) which usually recovers within 24 h of
exposure [8]. If there is repeated sustained
exposure, the threshold shift becomes per-
manent (permanent threshold shift) due
to nerve fiber degeneration. Acute acoustic
trauma is defined as sudden exposure to a
loud sound like an explosion which can re-
sult in permanent hearing loss.
The first signs of NIHL can be observed
in the typical 4000-Hz “notch” observed
on audiograms, indicating a loss of hearing
ability in the middle of the frequency range
of human voices [9].
Occupational noise is a widespread risk
factor, with strong evidence base linking it
to an important health outcome (hearing
loss) [3].An assessment of the burden of
disease associated with occupational noise
can help guide policy and focus research on
this problem. This is particularly important
in light of the fact that policy and practical
measures can be used to reduce exposure to
occupational noise [10].
Traffic or vehicular noise is becoming a sig-
nificant health hazard in India. The traffic
police personnel are affected the most due to
this increasing noise pollution and are at high
risk for noise induced hearing loss. There are
very few studies carried out regarding the
estimation of auditory effects of noise gen-
erated by automobiles among traffic police
personnel in India. Moreover, because of the
insidious nature of the disease and lack of aware-
ness, the majority of them are unaware of the ef-
fects of noise pollution. The present study was
undertaken to study the effect of noise pollu-
tion on the hearing in traffic police personnel
across various cities in India.
In this study, 588 police personnel were
screenedin8citiesacrossIndia.266(45.23%)
had normal hearing while 320(54.42%) had
some form of sensorineural hearing loss.
The results of this study are in concordance
with similar studies done in India where the
prevalence of NIHL among Pune traffic
police is 81.2%, 66.4% among traffic po-
lice personnel in Kathmandu city, 22% in
Jammu traffic police personnel, 63.48% in
Madurai and 94% in Thoothukudi .
The strength of the present study is the data
size as well as the study being conducted in
different parts of India and hence it gives a
larger picture of the effect of noise induced
hearing loss among police personnel. All
the police personnel are actively working
and medically fit and hence it also provides
an insight into the burden hearing loss in
our country, which by and large, remains
undiagnosed or untreated. Since the study
was only a one time screening for hearing
evaluation, we were not able to measure the
exact level of noise exposure. Also age relat-
ed hearing loss was not taken into account.
According to WHO recommendations
• For average noise exposure,the Guideline
Development G roup (GDG) strongly
recommends reducing noise levels pro-
duced by road traffic below 53  decibels
(dB), as road traffic noise above this level
is associated with adverse health effects.
• For night noise exposure, the GDG
strongly recommends reducing noise lev-
els produced by road traffic during night
time below 45  dB, as night-time road
traffic noise above this level is associated
with adverse effects on sleep.
• To reduce health effects, the GDG
strongly recommends that policymakers
implement suitable measures to reduce
noise exposure from road traffic in the
population exposed to levels above the
guideline values for average and night
noise exposure. For specific interventions,
the GDG recommends reducing noise
both at the source and on the route be-
tween the source and the affected popula-
tion by changes in infrastructure.
NIHL is a major avoidable cause of per-
manent hearing impairment. Some effec-
tive ways to prevent NIHL in traffic police
personnel
• Strict Implementation of the existing Noise
Rules 2000 including fine for unnecessary
honking on Indian roads, Implementa-
tion of Silent Zones in Towns and Cit-
ies and removal of loudspeakers from all
places of worship.
Table 3: Data from individual cities
Sr.No. Centre Doctor in charge
Total no.
of per-
sonnel
screened
Number of
personnel
with normal
hearing
Number of
personnel with
sensorineural
hearing loss
1 Gurgaon Dr. Sarika Verma 124 67 (54.03%) 57 (45.96%)
2 Nawashahar
Dr. Harinder Pal
Singh
24 8 (33.33%) 16 (66.66%)
3 Guwahati Dr. Swagata Khanna 27 9 (33.33%) 18 (66.66%)
4 Dibrugarh Dr. Swagata Khanna 43 17 (39.53%) 25 (58.13%)
5 Agra Dr. Rajiv Pachauri 11 5 (45.45%) 5 (45.45%)
6 Rewari Dr. Adesh Saxena 52 48 (92.31%) 4 (7.69%)
7 Panipat Dr. Pritam Arora 169 77 (45.56%) 92 (54.43%)
8 Karnal Dr. Sanjay Khanna 138 35 (25.36%) 103 (74.63%)
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Universal Health Coverage
Environmental Health
• Use of hearing protective devices such as
ear muffs, ear plugs and ear canal caps.
• Periodic health check-ups and hearing
assessment of police personnel.
• Duty scheduling or duty rotation for ex-
posure limitation.
• Health authorities and NGOs must cre-
ate awareness among traffic police personnel
about the auditory and non auditory effects
of noise by implementing education and
training programmes for traffic police
personnel about the auditory and non-
auditory effects of noise.
• At policy level, the government should
take adequate steps to reduce the level of
the horn from present levels of 90–112dB
to 50–65dB. Efforts should also be
made to reduce the engine noise of ve-
hicles towards lowering levels of traffic
noise.
• Noise Mapping of India should be under-
taken with urgency to document the ex-
isting noise levels and then address the
problem of ambient noise higher than the
permissible limits as recommended by the
WHO.
• School text books should educate children
about good driving habits including driv-
ing without using the horn except in life
threatening situations. The habits of sev-
eral decades can only be changed through
educating the next generation.
Conclusion
As can be seen of this preliminary screen-
ing of 588 traffic police personnel, con-
tinuous exposure to loud and chronic
noise causes sensorineural hearing loss in
the long run. 54.42% of those screened
had hearing loss. Considering that India
has the highest number of SNHL people
above the age of 65 years, it is time to put
WHO and European Guidelines 2018
into practice along with enforcing Noise
Rules 2000. Immediate and urgent steps
must be taken to prevent Noise Induced
Hearing Loss (NIHL) develop into a seri-
ous health issue in India.
Table 4: Comparison of our study with other studies in India
Title of the study
City/Year of
study
Number of traffic
police personnel
screened
Results
Prevalence of occupational noise induced hear-
ing loss amongst traffic police personnel VK
Singh, AK Mehta [11]
Pune
(Maharashtra)
1995
421
Total number with hearing loss – 342 (81.2%)
Mild hearing loss – 213 (62.3%)
Moderate to severe hearing loss – 129 (37.7%)
Prevalence of noise induced hearing loss among
traffic police personnel of Kathmandu Metro-
politan City Shrestha I, Shrestha BL, Pokharel
M [12]
Kathmandu
(Nepal)
2011
110
Total number with hearing loss – 73 (66.36%)
Mild hearing loss – 57 (51.8%)
Moderate hearing loss – 15 (13.6%)
Severe hearing loss – 1 (0.9%)
4000 Hz notch – 73 (66.4%)
Pattern of noise induced hearing loss and its re-
lation with duration of exposure in traffic police
personnel M. Gupta, V. Khajuria, M. Manhas
[13]
Jammu city
(Jammu and
Kashmir)
2015
150 Total number with hearing loss – 33 (22%)
Prevalence of noise induced hearing loss among
police personnel in Madurai city
Dhinakaran N, Karthikeyan B. M [14]
Madurai
(Tamil Nadu)
2017
241 Total number with hearing loss – 153 (63.48%)
A Study on noise-induced hearing loss of po-
lice constables M Senthil Kanitha, C Balasub-
ramanian, Heber Anandan [15]
Thoothukudi
(Tamil Nadu)
2018
50
Total number with hearing loss – 94%
Mild hearing loss – 26%
Moderate hearing loss – 38%
Severe hearing loss – 36%
4000 Hz notch – 92%
Effect of road traffic noise on auditory thresh-
old in traffic police personnel KG Venkatappa,
V S hankar, Dr. Sparshadeep [16]
Kolar
(Karnataka)
2018
30
Total number with hearing loss – 8 (26.66%)
Mild hearing loss – 5
Moderate hearing loss – 3
Our Study
Multiple cities
across India
2019
450
Total number with hearing loss – 320 (54.42 %)
Mild hearing loss – 175 (54.68%)
Moderate hearing loss – 91 (28.43%)
Severe to profound hearing loss – 25 (7.81%)
4000 Hz notch – 29 (9.06%)
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9. McBride DI,William S. Audiometric notch as a
sign of noise induced hearing loss. Occup Envi-
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Dr. Sarika Verma,
Dr. Mehak Maheshwary
Gurugram, India
The Global Fund to fight AIDS, Tuber-
culosis and Malaria (the Global Fund)
was invited to H20 Meeting co-hosted by
World Medical Association (WMA) and
Japan Medical Association (JMA) on June
13 and 14 in Tokyo to present the Global
Fund’s contribution towards achieving uni-
versal health coverage (UHC) and Sustain-
able Development Goal 3 (SDG 3) “Ensure
healthy lives and promote wellbeing for all
at all ages”.
Based on this presentation, this article de-
scribes the role, achievement and challenge
of the Global Fund towards UHC and SDG
3, a country’s good practice of tremendous
progress, and shares my personal expecta-
tions for medical professionals, national
medical associations, and WMA to achieve
global common goals of UHC and SDG 3.
Role of the Global Fund
to achieve UHC
Since its inception in 2002,the Global Fund
has mobilized financial resources from all
over the world and has been supporting
more than 140 countries by disbursing more
than US$41 billion [1],making it one of the
largest financiers or channels of assistance
for global health [2].
The Global Fund is called the 21st
century
partnership organization because relevant
key partners such as donor and implement-
Achieving Universal Health Coverage and Sustainable
Development Goals: The Global Fund’s contribution and my
expectation for medical professionals, national medical associations
and World Medical Association
Osamu Kunii
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18 19
Universal Health Coverage
Universal Health Coverage
ing governments, UN and international aid
organizations, private sector, civil society
and affected communities are engaged in
and highly committed to the whole process-
es of the Global Fund to maximize impact,
including decision making in the Board
and its committees, resource mobilization,
strategy development, in-country planning
and implementation of the Global Fund-
supported programs.
As a result, this Global Fund partnership
has brought a drastic progress in scaling up
of essential services in the fight against three
diseases (Figure 1) and building health sys-
tems, which has saved a total of 32 million
lives as of the end of 2018 with 56%, 22%
and 46% reduction of the number of deaths
due to HIV, tuberculosis and malaria re-
spectively since 2002 when nearly 5 million
people had died of the three diseases [1].
For example, Rwanda demonstrated a mas-
sive scale-up of essential HIV services sup-
ported by the Global Fund and partners
(Figure 2) and consequently led to an out-
standing reduction of AIDS-related mor-
tality (Figure 3) [3].There was a time when
almost none of the HIV infected people
in Africa could get access to antiretroviral
therapy (ART) while it was available and
accessible among those in developed coun-
tries. Thus, this is the remarkable result and
victory of human beings with collective ef-
forts and shared responsibility.
Without cross-cutting interventions or hori-
zontal approach of health systems it is impos-
sible to control and end major epidemics like
AIDS, tuberculosis and malaria. Therefore,
the Global Fund has been assisting countries
in building resilient and sustainable systems
for health (RSSH), and promoting and pro-
tecting human rights and gender equality, as
two of the four pillars of the Global Fund
Strategy for 2017– 2022 and two critical
foundations of UHC. Notably, the Global
Fund invests more than US$1 billion per
year in building RSSH, which is among the
largest multilateral financiers in this area,and
has supported the low- and middle-income
countries in improving procurement and
supply chains; strengthening data systems
and its use; training health workers; building
stronger community responses and systems;
and promoting the delivery of more integrat-
ed, people-centered health services.
Challenges to Achieve
Ending Epidemics
Despite the progresses made, HIV, tubercu-
losis and malaria still infected more than 230
million people and killed more than 8,000
people daily in the world in 2017, which
means that the two-day death toll of three
infections is more than the two-year death
toll of Ebola outbreaks in 2014–15 [4,5,6,7].
Recognized as the world’s unmet agenda
and still leading causes of deaths among in-
fections in many countries, the fight against
these three diseases are included in SDG 3
as Target 3.3 “By 2030, end the epidemics
of AIDS, tuberculosis, malaria and neglect-
ed tropical diseases and combat hepatitis,
water-borne diseases and other communi-
cable diseases.”
Each disease in this target has its own glob-
ally agreed specific targets such as 95-95-95
by 2030 of Fast-Track Strategy for HIV [8];
reduction in deaths by 90% (95%), and new
cases by 80% (90%) by 2030 (2035) com-
pared with 2015 levels for tuberculosis [9];
reduction in mortality and incidence rates
by 90% by 2030 for malaria [10].
While these targets are set based on data,
global consultations and discussions [8,
9, 10, 11], there are challenges to achieve
those targets [12]. Especially, the global
target against tuberculosis looks ambitious
to reach unless the current global trend of
annual 2% reduction of incidence is dra-
matically geared toward more than 10% re-
duction (Figure 4). At the current trend of
decline in incidence, it will take humanity
130 years to end tuberculosis [13].
Tuberculosis is now the top killer pathogen
among infections with 1.6 million deaths
and 10 million new cases in 2017, and 36%
of those new cases are left “missing”– unde-
tected, untreated or unreported, which leads
to ongoing transmission of the disease and
the spread of drug-resistant tuberculosis [5].
To break through these challenges, the
world is pursuing new scientific knowledge
and innovations such as new diagnostics
and treatments more effective and efficient
to find and treat cases and latent infections,
and vaccines and others to prevent infec-
tions. Yet, it is also considered possible to
bend the curve by optimizing even the cur-
rently existing tools and pursuing UHC and
social protection [13]. Some counties have
shown rapidly bending curves of tuberculo-
sis mortality and morbidity in the past even
before effective diagnostics and medications
came into existence.
Good Practice of Japan
One of those countries is Japan where tu-
berculosis killed more than 100,000 people
annually before 1950.Tuberculosis was then
called “the national disease” as the leading
cause of death and accounting for 15% of all
deaths [14,15].However,Japan demonstrat-
ed one of the sharpest declines in tuberculo-
sis mortality in the world from 1950 to 1970
– with mortality reduction of 50% by 1955,
80% by 1960, and 90% by 1970 compared
to the mortality in 1950, which brought an
average annual reduction of almost 12% in
this period [14,15,16] (Figure 5).
What made this happen? Besides economic
growth and social development after World
War II, several factors were identified as as-
sociated with this success, which include
strong political commitment and actions,
public-private partnership, multisectoral ap-
proach and community engagement [14,15].
Political commitment and actions encom-
pass enactment and enforcement of various
laws and acts such as Health Center Law
(enacted in 1947), new Tuberculosis Con-
trol Law (enacted in 1951),National Health
Insurance Act (enacted in 1958), which en-
abled rapid scale-up of mass tuberculosis
screening by chest X-ray, BCG inoculation,
test and treatment with public financial and
social protection of tuberculosis patients,
which accelerated and finally led to univer-
sal health coverage in 1961 in Japan.
Public-private partnership, especially be-
tween public health centers (PHC) and pri-
vate clinics/hospitals facilitated scale-up and
quality improvement of diagnosis, treatment
and care of tuberculosis patients [17]. Public
health centers as local government authori-
ties had substantial contribution to Japan’s
success in tuberculosis control, especially by
overseeing various programs such as mass
screening, surveillance, patient registration,
and by handling public subsidy of medical
expenses for tuberculosis treatments [18].
Each PHC set up Tuberculosis Advisory
Committee, which was composed of PHC
staff, tuberculosis specialists and physicians
recommended by a local medical associa-
tion,for checking medical records from gen-
eral physicians, most of whom run a private
clinic, and recommending public subsidy to
those treatment. This public-private part-
nership contributed to quality improvement
and assurance of tuberculosis control.
Multisectoral approach was also critical suc-
cess factor for tuberculosis control in Japan.
Under the Tuberculosis Control Law,all the
municipalities, schools and private compa-
nies were required to engage in tuberculosis
mass screening towards the common target
and slogan “100% uptake”. Public health
centers played key roles in driving commu-
nities to attend mass tuberculosis screenings
towards 100% uptake in close collaboration
with local community organizations such
as the Anti-Tuberculosis Women’s Associa-
tion. The Japan Anti-tuberculosis Associa-
tion (JATA) also played an important role
in promoting community mobilization and
facilitating collaboration between govern-
ments, academia and the private sector for
effective tuberculosis control [19].
Expectation for Medical
Professionals, National Medical
Associations and WMA
Toward UHC and SDG 3
While medical professionals, national med-
ical associations and WMA are crucial ac-
tors on the road toward UHC and SDG 3,
they could play more active or even proac-
tive roles in accelerating the efforts for their
achievement in many countries. In particu-
lar, I would like to highlight the following
three roles and expect them to take those
in addressing challenges and gearing up to-
ward UHC and SDG 3.
Influencer: UHC requires political com-
mitment from the highest levels, notably
for policy-makers to develop and imple-
ment policies and regulations that facilitate
the movement towards UHC [20] and to
raise significant funds that will enable it to
happen. Since medical professions and their
associations have leadership and political
power in many countries, they could serve
as influencer to enhance the country’s po-
litical will and leadership toward UHC and
health SDG.
Especially, political will and actions are
needed to mobilize domestic resources for
financial risk protection and equitable ac-
cess to essential services. Since only 3% of
global health spending occurs in lower- or
lower-middle-income countries where 49%
of the global populations live (Figure 6)
[21, 22], development assistance for health
(DAH) by donor countries and aid agen-
cies remains critical for those countries to
improve health, which accounts for more
than 50% of their health spending in some
countries. However, DAH has been stag-
gered at approximately US$39 billion in
the past several years (Figure 7)[2] while
it had increased 5 times between 1990 and
2010. Therefore, government spending on
health is suggested at least 5% of GDP or
per capita target of $86 [23,24] to promote
universal access to primary care services and
realize UHC in low-income countries.
Driver: Medical associations and their
members could play a driving role in imple-
menting those policies and strategies toward
UHC, especially delivering primary health
care and essential services and improving
quality of those services at a community
level. One of the three dimensions of UHC
is population coverage. While monitoring
the progress toward UHC, increasing pop-
ulation coverage with essential services is
important. Yet at the same time which sub-
populations are covered is also critical as the
vulnerable and marginalized populations are
often left behind and hardly covered. Since
the members of medical associations are
working close to communities, they are in
a good position to listen to and understand
the needs of the communities including vul-
nerable and marginalized populations, and
to reach out to them with essential services.
The government and national health pro-
fessional associations including a medical
association need to work together to iden-
tify the populations left behind and health
services in need,and find the ways to deliver
those for achieving UHC.
Facilitator: Leading medical and health
field, medical professionals and their associ-
ation could play more active role in facilitat-
ing collaboration and coordination among
different health workforce and their associa-
tions including nurses,midwife,pharmacists,
and community health workers. As shown
by an example of Japan and other good prac-
tices in the world, achieving UHC requires
effective and efficient collaboration among
all the stakeholders including public-private
partnership and multisectoral collaboration.
Medical professionals are usually respected
in a community and could take a facilitating
role in scaling up of essential health services
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20 21
Information from National Medical Associations
Universal Health Coverage
and promoting health-seeking and healthy
behavioral changes with various stakehold-
ers in the community including a village
mayor, community development work-
ers, school teachers and factory managers.
Medical associations could also contribute
to empowerment of other health personnel
and community resources who could drive
primary health care and health activities
among populations [25].
The Global Fund’s Way forwards
The Global Fund has succeeded in mobi-
lizing US$14.02 billion from over 70 do-
nors including governments, private sector
and nongovernment organizations through
the 6th
Replenishment meeting hosted by
French President Macron on 9–10 October
2019 in Lyon, France [26]. The fund will be
used for the next three years to support more
than 130 countries,whose impact is estimat-
ed to save 16 million lives and avert 234 mil-
lion infections according to the investment
case developed with global experts and part-
ners.The fund will be used for strengthening
RSSH for achieving UHC with estimation
of over US$1 billion per year.
I would like medical professionals to join our
efforts for the global common goal of ending
epidemics and achieving UHC and SDGs.
References
1. The Global Fund. Results Report 2019. [Cited
2019 Oct 05]. Available from: https://www.the-
globalfund.org/en/impact/
2. Institute for Health Metrics and Evaluation,
University of Washington. Financing Global
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sition. [Cited 2019 Oct 05]. Available from:
http://www.healthdata.org/sites/default/files/
files/policy_report/FGH/2019/FGH_2018_
full-report.pdf
3. Nsanzimana S, Prabhu K, McDermott H, Ka-
rita E, Forrest JI, Drobac P, et al. Improving
health outcomes through concurrent HIV pro-
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[Cited 2019 Oct 10].Available from:https://www.
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4. UNAIDS. UNAIDS Data 2018. [Cited 2019
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ta-2018_en.pdf
5. WHO. Global Tuberculosis Report 2018. [Cit-
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who.int/tb/publications/global_report/en/
6. WHO. World Malaria Report 2018. [Cited
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report-2018/en/
7. WHO. Ebola virus disease. [Cited 2019 Oct
05]. Available from: https://www.who.int/news-
room/fact-sheets/detail/ebola-virus-disease
8. UNAIDS. Fast-Track: ending the AIDS epi-
demic by 2030. 2014. [Cited 2019 Oct 05].
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sites/default/files/media_asset/JC2686_WA-
D2014report_en.pdf
9. WHO. The End TB Strategy: Global strat-
egy and targets for tuberculosis prevention, care
and control after 2015. 2015. [Cited 2019 Oct
30]. Available from: https://www.who.int/tb/
post2015_strategy/en/
10. WHO. Global technical strategy for malaria,
2016-2030. 2015. [Cited 2019 Oct 10]. Avail-
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cations/atoz/9789241564991/en/
11. Floyd K, Glaziou P, Houben RMGJ, Sumner
T, White RG, Raviglione M. Global tubercu-
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2018;22(7):723-730. doi: 10.5588/ijtld.17.0835.
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tainment to 2030 of the health-related Sus-
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Global Burden of Disease Study 2017. Lan-
cet. 2018;392(10159):2091-2138. doi:10.1016/
S0140-6736(18)32281-5.
13. The Global Fund, WHO, Stop TB Partner-
ship. Joint Initiative "FIND. TREAT. ALL.
#ENDTB" [Cited 2019 Oct 10]. Available
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en/
14. Mori T, Ishikawa N. Tuberculosis in Japan be-
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ray JF, Loddenkemper R (eds): Tuberculosis and
War. Lessons Learned from World War II. Prog
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15. Seita A. How Japan had addressed control of
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[Cited 2019 Oct 05]. Available from: https://
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16. Mori T. Recent trends in tuberculosis, Japan.
Emerg Infect Dis 2000; 6: 566–68.
17. Shimao T. [PECULIARITY OF NATIONAL
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Practitioner's Clinics]. Kekkaku. 2016;91(2):69-
74. Japanese.
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19. The Japan Research Institute of Tuberculosis,
Japan Anti-tuberculosis Association (JATA). "
[Cited 2019 Oct 30]. Available from: https://
jata.or.jp/english/
20. WHO. Together on the road to UHC: A Call
To Action. 2017. [Cited 2019 Oct 10] Available
from: https://www.who.int/universal_health_
coverage/road-to-uhc/en/
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private spending on health for 195 countries,
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Health Spending and Development Assistance
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23. Mcintyre D, Meheus F, Røttingen JA. What
level of domestic government health expenditure
should we aspire to for universal health coverage?
Health Econ Policy Law. 2017;12(2):125-137.
24. Mcintyre, D.M., F. Shared Responsibilities for
Health: A Coherent Global Framework for
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https://www.chathamhouse.org/sites/default/
files/field/field_document/20140521HealthFin
ancing.pdf
25. Tulenko K, Møgedal S, Afzal MM, Frymus
D, Oshin A, Pate M, et al. Community health
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[Cited 2019 Oct 10]. Available from: https://
www.theglobalfund.org/en/stepupthefight/
Osamu Kunii, MD, MPH, PhD
The Global Fund to fight AIDS, Tuberculosis
and Malaria, Geneva, Switzerland
Head, Strategy, Investment
and Impact Division
The rapid economy development of the
Azerbaijan Republic (AR) in recent years has
made it possible to ensure the formation of
socially oriented domestic policy, to develop
programs aimed at improving health of the
population and development of the health-
care system.The level of economic well-being
of the country and quality of healthcare sys-
tem’s functioning are interrelated factors that
directly determine health of the population.
The degree of the healthcare system devel-
opment, in turn, reflects the socio-economic
development of the country. The growing
economy made possible modernization of
the healthcare system and its harmonization
with global trends of developed countries.
The modern healthcare system of Azerbaijan
is in a transitional period, which is charac-
terized by the reform of healthcare financ-
ing, introduction of electronic services and
renewal of the insurance system. The reform
is based on legislation, which is updated and
supplemented in accordance with new needs.
Taking into account the tense internal situ-
ation in the country [1] after the collapse of
the Soviet Union and restoration of inde-
pendence, the national leader Heydar Aliyev
directed his efforts to ensure development
of the Republic through foreign economic
relations. A targeted policy of integration
into the world community, establishing re-
lations with international structures and
aimed at attracting investment and develop-
ing the country’s economy was based on the
“oil strategy” of Heydar Aliyev, which laid
the foundation for the country’s prosperity.
An agreement known as the 1994 Contract
of the Century [2] was signed within the
framework of the strategy; oil pipelines were
commissioned, including the Baku-Tbilisi-
Jeyhan pipeline. The strategy ensured social
economic development [3], and as a result,
the rise of the healthcare sector.
In the first years of the restoration of in-
dependence, Azerbaijan sought to actively
cooperate with international organizations
in order to ensure compliance of domestic
policies with global trends. So, one of the
tasks of health policy has become and is
now cooperation with international organi-
zations such as the United Nations (UN),
World Health Organization (WHO), the
Council of Europe (CoE) and the Europe-
an Union (EU). Thus, the Partnership and
Cooperation Agreement between the EU
and Azerbaijan, signed in 1999, established
a number of requirements in the field of so-
cial development and health. Subsequently,
the Agreement was expanded to the Euro-
pean Neighborhood Policy (ENP). In the
framework of the ENP,cooperation covered
various areas and was reflected in the Ac-
tion Plan (AP), which Azerbaijan joined in
2006. The AP included the following tasks:
reforming the healthcare system, creating
a social policy closer to EU standards, fa-
cilitating exchange of new technologies, in-
cluding e-health.
During Soviet times, Azerbaijan’s health-
care was based on all-Union standards; the
central leadership directly determined its
infrastructure. Accordingly, the standards of
domestic health policy were practically ab-
sent. The urgent need to improve the social
protection of citizens, primarily the health-
care system,is reflected in the domestic pol-
icy of the state. As a result, in 1998, by an
order of the national leader Heydar Aliyev,
the State Commission on Health Care Re-
forms was created, which developed a docu-
ment on the reform concept. Fundamental
steps on the reformation of the healthcare
system included the expansion of medical
educational programs, updating medical
equipment, monitoring of environmental
factors affecting health,and study of health-
care trends in high-income countries.
The key factor determining public health
policy and the corresponding programs
arising from it is the level of development
of medicine and related areas. Only highly
effective medical services and the develop-
ment of medicine can ensure public health,
Vugar Mammadov
Short Overview of Developments in Azerbaijan Healthcare Policy
and Legislation During Last Decades
Lala Jafarova
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which begins with the health of a single
person (citizen). Health policy itself may
include various directions and fields, such
as healthcare, insurance, vaccination, mental
health, pharmaceutical, healthy life styles
and environmental health policies, includ-
ing anti-smoking, anti-obesity, reproductive
policies,etc.Being complex in nature,it also
covers issues of financing, improving leg-
islation, ensuring social justice and imple-
menting many targeted programs to solve
various problems in this area. Health policy
is multilevel and comprehensive, since deci-
sions made at the state level are passed for
execution to separate bodies such as the
Ministry of Health and municipalities. The
importance in this regard is given to solving
the most urgent problems in the country.So,
for example, the problem of obesity is not as
acute as the problem of thalassemia / he-
mophilia in Azerbaijan. In this regard, the
Cabinet of Ministers of the AR approved
the Resolution on the State Program on
Hereditary Blood Diseases of Hemophilia
and Thalassemia [5] adopted in 2006.
Today, the development concept  – Azer-
baijan 2020: A Look into the Future – ap-
proved by the Decree of the President of
Azerbaijan Ilham Aliyev in 2012, defines
priorities in state policy and reformation in
the field of healthcare, as well as in other
areas. Paragraph 7 of the Concept gives pri-
ority to “the development of human capital
and creation of an effective social security
system”[6].This paragraph defines the goals
and objectives in the healthcare system, sets
other goals, such as improving social secu-
rity, developing modern education, devel-
oping youth and sports potential, ensuring
gender equality and family development.
One of the main tasks in modern healthcare
policy is increasing government allocations
for the development and modernization in
the field of medicine.The public health sys-
tem in Azerbaijan is financed from the state
budget. The Ministry of Health is the cen-
tral authority in the field of healthcare [7]
coordinating relevant issues. In 2014 the
Ministry adopted the Decree on Approval
of the Strategic Plan of the Ministry of
Health of the Republic of Azerbaijan for
2014–2020 [8], which outlined the social
orientation of its activities. The Ministry of
Finance develops and determines the bud-
get of the Ministry of Health, which is ap-
proved by the Milli Majlis (Parliament). In
2017, more than 775 million manats were
allocated to healthcare; expenditures on sci-
ence, education, healthcare, social protec-
tion and other related categories accounted
for 32.5% of the total state budget, of which
4.7% was allocated for healthcare [9]. By
Decree of November 30, 2018, President
of Azerbaijan Ilham Aliyev approved the
country’s budget for 2019 [10], in which
more than 1 billion manats were allocated
to the healthcare sector. An increase in the
amount of budgetary funds for health care
underlines the priority of this sphere in the
domestic political course and indicates in-
creased attention to this sphere from the top
leadership of Azerbaijan.
The key task of modern healthcare refor-
mation is the introduction of the compul-
sory medical insurance system. Although,
the use of insurance in healthcare was laid
down in 1999, by the adoption of the Law
on Medical Insurance [11], the text of the
law is still being edited, and its updated ver-
sion will come into force only in 2020. In
2007, by the Decree of the AR President,
the State Agency for Compulsory Health
Insurance was established [12] under the
Cabinet of Ministers. Formation of a uni-
fied policy of compulsory insurance is one
of the Agency’s main tasks.
The Concept of Reforming the Health
Financing System and the Application of
Compulsory Health Insurance was adopted
in 2008 [13]; its implementation requires
a complete reorganization of the financ-
ing system, a new healthcare restructuring,
etc. According to the Concept, the reform
of healthcare financing is aimed at creat-
ing new economic principles, improving
access to medical services, increasing the
efficiency of using budget funds; the state
provides free budget-funded medical ser-
vices, however, publicly guaranteed health
care is not universal,and some services must
be paid by citizens [14].The reform implies
creation of an integrated healthcare system,
i.e. combining a universal type of public
health insurance system (financed from the
state budget) and a private system partially
funded by citizens, which is a lengthy pro-
cess. So, since 2016, two cities of Azerbai-
jan – Mingachevir and Yevlakh with their
regions – have been selected as pilot territo-
ries for testing a new type of health insur-
ance [15]. In December 2017, by a decree of
the President, the Agdash district [16] was
also included in the pilot program.
The Center for Public Health and Reforms
(CPHR) under the Ministry of Health es-
tablished in 2006 is financed from the state
budget and implements the state health pol-
icy in the direction of its reformation. Ac-
cording to the Regulation on the CPHR, it
participates in the development and imple-
mentation of health policy, ensures the or-
ganization of healthcare, develops proposals
for reforms in this area,implements reforms
in primary health care, etc. The Center has
already implemented many projects, such as
Creating Schools for Diabetics, Developing
a National Tobacco Control Strategy [17].
The Health Informatization Center under
the Ministry of Health, established in 2010,
[18] operates as an online resource that pro-
vides numerous services, such as request-
ing outpatient medical facilities for home
services or electronic registration to visit a
doctor. However, the electronic system is
still under development and has a limited
number of services. In addition, the use of
electronic services is not popular among
citizens living away from the capital.
Preventive measures to improve the health
of the population, as one of the priorities of
the health policy, include many programs
to help patients with infectious and non-
infectious (social) diseases. The preventive
policy on infectious diseases is based on le-
gal norms formulated in numerous laws of
the Republic of Azerbaijan, such as On the
Immunoprophylaxis of Infectious Diseases
[19] and On Fight Against Tuberculosis in
the Republic of Azerbaijan [20], adopted in
2000. Both of these laws indicate state sup-
port for their implementation.
Non-communicable diseases,such as cardio-
vascular, oncological, diabetes, etc., and risk
factors like smoking, drug addiction, obesity,
alcohol abuse, constitute a significant threat
to public health, especially to young people.
For example,smoking harms not only smok-
ers, but also people around them (second-
hand smoke) and, no less important, the
environment. So, in 2015, by Decree of the
President of the Republic of Azerbaijan, the
Strategy to Combat Non-communicable
Diseases in the Republic of Azerbaijan for
2015–2020 [21] was approved.The adoption
of such a strategy has two important aspects.
Firstly, it is a striking example of the tasks
of domestic health policy corresponding
with international trends and responding to
modern challenges. Secondly, the adoption
of the program in the framework of coop-
eration with the UN and WHO speaks of
a policy of harmonization of internal health
goals with global goals, i.e., the adoption
of the Strategy of 2015 was a direct result
of the close cooperation of the Republic of
Azerbaijan with the WHO and UN.Name-
ly, the UN adopted the Political Declaration
of the High-level Meeting of the General
Assembly on the Prevention and Control of
Noncommunicable Diseases in 2011, which
gave impetus to the further development of
the WHO Global Action Plan on Noncom-
municable Diseases 2013–2020 [22]. Since
non-communicable diseases cause concern
of the world community, the Azerbaijani
leadership also responds to the need to solve
the problems arising by adopting relevant
decrees and regulatory documents aimed at
eliminating them.
Moreover, the State Program for Improv-
ing Maternal and Child Health for 2014–
2020 [23] was adopted in 2014. Because of
improvements in the public health system,
demographic indicators have increased and,
according to data for 2015 over the past 10
years, infant mortality per 1000 live births
decreased from 11.9 to 11.0, and maternal
mortality decreased from 30.2 to 14.4 [24].
The political course of the country is closely
connected with legislation, since it is the
legal norms that govern the implementa-
tion of decisions taken at the political level.
Legislation in turn is based on international
principles and norms, such as universal bio-
ethical principles. The basis of state policy
related to the protection of public health
lies in the country’s main law – the Con-
stitution, which declares that ensuring a
decent standard of living of a citizen “is the
supreme goal of the state”[25]. Article 41
(The right to health care) declares the right
to medical care and a state role in the de-
velopment of all types of healthcare, which
operates on the basis of various types of
property and various forms of health insur-
ance [25].The Article is consistent with the
provisions of the Universal Declaration on
Bioethics and Human Rights that empha-
sizes “role of the state” [26] in the imple-
mentation of bioethical principles.
Medical law in Azerbaijan is somewhat
fragmented due to the lack of systematic
approach of national health authorities to
this matter, lack of understanding of in-
formed consent doctrine and equality of
rights of medical professionals and patients
during the treatment process. However, pa-
tient’s rights are protected by different legal
documents and represent part of the Law
on Protection of Public Health of 1997
[27]. The Law defines state obligations in
the field of public health protection, such
as determining state policy and develop-
ing programs, financing in the field of
healthcare and environment, as well as the
rules for organizing and functioning of the
healthcare system. The Law encompasses
also numerous bioethical principles, such
as protection of environment, biosphere
and biodiversity, social responsibility and
health.The universal bioethical principles of
justice and equal rights are also reflected in
Article 10 (Chapter III) of the Law, which
indicates equality in health issues between
citizens and non-citizens, and Article 12,
which protects the right to receive not only
medical, but also social assistance in case of
disability [27], etc.
Health of the people in research and clini-
cal experimentation is protected by Decree
of the AR Cabinet of Ministers (No.83)
of 2010 on the Rules for the Conduct of
Scientific Research of Drugs, Preclinical
Research and Testing. Despite the fact that
this Decision is not directly related to the
protection of public health, its importance
for the development of the field of medi-
cine in the country is obvious. It is clinical
research that underlies the development
of new drugs  – an integral element that
ensures the development of medicine. So,
Clause 4.4 of the Decree states “The safety
and health of the person in whom the tests
are conducted are of paramount importance,
and they must be above public and scien-
tific interests.” [28] This norm corresponds
to the bioethical principle “human dignity
and human rights”, which proclaims the
paramount importance of the interests of
an individual over the interests of science or
society. Moreover, the resolution indicates
the obligation to obtain informed consent
(written or oral, with the participation of
two witnesses, if the person cannot write),
which directly corresponds to the bioethi-
cal principles of “consent” (informed) and
“persons without the legal capacity to give
consent”.
The principle of “consent” is also widely
reflected in the Law on Psychiatric Care
[29]. The Law obliges medical institutions
to provide appropriate assistance (with the
exception of involuntary hospitalization), to
attract (with the right to refuse at any time)
patients to research as an object, as well as
their use in the educational process only af-
ter receiving consent.
BACK TO CONTENTS
BACK TO CONTENTS
24 25
Information from National Medical Associations
Information from National Medical Associations
Article 3 of the Law on the Immunoprophy-
laxis of Infectious Diseases of 2000 defines
the basic principles of preventive measures
of state policy, such as free vaccination. The
bioethical principle of “consent” is reflected
in Article 6 of the Law [30], which requires
obtaining consent to immunize persons,
including minors or those who have been
recognized as legally incompetent in accor-
dance with the norms established by law.
It must be emphasized that the issue of
protecting the rights of the population were
significantly affected during the Armenian-
Azerbaijani Nagorno-Karabakh conflict
that occupies a special place in the state
policy of Azerbaijan. Despite the political
nature, these events negatively affected all
spheres of the state’s life, including health-
care. As a result of hostilities and the oc-
cupation of 20% of the Azerbaijan territory,
more than 1 million Azerbaijani citizens
were in the situation of refugees and inter-
nally displaced persons, 50 thousand people
became disabled, and 20 thousand people
died; in 1988–1993,in Karabakh,695 medi-
cal institutions were destroyed,among other
things [31]. Thus, a large part of the coun-
try’s population was in a socially vulnerable
position and resolution of their problems
needed urgent actions from the state. In
accordance with the Law on the Status of
Refugees and Internally Displaced Persons
(Displaced Persons within the Country) of
the AR in 1999 [32], their right to medi-
cal care is guaranteed. The construction
and rehabilitation of medical facilities in
the territories affected by the conflict, the
provision of mobile medical services, re-
habilitation and preventive work among
the affected population are implemented
through numerous state programs. Many
state programs have been implemented, and
their implementation continues to this day.
Thus, in 2004, by decree of the President of
the Republic of Azerbaijan, the State Pro-
gram on improving housing conditions and
increasing the employment of refugees and
internally displaced persons [33] was ap-
proved, in which much attention was paid
to health issues, namely, the construction of
medical facilities, the provision of free med-
ical care, etc. The state implements many
measures to ensure the benefits of citizens
who, as a result of the occupation, find
themselves in a group of a vulnerable part
of the population,which requires significant
financial and other resources.
Another important factor in the state’s in-
ternal health policy is the leveling of ethical
problems. As said, the 1997 main health law
covers the main provisions, including the
patients’ rights [27], and confirms the right
of all citizens to medical care. Inequalities in
the level of medical services for various so-
cial groups of the population are prevented
by access to state medical institutions, such
as clinics,free of charge.Moreover,according
to numerous legal acts, vulnerable segments
of the population, especially those who are
chronically ill,receive medicines and medical
assistance from the state. Thus, the Law on
State Assistance to Patients with Diabetes
[34] was adopted in 2003, which defines free
diagnosis and treatment of this group of pa-
tients. Similar legislation was adopted con-
cerning oncology patients as well. In 2013,
the Law on Compulsory Medical Examina-
tion of Children [35] approved state fund-
ing for the implementation of comprehen-
sive measures of medical examination. The
mentioned provisions reflect the essence of
universal bioethical principles,such as equal-
ity, justice and equality, protection of future
generations. Today, the introduction of bio-
ethical principles and the harmonization of
national legislation, respectively, are one of
the main goals of domestic public policy.
Bioethics,which is closely linked to medical
law and human rights, is the one of the pri-
ority fields of UNESCO activities, of which
Azerbaijan is a member. This is one of the
factors that has widely contributed to the
origin and development of interest in the
field in the country. Azerbaijan has already
achieved successes in the development of
bioethics in general, and there is increas-
ing interest in this area from specialists.The
UNESCO National Committee on Bioeth-
ics,Ethics of Science and Technology under
the Presidium of the National Academy of
Sciences of Azerbaijan monitors bioethical
issues, their scientific research, educational
and counseling activities [36]. However,
unfortunately, this body does not have the
legal ability to regulate bioethical issues in
healthcare.
The Azerbaijan Unit of the UNESCO Chair
in Bioethics has translated into Azerbaijani
the UNESCO Basic Program on Bioethics.
Moreover, the Unit initiated the Training of
Teachers on Ethical Education of UNESCO
that was held in Baku in 2012, introduction
of the subject Bioethics and Medical Law as
a scientific discipline in the educational pro-
gram of students of the law school of Baku
State University and inclusion of bioethics in
the code of scientific specialties [37].The 18th
session of the UNESCO International Com-
mittee on Bioethics, the 23rd
World Medical
Law Congress (WAML) – the 50th
Anniver-
sary Congress – under the title Medical Law,
Bioethics and Multiculturalism were held in
the capital of Azerbaijan in 2011 and 2017
respectively. Since the WAML has an im-
portant role in shaping medical law in post-
Soviet countries [38], the holding of such a
congress first time ever during its 52 year his-
tory in this part of Eastern Europe and Near
Asia confirms the development of this field
in the Republic.
Thus, based on the analysis of the state’s
policies and legislative acts of Azerbaijan in
the field of healthcare, it can be concluded
that the field is actively developing, and al-
though the bioethical principles are widely
reflected in legislation, yet there is much
to be done. Given the close relationship
between policy and law, it is obvious that
the norms reflected in legislation, includ-
ing bioethical principles, are a determining
vector in the formation of healthcare policy.
Azerbaijan implements many activities in
order to harmonize medical legislation with
international standards and its reformation
is in progress.
References
1. Hasanov A. Azərbaycan Respublikasının Milli
İnkişaf və Təhlükəsizlıik Siyasəi. Baku: Letter-
press; 2011. p.25
2. “Əsrin müqaviləsi” – 10 il. http://www.ebooks.az/
view/wlAHFgSX.pdf (accessed 15 April 2019)
3. Aliyev H.  “Müstəqilliyimiz əbədidir” çoxcild-
liyin elmi-biblioqrafik göstəricisi: I cild.  Baku:
«Şərq-Qərb»; 2013. http://www.ebooks.az/view/
FiCv3BWh.pdf (accessed 03 March 2019) 
4. Bioethics, Medical Law and New Technologies,
Institute on Human Rights of ANAS; Baku; 2013
5. “Hemofiliya və talassemiya irsi qan xəstəlikləri
üzrə Dövlət Proqramı”nın təsdiq edilməsi
haqqında Azərbaycan Respublikasi Nazirlər Ka-
binetinin Qərari. № 15, 18 yanvar, 2006-cı il.
6. The official website of the President of the Azer-
baijan Republic.“Azerbaijan 2020: Look Into the
Future” Concept of Development. https://presi-
dent.az/files/future_en.pdf (accessed 15 August
2019)
7. Mammadov V. Health care in Azerbaijan.
World Association for Medical Law Newsletter
2014; (October-December): 5–7
8. Azərbaycan Respublikası Səhiyyə Nazirliyi.
Əmr №30 “Azərbaycan Respublikası Səıhiyyə
Nazirliyinin 2014-2020-ci illər üzrə Strateji
Plan”nın təsdiq edilməsi haqqında. http://www.
sehiyye.gov.az/files/pdf/emr_2014_30.pdf (ac-
cessed 10 March 2019)
9. The Ministry of Finances. Azərbaycan
Respublikasının 2017-ci il dövlət büdcəsi haqqında
Qanunu. http://www.maliyye.gov.az/sites/default/
files/2017-qanun.pdf (accessed 23 April 2019)
10. “Azərbaycan Respublikasının 2019-cu il dövlət
büdcəsi haqqında” Azərbaycan Respublikası Qa-
nununun tətbiqi ilə bağlı bir sıra məsələlər barədə
Фzərbaycan Respublikasi Prezidentinin Fərmanı.
http://www.e-qanun.az/framework/41117 (ac-
cessed 11 March 2019)
11. Tibbi sığorta haqqında Azərbaycan Respub-
likasinin Qanunu http://www.e-qanun.az/
framework/80 (accessed 24 April 2019)
12. Azərbaycan Respublikasının Nazirlər Kabineti
yanında İcbari Tibbi Sığorta üzrə Dövlət Agen-
tliyi. https://its.gov.az/az/i-tsda-haqq-nda/
umumi-m-lumat/ (accessed 24 April 2019)
13. “Azərbaycan Respublikasında səhiyyənin
maliyyələşdirilməsi sisteminin islahatı və icbari
tibbi sığortanın tətbiqi Konsepsiyası”nın təsdiq
edilməsi haqqında Azərbaycan Respublikasi
Prezidentinin sərəncami. http://www.e-qanun.
az/framework/13091 (accessed 25 April 2019)
14. Decree of President of Azerbaijan Republic on
Concept for Health Reformation and Manda-
tory Medical Insurance. Baku, 10 January 2008.
№ 2620
15. Official website of the State Agency on Man-
datory Medical Insurance under the Cabinet
of Ministers of Azerbaijan. http://its.gov.az/
az/media/press-reliz/ming-cevir-h-ri-v-yevlax-
rayonu-pilot-razil-r-olaraq-secildi-1/ (accessed
17 February 2017)
16. Trend. İcbari tibbi sığorta pilot layihə olaraq
Ağdaş rayonunda da tətbiq olunacaq. https://
az.trend.az/azerbaijan/politics/2862045.html
(accessed 16 February 2018).
17. İctimaiSəhiyyəvəİslahatlarMərkəzi(İSİM). About
us.https://isim.az/en/pages/2 (accessed 16 January
2019)
18. Elektron səhiyyə portalı. Səhiyyənin İnforma­
si­ya­laşdırılması Mərkəzi. http://www.e-health.
gov.az/az/s/21/Health+Informatization+Center
(accessed 17 January 2019)
19. Ministry of Health. Yoluxucu xəstəliklərin
immunoprofilaktikası barədə qanunvericilik
aktlarına dair BƏLƏDÇİ QAYDALAR. http://
health.gov.az/yoluxucu_xesteliklerin_haqqnda_
beledci.html (accessed 25 January 2019)Səhiyyə
Nazirliyi “Azərbaycan Respublikasında vərəmlə
mübarizə haqqında”, 2000. http://sehiyye.gov.az//
files/pdf/qanun/875.pdf (accessed 18 January 2019).
20. “Azərbaycan Respublikasında qeyri-infek-
sion xəstəliklərlə mübarizəyə dair 2015-2020-
ci illər üçün Strategiya”nın təsdiq edilməsi
haqqında AZƏRBAYCAN RESPUBLİKASI
PREZİDENTİNİN SƏRƏNCAMI. 2015.
http://www.e-qanun.az/framework/doc/31727
(accessed 27 January 2019)WHO.  Noncom-
municable diseases prematurely take 16 million
lives annually, WHO urges more action. https://
www.who.int/mediacentre/news/releases/2015/
noncommunicable-diseases/en/ (accessed 10
May 2019)
21. “Anavəuşaqlarınsağlamlığınınyaxşılaşdırılmasına
dair 2014-2020-ci illər üçün Dövlət Proqramı”nın
təsdiq edilməsi haqqında Azərbaycan Respublika-
si Prezidentinin Sərəncami. http://www.e-qanun.
az/framework/27839 (accessed 15 May 2019)
22. Administrative Department of the President of
the Republic of Azerbaijan. Presidential Library.
Independent Azerbaijan. Public Health. http://
republic.preslib.az/en_c7-4.html (accessed 01
May 2017)
23. Azərbaycan Respublikası Prezidentinin rəsmi in-
ternet saytı. Constitution. https://president.az/
azerbaijan/constitution (accessed 10 August 2019)
24. UNESCO.  Universal Declaration on Bioeth-
ics and Human Rights. http://www.unesco.org/
new/en/social-and-human-sciences/themes/bi-
oethics/bioethics-and-human-rights/ (accessed
11 August 2019)
25. Əhalinin sağlamlığının qorunması haqqında
Azərbaycan Respublikasinin Qanunu. http://
www.e-qanun.az/framework/4078 (accessed 12
August 2019)
26. “Dərman vasitələrinin elmi tədqiqatlarının, klini-
kaya qədər tədqiqatlarının və klinik sınaqlarının
aparılması Qaydaları”nın təsdiq edilməsi
haqqında Azərbaycan Respublikasinin Nazirlər
Kabinetinin Qərar. http://www.e-qanun.az/
framework/19529 (accessed 12 August 2019)
27. Psixiatriya yardımı haqqında. http://sehiyye.gov.
az//files/pdf/qanun/142.pdf (accessed 12 Au-
gust 2019)
28. Azərbaycan Respublikası Səhiyyə Nazirliyi.
“Yoluxucu xəstəliklərin immunoprofilaktikası
haqqında” Azərbaycan Respublikasının Qanunu
http://sehiyye.gov.az/yoluxucu_xesteliklerin_
haqqnda.html (accessed 15 August 2019)
29. Official website of the President of the Republic
of Azerbaijan. Armenia-Azerbaijan Nagorno-
Karabakh conflict. https://en.president.az/azer-
baijan/karabakh (accessed 15 August 2019)
30. Qaçqınların və məcburi köçkünlərin (ölkə
daxilində köçürülmüş şəxslərin) statusu haqqında
Azərbaycan Respublikasinin qanunu http://
www.e-qanun.az/framework/4757 (accessed 15
August 2019)
31. “Qaçqınların və məcburi köçkünlərin yaşayış
şəraitinin yaxşılaşdırılması və məşğulluğunun
artırılması üzrə Dövlət Proqramı”nın təsdiq
edilməsi haqqında. http://www.e-qanun.az/
framework/6261 (accessed 15 August 2019)
32. “Şəkərli diabet xəstəliyinə tutulmuş şəxslərə dövlət
qayğısı haqqında” Azərbaycan Respublikasının
Qanunu. http://sehiyye.gov.az/diabet_xesteli-
yine_tutulmus.html#sel=1:1,1:11 (accessed 15
August 2019)
33. Uşaqların icbari dispanserizasiyası haqqında
Azərbaycan Respublikasinin Qanunu http://
www.e-qanun.az/framework/25600 (accessed
17 August 2019)
34. Mammadov V., Munir K., Jafarova L. Bioethics
Education in Azerbaijan: Preconditions, Devel-
opment and Current State. World Association
for Medical Law Newsletter  2017; Medicine
and Law (Volume 36, Number 3): 1-13
35. Mammadov V., Munir K., Jafarova L. Medi-
cal science, Research and Higher education in
Azerbaijan from bioethical developments per-
spective. Medychne pravo. 2016; 2(18):18-43.
36. Sergeyev Y., Mammadov V. Development of
Medical Law in Post-Soviet Countries and Role
of WAML. Med. & L. 2018; 37:701
Prof. Dr. Vugar Mammadov
Head, Azerbaijan unit, UNESCO
Chair in Bioethics
Deputy Chairman, UNESCO
National Bioethics Committee,
Azerbaijan National Academy of Sciences
E-mail: vumammadov@yahoo.com
Lala Jafarova
PhD student, Institute of Law
and Human rights, Azerbaijan
National Academy of Sciences
E-mail: lala-j@hotmail.com
BACK TO CONTENTS
BACK TO CONTENTS
26 27
Health Care in Developing Countries
Cooperation Organisations
“Medicine is an art whose magic and creative
ability have long been recognized as residing
in the inter- personal aspects of patient-phy-
sician relationship” [1]. It is based on trust
and mutual respect and it is a well known
fact that clinical outcomes are determined by
the confidence a patient has in his treating
healthcare professional.
Today, effective doctor-patient relationship is
one of the central clinical elements, as it con-
tributes to more patient-centered healthcare
delivery. Alongside creating a good interper-
sonal relationship and facilitating exchange
of information, it also constitutes including
patients in the decision-making, regard-
ing their condition and treatments vis-à-vis
health benefits and quality of life [2; 3].Thus,
shared decision-making requires close and
continuous communication between patients
and doctors – at inter-personal level for im-
proved individual care, as well as between
their associated communities, in order to in-
fluence policies for better access to and quality
of health care at wider population scale, while
ensuring respect and decent workplace for the
medical profession. Therefore, collaboration
between medical professional associations
like the World Medical Association and pa-
tients’alliances like the International Alliance
of Patients Organisations is a natural synergy
working towards the goal of more efficient,
better and safer care for all patients worldwide.
The International Alliance of Patients’ Or-
ganizations (IAPO) was founded in 1999,
with the vision to see patients at the cen-
tre of healthcare and to help build patient-
centred healthcare worldwide.
Our founders aspired that we should im-
prove the quality and standard of patient
advocacy globally by developing and em-
powering patient advocate leaders within
all patient organisations and healthcare sys-
tems.This was to be accomplished by:
• Firstly, creating an enabling environment,
globally and within a patient organisation,
that encouraged and gave a greater number of
patient organisations the opportunity to have
their representative serve on international
Boards,committeesandpolicymakingbodies.
• Secondly, through carefully designed
leadership training, capacity building pro-
grammes and attendance at WHO and
World Bank forums expose more patient
representatives to the global healthcare
institutional, legal, policy, and practice and
standards framework and develop their
skills and confidence to undertake national
or regional patient advocacy.
• Thirdly, by focusing on cross cutting issues
of safety and quality,research & innovation
and disruptive technologies,every member
organisation could have the opportunity to
participate in IAPOs programs and proj-
ects thus improving the quality of patient
advocacy skills in our networks and
• Lastly,using this diverse global Governance
Board to develop innovative programmes,
projects and tools for our members that had
a high reach and impact on healthcare.
Today, IAPO movement has matured and
has come of age. Where in the past we were
excluded from the healthcare institutional,
legal, policy, practice and standards frame-
work,today we are feted to join them.We are
valued because we bring special insight and
experience of healthcare and have developed
a considerable voice to reach out to the key
healthcare decision-makers. This transfor-
mation of an exclusory healthcare infrastruc-
ture into a positive patient centric one has
permeated all levels and institutions in many
healthcare settings and systems.
Many WHO Member States are now wak-
ing up to the idea that they need the patients’
perspective and experience to make their
healthcare policy and services effective and
efficient. This realisation has also drip-fed to
the regulators who want patient insights and
perspectives on market authorisation of inno-
vative medicines and devices.The pharmaceu-
tical industry has long benefited from patient
participation and engagement in medicines re-
search and development.They are now looking
at co-creation and co-designing to maximise
patient value and efficiency in their industry.
Most countries now aspire to have universal
health coverage by 2030.IAPO strives to en-
sure that patients have a high quality of pa-
tient advocacy in place so that we can ensure
that they have a sufficient quantity of acces-
sible, acceptable and affordable preventative,
therapeutic, curative, rehabilitative and pal-
liative healthcare by 2030. But much more
than this, we must ensure this healthcare is
delivered in a safe and compassionate man-
ner, to WHO acceptable quality standards.
One of your colleagues has rightfully said,
“the patient will never care how much
you know, until they know how much you
care” [4]. Thus, IAPO wishes to call upon
all medical and health professional asso-
ciations to closely work together and col-
laborate with patient organizations in their
respective countries. It is only through the
involvement of patients and patient-doctor
synergies that we can have a comprehensive
holistic health service delivery to all.
References
1. Hall JA, Roter DL, Rand CS: Communication
of affect between patient and physician. Journal
of Health and Social Behavior 1981.
2. Platt F, Keating K: Differences in physician
and patient perceptions of uncomplicated UTI
symptom severity: understanding the communi-
cation gap.International journal of clinical practice
2007, 61(2):303-308.
3. Bredart A, Bouleuc C, Dolbeault S: Doctor-pa-
tient communication and satisfaction with care
in oncology. Current opinion in oncology 2005,
17(4):351-354.
4. Ha JF, Longnecker N: Doctor-patient communi-
cation: a review. Ochsner Journal 2010, 10(1):38-43.
Ellos Lodzeni
Governance, Health and Social
Justice advocate and WHO Patient
for Patient Safety Champion.
The Welfare and Good Health of Patients
is not Possible Without the Doctor:
Let’s Work Together
Somaliland, one of the regions in Somalia
with an estimated population of 3.5 million
people, has a history of conflict, which last-
ed from the late 1980s to early 1990s, and
this resulted in the collapse of the health
sector.Some years of relative stability evince
that Somaliland is ready to realign its focus
towards long-term development plans.
The health and demographic situation in
Somaliland leaves much to desire, and ac-
cording to UN data,the country has some of
the worst health and nutrition indicators in
the world and is unlikely to reach the health
related MDGs; women, girls and the poor-
est groups are most affected in this context.
The health of women, adolescent girls and
children and their access to health care are
disproportionately affected, with particular
risks to sexual and gender based violence.
UNDP Human Development Report 2000
ranked Somalia the lowest globally in all
health indicators, except life expectancy.
According to the UNICEF MICS 2011
and other surveys, Somaliland has some of
the worst health indicators in the world: un-
der-five mortality 90/1000, infant mortality
72/1000, neonatal mortality 35–48/1000,
maternal mortality ratio 1044/100,000
(MIS, 2006). Only 5% of children are fully
immunized by age 1, 26–37% of women are
married before age 18, use of effective con-
traception stands at 3%, skilled attendance
at delivery stands at 60-30% and 98% prev-
alence of FGM.
Limited access to primary health care, in-
adequate quality of service, poor hygiene,
sanitation, and low supply levels are just
some of the factors which contribute to
these desperately poor health indicators.
The human resource deficit in all regions is
enormous. Acute and chronic skilled staff
shortages, structural fragmentation, insuf-
ficient and distorted incentives to motivate
staff, limited supervision and mostly ad-hoc
management arrangements are issues in all
areas. Although Somaliland’s health au-
thorities are developing strategies and tools
for improved governance of the sector, huge
gaps are still evident, necessitating contin-
ued capacity building and support.
Somaliland is not a unique case; it shares a
lot with other post conflict settings around
the world. The disruption of health systems
affected the human resource in the health-
care sector greatly. Somaliland is struggling
with a chronic shortage of skilled healthcare
workers which is the result of the large-scale
emigration from the country during the
war; in the last 25 years there were efforts
to produce skilled healthcare workers to fill
the gap, but the weak government and the
poor resource deployment is a huge chal-
lenge as well as the retention of the skilled
health-care workers in remote regions.
Somaliland is among those countries faced
with a critical shortage of competent health
workforce (WHO,2006),doctor-to-patient
ratio as well as the number of other health-
care workers being the lowest in the world.
WHO reports show 1 doctor per 30,000
population, 1 nurse per 9000 population
and 1 midwife per 27000 women.
In every post conflict setting there is ad-
aptation of alternative medicine or tradi-
tional healers. Traditional birth attendance
is caused by the disruptions of the health
care services. Somali community prefers the
traditional medicine and people first seek to
attend traditional healers,therefore it takes a
long time to phase out this traditional birth
attendant at deliveries in the country with
the highest maternal and neonatal deaths.
As the country is emerging from the post
conflict setting, individuals who have expe-
rienced the horror and trauma of the war
widely suffer from mental disorders and
illnesses; unemployment and poverty con-
tribute largely to the development of these
illnesses, while there are only 4 trained psy-
chiatrists for the population of 3.5 million.
The other challenge is surgical operations,
which are costly,and difficult to access.Nei-
ther the poor people can afford the cost and
die from complications nor do the rich have
access to a good quality of surgical care.
Junior doctors working without senior su-
pervision is another challenge because this
can lead to malpractice and be a cause of
death. Although there are nurse anesthe-
tists, few of them can perform pediatric or
geriatric anesthesia and to people with co-
morbidities.
Nevertheless, for the last 27 years, doctors
without specialization were operating. The
only available surgeons are practitioners;
operating rooms, equipment and special-
ized surgeons are a challenge Somaliland is
currently facing. Much is donated by either
charities or partner organizations for pro-
grams or as support to strengthening the
general health system.
Hospitals have very few maintenance staff
responsible for medical equipment. Main-
tenance staffs were very resourceful but did
not have formal training on medical equip-
ment, nor did they have the resources (tools,
engineering equipment or a functional
workshop) to do their job.There are current-
ly no training programmes for biomedical
engineering personnel in Somaliland at any
skill level, from craftsperson to technician,
technologist or engineer.Thus,there seem to
be no qualified biomedical engineers work-
ing full time in the country, let alone within
the health system. One of the most skilled
technical service providers in Somaliland is
the lead technician for the largest laboratory
equipment supplier in the country.
Health Systems in Post Conflict;
Case of Somaliland
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28 29
Health Care in Developing Countries
Health Care in Developing Countries
Health is wealth, and any nation worth
its salt will provide for a healthy popula-
tion for sustained economic productivity.
The right to health is enshrined in vari-
ous international and Ugandan laws and
instruments including our 1995 constitu-
tion. However, beyond dry ink on paper
what is our role as Doctors in guaranteeing
the common Ugandan citizen the right to
health?
Doctors are the natural leaders in medi-
cal teams and principals in guiding society
about healthy living. To support this claim,
one of our forefathers Dr. Carl Ludwig Vir-
chow (1821–1902), who wrote about the
Virchow’s triad of circulation, asserted, “…
Physicians are the natural attorneys of the
poor, and social problems fall to a large ex-
tent within their jurisdiction…”.
When health fails, doctors are the ultimate
“mechanics” who attempt to repair one’s
health. Indeed, we are privileged to serve
Ugandans (and humanity) in this delicate
space between disease, health and death
which is God’s calling. We therefore are
no arrogant about it, rather take this role
very seriously beyond diagnosis, prescribing
medicines and care.
Uganda’s public sector relies on a tax-based
system that is undemocratic, inefficient and
excludes the very poor. The result is pre-
ventable deaths among the rural and poor
Ugandans due to malaria in children or
15  pregnancy related deaths daily due to
bleeding, high blood pressure or infection.
Without effective health financing, Ugan-
dans, especially the very poor, will continue
in a state of poor health with resultant sub-
One of the most important steps in laying
the foundation of a functioning health sys-
tem was the establishment of Amoud Uni-
versity Medical Faculty in October 2000
and later Hargeisa University Medical Fac-
ulty in 2004.The establishment of the Edna
Adan Nursing School and the opening of
Nursing & Midwifery Training Institutions
such as Hargeisa Institute of Health Sci-
ences, Burao Institute of Health Sciences
and Amoud Nursing School.The first group
of locally trained doctors graduated in Au-
gust 2007 from Amoud Medical School.
Patient safety is not sufficiently taken into
account; theoretical understanding about
quality is good but the application is not
widely practiced.The existence of guidelines
is limited and not readily available, reducing
the accessibility to knowledge about the ex-
pected standards of care. Supervision from
the hospital management and leadership is
limited,requiring capacity development and
investment in their workforce.
Unfortunately, Somaliland has not yet op-
erationalized health sector regulation to
include functions like the registration, li-
censing and accreditation of health pro-
fessionals and institutions and programs
to properly protect the patients’ right to
get quality health care. The unregulated
nature of the health sector and the short-
age of health professionals have created a
health system where an unknown number
of persons work as unqualified “health pro-
fessionals” and proliferation of unregulated
healthcare facilities such as clinics, pharma-
cies and medical laboratories and education
program for healthcare workers. This situa-
tion has raised public safety concerns, and is
a barrier to improving the quality of health
services. Furthermore, the emergence of the
so called training program provided by un-
accredited institutions means that the coun-
try continues to produce “graduates” whose
qualifications are currently unrecognized by
the government of Somaliland.
There are opportunities to address these
gaps; Somaliland’s health system is young,
it requires providing equitable, efficient and
affordable quality priority health services as
close to the communities and families as pos-
sible based on primary health care approach.
The policy makers’ involvement is crucial
to have a willing leadership to improve
the quality of health care and increase the
patient safety standards; this is to develop
standard operating procedures for the qual-
ity of care that includes checklists and rou-
tine/regular monitoring and training.
Improving infrastructure and equipment,
surgical training residency specialization
and anesthesia, health workforce plan adap-
tation and regulation are essential.
Mariam Abdullahi Dahir
MBBS, MPH
Health systems specialist in
Somaliland Medical Association
The Right to Health; What is the Role of the
Doctor in Uganda?
Ekwaro A. Obuku
optimal economic production reflected in
our low-income (GDP).
Only a national health insurance scheme
could come close to bridging this health-
financing gap and empowering the citizen
to fight corruption in the health sector. This
mechanism permits for solidarity that the
rich pay for the poor, the employed pay for
those not working (retired and children) and
those who fall sick often are catered for by
contributions from those who are healthy.By
directly contributing to a national scheme
Ugandans will be empowered to demand for
quality of health care, less so in the current
“free health care”regime (tokenism).
I would argue that the modern Ugandan
Doctor ought to actively participate in
three aspects:First, report for duty, in time
and actually attend to patients as our first
consideration due to Hippocratic Oath. A
doctor’s presence guarantees quality of care
to Ugandans in immediate need, including
children with severe malaria and mothers in
obstructed labour.
Secondly, take leadership and have operat-
ing theatres in our Health Centres IV.Many
doctors have shied away from our health
system due to its weakness. Yet, strengthen-
ing the health system is in our interest by
promoting the practice of medicine as well
as securing our lives as potential patients or
victims of road traffic accidents.
Third, let us speak-up for our patients to ad-
vise and call to action our decision makers
at various levels from health facility to Local
Governments,Parliament and the Executive.
This is in line with the utilitarian principle
(greatest good for the greatest majority), and
our Hippocratic Oath that “…the health of
my patient shall be my first consideration…”.
With this three-pronged approach, Ugan-
dan doctors will make a meaningful contri-
bution towards the Universal Health Cov-
erage of 2030.
Ugandan doctors have been engaged with
making the state highlight the key policy con-
cerns plaguing the health sector, with a par-
ticular focus on human capital.More recently,
this culminated into the 3-week countrywide
doctors industrial action during November
2017. Indeed, the government of Uganda
responded positively by increasing the health
sector budget in the subsequent fiscal years
2018/19 and 2019/2020, specifically target-
ing medicines and essential supplies via the
National Medical Stores by Uganda shillings
138 billion (+60%), Uganda Blood Transfu-
sion Services by Uganda shillings 21 billion
(100%) and salary enhancement for all health
workers by 30% to nearly 300% depend-
ing on the cadre. Consequently, it is obvious
even to the blindfold that the government
has heavily invested in physical infrastructure
and equipment, such as the numerous hospi-
tals renovated or newly constructed: Kirrud-
du, Naguru, Kawempe, Karamoja, Mubende,
Mityana, Masaka, Entebbe and the Mulago
complex with the new Cancer Institute and
specialized one for Women in Mulago.
John Iliffe, in his book East African Doctors,
writes about doctors in Uganda conducting
industrial action to better the health sector
since 1911 when the Uganda branch of the
British Medical Association was formed.
Between 1918 and 1921, the BMA secured
major salary improvements to attract and re-
tain its members to practice in East Africa.
Soon after, between 1930 and 1950 the doc-
tors’ Association concerned itself with hos-
pital conditions and public health. Around
the time Uganda gained independence, the
struggle was for African doctors to be rec-
ognized as such and not Medical Assistants.
The late Prof. Alex Mwa Odonga, in his
book The First Fifty Years of Makerere Medical
School and the Foundation of Scientific Medical
Education in East Africa, recalls how African
doctors would travel to the United Kingdom
to sit for examinations and return even be-
fore the results were released as a sign of pa-
triotism. Indeed, Makerere was the breeding
ground for African doctors continent-wide.
Overall, Uganda has come a long way and
made significant achievements in key health
outcomes. The life expectancy at birth is
now at 60 years and above from below
45 years due to the wrath of HIV/AIDS;
maternal deaths have dropped from above
500 to less than 350 per 100,000 live births,
which is still very high; tremendous reduc-
tions in child mortality with simultaneous
reduction of malaria in the recent past.
However, is it yet Uhuru for the health ser-
vices Ugandans are subjected to? Uhuru in
Swahili means freedom from poverty of
self-determination. How many Ugandans
are increasingly impoverished by enormous
costs for their medical care (catastrophic
health expenditure)? In the next paragraphs,
I describe that there are three game chang-
ers the government could build on to realize
the Universal Health Coverage especially to
the poor and very poor Ugandans.
First, the most effective intervention for
Uganda is to increase the money available
for health services through the long awaited
national health insurance scheme. This in-
surance scheme idea has stagnated for over
3 decades, appearing in over 3 presidential
manifestos, since the time Uganda’s health
sector budget share was 3%. The budget of
the health sector has not been responsive,
stagnating between 7% and 9% for the past
decade, while that for roads has tripled to
about 20% share of the national cake. The
ideology of a national health scheme is that
of solidarity in the sense that the rich pay
for the poor, the working class pays for the
indigent, retired and children; whilst the
healthy population pays for the sick. Most
of all, every citizen shares this ­
collective
Health Sector Reforms in Uganda, not yet Uhuru!
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30 31
One Health, One Planet
Health Care in Developing Countries
Ways forward to ensure the sustainability of
people and the planet are needed at a time
when the interdependencies among humans,
animals, plants and the environment are
to be recognized as the cornerstone to drive/
steer the UN 2030 Sustainable Development
Goals (SDGs). In this connection, PEAH
had the pleasure to interview Dr George
Lueddeke as the author of the recently pub-
lished cross-disciplinary book Survival: One
Health, One Planet, One Future Rout-
ledge, 1st
edition, 2019. Including contri-
butions from the World Bank, InterAction
Council, Chatham House, UNESCO, World
Economic Forum, the Tripartite One Health
collaboration (UN Food and Agriculture Or-
ganization, World Organisation for Animal
Health and World Health Organization),
One Health Commission and more – this
book cuts across sociopolitical, economic and
environmental lines
George Lueddeke
Chair, One Health Education Task Force
Chair, international One Health for One
Planet Education Initiative (1 HOPE)
One Health Commission and One Health
Initiative
Consultant in Higher and Medical Education,
Southampton, UK
George R. Lueddeke PhD MEd Dipl.AVES
(Hon.) is an educational advisor in higher
and medical education and chairs the global
One Health Education Task Force for the
One Health Commission and the One Health
Initiative as well as the international One
Health for One Planet Education Initiative
(1 HOPE). He has published widely on educa-
tional transformation, innovation and leader-
ship and been invited as a plenary speaker to
different corners of the world. Bio
PEAH: Dr. Lueddeke, the internation-
al One Health for One Planet Education
(1 HOPE) initiative was created to address
perhaps the most important social problem
of our time:‘How to change the way hu-
mans relate to the planet and each other to
ensure a more sustainable future to all life’.
On this wavelength,
what about the main
purpose of Surviv-
al: One Health, One
Planet, One Future?
Lueddeke: The book
tries to make sense
of the uncertain and
tense (“rattling”) times
we are experiencing and asserts that the One
Health & Well-Being concept (OHWB) –
that recognises the interdependencies among
humans,animals,plants and their shared en-
vironment – is critical to safeguarding our
future while also providing a “unity around
a common purpose” that seems to be miss-
ing globally. I prefer the term One Health
& Well-Being (vs just ‘One Health’) as it
emphasises not only the crucial importance
of human physical and mental well-being
but also the need to strive toward meeting
socioeconomic, geopolitical and ecological
conditions to ensure the sustainability of all
living species and the planet.
I also argue that the OHWB approach
ought to drive/steer the 17 UN-2030 Sus-
tainable Development Goals (SDGs) that
were agreed by all 193 Member States of
the United Nations in September 2015.
The main aim of the UN Global Goals is
to create ‘a more just, sustainable and peace-
ful world.’ The OHWB perspective needs
to inform and encourage decision-makers
at all levels  – especially Civil Society- to
get behind the UN global initiative regard-
less of ideological persuasion or divisions.
The challenge is how to get government,
­
business and civil society behind OHWB
­
responsibility further entrenching patrio-
tism whose curriculum would hardly be
taught in formal classes. A prepayment
scheme of this kind is inherently demo-
cratic as it improves the demand for quality
services and acceptability by the tax paying
citizenry. Indeed, it is such a scheme that
would subsidize the service costs at the
newly commissioned Women Hospital in
Mulago that has generated uproar from the
populace.
The second game changer is Mr. Museveni’s
focus on health promotion and disease pre-
vention.In September 2017,our 2nd
Grande
Doctors Conference was held, the theme
was “promoting healthy lives”.The cost sav-
ings for disease prevention programmes are
unprecedented for low-income countries
like Uganda whose investment in health
mismatches the burden of diseases. Indeed,
after the mass distribution of insecticide
treated mosquito nets, malariologists have
consistently documented that in some areas
in Uganda, such as Kampala, malaria has
disappeared. Gone are the days that every
fever would likely be malaria. Certainly,
Mr. Museveni’s response to the epidemic
of non-communicable diseases is a game
changer akin to the “ABC strategy” of the
late 1980s and early 1990s when, in the
absence of antiretroviral therapy, Uganda’s
homegrown solution dealt a major blow
to the HIV/AIDS scourge. Ugandan doc-
tors have hardly been spared by the cancer
epidemic to which we lost over 5 doctors in
the past year alone including our icon Dr.
Margaret Mungherera who passed away on
the World Cancer Day, 4 February 2017.
Consequently, the Uganda Medical As-
sociation initiated the Physician Wellness
Programme for screening all medical doc-
tors for cancer and other diseases of life-
style, as we lead by example. We are pleased
that the government has purchased several
radiotherapy machines that will be installed
as soon as the bunkers at Mulago are com-
pleted.
Third, solutions for human capital weak-
nesses in Uganda’s health system should be
in sync with the progressive global strate-
gies on human resources for health recom-
mended by the World Health Organization
and Global Health Workforce Alliance.The
recent increase in salaries will definitely at-
tract health workers to report early,report in
hard to reach areas and remain productive at
the health facility. This move may comple-
ment the proposed biometric surveillance
machines. However, where health worker
staffing is chronically low or with perennial
shortage of medicines and limited access to
medical technologies, Ugandans cannot be
guaranteed quality services.These data from
5,600 absentee health workers suggest that
the sheer scarcity of a robust health work-
force is a bigger underlying problem for
which we should invest as a country. With
the new competitive salaries, Moroto Re-
gional Referral Hospital that returned its
wage bill for failure to attract 14 special-
ists in 2017/18 is unlikely to the same this
year as the Uganda Medical Association
has pledge to mobilize its members to fill
up these posts.
Lawrence Bossidy, a former chief executive
of General Electric, could not emphasize
more the importance of human capital in
his world famous quote “…nothing we do
is more important than hiring and develop-
ing people. At the end of the day you bet on
people, not on strategies…”. As a successful
revolutionary who shot himself to power,no
one understands the power of foot soldiers
than our fountain of honor, the President.
In this case, frontline health workers are the
Field Force Unit of the health sector! Let
us strive to inspire them to be better civil
servants!
Dr. Ekwaro A. Obuku
President, Uganda Medical Association;
Email: president@uma.ug
Website: www.uma.ug
In most homes, the air inside is dirtier than
the air outside, contributing to asthma and
other pulmonary complaints. This month,
the WMA’s My Green Doctor program has
a short guide to help your patients improve
indoor air quality, “Go Green at Home to
Prevent Asthma and Breathing Problems”.
You might print copies to share with your
office colleagues and for the waiting room:
https://www.mygreendoctor.org/go-green-at-
home-to-prevent-asthma-breathing-­problems.
There’s also a link to a free waiting room
poster.
My Green Doctor is a free membership
benefit from the World Medical Associa-
tion that is saving members money as their
offices adopt wise environmental practices
and share these ideas with their patients.
Hundreds of healthcare offices and clinics
of WMA members use My Green Doc-
tor. It adds just five minutes to each regular
office organizational meeting. My Green
Doctor explains what to say and do at each
meeting so there is nothing for the office
manager to study. Your patients will be im-
pressed! Ask your clinic manager to regis-
ter: https://www.MyGreenDoctor.org.
If you are a leader in your national medi-
cal association, please add this message to
your organization’s newsletter so that your
members can enjoy this free membership
benefit. To receive this e-newsletter an-
nouncement in a language other than Eng-
lish, simply contact My Green Doctor’s
Editor: tsack8@gmail.com.
Clean Indoor Air is Key
to Asthma Prevention
Interview – Survival: One Health, One Planet, One Future –
Routledge, 1st
edition, 2019, by Daniele Dionisio PEAH – Policies for
Equitable Access to Health
Re-published with permission from Dr. Daniele Dionisio, Member, European Parliament Working Group on Innovation, Access to
Medicines and Poverty-Related Diseases. http://www.peah.it/2019/10/interview-survival-one-health-one-planet-one-future-routledge-1st-
edition-2019
George Lueddeke
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32 33
One Health, One Planet
One Health, One Planet
and the SDGs across all nations  – those
that are more economically developed and
those that are developing and of course
those that are in disarray – many for rea-
sons that defy logic. Concentrating on local
needs guided by global/national priorities
that are in keeping with sustainability val-
ues and practices is without a doubt the best
way forward.
There are about 7.7 billion people on the
planet, and it is estimated that there will
be over 9.8 billion by 2050 and 11.2 bil-
lion in 2100. Climate change, urbanisation,
pandemics, conflicts (globally we spend
over US $7 trillion on war and only $ 3%
on peace-c. $6 billion!) and food security
are main issues we need to tackle now and
feature in the book along with health care –
perhaps prompting reconsideration of the
term “Public Health” and widening its re-
mit to the more inclusive “Global Health
and Well-Being” as the focus must shift to
ecocentrism.
Changing the way we think and behave
should no longer be a question of why but
how -although our main concerns continue
to be political and economic rather than
sustaining the planet. Populism, national-
ism and isolationism are the antithesis of
the paths toward which we ought to be
striving. The root causes of these move-
ments need to be investigated and solutions
found that ensure global equity, peace and
sustainability. It may be important to re-
mind global decision-makers that if we fail
to save the planet none of the other human
activities will matter. Shelley’s poem Ozy-
mandias (1818) comes to mind. I am also
reminded of a quote by economist and au-
thor John Kenneth Galbraith  – ‘A nuclear
war does not defend a country and it does
not defend a system …not even the most
accomplished ideologue will be able to tell
the difference between the ashes of capital-
ism and the ashes of communism.’
PEAH: The book highlights two of our
greatest social problems: changing the way
we relate to the planet and to one another
and confronting how we use technology
for the benefit of both humankind and the
planet.How to translate theory into practice?
Lueddeke: Several years ago, Marco Lam-
bertini, executive director at WWF, made
clear why there has to be a major societal
transformation. As one example, he ob-
served that ‘in less than two human genera-
tions, population sizes of vertebrate species
have dropped by half.’Further, he reminded
us: ‘These are the living forms that consti-
tute the fabric of the ecosystems which sus-
tain life on earth and the barometer of what
we are doing to our planet, our only home.’
He also warned that ‘We ignore their de-
cline at our peril.’ Echoing the book’s main
theme, he also emphasised the need for
‘unity around a common cause,’ collabora-
tion, and leadership ‘to start thinking glob-
ally and to stop behaving as if we have a
limitless world.’
In the intervening five years since the WWF
report was published, too few leaders – G7
(France, United States, United Kingdom,
Germany, Japan, Italy, Canada [ Russia
suspended] and E7 (emerging – China, In-
dia, Brazil, Mexico, Russia, Indonesia and
Turkey) have listened. Given the available
evidence today (e.g., the UN biodiversity re-
port published in May 2019!), there is now,
unquestionably, a pressing need to re-orient
society towards a sustainable future. The
challenge is to shift our perspective from
two-dimensional to three-dimensional, ‘or-
bital’thinking,as NASA International Space
Station astronaut Col Ron Garan contends
–‘bringing to the forefront the long-term
and global effects of every decision.’
PEAH: Relevantly, you maintain in the
book that two fundamental changes are
necessary if we – and all other species – are
to survive in the coming decades. Tell us
more, please, around these changes.
Lueddeke: In terms of sustainability we are
challenged to make a fundamental mind-
shift – adopt a new worldview – to ensure
our needs as human beings are compatible
with the needs of our outer world – our eco-
system. Education is key in this regard as
are global/national/local policies and strate-
gies that underpin OHWB and the SDGs.
Secondly, we must ensure that technology
/ AI is used only for peaceful purposes and
in support of the health and well-being of
allspecies and the planet. The dangers of
techno warfare and genetically engineered
viruses are all too real and we must learn
from history. The late physicist, Stephen
Hawking, said it best ‘We are all different
we all share the human spirit’ but ‘unless
crucial societal transformations occur, in-
cluding the prevention of nuclear war, glob-
al warming and genetically engineered vi-
ruses – the shelf life of Homo sapiens could
be extremely short.’
The battle between technology and human-
ity may yet become our greatest threat. As
we head further into a techno-driven so-
ciety – age of quantum computers (where
computations can be done in minutes vs
10,000 years on today’s supercomputers),
there is a real danger that we become in-
creasingly dehumanised rather than as
Klaus Schwab, executive chair of the World
Economic Forum, aspired, that we refocus
on becoming ‘better humans.’
PEAH: Summarised in *Ten Propositions
for Global Sustainability*(Ch. 12), the vol-
ume calls for the One Health and Well-
Being concept to become the cornerstone
of our educational systems and societal in-
stitutions – helping to create – in keeping
with the UN 2030 Global Goals – a more
“just, sustainable and peaceful world.” Can
you detail about the Propositions in their
connection with the One Health and Well-
Being concept?
Lueddeke: Two of the main recommenda-
tions of Survival is that the One Health
& Well-Being concept should become the
cornerstone of our educational systems and
society at large and that OHWB principles
and approach should underpin the UN-
2030 Sustainable Development Goals.
The Propositions cut across socioeconomic,
geopolitical and environmental lines. The
need for a paradigm shift and peaceful use
of technology have already been mentioned.
Others relate to migration, genuine col-
laboration among government, business,
civil society, and actively promoting ‘the
values of equality, democracy, tolerance and
respect.’ The need for global discussion on
these and other propositions seems essen-
tial.The UN could be best placed to lead on
the initiative perhaps supported by higher
education institutions (universities, colleges,
etc) of which there are about 26,000 im-
pacting on the lives of millions.
To raise awareness across education systems
and communities, the One Health Educa-
tion Task Force along with a global plan-
ning teamare evolving an international One
Health for One Planet Education Initiative
(1 HOPE). Anyone interested in joining a
working group can sign up https://tinyurl.
com/y2ux5b5g
PEAH: Proposition 10, inter alia, focuses
on reforming the UN Security Council es-
tablished right after WWII (1946).What
does this mean?
Lueddeke: Well, the UNSC was formed
after WWII (1946) consisting of 5 per-
manent members (US, China, Russia, UK,
France), while in 2019, the most densely
populated regions with the greatest pov-
erty and conflicts – Africa (c. 1.2 bill), India
(c.1.3 bill), SE Asia (c. 600 mill), Middle
East (c. 400 mill) – c. 50 % [3.5 bill out of
c 7.7 bill] – are NOT permanently repre-
sented. Shifting to regional (6) representa-
tion (vs countries) would clearly be in the
best interest of the world given the need for
global accountability and sustainability.
UNSC members should also be held glob-
ally accountable by key stakeholders – gov-
ernmnet, business, civil society  – for their
role in maintaining world peace and secu-
rity – based on a genuine commitment to
shared people and planet values. The ques-
tion is how can we achieve these ends when
forces are pushing the world in the opposite
direction. Surely, these decision-makers also
have children and grand-children and would
like to see them thrive in a better world
where hopes and dreams can be realised.
PEAH: As for the range of key topics cov-
ered in the book?
Lueddeke: This is my third book this decade
and in a way represents a personal journey of
discovery trying to understand the world and
healthcare – first from a more narrow human-
centric medical education perspective (Medi-
cal Education for the 21st
Century), moving
to the wider public health horizon and rec-
ognizing the limitations of my assumptions
(Global Population Health &Well-Being in
the 21st
Century) to pulling various strands
together in Survival: One Health, One Plan-
et, One Future. I don’t think I could have
written the latter without the former. The
new publication is really a building block of
personal knowledge acquisition tinged by
personal and professional experience in Can-
ada and the UK plus other countries.
PEAH: As reported ‘…The sub-discipline
that has perhaps come closest to integrating
other disciplines, including medicine and
environmental science, is public health. In
Survival: One Health, One Planet, One Fu-
ture, George R. Lueddeke, the chair of the
One Health Education Task Force, shows
how public health can be incorporated into
a wide range of fields to address individual,
population, and ecosystem health…’With
respect to this, kindly let us know more.
Lueddeke: This quote appears in one of
the on-line book reviews and comes from
a World Economic Forum / Political Syn-
dicate on-line article, “Economics can no
longer ignore the earth’s natural boundar-
ies,” written by Erik Berglof at the London
School of Economics. Three key messages
are that 1) economists have treated inequal-
ity too narrowly and that income dispari-
ties within countries are caused mainly by
global financial forces rather than local
labor-market conditions; 2) policies are
required to make society more sustainable;
and 3) a new field of planetary social science
is needed to bring together ‘different per-
spectives, conceptual frameworks, and ana-
lytical tools.’He affirms that public health is
closest to integrating other disciplines and
refers to Survival: One Health, One Planet,
One Future, and ‘how public health can be
incorporated into a wide range of fields to
address individual, population, and ecosys-
tem health.’
Survival concludes with a discussion on the
leadership role that Generation Z – those –
the ‘fixers’ born in the mid 90s – need to
play in the decades that lie ahead . They
are becoming the face of the planet and are
much more tolerant of others and thrive on
collaboration. Recalling the eloquent words
of civil rights leader Martin Luther King Jr,
Gen Z are certainly far from silent ‘about
things that matter.’ Their voices must be
heard across the globe as their future de-
pends on decisions we make today!
PEAH: Your insightful answers best en-
hance the book. So compounded, the vol-
ume is of great interest to policy-makers,
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34 35
Digital Transformation Initiatives
Digital Transformation Initiatives
multi-professional practitioners, academics,
students across all disciplines and concerned
members of the general public – especially
the younger generation – in both developed
and developing nations. For many reviewers
to date, your book is indeed a wake-up call
which needs to be heard “loud and clear”
globally.
Just echoing a recent endorsement by Tracy
Collins, founder at The Island Retreat, County
Cork, Ireland ‘…When we accept that human-
kind is part of something bigger, then the world
will be a better place. Our natural world is not
there to provide us with unlimited resources…
it really is time to start learning to respect it.
Thank you George R. Lueddeke for being a
voice of reason in a world of chaos!’
Posted on28th
October 2019
Author Daniele Dionisio
Advisor, “Medicines for the Developing
Countries”​
, SIMIT (Italian Society for
Infectious and Tropical Diseases).
Head of the research project Policies for
Equitable Access to Health (PEAH).
Former Director, Infectious Disease
Division, Pistoia Hospital, Pistoia (Italy).

Tweets by DanieleDionisio
https://www.linkedin.com/in/
da niele-dionisio-67032053
http://www.peah.it/spontaneous-
article-submissions/
https://www.facebook.com/
PEAH51/?modal=admin_todo_tour
by members [7]. The survey revealed than
more than seventy-five percent (75%) of the
respondents did not have the app installed.
Some of the reasons given for not using the
app were:
• Lack of awareness about the app;
• The app is complex;
• No reason to use the app;
• Does not meet my needs.
Digital disruption has great potential in
healthcare. The main areas of investments
are certainly Big Data analytics and AI (Ar-
tificial Intelligence). Some of the Big Data
analytics tools are useful for improving ef-
ficiencies, where some of the tools can be
automated. This could potentially yield bet-
ter utilization of human resources and could
potentially create huge cost savings. In the
main,Big Data and AI tools are used to pro-
file clients, medical service providers and to
look at healthcare utilization patterns and
trends. Some of the techniques such as pre-
dictive analytics are important; in that they
can be used, not only to profile members but
also to create a strategy to combat attrition.
Insights from the data could be useful for
data-driven decision-making processes that
could potentially save huge downstream
costs for medical schemes.There is also great
potential in investing in digital marketing
and in the optimal use of mobile apps.
Digital Transformation
Initiatives In The Public
Sector – In South
African Healthcare
There are several innovations that must take
place in the public sector in South Africa
as far as digital transformation is concerned.
Chiefly, these are still at beta phases and
their overall impact and outcomes are still
to be realized. Furthermore, there are pock-
ets of digital innovations in the public sec-
tor dating back to 2014.Some are ­
initiatives
employed at provincial level, while others
Digital transformation is growing at a slow
rate in medical schemes and healthcare
when compared with other industries such
as banking and insurance. The healthcare
sector needs to embrace the digital trans-
formation and adopt and optimize the use
of technology. Otherwise, the sector will
be left behind. Other sectors have taken
advantage of technology; typically, in the
retail sector; nowadays consumers shop
online, bank, and do travel bookings on-
line. The logistics business has also em-
braced digital transformation in that most
activities are now done through devices
using the convenience of one’s office or
home.
The recent HPCSA1
conference included
topics such as Telemedicine’s where several
digital transformations and innovations in
the health sector were presented. What was
evident in the discussions was that prog-
ress in accelerating digital transformation
is hampered by the slow pace of regulation
and other relevant guidelines. The topics
discussed clearly revealed that the health
sector is still far behind, compared with
other countries. For example, there is a gap
in the adoption of digitally enabled tools
for diagnosing, providing treatment, and
better management of chronic and other
conditions. Electronic medical records are
still not a part of routine care, both from
the supply and the funders side, except for a
handful of players.
On the funders’ side, you do find several
medical schemes2
that invest in technol-
1 
The Health Professions Council of South Africa
is a statutory regulator of healthcare professions
in South Africa.
2 
Medical schemes are non-profit organisations
which are registered with the Registrar of Medi-
cal Schemes. Members belonging to a scheme
make contributions and in return, receive medical
cover according to the rules of the scheme.
ogy. For example, there are schemes that
are already implementing digital applica-
tion forms for smooth onboarding of new
members. This is with the aim of going
digital and reduce paper application forms.
Similarly, the submission of claims of which
more than ninety-eight (98%) are submit-
ted in electronic form has transformed
claims significantly. Strategies such as digi-
tal marketing are typically used to reach the
target market and to communicate more
effectively with members. Several schemes
have invested a lot in product development,
such as mobile apps, and by developing
communication channels through online
and social media platforms. Social media
platforms provide an opportunity for brand
repositioning. They also provide an oppor-
tunity to reach a new target market and gain
access to a larger pool potential client base.
Social media platforms could also be used as
a tool to improve services to clients, create
convenience and provide instant interaction
with clients. However, very few medical
schemes optimize on these platforms; par-
ticularly small to medium schemes. There
is still a need to measure the value add of
digital transformation to members; chiefly
where the quality of care is concerned.
A recent study was conducted by Wil-
lie, which was an unstructured survey on
the use of medical scheme mobile apps
Digital Transformation In Healthcare – South African Context
Michael Mncedisi Willie
Box 1: Digital developments in the public sector
Year Digital developments
2014
• Aviro launched their innovative eHealth app.
• North West department of health outlines eHealth plans (RHIS).
• Cell – Life’s iDART hits the target.
• Tier.Net, the software application that monitors patients on HIV and TB
treatment.
• The NDoH has issued a tender for a service provider to conduct an evaluation
of the use of the Tier.Net software.
• NDoH sets out eHealth standards evaluation process.
2015
• The Mpumalanga DoH issues eHealth tender.
• eHealth rollout high on Gauteng’s agenda.
• Mobenzi has partnered with the Anova Health Institute to support the
Limpopo (DoH) with the deployment of Mobenzi mHealth technology.
• eMocha launches TB mHealth platform in South Africa.
• NDoH is working with the CSIR to develop an eHealth system to accompany
the rollout of NHI.
• North West DoH announce eHealth pilot.
2016
• eMocha Boosting MDR-TB linkage to care in South Africa.
• eMocha’s miLINC for MDR-TB mHealth platform was designed after the
NDoH approached Johns Hopkins University.
• The Human Research Science Council (HSRC) has announced the
development of a new mHealth app aimed specifically at pregnant teens.
• NDoH using eHealth to improve health facilities.
• South Africa adopts WHO’s HIV ‘Test and Treat’ guidelines.
2017
• mHealth aiding in the diagnoses of burn injuries.
• Generic and Biosimilar Medicine of Southern Africa has asked the South
African government to accelerate the evaluation and the registration of more
affordable biosimilar medicines in South Africa.
• South African medical information-exchange company, Healthbridge, has
announced their acquisition of Infosys Software Solutions’ Healthcare division.
• WHO and ITU to use eHealth to strengthen health services in Africa.
• South Africa digital health accelerator attracts top eHealth start-ups.
2018
• The National Department of Health (NDoH) has identified IT and health
information systems (HIS).
• The South African Medical Research Council (SAMRC) has partnered with
Jembi Health Systems NPC.
• Philips and UJ renew MoU to empower healthcare professionals.
• Digital Health Cape Town have announced the commencement of their
second accelerator programme.
• A new mobile app, called ViaOpta Hello, has been unveiled, to help hundreds
of thousands of South African living with blindness and severe visual
impairment.
2019
• A subsidiary of CompuGroup Medical SE has developed an e-scripting so-
lution that is helping over 1,000 South African doctors to ensure medication
adherence among their patients.
• Aviro Health launches whatsapp channel to support HIV self-testing.
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36 37
Digital Transformation Initiatives
Digital Transformation Initiatives
are deployed at the national level. An in-
tegrated holistic approach at the national
level could ascertain value added and im-
pact in the sector. Box 1 below depicts the
Department of Health’s (DoH) digital and
eHealth developments and implementation
from 2014.
The Use of Artificial
Intelligence in Healthcare
Artificial Intelligence (AI), Machine
Learning (ML) and Big Data analytics are
some of the most talked-about technologies
in recent years. According to Bali, Garg,
and Bali, AI aims to mimic human cogni-
tive functions, such as the ability to reason,
discover meaning, generalize, or learn from
experience [9].
Popular AI techniques include machine
learning methods for structured data, such
as the classical support vector machine and
neural network,and the modern deep learn-
ing; as well as natural language processing
for unstructured data [10]. Machine learn-
ing is the foundation of modern AI and it
is essentially an algorithm that allows com-
puters to learn independently without fol-
lowing any explicit programming [6].
The use of AI is already at advanced stages in
other industries.Its adoption in healthcare is
growing at a steady rate; however,there is no
doubt that AI is certainly going to change
the face of healthcare delivery. AI is being
employed in numerous settings; for example,
funders, as well as administrators, use it to
adjudicate and to process claims and hospi-
tal facilities for assessing bed occupancy.
AI is also used to analyses unstructured data
such as images, videos, and physicians’notes
to enable clinical decision-making and in-
formation sharing. Other commentators
such as argued that AI is more prevent in
the area of medical diagnosis. AI systems
can analyse huge volumes of data faster and
far better than humans [8].
These improvements can improve efficien-
cies in identifying medical diagnoses better
than doctors.It should be noted that AI can-
not completely replace the medical profes-
sion,but it could be used as a tool to optimize
current processes, reach medical conclusions
and aid with decision-making factors, thus
saving costs and improving quality of life.
Applications of Artificial
Intelligence
Artificial Intelligence has the potential to
change the healthcare industry in South Af-
rica for the better.This is subject to its opti-
mal use in both the supply and demand side
of the health care ecosystem.AI is delivering
high value, including the following areas:
Overutilization, Waste and
Abuse of Medical Services
The South African private health sector
expenditure is viewed as one of the most
expensive models, when compared to other
similar countries, South Africa spends nine
percent (9%) of its GDP on healthcare,
which is four percent (4%) higher than
the WHO3
’s recommended spending for
a country of its socioeconomic status [5].
Furthermore, South Africa has one of the
highest government health spending per
person [12], particularly the private health
sector.According to the Competition Com-
missioner (CC), private hospital admission
rates in South Africa are higher compared
to most OECD countries, partially proce-
dures such as arthroplasty, tonsillectomy
and caesarean section [13]. The over-utili-
zation of healthcare services is also cited as
one of the cost drivers in the health sector,
which ultimately impacts the premiums
paid by the members. Providing lower levels
of or faulty care to patients also results in
wasteful expenditure from the funders’ side.
Other examples of possible waste include
medically unnecessary caesarean sections
(C-section) or imaging.
3 
The Health Professions Council of South Africa
is a statutory regulator of healthcare professions
in South Africa.
The C-section rate in South Africa is
higher than the WHO’s recommendation
at about twenty-six percent (26%) [1]. In
the private sector, the C-section rate is
three (3) times higher when compared to
the national rate at more than seventy-
seven percent (77%), which is significantly
higher than the recommended rate [2].The
recommended rate of Caesarean sections is
around ten to fifteen percent (10% -15%)
of all births. A  study by Manyeh argued
that the increase in the C-section rate in
developing countries has not been clinical-
ly justified and that these increasing trends
have become a major health issue, due to
potential maternal and perinatal risks, in-
equality of access and the costs involved
[3].
Waste and inefficiency occur at every level
in a health care system; waste also includes
unnecessary procedures done on patients.
Other examples include instances where
repeat tests on the same patients are done
by several providers but billed separately.
This could be avoided if the various medi-
cal providers in the value chain could ac-
cess the same patient records for clinical
decision-making. Thus, there is value in
investing in a healthcare delivery model
that is not fragmented and encourages care
co-ordination.
According to Albejaidi and Nair, failures
of care co-ordination typically occur when
patients experience care that is fragmented
[4]. Other examples include poorly man-
aged care co-ordination which may result
in a patient being referred from one health
care setting to another. Figure 2 below de-
picts various categories of waste, as defined
by Albejaidi and Nair [4].
One of the highlighted categories which are
frequently prevalent in an uncoordinated
health system is typically where patients’
records are not stored in a central secure
data repository. As a result, duplication of
services, tests and procedures are done more
frequently than is clinically necessary.
Box 2: Applications of AI- select list
Medical Diagnosis
AI systems can analyse far more data far faster than humans, which may make them
more adept at identifying medical diagnoses than doctors.
Neurology
Neurological healthcare deals with nervous systems disorders such as Parkinson’s disease,
Alzheimer’s disease, epilepsy, stroke, and multiple sclerosis. AI can also predict strokes
and monitor seizure frequency.
Pathology Images
Most diagnoses depend on a pathology result, so a pathology report’s accuracy can make
the difference between diagnosis and misdiagnosis.
Radiology Tools
Various forms of radiology, such as CT scans, MRIs and X-rays provide healthcare pro-
viders with an inside view of a patient’s body. However, different radiology experts and
doctors tend to interpret such images differently.
Smart Devices
Hospitals are big purchasers of smart devices.The devices, which take the form of tablets
and hospital equipment, exist in intensive care units (ICUs), emergency rooms, surgeries
and regular hospital rooms.
Source: [11]
Figure 1. Caesarean sections by country
Source: [11]
Figure 2. Various categories of waste in health care
Source: [4]
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38 39
Health Care in Developing Countries
Health Care in Developing Countries
References
1. World Health Organization: Monitoring emer-
gency obstetric care: a handbook. 2009.
2. Council for Medical Schemes. CMS Annual
Report 2018-2019, 2019, www.medicalschemes.
com/Publications.aspx.
3. Alfred Kwesi Manyeh, Alberta Amu, David
Etsey Akpakli, John Williams & Margaret
Gyapong. Socioeconomic and demographic fac-
tors associated with caesarean section delivery
in Southern Ghana: evidence from INDEPTH
Network member site. BMC Pregnancy and
Childbirth volume 18, Article number: 405
(2018).
4. Albejaidi and Nair, American International
Journal of Research in Humanities, Arts and
Social Sciences, 18(1), March-May 2017, pp.
01-09.
5. Bidzha, L.., Greyling, T., Mahabir, J. Has South
Africa’ s Investment in Public Health Care Im-
proved Health Outcomes? ERSA Work. Paper.
663; ERSA: Cape Town, South Africa, 2017; pp.
1–28.
6. Adam C. Uzialko. Artificial Intelligence Will
Change Healthcare as We Know It. 2019. Availa-
ble at:https://www.businessnewsdaily.com/15096-
artificial-intelligence-in-healthcare.html
7. Willie M.M, Optimal Use of Telemedicine by
Medical Schemes to Manage Chronic Condi-
tions and Educate Beneficiaries. HPCSA Na-
tional Conference 18 – 20 August 2019. Emper-
ors Palace, Ekurhuleni, Gauteng. 2019.
8. Loh, E. Medicine and the rise of the robots: a
qualitative review of recent advances of artificial
intelligence in healthBMJ Leader 2018;2:59-63.
9. Bali, J., Garg, R., Bali, R.T. Artificial intelligence
(AI) in healthcare and biomedical research: Why
a strong computational/AI bioethics framework
is required? Indian J Ophthalmol. 2019; 67:3-6.
10. Jiang, F., Jiang, Y., Zhi, H., et al. Artificial in-
telligence in healthcare: past, present and future
Stroke and Vascular Neurology 2017. https://
www.businessnewsdaily.com/15096-artificial-
intelligence-in-healthcare.html
11. Lisa Morgan.Artificial Intelligence in Health-
care: How AI Shapes Medicine. 2019. Avail-
able at https://www.datamation.com/artificial-
intelligence/artificial-intelligence-in-healthcare.
html
12. Micah AE, Chen CS, Zlavog BS, et al.Trends
and drivers of overnment health spending in
sub-Saharan Africa, 1995–2015 BMJ Global
Health 2019.10.25
13. South African Competition Commission.
Health Market Inquiry. FINAL FINDINGS
AND RECOMMENDATIONS REPORT.
Pretoria: Competition Commission; 2019.
Michael Mncedisi Willie,
General Manager Research & Monitoring,
Council for Medical Schemes, South Africa
E-mail: m.willie@medicalschemes.com
in high quality for everyone across coun-
tries [3].
The active engagement of young people is
imperative to achieve Sustainable Develop-
ment Goals (SDGs). In 2019, more than
3.8 billion people (49% of the world popu-
lation) are under the age of 24 years,and 2.4
billion (32%) are between the ages of 10-
24 [4]. The distribution of this youth bulge
is especially important, with nine out of ten
young people live in low and middle income
countries [5]. While a youth bulge is often
seen as a challenge, it also creates an oppor-
tunity for a demographic dividend,a relative
myriad of working-age people which could
lead to higher productivity, positive impact
on economic growth, political stability and
social and sustainable development. How-
ever, the ability of countries in harnessing
demographic dividend depends on their
investment in the workforce, particularly in
youth.Investing in quality education,decent
employment opportunities and health and
wellbeing of young people, will enable them
to develop skills and values that positively
contribute to economic growth and sustain-
able development of their community [6].
The Global Health Workforce Network
(GHWN) Youth Hub, established in 2017,
aims to promote youth engagement in the
health workforce agenda, strengthen data
and evidence on education and youth em-
ployment issues in health and social care
and facilitate inter-professional collabora-
tion to address these. The Youth Hub was
created by the World Health Organiza-
tion (WHO), as an intersectoral, inter-
professional community of practice to drive
youth-inclusive policy locally, nationally,
regionally and globally.
Findings from the
Youth Hub paper
This paper describes findings from the rapid
review [7] conducted by the Youth Hub on
youth and decent work in the health and so-
cial care sector. The review was designed to
give a rapid assessment on existing research,
and focused specifically on decent work in-
cluding equal opportunities and treatment
in employment, safe work environments
and social security/adequate earnings. In
addition, gender equality was included as a
cross-cutting theme [8].
There were a number of pertinent findings
from the review, shedding new light on
youth employment in the health workforce.
In terms of equal opportunities and treat-
ment, a number of barriers were identified
that influenced youth occupational deci-
sions, including issues of work-life balance,
inadequate mentorship and occupational
segregation. Experiences of gender (and
other) stereotyping,bias,discrimination and
violence in the health and social care work-
force begin in training programmes and are
experienced with staggering prevalence by
young and newly qualified workers. Find-
ings on safe work environments revealed
higher rates of burnout for young health
workers and students, and alarmingly high
rates of violence including verbal, psycho-
logical, physical and sexual violence. Social
security and adequate earnings emerged as
an important determinant of youth wellbe-
ing in the health workforce, with students
and new graduates across professions often
carrying large debts from their training.
The review also revealed significant research
gaps in the topic of youth in the health
workforce. The literature identified was not
sufficiently diverse to give an assessment of
the challenges faced globally. Existing liter-
ature is focused on high-income countries,
and largely on health disciplines such as
nursing and medicine as opposed to social
work and other allied health, community
health workers, and other social care occu-
pations. The vast majority of the literature
retrieved described, analysed and explored
the challenges present for youth and decent
work in the context of the health and social
care sector; there was less focus on solu-
tions, interventions and best practices – in
particular, organizational or system-level
interventions or programmes.
Proposed Solutions
The challenges facing youth in the health
workforce are significant. Closing the pre-
dicted 18 million health worker gap [9]
by 2030 will require significant and stra-
tegic youth-responsive investments at the
national, regional, and local levels. Firstly,
ensuring decent conditions for work and
study is essential to recruit and retain youth
into the health and social care sectors. This
includes addressing financial hardship as
a significant factor for early attrition and
migration of young health workers. Sec-
ondly, interventions, employment strategies
and policies for young workers must use
gender-transformative and intersectional
approaches to ensure equitable impact and
reach. This includes widening the youth
health workforce research agenda to high-
light the issues in low- and middle-income
countries where shortage of health workers,
higher disease burden, higher youth unem-
ployment rates, and the largest population
of youth reside. All of the above solutions
must take a health systems approach that
includes organizational interventions, not
only individual interventions targeting
youth workers.Lastly,meaningful youth en-
gagement mechanisms must exist at local,
regional, national and global level on decent
work agendas, including both programme
planning and policy-making. Students and
early career professionals need to be at the
decision-making table for effective policy-
making on human resources for health.
Conclusions
Meaningful youth engagement is required
to achieve Sustainable Development Goals
(SDGs). Ensuring decent working condi-
tions is essential to recruit and retain youth
into the health and social care sector. Barri-
ers to retention and factors that lead to mi-
Charlotte O’Leary
Youth in the Health and Social Care Sector, challenges and
opportunities
Sherly Meilianti Behrouz Nezafat Maldonado
Background/introduction
The Sustainable Development Goals
(SDGs), established by the United Nation
(UN), aim to address global challenges
worldwide to achieve a better and sus-
tainable future for all [1]. Goal 3, “Good
health and well-being”, aims to ensure
healthy lives and promote well-being at all
ages [2]. It also aims to achieve universal
health coverage (UHC), and provide ac-
cess to safe and effective medicines and
vaccines for all. UHC aims to leave no one
behind and ensure that health services are
available, accessible, acceptable and served
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40
Memorandum of Tokyo
iii
Health Care in Developing Countries
gration of young health workers should be
identified and considered by policy makers
through youth engagement.
The findings from the rapid review will be
used to advance youth-responsive work-
force action and support the substantive
work of the Youth Hub. Effective and
strategic youth-inclusive policies will have
sustainable effects on Sustainable Develop-
ment targets. Not only will these policies
support the challenges facing global health
today,but they will also yield impact far into
the future for youth and for the health of
populations.
References
1. United Nations Sustainable Development
(2019). About the Sustainable Development
Goals – United Nations Sustainable Develop-
ment.[online] Available at: https://www.un.org/
sustainabledevelopment/sustainable-develop-
ment-goals/ [Accessed 12 Oct. 2019].
2. United Nations Sustainable Development
(2019). Goal 3 .:. Sustainable Development
Knowledge Platform. [online] Available at: htt-
ps://sustainabledevelopment.un.org/sdg3 [Ac-
cessed 12 Oct. 2019].
3. World Health Organization (2019). Universal
health coverage (UHC). [online] Available at:
https://www.who.int/news-room/fact-sheets/
detail/universal-health-coverage-(uhc) [Ac-
cessed 12 Oct. 2019].
4. World Bank (2019). Health, Nutrition and
Population Data and Statistics, World Bank.
[online] Datatopics.worldbank.org. Available at:
http://datatopics.worldbank.org/health/popula-
tion [Accessed 12 Oct. 2019]..
5. Gupta, M. D. (2014). The Power of 18 Billion:
Adolescents, Youth, and the Transformation of
the Future.The State of World Population.
6. United Nations Youth (2019). Youth and the
2030 Agenda for Sustainable Development |
United Nations For Youth. [online] Available at:
https://www.un.org/development/desa/youth/
world-youth-report/wyr2018.html. [Accessed
12 Oct. 2019].
7. World Health Organization (2019). Youth and
decent work in the health and social care sector
[online] Available at: https://www.who.int/hrh/
network/YouthPaper-PS-SR_23May2019.pdf
[Accessed 12 Oct. 2019].
8. International Labour Organization (2019). De-
cent work. [online] Available at: https://www.
ilo.org/global/topics/decent-work/lang–en/in-
dex.htm [Accessed 21 Oct. 2019].
9. World Health Organization (2019). Call to ac-
tion: Addressing the 18 Million Health Worker
Shortfall [online] Available at: https://www.
who.int/hrh/news/2019/call-to-action-address-
ing18million-health-worker-shortfall.pdf?ua=1
[Accessed 20 Oct. 2019].
Charlotte O’Leary,
Youth Hub, Global Health Workforce
Network; Monash University, Australia
Sherly Meilianti,
Youth Hub, Global Health Workforce
Network; University College London, UK
Behrouz Nezafat Maldonado,
Youth Hub, Global Health Workforce
Network, Oxford University hospitals, UK
At the Health Professional Meeting (H20) 2019 in Tokyo, the
World Medical Association and the Japan Medical Association
welcome the efforts by the World Health Organization, national
governments, intergovernmental and United Nations agencies as
well as other organizations to foster the development of healthcare
systems providing Universal Health Coverage (UHC).
We notice that UHC means ”that all people and communities can
use the promotive, preventive, curative, rehabilitative and palliative
health services they need, of sufficient quality to be effective, while
also ensuring that the use of these services does not expose the user
to financial hardship.” (WHO definition of UHC)
UHC is a tool to overcome inequities in the health systems them-
selves.
UHC is for people, but also by people.
Human resources for healthcare in many countries are scarce. We
urge all in responsible positions to invest in the education and reten-
tion of health professionals to make UHC possible.
This must include quality education, opportunities for continu-
ing professional development and most important safe, dignifying
and attractive working and living conditions for those who provide
healthcare to their communities and patients.
The WMA encourages physicians and their associations in all parts
of this world to play a profound role in the advocacy for and the
realization of UHC.
From the side of the medical profession, there should be no hesi-
tancy in embracing the concept of UHC,including a strong engage-
ment for the development of quality primary care as the core part of
a comprehensive health system.
We welcome the recent attention that G20 Finance Ministers give
to the development of UHC as a contribution “to human capital
development, sustainable and inclusive growth and development,
and prevention, detection and response to health emergencies, such
as pandemics and anti-microbial resistance, in developing coun-
tries.”
We express our expectation to the G20 Summit that this inspires
the way to improved and sustainable investments in healthcare sys-
tem not only in G20 countries but also and most importantly in
other economies, which still invest insufficiently in their healthcare
systems, irrespective of the reasons for such shortfalls.
Memorandum of Tokyo on Universal Health Coverage and the
Medical Profession
Health Professional Meeting (H20), June 14th
, 2019,Tokyo
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IV
General Assembly Report
215th
WMA Council Session, Porto 2020
Sheraton Porto Hotel & Spa, Portugal
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