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2005 Volume 41 Number 3
International Hospital Federation | Fédération Internationale des Hôpitaux | Federación Internacional de Hospitales
World Hospitals and Health Services
The Official Journal of the International Hospital Federation
www.ihf-publications.org
IHF Congress Issue
IHF Newsletter
International Hospital Federation news
Calendar
International news round up
Country profile
The French healthcare system: presentation, changes
and challenges
Policy
Building capacity for public health research
Management
Management of hospitals in Aceh during the tsunami
Please tick your box and pass this on:
■ CEO
■ Medical director
■ Nursing director
■ Head of radiology
■ Head of physiotherapy
■ Senior pharmacist
■ Head of IS/IT
■ Laboratory director
■ Head of purchasing
■ Facility manager
Experiences of a hospital in Thailand in treating
tsunami patients
Clinical care
Diabetes care in China: meeting the challenge
eHealth supplement
Open source approaches to health information systems
in Kenya
Opinion matters
The global chronic care epidemic and the international
expansion of disease management programmes

CONTENTS
World Hospitals and Health Services
2005 Volume 41 Number 3
The Official Journal of the International Hospital Federation
Contents
03
Editorial Professor Per-Gunnar Svensson
IHF IHF NEWSLETTER Newsletter
04 International Hospital Federation news
06
Conference and event calendar
07 International news round up
COUNTRY PROFILE
10 The French healthcare system: presentation, changes and
challenges Gérard Vincent
ARTICLES
Policy
14 Policy
Building capacity for public health research
Andrew Y Kitua
19
24
29
36
40
43
46
Management
Management of hospitals in Aceh during the tsunami
Dr Hermansyur Kartowisastro
Experiences of a hospital in Thailand in treating tsunami patients
Senior Management Team, Bumrungrad International
Hospital
Clinical care
Diabetes care in China: meeting the challenge Changyu Pan
E-HEALTH SUPPLEMENT
Open source approaches to health information systems in Kenya
Dr Peter Drury and Dr Bruce Dahlman
REFERENCE
Abstract translations in French and Spanish
Directory of IHF professional and industry members
OPINION MATTERS
The global chronic care epidemic and the international
expansion of disease management programmes Warren E Todd
EDITORIAL STAFF
Executive Editor:
Professor Per-Gunnar Svensson
Desk Editor:
Sheila Anazonwu, BA (Hons), MSc
EDITORIAL BOARD
Dr Rene Peters
Dutch Hospital Association
Dr Hiroshi Akiyama
Japan Hospital Association
Norberto Larroca
Camara Argentina de Empresas de Salud
Dr Harry McConnell,
ISHED
Dr Persephone Doupi
OSKE
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Vol. 41 No. 3 WORLD | World hospitals Hospitals and and health Health services Services | 13| 01

EDITORIAL
Learning from
the tsunami
PROFESSOR PER-GUNNAR SVENSSON
DIRECTOR GENERAL, INTERNATIONAL HOSPITAL FEDERATION
This issue of World Hospitals and Health Services will be
released at the 34th IHF International Hospital
Congress to be held in Nice, France, 20-22
September 2005. It is therefore my pleasure to welcome
participants to this important event, where many challenges
for hospitals and health services will be on the agenda; the
role of hospitals in sustainable development, malpractice
insurance and patient safety, research in hospital and
management, ranking of hospitals, valuation of hospital
personnel, e-health and much more are on the programme.
We look forward to seeing many participants and engaging
in intensive dialogue on these important issues.
The content of this issue of the journal includes a country
profile of France, a country that has ranked number one in
a WHO World Health Report in 2003. It is interesting to see
that in spite of this high ranking, the French health service
system is still evolving and changing in order to adapt to the
demands of today and the perceived ones of tomorrow.
In another article, appraisals of work undertaken together
with the many lessons learnt from tsunami, are
summarized. At the same time, it is worth noting that in
some cases, assessment of the assistance provided to the
victims of the tsunami by national and international
sources, has been positive. However, in others, as in
Sweden and Finland, countries from which victims were
also counted, the national assessment encountered some
criticism.
Finally, there is an article on e-health, a topic which is
gaining in importance. The IHF Governing Council decided
in 2004 to form a new chapter on IT. In many countries,
huge investments are being made in order to form, for
example, unified national electronic medical record
systems; create information services targeting staff and the
general public; introduction or planned introduction, in
many countries, of booking systems.
PROFESSOR PER-GUNNAR SVENSSON
Director General
International Hospital Federation
Vol. 41 No. 3 WORLD | World hospitals Hospitals and and health Health services Services | 13| 03

IHF NEWSLETTER
International Hospital
Federation news
INTERNATIONAL HONOUR FOR HAMDAN AT IMD-IHF CONference
The fifth annual IMD-IHF International Medical Care
and Diagnostic Conference and Exhibition, was held
10-12 September 2005 in Dubai, United Arab
Emirates.
The three-day conference and exhibition, held under the
patronage of Shaikh Hamdan Bin Rashid Al Maktoum,
Deputy Ruler of Dubai, Minister of Finance and Industry and
Head of the Dubai Department of Health and Medical
Services (Dohms), was inaugurated by Hamad Abdul Rahman
Al Midfa, Minister for Health. Gadi Marshoud, Director
General of Dubai Health and Medical Services Department,
together with some 40,000 healthcare professionals and
experts and 100 international specialist companies, also
attended the conference.
Shaikh Hamdan Bin Rashid Al Maktoum, himself, at the
opening ceremony of the conference, was presented with an
award by Professor Per-Gunnar Svensson, Director General of
the International Hospital Federation, in recognition as the
best international personality and for his contributions in the
fields of health, education and sports from 2001 to 2005. The
award was received by Shaikh Rashid Bin Hamdan Bin Rashid
Al Maktoum on behalf of his father.
Professor Svensson upon presentation of the award
commented that, “Shaikh Hamdan’s winning of the title is
because he is a prominent personality in the Arab world, who
The award is presented
has a great record of accomplishments in the areas of health,
education and sports.”
The Conference hosted 9 other conferences simultaneously,
including the International Emergency and Catastrophe
Management Conference and Exhibition, the Dubai
International Pathology and Genetics Conference and
Exhibition and the International Obstetrics and Gynaecology
and Fertility Conference and Exhibition.
Governing Council member profile: Dr Owen Gregan Curteis
Dr Owen Gregan Curteis became in 2001 the
Australian Representative on the IHF Governing
Council as well as IHF Representative on the
Australian Healthcare Association National Council.
Dr Curteis graduated in Medicine from the University of
Sydney in 1960 and received his Graduate Diploma in
Health Administration from the University of New South
Wales in 1973. In 1975 he became a Fellow of the Royal
Australian College of Medical Administrators and in 1989
Fellow of the Australian College of Health Service Executives.
He undertook his residency training at the Mater
Misericordiae Hospital in north Sydney from 1961 to 1965
and registrar training at the Repatriation General Hospital at
Concord from 1966 to 1971. Of the 25 years he spent at
Concord (1966–1990), 15 of those were as Chief Executive
Officer (1975–1990), after which he was appointed Chief
Executive Officer of the Western Sydney Area Health
Service. In 1996, he took the unusal step of re-entering
clinical medicine in his appointment as Career/Senior
Medical Officer for the Brisbane Waters Private Hospital.
Dr Curteis is an active member of both the Royal
Australian College of Medical Administrators and the
Australian College of Health Service Executives. He was
Chairman of the News South Wales Branch of the Royal
Australasian College of Medical Administrators (RACMA) in
1982-83 and has been a member of the Federal Council of
that College since 1998. Since 2001 he has been the
Australian representative on the Board of Governors of the
Asian Hospitals Federation.
He also has been a surveyor for the Australian Council on
Healthcare Standards (ACHS) since 1976 and is a member
of the Council’s Board, representing the Royal Australian
College of Medical Administrators.
Dr Curteis has encompassed a wide range of
extracurricular activities as well, including time as an
executive member and Treasurer of the Postgraduate
Medical Council and member of the Minister’s Health
Advisory Council.
04 | 12 World | WORLD Hospitals hospitals and Health and health Services services | Vol. 41 No. 3

Board of the Ambulance Service of New South Wales and
a director of various health credit unions, namely, Endeavour
Credit Union and Premier Credit Union.
He has been a stalwart supporter of both the Health
Services Association of New South Wales, of which he was
President between 1996 and 1997 and of the Australian
Healthcare Association (AHA), of which he was President of
the New South Wales Branch from 1988–1990.
His expertise, knowledge, understanding and experience
have often been sought after and used extensively by Health
Departments at State and Commonwealth level, various
medical colleges, hospital industry associations,
accreditation bodies, academic and postgraduate medical
councils and international healthcare organisations.
In 1997 he received both the Australian Healthcare
Association Sidney Sax Gold Medal Award and an Honorary
Life Membership of the Faculty of Medicine at the University
of Sydney. In 1998, was awarded the RACMA College
Medallion.
His commitment to developing continuous improvement
and quality throughout the health system and indeed
sharing this experience and expertise is reflected in his
commitment and service to the Australian Council on
Healthcare Standards accreditation process.

IHF NEWSLETTER
International news round up
WORLD
ICN responds to tuberculosis crisis
with a capacity building programme
for nurses
THE INTERNATIONAL COUNCIL OF NURSES (ICN) on
31 August 2005 launched a broad based training
programme for nurses in high TB and MDR-TB* burden
countries, aimed at building capacity and mobilizing this
key corps of health care workers.
The first in a series of training initiatives was initiated in
South Africa with the ICN member association DENOSA
and will prepare senior nurses as trainers for nurses working
in all settings in South Africa. The programme will also roll
out in the Philippines, Russia and other high-burden
countries in Africa, Europe and Latin America over the next
two years.
Roughly three million nurses work or are registered in the
22 countries where 80% of TB cases are found. In most of
these countries nurses are the primary healthcare provider,
and often the only source of care, though they often work in
deficient systems, with poor access to adequate training,
supplies and resources.
The training programme compliments a broader ICN
initiative to address the TB crisis and ramp up the support
and capacity of nurses in treating and caring for patients with
tuberculosis and multi-drug resistant tuberculosis (MDR-TB).
As part of the initiative, ICN has also created a TB
Resource Centre, providing multiple tools for nurses, who
are increasingly finding TB a major health issue across the
spectrum of practice.
For further information see www.icn.ch
WMA council adopts new resolution
on the healthcare skills drain
ADOPTED AT THE 170 TH WORLD MEDICAL
ASSOCIATION COUNCIL SESSION, on 15 May 2005, a
council resolution recognises that the lack of healthcare
workers in developing countries, particularly those in sub-
Saharan Africa, is one of the most serious global problems of
today and that the impact of healthcare worker migration from
developing to developed countries is a significant component
in the crisis. It resolved that:
1. “Every country should do its utmost to educate an
adequate number of physicians, taking into account its needs
and resources. A country should not rely on immigration from
other countries to meet its need for physicians”; and: “Every
country should do its utmost to retain its physicians in the
profession as well as in the country by providing them with
the support they need to meet their personal and professional
goals, taking into account the country's needs and resources.”
2. That developed countries must assist developing
countries to expand their capacity to train and retain
physicians and nurses, to enable developing countries to
become self-sufficient.
3. That action to combat the skills drain in this area must
balance the right to health of populations and other individual
human rights.
4. That the WMA reconvene the expert working group on
physician resources to coordinate development of WMA
input to WHO.
5. That the WMA commend WHO for taking a leadership
role in the global challenges of human resources.
For further information see: www.wma.org
World Health Professions Alliance expands to include dentists
GENEVA, SWITZERLAND, 22 AUGUST 2005 – THE
WORLD HEALTH PROFESSIONS ALLIANCE (WHPA)
has expandedin August 2005 to include the World Dental
Federation (FDI), representing over 900,000 dentists
worldwide. The WHPA was founded in 1999 by the
International Council of Nurses (ICN), the International
Pharmaceutical Federation (FIP) and the World Medical
Association (WMA) and represents more than 20 million
health professionals worldwide.
The principle goals of the WHPA are to more effectively
represent the interests of patients and the core health
professions at the global level, and to facilitate closer
collaboration among health professionals at the global,
national and local levels. Communication among the four
major health professions is vital for the prevention and
treatment of illnesses and the strengthening of health
policy. The alliance has collaborated on several important
initiatives in human rights, patient safety, tobacco control
and antimicrobial resistance and will be meeting in
Geneva, Switzerland in May 2006 for a Global Forum on
Patient Safety.
Oral health has a great impact on quality of life and
represents a substantial burden for healthcare systems and
national economies worldwide. Dentists are crucial in the
prevention, detection and treatment of chronic diseases,
including HIV/AIDS and are often the first to detect signs
of illness. Their participation and input in the World
Health Professionals Alliance will be vital to all the
Alliance’s work.
For further information see: www.whpa.org
Vol. 41 No. 3 WORLD | World hospitals Hospitals and and health Health services Services | 13| 07

IHF NEWSLETTER
AMERICAS
Hurricane Katrina raises health concerns
HURRICANE KATRINA MADE LANDFALL near New
Orleans, Louisiana on 29 August 2005. With a sustained
wind speed of approximately 200 km/h, Katrina destroyed
many buildings and caused extensive damage. Eighty
percent of the city was submerged under water.
The United States Department of Health and Human
Services declared a public health emergency in all affected
areas. According to the Federal Emergency Management
Agency (FEMA), close to 90,000 square miles (233,000
km) were declared as disaster areas (an area greater than the
size of the United Kingdom).
The Pan American Health Organization / World Health
Organization are collaborating with the United States
Department of Health and Human Services (HHS) at the
federal and state levels and with the Centers for Disease
Control (CDC), providing technical collaboration in a
number of public health areas. Public health experts are
evaluating the health impact of hurricane Katrina and its
aftermath among survivors in the states of Louisiana,
Mississippi, and Alabama.
The director of the Pan American Health Organization
(PAHO), Dr Mirta Roses, today conveyed her condolences
for the loss of human life to US Secretary of Health and
Human Services Mike Leavitt and offered PAHO’s
experience and assistance in dealing with the disaster’s
aftermath.
For more information, please visit PAHO's special
page on Hurricane Katrina at www.paho.org/English/
DD/PED/huracan-katrinahome.htm
AFRICA
African partners to tackle the crisis on human resources for health
IN AN UNPRECEDENTED PARTNERSHIP, an African
Regional Consultation on human resources for health (HRH)
was jointly organized by the World Health Organization
Regional Office for Africa (WHO/AFRO), the New
Partnership for Africa’s Development (NEPAD) and the
African Council for Sustainable Health Development
(ACOSHED). The Consultation was held from 18 to 20 July
2005 at WHO/AFRO in Brazzaville, Republic of Congo, with
the theme “Taking the HRH Agenda forward at the Country
level”. The Consultation identified innovative actions to
move Africa forward and ensure that regional and global
investments yield intended results. Key actions include:
➜ Establishment of a Regional Platform – to assure that
the African voice and perspective is not lost in the
global dialogue, and that there is accountability for
country level action.
WHO declares TB an emergency in
Africa
IN AUGUST 2005, The World Health Organization
(WHO) Regional Committee for Africa comprising
health ministers from 46 Member States has declared
tuberculosis an emergency in the African region – a
response to an epidemic that has more than
quadrupled the annual number of new TB cases in most
African countries since 1990 and is continuing to rise
across the continent, killing more than half a million
people every year.
WHO/AFRO proposes US$949.5 million
budget for the African region in 2006-07
THE WORLD HEALTH ORGANIZATION proposes to
spend US$949.5 million in its African Region during the
2006-2007 biennium, compared to US$774.7 million in the
➜ Setting up of the African HRH Observatory to serve as
an essential, action-oriented mechanism in HRH
development.
➜ Responding to flows of health workers from Africa.
Increased resources need to be efficiently targeted to
assure that there is HRH development in the broader
context of health systems strengthening.
➜ Tools to promote performance-based incentives and
reward systems in the health sector.
➜ Focus on the need to implement HRH development
actions at country level.
For further information visit
http://www.afro.who.int/press/2005/hrh_press_2.pdf
2004-2005 biennium. This is contained in a report to be
presented by the WHO Regional Director for Africa, Dr Luis
Sambo, to the fifty-fifth session of the WHO Regional
Committee for Africa taking place from 22 to 26 August in
Maputo, Mozambique. Dr Sambo states that US$203.6
million, representing 21.4% of the 2006-2007 Programme
Budget, is from the Regular Budget while US$745.8,
representing 78.6%, is from Voluntary Funds (Other
Sources).
Of the total of US$949.5 million approved for 2006-2007,
U$784.3 million has been allocated for Regional Priorities,
representing an increase of US $177.3 million (29.2%)
compared to the 2004-2005 Programme Budget. This
accounts for 86.6% of the total budget increase. The guiding
principles for implementing the proposed 2006-2007
Programme Budget in the African Region are
decentralization, integration of interventions, strengthening
of WHO presence in countries and strengthening
monitoring and evaluation.
08 | 12 World | WORLD Hospitals hospitals and Health and health Services services | Vol. 41 No. 3

IHF NEWSLETTER
MIDDLE-EAST
Queen Rania has consented to become
WHO Patron for Violence Prevention in
the Eastern Mediterranean Region
AS WHO PATRON FOR VIOLENCE PREVENTION, Queen
Rania will play a leading role in drawing attention to the
importance of the issues that need to be addressed and in
promoting action in the areas of prevention of violence and
improvement of services to victims of violence, especially in
the Middle East. She will also play a role in encouraging
political leaders in the region and globally to take action to
prevent family and community violence.
Across the WHO Eastern Mediterranean Region, which
includes most Arab countries, more than 130,000 people die
on the roads every year, and road traffic injuries are the eighth
leading cause of death for people of all ages. The vast majority
of these deaths occur in the Region’s low and middle-income
countries. Unlike high-income countries, where those most
at risk of injury or death are drivers and passengers in cars,
equally at risk of being involved in a road traffic crash in lowincome
and middle-income countries are pedestrians,
cyclists and users of informal modes of public transport.
For further information contact:
WHO Representative Office in Jordan;
E-mail: who@jor.emro.who.int
SOUTH -EAST ASIA
Tsunami recovery process focuses
on long-term health capacity
development
THE TSUNAMI OF 26 DECEMBER 2004 was one of the
worst natural disasters in recent memory. Six months after
the tragedy, the rebuilding and recovery process has provided
an opportunity for the health sectors in the affected countries,
assisted by the World Health Organization (WHO), to
strengthen their health systems in a long-term, sustainable
manner. Local health capacity and infrastructure are being
fortified and local people have been trained in skills that will
serve their communities better.
Health systems in many affected countries had been
devastated by the tsunami. For example, in Aceh, Indonesia,
53 of the 244 health facilities were destroyed or severely
incapacitated. Fifty-seven of the 497 provincial health office
staff died, while 59 were reported missing. WHO assisted the
health sectors of the affected countries, at their request, in
strengthening their resources and in setting up systems where
they had been destroyed. In meeting the needs of the
affected areas, WHO also provided technical guidelines, and
medical supplies. Resources were mobilized in partnership
with the government health authorities.
The large numbers of displaced persons, crowded
conditions, flooding and a vulnerable population posed an
increased risk of communicable diseases following the
tsunami. However, timely establishment of disease
surveillance systems by health authorities, helped prevent any
major outbreak. In Aceh, so far, the surveillance team has
responded to 352 cumulative cases through alerts and
response systems. This system of epidemiological
surveillance and outbreak response system will now be used
as part of the routine integrated disease surveillance.
In India, with assistance from WHO, the state of Tamil
Nadu had established disease surveillance units in four of the
worst affected districts in the state. Surveillance for both water
and vector borne communicable diseases was established.
Except for sporadic cases, no major outbreak was reported
from the affected communities. A mass measles and vitamin
A immunization campaign reached out to more than 75,000
children below five years of age.
Damaged hospitals and clinics were also upgraded and
equipped with relevant instruments and resources. In Aceh,
for example, the Meulaboh District Laboratory as well as the
Provincial Food and Drug laboratory have been equipped by
WHO. In the Maldives, the Public Health Laboratory has
been provided with laboratory equipment such as a water
purification system and accessories to assist in surveillance
and monitoring of chemical and microbiological
contaminants in food.
As part of the United Nations country team, WHO is
working closely with the government in the Maldives in the
‘Recovery Plus” process. Here, the challenges of the tsunami
disaster are being transformed into opportunities to accelerate
sustainable long-term development. Three thousand drums
have been procured for collecting hazardous waste from
tsunami-affected islands, and 13 health professionals have
undergone training to develop and implement a national
strategy for management of healthcare waste. With a view to
long-term, sustainable use of water resources, ‘template’ water
safety plans are being developed, and the needs for water
quality surveillance assessed. Draft guidelines for food safety
have been developed and 25 food inspectors trained.
In India, through local efforts, WHO has initiated rigorous
water quality monitoring and social mobilization for
environmental sanitation and hygiene in the relief shelters in
the worst affected district in Tamil Nadu. In addition, a long
term project to monitor the changes in ground water quality
following the disaster has been initiated in all the coastal
districts of Tamil Nadu.
Mental health of the affected populations has been a key
concern. In every affected country, WHO, along with the
concerned governments, has provided training for
psychosocial support, with help from the communities. This
emphasis on mental health in the tsunami-affected countries
has set in motion some far-reaching changes. The Sri Lankan
government plans to review its national mental health act and
mental health policies. In Indonesia, Aceh will become the
first province to have community mental health services.
For more information, contact: pandeyh@whosea.org
The Editor would like to thank the World Health Organization,
the Amercian Hospital Association, the Pan American Health
Organisation, World Medical Association, International Council
od Nurses and the World Health Professing Alliance for their
help in compiling the International news. Should you have any
suitable news items, please email your information to
Sheila@ihf-fih.org.
Vol. 41 No. 3 | World Hospitals and Health Services | 09

COUNTRY PROFILE: FRANCE
The French healthcare system: N
presentation, changes and challenges
GÉRARD VINCENT
DIRECTOR GENERAL, FRENCH HOSPITAL FEDERATION, PRESIDENT OF HOPE AND PRESIDENT DESIGNATE,
INTERNATIONAL HOSPITAL FEDERATION
O
S
The French system is considered the one of best in the
world for several reasons. Firstly, it is characterized by
fee-for-service payment of doctors, retrospective
reimbursement and unrestricted freedom of choice for
patients. France spends more on healthcare than most
OECD countries.
Secondly, the number of doctors was almost multiplied by
three between 1975 and 2000, reaching a ratio of 3.3
doctors per 1,000 inhabitants. Today, the total number of
doctors is stabilizing and will decrease from 2010 onwards.
Thirdly, an important reform recently took place in the
form of the Universal Health Coverage Act (CMU), which
was passed in June 1999 and came into force on 1 January
2000. This act, as its name suggests, established universal
health coverage, opening up the right to statutory health
insurance coverage on the basis of residence in France.
As a result, life expectancy increases regularly, by three
months a year for men and by two months a year for
women. While French women have one of the highest life
expectancies, men suffer from mortality due to smoking and
accidents. On the one hand, this indicator shows that the
health of the population is good. On the other hand, social
and geographical inequalities in health remain substantial.
Doctors benefit from the total freedom to choose where
they wish to practice, and geographical L disparities in the S
distribution of doctors have existed for a long time, and are
still a burning issue.
The social security system
The present system of social security, including statutory
health insurance, was established in 1945, at the end of the
Second World War.
R
In addition to the expanding coverage, the founders C of the
social security system aimed to create a single system
guaranteeing uniform rights for all. However, this goal could
not be achieved due to opposition from certain socioprofessional
groups who already benefited from insurance
coverage that had more favourable terms, and who
succeeded in maintaining their particular systems.
Since 1999, the CMU Act, which represents a major
development in the French social security, has further
shifted the balance of the health insurance system away from
S
M
RELAND
Dublin
Bay of Biscay
amanca
N
Cork
Bilbao
Valladolid
Madrid
Valencia
Liverpool
rdoba
Figure 1: France
U. K.
London
ANDORRA
Leeds
Leicester
FRANCE
NETHERLANDS
DENMARK
The Hague
Amsterdam
Plymouth
Essen
Brussels
English Channel
Bonn
Le Havre
BELGIUM Frankfurt Am Main
LUX.
Luxembourg
Paris
Nurnberg
Nantes
Strasbourg Stuttgart
Clermont-Ferrand
Bordeaux
Sunderland
Toulouse
Palma
BALEARIC
Marseille
Barcelona
North Sea
Geneva
Lyon
GERMANY
Bern
Vaduz (LIECH.)
SWITZERLAND
CORSICA
SARDINIA
Milano
Genova
SLOVENIA
Firenze
Monaco
ITALY
Ty rhenian Sea
a work-based system towards a system of universal health
coverage.
T
So the French social security is a mixed system, which lies
between the Beveridge and Bismarck models, with health
insurance funds and strong state intervention.
Vejle
Venezia
Hamburg
Hospital and self employed doctors:
a superposition of two systems
In 1958, reform of the hospital sector reinforced the powers
of the Minister of Health, extending the Minister’s control
over hospital building programmes and the appointment of
hospital directors, who became executive agents of the
central authority.
Go
Co
Berlin
Rom
Napl
A
M
M
10 | World Hospitals and Health Services | Vol. 41 No. 3

COUNTRY PROFILE: FRANCE
The reform also established teaching hospitals, by
means of agreements negotiated between regional
hospitals and faculties of medicine. Moreover, the
introduction of the principle of full-time employment of
doctors in hospitals represented a genuine transformation
of these institutions. This contributed a lot to improving
the French health system.
The hospital system
Hospitals in France can be public, private non-profit or
private for-profit. They can be specialized or non-specialized.
Public hospitals account for a quarter of all hospitals (about
1,000 out of 4,000) and two-thirds of the inpatient beds
(about 320,000 out of 490,000). They are legally
autonomous and manage their own budget. With an average
of 8.4 hospitals beds per 1,000 inhabitants, France is close
to the European average. In 1998, health care institutions
employed just over one million people, 80% of whom were
on the payrolls of public hospitals.
Self employed doctors
Self-employed doctors are free to work wherever they like,
whereas hospital work is dependent on post offered by
institutions. They are working in their own practices and
most of them work alone. However, almost all self-employed
healthcare professionals practice within the framework of
the national agreements signed by professionals’
representatives and the health insurance funds. In general,
patients pay the health care provider and they are
subsequently reimbursed by their health insurance fund at
the rate listed in the agreement.
Current challenges
Healthcare expenditure out of control
As in other countries, healthcare expenditure in France has
grown more rapidly than national wealth for many years.
The founding fathers of the social security system hoped
that the access to healthcare provided by statutory health
insurance would make it possible to maintain good health
among the whole population, and that as a result, the need
for treatment would diminish over time. In practice, the
pattern of development has been quite different, if not the
opposite, and the demand of health services lead to
unrelenting growth in expenditure on healthcare. The onset
of economic difficulties in the 1970s marked a turning point
in policies towards the provision of healthcare, which
became increasingly influenced by financial constraints.
In the past 25 years a succession of cost containment
policies (both on the demand side and the supply side) has
attempted to balance the accounts of the health insurance
system.
Measures to limit demand have been anticipated from the
outset, with consumers’ responsibility fostered through cost
sharing. The portion of the costs of treatment not
reimbursed by the health insurance was named “ticket
modérateur” precisely because of its intended aim of
moderating demand. Over and above the problems of equity
and access to treatment posed by this financial burden on
the patient, the theoretical effectiveness of this measure, in
terms of reducing expenditure, has been impaired by the
massive extension of complementary health insurance
coverage. However the 2003 reform raised the ticket
modérateur.
Measures to limit the supply of treatment have targeted
capacity as well as professional practices and charges for
goods and services. This type of control has been exercised
in two ways: by the medical map (carte sanitaire), which
until 2003 made the provision of hospitals beds subject to
authorization, and by the numerous clauses system, which
regulates access to medical training.
A lot of reforms tried to overcome this burning issue. The
so-called “Juppé reform” of 1996 for example took real
measures to limit the supply side but care professionals have
remained fiercely opposed to this policy and that side of the
“Juppé reform” failed.
This incapacity to control the healthcare expenditure is
mainly due to the complexity of the entire system.
Responsibilities and decision-makers are difficult to identify.
The complexity of the institutional organization
One of the aims of the “Juppé reform” was to clarify the role
of each healthcare system agent.
That important reform involved a more radical
reorganization of institutions and powers. To many, it was
seen as giving the state the control of the health care system
and it is true that some of the most significant measures
increased the role of the state, for example the reinforcement
of the role of parliament and the creation of regional hospital
agencies (ARH).
The ARH are responsible for hospital planning and
financial allocation to public hospitals. As for the
parliament, it votes on a national ceiling for health insurance
expenditure (ONDAM) for the year to come. This vote takes
place each year since 1996, and it is one of the great
achievements of the “Juppé reform”. Within the ONDAM, a
separate budget is defined for public hospitals. It is then
divided between regions and the ARH allocated individual
budgets to each hospital in a framework of regional resource
allocation. This was a response to the increase of health
expenditure.
Although a whole reform was needed, in practice this one
has been difficult to apply because of the series of conflicts
that has punctuated relations between medical unions,
health insurance and states authorities over the last 50 years.
Quality and safety challenges
In spite of the complexity of the French healthcare system
and the difficulty of managing it, until recently its
performance was not denied. This positive perception was
somehow dented by the “contaminated blood scandal”,
which drew attention to organizational weakness in the
system and led to the trial of three government ministers.
Since then, decision-makers and the public have been
increasingly concerned by safety issues. For instance, the
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COUNTRY PROFILE: FRANCE
precautionary principle has been used in the government’s
handling of the so-called “mad cow” crisis.
Beyond this question of safety, quality of care and public
health concerns have emerged as new priorities.
Promoting the quality of care provided and the evaluation
of medical practice only became visible issues in the mid-
1990s. It became a matter of concern to public authority
that was influenced by hospital ranking published by the
popular press on the basis of rather crude indicators.
Many steps have been taken in these areas in the last few
years. One of the most significant is the establishment by
the state of committees and agencies to fulfil specific
functions.
With regard to medical safety, vigilance and warning
systems, a new set of provisions has been put in place in the
last few years, consisting of two agencies responsible for the
safety of health product (AFSSAPS) and food product
(AFSSA) and the Institute for Monitoring Public Health
(InVS). Coordination of the activities of these three bodies is
provided by the National Committee on Medical Safety.
More recently, in April 2001 the French Agency for
Environmental Health and Safety (AFSSE) was added to this
structure.
As for quality issues, a National Agency for Accreditation
and Evaluation of Health Care (ANAES) was also created in
1997 and transformed to High Health Authority (HAS) in
2005. Its main functions are to elaborate and disseminate
practice guidelines and to carry out an accreditation process
for all hospitals.
New reforms and new challenges:
French healthcare system is in transition
The so-called “loi Kouchner” of 2002: a new focus on
patients
In recent years, the search for ways to take more accounts of
health care users’ expectations has been an important issue
of public debate. The activities of patients’ associations have
been a factor in this development. AIDS was source of
transformation in the types of action used by associations
concerned with healthcare. Having achieved visibility
through public interventions, these associations are no
longer restricted to their traditional role (patient support,
fund-raising to finance research), but seek to influence the
direction of research and enforce the concept of the patient
as an active agent.
Recently, associations related to healthcare formed a
collective unit (CISS), thereby increasing pressure to
accommodate the interests of healthcare users. Legislation
enacted in March 2002 reinforced the role of these
associations.
The issue of the place of the patient within the national
healthcare system is bound to develop for the coming years.
“Plan Hôpital 2007”: a major reform for a healthcare
system in transition
The hospital 2007 programme was launched by the Ministry
of Health in 2003. The goals of this new reform are very
ambitious and hard to achieve, but it is an attempt to answer
to current problems of French healthcare system. The main
axes of the reform are:
➜ Providing a much needed boost to investment aimed at
optimizing economic performance by modernizing and
reorganizing healthcare facilities. The aggregate capital
value is estimated at approximately €6 billion.
➜ Giving hospitals more possibilities for innovation and
adaptation by helping their development and
simplifying the hospitals’ management.
➜ The main point of the reform is to change completely
the way of financing hospitals. Until then, hospitals
received an amount of money for one year; with this
reform, this amount will depend on the activities of the
hospital (DRG financing).
The future
In spite of recent reforms, the French healthcare system is
still facing major issues today.
➜ Cost containment: a permanent objective The
organizational structure of French healthcare system
makes cost containment a goal difficult to achieve. The
French system is relatively expensive. Whereas the
slowing down of expenditure growth has been achieved
by most countries during the 1980s, cost containment
remains a permanent subject of debate in France, since
many of the measures taken to reduce expenditure
growth have been ineffective.
➜ Problem of geographical equity and workforce
shortage: The geographical distribution of healthcare
supply is characterized by a wide disparity in regional
doctor/population ratios. Policies intended to influence
the regional number of medical students have not
always had the expected results, because many doctors
return to their region to practice. Some studies think
that the situation will be worst within a few years. It is
possible that this subject will become rapidly a real
challenge for decision-makers.
Nowadays, hospitals complain about pressures on staff:
the implantation of the EU Working Time Directive and
the enforcement of the French “35 hours per week law”
has increased staff pressure already observed in some
hospitals. Projections show that some parts of the health
sector will still be confronted by a lack of professionals
within few years.
Coordination and organization of care: current experiments
A weakness of the French health care system lies in the
lack of coordination and continuity of care provided by
isolated professionals. This can lead to over-prescription
and waste, but also inadequate care paths and
insufficient quality. It means that even if doctors advise
their patients correctly, they are not in a position to
monitor the whole process of care.
The lack of coordination is not limited to self-employed
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COUNTRY PROFILE: FRANCE
professionals: the interface between hospital care and
ambulatory care on the one hand and between healthcare
and social care on the other hand, is also often a problem.
The implementation of the 2004 social security reform
began in 2005 with the introduction of several measures.
➜ Patients have to designate a GP through whom
treatment will be managed. The GP will decide on
referrals to specialists etc. Patients wishing to consult
specialists directly will still be able to do so but it will
cost more.
➜ The cost of a consultation remains at €20 but
reimbursement by social security is reduced from €14
to €13 (the rest can still be covered by complementary
insurance).
➜ A Higher Health Authority was created at the
beginning of 2005. It constitutes a major element of
the new organization of the French medical landscape;
it is an independent public organization in scientific
matters. Created within the framework of the law of
August 13th, 2004 concerning sickness insurance, the
Higher Health Authority is in charge of the evaluation
of the medical utility of medical acts and services
reimbursed by the sickness insurance, the
accreditation of the hospitals, the promotion of good
practices and good use of care beyond health
professionals and public. The Higher Health Authority
takes over the missions of the National Agency of
Accreditation and Evaluation in health (Anaes), those
of the Commission of Transparency and of the
Commission of Evaluation of Products and Services. ❑

POLICY: PUBLIC HEALTH RESEARCH
Building capacity for
public health research
ANDREW Y KITUA
DIRECTOR GENERAL, NATIONAL INSTITUTE FOR MEDICAL RESEARCH, TANZANIA
The developing world bears 90% of the global burden
of disease (WHO Ad-Hoc Committee, 1996; Global
Forum for Health Research, 2002), much of it in the
tropical countries. Here the climatic and environmental
conditions are most favourable for the survival and
propagation of disease vectors and pathogens (bacteria,
parasite or virus). These are the countries with the lowest
economic status and often experience a vicious cycle of
disease, poverty and more disease.
Africa bears the brunt of this unfortunate situation,
contributing 90% of the 300-500 million annual malaria
cases, and around a million child deaths each year. Except
for leishmaniasis, the burden of the other tropical diseases
like schistosomiasis, lymphatic filariasis, leprosy,
tuberculosis, African trypanosomiasis, etc., are also greatest
in Africa. Children are the most affected and the huge
burden of childhood diseases demonstrates the grave
situation in Africa (see Table 1).
In recent years, HIV/AIDS has spread like bush fire in
Africa and is causing irreparable damage to the economical
productive section of its populations.
In the case of available capacities for public health
research, we find the reverse. About four-fifths of global
working scientists of all disciplines, including health are
concentrated in the Western industrialised nations, Japan
and large Asian countries. Africa, Latin America and the
Middle East have together 13% of the world’s scientists.
While Japan has one scientist for every 250 people, the ratio
in many developing countries is one in thousands (WHO
Ad-Hoc Committee, 1996). The developed/rich world,
which only bears 10% of the global disease burden, has the
lion’s share of well trained scientists available globally and
due to its better economic status continues to suck in
further skilled people from the developing world, causing
the brain drain phenomenon.
The core problem is the inequity in the distribution of the
capacity to generate public health knowledge, make it
accessible and affordable to the needy and ensure adequate
utilisation of current knowledge.
Therefore, while there is general agreement that there is a
need for capacity building for public health research, this
need is greatest in developing countries and for Africa it is a
matter of urgency.
Consequences of the lack of capacity
Developing countries are not able to access the available
global resources for health research due to:
➜ insufficient research capacities to compete for the
funds;
➜ shortage of well-trained and competent scientists;
➜ lack of well-equipped laboratories adapted for high
quality research and good practices;
➜ unfavourable conditions for access to funding by
developing country scientists;
Lack of critical mass of scientists for R&D makes it hard
for developing countries to use and implement effectively
the available tools for improving their health status.
Diarrhoeal diseases, intestinal worms and vaccinable
diseases continue to spread even when tools and knowledge
for their prevention are available, because of lack of capacity
to translate the knowledge into action.
Because of the absence of researchers capable of
generating the evidence, policy-makers are unable to benefit
from the much-needed evidence base for taking decisions
about the use of alternative strategies for intervention or for
planning healthcare services (Nchinda TC, 2002).
Lack of scientific capacity is therefore greatly pronounced
in poor developing countries. This exacerbates the vicious
cycle of ‘poverty – disease – poverty’ through the following
chain of events:
➜ Lack of scientists results in low generation and
utilisation of knowledge.
➜ Low technology development and utilisation of current
technology.
➜ Low level of competition for global health research funds.
➜ Lack of power to drive the global agenda.
➜ Poor and dilapidated facilities.
➜ Scientific frustration hence departure to better pastures.
➜ Heavy disease burden, low productivity and increase of
poverty.
➜ Limited technology transfer.
➜ Failure to implement and sustain health research
programmes including disease interventions.
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POLICY: PUBLIC HEALTH RESEARCH
Causes of the problem at global level
The global agenda has for too long neglected the diseases
affecting the poor populations. Malaria research has just
started to receive its due recognition after decades of despair
in the period 1960s and 1980s although it still receives
comparatively low funding compared to the size of the
problem. Michaud and Murray (1996) estimated that the
global expenditure on research for HIV/AIDS and asthma
was, respectively, US$952 million and US$143 million,
whereas for malaria and tuberculosis it was about 15- and 5-
fold less at US$60 million and US$26 million respectively.
Taking cancer as an example, the UK expenditure is about
US$225 million, equivalent to US$1,525 per single UK
cancer death (Anderson et al, 1996). Malaria, on the
contrary, has global expenditure of the order of US$65 per
single death, while it is responsible for a much higher death
toll. Priority setting at the global level has not yet involved
sufficiently for the developing world’s voice to have a strong
focus on the causes of the greater global burden.
The facilities for generating powerful scientists are lacking
in the developing world due to historical reasons, and the
tendency not to invest for the creation of infrastructure in
the developing world is still a major stumbling block. Many
funding agencies do not allow the inclusion of capacity
building in developing countries in proposals seeking funds
for public health research. It is difficult to persuade
development agencies to allow for the inclusion of a research
component when obviously the success of development
projects depends on good data and monitoring processes.
There is a glaring lack of strong training institutions for
tropical medicine, low production of medical doctors and
other scientists in biomedical fields.
The brain drain from developing countries continues
thrive, even when we are aware of the negative
consequences and there are no policies to halt it.
Causes of the problem at regional level
At the regional level, there is lack of strong research
advocacy and coordination. Such mechanisms either do not
exist or, as in Africa, have just been started and are still
struggling to get on their feet. A few developing countries
like India, Brazil and China have moved faster forward,
because they rectified this anomaly earlier on.
Consequently, there is little advocacy for political support
and financial support by regional economic bodies.
Funding mechanisms are lacking or poor, leading to little
sense of ownership of the research agenda and of strategies
for capacity building. It is not right that Africa has no
common research funding mechanism similar to Europe or
America. It is even unethical, given the huge disease burden.
Regional priority setting is absent and regions have little
influence on the global agenda. Networking at the regional
level is especially poor and uncoordinated in Africa,
resulting in poor research output – unlike the PAHO region
and India.
There is poor development of peer review systems,
research monitoring and control bodies, leaving developing
countries as sites to be used for sample and data collection
for developed world laboratories, rather than being equal
partners in research.
Causes of the problem at national levels
At the country level there is also weak research coordination,
advocacy and promotion, leading to poor quality or lack of
research prioritisation. Only a few countries in Africa have
well-functioning national health research mechanisms. The
industrial base is lacking and product development efforts
linking research and industry are rare. National guidelines for
partnership are lacking and ethical review bodies are weak or
inexistent. Research funding is negligible and mechanisms to
facilitate research to implementation are missing.
Burden (as % of total DALYs), 1990
Condition World Sub-Saharan Africa
Childhood communicable diseases
Lower respiratory tract infections (pneumonia) 8.2 10.2
Diarrhoeal diseases 7.2 10.9
Vaccine-preventable childhood infections* 5.2 10.3
Malaria 2.3 9.2
Bacterial meningitis and meningococcaemia 0.5 0.3
Intestinal nematodes 0.4 0.2
Malnutrition (direct effects only) 3.7 3.2
Total burden from these conditions 27.5 44.3
*Diseases preventable with the vaccines currently available through the Expanded Programme on
Immunization: diphtheria, pertussis, tetanus, polio, measles.
Adopted from: WHO Ad-Hoc Committee, 1996
Table 1: The burden of childhood disease
Vol. 41 No. 3 | World Hospitals and Health Services | 15

POLICY: PUBLIC HEALTH RESEARCH
Recommended strategic approaches to solve the problem:
Global level:
➜ The setting of the global agenda should involve
researchers from developing countries.
➜ Dialogue between northern and southern researchers
should be formally conducted to make northern
researchers understand the difficulties of southern
researchers.
➜ Global legislation and regulations should be put in
place, requiring compensation to developing countries
whenever any of their scientists is taken up for
employment in the developed world.
➜ Funding agencies should make it obligatory to have
good capacity building in any research activity
conducted in a developing country.
➜ Equal partnership in research should be emphasised
and there should be equal treatment to northern and
southern researchers when conducting collaborative
research.
➜ The creation of strong and high quality laboratories in
the south must be treated as a matter of urgency.
➜ Conditions should be put in place to encourage
leadership and coordination by the south in
collaborative research.
➜ Global funding mechanisms should network and create
complementary funding programmes with long-term
commitments to ensure adequate funding and
integration into the health systems for sustainability.
➜ Negative competition should be discouraged. WHO
has had a long-term, successful programme in Africa
which has created good capacities. These efforts should
be complemented by the creation of similar
programmes targeting complementary capacities for
other diseases and health conditions.
Regional level:
➜ Regional public health research coordination and
promotion mechanisms should be created in
developing countries
➜ Research funding mechanisms at regional level should
be set and be adequately supported by regional
governments.
➜ Regional participation in global public health research
should be enhanced.
➜ Regional networks should be created and coordinated
by regional mechanisms for greater impact.
➜ The excellent and vast northern capacities for research
should be harnessed to support capacity building in
developing countries.
National level:
➜ Research coordination, promotion and monitoring
mechanisms should be strengthened and national
governments should provide more funding for research.
➜ Capacity strengthening at national level should be given
priority and be strategically planned to fill in the major
glaring gaps.
➜ Active creation of facilities for training and centres of
excellence must be created. Partnerships with
developing countries should be encouraged but guided
by national and regional regulations, which prevent
exploitation (Swiss Commission, 2001).
➜ Creation of facilities run and owned by the northern
institutions in the south should be discouraged and
existing ones should be run in partnership or integrated
into country-owned systems.
➜ In addition to putting emphasis on research, countries
must put in place effective plans to improve their health
services and increase their capacity to absorb new
interventions and scale them up at national level.
➜ Twining of laboratories and research institutions
allowing for exchange of students and faculties should
be encouraged.
➜ Inter country networking should be encouraged to
enhance south-south collaboration.
Discussion
The world has set for itself the Millennium Development
Goals and achieving them will require good information,
evidence-based guidance on the implementation of effective
interventions and continuous monitoring of more activities.
Without a good base of scientific resources, this will not be
possible even if resources are available. This provides an
opportunity, to press for increased efforts in support of
capacity building for public health research, to improve
health status and reduce poverty.
The Millennium Development Goals demand country
actions and the actions of partners to provide assistance to
poor countries. The goals do not require rich countries to
solve the problems of the poor for them, but to help them
solve their own problems. Charity does not work and is not
sustainable.
Globalisation is another opportunity, for uniting the world
against the global problems and threats by disease and ill
health. As Dr Pascoal Mocumbi put it “Above all we need to
think in radical new ways – ways that show we are more
conscious of our common humanity in this third
millennium. Ways that make the obligation to help our
weakest members the rule and the priority, rather than the
exception. And ways in which there is no longer any place
for the ‘my problem versus your problem” attitude that is
still too prevalent in today’s otherwise globalised world
(Mocumbi, 2004).
The United Nations should take upon itself the
responsibility of changing the global order and it is
encouraging that this has been emphasised recently by
world leaders, “Global problems need global multilateral
solutions and the United Nations is best equipped to lead
us”. It should push for more debt relief and use of such relief
to build national scientific capacities especially in public
health research. It should urge rich countries to contribute
generously to the Global Fund to Fight AIDS, TB and
Malaria, which should be maintained and used not only for
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POLICY: PUBLIC HEALTH RESEARCH
providing the goods but especially for enabling countries to
generate knowledge, tools and capacities to utilise effectively
the available public health goods. Emphasis should be on
strengthening the weak health systems in poor countries so
that they can introduce and scale up interventions effectively.
The international community must recognise the
inadequacy of public health research capacities especially in
developing countries, to solve the increasing global disease
burden.
Hence funding for research affecting the majority of the
world population who are poor must not only be increased
but audited to ascertain that funds reach and are used in
disease endemic countries. Direct channelling of funds to
developing countries’ institutions, instead of using
intermediaries, will enhance capacity building for research
management, coordination and accountability.
Current initiatives like the European-Developing
Countries Clinical Research Partnership (EDCTP) should be
encouraged.
Governments and regional organisations should provide
the enabling environment for research through the
enactment of appropriate policies that are relevant to
research and product development. The lack of public
health training facilities in disease endemic countries must
be corrected and while endemic countries should take the
lead, developed countries should help in providing technical
and financial support. ❑
Reprinted from Global Forum Update on research for Health
2005, © Global Forum for Health Research 2005.
References
Anderson J, Maclean M, and Davies C, 1996. Malaria Research. An audit of
International activities. Unit for Policy Research in Science and Medicine. PRISM
Report No. 7, September 1996..
Global Forum for Health Research, 2002. The 10/90 Report on Health Research
2001-2002. Global Forum for Health Research, Geneva .
Michaud C, Murray CCJL, 1996. Resources for health research and development in
1992; a global overview. In: WHO Ad-Hoc Committee, 1996. Investing In Health
Research and Development. Report of the Ad-Hoc Committee on Health Research
Relating to Future Intervention options. WHO, Geneva.
Mocumbi P, 2004. ‘Plague of my People’. Nature 430: 925.
Nchinda TC, 2002. ‘Research Capacity Strengthening in the South’. Social Science
and Medicine 54: 1699-1711.
Swiss Commission for Research Partnerships with Developing Countries, 2001.
Enhancing Research Capacity in Developing and Transition Countries. Experiences,
discussions, strategies and tools for building research capacity and strengthening
institutions in view of promoting research for sustainable development. Swiss
Commission for Research Partnerships with Developing Countries KFPE 2001.
WHO Ad-Hoc Committee, 1996. Investing In Health Research and Development.
Report of the Ad-Hoc Committee on Health Research Relating to Future
Intervention options. WHO, Geneva.
Vol. 41 No. 3 | World Hospitals and Health Services | 17

MANAGEMENT: TSUNAMI EVALUATION
Management of hospitals in
Aceh during the tsunami
DR HERMANSYUR KARTOWISASTRO
CHAIRMAN OF THE INTERNATIONAL AFFAIRS DEPARTMENT, INDONESIAN HOSPITAL ASSOCIATION
Abstract
On December 26th, 2004, Aceh and its vicinity was hit by two natural forces consecutively, an earthquake and a
tsunami. Hundreds of thousands of people perished, leaving the remaining of about the same number to become
refugees. The writer was assigned by the Ministry of Health to Aceh on duty on the second and third week after the
catastrophe, to help the management of Zainoel Abidin General Hospital in Banda Aceh, the province’s biggest
hospital, revive its operation.
The hospital once had 400 beds with 911 employees
and 61 doctors, not to mention the facilities of CT
Scan, operating microscope and others. Besides giving
health services for the local people, the hospital also stood
as an educational hospital for Syiah Kuala University Medical
School’s students.
Besides the writer, the other members of the hospital’s
reviving team were two senior nurses (nursing managers),
one engineer and one administration clerk. When I left
Jakarta, I had already in mind the approach of man, money,
material and method that I was going to apply there,
however, the real condition in the field was totally different
from what I had pictured.
The healthcare activities for in-patients and out-patients
were only given in the emergency unit, and conducted by
the Jakarta province’s health team. When I assessed the
management on 8 January, 2005 (two weeks after the
tsunami), I came up with conclusion:
➜ Manpower: Only six out of 911 staff came to work that
day. They were: the director, one department head, one
technical officer, 1 administration clerk dan one lab
staff. Since the lab was closed, the staff was assigned to
cater foods for hundreds of volunteers.
➜ Money: The hospital’s director did not have a fixed
source of income to run its daily operation. And there
were hundreds of volunteers who worked hard to clean
mud in the vicinity who needed to be fed. Not to
mention the needs for diesel gasoline to run the
generator (The country’s electricity company was not
operating at that time), etc.
➜ Material: All the hospital’s areas were inundated with
mud. The height could reached upto one metre in
several areas, meaning, all the beds, cupboards, tables,
chairs and medical equipments were submerged in
mud. All rooms had to be cleaned and disinfected, as
well as all the equipment. We decided to dispose of all
wooden equipments that had been submerged in mud
and sort the metal equipments according to their
conditions (still functioning or not).
➜ Method: All the systems and operations was practically
shut down since all the equipments were broken and
there was no manpower. No financial management,
accounting, administration, documentary, management
information system, medical records, etc, was going on
at that time. Basically, the only activity running at that
time was a cleaning up operation to sanitize the
hospital and emergency unit.
On 8 January, 2005, 20 patients were treated in the
emergency unit. They were suffering from: tetanus, 12
people (60%), aspiration pneumonia and malnutrition, each
two people (10%) and stroke, fracture, enterithys, heart
failure, each 12 people (5%).
After conducting a managerial assessment, the decision to
have a daily coordination meeting at 9 am among all the
parties working in the hospital (locals and foreigners) was
taken. The forum would be the place to discuss all the
problems concerning the hospital’s operations, from
management, case handling to security issues.
The mud cleaning effort continuously took place.
Gradually, medical operations began to start as several
rooms were already clean. It started with turning the former
ICU into an adult treatment ward. Children and cardiology
wards were transformed into some kind of a small hospital
by the Australian and New Zealand armies. Progress
continued with the opening of the infection ward in the
Kulu Room. The consideration to use the Kulu room,
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MANAGEMENT: TSUNAMI EVALUATION
No Diagnosis of Illness Number Percentage
1 Trauma (wound, bone fractures, etc) 19 35.18%
2 Tetanus 1 629.62%
3 Aspiration Pneumonia 15 27.77%
4 Diaorhea 4 7.40%
5 Diabetes Mellitus 2 %
6Tubercolosis 1 %
7 Febris 1 %
8 Thalasemia 1 %
9 Hernia 1 %
10 Patent Ductus Arteriosus (PDA) 1 %
11 Malnutrition 1 %
12 Chronic Obstructive Pulmonary Dissease 1 %
13 Asthma Bronchial 1 %
Total 54 100%
Table 1: Zainoel Abidin Hospital In-patients’ patterns of disease on 14 January, 2005
cardiology and ICU wards were taken since the location of
these three buildings/wards were relatively higher than other
buildings/wards in order to avoid the flood that still
inundated the hospital’s yard.
At that time, another problem emerged since there were
only two Zainoel Abidin Hospital’s medical staff present;
one pediatrician and one doctor from surgery and ICU
units. For the operations to run, doctors from Jakarta, South
Sulawesi, Langsa Regent, Australia, Singapore, Belgium and
other countries volunteer to lend their hands to care for
patients in these wards.
Gradually, ZA Hospital’s nurses started to return to work
and were directly involved in caring for the patients. After
the third and fourth week, several specialists had also
returned to work and progressively, the operations in the
hospital started to run again.
The disease pattern
First, as a doctor, one occurrence that really caught my eyes
as I handled patients in Aceh was that there was a difference
of disease pattern between the disaster area and non disaster
area, even among different disaster areas.
Since many people were rolled around inside the sea
wave, there were many cases of Aspiration Pneumonia or
lung infection (pulmonary infection due to seawater, mud
and others sewage inhalation) occurred. From our
experience on site, the disease was hard to cure and had a
high mortality rate. Sometimes special equipment
(bronchoscope, ventilator) were also needed to treat the
patients.
The second common dissease to occur in the first two
weeks after the tsunami was tetanus. WHO especially
assigned one of their researchers to observe the dissease’s
high occurence rate. The same situation happened in
Phuket, but not in Sri Lanka. As we know, both places were
also hit by the tsunami.
One other situation that must be realized and understood
by all the aid providers was that most patients had multiple
diseases. They could be suffering from cough, wounds on
their legs, mud in their ears, etc at the same time, not to
mention all the stress that they had to bear due to the loss
of their relatives and possessions. It is difficult to heal a
person with multiple disseases, that is why highly dedicated
doctors and nurses with up to date knowledge, along with
sufficient supply of medicine are needed to handle these
different patterns of diseases.
The tables below will give comprehensive description of
the dissease patterns during the first few weeks after the
tsunami. The first table shows the dissease patterns of
Zainoel Abidin Hospital’s in-patients on 14 January, 2005.
The first few weeks after the tsunami, numbers of patients
were referred to Medan, the capital of North Sumatera
Province, which is located adjacent to Aceh and equipped
with complete medical facilities. Table 2 describes the
disease patterns of Aceh’s tsunami victims that were being
referred to Medan for the period of 27 December, 2004 (one
day after the catastrophe) to 12 January, 2005.
To accelerate the analyzing process, the diseases in table 2
were classified according to their major disease groups, as
shown in Table 3 below. The data showed that surgery,
minor or major, was needed in majority of the cases. The
second highest rate of diseases was pulmonary and
respiratory malfunctions.
Hospital staff
Many of the local paramedics, about 20%, were directly or
indirectly effected by the catastrophe. Direct victims
encompass those who were missing, perished or suffering
from diseases, as well as those who were no longer have a
place to stay in Aceh and were forced to leave Aceh. While
indirect victims encompass those who lost their family
members or had to accompany their children to other cities
because many school buildings were destroyed, etc.
Reality on site showed that two to three weeks after the
catastrophe, survived paramedics were still inactive since
most of them were deeply affected by this calamity. Some
were wounded, some lost their family members or had to
take their children out of Aceh in order to go to school. Not
to mention the many victims that suffered from severe
trauma or stress.
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No Dissease Numbers Deceased
1 Laceration, Vulnus Excoriation 105 3
2 Aspiration Pneumonia 33 3
3 Fracture, Dislocation, Amputation 17 1
4 Trauma of the Thorax 17 0
5 Acute Respiratory Infection 17 0
6Dyspepsia 17 0
7 Rhino sinusitis 14 0
8 Gastroenteritis 11 1
9 Capitis Trauma 60
10 Bronchitis 60
11 Tuba Catarh 60
12 Cerumen prop 5 0
13 Tympanic Membrane Perforation 5 0
14 Mialgia 5 0
15 Pedical ulcer, Diabetical ulcery 4 0
16Pregnancy, weeks 22 - 24 4 0
17 Blunt abdominal injury.
Post Laparotomi, Post Grift 3 1
18 Mandibula 3 0
19 Corpus Alienum 3 0
20 Sefalgia 3 0
21 Chest pain 3 0
22 Tonsillopharignytis 2 0
23 Otitis Media 2 0
24 Osteo arthritis 2 0
25 Abdomen Discomfort 2 0
26Trauma Oculi 2 0
27 Tetanus 2 1
28 Stroke 2 0
29 Mild Depression 2 0
30 Undiagnosed 2 0
31 Obstructive Illus 1 0
32 Hernia Incarcerate 1 0
33 Scalp Injury 1 1
34 Urolithiasis 1 0
35 Abces Antebrachii 1 0
36Bronchial Asthma 1 0
37 Pneumothorax 1 0
38 Hermatothorax 1 0
39 Tuberculosis 1 0
40 Auricular Excoriation 1 0
41 GGK 1 1 0
42 Febris Observation 1 0
43 Typhus Abdominalis 1 0
44 Back Pain 1 0
45 Fatique 1 0
46Post Abortum 1 0
47 PEB + Laparotomi 1 0
48 Hemato, Palpebra 1 0
49 Conjunctivitis 1 0
50 Contact Dermatitis 1 0
51 Snake Bite 1 0
52 Skin Avulsion of Heart 1 0
53 Avulse Wound 1 0
54 Chemosis 1 0
55 Death on arrival 1 1
TOTAL 330 12
Table 2: The diagnosis of disease patterns of referred Aceh’s tsunami
victims at Adam Malik Hospital, Medan, from December 27, 2004 to
January 12, 2005
Due to a limited number of manpower, the
healthcare services were performed by doctors
and nurses from various countries
simultaneously. At Zainoel Abidin Hospital for
example, once, paramedics from 11 countries
worked together hand in hand, a true
international hospital. Other hospitals in Banda
Aceh, Kosdam Hospital and Fakinah Hospital,
were also served by paramedics from various
countries at the same time.
Paramedics’ various nationality had several
impacts on the patients. One of them was
communication difficulty due to language
barrier, especially since few patients could only
speak Acehnese. The way they conduct the
healthcare services, theoretically and in practice,
might also have an impact on the patients. On
the other hand, however, there was “transfer of
knowledge” among working paramedics. From
the experience, it seemed that the transfer of
knowledge went smoothly. Several Indonesian
surgeons and gynaecologists were operating
together with Australian doctors. The same
happened with our nurses who worked with
nurses from Singapore, etc.
One matter that we have to take under
consideration is the education continuation for
all the medical, nursing and other health
officials (paramedic) schools students in Aceh.
Their university and school buildings were
destroyed, not to mention the laboratory.
Teaching Hospital did not function at its
maximum capacity, significant number of
lecturers were perished or moved out of town.
To recover the condition, actions such as
inviting guest lecturers, rehabilitating medical
schools facilities and temporarily sending Aceh’s
medical students to other medical schools
outside Aceh have to be taken.
Patients
Some patients came to the hospital alone,
without any family member at their sides. They
might be the only survivor in their family. Some
No Diassease Numbers Deceased
1 Surgery 143 6
2 Pulmonary 177 3
3 ENT 138 0
4 Ob-Gyn 60
5 Ophthalmology 4 0
6Others 30 1
Total 330 11
Table 3: The Diagnosis of disease patterns
classification of referred Aceh’s tsunami victims
at Adam Malik Hospital, Medan, From December
27, 2004 – January 12, 2005
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MANAGEMENT: TSUNAMI EVALUATION
The numbers of patients that
exceeded hospitals’ capacity,
the many computers that were
broken after they had been
immersed in the water and the
lack of medical record staff
were among causes of the
problems
“
”
were found by volunteers who then took them to the
hospitals for further care. The others came with their family,
not only because they wanted to be with each other, but
they no longer had a place to stay and turned the hospital
into their new home. To cater for all the food for the
patients, as well as their family, the hospitals were equipped
with a public kitchen. Here, the hospital’s responsibility was
not only to care for the patients, but for their family as well.
This is a heavy duty since the number of local paramedics
was still very limited.
When the patients were healed, the families were often
confused where to bring them since their home had turned
into ground zero. International Red Cross opened a field
hospital in Banda Aceh Stadium area that could also
function as temporary shelters for hospital discharged
patients without complete recovery.
So other patients with more severe injuries and in need for
more intensive care could take their places in the hospital.
The more disheartening situation applied for patients that
passed away in the hospital. Usually the deceased body were
given to the family who then would take care for the burial
process. However, that was not always the case here in Aceh,
especially if the deceased no longer had a house or family. In
many cases, it was also difficult to find a piece of land for the
burial to take place.
At the end, not only the in-patients that the hospital have
to take care, but also their family and the discharged
patients, the healing ones and the deceased ones. This is
additional work that is not included in our hospitals’ scope
of work.
With improper shelter, inadequate food and trauma as
well as stress, the refugees’ body resistance had weakened
with time. Nutritious food feeding, along with suitable stress
and trauma management programmes are the best option to
solve this problem.
Facilities
Another problem that needed to be dealt with is the
destruction of health facilities, hospitals and public health
centres. Our experience showed that despite hundreds of
volunteers who had worked full time for up to two weeks
after the catastrophe, the Zainoel Abidin Hospital was still
not fully cleaned although several rooms could already be
used.
Several hospitals lost all their archives, including all the
records and status that they use to write patients’ medical
development. Because of this, hospitals used blank papers
as its replacement to write patients’ medical status and were
not filed orderly as in other hospitals. However, the archives
problem would not stop all the paramedics to give their best
services.
Medical record system also had not functioned at its full
capacity yet due to some problems in the data entry process.
The numbers of patients that exceeded hospitals’ capacity,
the many computers that were broken after had been
immersed in the water and the lack of medical record staff
were among cause of the problems.
The hospital environment was also surrounded by waste
management problem. Every activity in the hospital would
generate a variety of waste. Some solid wastes were
processed in the incinerator (by burning them), while the
remaining were dumped in a localized waste ground to be
picked up by the city sanitation service. At the moment, the
waste is not processed as it should be, creating stacks of
waste in the hospital area.
Another sanitation problem was also created by mud. The
cleaning process had reached only the rooms and the
buildings of hospitals, the drainage channels were still
untouched. As a result, water often inundated the hospitals’
yards, especially since the city drainage system itself was still
clogged with mud and woods from tsunami.
With all the hospitals and public health centres destroyed,
majority of medical equipment were lost or broken. Two to
three weeks after the tsunami for example, medical
equipments were mounting high in Zainoel Abidin
Hospital’s yard. Part of the equipment such as wooden beds,
racks and cupboards could be cleaned and used again, while
the others, such as high technology medical equipment, had
to be checked first. Many countries offered to donate
medical equipment. Good coordination is needed in order
to get the best result out of the donation. To maximize the
healthcare rehabilitation process, it is best to evaluate the
form of future healthcare service in Aceh from now.
Conclusion
There are five basic steps that can be done to revive
hospital services in Aceh. First, there is a need to map the
condition of all hospitals in the disaster areas. It is best to
conduct the mapping with the management system
approach of Manpower, Money, Material and Method.
Second, the system of hospital services should be
designated, which disaster area does each hospital have to
serve. It is possible that the area specification will change
after the catastrophe. City centre might move to another
area, so, the hospital location has to be readjusted
accordingly or a change in population that makes the
hospitals have to downsize or upsize its capacity. The act
of downsizing, relocating or determining hospital
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MANAGEMENT: TSUNAMI EVALUATION
specialization might need to be applied. Maybe the
presence of hospital that specializes in infection,
pulmonary or psychology trauma, etc, will help hospitals
to deliver more intensive healthcare services. In order to
achieve all the above, some hospitals might have to modify
their vision and mission, as well as their master plans, etc.
A question of the possibility to have a private practice in
Banda Aceh in the future was asked by doctors here since
there are still many infrastructures that need to be built
and many of Banda Aceh residents with strong financial
background have moved to other cities. We need to
analyze this matter thoroughly before setting the role of a
hospital in an area in the future.
Third, it is needed to identify all available healthcare
services, besides hospital, such as private clinics, public
health centres, etc. After the tsunami, several intact private
hospitals were actively giving their hands to help the
victims for free.
Fourth, we need to put all the effort to encourage the
activation of self sufficient hospitals that operate with local
capacity, manpower as well as the facilities and the
infrastructures. Let the local manpower be the backbone of
the hospitals. External parties such as the central
government, other provinces and countries will only
support and complement the hospitals’ operation. All
parties should show their optimal support in order for our
colleagues in Aceh to work at their optimum capacity.
Fifth, due to Aceh’s limited condition, “sister hospital”,
a joint operation between a hospital in Aceh and another
hospital outside Aceh, can be formed. The sister hospital
will have the responsibility of helping its “sister” in Aceh
to deliver healthcare services for Aceh people who are in
need of excellent hospital services.
The experience in managing hospitals right after the
tsunami was a valuable and enriching experience. It really
enhances our knowledge in hospital management which at
the end will accomplish in excellent healthcare services for
the people. ❑
Vol. 41 No. 3 | World Hospitals and Health Services | 23

MANAGEMENT: TSUNAMI EVALUATION
Experiences of a hospital in
Thailand in treating tsunami
patients
SENIOR MANAGEMENT TEAM
BUMRUNGRAD INTERNATIONAL HOSPITAL
Abstract
No one was prepared when the tsunami hit on that sunny Sunday morning of 26 December 2004—not the villagers,
not the hotel employees, not the tourists on holiday enjoying the clear skies and calm waters. Yet days later,
Bumrungrad International Hospital (BI), a Joint Commission International-accredited, 554-bed medical centre in
Bangkok, Thailand, quickly became prepared as it began treating patients from the tsunami. This article highlights
the efforts of Bumrungrad International Hospital in treating tsunami patients. Information for this article has been
provided by Bumrungrad International’s Senior Management team.
When the tsunami hit, logistical problems delayed
many victims from immediately leaving the
affected areas. The first group of patients – even
adults who rode on the back of a truck for 10 hours to get
to BI – arrived at approximately noon on 27 December.
Beginning Tuesday, 28 December, BI started to see more
patients and got a firsthand look at the damage inflicted by
the tsunami. BI had its ambulance waiting at the airport for
the arrival of the injured who were medically evacuated from
Phuket and Krabi. What BI did not expect were the injured
who took commercial flights out of Phuket and then took
taxis to the hospital. In total, BI treated 234 patients, mostly
Dutch, Swedish, and British nationals on holiday. BI
admitted 134 patients and had 100 outpatient visits.
Preparing for an influx of patients
BI’s Group chief executive officer (Group CEO) and Group
chief operating officer (Group COO) happened to be
vacationing on Phuket when the tsunami hit. The Group
CEO called the hospital and told staff to start preparing for
the arrival of patients. At the time, BI was not aware of how
many people were injured. However, early on, BI staff began
discussing the situation and preparing its response. BI’s
medical director took the lead and immediately started
alerting specialists to be available while organizing a medical
task force to prepare for incoming patients. Extra staff were
called in and in some cases, they cancelled or postponed
their New Year holiday plans to help.
Fortunately, BI had more time to prepare for this
emergency, unlike the hospitals in Phuket. BI activated its
disaster plan and began taking an inventory of supplies,
medicines, available rooms, food – everything that might
be needed in an emergency. Physicians were requested to
review patients, and if possible, discharge noncritical
patients to make room for the injured. A staging area in
the emergency room (ER) was set up per BI’s disaster
plan to triage patients as they arrived.
Working with other hospitals to treat patients
By 9:00 pm. on Tuesday, 28 December, BI was reaching
capacity levels in its inpatient rooms, critical care wards, and
in some of its ancillary services. As a tertiary hospital with
160 full-time and 600 part-time consultants and specialists,
BI found that there were no cases that it could not treat. As
part of its emergency response plan, however, BI
coordinated with three smaller hospitals in the vicinity to
handle patient overflow. BI activated this by having the other
hospitals’ ambulances on standby at its ER.
In addition, BI made it a point to keep families together and
to manage cases that required high-level specialty treatment.
Furthermore, its referral team continually tracked all patient
movements and maintained constant communication with
embassies and consulates.
Addressing the unique needs of the disaster
BI has highlighted the following reasons why this disaster
was very different from a “standard” disaster situation that
most hospitals would prepare for in their disaster plan:
➜ Patients were delayed in arriving at the hospital. The
usual situation is for many patients to arrive within a
few hours of a disaster. Because Phuket, Krabi, and
Khao Lak are located nearly 1000 km south of
Bangkok, the journey by land takes approximately 10
hours. Phuket is an island off the mainland, with one
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MANAGEMENT: TSUNAMI EVALUATION
bridge linking it to the coast. Many of the tsunami
victims were also stuck on smaller islands off the
mainland such as Phi Phi Island and Phang-Nga Island,
which were almost completely overrun with waves.
These islands have no medical facilities at all. With
such widespread destruction in a relatively remote part
of the country, the infrastructure was not sophisticated
enough to cope with a disaster of this magnitude. The
phone lines were down, and transport in and out of
Phuket and the rest of the region was almost impossible
on the first day. While Phuket has hospitals, there were
simply not enough beds to admit all the patients who
kept arriving. One 150-bed hospital had almost 700
patients trying to get medical treatment.
➜ The continuous inflow of patients lasted over a
prolonged period of approximately 10 days, instead
of all patients arriving at the ER a few hours after the
disaster. Because of the sheer distance from the site of
the disaster, BI received a very high volume of patients
during the first week or so and then continued to see a
few more patients in smaller numbers by the first week
of 2005. This affected its regular services. From 27-28
December and on, BI sent ambulances to pick up
patients on request from Phuket and other areas. The
challenge with this approach was that a single journey
to pick up one patient took a total of 20 hours’ travel
time. With such a massive number of patients and
numerous simultaneous requests, the ER team had to
juggle the limited number of ambulances to send at any
one time.
➜ Patients arriving at the ER did not follow a typical
triage route. In a “standard” disaster, most patients
would come to the hospital through the emergency
services route. Patients from the tsunami had to go
through multiple staging areas and received help along
the way from whomever was available to help, not
necessarily from medical personnel. In this case, many
of the patients who were well enough to walk took a
free airplane flight from Phuket (provided by the Thai
aviation authorities) and then took a taxi from the
Bangkok airport to BI or to other hospitals. As such,
much of the first influx of patients had relatively lesssevere
injuries, though some were badly injured. The
Thai authorities also set up a triage area at the airport
and directed hospitals from every area to send
ambulances to the airport to pick up patients as
designated by the authorities.
➜ Because of communication system breakdowns in
southern Thailand on the day of the tsunami, there
were many holes in communication when preparing
for the patients. When BI received a call from Khao
Lak that 50 guests from a badly hit hotel were
supposed to arrive by bus by 23:00 hours, it called
back approximately 10 senior surgeons as part of its
disaster code; in addition, BI added many staff in the
ER and the ancillary services. The three other hospitals
designated for overflow patients were also called and
sent their ambulances to standby. The hotel patients
did arrive in the ER past midnight, but they arrived in
smaller groups of 8 to12 and not in a busload of 50.
➜ Victims were from many different countries and the
language problems hampered care and
communications. BI is poised to take care of
international patients, with almost 350,000 international
patients receiving outpatient care in 2004. BI has more
than 60 full-time interpreters/customer service staff who
speak a total of 17 languages, including English,
Bengali, Arabic, Japanese, and French. Despite this
advantage, BI found itself lacking some translators
simply because of the sheer number of nationalities and
languages among the patients. Many patients spoke
some English, but BI had problems with language
capabilities for some of the German, Swedish, and
Swiss patients. BI’s experience in treating international
patients helped staff deal with the many issues they
encountered. BI’s medical referral team has many years
of experience in dealing with referrals from foreign
doctors and overseas insurance companies. As such, the
referral doctors were able to coordinate reports and
feedback to embassies, consulates, and insurance
companies, many of which sent doctors specially flown
in to handle the situation in Bangkok.
➜ An unusual number of volunteers from many
nationalities (mostly local expatriates living in
Bangkok) came to the hospital offering to counsel
patients and translate for them. BI’s
management appreciated the many offers of help, but after
a time, BI had to turn away some of the volunteers. One
reason was that the patients themselves began asking to be
left alone, as many were “over visited” by insurance
companies, embassy representatives, Thai government
authorities, and so forth.
Sharing lessons learned
BI would like to share the following lessons:
➜ Have an up-to-date emergency response/disaster plan
that can be implemented quickly. BI has a disaster plan
Standards Link
GLD.3.1.1: Organization leaders develop a plan to
respond to likely community emergencies, epidemics,
and natural or other disasters.
Measurable Elements:
1. The organization plans its response to likely
community emergencies, epidemics, and natural or
other disasters.
2. The organization participates in communitywide
disaster planning.
3. The organization tests its plan once a year when
designated as a receiving site.
4. The organization has the supplies to carry out its
plan.
Figure 1: JCI standard for having a disaster plan
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MANAGEMENT: TSUNAMI EVALUATION
that it activated immediately, but because of the
uniqueness of the situation, it had to adapt and adjust
accordingly. (See the Figure 1 for the JCI standard
addressing having a disaster plan.)
➜ Assign one medical and one administrative decision
maker to take the lead and make quick decisions.
Organizations should have one commander – BI chose
the medical director or his designee as the commander.
However, it is important to have the COO or his or her
designee be part of the disaster management committee
➜ BI found there were many nonmedical-related decisions
for which the medical and nursing teams need not be
responsible. As this was the holiday season, most of
BI’s senior management was not in Bangkok. However,
its disaster planning prepared BI for this situation, and
the one senior manager on duty handled all
administrative decisions.
➜ Be able to take a quick inventory of resources and
capacity. As a result of the year-end holidays, many of
BI’s employees were away on vacation. Even with the
lag time before the first patient reached BI, there were
still small gaps with some shortage of porters and
drivers for a few hours early on 27 December. This
demonstrated that BI needed to review all resources
during its planning activities.
➜ Conduct a postevent review of the emergency response
to identify any weak links in the system. Bumrungrad
International held two postevent reviews with the
operations team, including the porter supervisor and
ER nurses, and held another review with the senior
management team that coordinated the crisis. Based on
these reviews, BI quickly readjusted its disaster plan.
One lesson BI learned was to have a checklist for the
commander to begin using immediately when learning
of a potential crisis.
➜ Assign a coordinator to manage volunteers during a
disaster.
Bumrungrad International also took the initiative to send
a medical team consisting of five surgeons and six nurses –
with an ambulance loaded with medications and medical
supplies – on the morning of 27 December, when flights
resumed and airlines were offering free flights to physicians
and nurses who were flying to Phuket. By having the team
on the ground, BI was able to remain aware of the patient
situation and provide critical medical assistance where it was
most needed in Phuket the day after the tsunami. Because of
the feedback from this onsite medical team, BI knew the
extent of the disaster and injuries and staff were able to
anticipate and prepare for the high volume of patients. ❑
Note to readers: Bumrungrad International Hospital would
like to pay a special tribute to the physicians, nurses, and staff of
the many hospitals in southern Thailand who worked day and
night coping with the massive number of patients in the tsunami’s
aftermath. Many Thai doctors and nurses flew in from various
parts of the country to assist in the South. Some volunteer medical
and nursing teams from neighbouring countries also flew in to
help. In Bangkok, Bumrungrad International recognized that it
saw only a fraction of the patients that the Southern hospitals had
to cope with, and they did their work under very difficult
circumstances and with limited resources. The Thai government
authorities were very responsive in restoring communications and
providing other infrastructure support to the South in the week
following the tsunami disaster.
Acknowledgements
© Joint Commission Resources: “Bumrungrad International Hospital in Thailand
helped treat tsunami patients” Joint Commission International Newsletter 3(2):1-4,
2005. Reprinted with permission.
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IPSI ihf 7 9/30/05 12:38 Page 27
MANAGEMENT: COMMERCIAL FEATURE
IPSI: the global benchmark
for strategic analysis and
improvement
IPSI (INTERNATIONAL PATIENT SATISFACTION INDEX)
has been established in order to support progressive
hospitals in developing their performance based on direct
feedback from the patients’ perspective. The framework
offers systematic comparisons with best practice
benchmarks, both within the sector and with other areas of
the economy and society at large.
IPSI because:
The International Hospital Federation’s (IHF) mission is to
improve world health. The IHF achieves this through the
global exchange of experience and management techniques
and by encouraging the international cross-fertilisation of
ideas among health service professionals in its hospitals. The
IHF has identified definite requirements among hospitals for
further knowledge on hospital management in general and
patient satisfaction in particular. From this, it is observed that:
Hospitals search for:
➜ Global benchmarking possibilities within the hospital
sector and with other industries to establish best
practise performance.
➜ Global benchmarking possibilities of ‘excellence
centres’ within the hospital sector.
➜ Better strategic and operational management tools to
enhance improvements and to meet increasing
competition due to growing internationalisation.
➜ Scientifically based methods to measure patient
satisfaction to meet the needs of a customer focused
approach.
➜ Methods to sharpen cost effectiveness and quality.
IPSI is the answer to such challenges. It is the first global
index focusing on patient satisfaction. It uses state-of-the-art
methodology and is conducted by a neutral organisation.
Behind IPSI stands the IHF as well as the EPSI Rating (the
global network for customer satisfaction improvements in
the economy) and European Health Economics. This brings
together competences from the hospital industry,
health economics and quality management including
contemporary statistical research and performance analysis.
IPSI is different from other initiatives and models to
capture customer satisfaction by its strong integration with
strategy, and the cause-effect approach. Thus, it does not
only tell you what patients think and prefer, but also why
they have the perceived preferences and how the hospital
can improve effectiveness based on this information.
IPSI characteristics include:
➜ It is worldwide in scope and coverage.
➜ It offers a global standard using best practice survey
methodology.
➜ It is built around also non-clinic patient satisfaction
focusing on strategic issues establishing the crucial
framework for future.
➜ It reveals cause and effect in terms of patient
satisfaction.
➜ It enables hospitals to analyse what financial effects
improvements have.
➜ It enables hospitals to benchmark their operations with
other industries.
➜ It enables hospitals to benchmark themselves within
the hospital sector and peers in crucial areas of
excellence.
The IPSI Framework
The framework is developed around a structural model
featuring crucial aspects of the hospital cause – effect chain.
The aspects (latent variables) in the model are divided into
Effects (right hand side) and Drivers (left hand side). Values
of the aspects are estimated based on empirical surveys to
participating hospitals. Each aspect is measured with a
number of (manifest) questions, usually no less than three.
Drivers (enablers):
➜ Hospital image.
➜ Patient expectations.
➜ Available resources.
➜ Process quality.
➜ Quality and structure.
➜ Perceived value.
Effects:
➜ Perceived medical outcome.
➜ Quality of life.
➜ Loyalty and Trust.
➜ IPSI Index.
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IPSI ihf 7 9/30/05 12:38 Page 28
MANAGEMENT: COMMERCIAL FEATURE
The IPSI Index is the main performance indicator giving
the weighted score for hospital performance. The entire
model, including the cause – effect relationships between
the aspects (impacts) are estimated using Structural
Equation Methods and analysed simultaneously. This gives
information about the levels of performance as well as about
possible improvement strategies. All results may be
compared with other hospitals and also with benchmark
figures in other sectors.
Results presentations for hospitals
For each of the aspects both levels on the index (between 0
–100) and impact (that is the strength of the causal
relationship from a driver to another or to the effects) are
given. The comprehensive results are presented in priority
matrix format sorted in the four sectors (low – high priority;
maintain – improve).
For each result both the scores for the present
measurement/study and any time-series are given.
Similarly benchmarks for comparable hospitals/clinics are
also given in the form of averages. The value of the
approach will increase successively as more and more time
series comparisons, and analyses of effects from
improvements, may be added. Also comparisons with
other industries and sectors of the economy will be
available for participating hospitals.
A pilot study underway
A pilot study in four countries – UK, France, Germany and
Sweden – is now underway. This aims at calibrating the
measurement and analysis system, including the data
collection schemes. At the same time, substantive results
constituting a baseline and benchmark for future work will
be obtained. The results will be available in early fall. This
pilot is financially supported by Pfizer.
All hospitals welcome to join
IPSI will be available to conduct hospital-specific studies on
an ongoing basis from Autumn 2005. Any hospital, both in
Europe and overseas, is welcome to contact IPSI to discuss
joining the initiative. As it is based on the framework of
syndicated research cost-efficiency and value for money for
client hospitals is guaranteed. ❑
Dr. Jan Eklöf
IPSI Secretariat
E-mail: jan.eklof@epsi-rating.com
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CLINICAL CARE: DIABETES
Diabetes care in China:
meeting the challenge
CHANGYU PAN
PHYSICIAN, DEPARTMENT OF ENDOCRINOLOGY, PLA GENERAL HOSPITAL, BEIJING,CHINA
Abstract
In both human and economic terms, diabetes is becoming one of the most serious and costly health conditions
worldwide. Economic development, bringing changes from a traditional to a modernized lifestyle, is driving a huge
increase in the number of people with obesity-related type 2 diabetes in China. The extraordinary size of the
problem is worrying; if current trends continue, diabetes will become a massive health burden in China. In this
article, Changyu Pan looks at the status of diabetes care in China and highlights the need for regional and national
initiatives to increase awareness amongst the general population of the risk factors for diabetes, and thus prevent
a further rapid increase in the prevalence of the condition
Since the early 1990s, China’s soaring economy has
apparently raised the population’s quality of life.
However, as China modernizes, Chinese people eat
more and exercise less. Huge numbers of people in China,
who previously walked or cycled, now drive cars or ride
motorcycles; nowadays there are more high-calorie, high-fat,
processed foods on dining tables in China. Such factors have
triggered a rapid increase in the prevalence of obesity-driven
diabetes in the country.
How many millions have diabetes?
Over the past two decades, the number of people in China
with diabetes or the pre-diabetes condition impaired glucose
tolerance has increased dramatically. The data presented 10
years ago from a national diabetes survey of 19 provinces –
including cities and rural areas – demonstrated that the
overall prevalence of diabetes and impaired glucose
tolerance in people in China aged 25-64 years was 2.5% and
3.2% respectively. This prevalence is about three times
higher than it was 20 years ago. It was estimated that the
diabetes prevalence in rural areas was around half that of
urban areas.
Compared with those of developed countries, these
prevalence figures for China appear to be low. The estimates
may in fact be artificially reduced due to the differences in
diagnostic methods and criteria, and an overall lack of data
in the country. China has a huge population, estimated at
1.3 billion, with the number of adults with diabetes
estimated at about 30 million. This total number of people
with diabetes in China may be the largest diabetes
population in the world. Indeed, two years ago, with a
diabetes population of 23.8 million, China was second in
the world to India (35.5 million). 1
Twenty years from now, this figure is expected to rise
above 46 million. 1
These numbers are alarming; they will inevitably impact on
society and individuals in China unless drastic country-wide
measures are taken. The health-care and financial costsof the
rise in the number of people with diabetes complications are
compounded by the psycho-social burden to people with the
condition. Theirs is a life-long chronic condition that requires
around-the-clock self-care to optimize daily and long-term
health outcomes and quality of life.
Moreover, not only is there an increase in diabetes
prevalence in China, the number of diabetes-related deaths is
also on the rise. Data from the Annual Statistical Reports of
Death, Injuries and Causes of Death 2002 revealed a three-fold
increase in the mortality rate per 100 000 people – from 5.1
per 100 000, 20 years ago, to 15.4, five years ago. 2
Limited resources
With a limited infrastructure for diabetes care, China is illequipped
to deal with this pandemic, particularly in the
context of continued rapid urbanization. Lifestyle-driven
conditions such as diabetes are likely to have a greater
negative impact on societies in which the unhealthy lifestyle
changes that are forced by economic development continue
to occur at a much faster rate than in other countries.
According to health-economic studies, the delivery of
health care varies considerably from one setting to another,
depending on the resources available, training and interest
in diabetes amongst healthcare professionals, and the ability
of people to pay for treatment where necessary. The
disparity between rural and urban health in China has been
exacerbated by increased privatization. In most rural areas,
healthcare has shifted to a fee-for-service system. While the
number of urban healthcare centres is increasing, people in
the rural areas have experienced reduced access to medical
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CLINICAL CARE: DIABETES
care. In fact, the number of village health officials has been
reduced by up to a third; the number of healthcare centres
has decreased significantly in the townships and villages.
The status of care
Given the limited data available on diabetes epidemiology
(the last nationwide study was performed over a decade
ago), it is essential that a reliable overview be obtained of the
status of diabetes care in China. This will form the basis for
any initiatives to reduce the medical and socio-economic
burden of diabetes complications.
A contribution to this knowledge was made recently by
the Diabcare-China 2003 study. As part of the Diabcare-Asia
2003 study, this Chinese research collected data from a
cohort of around 2,700 people with diabetes at 30 specialist
centres across China.
Status of people with diabetes
Of the people who participated in the study, around 97%
had type 2 diabetes. More than half of the people with
diabetes had poor blood glucose control (glycaemic
control). Only half of the people had an HbAlc
measurement (an indicator of long-term blood glucose
levels) during the previous 12 months. Furthermore, about
three-in-five people with diabetes had poor metabolic
control, showing above-average levels of triglycerides and
LDL cholesterol (so-called “bad” cholesterol).
The American Association of Clinical Endocrinologists has
declared that, as well as intensive glycaemic control, optimal
diabetes care must also include proper nutrition, weight
control, physical activity programmes and smoking
cessation. 3 It was therefore encouraging to find that a good
proportion of the people with diabetes in this study were
following a controlled diet (77%) and exercising regularly
(62%). In this study, 65% of people with diabetes had had
an eye examination in the previous 12 months; 31%
underwent foot examinations.
Psycho-social well-being and quality of life
Interestingly, responses to questions on psycho-social wellbeing
indicated that many people with diabetes either all or
most of the time felt “cheerful and in good spirits” (67%),
“calm and relaxed” (66%) and “active and vigorous” (53%).
There was a statistically significant relationship between
glycaemic control and psycho-social well-being.
The study outcomes also revealed that more than half of the
people with diabetes rated their quality of life to be good or at
least acceptable, with 65% agreeing that they felt that their
diabetes is “well regulated”. Again, a statistically significant
correlation was seen between glycaemic control and quality of
life. These findings underline the importance of identifying and
developing models and systems of care that better support
people with diabetes to achieve a desirable quality of life.
Education and awareness in the community
There is a lack of diabetes awareness in countries around the
world; but this lack of education has a tremendous
significance in China, with its huge population. The low
diabetes awareness among the general public is
compounded by misunderstandings around various aspects
of diabetes care, such as the use of insulin. Indeed, only a
decade ago, it was unthinkable that people with diabetes
could inject themselves with insulin.
The lack of diabetes awareness in China results in
relatively low rates of diagnosis – about 10%-15% for people
with type 2 diabetes, compared with 50% in Europe. In
order to address this gap, many diabetes education
programmes have been initiated for healthcare professionals.
It is estimated that during the past five years, 3000-5000
doctors in 300 provinces in China have received diabetes
education. Nurse education programmes are increasing also.
Encouragingly, there is growing recognition in China of the
need for healthcare providers to work together in a teambased
approach to care.
Given the size of the population, the growing body of
evidence that the cost of diabetes to societies can be
reduced through the provision of diabetes education is
particularly relevant in China.
In an effort to resolve widely held misunderstandings,
between 1997 and 2004, 490 lectures were held at the
People’s Liberation Army (PLA) General Hospital in Beijing,
offering diabetes education to over 15,000 people with the
condition. The objective of these events is to encourage a
greater degree of self-care for people with diabetes and nthus
reduce disabling complications.
A person has impaired glucose tolerance (IGT) when their
Triglycerides in the blood come from fats eaten in
foods but are also made in the body from other
energy sources such as carbohydrates. Any
calories consumed in a meal which are excess to
requirements are converted into triglycerides and
transported to fat cells to be stored. Excess
triglycerides in the blood are linked to
cardiovascular disease and other diseases of the
arteries. Elevated triglycerides may be a
consequence of inadequately controlled diabetes.
blood glucose levels are higher than normal, but below the
level of a person with diabetes. Most people with IGT are at
increased risk for developing type 2 diabetes.
In addition, the Chinese Ministry of Health, in accordance
with the guidelines of the International Diabetes Federation-
Western Pacific Region and the American Diabetes
Association, launched in 2003 their Guidelines for
Diabetes Prevention and Treatment, which were designed to
reduce the rates of death and disability due to diabetes. In
the guidelines, emphasis has been placed on regular
screening, lifestyle modifications supported by dietary and
behavioural advice, and drug therapy options.
Country-wide interventions
The Chinese media has been used to enhance the public
awareness of diabetes. In 2002, television programmes
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diabetes_care 9/30/05 12:40 Page 32
CLINICAL CARE: DIABETES
featuring diabetes issues reached about 600 million people.
It is hoped that the Chinese Ministry of Health will be
able to employ its infrastructure and administrative
resources to greatly increase the capacity of diabetes
education programmes to reach people with diabetes,
health-care providers and the general public. In
collaboration with the World Diabetes Foundation, the
Ministry recently launched the National Diabetes
Management Project, which aims to provide diabetes
education and training to healthcare providers and establish
state-of-the-art models of diabetes care in hospitals and
community health centres throughout the country.
Meeting the challenge
The data from the Diabcare-China 2003 study suggest the
strong need for improvements in diabetes management in
China. Current goals for diabetes treatment focus
predominantly on the achievement and maintenance of
normal healthy blood glucose levels to prevent the onset of
diabetes complications. However, there is a growing
recognition from the Chinese government of the need to
adopt best-practice medical management, including the
provision of diabetes self-care education and the promotion
of healthy lifestyle choices. ❑
References
1.
International Diabetes Federation. Diabetes Atlas, Second Edition. International
Diabetes Federation, Brussels 2003.
2.
The Western Pacific Declaration on Diabetes: Kuala Lumpur, June 2000.
International Diabetes Foundation (Western Pacific Regional Office), The World
Health Organization, Regional Office for the Western Pacific Community,
Secretariat of the Pacific Community. Manila 2000.
3
The American Association of Clinical Endocrinologists. Medical guidelines for
the management of diabetes mellitus: The AACE system of intensive diabetes
self-management – 2002 update. Endo Prac 2002; 8: 40–65.
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World Hospitals and Health Services 2005 Volume 41 Number 3
Résumés en Français
LE DEVELOPPEMENT D’UN SYSTEME
D’INFORMATIONS MEDICALES PAR LOGICIEL
LIBRE D’ACCES AU KENYA
(DEVELOPING AN OPEN SOURCE HEALTH
INFORMATION SYSTEM IN KENYA)
Cet article traite de l’expérience actuelle de la mise en
place d’un logiciel FOSS (logiciel libre et gratuit) Care2X,
dans un hôpital religieux du Kenya. Le mouvement FOSS
s’est rapidement implanté. Dans les pays développés, ses
avantages par rapport aux logiciels propriétaires ont été
longuement discutés, et des moyens de chiffrer les coûts
totaux de mise au point ont été trouvés. Toutefois, des
données empiriques sur l’impact des FOSS, notamment
sous l’aspect de leur utilisation et de leur mise au point,
notamment dans le tiers monde sous l’aspect utilisation
et développement, sont encore assez limitées, bien que
les possibilités des FOSS semblent de plus en plus
intéressantes.
GESTION DES HOPITAUX A ACEH PENDANT LE
TSUNAMI
(MANAGEMENT OF HOSPITALS IN ACEH DURING
THE TSUNAMI)
Le 26 décembre 2004, Aceh et ses environs ont été
frappés par deux catastrophes naturelles consécutives,
un tremblement de terre suivi d’un tsunami. Des
centaines de milliers de gens ont péri, laissant sans abri
des centaines de milliers d’autres. L’auteur du présent
article a été envoyé en mission à Aceh par le ministère
de la santé pendant les deuxième et troisième semaines
après la catastrophe pour aider les directeurs de
l’hôpital général de Zainoel Abidin à Banda Aceh, le plus
grand hôpital de la province, à relancer ses opérations.
Cet hôpital disposait autrefois de 400 lits, de 911
employés et de 61 médecins, sans compter un CT Scan,
un microscope à usage opératoire et bien d’autres
installations. Outre qu’il dispensait des soins de santé
aux populations locales, cet hôpital servait également à
la formation des étudiants en médecine de l’Ecole de
médecine de Syiah Kuala. Outre l’auteur, l’équipe de
remise en service de l’hôpital comptait deux infirmières
de haut grade (directrices des soins infirmiers), un
ingénieur et un secrétaire administratif. Lorsque j’ai
quitté Jakarta, j’avais déjà choisi la démarche que
j’utiliserai pour obtenir le personnel, les fonds, le
matériel et les méthodes que j’appliquerai. Mais les
conditions sur le terrain se sont avérées totalement
différentes de ce à quoi je m’attendais.
EN THAILANDE, L’HOPITAL INTERNATIONAL DE
BUMRUNGRAD AIDE A TRAITER LES VICTIMES
DU TSUNAMI
(BUMRUNGRAD INTERNATIONAL HOSPITAL IN
THAILAND HELPS TREAT TSUNAMI PATIENTS)
Personne ne s’attendait au tsunami qui a frappé, un
beau dimanche ensoleillé le 26 décembre 2004 – ni les
villageois, ni le personnel de l’hôtel, ni les touristes qui
jouissaient de leurs vacances dans les eaux calmes sous
le ciel bleu. Mais quelques jours plus tard, l’hôpital
international de Bumrungrad (BI), un centre médical de
554 lits accrédité par une Commission internationale
mixte à Bangkok, en Thaïlande, s’est rapidement
préparé pour commmencer à traiter les victimes du
tsunami. Cet article montre les efforts déployés par
l’hôpital international de Bumrungrad pour traiter les
victimes du tsunami.
Les informations concernant cet this article ont été
fournies par l’équipe de cadres gestionnaires de
Bumrungrad International.
LA PRISE EN CHARGE DU DIABETE EN CHINE:
RELEVER LE DEFI
(DIABETES CARE IN CHINA: MEETING THE
CHALLENGE)
En termes tant économiques qu’humains, le diabète est
en train de devenir l’une des maladies les plus graves et
les plus coûteuses du monde entier. Le développement
économique, entraînant la modernisation d’un mode de
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REFERENCE
vie antérieurement traditionnel, provoque une
augmentation très importante du nombre de patients
porteurs d’un diabète de type 2 lié à l’obésité en Chine.
L’extraordinaire ampleur du problème est préoccupante; si
les tendances actuelles se maintiennent, le diabète est en
passe de devenir un lourd fardeau de santé en Chine. Cet
article examine le statut des soins antidiabétiques en
Chine et souligne la nécessité d’initiatives régionales et
nationales pour favoriser la prise de conscience des
facteurs de risque diabétique par la population générale,
et prévenir toute nouvelle recrudescence de
l’épimédiologie diabétique actuelle.
CREER UNE NOUVELLE CAPACITE POUR LA
RECHERCHE DE SANTE PUBLIQUE
(BUILDING CAPACITY FOR PUBLIC HEALTH
RESEARCH)
Le tiers monde supporte 19% du fardeau mondial de
morbidité, alors que les pays développés possèdent la plus
grande partie de la capacité de recherche médicale pour faire
face à ce fardeau. Cet article examine les moyens de changer
cette disparité. Il recherche pourquoi il existe un manque de
capacité à l’échelle nationale et régionale et quelles en sont les
conséquences, et recommande des approches stratégiques
pour résoudre ce problème. Une brève discussion considère
l’impact des objectifs de dévelopement du millénaire et la
mondialisation de cette question.
World Hospitals and Health Services 2005 Volume 41 Number 3
Resumen en Español
INTRODUCCION DE UN SISTEMA DE INFORMACION
SANITARIA DE FUENTE ABIERTA AL PUBLICO EN
KENIA
(DEVELOPING AN OPEN SOURCE HEALTH
INFORMATION SYSTEM IN KENYA)
Este artículo se concentra en la experiencia hasta la fecha de
la instalación de un programa informático gratuito de fuente
abierta al público (en inglés FOSS) en un hospital de la
iglesia, en Kenia. Esta iniciativa se ha desarrollado con éxito
en poco tiempo. En los países desarrollados se ha hablado
mucho sobre sus ventajas en relación con los componentes
lógicos patentados y se ha encontrado un medio de
cuantificar el coste total del sistema. No obstante, los datos
empíricos sobre las repercusiones de este mecanismo,
especialmente en los países en desarrollo en lo que respecta
a su uso y ampliación sigue siendo bastante limitado, si bien
las posibilidades que presenta son cada día más interesantes.
GESTION DE LOS HOSPITALES DE BANDA ACEH
TRAS EL TSUNAMI
(MANAGEMENT OF HOSPITALS IN ACEH DURING
THE TSUNAMI)
El 26 de diciembre de 2004 Aceh y otras ciudades de la
región sufrieron dos desastres naturales sucesivamente, un
terremoto y un tsunami. En ellos perdieron la vida
centenares de miles de personas y otros tantos se quedaron
sin hogar. El Ministerio de Salud destinó al autor de este
artículo a Aceh durante las dos semanas siguientes a la
catástrofe con el fin de colaborar con la dirección del
Hospital General Zainoel Abidin, el hospital más
importante de la región de Banda Aceh, con el
restablecimiento de su funcionamiento. Antes del desastre
el hospital tenía 400 camas y contaba con 911 empleados
y 61 doctores además de un servicio de tomografía axial
computerizada, microscopio de operaciones y otros
adelantos. Además de prestar asistencia sanitaria a la
población del lugar, este hospital sirvió de centro docente
para los estudiantes de la Facultad de Medicina de la
Universidad Syiah Kuala. Además del autor de este
artículo, entre los miembros del equipo de
restablecimiento del hospital se encontraban dos
enfermeras-jefe, un ingeniero y un empleado de
administración. Si bien cuando salí de Yakarta, ya tenía una
idea sobre el modo de abordar la situación en cuanto a los
recursos humanos, económicos y el material y métodos
necesarios, cuando me encontré sobre el terreno, la
situación no tenía nada que ver con lo que había
imaginado.
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REFERENCE
EL HOSPITAL INTERNACIONAL BUMRUNGRAD DE
TAILANDIA COLABORA PRESTANDO ASISTENCIA
SANITARIA A LOS PACIENTES DEL TSUNAMI
(BUMRUNGRAD INTERNATIONAL HOSPITAL IN
THAILAND HELPS TREAT TSUNAMI PATIENTS)
Cuando el tsunami arrasó su aldea aquella mañana de un
domingo soleado, el 26 de diciembre de 2004, nadie
contaba con tal tragedia, ni los habitantes del lugar, ni los
empleados de hotel, ni los turistas que disfrutaban de sus
vacaciones bajo un cielo despejado y un mar en calma. Sin
embargo días más tarde el Hospital Internacional
Bumrungrad, una comisión conjunta internacional de
acreditación hospitalaria, dotada de 554 camas en Bangkok,
Tailandia, enseguida estuvo dispuesto para asistir a las
víctimas del tsunami. Este artículo pone de relieve la labor
que realizó el Hospital Internacional Bumrungrad al prestar
asistencia médica a las personas afectadas por el tsunami.
Esta información la ha proporcionado el equipo directivo
superior del Hospital Internacional Bumrungrad.
ASISTENCIA MEDICA DE LA DIABETES EN CHINA:
HACIENDO FRENTE AL RETO
(DIABETES CARE IN CHINA: MEETING THE
CHALLENGE)
Tanto desde el punto de vista de los recursos humanos,
como en términos económicos, la diabetes se está
convirtiendo en una de las enfermedades más graves y
costosas a nivel mundial. El desarrollo económico y el
consiguiente cambio en el estilo de vida de uno tradicional
a otro más moderno está dando lugar a un enorme aumento
en el número de personas que padecen diabetes grado 2
(relacionada con la obesidad) en China. La magnitud de este
problema es motivo de preocupación ya que de continuar
esta tendencia la diabetes se convertiría en una enorme carga
para los servicios de salud de China. Este artículo examina la
situación en lo concerniente a la asistencia médica de la
diabetes en China y pone de relieve la necesidad de
introducir una serie de iniciativas regionales y nacionales con
el fin de concienciar a la población en general sobre los
factores de riesgo de la diabetes, evitando con ello otro
aumento acelerado en el número de casos de esta
enfermedad.
AUMENTO DE LOS MEDIOS DESTINADOS A LA
INVESTIGACION EN SALUD PUBLICA
(BUILDING CAPACITY FOR PUBLIC HEALTH
RESEARCH)
A pesar de que el noventa por ciento de las enfermedades se
concentran en los países en desarrollo, la mayor parte de los
medios destinados a la investigación en salud con miras a
afrontar esta carga se encuentra en los países desarrollados.
Además de estudiar la manera de cambiar esta situación, este
artículo considera los motivos por los que existe tal
disparidad, tanto a nivel nacional como regional, y tras
examinar sus consecuencias recomienda un enfoque
estratégico para solucionar el problema. En un breve debate
se analizan las repercusiones de los Objetivos de Desarrollo
del Milenio y la globalización, con respecto a esta cuestión.
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Directory of IHF professional
and industry members
The International Hospital Federation is grafeful to its 'D' members (listed below) who support the world wide activities of the IHF
through their membership. The IHF recommends that you give consideration to their products and services.
BARBADOS
TVA CONSULTANTS LIMITED
The TVA Consultants consortium has an abundance
of experience as architects and quantity surveyors in
the design, construction, and expansion of the major
hospitals and health care related facilities
throughout the West Indies.
Mr Jeremy A.N. Voss
Chief Architect
Grosvenor House,
Harts Gap
Hastings, Christ Church
Tel: +246 426 4696
Fax: +246 429 3014
Email: tvabgi@sunbeach.net
BELGIUM
Ms Birgitte Baten
AGFA-GEVAERT NV
Septestraat 27, B-2650 Mortsel
Tel: +32 3 444 2111
Fax: +32 3 444 7908
Email: birgitte.baten@agfa.com
Internet: www.agfa.com
Mr Frederic Petit
FHP VILEDA PROFESSIONAL DIVISION
Avenue Andre Ernst 3-B
Verviers
Tel: +32 87322137
Fax: +32 87322158
Email: frederic.petit@fhp-ww.com
Internet: www.vileda.com
Dr Tamara Kunert-Latus
TERUMO EUROPE NV
Research Park Zone 2,
Haasrode, Interleuvenlaan 40,
B-3001 Leuven,
Tel: +32 16 38 1222
Fax: +32 16 400 249
Email: Tamara.kunert_latus@ terumoeurope.com
Mr. Hugo Schellens, CEO
ULTRAGENDA NV/SA
Antwerpsesteenweg 19
9080 Lochristi
Tel: +32 9 230 20 20
Fax: +32 9 230 02 02
BRAZIL
Dra W Santos/
Mr J Fco dos Santos
HOSPITALAR FEIRAS CONGRESSOS E
EMPREENDIMENTOS LTDA
Rua Oscar Freire 379, 19° Andar
São Paulo 01426–001
Tel: +55 11 3897 6199
Fax: +55 11 3897 6191
Email:hospitalar@hospitalar.com.br
Internet: www.hospitalar.com.br
DENMARK
NOVO NORDISK, A/S
Novo Allé
2880 Bagsvaerd
Tel: +45 4444 8888
Fax: +45 4449 0555
Email: webmaster@novonordisk.com
Internet: www.novonordisk.com
FINLAND
Mr Sami Aromaa
Director Global Communications
INSTRUMENTARIUM 0YJ
PO Box 900
31 Datex, FIN-00031 Datex-Ohmeda
Tel: +358 10 394 11
Fax: +358 9 146 3310
Email: webmaster@datex-ohmeda.com
Internet: www.datex-engstrom.com
GERMANY
Managing Director
FAUST CONSULT GmBH
Architects and Engineers
Biebricher Allee 36, D-65187 Wiesbaden
Tel: +49 611 890410
Fax: +49 611 8904199
Email: faust@faust-consult.de
Internet: www.faust-consult.de
Mr Harmut Loewe
MCC MANAGEMENT CENTER OF
COMPETENCE
Scharnhorststrasse, 67a,
D-52351 Duren
Tel: +49 2421 121 77 11
Fax: +49 2421 121 77 27
E-mail: loew@mcc-seminare.de
Internet: www.mcc-seminare.de
Mr H Giesen
Project Director
MESSE DUSSELDORF GmbH
Messe Dusseldorf is the organizer of medical
trade fairs all over the world, the leading one of
which is MEDICA
Messeplatz 1,
D-40474,
Düsseldorf
Tel: +49 211 456 001
Fax: +49 211 456 0668
Email: giesen@messe-dusseldorf.de
Internet: www.messe-dusseldorf.de
Mr. Martin Rudmann
Commercial Director
SOLVAY GmbH
Hans-Boeckler-Allee 20
30173 Hannover
Martin.rudmann@solvay.com
Tel: +49 511 857-0
Internet: www.solvay.com
Dr Daniel Zeidler
PENTAX EUROPE GmbH
Head of Medical Marketing
Julius-Vosseler-Strasse, 104
22527 Hamburg
Tel: +49 4056192
Fax: +49 4055945
Email: zeidler.daniel@pentax.de
Internet: www.pentax.de
Herr H. Hassenpflug
Director of Communications and Promotion
SYSMEX EUROPE GmbH
Bornbach, 22848 Norderstedt
Tel: +49 40 527 26 0
Fax: +49 40 527 26 10 0
E-Mail: Hassenpflug@sysmex-europe.com
Internet: http://www.sysmex-europe.com
HONG KONG
Alfred Sit Wing-Hang
Health Sector Manager
HKSAR GOVERNMENT
ELECTRICAL & MECHANICAL SERVICES
DEPARTMENT
3/F Multi-Centre Block C
Pamela Youde Nethersole Eastern Hospital
Chai Wan
Tel: +852 2505 0084
Fax: +852 2904 5307
Email: alfredsit@emsd.gov.hk
Internet: www.emsd.gov.hk
Mr Andrew Lee
Manager
TUV ASIA PACIFIC MANAGEMENT
HOLDING
Unit 602C Tech Center
72 TAT Chee Avenue
Kowloon Tong, Kowloon
Tel: +852 2788 5150
Fax: +852 2784 1550
Email:alee@tuvpc.com.hk
Internet:www.tuvglobal.com
INDIA
Dr Shyama S. Nagarajan
INV. ANF INFORMATION CREDIT
RATING AGA +ICRA
4th Floor Kailash Building
26 Kasturba Gandhi Marg
110001,
New Dehli
Tel: +91 11 233 57940
Fax: +91 11 233 55239
Email: shyama@icraindia.com
Internet: www.icraindia.com
ISRAEL
Dr M. Modai
President and CEO
SAREL SUPPLIES & SERVICES FOR
MEDIC ISRAEL
SAREL Ltd is the largest Israeli dealer in
pharmaceuticals and medical supplies and the
major supplier to all Ministry of Health hospitals
and clinics.
Sarel House
Hagavish St Industrial Zone
Sth Netanya,
42504 Nethanya
Tel: +972 9 892 2089
Fax: +972 9 892 2147
Email: joshua@sarel.co.il
Internet: www.sarel.co.il
Vol. 41 No. 3 | World Hospitals and Health Services | 43

Members_D_list IHF7 9/30/05 12:36 Page 44
REFERENCE
LEBANON
Dr Faouzi Adaimi
President
FEDERATION DES HOPITAUX ARABES
PO Box 7,
Journieh Notre Dame
Hospital, Journieh
Tel/Fax: +961 964 4644
Email: HNDL@terra.net.lb
LUXEMBOURG
Mr Rene Christensen
Senior Economist
EUROPEAN INVESTMENT BANK
100 Boulevard Konrad Adenauer
2950 Luxembourg
Tel: +352 43798 540
Fax: +352 43798827
Email: r.christensen@eib.org
Internet: www.eib.org
PHILIPPINES
Ashok K. Nath
Chairman
OPTIONS INFORMATION COMPANY
A publishing and event management company.
#10 Garcia Villa Street,
St Lorenzo Village
1223 Makati City
Tel: +632 813 0711
Fax: +632 819 3752
Email: ashok@optionsinfo.com
Internet: www.optionsinfo.com
SOUTH AFRICA
Dr Susan Chalmers
WOUND CARE (PTY) LIMTED
PO Box 2763
7129 Somerset West
Tel: +272 18528655
Fax: +272 18528656
Email: info@chemspunge.co.za
Internet: www.woundcare.co.za
SWEDEN
Robert Harju-Jeanty
Vice President, Marketing
BOULE MEDICAL AB
Boule Medical AB
PO Box 42056
SE-12613 Stockholm,
Tel: +46 8-744 77 00
Fax: +46 8-744 77 20
Email: robert.harju-jeanty@boule.se
Internet: www.boule.se
CAPIO HEALTHCARE
Capio is one of Europe’s leading health and
medical care providers, with operations in
Sweden, Norway, Denmark, Finland, the
United Kingdom, France, Switzerland and
Spain. Capio has revenues of SEK 11 billion
on an annualised basis and approximately
16,000 employees. Capio Healthcare France,
which is a business area within the Capio
Group, is one of the largest private
healthcare providers in France.
Prof. Gunnar Németh, MD, PhD, MBA
Professor of Orthopaedic Surgery senior Vice
President, Chief Medical Officer
Capio Group
Gullbergstrandgata 9
Box 1064,
S-405 22 Göteborg
Sweden
Tel: +46 (31) 732 40 00
Facs: +46 (31) 732 40 99
Gunnar.Nemeth2@capio.com /
info@capio.com
Web: www.capio.com / www.ki.se
John Hansson
GETINGE INTERNATIONAL AB
PO Box 69
SE-31044 Getinge
Tel: +46 3515 5500
Email: John.Hansson@Getinge.com
Internet: www.getinge.com
H Josefsson
Partner/Architect SAR, SPA
WHITE ARKITEKTER AB
PO Box 2502
S-40317 Goteborg
Tel: +46 31 608 600
Fax: +46 31 608 610
Email: hakan.josefsson@white.se
Internet: www.white.se
SWITZERLAND
Mr Hans Strobel
JOHNSON & JOHNSON ADVANCED
STERILIZATION PRODUCTS
Rotzenbuelstrasse 55
CH 8957 Spreltenbach
Tel: +41 56 417 3363
Fax: +41 56 417 3333
Email: hstrobel@cscch.jnj.com
UNITED ARAB EMIRATES
Mr Thumbay Moideen
President
GULF MEDICAL COLLEGE HOSPITAL
AND RESEARCH CENTRE
P O Box 4184, Ajman
Tel: +971 6 743 1333
Fax: +971 6 743 1222
Email: gmcajman@emirates.net.ae
Internet: www.gmcajman.com
INDEX CONFERENCES AND
EXHIBITION EST
PO Box 13636,
Dubai
Tel: +971 4 265 1585
Fax: +971 4 265 1581
Email: index@emirates.net.ae
Internet: www.indexexhibitions.com
UNITED KINGDOM
Mr David Selwyn
Secretary
ASSOCIATION OF PRIMARY CARE GROUPS
AND TRUSTS (APCGT)
5-8 Brigstock Parade
London Road, Thornton Heath,
Surrey CR7 7HW
Tel: +44 20 8665 1138
Fax: +44 20 8665 1118
Email: mail@apcgt.org
Internet: www.apcgt.co.uk
Mr Ben Mansell
Government and HealthCare Strategy Manager
EXTENDED SYSTEMS LIMITED
Mobile Data Management
7-8 Portland Square
Bristol BS2 8SN
Tel: +44 117 901 5000
or 0800 085 7090
Fax: +44 117 901 5001
Email: ben.mansell@extendedsystems.co.uk
Internet: www.extendsys.com
Mr Bryan Pearson
Managing Director
FSG COMMUNICATIONS LIMITED
FSG Communications limited provides
publishing, conferences and exhibitions for
health professionals and the medical industry
involved or interested in Africa.
Vine House,
Fair Green, Reach,
Cambridge CB5 0JD
Tel:+44 1638 743 633
Fax: +44 1638 743 998
Email: bryan@fsg.co.uk
Internet: www.fsg.co.uk
GAEL LIMITED
Tulloch Gael
S.E. Technology Park
East Kilbride
Scotland G75 0QR.
Tel: +44 1355 247766
Fax: +44 1355 579191
Email: info@mindgenius.com
Internet: www.mindgenius.com
Mr Witney M. King
Managing Director
INTERNATIONAL HOSPITALS GROUP
LIMITED
Hertford Place, Maple Cross,
Herts WD3 2XB
Tel: +44 1923 726 000
Fax:+44 1923 896 759
Email: wmk@igroup.co.uk
Internet: www.ihg.co.uk
Mr Nicholas Shapland
Managing Director
JONATHAN BAILEY ASSOCIATES (UK)
LIMITED
3rd Floor, Stephen Building
30 Gresse Street
London W1T 1QR
Tel:+44 20 7323 4578 Fax: +44 20 637 9350
Email: nickshapland@jonathanbailey.com
Internet: www.jonathanbailey.com
Mr S. Robert Wendin
MARSH EUROPE
Marsh is the leading advisor in integrated
governance, quality, risk management and
insurance matters to healthcare providers
around the globe. Our focus is to reduce the
total costs of risk whilst increasing quality and
patient safety throughintegrated healthcare
services and solutions.
Tower Place, West Tower
London EC3R 5BU
Tel: +44 20 7357 1000
Fax: +44 20 7929 2705
Email: robert.wendin@marsh.com
Internet: www.marsh.com
Mr Peter Wognum
Channel Development Manager
OLYMPUS osYris
Dean Way,
Great Western Industrial Park,
Southall, Middlesex UB2 4SB
Tel: +44 20 7250 4800
Fax: +44 20 7250 4801
Email: peterwognum@olympus- europa.com
Internet: www.olympusosyris.co.uk
The Directors
PRO-BROOK PUBLISHING LIMITED
Publishers for international government
organizations, NGOs and associations including
the International Hospital Federation, The
Global Forum for Health Research and the
Commonwealth Secretariat.
Pro-Brook Publishing Limited,
Alpha House,
100 Borough High Street,
London SE1 1LB, UK
Tel: +44 20 7863 3350
Fax: +44 20 7863 3351
Email: info@pro-brook.com
Internet: www.pro-brook.com
Mr Alun Williams
Managing Director – Health
QINETIQ
Cody Technology Park
A1 Building, Ively Road
Farnborough
Hampshire GU14 0LX
Tel: +44 1252 394 643
Fax: +44 1252 393 625
Email: ahwilliams@qinetiq.com
Internet: www.qinetiq.com
Mr Paddy Markey
Manager
REGENT MEDICAL LIMITED
Two Omega Drive Irlam
Manchester
Tel: +44161 777 2611
Fax: +44161 777 2601
Email: paddy.markey@regentmedical.com
Internet: www.regentmedical.com
Director
THE INTERNATIONAL eHEALTH
ASSOCIATION
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REFERENCE
Interactive Health Network,
Belvin house,
38 George street
London SW1P 4QP
Tel: +44 20 8325 7287
Fax: +44 7681 1523
Email: harry@ihn-info
Internet: www.ehealth2002.org
UNITED STATES OF AMERICA
Mr Markus E. Zettner
CIGNA - International Expatriate Benefits
590 Naamans Road Claymont,
DE 19703
Tel: +302 797 3494
Fax: +302 797 3055
Email: Markus.zettner@cigna.com
Internet: www.cigna.com/expatriates
Sherry Hayes
Director
ERNST & YOUNG LLP
1225 Connecticut Avenue, NW
Washington DC 20036
Tel: +202 327 6000
Fax: +202 327 6200
Email: sherry.hayes@ey.com
Internet: www.ey.com
Mr W Davenhall
Health & Human Services Solution Manager
ESRI
380, New York Street, Redlands,
CA 92373
Tel: +909 793 2853
Fax: +909 307 3039
Email: bdavenhall@esri.com
Internet: www.esri.com
Anthony M. Montville
HEALTHTEK SOLUTIONS INC
Dominion Tower,
999 Waterside Drive,
Suite 1910,
Norfolk, VA 23510
Tel: +804 757 625 0800
Fax: +804 757 625 2957
Email: solutions@healthtek.com
Internet: www.healthtek.com
Mr Ahmed Ahsan
President & CEO
HORIZON STAFFING SERVICES
Corporate Headquarters
1169 Main street, Suite 350,
East Hartford , CT 06018
Tel: +860 282 6124
Fax: +860 610 0078
Email: ahmed@horizonstaff.com
Internet: www.horizonstaff.com
Dr Christos A Papatheodorou MPH, FACS
INTERACTIVE HEALTH MANAGEMENT
SOLUTIONS LLS
1200 South Federal Highway
Suite 202
Boyton Beach
Florida
Tel: +561 7315881
Fax: +561 7315877
The President
MEDICAL SERVICES INTERNATIONAL
20770 Hwy, 281 No.
Suite 108, #184, San Antonio,
TX 78258-7500
Tel: +210 497 0243
Fax: +210 497 2047
Email:jramseymsi@aol.com
Jeff Fadler
MEDIFAX EDI INC.
Medifax provides electronic connectivity services
between health plans and health care providers
for processing of health care transactions.
1283 Murfreesboro Road, Nashville,
Tennessee 37217
Tel: +615 843 2500 - Ext 2103
Fax: +615 843 2539
Email: jeff.fadler@medifax.com
Internet: www.medifax.com
Heather N. Ficchi
Marketing Assistant
MEDIGUIDE
MediGuide provides international healthcare
services to multinational organizations and
operates the world’s only online directory of
hospitals and physicians that is fully functional
in 16 languages.
300 Delaware Avenue, Suite 850,
Wilmington, DE 19801
Tel: +302 425 0190
Fax: +302 425 0191
Email: hficchi@mediguide.com
Internet: www.mediguide.com
Mr John R Schlosser
Senior Director
SPENCER STUART
10900 Wilshire Blvd; Suite 800
Los Angeles; CA
Tel: +310 2090610
Fax: +310 2090912
Email: jschlosser@spencerstuart.coma
Vol. 40 No. 3 | World Hospitals and Health Services | 45

opinion matters 9/30/05 12:39 Page 46
OPINION MATTERS
The global chronic care epidemic
and international expansion of
disease management programmes
WARREN E TODD, MBA
EXECUTIVE DIRECTOR, INTERNATIONAL DISEASE MANAGEMENT ALLIANCE
As hospitals around the world struggle to respond to
increasing demands on their capabilities from
tsunamis, the epidemic HIV/AIDS crisis, war
casualties and starvation in developing countries, another
global crisis is rapidly brewing. As suggested by the World
Health Organization, chronic disease promises to be “the
epidemic of the 21st century.”
While this near-term crisis threatens the basic economic
structure of both developed and developing countries, the
unhealthy lifestyles and global proliferation of obesity in our
younger population poses an even great threat as the “next
generation/wave” of chronic disease sufferers will emerge
decades sooner than historical demographics would
anticipate. Truly we have bi-modal healthcare crisis as
depicted in Figure 1. In short, today’s obese society will
likely become the next generation of chronic disease
sufferers and “hit our systems” in their 30s and 40s versus
over age 50 and expanded life expectancy can extend our
current near term challenge.
Our immediate short term
threat is of course that of
aging/chronic disease. This crisis
is literally “at our doorstep.”
This “Opinion Matters” will
deal only with the status of
disease management around the
world. Future articles may in fact
address the second crisis of
obesity and lifestyle erosion
around the world.
What is disease management?
There remains considerable
confusion, even today, concerning
this question. In many countries,
healthcare leaders confuse disease
management with disease
prevention. Very simply, disease
management is about the
prevention of the exacerbations
of disease post-diagnosis while
Next
Generation
Obesity
Prevention
& DM
wellness and prevention are about the actual prevention of
the disease. An accepted definition of disease management
as developed by the Disease Management Association of
America and accepted by all three United States
accreditation organizations is indicated below.
Definition: Disease management is a system of
coordinated healthcare interventions and communications
for populations with conditions in which patient self-care
efforts are significant.
Disease management:
➜ supports the physician or practitioner/patient
relationship and plan of care;
➜ emphasizes prevention of exacerbations and
complications utilizing evidence-based practice
guidelines and patient empowerment strategies, and
➜ evaluates clinical, humanistic, and economic
outcomes on an going basis with the goal of
I N N O V A T I O N
Boomers
Chronic
Disease
Disease
Management
& Prevention
18 -50 Age Group 50 - 90 Age Group
Figure 1: Bi-modal healthcare crisis
?
Life
Expectancy
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opinion matters 9/30/05 12:39 Page 47
OPINION MATTERS
improving overall health.
Disease management components include:
➜ Population identification processes;
➜ Evidence-based practice guidelines;
➜ Collaborative practice models to include physician and
support-service providers;
➜ Patient self-management education (may include
primary prevention, behavior modification programmes,
and compliance/surveillance);
➜ Process and outcomes measurement, evaluation, and
management;
➜ Routine reporting/feedback loop (may include
communication with patient, physician, health plan and
ancillary providers, and practice profiling).
Full service disease management programmes must
include all six components. Programmes consisting of fewer
components are Disease Management Support Services
Outcomes…
Reduced: Range of Results
ER Visits - 8-27%
Hospitalizations - 18-38%
Hospital Days - 15-17%
Total Cost - 9-15%
Increased EBM
Compliance + 49%
Table 1: Matria DM Programme outcomes
Unfortunately, many “disease management” initiatives do
not meet this definition. There is also considerable
confusion about DM because a number of partial programs
were implemented in order to fit them into existing systems
of reimbursement. The results were less than ideal… and
created confusion.
Forces driving expansion of disease management - The
forces fueling disease management remain largely financial
in most countries. In the United States total healthcare costs
are expected to expand from $1.7 trillion dollars in 2002 to
over $2.6 trillion in 2010. In addition, the World Health
Organization also projects that the global burden of chronic
disease will increase from 27% of GNP in 1990 to over 43%
in 2020.
Another disturbing statistic that will drive DM expansion
is the declining ratio of workers/employees to retirees: 25:1
in 1935 to less than 2:1 in 2025. Fewer working age people
funding an expanding chronically ill population will add
further pressure to our economic systems.
Finally, there is also increasing recognition that DM also
represents an opportunity to improve clinical outcomes.
Based on figures in the United States, people with chronic
illness receive only 56.1% of recommended care.
DM performance – DM expansion has been stimulated
by the success of DM in the United States. A study by the
DMAA of almost 200 peer-reviewed articles on DM showed
consistently positive outcomes including economic, clinical
and humanistic benefits.
In addition, a review of the outcomes from one of the
leading United States disease management organizations
confirms the potential power of DM to generate favorable
clinical, economic and humanistic outcomes. Table 1
highlights the range of outcomes covering seven asthma,
diabetes, CHF, COPD, CAD, depression, and cancer
produced by Matria.
Importantly, DM has been successful despite having to
operate in a healthcare infrastructure that has been
defined by the Institutes of Medicine as “…inadequate,
fragmented, and broken” in regards to the system’s ability to
foster the better management of chronic disease.
Global expansion of DM - The success of disease
management in the United States has resulted in its global
expansion. Countries on five continents are now
experimenting with the adaptation of US-style disease
management programmes to the unique characteristics of
their own systems.
The next generation of disease management – DM
program success in the private sector has also led to
adoption by the public sector Medicare and Medicaid where
private sectors models are now being adapted for new
populations, the elderly and the poor. These new challenges
will undoubtedly lead to the further enhancement to DM
programmes.
In the meantime, there are many challenges and
opportunities to increase both the efficiency and the
effectiveness of disease management. The expanded use of
new technologies and the aggressive adaptation of behaviour
change science will certainly be at the core of these
improvements.
Technology - Unfortunately first generation DM
programmes have not been very successful in
operationalizing the abundance of technology available to us
today. According to Dr Joseph Coughlin of AgeTel, the very
real threat of an aging population will serve to significantly
accelerate adoption of technology.
New technologies offer a huge potential to improve the
efficiency and effectiveness of healthcare systems
and DM programmes. New developments in patient
communications and remote patient monitoring have been
especially noteworthy. Predictive modeling represents
another area where we have made considerable progress in
identifying which low utilizers today will become high cost
utilizers tomorrow, and therefore expedite interventions.
Behaviour Change Science represents another major
opportunity for enhancing future disease management
programmes. Changing consumer expectation and
empowering patients to take accountability for their chronic
disease is not an easy process. As noted by the famous
behaviouralist, Dr James Prochaska, “…only 20% of people
in a population that need to make a change are prepared to
do so at any one time. However, 90% of behaviour change
programs are designed with only this 20% in mind.”
According to Dr Prochaska most behavior change
programmes today fail to deal with the fact that, at the
moment they are asked to change, most people cannot
Vol. 41 No. 3 | World Hospitals and Health Services | 47

opinion matters 9/30/05 12:39 Page 48
OPINION MATTERS
Country DM Status
Australia Over $400 million being spent on demonstration projects the driving decision has
been to build new expensive hospitals or to keep people out of them via DM – a new
DM association was formed
Germany DM legislated with reimbursement for sick funds that provide DM
Singapore National initiative initiated in 2000 – leveraging public sector infrastructure
United Several models in early testing. NHS Strategic Health Authorities developing RFP’s
Kingdom
South Africa Private sector programmes achieving good results; DM is being combined with
wellness programmes.
India Several pharma-backed DM pilots being tested
Spain Government initiated pilot being developed and tested in Barcelona
Brazil Favorable system. Free standing DMO and health plan models.
Argentina Private hospital initiatives with good use of technology/EMR
Japan Ministry of Health interest; private sector pilots; New DM Association, book,
newsletter
Netherlands Academia-driven assessment of DM programmes in progress; private and public
sector interest
Italy US company pilots being developed…early stages
Taiwan Pilot programmes in five disease states
Poland Physician-based model being developed and tested for “proof of concept”
Canada Calgary, Vancouver and Ontario are leading public adoption of disease management
Greece Unusually large private sector [47% of total healthcare expenditures]; expect private
sector pilots in late 2005/early 2006; pharma-centric models are likely
South Korea Pilot programmes initiated in 2004; no feedback to date
imagine or believe that they could. The United States DM
industry is beginning to become more aggressive in finding
ways to operationalize over 30 years of behaviour change
research. The next 2-3 years should produce interesting
results in this area.
Conclusion
A decade of United States DM experience has produced a
wealth of knowledge concerning how we can better manage
chronic disease. In the next decade, the expansion of DM
into the public sector and internationally will increase our
understanding of how to best address the chronic disease
crisis. More robust use of technology and the effective
operationalizing of behaviour change science will also
contribute considerable to better DM outcomes. Finally,
research into different models of DM and integration with
health management will lead to a greater benefit to
societies around the world. As disease management
expands globally the hospital community has the
opportunity to explore how DM can help establish
stronger relationships with their patients. ❑
Curriculum Vitae
Warren E Todd, MBA, author of the first
published book on disease management, has
pioneered the concept around the world for the
past decade as founding board member, past
President and Executive Director of the Disease
Management Association of America (DMAA) and
as the founder of the International Disease
Management Alliance (IDMA).
48 | World Hospitals and Health Services | Vol. 41 No. 3