ISSN 0049-8122 General Assembly Report World Medical Journal Official Journal of The World Medical Association, Inc. Nr. 1, January 2020 vol. 66

Contents

Editorial ...... 1 Interview with Miguel Roberto Jorge, President of the World Medical Association by WMJ Editor Peteris Apinis ...... 2 Interview with Dr . Robert Twycross, 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 Editorial

World Medical Association Officers, Chairpersons and Officials

Dr . Miguel Roberto JORGE Dr . David Barbe Dr . Leonid EIDELMAN Prof . Dr . Frank Ulrich WMA President, WMA President-Elect, WMA Immediate Past-President MONTGOMERY Brazilian Medical Association American Medical Association Israeli Medical Association Chairperson of Council Rua-Sao Carlos do Pinhal 324, AMA Plaza, 330 N. Wabash, Suite 2 Twin Towers, 35 Jabotinsky St., Bundesärztekammer CEP-01333-903 Sao Paulo-SP 39300 P.O. Box 3566 Herbert-Lewin-Platz 1 (Wegelystrasse) Brazil 60611-5885 Chicago, Illinois 52136 Ramat-Gan 10623 Berlin United States Israel Germany

Dr . Otmar KLOIBER Dr . Mari MICHINAGA Dr . Ravindra Sitaram Dr . Andreas RUDKJØBING Secretary General WMA Vice-Chairperson of Council WANKHEDKAR WMA Chairperson of the Medical World Medical Association Japan Medical Association WMA Treasurer Ethics Committee 13 chemin du Levant 2-28-16 Honkomagome Indian Medical Association Danish Medical Association 01212 Ferney-Voltaire 113-8621 Bunkyo-ku, Tokyo Indraprastha Marg Kristianiagade 12 France Japan 110 002 New Delhi 2100 Copenhagen 0 India Denmark

Dr . Jung Yul PARK Dr . Osahon ENABULELE Dr . Joseph HEYMAN WMA Chairperson of the Finance WMA Chairperson of the Socio- WMA Chairperson of the Associate and Planning Committee Medical Affairs Committee Members Korean Medical Association Nigerian Medical Association 163 Middle Street Samgu B/D 7F 8F 40 Cheongpa-ro, 8 Benghazi Street, Off Addis Ababa West Newbury, Massachusetts 01985 Yongsan-gu Crescent Wuse Zone 4, FCT, United States 04373 Seoul PO Box 8829 Wuse Korea, Rep. Abuja Editorial Nigeria

A low dose of any chemical compound may be virtually harmless, pesticides is similar to that of synthetic female sex hormones, while www wma. .net while its higher dose may cause diseases, but the highest dose may part of them – to modern antibiotics. These pesticides are ruthlessly turn into a deadly poison (there are exceptions – even the smallest sprinkled on the fields of the globe. In the world, the production drop of hydrocyanic acid and some other chemicals used in warfare of chemicals has doubled since 2000, and man depends on it more is deadly). And too large a dose of a chemical compound is a global than ever before. poison for our planet. This idea has already been known since the time of Hippocrates because the Greek word “pharmakon” means It is similar with global warming – a hot day usually means switch- either ‘medicine’ or ‘poison’ depending on the context. The father of ing on air conditioners on this planet. A heatwave means the deaths toxicology, Swiss doctor and alchemist Paracelsus (1493-1541), said, of patients with chronic cardiovascular diseases. Global warming Official Journal of The World Medical Association “The dose makes it clear that a thing is not a poison.” means new infectious diseases, injuries A swallowed tablet is medicine, but exaggerated dosing of medi- caused by catastrophic floods and hurricanes, psychosomatic dis- cines mean poisoning. Discharge in Asian rivers of substances from eases. Global challenges can only be tackled by reducing environ- Editor in Chief chemical plants manufacturing pharmaceutical raw material due to mental poisoning with pesticides, fertilizers and consumer chemi- Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia insufficient wastewater treatment means an ocean poisoned with cals, greenhouse gas emissions, deforestation, cleaning the ocean of [email protected] biologically active substances. However, the raw materials of these plastic and implementing other planet rescue programmes. medicines are manufactured in Asia exactly because of their lower Co-Editor Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany cost and lower environmental standards there. The chemical indus- Dr. med. h. c. Peteris Apinis, try and pharmaceutical industry are often in the hands of one busi- Editor-in-Chief Assistant Editor ness group. The chemical structure of some consumer chemicals and of the World Medical Journal Maira Sudraba, Velta Pozņaka; [email protected]

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

Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions

1 WMA News Medical Ethics

we find a global approach to assisting sick Apinis:World experience today shows that the WMA has its General Assembly. The Interview with Miguel Roberto Jorge, President of the doctors? these are doctors who most energetically WMA has been producing a series of poli- and honestly speak about the climate crisis cies dealing with themes of interest to the World Medical Association by WMJ Editor Peteris Apinis As said before, when physicians become and pollution of the planet, protest against environment with recommendations to be a patient, they act as any other patient. burning of forests, against the reduction of followed by physicians around the globe. the consequences of this kind of situation. meaningful investments. And I do not be- So, medical doctors need to treat them as biodiversity on the planet. What are you go- So, as the current WMA President, I will On regards of anxiety and depression, some lieve that to prepare good primary care any other patient, with courtesy, empathy, ing to do, as President of the World Medical continue to develop activities as the leaders data suggest that physicians do not present physicians will cost less than to train a good compassion, and respect. There is not other Association, in the fight for the well-being who came before me in highlighting the more depression than other people but the specialist. Any system of care, and particu- global approach than to treat well every pa- of our planet? importance of fighting against any situa- rate of suicides among physicians is higher larly those under the Universal Health Cov- tient we can have, being them physicians or tion that can decrease the world health than in the general population and, again, erage, requires good primary care physicians not. But the attending physician needs to Jorge: The World Medical Association levels. the distribution of suicide rates among dif- as well as good specialists. consider the possibility of facing colleagues counts for many years with an Environ- ferent medical specialties is not equal. In my as more difficult patients to treat. mental Caucus that meets yearly when personal opinion, the best way for a physi- Apinis: In Tbilisi, the WMA accepted a cian to feel appreciation and reduce the risk declaration on euthanasia. In this declara- of burnout is to dedicate to build a good tion, the WMA condemned euthanasia and relation with patients and share with them assisted suicide. As physicians, they can't Interview with Dr . Robert Twycross, DM Oxon, FRCP, FRCR, the power to take decisions on treatment and don't want to perform euthanasia or as- alternatives. sisted suicide. However, surveys show that Emeritus Clinical Reader in Palliative Medicine, Oxford University, physicians as patients would like to shorten Apinis: We see a new trend in world poli- their lives when they encounter major phys- Oxford, UK by WMJ Editor Peteris Apinis tics – doctors are undervalued. The global ical and mental health problems. These are Miguel Roberto Jorge trend is growing: doctors' earnings are doctors as patients who are most likely to Twycross: I am aware that in countries for a patient who fulfilled the legal criteria declining against average earnings in the refuse complicated and excessive treatment where euthanasia and/or assisted suicide could be set up and monitored. Any EAS Jorge: Peteris, An initial suggestion: ask country. Politicians and financiers, mean- if it can't significantly prolong survival and (EAS) are legal options there are palliative law is likely to lead to a negative change someone to review the English language while, talk publicly that preparing doc- improve the quality of life. How would you care services that have integrated EAS with in the way that disability and dependency in your questions. I believe they can be im- tors is too expensive, that universal health comment on a situation where a doctor, as a palliative care. However, for me, EAS and are viewed by society generally – as increas- proved. And I delete a phrase in your ques- coverage should be cheaper to have health patient, requires euthanasia or assisted sui- palliative care are mutually exclusive phi- ingly financially burdensome. Indeed, it is tion number 3 not because of the language specialists. How can we build the prestige cide? losophies. Expecting doctors to switch from for this reason that most disabled people but because I do not think it was correct. of our global profession and restore the re- one to the other is an expectation too far. are strongly opposed to any liberalisation muneration? Jorge: Indeed, the WMA took a very clear Further, palliative care specialists know that of the law. Apinis: You are a physician known world- position opposing physician assisted suicide almost all patients who begin by asking for wide and a leader among psychiatrists. Jorge: I can identify different situations in and euthanasia. We think that physicians EAS change their mind when adequately Apinis: Every doctor becomes a patient Could you comment on whether doctors in your question. Nowadays, compared to past should not involve in such practices. We supported by palliative care. What of those sooner or later. We know that medical doc- the world are burned out? Are doctors more times, medical doctors are given less value want our patients to be sure that we value who do not? In my opinion, it is perfectly tors are more open to shorten their lives threatened by anxiety and depression than and I believe the dehumanization of the their lives and that we are there to protect consistent to argue that, ethically speaking, when severe physical or mental health other people? Is it true that doctors in cer- medical practice has contributed to this sit- and to help them even in very difficult situ- EAS might be permissible in some extreme problems arise. Does a doctor as a palliative tain professions (such as anesthesiologists uation. Physicians not always have enough ations. Physicians, when they become pa- cases but that it would be unwise to change patient differ from other palliative patients and psychiatrists) are more at risk of suicide time to dedicate themselves to build a good tients, are patients like any other person. the law. As at present, it could be better to and how is it to work with a doctor as a pal- than people of other professions? How can physician-patient relationship that takes There is no different ethics for physicians Robert Twycross allow hard cases to be taken care of by vari- liative patient? we help doctors in the world to feel appreci- the individuality of each patient in consid- being patients. But the same is also true ous expedients than to introduce new leg- ated and reduce the risk of burnout? eration. And even when they have that time, as for any other person: we should abstain Apinis: The WMA adopted Declara- islation that would inevitably become too Twycross: It is harder caring for medical they are more prone to pay attention to lab from futile and undesired treatment, we tion on Euthanasia in October. In the permissive as has happened, for example, in colleagues – it is too easy to become emo- Jorge: There are studies indicating a high exams than to listen to the person they have must respect a demand for ending treat- world, there is often sought interrelation both the Netherlands and Belgium. tionally over-involved – but, in 30 years, prevalence of burnout among physicians in front. I do not know if just earnings of ment and we have to give comfort and to between the last weeks of life under the only one doctor-patient unwaveringly worldwide even considering that burnout medical doctors are declining but I believe alleviate pain. care of a palliative medicine specialist and However, if the law were to be changed, wanted to pursue EAS. This was because of is not equally distributed among them. the reasons for that are multiple and linked the possibility of ending life through as- there is no reason why doctors and nurs- existential distress, not for unrelieved physi- Providing medical care usually in difficult to profound changes in the work market Apinis: Every doctor turns into a patient sisted suicide or euthanasia. Could you es should be involved. A separate service cal symptoms. Indeed, despair is the com- circumstances exposes physicians to con- everywhere in the globe. To prepare good sooner or later. Shouldn't we be more open comment on this relationship from your staffed by registered individuals able to pre- monest reason for a consistent desire for tinuous stress at work and burnout is one of professionals, in any area of work, deserves to helping our sick colleagues? Shouldn't viewpoint? scribe or administer a single lethal overdose EAS. Even in such cases, given adequate

2 3 Medical Ethics Medical Ethics

support (including appropriate palliative as well as patients with cancer (cured or palliative care to take root requires a com- much we need painkillers in palliative treat- an established palliative care service and tors would accept that it is ethically accept- psychotherapy), there is often resolution. end-stage). In Moldova, the Angelus Hos- bination of a local charismatic champion ment? meet some of the many patients who have able to shorten survival by a few hours, or The question remains: if EAS was permit- pice in Chisinau is the only service in the (often but not always a doctor) who can rehabilitated largely because of morphine. maybe even by a few days. However, when ted, how long ought one to work for resolu- country offering ostomy care; and, in Mos- inspire fellow healthcare professionals and Twycross: Medicinal availability of opi- continuous sedation continues beyond this, tion before concluding that the distress is cow, long-term inpatient post-stroke and key supporters within civil society, together oids, particularly morphine, has been 6. There is an ongoing discussion about the it is tantamount to ‘slow euthanasia’. definitely intractable? long-term inpatient ventilation care have with media publicity, and the enthusiastic championed for some 40 years by the use of sedative drugs in palliative care. These been integrated into palliative care. support of at least one celebrity and several World Health Organization, among others. medicinal products should be administered Regrettably, there is plenty of evidence that Apinis: Three concepts – care, rehabilitation local and national politicians. Even so, there National governments have a dual interna- in accordance with ethical and pharmaco- the sedation is not always proportionate. and palliative care – are often mixed up [in Rehabilitation – helping someone to achieve may need to be an element of luck – being tional legal responsibility both to prevent logical principles the same way other pa- Further, in the Netherlands and Belgium the whole world]. By care, we understand their maximum potential in any of the do- in the right place at the right time in a com- illicit use of opioid drugs and to ensure that tients are treated in hospital for acute and for example, CDS is sometimes used as a long-term care services for patients whose mains of personhood – is integral to pallia- munity responsive to your message. Adopt- such drugs are readily available and easily chronic diseases. What is the difference proxy for EAS because it is more straight- functioning restrictions have stabilized so tive care. With the relief of pain and other ing a human rights approach can help but accessible for patients in whom other types between primary or palliative sedation and forward in terms of implementation, docu- far that further improvement is unlikely to distressing symptoms, adequate sleep and is unlikely to be successful unless associated of analgesic are inadequate. Indeed, the sedation as a significant treatment for sec- mentation, and external monitoring. In occur. By rehabilitation, we understand a set gentle encouragement, many palliative care with an appeal to the emotions. amount of morphine used per capita per ondary symptoms? How to avoid sedation France, CDS is now a legal right for termi- of measures to improve the functioning of patients improve physically, sometimes dra- annum is used as an approximation of the to hasten death? nally ill patients should they request it on patients with at least six-month potential matically. Of course, sooner or later, there In addition, palliative care will flourish only adequacy of palliative care provision. Thus, the grounds of unbearable suffering, and the survival, but by palliative care – individual will come a time when physical improve- if there is a combination of governmental in Georgia, if palliative care was available Twycross: my review Reflections on palliative activists who campaigned for this regard it services for people with very poor treatment ment is no longer possible. This is the time and philanthropic funding. This is true even to all who need it, the annual necessary sedation was published in the on-line journal as substitute for EAS. forecasts and survival. Is there any tendency when the challenge for many people is to in the UK. For example, in middle England, consumption of medicinal morphine is es- Palliative Care: Research and Treatment ear- for these different types of care to overlap? change from being a ‘human-doing’ to a one particular comprehensive inpatient timated to be 45 kg, but the actual amount lier this year, and I urge members of WMA Apinis: What should the WMA and na- Is there a place for rehabilitation in pallia- ‘human-being’ sustained within the embrace and community-based palliative care ser- currently used is only 8kg. In fact, the pro- to share it with their colleagues [https://doi. tional medical associations do to teach their tive care? Palliative care, in particular hos- of supportive loving relationships. vice costs £8 million per annum, but only portion of morphine that is used in low org/10.1177/1178224218823511]. First, doctors to improve their respective knowl- pice care, should be distinguished as the one some £3 million is provided by the National and middle income countries is less than there is a problem with terminology which edge, and their national politicians and fi- the provision of which must not be a source The norm worldwide is for palliative and Health Service, leaving a deficit of £100,000 10% of the world’s total (with about 85% means that the vast literature on the sub- nanciers that they should invest in hospice of profit for the organisation concerned. hospice care to be free of charge, typically per week to be secured through fund-rais- of the world’s population), compared with ject is often difficult to make sense of. The and palliative care? funded partly by government and partly ing, donations, legacies, and grants. In the over 90% in high income countries (with original definition was too wide: it included Twycross: All definitions of palliative care with charitable monies. In the USA two County of Oxford (where I live) with a about 15% of the world’s population). This both intermittent as well as continuous Twycross: Fortunately, palliative care does have fluffy boundaries. Fifty years ago, it thirds of hospices are ‘for profit’. This im- population of about 700,000, the provision is a terrible injustice, and one which the sedation in ‘imminently dying’ patients. now have greater global visibility than 30– was largely limited to comfort care at the mediately introduces a conflict of interest of palliative care costs around £24 million medical profession, actively supported by However, it did specifically exclude seda- 40 years ago. Every little helps; and hopeful- end of life. Since then the scope of palliative with an inevitable focus on reducing costs per annum, but statutory funding accounts the national and international Medical As- tion secondary to justifiable symptom man- ly the recent Scientific Session on palliative care has expanded considerably, and prob- and maximizing profit for the shareholders for only one third of this. sociations, must strive to correct. agement measures. I agree with you when care at the Annual Assembly of the WMA ably can best be described as ‘care beyond and owners rather than there being a single- you say that sedative drugs should always will lead to several delegates from ‘palliative cure’. It is holistic (addressing physical, minded focus on quality of care. Ultimately, Apinis: Reducing pain in palliative care is However, changing overly restrictive laws is be administered in accordance with ethical care poor countries’ returning home deter- psychological, social/family, and spiritual/ this cannot be a good thing, and should a very important aspect. [Isn’t it still that only part of the answer: changing medical and pharmacological principles – justified mined to move things forward. Guidance is existential concerns); focused on quality of definitely be discouraged. doses of medicines are administered to pa- and societal cultural attitudes to opioids is by need and administered proportionately. available through such organizations as the life (but can be provided in tandem with tients with unbearable pain based on the ac- equally necessary. For this, centres of ex- In my opinion, the term ‘palliative sedation’ International Association for Hospice and life-prolonging treatments); based on need Apinis: Palliative care is not a priority in cepted doses of medicines and bureaucratic cellence must establish and propagate best should be dropped because of ambiguity in Palliative Care and the Worldwide Hospice (not limited by diagnosis or prognosis); ap- many countries of the world, politicians settings?] From your publications, I have practice, accepting responsibility for train- its use, and discussion should focus specifi- and Palliative Care Alliance, and regional plicable across all age groups; and ideally often forget about it. Universal health cov- learned that, when used properly, morphine ing the trainers to counter the many mis- cally on continuous deep sedation (CDS) bodies such as the European Association provided by a multidisciplinary healthcare erage does not really provide for palliative and other powerful opioids are safe – safer conceptions that abound around morphine until death in dying patients. CDS is clearly for Palliative Care. team. In other words: humane care for hu- care either. However, the lifespan of people than non-steroidal drugs the prescrip- use. Rightly used, morphine is a remarkably ethically challenging because it ends a pa- man beings, not mechanical care for human extends and the role of palliative care is in- tion of which goes unpunished. The use of safe analgesic, and may well be safer than tient’s biographical (social) life and, if truly E-mail: [email protected] machines. creasing. How to make world politicians both types of painkillers is justified on the traditional non-steroidal anti-inflammatory deep (no response to noxious stimuli), will and financiers be aware of the importance grounds that the benefits of pain relief are drugs (also vitally important for cancer pain shorten biological life because the nega- However, to a certain extent, palliative care of palliative care? significantly greater than the risk of seri- management). Pain is an antagonist to the tive impact on the brainstem will lead to tends to fill gaps in the provision for long- ous harmful effects. Clinical experience has respiratory depressant effect of morphine; cardiorespiratory failure. Thus, CDS must term care. For example, in the UK in the Twycross: At the recent High Level Meet- shown that cancer patients whose pain has and psychological dependence (‘addic- be viewed as an extra-ordinary ‘last resort’ 1980s and 1990s, many palliative care ser- ing at the United Nations, palliative care been relieved live longer than in case they tion’) is rare when morphine is used within measure, and should never be seen as the vices established lymphoedema clinics, car- was recognized as an essential component continued to be exhausted and demoralised the context of holistic ‘whole-person’ care. default position for terminal distress. In ex- ing for those with congenital lymphoedema of universal health coverage. However, for by severe pain. Could you comment on how Those who cannot accept this should visit treme circumstances, I imagine most doc-

4 5 WMA Representatives WMA Representatives

major natural disasters, such as earthquakes, tions in Asia-Oceania and to which I serve • Dr. Masamine Jimba, Professor, Department Interview with Mari Michinaga, Vice-Chairperson of Council of the major typhoons, and torrential rains. as the Secretary General. of Community and Global Health, Gradu- ate School of Medicine, University of Tokyo World Medical Association by WMJ Editor Peteris Apinis The JMA is also planning various efforts Apinis: You are the editor-in-chief of the • Dr. Osamu Kunii, Head, Strategy, Invest- within the Confederation of Medical As- Japanese Medical Journal. What is dis- ment and Impact Division (SIID) port concerning pregnancy, childbirth, and medicine is growing in the Japanese health sociations in Asia and Oceania (CMAAO) cussed and advised by the Journal, and how • The Global Fund to Fight AIDS, Tuber- childcare in May 2006. care. Japan focuses on the extension of region as the World Disaster Medicine does it help in the work of Japanese doctors? culosis and Malaria healthy life expectancy. Please tell us about Platform plan, and an event to mark the • Dr. Kenji Shibuya, Professor and Direc- The Declaration states the following: the performance of the Japan Medical As- launch of the platform is scheduled for May Michinaga: I should note that I am the As- tor, University Institute for Population • Support those who wish to become preg- sociation in this area. 2020. sociate Editor of the JMA Journal, not the Health, King’s College London nant Editor-in-Chief. The JMA Journal accepts • Enhance medical environment for safer Michinaga: The public health check-up The JMA will be promoting the activity to a wide range of research papers in all fields Apinis: We know that your special interest pregnancy and childbirth program in Japan is well established from extend this plan to other WMA regions as of medicine including clinical medicine, is medical science. Could you tell us what • Ensure social environment for satisfying infancy to elderly, but the program is not well. basic medicine, and public health, as well was essential in medical science in 2019 and (fulfilling, comfortable) pregnancy and systematized. The JMA is proposing the as the submission on heathcare policy and what to expect from 2020? childbirth necessity of the systems as life-long health Apinis: You have become the WMA Vice- opinions. Its purpose is to develop global • Enhance medical environment where services, In order to contribute to lifelong Chairperson of the Council. What are your and broad perspectives and grow into a Michinaga: In December 2017, Japan’s children can comfortably grow up health management for each individual citi- successes, reflections and conclusions? widely shared journal in the international Prime Minister Shinzo Abe, with world • Ensure social environment for childcare zen, the data obtained from health check- community by collecting excellent study re- health leaders, supported the promotion • Enhance school health ups should be centralized and managed un- Michinaga: In June 2019, the Health Pro- sults from around the world. The JMA Jour- of universal health coverage (UHC) at the • Support children with disabilities/diffi- der a strict privacy protection. fessional Meeting (H20) 2019, co-hosted nal is intended to serve as a powerful media UHC Forum 2017. culties by the WMA and JMA, was held in To- particularly for Japanese physicians and Mari Michinaga • Advocate various measures for children In addition, the Japan Health Conference kyo, Japan. As the vice-chair of the WMA medical researchers to speak out about their It grew into a global movement and led to and child support to government officials was launched in 2015, with the JMA Presi- Council, I served as a moderator for the achievements to the international commu- the Memorandum of Understanding be- Apinis: Japan is among the top countries in and others involved dent and Head of the Japan Chamber of entire meeting and announced the adoption nity. Its impact factor needs to be improved tween the WMA and the WHO in April the world as to low infant mortality rate and Commerce and Industry in joint represen- of the Memorandum of Tokyo on Universal to reach these goals. 2018, establishing their collaboration on the highest average life expectancy. What is It is worth noting that The Basic Law for tation roles. Health Coverage and Medical Professions UHC. In June 2019, the Health Profes- the contribution of the Japan Medical As- Child and Maternal Health and Child De- with the Council chair. I also prepared its The publication of this type of compre- sional Meeting (H20) 2019 was held as the sociation in this area? velopment was enacted in December 2018 The Conference is a place for leaders of the report and submitted it to the WMJ. hensive English medical Journal is the first place to practice their cooperation. because of outreach activities by the JMA business community, healthcare organiza- challenge in Japan. The JMA Journal is ex- Michinaga: In Japan, maternal and child and others. tions, local governments, and others in- In addition, the JMA and the International pected to contribute to the enhancement of At the G20 Osaka Summit and the Joint health measures that seamlessly offer sup- volved to work together to extend healthy College of Person-centered Medicine co- medicine and the improvement of health- Session of Finance and Health Ministers port from pregnancy to childcare based on The Basic Law clearly states that the na- life expectancy. hosted the 7th International Congress of care quality on a global scale by being read (held at the end of the same month), the health checkups for expectant and nurs- tional and local governments and other Person-Centered Medicine on the theme and cited by many readers. importance of strengthening finance in ing mothers and infants and Maternal and organizations involved are responsible for Apinis: You have done a lot to help the vic- “Work-Life Balance: Challenges and So- health to promote UHC and the shared Child Health Notebooks are well estab- implementing necessary measures. tims of the earthquake and nuclear disaster. lutions”, featuring physician burnout and Apinis: Could you recommend good ar- understanding for the need of sustainable lished. This background leads to our glob- Could you describe the situation in these work style reforms (November 2019). ticles of Japanese authors for the WMJ? finance were expressed. ally high level of maternal and child health, Under the public health insurance program areas at present? There, I chaired some sessions in which the which further leads to low infant mortality delivering Universal Health Coverage in WMA president, council members, and Michinaga: It seems to us that the WMJ Last September, the United Nations High rate. Japan, community planning is underway Michinaga: In the Great East Japan Earth- immediate past/former presidents partici- would merit to have in every number an ar- Level Meeting on UHC was also held for wherein kakaritsuke physicians play the main quake of March 2011, the JMA organized pated. ticle by some Japanese doctor presenting a the first time, which raised the interest in Recognizing the importance of the roles role. Its core is the collaboration of medical the Japan Medical Association Team global view. UHC promotion and led to concrete efforts of physicians and medical associations in and long-term care through the Commu- ( JMAT) – consisting of the members of all Furthermore, at the CMAAO General As- for its promotion among nations. promoting the establishment of medi- nity-based Integrated Care System model; prefectural medical associations, excluding sembly in Goa in September 2019, I gave I recommend the following Japanese doc- cal, health, and welfare environments for moreover, efforts for prevention and healthy the four that suffered major damage – and a report on WMA meetings and related tors as authors for the WMJ: I believe that it was important that these the mother and child and supporting the living for local residents are underway. provided medical assistance in the affected events to CMAAO, which is positioned as a • Dr. Shigeru Suganami, President, AMDA movements of UHC promotion and its ac- healthy mental/physical development of areas. WMA regional conference with the mem- (Association of Medical Doctors of Asia) celeration shifted from theory and moved children who will lead our next generations, Apinis: In Japan, the proportion of old peo- bership of 19 National Medical Associa- https://en.amda.or.jp/ into practice. the Japan Medical Association ( JMA) pro- ple is increasing. There is rising incidence This experience has been applied further in posed the JMA Declaration on Child Sup- of chronic diseases. The role of preventive subsequent medical assistance activities in

6 7 WMA Actualites WMA Actualites

Session 1: Viewpoints on Session 2: Health In Thailand, UHC was successfully imple- Report on the Health Professional Meeting (H20) 2019 How to Achieve UHC Security and UHC mented nationwide during the 2001-2002 period. This achievement is attributable to The Japan Medical Association According to the WHO, half of the world’s Disasters and disease epidemics are major the resilience of the health system, which population still lacks full coverage of essen- threats to ongoing efforts to achieve UHC. fostered the resilience of other essential The Health Professional Meeting (H20) operation among the concerned parties in it is imperative for health professionals to tial health services, with about 100 million However, once attained, UHC can provide systems. The dynamics and interactions of 2019 was held in Tokyo on June 13-14. The each country. take action to ensure that the global popula- people being pushed into extreme poverty a strong foundation for overcoming such various groups and institutions within and theme of the meeting, jointly hosted by the tion has access to better health. Health gaps by having to pay for healthcare. In this ses- threats. This session addressed two major is- outside the health sector also reportedly Japan Medical Association ( JMA) and the Subsequently, Her Imperial Highness the resulting from country-specific inequities in sion, presentations were made from the sues: (1) the potential for controlling health contributed to the marked effectiveness of World Medical Association (WMA), was Crown Princess delivered a congratulatory healthcare constitute a social crisis impact- viewpoints of patients, international health threats to contribute to achieving UHC, (2) UHC and the resilience of the health sys- the Road to Universal Health Coverage message. She referred to the high rates of ing much of the world. Thus, in addition to authorities, and medical associations. how UHC can be a key to overcoming vari- tem. (UHC). tuberculosis incidence and infant mortality the promotion of UHC, the following must ous devastating health threats. until the mid-twentieth century in Japan, be ensured: (1) optimal childhood environ- From the perspective of a patient organiza- In April 2018, JMA President Dr. Yoshita- and to the fact that the Tuberculosis Con- ment, (2) lifelong learning, (3) adequate tion, the International Alliance of Patients’ Trust is important for responding to health Session 3: Political ke Yokokura, also the then President of the trol Law was enacted and the Mother and employment, (4) minimum income neces- Organizations (IAPO), equitable and uni- threats, such as natural disasters and dis- Dimension of UHC/PHC WMA, concluded a memorandum of un- Child Health Handbooks were introduced sary for maintaining an acceptable stan- versal access to quality and affordable medi- ease epidemics, as it can build resilient derstanding (MOU) with WHO Director- in order to improve the situation. She ap- dard of living, and (5) disease prevention. cations is indispensable. It was assured that social systems bonding individuals, local and Role of Medical General Dr. Tedros Adhanom Ghebreyesus, preciated that the realization of Universal He called on all governments to act to aid the IAPO is ready to work with the WMA communities, and countries. It makes a Professionals the purpose of which was to promote UHC Health Insurance in 1961 facilitated great people in leading lives of dignity. and its members to achieve UHC, placing major contribution to overcoming dev- and emergency disaster preparedness. Thus, improvements in living conditions in Japan. top priority on patient safety. astating health threats and, thereby, to UHC/PHC is more than simply a technical the H20 meeting was organized as an op- She also lauded the efforts of health pro- In the second speech, titled Toward UHC – achieving UHC. challenge; its progress also depends on the portunity to expound the implementation fessionals in various organizations, includ- What We Need, Dr. Naoko Yamamoto, Medical professionals play a crucial role in of the MOU, focusing on the roles of physi- ing the JMA, in supporting the health of Assistant Director-General, Universal UHC. The expansion and transformation of The international cians and medical associations in promot- all Japanese people against the population Health Coverage/Healthier Populations, the health workforce is an investment an- community needs to ing UHC. Approximately 220 people from aging. In closing, she stated, “I wish that the WHO, pointed out that the realization ticipated to pay a triple dividend: improved strengthen efforts to 38 countries, including eight countries from your efforts will be fruitful in helping cre- of UHC by 2030 would require the follow- health outcomes, enhanced global health support healthcare the African region, were in attendance. ate a world in which all people can enjoy a ing: (1) strong political leadership, (2) infu- security, and economic growth through the systems in prepara- healthy and happy life.” sion of funds into the field of healthcare, (3) creation of employment opportunities. It is tion for crises. UHC is fostering of human resources, (4) primary necessary to ensure adequate public-sector not possible until the Opening ceremony Japanese Prime Minister Shinzo Abe stated health care (PHC), and (5) development of investment for education and employment right to healthcare is in his video message that the promotion of communities. Then, she enumerated the fol- of health workers. It is anticipated that protected. It is neces- The opening ceremony took place in the UHC is an essential element of our society, lowing expectations from medical associa- medical associations will facilitate govern- sary to urge those re- presence of Her Imperial Highness the and appreciated that this meeting was be- tions: (1) participation in various fields be- mental development and implementation sponsible for inflicting Crown Princess. At the opening of the ing held in 2019, the year of the Japanese yond healthcare and advocacy and support of robust national health plans and strate- conflict and violence H20, Dr. Yoshitake Yokokura emphasized Presidency of the G20 Osaka Summit. He of activities placing a high value on human gies, and aid in the creation of resilient and to allow for neutral the increasing importance of cross-border expressed his hopefulness regarding the health, (2) finding evidence, as well as effec- sustainable healthcare systems. and impartial treat- unity among physicians worldwide, and ex- continued efforts of the concerned parties tive policy formulation and implementation ment of all victims. In pressed the desire to witness further UHC toward the achievement of UHC. based on the evidence collected, (3) playing From the perspective of medical associa- addition, amidst the progress under “beautiful harmony,” which a role in cultivating human resources and tions, advancing UHC requires addressing global health narrative is the meaning of the new imperial era career path building, (4) improvement of the need for an adequate and well-trained of achieving UHC, Reiwa. The WMA President Dr. Leonid Keynote addresses healthcare quality and promotion of peo- workforce, preventive care and health pro- doctors need to facili- Eidelman (the immediate past President ple-centered care, (5) contributing to fields motion efforts, sustainable health financing tate patient-centered of the Israeli Medical Association) stated The first keynote speech, titled Health In- that require further research, education, mechanisms, and strategic purchasing using discussions. To pro- that UHC promotion is a priority for the equities and Social Determinants of Health, and practice, (6) taking action to manage public funds. For example, to achieve UHC, mote UHC, healthcare achievement of the Sustainable Develop- was delivered by Sir Michael Marmot, Pro- emerging infectious diseases and disasters, the Indian Medical Association provides should be delivered ment Goals, a global political objective, by fessor of Epidemiology, University College and (7) cooperating and participating in inputs into health governance and aids in safely, and criminaliz- 2030. He also called on the attendees to use London, Past President of the WMA. He creating an environment where people have service delivery, particularly in fragile popu- ing medical colleagues this meeting as an opportunity to debate highlighted the fact that health is largely af- basic knowledge of health and make efforts lations. It further advocated that to improve must be condemned and discuss viable solutions for the further fected by social situations, including wealth to develop communities that promote and health service delivery the deployment of when they provide care Yoshitake Yokokura, President of the World Medical promotion of UHC by strengthening co- gaps and poverty. He also pointed out that foster healthy living. highly skilled health workers is crucial. to patients. Association 2017–2018

8 9 WMA Actualites Tobacco Control

political processes unique to the context of Session 4: Shared shown to be related to the global shortage later. Other factors include smoking-ac- each country and healthcare system. Medi- Responsibilities and Individual of human resources involved in primary The FCTC and Tobacco Industry cepting cultures [23]; ineffective implemen- cal professionals have a crucial role to play care, concentration of human resources in tation of existing guidelines [9; 13]; illicit in health policy. In this session, discussions Obligations toward UHC urban areas that are advantageous in terms trade [18]; lack of stakeholder involvement focused on the presentations of distin- of pay and education, and the trend of med- • Enforcing bans on tobacco advertising, [6; 9; 11]; lack of a multisectoral approach guished speakers from different angles such In this session, Dr. Yoshitake Yokokura ical students from developing countries sent promotion, and sponsorship [6; 17; 25]; and lack of sufficient resources, as the national government, global health made a speech on the steps necessary for to developed countries for educational pur- • Raising tobacco taxes capacity, and support, especially for LMICs academia, and national and world medical achieving UHC in Japan. In Japan, the pro- poses not returning home. Thus, the prob- [6; 9; 14; 17]. In addition, not enough spe- associations. vision of health insurance as an essential lem is not only of absolute numbers but also The FCTC has contributed to an overall cial action has been made for vulnerable or part of UHC, in which all citizens are cov- uneven distribution of resources. Further, decrease in smoking prevalence [6]. Nota- disadvantaged groups, such as youth, which In the case of Lebanon, it was shown that ered by insurance, was achieved in 1961. Dr. the importance of trusting relationships bly, countries that have higher MPOWER the tobacco industry targets [6]. the active involvement of medical pro- Yokokura explained that until this achieve- between healthcare providers and receivers composite scores see a greater decrease in fessionals contributed to conversion to ment, there had been extensive discussions was highlighted. Continuing efforts in each current tobacco smoking [19]. people-centered healthcare in the PHC among physicians, medical associations, and country and unity among physicians across Møller’s Memo network. World health systems are chal- governments about the medical practices of countries were identified as essential for Using the FCTC as a guiding document, lenged by population aging, chronic dis- physicians and healthcare expenditures, as solving a variety of problems and ultimately many countries, such as Spain and Kenya, On June 28, 2019, Michael Møller, the out- eases, an explosion of health technologies, well as many other relevant factors. Given achieving the aim of providing UHC. have created national coordination strate- going director of the UN Office at Geneva, and globalization. System transformation that Japan is currently facing the challenge gies that adopt a multi-sectoral approach raised skepticism against the tobacco-in- is required to ensure that no one is left of population aging, the national health in- to control tobacco [6; 9]. There has been dustry ban imposed by the FCTC by writ- behind. surance program must be firmly maintained Adoption of Memorandum substantial progress in FCTC articles that ing a memo directed to UN Secretary Gen- as the cornerstone of UHC. The JMA ex- of Tokyo on UHC and the address the packaging of tobacco products, eral António Guterres. In this memo, he In the US, whether to continue with or re- presses its views to the government based Ruth T. Lee protection from exposure to tobacco smoke, proposes that engaging the tobacco indus- peal the Affordable Care Act (ACA, widely on two criteria: does any policy contribute Medical Profession public awareness and education, and the try in discussions may help better achieve referred to as “Obamacare”) is the major to safe healthcare for the public and does Introduction reporting and exchange of information [6; the 2030 SDGs for a “more nuanced ap- subject in current debates on healthcare such a policy allow for UHC to be main- The H20 adopted the Memorandum of To- 9]. There has been some progress in articles proach”, since “businesses which are legiti- reform. The new administration is eager to tained through public health insurance? He kyo on UHC and the Medical Profession Unanimously adopted by the World Health that address regulations on taxes, advertis- mate enough to pay taxes to governments repeal the ACA, which has led to concerns concluded by stating that with this in mind, that prescribed mainly (1) strengthening the Assembly in 2003, the Framework Conven- ing, sponsorship, illicit trade, and research should also be legitimate enough to partici- regarding the erosion of patient protec- it is important for the JMA to continue understanding and involvement of UHC tion on Tobacco Control (FCTC) is a land- [6; 9]. While not as significant, there has pate in discussions concerning joint efforts tion. The American Medical Association making proposals aimed at promoting and and primary care, (2) designing long-term mark instrument due to its multifaceted also been progress in articles that address to minimize health risks and address other forms a broad alliance that aims to take the maintaining the most appropriate health- national policies aimed at achieving UHC, international legal approach [3; 20]. At that environmental protection, liability, and problems of a common nature” (memo). necessary actions to protect the interests of care system in which medical practitioners and (3) defining the roles of physicians and point, the FCTC had been a decade in the economically viable alternatives for farmers patients and their families. An appeal was can provide optimal level of care. medical associations and formulating pro- making. It seeks to address tobacco’s deadly who grow tobacco [6; 9]. While this memo is worthy of consideration made for medical associations to engage posals relevant to governmental policies and effect on public health, as it prematurely kills as a “think piece” (foreign policy article), its more actively in the ongoing debate on how In the subsequent panel discussions among to all aspects of society. between 5–6 million people each year [8]. It Successful implementation of the FCTC is purpose as suggested by Møller’s chief of to deliver PHC. representatives of the government, JMA, may increase to killing more than 8 million supported by a variety of factors. A crucial staff, David Chikvaidze, is clear – the UN WHO, and international organizations, This memorandum calls on physicians and people per year by 2030 if current trends element is a stable, effective political system should not engage the tobacco industry in To strengthen PHC, which is an essential sharing the ongoing global UHC initiatives their medical associations worldwide to continue, with 80% of premature deaths oc- with a national tobacco control plan and the matters relating to tobacco control. component of UHC, it is important to and approaches, challenges and opportuni- play a profound role in the advocacy for and curring in low- and middle-income coun- capabilities to successfully enforce tobacco- achieve sustainable healthcare system fi- ties for achieving UHC, and a proposal of achievement of UHC. In addition, it ex- tries (LMICs) [9]. control policies [9; 15; 16]. Other beneficial nance, invest in efficient PHC, implement solutions and actions for promoting UHC presses hope that the G20 Summit will focus factors include having accountability across Evidence of TII performance evaluation and data collection were discussed, and various issues impeding on pursuing sustainable investments in the The FCTC uses six evidence-based strate- stakeholders, including NGOs, and having relevant to PHC, and strengthen partner- the achievement of UHC were highlighted. healthcare systems of not only the G20 coun- gies, contained in the acronym MPOWER, higher levels of FCTC implementation, A substantial reason is the evident history ships among international health institu- These issues include shortage of human re- tries but also other economies where health- to reduce tobacco use [11]: such as having mandated graphic warn- of persistent tobacco industry interference tions. It was also pointed out that the es- sources in healthcare, regional issues such care system investments are still insufficient. • Monitoring tobacco use and tobacco con- ing labels (GWLs) on tobacco packaging (TII), which has been recognized as the tablishment of healthcare systems is the as Ebola hemorrhagic fever, differences in trol policies [10; 12]. most important barrier against FCTC most important element of social common health insurance systems across countries, Memorandum of Tokyo on Universal Health • Protecting people from dangers of to- implementation [2; 6]. Investigative re- capital, ultimately serving as the foundation and relationships with patients. In particu- Coverage and the Medical Profession bacco smoke There are also many factors that impede ports into TII have shown that the industry of an affluent society. lar, the shortage of human resources was see on the cover p. iii • Offering help to quit tobacco FCTC adoption and implementation. The views the WHO as an enemy and has paid • Warning the public about the dangers of global tobacco industry is a hugely impor- consultants to discredit key individuals and tobacco tant obstructing factor, as will be discussed the WHO, with a key strategy to “contain,

10 11 Tobacco Control Environmental Health

neutralize, and reorient WHO” (as quoted products’ like heated tobacco products and cret meetings with representatives of British 7. http://www.who.int/fctc/reporting/2016_glob- 22. http://www.scielo.org.za/pdf/samj/v105n8/13. 34. https://www.ncbi.nlm.nih.gov/pmc/articles/ in 10) away from tobacco control and other e-cigarettes [16], which Møller references American Tobacco, and there is evidence of al_progress_report.pdf pdf PMC2630219/ 8. https://academic.oup.com/eurpub/arti- 23. https://www.ncbi.nlm.nih.gov/pub- NCDs. in his memo as “highly advanced research bribery from British American Tobacco in 35. http://siteresources.worldbank.org/HEALTH- cle/26/1/1/2467458 med/27087176 NUTRITIONANDPOPULATION/Resourc- efforts to minimize the harmful effects of East Africa [16]. 9. https://tobaccocontrol.bmj.com/content/ear- 24. https://blogs.bmj.com/tc/2014/09/15/the- es/281627-1095698140167/Aloui-Analysis_of- The tobacco ‘big five’ – Philip Morris In- their own products.” However, the research ly/2018/07/25/tobaccocontrol-2018-054374 netherlands-dutch-government-sued-over- whole.pdf ternational, British American Tobacco, Im- is clear that these products are still harmful 10. https://www.ncbi.nlm.nih.gov/pmc/articles/ who-fctc-violations/ 36. http://www.freemarketfoundation.com/ perial Brands, Japan Tobacco International, to health [44]. PMC4884895/pdf/je-26-279.pdf 25. http://fctc.wpengine.com/wp-content/up- article-view/feature-article-tobacco-control-in- Conclusion 11. https://www.thelancet.com/journals/lancet/arti- loads/2015/02/FCTC_Shadow_Report_2014. and China National Tobacco Company – south-africa-the-fctc-and-lessons-from-other- cle/PIIS0140-6736(13)62155-8/abstract pdf countries has substantive economic power, with reve- A significant portion of TII is directed to- While Møller’s memo raises important 12. https://www.ncbi.nlm.nih.gov/pmc/articles/ 26. http://www.itcproject.org/node/70 37. https://escholarship.org/uc/item/09t535s7 nues of one of these companies itself match- wards warning labels on cigarette packag- points regarding the tobacco industry, his- PMC3795937/ 27. https://tobaccocontrol.bmj.com/con- 38. http://journals.plos.org/plosmedicine/ ing the GDPs of countries like Morocco ing. A result, for example, is that between tory overwhelmingly shows that there is no 13. https://bmcpublichealth.biomedcentral.com/ tent/9/2/129.8 article?id=10.1371/journal.pmed.1001639 and Ecuador [10]. Their economic leverage 1992 and 2012, sixteen countries made vol- place for the tobacco industry in discussions articles/10.1186/1471-2458-10-1 28. https://www.vox.com/2016/6/2/11818692/ 39. https://globalizationandhealth.biomedcentral. 14. https://www.tobaccofreekids.org/assets/global/ plain-packaging-policy-us-australia and financial interests have caused them to untary agreements with the tobacco indus- of surrounding tobacco control. As private com/articles/10.1186/s12992-015-0139-3 pdfs/en/fctc_implementation_guide.pdf 29. https://academic.oup.com/eurpub/arti- 40. http://www.searo.who.int/indonesia/mediacen- interfere with tobacco control by lobbying try to put weak, text-only health warning corporations, tobacco companies are natu- 15. https://www.ncbi.nlm.nih.gov/pub- cle/26/1/1/2467458 tre/who-urges-indonesiato-ratify-fctc/en/ governments and advocating for regulations labels (HWLs) on cigarette packages [12]. rally interested in financial profit and have med/22163209 30. https://seatca.org/dmdocuments/SEATCA%20 41. http://www.ghspjournal.org/content/ concerning looser advertising restrictions, Philip Morris in 1992 put English-language been shown to influence policies for their 16. https://www.ncbi.nlm.nih.gov/pub- WNTD%202013%20on%20TAPS_new.pdf ghsp/5/3/476.full.pdf voluntary warning labels, and lower taxes HWLs on the sides of packages being sold self-interest. Engaging them in tobacco med/28492203 31. https://www.indonesia-investments.com/news/ 42. https://bmjopen.bmj.com/content/bmjo- 17. https://www.ncbi.nlm.nih.gov/pub- todays-headlines/why-indonesia-doesn-t-rati- pen/3/12/e003982.full.pdf under a guise of ‘social responsibility’ for in 49 small, mostly African countries whose control discussions will only be a slippery med/26876626 fy-who-s-framework-convention-on-tobacco- the public interest [6; 12]. This is apparent native languages are not English [12]. In slope, undermining the WHO and other 43. https://tobaccocontrol.bmj.com/content/tobac- 18. https://tobaccocontrol.bmj.com/con- control/item6932? cocontrol/28/Suppl_2/s113.full.pdf in the issue of illicit tobacco trade, which 2008 in Vietnam, text-only health warnings UN agencies’ goals of protecting human tent/23/4/279 32. http://www.academia.edu/17889167/ 44. https://www.cancer.net/navigating-cancer-care/ has been used by tobacco industry – even of “Smoking can cause lung cancer” and health and environment and promoting 19. https://www.thelancet.com/journals/lanpub/ POLITICAL_ECONOMY_ANALY- prevention-and-healthy-living/stopping-tobac- though research has shown that the major “Smoking can cause COPD” covering 30% sustainable development. The industry has article/PIIS2468-2667(17)30045-2/fulltext SIS_IN_NON-COMPLIANCE_INDONE- co-use-after-cancer-diagnosis/health-risks-e- 20. https://www.ncbi.nlm.nih.gov/pmc/articles/ SIA_TOWARDS_FRAMEWORK_CON- cigarettes-smokeless-tobacco-and-waterpipes multinational tobacco companies them- of the cigarette package became the mini- tried to present itself as a partner, especially PMC4295830/ VENTION_ON_TOBACCO_CONTROL selves have been involved in tobacco smug- mum requirement after successful TII, con- through promoting smokeless alternatives. 21. https://www.ncbi.nlm.nih.gov/pub- 33. http://www.archive.healthycaribbean.org/publi- gling – to prevent governments without ducted against the MOH’s effort to push But no matter what form it takes, tobacco med/21243194 cations/documents/reporte_cmct_ingles_1.pdf Ruth T. Lee adequate financial capacity to pass stronger through legislation requiring GWLs that kills. If the goal truly is to achieve the high- tobacco control policies [18]. The industry would cover 50% of the package [3]. est attainable standard of health, then it is has been shown to fund surveys of dubi- plain that the tobacco industry cannot be ous methodology that show associations A once-secret document of British Ameri- given a legitimate voice at the table. Hearing Screening in Traffic Police between tobacco control and large increases can Tobacco revealed that the industry tries Introduction in illicit trade – a finding inconsistent with to foster government relations and com- Personnel in Multiple Centers in India independent research [18]. Tobacco com- munity involvement programs to maintain References Noise pollution is regular exposure of panies also have a history of exaggerating looser regulations, especially in marketing, Memo: https://assets.documentcloud.org/ undesirable or hostile sounds at elevated the number of job losses if tobacco control with results like a proposed ad ban in Sierra documents/6188745/UN-Secretary-General- sound levels that can lead to adverse ef- Tobacco-Agenda.pdf measures are taken, especially on alternative Leone removed from the Cabinet at the vot- Foreign policy article: https://foreignpolicy. fects in humans or other living organisms. crops to reduce tobacco farming [40]. The ing stage [15]. In Botswana, the industry in- com/2019/07/12/document-of-the-week-is- According to WHO guidelines 2018 for reality is that these measures cause no im- directly advertises their products by printing the-u-n-revisiting-the-ban-on-big-tobacco/ average noise exposure, the Guideline De- mediate negative impact on tobacco farm- their tobacco product logos on clothing and 1. https://www.reuters.com/investigates/special- velopment Group (GDG) strongly rec- ing or job losses in many countries [40]. even school bags, effectively making chil- report/pmi-who-fctc/ ommends reducing noise levels produced dren “walking billboards” [15]. The tobacco 2. http://www.who.int/fctc/cop/cop7/FCTC_ by road traffic below 53 decibels (dB), as COP_7_4_EN.pdf The tobacco industry also tries to present it- industry has also gone to court to challenge 3. http://apps.who.int/iris/bitstream/han- road traffic noise above this level is asso- self as a partner to governments. One tactic, tobacco control policies, with results like the dle/10665/44244/9789241563925_eng.pdf;jses ciated with adverse health effects. Noise demonstrated by a reported visit by a Turk- suspension of the public smoking ban set by sionid=84182F40181983FCD2648F5FCB099 pollution is increasingly becoming a po- ish ambassador to the Philip Morris Inter- the Tobacco Control Act of 2007 in Kenya B39?sequence=1 tential hazard to health, physically and national Jordan headquarters, is one where [15]. Furthermore, the Dutch government 4. http://www.who.int/fctc/reporting/sum- psychologically, and affects the general mary_2007_document_cop_2_6.pdf the industry advocates for a strategy on com- has held frequent consultations with the to- well-being of an individual [1]. It can dis- 5. http://apps.who.int/iris/bitstream/han- bating illicit trade: reducing tobacco prices bacco industry concerning current policies, dle/10665/147117/FCTC_COP6_15-en. turb sleep, cause cardiovascular and psy- [18]. Another tactic to present the industry but there is no transparency and no minutes pdf?sequence=1&isAllowed=y cho physiological effects, reduce perfor- as a partner is by developing and market- of these meetings recorded in many cases 6. http://www.who.int/fctc/cop/cop7/FCTC_ mance and provoke annoyance responses ing new product strategies of ‘reduced-risk [24]. Ugandan policymakers have held se- COP_7_6_EN.pdf Sarika Verma Mehak Maheshwary and changes in social behavior [2]. The

12 13 Environmental Health Environmental Health

first effects of exposure to excess noise are Table 1: Grades of hearing according to Table 2: Results of screening showing per- Table 3: Data from individual cities The strength of the present study is the data typically an increase in the threshold of WHO centage of police personnel with hearing Total no . Number of Number of size as well as the study being conducted in hearing (threshold shift), which is defined Grade of hearing Degree of hearing loss loss of per- personnel personnel with different parts of India and hence it gives a Sr No. . Centre Doctor in charge as a change in hearing thresholds of an 0–25 dB or loss (bet- Total number of police sonnel with normal sensorineural larger picture of the effect of noise induced Normal hearing 588 average 10 dB or more at 2000, 3000 and ter ear) personnel screened screened hearing hearing loss hearing loss among police personnel. All 4000 Hz in either ear (NIOSH, 1998). the police personnel are actively working Mild impairment 26–40 dB (better ear) Number of police person- 1 Gurgaon Dr. Sarika Verma 124 67 (54.03%) 57 (45.96%) Threshold shift is the precursor of noise and medically fit and hence it also provides Moderate im- nel with normal hearing 266 45.23% Dr. Harinder Pal induced hearing loss (NIHL), the main 41–60 dB (better ear) 2 Nawashahar 24 8 (33.33%) 16 (66.66%) an insight into the burden hearing loss in pairment (<25 dB) Singh outcome of occupational noise. Because our country, which by and large, remains Number of police person- 3 Guwahati Dr. Swagata Khanna 27 9 (33.33%) 18 (66.66%) hearing impairment is usually gradual, the Severe impair- undiagnosed or untreated. Since the study 61–80 dB (better ear) nel with sensorineural 320 54.42% affected worker will not notice changes ment 4 Dibrugarh Dr. Swagata Khanna 43 17 (39.53%) 25 (58.13%) was only a one time screening for hearing hearing loss in hearing ability until a large threshold Profound impair- 5 Agra Dr. Rajiv Pachauri 11 5 (45.45%) 5 (45.45%) evaluation, we were not able to measure the >80 dB (better ear) Number of police person- shift has occurred. Noise-induced hear- ment 6 Rewari Dr. Adesh Saxena 52 48 (92.31%) 4 (7.69%) exact level of noise exposure. Also age relat- nel with conductive hear- 2 0.34% ing impairment occurs predominantly at 7 Panipat Dr. Pritam Arora 169 77 (45.56%) 92 (54.43%) ed hearing loss was not taken into account. ing loss higher frequencies (3000−6000 Hz), with The subjects have never used any form of 8 Karnal Dr. Sanjay Khanna 138 35 (25.36%) 103 (74.63%) the largest effect at 4000 Hz. It is irrevers- protective equipment to insulate their ears According to WHO recommendations ible and increases in severity with contin- from high traffic noise levels. Police person- Discussion • For average noise exposure, the Guideline ued exposure [3]. According to WHO, nel with pre-existing ear disease were ex- a day [4,5]. The maximum hearing loss due can help guide policy and focus research on Development G roup (GDG) strongly disabled hearing loss is defined as “per- cluded from the study. Noise pollution has several detrimental ef- to noise exposure is 40 dB at low frequency this problem. This is particularly important recommends reducing noise levels pro- manent unaided hearing threshold level fects on the human body, the most important and 75 dB at high frequencies but when the in light of the fact that policy and practical duced by road traffic below 53 decibels for the better ear of 41 dB hearing loss or being hearing impairment. Noise-induced effects of presbycusis are added, the thresh- measures can be used to reduce exposure to (dB), as road traffic noise above this level greater for the four frequencies 500, 1000, Results hearing loss (NIHL) is the second most olds may become greater [6,7]. occupational noise [10]. is associated with adverse health effects. 2000 and 4000 kHz” [3]. In India, due to common cause of sensorineural hearing loss • For night noise exposure, the GDG urbanization and marked increase in ve- A total of 588 traffic police personnel were after age induced hearing loss or presbycu- Noise related hearing changes can be cat- Traffic or vehicular noise is becoming a sig- strongly recommends reducing noise lev- hicular traffic in the past few years, there screened across 8 cities in India using pure sis. Sustained exposure to loud noise is as- egorized into three groups: noise-induced nificant health hazard in India. The traffic els produced by road traffic during night has been an exponential rise in the levels tone audiometry. 266 (45.23%) had normal sociated with damage to outer hair cells of temporary threshold shift (NITTS), noise- police personnel are affected the most due to time below 45 dB, as night-time road of noise pollution generated on road. Since hearing while 320 (54.42%) had some form the cochlea in the inner ear. These hair cells induced permanent threshold shift (NIPTS) this increasing noise pollution and are at high traffic noise above this level is associated the traffic police personnel have continu- of sensorineural hearing loss. 2 (0.34%) per- are responsible for conversion of sound en- and acute acoustic trauma. Initial exposure risk for noise induced hearing loss. There are with adverse effects on sleep. ous and prolonged exposure to such high- sonnel had conductive hearing loss. Out of ergy to electrical signals transmitted to the to excessive sound level causes temporary very few studies carried out regarding the • To reduce health effects, the GDG level of noise from these vehicles, they are the 320 police personnel who had hearing brain. The damage is irreversible. In gen- dullness of hearing (temporary threshold estimation of auditory effects of noise gen- strongly recommends that policymakers at a very high risk of developing NIHL. In loss, 175 (54.68%) had mild hearing loss, eral, the amount of noise required to cause shift) which usually recovers within 24 h of erated by automobiles among traffic police implement suitable measures to reduce this study we aim to determine the effect 91(28.43%) had moderate, 25 (7.81%) had permanent damage from chronic exposure exposure [8]. If there is repeated sustained personnel in India. Moreover, because of the noise exposure from road traffic in the of noise pollution on the hearing of traffic severe to profound and 29 (9.06%) had high is anything equivalent to 10 years or more exposure, the threshold shift becomes per- insidious nature of the disease and lack of aware- population exposed to levels above the police personnel. frequency dip at 4000 Hz. at a level of 85 dB for more than 8 hours manent (permanent threshold shift) due ness, the majority of them are unaware of the ef- guideline values for average and night to nerve fiber degeneration. Acute acoustic fects of noise pollution. The present study was noise exposure. For specific interventions, trauma is defined as sudden exposure to a undertaken to study the effect of noise pollu- the GDG recommends reducing noise 29 Materials and methods loud sound like an explosion which can re- tion on the hearing in traffic police personnel both at the source and on the route be- 25 9% sult in permanent hearing loss. across various cities in India. tween the source and the affected popula- Personnel with mild hearing loss On the occasion of International Noise 8% tion by changes in infrastructure. Awareness Day 2019, Indian Medical Asso- The first signs of NIHL can be observed In this study, 588 police personnel were ciation’s National Initiative for Safe Sound Personnel with moderate hearing loss in the typical 4000-Hz “notch” observed screened in 8 cities across India. 266(45.23%) NIHL is a major avoidable cause of per- (NISS) carried out a screening study to as- on audiograms, indicating a loss of hearing had normal hearing while 320(54.42%) had manent hearing impairment. Some effec- sess hearing in traffic police personnel in 91 175 Personnel with severe to profoundhearin g loss ability in the middle of the frequency range some form of sensorineural hearing loss. tive ways to prevent NIHL in traffic police Gurugram, Agra, Nawashahar, Dibrugrah, 28% 55% of human voices [9]. The results of this study are in concordance personnel Guwahati, Panipat, Rewari and Karnal. This Personnel with notch at 4000 Hz with similar studies done in India where the • Strict Implementation of the existing Noise cross-sectional study was done to screen the Occupational noise is a widespread risk prevalence of NIHL among Pune traffic Rules 2000 including fine for unnecessary traffic police personnel for hearing loss. factor, with strong evidence base linking it police is 81.2%, 66.4% among traffic po- honking on Indian roads, Implementa- Screening was done using Pure Tone Audi- to an important health outcome (hearing lice personnel in Kathmandu city, 22% in tion of Silent Zones in Towns and Cit- ometry. The severity of NIHL was based on loss) [3].An assessment of the burden of Jammu traffic police personnel, 63.48% in ies and removal of loudspeakers from all the WHO grading. Figure 1: Type of hearing loss in police personnel disease associated with occupational noise Madurai and 94% in Thoothukudi . places of worship.

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Table 4: Comparison of our study with other studies in India References EM Task Force on Occupational Hearing Loss. 13. Gupta, Mrityunjay & Khajuria, Vijay & Man- 1. Goswami S, Nayak SK, Pradhan AC, Dey SK. J Occup Environ Med 2012; 54(1):106-108. has, Monica & Lal Gupta, Kasturi & Singh, Number of traffic City/Year of A study on traffic noise of two campuses of 8. Venkatappa KG, Shankar V, Annamalai N. As- Onkar. (2015). Pattern of Noise Induced Hear- Title of the study police personnel Results study University, Balasore, India. J Environ Biol. 2011; sessment of knowledge, attitude and practices of ing Loss and its Relation with Duration of Ex- screened 32:105–9. traffic police personnel regarding the auditory posure in Traffic Police Personnel.Indian Journal Prevalence of occupational noise induced hear- Pune Total number with hearing loss – 342 (81.2%) 2. Noise. World Health Organization. 2011. [Last effects of noise. Indian J Physiol Pharmacol 2012; of Community Health. 27. 276-280. 56:69-73. 14. Dhinakaran N & Karthikeyan MB. (2017). ing loss amongst traffic police personnel VK (Maharashtra) 421 Mild hearing loss – 213 (62.3%) accessed on 2012 Aug 13]. Available from: http://www.euro.who.int/en/what-we-do/ 9. McBride DI, William S. Audiometric notch as a Prevalence Of Noise Induced Hearing Loss Singh, AK Mehta [11] 1995 Moderate to severe hearing loss – 129 (37.7%) health-topics/environmentand-health/noise. sign of noise induced hearing loss. Occup Envi- Among Police Personnel In Madurai City. Inter- Total number with hearing loss – 73 (66.36%) 3. Concha-Barrientos M, Campbell-Lendrum D, ron Med 2001;58:46-51. national Journal of Advanced Research 5. 410-416. Prevalence of noise induced hearing loss among Kathmandu Mild hearing loss – 57 (51.8%) Steenland K. Occupational noise: assessing the 10. Goelzer B, Hansen CH, Sehrndt GA, eds. Oc- 10.21474/IJAR01/5075. traffic police personnel of Kathmandu Metro- (Nepal) 110 Moderate hearing loss – 15 (13.6%) burden of disease from work-related hearing cupational exposure to noise: evaluation, prevention 15. Kanitha MS, Balasubramanian C, Anandan H. politan City Shrestha I, Shrestha BL, Pokharel impairment at national and local levels. Geneva, and control. Geneva, World Health Organiza- A Study on Noise-Induced Hearing Loss of Po- 2011 Severe hearing loss – 1 (0.9%) M [12] World Health Organization, 2004. (WHO En- tion, and Dortmund/Berlin, the Federal Insti- lice Constables. Int J Sci Stud 2018; 5(11):122- 4000 Hz notch – 73 (66.4%) vironmental Burden of Disease Series, No. 9). tute for Occupational Safety and Health.WHO/ 124. Pattern of noise induced hearing loss and its re- Jammu city 4. Rabinowitz, P. Noise-induced hearing loss. Am FIOSH (2001). 16. Kavana G Venkatappa, Vinutha Shankar, Spar- lation with duration of exposure in traffic police ( Jammu and Fam Phys 2000; 61:2749-56, 2759-60. 11. Singh VK, Mehta AK. Prevalence of occupa- shadeep EM. (2018). Effect of road traffic noise 150 Total number with hearing loss – 33 (22%) on auditory threshold in traffic police personnel. personnel M. Gupta, V. Khajuria, M. Manhas Kashmir) 5. National Institute of Deafness and Other Com- tional noise induced hearing loss amongst traf- munication Disorders (NIDCD). Fact Sheet: fic police personnel. Indian J Otolaryngol Head Int. J. Curr. Res. Biol. Med. 3(6): 12-17. [13] 2015 Noise-induced hearing loss. NIH Publication Neck Surg. 1999;51(2):23–26. doi:10.1007/ Prevalence of noise induced hearing loss among Madurai 2007; 97(4):4233. BF02997985 Dr. Sarika Verma, 6. Kircher DB. Noise-induced hearing loss. J Occup police personnel in Madurai city (Tamil Nadu) 241 Total number with hearing loss – 153 (63.48%) 12. Shrestha I, Shrestha BL, Pokharel M, Amatya Dr. Mehak Maheshwary Dhinakaran N, Karthikeyan B. M [14] 2017 Environ Med 2003; 45(6):579-581. RCM, Karki DR. Prevalnace of Noise Induced 7. Kircher DB, Evenson E, Dobie RA, Rabinow- Hearing Loss among Traffic Police Personnel Gurugram, India Total number with hearing loss – 94% itz PM, Crawford J, Kopke R and Hudson TW. of Kathmandu Metropolitan City. Kathmandu A Study on noise-induced hearing loss of po- Thoothukudi Mild hearing loss – 26% Occupational noise-induced hearing loss. ACO- Univ Med J 2011;36(4):274-8 lice constables M Senthil Kanitha, C Balasub- (Tamil Nadu) 50 Moderate hearing loss – 38% ramanian, Heber Anandan [15] 2018 Severe hearing loss – 36% 4000 Hz notch – 92% Effect of road traffic noise on auditory thresh- Kolar Total number with hearing loss – 8 (26.66%) Achieving Universal Health Coverage and Sustainable old in traffic police personnel KG Venkatappa, (Karnataka) 30 Mild hearing loss – 5 V S hankar, Dr. Sparshadeep [16] 2018 Moderate hearing loss – 3 Development Goals: The Global Fund’s contribution and my Total number with hearing loss – 320 (54.42 %) expectation for medical professionals, national medical associations Multiple cities Mild hearing loss – 175 (54.68%) Our Study across India 450 Moderate hearing loss – 91 (28.43%) and World Medical Association 2019 Severe to profound hearing loss – 25 (7.81%) 4000 Hz notch – 29 (9.06%) The Global Fund to fight AIDS, Tuber- medical associations, and WMA to achieve culosis and Malaria (the Global Fund) global common goals of UHC and SDG 3. • Use of hearing protective devices such as to 50–65dB. Efforts should also be Conclusion was invited to H20 Meeting co-hosted by ear muffs, ear plugs and ear canal caps. made to reduce the engine noise of ve- World Medical Association (WMA) and • Periodic health check-ups and hearing hicles towards lowering levels of traffic As can be seen of this preliminary screen- Japan Medical Association ( JMA) on June Role of the Global Fund assessment of police personnel. noise. ing of 588 traffic police personnel, con- 13 and 14 in Tokyo to present the Global to achieve UHC • Duty scheduling or duty rotation for ex- • Noise Mapping of India should be under- tinuous exposure to loud and chronic Fund’s contribution towards achieving uni- posure limitation. taken with urgency to document the ex- noise causes sensorineural hearing loss in versal health coverage (UHC) and Sustain- Since its inception in 2002, the Global Fund • Health authorities and NGOs must cre- isting noise levels and then address the the long run. 54.42% of those screened able Development Goal 3 (SDG 3) “Ensure has mobilized financial resources from all ate awareness among traffic police personnel problem of ambient noise higher than the had hearing loss. Considering that India healthy lives and promote wellbeing for all over the world and has been supporting about the auditory and non auditory effects permissible limits as recommended by the has the highest number of SNHL people at all ages”. more than 140 countries by disbursing more of noise by implementing education and WHO. above the age of 65 years, it is time to put than US$41 billion [1], making it one of the training programmes for traffic police • School text books should educate children WHO and European Guidelines 2018 Based on this presentation, this article de- largest financiers or channels of assistance personnel about the auditory and non- about good driving habits including driv- into practice along with enforcing Noise scribes the role, achievement and challenge for global health [2]. auditory effects of noise. ing without using the horn except in life Rules 2000. Immediate and urgent steps of the Global Fund towards UHC and SDG • At policy level, the government should threatening situations. The habits of sev- must be taken to prevent Noise Induced 3, a country’s good practice of tremendous The Global Fund is called the 21st century take adequate steps to reduce the level of eral decades can only be changed through Hearing Loss (NIHL) develop into a seri- progress, and shares my personal expecta- partnership organization because relevant the horn from present levels of 90–112dB educating the next generation. ous health issue in India. Osamu Kunii tions for medical professionals, national key partners such as donor and implement-

16 17 Universal Health Coverage Universal Health Coverage

ing governments, UN and international aid has supported the low- and middle-income Tuberculosis is now the top killer pathogen laws and acts such as Health Center Law facilitating collaboration between govern- it had increased 5 times between 1990 and organizations, private sector, civil society countries in improving procurement and among infections with 1.6 million deaths (enacted in 1947), new Tuberculosis Con- ments, academia and the private sector for 2010. Therefore, government spending on and affected communities are engaged in supply chains; strengthening data systems and 10 million new cases in 2017, and 36% trol Law (enacted in 1951), National Health effective tuberculosis control [19]. health is suggested at least 5% of GDP or and highly committed to the whole process- and its use; training health workers; building of those new cases are left “missing”– unde- Insurance Act (enacted in 1958), which en- per capita target of $86 [23,24] to promote es of the Global Fund to maximize impact, stronger community responses and systems; tected, untreated or unreported, which leads abled rapid scale-up of mass tuberculosis universal access to primary care services and including decision making in the Board and promoting the delivery of more integrat- to ongoing transmission of the disease and screening by chest X-ray, BCG inoculation, Expectation for Medical realize UHC in low-income countries. and its committees, resource mobilization, ed, people-centered health services. the spread of drug-resistant tuberculosis [5]. test and treatment with public financial and Professionals, National Medical strategy development, in-country planning social protection of tuberculosis patients, Driver: Medical associations and their and implementation of the Global Fund- To break through these challenges, the which accelerated and finally led to univer- Associations and WMA members could play a driving role in imple- supported programs. Challenges to Achieve world is pursuing new scientific knowledge sal health coverage in 1961 in Japan. Toward UHC and SDG 3 menting those policies and strategies toward Ending Epidemics and innovations such as new diagnostics UHC, especially delivering primary health As a result, this Global Fund partnership and treatments more effective and efficient Public-private partnership, especially be- While medical professionals, national med- care and essential services and improving has brought a drastic progress in scaling up Despite the progresses made, HIV, tubercu- to find and treat cases and latent infections, tween public health centers (PHC) and pri- ical associations and WMA are crucial ac- quality of those services at a community of essential services in the fight against three losis and malaria still infected more than 230 and vaccines and others to prevent infec- vate clinics/hospitals facilitated scale-up and tors on the road toward UHC and SDG 3, level. One of the three dimensions of UHC diseases (Figure 1) and building health sys- million people and killed more than 8,000 tions. Yet, it is also considered possible to quality improvement of diagnosis, treatment they could play more active or even proac- is population coverage. While monitoring tems, which has saved a total of 32 million people daily in the world in 2017, which bend the curve by optimizing even the cur- and care of tuberculosis patients [17]. Public tive roles in accelerating the efforts for their the progress toward UHC, increasing pop- lives as of the end of 2018 with 56%, 22% means that the two-day death toll of three rently existing tools and pursuing UHC and health centers as local government authori- achievement in many countries. In particu- ulation coverage with essential services is and 46% reduction of the number of deaths infections is more than the two-year death social protection [13]. Some counties have ties had substantial contribution to Japan’s lar, I would like to highlight the following important. Yet at the same time which sub- due to HIV, tuberculosis and malaria re- toll of Ebola outbreaks in 2014–15 [4, 5, 6, 7]. shown rapidly bending curves of tuberculo- success in tuberculosis control, especially by three roles and expect them to take those populations are covered is also critical as the spectively since 2002 when nearly 5 million sis mortality and morbidity in the past even overseeing various programs such as mass in addressing challenges and gearing up to- vulnerable and marginalized populations are people had died of the three diseases [1]. Recognized as the world’s unmet agenda before effective diagnostics and medications screening, surveillance, patient registration, ward UHC and SDG 3. often left behind and hardly covered. Since and still leading causes of deaths among in- came into existence. and by handling public subsidy of medical the members of medical associations are For example, Rwanda demonstrated a mas- fections in many countries, the fight against expenses for tuberculosis treatments [18]. Influencer: UHC requires political com- working close to communities, they are in sive scale-up of essential HIV services sup- these three diseases are included in SDG 3 Each PHC set up Tuberculosis Advisory mitment from the highest levels, notably a good position to listen to and understand ported by the Global Fund and partners as Target 3.3 “By 2030, end the epidemics Good Practice of Japan Committee, which was composed of PHC for policy-makers to develop and imple- the needs of the communities including vul- (Figure 2) and consequently led to an out- of AIDS, tuberculosis, malaria and neglect- staff, tuberculosis specialists and physicians ment policies and regulations that facilitate nerable and marginalized populations, and standing reduction of AIDS-related mor- ed tropical diseases and combat hepatitis, One of those countries is Japan where tu- recommended by a local medical associa- the movement towards UHC [20] and to to reach out to them with essential services. tality (Figure 3) [3]. There was a time when water-borne diseases and other communi- berculosis killed more than 100,000 people tion, for checking medical records from gen- raise significant funds that will enable it to almost none of the HIV infected people cable diseases.” annually before 1950. Tuberculosis was then eral physicians, most of whom run a private happen. Since medical professions and their The government and national health pro- in Africa could get access to antiretroviral called “the national disease” as the leading clinic, and recommending public subsidy to associations have leadership and political fessional associations including a medical therapy (ART) while it was available and Each disease in this target has its own glob- cause of death and accounting for 15% of all those treatment. This public-private part- power in many countries, they could serve association need to work together to iden- accessible among those in developed coun- ally agreed specific targets such as 95-95-95 deaths [14, 15]. However, Japan demonstrat- nership contributed to quality improvement as influencer to enhance the country’s po- tify the populations left behind and health tries. Thus, this is the remarkable result and by 2030 of Fast-Track Strategy for HIV [8]; ed one of the sharpest declines in tuberculo- and assurance of tuberculosis control. litical will and leadership toward UHC and services in need, and find the ways to deliver victory of human beings with collective ef- reduction in deaths by 90% (95%), and new sis mortality in the world from 1950 to 1970 health SDG. those for achieving UHC. forts and shared responsibility. cases by 80% (90%) by 2030 (2035) com- - with mortality reduction of 50% by 1955, Multisectoral approach was also critical suc- pared with 2015 levels for tuberculosis [9]; 80% by 1960, and 90% by 1970 compared cess factor for tuberculosis control in Japan. Especially, political will and actions are Facilitator: Leading medical and health Without cross-cutting interventions or hori- reduction in mortality and incidence rates to the mortality in 1950, which brought an needed to mobilize domestic resources for field, medical professionals and their associ- zontal approach of health systems it is impos- by 90% by 2030 for malaria [10]. average annual reduction of almost 12% in Under the Tuberculosis Control Law, all the financial risk protection and equitable ac- ation could play more active role in facilitat- sible to control and end major epidemics like this period [14,15,16] (Figure 5). municipalities, schools and private compa- cess to essential services. Since only 3% of ing collaboration and coordination among AIDS, tuberculosis and malaria. Therefore, While these targets are set based on data, nies were required to engage in tuberculosis global health spending occurs in lower- or different health workforce and their associa- the Global Fund has been assisting countries global consultations and discussions [8, What made this happen? Besides economic mass screening towards the common target lower-middle-income countries where 49% tions including nurses, midwife, pharmacists, in building resilient and sustainable systems 9, 10, 11], there are challenges to achieve growth and social development after World and slogan “100% uptake”. Public health of the global populations live (Figure 6) and community health workers. As shown for health (RSSH), and promoting and pro- those targets [12]. Especially, the global War II, several factors were identified as as- centers played key roles in driving commu- [21, 22], development assistance for health by an example of Japan and other good prac- tecting human rights and gender equality, as target against tuberculosis looks ambitious sociated with this success, which include nities to attend mass tuberculosis screenings (DAH) by donor countries and aid agen- tices in the world, achieving UHC requires two of the four pillars of the Global Fund to reach unless the current global trend of strong political commitment and actions, towards 100% uptake in close collaboration cies remains critical for those countries to effective and efficient collaboration among Strategy for 2017– 2022 and two critical annual 2% reduction of incidence is dra- public-private partnership, multisectoral ap- with local community organizations such improve health, which accounts for more all the stakeholders including public-private foundations of UHC. Notably, the Global matically geared toward more than 10% re- proach and community engagement [14,15]. as the Anti-Tuberculosis Women’s Associa- than 50% of their health spending in some partnership and multisectoral collaboration. Fund invests more than US$1 billion per duction (Figure 4). At the current trend of tion. The Japan Anti-tuberculosis Associa- countries. However, DAH has been stag- Medical professionals are usually respected year in building RSSH, which is among the decline in incidence, it will take humanity Political commitment and actions encom- tion ( JATA) also played an important role gered at approximately US$39 billion in in a community and could take a facilitating largest multilateral financiers in this area, and 130 years to end tuberculosis [13]. pass enactment and enforcement of various in promoting community mobilization and the past several years (Figure 7)[2] while role in scaling up of essential health services

18 19 Universal Health Coverage Information from National Medical Associations

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Global tubercu- RSSH for achieving UHC with estimation level of domestic government health expenditure socially oriented domestic policy, to develop of the Republic through foreign economic infrastructure. Accordingly, the standards of losis targets and milestones set for 2016-2035: of over US$1 billion per year. should we aspire to for universal health coverage? programs aimed at improving health of the relations. A targeted policy of integration domestic health policy were practically ab- definition and rationale. Int J Tuberc Lung Dis. Health Econ Policy Law. 2017;12(2):125-137. population and development of the health- into the world community, establishing re- sent. The urgent need to improve the social 2018;22(7):723-730. doi: 10.5588/ijtld.17.0835. 24. Mcintyre, D.M., F. Shared Responsibilities for I would like medical professionals to join our 12. GBD 2017 SDG Collaborators. Measuring care system. The level of economic well-being lations with international structures and protection of citizens, primarily the health- efforts for the global common goal of ending Health: A Coherent Global Framework for of the country and quality of healthcare sys- aimed at attracting investment and develop- care system, is reflected in the domestic pol- progress from 1990 to 2017 and projecting at- Health Financing, in Final Report of the Centre epidemics and achieving UHC and SDGs. tainment to 2030 of the health-related Sus- on Global Health Security Working Group on tem’s functioning are interrelated factors that ing the country’s economy was based on the icy of the state. As a result, in 1998, by an tainable Development Goals for 195 countries Health Financing. 2014, Chatham House: Lon- directly determine health of the population. “oil strategy” of Heydar Aliyev, which laid order of the national leader Heydar Aliyev, and territories: a systematic analysis for the don, UK. [Cited 2019 Oct 30]. 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ALL. the healthcare system and its harmonization commissioned, including the Baku-Tbilisi- system included the expansion of medical 2. Institute for Health Metrics and Evaluation, D, Oshin A, Pate M, et al. Community health #ENDTB" [Cited 2019 Oct 10]. Available workers for universal health-care coverage: from University of Washington. Financing Global with global trends of developed countries. Jeyhan pipeline. The strategy ensured social educational programs, updating medical from: https://www.who.int/tb/joint-initiative/ fragmentation to synergy. Bull World Health Health 2018: Countries and Programs in Tran- The modern healthcare system of Azerbaijan economic development [3], and as a result, equipment, monitoring of environmental en/ Organ. 2013;91(11):847-52. sition. [Cited 2019 Oct 05]. Available from: is in a transitional period, which is charac- the rise of the healthcare sector. factors affecting health, and study of health- 14. Mori T, Ishikawa N. Tuberculosis in Japan be- 26. The Global Fund. Step Up the Fight. 2019. http://www.healthdata.org/sites/default/files/ fore, during, and after World War II. In: Mur- [Cited 2019 Oct 10]. Available from: https:// terized by the reform of healthcare financ- care trends in high-income countries. files/policy_report/FGH/2019/FGH_2018_ ray JF, Loddenkemper R (eds): Tuberculosis and www.theglobalfund.org/en/stepupthefight/ ing, introduction of electronic services and In the first years of the restoration of in- full-report.pdf War. Lessons Learned from World War II. Prog renewal of the insurance system. The reform dependence, Azerbaijan sought to actively The key factor determining public health 3. Nsanzimana S, Prabhu K, McDermott H, Ka- Respir Res. Basel: Karger; 2018. vol 43, p.188- Osamu Kunii, MD, MPH, PhD is based on legislation, which is updated and cooperate with international organizations policy and the corresponding programs rita E, Forrest JI, Drobac P, et al. Improving 196. health outcomes through concurrent HIV pro- 15. Seita A. How Japan had addressed control of The Global Fund to fight AIDS, Tuberculosis supplemented in accordance with new needs. in order to ensure compliance of domestic arising from it is the level of development gram scale-up and health system development tuberculosis: “Think PHC, Do TB” Integration- and Malaria, Geneva, Switzerland policies with global trends. So, one of the of medicine and related areas. Only highly in Rwanda: 20 years of experience. BMC Med. based scale up of tuberculosis control in Japan. Head, Strategy, Investment Taking into account the tense internal situ- tasks of health policy has become and is effective medical services and the develop- 2015;13:216. doi: 10.1186/s12916-015-0443-z. [dissertation], Harvard School of Public Health. and Impact Division ation in the country [1] after the collapse of now cooperation with international organi- ment of medicine can ensure public health,

20 21 Information from National Medical Associations Information from National Medical Associations

which begins with the health of a single Ministry adopted the Decree on Approval efficiency of using budget funds; the state policy on infectious diseases is based on le- 2020 [23] was adopted in 2014. Because of and biodiversity, social responsibility and person (citizen). Health policy itself may of the Strategic Plan of the Ministry of provides free budget-funded medical ser- gal norms formulated in numerous laws of improvements in the public health system, health. The universal bioethical principles of include various directions and fields, such Health of the Republic of Azerbaijan for vices, however, publicly guaranteed health the Republic of Azerbaijan, such as On the demographic indicators have increased and, justice and equal rights are also reflected in as healthcare, insurance, vaccination, mental 2014–2020 [8], which outlined the social care is not universal, and some services must Immunoprophylaxis of Infectious Diseases according to data for 2015 over the past 10 Article 10 (Chapter III) of the Law, which health, pharmaceutical, healthy life styles orientation of its activities. The Ministry of be paid by citizens [14]. The reform implies [19] and On Fight Against Tuberculosis in years, infant mortality per 1000 live births indicates equality in health issues between and environmental health policies, includ- Finance develops and determines the bud- creation of an integrated healthcare system, the Republic of Azerbaijan [20], adopted in decreased from 11.9 to 11.0, and maternal citizens and non-citizens, and Article 12, ing anti-smoking, anti-obesity, reproductive get of the Ministry of Health, which is ap- i.e. combining a universal type of public 2000. Both of these laws indicate state sup- mortality decreased from 30.2 to 14.4 [24]. which protects the right to receive not only policies, etc. Being complex in nature, it also proved by the Milli Majlis (Parliament). In health insurance system (financed from the port for their implementation. medical, but also social assistance in case of covers issues of financing, improving leg- 2017, more than 775 million manats were state budget) and a private system partially The political course of the country is closely disability [27], etc. islation, ensuring social justice and imple- allocated to healthcare; expenditures on sci- funded by citizens, which is a lengthy pro- Non-communicable diseases, such as cardio- connected with legislation, since it is the menting many targeted programs to solve ence, education, healthcare, social protec- cess. So, since 2016, two cities of Azerbai- vascular, oncological, diabetes, etc., and risk legal norms that govern the implementa- Health of the people in research and clini- various problems in this area. Health policy tion and other related categories accounted jan – Mingachevir and Yevlakh with their factors like smoking, drug addiction, obesity, tion of decisions taken at the political level. cal experimentation is protected by Decree is multilevel and comprehensive, since deci- for 32.5% of the total state budget, of which regions – have been selected as pilot territo- alcohol abuse, constitute a significant threat Legislation in turn is based on international of the AR Cabinet of Ministers (No.83) sions made at the state level are passed for 4.7% was allocated for healthcare [9]. By ries for testing a new type of health insur- to public health, especially to young people. principles and norms, such as universal bio- of 2010 on the Rules for the Conduct of execution to separate bodies such as the Decree of November 30, 2018, President ance [15]. In December 2017, by a decree of For example, smoking harms not only smok- ethical principles. The basis of state policy Scientific Research of Drugs, Preclinical Ministry of Health and municipalities. The of Azerbaijan Ilham Aliyev approved the the President, the Agdash district [16] was ers, but also people around them (second- related to the protection of public health Research and Testing. Despite the fact that importance in this regard is given to solving country’s budget for 2019 [10], in which also included in the pilot program. hand smoke) and, no less important, the lies in the country’s main law – the Con- this Decision is not directly related to the the most urgent problems in the country. So, more than 1 billion manats were allocated environment. So, in 2015, by Decree of the stitution, which declares that ensuring a protection of public health, its importance for example, the problem of obesity is not as to the healthcare sector. An increase in the The Center for Public Health and Reforms President of the Republic of Azerbaijan, the decent standard of living of a citizen “is the for the development of the field of medi- acute as the problem of thalassemia / he- amount of budgetary funds for health care (CPHR) under the Ministry of Health es- Strategy to Combat Non-communicable supreme goal of the state”[25]. Article 41 cine in the country is obvious. It is clinical mophilia in Azerbaijan. In this regard, the underlines the priority of this sphere in the tablished in 2006 is financed from the state Diseases in the Republic of Azerbaijan for (The right to health care) declares the right research that underlies the development Cabinet of Ministers of the AR approved domestic political course and indicates in- budget and implements the state health pol- 2015–2020 [21] was approved. The adoption to medical care and a state role in the de- of new drugs – an integral element that the Resolution on the State Program on creased attention to this sphere from the top icy in the direction of its reformation. Ac- of such a strategy has two important aspects. velopment of all types of healthcare, which ensures the development of medicine. So, Hereditary Blood Diseases of Hemophilia leadership of Azerbaijan. cording to the Regulation on the CPHR, it Firstly, it is a striking example of the tasks operates on the basis of various types of Clause 4.4 of the Decree states “The safety and Thalassemia [5] adopted in 2006. participates in the development and imple- of domestic health policy corresponding property and various forms of health insur- and health of the person in whom the tests The key task of modern healthcare refor- mentation of health policy, ensures the or- with international trends and responding to ance [25]. The Article is consistent with the are conducted are of paramount importance, Today, the development concept – Azer- mation is the introduction of the compul- ganization of healthcare, develops proposals modern challenges. Secondly, the adoption provisions of the Universal Declaration on and they must be above public and scien- baijan 2020: A Look into the Future – ap- sory medical insurance system. Although, for reforms in this area, implements reforms of the program in the framework of coop- Bioethics and Human Rights that empha- tific interests.” [28] This norm corresponds proved by the Decree of the President of the use of insurance in healthcare was laid in primary health care, etc. The Center has eration with the UN and WHO speaks of sizes “role of the state” [26] in the imple- to the bioethical principle “human dignity Azerbaijan Ilham Aliyev in 2012, defines down in 1999, by the adoption of the Law already implemented many projects, such as a policy of harmonization of internal health mentation of bioethical principles. and human rights”, which proclaims the priorities in state policy and reformation in on Medical Insurance [11], the text of the Creating Schools for Diabetics, Developing goals with global goals, i.e., the adoption paramount importance of the interests of the field of healthcare, as well as in other law is still being edited, and its updated ver- a National Tobacco Control Strategy [17]. of the Strategy of 2015 was a direct result Medical law in Azerbaijan is somewhat an individual over the interests of science or areas. Paragraph 7 of the Concept gives pri- sion will come into force only in 2020. In of the close cooperation of the Republic of fragmented due to the lack of systematic society. Moreover, the resolution indicates ority to “the development of human capital 2007, by the Decree of the AR President, The Health Informatization Center under Azerbaijan with the WHO and UN. Name- approach of national health authorities to the obligation to obtain informed consent and creation of an effective social security the State Agency for Compulsory Health the Ministry of Health, established in 2010, ly, the UN adopted the Political Declaration this matter, lack of understanding of in- (written or oral, with the participation of system” [6]. This paragraph defines the goals Insurance was established [12] under the [18] operates as an online resource that pro- of the High-level Meeting of the General formed consent doctrine and equality of two witnesses, if the person cannot write), and objectives in the healthcare system, sets Cabinet of Ministers. Formation of a uni- vides numerous services, such as request- Assembly on the Prevention and Control of rights of medical professionals and patients which directly corresponds to the bioethi- other goals, such as improving social secu- fied policy of compulsory insurance is one ing outpatient medical facilities for home Noncommunicable Diseases in 2011, which during the treatment process. However, pa- cal principles of “consent” (informed) and rity, developing modern education, devel- of the Agency’s main tasks. services or electronic registration to visit a gave impetus to the further development of tient’s rights are protected by different legal “persons without the legal capacity to give oping youth and sports potential, ensuring doctor. However, the electronic system is the WHO Global Action Plan on Noncom- documents and represent part of the Law consent”. gender equality and family development. The Concept of Reforming the Health still under development and has a limited municable Diseases 2013–2020 [22]. Since on Protection of Public Health of 1997 Financing System and the Application of number of services. In addition, the use of non-communicable diseases cause concern [27]. The Law defines state obligations in The principle of “consent” is also widely One of the main tasks in modern healthcare Compulsory Health Insurance was adopted electronic services is not popular among of the world community, the Azerbaijani the field of public health protection, such reflected in the Law on Psychiatric Care policy is increasing government allocations in 2008 [13]; its implementation requires citizens living away from the capital. leadership also responds to the need to solve as determining state policy and develop- [29]. The Law obliges medical institutions for the development and modernization in a complete reorganization of the financ- the problems arising by adopting relevant ing programs, financing in the field of to provide appropriate assistance (with the the field of medicine. The public health sys- ing system, a new healthcare restructuring, Preventive measures to improve the health decrees and regulatory documents aimed at healthcare and environment, as well as the exception of involuntary hospitalization), to tem in Azerbaijan is financed from the state etc. According to the Concept, the reform of the population, as one of the priorities of eliminating them. rules for organizing and functioning of the attract (with the right to refuse at any time) budget. The Ministry of Health is the cen- of healthcare financing is aimed at creat- the health policy, include many programs healthcare system. The Law encompasses patients to research as an object, as well as tral authority in the field of healthcare [7] ing new economic principles, improving to help patients with infectious and non- Moreover, the State Program for Improv- also numerous bioethical principles, such their use in the educational process only af- coordinating relevant issues. In 2014 the access to medical services, increasing the infectious (social) diseases. The preventive ing Maternal and Child Health for 2014– as protection of environment, biosphere ter receiving consent.

22 23 Information from National Medical Associations Information from National Medical Associations

Article 3 of the Law on the Immunoprophy- to health issues, namely, the construction of UNESCO National Committee on Bioeth- References rayonu-pilot-razil-r-olaraq-secildi-1/ (accessed 27. Psixiatriya yardımı haqqında. http://sehiyye.gov. 1. Hasanov A. Azərbaycan Respublikasının Milli 17 February 2017) az//files/pdf/qanun/142.pdf (accessed 12 Au- laxis of Infectious Diseases of 2000 defines medical facilities, the provision of free med- ics, Ethics of Science and Technology under ə İnkişaf və Təhlükəsizlıik Siyasəi. Baku: Letter- 16. Trend. İcbari tibbi sığorta pilot layih olaraq gust 2019) the basic principles of preventive measures ical care, etc. The state implements many the Presidium of the National Academy of ə ə ə ə press; 2011. p.25 Ağdaş rayonunda da t tbiq olunacaq. https:// 28. Az rbaycan Respublikası S hiyy Nazirliyi. ə ə ə of state policy, such as free vaccination. The measures to ensure the benefits of citizens Sciences of Azerbaijan monitors bioethical 2. “Əsrin müqaviləsi” - 10 il. http://www.ebooks.az/ az.trend.az/azerbaijan/politics/2862045.html “Yoluxucu x st likl rin immunoprofilaktikası ə bioethical principle of “consent” is reflected who, as a result of the occupation, find issues, their scientific research, educational view/wlAHFgSX.pdf (accessed 15 April 2019) (accessed 16 February 2018). haqqında” Az rbaycan Respublikasının Qanunu ə ə ə ə ə in Article 6 of the Law [30], which requires themselves in a group of a vulnerable part and counseling activities [36]. However, 3. Aliyev H. “Müstəqilliyimiz əbədidir” çoxcild- 17. İctimai S hiyy v İslahatlar M rk zi (İSİM). About http://sehiyye.gov.az/yoluxucu_xesteliklerin_ ə us. https://isim.az/en/pages/2 (accessed 16 January obtaining consent to immunize persons, of the population, which requires significant unfortunately, this body does not have the liyin elmi-biblioqrafik göst ricisi: I cild. Baku: haqqnda.html (accessed 15 August 2019) «Şərq-Qərb»; 2013. http://www.ebooks.az/view/ 2019) 29. Official website of the President of the Republic ə ə ə ə including minors or those who have been financial and other resources. legal ability to regulate bioethical issues in FiCv3BWh.pdf (accessed 03 March 2019) 18. Elektron s hiyy portalı. S hiyy nin İnforma­ of Azerbaijan. Armenia-Azerbaijan Nagorno- ə ə recognized as legally incompetent in accor- healthcare. 4. Bioethics, Medical Law and New Technologies, siya­ laşdırılması­ M rk zi. http://www.e-health. Karabakh conflict. https://en.president.az/azer- dance with the norms established by law. Another important factor in the state’s in- Institute on Human Rights of ANAS; Baku; 2013 gov.az/az/s/21/Health+Informatization+Center baijan/karabakh (accessed 15 August 2019) 5. “Hemofiliya və talassemiya irsi qan xəstəlikləri (accessed 17 January 2019) 30. Qaçqınların və məcburi köçkünlərin (ölkə ternal health policy is the leveling of ethical The Azerbaijan Unit of the UNESCO Chair ə ə ə üzrə Dövlət Proqramı”nın təsdiq edilməsi 19. Ministry of Health. Yoluxucu x st likl rin daxilində köçürülmüş şəxslərin) statusu haqqında ə ə It must be emphasized that the issue of problems. As said, the 1997 main health law in Bioethics has translated into Azerbaijani haqqında Azərbaycan Respublikasi Nazirlər Ka- immunoprofilaktikası bar d qanunvericilik Azərbaycan Respublikasinin qanunu http:// Ə Ə protecting the rights of the population were covers the main provisions, including the the UNESCO Basic Program on Bioethics. binetinin Qərari. № 15, 18 yanvar, 2006-cı il. aktlarına dair B L DÇİ QAYDALAR. http:// www.e-qanun.az/framework/4757 (accessed 15 significantly affected during the Armenian- patients’ rights [27], and confirms the right Moreover, the Unit initiated the Training of 6. The official website of the President of the Azer- health.gov.az/yoluxucu_xesteliklerin_haqqnda_ August 2019) ə ə baijan Republic. “Azerbaijan 2020: Look Into the beledci.html (accessed 25 January 2019)S hiyy 31. “Qaçqınların və məcburi köçkünlərin yaşayış Azerbaijani Nagorno-Karabakh conflict of all citizens to medical care. Inequalities in Teachers on Ethical Education of UNESCO ə ə ə ə Future” Concept of Development. https://presi- Nazirliyi “Az rbaycan Respublikasında v r ml şəraitinin yaxşılaşdırılması və məşğulluğunun that occupies a special place in the state the level of medical services for various so- that was held in Baku in 2012, introduction ə dent.az/files/future_en.pdf (accessed 15 August mübariz haqqında”, 2000. http://sehiyye.gov.az// artırılması üzrə Dövlət Proqramı”nın təsdiq policy of Azerbaijan. Despite the political cial groups of the population are prevented of the subject Bioethics and Medical Law as 2019) files/pdf/qanun/875.pdf (accessed 18 January 2019). edilməsi haqqında. http://www.e-qanun.az/ ə nature, these events negatively affected all by access to state medical institutions, such a scientific discipline in the educational pro- 7. Mammadov V. Health care in Azerbaijan. 20. “Az rbaycan Respublikasında qeyri-infek- framework/6261 (accessed 15 August 2019) ə ə ə ə ə ə World Association for Medical Law Newsletter sion x st likl rl mübariz y dair 2015-2020- 32. “Şəkərli diabet xəstəliyinə tutulmuş şəxslərə dövlət spheres of the state’s life, including health- as clinics, free of charge. Moreover, according gram of students of the law school of Baku ə ə ə 2014; (October-December): 5–7 ci ill r üçün Strategiya”nın t sdiq edilm si qayğısı haqqında” Azərbaycan Respublikasının care. As a result of hostilities and the oc- to numerous legal acts, vulnerable segments State University and inclusion of bioethics in ə ə ə Ə th 8. Az rbaycan Respublikası S hiyy Nazirliyi. haqqında AZ RBAYCAN RESPUBLİKASI Qanunu. http://sehiyye.gov.az/diabet_xesteli- cupation of 20% of the Azerbaijan territory, of the population, especially those who are the code of scientific specialties [37]. The 18 Ə № ə ə ə Ə Ə mr 30 “Az rbaycan Respublikası S ıhiyy PREZİDENTİNİN S R NCAMI. 2015. yine_tutulmus.html#sel=1:1,1:11 (accessed 15 ə ə more than 1 million Azerbaijani citizens chronically ill, receive medicines and medical session of the UNESCO International Com- Nazirliyinin 2014-2020-ci ill r üzr Strateji http://www.e-qanun.az/framework/doc/31727 August 2019) rd ə ə were in the situation of refugees and inter- assistance from the state. Thus, the Law on mittee on Bioethics, the 23 World Medical Plan”nın t sdiq edilm si haqqında. http://www. (accessed 27 January 2019)WHO. Noncom- 33. Uşaqların icbari dispanserizasiyası haqqında nally displaced persons, 50 thousand people State Assistance to Patients with Diabetes Law Congress (WAML) – the 50th Anniver- sehiyye.gov.az/files/pdf/emr_2014_30.pdf (ac- municable diseases prematurely take 16 million Azərbaycan Respublikasinin Qanunu http:// cessed 10 March 2019) lives annually, WHO urges more action. https:// www.e-qanun.az/framework/25600 (accessed became disabled, and 20 thousand people [34] was adopted in 2003, which defines free sary Congress – under the title Medical Law, ə 9. The Ministry of Finances. Az rbaycan www.who.int/mediacentre/news/releases/2015/ 17 August 2019) ə ə died; in 1988–1993, in Karabakh, 695 medi- diagnosis and treatment of this group of pa- Bioethics and Multiculturalism were held in Respublikasının 2017-ci il dövl t büdc si haqqında noncommunicable-diseases/en/ (accessed 10 34. Mammadov V., Munir K., Jafarova L. Bioethics cal institutions were destroyed, among other tients. Similar legislation was adopted con- the capital of Azerbaijan in 2011 and 2017 Qanunu. http://www.maliyye.gov.az/sites/default/ May 2019) ə Education in Azerbaijan: Preconditions, Devel- things [31]. Thus, a large part of the coun- cerning oncology patients as well. In 2013, respectively. Since the WAML has an im- files/2017-qanun.pdf (accessed 23 April 2019) 21. “Ana v uşaqların sağlamlığının yaxşılaşdırılmasına opment and Current State. World Association ə ə ə ə 10. “Az rbaycan Respublikasının 2019-cu il dövl t dair 2014-2020-ci ill r üçün Dövl t Proqramı”nın for Medical Law Newsletter 2017; Medicine try’s population was in a socially vulnerable the Law on Compulsory Medical Examina- portant role in shaping medical law in post- ə ə ə ə ə büdc si haqqında” Az rbaycan Respublikası Qa- t sdiq edilm si haqqında Az rbaycan Respublika- and Law (Volume 36, Number 3): 1-13 position and resolution of their problems tion of Children [35] approved state fund- Soviet countries [38], the holding of such a ə ə ə ə ə ə ə ə ə ə nununun t tbiqi il bağlı bir sıra m s l l r bar d si Prezidentinin S r ncami. http://www.e-qanun. 35. Mammadov V., Munir K., Jafarova L. Medi- Ф ə ə needed urgent actions from the state. In ing for the implementation of comprehen- congress first time ever during its 52 year his- z rbaycan Respublikasi Prezidentinin F rmanı. az/framework/27839 (accessed 15 May 2019) cal science, Research and Higher education in accordance with the Law on the Status of sive measures of medical examination. The tory in this part of Eastern Europe and Near http://www.e-qanun.az/framework/41117 (ac- 22. Administrative Department of the President of Azerbaijan from bioethical developments per- Refugees and Internally Displaced Persons mentioned provisions reflect the essence of Asia confirms the development of this field cessed 11 March 2019) the Republic of Azerbaijan. Presidential Library. spective. Medychne pravo. 2016; 2(18):18-43. ə Independent Azerbaijan. Public Health. http:// (Displaced Persons within the Country) of universal bioethical principles, such as equal- in the Republic. 11. Tibbi sığorta haqqında Az rbaycan Respub- 36. Sergeyev Y., Mammadov V. Development of likasinin Qanunu http://www.e-qanun.az/ republic.preslib.az/en_c7-4.html (accessed 01 the AR in 1999 [32], their right to medi- ity, justice and equality, protection of future Medical Law in Post-Soviet Countries and Role framework/80 (accessed 24 April 2019) May 2017) of WAML. Med. & L. 2018; 37:701 cal care is guaranteed. The construction generations. Today, the introduction of bio- Thus, based on the analysis of the state’s 12. Azərbaycan Respublikasının Nazirlər Kabineti 23. Azərbaycan Respublikası Prezidentinin rəsmi in- and rehabilitation of medical facilities in ethical principles and the harmonization of policies and legislative acts of Azerbaijan in yanında İcbari Tibbi Sığorta üzrə Dövlət Agen- ternet saytı. Constitution. https://president.az/ the territories affected by the conflict, the national legislation, respectively, are one of the field of healthcare, it can be concluded tliyi. https://its.gov.az/az/i-tsda-haqq-nda/ azerbaijan/constitution (accessed 10 August 2019) Prof. Dr. Vugar Mammadov umumi-m-lumat/ (accessed 24 April 2019) 24. UNESCO. Universal Declaration on Bioeth- provision of mobile medical services, re- the main goals of domestic public policy. that the field is actively developing, and al- 13. “Azərbaycan Respublikasında səhiyyənin ics and Human Rights. http://www.unesco.org/ Head, Azerbaijan unit, UNESCO habilitation and preventive work among though the bioethical principles are widely maliyyələşdirilməsi sisteminin islahatı və icbari new/en/social-and-human-sciences/themes/bi- Chair in Bioethics the affected population are implemented Bioethics, which is closely linked to medical reflected in legislation, yet there is much tibbi sığortanın tətbiqi Konsepsiyası”nın təsdiq oethics/bioethics-and-human-rights/ (accessed Deputy Chairman, UNESCO ə ə through numerous state programs. Many law and human rights, is the one of the pri- to be done. Given the close relationship edilm si haqqında Az rbaycan Respublikasi 11 August 2019) National Bioethics Committee, Prezidentinin sərəncami. http://www.e-qanun. 25. Əhalinin sağlamlığının qorunması haqqında state programs have been implemented, and ority fields of UNESCO activities, of which between policy and law, it is obvious that az/framework/13091 (accessed 25 April 2019) Azərbaycan Respublikasinin Qanunu. http:// Azerbaijan National Academy of Sciences their implementation continues to this day. Azerbaijan is a member. This is one of the the norms reflected in legislation, includ- 14. Decree of President of Azerbaijan Republic on www.e-qanun.az/framework/4078 (accessed 12 E-mail: [email protected] Thus, in 2004, by decree of the President of factors that has widely contributed to the ing bioethical principles, are a determining Concept for Health Reformation and Manda- August 2019) tory Medical Insurance. Baku, 10 January 2008. 26. “Dərman vasitələrinin elmi tədqiqatlarının, klini- the Republic of Azerbaijan, the State Pro- origin and development of interest in the vector in the formation of healthcare policy. № ə ə ə ə Lala Jafarova gram on improving housing conditions and field in the country. Azerbaijan has already Azerbaijan implements many activities in 2620 kaya q d r t dqiqatlarının v klinik sınaqlarının PhD student, Institute of Law 15. Official website of the State Agency on Man- aparılması Qaydaları”nın təsdiq edilməsi increasing the employment of refugees and achieved successes in the development of order to harmonize medical legislation with datory Medical Insurance under the Cabinet haqqında Azərbaycan Respublikasinin Nazirlər and Human rights, Azerbaijan internally displaced persons [33] was ap- bioethics in general, and there is increas- international standards and its reformation of Ministers of Azerbaijan. http://its.gov.az/ Kabinetinin Qərar. http://www.e-qanun.az/ National Academy of Sciences proved, in which much attention was paid ing interest in this area from specialists. The is in progress. az/media/press-reliz/ming-cevir-h-ri-v-yevlax- framework/19529 (accessed 12 August 2019) E-mail: [email protected]

24 25 Cooperation Organisations Health Care in Developing Countries

efficient. This realisation has also drip-fed to As the country is emerging from the post The Welfare and Good Health of Patients the regulators who want patient insights and Health Systems in Post Conflict; conflict setting, individuals who have expe- perspectives on market authorisation of inno- rienced the horror and trauma of the war is not Possible Without the Doctor: vative medicines and devices. The pharmaceu- Case of Somaliland widely suffer from mental disorders and tical industry has long benefited from patient illnesses; unemployment and poverty con- Let’s Work Together participation and engagement in medicines re- tribute largely to the development of these search and development. They are now looking Somaliland, one of the regions in Somalia shortages, structural fragmentation, insuf- illnesses, while there are only 4 trained psy- “Medicine is an art whose magic and creative • Firstly, creating an enabling environment, at co-creation and co-designing to maximise with an estimated population of 3.5 million ficient and distorted incentives to motivate chiatrists for the population of 3.5 million. ability have long been recognized as residing globally and within a patient organisation, patient value and efficiency in their industry. people, has a history of conflict, which last- staff, limited supervision and mostly ad-hoc in the inter- personal aspects of patient-phy- that encouraged and gave a greater number of Most countries now aspire to have universal ed from the late 1980s to early 1990s, and management arrangements are issues in all The other challenge is surgical operations, sician relationship” [1]. It is based on trust patient organisations the opportunity to have health coverage by 2030. IAPO strives to en- this resulted in the collapse of the health areas. Although Somaliland’s health au- which are costly, and difficult to access. Nei- and mutual respect and it is a well known their representative serve on international sure that patients have a high quality of pa- sector. Some years of relative stability evince thorities are developing strategies and tools ther the poor people can afford the cost and fact that clinical outcomes are determined by Boards, committees and policy making bodies. tient advocacy in place so that we can ensure that Somaliland is ready to realign its focus for improved governance of the sector, huge die from complications nor do the rich have the confidence a patient has in his treating • Secondly, through carefully designed that they have a sufficient quantity of acces- towards long-term development plans. gaps are still evident, necessitating contin- access to a good quality of surgical care. healthcare professional. leadership training, capacity building pro- sible, acceptable and affordable preventative, ued capacity building and support. Today, effective doctor-patient relationship is grammes and attendance at WHO and therapeutic, curative, rehabilitative and pal- The health and demographic situation in Junior doctors working without senior su- one of the central clinical elements, as it con- World Bank forums expose more patient liative healthcare by 2030. But much more Somaliland leaves much to desire, and ac- Somaliland is not a unique case; it shares a pervision is another challenge because this tributes to more patient-centered healthcare representatives to the global healthcare than this, we must ensure this healthcare is cording to UN data, the country has some of lot with other post conflict settings around can lead to malpractice and be a cause of delivery. Alongside creating a good interper- institutional, legal, policy, and practice and delivered in a safe and compassionate man- the worst health and nutrition indicators in the world. The disruption of health systems death. Although there are nurse anesthe- sonal relationship and facilitating exchange standards framework and develop their ner, to WHO acceptable quality standards. the world and is unlikely to reach the health affected the human resource in the health- tists, few of them can perform pediatric or of information, it also constitutes including skills and confidence to undertake national One of your colleagues has rightfully said, related MDGs; women, girls and the poor- care sector greatly. Somaliland is struggling geriatric anesthesia and to people with co- patients in the decision-making, regard- or regional patient advocacy. “the patient will never care how much est groups are most affected in this context. with a chronic shortage of skilled healthcare morbidities. ing their condition and treatments vis-à-vis • Thirdly, by focusing on cross cutting issues you know, until they know how much you The health of women, adolescent girls and workers which is the result of the large-scale health benefits and quality of life [2; 3]. Thus, of safety and quality, research & innovation care” [4]. Thus, IAPO wishes to call upon children and their access to health care are emigration from the country during the Nevertheless, for the last 27 years, doctors shared decision-making requires close and and disruptive technologies, every member all medical and health professional asso- disproportionately affected, with particular war; in the last 25 years there were efforts without specialization were operating. The continuous communication between patients organisation could have the opportunity to ciations to closely work together and col- risks to sexual and gender based violence. to produce skilled healthcare workers to fill only available surgeons are practitioners; and doctors – at inter-personal level for im- participate in IAPOs programs and proj- laborate with patient organizations in their UNDP Human Development Report 2000 the gap, but the weak government and the operating rooms, equipment and special- proved individual care, as well as between ects thus improving the quality of patient respective countries. It is only through the ranked Somalia the lowest globally in all poor resource deployment is a huge chal- ized surgeons are a challenge Somaliland is their associated communities, in order to in- advocacy skills in our networks and involvement of patients and patient-doctor health indicators, except life expectancy. lenge as well as the retention of the skilled currently facing. Much is donated by either fluence policies for better access to and quality • Lastly, using this diverse global Governance synergies that we can have a comprehensive health-care workers in remote regions. charities or partner organizations for pro- of health care at wider population scale, while Board to develop innovative programmes, holistic health service delivery to all. According to the UNICEF MICS 2011 grams or as support to strengthening the ensuring respect and decent workplace for the projects and tools for our members that had and other surveys, Somaliland has some of Somaliland is among those countries faced general health system. medical profession. Therefore, collaboration a high reach and impact on healthcare. References the worst health indicators in the world: un- with a critical shortage of competent health between medical professional associations Today, IAPO movement has matured and 1. Hall JA, Roter DL, Rand CS: Communication der-five mortality 90/1000, infant mortality workforce (WHO, 2006), doctor-to-patient Hospitals have very few maintenance staff like the World Medical Association and pa- has come of age. Where in the past we were of affect between patient and physician. Journal 72/1000, neonatal mortality 35–48/1000, ratio as well as the number of other health- responsible for medical equipment. Main- of Health and Social Behavior 1981. tients’ alliances like the International Alliance excluded from the healthcare institutional, 2. Platt F, Keating K: Differences in physician maternal mortality ratio 1044/100,000 care workers being the lowest in the world. tenance staffs were very resourceful but did of Patients Organisations is a natural synergy legal, policy, practice and standards frame- and patient perceptions of uncomplicated UTI (MIS, 2006). Only 5% of children are fully WHO reports show 1 doctor per 30,000 not have formal training on medical equip- working towards the goal of more efficient, work, today we are feted to join them. We are symptom severity: understanding the communi- immunized by age 1, 26–37% of women are population, 1 nurse per 9000 population ment, nor did they have the resources (tools, better and safer care for all patients worldwide. valued because we bring special insight and cation gap. International journal of clinical practice married before age 18, use of effective con- and 1 midwife per 27000 women. engineering equipment or a functional The International Alliance of Patients’ Or- experience of healthcare and have developed 2007, 61(2):303-308. traception stands at 3%, skilled attendance workshop) to do their job. There are current- ganizations (IAPO) was founded in 1999, a considerable voice to reach out to the key 3. Bredart A, Bouleuc C, Dolbeault S: Doctor-pa- at delivery stands at 60-30% and 98% prev- In every post conflict setting there is ad- ly no training programmes for biomedical tient communication and satisfaction with care with the vision to see patients at the cen- healthcare decision-makers. This transfor- in oncology. Current opinion in oncology 2005, alence of FGM. aptation of alternative medicine or tradi- engineering personnel in Somaliland at any tre of healthcare and to help build patient- mation of an exclusory healthcare infrastruc- 17(4):351-354. tional healers. Traditional birth attendance skill level, from craftsperson to technician, centred healthcare worldwide . ture into a positive patient centric one has 4. Ha JF, Longnecker N: Doctor-patient communi- Limited access to primary health care, in- is caused by the disruptions of the health technologist or engineer. Thus, there seem to Our founders aspired that we should im- permeated all levels and institutions in many cation: a review. Ochsner Journal 2010, 10(1):38-43. adequate quality of service, poor hygiene, care services. Somali community prefers the be no qualified biomedical engineers work- prove the quality and standard of patient healthcare settings and systems. sanitation, and low supply levels are just traditional medicine and people first seek to ing full time in the country, let alone within advocacy globally by developing and em- Many WHO Member States are now wak- Ellos Lodzeni some of the factors which contribute to attend traditional healers, therefore it takes a the health system. One of the most skilled powering patient advocate leaders within ing up to the idea that they need the patients’ Governance, Health and Social these desperately poor health indicators. long time to phase out this traditional birth technical service providers in Somaliland is all patient organisations and healthcare sys- perspective and experience to make their Justice advocate and WHO Patient The human resource deficit in all regions is attendant at deliveries in the country with the lead technician for the largest laboratory tems. This was to be accomplished by: healthcare policy and services effective and for Patient Safety Champion. enormous. Acute and chronic skilled staff the highest maternal and neonatal deaths. equipment supplier in the country.

26 27 Health Care in Developing Countries Health Care in Developing Countries

One of the most important steps in laying Unfortunately, Somaliland has not yet op- There are opportunities to address these optimal economic production reflected in I would argue that the modern Ugandan as securing our lives as potential patients or the foundation of a functioning health sys- erationalized health sector regulation to gaps; Somaliland’s health system is young, our low-income (GDP). Doctor ought to actively participate in victims of road traffic accidents. tem was the establishment of Amoud Uni- include functions like the registration, li- it requires providing equitable, efficient and three aspects:First, report for duty, in time versity Medical Faculty in October 2000 censing and accreditation of health pro- affordable quality priority health services as Only a national health insurance scheme and actually attend to patients as our first Third, let us speak-up for our patients to ad- and later Hargeisa University Medical Fac- fessionals and institutions and programs close to the communities and families as pos- could come close to bridging this health- consideration due to Hippocratic Oath. A vise and call to action our decision makers ulty in 2004. The establishment of the Edna to properly protect the patients’ right to sible based on primary health care approach. financing gap and empowering the citizen doctor’s presence guarantees quality of care at various levels from health facility to Local Adan Nursing School and the opening of get quality health care. The unregulated to fight corruption in the health sector. This to Ugandans in immediate need, including Governments, Parliament and the Executive. Nursing & Midwifery Training Institutions nature of the health sector and the short- The policy makers’ involvement is crucial mechanism permits for solidarity that the children with severe malaria and mothers in This is in line with the utilitarian principle such as Hargeisa Institute of Health Sci- age of health professionals have created a to have a willing leadership to improve rich pay for the poor, the employed pay for obstructed labour. (greatest good for the greatest majority), and ences, Burao Institute of Health Sciences health system where an unknown number the quality of health care and increase the those not working (retired and children) and our Hippocratic Oath that “...the health of and Amoud Nursing School. The first group of persons work as unqualified “health pro- patient safety standards; this is to develop those who fall sick often are catered for by Secondly, take leadership and have operat- my patient shall be my first consideration...”. of locally trained doctors graduated in Au- fessionals” and proliferation of unregulated standard operating procedures for the qual- contributions from those who are healthy. By ing theatres in our Health Centres IV. Many gust 2007 from Amoud Medical School. healthcare facilities such as clinics, pharma- ity of care that includes checklists and rou- directly contributing to a national scheme doctors have shied away from our health With this three-pronged approach, Ugan- cies and medical laboratories and education tine/regular monitoring and training. Ugandans will be empowered to demand for system due to its weakness. Yet, strengthen- dan doctors will make a meaningful contri- Patient safety is not sufficiently taken into program for healthcare workers. This situa- quality of health care, less so in the current ing the health system is in our interest by bution towards the Universal Health Cov- account; theoretical understanding about tion has raised public safety concerns, and is Improving infrastructure and equipment, “free health care” regime (tokenism). promoting the practice of medicine as well erage of 2030. quality is good but the application is not a barrier to improving the quality of health surgical training residency specialization widely practiced. The existence of guidelines services. Furthermore, the emergence of the and anesthesia, health workforce plan adap- is limited and not readily available, reducing so called training program provided by un- tation and regulation are essential. Health Sector Reforms in Uganda, not yet Uhuru! the accessibility to knowledge about the ex- accredited institutions means that the coun- pected standards of care. Supervision from try continues to produce “graduates” whose Mariam Abdullahi Dahir Ugandan doctors have been engaged with British Medical Association was formed. However, is it yet Uhuru for the health ser- the hospital management and leadership is qualifications are currently unrecognized by MBBS, MPH making the state highlight the key policy con- Between 1918 and 1921, the BMA secured vices Ugandans are subjected to? Uhuru in limited, requiring capacity development and the government of Somaliland. Health systems specialist in cerns plaguing the health sector, with a par- major salary improvements to attract and re- Swahili means freedom from poverty of investment in their workforce. Somaliland Medical Association ticular focus on human capital. More recently, tain its members to practice in East Africa. self-determination. How many Ugandans this culminated into the 3-week countrywide Soon after, between 1930 and 1950 the doc- are increasingly impoverished by enormous doctors industrial action during November tors’ Association concerned itself with hos- costs for their medical care (catastrophic 2017. Indeed, the government of Uganda pital conditions and public health. Around health expenditure)? In the next paragraphs, The Right to Health; What is the Role of the responded positively by increasing the health the time Uganda gained independence, the I describe that there are three game chang- sector budget in the subsequent fiscal years struggle was for African doctors to be rec- ers the government could build on to realize Doctor in Uganda? 2018/19 and 2019/2020, specifically target- ognized as such and not Medical Assistants. the Universal Health Coverage especially to ing medicines and essential supplies via the The late Prof. Alex Mwa Odonga, in his the poor and very poor Ugandans. National Medical Stores by Uganda shillings book The First Fifty Years of Makerere Medical Health is wealth, and any nation worth poor, and social problems fall to a large ex- 138 billion (+60%), Uganda Blood Transfu- School and the Foundation of Scientific Medical First, the most effective intervention for its salt will provide for a healthy popula- tent within their jurisdiction...”. sion Services by Uganda shillings 21 billion Education in East Africa, recalls how African Uganda is to increase the money available tion for sustained economic productivity. (100%) and salary enhancement for all health doctors would travel to the United Kingdom for health services through the long awaited The right to health is enshrined in vari- When health fails, doctors are the ultimate workers by 30% to nearly 300% depend- to sit for examinations and return even be- national health insurance scheme. This in- ous international and Ugandan laws and “mechanics” who attempt to repair one’s ing on the cadre. Consequently, it is obvious fore the results were released as a sign of pa- surance scheme idea has stagnated for over instruments including our 1995 constitu- health. Indeed, we are privileged to serve even to the blindfold that the government triotism. Indeed, Makerere was the breeding 3 decades, appearing in over 3 presidential tion. However, beyond dry ink on paper Ugandans (and humanity) in this delicate has heavily invested in physical infrastructure ground for African doctors continent-wide. manifestos, since the time Uganda’s health what is our role as Doctors in guaranteeing space between disease, health and death and equipment, such as the numerous hospi- sector budget share was 3%. The budget of the common Ugandan citizen the right to which is God’s calling. We therefore are tals renovated or newly constructed: Kirrud- Overall, Uganda has come a long way and the health sector has not been responsive, health? no arrogant about it, rather take this role du, Naguru, Kawempe, Karamoja, Mubende, made significant achievements in key health stagnating between 7% and 9% for the past very seriously beyond diagnosis, prescribing Mityana, Masaka, Entebbe and the Mulago outcomes. The life expectancy at birth is decade, while that for roads has tripled to Doctors are the natural leaders in medi- medicines and care. Ekwaro A. Obuku complex with the new Cancer Institute and now at 60 years and above from below about 20% share of the national cake. The cal teams and principals in guiding society specialized one for Women in Mulago. 45 years due to the wrath of HIV/AIDS; ideology of a national health scheme is that about healthy living. To support this claim, Uganda’s public sector relies on a tax-based 15 pregnancy related deaths daily due to maternal deaths have dropped from above of solidarity in the sense that the rich pay one of our forefathers Dr. Carl Ludwig Vir- system that is undemocratic, inefficient and bleeding, high blood pressure or infection. John Iliffe, in his book East African Doctors, 500 to less than 350 per 100,000 live births, for the poor, the working class pays for the chow (1821–1902), who wrote about the excludes the very poor. The result is pre- Without effective health financing, Ugan- writes about doctors in Uganda conducting which is still very high; tremendous reduc- indigent, retired and children; whilst the Virchow’s triad of circulation, asserted, “... ventable deaths among the rural and poor dans, especially the very poor, will continue industrial action to better the health sector tions in child mortality with simultaneous healthy population pays for the sick. Most Physicians are the natural attorneys of the Ugandans due to malaria in children or in a state of poor health with resultant sub- since 1911 when the Uganda branch of the reduction of malaria in the recent past. of all, every citizen shares this ­collective

28 29 Health Care in Developing Countries One Health, One Planet

­responsibility further entrenching patrio- homegrown solution dealt a major blow guaranteed quality services. These data from tism whose curriculum would hardly be to the HIV/AIDS scourge. Ugandan doc- 5,600 absentee health workers suggest that Interview – Survival: One Health, One Planet, One Future – taught in formal classes. A prepayment tors have hardly been spared by the cancer the sheer scarcity of a robust health work- st scheme of this kind is inherently demo- epidemic to which we lost over 5 doctors in force is a bigger underlying problem for Routledge, 1 edition, 2019, by Daniele Dionisio PEAH – Policies for cratic as it improves the demand for quality the past year alone including our icon Dr. which we should invest as a country. With services and acceptability by the tax paying Margaret Mungherera who passed away on the new competitive salaries, Moroto Re- Equitable Access to Health citizenry. Indeed, it is such a scheme that the World Cancer Day, 4 February 2017. gional Referral Hospital that returned its would subsidize the service costs at the Consequently, the Uganda Medical As- wage bill for failure to attract 14 special- Re-published with permission from Dr . Daniele Dionisio, Member, European Parliament Working Group on Innovation, Access to newly commissioned Women Hospital in sociation initiated the Physician Wellness ists in 2017/18 is unlikely to the same this Medicines and Poverty-Related Diseases. http://www.peah.it/2019/10/interview-survival-one-health-one-planet-one-future-routledge-1st- Mulago that has generated uproar from the Programme for screening all medical doc- year as the Uganda Medical Association edition-2019 populace. tors for cancer and other diseases of life- has pledge to mobilize its members to fill George Lueddeke On this wavelength, style, as we lead by example. We are pleased up these posts. Chair, One Health Education Task Force what about the main The second game changer is Mr. Museveni’s that the government has purchased several Chair, international One Health for One purpose of Surviv- focus on health promotion and disease pre- radiotherapy machines that will be installed Lawrence Bossidy, a former chief executive Planet Education Initiative (1 HOPE) al: One Health, One vention. In September 2017, our 2nd Grande as soon as the bunkers at Mulago are com- of General Electric, could not emphasize One Health Commission and One Health Planet, One Future? Doctors Conference was held, the theme pleted. more the importance of human capital in Initiative was “promoting healthy lives”. The cost sav- his world famous quote “…nothing we do Consultant in Higher and Medical Education, Lueddeke: The book ings for disease prevention programmes are Third, solutions for human capital weak- is more important than hiring and develop- Southampton, UK tries to make sense unprecedented for low-income countries nesses in Uganda’s health system should be ing people. At the end of the day you bet on of the uncertain and like Uganda whose investment in health in sync with the progressive global strate- people, not on strategies…”. As a successful George R. Lueddeke PhD MEd Dipl.AVES tense (“rattling”) times mismatches the burden of diseases. Indeed, gies on human resources for health recom- revolutionary who shot himself to power, no (Hon.) is an educational advisor in higher we are experiencing and asserts that the One after the mass distribution of insecticide mended by the World Health Organization one understands the power of foot soldiers and medical education and chairs the global Health & Well-Being concept (OHWB) – treated mosquito nets, malariologists have and Global Health Workforce Alliance. The than our fountain of honor, the President. One Health Education Task Force for the that recognises the interdependencies among consistently documented that in some areas recent increase in salaries will definitely at- In this case, frontline health workers are the One Health Commission and the One Health humans, animals, plants and their shared en- in Uganda, such as Kampala, malaria has tract health workers to report early, report in Field Force Unit of the health sector! Let Initiative as well as the international One vironment – is critical to safeguarding our disappeared. Gone are the days that every hard to reach areas and remain productive at us strive to inspire them to be better civil Health for One Planet Education Initiative future while also providing a “unity around fever would likely be malaria. Certainly, the health facility. This move may comple- servants! (1 HOPE). He has published widely on educa- a common purpose” that seems to be miss- Mr. Museveni’s response to the epidemic ment the proposed biometric surveillance George Lueddeke tional transformation, innovation and leader- ing globally. I prefer the term One Health of non-communicable diseases is a game machines. However, where health worker Dr. Ekwaro A. Obuku ship and been invited as a plenary speaker to & Well-Being (vs just ‘One Health’) as it changer akin to the “ABC strategy” of the staffing is chronically low or with perennial President, Uganda Medical Association; Ways forward to ensure the sustainability of different corners of the world. Bio emphasises not only the crucial importance late 1980s and early 1990s when, in the shortage of medicines and limited access to Email: [email protected] people and the planet are needed at a time of human physical and mental well-being absence of antiretroviral therapy, Uganda’s medical technologies, Ugandans cannot be Website: www.uma.ug when the interdependencies among humans, PEAH: Dr. Lueddeke, the internation- but also the need to strive toward meeting animals, plants and the environment are al One Health for One Planet Education socioeconomic, geopolitical and ecological to be recognized as the cornerstone to drive/ (1 HOPE) initiative was created to address conditions to ensure the sustainability of all steer the UN 2030 Sustainable Development perhaps the most important social problem living species and the planet. Clean Indoor Air is Key office organizational meeting. My Green Goals (SDGs). In this connection, PEAH of our time:‘How to change the way hu- Doctor explains what to say and do at each had the pleasure to interview Dr George mans relate to the planet and each other to I also argue that the OHWB approach to Asthma Prevention meeting so there is nothing for the office Lueddeke as the author of the recently pub- ensure a more sustainable future to all life’. ought to drive/steer the 17 UN-2030 Sus- manager to study. Your patients will be im- lished cross-disciplinary book Survival: One tainable Development Goals (SDGs) that In most homes, the air inside is dirtier than There’s also a link to a free waiting room pressed! Ask your clinic manager to regis- Health, One Planet, One Future Rout- were agreed by all 193 Member States of the air outside, contributing to asthma and poster. ter: https://www.MyGreenDoctor.org. ledge, 1st edition, 2019. Including contri- the United Nations in September 2015. other pulmonary complaints. This month, butions from the World Bank, InterAction The main aim of the UN Global Goals is the WMA’s My Green Doctor program has My Green Doctor is a free membership If you are a leader in your national medi- Council, Chatham House, UNESCO, World to create ‘a more just, sustainable and peace- a short guide to help your patients improve benefit from the World Medical Associa- cal association, please add this message to Economic Forum, the Tripartite One Health ful world.’ The OHWB perspective needs indoor air quality, “Go Green at Home to tion that is saving members money as their your organization’s newsletter so that your collaboration (UN Food and Agriculture Or- to inform and encourage decision-makers Prevent Asthma and Breathing Problems”. offices adopt wise environmental practices members can enjoy this free membership ganization, World Organisation for Animal at all levels – especially Civil Society- to You might print copies to share with your and share these ideas with their patients. benefit. To receive this e-newsletter an- Health and World Health Organization), get behind the UN global initiative regard- office colleagues and for the waiting room: Hundreds of healthcare offices and clinics nouncement in a language other than Eng- One Health Commission and more - this less of ideological persuasion or divisions. https://www.mygreendoctor.org/go-green-at- of WMA members use My Green Doc- lish, simply contact My Green Doctor’s book cuts across sociopolitical, economic and The challenge is how to get government, home-to-prevent-asthma-breathing-­problems. tor. It adds just five minutes to each regular Editor: [email protected]. environmental lines ­business and civil society behind OHWB

30 31 One Health, One Planet One Health, One Planet

and the SDGs across all nations – those we relate to the planet and to one another shift – adopt a new worldview – to ensure society at large and that OHWB principles Lueddeke: Well, the UNSC was formed other disciplines, including medicine and that are more economically developed and and confronting how we use technology our needs as human beings are compatible and approach should underpin the UN- after WWII (1946) consisting of 5 per- environmental science, is public health. In those that are developing and of course for the benefit of both humankind and the with the needs of our outer world – our eco- 2030 Sustainable Development Goals. manent members (US, China, Russia, UK, Survival: One Health, One Planet, One Fu- those that are in disarray – many for rea- planet. How to translate theory into practice? system. Education is key in this regard as France), while in 2019, the most densely ture, George R. Lueddeke, the chair of the sons that defy logic. Concentrating on local are global/national/local policies and strate- populated regions with the greatest pov- One Health Education Task Force, shows needs guided by global/national priorities Lueddeke: Several years ago, Marco Lam- gies that underpin OHWB and the SDGs. erty and conflicts – Africa (c. 1.2 bill), India how public health can be incorporated into that are in keeping with sustainability val- bertini, executive director at WWF, made (c.1.3 bill), SE Asia (c. 600 mill), Middle a wide range of fields to address individual, ues and practices is without a doubt the best clear why there has to be a major societal Secondly, we must ensure that technology East (c. 400 mill) – c. 50 % [3.5 bill out of population, and ecosystem health…’With way forward. transformation. As one example, he ob- / AI is used only for peaceful purposes and c 7.7 bill] – are NOT permanently repre- respect to this, kindly let us know more. served that ‘in less than two human genera- in support of the health and well-being of sented. Shifting to regional (6) representa- There are about 7.7 billion people on the tions, population sizes of vertebrate species allspecies and the planet. The dangers of tion (vs countries) would clearly be in the Lueddeke: This quote appears in one of planet, and it is estimated that there will have dropped by half.’ Further, he reminded techno warfare and genetically engineered best interest of the world given the need for the on-line book reviews and comes from be over 9.8 billion by 2050 and 11.2 bil- us: ‘These are the living forms that consti- viruses are all too real and we must learn global accountability and sustainability. a World Economic Forum / Political Syn- lion in 2100. Climate change, urbanisation, tute the fabric of the ecosystems which sus- from history. The late physicist, Stephen dicate on-line article, “Economics can no pandemics, conflicts (globally we spend tain life on earth and the barometer of what Hawking, said it best ‘We are all different UNSC members should also be held glob- longer ignore the earth’s natural boundar- over US $7 trillion on war and only $ 3% we are doing to our planet, our only home.’ we all share the human spirit’ but ‘unless ally accountable by key stakeholders – gov- ies,” written by Erik Berglof at the London on peace-c. $6 billion!) and food security He also warned that ‘We ignore their de- crucial societal transformations occur, in- ernmnet, business, civil society – for their School of Economics. Three key messages are main issues we need to tackle now and cline at our peril.’ Echoing the book’s main cluding the prevention of nuclear war, glob- role in maintaining world peace and secu- are that 1) economists have treated inequal- feature in the book along with health care – theme, he also emphasised the need for al warming and genetically engineered vi- rity – based on a genuine commitment to ity too narrowly and that income dispari- perhaps prompting reconsideration of the ‘unity around a common cause,’ collabora- ruses – the shelf life of Homo sapiens could shared people and planet values. The ques- ties within countries are caused mainly by term “Public Health” and widening its re- tion, and leadership ‘to start thinking glob- be extremely short.’ tion is how can we achieve these ends when global financial forces rather than local mit to the more inclusive “Global Health ally and to stop behaving as if we have a The Propositions cut across socioeconomic, forces are pushing the world in the opposite labor-market conditions; 2) policies are and Well-Being” as the focus must shift to limitless world.’ The battle between technology and human- geopolitical and environmental lines. The direction. Surely, these decision-makers also required to make society more sustainable; ecocentrism. ity may yet become our greatest threat. As need for a paradigm shift and peaceful use have children and grand-children and would and 3) a new field of planetary social science In the intervening five years since the WWF we head further into a techno-driven so- of technology have already been mentioned. like to see them thrive in a better world is needed to bring together ‘different per- Changing the way we think and behave report was published, too few leaders – G7 ciety – age of quantum computers (where Others relate to migration, genuine col- where hopes and dreams can be realised. spectives, conceptual frameworks, and ana- should no longer be a question of why but (France, United States, United Kingdom, computations can be done in minutes vs laboration among government, business, lytical tools.’ He affirms that public health is how -although our main concerns continue Germany, Japan, Italy, Canada [ Russia 10,000 years on today’s supercomputers), civil society, and actively promoting ‘the PEAH: As for the range of key topics cov- closest to integrating other disciplines and to be political and economic rather than suspended] and E7 (emerging – China, In- there is a real danger that we become in- values of equality, democracy, tolerance and ered in the book? refers to Survival: One Health, One Planet, sustaining the planet. Populism, national- dia, Brazil, Mexico, Russia, Indonesia and creasingly dehumanised rather than as respect.’ The need for global discussion on One Future, and ‘how public health can be ism and isolationism are the antithesis of Turkey) have listened. Given the available Klaus Schwab, executive chair of the World these and other propositions seems essen- Lueddeke: This is my third book this decade incorporated into a wide range of fields to the paths toward which we ought to be evidence today (e.g., the UN biodiversity re- Economic Forum, aspired, that we refocus tial. The UN could be best placed to lead on and in a way represents a personal journey of address individual, population, and ecosys- striving. The root causes of these move- port published in May 2019!), there is now, on becoming ‘better humans.’ the initiative perhaps supported by higher discovery trying to understand the world and tem health.’ ments need to be investigated and solutions unquestionably, a pressing need to re-orient education institutions (universities, colleges, healthcare – first from a more narrow human- found that ensure global equity, peace and society towards a sustainable future. The PEAH: Summarised in *Ten Propositions etc) of which there are about 26,000 im- centric medical education perspective (Medi- Survival concludes with a discussion on the sustainability. It may be important to re- challenge is to shift our perspective from for Global Sustainability*(Ch. 12), the vol- pacting on the lives of millions. cal Education for the 21st Century), moving leadership role that Generation Z – those – mind global decision-makers that if we fail two-dimensional to three-dimensional, ‘or- ume calls for the One Health and Well- to the wider public health horizon and rec- the ‘fixers’ born in the mid 90s – need to to save the planet none of the other human bital’ thinking, as NASA International Space Being concept to become the cornerstone To raise awareness across education systems ognizing the limitations of my assumptions play in the decades that lie ahead . They activities will matter. Shelley’s poem Ozy- Station astronaut Col Ron Garan contends of our educational systems and societal in- and communities, the One Health Educa- (Global Population Health &Well-Being in are becoming the face of the planet and are mandias (1818) comes to mind. I am also –‘bringing to the forefront the long-term stitutions – helping to create – in keeping tion Task Force along with a global plan- the 21st Century) to pulling various strands much more tolerant of others and thrive on reminded of a quote by economist and au- and global effects of every decision.’ with the UN 2030 Global Goals – a more ning teamare evolving an international One together in Survival: One Health, One Plan- collaboration. Recalling the eloquent words thor John Kenneth Galbraith – ‘A nuclear “just, sustainable and peaceful world.” Can Health for One Planet Education Initiative et, One Future. I don’t think I could have of civil rights leader Martin Luther King Jr, war does not defend a country and it does PEAH: Relevantly, you maintain in the you detail about the Propositions in their (1 HOPE). Anyone interested in joining a written the latter without the former. The Gen Z are certainly far from silent ‘about not defend a system …not even the most book that two fundamental changes are connection with the One Health and Well- working group can sign up https://tinyurl. new publication is really a building block of things that matter.’ Their voices must be accomplished ideologue will be able to tell necessary if we – and all other species – are Being concept? com/y2ux5b5g personal knowledge acquisition tinged by heard across the globe as their future de- the difference between the ashes of capital- to survive in the coming decades. Tell us personal and professional experience in Can- pends on decisions we make today! ism and the ashes of communism.’ more, please, around these changes. Lueddeke: Two of the main recommenda- PEAH: Proposition 10, inter alia, focuses ada and the UK plus other countries. tions of Survival is that the One Health on reforming the UN Security Council es- PEAH: Your insightful answers best en- PEAH: The book highlights two of our Lueddeke: In terms of sustainability we are & Well-Being concept should become the tablished right after WWII (1946).What PEAH: As reported ‘…The sub-discipline hance the book. So compounded, the vol- greatest social problems: changing the way challenged to make a fundamental mind- cornerstone of our educational systems and does this mean? that has perhaps come closest to integrating ume is of great interest to policy-makers,

32 33 Digital Transformation Initiatives Digital Transformation Initiatives

multi-professional practitioners, academics, kind is part of something bigger, then the world Head of the research project Policies for by members [7]. The survey revealed than Box 1: Digital developments in the public sector students across all disciplines and concerned will be a better place. Our natural world is not Equitable Access to Health (PEAH). more than seventy-five percent (75%) of the members of the general public – especially there to provide us with unlimited resources… Former Director, Infectious Disease respondents did not have the app installed. Year Digital developments the younger generation – in both developed it really is time to start learning to respect it. Division, Pistoia Hospital, Pistoia (Italy). • Aviro launched their innovative eHealth app. and developing nations. For many reviewers Thank you George R. Lueddeke for being a http://www.peah.it/ Some of the reasons given for not using the • North West department of health outlines eHealth plans (RHIS). to date, your book is indeed a wake-up call voice of reason in a world of chaos!’ https://twitter.com/DanieleDionisio app were: • Cell – Life’s iDART hits the target. which needs to be heard “loud and clear” https://www.linkedin.com/in/ • Lack of awareness about the app; • Tier.Net, the software application that monitors patients on HIV and TB th 2014 globally. Posted on28 October 2019 da niele-dionisio-67032053 • The app is complex; treatment. Author Daniele Dionisio http://www.peah.it/spontaneous- • No reason to use the app; • The NDoH has issued a tender for a service provider to conduct an evaluation Just echoing a recent endorsement by Tracy Advisor, “Medicines for the Developing article-submissions/ • Does not meet my needs. of the use of the Tier.Net software. Collins, founder at The Island Retreat, County Countries”​, SIMIT (Italian Society for https://www.facebook.com/ • NDoH sets out eHealth standards evaluation process. Cork, Ireland ‘… When we accept that human- Infectious and Tropical Diseases). PEAH51/?modal=admin_todo_tour Digital disruption has great potential in • The Mpumalanga DoH issues eHealth tender. healthcare. The main areas of investments • eHealth rollout high on Gauteng’s agenda. are certainly Big Data analytics and AI (Ar- • Mobenzi has partnered with the Anova Health Institute to support the tificial Intelligence). Some of the Big Data Limpopo (DoH) with the deployment of Mobenzi mHealth technology. 2015 Digital Transformation In Healthcare – South African Context analytics tools are useful for improving ef- • eMocha launches TB mHealth platform in South Africa. ficiencies, where some of the tools can be • NDoH is working with the CSIR to develop an eHealth system to accompany using the convenience of one’s office or ogy. For example, there are schemes that automated. This could potentially yield bet- the rollout of NHI. home. are already implementing digital applica- ter utilization of human resources and could • North West DoH announce eHealth pilot. tion forms for smooth onboarding of new potentially create huge cost savings. In the The recent HPCSA1 conference included members. This is with the aim of going main, Big Data and AI tools are used to pro- • eMocha Boosting MDR-TB linkage to care in South Africa. topics such as Telemedicine’s where several digital and reduce paper application forms. file clients, medical service providers and to • eMocha’s miLINC for MDR-TB mHealth platform was designed after the digital transformations and innovations in Similarly, the submission of claims of which look at healthcare utilization patterns and NDoH approached Johns Hopkins University. the health sector were presented. What was more than ninety-eight (98%) are submit- trends. Some of the techniques such as pre- 2016 • The Human Research Science Council (HSRC) has announced the evident in the discussions was that prog- ted in electronic form has transformed dictive analytics are important; in that they development of a new mHealth app aimed specifically at pregnant teens. ress in accelerating digital transformation claims significantly. Strategies such as digi- can be used, not only to profile members but • NDoH using eHealth to improve health facilities. is hampered by the slow pace of regulation tal marketing are typically used to reach the also to create a strategy to combat attrition. • South Africa adopts WHO’s HIV ‘Test and Treat’ guidelines. and other relevant guidelines. The topics target market and to communicate more Insights from the data could be useful for • mHealth aiding in the diagnoses of burn injuries. discussed clearly revealed that the health effectively with members. Several schemes data-driven decision-making processes that • Generic and Biosimilar Medicine of Southern Africa has asked the South sector is still far behind, compared with have invested a lot in product development, could potentially save huge downstream African government to accelerate the evaluation and the registration of more other countries. For example, there is a gap such as mobile apps, and by developing costs for medical schemes. There is also great affordable biosimilar medicines in South Africa. 2017 in the adoption of digitally enabled tools communication channels through online potential in investing in digital marketing • South African medical information-exchange company, Healthbridge, has for diagnosing, providing treatment, and and social media platforms. Social media and in the optimal use of mobile apps. announced their acquisition of Infosys Software Solutions’ Healthcare division. better management of chronic and other platforms provide an opportunity for brand • WHO and ITU to use eHealth to strengthen health services in Africa. Michael Mncedisi Willie conditions. Electronic medical records are repositioning. They also provide an oppor- • South Africa digital health accelerator attracts top eHealth start-ups. still not a part of routine care, both from tunity to reach a new target market and gain Digital Transformation • The National Department of Health (NDoH) has identified IT and health Digital transformation is growing at a slow the supply and the funders side, except for a access to a larger pool potential client base. Initiatives In The Public information systems (HIS). rate in medical schemes and healthcare handful of players. Social media platforms could also be used as Sector – In South • The South African Medical Research Council (SAMRC) has partnered with when compared with other industries such a tool to improve services to clients, create Jembi Health Systems NPC. as banking and insurance. The healthcare On the funders’ side, you do find several convenience and provide instant interaction African Healthcare • Philips and UJ renew MoU to empower healthcare professionals. 2 2018 sector needs to embrace the digital trans- medical schemes that invest in technol- with clients. However, very few medical • Digital Health Cape Town have announced the commencement of their formation and adopt and optimize the use schemes optimize on these platforms; par- There are several innovations that must take second accelerator programme. of technology. Otherwise, the sector will ticularly small to medium schemes. There place in the public sector in South Africa 1 The Health Professions Council of South Africa • A new mobile app, called ViaOpta Hello, has been unveiled, to help hundreds be left behind. Other sectors have taken is still a need to measure the value add of as far as digital transformation is concerned. is a statutory regulator of healthcare professions of thousands of South African living with blindness and severe visual advantage of technology; typically, in the in South Africa. digital transformation to members; chiefly Chiefly, these are still at beta phases and impairment. retail sector; nowadays consumers shop where the quality of care is concerned. their overall impact and outcomes are still 2 Medical schemes are non-profit organisations • A subsidiary of CompuGroup Medical SE has developed an e-scripting so- online, bank, and do travel bookings on- to be realized. Furthermore, there are pock- which are registered with the Registrar of Medi- lution that is helping over 1,000 South African doctors to ensure medication line. The logistics business has also em- A recent study was conducted by Wil- ets of digital innovations in the public sec- 2019 cal Schemes. Members belonging to a scheme adherence among their patients. braced digital transformation in that most make contributions and in return, receive medical lie, which was an unstructured survey on tor dating back to 2014. Some are ­initiatives • Aviro Health launches whatsapp channel to support HIV self-testing. activities are now done through devices cover according to the rules of the scheme. the use of medical scheme mobile apps employed at provincial level, while others

34 35 Digital Transformation Initiatives Digital Transformation Initiatives

are deployed at the national level. An in- Box 2: Applications of AI- select list The C-section rate in South Africa is tegrated holistic approach at the national higher than the WHO’s recommendation level could ascertain value added and im- Medical Diagnosis at about twenty-six percent (26%) [1]. In pact in the sector. Box 1 below depicts the AI systems can analyse far more data far faster than humans, which may make them the private sector, the C-section rate is Department of Health’s (DoH) digital and more adept at identifying medical diagnoses than doctors. three (3) times higher when compared to eHealth developments and implementation Neurology the national rate at more than seventy- from 2014. Neurological healthcare deals with nervous systems disorders such as Parkinson’s disease, seven percent (77%), which is significantly Alzheimer’s disease, epilepsy, stroke, and multiple sclerosis. AI can also predict strokes higher than the recommended rate [2]. The and monitor seizure frequency. recommended rate of Caesarean sections is The Use of Artificial Pathology Images around ten to fifteen percent (10% -15%) Intelligence in Healthcare Most diagnoses depend on a pathology result, so a pathology report’s accuracy can make of all births. A study by Manyeh argued the difference between diagnosis and misdiagnosis. that the increase in the C-section rate in Artificial Intelligence (AI), Machine Radiology Tools developing countries has not been clinical- Learning (ML) and Big Data analytics are Various forms of radiology, such as CT scans, MRIs and X-rays provide healthcare pro- ly justified and that these increasing trends some of the most talked-about technologies viders with an inside view of a patient’s body. However, different radiology experts and have become a major health issue, due to in recent years. According to Bali, Garg, doctors tend to interpret such images differently. potential maternal and perinatal risks, in- and Bali, AI aims to mimic human cogni- Smart Devices equality of access and the costs involved tive functions, such as the ability to reason, Hospitals are big purchasers of smart devices. The devices, which take the form of tablets [3]. discover meaning, generalize, or learn from and hospital equipment, exist in intensive care units (ICUs), emergency rooms, surgeries experience [9]. and regular hospital rooms. Waste and inefficiency occur at every level in a health care system; waste also includes Popular AI techniques include machine Source: [11] unnecessary procedures done on patients. learning methods for structured data, such Other examples include instances where as the classical support vector machine and These improvements can improve efficien- similar countries, South Africa spends nine repeat tests on the same patients are done neural network, and the modern deep learn- cies in identifying medical diagnoses better percent (9%) of its GDP on healthcare, by several providers but billed separately. ing; as well as natural language processing than doctors. It should be noted that AI can- which is four percent (4%) higher than This could be avoided if the various medi- 3 Figure 1 . Caesarean sections by country for unstructured data [10]. Machine learn- not completely replace the medical profes- the WHO ’s recommended spending for cal providers in the value chain could ac- ing is the foundation of modern AI and it sion, but it could be used as a tool to optimize a country of its socioeconomic status [5]. Source: [11] cess the same patient records for clinical is essentially an algorithm that allows com- current processes, reach medical conclusions Furthermore, South Africa has one of the decision-making. Thus, there is value in puters to learn independently without fol- and aid with decision-making factors, thus highest government health spending per investing in a healthcare delivery model lowing any explicit programming [6]. saving costs and improving quality of life. person [12], particularly the private health that is not fragmented and encourages care sector. According to the Competition Com- co-ordination. The use of AI is already at advanced stages in missioner (CC), private hospital admission other industries. Its adoption in healthcare is Applications of Artificial rates in South Africa are higher compared According to Albejaidi and Nair, failures growing at a steady rate; however, there is no Intelligence to most OECD countries, partially proce- of care co-ordination typically occur when doubt that AI is certainly going to change dures such as arthroplasty, tonsillectomy patients experience care that is fragmented the face of healthcare delivery. AI is being Artificial Intelligence has the potential to and caesarean section [13]. The over-utili- [4]. Other examples include poorly man- employed in numerous settings; for example, change the healthcare industry in South Af- zation of healthcare services is also cited as aged care co-ordination which may result funders, as well as administrators, use it to rica for the better. This is subject to its opti- one of the cost drivers in the health sector, in a patient being referred from one health adjudicate and to process claims and hospi- mal use in both the supply and demand side which ultimately impacts the premiums care setting to another. Figure 2 below de- tal facilities for assessing bed occupancy. of the health care ecosystem. AI is delivering paid by the members. Providing lower levels picts various categories of waste, as defined high value, including the following areas: of or faulty care to patients also results in by Albejaidi and Nair [4]. AI is also used to analyses unstructured data wasteful expenditure from the funders’ side. such as images, videos, and physicians’ notes Other examples of possible waste include One of the highlighted categories which are to enable clinical decision-making and in- Overutilization, Waste and medically unnecessary caesarean sections frequently prevalent in an uncoordinated formation sharing. Other commentators Abuse of Medical Services (C-section) or imaging. health system is typically where patients’ such as argued that AI is more prevent in records are not stored in a central secure the area of medical diagnosis. AI systems The South African private health sector data repository. As a result, duplication of 3 The Health Professions Council of South Africa Figure 2 . Various categories of waste in health care can analyse huge volumes of data faster and expenditure is viewed as one of the most is a statutory regulator of healthcare professions services, tests and procedures are done more far better than humans [8]. expensive models, when compared to other in South Africa. Source: [4] frequently than is clinically necessary.

36 37 Health Care in Developing Countries Health Care in Developing Countries

References 663; ERSA: Cape Town, South Africa, 2017; pp. www.businessnewsdaily.com/15096-artificial- in high quality for everyone across coun- cial care sector. The review was designed to particular, organizational or system-level 1. World Health Organization: Monitoring emer- 1–28. intelligence-in-healthcare.html tries [3]. give a rapid assessment on existing research, interventions or programmes. 6. Adam C. Uzialko. Artificial Intelligence Will 11. Lisa Morgan.Artificial Intelligence in Health- gency obstetric care: a handbook. 2009. and focused specifically on decent work in- 2. Council for Medical Schemes. CMS Annual Change Healthcare as We Know It. 2019. Availa- care: How AI Shapes Medicine. 2019. Avail- Report 2018-2019, 2019, www.medicalschemes. ble at: https://www.businessnewsdaily.com/15096- able at https://www.datamation.com/artificial- The active engagement of young people is cluding equal opportunities and treatment com/Publications.aspx. artificial-intelligence-in-healthcare.html intelligence/artificial-intelligence-in-healthcare. imperative to achieve Sustainable Develop- in employment, safe work environments Proposed Solutions 3. Alfred Kwesi Manyeh, Alberta Amu, David 7. Willie M.M, Optimal Use of Telemedicine by html ment Goals (SDGs). In 2019, more than and social security/adequate earnings. In Etsey Akpakli, John Williams & Margaret Medical Schemes to Manage Chronic Condi- 12. Micah AE, Chen CS, Zlavog BS, et al.Trends 3.8 billion people (49% of the world popu- addition, gender equality was included as a The challenges facing youth in the health and drivers of overnment health spending in Gyapong. Socioeconomic and demographic fac- tions and Educate Beneficiaries. HPCSA Na- lation) are under the age of 24 years, and 2.4 cross-cutting theme [8]. workforce are significant. Closing the pre- tional Conference 18 – 20 August 2019. Emper- sub-Saharan Africa, 1995–2015 BMJ Global tors associated with caesarean section delivery billion (32%) are between the ages of 10- dicted 18 million health worker gap [9] in Southern Ghana: evidence from INDEPTH ors Palace, Ekurhuleni, Gauteng. 2019. Health 2019.10.25 Network member site. BMC Pregnancy and 8. Loh, E. Medicine and the rise of the robots: a 13. South African Competition Commission. 24 [4]. The distribution of this youth bulge There were a number of pertinent findings by 2030 will require significant and stra- Childbirth volume 18, Article number: 405 qualitative review of recent advances of artificial Health Market Inquiry. FINAL FINDINGS is especially important, with nine out of ten from the review, shedding new light on tegic youth-responsive investments at the (2018). intelligence in healthBMJ Leader 2018;2:59-63. AND RECOMMENDATIONS REPORT. young people live in low and middle income youth employment in the health workforce. national, regional, and local levels. Firstly, 4. Albejaidi and Nair, American International 9. Bali, J., Garg, R., Bali, R.T. Artificial intelligence Pretoria: Competition Commission; 2019. countries [5]. While a youth bulge is often In terms of equal opportunities and treat- ensuring decent conditions for work and Journal of Research in Humanities, Arts and (AI) in healthcare and biomedical research: Why seen as a challenge, it also creates an oppor- ment, a number of barriers were identified study is essential to recruit and retain youth Social Sciences, 18(1), March-May 2017, pp. a strong computational/AI bioethics framework 01-09. is required? Indian J Ophthalmol. 2019; 67:3-6. Michael Mncedisi Willie, tunity for a demographic dividend, a relative that influenced youth occupational deci- into the health and social care sectors. This 5. Bidzha, L.., Greyling, T., Mahabir, J. Has South 10. Jiang, F., Jiang, Y., Zhi, H., et al. Artificial in- General Manager Research & Monitoring, myriad of working-age people which could sions, including issues of work-life balance, includes addressing financial hardship as Africa’ s Investment in Public Health Care Im- telligence in healthcare: past, present and future Council for Medical Schemes, South Africa lead to higher productivity, positive impact inadequate mentorship and occupational a significant factor for early attrition and proved Health Outcomes? ERSA Work. Paper. Stroke and Vascular Neurology 2017. https:// E-mail: [email protected] on economic growth, political stability and segregation. Experiences of gender (and migration of young health workers. Sec- social and sustainable development. How- other) stereotyping, bias, discrimination and ondly, interventions, employment strategies ever, the ability of countries in harnessing violence in the health and social care work- and policies for young workers must use demographic dividend depends on their force begin in training programmes and are gender-transformative and intersectional Youth in the Health and Social Care Sector, challenges and investment in the workforce, particularly in experienced with staggering prevalence by approaches to ensure equitable impact and youth. Investing in quality education, decent young and newly qualified workers. Find- reach. This includes widening the youth opportunities employment opportunities and health and ings on safe work environments revealed health workforce research agenda to high- wellbeing of young people, will enable them higher rates of burnout for young health light the issues in low- and middle-income to develop skills and values that positively workers and students, and alarmingly high countries where shortage of health workers, contribute to economic growth and sustain- rates of violence including verbal, psycho- higher disease burden, higher youth unem- able development of their community [6]. logical, physical and sexual violence. Social ployment rates, and the largest population security and adequate earnings emerged as of youth reside. All of the above solutions The Global Health Workforce Network an important determinant of youth wellbe- must take a health systems approach that (GHWN) Youth Hub, established in 2017, ing in the health workforce, with students includes organizational interventions, not aims to promote youth engagement in the and new graduates across professions often only individual interventions targeting health workforce agenda, strengthen data carrying large debts from their training. youth workers. Lastly, meaningful youth en- and evidence on education and youth em- gagement mechanisms must exist at local, ployment issues in health and social care The review also revealed significant research regional, national and global level on decent and facilitate inter-professional collabora- gaps in the topic of youth in the health work agendas, including both programme tion to address these. The Youth Hub was workforce. The literature identified was not planning and policy-making. Students and created by the World Health Organiza- sufficiently diverse to give an assessment of early career professionals need to be at the tion (WHO), as an intersectoral, inter- the challenges faced globally. Existing liter- decision-making table for effective policy- professional community of practice to drive ature is focused on high-income countries, making on human resources for health. youth-inclusive policy locally, nationally, and largely on health disciplines such as regionally and globally. nursing and medicine as opposed to social Charlotte O’Leary Sherly Meilianti Behrouz Nezafat Maldonado work and other allied health, community Conclusions health workers, and other social care occu- Findings from the pations. The vast majority of the literature Meaningful youth engagement is required Background/introduction worldwide to achieve a better and sus- health coverage (UHC), and provide ac- Youth Hub paper retrieved described, analysed and explored to achieve Sustainable Development Goals tainable future for all [1]. Goal 3, “Good cess to safe and effective medicines and the challenges present for youth and decent (SDGs). Ensuring decent working condi- The Sustainable Development Goals health and well-being”, aims to ensure vaccines for all. UHC aims to leave no one This paper describes findings from the rapid work in the context of the health and social tions is essential to recruit and retain youth (SDGs), established by the United Nation healthy lives and promote well-being at all behind and ensure that health services are review [7] conducted by the Youth Hub on care sector; there was less focus on solu- into the health and social care sector. Barri- (UN), aim to address global challenges ages [2]. It also aims to achieve universal available, accessible, acceptable and served youth and decent work in the health and so- tions, interventions and best practices – in ers to retention and factors that lead to mi-

38 39 Health Care in Developing Countries Memorandum of Tokyo

gration of young health workers should be 2. United Nations Sustainable Development network/YouthPaper-PS-SR_23May2019.pdf identified and considered by policy makers (2019). Goal 3 .:. Sustainable Development [Accessed 12 Oct. 2019]. Knowledge Platform. [online] Available at: htt- 8. International Labour Organization (2019). De- Memorandum of Tokyo on Universal Health Coverage and the through youth engagement. ps://sustainabledevelopment.un.org/sdg3 [Ac- cent work. [online] Available at: https://www. cessed 12 Oct. 2019]. ilo.org/global/topics/decent-work/lang--en/in- Medical Profession The findings from the rapid review will be 3. World Health Organization (2019). Universal dex.htm [Accessed 21 Oct. 2019]. used to advance youth-responsive work- health coverage (UHC). [online] Available at: 9. World Health Organization (2019). Call to ac- Health Professional Meeting (H20), June 14th, 2019, Tokyo force action and support the substantive https://www.who.int/news-room/fact-sheets/ tion: Addressing the 18 Million Health Worker Shortfall [online] Available at: https://www. work of the Youth Hub. Effective and detail/universal-health-coverage-(uhc) [Ac- cessed 12 Oct. 2019]. who.int/hrh/news/2019/call-to-action-address- strategic youth-inclusive policies will have 4. World Bank (2019). Health, Nutrition and ing18million-health-worker-shortfall.pdf?ua=1 At the Health Professional Meeting (H20) 2019 in Tokyo, the and attractive working and living conditions for those who provide sustainable effects on Sustainable Develop- Population Data and Statistics, World Bank. [Accessed 20 Oct. 2019]. World Medical Association and the Japan Medical Association healthcare to their communities and patients. ment targets. Not only will these policies [online] Datatopics.worldbank.org. Available at: welcome the efforts by the World Health Organization, national support the challenges facing global health http://datatopics.worldbank.org/health/popula- governments, intergovernmental and United Nations agencies as The WMA encourages physicians and their associations in all parts today, but they will also yield impact far into tion [Accessed 12 Oct. 2019].. Charlotte O’Leary, well as other organizations to foster the development of healthcare of this world to play a profound role in the advocacy for and the 5. Gupta, M. D. (2014). The Power of 18 Billion: the future for youth and for the health of Youth Hub, Global Health Workforce systems providing Universal Health Coverage (UHC). realization of UHC. Adolescents, Youth, and the Transformation of populations. the Future. The State of World Population. Network; Monash University, Australia 6. United Nations Youth (2019). Youth and the We notice that UHC means ”that all people and communities can From the side of the medical profession, there should be no hesi- 2030 Agenda for Sustainable Development | Sherly Meilianti, use the promotive, preventive, curative, rehabilitative and palliative tancy in embracing the concept of UHC, including a strong engage- References United Nations For Youth. [online] Available at: Youth Hub, Global Health Workforce health services they need, of sufficient quality to be effective, while ment for the development of quality primary care as the core part of 1. United Nations Sustainable Development https://www.un.org/development/desa/youth/ Network; University College London, UK also ensuring that the use of these services does not expose the user a comprehensive health system. world-youth-report/wyr2018.html. [Accessed (2019). About the Sustainable Development to financial hardship.” (WHO definition of UHC) Goals - United Nations Sustainable Develop- 12 Oct. 2019]. ment. [online] Available at: https://www.un.org/ 7. World Health Organization (2019). Youth and Behrouz Nezafat Maldonado, We welcome the recent attention that G20 Finance Ministers give sustainabledevelopment/sustainable-develop- decent work in the health and social care sector Youth Hub, Global Health Workforce UHC is a tool to overcome inequities in the health systems them- to the development of UHC as a contribution “to human capital ment-goals/ [Accessed 12 Oct. 2019]. [online] Available at: https://www.who.int/hrh/ Network, Oxford University hospitals, UK selves. development, sustainable and inclusive growth and development, and prevention, detection and response to health emergencies, such UHC is for people, but also by people. as pandemics and anti-microbial resistance, in developing coun- tries.” Human resources for healthcare in many countries are scarce. We urge all in responsible positions to invest in the education and reten- We express our expectation to the G20 Summit that this inspires tion of health professionals to make UHC possible. the way to improved and sustainable investments in healthcare sys- tem not only in G20 countries but also and most importantly in This must include quality education, opportunities for continu- other economies, which still invest insufficiently in their healthcare ing professional development and most important safe, dignifying systems, irrespective of the reasons for such shortfalls.

40 iii General Assembly Report

215th WMA Council Session, Porto 2020 Sheraton Porto Hotel & Spa, Portugal

IV