The Global Health Workforce Alliance ¦ News from WHO and part
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This Week's News 18-22 April 2011 Weekly news clippings service featuring articles on the Global Health Workforce Alliance and selection of articles from around the world on the issue of the health workforce crisis The Global Health Workforce Alliance ¦ News from WHO and partners ¦ Africa & Middle East ¦ Asia & Pacific ¦ North America ¦ Europe ¦ Latin America & Caribbean This compilation is for your information only and should not be redistributed Global Health Workforce Alliance Date Headline Publication 21.04.11 Merlin in Liberia: influx of refugees from Côte d'Ivoire puts added pressure on health services The Alliance News from WHO and partners Date Headline Publication 07.04.11 Linking Up to Use Health Information for Improving Health Outcomes Capacity Plus Investing in health for Africa: The case for strengthening systems for better health outcomes 04.11 19.04.11 Celebrating the Essential Work of Midwives Partnership on Maternal, Newborn and Child Health/WHO. UNFPA 13.04.11 AMREF’s New Partnership with Open University AMREF Africa & Middle East Date Headline Publication 15.04.11 African Ministers of Finance to Improve Investments in Health 18.04.11 SUDAN: Lack of justice "entrenching impunity" in Darfur Africa Science News UN IRIN 14.04.11 FG to review residency training Nigerian Tribune 18.04.11 A Strong Health Care Has Made an Enormous Difference (Editorial) The New Times, Rwanda 19.04.11 Cote d'Ivoire: UN Health Team Travels to Western Côte d'Ivoire to Review Medical Needs UN News Service 13.04.11 Inside the Accra Psychiatric Hospital 18.04.11 Tragedy of baby deaths The Chronicle, Ghana Times Live, SA 1 21.04.11 Public sector nurses demand higher salaries The Jordan Times Asia & Pacific Date Headline Publication 17.04.11 PMA criticises evening classes proposal 14.04.11 Spending reforms vital for saving health insurance program: experts DAWN.com, Pakistan Focus Taiwan News Channel 15.04.11 Shunning Hippocrates 15.04.11 Birth pains 19.04.11 Emergency care 'immobilised' 19.04.11 Discourage treatment in abroad: NMA 19.04.11 Taiwan Medical Mission awarded for providing medical aid in Africa 16.04.11 Mental illness putting stress on hospitals 19.04.11 How can the decline in the rural health workforce be stopped? Thanh Nien News, Vietnam The Standard, Hong Kong Mid Day, India The Himalayan Times, Nepal China Post The West Australian The Age, AU North America Date Headline Publication 14.04.11 Foreign-trained doctors kept out of practice in US PRI’s The World 15.04.11 How patients can help doctors practice better, less costly medicine 14.04.11 Hungarian Doctors Seek Fortune Abroad 18.04.11 Doctors could learn something about medical handoffs from the Navy The Washington Post The Wall Street Journal Los Angeles Times 20.04.11 Doctor tells Putin of Russia’s medical shortcomings 18.04.11 Health reform may boost medical office building market 19.04.11 Aging corps of midwives poses shortage 14.04.11 Public review urged into intimidation of ER doctors 17.04.11 Who cares for the caregivers? The Washington Post American Medical News Boston Herald Edmonton Journal, CA The Province, CA Europe Date Headline Publication 14.04.11 Stillbirths: the professional organisations' perspective The Lancet, UK 16.04.11 Shershah Syed: improving maternal care in Pakistan The Lancet, UK 20.04.11 Community Health – Fashion or Function? ISN ETH-Zurich 19.04.11 How the government's immigration cap squashes the NHS The Guardian, UK 17.04.11 Impoverished Afghans shouldering burden of health care Reuters 18.04.11 HSE says up to 400 junior doctor posts may be vacant Irish Times 21.04.11 NHS children's care at risk through lack of well-qualified doctors and nurses The Guardian, UK 2 14.04.11 Israeli doctors cancel elective surgery in dispute over pay 15.04.11 Dans les déserts médicaux, les retraités restent actifs British Medical Journal Le Monde, France 16.04.11 La huida de enfermeras catalanas al extranjero crece el 70% en un año El Periódico de Catalunya, Spain Latin America & Caribbean Date Headline Publication 13.04.11 Faltan especialistas para atender adultos mayores La Capital, Mexico 14.04.11 Limitada atención a pacientes con VIH en Honduras 18.04.11 Los médicos bonaerenses aceptaron “en disconformidad” un aumento del 29% La Prensa, Honduras Clarín, Argentina 19.04.11 Una nueva escala salarial ayudará a que la Amazonía tenga más médicos especialistas Andes, Ecuador 15.04.11 Piden aumento para los médicos rurales 20.04.11 CSS se queda sin insumos médicos 15.04.11 Federación Médica expresa su apoyo a enfermeros 20.04.11 Make HIV part of mainstream health system - study El Siglo de Durango, Mexico La Estrella, Panamá El Impulso.com, Venezuela Demerara Waves, Guyana Global Health Workforce Alliance Merlin in Liberia: influx of refugees from Côte d'Ivoire puts added pressure on health services The Alliance 21/04/2011 The number of refugees from Côte d'Ivoire crossing the border to Liberia is growing steadily, adding to the country's struggle to recover from over a decade of civil war and rebuild its health services. The large number of refugees escaping violence in their home country are in need of food, shelter and emergency medical assistance. Alliance member Merlin has been active in Liberia since 1997, assisting the Ministry of Health and Social Welfare in renovating health facilities, supplying medicine and equipment and training and supervising health workers to strengthen the country's healthcare system. Merlin's communications officer Lotte Deckers Dowber has recently travelled to Liberia and reported on her blog about the critical situation facing the refugees. Read Lotte's blog Back to top News from WHO and partners 1 Linking Up to Use Health Information for Improving Health Outcomes Capacity Plus 07/04/2011 Dr. Alvin Marcelo, director of the University of the Philippines Manila National Telehealth Center, will present CapacityPlus’s iHRIS Manage software to the country’s secretary of health at a “Connectathon” on April 12. iHRIS Manage is designed for managing the health workforce—a Ministry of Health, district health office, or health care facility can use it to manage and analyze information about employed health workers and applicants. It is part of the larger iHRIS Suite of Open Source software that supplies health sector leaders with information to track, manage, and plan the health workforce. Since the software is Open Source, it can be downloaded for free and customized for specific country contexts. The National Telehealth Center and the Department of Health will cohost the Connectathon. Dr. Marcelo and others will demonstrate to the Secretary established and forthcoming Open Source health applications for use in government health care facilities around the country. They will show how these applications—such as OpenMRS, DHIS2, iHRIS, and a Community Health Information Tracking System developed by the University—can work together to produce aggregated health information that national health leaders can use to address health concerns and improve health outcomes. 3 As one example, Dr. Marcelo will show district disease prevalence statistics (from DHIS2) alongside the number and skill mix of health workers for the same district (from iHRIS Manage). He hopes the event will encourage the Secretary to support open standards and invest in building the capacity of staff at the Department of Health to implement and use the various systems. Related items: · · · Building Local Capacity in Health Worker Information Systems New Translation Option Supports Country Use of Health Workforce Software iHRIS Manage: A Tool for Managing the Health Workforce 2 Investing in health for Africa: The case for strengthening systems for better health outcomes Partnership on Maternal, Newborn and Child Health/WHO April 2011 Published by: Harmonization for Health in Africa: consisting of WHO, World Bank, UNFPA, USAID, UNICEF, UNAIDS, JICA, the African Development Bank, in collaboration with the Partnership for Maternal, Newborn and Child Health, “Investing in Health for Africa” argues that Africa’s current economic growth can be improved if concerted efforts are made to improve the continent’s health care systems. The Report says investing in the African health sector could help save millions of lives and prevent life-long disabilities. At the same time, investments in health would accelerate the move towards attaining the U.N. Millennium Development Goals (MDGs). To promote increased and improved health investment, the Africa Investment Case is developed by the Harmonization for Health in Africa to: i. ii. iii. iv. support African leaders, and their regional and global partners focus their attention and resources on health investment that works, provide an evidence base for Ministries of Health to make the case to Ministries of Finance, national Parliaments, and other key stakeholders that investing in health makes economic sense and will bring considerable returns promote value for money by demonstrating how the effciency with which existing and new resources are deployed in the health system can be increased through priority- setting processes based on demographic trends and the burden of disease, and to mobilize leadership at the national, regional, and global levels to support national health systems in Africa in their efforts to increase the pace and sustainability of achieving better health and economic development outcomes for the people of Africa “Healthier is wealthier,” says the 51-page report. “In addition to the fact that there’s an intrinsic value of health and that health is a human right, the economic case for investing is robust.” According to experts, improved healthcare is essential for sustainable development. Healthy citizens are more productive, earn more, consume more and work longer, all of which have a positive impact on the Gross Domestic Product (GDP) of a country. “Better health also reduces the financial costs of health care for the family, the community, the private sector and the government.” The report notes that an average additional spending in Sub-Saharan Africa of US$21-36 could in 2015 alone save over 3 million lives, 90% of which would be women and children and generate US$100 billion in economic benefits. Recent findings on the impact of health – as measured by life expectancy – on economic growth, suggest that one extra year of life raises GDP by 4%. The Report also points to the need for more efficient health spending. The study also notes that mechanisms need to be put in place to pool risks and ensure a more equitable approach to health, better manage health financing (i.e. results based financing) and promote crosssectoral initiatives and programs among others. Download the full report: Investing in health for Africa pdf, 31.72Mb Executive Summary pdf, 3.98Mb Related documents LINK to the press release: African Ministers of Finance commit to improving investments in health Link to the report: AU and ECA Ministers adopt a health resolution 2010 Africa Health Financing Scorecard pdf, 376kb Report of the Committee of Experts pdf, 235kb Draft report of Panel Session 2: Health financing in Africa pdf, 249kb 4 3 Celebrating the Essential Work of Midwives UNFPA 19/04/2011 From time immemorial, women have helped other women through the dangerous passage of childbirth. Today, equipped with medical skills, medicines, equipment and knowledge, trained midwives can save nearly all women who experience complications of delivery – or make timely referrals to a higher level of care. But midwives deliver more than babies, as a new multimedia presentation from UNFPA makes clear. They support babies through those first vulnerable hours out of the womb. They help mothers and fathers become parents. Often they are women’s first contact with the health sector, and deliver a range of primary health care interventions, including family planning counselling and supplies. The critical role of midwives in the challenge to save the lives of mothers and newborns is also the theme of a major report that will be launched at the Triennial Conference of the International Confederation of Midwives in June of this year. The State of World Midwifery, which will be the first of its kind, aims to strengthen midwifery, in part, by providing new information and data gathered from 60 countries in all regions of the world to: examine the number and distribution of health professionals involved in the delivery of midwifery services explore emerging issues related to education, regulation, professional associations, policies and external aid analyse global issues regarding health personnel with midwifery skills, most of whom are women, and the constraints and challenges that they face in their lives and work call for accelerating investments for scaling up midwifery services, as well as “skilling up” the respective providers. The report will include statistical tables and applicable global standards, collating relevant midwifery information. The world currently faces a shortage of some 350,000 midwives, which results in the needless deaths of hundreds of thousands infants and women each year. 4 AMREF’s New Partnership with Open University AMREF 13/04/2011 AMREF is pleased to announce a new and exciting partnership with the Open University (UK). Africa has a serious shortage of health workers and many have little or no formal training; yet, they are the ‘front line’ of health care across Africa. Recognising a mutual belief that empowered, well-trained and well-supported health workers (including doctors, nurses, clinical officers, midwives, and community health workers) are critical to the development and success of African health systems, AMREF and the Open University will soon be embarking on a partnership to train health workers through distance learning. The partnership was formed after recognising the common goals and ambitions of AMREF and the OU: AMREF, Africa’s leading health development organisation, provides training for health workers in 33 African countries, equipping them with the necessary skills to address their countries’ biggest health issues; from HIV/AIDS, to antenatal care, malaria, waterborne diseases, cervical cancer to cleft palate repair. Committed to providing the best, most relevant service possible, AMREF is an expert in curricula and Human Resources for Health (HRH) development. Using an array of training methods; from classroom-based, to print-based distance learning courses to eLearning and online trainings, AMREF brings training opportunities to those who need it the most. Open University is a world leader in modern distance learning and has recently launched the Health Education and Training (HEAT) programme in Africa. This ambitious programme aims to train 250,000 Community Health Workers (CHW) over the next five years through providing distance learning modules to increase their skills and capabilities. The HEAT programme is now piloting in Ethiopia, but is ready to be taken to other African countries, and has the flexibility and potential to be adapted for use by midwives, doctors, nurses, and other health workers. Recognising this shared commitment to increasing Human Resources for Health (HRH) in Africa, through this new partnership AMREF and OU will share experience and expertise, working together to develop, implement and manage distance training programmes for mid-level and community health workers. AMREF and OU will collaborate in submitting applications for joint funding, build partnerships with organisations with similar goals, and work together to roll out OU’s HEAT programme beyond Ethiopia. 5 “We believe that this collaboration will take AMREF’s innovative e-learning, m-learning and broader distance learning interventions further afield in Africa”, says Peter Ngatia, AMREF’s Director of Capacity Building. “We hope to dramatically assist in the global effort to scale-up training of Human Resources for Health to ensure countries have the right numbers and competencies required for quality health delivery and attainment of the Millennium Development Goals.” More about AMREF's work training health workers across Africa More about Open University's Health Education and Training (HEAT) programme Back to top Africa & Middle East 1 African Ministers of Finance to Improve Investments in Health Africa Science News 15/04/2011 Written by Henry Neondo African Ministers of Finance, Planning and Economic Development have recently reaffirmed the continent’s desire to boost health spending to 15% of national budgets as envisioned by the 2010 Head of State Declaration on Maternal, Infant and Child Health and Development. Making the agreement at a recent joint conference of African Union ministers of finance, planning and economic affairs, and the U.N. Economic Commission for Africa, held in Addis Ababa,Ethiopia, the ministers noted that the importance of investing in human development broadly and health more specifically was a prerequisite for sustainable and equitable development. In line with the 2000 Abuja commitment, only 6 countries out of 52 in a continent with 11% of the world’s population, have achieved the 15% target. According to the 2010 health financing scorecard created by the Africa Public Health Alliance and 15%+ Campaign, only six countries, Rwanda, 18.8%, Botswana, 17.8%, Niger, 17.8%, Malawi, 17.1%, Zambia, 16.4% and Burkina Faso, 15.8% are spending at least 15% of their national budgets on health . Additionally, 32 out of 53 AU member states invest less than half of WHO recommended $40 per person. 11 of these countries are invest a mere $5 or less per capita. Sub-Saharan Africa accounts for 53% of maternal deaths, 50% of under-five child deaths and 67% of HIV/Aids cases. Experts attribute the current weak health systems to insufficient and inefficient health spending among most African countries. They lament that only 32 out of the 53 African countries invest less than the WHO-recommended US$40 per person on health. Poor social and physical infrastructure, political crises, lack of partner alignment in their health and development assistance efforts and poor regional production capacity also contribute to suboptimal health of populations. At a special parallel session for health and finance ministers, African Union Commissioner for Social Affairs, Bience Gawanas said “Africa’s wealth is its people… Human development is a crucial component of economic growth and development, and we must invest in the health of our populations”. UNAIDS, Executive Secretary, Michel Sidibe said “95% of Africans receiving treatment for HIV/AIDS on the continent are receiving those treatments because of donor support. It is important for Africa to increase its investments in health to ensure that we able to care for our own, especially now in light of the financial crises and other constraints faced by donor countries.” Essimi Menye Lazare, the Minister of Finance of Cameroon, said “while we recognize the importance of investing in health, we must ensure that health spending is efficient. To this end institutions have a role to play in promoting regional capacity to produce drugs and commodities and/or reducing the price of commodities to countries by facilitating economies of scale and increasing bargaining power.” Rotimi Sankore, the coordinator of the Africa Public Health Alliance and 15+ Campaign, notes that “currently health financing trends on the continent are worrisome. He says: “Even in many countries where per capita investment is higher, performance is poor because of inadequate investment in key social determinants such as clean water and in some countries where percentage based on spending is high, actual per capita investment is low.” 6 While it is crucial for health investment to increase, officials say it is important to ensure that this increase is efficient and anchored on evidence based health planning accompanied by equally important investments in the social determinants of health. “Without clean water and sanitation among others, efforts to improve health are compromised,” says Sankore. Africa’s current economic growth can be improved if concerted efforts are made to improve the continent’s health care systems, a new study reveals. Recent findings on the impact of health – as measured by life expectancy – on economic growth, suggest that one extra year of life raises GDP by 4%. The 2010 World Health report notes that globally between 20 and 40% of health system spending is wasted with poorer countries wasting an even higher proportion. While the WHO recommends a minimum of 2.3 doctors per 1000 people to achieve 80% skilled attendance at delivery, Sub-Saharan Africa is grossly understaffed at 1.15 health workers per 1000. This shortage of health workers is compounded by issues of quality, motivation and distribution. There are 61 countries with a critical shortage of healthcare workers – 41 of them in Africa. Niger only has one health worker for every 6,000 people, Sierra Leone has one for every 5,000. By comparison, in the UK there is one health worker for every 119 people The United Nations Secretary General’s Global Strategy for Women’s and Children’s Health notes that an additional 2.5 to 3.5 million health workers will be needed to achieve millennium development goals 4 and 5 in the 49 low income countries (33 of which are in Africa). A recently published Save the Children report entitled Missing Midwives notes that a global shortage of 350 000 midwives contributes to poor health outcomes for many women and children. A report entitled The State of the World’s Midwifery – developed by 21 partners – will be launched in June 2011 at the International Confederation of Midwives Triennial Congress and will provide an overview of the state of midwifery in countries. Some countries in the region have focused on health workforce, as a means of improving their health outcomes. In Ethiopia where 85% of the population lives in rural areas and has traditionally been underserved, the Ministry implemented a Health Extension Programme aiming to train 30,000 new Health Extension Workers (HEWs) to work at local health posts and to provide a package of essential interventions to meet needs at this level. While 18 African countries that committed to the Global Strategy in September 2010 accounted over US$8.5 billion, 11 of these countries made specific commitments related to increasing and improving their health workforce, for instance Rwanda committed to train five times more midwives (increasing the current ratio from 1/100,000 to 1/20,000). 2 SUDAN: Lack of justice "entrenching impunity" in Darfur UN IRIN 18/04/2011 NAIROBI, 18 April 2011 (IRIN) - Aid workers have raised serious concerns about the deteriorating humanitarian situation in Sudan's troubled Darfur region where, they say, a prevailing climate of impunity has often resulted in humanitarians being killed, injured, abducted or car-jacked. "There have been very few successful investigations of criminality against aid agencies, and understandably this has only encouraged greater caution and aversion to risk in the conduct of humanitarian activities," Aly Verjee, senior researcher at Rift Valley Institute, told IRIN. As a result, humanitarian space has been affected as organizations do only what is most necessary, for fear that anything more will increase the danger to staff, risk damaging ongoing essential activities and signal to the authorities unwelcome ambitions to do more, Verjee added. The latest incident against aid workers was resolved on 13 April when the African Union-UN Mission in Darfur (UNAMID), the UN Office for the Coordination of Humanitarian Affairs (OCHA) and camp leaders successfully mediated the release of 12 Sudanese aid workers who had been taken hostage by a youth group at Kalma camp for the internally displaced in South Darfur. The aid workers had been conducting a vaccination campaign and were taken hostage in retaliation for the arrest, four days earlier, of an IDP who worked for a national NGO. "We cannot understand whether crimes against UN and NGO workers are orchestrated to reduce the range of our activities or if they are a result of banditry and getting concessions from whoever wishes to pay," a UN worker, who requested anonymity, told IRIN. "However, the lack of prosecution indirectly leads to a further 7 reduction of humanitarian space, which is already quite small in Darfur due to government's imposed security restrictions to conflict-affected areas. "We are afraid if we push into areas we are not allowed to reach we could be targeted. But if the level of risk for humanitarian security becomes too high, how long can we resist till we are forced to withdraw?" Impossible choices Abby Stoddard, co-author of the 2009 study, Providing Aid in Insecure Environments, notes that "aid workers in the most dangerous settings face few options. In places like Sudan [Darfur], Somalia and Afghanistan, the choice boils down to reducing or withdrawing essential aid from needy populations, or running intolerable risks to the lives of staff and partners." According to the study, attacks have increased sharply since 2006 and Sudan, Afghanistan, Somalia, Sri Lanka, Chad, Iraq and Pakistan top the list of the most violent contexts for aid work. An OCHA report published on 12 April 2011, To Stay and Deliver, highlights Darfur as "hosting numerous and fragmented armed non-state actors and criminal bands that operate with impunity in parts of the vast region beyond the reach of any official or security presence". However, despite being ranked second in the Aid Worker Security Database's incident statistics against aid workers between 2005 and 2010, UNAMID sources said attacks against staff declined in 2010, compared with 2009. This year, some 16 UNAMID peacekeepers have been killed and at least 80 injured. Since March 2009, armed groups in Darfur have kidnapped 30 aid workers, all of whom have been released, with the exception of three Bulgarian air crew, contracted by the UN World Food Programme and seized in January 2011. "NGOs have their own security system but fall under the UN security management system, which means that if they request assistance by UN security, the UN will always provide support," said a UN staffer, who requested anonymity. To maintain their neutrality and not be associated with the peacekeeping mission, he said, NGOs often chose not to request support from the UN and prefer to handle kidnappings and other crimes against their staff themselves. Government under pressure In a statement on 28 January, the US-based Human Rights Watch (HRW) called on UNAMID to put pressure on the government of Sudan to guarantee the security of peacekeepers and civilians. Jehanne Henry, HRW's senior researcher on Sudan, told IRIN the issue of impunity was entrenched and unrelenting in Darfur. "Despite the government appointing a new special prosecutor to deal with crimes in Darfur, the protection system remains weak and the immunity of people in position of power continues to be problematic." Abdel-Dayem Zumrawi, the special attorney for Darfur crimes appointed by the Sudanese in October 2010, stepped aside recently after two years of service. At a news conference on 27 December 2010, Zumrawi said "efforts to serve justice in the war-torn western region have been overshadowed by the political situation in the country". Henry said: "If Khartoum wants to convince the people of Darfur of its commitment to lasting peace and reconciliation, there must be a credible threat of prosecution for those who are implicated in the crimes committed against the people of Darfur. "There is a sentiment among many in Darfur that there is no accountability for any act, and that those connected to power can get away with anything," she said. See Graphic: http://www.irinnews.org/Report.aspx?ReportID=92511 3 FG to review residency training Nigerian Tribune 14/04/2011 For the first time in 32years, the Federal Government is set to review the residency training programme as the ministerial committee on the review of residency training programme submits report to the Minister of Health, Professor Onyebuchi Chukwu. Receiving the report, the Health minister noted that the present administration has been very responsible to the various concerns of health workers, and urged the health professionals to refrain from the incessant strike actions. He said government had demonstrated its commitment to the welfare of workers; they also should appreciate such gesture by putting the interest of the country first. by using strikes as the last as weapon of resort. 8 He noted that the Federal Government was not relenting in its effort to reposition the healthcare delivery system, urging that incessant strike will erode the confidence of the public on the sector. While acknowledging the problems of the tertiary healthcare system in the country, he said that government was not leaving anything to chance to ensure that Nigeria had a robust programme for tertiary health system. Earlier in his remark, the chairman of the committee, Professor Rowland Ndoma-Egba, hinted that any programme not subjected to review was bound to lose its relevance and objectives. He noted that the decay in the country’s healthcare system, saying that the health indices are unacceptable. He urged that urgent steps be taken to address the situation. He said that if a lot of efforts were geared towards correcting anomalies in the sector, a lot of the Millennium Development Goals would be achieved. He said that the committee has recommended what government should do to improve the residency training programme to enable the doctors get the requisite training to meet international standard. While thanking the minister for giving him the opportunity to serve on the Committee, he also thanked him for addressing the challenges confronting the health sector and urged the ministry to take the report very seriously. 4 A Strong Health Care Has Made an Enormous Difference (Editorial) The New Times, Rwanda 18/04/2011 The ministry of health has, on several occasions, made it clear that the increase in premiums for the community-baesd health insurance scheme - Mutuelle de Sante - is to ensure delivery of quality health care. With over 90 percent of the population covered under the health insurance scheme, Mutuelle de Sante is among the most successful programs within the health sector, that have that drastically improved the lives of the Rwandan people. The health care system, has proved that, even with minimal contributions, the difference made in the well being of the citizens is enormous. Indeed, there are many more including the mobile phone initiative where community health workers are provided with cell phones that enable them to offer better quality health care, to Rwandans, especially in the rural areas. With the phones, the community health workers communicate with medical experts who in turn follow up on patients in a timely manner. As a result, Rwandans now live healthy lives and within the last couple of years, the national life expectancy has risen from 48 to 52 years of age. Additionally, there is no doubt that a healthy population is a wealthy one. Over the last 17 years, Rwanda has had to reconstruct from scratch and its population is key to achieving the development goals. Access to health care is a fundamental right which the government of Rwanda is evidently upholding. 5 Cote d'Ivoire: UN Health Team Travels to Western Côte d'Ivoire to Review Medical Needs UN News Service 19/04/2011 A team of United Nations health experts have visited western Côte d'Ivoire in an effort to identify what needs to be done to improve access to health services, which were severely disrupted by the post-election conflict. The Moyen Cavally region was one of the worst affected areas with only 10 of 44 health centres now open and providing limited services, the UN World Health Organization (WHO) reported today, adding that all surgeons and gynaecologists fled, as well as most general practitioners and specialized nurses. "Those who stayed have not received salaries for three months," Tarik Jasarevic, WHO spokesperson, told reporters in Geneva. "In the districts of Touslepleu and Blolequin, all health facilities have been looted and destroyed," he added. The treatment of patients who require surgery has become difficult because two of four district hospitals remain closed and the other two have no sufficient capacity and lack ambulances, Mr. Jasarevic said. "Patients were left to find their own means of transportation for travelling to the nearest functioning referral structure, sometimes hundreds of kilometres away," he added. 9 He said that the WHO team had also visited the Catholic mission in the town of Duékoué, where more than 27,000 people who had fled from violence found refuge. Hygiene and sanitation conditions have deteriorated in the overcrowded compound, putting the internally displaced persons at risk of disease outbreaks, he said. Mr. Jasarevic said WHO and its partners have so far received only 28 per cent of the $6.5 million requested to address the health needs of those affected by the crisis inside Côte d'Ivoire and neighbouring countries. 6 Inside the Accra Psychiatric Hospital The Chronicle, Ghana 13/04/2011 Helena Selby Mental health in Ghana is one thing the government does not really give priority to. It seems to be content with the situation in the psychiatric hospitals in the country, despite the insurmountable problems they face. Even though the state of mind of every country's citizens has a reflection on its economic productivity, there still seems to be no attention for them on the side of the government. If the research of the World Health Organisation's (WHO) official figures indicates that about 10% of Ghanaians suffer from mental disorder, then mental health is an issue worth looking into by the government. As the poor people with mental illness in the developing countries have a higher risk of being deprived of life's chances, then Ghana, being a developing country, must give priority to its psychiatric hospitals to have a safe future, and if any step needs to be taken, then the Accra Psychiatric Hospital should be their first and foremost step toward the upgrading of mental health hospitals. Psychiatric hospitals in Ghana The Accra Psychiatric Hospital is about 100 years old and obviously, one of the oldest mental hospitals in Ghana. Its long years of existence has however, not caught the attention of the various government who come and go out of power since the regime of the first President, Osagyefo Dr. Kwame Nkrumah. The lack of innovation and attention has resulted in this hospital being rated as one of the worst in the country. The Director, Dr. Akwasi Osei, might be doing his best to turn things around however, the reluctance of the government, even to pass the mental health bill, makes it evident that the government, in every way, is not very much bothered about the wellbeing of the inmates, making the Director's efforts invisible. According to research, more than two million of Ghana's population fall within the category of mental illness and need urgent attention. The number might be a disbelief for many people, however, it must be put into consideration that these mentally ill people are spread throughout the regions of the country, as some are left on the streets, other find themselves in prayer camps, shrines, herbalists, and the rest in psychiatric hospitals. A psychiatric hospital, for many Ghanaians, is one of the trusted ways of treating mental illness, apart from the medication being free. In Ghana, research indicates that there used to be about 11 psychiatric hospitals, but unfortunately, the number has gradually reduced to three, which can be found in the Greater Accra, Eastern and Central regions. Among these three hospitals, the Accra Psychiatric Hospital is in the worst state, and ironically has the most number of patients. Inside the wards A visit by this reporter into the ward indeed, proved how dearly the hospital needs help. It was a hospital though, with beds, nurses, a few doctors to attend to the inmates, and cleaners to clean the place. Some sections looked like a hospital, and others looked so different, way below the likeness of a hospital. The hospital has about 22 wards, but only a few looked like wards in a hospital. The outlook of the rest, indeed, proved that the inmates were being taken advantage of by the government; it shows how extremely they are exempted from the sharing of the national cake. Surely, the medication is free, but the atmosphere and most parts of the environment don't look free enough, considering the situation of these inmates, the environment and atmosphere create a kind of cage, coupled with the lack of freedom for these inmates. Most of these wards, despite the fact that the hospital is a clinic, look almost exactly like the normal situations of the mentally ill people on the streets, the difference being that in the clinic they are fed, given medication and sometimes, given a bath. Their place of abode is very unfavorable, in the sense that it might even hinder the progress of their recovery. They sleep in wards which look like a wide open public bath house, which according to the nurse, during the night, takes about 100 inmates per room when they are using their mats. According to him, the lack of wards has compelled the hospital's administration to convert some of the bathrooms into wards. The wards have canals into which the inmates urinate into during the night. The number of inmates in the wards, and the number who urinate into the canal, makes the place really stinky, even after being scrubbed with antiseptics or disinfectant. All the inmates are told to sit outside during the day, with no enough recreation or sheds to sit under. Some choose to have a nap, sometimes on the bare floor; those whose cases are fresh, and find it difficult to do the right thing, choose to sit in the scorching sun in the ward, until a nurse comes to tells them to leave. During the visit of this reporter, the female rehabilitation ward, which has 17 beds, had 15 patients at that time, and according to the nurses in that ward, the high level of congestion has made the hospital to receive all 10 stages of mental health patients in that ward. In admission Ward 1, there are 17 beds but 130 patients, in Ward E, there are 14 beds 106 patients, in Ward C, 25 beds 100 patients. According to the nurses, those without beds or mats sleep on the bare floor, exposing them to the risk of getting pneumonia. The situation become worse during the rainy season, apart from them getting a conducive place to stay, when it rains during the day, they also have to face the trauma of sleeping in wards with broken windows through which mosquitoes invade the place. The Occupational Therapy Department After thorough treatment and therapy by the hospital, patients who seem to be getting better are referred to the Occupational Therapy Department (OT Department). In this department, patients learn all sorts of craft and vocations to enable them take care of themselves and not become a burden to the family or the society, when discharged. Patients, who already have an idea of craft and other vocations, are helped to better them, in order not to forget their skills. The existing craft and vocations in the hospital at the moment include carpentry, tailoring, ceramics and cane weaving. One of the main ideas behind the creation of this department is to help patients stay focused and not misbehave. As good as this project sounds, during the visit of this reporter to the hospital, this department seemed to be non-functional, as the only part which seemed functional was the carpentry section, which at that moment, had only 12 patients. The cane weaving section had almost collapsed due to the lack of raw material, the tailoring department was so pathetic, in the sense that not only was the room extremely congested, but also the section had only two tailoring machines to teach patients who are referred there. As for the ceramics section, thanks to Mr. Jojo Peter Abdullah, a product of the University of Ghana, Legon and an inmate who has almost recovered, is making use of his talent. It is his creative skills and talent which has beautified the ceramic section. According to the nurse, who took this reporter around the arts of Mr. Abdullah, his works are sometimes sold and he is given 10% of the amount for his efforts. He said the OT Department has about 50 patients, however, since there is not enough material to use to teach them, most of the inmates resort to the playing of games to occupy their minds. Apart from the playing of games, some of the patients sometimes go to the library to read, however, it is a shame that the library does not exist anymore, and there seems to be no trace of it coming back to life again. At certain points too, patients occupy themselves in group therapy or therapeutic community, that is they gather themselves in groups to share their problems, give advice to each other, and sometimes, they even have discussions about their medication. The OT Department helps patients recover quickly to face life once again, but due to the lack of enough material the teachers find it difficult to teach, resulting in the department deteriorating daily. Challenges of the hospital Disclosing one reason for the congestion in the male ward, the nurse noted that inmates brought by the police with a court order, are abandoned in the hospital. He said inmates brought by court order are supposed to stay in the clinic between to two weeks to six months at most, but the refusal of the police to go for feedback about the condition of the inmates, and the inefficiency of the country's system, makes the inmates stay in the hospital for between 7 to 20 years, hence making the place overcrowded, since the number increases almost every day. The hospital does not have the facilities to separate the wild inmates from the calm ones, so they end up mixing them up, and one is only locked alone in a room when he becomes too aggressive and violent. The hospital has the problem of insufficient water suppy, and not enough food to feed the inmates. Most of the nurses complained that they always have to write a memo to the authorities before they get water. Apart from this problem they face, they as well have problems locating the families of patients once their treatment is over. It is unfortunate that some relatives, due to reasons known to themselves, do not come to visit their wards once they are put on admission, or even come for them when they have been discharged. The hospital, therefore, refers them to the Department of Social Welfare to find their families, as most families who do not want to be stigmatised by society give wrong addresses to the hospital, making it difficult locating them when the patient is fine, however, if the patient is able to remember the whereabouts of his family, then the hospital allows him to go home by himself. Conclusion It has always been the dream of many stakeholders on the mental health bill that once the bill is passed into a law, situations in the mental health will change for the better, however, looking at how severe the situation is in the Accra Psychiatric Hospital, one can hardly tell how things will change for the better when the bill is enacted into law. 7 Tragedy of baby deaths Times Live, SA 18/04/2011 In response to a question in the National Council of Provinces last week, Health Minister Aaron Motsoaledi said there was a severe shortage of "highly trained paediatricians, advanced midwives and highly trained paediatric nurses". "We do not have many of these in many of our hospitals," he said. Motsoaledi admitted that the percentage of vacant nursing posts filled in each province was "very bad". 11 The worst-performing province was Eastern Cape, where less than 40% of an unspecified number of vacancies had been filled. The best-performing province was the Free State, where almost 89% of vacant posts had been filled. "Eastern Cape is suffering because of a lack of funds and I'm going to have to sit down and discuss this [with the provincial health department]," Motsoaledi said. But he said the department had filled more than 3000 nursing posts in Limpopo since February . The shortage of skilled midwives has contributed to South Africa's failure in meeting the UN's fourth Millennium Development Goal - reducing child mortality. Statistics released last week by The Lancet, the UK medical journal, show that every day more than 61 babies are stillborn and 58 die shortly after birth. Motsoaledi admitted that maternal and infant mortality rates "are so high that we can say they are starting to be out of control". Dr Joy Lawn, of Save the Children, said that district hospitals were the biggest culprits in respect of "avoidable" stillbirths because many of their nurses were unskilled or negligent. South Africa ranks 148th of 193 countries for its still-birth rate. It is in 10th position in Africa. Motsoaledi told the National Council of Provinces on Thursday that more than 1.1million babies were delivered at public hospitals each year but that "most of the skilled personnel . are in the private sector in much more larger numbers than in the public sector". "I am aware that, due to statements made in the media, many . believe that there are individual health workers who are going all out to negligently cause the death of babies." He said that negligence would be investigated by the Health Professions' Council. Motsoaledi said yesterday that training more midwives was part of his plan to tackle the staff shortage. 10 Public sector nurses demand higher salaries The Jordan Times 21/04/2011 By Mohammad Ben Hussein AMMAN - A group of public sector nurses on Wednesday gathered outside the Prime Ministry, demanding higher salaries. The Jordan Nurses and Midwives Association (JNMA) also sent a letter to Prime Minister Marouf Bakhit listing their demands and urging the government to respond quickly, according to JNMA President Khalid Abu Azizeh, who was among the protesters. “We are here to make our voice heard. The promises we received are not enough. We need action. Nurses are pioneers in the field of medical services and they must be treated better,” he said on the sidelines of the protest. In their letter to the government, the nurses detailed their demands for better pay as well as an amendment to administrative regulations governing the work of public sector nurses, Abu Azizeh said “Nurses are not only underpaid, they are also badly treated in terms of promotion or transfer from one institution to another,” he told The Jordan Times. The protesters stood silently for half an hour at the Fourth Circle, holding banners which called for a salary increase and justice for nurses. “Although this sit-in coincides with other strikes and protests in Jordan, our demands are not new. We have been suffering for years,” said Yasser Ahmed, a staff nurse at Al Bashir Hospital. He blamed the government for the shortage of Jordanian nurses. “Most hospitals resort to bringing Asians or other nationals to fill vacancies, because the pay is good for them, but not for Jordanians who want to start families,” he told The Jordan Times. In a previous statement, Abu Azizeh said nurses working in the public sector start with a basic salary of JD350 if they are employed through the Civil Service Bureau, and JD250 if they are hired on a contract basis. The government has promised to look into the demands of nurses and other medics, including public sector doctors and dentists, who are currently on strike. 12 Minister of Health Yassin Husban has criticised the related associations, noting that their actions are prompted by election concerns. "We met with all associations… and supported their demands for improved financial benefits, but they cannot expect the government to approve a package of JD40 million overnight," he told The Jordan Times earlier this week. Back to top Asia & Pacific 1 PMA criticises evening classes proposal DAWN.com, Pakistan 17/04/2011 LAHORE, April 17: The Pakistan Medical Association (PMA) has condemned a proposal forwarded by the Pakistan Medical and Dental Council (PMDC) to President Asif Ali Zardari regarding launching of evening shifts in the public and private medical colleges of the country. In a press release issued here on Sunday, the PMA has termed the proposal an attempt by some influential PMDC office-bearers to please the owners of the private medical colleges. PMA office-bearers Dr Mirza Ali Azhar, Dr Ashraf Nizami, Dr Akhtar Rashid, Dr Tanveer Anwar, Dr Izhar Chaudhry, Dr Shahid Malik, and Dr Salman Kazmi have threatened to launch a strong agitation if the PMDC did not withdraw the proposal. “PMA and medical educationists are in a state of shock that how a person no less than the president of the country can take such an impracticable idea seriously,” they said in a joint statement, adding that it seemed the president had been misguided by a group with vested interest. Dr Salman Kazmi said at the moment there were 108 public and private medical colleges in the country and at least more than a dozen others were in the pipeline. Each medical college was producing more than 100 doctors every year that meant on an average 15,000 doctors were being churned out annually, he said. “So it is not the matter of shortage of doctors which is compelling our policy makers to adopt a strategy which, if adopted, will further deteriorate medical education in the country that was already sub-standard,” Dr Kazmi said. He emphasised the need to focus on quality of healthcare in medical institutions instead of the number of doctors. As far as the quality of medical education in the existing medical colleges was concerned, it was far below the standards set by the PMDC, he added. “Not even one medical college in the country fulfills the criteria of a complete medical faculty,” Dr Kazmi claimed. He said even teachers of basic medical sciences were not available to teach the students. Regarding the clinical training of the doctors, he said, according to the PMDC regulations, every 500-bed hospital was required to be attached with a teaching institution, which was not the case with most of the medical colleges. Terming it an unrealistic idea, the PMA says: “If allowed to happen, it will destroy the medical education in the country, open the doors of corruption, produce ill-trained medical graduates or glorified quacks at a heavy cost,” Dr Kazmi stated. The PMA has demanded the proposal should immediately be shelved and all steps be taken to improve the existing medical education in the country as per PMDC guidelines. 2 Spending reforms vital for saving health insurance program: experts Focus Taiwan News Channel 14/04/2011 By Nancy Liu Taipei, April 14 (CNA) The key to saving the cash-strapped national health insurance (NHI) system lies in the reform of its spending structure, experts said Thursday. 13 Chiang Tung-liang, dean of the College of Public Health at National Taiwan University (NTU) , said that although a recent legislative amendment to increase premiums has temporarily saved the system from collapse, more attention should be paid to effectively distributing the additional resources. "This is a sensitive issue that no-one wants to touch, " said Huang Huang-hsiung, a member of the Control Yuan and an advocate of further NHI reforms. "But we need to tackle the problem if we want a sustainable health insurance system," he added. Under the current system, for example, there is a serious shortage of doctors specialized in pediatrics, gynecology, surgery and internal medicine, Huang said. This is because although the work is more difficult, such doctors do not get paid more than doctors in much more forgiving areas, he said. If the NHI payment system does not improve, there will be no doctors to look after the country's children in the future, Huang added. Huang listed several other problems stemming from the existing expenditure system, which include the waste of medical resources and the difficulty in running municipal hospitals. "There should be fairer regulations on who gets money and who doesn't, " Chiang said. "We ask everyone to examine the problems of the NHI expenditure structure and think of improvements." An academic conference on the issue is scheduled to take place on April 16 in Taipei, with more than 380 expected participants. 3 Shunning Hippocrates Thanh Nien News, Vietnam 15/04/2011 Reported by Minh Hung The “socialization” of healthcare in Vietnam is turning even public hospitals into “profit-making machines” denying patients, especially poorer ones, experts say. Socialization in Vietnam refers to the opening up of various sectors to multiple sources of investment. Many public hospitals are focusing on ways to increase their revenue and in the process foisting unnecessary medical tests on patients, they add. “Health centers have become profit making opportunities for the doctors and the nurses. That might be creating some pressure for poor people because they cannot afford the increasing fees,” said Jairo AcuñaAlfaro, policy advisor on public administrative reform and anti-corruption with the United Nations Development Program (UNDP) Vietnam. Acuña-Alfaro said that healthcare privatization, besides its benefits, could make some hospitals pay more attention to maintaining targeted revenue rather than to providing good service. On April 5, the Vietnam Social Insurance, which overviews health insurance in the country, announced an inspection of reimbursements made at hospitals in Phu Tho, Ben Tre and Ha Giang provinces. The inspection, to be launched next month, follows a scandal involving a hospital in the northern province of Phu Tho found illegally setting quotas for its departments and divisions. In 2011, the Phu Tho Area General Hospital aims to get 16,050 inpatients and 80,000 outpatients. It plans to have 3,700 patients undergo CT scans and 16,000 take ultrasound scans. For the pediatric division, this means receiving a minimum 140 child patients a month, each paying at least VND1 million (US$48) for treatment and running a minimum prescription bill of VND230,000 ($11). For the emergency department, the target is to get 108 to 114 patients per month, with an average 5-day treatment time and an average VND2.3 million in fees per person. If these targets are reached, the hospital staff would be rewarded with bonus payments, the Tuoi Tre newspaper reported March 24. A week after the exposé, the Health Ministry’s Examination and Treatment Management Department confirmed that the hospital had set up quotas for its divisions, breaching an instruction given by the ministry in June 2010. Pham Luong Son, head of Central Health Insurance Policy committee, said that the Phu Tho Area General Hospital was just one among many hospitals in Vietnam to have imposed such a quota system to bring in more money by inflating patient bill. 14 “A patient who had dorsal vertebrae pain is required to take an MRI (magnetic resonance imaging) scan, which costs over VND2 million ($95.5), or one with a sore throat has to go through all kinds of tests, including the HIV test,” Son said. “Test fees alone can go up to VND500,000-700,000, which is a lot of money for many patients,” he said. Commenting on the quota, Acuña-Alfaro said, “It is hard to believe that this is happening. “It is creating a wrong incentive. Hospitals are just becoming profit making machines. It should not be about the number of patients. It should not be about how much [money] the prescriptions given to those patients (cost),” he told Thanh Nien Weekly on the phone April 12. “The incentive has to be in terms of quality of services. And not about how many people come to the hospitals and how many people go back to their houses with medicines they don’t need,” he added. Privatization’s side effects The push for healthcare privatization that Vietnam embarked on in the nineties under the “socialization” model has had undeniable benefits but also adverse impacts on poor people, experts say. Statistics from the Health Ministry’s Examination and Treatment Management Department shows that there are 34 public hospitals directly under the ministry’s management and 83 private hospitals nationwide. The list, posted on the department’s website in October, 2010, mentions that public hospitals at provincial and district levels are waiting to be updated. A study released last week by ActionAid, an anti-poverty NGO, on the possible impacts privatization could have on access to public services in Vietnam said that the “socialization” would mobilize investment to extend service supply resources, diversify types of healthcare services, and create pressure to increase service quality. The poor have benefited indirectly because of decreased burden on public hospitals, while support policies like health insurance cards have reduced barriers limiting access to health care services, the report found. “This is considered a success of state support policies designed to limit the negative impacts of privatization on the poor,” the report said. However, it also found that financial abuse in service costs at public hospitals in the context of privatization has not been resolved. A doctor at a public hospital in Ho Chi Minh City admitted that health privatization has created pressure on public hospitals in terms of revenue because rich people have shifted to private hospitals. “Thus, public hospitals have to use hundreds of ways to earn money, especially from outpatients, through unnecessary services,” he told Thanh Nien Weekly, on condition of anonymity. “I am well aware that many doctors at public hospitals prescribe unnecessary ultrasound scans and other medical tests.” He said healthcare privatization had also triggered a brain drain from public health care services, the quality of services provided to people who can not afford treatment at private clinics and hospitals has also suffered. The doctor said that under the health autonomy policy, public hospitals contribute 70 percent of their revenue to the state budget. They had only the remaining 30 percent with which to pay salaries and other overheads. Considering the official salary for a new doctor at a public hospital is a mere VND1.5 million ($75), this 30 percent had to be augmented to provide the staff with “bonuses” for a reasonable remuneration, he said. Revise autonomy decree With the negative impacts of privatization on poor people becoming apparent, the government should take immediate action to redress them, said Acuña-Alfaro of UNDP Vietnam. He said a decree on hospital autonomy needs to be revised to make sure it does not create incentives for public hospitals to become profit-making concerns, he said. “They need to ensure a wider coverage of protection policies so that poor people have access to basic services. They need to strengthen the health insurance program,” he said, adding that services at communal levels should be improved. The team that conducted the ActionAid study suggested the government increase supervision to limit abuse of healthcare costs and unnecessary procedures in public hospitals. “Survey data shows that both people and local authorities are worried about unnecessary tests,” the report said. One person who has drawn no benefit from the socialization aka privatization of healthcare is Pham Thi Dai, a small trader at a roadside market in HCMC’s Go Vap District. 15 She has never thought about going to a private hospital. “It’s too expensive and I couldn’t afford the fees,” said Dai, who migrated to the city from the northern province of Bac Giang almost ten years ago after a divorce, and has two school-going children to take care of. “We also avoid getting examined at public hospitals. Usually, I just buy medicines from pharmacies whenever my children or I get a cold or sore-throat.” 4 Birth pains The Standard, Hong Kong 15/04/2011 Dennis Chong Pregnant and looking for lifelong privileges for the child that you're carrying? Then give birth in Hong Kong, where good things come to residents as a matter of course. That's the pitch from mainland salespeople and their Hong Kong partners, who are cashing in big time on the pregnant pause at a time when there's plenty of money sloshing around in China and expectant parents are, as always, outlaying whatever it takes to give their kids a head start. From cradle to grave, the salespeople say, the SAR is the place to have your baobao delivered. One Hong Kong-based consultant's website promises "education vouchers for kindergarten" and an "old-age allowance." In between are plenty of other benefits for those born in the SAR, such as nine years of free education, "100 percent employment for university graduates" and visa-free travel possibilities to more than 100 countries. Trumped-up or overblown some of the promises may be in the list of come- ons, but enough of them are indeed real benefits for residents. Certainly there has been more than enough for tens of thousands of pregnant mainlanders to visit and give birth in recent years, paying HK$39,000 at a public hospital or much more at a private one. The land-and-deliver business has become such a rush - more than 40 percent of all recent births in Hong Kong have been to visitors - that a stop sign has now been posted. In a deviation from Kong's liberal and open-door policy, the government announced last Frida y that public hospitals will not be accepting any more bookings from non- resident pregnant women for the rest of the year. The reason given is that the combined weight of pregnant mainlanders is straining Hong Kong's hospital facilities to such an extent that a major part of the system could collapse. It's claimed that a local woman seeking obstetric services could be left, well, holding the baby. That comes just when public-sector doctors in a variety of disciplines are threatening direct action because they say - with cause - that they are being pushed beyond limits while trying to give each and every patient the care and attention they deserve. But private hospitals are going to undermine the delivery reduction effort. They refuse to go along with a block on mainland women. That's because the maternity business is too big a moneyspinner to let go. You may well ask how private business can hurt Hong Kong's public health system, but we're assured it can. For one thing, private operators short of staff to take care of pregnant mainlanders and then their newborns are luring doctors from public hospitals. For another, the vast majority of births may be without complications, but some infants need treatment in an intensive care unit. And while private hospital operators may have state-of- the-art accounting systems, they lack ICUs and other facilities, So they shunt problem infants into public hospitals, where no one is going to reject an infant in distress. And, longer term, all of the kids born to mainland mothers in Hong Kong can one day seek public sector health care just as they can chase school places, homes, jobs and all the other things that society offers, or is supposed to offer. But the medium- and long-term effects of the demand from the mainland and the new SAR residents are not yet being debated at length. The immediate question is simply the number of births, which is hardly surprising when you consider recent trends. Babies born here but whose parents are not from Hong Kong soared from 620 in 2001 to 16,000 by 2006. The figure continued to rise by thousands annually to 32,000 last year, with nearly 11,000 in public hospitals. There were 88,000 births overall, and doctors and public hospital administrators say that's too many to handle in safety. The birth challenge has seen government officials meeting representatives of private and public hospitals to seek solutions. But they have failed to persuade the private sector to at least hold the line at last year's 88,000 16 births by limiting admissions. That makes for a likelihood of 100,000 births in 2102 for it's the Year of the Dragon, an auspicious birthing time. One person sounding the warning of too many more to come is Cheung Tak-hong, chief of service in obstetrics and gynecology at Prince of Wales Hospital and leader of a concern group of public doctors arguing for a reduction in births in order to secure the future of the overall health-care system. With the government unable to persuade private hospitals to apply a limit, Cheung expects births to top 90,000 this year before a big leap for the Dragon. While the brain-drain of doctors from the public sector is a big problem, his concern group says, more worrying is the fact that the private sector must turn to public hospitals when newborns need intensive care. Two newborns in every 100 need intensive care, but public hospitals are already overstretched in that regard. There are only 100 ICU beds for infants. Going by international guidelines, Hong Kong can handle no more than 75,000 births each year. Intensive care "One day there could be a situation where a newborn baby needs intensive care but public hospitals cannot take the child because they are full," Cheung muses gloomily. "Then the baby dies." He adds: "I really hope that it is not going to happen." That private hospitals refuse to reduce obstetric services - which bring them revenues of more than HK$1 billion annually by some estimates - keeps the numbers game running hot. Private hospitals have only pledged to keep the number of overall births steady at 47,000, and they claim there is a system for giving local woman priority. Alan Lau Kwok-lam, head of a union of private hospitals, claims the 47,000 level means that safe deliveries and good standards of service can be maintained. But he then adds that public authorities could consider adding another 20-40 intensive-care beds for infants. He admits that would take some time. Additionally, it would cost taxpayers HK$100 million a year for additional facilities and the doctors and nurses to staff the units. Legislator Leung Ka-lau, who represents the medical sector, doesn't hold out much hope that private hospital operators will even coordinate among themselves, let alone work with the government in limiting admissions from the mainland. "You're asking them to decide who is going to get how much market share," he says. As for the line about locals going to the head of queues for births at private hospitals, it's now being noted that mainlanders are ready to pay premiums to replace them. Indeed, with the block in place at public hospitals, agents are busier than ever, soliciting business from those who are willing to pay extra to secure a place in a private hospital, an investigation by The Standard finds. A call at a To Kwa Wan-based consultancy company that provides "delivery packages" leads to a meeting with Miss Yuen, who admits that the "arrangement fee" has been hiked because of recent developments, though demand remains strong. "It's difficult to get space now," she says. Some agents are starting at HK$200,000 for arranging a "first- class" hospital room in Hong Kong and a wellequipped apartment in Shenzhen where expectant mothers can wait until it's time to cross the border and take up their booking. Cashing in High asking prices by arrangers also follow on from private hospitals in Hong Kong moving to raise fees for obstetric services - though no one admits they are cashing in on the ban on bookings by outsiders at public hospitals. General demand amid inflationary times is the sort of reason offered. Baptist Hospital and the Adventist Hospital have let it be known that increases in fees for obstetric services are on the cards. Also from Baptist Hospital comes word that, in the spirit of cooperation, its bosses are considering reducing the quota for mainland mothers so that they only make up 80 percent of their baby business. At Union Hospital, meanwhile, plans are being laid to shorten the duration of average stays for new mothers from three nights to two so that admissions can be increased. Cheung predicts disappointment for some Hong Kong women who want to go private for a birth but who cannot compete with the new-money clout of the mainland. "If the package for locals is HK$60,000 but mainlanders are willing to pay HK$120,000, of course [private hospitals] will take the HK$120,000 business," he says. He also sees unfair fallout from the booking ban at public hospitals. 17 Mainland women with Hong Kong husbands, who accounted for 4,000 of the 10,695 non-local births in public hospitals last year, are now on the no- booking list, he says, and that's wrong. While it has yet to become a hot issue - it will be soon enough - the implications of mainlanders producing Hong Kong residents by the tens of thousands are being debated quietly. Experts point to the youngsters being huge challenges for the Hong Kong government when setting social policies. Yet it's a challenge that must be faced: from the moment they take their first breaths in Hong Kong the babies are going to be counted as residents or people who qualify by birth for such status - and all the services and support that it confers. (It should be noted that these kids are not counted in the daily quota of 150 mainlanders who can make their homes here. But just how many of the newborns remain with friends or relatives in Hong Kong or, their status assured, go home with their visitor mothers is not known.) Some people might think they are hearing the worrying patter of many tiny feet, but others see little bundles of joy for Hong Kong demographics. In 2003 - when SARS struck Hong Kong and set off all sorts of family scares - the number of births was 46,200. That figure meant the overall population was almost static and nudged Hong Kong toward the Japan situation of an ever-older population - a graying dilemma. Now there's a baby boom, which can be viewed as a mighty force in the making. "These babies are Hongkongers," says legislator Leung. "Some will grow up in Hong Kong, so you've got to plan for education, housing and employment with regards to this change. That will require studies to see whether the parents intend to let their offspring live in Hong Kong for good. "But the right policies can turn this new blood into a constructive force for the Hong Kong economy." 5 Emergency care 'immobilised' Mid Day, India 19/04/2011 By: Astha Saxena What good are ambulances that remain immobile? That's a question Delhi government needs to find answers to. Another Commonwealth Games (CWG) controversy has emerged to vex the authorities. Apart from the beautiful stadiums, roads, flyovers etc that were constructed ahead of the event, the city government also procured 21 Advanced Life Support (ALS) ambulances to cater to the needs of athletes, visitors and Delhiites in general. Now more than six months after the culmination of the Games, these vehicles have hardly been used -- at least 10 of them are gathering dust at various hospitals, a few others allegedly malfunction and the rest run only a few hours every day. That's because in an RTI reply, the Delhi government has conceded that so far only one paramedic has been trained to operate these vehicles. MiD DAY has a copy of the documents. Emergency! That means, if at any point of time you need help and call for an ambulance, it's likely that your request will be denied and you will have to find other means to reach the hospital. The cost of one ALS ambulance is Rs 35 lakh. The ministry also spent Rs 7 crore on the fabrication of CATS ambulances. Previously, only Basic Life Support (BLS) ambulances were available with the health department, which just have Automated External Defibrillators (AED), oxygen masks, stethoscope and other basic equipments. But ALS ambulances are equipped with all the necessary equipments such as Cardiac Monitoring, Cardiac Defibrillation, ventilators, and other life-support equipment. According to the Centralised Accident and Trauma Services (CATS) officials, many of the ALS ambulances are standing unused outside hospitals as there aren't enough trained personnel to operate them or attend to their maintenance. Less is more? "We were told that proper training would be given to 21 of our members so that they can operate the ambulances and help patients. These ambulances are complex and no common driver can understand how to manage them," said a CATS official on the condition of anonymity. "The only trained member is also posted in the administration centre. We do not understand what he will do there. If he was trained then he must give training to others," added the official. Interestingly, the working hours of the functioning ambulances are also odd. According to an order by Directorate of Health Services (DHS), ALS ambulances are operational only from 8 in the morning till 4 in the evening. "Many of the accidents and emergencies occur at night; very few ambulances are required during the day time. We see accident patients coming in generally at late hours. These ALS ambulances are so well-equipped that 18 they can at least save someone's life. But if they function only part of the time then what good are they?" said a senior doctor from AIIMS on the condition of anonymity. According to guidelines by DHS, every such ambulance will have one driver and a doctor, to be provided by the hospital and one personnel from CATS. But due to the unavailability of doctors and properly trained CATS staff, the vehicles largely remain anchored. Stand by "Though the ambulances are standing outside the hospital, I have not seen them working any day. We don't have doctors to go with them," said a doctor from Babu Jagjivan Ram Hospital on the condition of anonymity. Even the Basic Life Support (BLS) ambulances are facing an acute shortage of staff. Of the total 35 ambulances, five to six are redundant because of engine problems and other technical snags. 'We're helpless' "This is a complete waste of public money. These ambulances which are designed to serve the public are not being used properly. We feel terrible when we have to turn down emergency calls. But what can we do?" said a CATS official. When MiD DAY contacted Delhi health ministry officials, they refused to confirm the allegations. They also were not prepared to comment on the RTI. "We have placed the ambulances with the hospitals so that they can also look after them. And regarding the training, we have started training CATS members, but I have to check that RTI for the further information," said Diwan Chand, Secretary, Health Department, Delhi government. However, city Health Minister Dr AK Walia and Health Secretary Rajendra Kumar did not respond to any calls or messages from MiD DAY. CATS scan Centralised Accident and Trauma Services (CATS) was conceptualised as a plan scheme in 1984 during the 6th Five Year Plan. The scheme was to be implemented under the aegis of All India Institute of Medical Science (AllMS). In April, 1988, the ambulance service was transferred to the Delhi Fire Service (DFS) with a fleet of 14 ambulances. Since the service required multi sectoral coordination, it was later decided that the scheme may be implemented by a society registered for the purpose. Consequently, CATS society was formed by Delhi Administration as a registered society In June, 1989. The West Zone Pilot Project (WZPP) was inaugurated on 15.3.1991 by then Lt. Governor Markandey Singh after the second annual meeting, of the Governing Body of CATS. The primary objectives of CATS are to reach the site of the accident as quickly as possible, to give first-aid to the patient, quick and safe transportation of the patient to the hospital, to involve liaise with other organisation as Delhi Police, Delhi Fire Service and any other governmental agencies for the benefit and the care of the accident victims. Central Control Room of CATS is situated at Deen Dayal Upadhyay Hospital at Hari Nagar. Calls are received through the four digit no. "1099" allotted to CATS. There are 10 lines available on telephone No.1099. Calls are also received through Delhi Police and Delhi Fire Service through wireless sets. 'Stop the rot' "The condition of the ambulances with us is so bad that they can't even travel for 1 km," said a senior official from CATS on condition of anonymity. "Most of these ambulances have faulty brakes and problems in their engines as well," said an ambulance driver. The CATS services were also suffering from severe staff crunch as the last recruitment drive took place in 1999. 6 Discourage treatment in abroad: NMA The Himalayan Times, Nepal 19/04/2011 KATHMANDU: The Nepal Medical Association (NMA) has pointed out the need of conducting entrance exam including other examinations through a one-door system at a time when the health service and health education are not making any quality improvement. A national level directory should be formulated on the initiative of the Nepal Medical Council, the NMA and concerned health institutions, said the NMA. Making public the concept paper of the commitment its newly-elected office bearers made during election at the press conference organised here on Monday, NMA general secretary Dr. Bhupendra Kumar Basnet said the health service should not rather be limited to constitution; quality and convenient health facilities should be expanded to the reach of all classes and communities in a practical manner. NMA Chair Dr. Kiran Prasad Shrestha stressed that the health sector should be secure and peaceful since it will be difficult for the doctors and health workers to provide with quality service while they have been working in a fearful situation for the past few years. There is no clear definition of basic service, however it is said that the State has an obligation to render health services to every citizen free of cost, the NMA further said. 19 Demanding that the Act formulated regarding the security of health workers and health institutions be immediately implemented, the NMA also urged the government to take action against those doctors providing health services without registering themselves in the NMC. The Nepal Medical Board should discourage the system to recommend patients for the treatment in health institutions outside the country since this trend has raised questions on the credibility and competence of health service providers of Nepal, stated the concept paper. 7 Taiwan Medical Mission awarded for providing medical aid in Africa China Post 19/04/2011 The Department of Health (DOH) and the Ministry of Foreign Affairs (MOFA) yesterday recognized and celebrated the efforts of Taipei Medical University Hospital doctors who provided medical aid and education to the Kingdom of Swaziland and the Democratic Republic of Sao Tome and Principe through the Taiwan Medical Mission. DOH Minister Chiu Wen-ta praised the fruitfulness of the mission team, and was on hand to present awards to the 12 medical pioneers who had served in Swaziland in a ceremony honoring their hard work in bettering the lives of those they helped. Su Ching-hua, acting president of Taipei Medical University (TMU), said local doctors gave up the luxury of treating patient in familiar hospitals for missions in Swaziland. The university and the hospital's doctors will continue to take part in future missions, Su promised, in order to expand the international borders of Taiwan's medical expertise. Bruno Shen, deputy director-general of the Department of African Affairs at the MOFA said the ministry has been supporting the medical mission for a number of years now and will do its best to continue to aid and improve the efficacy of the team in everyway. During the forum held at the Taipei Medical University Hospital yesterday, Tu Chi-cheng, who served as chief of Taiwan Medical Mission, gave a brief history of the medical mission while presenting their findings while performing care. According to Tu, the Taiwan Medical Mission to Swaziland was first created in May, 2008, through the Changhua Christian Hospital. TMU created it's own medical mission team between 2009 to 2010. Swaziland developed diplomatic ties with the Republic of China (R.O.C.) as soon as it gained independence in Sept. 6, 1968, as detailed in Tu's report. Statistics show that am estimated 30 percent of the population was afflicted with acquired immune deficiency syndrome (AIDS) and 70 percent of the people lived below the poverty line. Tu said the majority of the people lived in rural countryside. Tu led a team of doctors specializing in the fields of general internal medicine, infectious diseases, neurology, pediatrics and dental care into the Mbabane Government Hospital (MGH). The team conducted CT scans, treated gunshot wounds and performed open surgery, 30 percent of which were on deformed infants. Tu said that on top of educating local medical staff on improving outpatient services, conducting ward rounds and upping clinical research, the team successfully improved the water quality in five elementary schools across Swaziland. Tu concluded in his report that, from 2009 until now, the Taiwan Mission Team to Swaziland has treated a total of 4,000 people across 12 districts. Within three years, the university also upgraded the medical equipment at hospitals, provided scholarships for local medical students and developed invaluable relationships with locals along the way. One such relationship was with Her Majesty the Queen Mother of the Kingdom of Swaziland, who the team treated, providing medical exams and advice for her continued health. Tu recounted with particular pride, the Queen Mother's visit to Taiwan from March 11 to 22 last year, which greatly enhanced diplomatic relations between Taiwan and Swaziland. Concerning the future of the Taiwan Medical Mission, Tu said more aid is needed in the form of medical equipment, manpower and financial support for the Kingdom of Swaziland. 9 Mental illness putting stress on hospitals The West Australian 16/04/2011 ANGELA POWNALL Mental illness is putting huge pressure on WA's hospitals, with 21,507 mental health patients admitted to major city emergency wards in the past year at a cost of more than $10 million. 20 Hospital figures show mentally ill people make up as much as a fifth of emergency ward admissions with a 20 per cent jump in December compared with that month in 2009. Doctors say emergency wards are the wrong places to treat mentally ill patients who need specialist care and where high levels of noise and stress can worsen their condition. But a shortage of psychiatric beds means mentally ill patients stay in emergency departments up to six days. Australian Medical Association WA president David Mountain said the proportion of mentally ill people in emergency wards had risen dramatically. "Clearly these patients are high maintenance," he said. "It's a terrible environment for these patients. It's extremely stressful. "These patients are more likely to have violent outbursts and need to be restrained." Associate Professor Mountain said some patients went to emergency departments repeatedly after being discharged too soon from psychiatric wards. He said better management in recent years meant fewer were staying on emergency wards longer than a day or two, but they needed to be assessed and transferred within one or two hours. "There's no doubt we are very short of acute, sub-acute and community beds and resources at all levels of our system and we need to improve capacity to actually deal with patients in a much more co-ordinated way to make sure people do not fall through the gaps," he said. Arafmi Mental Health Carers and Friends Association director Mike Seward said admissions would be reduced if mental health professionals listened more to patients and carers. They could often flag a patient was going downhill and needed intervention but found it hard to get the system to take heed. WA Mental Health Minister Helen Morton said she would look into setting up a trial mental health emergency department at a WA hospital. Shadow minister Ljiljanna Ravlich said mentally ill people went to emergency departments because there was nowhere else to go, which was a sad reflection on the State Government. Emma, who did not want her surname used, said her 40-year-old husband spent four days in and out of emergency wards this week after a "psychotic episode" before being sent home. "I'm shocked. Less than 24 hours after I saw four people holding him down they wanted me to take him home," she said. "That's not what a normal person would consider right." He was given medication for a few days and an appointment to a psychiatrist for a week after he went to the hospital. 10 How can the decline in the rural health workforce be stopped? The Age, AU 19/04/2011 Deb Anderson DOCTORS and medical specialists have been in short supply but high demand in country Victoria for four decades. Deakin University hopes to help turn the tide with a new Regional Community Health Hub, dubbed REACH. The $50 million project, due for completion late next year, will be linked to the university's medical school in Geelong. According to the dean of Deakin's health faculty, John Catford, the hub will target the myriad underlying socio-economic and geographic challenges in order to recruit, train and keep health workers in country areas. What's behind this workforce shortage? It's a layered problem. For a start, we need to think about how students get into medical school or health programs. Often, regional students don't quite have the same advantages that city-based students have, particularly those who have the privilege of a private education. In effect, rural public school students face entrance hurdles? It's a much harder road to follow to get into some of these prestigious courses — the ones we offer have very high ATAR scores, so often country students don't get in. Then you need to think about where these students are being trained. Often they're being trained in Melbourne and the metropolitan locations. And, if you are from the city, or being trained in the city, and you've married a partner who is also from the city — who has parents, friends and siblings there, or children in school — it is much harder to make the break to the country. 21 What about working conditions and support in rural areas? That's another layer — and that's not something the university can fix. But we can help advocate for that; we are a voice and we do talk to governments. Certainly something that needs to improve is the quality of support for health professionals in rural and regional areas. Can you describe the state of demand for medical jobs in rural Victoria? It varies according to discipline, but by and large there are serious staff shortages virtually everywhere. If you were to look at what the number of health professionals is per 1000 population, you would see a big imbalance between city and country. It's easier to access a health professional — whether a physiotherapist, occupational therapist, doctor, nurse and so on — in the metropolitan areas. Even in Geelong, we're something like 50 GPs short. And as you move further out from the regional centres, it tends to be even more difficult to fill medical posts. Tell us about Deakin's new health hub. Our model is: if you recruit in regional areas, then train in regional areas, you're much more likely to keep health professionals in country Victoria. So the hub will focus on selecting rural and regional students? Yes, in the selection process, because we know if students come from regional areas and are trained in regional areas, they're much more likely to return there. That's very much been our philosophy with other programs in Geelong and Warrnambool, our two campuses. Through REACH, we will be starting programs in optometry, pharmacy and exercise sport science, and a community-based program in sport for Aboriginal students. We're also going to run an e-health education program to link practitioners, hospitals, TAFES and other educational centres across regional Victoria, using the internet to reach out to students. How will e-health support students? That's a relevant issue. The e-health program will support students in disciplines such as nursing and occupational therapy when they're out on placements in the country. We've also got a program called Deakin at Your Doorstep, through which we'll try to recruit students in rural areas and teach them locally — before they come down to one of our campuses. It's a distance-based program to start students off in smaller country areas, getting them more comfortable with studying university programs, so they might feel more able to come through to the big campuses Back to top North America 1 Foreign-trained doctors kept out of practice in US PRI’s The World 14/04/2011 By Marina Giovannelli The Jefferson Reaves community health center in Miami provides care to people who cannot afford it elsewhere. The clinic helps patients control diabetes, treats colds, gives vaccines, and offers other sorts of general care. Dr. Robert Schwartz, who trains young physicians at the clinic, said it has become difficult to find doctors willing to practice this kind of medicine. “There’s been a significant decline of medical students who are interested in family medicine,” he said. “I see this as an enormous challenge to the delivery of care.” The United States suffers from a shortage of primary care physicians, and the problem is expected to worsen. America’s baby boom generation is aging, and health care reform could put greater demands on doctors as more Americans gain medical insurance. A potential solution to the physician shortage would be to allow more foreign-trained doctors to work in the United States. In fact, thousands of such doctors are ready to step in, but some say the system is stacked against them. Wilson Questa practiced family medicine in Colombia before moving to the United States five years ago. “Medicine is my passion,” he said. Questa would like to practice in America, but he cannot. “I don’t have any type of license,” he explained. For a doctor trained abroad, getting a license in the US requires several things. First, the physician must to take board exams and an English language test. Questa passed those tests quickly. Second, a foreign-trained physician must go through a residency program. For Questa, that requirement has proved difficult. He has applied for hundreds of residency positions, but so far he has not been offered one. Residency positions 22 If Questa had been trained in the United States, he likely would have been accepted for a residency position. Among doctors who went to medical school in the US, nearly 95 percent of those who apply for residencies get one. Yet for doctors trained in other countries, fewer than 40 percent of those who apply for a US residency are accepted. About 10,000 international medical school graduates are in the US and are trying to practice here but cannot. Questa considers the residency system unfair, biased against people like him. “If you have the same knowledge as a graduate from the United States, I don’t see any difference,” Questa said. “We are going to give the same level of care as any other doctor.” But residency programs do not just consider talent when offering slots to doctors. Prof. Fitzhugh Mullan of George Washington University School of Medicine studies the global migration of doctors. He said there are several reasons why US residency programs prefer US graduates. “A doctor in almost every country in the world is a product of the taxpayers or the tax base of that country,” Mullan explained. Because governments spend money on medical education, countries want a return on their investment. For that reason, he said, it is appropriate for US residency programs to select US graduates over those from foreign countries. On the flip side, Mullan said that if the US made it easy for foreign doctors to work here, that would be unfair to other countries. “Should we count on the government of India or the government of the Philippines or the government of Colombia to train our doctors?” Mullan asked. “[That] isn’t good for the countries who are losing their doctors to the United States.” As things stand, many counties are already losing their doctors to the US. Although foreign-trained doctors have trouble getting residencies here, some succeed. In fact, a quarter of the doctors currently practicing in the US were trained abroad. Dependent on foreign doctors Some health analysts would like to see the US become less dependent on foreign doctors. And soon it will be. With new medical schools being built across the US and existing schools expanding, the number of American medical graduates is expected to jump 30 percent in the next decade. That may provide enough US-trained doctors to meet the country’s needs. Yet Colombian doctor Wilson Questa says he won’t give up trying to practice here. He did not get a single interview for a residency this year, but he recently landed a job at a pediatric clinic – in the billing department. “Even though when I come [to the clinic] I don’t see any patients,” Questa said, “at least [when] I wake up in the morning, I say, ‘okay, I have to be ready to go to the medical office to work.” 2 How patients can help doctors practice better, less costly medicine The Washington Post 15/04/2011 By Sean Palfrey The past few decades have been exciting for the practice of medicine. We have made many dramatic scientific advances and developed many tests, medications and therapies. In pediatrics, we have been blessed with breakthroughs such as vaccines that eliminate deadly infant diseases and vastly improved asthma and diabetes medications. Doctors, always eager to take advantage of discoveries, are now often ordering expensive tests and therapies without considering how essential they might be for their patients. In the process, we are bankrupting our nation’s health system and depriving millions of people of any health care at all. Ironically, however, the United States has fallen behind in many categories of child health outcomes compared with other developed countries, including higher rates of infant mortality and teen pregnancy, more serious accidents, and more obesity and diabetes. Every doctor I know in this country wants to provide the best medical services. We have embraced the new technologies, tests and medications, and we are encouraged by everyone to use them all: by our patients who want us to do everything possible; by hospitals that want us to use all their resources; by insurance companies that “cover” most of these interventions; by health administrators who develop detailed protocols; and by our legal system, which frightens us into practicing defensively. Incentives are everywhere; disincentives are few. Medical students and residents are learning vast amounts of science, but they are given little time and opportunity to develop proficiency in the true cornerstones of medical practice: taking patient histories, physical examination, developing interpersonal skills and clinical judgment. They are rightly worried about this. Their models are doctors in practices, emergency departments and inpatient services who are spending less time examining and watching their patients and more time sitting at computers ordering tests, procedures and 23 medications, monitoring results and documenting findings. Because doctors have such easy access to them, we order tests and therapies whose cost we do not know and whose safety and clinical value we do not fully understand. Obviously, there are some patients who are very ill and need access to all that today’s advanced science and technologies have to offer. If we practice intelligently, there should always be the money, skills and specialists to help those in need. If we don’t, there won’t be. Tests and medicines, like food, seem as if they should be good for you, but they aren’t always. Test results can be inaccurate or unclear, leading to incorrect diagnoses or the ordering of more tests. Medicines can be harmful. Our bodies are good at healing themselves, and a doctor’s challenge has always been to decide when, how and even if we should do anything to help this process. This is one of the major challenges of modern medicine. By practicing expensive and unrestrained clinical care, we are over-spending precious resources on some patients while depriving others of care. There are not only ethical but deadly serious financial and public health reasons to provide some care to everyone. The health of each of us depends on the health of those around us. If someone gets a preventable infectious disease such as measles, whooping cough or flu, they put many people around them, especially infants and elders, at serious risk. Health disparities in this country are the prime reasons our health statistics are poorer than those in many other countries. Few elements of the U.S. health-care system encourage doctors to practice in this sensible, thoughtful way. Doctors need to be given permission — in fact, a mandate — to practice more preventive medicine, not to test so much, to listen more and to watch our patients over time when they are ill. We need research on effectiveness and cost benefits to teach us which tests and treatments result in better outcomes. How can we do this? All of us — doctors, parents, patients, health administrators, insurance companies and lawyers — must redefine our concepts of “reasonable care” and “reasonable outcome.” As a pediatrician, I want to help parents fulfill their dreams for their children. The Affordable Care Act started this process, but it will never succeed in reducing health-care costs and providing health services to all children (and adults for that matter) unless we all change our practices and our understanding of appropriate medical care. Doctors need patients’ and parents’ help, support and empowerment. Every time you see your doctor, ask for the best and simplest treatment. Ask all the questions that are most important to you; ask what you can do to prevent illness; and ask how you can help us practice as effectively, and frugally, as possible. We all need to play an active part in health-care reform. The writer is a pediatrician at Boston Medical Center and a clinical professor of pediatrics and public health at Boston University School of Medicine. 3 Hungarian Doctors Seek Fortune Abroad The Wall Street Journal 14/04/2011 By Margit Feher Like governments the world over, Hungary is seeking ways to rein in spending on health care. If anything, the problem may be even more acute for the Fidesz party-led Hungarian government, which has the highest debtto-GDP ratio in Central and Eastern Europe and aims to trim its budget deficit to close to 3% of GDP this year. The government and the country’s pharmaceutical industry are at loggerheads on how to best tackle the issue of bringing down the roughly 340 billion forints ($1.84 billion), or 1.4% of GDP, Budapest is spending on subsidizing drugs. While the government proposes to cut the subsidies, the pharmaceutical lobby suggests levying a new tax to help raise the money to keep the subsidies flowing. While the industry’s proposal will do little to address the issue of outsized spending on healthcare, the lobby does address an important issue. They want the extra tax income to be spent on higher wages for physicians and other healthcare professionals. Hungarian doctors, including job starters, have been leaving the country in increasing numbers to seek higher wages elsewhere in Europe. Some of them work part-time in neighboring Austria or even hop on a plane to work weekends, or for a week or two each month in the U.K. Latest data from Hungary’s health care license office, or EEKH, show that 1,777 health care workers requested a license to work abroad last year, more than twice as many as just four years ago. Within that, the number of doctors wanting to work abroad totaled 1,111, double, again, from 2006. The most popular country of destination was the UK, followed by Germany, Austria, Ireland, and Sweden. Those aged between 25 and 44 were most keen to go abroad in recent years, but the number of those hardly out of med school also started rising sharply last year. 24 While those numbers may seem low, the departure of doctors for better pay elsewhere is reducing Hungary’s quality of health services. The number of doctors per 1,000 Hungarians was 3.1 in 2008, Organization for Economic Cooperation and Development figures show, ranking Hungary above Finland, the UK, and Japan. Not to mention the doctors’ training costs to the taxpayers. Faced with the prospect of relatively poor pay, many of those doctors who have the opportunity and the ability are opting to leave. Dentists, gynecologists, plastic surgeons or dermatologists–those who can have a private practice–can live well-off. Not least, because they can take in patients from abroad who travel to Hungary because of the relatively cheap service there. But an anesthesiologist or a radiologist–who can hardly conduct a practice outside the mostly state-run health sector–has not much choice. Many doctors have turned drug sales agents for a higher wage, a company car and other benefits. A specialized doctor earned a gross HUF4.18 million, or $20,700 a year in 2009, data from the National Employment Service NFSZ show. That’s the official figure, but wages are so low that many health care workers do accept additional payment, untaxed and illegal, termed parasolvency, from their patients, who feel obliged and ready to pay extra in hope of extra care. The government has turned down the drug association’s proposal to use the extra tax to raise health sector wages. The number of doctors wanting to work abroad will likely continue to rise and parasolvency will remain an accepted form of gratitude for doctors’ and nurses’ work. 4 Doctors could learn something about medical handoffs from the Navy Los Angeles Times 18/04/2011 By Rahul Parikh Consider the following story, from a doctor during his training: During a night on call, a patient he was "cross covering" — caring for during the night shift — went into cardiac and respiratory arrest. Dutifully, the resident and his team began to resuscitate the patient. They performed CPR for well over a minute. Then, suddenly, they stopped — and not because the patient was beyond saving. Another team member had reviewed the patient's chart and learned he was not a "full code." The patient, in other words, had requested as part of his treatment plan that he not be revived should his body fail. Trying to save him had been wrong. This mess-up — like many other errors in medicine — happened because of a botched handoff, the process by which a physician going off duty transfers responsibility of a patient to another doctor. In this case, the doctor going off duty had failed to communicate the patient's code status to the resident taking over his care. Handoffs are the glue that holds together a patient's care in the hospital. Yet traditionally they have been a disorganized — even sloppy — process. During my residency, we used paper and pencil to keep track of patients and transfer their care to others. We kept these pieces of paper folded in our pockets and constantly updated them by erasing and rewriting on them. Over the course of a day and a night on call, that pristine piece of paper got tattered and torn, confused with scribbles, eraser marks and shorthand made by many doctors. Somewhere on that paper was the right information, but it wasn't always easy to find. It was probably more luck than smarts that saved me from making any major mistakes through my own imperfect handoffs. Statistics show that some 80% of adverse events in hospitals involve communication problems between healthcare professionals, often in the form of a fumbled handoff. A review of surgery malpractice cases from 1991 to 2000 reported that inadequate information-sharing among team members was the primary trigger for lawsuits. Other studies show that such lapses in communication lead to problems even when patients do not get injured or die and doctors do not get sued. Fumbled handoffs can lead to redundant tests, prolonged hospitalizations or readmissions after discharge, all of which lower the quality of care for patients and drive up healthcare costs. To learn more about the issue, I talked to Dr. Vineet Arora, assistant director of the Internal Medicine Program at the University of Chicago Pritzker School of Medicine, who has made understanding and improving handoffs the focus of her career. She told me that handoffs have come under fresh scrutiny because of the way medicine has changed over the last decade. There was a time in American medicine when each person had a doctor who followed him or her whether well or sick, in or out of the hospital. These days, you may see your family doctor when you are well, but if you are sick and need to be hospitalized, an expert in inpatient medicine — a hospitalist — will assume your care. And since no single hospitalist can be present around the clock, patients end up receiving care from several different ones, in shifts. 25 "We've traded familiarity and continuity for safety," Arora told me. The trend toward more shift changes — so that residents don't have to work as many hours without a break, a safety move — has led to far more handoffs and, ironically, to a new set of dangers. Experts like Arora cite a host of reasons why handoffs fail. Some seem trivial — such as the fact that one doctor's shorthand can mean something entirely different to another. The notation "MI," for example, may mean "myocardial infarction" (heart attack in plain English) to one physician and "mitral insufficiency" (a condition affecting one of the valves of the heart) to another. Frequent interruptions during the handoff process are another problem — an extremely common one. In the middle of a discussion, a doctor's beeper may go off, or a nurse or other staff member will come over needing something right away, breaking the rhythm of discussion and the doctor's concentration. Hospitalists also care for large numbers of patients, many of whom have multiple, chronic, complex medical problems such as cancer, heart disease or dementia. With such patients come many drugs and much data to track — and more opportunities for a mix-up. A "typical" primary-care doctor may review up to 800 lab results, 40 radiology reports and 12 pathology reports per week. Those numbers are undoubtedly far higher for hospitalists. There's a cultural issue as well. Many doctors seem to view handoffs as an annoyance, even with disdain. Often, the question doctors are asking when they hand patients off isn't "How do I get this right each time so that my patients stay safe?" but "How do I get this done so I can get out of here fast?" The reasons go on and on, but the tough question is how to make handoffs safe and effective. In their search for solutions, many patient-safety experts are looking for answers outside of healthcare. At Kaiser Permanente, where I practice, Doug Bonacum, vice president of Safety Management, is tasked with making handoffs work. He's not a doctor himself — he's a nuclear engineer and former Navy submariner. He is trying to show that the techniques he learned in the military to communicate are the exact same ones doctors need to use during handoffs. "When I set foot on a nuclear submarine fresh out of the Naval Academy, the very first thing I had to prove was that I could use the phone," he recalls. "That really surprised me, given that we had nuclear generators and weapons on this ship. But I wasn't allowed to do anything more until I had shown that I could receive, and read back, an order. If I couldn't, the officer on the line would say 'Wrong' and 'Repeat again' until I got it right." Bonacum shared example after example of how care of the submarine was handed off during a change of shift. "I would sign out the issues and events that happened on my watch the same way each day," he says. "Anybody who assumed my post would do it the exact same way to their relief as well. In medicine, if I follow three different doctors around on three different days, I'll see three different ways of signing out patients." Doctors are also learning from aviation, where critical processes are handled using checklists. Checklists have already improved patient safety in intensive care units and operating rooms. Some centers have created handoff checklists too to ensure crucial items (such as a patient's code status) are never missed. But there's more to be learned from the field. Another aviation technique — the "sterile cockpit" — requires that pilots refrain from nonessential activities during certain points during flight. It's designed to limit interruptions when the crew talks about critical issues related to the flight. In medicine, that would mean setting aside a quiet place for handoffs that are buffered from beepers, phones and other distractions. We doctors could also learn a lot by just looking over our shoulder at nurses. Anybody trying to talk to a nurse during a shift change, be it a doctor, a family member or a patient, gets mildly reprimanded. Nurses are simply off-limits while they're handing off patients. At Kaiser, nurses have adopted another innovative technique: signing off at a patient's bedside so that patients and family members will hear the plan and have an opportunity to ask questions or correct something if it does not sound right. Bonacum and Arora say they see generational differences in doctors' willingness to embrace better handoff techniques, which is a hopeful sign. Residents, who are increasingly required to have formal training in handoffs, are fast adopting new techniques. They seem to have the perspective that teams of people working together keep patients safe. Yet for more seasoned doctors, there's inertia. Many consider advice or a mandate to do things one way every time — be it a handoff or something else, like using a checklist — as an insult to their intelligence and authority. The sad thing is, they often feel a deep sense of personal responsibility for their patients, which leads them to blame themselves when things go wrong. Yet the very systems they bristle against could well prevent those errors to begin with. 5 Doctor tells Putin of Russia’s medical shortcomings 26 The Washington Post 20/04/2011 By Will Englund, MOSCOW — Russian medical care is hobbled by corruption, meager salaries, ill-conceived laws, a shortage of medical workers and an overbearing government bureaucracy, one of Russia’s most prominent doctors told a recent medical conference here. He addressed his remarks directly to Prime Minister Vladimir Putin, who was sitting just a few feet away. Putin did not directly dispute the comments; in fact, he said he knew what Leonid Roshal was going to say and wanted to make sure the conference heard it. But the Health Ministry later posted an unsigned “collective” letter denouncing Roshal and asking Putin to “protect our honor and dignity against such criticism.” Roshal’s address was made public Wednesday, a week after the conference, when it was reprinted in the newspaper Novaya Gazeta. It quickly became a leading topic on Russian blogs, which also noted the Sovietstyle letter of denunciation that followed. A Health Ministry representative said Wednesday that it would not comment on the letter or Roshal’s accusations. Roshal could not be reached for comment. “He’s been thinking about this for a very long time,” said Kirill Danishevsky, an expert on Russian health-care reform who is also a doctor. “It’s impossible to disagree with some of the main points Roshal made.” Roshal, a leading pediatrician and president of the National Medical Chamber, is perhaps best known here for his efforts to mediate during hostage-takings at a school in Beslan in 2004 and at a Moscow theater in 2002. In his remarks, he said too much money is being budgeted for equipment, much of it useless, because it is easy for bureaucrats to “saw off” a kickback for themselves. Doctors, he noted, have to make do on official salaries of less than $300 a month. (He didn’t mention that most doctors here insist on under-the-table payments from their patients.) With just 3.9 percent of gross domestic product going to health care, he said, the result is a shortage of doctors, especially in rural areas, and of hospitals. “There are regions where more than 50 percent of physicians are of retirement age and only 7 percent are young specialists,” he said. And all of this, he concluded, is directed by a Health Ministry bureaucracy that is painfully lacking in people with medical training. On Monday, when a presidential advisory committee visited the Siberian city of Irkutsk, protesters stood along the city’s main streets with signs detailing the conditions that health-care workers and teachers face. Nationally, statistics show, almost half of Russia’s hospitals lack heat or running water. Potemkin hospital Last week was not the first time that Putin had heard a doctor complain publicly about the health-care system here. During a TV call-in show in December, a cardiologist in Ivanovo told the prime minister that much of what Putin saw during a recent visit to a hospital there was faked for his benefit. Putin has also dropped in on some of Moscow’s less prestigious hospitals in a way that has highlighted their problems. Despite his apparent sympathy, Putin said in reply to Roshal’s comments last week that the big problem is figuring out where more money would come from. On Wednesday, though, Putin told parliament that Russia will spend about $50 billion over the next five years on its “demographic policy.” He said the government wants life expectancy to grow from the current 69 years to 71, the birth rate to increase by 25 to 30 percent and the mortality rate to drop. But he didn’t detail how that would be achieved. At the conference, Putin also said he is receptive, in theory, to Roshal’s proposal that medical workers be allowed more self-regulation, at the expense of the Health Ministry, although he described Roshal’s understanding of what was required as “naive.” At the same time, he praised Roshal’s commitment to solving Russia’s medical problems. “He is constantly criticizing the Health Ministry, which I actually can appreciate,” Putin said. “I wish there were more people in other sectors who, calmly and phlegmatically, kept picking away at problem spots.” ‘Intrusive flies’ For his part, Roshal said the ministry treats doctors who care about the quality of medical attention as “intrusive flies.” He complained about its rigid, illogical directives and asked Putin when the country will have a plan for reform. Putin replied that Russia has such a plan but that if Roshal was unaware of it, it clearly needs more promotion. He did not say what that plan entails. Danishevsky said he believes that Putin wanted to force health officials to hear Roshal’s comments because they are not generally receptive to outside opinion. “People are so frustrated that they’re not being listened to,” Danishevsky said. He said he hopes the incident leads to more open discussion of upcoming health legislation. 27 “This should be in the public domain,” he said. The prime minister’s Web site posted Putin’s comments from the medical conference, as well as the letter from the Health Ministry, but not Roshal’s remarks. “It is unacceptable to provoke conflict and breed alienation between us and our colleagues: doctors, nurses and other medical personnel,” the unsigned letter from the ministry said. “. . . Roshal’s hobnobbing and unrestrained behavior at the forum caused sincere bewilderment and derision, even if at first his remarks were not taken seriously. It was not until later that our colleagues in the regions reacted with condemnation.” 6 Health reform may boost medical office building market American Medical News 18/04/2011 By Victoria Stagg Elliott When Mercy Health Partners in Knoxville, Tenn., opened a medical office and diagnostic center in a former grocery store in South Knoxville, a big challenge was ensuring that people felt they were there for medical care and not a gallon of milk. "We want patients to feel like they are in a nice, safe and leading-edge medical environment, rather than in aisle three," said Melanie Robinson, the health system's director of business development. Mercy Ambulatory Care Center South is one of many medical office spaces either opening or in the planning stages as hospitals -- and real estate investors -- prepare for the growing number of people expected to become newly insured as health system reform takes effect. Hospitals are creating more space for physicians, though so far it appears practices are not preparing to expand. "Ambulatory care is more and more important," Robinson said. "We are doing our research now to determine where we will build next." Analysts said helping the market is the relatively large amount of prime commercial real estate available because of the stores that closed and the offices that vacated during the recession. Financing is becoming easier as the recession's credit crunch loosens its grip. In addition, the relative stability of the medical office building sector has attracted investors who are putting more money into this type of real estate or health care real estate investment trusts, or REITs. "REITS are strong players and looking to buy buildings," said Paul Heiserman, brokerage senior associate with the health care services group at Colliers International in Columbus, Ohio. Some of this space is on hospital campuses, but much of it is off campus, such as the Mercy project. "More physicians are now looking to be employed by the hospital, and a lot of the hospitals are moving these doctors into the community to expand their market share," said Chris Bodnar, first vice president and head of the national health care capital markets group in CB Richard Ellis' Denver office. "These retail centers that are being converted are more in the community and are places where people frequent." This means that physicians who own medical office buildings may discover more interest if they want to sell, especially if the space will be leased back to the practice, analysts said. Buildings with tenants tend to be more valuable than those without. Physicians are usually seen as attractive tenants because medical practices tend to move less frequently than other small businesses. "There's ... an immediate opportunity for hospitals and medical groups to monetize their real estate investments," said Bryan Lewitt, senior vice president of CB Richard Ellis' Southern California health care services practice in Los Angeles. The real estate services firm projects that significant new space will be needed. It estimated on March 16 that the state would need 7.2 million square feet of medical space to handle 3.1 million newly insured Californians. "These newly insured patients will need a place to receive medical attention, and currently the space does not exist," Lewitt said. "In this recovery, no industry is better positioned than health care to take advantage of the reduced pricing and lower lease rates available in the current market." A May 24, 2010, report by Marcus & Millichap, a national real estate services firm based in Encino, Calif., predicted that an extra 60 million square feet of medical office space would be needed nationally by 2019 because of health reform expansions. The impact of health reform on medical office buildings will be the subject of several sessions at the Building Owners and Managers Assn. International's Medical Office Buildings & Healthcare Facilities Conference on May 4-6 in Dallas. The significance of the Patient Protection and Affordable Care Act to real estate is a matter of debate. Many projections use two square feet per new patient as a multiplier to determine how much space will be needed. 28 "No one is sure where that number came from, and I don't think any of us really knows," said P.J. Camp, managing director of Shattuck Hammond Partners' New York office. Most experts agree that more outpatient medical office space will be needed. They also advise to start planning now because of time needed for projects. There is disagreement, however, about whether this will be new medical space or whether a significant amount will come from space conversion. "We're moving towards an ambulatory strategy, but we are rehabbing what we have got," said Neil Carolan, vice president and chief of physician development and real estate at Carondelet Health Network in Tucson, Ariz. Physicians are uncertain how health reform will affect their needs for space. Many in the real estate industry have noticed increased activity from hospitals but not physician practices. "Hospitals are moving forward with their plans to prepare for an increased demand for health care," Heiserman said. "Physicians have more of a watch-and-wait attitude and want to see exactly what happens. Small practices are being a little more conservative." Another complicating issue for physicians is that hospitals are acquiring medical practices at a faster clip, and it's unclear how a medical office building will be a part of the deal. "Will the hospital keep the physicians in the existing building or put them in a new building?" Heiserman asked. "Many physician practices are holding off from doing major projects." 7 Aging corps of midwives poses shortage Boston Herald 19/04/2011 By Christine McConville Gisele’s done it, and apparently, so have plenty of others. The number of nurse/midwife-attended births in Massachusetts more than doubled between 1990 and 2008, according to a new study from the Center for Women in Politics & Public Policy at the University of Massachusetts Boston. But with most of the state’s midwives now in their 50s, the study says the state needs a new crop of this specialized medical professional to keep the benefits that midwives provide. The study, which also found an increase in out-of-hospital births in the Bay State, lands at a time when legions of pregnant women are looking past the hospital room, and toward more traditional, less institutional places to give birth. For some, it’s the fear of an unnecessary Caesarean section. Others want the comfort of at-home water births, surrounded by friends. For others, it’s about cost. And then, there’s the huge disparity in infant and maternal health among different racial and ethnic groups. Christa Kelleher, a UMass Boston researcher who co-wrote the report, makes the case that certified nurse midwives play a big role in lessening these concerns. When looking to improve care, cut costs and ensure access to care, “policy makers and health care stakeholders should consider the significant contributions of midwives to the Massachusetts health care system,” she wrote. It’s been 33 years since nurse-midwifery was legalized in Massachusetts. It’s a highly specialized profession that requires advanced degrees. The report, “Caring for Women: A Profile of the Midwifery Workforce in Massachusetts,” which Kelleher wrote with Dorothy Brewin, an assistant nursing professor at UMass Lowell, found that midwives serve women at all stages of life. The study also shows that low-income women are more likely to receive health care from midwives. Most of the state’s midwives say “a significant proportion” of their service reimbursement comes through government-assisted health care, while safety net hospitals, which provide disproportionately more care to lower-income people, say 20 percent or more of their care comes from midwives. But the study also finds that at least one-third of Massachusetts midwives are looking to retire in the next decade. 29 9 Public review urged into intimidation of ER doctors Edmonton Journal, CA 14/04/2011 By Jodie Sinnema A review into the recent hospital death of a patient heaped blame on an emergency doctor, triage nurse and paramedics, but ignored the systemic problems of overcrowding and emergency room waits, says one of the most vocal physician advocates in the province. Blaming individual health staff continues despite rising public awareness and government promises to deal with systemic ER problems, and will prevent doctors from sharing crucial stories with Health Quality Council of Alberta, said Dr. Paul Parks, the Alberta Medical Association's section president of emergency medicine. His letter, warning of a "potential catastrophic collapse" of emergency care last fall, sparked government action. Parks is among thousands of provincial doctors calling for a public judicial review into concerns over alleged intimidation of doctors who speak up on behalf of patients. He also believes a closed-door review being done by the Health Quality Council remains vital to explain the state of emergency care in Alberta the past six years. "Our support of a call for a public inquiry is not about politics," Parks said. The emergency medical section "is calling for a public inquiry to ensure a similar culture of intimidation and the punishment of patient advocates never occurs again." So far, that hasn't worked well, he said. Alberta Health Services' acting CEO Chris Eagle is trying to change the culture of intimidation, Parks said. "Have they changed the culture? No." Parks said when he and 25 emergency doctors at the University Hospital decided to document 322 cases of bad patient outcomes due to long emergency waits in 2008, they purposely didn't record patient deaths because they feared they would be forced to individually explain why they didn't give faster care. "The other hospitals refused to document these cases because of the culture of intimidation and punishment," Parks said of other hospitals he tried to convince to participate in the documentation. "They were very certain they would be individually punished if they collected these cases." Parks said he faced that when a family wrote a letter wondering why their loved one, suffering from acute appendicitis, had to wait more than 12 hours for care without pain medication. Parks was called by hospital administrators to explain himself, even though they knew 70 per cent of emergency stretchers were filled with admitted patients, blocking beds for new patients and preventing speedy care. "The entire response was for me personally to be held accountable as to why I failed this patient," said Parks, who was writing letters at the time to senior health administrators and then-health minister Ron Liepert outlining the emergency crisis and calling for help. He said he will participate in the review being done by the Health Quality Council into those cases and will encourage other emergency doctors to do the same, though he suspects few will. "I think they'll do a good job," Parks said of the council's investigative team, some of whom he met Tuesday in Edmonton to discuss his concerns. "They'll be able to paint an excellent picture saying, 'This is what you guys were operating in, these were the issues they were facing. It was grossly undercapacity.' " A documented summary of data is essential, he said. "If we don't get a formal document out there showing what's happened in the last six years of the actual state of access and block, then there's a fear in six months from now, if there's a new (health) minister and a new CEO of AHS, do we have to start all over again?" That was necessary when he had to brief Health Minister Gene Zwozdesky on the issue last fall, even though his predecessor had been alerted years earlier. Parks said a public inquiry is also needed to give doctors "herd immunity." "If 20, 30, 40 physicians come forward publicly (under a judicial inquiry) and discuss the same concerns and the same issues, it would be impossible to discredit every single one of those physicians and say, 'Your care was suboptimal. You made mistakes,'" Parks said. "A public inquiry is going to be a painful process." A judicial inquiry is also needed to make sure the public finds out what actions senior officials took three years ago when they were first made aware of the problem through monthly updates from emergency doctors, Parks said. 30 The Health Quality Council can't compel government officials, such as Liepert, or former Capital Health administrators, such as former CEO Sheila Weatherill, to explain what they did when Parks and other emergency doctors warned of patients having strokes, not getting pain medication or having seizures while waiting too long for emergency care. Even if they voluntarily told their stories, people will never know if they told the Health Quality Council useful information or simply said they don't remember the details, Parks said. The entire process is behind closed doors and the final report won't detail who testified or what they shared but will provide a summary and recommendations. "The only way you're going to get meaningful change is a public airing," he said. While a judicial inquiry will cost millions more and could take years to conclude, Alberta Health Services could make meaningful changes in the system in response to public testimony in real time, Parks said. Dr. John Cowell, executive director with the Health Quality Council, said he has reassured Parks his investigative approach is solid and will provide safety to doctors with complete confidentiality. Cowell wasn't at Tuesday's meeting. 10 Who cares for the caregivers? The Province, CA 17/04/2011 By Paul Luke B.C., for now, has enough workers to care for its growing mass of seniors -but keeping those workers is another matter. A report released today identifies worker retention as the biggest challenge for employers in the private and non-profit stream of elder care. Turnover among nurses, residential aides and community workers is a costly problem affecting the well-being of seniors and workers, according to a draft of the report by the B.C. Care Providers Association. "Turnover in residential care and home care is impacting the cost, acceptability and safety of seniors care," warns the report, called Planning, Attracting, Engaging and Sharing Knowledge. "An unstable work environment will impact the ability of sector employers, especially those in home care, to compete for a shrinking labour force to provide safe and high-quality care for B.C.'s aging population." In other words, the sector could get into a labour crunch if it can't get its recruitment-and-retention act together. It's not only seniors who would then suffer -it's employees staggering under mounting workloads. "We want to ensure that people who enter the field will remain in the field," association CEO Ed Helfrich said in an interview. "If we can't retain them, we'll have a supply problem." The cost of turnover is estimated to average $4,100 per permanent worker -a big hit for employers with lean profit margins, Helfrich said. The private and non-profit side of the seniors care sector employs about 14,000 people, according to the study. Its workforce consists of community health workers (CHWs), residential care aides and licensed practical nurses (LPNs). When these people quit a job, where do they go? Some retire, others move from home to residential care, some find better-paying jobs with provincial health authorities. Others abandon the sector. The casual nature of much of the work in the sector, which comes without guaranteed hours of work, is a big contributor to turnover, according to the report. Fifty-eight per cent of new home support hires in the past 12 months were casual workers. An estimated 43 per cent of residential-care aides work on a casual basis. For people entering the care field with unrealistic expectations, casual work can come as a blow. "Employees who have finished training at community college may expect to move into a full-time position immediately and are unaware that they may have to take temporary positions in the short term," Helfrich said. "If they were unaware of that, often they'll leave the sector." The report found that employers have a "low" level of commitment to community health workers, with lastminute shift changes and split shifts commonplace. 31 "A clear tension exists between the provincewide desire to provide consistent, high-quality care to B.C.'s seniors and the economic pressures to lower labour costs, often through casual employment," the report said. "CHWs often work mere two-hour shifts. Making a living as a CHW is undeniably difficult." In an occupation has low barriers to entry and exit, it's easy for CHWs to leave a job if making a living becomes too difficult, the report said. Those who stay do so because they like working with seniors. "They're a special breed of people who aren't in it for the money as much as for a love of people and caring for them," said Bob Attfield, western Canadian regional director for We Care Health Services. The report offers more than 20 suggestions, mainly for improving retention and reducing turnover. Underlying many of those suggestions is the need to better align workers with their passion for caring. Attfield, whose company provides home care and support from 14 locations across B.C., endorses a recommendation for more "cluster care" opportunities for workers. This approach "clusters" the care for groups of seniors living near each other, often in the same building. Rather than driving long distances between clients, workers get to spend more time with them. Workers operating within this model are more satisfied and have fewer injuries and sick days, the report said. Attfield said scheduling innovations such as cluster care give workers more predictability. "If people are working in a neighbourhood, there's a greater likelihood of getting regular work as opposed to more fragmented work," Attfield said. "If cluster care helps provide them with more guaranteed hours of work, it would help to meet their financial expectations and reduce turnover." Back to top Europe 1 Stillbirths: the professional organisations' perspective The Lancet, UK 14/04/2011 doi:10.1016/S0140-6736(10)62357-4 Gamal I Serour a, Sergio A Cabral b, Bridget Lynch c The International Federation of Gynecology and Obstetrics (FIGO), the International Paediatric Association (IPA), and the International Confederation of Midwives (ICM) are well aware of the often forgotten issue of stillbirth, and recognise it as one of the most common adverse pregnancy outcomes worldwide—with about 2·6 million or more stillbirths happening every year.1 The explanation for many of these deaths is straightforward and terrible: all too often a trained health worker is not available when an expectant mother or woman in labour faces a situation endangering her baby's life. When confronted with a stillbirth, obstetricians, midwives, and paediatricians have to contend not only with the loss of life, but also the distress of parents and disappointment of family at a time that should be joyous and about bringing a new life into the world. Furthermore, the outcome of the next pregnancy is often a major concern for parents, because a previous stillbirth is, depending on the population, associated with a two-fold to four-fold increased risk2—4 of recurrence compared with women who have had a previous livebirth. Additionally, risk of pregnancy and birth complications in the subsequent pregnancy is heightened.5 Maternal and fetal outcomes at birth are a sensitive indicator of the status of health systems. They show the quality of care that is available to manage maternal and fetal life-threatening complications, which are often unpredictable and need a rapid, skilled response and access to tertiary emergency obstetric services, including well coordinated teamwork between obstetricians, midwives, and paediatricians. Access to such services in 33 of 51 Countdown countries is poor, resulting in rural coverage rates for caesarean section below 5%, which are indicative of challenges to human resources and other health systems. Four countries, Burkina Faso, Chad, Ethiopia, and Niger, have rural rates below 1%.6 Only 15 Countdown countries meet the crucial threshold of 23 doctors, nurses, and midwives per 10 000 people. These numbers are estimated to be necessary to ensure that 80% of all births have assistance from a skilled attendant to deliver essential health services.7 This shortage is compounded by uneven geographical distribution of these health-care workers within countries.8 FIGO's mission to improve women's health, rights, and access to reproductive and sexual health services, and reduce disparities in health care for women and newborn babies places prevention and management of stillbirth in the centre of its interest and activities.9 The ultimate goal of obstetricians, midwives, and paediatricians is that every pregnancy is wanted, every birth safe, every newborn baby healthy, and every woman, including adolescents, treated with dignity and respect. In cases of stillbirth, obstetricians, midwives, and paediatricians face the psychological and emotional issues arising for women, their partners, and families. Unfortunately, many of these women and couples do not receive comprehensive counselling about the reasons behind the stillbirth, the potential for it to recur, and how to prevent it in a subsequent pregnancy. Because a definitive cause cannot be identified in about half of cases,2 stillbirth baffles obstetricians, midwives, neonatologists, and paediatricians, making counselling very difficult, even in developed countries where 32 advances in socioeconomic standards and high-quality antenatal and intrapartum care have contributed to reduced rates. Obstetricians, midwives, and paediatricians should be pleased that The Lancet has published a Series on this important health issue. We believe that FIGO, IPA, and ICM have a major part to play in saving the lives of millions of stillborn babies worldwide, especially in developing countries. We must also address the distress of millions of couples who are affected. At the microlevel, obstetricians, midwives, and paediatricians can contribute to important measures such as advocacy, health education, high-quality health-care services during pregnancy and childbirth, including addressing the leading causes of stillbirths, and access to emergency obstetric care when needed. We must also work together to provide proper informative and supportive counselling of parents of a stillborn baby. At the macrolevel, these three organisations can make a difference through advocacy, partnership with UN and other organisations, training and education, capacity building of member associations to provide high-quality maternal and neonatology care, and task shifting when specialists are in short supply.10 GIS is the President of FIGO, SAC is the President of IPA, and BL is the President of ICM. References 1 Cousens S, Stanton C, Blencowe H, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet 201110.1016/S0140-6736(10)62310-0. published online April 14. PubMed 2 Herring A, Reddy U. Recurrence risk of stillbirth in the second pregnancy. BJOG 2010; 117: 1173-1174. CrossRef | PubMed 3 Sharma PP, Salihu HM, Kirby RS. Stillbirth recurrence in a population of relatively low risk mothers. Paediatric Perinat Epidemiol 2007; 21 (supp 1): 24-30. PubMed 4 Bhattacharya S, Prescott G, Black M, Shelty A. Recurrence risk of stillbirth in a second pregnancy. BJOG 2010; 117: 1234-1247. PubMed 5 Black M, Sheltie A, Bhattacharya S. Obstetric outcomes subsequent to intrauterine death in the first pregnancy. BJOG 2008; 115: 269-274. CrossRef | PubMed 6 WHO, UNICEF. Countdown to 2015: decade report (2000—2010). Taking stock of maternal, newborn and child survival. http://www.countdown2015mnch.org/documents/2010report/CountdownReportOnly.pdf. (accessed Jan 16, 2011). 7 WHO. Working together for health: the world health report 2006. http://www.who.int/whr/2006/whr06_en.pdf. (accessed Jan 16, 2011). 8 WHO. Global health atlas. http://apps.who.int/globalatlas/default.asp. (accessed Jan 16, 2011). 9 Serour GI. A vision for FIGO 2009—2012. Int J Gynaecol Obstet 2010; 108: 93-96. CrossRef | PubMed 10 Serour GI. Brain drain. Int J Gynaecol Obstet 2009; 106: 175-178. CrossRef | PubMed a International Islamic Centre For Population Studies and Research, Al Azhar University, Cairo, Egypt b International Pediatric Association, Estacio de Sa University, Rio de Janeiro, Brazil c Canadian Association of Midwives, Montréal, Québec, Canada 2 Shershah Syed: improving maternal care in Pakistan The Lancet, UK 16/04/2011 Volume 377, Issue 9774, Page 1309 Kelly Morris Each year at Koohi Goth Women's Hospital, Karachi, Pakistan, obstetrician-gynaecologist Shershah Syed and his team operate in their spare time to treat more than 1000 patients with vaginal fistulae—a highly debilitating, distressing, and hidden result of complicated labour and stillbirth. As Syed explains “Safe motherhood includes providing emergency obstetric care and working to prevent maternal deaths, stillbirths, and fistulae.” Syed recalls how “I had never seen a maternal death or a chronic fistula until I returned to Pakistan after overseas postgraduate training”. Witnessing the complications of childbirth that women in Pakistan endured had a profound effect on him: he abandoned his plans to establish a private infertility clinic and, in 1994, headed to Ethiopia to train in vesico-vaginal and recto-vaginal surgery at the Addis Abbaba Fistula Hospital. Since then, he has remained in Pakistan providing obstetric care to impoverished women. The Lancet spoke to Syed after his Sunday fistula list, and just before the premier of Every Woman is Priceless, a play written by Shema Kirmani for Koohi Goth Women's Hospital to create awareness about maternal death. In addition to Koohi Goth Women's Hospital, Syed works at the Qatar Hospital in Oranji, a Karachi slum where some 3·5 million people live. But he is characteristically humble about his many contributions in clinical practice, training and education, and fundraising and campaigning for women's rights, safe motherhood, and the need for emergency obstetric care. “Shershah has always been a great advocate for women's causes. His unbelievable stamina and ability to speak his mind against all odds are admirable”, says Shereen Bhutta, professor and head of the Department of Obstetrics and Gynaecology at Jinnah Postgraduate Medical Centre, Karachi. 33 Syed says that his priority is “to train more community midwives, nurses, and doctors to help improve maternal care”. These health professionals are vital to deliver safe motherhood and prevent stillbirth and complications such as fistula in Pakistan. “Safe motherhood cannot be improved without an army of trained midwives. We need at least 150 000 skilled midwives who should work in villages”, Syed urges. But, he continues, “90% of our midwifery schools have no trained faculty and our system has failed in producing resource material”. This problem is compounded by the way that “many well-trained, competent midwives leave the country quickly—often actively recruited by richer countries—while midwives who remain are often poorly trained”, he says. Established almost 4 years ago, with help from the United Nations Population Fund and Syed's family, Koohi Goth Women's Hospital now has a maternity unit and schools for training midwives and nurses. Syed and his colleagues have also translated and produced books on midwifery in Urdu and Sindhi and have now established the first unit in Pakistan to train nurse midwifery tutors. For Syed, education and women's rights are at the core of his values and his background. Born into a Karachi slum, he was strongly influenced by his schoolteacher father, a follower of Mahatma Gandhi in India. Syed's father was a strong proponent of education for women and girls, so he supported his wife's education. By the time Syed's mother was about to qualify as a doctor, his oldest brother had started medical school. His mother's income then enabled Syed and the rest of his seven siblings to attend medical school. All went overseas for further training and all returned home to work, and have married doctors. Now, Syed has 36 doctors in his immediate family, including his paediatrician wife, with whom he has a 5-year-old daughter. As a young man, Syed wanted to be a journalist, but his father insisted that the primary qualification in the family was MBBS. On his third attempt, Syed passed the exam for medical school, intending to do a master's degree in journalism afterwards. But he became interested in medicine, and after he left Pakistan to avoid military service, he developed a career in obstetrics and gynaecology in Kenya, Ireland, and the UK, before returning to practise in Pakistan. Yet his interest in journalism remains and alongside his medical career Syed writes Urdu short stories that reflect life in Pakistan's poor communities and contributes regularly to the Daily Dawn newspaper about safe motherhood, women's rights, and against nuclear proliferation. Working in the front line, and as representative of the Pakistan Medical and Dental Council, Syed is outspoken about problems with postgraduate medical training in Pakistan and the role of the medical elite who promote sophisticated and expensive medical technologies and treatments. He believes that these priorities are wrong. “Isn't it crazy? Isn't it shameful that a country with the atomic bomb, F16s, and a large army, is not able to control polio and its women are dying like flies and its children work on the roads rather than going to school? And, if the basic investment is wrong, how will things ever improve?”, Syed asks. “The tragedy is that the government understands the situation but has no will to act. I don't see in the near future that the government is going to organise emergency obstetric care or do anything about MDG5”, Syed told The Lancet. Yet he finds hope in his efforts with colleagues to improve maternal health: “If I train one midwife from a poor community, she may save one woman's life, and her income will also improve her situation and the situation for her family.” 3 Community Health – Fashion or Function? ISN ETH-Zurich 20/04/2011 The 1980s witnessed a proliferation of community health worker programs that subsequently declined in the 1990s as donor funding was directed to vertical programs with specialized workers. With global health funding flows tightening once again, community health workers are gaining resurgent attention as the panacea for human resource shortages - but can they really be the hoped for cure-all? By Cynthia Schweer for ISN Insights The shortage of healthcare workers now stands at more than four million globally. The WHO estimates that 57 countries, most in Africa and Asia, face critical shortages which hinder their ability to meet the Millennium Development Goals and provide basic primary health services. With long lead times for training and development, as well as structural inefficiencies in health worker placement (migration, for example), this gap will not be filled by physicians and nurses quickly or cheaply. Health worker shortages have caused many countries, donors and implementers to scramble for human resources to fill the void. In particular, the rollout of treatment for HIV/AIDS in sub-Saharan Africa has underscored the need for quick yet sustainable human capacity in health systems. Looming funding shortages have shifted any expectation that resources will be available for costly and long-term solutions. In this context, Community Health Workers (CHWs) have re-emerged as a solution to the workforce crisis. Recent evidence has shown that CHW programs can significantly improve health outcomes in countries with the most critical shortages. Global and country policymakers have lauded the approach as cost effective and called upon health systems to delegate tasks to lesser skilled workers including CHWs (known as 'task-shifting'). However, CHW programs vary considerably by country and program. Is the CHW renaissance merely fad, or truly functional? Definitions and controversies Community Health Workers (CHWs) are not a new phenomenon. Barefoot doctors emerged in China in the 1950s and became a national program in the 1960s, to wide acclaim. The Alma Ata Declaration of 1978 then put CHWs on the global policy stage by highlighting their contribution to the health workforce. The 1980s 34 witnessed a proliferation of programs as population health programs became popularized and the sheer scope of public health overwhelmed the existing, traditional workforce. Community health programs have struggled to define the CHW role, which has caused some of the controversy around their deployment. Much of the literature defines a CHW as a multi-disciplinary health advocate, chosen by the community, working exclusively in the community in which they live. This strict definition has often been loosened by program designers and policymakers to include any lay worker who is working in facilities or communities in a health capacity. This wide ranging application of the term has led to confusion, most tellingly amongst community members and health professionals. The WHO has recently released a typology of CHWs, which may help to clarify the situation. Training duration and supervision also vary significantly. In Brazil, where CHWs, or 'Community Health Agents,' provide comprehensive services to half the Brazilian population, CHW training includes a two-month residential course and one month of field work. They are supervised by a nurse and operate as a family health team. By contrast, CHWs in Kenya receive three weeks of training, are responsible for just a small subset of health issues and are supervised by field staff. Payment and incentives are also a source of much divergence. Programs and policies range from voluntary roles to - although rare - salaried workers. Studies have found that a mix of financial and non-financial incentives is best suited to motivating workers. However, programs may try to cut costs by limiting compensation to CHWs, compromising the effectiveness of incentives andpossibly even undermining the role. In a high-profile case involving 'Lady Health Workers' in Pakistan, a six-month delay of salaries hindered the roll-out of the country's anti-polio campaign. The disparity in program quality has led to under-representation of successful CHW programs or, at the opposite end, hype about programs that are less-than-effective. The risk is that CHW programs will be dismissed as a "human resource flash-in-the-pan", as one study quipped. What matters? Policy and programming A recent report by the WHO provides a comprehensive assessment of the evidence supporting CHW programs and outlines recommended policies derived from the literature. Key among these recommendations is that "programs should be coherently inserted in the wider health systems." But this is easier said than done. Since CHW programs are often donor-funded, implementation by multiple stakeholders and the resulting lack of integration into government employment cadres and training platforms often results in fragmentation. The WHO goes on to recommend that "CHW programs should also ensure a regular and sustainable remuneration package that is complemented with other rewards and incentives" and that "programs should have regular and continuous supervision and monitoring systems in place". Systems for compensation and supervision do not come cheaply, lessening the possibility that CHW programs are a 'cheap fix' for human resource challenges in healthcare. These recent WHO recommendations represent two key points for policymakers and implementers. First, CHW programming, which has classically been separate from facility care, is now being promoted as an integrated component of health systems. Rather than acting as a second-class supplement to facility care, CHWs are seen to play a role in creating linkages for healthcare from facility to community. Second, and related, the CHW role is being 'professionalized', through higher standards for training, supervision and remuneration. No silver bullet, but a component of care Increased exposure and recognition of CHW policies and programming is a welcome addition to the human resources for health dialogue. However, it is important that CHWs do not get classified as a "cheap and easy" solution to the health worker shortage. Integration of CHWs into national health systems, and the corresponding necessity of sustainable remuneration, supervision and training platforms, requires careful and sustained planning and funding. The emerging consensus is that CHWs can make a significant contribution to health outcomes in cases where considerable investment is made in policy and program design. Community health workers are not a panacea for the health worker shortage, but, with careful planning and implementation, they can be a successful solution to bridge the human capacity gap in resource-constrained countries. Cynthia Schweer is a consultant and writer specializing in global health, public policy and scalable models for positive social change. She is based in Cape Town, South Africa and is the lead blogger for Global Health on the Foreign Policy Association's Foreign Affairs Blog Network (http://globalhealth.foreignpolicyblogs.com). 4 How the government's immigration cap squashes the NHS The Guardian, UK 19/04/2011 Cath Everett Although the NHS has struggled to fill some clinical positions for a while, some now fear that the coalition government's immigration cap could lead to skills shortages of such severity that they will impact frontline services. 35 The UK Border Agency followed up the introduction of a temporary immigration cap in July last year with a permanent one on 6 April this year. This means that UK employers are now limited to recruiting 20,700 nonEuropean Union workers in skilled professions under tier 2 (general) of the UK's points based system. The old tier 1 (general) category for those without firm job offers has been abolished completely. Tier 2 staff who are paid between £24,000 and £40,000 a year to work in a graduate-level job will be allowed to stay in the country for no longer than 12 months, at which point they have to leave and cannot re-apply for a further 12 months. Those paid £40,000 or more can remain for an initial three-year period, however, with the possibility of extending it for a further two. But the clampdown has raised concerns that the NHS, which has a workforce of 1.4 million people in England alone and has relied on migrant labour since its inception in 1948, will start suffering acute skills shortages over the next 18 months. According to NHS Employers, a third of all medical staff that the health service employs were qualified overseas, while NHS specialist Your World Recruitment indicates that about 20% of the locums (temporary personnel) that it has on its books are non-EU nationals. They come mainly from Australia, New Zealand and South Africa due to linguistic and cultural similarities, and their placements generally last for an average of two years. But Dylan Morgan, group business development at the firm, indicates that budget cuts and the uncertainty faced by the health service as a result of the government's proposed reorganisation meant that "the flow of staff peaked about 12 to 18 months ago". Skills shortages are currently not acute beyond certain key professions such as midwives, community nurses, sonographers and echocardiographers that have struggled to hire in adequate numbers for a few years. But Morgan believes that demand, "exacerbated by a cap on highly skilled workers", will come back strongly in the next 12 to 18 months. "The requirement for frontline care is as big as ever and it won't go away," Morgan says. The cap doesn't fit Tom Hadley, head of policy and professional services at the Recruitment and Employers Federation (REC), agrees. He likewise fears that the immigration cap will generate "real pressure in the short-term" which, as a result, "is likely to hit on frontline services". However, not only does it take significant periods of time to train British clinicians to take over from overseas workers, but the UK is facing significant competition from overseas due to a global shortage of medical staff, which is estimated to amount to around half a million vacancies at any one time. As an indication of the scale of the challenge, the winter 2010-11 Labour Market Outlook report published by the Chartered Institute of Personnel and Development (CIPD) and management consultancy KPMG showed that about 46% of employers reported difficulties in filling vacancies for doctors and 43% in hiring nurses. As a result, two out of five respondents said that they planned to continue recruiting migrant workers during the first quarter of this year, even though 36% felt that the immigration cap had had a disproportionate impact on them compared with the private sector. To make matters worse, however, many non-EU personnel who are already working in the country are finding that their visas are running out, according to Gerwyn Davies, the CIPD's policy adviser, causing big problems over the next couple of years. "The advent of cap restrictions being placed on those who are here and the probability of them staying as the NHS tightens its settlement criteria will lead to an equally bad situation if not worse," he adds. Another concern is that many employers are already starting to cut back on locum personnel as they gear up for cuts in their wider staffing budgets, a situation that is putting increasingly levels of pressure on employees who are already stretched. "I'm starting to see a slightly worrying picture of hospitals that are already understaffed and starting to struggle. We're already starting to see shortages of workers with necessary skills such as radiologists and anaesthetists so there's pressure on the frontline now. But there'll be real pressure in the short-term," the REC's Hadley says. There is a particularly acute problem among community and practice nurses, one in five of whom are over 55, meaning that many will retire over the next few years. A similar situation may occur in other only professions as a result of the UK's ageing demographic, although the removal of the default retirement age in the autumn is expected to stem the flow of Baby Boomers beginning to leave the workforce. Wilkommen, bienvenue, welcome So what NHS employers can do about this? The most obvious solution is to introduce targeted recruitment drives to potential workers elsewhere in the European Union - although this has traditionally been a less attractive option due to language barriers and differences in training. Due to what the CIPD's Davies describes as an "international war for talent", such activity may have to become more sophisticated than simply advertising in the local trade press. But potential options here include the use of social media or the milk rounds traditionally employed by large corporate in order to attract the best graduate talent. 36 There are other possibilities to get the most of existing staff, including the introduction of e-rostering systems to allow the creation of pools of workers, who can be redeployed when and where required. The implementation of flexible resourcing policies, such as those used by NHS Direct, could also prove useful, not least to cater to the needs of older staff members, who may not wish to work full-time but could be interested in ad hoc assignments or a range of part-time options. But given the importance of non-EU staff to the NHS, employers should also start planning their short, medium- and long-term staffing requirements, then actively engaging with the UK Border Agency's migration advisory committee, to ensure it is aware of which roles should be excluded from the cap before it makes its recommendations to the government. As Your World Recruitment's Morgan concludes: "What this boils down to is that there may be long-term vacancies in the NHS that simply can't be filled and it's not a situation that the health service wants to find itself in, particularly if there are suitably qualified candidates from outside the EU with the right experience available." 5 Impoverished Afghans shouldering burden of health care Reuters 17/04/2011 By Rob Taylor (Reuters) - Afghanistan's government and foreign donors spend barely $10 a person on health, despite pointing to it as key to winning back support against a worsening insurgency that has dragged on for nearly a decade, a study said Sunday. The other $31 per person that makes up the country's meager health spend comes from Afghans themselves, many of whom struggle to provide doctors and drug care for their families from the $426 per capita they earn each year. "High expenses pose severe barriers to accessing healthcare, particularly for the rural poor. Catastrophic payments in particular can push households into debt," the study said. The two-year study provided the first ever snapshot into spending within the rudimentary health system, and aid donors said the information should help improve health quality in a nation where life expectancy is only 44 years. Acting Health Minister Suraya Dalil said the study would also help President Hamid Karzai's government fight corruption in the health system, which in turn could improve public trust in the U.S.-backed administration, dogged by frequent accusations of widespread wastage and graft. "How money is spent is just as important as how much we spend. More money is needed to overcome Afghanistan's health challenges," Dalil said at the study launch. The report found Afghanistan spends close to 10 percent of its GDP wealth each year on health, or just over $1 billion. But that amounted to only around $42 per person on health services, well below even regional neighbors like India, Pakistan and Iran. Wealthy nations average around $3,060 per head, according to World Health Organization figures. Afghan government spending supplied only 6 percent of total health financing, while donors provided 18 percent and private sources accounted for 76 percent. Most of that burden was met by households in a nation where 10.5 million people -- 42 percent of the population -- live below the national poverty line of earning $1 a day or less. "This type of spending is disconcerting and unsustainable," the report said, calling for policy changes including increased government spending and community-based health finance schemes. Afghanistan's health system is one of the world's worst, a decade after the U.S.-backed overthrow of the Taliban, with life expectancy roughly 10 years lower than sub-Saharan Africa. Maternal mortality, estimated at 1,400 deaths for every 100,000 live births, is the highest in the world, while infant and under five mortality are estimated at 111 and 161 deaths per 1,000 births respectively. But the health accounts showed only two percent of total health spending went to maternal and child health improvement. Ordinary Afghans want peace, but they also want improved governance, and better health and education services, according to humanitarian agencies working in the country. 37 In provinces heavily affected by fighting, like the Taliban strongholds of Helmand and Kandahar in the south, U.S. and NATO troops have been building schools and health clinics in hopes of denting public backing for the insurgency, but there has been less spending in more peaceful areas. Dalil said the expenditure snapshop would help the government direct money in future to where it was most needed, including cutting child and maternal death rates. 6 HSE says up to 400 junior doctor posts may be vacant Irish Times 18/04/2011 EITHNE DONNELLAN UP TO 400 junior doctor posts across the State could be left vacant in July due to a shortage of applicants for the jobs, it has emerged. In a briefing last week, senior Health Service Executive officials confirmed to the Irish Hospital Consultants Association that there had been about 950 applicants for its recent centralised competition for junior doctor posts, leaving it potentially short of 300-400 doctors. Junior doctors or non-consultant hospital doctors (NCHDs) usually rotate posts every six months as part of their training. Since the last rotations in January, there are around 150 posts vacant. Donal Duffy, assistant secretary general of the consultants’ association, said however the latest figures indicated the problem of trying to fill posts was getting worse. “What is most worrying this time round is the training bodies are unable to fill the training posts they have in a range of specialities,” he said. Traditionally recognised training posts would be first to be filled, with so-called service posts not recognised for training always proving more difficult to fill. The HSE hopes to fill some of the gaps through a recruitment campaign in India and Pakistan. However, Mr Duffy said that even if doctors were recruited from there in the coming months it would take time for the Garda to vet them and register them with the Medical Council. This meant it was unlikely they would be ready to take up jobs on July 1st. “We are facing a situation where hospitals are going to be short NCHD staff in July. That will clearly have an impact on services. There will be some hospitals much more adversely effected than others.” Already it looks like Letterkenny General Hospital is particularly short of applicants. There are also worries about a shortage of applicants for posts at the Mid-Western Regional Hospital in Limerick and for mental health services in Kerry. Mr Duffy criticised the HSE for not beginning the centralised recruitment process earlier and said there were problems with the online process that required applicants to indicate their preferred speciality and hospital. This meant a doctor applying for a post from abroad could register an interest in getting a job in neurology in Mayo when in fact no such post existed, he said. The national council of the consultants’ association, at its monthly meeting on Saturday, expressed concerns about difficulties in retaining and recruiting hospital consultants. “Any further decline in medical staffing will undermine the safety of the public health services and its capacity to treat patients,” Mr Duffy said. “These much-sought-after doctors are now working in other countries where their talents are more valued or are simply retiring early.” A HSE spokeswoman said the shortage of junior doctors was a worldwide problem. She said the HSE was working with the Irish Medical Organisation, the consultants’ association and the Medical Council to find solutions. “There are more doctors working in the Irish healthcare system now than previously,” she said. “We have had a 25 per cent increase in the number of consultants since 2005.” 7 NHS children's care at risk through lack of well-qualified doctors and nurses The Guardian, UK 21/04/2011 Sarah Boseley 38 Children's lives are being put at risk by failings in hospital care where the service is being run by crisis management because there are not enough well-qualified doctors and nurses, paediatricians have warned. A radical blueprint for improving children's care from the Royal College of Paediatrics and Child Health urges greater specialisation – with a 50% increase in consultants and many more children's nurses and GPs with paediatric experience. It warns that acute children's units are functioning with "dangerously low levels of staff". Trainees are left in charge of wards because there are too few consultant paediatricians. Consultants are forced into unscheduled overnight stays because there is nobody else to take over. Yet the number of children arriving at accident and emergency has been soaring, possibly because too few GPs have training in children's medicine and they do not spot problems early. Children's care has long been regarded as a Cinderella service within an NHS that is orientated towards adults, and there is growing evidence that in mainland Europe and elsewhere, children get a higher priority and better care – often seeing specialists from the outset instead of a GP. Professor Terence Stephenson, president of the college which is launching an ambitious report aimed at reshaping children's hospital services, says the solution is not only more consultants but also fewer children's acute hospitals, in order to concentrate services. While he recognises the political sensitivity of closing or amalgamating hospitals, he says there are 220 children's hospital units in the UK, of which a third are not compliant with the European working time directive that no doctor should work more than 48 hours a week. "The public are probably not aware that that's being solved by crisis management, particularly during midwinter with things like flu, with consultants stepping in overnight or employing locums at the last moment. I'm sure the public is not aware of this. "Because it's difficult to find individual cases where you can say this child died or that was harmed, people can ignore all that and say we want our local hospitals." A year ago, an inquiry into the unexpected deaths of three children at two Birmingham hospitals said more consultants and specialist nurses were needed at the Good Hope and Heartlands hospitals. "I always say to people if you were to fly EasyJet tomorrow would you prefer to fly with a fully-trained pilot or a trainee? They don't have to think about that too long," said Stephenson. "We're suggesting children in the UK need to have a service that is predominantly staffed by fully-trained consultants." 8 Israeli doctors cancel elective surgery in dispute over pay British Medical Journal 14/04/2011 BMJ 2011; 342:d2433 doi: 10.1136/bmj.d2433 (Published 14 April 2011) 1. Judy Siegel-Itzkovich + Author Affiliations 1. 1Jerusalem The Israel Medical Association has declared a dispute with the government over pay, and members have cancelled elective surgery for several days, 11 years after the association agreed to a no strike clause. It is also calling for the healthcare system to be reorganised and given substantially more state funding. The association gave up the right to strike in exchange for arbitration in a dispute over its salaries contract in 2000, at the end of a 127 day stoppage. But it has become frustrated with the present deadlock after “intermittent” talks with the Treasury. So far the government has not offered any pay rise across the board. The Treasury claims that the “average” doctor earns “enough,” at the equivalent of $84 000 (£52 000; €58 000) a year. The association points out that although some senior doctors earn much more than that, some young doctors earn close to the national minimum wage, despite working long hours, including at nights and weekends. Many senior doctors boost their income by working in private clinics and hospitals, while others provide private medical services inside public hospitals. This only occurs in Jerusalem, however, because elsewhere such arrangements are illegal. The association also says that retired doctors’ pensions are low, as they are calculated from basic wages without overtime and other special benefits. Another point of contention between the association and the government is the requirement for doctors to “clock on” to prove that they are working and not “moonlighting.” The association, which represents more than 20 000 doctors, says that this is inappropriate to their profession and says that cheating is rare. The government is willing to offer a pay rise only to younger doctors and those working in the less attractive periphery of the country, where private work is hard to find. This would result in differential salary rates. 39 During the 2000 strike only urgent treatment was provided. The association is aware that patients wanting elective treatment may try to access the country’s burgeoning private medical centres, even though such treatment is expensive. Leonid Eidelman, the association’s chairman, said that Israel’s proportion of 43% of health expenditure on private treatment was too high and that such a large private sector would create a “two tier system,” one for rich people and one for poor people. Notes Cite this as: BMJ 2011;342:d2433 9 Dans les déserts médicaux, les retraités restent actifs Le Monde, France 15/04/2011 Laetitia Clavreul Les anciens enseignants reviennent dans les classes jouer les remplaçants, faute de bras. Du côté des médecins aussi, l'idée fait son chemin. Déjà, le nombre de médecins « retraités actifs » a augmenté. Rien qu'en un an, de janvier 2010 à janvier 2011, il est passé de 5 600 à 7 326, selon le conseil de l'ordre. Certains prennent leur retraite mais ne ferment pas leur cabinet pour autant, d'autres, surtout, deviennent remplaçants. Ils travaillent toujours, juste un peu moins. Bien sûr, il y a ceux qui y trouvent un intérêt financier. Ceux aussi qui ne veulent pas arrêter brutalement, après une vie active intense. Mais désormais, il y a aussi ceux qui poursuivent leur activité par « civisme », « pour rendre service ». « Dans les déserts médicaux, mais aussi pratiquement partout aujourd'hui, les professionnels sont débordés. Ils savent donc qu'à leur départ, les patients auront du mal à trouver un nouveau médecin s'il n'y a pas de successeur sur le cabinet », explique le docteur Patrick Romestaing, chargé de la démographie à l'ordre. C'est le cas du docteur Christian Roget, généraliste à Barcus, un village des Pyrénées-Atlantiques de 800 habitants. A 62 ans, il souhaitait « lever le pied », et avait toutes ses annuités en poche pour prétendre à la retraite. Sans successeur, alors que dans les cantons de cette zone de montagne les médecins se font partout moins nombreux, il a jugé impossible de fermer son cabinet. « Je suis le seul médecin à Barcus, je ne pouvais pas abandonner les patients », explique-t-il. Le docteur Roget a activé sa retraite en janvier. Il exerce toujours autant, mais compte passer peu à peu de six jours de travail par semaine à quatre. Il arrêtera quand une solution pérenne et globale aura été trouvée pour l'ensemble des environs, car il le sait bien, aucun médecin n'acceptera plus de s'installer, seul, dans le village. « C'est symptomatique. Avant, dans les réunions entre confrères, on échangeait sur les cas que nous rencontrions. Aujourd'hui, on parle de la retraite et on compte les médecins qui s'apprêtent à partir », dit-il. « Cela fait pourtant longtemps qu'on voyait venir cet échec de la politique de santé », ajoute le docteur Roget. Jacqueline Fayat-Picard, psychiatre, 64 ans, exerce en ville, à Toulouse. Pourtant, elle se retrouve dans la même situation. « Mes confrères sont débordés. Je savais que si j'arrêtais, mes patients auraient des difficultés à continuer à se faire suivre, explique-t-elle. Certains risquaient d'arrêter les soins ou de ne consulter qu'en cas de crise, et ainsi d'encombrer les urgences. » Depuis qu'elle a activé sa retraite, en septembre 2010, cette psychiatre exerce à mi-temps. Elle ne prend plus de nouveaux patients, sauf en cas d'urgence, et compte ainsi réduire peu à peu leur nombre. Elle commence aussi à en orienter vers des confrères. Travailler moins, « cela change la vie », ajoute-t-elle, mais elle estime qu'être retraité actif, « financièrement, ce n'est pas intéressant ». Ce constat est partagé par de nombreux médecins et leurs représentants, qui commencent à faire pression sur les pouvoirs publics. Ils savent que ceux-ci auront bien besoin des médecins âgés pour amortir, au moins un peu, l'effet des nombreuses cessations d'activité à venir. D'autant plus que l'exécutif se refuse à toute mesure de contrainte pour mieux répartir les médecins sur le territoire. Fin mars, la secrétaire d'Etat à la santé, Nora Berra, a d'ailleurs déclaré à l'Assemblée que le gouvernement souhaitait inciter les médecins retraités à poursuivre leur activité. Le ministère de la santé estime plus urgent de mieux faire connaître les mesures prises en faveur des médecins, comme la suppression du plafonnement des revenus à 15 000 euros pour pouvoir toucher sa retraite à taux plein tout en travaillant. Des mesures qui expliquent déjà, en partie, la hausse du nombre de médecins cumulant emploi et retraite. « A l'approche de la retraite, les médecins sont fatigués, si le gouvernement veut pouvoir compter sur eux, il faut qu'il fasse des efforts pour rendre la poursuite de l'exercice attractive », juge Christian Jeambrun, président du Syndicat des médecins libéraux. Celui-ci souhaite même la création d'un statut de « retraité actif », avec divers avantages, avec la prise en charge du cabinet par la collectivité dans les zones sous-dotées. Une autre idée serait, vu l'âge de ces médecins, de rendre facultative leur participation aux gardes. 40 Si les retraités acceptent d'assurer la transition le temps que les mesures incitatives, comme l'aide à la création de maisons de santé fassent revenir des praticiens dans les zones désertées, tout le monde y gagnera. La profession, hostile aux mesures de contrainte. Et le gouvernement, bien décidé à ne pas se fâcher avec un électorat qui lui avait été jusque-là fidèle, et semble l'être un peu moins. 10 La huida de enfermeras catalanas al extranjero crece el 70% en un año El Periódico de Catalunya, Spain 16/04/2011 BARCELONA - El único personal sanitario que ya ha empezado a sufrir los efectos del recorte presupuestario es el de enfermería, sector que en Catalunya ocupa en la actualidad a cerca de 40.000 profesionales. El Col·legi d’Infermeria de Barcelona (que afilia a 34.000 tituladas) ha recibido en el último año un 70% más de solicitudes de trabajo en el extranjero que en el 2009, informó ayer Josep Paris, portavoz de dicha institución. En el primer trimestre del 2011 han tramitado 250 solicitudes, que se suman a las 740 recibidas en el 2010, explicó. La formación de las enfermeras catalanas es valorada por su alta cualificación y, como ya ocurrió hace 10 años, son muy bien acogidas en hospitales de Reino Unido e Italia, deficitarios de este personal. Los hospitales británicos ofrecen a la enfermería procedente de Catalunya un contrato de como mínimo un año de duración –los de aquí son de pocas semanas–, un sueldo neto no inferior a los 1.700 euros, similar al de los centros catalanes, y una amplia gama de complementos. Tienen alojamiento y cursos de idiomas gratuitos, se les abona el desplazamiento desde España y pueden disponer de un traductor guía. «Algunas enfermeras nos piden trabajo de forma desesperada», explicó París. Back to top Latin America & Caribbean 1 Faltan especialistas para atender adultos mayores La Capital, Mexico 13/04/2011 DAISY VERÓNICA HERRERA MEDRANO CIUDAD VICTORIA, TAM.- Los 413 mil 912 adultos mayores que viven en Tamaulipas solo tienen 5 especialistas que velen por su salud, informó Genny Solís Martínez, delegada del Instituto Nacional para el Adulto Mayor INAPAM. Dijo que mientras la población mayor de 60 años representa el 9.4 por ciento del total de la población en el estado, se sigue padeciendo la falta de geriatras que presten la atención requerida a estos pacientes. No obstante, la funcionaria dijo que este no es un problema privativo de nuestro Estado, ya que a nivel nacional solo se cuenta con 300 geriatras para atender a los más de 10 millones de adultos mayores. En este sentido, dijo que contar con más especialistas es tarea de todos, incluidas la universidades de medicina que deben promover esta especialidad como los entes de gobierno que deben ofrecer más plazas laborales para estos especialistas. Indicó que por el bienestar de los adultos mayores, su atención médica debe ser con geriatras que entiendan y atiendan a la perfección su salud. “Cuando se siente mal un niño lo llevamos con el pediatra, cuando una mujer va a parir con el ginecólogo, así cuando un abuelito se siente mal le debemos llevar con el geriatra, esto es una cuestión cultural, que todos debemos estar inmersos”, puntualizó. 2 Limitada atención a pacientes con VIH en Honduras La Prensa, Honduras 14/04/2011 La atención a las personas con VIH en el país va en detrimento, según un informe revelado por el Comisionado Nacional de los Derechos Humanos, Conadeh. Entre las dificultades que arrojó el estudio está el déficit de personal, la falta de instalaciones adecuadas, así como la disminución de las horas de atención y no distribuir oportunamente los medicamentos antirretrovirales. El informe es el resultado de una serie de reuniones y entrevistas entre miembros del Conadeh con grupos de apoyo, personas con VIH e instituciones que trabajan en esa problemática. 41 Entre los hallazgos encontrados se menciona que el 100% del personal entrevistado expresó su insatisfacción por la disminución de horas de atención a las personas con VIH. Además, en la mayor parte de los Centros de Atención Integral, CAI, también se quejan por no contar con un equipo multidisciplinario que permita brindar atención integral a estas personas. Ante ello, Ramón Custodio, defensor de los derechos humanos en país, recomienda que para garantizar la estrategia de atención integral es necesaria la presencia de un equipo multidisciplinario cuya formación se adecue a garantizar el derecho a la salud que tienen las personas con VIH. “El Centro de Atención Integral debe contar con un médico con conocimiento en enfermedades infecciosas, por lo que se vuelve indispensable que los infectólogos, psicólogos y de otras carreras ayuden a capacitar al personal sobre ese tipo de atenciones”, dijo Custodio. Más deficiencias Algunas de las personas consultadas informaron que hay regiones del país que no cuentan con pediatras especialistas; por ello remit en a los pacientes a los hospitales más cercanos como es el caso de El Progreso y Puerto Cortés al hospital Mario Catarino Rivas de San Pedro Sula o cuando el número de horas es insuficiente al Hospital Escuela. También mencionaron el caso del CAI del hospital de San Marcos de Ocotepeque que no cuenta con un médico general que brinde funciones regulares de atención a personas con VIH, por lo cual la sociedad civil de esa región ha hecho solicitudes para evitar el cierre del mismo, porque “según las autoridades hay muy pocos pacientes”. En lo que respecta al departamento de Lempira existe una situación similar, ya que la falta de un médico genera una sobrecarga de trabajo para el personal de atención que incluso laboran horas extras sin remuneración. 3 Los médicos bonaerenses aceptaron “en disconformidad” un aumento del 29% Clarín, Argentina 18/04/2011 Con duras críticas al modo en el que el gobierno de Daniel Scioli llevó adelante la negociación y manteniendo varios de sus reclamos, los médicos nucleados en la Asociación Sindical de Profesionales de la Salud de la Provincia de Buenos Aires (CICOP) aceptaron "en disconformidad" la propuesta de un aumento salarial del 29 %. El sábado, el Congreso del gremio había condicionado la aceptación de ese aumento a la regularización de los reemplazantes de guardia que, según el sindicato, se encontraban en el extremo de la precarización laboral. Como el gobierno de Scioli reglamentó, a través del decreto 340/2011, el artículo 48 que nominaliza los reemplazos de guardia y aumenta los montos, el acuerdo fue firmado este mediodía. Pese a aceptar el aumento, el sindicato acusó: "La estrategia de intimidación del gobierno sufrió un duro revés y solo agregó leña al fuego aumentando la indignación y la adhesión a las medidas de fuerza. Las ´Listas Negras con los afilados a la CICOP se corroboraron en los descuentos a los afiliados, algunos de los cuales estaban de licencia. No vamos a aceptar que se persiga a los trabajadores cuando ejercen su legítimo derecho a la huelga. En este sentido, exigimos la devolución de los días descontados a los afiliados de la CICOP". Por su parte, Scioli se manifestó "satisfecho" por el acuerdo y destacó la "responsabilidad" que privó en la negociación. El aumento, con vigencia desde el 1º de marzo de 2011, consiste en un incremento del 26,03% del sueldo básico, un aumento de $128 a $258 en la bonificación remunerativa y un incremento del 50% en la bonificación por escalafón. Según el gobierno bonaerense, ahora un médico asistente con 36 horas semanales de labor "ingresante" percibirá un sueldo de bolsillo de $4.500. 4 Una nueva escala salarial ayudará a que la Amazonía tenga más médicos especialistas Andes, Ecuador 19/04/2011 Loreto (Orellana), 19 abr.- El ministro de Salud, David Chiriboga, informó que una de las medidas para elevar el nivel de atención médica en la región amazónica es la aplicación de una nueva escala salarial de conformidad con la Ley Orgánica del Servicio Público (Losep). En diálogo con Andes, el funcionario explicó que se prevé un salario máximo de 3.250 dólares para los especialistas que presten sus servicios en está zonas del país. Actualmente, el salario mensual de un médico es de 1.590 dólares, con la aplicación de la Ley sube a un tope de 2.505 dólares más bonos de eficiencia y ubicación geográfica. 42 ¿Cuáles son las principales medidas que se tomarán para mejorar la calidad de la salud en la región? Estamos con un plan a nivel nacional para que con la aprobación de la Ley Orgánica de Servicio Públicos se incluya una propuesta salarial importante que va a permitirnos tener especialistas en la Amazonía, que es donde los necesitamos. ¿Por qué se iniciará el programa en esta región? Vamos a empezar la implementación de ese programa en la Amazonía porque es la zona del país que tiene menor proporción de especialistas y eso está muy relacionado con la cuestión salarial. ¿En qué consiste la readecuación salarial? Antes, el salario máximo para un médico era 1.590 dólares al mes, eso se ha incrementado; el salario máximo va a ser de 2.505 dólares, pero, además del salario, hay un incentivo que se conoce como el bono de la eficiencia, que representa al menos 200 dólares más y otro, por ubicación geográfica. En la mayor parte de las provincias de la Amazonía se consideran como la categoría más alta y eso tiene un subsidio del 20 por ciento, es decir, 500 dólares más. ¿Al incrementar el salario se espera que se incremente el número de especialistas? Estaríamos con un salario de 3.250 dólares, el máximo para los especialistas. Con eso pienso que la posibilidad de conseguir especialistas que vengan a trabajar en estas áreas es mucho mayor. ¿Cómo se distribuirán estos recursos? Tenemos que hacer un programa de racionalización de recursos. Si tenemos centro de salud o un hospital pequeño donde se realiza una cirugía al día, entonces no convendría tener un especialista permanente, tenemos que ver cómo tener cirujanos de llamado para que cuando se necesite acudan inmediatamente, por ejemplo. Tras su visita a Orellana, ¿cuál es la evaluación a la situación de esta provincia? Ha sido una visita muy positiva, se pudo ver todos los avances del Hospital de El Coca, que es un hospital de 60 camas que está prácticamente concluido; ya se ha hecho la petición de algunos equipos y otros ya están en la provincia, esperamos que en un par de meses se pueda entregar. Aún faltan algunas obras complementarias ¿Qué medidas se tomarán? Tuvimos una reunión con el Presidente y ministros y hemos discutido una propuesto para realizar el alcantarillado y accesos. La alcaldía a está en proceso de avanzar. Lo que el hospital necesitaría es conectarse con la alcantarilla externa y lo que haremos es dejar la tubería ubicada con la ayuda del Ministerio de Transporte y del Municipio de El Coca. También se está trabajando en proceso de reestructuración del Ministerio de Salud, ¿Qué tipo de avances implica? Estamos en un proceso de desconcentración del Ministerio. Se va a distribuir en zonas y luego las zonas en distritos y en cada distrito una estructura donde se resuelva localmente los problemas. Por ejemplo, un buen hospital básico deberá tener médico cirujano general, anestesiólogo, pediatra, obstetra, internista y traumatólogo para fortalecer la atención en las unidades operativas periféricas. Y en los centros de atención primaria… La idea es fortalecer centros de laboratorio e imagen, sea ecografía o radiología, porque esa es una de las limitantes en los centros pequeños; al no haber ayuda diagnóstica los pacientes tienen que salir al hospital y queremos descongestionar eso. El presidente anunció que el 12 por ciento de las regalías petroleras se destinarán a desarrollo social, ¿cómo se incluye la salud en este eje? Las dos prioridades de ese 12 por ciento son salud y educación, entonces estamos trabajando en un programa agresivo de fortalecimiento de las unidades a nivel de toda la Amazonía. 5 Piden aumento para los médicos rurales El Siglo de Durango, Mexico 15/04/2011 Carolina Heredia Los médicos que laboran en zonas rurales pagan altos costos por su estadía, problema que, junto a la inseguridad, ha provocado la falta de personal, expuso el director de la Facultad de Medicina de la Universidad Juárez del Estado de Durango (UJED), Antonio Bracho Huemoeller. Una propuesta para lograr la permanencia de los médicos es mejorar las condiciones económicas con un aumento a su sueldo. Sobre la necesidad expuesta, el secretario de Salud, Alejandro Campa Avitia, refirió que la estrategia para disminuir la ausencia de los médicos en comunidades ha sido el contrato por 15 días. No es un aumento salarial, pues terminado el plazo otro doctor los suple. 43 También que "sean del municipio para evitar cambios o argumenten situaciones de inseguridad; en la gran mayoría de los casos se ha respetado al personal de salud", agregó. NO COMPLETAN "Apenas salen los gastos para sobrevivir en el área", comentó el catedrático con base en experiencias que le han expresado. Los médicos pagan traslado, alimentación y hospedaje; "a veces es más caro que en las zonas urbanas". Estas necesidades son cubiertas con sueldos de hasta 7 mil pesos al mes. Las dificultades económicas de los profesionistas en las comunidades recaen en que en aquellos lugares no hay oportunidades para participar en otras actividades, como las hay en las ciudades. Por ejemplo, en la zona urbana un médico trabaja para varias instituciones. Sobre el monto requerido del aumento, Antonio Bracho comentó que sería equiparable al sueldo de un médico en zona urbana. El sueldo del médico en Durango se maneja alrededor de los 12 mil pesos mensuales. VIOLENCIA El Director de la Facultad de Medicina reconoció que médicos se han tenido que retirar de algunas zonas por la violencia. "Hay una generalización de los problemas de violencia"; en este contexto, no señaló sitios en donde se ha acentuado más, pero mencionó a manera de ejemplo los municipios de Lerdo, Gómez Palacio, Vicente Guerrero, Santiago Papasquiaro y Tepehuanes. Para los médicos ya no es garantía de seguridad laborar en una zona urbana, pues se corren los mismos riesgos. 6 CSS se queda sin insumos médicos La Estrella, Panamá 20/04/2011 CARLOS ATENCIO PANAMÁ. No solo los medicamentos escasean en las farmacias de la Caja de Seguro Social (CSS). Un documento de esta institución señala que el problema de los insumos médicos quirúrgicos preocupa hasta a los propios médicos. Un reporte de marzo señaló que durante la primera semana de ese mes el abastecimiento de insumos médicos quirúrgicos fue de 53%, mientras que el desabastecimiento alcanzó el 46%. Para la segunda semana la situación apenas mejoró. El desabastecimiento fue de 40.3% y el abastecimiento de 59.6%. No obstante, lo crítico es la cifra promedio del primer trimestre del año: desabastecimiento de 54%; es decir, que los hospitales han funcionado con menos de la mitad de los insumos necesarios para la atención médica. Entre las causas del problema, el documento cita la programación tardía del Departamento de Compras, la falta de presupuesto y los consumos abultados de las unidades ejecutoras (policlínicas y hospitales). Para Julio Osorio, presidente de la Comisión Médica Negociadora Nacional (Comenenal), la crisis de insumos se ha agudizado durante el primer trimestre del año; sin embargo, esto ha sido una enfermedad crónica en la CSS. ‘En enero no había gasa, en febrero no había guantes, ahorita no hay analgésicos, con esta carestía no podemos trabajar’, aseguró el doctor. El dirigente manifestó que ya le han hecho saber estos inconvenientes a los directivos de la institución, pero aún no los han corregido. OTRAS CIFRAS Adelys Varela, directora Nacional del Servicio al Asegurado de la CSS, explica que el abastecimiento de medicamentos e insumos en la CSS es de 95% en promedio; es decir, que solo no cumplen en 5% en los fármacos que demandan los asegurados y beneficiarios. Con esta cifra que expone Varela, los asegurados más bien deberían estar satisfechos; sin embargo, ni los propios especialistas están conformes. ‘Esas cifras no son correctas, no son la realidad, porque la demanda crece por días, si hoy abastecen equis fármaco, mañana faltan otros; esa cifra podría reflejar un instante, no una realidad’, dice Osorio. 44 7 Federación Médica expresa su apoyo a enfermeros El Impulso.com, Venezuela 15/04/2011 Juan Carlos Salas Los médicos de todo el país expresaron este jueves su solidaridad con los enfermeros y enfermeras del sector público, que llevan varios meses luchando por merecidas y justas reivindicaciones laborales establecidas en la Constitución de la República Bolivariana de Venezuela. El pronunciamiento fue realizado por el presidente de la Federación Médica Venezolana, Douglas León Natera, quien explicó que el comité ejecutivo de esta institución ha decidido ratificar el respaldo a todos los profesionales de la salud, ya que el Gobierno nacional está haciendo caso omiso a las peticiones que ha realizado un grupo de enfermeros que ya tienen casi un mes en huelga de hambre. "El Gobierno no ha querido hacer cumplir lo que ellos mismos establecieron en el decreto presidencial 6054, cuando aprobaron las tablas de salarios y lo peor es que han sido los propios funcionarios del Ministerio de Salud quienes no han cumplido con los enfermeros y enfermeras", precisó. Recordó que el decreto, el cual fue publicado en Gaceta Oficial hace 4 años, inclusive establece sanciones para todos los funcionarios públicos que no realicen la aplicación, "es por ello que la ministra Eugenia Sader debe ser la primera en cumplir con esta norma que hoy se niega a firmar". Como gremio médico exigió a la cartera de Salud que cumpla con lo establecido en la norma y que firme el acuerdo lo más rápido posible ya que la salud de los enfermeros que se encuentran en huelga de hambre en la sede diplomática de Brasil, en Caracas, se encuentran en un delicado estado de salud. "Consideramos que la lucha que han emprendido los enfermeros y las enfermeras es justa; por tal razón, el comité ejecutivo nacional de la Federación Médica le da el respaldo a esta manifestación, tanto así que exhortamos a las directivas de los Colegios de Médicos a permanecer activamente en las acciones que decidan los enfermeros para los próximos días", precisó. Asimismo, León Natera responsabilizó al Gobierno nacional y a la ministra de salud , Eugenia Sader, de la vida de estos 40 enfermeros que se encuentran en huelga de hambre en todo el territorio nacional. "Le pedimos a la Ministra que no permita que esta huelga continúe en Semana Santa y que en las próximas 48 horas resuelva esta situación, porque de existir una pérdida de estos enfermeros usted será la única responsable", insistió. Salud en estado crítico Por otra parte, Reinaldo Contreras, médico tratante de los huelguistas que se encuentran en la ciudad de Caracas, declaró desde la sede de la Federación Médica Venezolana, que la salud del 100% de los enfermeros y enfermeras que se encuentran en huelga de hambre es crítica. "Les puedo decir que el 100% de los 10 enfermeros que se encuentran en huelga de hambre, están inmunocomprometidos, lo que significa que tienen un descenso de sus glóbulos blancos, lo cual se traduce en que, con una simple gripe, pueden aparecer graves lesiones de su salud", explicó. Indicó que por la falta de ingesta de líquido, igualmente los huelguistas presentan una tensión arterial muy baja, lo que podría traer consecuencias en su sistema cardiovascular, cerebral y renal. Indicó que la pérdida de peso se encuentra entre 5 y 7 kilos y desmintió que los enfermeros estén consumiendo alimentos escondidos, ya que de hacerlo no presentarían estas condiciones tan delicadas de salud. AH1N1 no está controlada Al ser consultado sobre el brote de gripe AH1N1 que todavía existe en el país, el presidente de la FMV, Douglas León Natera, exigió al Gobierno nacional que se multiplique la campaña de inmunización ya que la enfermedad no se encuentra controlada, debido a que el número de casos pasa de las 1.300 personas y continúa en franco aumento. También pidió a las autoridades sanitarias que informen, de manera rápida, lo que está pasando con los casos y hagan énfasis en las medidas de prevención, que en muchos casos pueden salvar vidas. 8 Make HIV part of mainstream health system - study Demerara Waves, Guyana 20/04/2011 Guyana must integrate its HIV services into the general healthcare system in order to better utilise the limited resources available to the sector, according to a study released on Wednesday. 45 The report, done with USAID support, notes that Guyana provides high coverage and quality HIV services, but for this to continue there is a need to secure financial and human resources. “Decrease in HIV funding requires continuing implementing sustainable solutions, mainly the integration of HIV services into other health and social services,” it stated. The study is aimed at providing Guyana with a preliminary analysis of the unit costs and financial and human resources available and needed to sustain its HIV/AIDS programme through 2015. Integration, it stated, is essential for sustaining HIV services over the long term. “The HIV response has seen a decline in the funding they receive from their largest donor, PEPFAR (President’s Emergency Plan for AIDS Relief), and competition on the remaining donors’ AIDS funding, also increasingly limited, is becoming fiercer due to improved absorptive capacity of many AIDS programmes globally,” it read. The summary provided to the media added that the need for capital investments is diminishing and Guyana’s AIDS programme can now focus its resources on the remaining programme gaps, such as services for vulnerable populations and youth. It noted that men who have sex with men (MSM) and commercial sex workers (CSWs) have the highest HIV prevalence in Guyana and while it is estimated that HIV prevention reaches a large portion of CSWs, the coverage of MSM seems to be low. “According to UNAIDS, it is very probable that the transmission of HIV from MSM to the wider sexually active population is an important route of HIV transmission in Guyana. There is a need to scale up outreach to MSM,” the report stated. It also calls for an increase in targeted use of mass media and an increase in the use of effective stigma reduction interventions. According to the study, HIV-related stigma and discrimination remains a major concern despite the high knowledge levels of the disease. “Based on the recommendations of a 2009 report on stigma and discrimination in Guyana, stigma reduction training is needed for all health professionals across Guyana’s health facilities. In addition, community leaders should be trained on this topic,” it continued. According to the report, stigma reduction is likely to increase adherence to anti-retroviral treatment since adherence is linked to “self-HIV stigma.” Health minister Dr. Leslie Ramsammy, who was present at the opening of a workshop where the report was handed over, laid out similar sentiments. “I am not certain that in the face of climate change, in the face of a real calamity facing us in terms of diabetes and hypertension and heart diseases and so on, that we can continue diverting as much resources to HIV. And yet we need to spend even more in the fight against HIV; so how we do that will be a major challenge,” the minister said. The challenge, he added, would be in ensuring that the cost of HIV treatment does not escalate and the only way to do that was by mainstreaming it in a strengthened health system. “The initial approach of separating the human resource cannot be a wise one. We maintain primary healthcare physicians that are suppose to be dealing with diabetes and heart diseases and malaria and other infection; they will also have to be able to deal with HIV and that is the truth,” Dr. Ramsammy stated. Back to top ----------------------------------------------------------------------The weekly news is a compilation of selected articles on the issue of the health workforce crisis, and is provided for information purposes only. The Alliance is not responsible for the content on third party web sites, and any link to external web sites does not imply any endorsement by the Alliance. If you wish to receive the Alliance weekly news compilation in your e-mail, please send a request to ghwa@who.int. You can also suggest or contribute articles that should be in the compilation, by writing to ghwa@who.int, for inclusion in the next distribution. 46
