World Hospitals and Health Services - International Hospital ...

2004 Volume 40 Number 4 

International Hospital Federation | Fédération Internationale des Hôpitaux | Federación Internacional de Hospitales 

World Hospitals and Health Services 

The Official Journal of the International Hospital Federation 

e-Health supplement 

Richard C Alvarez, CEO of 

Canada Health Infoway outlines 

the promise of e-health 

Editorial 

IHF Newsletter 

International Hospital Federation news 

Conference and event calendar 

International news round up 

Country profile 

The Argentine health system: trends and challenges 

Policy 

Health and citizenship: the characteristics of 21st 

century health 

Equal future prospects for all hospitals in Europe? 

Trends in development within the European Union 

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 

Management 

The impact on Asian health care systems of nursing 

migration 

Clinical care 

Essential emergency surgical procedures in resourcelimited 

facilities: a WHO workshop in Mongolia 

eHealth supplement 

e-Health news 

The promise of e-health: a Canadian perspective 

The World Health Channel: an innovation for health 

and development 

Opinion matters 

Major international concerns for 2005

CONTENTS 

World Hospitals and Health Services 

2004 Volume 40 Number 4 

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 

07 

Conference and event calendar 


COUNTRY PROFILE 

10 The Argentine health system: trends and challenges 

Norberto Larroca 

ARTICLES 

Policy 

12 Health and citizenship: the characteristics of 21st century health 

Professor Illona Kickbusch 

15 

19 

24 

Equal future prospects for all hospitals in Europe? Trends in 

development within the European Union Dr Burghard Rocke 

Management 

The impact on Asian health care systems of nursing migration 

Khurshid Khowaja, RN, BSCN, PHD 

Clinical care 

Essential emergency surgical procedures in resource-limited 

facilities: a WHO workshop in Mongolia Dr Meena Nathan 

Cherian, Dr Luc Noel, Dr Ya Buyanjargal and Dr Govind Salik 

E-HEALTH eHealth SUPPLEMENT 

30 e-Health news 

31 

36 

40 

41 

44 

47 

The promise of e-health: a Canadian perspective 

Richard C Alvarez 

The World Health Channel: an innovation for health and 

development Dr Harry McConnell, Dr Tenagne Haile-Mariam 

and Dr S Rangarajan 

REFERENCE 

Letters to the Editor 

Abstract translations in French and Spanish 

Directory of IHF professional and industry members 

OPINION MATTERS 

Major international concerns for 2005 Gérard Vincent 

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, 

International e-Health Association 

EDITORIAL OFFICE 

Immeuble JB SAY 

13 Chemin du Levant, 

01210 Ferney Voltaire, France 

Email: info@ihf-fih.org; 

Internet: www.hospitalmanagement.net 

SUBSCRIPTION OFFICE 

International Hospital Federation 

c/o MB Associates 

52 Bow Lane, London EC4M 9ET, UK 

Telephone: +44 (0) 20 7236 0845 

Fax: +44 (0) 20 7236 0848 

ISSN: 0512-3135 

Published by Pro-Brook Publishing Limited for the 


Alpha House, 

100 Borough High Street, 

London SE1 1LB, UK 

Telephone: +44 (0) 20 7863 3350 

Fax: +44 (0) 20 7863 3351 

Internet: www.pro-brook.com 

For advertising enquiries contact 

Pro-Brook Publishing Limited 

on +44 (0) 20 7863 3350 

World Hospitals and Health Services is published 

quarterly. All subscribers automatically receive a 

copy of the IHF reference books. The annual 

subscription to non-members for 2004 

costs £125 or US$175. 

World Hospitals and Health Services is listed in Hospital Literature 

Index, the single most comprehensive index to English language 

articles on health care policy, planning and administration. 

The index is produced by the American Hospital Association 

in co-operation with the National Library of Medicine. Articles 

published in World Hospitals and Health Services are selectively 

indexed in Health Care Literature Information Network. 

The International Hospital Federation is an independent, 

non-political body whose aims are to promote improvements 

in the planning and management of hospitals and health services. 

The opinions expressed in this journal are not necessarily those 

of the Federation or Pro-Brook Publishing Limited. 

Vol. 40 No. 4 WORLD | World hospitals Hospitals and and health Health services Services | 13| 01

EDITORIAL 

Embracing the 

‘health society’ 

PROFESSOR PER-GUNNAR SVENSSON 

DIRECTOR GENERAL, INTERNATIONAL HOSPITAL FEDERATION 

This issue is a fine example of what I think the 

International Hospital Federation does best which is to 

gather experiences from around the globe and share 

them and in this last edition of the year it is perhaps 

appropriate that we have contributions from every continent. 

They range in content from the higher principles behind 

policymaking to the first hand accounts of the nursing 

shortages in one Pakistani hospital with its dire and 

sometimes unexpected implications. What links them all is 

the constant change that they reflect and the intense 

thought and actions that go into improving hospitals and 

health systems. Change that will doubtless continue into 

2005. 

Sometimes to move forward we need to consider our 

fundamental beliefs. For example, is there such a thing as a 

‘health society’? Professor Kickbusch, a major figure in 

global public health, believes there is and that the territory 

of citizen health is on the march, offering opportunities for 

all types of organisations and individuals to participate in the 

governance of that society and embrace a radical new era of 

health policy. IHF members will doubtless be a part of the 

process she envisages. 

The Vice-President of the German Hospital Association 

sees a growing health society in Europe, where national 

borders can no longer limit a growing ‘Common Market’ in 

health care that looks to shared goals and competition to 

provide them. Argentina’s recent economic and political 

problems have had a devastating impact on the health 

system of that country, but the crisis has also brought a 

untied approach to unraveling a complex structure and the 

real chance of a more inclusive health society. We have this 

from a first hand account. 

Part of any health society will undoubtedly be the 

emerging reality of ehealth and in the first of our ehealth 

sections put together under the auspices of the International 

eHealth Association, we have the Canadian perspective from 

Richard C Alvarez who is contributing so much to its 

development there. We also take a look at the development 

of the World Health Channel, a pioneering medical 

education network. 

Over the coming year, I’m sure that the pace of change will 

not slacken and I hope that the journal will be able to help 

readers embrace that change and learn how others see the 

challenges and the solutions. I wish you a happy new year. 

Finally, I would like, on behalf of the IHF, to forward our 

deepest regrets and condolences to those countries hit by 

the Tsunami disaster in South-East Asia. We will in later 

issues of the journal, return to the issue of disaster 

preparedness and the role of hospitals and health services 

under such circumstances. ❑ 


IHF NEWSLETTER 

International Hospital 

Federation news 

Dr Pickering, former IHF Director General, addresses 

Hospital Management Asia 

IHF attends Hospital Management 

Asia 2004 

A TOTAL OF 294 DELEGATES attended Hospital 

Management Asia 2004 representing 106 hospitals and 43 

companies from 22 countries. The conference was held 

between 6–7 October 2004 at Plaza Athénée Hotel, 

Bangkok, Thailand. Sheila Anazonzu attended Hospital 

Management Asia 2004 on behalf of the International 

Hospital Federation. 

A highlight of the event was the Asian Hospital 

Management Awards held in the Grand Hall of the hotel 

with Thailand’s Deputy Minister of Health, Khun Yongyoot 

Wichaidit, as the guest of honour. The minister handed 

trophies to the winners and also gave a speech stressing the 

current status of the health care industry in Thailand, and 

Delegate profile: Dick Davidson, American Hospital Association 

Dick Davidson has been president of the 

American Hospital Association since July, 

1991. He came to the Amercian Hospital 

Association after 22 years as president of the 

Maryland Hospital Association. 

Born in Philadelphia in 1936, he earned his 

bachelor’s and master’s degrees in education 

from West Chester University and Temple 

University, respectively, both in Pennsylvania, 

and a doctorate in education from Washington, 

DC’s George Washington University. 

He began his health care career as a patient. 

He was recuperating from a back injury in a 

Delaware hospital in 1965 when the then-school 

teacher and principal was recruited by the 

hospital administrator for the job of director of 

education for the Maryland-District of Columbia- 

Delaware Hospital Association. 

Davidson became the Maryland Hospital 

Association’s first president in 1969. During his 

years there, he was involved in many local, state 

and national health policy groups and initiatives. 

Under his leadership, the organisation was 

recognised nationally for its work on trustee involvement in state association affairs, payment reform, the development of 

clinical quality indicators and medical and corporate values and ethics in the hospital setting. He has consulted for 

national foundations, served on editorial boards and earned a wide reputation as a writer and speaker on contemporary 

health issues, as well as the future of health care financing and delivery in America. He was also a volunteer leader and 

officer with a Maryland organisation devoted to the health care needs of the homeless. 

He serves on the boards of the Health, Research and Educational Trust and the International Hospital Federation. He is 

also a founding director of the Institute for Diversity in Healthcare Management. 

Mr Davidson resides in Maryland with his wife Janet. They are the parents of three sons and have six grandchildren. 

04 | 12 World | WORLD Hospitals hospitals and Health and health Services services | Vol. 40 No. 4


his appreciation for the Asian Hospital Management Awards 

as well as the whole HMA event. 

Nine outstanding projects from eight hospitals in four 

countries were honoured and recognised in eight categories. 

Some 165 entries were submitted for the Awards 

programme from 56 hospitals in 11 countries in the region. 

The Lifetime Achievement Award was also presented 

during the awards ceremony. Krungdhon Hospital’s, Dr Salai 

Sukapunphotaram received the coverted award, when he 

was recognised for his contribution to the improvement and 

development of the health care industry in Thailand. 

IHF’s newly welcomed member – Bangkok Pattaya 

Hospital was one of the institutions honored at the Awards. 

Lord Phillip Hunt addresses the IHF 

Governing Council Leadership Dinner on 

patient safety 

THE IHF GOVERNING COUNCIL LEADERSHIP DINNER 

was held on 2 December 2004 at the Chateau de Divonne 

just outside Geneva. The guest speaker was Lord Hunt, 

Chairman of the United Kingdom’s Patient Safety Agency 

and the whole event was sponsored by Olympus osYris, one 

of the IHF’s growing number of industry members. 

Lord Hunt delivered his speech on the progress to date of 

the work of the Patient Agency and the need to create an 

environment where patient safety events can be reported 

without fear of recrimination and the information used 

to make necessary improvements to medical and 

administrative processes. 

Andrew Dyckoff, the CEO of Olympus osYris, whose own 

company’s products are deeply concerned with patient 

safety issues, introduced Lord Hunt. Mr Dyckoff 

commented that ‘We accepted with pleasure the inivitation 

to become the the first commercial sponsor of an IHF 

Governing Council Leadership Dinner. We were privileged 

to support the gathering of outstanding leaders from the 

health care institutions around the world. I certainly learnt a 

Deputy Health Minister 

of Thailand presenting 

Dr Pirus Pradithavanij 

with the award 

IHF member hospital wins 

award at Asian Hospital 

Management Awards 

ONE OF THE IHF’S MEMBER 

HOSPITALS was delighted to 

receive a prestigious award from 

the Asian Hospital Management 

Awards Commission for the 

most outstanding project in the 

Technical Service Improvement 

category. The prize-winning 

project was the hospital’s 

medical technology instrument 

calibration centre, which 

consistently provided error-free 

calibration. 

The Bangkok Pattaya Hospital 

was also judged joint runner-up for its ‘Tender Loving Care 

Project’ from a field of 165 projects. The awards were 

presented at a Gala dinner in the Plaza Athénée Hotel in 

Bangkok on 7 October 2004. 

For more information see: 

www.bangkokpattayahospital.com 

great deal from the Governing Council delegates, in 

particular, we gained valuable insights into the international 

perspectives on patient safety developments.’ 

The dinner was closed by IHF President Dame Gill 

Morgan. 

For further information on sponsoring IHF events 

contact: info@pro-brook.com 

Members of the governing council with Lord Hunt (second left) 

and Andrew Dyckoff (second right) 

Lord Hunt addresses the dinner 

Vol. 40 No. WORLD 4 | World hospitals Hospitals and and health Health services Services | 13| 05


Conference and 

events calendar 

IHF EVENTS 

2005 

10-12 September 

International Medical Care and Diagnostic 

20-22 September 

34th International Hospital Congress * 

Conference and Exhibition – IMD 

Nice, France 

Dubai, UAE 

dwight@ihf-fih.org 

index@emirates.net.ae or dwight@ihf-fih.org 

www.nice2005-ihf-fhf.fr 

www.hospitalmanagement.net/ihf/events.html 

2006 

9-10 January 2-5 April 

Anti-Smoking Regional Conference 

Regional Conference 

Kuwait 

Taipei, Taiwan 





15-17 May 

MCC Hospital World 2006 

Hotel Radisson SAS Cologne, Germany 

dwight@ihf-fih.org or mcc@mcc-seminare.de 

www.hospitalmanagement.net/ihf/events.html/www.mcc-seminare.de 

2007 

5-9 November 

35th International Hospital Congress * 

Seoul, Korea 


COLLABORATIVE EVENTS 

2005 

13 - 15 May 29 - 30 September 

Medic Africa 

Hospital Management Asia 

Corinthia Bab Hotel, Tripoli, Libya 

Kuala Lumpur, Malaysia 

sheila@ihf-fih.org or info@fsg.co.uk 

sheila@ihf-fih.org or ashok@optionsinfo.com 

October 

Medic Africa 

Kampala, Uganda 

sheila@ihf-fih.org or info@fsg.co.uk/ 

FOR FURTHER DETAILS CONTACT : 

IHF Project & Event Manager, 

International Hospital Federation, 

Immeuble JB Say, 13 Chemin du Levant, 

01210 Ferney Voltaire, France 

E-Mail: dwight@ihf-fih.org 

Or visit the IHF website: 


Events marked * are interpreted into English, French and 

Spanish. All other events will be in English/host country 

language only. IHF members will automatically receive 

brochures and registration forms on all the above events 

approximately six months before the start date. IHF 

members will be entitled to a discount on IHF congresses, 

pan-regional conferences and field study courses. 

06 | World Hospitals and Health Services | Vol. 40 No. 4



WORLD 

WHO announces theme of 

World Health Day 2005 

HIGHLIGHTING AN INVISIBLE 

HEALTH CRISIS, the World Health 

Organization (WHO) is making 

maternal and child health the focus of 

World Health Day on 7 April 2005. 

The WHO is also launching the World 

Health Report – also dedicated to 

maternal and child health – on World 

Health Day for the first time ever. 

In developing countries, pregnancy 

and childbirth is one of the leading 

causes of death for women of 

reproductive age, and one child in 12 

does not reach his or her fifth birthday. 

Yet, the fate of these women and 

children is too often overlooked or 

ignored. 

The slogan for World Health Day 

2005 ‘Make Every Mother and Child 

Count’ reflects the reality that today, 

governments and the international 

community need to make the health of 

women and children a higher priority. 

World Health Day 2005 

Make every mother and child count 

Launch of new alliance to improve global patient safety 

A SERIES OF KEY ACTIONS to cut the number of illnesses, injuries and deaths 

suffered by patients during health care was announced by the World Health 

Organization (WHO) and its partners on 27 October 2004 with the launch of the 

World Alliance for Patient Safety under the chairmanship of Sir Liam Donaldson, 

Chief Medical Officer of the United Kingdom. 

The creation of the World Alliance comes two years after the Fifty-fifth World 

Health Assembly Resolution on Patient Safety in 2002 called on Member States 

to pay the closest possible attention to the problem of patient safety and to 

establish and strengthen science-based systems necessary for improving patient 

safety and quality of health care, including the monitoring of drugs, medical 

equipment and technology. 

The Alliance has a firm objective to deliver six programmes within the next two 

years: 

➜ a key element will be the Global Patient Safety Challenge, focusing over 

2005-2006 on the challenge of health care associated infection; 

➜ Patients for Patient Safety involving patient organisations and individuals in 

Alliance work; 

➜ Taxonomy for Patient Safety ensuring consistency in the concepts, 

principles, norms and terminology used in patient safety work; 

➜ Research for Patient Safety developing a rapid assessment tool for use in 

developing countries and undertaking global prevalence studies of adverse 

effects; 

➜ Solutions for Patient Safety promoting existing interventions and 

coordinating activity internationally to ensure new solutions are delivered; 

➜ Reporting and Learning generating best practice guidelines for existing and 

new reporting systems, and facilitating early learning from information 

available. 

The World Alliance for Patient Safety will build on existing national efforts and 

initiatives sharing the same vision and link with programmes for improving 

patient safety. It is expected that its work will eventually lead to much greater 

long-term safety in health care. 

For more information contact: Pauline Philip, Patient Safety Unit 

WHO/Geneva; philipp@who.int 

Global Forum addresses disparities in health research 

The World Health Day 2005 website, 

includes a toolkit for organisers of 

World Health Day activities and the 

World Health Day slogan and design 

shown above. 

For more information see: 

www.who.int/entity/world-healthday/2005/en 

THE EIGHTH ANNUAL MEETING of the Global Forum for Health Research, was 

held in Mexico City, 16–20 November 2004 in conjunction with the WHO 

Ministerial Summit on Health Research and brought together over 700 

participants from government, intergovernmental organisations, NGOs, the 

private sector, researchers and research councils to consider ‘health research to 

achieve the Millennium Development Goals (MDGs)’. 

The forum found that the vicious circle of poverty and ill health at which the 

MDGs are targeted will not be broken without intensified effort to close the 

continuing ‘10/90 gap’. In many developing countries, efforts for poverty 

eradication have been undermined by deterioration in the population’s health. 

The attainment of the MDG poverty target will depend on increased research 

directed to the health needs of those living in absolute poverty, and to improving 

access to affordable products and services in a variety of settings. Health policy 

and systems research and social sciences, behavioural and operational research 

are vital to this aim. 



WORLD 

The Global Forum came to the following conclusions: 

➜ The exercise of political commitment and power is the 

necessary pre-requisite to ensure the implementation of 

the health research agenda in support of the MDGs. 

➜ To provide the resources necessary for essential research 

within developing countries, governments of these 

countries to spend at least 2% of their national health 

budgets on health research, as recommended by the 

1990 Commission on Health Research for Development. 

These funds should be used locally for health research 

and research capacity strengthening. Also in line with the 

Commission’s recommendation, donors are urged to 

allocate 5% of their funding for the health sector to 

health research and research capacity strengthening in 

developing countries. Monitoring the use of funds is a 

vital complementary activity. 

➜ Civil society, NGOs and communities must be involved 

in the governance, definition, generation and conduct of 

health research; in the application of the knowledge and 

technologies it provides; in monitoring progress and in 

maintaining the public debate about resources and 

priorities. 

➜ Innovative research should be supported by the public 

and private sectors and by academic institutions. Priority 

should be given to research and development to create 

technologies and products directed to meeting 

developing country needs and to ensuring their delivery. 

The private sector and governments should more 

intensively explore avenues to ensure sustainable and 

equitable access to products, services and treatment. 

The not-for-profit private sector should continue its 

contributions to health and health research. 

➜ Research is needed into the roles of both intellectual 

property systems and public-private partnerships in 

creating health products and widening equitable access 

to them. 

Forum 9 will take place between 12–16 September 2005 

in Mumbai, India and will look at issues of poverty, equity 

and health research. 

For a full statement see: www.globalforumhealth.org 

ASIA-PACIFIC 

Devastating tsunami strikes southeast Asia 

A POWERFUL TSUNAMI caused by an underwater 

earthquake struck the shores of many southeast Asian and 

African countries on the 26 December 2004, in particular, 

Sri Lanka, Thailand, Indonesia and India. 

Urgent action is now needed to address the emerging 

public health needs of those affected. Between three and 

five million people in the region are unable to access the 

basic requirements they need to stay alive – clean water, 

adequate shelter, food, sanitation and health care. 

To address the immediate public health needs and respond 

to this major catastrophe, WHO estimates that it will need 

US$40 million.While information is still scarce after the 

tsunami, WHO and its United Nations and nongovernmental 

organisation partners are completing preliminary assessments 

of the human consequences of this disaster. 

At the time of going to press, estimates put the number of 

dead at more than 80,000, with as many as 300,000 people 

injured, many need urgent medical or surgical treatment. 

Countless other survivors are at risk of infectious diseases 

or aggravating existing health conditions. In Indonesia, for 

example, on the coast of Aceh, only one hospital remains 

operational. In Sri Lanka, much of the public health 

infrastructure in coastal areas is reportedly damaged and 

functional units are overwhelmed. 

WHO is helping local and national authorities respond to 

the human crisis and enable survivors to stay alive; to help 

the international community focus its aid so that it can be 

used quickly and well; and to ensure that health services are 

re-established as soon as possible. 

From for more information see: www.who.int 

Moves underway to strengthen nursing in the South Pacific 

EFFORTS ARE UNDERWAY to establish a network of 

nursing leaders in the South Pacific to ensure a more 

effective response to health challenges affecting countries in 

the region. 

A South Pacific Forum was convened from 15–19 

November 2004 in Raratonga, Cook Islands, during which 

South Pacific Government chief nurses addressed a number 

of issues, including the establishment of a network to 

strengthen nursing leadership. 

Other areas covered included the migration overseas of 

nurses and midwives and the resulting shortage of staff; the 

threat of emerging diseases such as severe acute respiratory 

syndrome (SARS); rising rates of noncommunicable 

diseases; the need for health systems reforms and building 

health leadership capacity and health service delivery, 

particularly in rural and remote areas, due to poor 

equipment, lack of essential drugs and trained competent 

personnel. 

The South Pacific Forum, ‘Challenges and Actions for 

Nursing and Nurses in the South Pacific,’ convenes every 

two years to enable nurses to share their interests, 

achievements and concerns, update their clinical 

knowledge, and make recommendations for united action 

over the next two years. 

For more information contact: Kathleen Fritsch, WHO 

Regional Adviser in Nursing, at fritsch@wpro.who.int 

08 | 12 World | WORLD Hospitals hospitals and Health and health Services services | Vol. 40 No. 4


AMERICAS 

Peru becomes the fortieth country to ratify 

WHO tobacco convention 

PERU BECAME THE 40TH STATE to ratify The World 

Health Organization Framework Convention on Tobacco 

Control (WHO FCTC) Treaty on 30 November 2004. In less 

than a year and a half, 40 countries from all regions of the 

world have taken the necessary steps to become contracting 

parties to the Treaty, making it the first international legally 

binding public health treaty under the auspices of WHO. 

The Treaty will enter into force and become part of 

international law in 90 days, following ratification by 40 

countries in the past 17 months and will improve health by 

contributing to the reduction of tobacco consumption, 

currently the cause of premature death for nearly five million 

people every year. 

For more information contact: The WHO/Tobacco Free 

Initiative on seoanem@who.int 

PAHO and USAID sign new regional 

partnership agreement worth US$20 million 

THE PAN AMERICAN HEALTH ORGANIZATION (PAHO) 

and the United States Agency for International Development 

(USAID) signed a new three-year US$20 million regional 

partnership agreement on the 15 November 2005 to 

improve maternal and child health, reduce infectious disease 

and strengthen health systems in the region. 

As part of the grant agreement, USAID will contribute 

US$4.168 million during the first year and US$12 million 

over the three-year period. PAHO’s contribution will be 

about US$8.1 million over the three-year period. 

In maternal and child health PAHO and USAID will work 

at the policy level to devote additional attention and 

resources to reduce maternal mortality. In the area of 

infectious disease, the partnership will focus on stemming 

the tide of increasing resistance to commonly used drugs; 

promoting rational pharmaceutical use, and building 

capacity to treat TB and malaria. To integrate and strengthen 

health systems, ie. will improve public health capacities, 

management and administration of health services, foster 

linkages and analyse health information systems. 

For more information see: www.paho.org 

Chronic kidney failure in the United States 

increases 104% over decade 

UNITED STATES CASES OF CHRONIC KIDNEY failure 

doubled from 1990–2001 to 1,424 per million, due to an 

increase in the prevalence of hypertension and diabetes, the 

aging of the population and a higher survival rate for those 

with the disease, the Centers for Disease Control and 

Prevention reported in October 2004. To reverse the trend, 

CDC recommends screening people at high risk, and 

treating and controlling risk factors such as hypertension 

and diabetes. About 19 million adults have chronic kidney 

disease, and an estimated 80,000 are diagnosed with kidney 

failure each year. 

For further information see: www.cdc.gov 

EUROPE 

WHO concerned about absence from work 

due to stress-related conditions 

STRESS-RELATED CONDITIONS ARE THE MAIN CAUSE 

of absence from work in several countries of the WHO 

European Region, costing society increasing amounts in 

sickness benefits and lost working days. Studies suggest 

that 50–60% of all working days lost in those countries are 

related to stress. Experts gathered in Tallinn, Estonia, on 

4–5 October 2004 to discuss mental health and working 

life, in preparation for the WHO European Ministerial 

Conference on Mental Health to be held in Helsinki in 

January 2005. 

According to a survey in 2000 by the European 

Foundation for the Improvement of Living and Working 

Conditions, 28% of the 160 million workers in the 

European Union complain of stress at work and over half 

the workers report working at very high speed, and to tight 

deadlines. Work-related stress factors contribute to a wide 

spectrum of ill health: 13% of the European Union 

workforce complain of headaches, 17% of muscular pains, 

and 30% of backache, in addition to many other, even 

potentially life-threatening diseases. 

The meeting of experts in Tallinn, hosted by the Estonian 

Ministry of Social Affairs, examined employment practices 

across Europe, how different companies tackle stress at the 

workplace and what measures can improve workers’ mental 

health. Its conclusions will form part of the Ministerial 

Conference in Helsinki in January 2005. 

For more information: press_office@euro.who.int 

New World Medical Association Secretary 

General appointed 

DR OTMAR KLOIBER, deputy Secretary General of the 

German Medical Association, has been unanimously 

appointed as the new Secretary General of the World 

Medical Association. He succeeds Dr Delon Human, a 

former family physician from Pretoria, South Africa, who is 

standing down as Secretary General in early 2005 after 

seven years in the position. 

Dr Kloiber, who is 47 and a pathophysiologist, has been 

working at the German Medical Association since 1991. 

Before then he was involved in research on neurotoxicology, 

first at the University of Minnesota in the United States and 

then on pathophysiological studies at the Max-Planck 

Institute for Neurological Research in Cologne, Germany. 

For more information see: www.wma.net 

The Editor would like to thank the World Health 

Organization, the World Medical Association, the 

Amercian Hospital Association, the Pan American 

Health Organisation and the Global Forum for 

Health Research 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. 40 No. 4 | World Hospitals and Health Services | 09

COUNTRY PROFILE: ARGENTINA 

The Argentine health 

system: trends and challenges 

NORBERTO LARROCA 

PRESIDENT, CAMARA ARGENTINA DE EMPRESAS DE SALUD, PRESIDENT, LATIN AMERICAN HOSPITAL 

FEDERATION AND IHF GOVERNING COUNCIL MEMBER 

The health of citizens in the Argentine Republic, the 

health services and national health system itself have 

all suffered (and continue to suffer) a deep crisis 

resulting from the dramatic political, economic and social 

changes that have been taking place since 2001. 

As a consequence of such developments – the fall of the 

national executive power and a succession of provisional 

presidents until the current constitutional president, Dr 

Néstor Kirchner – and the consequent economic changes – 

withdrawing from the conversion plan, the ‘pesificatión’ of 

the economy with a strong currency devaluation against the 

dollar, the retention of bank deposits, the collapse of the 

economy and the production of goods and services – all 

society was forced to a accept a brutal change in living 

conditions. The health system was also involved in this 

situation as well, and as a result it changed and adapted to 

the new situation. These changes will continue to take place 

until there is a balance that will allow normal working. 

Specifically, the care of the population’s health in 

Argentina has been affected in ways which we can 

summarise as follows: 

➜Macroeconomic reasons produced by the currency 

devaluation. This factor has made medicines, medical 

supplies, equipment and all imported medical 

technologies rise in cost to values that make them very 

difficult (and sometimes impossible) to afford, 

producing increases of up to 300% in their costs. 

The average increase in cost of health has been estimated 

to be 75% since the above mentioned incidents. 

➜ With 8% of the Gross Domestic Product assigned to 

health, this represents US$650 per inhabitant per year 

in 2001, this figure lowered after the devaluation to less 

than US$200 per person per year in 2003. 

➜Microeconomic reasons mainly caused the large decrease 

in the population’s spending power. Moreover, the great 

increase in unemployment and in informal work, which 

does not carry social security contributions, is 

decreasing the economic resources for this sub-sector of 

health. 

➜ As a result of the above mentioned issues, the number 

of people without medical insurance has increased 

Figure 1: Argentina 

ARGENTINA 

enormously (private and voluntary – as in the case of 

the paid systems and insurance, or the public and 

compulsory, as in the medical social insurance of the 

social security system linked to employment). 

➜ The state sector of health (public hospitals), is 

overwhelmed by the massive demand for assistance 

from the population without medical insurance 

(destitute people, poor people, the unemployed, the 

middle class with low incomes, etc), many of whom 

were assisted in the private sector before the crisis 

through public or private insurance. 

➜ The private sector of health (private hospitals), now 

lacks funds due to the decrease in the population with 

health benefits (public and private insurance), and due 


COUNTRY PROFILE: ARGENTINA 

to the decrease and delay in the payments of the public 

insurance. By 2004, this national structure of small and 

medium-sized health companies, is facing the biggest 

economic crisis in its history and the real danger of 

collapse. 

➜ Both sectors (state and private) have serious problems 

caused by tremendous demand on the one hand and 

low performance of the available resources on the other. 

Also, the elevated cost of medical supplies (medicine, 

disposable material, prosthesis, equipment, etc) affects 

the possibility of offering health care services at its 

historical level of quality. 

➜ Both sectors (state and private), face the challenge of 

re-emerging pathologies that we believed were 

extinguished and forgotten and that today are now 

increasing (infantile malnutrition, perinatologic diseases, 

maternal mortality, tuberculosis, leprosy, parasitosis, 

AIDS, Dengue Fever, etc), together with the traditional 

illnesses of the ‘developed world’ (cardiovascular 

diseases, cancer, accidents, etc) that nevertheless 

continue being the main cause of morbimortality in 

Argentina). 

➜ The high cost that families have to bear, reflects the 

inequity and inefficiency of the health system, since it 

punishes the less protected and vulnerable. 

Trends 

To combat the situation outlined above, the national 

government has called a round table conference that 

involves all sectors of society including our Association. 

The national health department organised the creation of 

a crisis committee whose duty was to directly advise the 

Minister of Health about the essential issues related to the 

improvement of the crisis. This committee was formed by 

representatives from all sectors of health and was 

instrumental in developing the measures that were being 

taken, and together with the work of the provinces through 

the Health Federal Council (COFESA), they provided 

materials and information for the creation of the Health 

Federal Plan. 

As its principles set out, the Health Federal Plan, 

establishes a programme or project that is to be carried out 

over the course of the next few years; specifically, it is 

planned for the four-year period from 2004 to 2007. 

To achieve its goals, some reforms are going to happen 

over time, avoiding the easy or urgent solutions. The plan 

mainly involves a cultural change: integrating the subsectors 

where the health system is fragmented; creating one 

health system that could improve the equity, accessibility 

and financing; putting emphasis on primary care and on 

prevention and promotion. 

All the indivuduals that belong to these sectors know 

that, in the way, they are traditionally answering to 

Argentine’s geographical and social characteristics and to 

the people’s idiosyncrasy that says it cannot think of a 

system that excludes some of its parts. Specifically, the 

Health Federal Plan recognises and includes the private 

sub-sector, with its technical capacity in physical resources, 

structure and human resources, to complement the actions 

of the state sub-sector. 

Health service suppliers, always based on the Primary 

Assistance Strategy, will create mixed assistance ‘Sanitary 

Networks’, formed by human and material resources 

(laboratories, assistance centres, surgeries, clinics and 

hospitals) coming from the state sub-sector and the private 

sub-sector. These networks will be in charge of different 

populations; people will have access to medical assistance 

with an organised transit through the different levels of 

complexity, organised by primary assistance doctors (head 

doctors). 

For a long time, our associations – the Argentine 

Confederation of Clinics, Sanatoriums and Hospitals 

(CONFECLISA), the Argentine Chamber of Health 

Enterprises (CAES) and the Latin-American Federation of 

Hospitals (FLH) – have worked to make people aware of the 

strange structure of the health system (it is not an only one 

system, it is formed by both the state and private subsectors, 

both in its organisation and in its financing system). 

A sectorial or isolated solution is not possible, all the 

resources and efforts of both parts must be united to face the 

crisis. In this way, we have been working intensively with the 

Health Department to create emergency plans based on 

mutual cooperation and the fundamental concepts of the 

Health Federal Plan. 

This fragmentation of the Health System works against the 

quick response that people need, that is why it is necessary 

to urgently unite the goals between the sub-sectors that 

form it. 

Challenges and proposals 

We want this Health Federal Plan to become a Health 

Federal Law so that it can really turn into a state policy. We 

know, that as a health private sector, health care is a public 

service which requires the convergence of all the existent 

resources, whether state or private. This means that all the 

resources created by civil society must be rationally used to 

create sector equity and to assure the accessibility of all the 

population to health care. 

The specific offer of our organizations is to help articulate 

the thoughts of both sub-sectors, under the modern forms 

of the health management, and not under the simple figure 

of contribution or complement to the services. 

The concept of the ‘health citizen’ must go beyond the 

‘treatment of the disease’, and be based on the prevention 

strategy and giving precedence to the primary care organised 

in integrated networks. 

The way of financing the health assistance must also be 

reconsidered, since the current one, mainly based on 

deductions for health at work has proved to be inadequate 

to assist all the population. 

In short, the answer to the crisis is, as far as our sector is 

concerned, a proactive attitude: the organisation, the 

training of human resources, the management of 

improvement, the quality programmes, the health services 

accreditation, and the struggle to make the health assistance 

a state policy, firmly articulating the components of all the 

health system, since a country without health, education 

and security is ungovernable. ❑ 


References 

1 

Chatzicocoli-Syrakou S, ‘The Asklepieion’s Healing Environment - Learning from 

the Past’, World Hospitals and Health Services Vol. 33, No. 2, 1997, pp. 22-27. 

2 

Aravantinos AP, Asklepios and Asklepieia, 1st ed: 1906, 2nd ed: Leon ed. 1975(GR). 

See also: Edelstein E & L, Asklepius. A collection and interpretation of the testimonies, 

Baltimore, 1945. 

3 

Apollodoros, Mythologia, III, 118-120. See also: Hesiodos [Hesiod]*, Apospasmata, 

Hoiai, 18 (51) ** 

4 

Chatzicocoli - Syrakou S, Syrakoy AC, The Birth of the Healing Hospital in Ancient 

Greece, 2004 International Conference and Exhibition on Health Facility PDC, 

ASHE, American Hospital Association, Tampa, Florida, USA, March 15-17, 2004. 

Pub. PDC 2004 Resource Manual, pp. 303-306. 

5 

Homeros [Homer]*, Ilias, B 731, D 194, L 518, etc. ** 

6 

Chatzicocoli-Syrakou S, Syrakoy C, Asklepieian Ideas Supporting Contemporary 

‘Holistic’ Healthcare Design, Chapter for Architecture, IHF Pan Regional Conference. 

Bahrain, 6-8 November 2000 

7 

Marketos S, Illustrated History of Medicine, Zeta Med Ed., 2000 (GR). 

8 

Chatzicocoli-Syrakou S, Syrakou C, Syrakos T, The Hellenic Mythology. A Source of 

Origin Research for the Philosophical and Ideological Foundations in Health Care, 

Human Centred Design for Health Care Buildings, International Conference and 

Workshop. 28-30 August 1997. Trondheim, Norway. Proceedings, Sintef, pp 107- 

111. 

9 

Miller TS, The Birth of the Hospital in the Byzantine Empire, The Johns Hopkins 

University Press, Greek ed: Trans. Kelermenos N, Hiera Metropolis of Thebes and 

Levadia, 1998. 

10 

Georgakopoulos K, ‘Ancient Greek Physicians’, Iaso, 1998, pp 481-484 (GR). 

11 

Rutkow IM, Surgery. An Illustrated History, Mosby, 1993, pp 45-52. 

12 

Anapliotou-Vasaiou E, International standards in Health and National Systems, Athens, 

p. 86 (GR). 

13 

National Statistical Service of Greece (NSSGr), Social Welfare and Health Statistics, 

Athens, 2001, p.7. 

14 

Platon [Plato]*, Symposion [Symposium]*, 214b. ** 

15 

NSSGr, Social Welfare and Health Statistics, Athens, 2001. 

16 

NSSGr, Greece through numbers, 2002, p. 18. 

17 

NSSGr, Statistical Yearbook of Greece, Athens 2002, p. 45. 

18 

Chatzicocoli-Syrakou S, ‘Healthcare in Greece’, Siokis Medical Editions, (to be 

published). 

*The terms in brackets [ ] state the Latinised or English version of the presiding 

Greek term. 

**The ancient texts are available in several editions in Greece e.g.: Prof. G. 

Mistriotou, Athens 1880, 1895. Papyros, 1957, 1959. Zacharopoulos, 1939-1956. 

Kaktos, 1993, 1994.

POLICY: THE HEALTH SOCIETY 

Health and citizenship: 

the characteristics of 

21st century health 

PROFESSOR ILONA KICKBUSCH, 

PROFESSOR FOR GLOABL HEALTH, YALE UNIVERSITY AND SENIOR 

ADVISOR, PAN AMERICAN HEALTH ORGANISATION 

Abstract 

Health is at the core of modernity and its governance has been characterised by two expansions: 

• an expansion of the territory of health into an increasing array of personal and political spaces; and 

• an expansion of the do-ability of health. 

Health is an exemplary area to study the ‘consequences of modernity’ in all its dimensions and it is inextricably 

linked to the concept of modern citizenship. 

Health governance as we know it begins with the 

European enlightenment – and while it draws on 

motifs from the Greek classics as all health debate 

does with great regularity – it falls squarely within the 

discourse on modernisation. The modes of life created by 

modernity sweep away traditional types of hierarchy and 

social order – initially on the European continent, presently 

on a worldwide scale in the processes of globalisation. Then 

as now the most intimate and personal features of day to day 

existence are shaped in new ways and health is (then and 

now) both a driving force and an outcome of these 

dynamics. 

And one of the consequences of denial of citizenship to 

women was – as widely documented in the feminist 

literature – a parallel denial of their control over their own 

bodies, their sexuality and their reproductive capacity. 

Indeed women’s health is an exemplary area of the interface 

between health rights and civil and political and social rights 

to this day. The neglect of women’s health and the 

ideological battle over reproductive rights is a defining factor 

of the development agenda of the 21st century – recently 

experienced again in the debates around the WHO 

resolution on reproductive health at this year’s World Health 

Assembly. 

On the political level the state begins to carry the 

responsibility for l’hygiene publique as part of the common 

good and a larger programme of social reform. The articles 

on hygiene and health by Diderot and d’Alembert in the 

Encyclopedie sound the beginning of the new age in which 

‘La perfectabilite de l’homme’ is proclaimed as part of a 

political programme and integral part of bourgeois culture. It 

opens the door for the professionalisation of health and the 

rise of the medical system and its power of definition. 

With Enlightenment ‘health’ becomes one major (if not 

the major) goal of modern society ‘Gesundheit als der 

perfekteste Zustand des Lebens’ (Hufeland) a notion echoed 

250 years later in the WHO definition of health: a complete 

state of physical mental and social well being. In 

consequence, health is also increasingly defined as both a 

public good and as an individual right and this 

understanding makes it a driving force of social and political 

movements who lay claim to citizenship – again first at the 

level of the nation state and now at the global level. 

These two themes and driving forces – the personal and 

the political dimension of health governance – intertwine in 

a wide variety of ways over the last two centuries as the 

expansion of territory and do-ability of health is acted out 

and promoted by a wide range of different actors in society. 

These two dimensions in turn oscillate between changing 

notions of risk and of empowerment. Social reformers and 

conservative politicians, radical social movements, 

professional societies, philanthropies and civil society – all 

participate in varying degrees in defining and ordering the 

territory of health around health risks, citizen’s rights and 

markers of inclusion and exclusion. 

Michel Foucault’s statement, ‘In modernity the sharpest 

discourse on difference always takes its starting point from 

the body’ has many illustrations in the health arena. As 



women’s role changes, health becomes a political 

programme through the women’s health movement of the 

1960s and 1970s and personal health exemplified in slogans 

such as ‘the personal is political’ or ‘my body belongs to 

me’. Also around this time the growing self help and mutual 

aid movements increasingly questions that the doctor always 

knows best and patient associations and ‘Betroffenengruppen’ 

constitute themselves as legitimate experts in ‘their’ disease 

and chronic condition. And the environmental movement 

explores and documents the impact of modern 

environmental risks on health. In the 1980s and 1990s 

health becomes an integrative force through the AIDS 

movements and a frame for the rights of the gay community. 

Today health – in particular the access to medicines such as 

ARV treatments – has become a key driving force in defining 

citizens’ rights in an era of globalisation. Three out of the 

eight United Nations, Millennium Development Goals are 

focused on health and health has become a key area that 

explores social innovation, social entrepreneurship and new 

kinds of policy networks and partnerships between the 

public and the private sector. 

And as health expands in modern societies the role of the 

citizen in health – as an individual who takes care of her own 

health, as a consumer in the health market place, as a 

patient in the health care system, as a voter on health care 

issues, and as a social actor together with others in NGOs 

and social movements – gains increasing importance. From 

the very beginning of modernity – when health moved 

beyond the confines of religion and charity to being defined 

as a right – health governance is always about inclusion and 

exclusion and health governance debates are always also 

debates about values and social justice. After long periods of 

expansion in the realm of the state in alliance with the power 

for the medical profession, health is now faced with the next 

great period of expansion: the market and biotechnology on 

the one hand the power of the citizen/patient/consumer on 

the other. 

Governance means no more and no less than managing 

power relationships and increasingly these are changing 

dramatically in the health arena. Health is both a coproduced 

good and an infinite good – and its governance is 

no longer possible without the involvement of the citizen (as 

voter, actor, consumer, patient). The involvement of the 

citizen is crucial in all three territories of health (whose 

boundaries become increasingly unclear) 

➜ personal health (hygiene, lifestyles, wellness), [souci de 

soi, empowerment] the self as a reflexive project: an 

individual must find her or his identity amid the 

strategies and options provided by abstract systems – not 

just narcissism but appropriation of knowledge and 

circumstances; 

➜ public health responsibility (medizinische polizey, public 

health and health policy), [social reform]; 

➜ expert medical health (treatment, drugs, genetics and 

bio-technology), [expert knowledge]. 

The access to knowledge and information plays an ever 

larger role which is one of the reasons why health literacy 

Three out of the eight United 

Nations Millennium 

Development Goals are 

focused on health and health 

has become a key area that 

explores social innovation, 

social entrepreneurship and 

new kinds of policy networks 

and partnerships between the 

public and the private sector. 

“ 

” 

will need to become one of the key literacies in modern 

societies. What sociologists call the reflexivity of modern 

social life consists in the fact that social practices are 

constantly examined and reformed in the light of new 

incoming information about those practices thus 

constitutively altering their character. Health is now one of 

the areas in which knowledge and do-ability and promise 

expand exponentially. Yet the hopes of The Enlightenment 

to claims of reason and of certitude in knowledge have not 

been fulfilled… in science today nothing is certain. What 

was healthy today is dangerous tomorrow. Blind trust in 

expert systems has been replaced by dialogue at best but 

also by increasing suspicion, one example is the recent 

debate on vaccination and autism. Health systems are 

becoming ever more complex to navigate, decisions on 

treatment need to be taken, complex drug regimes need to 

be adhered to, healthy lifestyles need to be lived – indeed 

both living with health and living with disease demand high 

health literacy, reflexivity and constant decision making not 

only within the medical system but within the context of 

every day life. 

To some extent the three governance systems – personal, 

public, expert medical – also represent a historical sequence 

in which the medical health system has gained increasing 

dominance both in terms of social definitions of health (the 

medical eye) and governance structures (the health system 

which is a system of curative medical care) clearly 

overshadowing the systems of personal health and public 

health. Now in the 21st century we are entering a new stage 

of health governance – which I call die Gesundheitsgesellschaft 

or health society. 

In the health society all three territories and systems of 

governance are expanding and as they move through society 

they increasingly overlap. The expansion of health in the 

health society is increasingly driven not by social reform or 

medical expert/knowledge systems but by the new mix 

between the driving force of empowerment of the 

citizen/consumer/patient and the driving force of the private 

market. This mix in turn shapes social reform (not classic 

political movements that shape social reform in health as in 



HIV/AIDS) and medical expert systems (privatisation of 

health care and increasing patient/consumer power). The 

latest incarnation of these developments is the wellness 

revolution which marries personal health and the market: 

the do-ability of health translates into a product that can be 

bought on the market. 

What are the defining characteristics of the health society? 

➜ demographics, a high life expectancy and an increasingly 

ageing population; 

➜ an expansive health and medical care system that takes 

up increasing parts of the GNP; 

➜ an expanding health market for information, products 

and services both alongside (for example wellness) and 

within the medical system; 

➜ the increasing prominence of health in the debate about 

political and social priorities, about solidarity rights and 

responsibilities; 

➜ the increasing importance of health as a major personal 

goal in life linked to its do-ability; 

➜ and, finally, health as a key component of modern 

citizenship. 

The mega trend of the expansion of the health territory is 

a fact, as is its increasing do-ability. It is a response to social, 

demographic and technological changes and it indicates that 

a discourse that focuses on medicalisation or cost control is 

out of sink with a view of health as part of life politics. The 

definition of what is disease and what is health and which 

action and intervention belongs to which governance system 

is becoming increasingly difficult – the system of order is 

upset and is being redefined. And this redefinition is 

increasingly being driven by citizens/patients and 

consumers. 

A healthy (more or less) and long life have become the 

norm in developed Western modern societies and – because 

of the expansion of territory – the disease has been 

normalised and integrated into society, as symbolized by the 

AIDS and breast cancer ribbons. The do-ability of health 

expands the legal territory of rights: the litigation cases 

against the tobacco and the fast food companies are a case 

in point as is the debate around TRIPS in the World Trade 

Organization. 

The expansion of territory means that it becomes 

increasingly difficult to define boundaries, for example 

between health and beauty or between pharmaceuticals/ 

food/drugs. In the United States the term ‘cosmetic 

psychopharmacology’ describes the increased acceptance of 

using pharmaceuticals to produce personal well-being in 

everyday life. ‘La perfectabilite de l’homme’ first proclaimed 

as part of a political programme with the Enlightenment is 

increasingly possible as a personal consumer choice. 

The development of the health society is part of a general 

change in social values linked to modernity which are 

usually described with the following characteristics: 

➜ individualisation; 

➜ differentiation; 

➜ recognition of the value of autonomy and selfresponsibility; 

“ 

A healthy (more or less) and 

long life have become the norm 

in developed Western modern 

societies and – because of the 

expansion of territory – the 

disease has been normalised 

and integrated into society, as 

symbolized by the AIDS and 

breast cancer ribbons. 

” 

➜ subjective/holistic well being; 

➜ high expectations; 

➜ quality of life. 

This move towards individualisation, privatisation and the 

commercialisation of health is one expression of larger 

trends in modern societies. It widens the debate from the 

classic approach to regulate industries that produce ill 

health (such as tobacco or junk food) to creating a consumer 

movement towards products and services that create health. 

But the danger of widening the health gap grows, as the 

healthy and better off buy an ever increasing amount of 

health promotion while cuts in the public sector not only 

reduce prevention and health education services for the 

poor (for example nutrition education) but also weaken 

public safeguards on harmful goods and services (for 

example, access to and advertising of soft drinks and junk 

food in United States schools). 

This implies a radical new era of health policy, which will 

be increasingly consumer driven and constantly in danger of 

losing its commitment to solidarity – risk solidarity and 

generational solidarity – and inclusion. In particular the 

continuous processes of individualisation have widened 

choices and life options (empowerment) but have also led to 

an increased delegation of risk management to the 

individual, the family the community. Increasing parts of 

health governance have moved to the market place 

excluding those with no buying power. And as the do-ability 

of health increases so do the dangers inherent in a quest for 

‘la perfectabilite de l’homme’. 

The health society needs the active involvement of 

citizens, patient’s organizations, health literate consumers 

and social movements in order to avoid the increased 

privatisation of risk and to counter act the establishment of 

health as only a market value or indeed as an ultimate value. 

That is why groups such as IAPO will gain increasing 

importance in shaping the future of the health society – that 

the key value remains the empowerment of the citizen and 

the acceptance of health as a public good. ❑ 

This paper was first given at an IAPO Reception in Geneva, 12 

July 2004 


POLICY: EUROPEAN DEVELOPMENT 

Equal future prospects for 

all hospitals in Europe? 

Trends in development 

within the European Union 

DR BURGHARD ROCKE 

DISTRICT MAGISTRATE OF STEINBURG AND VICE-PRESIDENT OF THE GERMAN HOSPITAL ASSOCIATION 

Abstract 

The Common Market does not stop at the national health systems of the European countries. Hospital systems are 

no longer compared only among themselves, but they increasingly affect each other and become closely connected. 

This development concerns the personnel level as well as the exchange of patients. The former president and now 

vice-president of the German Hospital Association draws a summary of European hospital development over 

the last few years. 

In jurisprudence, there is a subject called ‘comparative 

law’; it deals with the phenomenon that comparable 

cultures develop comparable life circumstances which – 

in principle – find similar solutions, even if they do not 

know anything about each other. This is a result of human 

logic and intellect. Therefore, one is always well advised – 

particularly in the European Union countries – to look 

beyond national borders in order to draw conclusions for its 

own future. This has to be taken into account, if the health 

service system is on the verge of a profound reform. 

Equal political goals in the European Union 

Recently and, once again, the German health system was 

reformed ‘comprehensively’. This idea is not new, as such 

attempts were undertaken in each electoral term over the last 

two decades. The durability of such diverse and extensive 

reforms is becoming increasing unsustainable. This leads to 

the development of a cycle of reforms that hospitals find 

themselves struggling to survive. leading to a situation as 

described by Darwin as one in which the battle for: ‘The 

survival of the fittest has begun’. 

Politicians of all European countries are trying to get their 

health systems into order. The current problems and the 

introduced measures are nearly all the same: everywhere, the 

crucial issue is about consolidation of expenditure, cuts in 

welfare assistance, increases in efficiency and improvement 

of quality. With an ageing population, the European Union 

has, since 1960, witnessed an eight year rise in life 

expectancy. This trend continues. Regarding the low birth 

rates, the number of old and very old people among the total 

population will increase within the next decades. This is the 

reason for the increased necessity of medical and nursery 

supply. At the same time, economic recovery in the 

European Union has been slow the impact of which is 

reflected in earning capacity of the national welfare systems 

and for tax revenues. On the other hand, advances in 

medicine and medical technology are opening new and 

often more expensive possibilities of treatment, which is 

another reason for the increase in health care expenditure. 

These trends have given rise to key questions such as: 

➜ What is their anticipated impact on health services, in 

particular on hospitals? 

➜ What challenges will the hospitals need to face in the 

coming years? 

The increasing argument for competition 

In the area of public health policy, the arguement in favour 

of competition is gaining in importance. Amongst the liberal 

proponents of competition in academic circles the arument 

seems to be in favour of its use as a miracle cure for all 

problems and by which progress will automatically be 

achieved. 

More competition by purchasing models 

An important process which takes place both in countries 

with public health services and those with health insurance 

systems, is the development of purchasing models. These 

are systems in which the financier buys defined service 

ranges from service companies described in special 

contracts. 

In the United Kingdom, this has led to a separation of the 

national health service into Purchasers (buyers) and into 

Providers (service providers). Meanwhile, other countries, 

such as Italy and Portugal, with public health services have 



adopted this model. In these countries, the regional health 

authorities contracts with – usually public – hospitals and 

health centres. 

In Germany, corresponding elements are being gradually 

introduced. There is more freedom for contracts between 

individual – public – health insurancs and particular service 

providers or even between groups. 

As service providers are unable to reverse theis trend 

towards the purchasing model, the likely consequence is the 

emergence of greater competition between established 

physicians and hospitals, between health insurance 

companies and between hospitals themselves. They all have 

to face the competition and try to get the best out of it for 

themselves and their patients. 

More competition by integrated supply and 

structured treatment programmes 

This constant increase in competition has been 

accompanied by a further trend in some European 

countries, for example in the United Kingdom and Austria, 

that is the development of integrated supplying forms and 

structured treatment programmes. 

The rationale for this is the optimum provision of service 

to patients is often obstructed by a lack of cohesion and by 

unsatisfactory co-operation of the different service 

providers. The resultant outcome is one of failed delivery 

service to the individual patient and failings in the health 

system. There is therfore on the one hand, expensive 

multiple investigations, and on the other hand, 

informational deficits and interrupted treatment chains. 

In Germany, these problems are significantly pronounced, 

one reason being the existence of the policy of strict 

separation of various health sectors. For many decades, 

politicians have tried to find solutions; usually, they failed 

because of a lack of courage and strength of will; the system 

thus has remained unhanged, and has instead became even 

further entrenched. The law of GSG about the out-patient 

surgery in 1993 brought a new hope and perspective. The 

new GMG of 2003 could start a significant further 

development into that direction. 

For the ‘integrated supply’, special financial resources 

were founded, which will increase the incentive of health 

insurance companies and service companies to offer more 

appropriate contracts. However, one must be aware that the 

financial resources (additional money) will not be used for 

the recent health-system. Any Euro that is spent for the 

system will be removed from the service providers budget 

before, particularly from the hospitals budget. 

More competition by opening hospitals 

In the context of current developments, one has to regard 

the increasing tendency of hospitals towards the supply of 

patients with out-patient treatment. 

Once again, we should investigate the German system: 

Not because the German system is a representative model, 

but because it clearly shows what was going wrong. It has 

not been allowed for German hospitals to offer out-patient 

treatment to normal patients. With the current health 

reform, this will improve in a few matters of detail. The full 

supply of the patients will increase, but only in hospitals 

that offer appropriate contracts to health insurance 

companies or that found new ‘supplying centres’. 

These trends are quite important for hospitals. Hospitals 

are nearly perfect for any organisation of integrated supply 

and integrated production; they also maintain strong 

management capacities, experts and interdisciplinary teams, 

and at least, they have an advantage in quality assurance 

compared to established physicians. Therefore, hospitals 

should participate actively in the development of integrated 

supplying forms, and they should enlarge the range of their 

out-patient treatments. 

More competition by defined lump sums for 

medical treatments 

The transition from daily rates to lump sums with respect to 

hospital remuneration has to be judged as an as innovative 

as daring contribution to the reinforcement of the 

competition thought. A recently published trade-off study 

by DKG (German Hospital Association) shows that the DRG 

system (medical lump sum system), is becoming more and 

more important in the whole of Europe. With exception of 

Luxembourg, every country in Europe is using the system of 

the DRG, for instance for benchmarking, for quality 

assurance, for the calculation or distribution of budgets or, 

however, – as in Germany – for remuneration of any 

individual case of treatment. 

Great Britain decided to change over to a medical lump 

sum system until 2008. Obviously, the ‘German system’ was 

taken as a model for Great Britain, because the British want 

to include all in-patient treatments and obviously intend to 

start a country-wide fixed price system for the DRGs. 

Besides that, some of the new European countries have 

experiences with the DRG system, too. For instance, 

Hungary already has used DRGs for more than 10 years, 

while Tschechia and Romania have just started to introduce 

the lump sums. 

Development of quality standards 

The pressure to ensure better medical and nursing quality 

will continue to increase, although the financial budgets 

will remain scarce. A current report by the European 

Union Commission shows that this topic is located at the 

top of the political agenda in most EU member states. In 

the last years, nearly every country achieved progress 

regarding the development of quality standards in the health 

service. According to the EU report, the in-patient sector 

leads the way in this respect. In contrast to that, the outpatient 

sector still has substantial implementation problems, 

even with regard to questions of structure quality, which 

could be measured and improved quite easily. 

In contrast to this, there is still a larger pent-up demand 

for all supply areas with respect to the quality of process and 

result. Hospitals should take the leading role within this 

movement, too. The call for public, measurable criteria for a 

high-quality achievement becomes louder and louder. 

Medical progress that one can afford 



Medical progress led to many new possibilities in diagnostics 

and therapy. At the same time, costs continued to rise. In 

order to be able to convert the medical progress further on, 

the use and cost of medicine technology has to be seen in an 

appropriate relation in future. 

Scarceness of medical and nursing personnel 

In Europe, the medical and nursing personnel are becoming 

scarcer. Nowadays, in Germany, there is a shortage of some 

thousand physicians. This problem will be reinforced, when 

the on-call service is treated as regular working-time, 

according to the European High Court decision about the 

‘on-call service’ for physicians. Countries with a long 

tradition of solid curbing cost expansion such as the 

Netherlands, Great Britain or Sweden already have serious 

problems with a lack of an appropriate amount of qualified 

medical personnel (nurses, physicians), especially in the 

countryside, with many patients have to be sent abroad for 

hospital treatment. 

Physicians in hospitals need good working-conditions and 

an appropriate payment, if you want to stop these 

tendencies throughout the whole of Europe. The situation 

will not change as long as physicians start to work for the 

pharmaceutical industry or for consulting firms, and as long 

as the European Union countries entice the remaining 

medical employees away from each other. 

Political influences from the European Union 

Although the authority of the European Union is limited in 

areas like public health policy, the political influence of 

Brussels affects the national health systems increasingly. For 

instance, the jurisdiction of the European High Court has a 

strong influence on hospitals, like the jurisdiction of a 

uniform medical treatment for every EU citizen in the EU 

(trans-national patient supply) or like EU sponsored models 

such as ‘Euregios’ and various kinds of EU advancement 

programmes. Measures from other European Union policies 

also have influences on the hospitals, for example the areas 

of consumer and equipment protection, medical products, 

the competition policy (‘precaution for existence!’) and 

protection of health and safety standards at work. Such 

measures often have financial, legal and organisational 

consequences. This view is supported once again by the 

recent decision of the European High Court regarding the 

‘on-call service’ in hospitals. 

As a result of the Amsterdam Treaty, the EU was provided 

with more authority with respect to the public health policy. 

While the European countries join more and more, it is 

necessary to adjust their public health policy to a higher 

degree. This need is enhanced by the thread of diseases such 

as SARS. In order to promote co-operation between the 

member states, Brussels implements the so called ‘scheme of 

public health’ since 2003 together with the member states. 

Its goal is to build up an health information system covering 

the whole EU, the task of which is to compare 

achievements, costs and qualities of health care within the 

EU. Based upon that information system, it is intended to 

develop recommendations in the sense of ‘best practices’ for 

the EU member states. It will have nothing but positive 

effects both for patients and for service providers, if such 

comparisons lead to useful recommendations – however, of 

course, one has to be careful not to compare totally different 

things. But if information and data about costs and quality is 

used for rankings and recommendations, this presupposes 

an exact examination of the comparability. The 

characteristics of the national health systems must be 

illustrated appropriately in their varieties. 

A regular information report about new developments in 

other EU member states and a systematic comparison of 

success and failures of new measures in neighbouring 

countries will push innovations in the health service ahead. 

In addition to that, the liberty of the Common Market will 

contribute to that development. The freedom of domicile 

and the general mobility of patients, physicians and nursing 

services will continue to increase. Why should a patient wait 

for months or even years for appropriate medical treatment 

in his country, if such treatment is faster, more economically 

or even qualitatively higher and more easily available in 

another member state? Recently, the European High Court 

pointed out that patients may ask for an out-patient 

treatment abroad without having to ask their health 

insurance company for permission before hand. Costs are 

refunded after the remuneration rates of their homeland. 

Concerning treatments in hospitals, a permission 

reservation by the insurance company is legal, but only 

under determined conditions. If a patient must wait for 

hospital treatment for a long time or if the regular 

international medical standard is not offered in his country, 

the patient can be treated as an out-patient abroad at the 

expenses of his health insurance company (and to their 

remuneration rates). 

Will hospital companies go abroad and be 

successful? 

Compared to its European neighbours, Germany is far ahead 

concerning the privatisation of public hospitals. It is 

predicted that, for instance, German, American and/or 

Swedish hospital companies will become very active beyond 

their national borders and merge into big ‘European hospital 

associations’. Anyway, this strategy will cause some 

difficulties as long as national health markets still remain 

different. So it is doubtful, whether European hospital 

managers may go abroad as easily as their colleagues in the 

motor industry, chemistry or food sectors. For example, a 

manager who does not know the tricky German legislation 

rules of the health sector, will hardly be able to manage a 

German hospital successfully. Moreover, one has to consider 

the rate of turnover capital in foreign countries and the 

question whether any business engagement would be 

successful at all. Usually, ‘free capital’ is invested in areas 

that have a high turnover and profit rate. Profit is definitely 

not a feature of the hospital sector in Europe. Nevertheless, 

it is not improbable that big private hospital companies 

could start to do acquisitions in other EU-countries in order 

to obtain sufficient know-how about that particular market 

to improve market conditions and to expand quickly. 



The end of Independent hospitals? 

Nowadays, it is quite common for consulting firms to point 

out that independent hospitals would not survive in the near 

future. Only big hospital companies and hospital 

associations would stand the competition and participate in 

the market – the larger, the better. This prediction is not 

confirmed by the past European development. A 

competitor’s size alone is not a guarantee for good business. 

Mergers often cause more problems than expected – just 

remember the huge problems after the merger of 

Daimler/Chrysler or BMW and Rover. The small and flexible 

competitors usually beat the large and slow ones in a free 

market economy. 

On the other hand, the disadvantages of smaller 

companies – certainly a minimum size has to be 

presupposed – can be outweighed by co-operating with 

other small companies. Co-operation has priority over 

mergers! Of course, it is important for a hospital to what 

degree its employees stand by their employer. The more they 

identify themselves with their hospital, the better are the 

results. This identification is essential in independent, 

harmonious and small hospitals. 

Scenario 2010 

We expect an increase of competition between the European 

hospitals, for example in acquiring foreign patients for 

medical treatment. Especially in border areas (‘Euregios’) the 

linkage of patient supply, medical treatment and coordinated 

services will become more important. Thus, let us 

view particularly the northern and eastern EU borders, 

especially Germany and Austria, but also the Scandinavian 

countries. New forms of exchange will arise which are visible 

even now in bilateral communication. The extension of the 

European Union brings out other standards to the public 

health policy, as well for the new member states as for the 

old EU countries. 

In Germany, the isolation of health sectors will get less 

strong, and therefore an adjustment to the other European 

countries will take place. The specialisation within the 

European Union countries will increase, with respect both 

to hospitals and established physicians. The increasing 

mobility of the people in Europe and the increasing use of 

the Internet will extend the demand for excellent 

achievements served by the ‘best’. In Europe, supra-national 

medical-centres of progress, like technological and scientific 

research institutes, will develop. Quality will become much 

more important than it is now because of sound 

comparisons of quality, which are easily accessible via 

Internet. 

The economic situation of hospitals depends completely 

on the general economic development of the Common 

Market. This applies even more to the new European Union 

countries which have – from a today’s point of view – an 

enormous pent-up demand in medical achievements and in 

medical technology. The large European countries already 

stand up for an intensified competition in the area of 

medical innovation. The international comparison does not 

only promote a kind of patient tourism from foreign 

countries, but also creates new jobs and produces a strong 

foundation for medical and medical-technical progress in the 

respective countries. ❑ 


MANAGEMENT: NURSING SHORTAGES 

The impact on Asian 

health care systems of 

nursing migration 

KHURSHID KHOWAJA, RN, RM, BSCN, PHD 

ASSISTANT PROFESSOR AND DIRECTOR NURSING SERVICES, AGA KHAN UNIVERSITY HOSPITAL, PAKISTAN 

Abstract 

Nurses are precious resource in every corner of the world and hospitals are facing serious challenges in providing 

high quality care with current nursing shortages. While the shortage of nurses is a worldwide issue, impacting 

currently more on under developed countries, little literature is available on this aspect of the issue. Lots of job 

opportunities are available for nurses in western countries, advertised on a daily basis, that attract nurses and 

result in major nursing migration from Asian countries to the western world. 

The nursing management group at the Aga Khan 

University Hospital (AKUH) is highly stressed because 

of the high turnover rate of nurses in this hospital. The 

average annual turnover rate is calculated at 23% (see Figure 

1), resulting in 60% of nurses having less than two years 

experience. 

Turnover rate and years of experience 

The turnover rate is high in the first three years where 71% of 

nurses resign with less than three years experience. Thirty-two 

percent of nurses resign before completion of one year’s 

service with AKUH as indicated in Figure 2. The major issue 

associated with these resignations is that 50% of nurses resign 

with a notice period of only 24 hours, where nursing 

management require three to six months to replace their 

positions and this time lapse impacts on the quality of care. 

Reasons for turnover 

The major reason for the high nursing turnover rate is the 

migration of 66% of nurses to countries such as the United 

States, the United Kingdom and Canada as indicated in Figure 

3, where the working wages offered are quite high compared 

to Pakistan. Out of these 66%, 70% migrate to the United 

Kingdom, where nurses are not required to pass any type of 

exam at entry level. 

Relationship of nursing turnover to patient safety 

The Institute of Medicine (2004) stated that nurses are 

considered the largest component of the health care workforce 

and their high turnover can have adverse consequences for 

patient safety. The Institute of Medicine further stated that 

leaner nurse staffing is associated with increased length of stay, 

nosocomial infection (urinary tract infection, post operative 

infection, and pneumonia), and pressure ulcers. These studies 

taken together, provide substantial evidence that increased 

nurse staffing is associated with better patient outcomes. 

Subsequent studies have added to this evidence base and 

substantiate the observation that greater numbers of patient 

deaths are associated with fewer nurses to provide care (Aiken 

et al., 2002) and less nursing time provided to patients is 

30% 

25% 

20% 

15% 

17% 

27% 

21% 23% 

10% 

5% 

0% 

2000 2001 2002 2003 

Figure 1: Turnover rate for nursing staff 2000-2003 



associated with higher rates of infection, gastrointestinal 

bleeding, pneumonia, cardiac arrest and death from these and 

other causes (Needleman et al., 2002). In caring for patients, 

nurses are indispensable to our safety. 

Berens (2000) in his article in the Chicago Tribune stated 

‘Nursing mistakes kill thousands annually’. This article 

reported that the results of an analysis of records from the 

United States’ Food and Drug Administration and other 

Department of Health and Human Services agencies, federal 

and state files of annual hospital surveys and complaint 

investigations, court and private health care files, and nurse 

disciplinary records for every state. The analysis detected 

1,720 deaths and 9,584 injuries among hospital patients 

resulting from the action or inactions of RNs over a five-year 

period. 

Peterson (2001) stated that numerous factors influence the 

shortages of nurses such as retention, recruitment, increase in 

age of working nurses and core compensation. However, 

developing countries have some other factors related to 

turnover and such under-developed countries like Pakistan 

where the population is deprived of many health facilities, 

now face a further challenge where they are deprived of good 

nursing care in quality driven institutions and turnover 

impacts on safety of the patients. 

Relationship of nursing turnover to cost of care 

The nursing shortage is a critical problem as it increases the 

cost of care and may compromise the quality of care. The 

hospital administrators, nursing organisations, and nursing 

schools are well aware that nurses are working in other fields 

everywhere; they just refuse to work in hospitals. Health is the 

responsibility of the people within the health care system of 

Pakistan. Insurance for health coverage is not available, 

therefore patients requiring health services in private health 

care institutions have to pay the cost of care from their own 

pockets. On the other hand, nurses, while they are attracted 

by the high nursing wages paid in the developed countries, do 

not think that Pakistani hospitals cannot pay such high wages 

as an increase in their salary will directly impact on the cost of 

care. 

Role of AKUH in nursing retention 

To overcome the nursing migration issue, the management of 

AKUH formulated a task force in 1998, which recommended 

37 strategies to improve nursing recruitment and retention 

(see Figure 4). Of these strategies, around 84% were 

implemented between 1999 and 2000, but no impact was 

observed on turnover. From 1998 to 2003, three research 

studies were conducted to further explore the reasons of 

nursing turnover and retention. They were: Job Satisfaction 

and Nurses’ Intent to Stay in a Private University Hospital in 

Karachi, Pakistan (Salma Jaffer, 2003); RN Perception of Work 

Satisfaction at Tertiary Care University Hospital, (Dr Khurshid 

Khowaja, 2004); and Turnover and Retention of Nurses, (Dr 

Khurshid Khowaja, 1998). 

In early 2002, the same task force was re-activated to reassess 

the issue of nursing shortages. This task force has 

implemented 27 recruitment and retention strategies (see 

Figure 5) in order to control nursing turnover rates. 

48, 10% 

86, 19% 

86, 19% 

91, 20% 

147, 32% 

0 - 1 year 1 - 2 years 2 - 3 years 

3 - 4 years > 4 years 

Figure 2: Turnover rate according to years 

of experience 2000–2003 

36, 6% 

75, 12% 

26, 4% 

40, 7% 

31, 5% 

395, 66% 

Migration Marriage Back to hometown within Pakistan 

Higher education Set resignation Other 

Figure 3: Reasons for turnover 

Mathews and Campbell (2001) and Aiken (2001) reported 

that an improvement in the degree of job satisfaction resulted 

in successful nurse retention and therefore decreased staff 

turnover. However, the nursing task force has revealed that 

despite many interventions implemented at AKUH the 

impact on turnover rate has not been achieved and in fact the 

turnover rate related to migration has increased from 45% in 

year 2002 to 66% in year 2004, in particular migration to the 

United Kingdom which in 2003 and 2004 was 70%. 

The task force whilst implementing these strategies raised 

many queries: 

➜ Will AKUH ever be successful in retaining nurses to 

provide quality care to its customers, while nursing 

recruiters from the United Kingdom and the United 

States are working hard to recruit nurses internationally as 

part of their business? 

➜ Who is responsible for putting the extra burden on Asian 

hospitals mentally as well as financially? 

➜ What is the role of the many world health organisations, 

which are well-aware that shortage of nurses will reduce 

the standards of practice in clinical settings in such 



Table 1: Summary of suggestions and recommendation of Nursing Task Force Committee 1998 

1. Approval of a one year service agreement after graduation. Not implemented 

2. Subsidised transport for nurses. Implemented 

3. Provision of economy meals. Implemented 

4. Five percent increment of onboard staff salary. Implemented 

5. Long service increment and incentives. Implemented 

6. Financial allowances for critical care. Implemented 

7. Pay scales for non-AKUSON nurses based on their experiences. Implemented 

8. Out station allowances for nurses. Implemented 

9. Efficient utilisation of proficiency and competency testing and proper monitoring and supervision of new staff. 

Implemented 

10. Hiring of para-medical staff for tasks such as phlebotomist for maintaining of IV line. Not implemented 

11. Floating nurses to cover the staffing needs. Implemented 

12. Female hostel with all facilities to share the burden of hostilities against staff and to provide them with security. 

Implemented 

13. Arrange recreational activities for management of work stress. Implemented 

14. Better communications between doctors and nurses, for effective team building. Implemented 

15. Human resource committee to listen to employees concerns and to find solutions to problems. Implemented 

16. Co-education for diploma programme. Implemented 

17. Employeed, clinical nurse specialist for all areas in the hospital. Implemented 

18. Joint appointment system between AKUSON, AKUH and CHS. Implemented 

19. Provide staff benefits such as general shift allowance. Not implemented 

20. Provision of round the clock child care centre facilities. Not implemented 

21. Nursing students should spend more time in clinical areas. Implemented 

22. Approach married nurses and to try to get them back by involving their families. Implemented 

23. Provide sponsorships to the nursing students. Implemented 

24. Faculty should also serve at clinical site. Not implemented 

25. Banks should be involved in the recruitment of students. Not implemented 

26. Poster and flyers should be sent to all over Pakistan by involving AKU network and government machinery. 

Implemented 

27. Enroll students from different diversities. Implemented 

28. Involve nurses in the recruitment process. Implemented 

29. Open forums should be arranged for parents and nursing candidates. Implemented 

30. Continue track one programme. Implemented 

31. Website could be made accessible to public at all levels in Pakistan and outside Pakistan. Implemented 

32. For students from outside Pakistan, concept of host parents could be introduced. Not implemented 

33. A study should be conducted to know about AKUSON graduates station and status. Implemented 

34. Concept of honorary part-time staff/faculty who may be given flexibility of days and hours to work with modified 

package and benefits. Implemented 

35. Nurses should be rotated in different areas after specific period of time. Five years was the suggested time 

period. Implemented 

36. Brining non-AKUSON to up to standard, where their knowledge is concern. Implemented 

37. Implement allied programmes for other nurse caregivers. Implemented 

Table 2: Recommendations of the task force were derived further research studies 

HIGH FOR RETENTION 

1. Ensure that the one year service agreement is strictly followed, which is currently mentioned in the university 

prospectus. Not implemented 

2. AKUH can sponsor nurses for diploma and generic programmes against service agreement such as current Post 

BScN programme. Not implemented 

3. Financial assistance could be waived if nurses agree to give service to AKUH for two to three years depending 

upon assistance given. Not implemented 

4. Increase monetary allowances 



a. Hiring salary for RN’s grade 7 enhanced from Rs. 6,500 to Rs. 7,000, 8% increase. It should be 

raised to Rs. 8,500 - Rs. 9,000. Implemented 

b. Increment in educational allowances as per plan. Implemented 

c. Introduction of retention allowances as per plan. Implemented 

d. Shift differential strategy as per plan. Implemented 

e. Initiation of nurses bank as per plan. Implemented 

5. Timely promotions. Implemented 

6. Flexible working hours. Implemented 

7. Supportive management style. Implemented 

8. Mentorship and training for novice nurses. Implemented 

9. Development of a contract with the nurses at the time of hiring to give services to the institution for two years. 

Implemented 

HIGH FOR RECRUITMENT 

10. Rigorous recruitment at national and international level. Contacting ex-employees and AKUSON graduates sitting 

at home for re-hiring. Implemented 

11.Developing contract with new nurses at entry level to prevent their drop out rate.Implemented 

12. Up country recruitment trips. Not implemented 

13. Monthly RN orientation programme. Implemented 

14. Accommodation and transport. Implemented 

MEDIUM 

15. Nursing recruiter. Implemented 

16. Seek help from senior nurses representative at STTI and WHO level to help AKUH in controlling staffing turnover 

at international level. Not implemented 

17. Exit interview at the time of resignation. Implemented 

18. Joint faculty should be treated with more caring and positive approach and selection criteria needs to be finalised. 

Implemented 

19. Joint faculty role should be defined in a joint retreat to enhance collaboration and clarity. Implemented 

20. Head Nurses (HNs) & Nursing Managers (NMs) should meet with their assigned Registered Nurses during 

Nursing Educational Services (NES) orientation programme and at three months, six months, nine months and 

twelve months intervals. Implemented 

21. Start unit-based campaign to mentor existing RNs to retain at AKUH through mentorship programme of team 

leaders and HNs & CNTs. All NMs of patient care areas. Implemented 

22. Positive role modeling by seniors to nursing students during their winter and summer clinicals. Implemented 

23. Presentations for onboard RNs to be organised by RNs who have returned from abroad to share their negative 

experiences abroad. Implemented 

24. Celebrate Nurses’ Week to raise their morale by appealing slogans such as 

a. Country needs you, 

b. AKU needs you, 

c. Nurses are Important etc. Implemented 

25. Start reward process on ‘Suggestions on Retention Strategy’ and give rewards to best suggestion that is practical 

and applicable. Implemented 

26. Nursing Students during their final year should be sent to units for summer clinical where they will be assigned 

after completion of their diploma/degree programme. This will enhance cooperation and facilitation by Staff 

Nurses of the units. Not implemented 

27. Open forums with nurses every quarter. Implemented their Nurses who they are unable to hire. Implemented 

31. Providing educational opportunities to nurses. Implemented 

LOW 

32. Service letter from Personnel Department should not be issued to employees without Director Nursing Services 

consultation, unless they have served at AKUH for two years. Implemented 

33. Continuing Education Certificates and NES checklist should not be issued to RNs unless they have completed two 

years services at AKUH. Implemented. 

28. Regular assessments of job satisfaction and workload management among nurses twice a year. Implemented 

29. Plan structured summer and winter clinical coverage in all shifts by 50% AKUSON faculty and 50% by Clinical 

Nurse Teachers to provide positive experience to nursing students. Implemented 



30. Liaison with other quality institutions such as Holy Family Hospital, Seventh Day, Liaquat National etc. to recruit 

the Nurses they are unable to hire. Implemented 

31. Providing educational opportunities to nurses. Implemented 

LOW 

32. Service letter from Personnel Department should not be issued to employees without Director Nursing Services 

consultation, unless they have served at AKUH for two years. Implemented 

33. Continuing Education Certificates and NES checklist should not be issued to RNs unless they have completed two 

years services at AKUH. Implemented. 

hospitals, inspite of the nurses are hired from developing 

countries? 

➜ Who will bear the cost of care for patients, who 

themselves are responsible for their health, if nursing 

wages are increased in developing countries to retain 

nurses? 

In conclusion, the serious issues outlined above must be 

reviewed and considered by many organisations in the 

developed countries as to how Pakistan and other developing 

countries in Asia and hospitals such as AKUH can retain their 

nurses and provide high quality care to its customers.❑ 

References 

Aiken, et al (2001). ‘Nurses’ reports on hospital care in five countries. Health 

Affairs, 20(3), P. 43-52. 

Aiken L, Clarke S, Sloane D, Sochalski J, Silber J. (2002). ‘Hospital nurse staffing 

and patient mortality, nurse burnout, and job dissatisfaction’. Journal of the 

American Medical Association 288:1987-1993. 

Berens M. (September 10, 2000). ‘Nursing Mistakes Kill, Injure Thousands’. 

Chicago Tribune. News Section. P. 20. 

Health Care Advisory Board (2001). Literature Review on Retention and 

Recruitment. 

IOM (Institute of Medicine). 2000. To Err Is Human: Building a Safer Health 

System. Washington, DC: National Academy Press. 

Khowaja, K. (1998). ‘Status of retention and turnover of registered nurse at 

AKUH’. Proceedings of 3rd International Conference, Brunei Darussalam. 

Khowaja, K., Merchant, R. J., Hirani D. (2004). ‘Registered Nurses perceptions on 

Job Satisfaction at a tertiary care university hospital’. Journal of Nursing 

Management. (publication process complete waiting for release of issue). 

Mathews, N., & Campbell, J., (2001). Nursing staff turnover in intensive care. 

Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. (2002). ‘Nursestaffing 

levels and the quality of care in hospital’. The New England Journal of 

Medicine 346(22):1715-1722. 

Peterson, C. A., (2001). ‘Nursing shortage: Not a simple problem – no easy 

answer’. Online journal of issues in nursing, 6(1), 1-14. 

IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. 

Washington, DC: National Academy Press. 


CLINICAL CARE: EMERGENCY SURGERY 

Essential emergency surgical 

procedures in resource-limited 

facilities: a WHO workshop 

in Mongolia 

DR MEENA NATHAN CHERIAN AND DR LUC NOEL 

CLINICAL PROCEDURES, ESSENTIAL HEALTH TECHNOLOGIES 

DR YA BUYANJARGAL 

HEAD OF QUALITY ASSURANCE DEPARTMENT, DIRECTORATE OF MEDICAL SERVICES, 

MINISTRY OF HEALTH, ULAANBAATAR, MONGOLIA 

DR GOVIND SALIK 

PUBLIC HEALTH SPECIALIST, WHO/ULAANBAATAR, MONGOLIA 

Abstract 

A WHO ‘Training of Trainers’ workshop on essential emergency surgical procedures was organised in collaboration 

with the Ministry of Health, Mongolia. The participants included doctors and nurses from the six selected aimags 

(provinces). 

Facilitators of the workshop included experts from the Faculty of Health Science University, Mongolian Surgeon's 

Association and Mongolian Association of Anaesthesiologists association with the swiss surgical team of the 

International College of Surgeons, Surgical Department of Nurse's College, Trauma Orthopaedic Clinical Hospital, 

the Department of Quality Assurance of the Directorate of Medical Services, Ministry of Health. Facilitators from the 

Hospital University of Geneva, Geneva Foundation of Medical Education and Research, and the World Health 

Organization departments of Reproductive Health and Research (RHR) and Evidence and Information for Policy in 

Geneva, Switzerland participated via video link. 

The workshop included lectures, discussions, role playing and 'hands on' basic skills training. Videoconference 

and e-learning sessions using the WHO e-learning tools were conducted at the Global Development Learning 

Centre. 

The topics covered during this training workshop included team responsibility and organisation in a health care 

facility; patient safety; disaster planning; appropriate use of oxygen; management of bleeding, burns and trauma; 

basic anaesthetic and resuscitation techniques; prevention of HIV transmission; sterilisation of equipment; waste 

disposal; hygiene; record keeping, monitoring and evaluation of quality of care and checklists prior to surgery to 

assure that the correct patient gets the correct surgery on the correct side at the correct time . 

Recommendations were made by the participants on the next steps after this training. 

The World Health Organization in collaboration with 

the Ministry of Health (MoH), Mongolia held its first 

training of trainers workshop to improve the quality of 

emergency and essential surgical care at resource-limited 

health care facilities. 

Situation analysis of health facilities needs an 

assessment of rural health facilities 

In Mongolia 42.5% of the total population lives in rural 

soums. The differences in geographical and settlement 

conditions creates significant disparities in health needs 

between rural and urban populations. Poor conditions for 

meeting the minimum sanitary requirement, unsafe water 

and a severe continental climate, create an unfavourable 

environment that negatively influences the health of the 

rural population. Eighty-five percent of soums are located 

within a distance of more than 100km and the most 

remote households are located within a distance of 380 km 

from the soum hospitals. The timely delivery of health 

services is thus impeded. 



The first point of contact between the population and the 

health system are the feldshers, (specialised nurses), who 

work in their own ‘gers’ (tent houses), and follow the 

nomadic community providing simple curative services and 

health education. The soum hospitals are the first level of 

fully operational health facilities with a doctor providing 

emergency curative services in poor resource settings. The 

aimag hospitals provide secondary care services with better 

equipment and specialist services in surgery and obstetrics. 

Tertiary care services with specialists and medical and 

nursing colleges are available in Ulaanbaatar city only. Rural 

areas are losing their health personnel as a result of an influx 

of doctors to urban areas. The lack of adequate 

infrastructure is one of the difficulties encountered in the 

provision of information, consultation and services to the 

population in remote areas. 

There are few ambulances equipped with specialised 

equipment for emergency care and that are appropriate for 

transporting patients in the lying position As a result, the 

quality of emergency services rendered to the population is 

adversely affected by the need to ensure preparedness of 

hospital ambulances and the continuous repair of the 

vehicles. A study in 2002 showed that only 47% of soum 

hospitals had equipment which is consistent with 

standards. Around 50% of the equipment utilised at soum 

hospitals was manufactured before 1990 and 25% of it is 

not utilised at all. 

In 2003, surgical services were provided to 1.4% or 1,812 

patients of soum hospitals; the majority of these cases 

(79.3%) were suffering from acute appendicitis. 

Cholecystitis, appendicitis, injuries, otitis media, 

glomerulonephritis, pneumonia, anaemia, liver cancer were 

some of the leading specific causes of inpatient morbidity in 

soum and intersoum hospitals in 2003. Socioeconomic 

“ 

Forty-one percent of 

maternal deaths occurred 

soum and bagh levels. 

Ulaanbaatar city has the 

highest non-communicable 

morbidity in the country, 

which is related to domestic 

injuries (57.7%), violence 

(23%) and traffic injuries 

(14.4%). 

” 

phenomena, such as alcoholism and domestic violence, 

result in the high rate of unwanted pregnancies and 

abortion. Forty-one percent of maternal deaths occurred at 

soum and bagh levels. Ulaanbaatar city has the highest noncommunicable 

morbidity in the country, which is related to 

domestic injuries (57.7%), violence (23%) and traffic 

injuries (14.4%). 

One of the important measures taken by the Ministry of 

Health in 2003 in order to rationally provide secondary level 

health services was the reorganisation of soum hospitals into 

general hospitals. 

The implementing agency of the Mongolian Government 

– the Directorate of Medical Services (DMS) is responsible 

for providing quality and accessible health care to the 

population by improving management and implementation 

of health services policy. 

Bayan 

-Ulgii 

Bulgan 

e 

U 

Tuv 

Khentii 

Bayankhongor 

Dundgovi 

g 

Figure 1: Provinces selected for implementing the project 



Planning meeting 

Prior to this training workshop, a visit was made by a team 

representing WHO, Geneva and the office of the WHO 

Representative in Mongolia, the Quality Assurance 

Department (MoH), to the teaching institutions in 

Ulaanbaatar, some aimag, intersoum, soum and bagh health 

care facilities in Tuv province. 

This was followed by a WHO meeting in May 2004, in 

Ulaanbaatar, Mongolia for the policy makers and decisions 

makers, managers at the MoH, professional societies with 

the objective of introducing the WHO project on essential 

emergency surgical care at resource-limited health care 

facilities and the utility of the training tools in basic surgical 

care. 

This meeting resulted in the identification of facilitators, 

partners and the development of a ‘Multidisciplinary 

Working Group’ (MWG). The MGW comprised surgeons, 

obstetricians, anaesthetists, doctors, nurses, public health 

specialists and members of professional bodies, the quality 

assurance department from MoH, and WHO/Mongolia. 

The MWG deliberations resulted in: 

➜ A project proposal to improve essential emergency 

surgical procedures, which was approved by the MoH, 

WHO country office, regional and head office. 

➜ Selection of six aimags in Mongolia, to use as a model for 

capacity-building and strengthening basic skills training 

of health providers in the aimag, intersoum and soum 

hospitals, including bagh feldshers (see figure 1). 

➜ Visit to the selected six aimags for needs assessment of 

the health facilities. 

➜ Identification of facilitators, participants and the handson 

skills training in hospitals for the trainers workshop. 

➜ Programme agenda for training of trainers. 

Objectives 

The overall objective was capacity-building and 

strengthening of basic skills training in integrated 

management of essential emergency and surgical procedures 

at resource-limited health care facilities in Mongolia. 

Specific objectives included: 

➜ Training in the use of the ‘Integrated Management 

Package on Emergency and Essential Surgical Care’ 

including e-learning tools, training videos, WHO 

training manual Surgical Care at the District Hospital for 

education and existing training programmes. 

➜ Plan the training programme to improve the knowledge 

and professional skills of health personnel in the six 

selected aimags, at aimag, soum, intersoum and bagh 

health facilities. 

Target audience – Master Trainers 

There were 42 participants including policy makers from the 

Ministry of Health (Quality assurance, Directorate of 

Medical Services, nursing) and health providers (directors, 

managers, doctors, nursing in-charge) representing intersoum 

and soum hospitals from each of the six selected provinces: 

ByanKhonkar, Bayan - Ulgii, Bulgan, Gundgobi, Kentii and 

Tuv aimags and Bor-Udar intersoum hospital of Khentii aimag. 

Participants represented teaching hospitals, medical and 

nursing schools in Ulaanbaatar, the Health Science Medical 

University, Nursing school, the Center of Emergency Care, 

Trauma and Orthopedic Clinical Hospital, Maternal and 

Child Research Center, anesthesia, nurses and surgery 

associations of Mongolia, including doctors and chief of 

nursing from Ministry of Health and Directorate Medical 

Services of Mongolia. 

Facilitators were specialists representing surgery, 

obstetrics, trauma, anaesthesia, orthopaedics, paediatric 

surgery, emergency services, disaster planning and surgical 

nursing. 

These participants were trained to become trainers in 

building capacity in integrated management basic skills at 

aimag, intersoum and soum hospitals and implement the 

WHO comprehensive training manual the Surgical Care at 

the District Hospital in the education programme in medical 

and nursing schools. 

Presentations on the situation analysis of six aimags 

health facilities 

A team from the ‘Multidisciplinary Working Group’ visited 

the six selected aimags, a month prior to the trainers 

workshop. An assessment was done by the team with the 

directors of the hospitals, using the WHO needs assessment 

tools for monitoring and evaluation of emergency care at the 

health care facilities. Directors from the selected health 

facilities in each of the six aimags reached the following 

conclusions: 

➜ Do not have a special room for emergency care in the 

all selected hospitals. 

➜ Lack of equipment and instruments for emergency care 

in the admission department. 

➜ Emergency care providers are not involved in a 

continuous training programme. 

➜ Lack of specialised health personnel in the selected 

aimag and soum hospitals, which necessitates the 

emergency and surgical procedures being performed by 

non-specialised health personnel. 

E-learning tools were pilottested 

for training and discussions 

with practical skills teaching 

done through video conference, 

facilitators including colleagues 

from WHO/RHR, WHO/EIP and 

partner organisations Hospital 

University Geneva and the Geneva 

Foundation of Medical Education 

and Research. 

“ 

” 



Training workshop methodology 

The workshop provided participants with the experience 

and tools for the implementation of effective education and 

training activities. The interactive learning methods were 

used to train participants with a focus that that they will be 

able to adapt and apply a standardised format to their 

teaching programmes. Through hands-on training, group 

exercises, role play, the participants were able to simulate 

their future training activities. 

This basic skills training of trainers workshop had several 

components with lectures, e-learning, working group 

discussions, role-play, and ‘hands-on basic skills training’. 

The teaching focussed on improving the quality of 

emergency and essential surgical care at resource-limited 

clinical settings. The trainers were trained to teach WHO 

integrated management basic skills in surgery, obstetrics, 

trauma, anaesthesia in their training and education 

programmes, in particular non-specialist doctors, nurses, 

technicians and paramedical staff. 

Lectures and discussions 

The topics covered in lectures and discussions included the 

following: team responsibility and organisation of health 

care facilities; patient safety; disaster planning; appropriate 

use of oxygen; management of bleeding; burns and trauma; 

basic anaesthetic and resuscitation techniques; prevention 

of nosocomial HIV transmission; sterilisation of equipment; 

waste disposal; hygiene; record keeping; monitoring and 

evaluation on quality of care, and well as checklists prior to 

surgery to assure that the correct patient gets the correct 

surgery on the correct side at the correct time. 

Participants discussed the applicability of the WHO 

integrated management package in emergency and 

essential surgical care to become a part of the teaching 

curriculum for medical and nursing students, nonspecialist 

doctors, nurses, technicians and paramedic staff, 

trauma, obstetrics, surgery, anaesthesia and emergency 

services. 

E-learning and video conferencing 

The video conference and e-learning sessions, supported by 

the World Bank included lectures, presentations, 

discussions and training using mannequins and video link. 

The topics included resuscitation, trauma and bleeding. 

Participants used the WHO integrated basic skills training 

tools (e-learning and training manual Surgical Care at District 

Hospital) and discussed the relevance of its contents on 

guiding day-to-day clinical practice and in training of health 

personnel at all levels of care. 

E-learning tools were pilot-tested for training and 

discussions with practical skills teaching done through video 

conference, facilitators including colleagues from 

WHO/RHR, WHO/EIP, and partner organisations Hospital 

University Geneva and the Geneva Foundation of Medical 

Education and Research. 

Participants were trained in using the training tools in the 

teaching of basic skills to health providers and in the 

implementation of best practice protocols for behaviour 

change at resource limited clinical settings. 

Practical skills teaching on patient safety best practices, 

basic life support, intravenous access and maintenance, 

airway management for resuscitation and safe use of 

equipment (oxygen, airways), management of postpartum 

bleeding, discussions on interesting case studies, access to 

guidelines, journals and useful links for training were done 

through video conference. The WHO Integrated 

Management Package of Essential Emergency Surgical Care 

(an e-Learning pilot version, based on the WHO manual 

Surgical Care at District Hospital) was demonstrated. The 

participants were trained in the use of these tools for the 

implementation of good practice. There was agreement on 

the relevance of its contents on guiding day-to-day practice 

and it was felt that these would be a useful resource for reenforcement 

and further enhancement of the training of 

health care providers. 

‘Hands on’ training in hospital 

Part of the training sessions were conducted at the hospital, 

for ‘hands on training’ on essential emergency procedures 

and equipment to manage trauma, prevention of HIV 

transmission, disaster planning, basic life support, 

anaesthetic equipment, hand hygiene, transportation of the 

critically ill, splint and plaster application and first aid. The 

facilitators from the University Hospital included the 

Mongolian Association of Surgeons linked to International 

College of Surgeons (Swiss team). The trainers were trained 

in the standard WHO best practice protocols with ‘handson 

basic skills training’ in hand washing, basic life support, 

safety of anaesthesia techniques, trauma, hygiene, universal 

precautions and prevention of HIV transmission using blood 

conservation, anaesthetic and surgical techniques, treatment 

of anaemia, since at soum and intersoums and some aimag 

hospitals there is no access to safe blood. 

Working group discussions and action plan 

The participants, divided into six working groups 

representing the six aimags, with one facilitator from the 

Health Science University Hospital, in Ulaanbaatar, 

developed an action plan for capacity-building of health 

facilities linked to their aimags. The following was developed 

by the working groups to improve the existing emergency 

and surgical care in the six identified aimags: 

➜ Conduct training on emergency and surgical care for 

service providers (doctors, nurses and midwives). 

➜ Provide basic emergency essential equipment, 

instruments and drugs. 

➜ Implement the WHO best practice intervention 

protocols and standards on emergency and essential 

surgical care. 

➜ The WHO training manual Surgical Care at the District 

Hospital to be translated into Mongolian, printed and 

distributed for the emergency and surgical care 

providers at aimag, soum and intersoum hospitals. 

➜ The trainers will organise local training sessions in 

each of the six selected aimag using the WHO training 

tools. 



Multidisciplinary approach for training at aimag, 

soum, intersoum hospitals 

The working group decided on the relevant topics at various 

levels of care for resuscitation, surgery, trauma, obstetrics 

and anaesthesia to be covered for training of all health 

personnel at aimag, soum, intersoum and bagh health care 

facilities: 

➜ Team management in trauma and disasters. 

➜ Assessment, emergency care and transportation of a 

critically ill, injured patient. 

➜ Basic life support, cardio-pulmonary resuscitation, 

management of shock and care of an unconscious 

patient. 

➜ Oxygen therapy and maintenance of equipment. 

➜ Venous cut down, how to find a vein, intravenous fluid 

therapy, fluid balance. 

➜ Blood conservation techniques, blood type and cross 

match. 

➜ Using and monitoring of the essential emergency 

equipment. 

➜ Psychotherapy. 

➜ Regional anaesthesia, prevention of complications 

during of anaesthesia, preoperative checklist. 

➜ Early diagnosis of anaemia, respiratory diseases prior to 

surgery. 

➜ Prevention and treatment of postoperative 

complications. 

➜ Early diagnoses and primary care of acute surgical 

diseases, abscess. 

➜ Diagnosis and emergency care of bleeding. 

➜ Sterilisation of instruments. 

➜ Hand washing techniques, wearing of gloves, 

disinfection, cleaning of the surgical site. 

➜ Splint and cast application, skeletal traction, 

immobilisation of fractures, dislocation. 

➜ Management of open fractures, injury of soft tissue and 

open fracture. 

➜ Hip disorders, dysplasia and congenital dislocation of 

the hip, and talpes equinovaris. 

➜ Burns, freezing and snake bites. 

➜ Guidelines of surgical procedures in the soum and 

intersoum. 

➜ Early diagnosis of complications in pregnancy. 

➜ Management of preeclamsia, normal labour, third stage 

of labour, vaginal bleeding. 

➜ Perinetomy, repair tears of cervix and vagina after delivery. 

➜ Record keeping. 

Support from the following organisations will be sought: 

Ministry of Health, WHO, Asian Development Bank, 

UNFPA, Directorate of Medical Services, Maternal and Child 

Research Center, Health Science Medical University, First 

General Hospital, Trauma-Orthopedical Clinic Hospital, 

Emergency Medical Centre Professional Associations 

(surgery, orthopaedic, paediatric, anaesthesiology obstetrics 

and gynaecology, nursing, trauma, Disaster Management). 

The following training materials will be used: 

➜ Integrated Management Package on Emergency and 

Essential Surgical Care (WHO E-learning tools). 

➜ Surgical care at the district hospital WHO 2003 

Mongolian edition. 

➜ Handbook of Best Practice Protocols, WHO and Ministry 

of Health 2004, Mongolian edition. 

➜ Management of Complication in Pregnancy and Delivery 

(WHO, 2001). 

➜ Clinical Guideline on Reproductive Health Care (UNFPA, 

2000). 

➜ Newborn management (WHO, 2004). 

➜ Essential Trauma Care Guidelines WHO 2004. 

➜ Training modules. 

➜ Surgical equipments. 

➜ Equipment and instruments for intensive care. 

➜ Training video. 

➜ TV, flipchart, markers, LCD (Powerpoint presentation) 

Recommendations 

The following recommendations were made on the 

concluding day of the workshop: 

Participants 

Participants agreed to undertake the following actions after 

the workshop: 

1. Share the workshop report with the recommendations to 

sensitise: 

➜ professional associations and the scientific 

society; 

➜ education and training institutions/libraries; 

➜ NGOs and other relevant organisations; 

➜ potential funding agencies. 

2. Act as focal points and facilitators in organising training 

workshops to promote emergency and essential surgical 

care for health personnel for aimag, intersoum and soum 

health facilities. 

3. Facilitate the dissemination of recommendations and 

WHO learning materials, on essential surgical care, in 

conjunction with appropriate institutions and 

organisations. 

4. Assist in the establishment of a system for the 

monitoring and evaluation of emergency and essential 

surgical care. 

National health authorities 

Participants recommended that Ministries of Health/national 

health authorities should: 

1. Support the development of national policies and 

guidelines on essential emergency and surgical care. 

2. Promote the integration of essential emergency and 

surgical care services into undergraduate and 

postgraduate programmes in medical, nursing and 

paramedical schools. 

3. Establish and promote education and training in 

emergency procedures and equipment for surgery, 

obstetrics and anaesthesia. 

WHO 

Participants recommended that the World Health 



Organization should: 

1. Support Ministry of Health, Mongolia in the 

implementation of national policies, guidelines and plans 

to link the essential emergency and surgical care projects 

with disaster planning, HIV, trauma, maternal and child 

health projects. 

2. Make WHO training manual Surgical Care at the District 

Hospital and other training materials adapted to needs of 

Mongolia to facilitate their wider use. 

3. Support the Ministry of Health in national initiatives to 

promote emergency and essential surgical care. 

4. Support professional associations involvement in 

promoting essential surgical skills. 

5. Plan and implement follow-up activities. 

6. Support research on outcome and public health impact 

of emergency and essential surgical care. 

Partnerships 

Participants found that the role of partnership is essential in 

supporting national initiatives to promote essential 

emergency and surgical care through training and education 

of health personnel in the prevention of HIV transmission 

and other infectious agents through: 

1. Implementation of best practice guidelines and 

education. 

2. Training in the use of universal precautions. 

3. Reduce unnecessary blood transfusions particularly in 

essential emergency and surgical procedures – in 

particular trauma and pregnancy related complications 

through the following: 

➜ reducing blood loss using surgical and 

anaesthetic techniques; 

➜ assessment and treatment of anaemia; 

➜ use of intravenous fluids. 

Evaluation and follow up 

At the end of the training workshop an evaluation was done, 

using the WHO training workshop evaluation tool 

(translated in Mongolian). The participants scored their 

opinions and gave comments on the training contents, 

presentations, training tools (training manual Surgical Care at 

the District Hospital, e-learning tools, best practice protocols), 

duration and their confidence to teach basic skills following 

this training workshop. The average mean score was 4.83 on 

a scale of 1 to 5. 

A decision was made that monitoring and evaluation to 

assess the impact of the trainers workshop at each of the six 

aimag will be organised by the ‘Multidisciplinary Working 

Group’, six months following this training workshop, using 

the WHO needs assessment tools. 

Conclusions 

In the closing session, the Ms Gandhi, the Minister of 

Health, was pleased that the e-learning was introduced in 

this training workshop and emphasised the need for training 

in basic skills to manage trauma and pregnancy-related 

complications, as the incidence of road traffic injury, post 

operative complications, burns in children, falls from 

horseback and frostbites was rising in Mongolia. 

Considering the difficulties in resources, geographical 

situation, long distances for referrals in between soum, 

intersoums and aimag hospitals, the participants reiterated 

that this project has enormous potential to fulfil the need of 

training health providers in the management of emergency 

procedures in trauma, pregnancy-related complications and 

anaesthesia. ❑ 


E-HEALTH SUPPLEMENT 

e-Health supplement 

Produced in association with the International e-Health Association 

E-HEALTH NEWS 

US health department awards $139 million in 

grants to speed adoption of health IT 

ON THE 13 OCTOBER 2005, the United States Department of Health and 

Human Services announced $139 million in grants and contracts to promote the 

adoption of health information technology. Awards include more than 100 grants 

totaling $96 million over three years to communities, hospitals, health care 

systems and providers in 38 states to support health information technology use 

and development, particularly in small and rural hospitals and communities. 

The initiative also includes five-year contracts totaling $25 million to help five 

states – Colorado, Indiana, Rhode Island, Tennessee and Utah – develop secure, 

private statewide IT networks that make individuals’ health information more 

readily available to health providers; and an $18.5 million contract with a 

research affiliate of the University of Chicago for the creation of a National Health 

Information Technology Resource Center. 

For further information see: 

www.hhs.gov/news/press/2004pres/20041013.html and to find more on 

grant recipients is available at www.ahrq.gov/research/hitfact.htm. 

WHO Pacific Open Learning Health Network 

enters new phase 

THE WORLD HEALTH ORGANIZATION (WHO) convened the Country Task 

Forces this week in Nadi to discuss the way forward for the WHO Pacific Open 

Learning Health Network (POLHN). 

POLHN was established to (1) provide access to continuing education for 

health care workers, (2) assist health care workers in upgrading their qualifications, 

(3) provide access to health information for health care workers and (4) 

provide a facility for inter-country consultations and learning with the Pacific. 

The following organisations have contributed to the development of the 

Network and/or to courses in this unique regional effort: 

➜ Australian International Health Institute; 

➜ Fiji School of Medicine and Itemedia (Suva, Fiji and Sydney, 

Australia); 

➜ James Cook University (Townsville, Australia); 

➜ Pacific Resources for Education and Learning (Honolulu, Hawaii); 

➜ Philippine Centre for Communication Programmes (Manila, Philippines); 

➜ University of New South Wales (Sydney, Australia); 

➜ James Cook University (Townsville, Australia); 

➜ Philippine Centre for Communication Programmes (Manila, Philippines); 

➜ University of Southern Queensland (Toowoomba, Australia); 

➜ University of Otago (Dunedin, New Zealand); 

➜ Fiji School of Medicine (Suva, Fiji); 

➜ Pacific Resources for Education and Learning (Honolulu, Hawaii); 

➜ Pacific Paramedical Training Centre (Wellington, New Zealand). 

Open Learning Centres have now 

been established on ten islands: 

Fiji, Samoa, Tonga, the Marshalls, 

Federated States of Micronesia, the 

Solomons, Pilau, Kiribati, Vanuatu and 

the Cook Islands. In each country 

there is a Country Task Force 

overseeing the operations of the Open 

Learning Centre. 

The network has just completed its 

pilot stage and is now entering a new 

stage in development. The workshop 

convened in Nadi saw specific 

recommendations made to take 

forward to the Pacific Island Ministers 

of Health Meeting in Apia this March. 

POLHN promises a new and exciting 

mechanism for the Pacific to work 

together as a region harnessing the 

opportunities put forward by 

Information and communications 

Technologies to improve the Health 

Services of the Pacific. This network is 

unique in its approach, and in its 

engagement with the countries in a way 

that recognises the independent needs 

of each country while maximizing the 

potential economies of scale and 

benefits of working together as a region 

using innovative learning techniques for 

health and capacity enhancement to 

improve health services locally and 

regionally. The learning centres will each 

work within their respective Ministries 

of Health in a way that works best for 

the human resource development needs 

for each island state. 

For further information see: 

www.who.int 

The e-Health Supplement is complied 

by Dr Harry McConnell a board 

member of the International e-Health 

Association. He can be contacted 

through Sheila Anazonwu at the 


on info@ihf-fih.org. 

12 | WORLD hospitals and health services 


E-HEALTH SUPPLEMENT: CANADIAN PERSPECTIVE 

The promise of e-health – 

a Canadian perspective 

RICHARD C ALVAREZ 

PRESIDENT AND CEO, CANADA HEALTH INFOWAY 

Abstract 

Canadians value their health care system above any other social programme. Canada’s system of health care faces 

significant financial and population pressures, relating to cost, access, quality, accountability, and the integration of 

information and communication technologies (ICTs). The health-system also faces certain unique challenges that 

include care delivery within a highly decentralised system of financing and accountability, and care delivery to a 

significant portion of the population sparsely distributed across a land mass of 10 million square kilometres, in 

areas of extreme climatic conditions. All of these challenges are significant catalysts in the development of 

technologies that aim to significantly mitigate or eliminate these selfsame challenges. 

The system is undergoing widespread review, nationally, and within each province and territory, where the bulk 

of care provision is financed and managed. The challenges are being addressed by national, regional and provincial 

initiatives in the public, private and not-for-profit sectors. 

The promise of e-health lies in the manner and degree to which it can mitigate or resolve these challenges to the 

health system and build on advancements in ICTs supporting the development of a health infostructure. Canada is 

actively developing and implementing technological solutions to deliver health information and health care services 

across the country. These solutions, while exciting and promising, also present new challenges, particularly in 

regard to acceptable standards, choice of technologies, overcoming traditional jurisdictional boundaries, up-front 

investment, and privacy and confidentially. 

Many organisations and governments are working to address these challenges. Canada Health Infoway, a notfor-profit 

corporation, was founded by the first ministers in 2001 to accelerate the establishment of an 

interoperable, pan-Canadian electronic health record. It works with partners in the federal, provincial and 

territorial jurisdictions to define replicable solutions for establishment of the major elements necessary to achieve 

this goal. The Canadian Institute for Health Information (CIHI) will also continue to play an increasingly significant 

role in these initiatives, as the management of health information becomes a more crucial factor in the successful 

delivery of health care services in the new millennium. 

Canada has a publicly financed system of health care, 

known as ‘Medicare’. The system provides access for 

all Canadians to comprehensive coverage for medically 

necessary services. The system is comprised of ten provincial 

and three territorial government health insurance plans. The 

provinces and territories plan, finance and manage the 

provision of hospital care, physician and allied health care 

services, some drug costs and public health. The system is 

‘national’ in that the federal government assists the financing 

of provincial and territorial plans, and that the plans share an 

adherence to national health care principles set at the federal 

level. An element of the health system is individual private 

expenditure, largely on prescription drugs, which currently 

accounts for approximately 27% of health care expenditure 

across the country. 

Challenges 

Our system of health care faces a number of pressures and 

challenges to both its national principles and plan financing. 

Since its inception, Medicare, has been faced with questions 

concerning its core principles of public administration, 

comprehensiveness (provision of medically necessary 

services), universality (availability to all citizens), accessibility 

and portability (entitlement to coverage across 

provincial/territorial lines). The old historic arguments have 

been renewed in the face of serious fiscal constraints. 

Geography has a significant place in the current critique and 

future development of the health system. Canada is a country 

of only 30 million people spread unevenly across 10 million 

square kilometres of the earth’s surface (3/km 2 ). While the 

majority is concentrated in a few urban areas, a significant 

proportion is scattered across the landscape in hundreds of 

geographically isolated communities, many in areas of 

extreme climatic conditions. Canada’s newest territory, 

Nunuvut, for example, has 27,000 people spread across 2.1 

million km2(.001/km 2 ); large communities on several remote 

Arctic islands locked in frozen sea ice and snow most of the 

year; temperatures varying seasonally between –50° to 30° C, 



and no intercity roads. These factors pose serious challenges 

to the provision of equitable, accessible and high quality care. 

The political structure of funding health services is a 

complicating factor and a matter currently of intense scrutiny 

and considerable controversy. The division of both political, 

managerial and fiscal accountability across provincial and 

federal lines has created tensions, particularly around the 

question of the current level, and most appropriate future 

level of funding. 

The demographic and human resource picture illustrates 

other challenges to health care. Seniors constitute one of the 

fastest growing groups in Canadian society. By 2041, about 

23% of the population will be over 65, up from 12% in 1995. 

This growing portion of the population will inevitably require, 

it is assumed, the devotion of a larger proportion of expensive 

health resources (Statistics Canada, January 2002). Within 

the various health professions there are challenges related to 

numbers of providers, and their distribution. It is a common 

and significant problem that many areas of the country remain 

un- or under-serviced even though there is a high proportion 

of professionals to general population. Canada is a country of 

cultural diversity, which has created some unique health 

challenges. From the last full national census, of 30 million 

people, 18 million speak English, 7 million French and 5 

million have a mother-tongue other than English or French 

(official languages). Not being able to speak either official 

language is an enormous obstacle for newcomers when 

seeking out or obtaining health care. The various rights of 

English or French speaking minorities to care in their own 

language directly impacts on government planning, fiscal 

considerations and distribution of services (which may 

overlap in kind, but differ in language). 

Total health care spending was $114 billion in 2002 and 

reached an estimated $123 billion in 2003 (current dollars), 

representing annual increases of 7.3% and 7.9%, respectively 

(CIHI, December 2004). The amount of federal funding and 

the proportion of federal vs provincial/territorial spending is at 

issue. Arguments abound about it being less or more than it 

was or should be, and whether it must increase or decrease. 

Is the growth sustainable? Are the private/public and 

federal/provincial funding proportions appropriate? There are 

many questions being considered. Alternative funding and 

management models are being actively explored and 

implemented at all levels of government. 

The history of Canada’s Medicare system, our geography, 

political structure, demography and finances are exerting 

pressures for change on the delivery of health care. Federal, 

provincial and territorial governments are struggling to renew 

or reinvent the health care system to make it ‘affordable’ while 

also living up to the commitments to and expectations for a 

public, accessible, comprehensive, universal and high quality 

health care system. In this context, advances in ICT, and the 

subsequent interest in e-health holds much promise in 

mitigating if not eliminating, a number of the challenges faced 

by our current and much valued health care system. 

Discussion 

Supporters of e-health initiatives generally recognise that 

advances in ICT, the wide-scale review of the health system, 

and the increasing interest in exploring new approaches to 

health care delivery, financing and management can benefit 

the continued development of e-health initiatives. It can be 

argued, as this author does, that e-health initiatives in Canada 

can play a significant role in mitigating the impact of some of 

the challenges to the system described above, if not eliminate 

many of them from the debate altogether. Health data is 

already essential to health services resource planning in 

Canada. It can also play a substantial role in reducing 

duplication of services, realising operational efficiencies, and 

improving the overall quality of health care. 

Promise of e-health 

But what exactly is e-health, and what is exactly is its promise? 

The term e-health has been used to describe a variety of 

activities including almost any electronic exchange of healthrelated 

data, voice or video. The definition that most nearly 

describes what is understood within the context of this article 

is the following: 

‘e-Health is a consumer-centred model of health care where 

stakeholders collaborate, utilising ICTs, including Internet 

technologies, to manage health, arrange, deliver and account 

for care, and manage the health care system’ (Ontario 

Hospital e-Health Council) 

While definitions of what correctly falls within the scope of 

e-health may vary, what is consistent is the excitement around 

perceived benefits and the rush to move forward with 

collaborative opportunities using advanced technologies in 

health information. 

e-Health has almost no ‘history’, nor baggage, as it enters 

the health care discussion. It offers a means to draw together, 

in collaborative partnerships, governments, organisations and 

professionals in ways that have not before been possible. 

Numerous stakeholders, including consumers, clinicians, 

administrators and politicians, are already actively involved in 

e-health initiatives. 

ICTs are able to reduce the effects of geographic isolation, 

harsh climate and low population densities by providing a 

mechanism for remote data access, health-information sharing 

and medical support; as well as clinical examination, 

diagnosis and treatment: bringing the health system and 

health care provider to the patient. 

ICTs in e-health initiatives increase our ability to meet 

challenges in the provision of primary and tertiary care. 

Subsequently, they may reduce or prevent adverse patient 

outcomes, reduce costs to the system of repeat diagnostic 

testing, redundant record-keeping, and high travel costs 

associated with seeking and receiving care in centres located 

far from the patient. 

Various new ICTs transcend traditional health system 

divides, offering a means to develop more complicated and 

advanced data sharing, cooperation and cost-sharing between 

jurisdictions, professionals and facilities. Political concerns 

about health system financing, viability and sustainability are 

moderated by the potential for cost- and risk-sharing provided 

by ICTs and e-health initiatives. 

The question of the provision of quality health services to a 

multi-lingual and multi-ethnic population are also met in part 

by e-health. The financial stress being felt by a burgeoning 



high-needs aging population will be somewhat alleviated as 

cost savings are found through e-health. The ageing 

population will be better served by a reduction in repeated 

testing and drug interactions of inappropriate prescriptions 

that can be facilitated by an easily accessible electronic health 

record. They will benefit from a reduced requirement for longdistance 

travel for care, and may even be able to remain in 

their own homes longer, without the oft required move to 

centralised facilities for higher-needs late-life care. 

e-Health initiatives provide a means to overcome linguistic 

and cultural challenges to the health system. In some 

jurisdictions, governments are legally required to provide care 

in French and English, in others they provide some level of 

service in dozens of languages, and in others the immigrant 

populations suffer for the lack of language-appropriate 

services. Repeated clinical interviews and tests, multiple 

referrals and other repetitive, and perhaps unnecessary, 

contacts with the health system and professionals is a barrier 

to care for many whose French and/or English are limited. 

All manner of health care providers can benefit from e- 

health initiatives and the use of ICTs in clinical settings. e- 

Health can allow for access to patient records by pharmacists, 

sharing of information between clinicians and even between 

same-site facilities. Desktop and live online access to patient 

records, information that supports clinical decision-making, 

and health system information, such as online booking of 

specialists, along with a host of other possible uses of the new 

technologies will improve the clinical bench strength of 

providers, patients and the consumer. e-health technologies 

also allow for the development of continuing professional 

education for providers in isolated locales. 

e-Health reduces the stress on an often overburdened 

system. Seasonal swings in transmittable diseases, such as the 

flu, have led to crippling overuse of the emergency services in 

hospitals. e-Health mitigates this by providing a means for 

some out-of-hospital care, and by providing information on 

what is a condition requiring immediate emergency treatment 

via teletriage centres. 

Fiscal challenges are mitigated by ICTs and e-health 

developments that, as described above, reduce travel 

requirements and waiting times, increase cost- and risksharing, 

reduce replication and redundancy, improve positive 

outcomes, reduce overall system-management and patient 

costs, and improve the quality of information available outside 

of acute-care facilities. 

By increasing our capacity to meet unique geographic, 

population and political challenges, ICTs and e-health 

moderate the political debate and public concerns about the 

sustainability of the current health system. 

e-Health challenges 

Canada faces a number of challenges in the development of 

effective e-health solutions. Of primary concern is the inertia 

of traditional agendas and ways of doing things. Divisions 

between health professions, the public-private sectors, 

facilities, levels of government and cultural communities 

generally mitigate against large national inter-jurisdictional 

projects in the public sector and new large-scale investments 

in the health sector. 

The technologies themselves, as well as their deployment, 

are challenging matters. There are questions about how to 

automate the health-system properly, and the desktops of 

clinicians. Which technical standards are to be adopted? Is the 

current level of technology and technological sophistication of 

the providers and public sufficient to the task? What 

proprietary products will the public sector invest tax dollars 

in? How do we integrate the current system’s data ‘silos’? 

Some of the technologies remain unproven in extremes of 

climate and in far north locations of the earth’s surface. There 

are limitations imposed by the fragility and newness of certain 

technologies and products in situations where ongoing 

technical maintenance and operational services are next to 

non-existent. 

Other challenges include the development of a national 

‘infostructure’ to support inter-jurisdictional data sharing; the 

establishment of data and technical standards and health 

informatics systems; and, financial investments in technology 

and deployment. There are challenges with the education of 

sufficient numbers of informatics specialists to implement, 

operate, manage and continue the development and 

improvement of the technologies and the system. 

Though Canada has claimed one of the highest Internet 

user rates in the world, this level of sophistication is not 

played out to the same degree across the country. 

Socioeconomic, cultural and geographic influences limit 

connectivity, performance and possibilities. Public and 

professional acceptance of the new technologies in the place 

of old ways – such as, keying up a live online Internet 

consultation instead of sitting in a waiting room – is essential. 

An increasing concern with personal privacy and 

information confidentiality and the recent proclamation of 

Privacy and Confidentiality legislation across the provinces 

and territories is a considerable challenge to the development 

of inter-jurisdictional data sharing arrangements and to storage 

and manipulation of data holdings (especially patient 

records). 

Clearly, large financial and human resources must be 

invested in e-health to realise the full potential of the 

technology. Actual expenditure on known Canadian e-health 

projects was a relatively low $31.7 million, in 1999-2000 

(Picot & Cradduck, 2000). Evidence suggests that e-health is 

at least ten years behind other information management 

intense sectors, such as banking. 

Meeting the challenges 

The Canadian health sector has positioned itself to address 

challenges to both the health system in general and to the 

development and implementation of e-health solutions. A 

number of initiatives and organisations have sprung up in the 

last decade to meet the challenges of geographic isolation, 

climate extremes, shifting population demographics, political 

dynamics, cultural differences, financial considerations, 

limitations imposed by technologies, lack of standards, low 

levels of automation in clinical settings and privacy and 

confidentiality. Two organisations which are contributing 

much to the development of e-health in Canada are the 

Canadian Institute for Health Information (CIHI) and Canada 

Health Infoway. 



In 1994, a number of government and nonprofit health and 

statistics agencies were consolidated under CIHI, to improve 

the health of Canadians and the health system. Mandated by 

Canada’s federal, provincial and territorial health ministers, 

CIHI is a national, not-for-profit organisation responsible for 

developing and maintaining the country's comprehensive 

health information system. 

CIHI’s core e-health related functions include identifying 

health information needs and priorities; and collecting, 

processing and maintaining data for comprehensive and 

growing health databases covering human resources, health 

services and expenditures. CIHI also coordinates the setting 

of national standards for financial, statistical and clinical 

data, as well as standards for health informatics, such as 

HL7, and telematics. 

Since 1999, CIHI has led the Roadmap Initiative 

collaborative effort between CIHI, Statistics Canada, Health 

Canada and many other groups at the national, provincial, 

territorial, regional and local levels. The initiative’s aims 

include the development of new national data holdings, 

expanding existing ones, and fostering better data and 

technical standards for gathering information and for data 

protection. 

CIHI has helped shape the national agenda for information 

management and information technology standards in health 

care. It provides a neutral forum for standards discussion 

among Canada’s health and health IT leaders. 

Also leading the way in the e-health domain is Canada 

Health Infoway, an independent, not-for-profit corporation 

established by the federal, provincial and territorial 

governments, whose mission is to accelerate the development 

of compatible electronic health information systems across 

Canada. These systems provide health care professionals with 

rapid access to complete and accurate patient information, 

enabling better decisions about treatment and diagnosis. The 

result is a sustainable, more cost-efficient health care system 

offering improved patient safety and better quality of care. 

Infoway began operations in 2001 with an initial funding of 

$500 million. This was increased twice – an additional $600 

million in 2003 and another 100 million in 2004. Its 

members are the federal, provincial and territorial deputy 

ministers of health. Infoway’s initial programme areas 

included infostructure, registries, drug, laboratory and digital 

imaging systems. Telehealth expansion and public health 

surveillance system development were added along with 

further funding in 2003 and 2004 respectively. 

The vision of Infoway is a high-quality, sustainable and 

effective health care system supported by an interoperable 

pan-Canadian electronic health record that provides residents 

and health care providers timely, appropriate and secure 

access to the right information whenever and wherever they 

enter the health care system. The goal is to have 50% of all 

Canadians connected to the EHR by the end of 2009. 

The Infoway mission is to foster and accelerate the 

development and adoption of electronic health information 

systems with compatible standards and communication 

technologies on a pan-Canadian basis. The objectives of the 

Infoway corporation are: 

➜ to accelerate the development and adoption of modern 

systems of health information and communication 

technologies; 

➜ to define and promote standards governing shared data 

to ensure the compatibility of health information 

networks; 

➜ to support the adoption of such standards for health 

information and compatible communications 

technologies for the health sector; 

➜ to enter into collaborative arrangements as required with 

the governments of Canada, provinces and territories, 

corporations, not-for-profit organisations and other public 

and private partners for the development and adoption of 

standards and technologies; and 

➜ to incorporate standards that protect personal privacy 

and confidentiality of individual records and security of 

health information. 

Infoway now has over 90 projects underway across Canada, 

working with partners in the jurisdictions to define replicable 

solutions for establishing the building blocks of the 

interoperable pan-Canadian Electronic Health Record. 

The provincial governments are active players in the 

development of these e-health initiatives. The Newfoundland 

and Labrador Centre for Health Information, for example, was 

mandated by the province to develop a Health Information 

Network (HIN) to link provincial hospitals, long-term care 

facilities, doctors, pharmacists, and health and community 

services. The Saskatchewan Health Information Network is 

establishing electronic connections to enable access to various 

types of health and patient information between health service 

sites across the province, including physicians’ offices, health 

centres, home care providers, hospitals, emergency response 

sites and nursing homes. Alberta Wellnet was founded in 

1997 to address access to and the quality of health care, and 

the increasing costs associated with care delivery. Alberta 

Wellnet is the umbrella for a series of province-wide and 

regional initiatives to build an integrated health information 

network in that province and to facilitate improvements to the 

delivery of health services by improving access to health 

information. Infoway is working with these groups to define 

solutions such as client registries and drug information 

systems that can be replicated in other parts of Canada and 

form the basis of an ‘interoperable’ electronic health record. 

Challenges presented by the accessibility and provision of 

care in remote communities have been under considerable 

scrutiny. In recent years numerous e-health initiatives have 

been actively addressing the challenge presented by 

geography. Programmes such as Ontario’s NORTH (Northern 

Ontario Remote Telecommunications Health) Network and 

the British Columbia Peace Liard Telemental Health provide 

remote specialist consultations, continuing medical education 

and patient education to isolated locations. They utilise twoway 

television and simultaneous transmission of visual and 

audio signals from various medical peripheral devices, such as 

electronic stethoscopes and otoscopes. Infoway is also 

working with partners in the jurisdictions to find ways of 

increasing and expanding the utilisation of telehealth 

solutions to better serve remote and aboriginal communities 

across the country. 

Challenges concerning standards, technologies and product 



choices are being considered at a number of levels. CIHI and 

the Canadian Standards Association lead Canada’s 

participation in the International Organization for 

Standardization’s Technical Committee on Health Informatics 

(ISO TC215). Through this committee Canada is active in the 

development of national and international standards for data 

encryption, country identifiers, data models and other matters 

that are the technical bedrock on which e-health initiatives are 

based. Technical and product considerations are being 

addressed by numerous provincial and inter-provincial 

organisations, such as Ontario’s NORTH (Northern Ontario 

Remote Telecommunications Health) Network, and the 

Central BC and Yukon Telemedicine Project. 

The promise of intergovernmental cooperation and 

partnership is being realised across all of the provinces and 

territories. The Western Health Information Collaborative 

(WHIC) is an example of such cooperation, between four 

western provinces and the three northern territories to explore 

collaborative e-health initiatives. WHIC is actively engaged in 

the utilisation and further development of standardised 

electronic insurance claims, implementation of electronic 

health records, inter-jurisdictional provider registries, 

consumer on-line information access and clinical information 

support networks. Infoway has been working with WHIC to 

determine a replicable solution for the provider registry which 

in essence is a ‘yellow pages’ in each jurisdiction providing 

comprehensive and unambiguous identification of 

participating providers. 

Integrating and coordinating public and private sector e- 

health initiatives is taking place along a number of lines. The 

National Electronic Claims Standard project, funded jointly 

by Infoway and CIHI, is working to develop a single 

electronic health claims standard leading to consistency in 

data capture, increased efficiency, accuracy and education 

throughout the health sector; and, providing the foundation 

for information exchange. The project is a collaborative effort 

of federal and provincial ministries, public associations and 

private companies. 

Governments and large national agencies are not the only 

driving forces in e-health. Private companies, hospitals and 

health care provider associations are actively and creatively 

involved in e-health initiatives. Numerous private companies 

have developed and are promoting the development of 

electronic health records, systems for health care transaction 

and business-to-business e-commerce, and clinical 

automation systems in networks of clinics, private doctor’s 

offices and local hospitals and specialists. Large hospital 

facilities and multi-site hospital corporations are developing 

mechanisms to share data, records and other information 

within and between sites and departments. The Hospital for 

Sick Children in Toronto, Ontario is active in the provision of 

national and international remote health consultation and 

care. Their International Telehealth Program currently 

provides second opinion patient referrals through Telehealth 

technology with facilities in Argentina and Israel. Numerous 

hospitals and paediatricians in Ontario collaborate in the 

Child Health Network – Health Information Network 

(HiNet.) In HiNet clinical records from consenting patients 

(or parents) are stored and access provided to health care 

professionals. The system is currently being extended across 

Ontario and to interested paediatricians in other jurisdictions. 

e-Health can help resolve questions of equitable access to 

services in French and English by directly addressing the 

question of multi-lingual service provision. Both the 

Telehealth Ontario telephone-nursing project and the British 

Columbia Healthguide Nurseline offer phone consultation 

with nurses that utilise over-the-phone translation services 

with a pool of 100 available languages. The development of 

integrated readily accessible electronic health records reduces 

redundant contacts with the system and providers, providing 

relief for non-English/French speakers from the stress of 

repeated unnecessary contacts with the system. 

Various legislation being enacted at all levels of government 

across the country, are aimed in part at improving confidence 

in the privacy and confidentiality of personal health 

information. In consultation with various health sector 

agencies, this legislation is being drafted, or applied through 

regulation, in a manner that also accommodates the 

appropriate use of health information for healthcare delivery 

and health system management. 

Patients have responded positively to many of the new 

technologies and their application. While many telehealth 

technologies and projects are relatively new, evaluations of 

early results suggest significant promise. Recent systematic 

reviews of studies of patient satisfaction with telemedicine 

indicated that under ideal circumstances patients and care 

providers accept and are generally satisfied with the care they 

receive and can give using e-health. 

Summary 

Canada is faced with challenges to the continued success of 

its healthcare system. Some of these challenges are uniquely 

Canadian, while others are common to many other countries. 

These challenges include geographic considerations, cost, 

demographics, service access, quality, accountability, and the 

integration of ICTs. 

ICTs appear to hold the key to meeting some of the 

challenges that face Canada’s health care system. The promise 

of e-health is yet to be realised but appears to be an inevitable 

part of Canada’s future reality. The issues that are linked to e- 

health are being addressed, in part, by numerous national, 

provincial and territorial initiatives, and in partnerships 

between the levels of government and across the public and 

private sectors. 

Canada is making significant strides in the development, 

implementation and ongoing management of ICTs within 

the context of an integrated inter-jurisdictional e-health 

component to the provision and management of health care. ❑ 

References 

1. Statistics Canada: The Daily. Friday, October 1, 1999. 

http://www.statcan.ca/Daily/English/991001/d991001a.htm 

2. Personal Communication. Canadian Institute for Health Information (CIHI), 

December, 2001. 

3. Ontario Hospital Assocition. Ontario Hospital e-Health Council draft blueprint. 

December, 2001. Available from www.oha.com. 


E-HEALTH SUPPLEMENT: WORLD HEALTH CHANNEL 

The World Health Channel: 

an innovation for health and 

development 

DR HARRY MCCONNELL 

DIRECTOR, INSTITUTE FOR SUSTAINABLE HEALTH EDUCATION AND DEVELOPMENT 

DR TENAGNE HAILE-MARIAM 

ASSISTANT PROFESSOR, ASSOCIATE DIRECTOR OF INTERNATIONAL PROGRAMS, GEORGE WASHINGTON UNIVERSITY 

MEDICAL CENTER AND THE RONALD REAGAN INSTITUTE OF EMERGENCY MEDICINE 

DR S RANGARAJAN 

SENIOR VICE PRESIDENT, NEW APPLICATIONS AND SERVICES, WORLDSPACE CORPORATION 

Abstract 

The issues of the digital divide and of accessing health information in areas of greatest need has been addressed by 

many. It has been a key component of the discussion of the World Summit for the Information Society and also the 

focus of an important new initiative, the Global Review for Health Information. Only approximately 1 in 700 people in 

Africa have internet access compared to a rate worldwide of approximately 10%. Access to essential health 

information and knowledge management for health care has been deemed a priority for the development of health 

systems and for the care of patients in areas with limited resources, prompting recent efforts by international 

organisations and by both governmental and non-governmental agencies (see Godlee et al, 2004 and McConnell, 

2004). 

Health care in developing countries can be limited by many different resources: lack of health care workers with 

sufficient training, lack of diagnostic equipment, lack of treatment facilities or essential pharmaceuticals; and lack 

of education or expertise in many relevant areas. Much of the health care done in developing countries is by local lay 

persons or practitioners or by volunteers working with a variety of NGOs. These volunteers are often very dedicated 

young people with a vision of health-for-all that is often frustrated in the limited time they are able to spend in these 

areas and further constrained by meager resources (including availability of appropriate information). The 

availability of medical expertise and consultation depends largely on the geographical location of the health 

practitioner and of the patient as well as the level of integration with local practitioners and extent of outside agency 

involvement. Furthermore, there are often many NGOs working simultaneously on similar projects in the same 

region without knowledge of each other’s activities. Often this occurs simply because a lack of communication exists 

between organisations, resulting in unnecessary duplication of effort. 

The availability of medical expertise and consultation depends largely on the geographical location of the health 

practitioner and of the patient as well as the level of integration with local practitioners and extent of outside agency 

involvement. The health care worker in developing countries is frequently faced with a paucity of information 

appropriate to the clinical situations on hand as well as a lack of locally available expertise. The lack of access to 

health care and other vital resources is one factor in the much lower (by approximately 1/3) life expectancy in the 

least developed countries compared to industrialised nations. In many developing countries there is only one doctor 

for 5-10,000 people, compared to a ratio of 1:200 in many developed countries. Textbooks, if they exist, may be 10-20 

years out of date and are often directed more at the needs of developed countries. 

There is thus a growing need for wider availability of training and information on health care in developing 

countries and support for health care workers. There is also a need for increased communication and collaboration 

between governmental and non-governmental organisations working in international health to share education, 

resources and to coordinate efforts in areas supporting improved health care delivery. 

In recognition of this, the Institute for Sustainable Health Education and Development (www.ished.org) is 

launching the World Health Channel (WHC) in the spring of 2005 in collaboration with WorldSpace. This will allow 

access to critical health information in developing countries and place the emphasis on issues important for clinical 

care for front line health workers in these areas. 



The World Health Channel (WHC) has been developed 

over the last three years with a series of trials 

emphasizing the need for specific content relevant to 

health and development and the interaction of WorldSpace 

with other telecommunications media, including both 

analogue and digital telephone lines, United Nations and 

commercial satellite links, email and the Internet. The 

content has ranged from clinical problems (including 

maternal to child transmission of HIV, malaria and individual 

case presentations) to issues dealing with public health such 

as HIV prevention, health care policy and health care 

management issues. Examples of the latter include debate 

on access to health information in developing countries as 

well as the organisation and broadcast of special interactive 

sessions using multiple networks such as International 

Congresses, the World Health Organization debate between 

Candidates for Director General and the Special Session on 

HIV, malaria and TB of the Heads of State of the African 

Union at last year’s Summit. Participants have included 

health care policy makers, including ministries of health and 

hospital managers, village health workers, physicians, NGOs 

and public health specialists in Africa and Asia. A variety of 

satellite, fixed line and wireless networks have been used to 

maximise the interactive potential of the digital radio 

broadcasts from WorldSpace. The formal and informal 

assessments of these trials (see Rangarajan and Ayenew, 

2002) have demonstrated that: 

➜ the relevance and interest in health and development 

topics is high; 

➜ the human touch of hearing and seeing adds interest to 

the material; 

➜ questions can be asked easily whenever needed; 

➜ the programme allowed interaction with some of the 

world’s leading experts in this field; 

➜ compared to a video conference, there was more focus 

on the lecture rather than video headshots and panning 

back to slide material; 

➜ the chat functionality added significantly to 

programmes; 

➜ the voice quality was excellent, once telephone 

feedback was muted at each site; 

➜ the forwarding of additional documents (‘datacasting’) 

adds to the relevance of the topics and maximises the 

potential of such interaction; and 

➜ the presenters were comfortable working in this format . 

The modalities used to maximise these networks for 

medical education have included an audio World Health 

Channel and an asynchronous learning community (ALC). 

The audio channel is the initial major focus of this project 

and which will integrate the use of data, video and other 

media used in WorldSpace datacasting and also all that 

broadcast or made available on other networks. This will 

involve many different programming formats. Selected 

sections may be rebroadcast on local analogue radio 

stations. 

The asynchronous learning community (ALC) will take 

the form of a combination of text-based information and 

interactive multimedia courses. It will access existing 

resources of websites with relevant information via hotlinks 

to those sites as well as offering health care workers online 

courses where no such education had previously existed. 

The material will be presented in relation to several different 

criteria depending on the location of the health care worker 

and their particular level of expertise and with clear reference 

to the degree of evidence-based criteria for a given topic. The 

Channel will set up three levels of health information for 

easy identification of relevant information in a form that will 

be easily understandable: 

➜ Level 1: content directed at lay persons working in 

health care in developing countries; this will be 

appropriate for patients, village workers, and parents but 

will be practical and skills-oriented (e.g. ‘Where there is 

no Doctor’ series). 

➜ Level 2: content directed at health care workers who 

have trained as health care professionals in developing 

countries. This may include any type of professional 

and the content will be directed thus at a wide audience 

but will be more specific for given conditions than Level 

1 material. 

➜ Level 3: Specialist-oriented information. This material 

is designed for specialists in international health, which 

may include physicians or public health specialists in 

both developed and developing countries. It may 

include information from sources such as recent 

international conferences in international health or peerreviewed 

journals in the area as well as courses from 

academic centres of excellence. 

In the process of development the WHC has maximised 

the potential offered by satellite digital radio including: 

➜ real time digital quality audio broadcasting; 

➜ asynchronous audio broadcasts; 

➜ ‘datacasting’ of multiple formats of media and files; 

➜ use of e-learning software designed specifically for 

digital satellite (‘CLASS’ platform); 

➜ real time and asynchronous interaction between 

participants using email, Internet Radio, telephone links 

and other networks; 

➜ use of receivers in areas with limited electricity supplies 

and little or no telecommunications infrastructure; and 

➜ use of a variety of formats including Power Point style 

lectures, panel discussions and debate. 

WorldSpace forms a key aspect of the Channel in 

making it accessible to health workers in developing 

countries without reliable access to the Internet, to 

telecommunications infrastructure or even to electricity. The 

Channel will be able to be accessed using cost effective 

WorldSpace specific digital radio receivers, costing less than 

US$100 and able to receive high quality digital audio signals 

in addition to datastreaming without the need for 

telecommunications infrastructure. Some units are able to 

run on kerosene or solar power and no fixed land line or 

mobile telephone infrastructure is necessary. 

Many types of data can be streamed including quality 

video. The use of the CLASS software system designed 

exclusive for WorldSpace allows real time interaction with a 

Power Point style presentation where the lecturer(s) may be 



Figure 1: coverage areas of the AfriStar, AsiaStar and (yet to be launched) AmeriStar satellites of 

WorldSpace. 

located anywhere and involve participation of the students 

through email or other networks in an interactive way. This 

uniquely replicates the classroom experience in a cost 

effective manner that can be used in rural and inaccessible 

regions where healthcare is delivered. 

The speaker software running in the ‘Live Presentation’ 

mode of the CLASS platform allows the presenter to navigate 

through the lecture. During the presentation, the speaker’s 

voice is delivered to the listener audience using an audio 

sub-channel, and any annotations made on the slides, along 

with the slide control information, is delivered over a data 

sub-channel to each listener PC. The control information 

sent from the Speaker PC to each listener PC tracks the 

Speaker PC’s current slide and annotation, effectively 

placing everyone (the speaker and all the listeners) on the 

same page. The CLASS solution allows a listener to locally 

cache an entire presentation and replay it later. There is also 

a provision to send any supplementary information (such as 

related documents, class handouts or web based materials) 

before, during or after the live presentation (see Rangarajan 

and Ayenew, 2002). 

Coverage 

The map (see figure 1) shows the coverage areas of the 

AfriStar, AsiaStar and (yet to be launched) AmeriStar 

satellites of WorldSpace. Additional coverage of WHC will be 

provided using analogue networks and Internet Radio to 

extend the reach of the World Health Channel. Emphasis 

of the WHC will be on coverage to rural and difficult 

to access countries, where information access is most 

limited. 

Content schedule and future development 

The following content ‘streams’ will serve as specifically 

timed programming through the day in conjunction with 

specific and related data streaming at night. This will assure 

that a given audience knows when to be aware of the 

programming that will interest them and serves also to 

clarify the funding and content organisation. Each stream 

will have a different group coordinating activities and will, 

along with partners, seek funding from commercial and 

charitable sources related to that area. 

Stream I: Policy into practice 

Topics: healthcare management, health policy, public 

health, epidemiology, preventive medicine, health equity, 

population health, environmental health. 

Stream II: The doctor in your home 

Topics: home and workplace safety, appropriate use of 

healthcare resources, harmful and helpful traditional health 

care practices where there is no doctor, P2P (patient to 

patient), carer information, community medicine, 

occupational medicine 



Stream III: The cutting edge 

Topics: appropriate technology, recent advances in 

medicine, e-health, biotechnology, Human Genome Project, 

pharmacogenomics, drug development, essential drugs. 

Stream IV: In and out of hospital 

Topics: medical and surgical specialty care, including 

neurology, cardiology, renal medicine, respiratory 

medicine, dermatology, opthalmology, ENT, general surgery, 

gastroenterology, rheumatology, pain management, 

neurophysiology. 

Stream V: Mother and child 

Topics: Reproductive health, paediatrics and child health, 

HIV AIDS, immunisations, health education for school aged 

children and adolescent medicine. 

Stream VI: Emergency 

Topics: emergency medicine, disaster management, refugee 

care, prehospital care, wilderness medicine, aviation 

medicine. 

Stream VII: Mental health 

Topics: psychiatry, community and outpatient mental health 

care, consultation – liaison, neuropsychiatry, behavioural 

neurology. 

The project will initially be geared towards members of 

governmental and non-governmental agencies working in 

the health care arena in developing countries with additional 

content phased gradually in as permitted by the network 

resources. This will also allow recognition of appropriate 

health care workers using the clinical components of the 

network. Local and international partner organisations will 

be asked to contribute content and/or an identified person 

with which to coordinate the network activities from within 

their system. It will, however, subsequently be offered to all 

health care workers in developing countries regardless of 

their affiliation to existing organisations. The courses, textbased 

education and patient support groups will be made 

fully accessible to all wishing to participate. The network 

may also be developed to include videoconferencing and 

real-time consultations as well as other multimedia 

applications of telehealth. As broad bandwidth access to the 

Internet becomes more widely available, videoconferencing 

and video streaming will be offered. Training and support 

will be built-in online, which will be made available to all 

members of the community. Recognition and inclusion of 

local content and programmes, specific needs assessments 

in developing countries as well as coordination with other 

international efforts in health information and knowledge 

management will be stressed throughout the development of 

the WHC. Continuous assessment of the impact of the 

WHC itself, and the relevance, applicability and quality of 

the content will also be emphasised, developing the WHC as 

a Community of Practice in Health and Development using 

WorldSpace and multiple networks to maximise 

accessibility. 

Even the most remote health workers now will be able to 

be supported and have their skills updated and retain a 

connection with their colleagues at a distance through access 

to the WHC. The professional support and maintenance of 

clinical standards in remote areas, a perennial problem in 

developing countries, can be served in a cost efficient and 

effective manner through this initiative. The potential for 

offering high quality, affordable and accessible health 

education, training and knowledge through the WHC is 

limitless. We welcome participation from all interested in 

health information and development. ❑ 

References 

1. Godlee, F Pakenham-Walsh, N Ncayiyana, D Cohen, B Packer, ‘A Can we 

achieve health information for all by 2015?’ Lancet 2004 (18 July); 364: 295- 

300) 

2. McConnell, H The Role of Health Communications in Combating HIV/AIDS, 

Malaria and TB. Mera, Medical Education Resource Africa, September, 2003 (7). 

3. McConnell, H The World Health Channel and Medical Education in Africa, 

Mera, Medical Education Resource Africa. July, 2003 (6). 

4. McConnell H International efforts in implementing national health information 

infrastructure and electronic health records World Hosp Health Serv. 

2004;40(1):33-7, 39-40, 50-2. 

5. S.Rangarajan and Mesfin Ayenew Virtual classroom via WorldSpace: A case 

study for Medical Information to developing countries, October, 2002. 

http://www.thinkcycle.org/tc-papers/?paper_id=37842&show_full=16. 

Rangarajan, J Soumagne and M.Samir, Reaching the Unreached worldwide 

using WorldSpace technology, 10th European Congress and Trade Fair for 

Educational and Information Technology, Learntec-UNESCO, Pp.129-134, 

2002. 

7. S.Rangarajan*, Wanjira Kamwere**and Victor Ajuoga Innovative Internet 

Access to a remote school in Kenya, October, 2002. 

http://www.thinkcycle.org/tc-papers/?paper_id=37806&show_full=1 


REFERENCE 

Letters to the editor 

Global strategy for infection control in hospitals 

To the Editor: 

Lazzari et al 1 have meticulously addressed the prevailing 

global scenario of the scourge of hospital infection. 

Undoubtedly, the recommended HAI international strategy 

of implementation of standardised procedures for 

surveillance of health care establishment-acquired infection 

would mitigate the associated morbidity and mortality. 

While the national level government agency would be the 

ideal nodal agency for promotion and implementation of 

any efficient plan, non-government hospitals would be 

important partners in an effective accomplishment of the 

prospective action plans. Moreover, even rather alternative 

surveillance for hospital infection might be a fairly effective 

approach. A laboratory based surveillance for hospitalised 

patients with a community acquired or nosocomial 

infection has been operational in a private sector hospital in 

the Indian capital metropolis. 

An infection control team comprising a clinical 

microbiologist, a gynecologist/obstetrician and two 

microbiology technologists was charged with the 

responsibility of surveillance of hospital infection at the Sant 

Parmanand Hospital. Located in the northern part of the 

Indian capital metropolis, the 140-bed tertiary care hospital 

caters to ordinary people in the national capital and 

adjoining townships. The team briefs the management 

through the Hospital Director. Episodes of bacterial and 

fungal infections among patients are picked up from 

microbiology cultures on clinical material. Isolates from 

patients within two to three days of hospital admission are 

recorded as ‘community acquired’. On the contrary, any 

isolate cultured after three days of hospitalisation is 

reported as ‘nosocomial’. The culture reports and the 

antibiotic susceptibility pattern are communicated to the 

clinician responsible for the patient care and the nursing 

personnel. Furthermore, there has been no secondary 

spread of infection from patients. The team has close 

association with clinicians and evaluates the hospital state 

of affairs regularly. 

During the past year, the rate of monthly nosocomial 

infections per 100 admissions has varied from 0- 0.57 per 

100 admissions (Table 1). There has been no administrative 

hurdle as no additional budget was sought form the 

management. The team members are well motivated and 

clinicians receive details about any infected patient under 

their charge punctually so that proper treatment can be 

instituted. 

Ward-based clinical surveillance has not been a 

component of our programme. We plan to strengthen the 

current surveillance for any missed episodes of hospital 

acquired cases, both during hospitalisation and in the postdischarge 

period. Undoubtedly, the future HAI strategy of 

standardised procedures for surveillance of health care 

establishment-acquired infection 1 would be of immense 

Month 

November 2003 0 

December 2003 0.13 

January 2004 0 

February 2004 0.31 

March 2004 0.12 

April 2004 0.14 

May 2004 0.43 

June 2004 0.44 

July 2004 0.57 

August 2004 0.4 

September 2004 0.39 

October 2004 0.51 

Nosocomial infections/ 

100 admissions 

value to health care establishments with almost negligible 

financial support from existing sources. 

Last but not least, microbial-culture-based strategy would 

be an effective weapon in reducing the incidence of 

hospital-acquired infection. Even without a comprehensive 

plan of ward-based surveillance in any hospital, that should 

strengthen efforts to tackle the global scourge of hospital 

infections. Such an infrastructure would be an asset to the 

future international efforts to introduce hospital 

surveillance protocols 1 . 

ARYA, Subhash C. 

AGARWAL, Nirmala 

Sant Parmanand Hospital, 18 Alipore Road, 

Delhi- 110054, India 

Email subhashji@hotmail.com 

References 

1. 

Lazzari S, Allengranzi B, Concia E. Making hospitals safer: 

the need for a global strategy for infection control in health 

settings. World Hospitals and Health Services 2004; 40: 32-39 

The secretarial assistance of Ms Sarita Kumar is 

acknowledged. 

Correction to Vol. 40 No. 3 

The following should have appeared on page 10 

GREECE 


REFERENCE 

World Hospitals and Health Services 2004 Volume 40 Number 4 

Résumés en Français 

SANTE ET CITOYENNETE : LES CARACTERISTIQUES 

DE LA SANTE AU 21è SIECLE 

(HEALTH AND CITIZENSHIP: THE CHARACTERISTICS 

OF 21ST CENTURY HEALTH) 

La santé est au coeur du modernisme et sa gestion se 

caractérise par deux développements : 

➜ Le développement du territoire de la santé dans des 

espaces sans cesse croissants de personnel et de 

politiques 

➜ Le développement de la faisabilité de la santé. La santé est 

un véritable modèle pour étudier ‘les conséquences du 

modernisme’ sous tous ses aspects et elle est 

inextricablement liées au concept de citoyenneté moderne. 

La gouvernance de la santé telle que nous la connaissons 

commence avec l’ère éclairée de l’Europe – et bien qu’elle 

s’inspire des motifs de la Grèce antique comme tout débat 

sur la santé le fait avec une grande régularité – elle appartient 

nettement aux préoccupations du modernisme. 

Avec l’âge ‘éclairé’, la santé devient l’un des principaux 

(sinon le principal) des objectifs de la société moderne, 

concept repris 250 ans plus tard par la définition de la santé 

par l’OMS : un état complet de bien-être physique, mental 

et social. En conséquence, la santé se définit de plus en plus 

comme un bien public et un droit individuel, ce qui en fait 

une des forces motrices des mouvements socio-politiques 

qui se réclame de la citoyenneté – là encore, d’abord au 

niveau de la nation, et maintenant au niveau mondial. 

Cet article tente de discuter de ces deux thèmes et forces 

motrices – la dimension personnelle et politique de la 

gouvernance de la santé – et les diverses façon dont ils 

s’enchevêtrent depuis deux siècles à mesure du 

développement et de la promotion du territoire et de la 

faisabilité de la santé par un vaste éventail d’acteurs au sein 

de la société. 

EGALITÉ DES PERSPECTIVES POUR TOUS LES 

HÔPITAUX EUROPÉENS?LES TENDANCES DU 

DÉVELOPPEMENT DANS L’UNION EUROPÉENNE 

(EQUAL FUTURE PROSPECTS FOR ALL HOSPITALS IN 

EUROPE DEVELOPMENT TRENDS IN THE EUROPEAN 

UNION) 

Le Marché Commun ne s’arrête pas avant les systèmes 

nationaux de santé des pays européens. Les systèmes 

hospitaliers ne se comparents plus simplement entre eux, ils 

s’affectent mutuellement de plus en plus et deviennent 

étroitement interdépendants. Ce développement concerne 

le niveau du personnel ainsi que les échanges de patients. 

L’ex-président, et vice-président actuel de l’Association 

hospitalière allemande dresse le tableau du développement 

hospitalier européen de ces dernières années. 

L’IMPACT DE LA MIGRATION DU PERSONNEL 

INFIRMIER SUR LES SYSTEMES DE SANTE DANS 

LES PAYS ASIATIQUES 

(THE IMPACT ON ASIAN HEALTH CARE SYSTEMS OF 

NURSING MIGRATION) 

Le personnel infirmier est une ressource précieuse aux 

quatre coins du monde et les hôpitaux vont connaître de 

graves difficultés pour assurer des services de qualité avec la 

pénurie actuelle d’infirmières. Bien que ce soit une question 

qui touche le monde entier, qui se répercute actuellement 

davantage sur les pays en développement, ce sujet est mal 

documenté. Beaucoup d’offres d’emploi de personnel 

infirmier dans les pays occidentaux sont publiées 

quotidiennement, elles attirent les infirmières et aboutissent 

à une émigration importante du personnel infirmier des pays 

asiatiques vers le monde occidental. 

TECHNIQUES CHIRURGICALES ESSENTIELLES 

D’URGENCE AVEC DES RESSOURCES 

MATERIELLES LIMITEES: ATELIER OMS EN 

MONGOLIE 

(ESSENTIAL EMERGENCY SURGICAL PROCEDURES IN 

RESOURCE–LIMITED FACILITIES: A WHO WORKSHOP 

IN MONGOLIA) 

Un atelier de l’OMS sur la formation des formateurs sur 

les techniques chirurgicales essentielles d’urgence a été 

organisé en collaboration avec le ministère de la santé de 

Mongolie. Les participants regroupaient des médecins et 

des infirmières des six Aimags (provinces) sélectionnées. 

Les organisateurs de l’atelier comprennent des experts de 

la faculté des sciences de santé, de l’Association des 

chirurgiens de Mongolie et de l’Association d’anesthésistes, 

associés à l’équipe chirurgicale suisse du Collège 

International de chirurgiens, du collège du département 

infirmier, de la clinique d’orthopédie traumatique, du 

département d’assurance de qualité du directorat des 

services médicaux, du ministère de la santé. Les 

organisateurs du CHU de Genève, de la Fondation de 


REFERENCE 

formation et de recherche médicales de Genève et les 

départements de santé et de recherche sur la reproduction 

(RHR) de l’Organisation mondiale de la santé et 

Observations et Informations de politique de Genève, en 

Suisse, ont participé par connexion vidéo. 

L’atelier comprend des conférences, discussions, jeux de 

rôle et formation pratique aux compétences de base. Des 

vidéo-conférences et séances de formation par Internet 

utilisant les outils de formation Internet de l’OMS ont été 

menées au Global Development Learning Centre. 

Les conférences et discussions portent sur des thèmes tels 

que: responsabilité de l’équipe et organisation des 

installations de santé, sécurité des patients; plan pour 

gestion des désastres, utilisation correcte de l’oxygène, prise 

en charge de l’hémorragie, brûlures et traumatismes, 

techniques de base d’anesthésie et réanimation, prévention 

de la transmission nosocomiale du VIH, stérilisation du 

matériel, élimination des déchets, hygiène, tenues des 

dossiers, surveillance et évaluation de la qualité des soins et 

listes de contrôle avant intervention chirurgicale, pour 

s’assurer que le patient voulu reçoit le traitement chirurgical 

voulu du côté voulu et au moment voulu. 

Les participants ont préparé des recommandations sur 

les prochaines étapes. 

PRINCIPALES PREOCCUPATIONS 

INTERNATIONALES 

(MAJOR INTERNATIONAL CONCERNS) 

2004 finit sur une note assez triste. Le rapport de 

l’UNICEF sur la santé de l’enfant nous rappelle le lourd 

tribut que les enfants paient encore aujourd’hui. En même 

temps, le sida poursuit son cours, de même que les autres 

grandes maladies transmissibles. Et sans oublier les guerres 

et la violence. Par contre, les hôpitaux et leurs professionnels 

sont plus que jamais fortement engagés à distribuer les soins 

et l’espoir. Le prochain Congrès de la Fédération 

Internationale des Hôpitaux, ‘Hospitals and their 

Challenges’ (‘Hôpitaux et Défis hospitaliers’, 20 - 22 

September 2005, Nice, France) focalisera particulièrement 

sur ce paradoxe. 

World Hospitals and Health Services 2004 Volume 40 Number 4 

Resumen en Español 

LA SALUD Y LA CIUDADANIA: CARACTERISTICAS DE 

LA SALUD EN EL SIGLO XXI 

(HEALTH AND CITIZENSHIP: THE CHARACTERISTICS 

OF 21ST CENTURY HEALTH) 

La salud es el centro de la modernidad y su 

administración se distingue por las dos extensiones 

siguientes: 

Una ampliación del área de la salud hacia un conjunto 

impresionante y cada vez mayor de aspectos personales y 

políticos y una expansión en su capacidad de acción. 

Además de estar vinculada con el concepto de una 

ciudadanía moderna de manera inextricable, la salud es un 

modelo ejemplar para estudiar las ‘consecuencias de la 

modernidad’ en todos sus aspectos. 

Tal y como se conoce hoy en día, la administración de la 

salud comienza con la ilustración europea y si bien se inspira 

en algunos de los clásicos griegos, como con frecuencia 

ocurre en los debates relativos a asuntos de salud, echa 

mano del discurso sobre la modernización. 

Con la ilustración “la salud” se convierte en uno de los 

más significativos (si no el más importante) objetivo de la 

sociedad moderna, idea de la que 250 años más tarde se 

hacía eco la OMS en su descripción de la salud: un estado 

de completo bienestar social físico y mental. Por 

consiguiente, la salud también se considera cada vez más un 

bien público a la vez que un derecho personal, lo que la 

convierte en un móvil de los movimientos sociales y 

políticos que reclama la ciudadanía, en primer lugar a nivel 

nacional y seguidamente a escala mundial. 

Este artículo se propone analizar estos dos temas y 

móviles - las dimensiones personales y políticas de la 

administración sanitaria - y la forma en la que éstas se 

entrelazan de diversas maneras en los dos últimos siglos, 

conforme se amplían los territorios y una amplia gama de 

diversos sectores de la sociedad aumenta y fomenta la 

capacidad de acción de la salud . 

¿IGUALDAD DE PERSPECTIVAS PARA TODOS LOS 

HOSPITALES EUROPEOS? TENDENCIAS DE 

DESARROLLO EN LA UNION EUROPEA 

(EQUAL FUTURE PROSPECTS FOR ALL HOSPITALS IN 

EUROPE? DEVELOPMENT TRENDS WITHIN THE 

EUROPEAN UNION) 

El Mercado Común no se para ante los sistemas 

nacionales de salud de los países europeos. Los sistemas 

hospitalarios ya no se comparan solamente entre sí, sino 

que cada vez ejercen mayor influencia entre sí y se 

relacionan más estrechamente. Además del efecto a nivel 

personal, este cambio afecta también al intercambio de 


REFERENCE 

pacientes. El antiguo presidente y actual vicepresidente de 

la Asociación alemana de hospitales elabora un resumen 

sobre la evolución de los hospitales europeos en los últimos 

años. 

¿HA PENSADO ALGUNA VEZ EN LAS 

CONSECUENCIAS DE LA MIGRACION DEL 

PERSONAL DE ENFERMERIA SOBRE LOS SISTEMAS 

DE SALUD DE LOS PAISES ASIATICOS? 

(THE IMPACT ON ASIAN HEALTH CARE SYSTEMS OF 

NURSING MIGRATION) 

El personal de enfermería es un recurso de gran valor en 

todos los rincones del mundo y los hospitales se enfrentan 

con un grave problema al tener que prestar unos cuidados 

de salud de alta calidad con la insuficiencia actual de 

enfermeras. Si bien la escasez de enfermeras es un problema 

de alcance mundial, que hoy en día se hace sentir todavía 

más en los países subdesarrollados, no hay mucha 

información disponible sobre este asunto. Las numerosas 

oportunidades de empleo para el personal de enfermería en 

los países occidentales y la gran cantidad de anuncios que se 

repiten a diario atraen a las enfermeras, dando lugar a una 

migración muy importante de los países asiáticos con 

dirección al mundo occidental. 

PROCEDIMIENTOS QUIRURGICOS ESENCIALES DE 

URGENCIA EN INSTALACIONES DE SALUD: CURSO 

PRACTICO DE LA OMS EN MONGOLIA 

(ESSENTIAL EMERGENCY SURGICAL PROCEDURES IN 

RESOURCE LIMITED FACILITIES : A WHO WORKSHOP 

IN MONGOLIA) 

En colaboración con el Ministerio de Sanidad de 

Mongolia, la OMS ha organizado un Curso práctico 

denominado “Adiestramiento de adiestradores” que trataba 

sobre los procedimientos quirúrgicos esenciales de urgencia. 

Entre los participantes se encontraban médicos y personal 

de enfermería de las seis provincias (Aimags) seleccionadas. 

Entre los instructores del curso cabe citar expertos de la 

Facultad de Ciencias de la Salud, la Asociación de Cirujanos 

de Mongolia y la Asociación de Anestesistas, en asociación 

con un equipo Suizo de cirujanos de la Escuela Internacional 

de Cirujanos, el Departamento Quirúrgico de la Escuela de 

Enfermería, el Hospital Clínico de Traumatología y 

Ortopedia, el Departamento de Garantía de Calidad de la 

Dirección de Servicios Médicos del Ministerio de Salud. 

Además, y a través de teleconferencia, en el curso 

participaron también profesores del Hospital Universitario 

de Ginebra, la Fundación Ginebrina para la Educación e 

Investigación en Medicina y los departamentos de la salud y 

la investigación reproductivas y la evidencia e información 

en materia de política de Ginebra, Suiza. 

El curso consistió en una serie de conferencias, debates, 

escenificaciones y ‘capacitación práctica’ en técnicas 

elementales. Las sesiones vía teleconferencia y aprendizaje 

electrónico, utilizando mecanismos electrónicos de 

enseñanza elaborados por la OMS, tuvo lugar en el Centro 

Mundial para el desarrollo del aprendizaje. 

Entre los temas tratados en las conferencias y los debates 

cabe citar las responsabilidades y la organización de las 

instalaciones sanitarias, la seguridad del paciente, la 

planificación para casos de desastres, el uso adecuado del 

oxígeno, el control de la pérdida de sangre, las quemaduras 

y el traumatismo, técnicas básicas en anestesiología y 

reanimación, la prevención de transmisiones nosocomiales 

del VIH, la esterilización del material y equipamiento 

médicos, la eliminación de desechos, la higiene, la custodia 

de historias clínicas, el seguimiento y la evaluación del 

control de la calidad y listas de control para antes de la 

cirugía con el fin de garantizar que el paciente correcto se 

somete a la cirugía adecuada, en el lugar adecuado y el 

momento adecuado. 

Los participantes del taller hicieron una serie de 

recomendaciones sobre los próximos temas a debatir. 

ASUNTOS DE MAXIMO INTERES INTERNACIONAL 

(MAJOR INTERNATIONAL CONCERNS) 

El año 2004 ha concluído con una imagen bastante 

deprimente. Un informe de la UNICEF sobre la salud 

infantil nos recuerda que todavía hoy en día hay un gran 

número de víctimas entre los niños. Al mismo tiempo, el 

sida sigue haciendo estragos, junto con las principales 

enfermedades transmisibles. Por otro lado, las guerras y la 

violencia continúan estando en las noticias. En cambio, 

tanto los hospitales como los profesionales de la salud cada 

vez se dedican más de lleno a prestar asistencia y dar 

esperanza a los pacientes. El próximo Congreso de la 

Federación Internacional de Hospitales, ‘los hospitales y sus 

retos’ (20-22 de septiembre, 2005, Niza, Francia) 

concentrará toda su atención en esta paradoja. 


REFERENCE 

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 

AGFA-GEVAERT NV 

Ms Birgitte Baten 

Septestraat 27, B-2650 Mortsel 

Tel: (32) 3 444 2111 

Fax: (32) 3 444 7908 

Email: birgitte.baten@agfa.com 

Internet: www.agfa.com 

FHP VILEDA PROFESSIONAL DIVISION 

Mr Frederic Petit 

Avenue Andre Ernst 3-B 

Verviers 

BELGIUM 

Tel: (32) 87322137 

Fax: (32) 81322158 

Email: frederic.petit@fhp-ww.com 

Internet: www.vileda.com 

ULTRAGENDA NV/SA 

Antwerpsesteenweg 19 

9080 Lochristi 

Belgium 

Contact: Mr. Hugo Schellens, CEO 

Tel: +32 9 230 20 20 

Fax: +32 9 230 02 02 

BRAZIL 

HOSPITALAR FEIRAS CONGRESSOS E 

EMPREENDIMENTOS LTDA 

Dra W Santos / 

Mr J Fco dos Santos 

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 

Denmark 

Tel: (45) 4444 8888 

Fax: (45) 4449 0555 

Email: webmaster@novonordisk.com 

Internet: www.novonordisk.com 

FINLAND 

INSTRUMENTARIUM 0YJ 

Mr Sami Aromaa 

Director Global Communications 

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 

FAUST CONSULT GmBH 

Managing Director 

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 

MCC MANAGEMENT CENTER OF 

COMPETENCE 

Mr Harmut Loewe 

Scharnhorststrasse, 67a, 

D-52351 Duren 

Tel: (49 2421) 121 77 11 

Fax: (49 2421) 121 77 27 

E-mail: loew@mcc-seminare.de 

Internet: http://www.mcc-seminare.de 

MESSE DUSSELDORF GmbH 

Messe Dusseldorf is the organizer of medical 

trade fairs all over the world, the leading one 

of which is MEDICA 

Mr H Giesen 

Project Director 

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 

SOLVAY GmbH 

Mr. Martin Rudmann 

Commercial Director 

Hans-Boeckler-Allee 20 

30173 Hannover 

Germany 

Martin.rudmann@solvay.com 

Tel: +49 511 857-0 

Internet: www.solvay.com 

PENTAX EUROPE GmbH 

Dr Daniel Zeidler 

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 

SYSMEX EUROPE GmbH 

Herr H. Hassenpflug 

Director of Communications and Promotion 

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 

HKSAR GOVERNMENT 

ELECTRICAL & MECHANICAL SERVICES 

DEPARTMENT 

Alfred Sit Wing-Hang 

Health Sector Manager 

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 

TUV ASIA PACIFIC MANAGEMENT 

HOLDING 

Mr Andrew Lee 

Manager 

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 

INV. ANF INFORMATION CREDIT 

RATING AGA (ICRA) 

Dr Shyama S. Nagarajan 

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 

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. 

Dr M. Modai 

President and CEO 

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 

LEBANON 

FEDERATION DES HOPITAUX ARABES 

Dr Faouzi Adaimi 

President 

PO Box 7, 

Journieh Notre Dame 

Hospital, Journieh 

Tel/Fax: (961) 964 4644 

Email: HNDL@terra.net.lb 

LUXEMBOURG 

EUROPEAN INVESTMENT BANK 

Mr Rene Christensen 

Senior Economist 

100 Boulevard Konrad Adenauer 

2950 Luxembourg 

Tel: (352) 43798 540 

Fax: (352) 43798827 

Email: r.christensen@eib.org 

Internet: www.eib.org 


REFERENCE 

PHILIPPINES 

OPTIONS INFORMATION COMPANY 

A publishing and event management company. 

Ashok K. Nath 

Chairman 

#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 

WOUND CARE (PTY) LIMTED 

Dr Susan Chalmers 

PO Box 2763 

7129 Somerset West 

Tel: (272) 18528655 

Fax: (272) 18528656 

Email: info@chemspunge.co.za 

Internet: www.woundcare.co.za 

SWEDEN 

BOULE MEDICAL AB 

Robert Harju-Jeanty 

Vice President, Marketing 

Boule Medical AB 

PO Box 42056 

SE-12613 Stockholm, Sweden 

Tel: (46) 8-744 77 00 

Fax: (46) 8-744 77 20 

Email: robert.harju-jeanty@boule.se 

Internet: www.boule.se 

CAPIO AB 

Leading player on the European healthcare 

market with units in Sweden, Denmark, 

Norway, Finland, UK, France and Switzerland. 

Ulrika Bohl 

PO Box 1064, 

SE-405 22 Gothenburg 

Tel: (46 31) 732 4000 

Fax: (46 31) 732 4099 

Email:info@capio.se 

Internet: www.capio.com 

GETINGE INTERNATIONAL AB 

John Hansson 

PO Box 69 

SE-31044 Getinge 

Tel: (46) 3515 5500 

Email: John.Hansson@Getinge.com 

Internet: www.getinge.com 

WHITE ARKITEKTER AB 

H Josefsson 

Partner/Architect SAR, SPA 

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 

DIAMED AG 

Patrick Jacquier 

Head of Parasitology and Infectious Diseases 

1785 Cressier sur Morat 

Tel: (41 26) 674 5111 

Fax: (41 26) 674 5145 

Email: p.jacquier@diamed.ch 

Internet: www.diamed.ch 

JOHNSON & JOHNSON ADVANCED 

STERILIZATION PRODUCTS 

Mr Hans Strobel 

Rotzenbuelstrasse 55 

CH 8957 Spreltenbach 

Tel: (41) 56 417 3363 

Fax: (41) 56 417 3333 

Email: hstrobel@cscch.jnj.com 

UNITED ARAB EMIRATES 

GULF MEDICAL COLLEGE HOSPITAL AND 

RESEARCH CENTRE 

Mr Thumbay Moideen 

President 

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 

ASSOCIATION OF PRIMARY CARE GROUPS 

AND TRUSTS (APCGT ) 

Mr David Selwyn 

Secretary 

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 

EXTENDED SYSTEMS LIMITED 

Mr Ben Mansell 

Government and HealthCare Strategy Manager 

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 

FSG COMMUNICATIONS LIMITED 

FSG Communications limited provides 

publishing, conferences and exhibitions for 

health professionals and the medical industry 

involved or interested in Africa. 

Mr Bryan Pearson 


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 

INTERNATIONAL HOSPITALS GROUP 

LIMITED 

Mr Witney M. King 


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 

JONATHAN BAILEY ASSOCIATES (UK) 

LIMITED 

Mr Nicholas Shapland 


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 

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. 

Mr S. Robert Wendin 

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 

OLYMPUS UK LIMITED 

Mr Peter Wognum 

Business Development Manager, EMEA 

Dean Way, 

Great Western Industrial Park, 

Southall, 

Middlesex UB2 4SB 

Tel: (44) 20 7250 4800 

Fax: (44) 20 7250 4801 

Email: peterw@olympus.uk.com 

Internet: www.olympus.co.uk 

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. 

The Directors 

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 

QINETIQ 

Mr Alun Williams 

Managing Director – Health 

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 

REGENT MEDICAL LIMITED 

Mr Paddy Markey 

Manger 

Two Omega Drive Irlam 

Manchester 

Tel: (44)161 777 2611 

Fax: (44)161 777 2601 

Email: paddy.markey@regentmedical.com 

Internet: www.regentmedical.com 

THE INTERNATIONAL eHEALTH 

ASSOCIATION 

Harry McConnell MD FRCPC 

Director 

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 

AEROMEDICAL GROUP INC 

Dr M.N. Cowans 

1828, El Camino, Suite 703, 

Burlingame, CA 94010 

CIGNA - International Expatriate Benefits 

Mr Markus E. Zettner 

590 Naamans Road Claymont, 

DE 19703 

Tel: (302) 797 3494 

Fax: (302) 797 3055 

Email: Markus.zettner@cigna.com 

Internet: www.cigna.com/expatriates 


REFERENCE 

ERNST & YOUNG LLP 

Sherry Hayes 

Director 

1225 Connecticut Avenue, NW 

Washington DC 20036 

Tel: (202) 327 6000 

Fax: (202) 327 6200 

Email: sherry.hayes@ey.com 

Internet: www.ey.com 

ESRI 

Mr W Davenhall 

Health & Human Services Solution Manager 

380, New York Street, Redlands, 

CA 92373 

Tel: (909) 793 2853 

Fax: (909) 307 3039 

Email: bdavenhall@esri.com 

Internet: www.esri.com 

HEALTHTEK SOLUTIONS INC 

Anthony M. Montville 

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 

HORIZON STAFFING SERVICES 

Mr Ahmed Ahsan 

President & CEO 

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 

INTERACTIVE HEALTH MANAGEMENT 

SOLUTIONS LLS 

Dr Christos A Papatheodorou MPH, FACS 

1200 South Federal Highway 

Suite 202 

Boyton Beach 

Florida 

Tel: (561) 7315881 

Fax: (561) 7315877 

MEDICAL SERVICES INTERNATIONAL 

The President 

20770 Hwy, 281 No. 

Suite 108, #184, San Antonio, 

TX 78258-7500 

Tel: (210) 497 0243 

Fax: (210) 497 2047 

Email:jramseymsi@aol.com 

MEDIFAX EDI INC. 

Medifax provides electronic connectivity 

services between health plans and health 

care providers for processing of health care 

transactions. 

Jeff Fadler 

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 

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. 

Heather N. Ficchi 

Marketing Assistant 

300 Delaware Avenue, Suite 850, 

Wilmington, DE 19801 

Tel: (302) 425 0190 

Fax: (302) 425 0191 

Email: hficchi@mediguide.com 

Internet: www.mediguide.com 

SPENCER STUART 

Mr John R Schlosser 

Senior Director 

10900 Wilshire Blvd; Suite 800 

Los Angeles; CA 

Tel: (310) 2090610 

Fax: (310) 2090912 

Email: jschlosser@spencerstuart.com


Major international 

concerns for 2005 

GÉRARD VINCENT 

DIRECTOR GENERAL, FRENCH HOSPITAL FEDERATION, PRESIDENT OF HOPE (EUROPEAN FEDERATION OF 

HOSPITALS AND HEALTH CARE) AND PRESIDENT DESIGNATE, INTERNATIONAL HOSPITAL FEDERATION 

The year 2004 ended on quite a sad note. The UNICEF 

report on child health reminded us of the toll still paid 

by children today. At the same time, AIDS is following 

its upward trend along with other major communicable 

diseases. And wars and violence are still in the picture. On 

the other side of the coin, hospitals and their professionals 

are deeply involved in giving care and hope more than ever 

before. The next International Hospital Federation Congress 

‘Hospitals and their Challenges’ (20–22 September 2005 in 

Nice, France) will keep this paradox at its very core. 

In fact, there is no time for pessimism in our ever active 

wards and we know that listing out the difficulties we are 

facing is already a start in solving them. Two recent 

developments among others are showing strong signs at 

international level. Patient safety is one of them. An 

estimated one in ten patients worldwide becomes sick, is 

injured or even dies as a result of the healthcare they receive, 

although many of these adverse events in healthcare delivery, 

including medical errors, are preventable. To combat this 

problem and improve patient safety, global health leaders 

and the World Health Organization (WHO) have launched 

the World Alliance for Patient Safety in October 2004. This 

is the first time that a coalition of partners has joined efforts 

to act globally to improve patient safety. 

The second one concerns the migration of health 

professionals. Employers and recruitment agencies in several 

wealthy countries are actively recruiting doctors and nurses 

from other parts of the world. But there is now a real 

concern about the ‘brain drain’ in the health sector and 

its consequences for population health. Charters, 

recommendations and rules are beginning to flourish aimed 

at promoting good recruitment practice and also to say that 

Employers and recruitment 

agencies in several wealthy 

countries are actively 

recruiting doctors and 

nurses from other parts of 

the world. 

“ 

” 

attention should be focused on retaining nurses rather than 

recruiting nurses from abroad. 

At the European level, hospitals are increasingly 

influenced by the European Union decisions. Mutual 

recognition of diplomas, public procurement regulations, 

EU drug policy and safety regulations, have among other 

things made a strong impact. Health was already present in 

“ 

An expanding agenda of cooperation 

and cross-border 

contacts in the healthcare 

field is also increasing with 

European integration. 

” 

the EU treaties because a high level of human health 

protection has to be ensured in the definition and 

implementation of all Union policies and actions. But now 

Europe will have a Constitution in which for the first time 

ever health care will be clearly included. 

An expanding agenda of co-operation and cross-border 

contacts in the health care field is also increasing with 

European integration. As health systems become more and 

more interdependent, the process of adaptation needed by 

health issues cannot take place solely at national level. The 

enlargement of the Union from 380 million to 450 million 

citizens is opening new perspectives. It takes place at a time 

when all European countries will have to adapt to numerous 

challenges, whereas candidate countries will look to the 

Community for advice and help in rebuilding their health 

systems, many of which are struggling to survive. 

In this context, France is now concluding, what is 

nowadays a recurring event for all systems, a series of major 

healthcare reforms. For hospitals, the progressive change of 

financing from a global envelop system to DRG-based 

financing is the most innovative element. More generally, 

confronting the lack of doctors and nurses, France has 

revised the number of medical students but is also looking 

00 | World Hospitals and Health Services | Vol.40 Vol. No.2 40 No. 4 | World Hospitals and Health Services | 47


for new ways of working. 

These issues, international as well as European ones, will 

be at the core of the next IHF Congress. It is a particular 

pleasure for French hospitals strongly involved in 

partnerships all over the world to receive their partners and 

others to this major event. The 34th Congress will be 

organised by the French Hospital Federation around four 

components: risks, quality, skills and research. Two major 

sessions will also draw attention to the developing world: a 

one-day seminar organised jointly by the World Bank and 

the French Ministry for Foreign Affairs on financing and 

health policy issues; and another one on hospital 

partnerships to facilitate access to care for people living with 

HIV/AIDS. 

Speakers invited to this Congress have been selected 

because of their expertise on these subjects and they are 

invited to share their observations and experience on these 

problems of major importance to us today. Topics range from 

hospital and sustainable development to patient safety, 

culture in the hospital, financing hospital research, etc. All 

the efforts will be made to organise this event as participative 

as possible for our mutual benefit: a high-quality of care for 

the patient. ❑ 

Curriculum Vitae 

Name: Gérrard Vincent 

Present occupation: Director General, French Hospital Federation, President of HOPE (European 

Federation of Hospitals and Healthcare) and President designate, International Hospital Federation 

Background: After nine years in the Ministry for Social Affairs, Gerard Vincent became Director 

General of the French Hospital Federation in March 1998. 

He holds a diploma in Hospital Management at the National School of Public Health Rennes in 

France followed by a degree in Political Sciences and a Master of Arts from Grenoble in France. 

Before becoming Chief Executive of the prestigious hospital ‘Hotel Dieu de Paris’ in 1977’, he worked 

for seven years as a deputy in various ‘Assistance Publique – Hopitaux de Paris’ hospitals: such as 

Bichat – Claude Bernard and Antoine Beclère. 

Recruited as Director for Hospitals in the Ministry of Health in 1989, he was in charge of the 1991 

Hospital Law, which reformed in depth the French hospital sector. He was promoted Social Affairs 

General Inspector in 1995. 

He was president of the SNCH, the public hospital managers’ trade union, from 1982 to 1989. 

In May 2002, he became President of the Standing Committee of the Hospitals of the European Union 

(HOPE). He is also President designate of the International Hospital Federation

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