Towards o 4 • OCTOBER 2001 Unity for Health · TOWARDS UNITY FOR HEALTH, OCTOBER 2001 3 GLOBAL...

COORDINATING CHANGES IN HEALTH SERVICES AND

HEALTH PROFESSIONS PRACTICE AND EDUCATION

TowardsUnity forHealth

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No 4 • OCTOBER 2001WHO/EIP/OSD/NL/A/2001.2

1 Medical schools and health care:Where is the synchrony?

2 Editorial: A people’s affair

4 Promoting international collabora-tion to enhance the quality ofhealth care

5 Publications

6 Accreditation and development ofmedical schools: a global project

9 New Journal: The Meducator

10 Primary health care is still on theagenda, but …

11 Making communities real partners

13 If I were Minister of Health: theGreek health paradox and thehealth policy conundrum

15 Family medicine: an asset for thehealth of Bangladesh

16 Better online access

17 The Five-Star Doctor award18 World conference 200219 The way forward for the health

workforce in South-East Asia

20 Towards unity for health

21 Distance learning: a response toovercome current challenges inmedical education?

23 Online help: What’s in a name?

23 Medical schools without walls:medical education and the WorldWide Web

25 Healing fragmentation: a Chineseviewpoint

26 The Making Pregnancy Saferinitiative: the power of partner-ships

28 Changing roles: a half-centuryodyssey on Planet “Health”

30 HIF-net at WHO

30 Diary dates

30 UNISOL congress in Nairobi

31 Till we meet again / Au revoir

33 Addresses

Medical schoolsand health careWhere is the synchrony?James A. Hallock, Educational Commission for ForeignMedical Graduates, Philadelphia, Pennsylvania, USA

the appropriate sites and locales forthe educational focus in these co-ordinated efforts (1).

Similarly, much has been writtenabout the need for a linkage be-tween medical education and thehealth of the population. Descrip-tors to identify this issue arereflected in the references cited(2,3,4,5,6,7). Each of these articlesattempts to indicate and define the

U pon assuming the presi-dency of the EducationalCommission for Foreign

Medical Graduates (ECFMG) on 1February 2001, I began to assembleinformation about internationalmedical education and the relativemerits of the linkage betweenmedical education and the healthof populations. The World HealthOrganization (WHO), through itspublication Towards unity forhealth, has been among the lead-ers in these efforts.

A recent publication of the WHO,a working paper entitled, Chal-lenges and opportunities for part-nerships in health development,placed proper emphasis upon theintegration of health care deliveryservices and the need for a compre-hensive approach in deliveringthese services. Multiple referenceson page 48 and page 56 challengemedical educational institutions as

James A. Hallock

2 ■ TOWARDS UNITY FOR HEALTH, OCTOBER 2001

EDITORIAL

A people’s affairCharles Boelen, World Health Organization, Geneva

if they lived in the most remote ar-eas and the equivalent of three dol-lars if they lived closer to towns.These sums were intended to coverbasic health services, such as vac-cinations and management ofcommon illnesses.

I met with the Dean one year af-ter they launched their project,which happened to be popular andfinancially viable. He explained thattaking such an initiative with littleexperience and no particular healthadministration skills exposed themto a number of surprises, one ofwhich was the visit of a delegationof peasants, who said: “Professor,you will remember that we gave youa dollar. As we haven’t been sickduring the past year, can you pleasegive us the dollar back?”

What was most surprising for mewas that leaders in a medical schooldecided to set standards for them-selves and for their institution—above the conventional ones—thatthey thought would best meet theirethical exigencies and social re-sponsibility. Behind this there wereno external constraints, only a con-viction that there was a better wayto perform their duties.

This school went “out of its way”and ventured into uncharted terri-tory through its own will, the will ofpeople. When one looks back andreflects on outstanding achieve-ments in the health, social or eco-

nomic fields, very often one findspeople who have gone “out of theirway”—beyond their traditionalrealm of responsibilities—to takeup new ones and build bridges withothers to better manage critical is-sues for society and humanity.

Isn’t it true that too often our be-haviour is constrained by conven-tional borders, traditional thinking,administrative rules or institutionalbarriers that we are too shy to cross,even in the interest of the obvious?We all know that sustainable healthgains are very often obtained whenborders are crossed, when differentstakeholders recognize the need toquestion their mandate and ways tobest contribute to people’s health,when these stakeholders furtherrecognize that they don’t have thetotal answer and need to express acommon vision and commitmentthrough efficient partnerships.Again, to create such a momentumtowards unity of action, what mat-ters most is the will of a few peoplewho have the courage to go “out oftheir way”. ■

Dr Charles Boelen, Coordinator for HumanResources for Health, WHO Department ofHealth Service Provision, and Executive Editorof this newsletter, contributes this regularfeature. He can be contacted as follows:World Health Organization OSD/HRH; 1211Geneva 27, SWITZERLAND (Telephone: +4122 791 2510; Fax: +41 22 791 4747; E-mail:[email protected]).

I must tell you about a recent en-counter with the dean of a medical school in one of the poorest

countries on the planet, in south-east Asia.

One could grade the school asexcellent, according to standardscommonly used by the promotersof quality assurance in medicaleducation. The curriculum is de-signed to meet the priority healthneeds of people; students are ex-posed to community health prob-lems very early in their training andthroughout it; the most efficient

learning proc-esses are beingused; learningmaterials exist ina b u n d a n c e ;teachers are of-fered continuingeducation op-portunities; andexternal evalua-tion of pro-grammes is

routinely carried out and remedialaction always taken when needed.

Despite managing a “centre ofexcellence” and an exemplary insti-tution for many other schools in hiscountry and in the region, the Deanlooked sad as he said: “Every time Ilook through the window of my of-fice and see peasants scratching thesurface of the earth and strugglingto grow something to feed theirfamilies, I am thinking that themajority of them and their familieshave no access to the most essen-tial health services.”

The Dean and some facultymembers decided to make a specialcontribution to help their compa-triots and reduce flagrant inequitiesin health. They undertook to set upa local health insurance scheme,and went through mountainousareas in four-wheel drive vehicles topersuade villagers to contribute theequivalent of one US dollar per year

Dr Charles Boelen

Soon to come …

Now in preparation by WHO is A view of the world’s medicalschools. Defining new roles. This document analyses theresults of a 250-question survey administered to more than

half of the world’s medical schools—895—in domains as variedas mission and mandate, financial support, admissions, studentbody, faculty, facilities, curriculum, credentials, accreditation, inter-actions with other groups and continuing education. Publicationwithin the next few months is anticipated. ■

TOWARDS UNITY FOR HEALTH, OCTOBER 2001 ■ 3

GLOBAL STANDARDS

need for a social contract betweenthe academic medical educationcommunity and the populationsthey serve. In Canada, and in On-tario in particular, this was takenquite seriously in a project entitledEducating Future Physicians forOntario (EFPO), the overall goal ofwhich was to “modify the charac-ter of medical education in Ontarioto make it more responsive to theevolving needs of Ontario society”(8).

The Educational Commissionfor Foreign Medical Graduates(ECFMG®) has also played a sig-nificant role in these discussions bycosponsoring two invitational con-sultations with the World HealthOrganization: (1) “Toward a GlobalConsensus on Quality MedicalEducation: Serving the Needs ofPopulations and Individuals”,Geneva, Switzerland, 1994 (9) and(2) ”Improving the Social Respon-siveness of Medical Schools”, Bar-celona, Spain, 1998 (10). Theseconferences highlighted a globalrecognition of the need for greatersynchrony between the products ofmedical education and the health-care needs of the populationsbeing served and of the need toshare information to a muchgreater extent.

To that end, the ECFMG has cre-ated the Foundation for Advance-ment of International MedicalEducation and Research (FAIMER)and has recently defined the mis-sion for this Foundation to be thelinkage of health care educationwith the health of the population,as measured by health care out-comes. The goal will be that allfuture programmes of ECFMG andthe Foundation, whether they befellowship programmes, existinggrant programmes, the consulta-tion programme or new grant pro-grammes, will be driven by thisvision.

There are currently several glo-bal initiatives to look at assessmentof medical schools with an eye to-wards international accreditation.

These efforts are being sponsoredby the World Health Organization,the World Federation for MedicalEducation and the China MedicalBoard of New York, Inc.

● The WHO has issued a call for aninternational Consortium forAccreditation of Medical Schools,suggesting that entities come to-gether to take a unified look atinternational accreditation. Thefocus of this effort is to examinethe social responsibility of medi-cal schools in the evaluationprocess.

● The World Federation for Medi-cal Education ( WFME) con-vened a Task Force for Definitionof International Standards inBasic (undergraduate) MedicalEducation, which has publishedQuality improvement in basicmedical education: WFME inter-national guidelines (11). This willbe the basis for medical schoolassessment and includes a sec-tion on social interaction.

● The trustees of the China Medi-cal Board of New York, Inc., havecreated the Institute for Interna-tional Medical Education, whichis working on a document enti-tled Global minimum essentialrequirements in medical educa-tion (12). The Institute was cre-ated to provide leadership indefining the global minimal es-sential requirements of under-graduate medical educationprogrammes.

While these initiatives are all tobe applauded and commended,they raise the very serious question

of the need for global coordinationof these efforts to minimize dupli-cation of efforts and maximize theimpact of the educational process.It would certainly be a wonderfulstep forward if the efforts could becoordinated, with an appeal to linkthe educational mission to thesocial contract of medical schools.

The agenda appears clear: thereis the need for synchrony betweenthe educational programme andthe health of the population beingserved. The mechanisms to accom-plish this agenda—accreditationand assessment—are available.

The challenge is before us: Canwe come together as a global edu-cation community and have animpact on health in a more signifi-cant way through the vehicle ofeducation? ■

References1. Towards unity for health.

Challenges and opportunities forpartnership in health develop-ment. A working paper. Geneva,World Health Organization, 2000(unpublished document WHO/EIP/OSD/2000.9; available onrequest from Department ofHealth Service Provision, WorldHealth Organization, 1211Geneva 27, Switzerland).

2. White KL, Connell JD (eds). Themedical school’s mission and thepopulation’s health. New York,Springer Verlag, 1992.

3. Maudsley RF. Content in con-text: medical education andsociety’s needs. AcademicMedicine, 1999, 74(2):143–145.

4. Schroeder SA, Zones JS,Showstack JA. Academic medi-

New WHO collaborating centre designated

The medical school of the University of Sherbrooke, in Quebec,Canada, was recently named a WHO collaborating centre in the

education and practice of health personnel in response to soci-ety’s needs. Sherbrooke strongly promotes the Towards Unityfor Health approach. As this issue went to press, an inaugurationceremony and programme were scheduled for 8 and 9 November2001. ■

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cine as a public trust. Journal ofthe American Medical Associa-tion, 1989, 262:803–811.

5. Mahmoud AA. Academicmedicine: the social conscious-ness of the profession. Journal ofLaboratory and Clinical Medi-cine, 1991, 121:635–637.

6. Boelen C, Heck JE. Defining andmeasuring the social account-ability of medical schools.Geneva, World Health Organiza-tion, 1995 (unpublished docu-ment WHO/HRH/95.7; availableon request from Department ofHealth Service Provision, WorldHealth Organization, 1211Geneva 27, Switzerland).

7. McCurdy L et al. Fulfilling thesocial contract between medicalschools and the public. Aca-demic Medicine, 1997, 72:1063–1070.

8. Maudsley RF et al. Educatingfuture physicians for Ontario:Phase II. Academic Medicine,2000, 74:114.

9. Gastel B, Wilson MP, Boelen C(eds). Toward a global consensuson quality medical education:serving the needs of populationsand individuals. Academic Medi-cine, 1995, 70 (supplement).

10. Gary NE et al. (eds.) Improvingthe social responsiveness ofmedical schools: proceedings ofthe 1998 Educational Commis-sion for Foreign Medical Gradu-ates/World Health Organizationinvitational conference. Aca-demic Medicine, 1999, 74(supplement).

11. Quality improvement in basicmedical education WFMEinternational guidelines. WorldFederation for Medical Educa-tion, 2001 (at web site http://www.sund.ku.dk.wfme).

12. Global minimum essentialrequirements (GMER). Institutefor International MedicalEducation, in draft, June 2001.

Dr. James A. Hallock is President and ChiefExecutive Officer of the Educational Commis-sion for Foreign Medical Graduates and Chairof the FAIMER Board of Directors. He can bereached at: ECFMG, 3624 Market Street,Philadelphia, PA 19104, USA (Telephone:+1 215 823 2101; Fax: +1 215 386 8151).

GLOBAL STANDARDS

Promoting internationalcollaboration to enhancethe quality of health careDale L. Austin, Federation of State Medical Boards,Euless, Texas, USA

licensure and discipline are notunique to any one nation; they de-cided to hold a second interna-tional conference in Australia.

The Second International Con-ference on Medical Regulation,held in Melbourne, Australia, inOctober 1996, experienced in-creased participation, with 20countries represented. Topics fordiscussion included disciplinaryprocedures and practices, registra-tion of medical students, assess-ment of international medicalgraduates, impaired physicians,recertification and maintenance ofcompetence, management of com-plaints, the international move-

ment of physicians and issuesrelative to telemedicine.

In September 1998, theSouth African Medical

and Dental Councilhosted the ThirdInternational Con-ference on MedicalRegulation, inCape Town, with

26 countries repre-sented. The Fourth In-

ternational Conference

Dale L. Austin

Recent history

The success of biennial interna-tional conferences on medicalregulation held since 1994 has

led medical licensing authoritiesaround the world to recognize thatinternational collaboration is anessential element in their role aspublic protectors. The readiness oflicensing and regulatory authoritiesto foster international relations hasprecipitated the formation of theInternational Association of Medi-cal Licensing Authorities (IAMLA).

In 1993, the Federation of StateMedical Boards of the United Statesof America, under contract with theUS Department of Health and Hu-man Services, planned and con-ducted the First InternationalConference on Medical Regulation.Participants met in Washington,DC, in May 1994 and included rep-resentatives of Australia, Canada,Ireland, New Zealand, South Africa,the United Kingdom and theUnited States. Observers were sentfrom Egypt, Israel, Mexico and Tai-wan.

Designed to initiate dialogueamong the participating nations,the conference focused on the cur-rent status of medical regulation inthe participating nations, examin-ing current research andidentifying future researchneeds. The conferencewas successful in stimu-lating discussion andcreating a consensusin favor of contin-ued internationaldialogue. Confereesconcluded thatproblems faced inthe field of medical


GLOBAL STANDARDS

on Medical Regulation, hosted bythe General Medical Council of theUnited Kingdom in September2000 in Oxford, was attended by 118medical professionals from 23countries.

A promising futureThese conferences have been suc-cessful in providing a forum for theexchange of ideas and discussion ofcommon problems affecting thedelivery of health care and the regu-lation of medical practice, and havegenerated support for establishingan international association. Nu-merous areas exist in which col-laboration among the internationalmedical community will signifi-cantly benefit the public. In the last25 years, we have experienced tre-mendous advances in electroniccommunication capabilities, in-creased migration of physiciansand other health care professionals,individuals choosing to receiveeducation and training outsidetheir home countries, and treatiesand trade agreements easing tradi-tional borders. These changes areexciting and have provided an op-portunity to draw upon the experi-ences of other medical licensingauthorities, thereby improvingmedical regulation in the interest ofenhancing public protection.

An Interim Governing Commit-tee (IGC) for IAMLA has been estab-lished and is composed of a coregroup of permanent members toprovide stability and continuity.Participating countries includeAustralia, Canada, Ireland, NewZealand, South Africa, Sweden, theUnited Kingdom, and the UnitedStates. The IGC approved a plan-ning document outlining steps thathave been or will be taken to de-velop a permanent governancestructure for IAMLA.

The following broadly definedgoals have been identified for theorganization:

● To facilitate international co-operation and collaborationamong licensing authorities

and the exchange of medicalregulatory information.

● Encourage and support highstandards for medical educa-tion, licensure and profes-sional conduct.

● Provide a forum for the devel-opment of concepts and newapproaches in medical regu-lation and thereby supportlicensing authorities in pro-tecting the public.

The IGC has resolved that twomatters be dealt with as priorities:the development of the bylaws ofthe Association and formulation ofmechanisms by which informationcan be exchanged between the par-ticipating regulatory authorities.Task forces have been created toformulate proposals on each ofthese issues, to be presented forapproval by IAMLA membership atthe Fifth International Conferenceon Medical Regulation, in Toronto,Canada, in June 2002. Final mem-bership criteria and a dues struc-ture will be included in the IAMLAbylaws. In addition, an accurate ref-erence listing for all known medi-cal licensing and regulatoryauthorities will be developed toenhance the exchange of informa-tion.

The challenge for medical regu-lation in the 21st century is tocreate a relevant, effective medicalregulatory system that can addressthe dynamics of global and rapidlychanging medical practice environ-ments, technologies and healthcare delivery systems. Internationalcooperation is the key to enhanc-ing the role of medical regulatoryauthorities as the primary vehiclefor public protection in health care.IAMLA will help this goal become areality. ■

Dale L. Austin, MA, is Interim Chief ExecutiveOfficer of the Federation of State MedicalBoards; 400 Fuller Wiser Road; Suite 300;Euless, TX 76039-3855, USA. Telephone: +1(817) 868-4067; Fax: +1 (817) 868-4097; E-mail: [email protected]).

MO

Publications■ Blumenthal DS, Boelen C, eds.Universities and the health of thedisadvantaged. Geneva, WorldHealth Organization, 2001 (unpub-lished document WHO/EIP/OSD/2000.10; available on request fromDepartment of Health ServiceProvision, World Health Organiza-tion, 1211 Geneva 27, Switzerland).

■ Boelen C. Towards unity forhealth. Challenges and opportuni-ties for partnership in healthdevelopment. A working paper.Geneva, World Health Organization,2000 (unpublished document WHO/EIP/OSD/2000.9; available on requestfrom Department of Health ServiceProvision, World Health Organiza-tion, 1211 Geneva 27, Switzerland.Translations into French and Spanishare in preparation.).

■ Collaboration between the WorldHealth Organization and the WorldOrganization of Family Doctors.Geneva, World Health Organization,and Singapore, World Organizationof Family Doctors, 2001 (For copiesof this 16-page brochure, pleasecontact Dr Alfred W.T. Loh, ChiefExecutive Officer, WONCA WorldSecretariat, College of MedicineBuilding, 16 College Road #01-02,Singapore 169854 (Telephone:+65 224 2886; Fax: +65 222 0204;E-mail: [email protected]).

Coming soon■ A view of the world’s medicalschools: defining new roles.Geneva, World Health Organization.

■ Improving health systems:the contribution of family medicine.A guidebook. Singapore, WorldOrganization of Family Doctors,and Geneva, World HealthOrganization. ■


Accreditation and development ofmedical schools: a global project1

Charles Boelen, World Health Organization, Geneva

Debates on the definition of asocial mandate, on the expressionof the social responsiveness of amedical school and on the neces-sity to consider these issues in thelight of specific socioeconomiccontexts are not new (6, 7). Similarconcerns have been expressedregarding health professions prac-tices and health service organiza-tions (8, 9, 10).

The wealth of available knowl-edge and recommendations shouldbe translated into sets of standardsand indicators to allow properassessment and promotion of so-cial responsiveness. The design ofaccreditation models should bebased on the following premises:

Accreditation: key leveragefor changeHealth service organizationsshould be guided by a universalquest for improved quality, equity,relevance and cost-effectiveness.Likewise, the health professionsand educational institutions, re-garded as key contributors tohealth development, should beheld equally accountable forachieving these values. The missionof educational institutions is inprinciple intimately linked to themission of the entire health systemof a nation, and the appraisal oftheir performance is a componentof that mission.

The main purpose of educationis to prepare future generations ofhealth professionals to efficientlyaddress people’s priority healthneeds. While the acquisition ofgiven sets of competences andskills should be influenced by auniversal corpus of values andknowledge unique to the healthprofessions and disciplines, themilieu in which they are expected

to practise should always be takeninto account.

Advocating the global relevanceof standards of social responsive-ness does not mean that features ofmedical schools and medical edu-cation should be made uniform. Akey concern is to respond as effi-ciently as possible to local healthneeds through optimal use of localhealth resources. But health care,medical practice and medical edu-cation are equally expected to beorganized to serve the values ofquality, equity, relevance and cost-effectiveness.

Because of the close relationshipbetween medical education, medi-cal practice and the health caresystem, the notion of social respon-siveness of medical schools shouldbe developed by including inter-ventions related to these threecomponents. The intimate inter-face between medical-school func-tions in education, research andservice provision also pleads for amore holistic approach in review-ing their mission. A framework foraccreditation would therefore en-compass elements related to theimpact of medical schools andmedical education on careerchoices of graduates, on the workof the medical profession and theon performance of the health sys-tem. It would also consider thecapacity of medical schools to con-tribute to creating productive andsustainable partnerships with otherimportant stakeholders on thehealth scene to improve the deliv-ery of health services as well aspeople’s health status.

The need to use such a compre-hensive approach was recognizedby the World Health Assembly in1995 and is being increasingly ad-vocated in national strategies (10).

GLOBAL STANDARDS

1 Extract of a paper in preparation forpublication.

Do schools contribute to im-proving people’s health asmuch as they potentially

can?” This question is furtherprompted by globalization trendsand their corollaries for more trans-parency and for more widely avail-able information for assessment.With the mobility of graduatesacross borders and the search forglobal consensuses on best prac-tices in medicine and education ofhealth professionals, internation-ally compatible evaluation schemesare needed.

Efforts have been made over theyears and worldwide to improve thequality of medical education andthe social responsiveness of medi-cal schools through proposedguidelines and benchmarks (1, 2, 3).The impact of these tools remainsquestionable regarding sustainablechanges in the mandate and scopeof interventions of medical schools.While some medical schools sub-mit themselves to a formal accredi-tation process, only a handful ofthem use measurement tools toassess their responsiveness oraccountability in meeting society’spriority concerns (4).

The “social accountability” ofmedical schools should be definedas the obligation to direct their edu-cation, research and service activi-ties towards addressing the priorityhealth concerns of the community,region and/or nation they have amandate to serve, with the under-standing that priority health con-cerns are to be identified jointly bygovernments, health care organiza-tions, the health professions andthe public (5).

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But it is submitted that because ofthe complexity of the task for indi-vidual countries and institutionsand the intimate internationalrelationships [required], thesestrategies will be sustainably imple-mented only if coordinated globalaction is taken with a view to sug-gesting standards and proceduresof accreditation and encouragingdevelopment in these areas.

A global projectTable 1 outlines a global project forthe accreditation of medicalschools on the basis of social re-sponsiveness, validated by a globalconsortium and publicized on theWorld Wide Web with the aim ofimproving the performance ofschools in health systems develop-ment. Each component is identi-fied by a number (1 to 9) and eachtransaction linking components isidentified by a letter (A to P).

Component 1. The world with its 6billion inhabitants has about 6 mil-lion physicians serving in 192 coun-tries, trained in about 1700 medicalschools. A scenario is proposed inwhich a medical school is aware ofthe existence of a global project foraccreditation and development.The school contacts the globalconsortium for accreditation ofmedical schools for assistance(transaction A).

Component 2. There is a globalconsortium of representatives ofthe main international and na-tional agencies active in interna-tional medical education. Theirwillingness to be part of the globalconsortium implies a shared visionthat medical schools can andshould play a significant role inhelping to attain national healthobjectives through collaborating toshape an optimal health system,and that their capacity in this re-gard should be assessed and be-come an important reference fortheir accreditation. One memberagency of the consortium is as-signed the responsibility of main-

taining a global database of medi-cal schools (transaction B). Themaintenance of the database cantake different forms: (1) each medi-cal school updates its own profileat its discretion through agreed ac-cess and validation procedures; (2)the consortium uses the databaseto assess progress in accreditationworldwide; (3) the consortium mayseek specific information frommedical schools with regard to im-portant issues.

The global consortium estab-lishes a pool of experts (transactionC) whose main task is to developsets of standards. It will, however,ensure that the purpose of accredi-tation and development of medical

schools is consistent with the basicprinciple of best serving society’shealth needs and is well reflected bythe proposed standards (transac-tion D).

Component 3. While several re-gional and subregional databasesof medical schools exist, very fewglobal databases have been devel-oped. The World Health Organiza-tion has been active in surveyingmedical schools over the last threedecades and publishing basic infor-mation on medical schools in itsWorld directory of medical schools.The seventh and last edition, issuedin the year 2000, was the occasionto develop an electronic database

GLOBAL STANDARDS

Table 1. Global project for accreditation and developmentof medical schools


is provided that it uses the mostappropriate educational strate-gies to train doctors to best servethe priority health needs ofsociety.

● A medical school is recognized asbeing of type B when evidenceis provided that it prepares itsgraduates to properly function ina practice environment—whichit would have contributed toadapting—to best serve the pri-ority health needs of society.

● A medical school is recognized asbeing of type A when evidenceis provided that it prepares itsgraduates to properly practise ina health system—which it wouldhave contributed to designing—to best serve the priority healthneeds of society.

Standards will lead to developingmeasurement tools for assessment(transaction F) and be reflected inthe notification (transaction G).

Component 5. The pool of expertsis the scientific core of the globalproject. They will develop stand-ards and measurement tools re-flecting the typology in threecategories (transaction H). Theywill suggest core standards that areuniversally applicable, as well ascontext-specific standards. Theywill also design and implement re-search and development activitiesto adapt and improve the definitionand use of standards and measure-ment tools.

While the pool of experts will bedrawn from the global consortium(transaction C), global networksactive in health professions educa-tion and practice are encouraged tosubmit names of candidates (trans-action N). The following criteria areproposed to be considered as a can-didate:

● recognized expertise in assessinginstitutional performance;

● extensive international experi-ence in medical educationand management of medicalschools;

● a history of developing strategiesfor more socially responsivehealth systems;

● current involvement in fieldprojects in different continents;

● full commitment to the principleof social responsiveness/ac-countability of medical schools;

● independence from undue influ-ences, particularly commercialones.

The pool of experts would becomposed of up to 50 membersreflecting socioeconomic and cul-tural specificities in the world anda fair geographical distribution.Experts will be in charge of theassessment of medical schools(transaction I).

Component 6. The assessmentcould be carried out under differ-ent modes. A medical school mayopt for a self-assessment mode andbe advised on how to independ-ently use an evaluation kit based onthe proposed standards. Further, itmay ask the pool of experts toexamine the results of its self-assessment and validate them. Ex-perts may be able to do this at adistance through an established setof procedures. Finally, a medicalschool may ask the experts to makea site visit and carry out the assess-ment, through a pre-determinedprotocol.

The results of the assessment areof primary interest to the medicalschool itself in order to improve itsperformance, identify areas requir-ing improvement (transaction K)and possibly call for collaborationwith global networks specialized ininstitutional development (trans-action L). A medical school may al-low the results to be publicly knownand accept these to be recorded inthe global database (transaction J).

Component 7. The assessment andaccreditation ought to be seen asmeans to stimulate and guide thedevelopment of a medical schooltowards fulfilment of its social

with information collected througha world survey on 250 questions(11, 4). The global database couldserve as a baseline. Under condi-tions that must be determined,WHO would allow the consortium,of which it would be a member, touse the database.

All or part of the database wouldbe accessible to the public (trans-

action E), which is an essential fea-ture of the global project. Due toclearly expressed profiles of medi-cal schools and transparency as tohow assessment is carried out, citi-zens would be in a better positionto make informed choices to takeadvantage of educational andresearch programmes. Medicalschools themselves and otherhealth institutions would have abetter base from which to negoti-ate collaborative ventures.

Component 4. The establishmentof standards to assess the quality ofmedical education and the per-formance of medical schools to bet-ter meet priority health needs ofindividuals and populations is cen-tral to the global project. Standardswill help to develop a typology ofsocial responsiveness of medicalschools. Medical schools could begrouped into three categories ac-cording to their degree of social re-sponsiveness: type C, type B andtype A. Type A is the highest andmost desirable category, and incor-porates the attributes of types Band C.

● A medical school is recognized asbeing of type C when evidence

GLOBAL STANDARDS


mandate through its different mis-sions: educating physicians,supporting optimal practice andcontributing to improving theworking environment in a healthsystem. A profile helps to capturepriority domains for the improve-ment. Strategies can be elaboratedwith a view to addressing capacitieswithin the confines of a Type (A, Bor C) or increasing the general scoreof the school from one Type to ahigher one.

The support proposed to theschool to implement its develop-mental strategy covers a wide rangeof resources: a list of “how to” ma-terials and experts, classified perType or capacity within a Type;citation of medical schools or otherinstitutions willing to serve as ref-erences for twinning arrangements;names and contacts of agenciesinterested in providing technicaladvisory services and possiblyfunding. The global consortium,through its membership and con-tacts with global networks, shouldbe able to guide the medical schoolin obtaining the necessary supportand assist in coordinating it withina coherent strategy for change andimprovement.

Component 8. The expertise andexperience of global networks con-cerned with the wide range ofhealth development and humanresources for health issues shouldbe tapped to both nurture the poolof experts (transaction N) and as-sist in development (transactionO).

Component 9. With the agreementof the school, its score in accredi-tation and information on its stateof development would be madepublic (transactions J and M). Re-garding accreditation, notificationwill refer to Type A, B or C.

As indicated earlier, the medicalschool may assess itself and reportits findings, which will be recordedas A, B or C. The second option isto have the results reviewed andpossibly validated at a distance by

designated experts from the pool.If validated, results will be noted asA+, B+ or C+. Finally, the third op-tion is an assessment made on-siteby three experts designated fromthe pool; their opinions will be re-corded as A++, B++ or C++. Notifi-cation related to options two andthree is officially endorsed by theglobal consortium.

It may be that a school expressesthe wish for its self-assessmentscore to be validated by the globalconsortium, either by distance re-view or site visit. In case of conflict

between scores from self-assess-ment and any other form of assess-ment (distance review or site visit),the last one will prevail and bereported in the global database(transaction P). Scores can alwaysbe reviewed after a given develop-mental process has taken place. ■

Further details on the global project for theaccreditation and development of medicalschools can be obtained from the Departmentof Health Service Provision, World HealthOrganization, 1211 Geneva 27, Switzerland(Fax: +41 22 791 4747).

GLOBAL STANDARDS

New journal: The meducatorEditors: Dr Kalyani Premkumar and Dr John S.Baumber; Faculty of Medicine, University of Calgary,Alberta, Canada; Meducational Skills, Tools &Technology Pvt. Ltd. India

Anew quarterly journal, The meducator, is presently available online andon paper. Independent and with no allegiance except to the world community, the journal is based on the belief that education is the key to

improving world health. It aims to provide a forum through which the globalvillage of medical educators can shareexperiences and discuss experimen-tation in medical education to serve thehealth needs of local communities andultimately nations.

Each issue will have a theme. Thefirst theme was “The Response of Medi-cal Schools to Societal Needs”. Thesecond was “Building Bridges betweenNations”; the third will be “CommonStandards for all Physicians?”

The initial features of this peer-reviewed journal include the follow-ing: reviews, research and develop-ment, communications, opinions,news, a handbook for physicians anda student forum. The meducator willcover the spectrum of education from premedical to continuing post-graduate education.

The editors describe The meducator as truly a grassroots enterprise, whosesuccess will depend on support, subscriptions and contributions. Dr CharlesBoelen, Executive Editor of this newsletter, is a member of The meducator’seditorial board.

The first issue is available free of charge. For more information, pleasecheck the Web site: http://www.meducational.com/journal ■


HEALTH SYSTEM IMPROVEMENT

Vincent De Brouwere

1 The Big Six as defined in the GeneralProgramme of Work of WHO in the1950s: malaria, tuberculosis, STDs,maternal and child health, environ-mental sanitation and nutrition.

Primary health care is stillon the agenda, but…Vincent De Brouwere and Bruno Marchal, Department of Public Health,Institute of Tropical Medicine, Antwerp, Belgium

“attention to felt needs” have beenreplaced by “fairness in financialcontribution” and by “responsive-ness”, respectively. Although thedebate about this report is notclosed, it is not the aim of thispaper to add to that polemic.

Threats to primary healthcare-based health systemsIn our opinion, the real threat1

against PHC is, first, the againincreasingly important role ofprioritizing in international healthpolicy and, second, the fragmenta-tion of aid programmes.

Setting top prioritiesAIDS, malaria and tuberculosis arecertainly the major killers in mostdeveloping countries. This beingthe case, it only makes sense to tryto obtain significant globaladvances by focusing on cost-effective control programmes forthese diseases—programmes thatoften are implemented under aproject format. But this priority-setting, which is allegedly based onactual needs, tends to be done at in-

ternational level withquite limited inputfrom recipient coun-tries, certainly fromthose in which AIDS isnot highly prevalent.

Believing it possibleto control such complexpoverty-related healthproblems without im-proving health systemsseems naïve regardingthe lessons learnt fromour 20th century history:“sustainable primary caremust be the first ambitionof any global fund forhealth” (1). Furthermore,

even if ap r o j e c t -o r i e n t e da p p r o a c hw o u l dprove to bemore effi-cient, itmay be incontradic-tion withthe WHR,

which stresses that health policydecision-making should be moreresponsive to people’s demands.

FragmentationThe interventions of the majoractors in health have become dis-persed and fragmented. First, therehas been a huge increase in thenumber of partner organizationsworking in the field of health. Theseinclude the international agencies,but also many smaller-scalenational or local NGOs and organi-zations. They all share an increas-ing market-driven orientation,leading to “economically sound”interventional logic’s obtaining theupper hand.

Second, bilateral cooperationagencies and private philanthropicfunds (for instance, the Bill &Melinda Gates Foundation) are in-creasingly influencing the agendaand policy of international healthby the sheer size of their contribu-tions and the specific conditionsconcerning the use of these funds(“earmarking”). But the socialaccountability of these donors canbe questioned, with regard to both

Primary health care (PHC) isstill high on the internationalhealth agenda, but it has lost

much of its prestige. Some alreadyconsider PHC to be an old-fashioned strategy that is doomed:20 years after its launching, it stilldoesn’t bring health for all.

The WHO World health report2000 (WHR) clearly expressed the“at least partial failure” of so-calledPHC programmes. The main criti-cism is about “too little attentiongiven to people’s demand for healthcare, which is greatly influenced byperceived quality and responsive-ness, and instead concentrating al-most exclusively on their presumedneeds.” The major innovationbrought by PHC, i.e. communityparticipation—the involvement ofindividuals and the community inhealth (care) decision-making—was thus restricted to its financialcomponent.

The WHR however brought a re-newed interest for the values un-derlying PHC, even if—andperhaps because—worn-out wordssuch as “financial equity” and



Making communitiesreal partnersAkin Osibogun, University of Lagos, Nigeria

their home communities in theNorth and the end-users in theSouth.

Thirdly, the managementapproach of international agencieshas contributed to misdirectedefforts. Programme managers inthese agencies are evaluated ontheir capacity to implement a pro-gramme (meaning sometimes“capacity to spend the budget”,whatever the content).

But implementing a programmeaimed at increasing the wealth of apopulation does not mean that thisis a felt need, or that it is a needidentified by local health person-nel. Therefore, health workers andthe population do not feel reallyconcerned by the outcome of suchdonor-driven programmes.

Also, agencies exert a perverseinfluence, as they cause a localbrain drain by diverting healthworkers from their assigned roles.In some cases, health personnelspend up to 50% of their time at-tending seminars and workshops,stimulated by incentives (2).

All this contributes to a viciouscircle that undermines attempts tobuild a public service that lives upto the legitimate demand for qual-ity care and this, with the tacitconsent of all the actors (healthworkers, policy-makers anddonors) (3).

Fourthly, verticalization, in aneffort to maximize effect for money,and the measurement trap—whereby preferably quantifiablegoals are pursued for results in theshortest time possible—contrib-utes to designing fragmented inter-ventions.

Unity: the next frontierThese four elements play a largepart in the lack of a systematic viewof the problems, which is essentialfor a “good” PHC approach. Com-petition, not cooperation, is at theheart of international health thesedays. Sector-wide approaches(SWAPs) have been attempted inseveral countries to overcome thefragmentation in health sector

interventions. Unfortunately, thisattempt showed how limited suchapproaches are unless essentialingredients—among which “acountry-led strategy around whichdonors can coalesce” is crucial—are missing (4). More than ever, weneed to summon up our strength toinsert integrated primary healthcare systems as the cornerstone ofa world strategy to achieve HealthCare for All. ■

References1. Anonymous. A global health

fund: heeding Koch’s caution. TheLancet, 2001, 358(9275):1.

2. Bodart C et al. The influence ofhealth sector reform and externalassistance in Burkina Faso.Health Policy & Planning, 2001,16(1):74–86.

3. Van Lerberghe W et al. Perform-ance, working conditions andcoping strategies: an introduc-tion. Studies in Health ServicesOrganisation & Policy, 2000, 16:1–5.

4. Walt G et al. Managing externalresources in the health sector: arethere lessons for SWAps. HealthPolicy & Planning, 1999,14(3):273–284.

Dr De Brouwere is a professor in theDepartment of Public Health, Institute ofTropical Medicine, Antwerp, Nationalestraat155, 2000 Antwerpen, BELGIUM. (Telephone:+32 3 247 62 86; Fax: +32 3 247 62 58;E-mail: [email protected]). Dr Marchal isAssistant, tutor of the International Course inHealth Development (Master’s in PublicHealth course).

Rationale for partnerships in health

Health care delivery in Nigeria,as in several other developingcountries, has been subject

to stresses such as inadequatefunding and improper manage-ment of resources that haveadversely affected the quality ofservice and consumer satisfaction.

In the mid 1970s it wasdiscovered—through hindsightand evaluation of past failedprogrammes—that communityinvolvement had been obviouslyabsent or lacking in most failedprogrammes. Most programmeswere not sustained after the exit ofthe initiator because the recipientsperceived the programmes to bealien and not their responsibility;they therefore made no effort to seethat they were maintained. Thisled to waning of the effects ofprogrammes such that the pro-

grammes never maintained theirinitial impact—if there was anyimpact (1).

It is thus of critical importancethat health workers work inpartnership with communitymembers. Individuals and familiesmust assume responsibility fortheir own health and welfare andthat of others in the community

Akin Osibogun


and develop the capa-city to contribute totheir own and thec o m m u n i t y ’ sdevelopment.

Communities andtheir mem-bers mustbe active partners inhealth development if anymeaningful progress is to bemade. A situation in whichcommunity representatives areincluded for “window-dressing”while power continues to becentralized cannot be consideredas genuine partici-pation (1).

If communities are to be realpartners in planning, implemen-tation and evaluation of healthprogrammes, managerial skills thatmost often were hitherto lackingare urgently required, not only forthe community members, but alsofor the health workers themselves.Support is therefore necessary fordurable partnerships to evolve andflourish. Such support shouldinclude political commitment ofthe highest levels of government.Ethiopia’s recent strides towardsachieving this are an example (2).

Another imperative for healthdevelopment is the presence of alocal administration that isapproachable and that can quicklyrespond to local communityinterests. There will also have to beadequate resources allocated to thelocal governments to achievehealth goals.

It is thus obvious that theevolving partnership must involvethe communities, the healthworkers, the local administration,the policy-makers and traininginstitutions that can influence theorientation of the present andfuture health worker. There isperhaps no further argument aboutthe desirability of empoweringcommunities to help themselvesand the sooner self-help is takeninto account as one of the basiccomponents of PHC in allcountries, the likelier it will be thatwe shall move towards achievinghealth for all (3).

The impact ofcommunities in thepartnershipA small study wasconducted in 19 LocalGovernment Areas in

Nigeria to determinethe spread of commu-

nity organizations forhealth development in

Nigeria, the role suchorganizations play in

health care delivery and theeffects they have on the utilizationand acceptance of health pro-grammes and health services. Thisstudy showed that services weremore acceptable, better utilizedand better supported financially bycommunity members in those localgovernments where different formsof partnerships existed between thehealth service and the commu-nities (Table 1).

The study also showed that thesehealth committees operate withinfavourable social and politicalconditions (78.9%) with good localleadership support (84.2%). Thisfinding supports the expansion ofpartnerships to involve policy-makers and health administrators.The role of the academic institutionwill then be to ensure the righttraining and orientation for presentand future health workers, as wellas to be active in pursuingparticipatory research as a meansof gathering evidence for decision-making by members in thepartnership.


Nigeria

Table 1. Community organization and implementationof health programmes

Health committee exists orcommunity organizationaffiliated with health centre

YES n=16 NO n=3

% with acceptable services 62.5% 33.3%

% with successful community projects 81.3% 33.3%

% with services publicized 68.8% 33.3%

% contributing labour or resources to health services 100.0% 66.7%

% in which community provides funds through fees or insurance 80.0% 66.7%

% in which community helps with community needs assessment 80.0% 33.3%

Parnerships that work:Nigerian experiencesThe Ode Remo Community in OgunState, Nigeria, is a quiet towninhabited mainly by farmers andpetty traders. The people, likethose of most other communitiesin southwestern Nigeria, havebenefited from early contact withmodern educational methods andare therefore highly enlightened.Members mobilized themselvesthrough traditional institutions inthe community and constructed a16-bed health centre for their ownuse.

This facility has been staffed bythe local government authority andthus effectively ensures an ongoingpartnership between the commu-nity, the medical school/teachinghospital, the administrators of thehealth department and the policy-makers at the local governmentlevel.

In Odogbolu Local GovernmentArea, also of Ogun State, membersof the community have beenmobilized to form a Health Societythat provides health insurancecover for its members. This societyis in active partnership with thehealth workers, the administrationof the health department, thepolicy-makers at the local govern-ment level, and the Department ofCommunity Health of the Collegeof Medicine of the University ofLagos. This partnership is alreadyabout five years old.

In Surulere Local Government


Area of Lagos State, about a one-hour drive from Odogbolu, adifferent kind of partnership isevolving between a nongovern-mental organization set up topromote the health of the elderly,the Surulere Local GovernmentCouncil health administrators andthe policy-makers, and the Depart-ment of Community Health. Thepartnership is ensuring the provi-sion of highly needed geriatrichealth services as well as theopportunity for training of post-graduate doctors.

Making partnerships workCertain preconditions found to benecessary for the success ofpartnerships include a willingnessto learn on the part of all partnersand more especially those fromacademic institutions. Members ofthe community are not totallyignorant and often have validexplanations for their ways of life.Members from academic institu-tions and health workers must be

patient enough to grasp theseexplanations.

Policy-makers must be helped tounderstand the new paradigm ofdevelopment, which is aboutpeople. There can be no develop-ment without people, and health iscentral to the lives of people. Thisunderstanding is expected totranslate into better funding andsupport for health programmes.

Most importantly, developmentcan happen only when all hands areon deck in the true spirit ofpartnership. The people must chipin their own contribution andassume responsibility for their ownhealth, while the administratorsmust discharge their respon-sibilities equitably. Such partner-ships will ensure that healthprogrammes have a better chanceof success, because health serviceswill be consistent with localperceptions of health needs andmanaged with the support of localpeople. ■

References1. Health system support for pri-

mary health care. A study basedon the technical discussion duringthe Thirty-fourth World HealthAssembly. Geneva, World HealthOrganization, 1981 (Public healthpapers, No. 80).

2. Oakley P, Marsden O. Approachesto participation in rural develop-ment. Geneva, InternationalLabour Office, 1985, 54–58.

3. David R. The self help compo-nent of primary health care.Social Science and Medicine,1981, 14(A):415–421.

4. Kahssay HM, Oakley, P. Commu-nity involvement in healthdevelopment: a review of theconcept and practice. Geneva,World Health Organization, 1999.

Akin Osibogun, MBBS., MPH., FMCPH.,FWACP., Dip. Mgt., is Senior Lecturer andActing Head, Department of CommunityHealth, College of Medicine of the Universityof Lagos, P.M.B. 12003, Surulere, Lagos,NIGERIA (E-mail: ).


If I were Minister of Health: the Greek healthparadox and the health policy conundrumAnastas E. Philalithis, University of Crete, Heraklion, Greece

When I was asked to contribute a piece to this journal entitled “If I were Minister of Health”, my immediate response wasthat the topic was quite intriguing, since this is the sort of game that one would play, preferably in a Greek café, but notnecessarily commit to paper. Still, as it was an interesting challenge, I accepted. The result is a policy statement that Iwould like to hear from the Minister of Health of my country today.

Health in Greece is character-ized by a paradox: no one iscontent with the health care

delivery system, yet health status isamong the best in the world. Lifeexpectancy is among the highest,maternal mortality and the stand-ardized death rate for most diseasecategories are among the lowest;infant and perinatal mortality aresteadily improving.

Of course, the apparent contra-

diction can be explained by thelifestyle, societal and environ-mental determinants of health. Theexcellent health indicators cameabout as a result of overall socialand economic development, of theMediterranean diet that we havenot yet abandoned, of the relativelyunspoilt environment, of the factthat many people still “exercise”because they are farmers. They arealso due to the preservation of

family bonds and social networkswhose contribution to healthmaintenance is increasingly beingrecognized. They cannot be attri-buted to the public health services,the staffing and performance ofwhich have been inadequate foryears.

Two significant exceptions to thefavourable omens are cancer of thelung, whose incidence is rising (percapita cigarette consumption is,


after all, among the three highest inthe world), and deaths from motorvehicle accidents, where we havethe worst record in the EuropeanUnion.

At the same time, the health caredelivery system is actually quiteeffective and—despite our geogra-phy (with its small islands and dis-tant mountain villages)—quiteaccessible, even while it is not “userfriendly”. Perhaps it is so “open”because Greek patients have theability to “find their way about”, i.e.to circumvent any bureaucratic,administrative or financial barriersthat exist, albeit while paying theadditional costs that they incur be-cause they break the rules.

But circumstances are changing.New lifestyles are being adopted,not always for the better. Family tiesare weakening; social solidarity isbecoming rare; the influx of a largenumber of immigrants is puttingconsiderable strain on society. Atthe same time, advances in medi-cal science, including genomics(and possibly cloning), and pro-gress in biomedical technology aremaking health care delivery morecomplex and more expensive. Weneed a health policy that will facethe challenges that loom aheadwithout destroying past achieve-ments.

My answer to this conundrum isa two-pronged policy. The first axisis a multisectoral health policy thataddresses the broad determinantsof health, underpinned by a reno-vated public health service. Thesecond axis is a reorganization ofthe national health system, based

on a strengthened primary healthcare (PHC) system. Both compo-nents must be supported by anappropriate health workforce man-agement and development policy.

A multisectoral health policy andpublic health servicesPolicies in all areas of governmentresponsibility must take intoaccount their effect on health. Twoexamples will illustrate the point:agricultural, commercial andindustrial policies affect nutritionand, Greece being a tobaccogrowing country, smoking.

Transport policy, better roads,stricter policing, seatbelts andhelmets and the ambulance servicecan reduce deaths from trafficaccidents. But these things willhappen only if the Public HealthService is overhauled to be able tocarry out regular health needsassessment and policy analysis andformulate, implement and advo-cate policies with a positive healthimpact. It should also monitor theperformance of the health caredelivery system, measuring itseffectiveness, efficiency andresponsiveness to needs.

Health care reform and primaryhealth careThe reorganization of the NationalHealth System is already under way.The creation of the 17 RegionalHealth Systems will decentralizedecision-making, and measures toimprove hospital management arebeing instituted. The next step,under preparation, addresses thefinancing of the system. It alsofocuses on PHC, with the creationof a general practice/family medi-cine service in urban areas and theconsolidation of the existing healthcentres in rural areas.

The aim is to create a PHCsystem that is comprehensive andaccessible 24 hours a day, sevendays a week, that provides continu-ity and home care, and that can actas a familiar guide to the patientwho is faced with the labyrinth ofincreasingly specialized services.

People will stop flocking tohospitals for the most minorailments, as they do now, onlywhen they have confidence in thealternative.

Health workforce developmentPolicies are formulated andimplemented by people. Workforceplanning and improving the edu-cation of health professionals arecrucial for the success of any healthpolicy. We must establish suitabletraining programmes for generalpractitioners and social medicinespecialists, and the education ofnurses must be upgraded. Themedical faculties must introduceundergraduate courses in PHC,following the example of theUniversity of Crete, and moreuniversity nursing faculties must beestablished, in addition to that inthe University of Athens.

Economists, social scientists andadministrators must be attracted tothe management of the healthsector. Of course, adequate pay forall health professionals andmanagers is necessary to recruitand retain people of a high calibre.

The political processSo far, I have presented thetechnical aspects of health policy.But nothing happens unless thepolitical issues are addressed: Inwhose interest is one acting? Whoseinterests are threatened? Who arethe allies you can rely on, and whoare the foes you should isolate?Who are those whose commitment,involvement and active partici-pation is forthcoming and who arethe stakeholders who will resist anychange?

Organized groups will lobby,overtly or covertly, for measuresthat favour their vested interests.But who will look after the interestsof the public at large? Fulfilling thispolitical role is a principal functionof the ministry of health. Otherwiseall technical solutions, includingthe laws that are passed, will justdecorate one more shelf in thelibrary of the ministry.


Anastas E. Philalithis


ConclusionGreece has achieved an enviableposition in the health league tables,without really trying. The NationalHealth System has attained asurprisingly high degree ofeffectiveness, without actuallyrealizing it. But things will notcontinue to improve on their own,and some trends are alreadydeteriorating.

We must strengthen positivetrends and reverse negative ones.We must face the new challenges,while building on the successes ofthe past. Public health services andprimary health care are the twoareas where any investment is mostlikely to bring big dividends in thefuture. ■

Anastas E. Philalithis, MB BS, MD, MRCP,MSc, is Associate Professor of SocialMedicine, Faculty of Medicine, University ofCrete, PO Box 1393, 711 10 Heraklion, Crete,GREECE (Telephone: +30 81 39 46 00;Fax: +30 81 39 46 06;E-mail: [email protected]).

Family medicineAn asset for the health ofthe BangladeshiKhaleda Islam, Centre for Medical Education,Dhaka, Bangladesh

patient load of district general hos-pitals, which are secondary-levelhealth centres, are entirely for pri-mary care (3). For Bangladesh, aneffective generalist approach to thehealth care has therefore becomeessential to provide cost-effectivecare.

But most of the country’s generalpractitioners have scarcely any op-portunity for education or training.

Considering this, some profes-sional groups and academic insti-tutions are making sporadicattempts to run family medicinecourses for general practitioners.The Bangladesh Private MedicalPractitioners Association estab-lished the Bangladesh College ofGeneral Practitioners, which offersfellowships in family medicine andis conducting a continuing medicaleducation course. The BangladeshCollege of Physicians and Surgeonshas started conducting member-ship examinations in family medi-cine and offering the designation“Member of the College of Physi-cians and Surgeons” (MCPS), butonly 37 MCPS have been confirmedto date. The University of Science

FIVE-STAR DOCTOR

The status andfuture of TUFH

Two years after the WHOinternational conference

on Towards Unity for Health,in Phuket, Thailand, the TUFHAdvisory Committee was toreview achievements atglobal, regional and nationallevels. As this issue was inproduction, the committeewas scheduled to meet from21 to 22 September inBarcelona, Spain. The agendaincluded planning the nextactions with respect to:TUFH field projects; educa-tional initiatives on TUFH;use of comprehensivemanagement of information tocreate unity amongstakeholders; TUFH and thehealth professions; and globalnetworking with NGOs.A report of the meeting will beavailable late in 2001. ■


Still facing great challenges

Bangladesh is making remark-able progress in the healthand family planning sector.

The country has developed aunique health care infrastructure,divided into primary, secondaryand tertiary facilities, that coverseverything from remote villages tobig cities.

Despite its advances, Bangla-desh remains one of the fewcountries in which life expectancyat birth is lower for females. Some70% of mothers suffer from nutri-tional deficiency anaemia, 75% ofpregnant women do not receiveantenatal care or assistance from atrained attendant at the time ofchildbirth, and the maternalmortality ratio (4.2) is still high. Lessthan 40% of the population hasaccess to basic health care, and useof primary and secondary healthcare services remains poor overall(1).

Essential Service Packageand family medicineThe concept of the Essential Serv-ice Package (ESP) was adopted bythe Health and Population SectorProgramme (HPSP) to provideprioritized primary care with spe-cial consideration for women, chil-dren and the poor (2).

Currently about 19,000 doctorsare either working in the privatesector or are self-employed in pro-fessional practice. Approximately70% of all doctors are in some formof medical practice but are notserving as true general practition-ers or family physicians. A recentstudy revealed that 30% of the out-

Khaleda Islam


Bangladesh

and Technology, Chittagong, hasstarted a postgraduate diplomacourse in family medicine, and theBangladesh Academy of FamilyMedicine is planning a Diploma inFamily Medicine course.

Need for a nationalconcerted effortWONCA and WHO are very muchbehind the whole initiative of de-veloping the discipline of GP/FM inBangladesh. A national workshopwas held in February 2000 in Dhakato identify the ways and means ofintroducing family medicine at theundergraduate level. As a result, afeasibility study for the establish-ment of units of family medicine isunder way, with the following termsof reference.

● To evaluate the current status offamily medicine/general prac-tice, and to identify the relation-ship between practice andeducation.

● To assess the current content ofeducation for family medicine inmedical schools, particularly atthe undergraduate level; to iden-tify opportunities and means tostrengthen it; and to assess the

feasibility of establishing depart-ments/units of family medicine

● To identify the means and proc-esses for sustainability of suchan initiative.

A report revealed a shortage oftrained teachers and other resourceconstraints, and recommendedthat selected medical colleges startdepartments of family medicine. Toensure an essential service pack-age, the country needs doctors whowill not only treat the patient com-petently, but also possess all theaptitudes of the “five-star doctor”(5).

The introduction of an effectivegeneralist approach is essential inBangladesh to improve theperformance of the health servicedelivery system. But such an effortshould be guided by a clearlydefined strategic action plan thatshould rally the most importantstakeholders in the health system:policy-makers, health managers,professional associations,academic institutions and repre-sentatives of civil society. Theapproaches imbedded in the“Towards Unity For Health” projectwould be useful for its successfulimplementation (6). ■

References1. Bangladesh Bureau of Statistics,

1999.

2. Health and population sectorprogramme 1998–2003, HPSP,program implementation plan,part 1. Dhaka, Ministry of Healthand Family Welfare, Governmentof the People’s Republic ofBangladesh. 1998.

3. Health Economics Institute,Dhaka University, 2001.

4. Sayeed AA. Prospect of generalpractice in Bangladesh: a feasibil-ity study. Dhaka, WHO ProjectOffice, 2000.

5. Boelen C. Frontline doctors oftomorrow. World Health, 1994,(5):4–5.

6. Towards unity for health. Chal-lenges and opportunities forpartnership in health develop-ment. A working paper. Geneva,World Health Organization, 2000(unpublished document WHO/EIP/OSD/2000.9; available onrequest from Department ofHealth Service Provision, WorldHealth Organization, 1211Geneva 27, Switzerland).

Dr Khaleda Islam is Assistant Professor,Centre for Medical Education, Mohakhali,Dhaka 1212, BANGLADESH(E-mail: [email protected]).

FIVE-STAR DOCTOR

Better online access to health informationfor developing countries

WHO and the world’s six biggest medical journal publishers recentlyannounced a new initiative that will enable almost 100 developing coun-tries to gain access to vital scientific information they otherwise could

not afford. According to the new arrangement, almost 1000 of the world’s lead-ing medical and scientific journals will become available through the Internet tomedical schools and research institutions in developing countries free of chargeor at sharply reduced rates.

Until now, biomedical journal subscriptions, both electronic and print, have beenpriced uniformly for medical schools, research centres and similar institutionsregardless of geographical location. Annual subscription prices cost on averageseveral hundred US dollars per title; many key titles cost more than USD 15 000per year.

Scheduled to start in January 2002, the initiative is expected to last for at leastthree years. For further information and to explore eligibility for reduced-costaccess, interested academic and research institutions are invited to contact WHO:Mrs Barbara Aronson, IMD/LNK, World Health Organization, 1211 Geneva 27,Switzerland (Telephone: +41 22 791 2034; Fax: +41 22 791 41 50; E-mail:[email protected]). ■


The Five-Star Doctor awardRobert Higgins, immediate past President of WONCA, Anacortes, Washington, USA

● The “Towards Unity for Health”criteria will be kept in mind.

Nominations for these annualawards are invited from throughoutthe medical world. Any national orinternational health agency, suchas WHO and the World Medical As-sociation (WMA) is welcome to for-ward a list of nominees to theWONCA regional vice presidentsand the WHO regional office. Wherepossible, the award will be pre-sented at the WONCA regional con-ference or at the regional WHOconference. Nominations for the2002 award must be received by theWONCA regional vice presidents by1 March 2002.

The nominees for the triennialworld award will be the winners ofthe regional awards over the priorthree years. The WONCA Nominat-ing and Awards Committee willmake this selection in consultationwith WHO. Where possible, theaward will be presented at theWONCA triennial world confer-ence. ■

FIVE-STAR DOCTOR

T he World Organization ofFamily Doctors (WONCA), inconsultation with the World

Health Organization (WHO), hasestablished an award to honourthose physicians who best meet theprecepts of the Five-Star Doctor, asset forth by WHO. Five annualawards will be presented, one ineach of the five WONCA regions.The winners of these awards willcompete for the world award,which will be presented once everythree years.

The winners of the annualregional awards will receive acertificate. The winner of the worldaward will receive a certificate anda plaque or sculpture. The awardwinners will be announced by bothWONCA and WHO.

Criteria for the annual regionalawards are as follows:

● A nominee must best meet theprinciples of the Five-StarDoctor

● A nominee should be a servingphysician in mid-career who inaddition to providing regularservices:— provides innovative services

for a community or specialgroup

— developed services wherethey were previously notavailable

— supported colleagues inanother region, country orcollege

— performed academic work(teaching, research, qualityassurance) of exceptionalquality and relevance

● A nominee need not be a familydoctor

● A nominee can work outside hisor her region, or create some-thing that can be used outsidehis or her region or serve as a rolemodel to other regions

The attributes of the Five-Star Doctor★ Care provider, who considers the patient as an integral part of a

family and the community and provides high standard clinicalcare (excluding or diagnosing serious illness and injury, manageschronic disease and disability) and personalizes preven-tive carewithin a long-term, trusting relationship.

★ Decision maker, who chooses which technologies to applyethically and cost-effectively while enhancing the care that he orshe provides.

★ Communicator, who is able to pro-mote healthy lifestyles byemphatic explanation, thereby empowering individuals andgroups to enhance and protect their health.

★ Community leader, who having won the trust of the peopleamong whom he or she works, can reconcile individual andcommunity health requirements and initiate action on behalf ofthe community.

★ Team member, who can work harmoniously with individuals andorganizations, within and outside the health care system, to meethis or her patients’ and community’s needs. (1)

Reference1. Boelen C. Frontline doctors of

tomorrow. World Health, 1994,5:4–5.

To contact the World Organizationof Family Doctors:

Dr Alfred W.T. Loh, Chief ExecutiveOfficer

WONCA World SecretariatCollege of Medicine Building16 College Road #01-02Singapore 169854Telephone: +65 224 2886Fax: +65 222 0204E-mail: [email protected]

Regional Vice PresidentsRVP African RegionDr Abra T. Fransch22A Jason Moyo StreetBulawayoZimbabweTelephone: +2639 66215Fax: +2639 67528E-mail: [email protected]


RVP: The Americas RegionWarren A. Heffron, MDDepartment of Family and Com-munity MedicineUNM School of Medicine2400 Tucker NEAlbuquerque, New Mexico 87131USATelephone: +1 505 272 3003Fax: +1 505 272 8045E-mail: [email protected]

RVP: Asia Pacific RegionProfessor Goh Lee Gan2D West Coast WalkSingapore 127139Telephone: +65 874 4978Fax: +65 779 1489E-mail: [email protected]: European RegionDr Philip EvansThe Guildhall SurgeryLower Baxter StreetBury St EdmundsSuffolk IP33 1RTUnited KingdomTelephone: +44 151 281 4041Fax: +44 151 281 8797E-mail: [email protected]

RVP: Middle East South Asia RegionProfessor Shatendra K. GuptaPO Box 1535KathmanduNepalTelephone: +977 1 418938Fax: +977 1 240063E-mail: [email protected]

To contact the WHO regionaloffices, please see the list ofaddresses at the end of this news-letter and address nominations tothe attention of the RegionalAdviser for Human Resources forHealth.

Dr Robert Higgins, immediate past Presidentof WONCA, can be reached at 2303 HighlandDrive, Anacortes WA 98221, USA (Telephone:+1 360 293 5917; Fax: +1 360 293 9598;E-mail: [email protected]).

FIVE-STAR DOCTOR

World conference 2002

Hans Karle

The World Federation for Medical Education (WFME)—in cooperationwith WHO, UNESCO and the World Medical Association—is organiz-

ing a world conference, “Global Standards in MedicalEducation for Better Health Care”. The conference, to behosted by the University of Copenhagen, Denmark, andthe University of Lund, Sweden, is scheduled to takeplace from 14 to 18 September 2002 in Copenhagen, withpre-conference symposia in Lund.

The three main themes for the conference will be:

● The interface of health care and medical education

● The concept of global standards

● Implementation of standards in medical education.

The conference is designed specificallyfor those responsible for furnishing doctorsand health services of the quality nowrequired worldwide: medical teachers;medical school administrators, includingdeans and vice-deans; other decision-makers in medical education and healthcare, particularly representatives fromministries of education and health, andinternational organizations concernedwith higher education and health; hospitaladministrations and other health careinstitutions; medical students’ associa-tions; postgraduate training bodies andinstitutions; and national and internationalmedical associations. Participation will berelevant to all those interested in medical

education and its relation to health care delivery systems.The WFME Web site (www.sund.ku.dk/wfme) will regularly update

information on this conference. Interested persons are invited also tocontact: Hans Karle, President WFME, World Federation for MedicalEducation, University of Copenhagen, Faculty of Health Sciences, ThePanum Institute, DK-2200 Copenhagen N, Denmark (Telephone: +453 5327103; Fax: +453 532 7070; E-mail: [email protected]). ■

Working together

Collaboration between the World Health Organization and the WorldOrganization of Family Doctors is a 16-page brochure that reviews eight

areas of collaboration between the two organizations: a world survey of generalpractice and family practice; improving health systems: the contribution of familymedicine; Towards Unity for Health; rural health initiatives; the Janus Project:family physicians meeting the needs of tomorrow’s society; tobacco—the globalissue; the health professions alliance; and the international classification ofprimary care. To receive one or more copies, please see the “Publications” sec-tion of this issue. ■

FIVE-STAR DOCTOR


The way forward for the health workforcein South-East AsiaPT Jayawickramarajah, World Health Organization Regional Officefor South-East Asia, New Delhi, India

The balance and relevance ofhuman resources for health(HRH) have steadily

improved since the WHO South-East Asia Regional Committeeresolved in 1992 to improve thesituation then prevailing. Balancerefers to numerical, distributionaland skill-related imbalances, whilerelevance implies the nature andadequacy of programmes andfacilities for pre-service andcontinuing education of healthprofessionals to match job-relatedcompetences.

Reorienting educationThe programme for the reorienta-tion of medical education (ROME)and nursing education has induceda number of interesting activities.The focus is on improving the rel-evance of educational programmesand developing appropriate profes-sional competences to work effec-tively in a comprehensive healthsystem based on primary healthcare (1). The main thrusts of ROMEare to strive for better coordinationof education and health systems;the introduction of a humanisticand holistic approach towardsmedical practice and use ofcommunity-oriented and problem-based approaches.

This programme resulted in thedevelopment of an educationalpolicy for health professions and amaster plan for HRH in somecountries of the South East Asia(SEA) region.

Training programmes at alllevels have been reoriented inmany countries to adopt a commu-nity-oriented, socially accountableapproach.

District hospital internship inrural settings for medical and nurs-ing personnel is being increasingly

of health workers in different Mem-ber Countries varying from tens tohundreds. Making HRH projectionsis impossible with the currentlyavailable computer programmes,without reducing the number intoclusters of health workers toaround 20 categories.

Quality assuranceAccreditation of educational insti-tutions and programmes is beingaccepted as a plausible means forimproving the quality of educa-tional programmes. Professionalassociations and licensing bodiesare responding to WHO-initiatedprogrammes on development ofaccreditation guidelines. The SouthEast Asia region is looking withgreat interest at opportunities forcollaboration with similar bodiesworldwide and therefore welcomesthe initiative of WHO headquartersin developing a global consortiumfor the accreditation and develop-ment of medical schools, with aview to improving their social re-sponsiveness in meeting people’shealth needs.

Partnerships in healthIn the area of public health practiceand education in South-East Asia,a regional consultation of experts

HUMAN RESOURCES DEVELOPMENT

seen. For instance, the MedicalCouncil of India has recommendedrotational internships that includerural hospitals. Family medicine/general practice is a relatively newspecialty in the region. Also, as aresult of WHO collaboration withWorld Organization of Family Doc-tors ( WONCA), more and moreinstitutionss are sensitized to rec-ognize the need for a family doctorto play a central role in achievingquality, cost-effectiveness and eq-uity in health care systems.

Linkages have been establishedacross countries to develop train-ing programmes in general prac-tice. As an example, the ChristianMedical College, Vellore, India, hasformed a linkage with the Instituteof Medicine in Tribhuvan, Nepal.

Correcting imbalancesNumerical imbalance in HRH isbeing solved by the creation of newinstitutions and programmes.However, there has been a mush-rooming of medical schools insome countries without adequateneed assessment and feasibilitystudies. WHO as a technical organi-zation had little impact in chang-ing this trend, due to politicalpatronage of promotors of medicalschools.

Although a regional consultativemeeting in Kathmandu resolved tolook into equivalence of educa-tional qualifications and degrees,progress in this direction has beenrather slow. Increasing attention isbeing given to quality assurance intraining programmes and pre-serv-ice education. Educational policyand HRH planning are some of theconcerns in streamlining the healthworkforce.

Recent work on HRH projectionsrevealed a multiplicity of categories

PT Jayawickramarajah


from a variety of disciplines inter-ested in population-based medi-cine was held. Participants at thismeeting considered the scope ofpublic health to include poverty al-leviation, equity, quality, social jus-tice, environmental protection,community development and glo-balization. The leadership role ofpublic health, creation of careerstructures and reforms in publichealth education, training and re-search are some of the key elementsof the “Calcutta Declaration” (2).

Community-academic partner-ships to improve health have beeninitiated in a few institutions, ex-emplified by community participa-tion in health programmes pilotedby academic institutions. Creationand nurturing of trust; respect forthe community’s knowledge and

the community’s priorities; com-promise; capacity strengthening ofthe community and communityownership are some of the keyelements identified (3). Multi-pro-fessional learning programmeshave been initiated in some profes-sional schools in India, Nepal andThailand to enable different cat-egories of students to work togetheras a team in community settings.

Approaches suggested by the“Towards Unity for Health” (TUFH)initiative should facilitate the crea-tion of productive and sustainablepartnerships in the interest of peo-ple’s health. ■

References1. Reorientation of medical educa-

tion. Regional publication no.18.New Delhi, World Health Organi-


MOVING TOWARDS UNITY FOR HEALTH

Towards unity for healthspecialists, providers andusers, the private andpublic sectors, and socialand economic aspects ofhealth. Unity of purposeand action must be cre-ated in order for all actorsto come nearer to theambitious goal of healthfor all and the underlyingvalues of quality, equity,relevance and cost-effectiveness.

The political, organi-zational and scientificconditions to create“unity” must be identi-fied, documented,measured, debated and respondedto. Alliances and synergies must bedeveloped at operational level aswell as policy level among key in-terest groups with specificstrengths and expectations.

The term “towards” expressesthe nature of the TUFH project,

“Towards Unity for Health” designatesa project—the TUFH project—whose aim is to improve the per-formance of the health servicedelivery system and make it morerelevant to people’s needs. To theseends, the TUFH project will facili-tate coordination and integrationof the wide spectrum of interven-tions geared towards individualhealth and community health atthe level of a given population. Itwill also encourage productive andsustainable partnerships amongkey stakeholders working at thatlevel: policy-makers, health man-agers, health professionals,academic institutions and commu-nities.

The approach promoted in theTUFH project is to reduce fragmen-tation in health service deliverycaused by divisions such as thosebetween individual health andcommunity health, preventive andcurative services, generalists and

Towards unity for health through sustainablepartnerships with key stakeholders

which is to mobilize different part-ners for greater social accountabil-ity and to promote continuouslearning from practical endeavoursin order to make steady progress incoordinating changes in healthservices and health professionspractice and education. ■

Healthprofessions

Healthmanagers

Academicinstitutions

Communities

Policymakers

HEALTHSYSTEM

BASED ONPEOPLE'S

NEEDS

PARTNERSHIP PENTAGON

zation Regional Office for South-East Asia, 1998.

2. World Health Organization.Calcutta declaration on publichealth. Journal of Health andPopulation in Developing Coun-tries, 2000, 3(1):5.

3. Wolff M, Maurana CA. Buildingeffective community-academicpartnerships to improve health: aqualitative study of perspectivefrom communities. AcademicMedicine, 2001, 76:166–172.

PT Jayawickramarajah, MD, PhD, is Scientist,Human Resources for Health, World HealthOrganization, Indraprastha Estate, MahatmaGandhi Marg, New Delhi-110 002, INDIA(Telephone: +91-11-337-0804;Fax: +91-11-3370197; E-mail:[email protected]).


Distance learning: a response to overcomecurrent challenges in medical education?Janet Grant, The Open University, Milton Keynes, United Kingdom

● Enables teaching to be deliveredto a wider audience

● Ensures quality● Ensures relevance to educational

needs● Ensures current knowledge● Draws on the knowledge and ex-

perience of many teachers● Enables teaching and learning to

be monitored● Provides information about stu-

dent progress● Provides support for the teacher● Can supplement the local faculty● Can free local teachers to do

other teaching.

For the society and the medicalschool, distance learning:

● Enables students to learn whilein community and rural settings

● Offers social accountability ofmedical education by support-ing learning in different physicalcontexts of health care systems

● Can be open to the input of thesociety and the medical schooland as a whole

● Is flexible enough in its design tofit local circumstances and con-straints.

What is distance learning?To offer each of the aboveadvantages to all,distance learningmust be muchmore than just theuse of technologyto deliver teaching.Indeed, effectivedistance learning canoccur without the useof technology at all. For the UKOpen University, which was theworld’s first distance learninguniversity, distance learning is:

Individual study of speciallyprepared learning materials,

usually print, supplemented byintegrated learning resources,other learning experiences,including face-to-face teachingand practical experience,feedback on learning andstudent support.

For this reason, The OpenUniversity terms its provision‘supported open learning’.

Who would distance learningmedical students be?The plans for distance learning dis-cussed here can apply to studentsin a number of circumstances:

● Those who are studying entirelyby distance learning with an in-stitution that is a quality-assureddistance learning provider

● Those who are jointly registeredwith a distance learning providerand an existing medical school

● Those who are students of anexisting medical school butrequire the support of distancelearning as part of their course,either off-campus (in thecommunity or a rural

attach-ment) or to supplementtheir on-campus studies (where,for example, certain teachers orsubjects are insufficient to coverthe curriculum).

Distance learning methods can

DISTANCE EDUCATION

Medical education alreadyoffers its students a wealthof educational provision.

Medicine has not been slow toadopt technology, not only fordiagnosis and treatment, but alsofor the education of patients andstudents. Despite this, the tradi-tional methods of teaching andlearning are still of central impor-tance—the teacher, patients, otherstudents, other health care profes-sionals, and printed books andother materials.

So why is there now such inter-est in distance learning in medicaleducation?

Why distance learning in medicine?In the United Kingdom, a nationalproject to look at the potential ofdistance learning for medical edu-cation has been completed and thisproject will now extend worldwide.Our work has shown that distancelearning is needed for the followingreasons:

For the learner, distance learn-ing:

● Makes expert teaching accessi-ble to all

● Offers rich learning resources● Allows flexibility of learning in

time and place● Provides quality-assured learn-

ing● Is cost-effective when large

numbers of students are in-volved

● Offers feedback on learning● Gives students the opportunity

to learn to manage theirpersonal time and learning

● Makes learning accessibleto otherwise disadvantagedgroups.

For the teacher or medicalschool, distance learning:


reach almost unlimited numbers ofstudents in any or all of thesecategories.

Can distance learning teachclinical medicine?During 1999 and 2000, a team fromThe Open University, along withseven partner medical schools inthe UK, developed plans for a fullyintegrated distance learning medi-cal course equivalent to the firsttwo years of medical school, theStage 1 course, after which studentswould move into year 3 of thepartner school. The feasibility ofusing distance learning techniquesto support students in developingthe knowledge, skills, professionalattitudes, clinical and problem-solving skills necessary in the firstyears of medical training wasrigorously tested and proven. Theboxes outline the course:

Stage 1 medicine course bydistance learning:■ designed by The Open

University and 7 partnermedical schools

■ equivalent to years 1 and 2 ofmedical school

■ prepares students to enteryear 3 of the partner school

■ fully integrated course■ residential schools■ local clinical placements for

early patient contact■ national network of clinical

teachers

How is knowledge to belearnt?■ Print, instructional texts,

course books■ Other media: CDs, virtual

microscope, internet re-sources, kits, simulations

■ Face-to-face and onlineteaching and peer discussion

■ Illustration and cases

Developing professionalattitudes:■ Practical experience of the

health care system with localtutors

■ Simulations■ Reflection on clinical experi-

ences■ Analysis of paper/media-

based cases■ Virtual clinical environment■ Face-to-face and online

discussion with peers andtutors

How are skills acquired?■ Simulation kits supported by

media demonstrations■ Specified clinical experience

with local [trained] tutors■ Local/national residential

schools in scientific andclinical skills labs.

Developing clinical problem-solving:■ Patient-management prob-

lems■ Reflection on clinical experi-

ence■ Problem-solving exercises■ Ethical challenges

Clinical experience at a distanceOne of the most important reasonsfor distance learning in medicine isto enable students to experiencetheir health care systems in a vari-ety of community and other set-tings outside the medical schooland teaching hospital, while ensur-ing that they are experiencing aproperly constructed and quality-assured curriculum. So a distancelearning course must be able tosupport that first-hand experience.

The Open University and itspartner medical schools designed aclinical practice module that runsthrough the whole length of thecourse. This would entail regular

clinical attachments in primaryand secondary care local to the stu-dent, with accredited teachers whoare part of a distance [ital]learningclinical network[endital]. The clini-cal experience would be managedby:

● A curriculum map of content tobe covered

● An analytical, reflective portfolio● Structured preparatory and re-

flective exercises and projects● Formative assessments● Ongoing assessments by the

clinical teachers.

The capacity of the local healthcare system to incorporate suchexperience is an important factor,as is its quality assurance.

Quality assurance in distancelearningBy definition, distance learningtakes place outside the mainresponsible institution. For thatreason, quality assurance is of para-mount importance. Quality assur-ance would incorporate:

● Awareness of the needs of stu-dents, teachers, the health caresystem and regulatory bodies

● Carefully managed partnershipswith existing medical schools

● Expert development of coursematerials by distance learningand subject specialists

● Drafting and testing all coursecomponents before final courseproduction

● Student support via local tutorsand advisory services

● Regular contact with andbetween students

● Formative assessments withfeedback to students

● Student records to chart progress● Selection, training, support and

monitoring of local teachers● Selection of and support for

local clinical sites● Regular evaluation and course

review to ensure the WHO crite-ria of relevance, equity, qualityand cost-effectiveness.


➤


The international networkedmedical schoolPlans for an International Net-worked Medical School (INMS) willbe developed over the next twoyears by an expert team, throughthe International Medical Educa-tion Trust (IMET2000) based in theNorthwick Park Institute forMedical Research in London, underProfessor Colin Green.

Enquiries from interested medi-cal schools about developing theINMS should be addressed [email protected]. ■

Janet Grant is Professor of Education inMedicine, Open University, Centre forEducation in Medicine, Walton Hall, MiltonKeynes, MK7 6AA, United Kingdom (Tel-ephone: +44 [0]1908 65 3776; Fax: +44 [0]1908 65 9374; E-mail: [email protected]).

Medical schools withoutwalls: medical educationand the World Wide WebRoderick Neame, Goodnestone, England,United Kingdom

better aligning the basic sciencesstudy with the realities of clinicalpractice, pointing out that medi-cine is “a technical or professionaldiscipline which calls for the pos-session of certain portions of manysciences arranged and organisedwith a distinct practical purpose inview”. That purpose is the key forselecting what content to includeand what to ignore: it provides theorganizing principle whereby thecomponents can be “organicallycombined” into a meaningful andpurposeful educational pro-gramme. “Medical educationshould be explicitly conscious of itsprofessional end and aim”, hewrote, in support of his observationthat the teaching of the basic sci-ences by those without any medi-cal knowledge or understandinghad become discredited as no morethan a mechanical drill, too oftenhaving lost sight of the main edu-cational objective.

A leap in qualitySome leaders in medical educationhave been improving the pro-grammes of study, to make themboth more stimulating and moreeffective. Some have introducedproblem-based or case-basedstudy, integrated programmes withnew discipline areas (e.g. commu-nity medicine) and a greater degreeof orientation towards the commu-nities they serve. Some have experi-mented with the use of newtechnology and the Internet. Theauthor has been privileged throughtime in the University of Newcas-tle, New South Wales, Australia, andelsewhere as a consultant to manynew medical schools, to be

DISTANCE EDUCATION

Online help:What’s in a name?Now available via the World WideWeb is Pharma-lexicon (http://www.pharma-lexicon.com),which offers the meanings ofsome 27 000 pharmaceuticalacronyms and abbreviations freeof charge. For more than a year, avolunteer team of health profes-sionals has laboured to build thedatabase and put it on the Web,all in the interest of providing auseful service and learning a newskill.

The Pharma-lexicon team wouldbe grateful to be informed ofabbreviations or acronyms notnow included. These must be inthe following fields: agrochemi-cals, biochemistry, biology,biotechnology, chemicals,general medicine, health care, labequipment, medical devices/diagnostics, nursing, pharmaceu-tical production, pharmacy,physiotherapy, public health,toxicology and veterinarymedicine. ■

For more information or to contributenew entries, please contact: ChristianNordqvist, Pharma-lexicon Interna-tional, 83 Filsham Road, St.Leonards-on-Sea, East SussexTN38OPE, United Kingdom(Telephone: +44 1424 434208;E-mail: [email protected]).

In 1827 Thomas Hodgkin, speak-ing of and to students at Guy’sHospital in London, said: “I con-

sider our present system of medi-cal education liable to objection …and confess that I regard it … asobjectionable in nearly all itsstages”. Some might still say thesame, and, indeed, the currentmedical programme in most insti-tutions would be clearly recogniz-able by Hodgkin’s students of thattime, at least in style if not in con-tent.

Learning from historyAlmost a century later, in 1910Abraham Flexner drew attentionpublicly to the sorry state of medi-cal education in the USA at thattime. His report was intended toconstitute a baseline and agendafrom which to move forward,although in the intervening 90years his report has been twistedout of context by conservatives andused as a justification for continu-ing outdated educationalapproaches.

His recommendations forchange have passed largely un-heeded. Flexner ensured that theeducational methodology used atthe time came in for well-deservedcriticism: he regarded the relianceon “didactic presentation” as“hopelessly antiquated”, belongingto “an age of accepted dogma orsupposedly complete information,when the professor knew and thestudents learned”. Medical educa-tion should be an active studentlearning process, and should con-tinue indefinitely as the biomedicalknowledge base extends.

He also addressed the issue of


involved in all of these initiatives—and now once again to be involvedin another new venture with the In-ternational University of the HealthSciences (IUHS).

The initiative I wish to report onin this article embraces problem-based learning and community ori-entation, and then goes one stepfurther—it introduces a high levelof flexibility, enabling the studentsto study as, when and where theychoose, to progress at a rate withwhich they feel comfortable, and todo so at a greatly reduced cost. Theconservatives will no doubt imme-diately retort that this must be atthe expense of quality and integrity:there is no evidence to supportsuch a contention, and the qualityof all the graduates of the pro-gramme is assured externally byindependent examining bodies,e.g. USMLE in North America.

WWW medical educationIUHS differs from the start, openingits doors to a much wider-than-normal range of students, based onresearch findings that are unable todemonstrate significant associa-tions between prior study ofspecific subjects or overallacademic grades and successfulperformance as a doctor. However,students with stronger academicbackgrounds in health andbiomedicine are preferred foradmission to the off-campusprogramme (see below).

The IUHS programme is dividedinto two parts: the first 80 weeks,which is problem-based, and thesecond 80 weeks, which is a seriesof conventional clinical rotations/attachments. It is especially duringthe first 80 weeks that IUHS pio-neers a new path. The basicsciences are learned in an inte-grated way in the context of aseries of prototypical problems, or-ganized into organ-system blocks.

The materials are all Web-basedand delivered to students over theInternet, and can be picked up bystudents wherever they are located.Whether on or off campus, the

student works through the struc-tured problem presentations, partof the time with an MD: the MD isa local health professional who actsas guide and mentor, as well as themeans whereby the student is ableto access both patients and localclinical facilities throughout thestudy period.

To support the students, the uni-versity has established a number ofonline services and facilities.

● Electronic messaging systems,each serving the needs of stu-dents at the same stage of thecourse: these enable students toshare information, advice, notesand comments with their col-leagues and with staff.

● Electronic conferences, dividedinto forums and “threaded dis-cussions”. Each discussion has acommon theme and allows stu-dents to pose questions or raiseissues they wish to share withcolleagues and staff experts.

● Online archives of materials pre-pared by a variety of experts fromdifferent disciplines. Some arespecific to a particular studyproblem, but many are of gen-eral interest and importance.

● Web links. Many links to a largenumber of excellent resourceson the Web have been included.

● Chat rooms, where staff andstudents can meet together inpre-arranged groups and at pre-determined times to discussspecific issues or topics.

● Streamed presentations wherebydidactic presentations and ma-terials prepared by staff can bedistributed according to a fixedschedule or on demand to stu-dents. This can include real-timeor delayed broadcasts of lecturesand presentations taking placein other locations and institu-tions.

● E-problem of the week: studentsare continually challenged by aseries of “problems-of-the-week”, which are used to stimu-

late thinking and reasoning. Stu-dents are required to submittheir response to the challengewithin a limited time period,after which the “correct”response is then circulated.Responses are reviewed andassessed.

● E-journal club: an electronicjournal club is held every week,with a different student takingthe lead, preparing the presen-tation and responding to com-ments and criticisms. These (andother) student-generated mate-rials are held in an archive forfuture students to study andlearn from.

Much of the cost of the conven-tional study programme is gener-ated by staff performing repetitivetasks (e.g. lectures): the content ofthese can be better disseminated inother ways. The conventional pro-gramme is based on inflexibility inthat all staff and students must bein the same place (usually awayfrom home) at the same time for asession, or else they miss it; all stu-dents have to progress at the samespeed in a lock-step approach.These restraints serve only to limitthe accessibility and affordability ofmedical education to the commu-nity. IUHS has taken some stepstowards changing these parametersand opening up the study of medi-cine to a wider group of potentiallywell-qualified and particularlywell-motivated candidates. ■

Dr Roderick Neame, Health InformaticsConsulting, can be reached at HomestallHouse, Homestall Lane, Goodnestone (NrFaversham), Kent ME13 8UT, UNITEDKINGDOM (Telephone: +44 795 539 996; Fax:+44 795 538 390; E-mail:[email protected]).



Healing fragmentationA Chinese viewpointYuhua Dai, Zhenglai Wu and Depei Liu, Peking Union Medical College, Beijing, China

of Beijing want most of all to be: (1)healthier and happier (63.4%); and(2) wealthier; with (3) a bigger andbrighter living space; and (4) moretime to stay with their family mem-bers. In 1995, the answers to thesame questions were ranked (4),(1), (3), (2).

Of course, the income diff-erences in China are important:urban people’s income is higherthan that of rural people; thecoastal area is richer than theinterior; and the economy of thewestern areas is just developing. Nomatter the actual difference, ahealthier and happier life is thedesire of all Chinese peopleeverywhere.

The TUFHpentagon con-cept summa-rizes well howorganizationsand stake-hold-ers shouldunite to meetpeople’s needsand make“Health for All”come true. Per-haps we canidentify some

PARTNERSHIPS

Depei Liu, Yuhua Dai, Zhenglai Wu.

Towards Unity for Health” is aconcept that is well acceptedand appreciated by Chinese

medical workers. There is a very fa-mous popular song in China enti-tled “Unity is Strength”. EveryChinese can sing it and interpret itwith his or her own experiences.The song’s message is: “When unitywas harder than iron and strongerthan steel, the enormous strengthof unity buried the feudalism, im-perialism and bureaucratic capital-ism of the old China and created apeaceful, independent and demo-cratic new China”.

It is also the enormous strengthof unity that has won for China astable environment in which tocarry out a series of reforms in dif-ferent areas. In the last two decades,China’s GNP has been growing at anannual rate of 7% to 8%. Althoughthe average GNP per capita is stilllow (about USD 800), this is themost important economic base forthe improvement of health care andmedical work in China for her 1.3billion people in the year 2001.

During the past century, Chinahas experienced some importantchanges in health status (Table 1).According to the most recent sur-vey by the Beijing Municipal

Bureau of Statistics, the people

❞

Table 1. Changes in health status in China

1950 2000

Population size 0.45 billion 1.3 billion

Average life expectancy 35 years of age 71 years of age

Maternal mortality 1500 per 100 000 56 per 100 000

Infant mortality 200 per 1000 32 per 1000

Major causes of death Infectious and Noncommunicable, chronicparasitic diseases diseases: cancer, cerebrovascular

disease, cardiovascular disease,chronic obstructive pulmonarydisease

other unities between health work-ers:● Unity between generalists,

specialists and paramedicalpersonnel

● Unity between practitioners ofChinese traditional medicineand allopathic medicine

● Unity between doctors in clini-cal medicine, preventive medi-cine and basic medical sciences

● Unity between the doctor andthe patient.

It is not necessary for a doctor toknow everything and do every-thing. No one is omnipotent. Buteveryone has his or her specialstrong point that may be useful toothers. Unity means with a com-

CHINA


mon desire: to serve the people bet-ter, health workers should knoweach other, learn from each otherand collaborate with others amica-bly and closely. Be agonists but notantagonists. Enhance cohesion toheal fragmentation.

Patients also should be activeparticipants in the whole process ofpreventing and healing their dis-eases: providing relevant informa-tion, symptoms and responses toany interventions. Patients are theirown masters in implementing pre-

ventive procedures, such as smok-ing and drinking cessation, andcompliance with the treatmentregimen.

Our opinion is that the TUFHapproach focuses on the most im-portant issues and challenges forour national health system as itstrives to make the best and mostcoordinated use of our talents andresources to provide high-quality,cost-effective and equitable healthservices to our people. ■

Yuhua Dai, MD, is Professor of InternalMedicine (Cardiology), Peking Union MedicalCollege, CAMS/PUMC; Zhenglai Wu, MD,MPH, is Professor of Public Health, CAMS/PUMC, and Dean, Office for Teaching Affairs;and Depei Liu, PhD, is Professor of Biochem-istry/Molecular Biology, CAMS/PUMC and amember of the Chinese Academy of Science.The authors can be contacted as follows:Peking Union Medical College, Office forTeaching Affairs, 9 Dong Dan San Tiao,Beijing 100730, CHINA (Telephone: +86 10652 959 63; Fax: +86 10 651 248 76 / +86651 330 91; E-mail: [email protected]).

PARTNERSHIPS

The Making Pregnancy Safer initiativeThe power of partnershipsLuc de Bernis, World Health Organization, Geneva, Switzerland

Many maternal and newborndeaths are unnecessaryand unacceptable, particu-

larly as we know that the five maincauses of direct obstetric deaths—which account for nearly 80% ofmaternal deaths—can be pre-vented by actions that are effectivewithin local settings and are afford-able even when resources are lim-ited. But to sustainably implementthese interventions is a complexchallenge that requires strong col-laboration between key partners atall levels of the health care system.

Experience has shown that inad-equate coordination between keyactors and partners has led to lackof progress in maternal health out-comes. Many safe-motherhoodprogrammes have suffered frompiecemeal efforts, with lack of co-ordination and poorly defined pri-orities between as well as withinprogrammes. In addition, availableresources have not been maxi-mized effectively and efforts haveoften been unnecessarily dupli-cated.

An important lesson learnt hasbeen that interventions to reduce

maternal deaths cannot be imple-mented as vertical, standalone pro-grammes. Maternal mortality is notmerely a “health disadvantage”, it isa “social disadvantage”. Health, so-cial and economic interventionsare most effective when they areimplemented simultaneously. Thisbeing the case, maternal and new-born health interventions must beimplemented through effectivepartnerships in the context ofbroader programmes.

Evidence clearly indicates thataddressing the complex challengeof maternal illness and death de-pends on a functioning health caresystem, together with interventionsat community and policy levels thatare needed to ensure that un-wanted pregnancies are reducedand appropriately managed, andthat women and their newbornshave access to and can use the carethey need, when they need it. Ex-perience over the past decade hasalso shown that no single interven-tion is sufficient by itself; what isneeded is a continuum of care.

Reducing maternal mortality re-quires coordinated, long-term

e f f o r t sa m o n gkey part-ners. Ac-tions aren e e d e dw i t h i nf a m i l i e sand com-m u n i t i e s ,in society as a whole, in healthsystems, and at the level of nationallegislation and policy. Further, in-teractions among the interventionsin these areas are critical to reduc-ing maternal mortality and tobuilding and supporting momen-tum for change. The challenge fac-ing the Making Pregnancy Saferinitiative is to create and buildeffective partnerships, which willlead to positive health outcomes formothers and their newborns.

Legislative and policy actionsLong-term political commitment isan essential prerequisite for mak-ing pregnancy safer. The necessaryresources are mobilized and theessential policy decisions are takenonly when decision-makers at the


highest levels are resolved to ad-dress maternal mortality. Withoutthis long term commitment, pro-grammes and activities cannot besustained.

Women may overcome the vari-ous obstacles that limit their accessto health care, such as distancefrom their homes to appropriatehealth facilities, lack of transportand, more critically, financial andsocial barriers, only if a supportivesocial, economic and legislativeenvironment exists. Experience hasshown that women are deprived ofproper maternal health care whenthey have to pay for services andessential drugs and when they mustbear substantial hidden costs, suchas time lost for child care, domesticchores, paid employment, food pro-duction and community services.

Furthermore, legislation thatsupports women’s access to caremust be formulated to permithealth workers at the periphery ofthe health system to performspecific life-saving functions.

Community interventionsCommunity and religious leaders,women’s groups, youth groups,other NGOs and families are keycontributors to reducing maternaland newborn mortality. Healthfacilities and communities maycreate partnerships in investigatingmaternal deaths and identifyingand implementing strategies forimprovement in such areas asreferral, emergency transport,deployment and support of healthcare providers, and cost-sharing.

Because many women deliveralone or with a relative, it is crucialto train community members torecognize danger signs. It is alsoessential to develop plans for emer-gencies, including transport tohospitals or health centres, andlocal insurance funds to help coverthe costs of care.

In some countries, communica-tion (radios, telephones and trans-port for emergency cases) has beenorganized with financial supportfrom communities. Partnerships

have been essential between healthcare providers, policy-makers,health professionals and the com-munities in ensuring the above, aswell as providing cheap and simpledelivery kits that are distributed topregnant women for deliveries inprimary health care facilities or forhome births.

Another area of essentialpartnership has been in instanceswhere services of skilled profes-sional health care providers are notavailable and traditional birthattendants ( TBAs) have beenwomen’s only source of care. Insuch cases it is crucial to establisheffective partnerships throughwhich TBAs are trained to recognizeproblems during delivery and,when necessary, to guide women toand through the formal health caresystem.

Health care providers mustinform, educate and mobilize thecommunity regarding danger signsand work with communities toimprove access to care, such asthrough development of transportschemes, better communicationsand maternity waiting homes, andlocal insurance schemes.

It is also crucial that health careproviders work with policy-makersto promote family and communitysupport for delayed marriage andchildbearing; timely and plannedpregnancies; and improved health,nutrition, and education for all girlsand women.

Health care providers andprofessionalsPartnerships between health careproviders, health professionals,teaching institutions, policy-makers and communities areessential to ensure that maternaldeaths are prevented through theprevention of unwanted pregnan-cies, prevention of complicationsduring pregnancy and appropriatemanagement of complications. Thepresence of skilled birth attendantsis crucial for the early detection andappropriate, timely managementof life-threatening complications. It

is also essential to strengthen thereferral system through supportivesupervision, regular communi-cation and logistic/managerialsupport, including ensuring theavailability of essential drugs andsupplies as a functioning referralsystem.

Partnership must be establishedwith teaching institutions to ensuremidwifery training programmes,and, for personnel already trained,in-service training based on up-dated standards for care. Experi-ence has shown that it is essentialto strengthen the midwifery skills ofrelevant staff and intensify trainingin counselling skills. Researchinstitutions should be involved topromote and coordinate researchand disseminate findings in areasthat are crucial to improvingmaternal and newborn health.

Lastly, partnership betweenhealth care providers, policy-makers and professional associa-tions is necessary in advocatingrevision and amendment oflegislation to enable an appropriatehealth service response to obstetricneeds, including delegation ofresponsibilities for essential life-saving interventions. Here, themass communications mediashould be a crucial partner. ■

References1. Reduction of maternal mortal-

ity—a joint WHO/UNFPA/UNICEFWorld Bank statement. Geneva,World Health Organization, 1999.

2. The safe motherhood actionagenda: priorities for the nextdecade. Report on the safe moth-erhood technical consultation,Colombo, Sri Lanka, 18–23October 1997. New York, FamilyCare International, 1998.

3. Making pregnancy safer. paper fordiscussion. Geneva, World HealthOrganization, 2001.

Dr Luc de Bernis can be reached at theDepartment of Reproductive Health andResearch (FCH/RHR), World Health Organiza-tion, 1211 Geneva 27, Switzerland(Telephone: +41 22 791 4133;E-mail: [email protected]).

PARTNERSHIPS


Changing roles: a half-century odysseyon Planet “Health”Christopher Wood, Nairobi, Kenya

Hygiene Department of theHarvard School of Public Health.

On returning to England, I joinedRichard Schilling at the LSHTM andhelped develop the new Depart-ment of Occupational Health,where we had a large number ofinternational postgraduate stu-dents. At the same time, myinvolvement with a chronic-bron-chitis prevention clinic at the Cen-tral Middlesex Hospital led tostarting the first anti-smoking clinicin England. I also developed afundraising office in London for mybrother’s East African Flying Doc-tor Service (the African Medical andResearch Foundation, Amref). Thisactivity led unexpectedly to thenext major change in my career—heading for Africa.

Shortly before Tanganyika’s in-dependence, Amref was invited tosurvey its health services and makerecommendations to the new gov-ernment for future development. Ijoined Professor Richard Titmus’team, which produced a report, Thehealth services of Tanganyika, onwhich the first post-independencedevelopment plan was based.

Shortly thereafter I received aphone call from the then-Ministerof Health, asking if I would come toDar es Salaam and help implementsome of our report’s recommenda-tions. A few months later, havingobtained two years’ leave of ab-sence from LSHTM, we—my wifeand I and our four children—wereon our way—and never returned!

From home to worldMy principal assignment, in whathad become Tanzania, was to helpupgrade the former Medical Assist-ant Training School to a MedicalPractitioner School. Starting amedical school for the Ministry ofHealth rather than a university had

many interesting and importantfeatures.

In particular, the ministry’sprime concern was that the gradu-ates be competent to perform asgovernment medical officers. Theministry was less interested in re-search or later specialization.

The new curriculum was there-fore based on the job description ofa District Medical Officer. Each ofthe five main subjects—medicine,surgery, child health, obstetrics andgynaecology, and communityhealth—was assigned one-fifth ofthe study time in each of the fiveyears.

While the structure and functionof the cell and individual humanbeing were taught as anatomy andphysiology, the structure and func-tion of the community were taughtas demography and behaviouralscience. When the director of theschool and I had problems, wewould visit the Principal Secretaryin the MOH (a triple gold medallistfrom Makerere). After hearing ourproblem he always replied, “I knownothing about medical education -that is why I appointed you. If youthink we should do it—do it—and Iwill support you”. What more couldtwo enthusiasts want!

PARTNERSHIPS

Three events shaped my earlycareer. As a wartime medicalstudent I spent my vacations

working at the face of a Welsh coalmine. There were doctors at the topof the mine repairing injuries andawarding compensation for pneu-moconiosis, but little thought wasgiven to preventing accidents andimproving ventilation at thebottom.

After qualification (as a result ofa mistake made by the hall porterat the Colonial Office, who usheredme into an interview for a job forwhich I had never applied) I did myinternship, and simultaneously myNational Service, in the SingaporeGeneral Teaching Hospital. I wasattached to the professorial surgi-cal unit and had the opportunity todo more surgery in three years thanmany surgical trainees would do inten.

After completing my Singaporeassignment I spent a year riding amotorcycle back to the UK, paus-ing to work in my sister’s missionhospital in India and my brother’ssurgical practice in Kenya.

From disease to healthSomewhere along the line I lostmuch of my interest in what to dowhen people are sick or injured,and became more concerned withhow to prevent this from happen-ing. So to learn more about preven-tive health services—a subjectgiven grossly inadequate attentionduring undergraduate training—I went to the London School ofHygiene and Tropical Medicine.

Then, after a spell in generalpractice, the best way to be in-volved in preventive medicine—without losing sight of individualpatients—seemed to be in the fieldof occupational health. So the nextyears were spent in the Industrial

Christopher Wood


From university to fieldIn addition to working in the medi-cal school, my duties also con-cerned the training of all the othercadres of health workers. In Africaonly a small proportion of sick peo-ple ever see a doctor—the majorityare managed by medical assistants,nurses and community-basedhealth workers.

I began to appreciate that one ofthe key causes of maldistribution ofhealth staff lies in the disparity be-tween the skills, interests, livinghabits and expectations of thehealth worker and the communityhe or she is to serve. If the gap is toogreat, the health worker migrates towhere the difference is less.

The health worker should be twoor three jumps ahead of the com-munity in his/her lifestyle—but notten, or he/she will leave. In otherwords, the development of healthservices cannot be separated fromdevelopment of the communities’other activities—education, agri-culture, administration, etc.

Putting “doctors” in re-mote areas doesn’t work.Paramedical and commu-nity-based health workersare an essential step in de-velopment.

Tanzania has developeda system of encouragingthe best in any one cadreto undertake further train-ing and be upgraded to thecadre above. This includesaccepting clinical officers,nurses and laboratorytechnicians as mature en-try students into the medi-cal school.

On one occasion, whenI was running a workshop for thestaff of the six Medical Assistanttraining schools, they indicatedthat they had trouble teachingcommunity health because of theabsence of a suitable textbook. Isuggested that together they shouldwrite the book they needed, and Iwould edit it. This started anothermainstream of my future activi-ties—publishing appropriate para-

medical health learning materials.I joined Amref, in Nairobi, when

they received a grant from the Dan-ish aid agency Danida to develop atraining programme. The Danidagrant gave us considerable freedomto do what we thought was best.Experience in Tanzania had shownboth the importance of para-medicals and that their training re-quirements received only a smallproportion of the attention, thestaff or the funds available for theeducation of health staff. I thereforeproposed three main activities forthe Amref training programme:training teachers of paramedicalstaff, providing continuing educa-tion for paramedicals, and develop-ing appropriate health learningmaterials for them.

The medical and allied profes-sions had been slow to appreciatethat teaching requires skills not al-ways present in those who may bevery competent in practice. Butteachers’ skills can be enhancedeven by short courses in educa-

tional methodology. Continuingeducation for paramedicals hadonly slowly been recognized as im-portant.

Looking at this problem encour-aged me to explore “the epidemiol-ogy of continuing ignorance”! It isa disease to which we are all sus-ceptible. The high-risk factors areshort initial training, a long inter-val since last training and isolation

PARTNERSHIPS

from any updating sources.A system of continuing educa-

tion is essential. Also the impor-tance of appropriate learningmaterials—in particular books/manuals—for paramedicals hasnow been appreciated. A key fea-ture of an “appropriate” book is thatnot only should it have the relevantinformation, clearly presented, butalso it should not have too muchirrelevant material. Postgraduatestudents may recognize irrelevantinformation (though sometimesthey don’t), whereas less-experi-enced students may take what theyare given as gospel!

From institution to peopleSince leaving Amref I have beenhelping with the training of differ-ent cadres of health staff in thesouthern Sudan. As a result of theongoing civil war, the governmenthealth services have disintegrated.Different NGOs started trainingpeople to run “emergency” serv-ices. A hotchpotch of programmes,

of varying duration, lead-ing to various certificates,were instituted.

To establish some sortof standardization, a Pro-visional Health PersonnelCouncil was formed andstandard curricula weredeveloped. To have onecouncil for all health cad-res instead of the usualmedical, nursing, etc.,councils with their turfwars, is an advantage.

Also, training lastingmore than one year is bro-ken into phases, each ofone year. Each phase leads

to a qualification and is followed bya period of service. This system,originally started to enable thosewho, in a war situation, could notbe away from their homes for longperiods, has worked well and islikely to be continued. Interspers-ing training and practice, as in con-tinuing education, can be startedduring basic training. If you want tointroduce changes, never underes-


timate the advantage of not havinga government!

Information and communica-tion technology has revolutionizedmany activities in big hospitals,universities and research institu-tions. However, it has as yet madevirtually no impact on communityhealth services. Recognizing thisfailure we have recently establisheda consortium of health NGOs andthe MOH to “harness informationand communication technology forcommunity health”. The partnermembers of the consortium—AfriAfya—are pooling both theirexperience and their ignorance tosee whether the use of computers,WorldSpace receivers, etc. can as-sist health communication at theperipheral level.

Having abandoned the heightsof “centres of excellence” (whichfrequently develop into “islands ofirrelevance”) I am, in my dotage, fi-nally looking at health from thecommunity up! ■

Dr Christopher Wood can be reached at POBox 15036, Nairobi, KENYA (Telephone: +2542 891550; Fax: +254 2 890747; E-mail:[email protected]).

PARTNERSHIPS

Diarydates✍ ✍ ✍TUFH field project managers“Health for All Rural people”27—29 APRIL 2002, TRARALGON, VICTORIA, AUSTRALIAThis worldwide consultation, cosponsored by of WHO and the World Organization ofFamily Doctors (WONCA) and drawing on their programmes and activities as well asspecific case scenarios of successful rural projects, will explore the major issues andchallenges of health and health services in rural and remote areas around the world.

For more information, please contact Professor Roger Strasser, Chair, WONCA WorkingParty on Rural Practice; Head of School, Monash University School of Rural Health;PO Box 424; Traralgon 3844, Victoria, Australia (Telephone: +61 3 5173 8181;Fax: +61 3 5173 8182: E-mail: [email protected]).

✍ ✍ ✍“Global Standards in Medical Education for Better Health Care”14—18 SEPTEMBER 2002, COPENHAGEN, DENMARKThis world conference is being organized by the World Federation for MedicalEducation, in cooperation with WHO, UNESCO and the World Medical Association.[Please see the article on this conference in this issue.]

For more information, please contact Dr Hans Karle, President WFME, University ofCopenhagen, Faculty of Health Sciences, The Panum Institute, DK-2000 Copenhagen N,Denmark (Telephone: +453 532 7103; Fax: +453 532 7070; E-mail: [email protected]).

EVENTS

UNISOL congress in Nairobi

More than 20 countries wererepresented at “Universities and

Health of the Disadvantaged”, acongress in Nairobi in June 2001. ADeclaration of Nairobi was adopted,engaging African universities to workin a multidisciplinary manner in favourof disadvantaged individuals andpopulations. “UNISOL” stands for“universities in solidarity for the healthof the disadvantaged”.

A temporary UNISOL African Council has beenformed to lead the development of the UNISOLproject in Africa. The next UNISOL Africanconference is planned for 2003 at the Universityof Capetown, South Africa, where the permanentUNISOL African Council will be constituted. ■

For information on UNISOL Africa, please contact Dr Dan Kaseje, TropicalInstitute of Community Health and Development in Africa, PO Box 60827,Nairobi, Kenya (Telephone: +254 2 441 046; Fax: +254 2 440 306;E-mail: [email protected]).

Nairobi

HIF-net at WHO

HIF-net at WHO is an e-maildiscussion list for all those

interested in improving access toreliable information for health careworkers in developing and transi-tional countries. HIF-net is a jointventure between the WHO and theHealth Information Forum, whichin turn is part of the InternationalNetwork for the Availability of Sci-entific Publications (INASP), itselfa programme of the InternationalCouncil for Science. Participationis free of charge, but subscriptionto the list requires the approval ofthe list moderator. To subscribe,send an e-mail message to the listmoderator, Neil Pakenham-Walsh,INASP Programme Manager:<[email protected]>asking to join the list and brieflydescribing your professional inter-est in health information. ■


MOVING ON

Till wemeet againDR CHARLES BOELEN, Coordinatorfor Human Resources for Health,WHO, Geneva, and ExecutiveEditor of this newsletter, will retirefrom WHO late this year. After 30years of service with WHO atnational, regional and global levelin health services and humanresources development, andinteraction with numerousnetworks worldwide, he will starta career as an independentconsultant in health systems andhealth personnel.

From 1 December 2001 he can bereached as follows: Routed’Excenevex, 74140 Sciez-sur-Leman, France (Telephone andFax: +33 450 72 51 41; E-mail:[email protected]).

Au revoirLE DR CHARLES BOELEN,Coordonateur des RessourcesHumaines à l’OMS à Genève etEditeur de cette revue, sera à laretraite de l’OMS à la fin de cetteannée. Après 30 années de serviceà l’OMS au niveau national,régional et mondial dans lesdomaines du développement desservices de santé et des ressourceshumaines pour la santé, et unecollaboration étroite avec denombreux réseaux à l’échellemondiale, il entreprend unenouvelle carrière de consultantindépendant en systèmes etpersonnels de santé.

A partir du 1 décembre 2001, ilpourra être contacté à l’adressesuivante: Route d’Excenevex,74140 Sciez-sur-Léman, France;Téléphone et Fax: +33 450 72 5141; Courriel: [email protected]).

Charles Boelen receiving his “graduation certificate” in Managing Field Projects inTUFH from Dean Salafsky

Dear Charles

As November draws near and youplan to take flight,

Your friends here in Rockford haveurged that I write.

“Write what?” I replied, to whichall uttered sighs.

“But of course, Buz, the truth!” SoI’ll tell you no lies.

Far be it from me to bend myperceptions,

Providing I maintain synapticconnections.

So here, dear friend Charles, iswhere it is at:

The consults, the speeches, theartwork and that;

The planning, the meetings, andall the discussion;

The reports in English, Spanish,French and some Russian.

Many may herald your ongoinginspiration;

Others may note hard work anddedication.

You traveled the globe, week inand week out,

But the voice of persuasion: thatwas your clout.

For as is well known, theOrganization lacks funds

And Human Resources was leftwith the crumbs.

Thankfully, though, your friendshave been legion,

So paucity in Geneva was gainfrom each region

(or at least in some).

And now, at last, as you preparefor your fling,

What, indeed, are the praises thatwe should all sing?

I think it is clear, and would statewith impunity,

The crowning achievement, aboveall, has been UNITY.

With fond wishes, and apologies tolimerick writers everywhere,

Buz Salafsky, Dean, University of Illinois,College of Medicine-Rockford, Rockford,Illinois, USA (WHO Collaborating Centre forEducational Development of Health Profes-sionals and Health Care Systems)


MOVING ON

Arthur Kaufman

A. Oriol-Bosch

Dear Charles

Among my very good memories isthe time (1991–92) that I spent atWHO working with you. I learneda lot in a wonderful setting.

I know you won’t be fadingfrom the scene; you have toomuch energy and too many greatideas for that to happen. I dohope your consulting practicebrings you this way from time totime.

I often think of you, my friend,sailing around Lac Léman; I hopeyou continue to sail through lifeas well.

Fondly,Dan

Daniel S. Blumenthal, MD; Associate Dean forCommunity Programs, Department ofCommunity Health and Preventive Medicine;Morehouse School of Medicine; Atlanta,Georgia, USA

Dear Charles

In my name as well as in the nameof our medical school, I want tothank you for all your help andsupport. Your counselling, ideasand suggestions have representedsome of the most

important inputs for thedirection our institution hasdecided to take. Many of thechanges we had already startedwere directly related to your workand your bright and clear ideas. Inthis way, you must know that youare part of this small institution atthe end of the world.

We wish the best for you, but Ihave to say: We will miss you.

Benjamin Stockins, MD; Professor of InternalMedicine and Cardiology; Former Dean,Medical Faculty; Universidad de la Frontera;Temuco, Chile (WHO Collaborating Centre forMedical Education and Practice)

Dear Charles

I want to express my deepestappreciation and that of the entireNetwork for the wonderful part-nership we have enjoyed with youand with WHO over the years and,more recently, with your visionaryTUFH project. Charles, youhelped rebuild these linksbetween WHO and The Network,envisioning how we couldbecome allies, share complemen-tary strengths and provide mutualsupport for each other.

You have never been shy aboutsharing your opinions. It waspartly at your prodding that wechanged our name and broad-ened our mission beyond educa-tion to include service andresearch for development, therebyincorporating all academicmissions in the struggle to makehealth professions universitiesrelevant and accountable towardcommunity health. We are thusnow called, The Network: Com-munity Partnerships for Healththrough Innovative Education,Service and Research.

On a more personal note, I willmiss your signature ascots, thegentle line sketches with whichyou illustrate your talks, and youranimated and theatrical bodylanguage during conversations. Ihave always been impressed withyour “can do” attitude, so rare inthe large, bureaucratic organiza-tions in which we work, wherecaution too often rules the day. Itis this energy that helped you driveso many important initiatives.

Though we will miss you in

your current role, we are sure youwill continue to struggle forrelevance and accountability ofour health institutions in what-ever endeavour you choose topursue in the future. You can restassured we will be ready to joinyou when asked.

Arthur Kaufman, MD; Professor and Chair,Department of Family and CommunityMedicine; University of New Mexico;Secretary General, The Network; Albuquerque,New Mexico, USA (WHO Collaborating Centrefor the Dissemination of Community-oriented,Problem-based Learning)

Charles: An unconventionalinternational officer

Charles is* an old-timer whobelongs to a limited group ofindividuals serving as reference tomany: a kind that should neverdisappear.

Charles is* an atypical expert inmany trades: a long-term civilservant who has managed to keepimproving himself withoutblending into his environment.

Charles is* a performer, a thinkerand a dreamer, with an artistic soulbranching into poetry and figura-tive representative drawings.

Charles is* to me an enjoyableperson with whom time flies andtopics of conversation are neverexhausted, no matter where theencounter happens to take place.

* I do not know really know whatcomplex Charles is, but at least thisis what he seems to be to me. ■

Professor A. Oriol-Bosch, Director, Institutd’Estudis de la Salut, Barcelona, Spain (WHOCollaborating Centre for Health CareProfessionals Development)


ADDRESSES

■ WHO headquartersWorld Health Organization

1211 Geneva 27, Switzerland(Telegraph: UNISANTE GENEVA;Telex: 415 416;Telephone: +(022) 791 21 11;Fax: +(022) 791 31 11)

■ WHO regional officesWHO Regional Office for Africa

Temporary address:Parirenyatwa Hospital; P.O. BoxBE 773; Harare, Zimbabwe(Telephone: +(001) 407 733 9244;Fax: +(001) 407 726 5062)

WHO Regional Office for the Americas/Pan American Sanitary Bureau

525-23rd Street, N.W.;Washington, D.C. 20037; USA(Telegraph: OFSANPANWASHINGTON;Telex: 248338;Telephone: +(1 202) 974 3000;Fax: +(1 202) 974 3663)

WHO Regional Office for the EasternMediterranean

P.O. Box 1517; Alexandria 21511, Egypt(Telegraph: UNISANTE ALEXANDRIA;Telex: 54028 or 54684;Telephone: +(203) 48 202 23;Fax: +(203) 48 38 916)

WHO Regional Office for Europe8, Scherfigsvej; DK-2100 Copenhagen(Telegraph: UNISANTE COPENHAGEN;Telex: 15348 or 15390;Telephone: +(45) 3917 1717;Fax: +(45) 3917 1818)

WHO Regional Office for South-EastAsia

World Health House; Indraprastha Estate;Mahatma Gandhi Road; New Delhi110002, India(Telegraph: WHO NEW DELHI;Telex: 3165095 or 3165031;Telephone: +(91) 11 331 7804;Fax: +(91) 11 332 7972)

WHO Regional Office for the WesternPacific

P.O. Box 2932; 1099 Manila, Philippines(Telegraph: UNISANTE MANILA;Telex: 27652;Telephone: +(632) 528 8001;Fax: +(632) 521 1036)

■ WHO regional training centreWHO Regional Training Centre forHealth Development

School of Medical Education;University of New South Wales;Sydney 2052, Australia(Telephone: +(612) 9 385 2500;Fax: +(612) 9 385 1526;E-mail: [email protected])

■ WHO collaborating centres inhuman resources development

Centre collaborateur de l’OMS pour laRecherche en matière deDéveloppement des Ressourceshumaines pour la Santé

Faculté des Sciences de la Santé;Université nationale de la République duBénin; B.P. 188; Cotonou, Benin(Telephone: +(229) 300 001;Fax: +(229) 301 288)

WHO Collaborating Centre forEducation and Medical Practice

Faculdade de Medicina; UniversidadeFederal de Minas Gerais; CP 100; BeloHorizonte, Minas Gerais 30.130-100,Brazil (Telephone: +(55 31) 3 248 9632;Fax: +(55 31) 3 248 9664)

WHO Collaborating Centre in MedicalEducation and Practice

Centro de Ciências da Saúde; UniversidadeEstadual de Londrina; Cx. Postal 6001;CEP 86051; Londrina, Paraná, Brazil(Telex: +(55 432) 268;Telephone: +(55 432) 21 2000;Fax: +(55 432) 27 6932)

WHO Collaborating Center for HealthManpower Development

McMaster Health Sciences International;McMaster University;1200 Main Street West; Hamilton, Ontario,Canada L8N 3Z5Please contact: Helen Wagner,Administrative Assistant;(Telephone: +(1905) 525 9140,ext. 22318; Fax: +(1905) 524 5199;E-mail: [email protected]))

PAHO/WHO Collaborating Centre forHealth Professionals Education andPractice Responsive to Health Needs ofCommunities

Faculté de Médecine; Université deSherbrooke; 3001, 12ème Avenue Nord;Sherbrooke, Québec, Canada(Telephone: +1 819 564 5204;Fax: +1 819 564 5378;E-mail: [email protected]).

WHO Collaborating Centre for MedicalEducation and Practice

Facultad de Medicina; Universidade de laFrontera; Montt 112 - Casilla 54-D;Temuco, Chile(Telephone: +(56 45) 212108Fax: +(56 45) 212108)

WHO Collaborating Centre forDevelopment of Human Resources forHealth

Faculty of Medicine; Suez CanalUniversity; Ismailia, Egypt(Telex: 63297 scufm un;Telephone: +(20 64) 328 935;Fax: +(20 64) 229 982)

WHO Collaborating Centre for theDevelopment of Human Resources forHealth and for Primary Health Care

Department of General Practice andPrimary Health Care; University ofHelsinki; Mannerheimintie 172; 00300Helsinki, Finland (Telephone: +(3589) 19127411; Fax: +(3589) 191 27536;E-mail: [email protected];URL: http://www.yle.helsinki.fi)

Centre collaborateur de l’OMS pour leDéveloppement des Ressourceshumaines pour la Santé

Département de Pédagogie des Sciencesde la Santé; U.F.R. sur la Santé, Médecineet Biologie humaine de Bobigny; 74, rueMarcel Cachin; 93012 Bobigny CEDEX,France(Telephone: +(3311) 48 38 76 40, ext. 224/ (3311) 48 38 76 41;Fax: +(3311) 48 38 77 77)

Centre collaborateur de l’OMS pour leDéveloppement des Ressourceshumaines

Fondation Mérieux, Centre des Pensières;55, avenue d’Annecy; 74290 Veyrier-du-Lac, France(Telephone: +(33) 50 64 80 80;Fax: +(33) 50 60 19 71)

WHO Collaborating Centre forEducational Development of Medicaland Health Personnel

Educational Development Centre; ShaheedBeheshti University of Medical Sciencesand Health Services; Teheran, IslamicRepublic of Iran(Telephone: +(98) 21 293 211;Fax: +(98) 21 294 228)

WHO Collaborating Centre for Problem-based Learning in Health ProfessionsEducation

International Health Management Centre;Istituto Superiore di Sanitá;Viale Regina Elena 299; I-00161 Rome;Italy(Telephone: +(396) 4938 7294;Fax: +(396) 4938 7295)

WHO Collaborating Centre for Trainingof Health Professionals

Department of Training in Public Healthand Bioethics; Istituto Superiore di StudiSanitari, Largo del l’Artide 11, Rome,Italy-00144

WHO Collaborating Centre for Problem-Based/Problem-Solving Approaches toEducation and Practice in Public Health

Faculty of Health Sciences;Moi University; PO Box 4606;Eldoret 0321, Kenya(Telex: moivarsity 35047;Telephone: +(254 321) 33059, 32781/2/3;Fax: +(254 321) 33041)

WHO Collaborating Centre forInternational Health

University of Texas Medical Branch atGalveston; 1.142 Bethel Hall; 301University Boulevard; Galveston, Texas77555-0862, USA(Telex: 765603;Telephone: +(1409) 772 0870;Fax: +(1409) 772 0875)

■ Nongovernmental organizationsin official relations with WHO ineducational development

Conférence internationale des Doyensdes Facultés de Médecine d’Expressionfrançaise

(Monsieur le Professeur Pierre Farah,Président); Doyen de la Faculté deMédecine; Université St.-Joseph; B.P. 11-5076, Beirut, Lebanon(Telephone: +(961) 1 614 004;Fax: +(961) 1 614 054;E-mail: [email protected])

International Federation of MedicalStudents’ Associations

IFMSA General Secretariat; c/o WorldMedical Association; B.P. 63; 01212Ferney-Voltaire, France(Telephone: +33 450 40 4759;Fax: +33 450 40 5937;E-mail: [email protected];URL: http://www.ifmsa.org)

The Network: Community Partnershipsfor Health through InnovativeEducation, Service and Research

(Coordinating Secretary:Mrs P. Vluggen); P.O. Box 616; NL-6200 MD Maastricht(Telephone: +(31 43) 388 1522/1524;Fax: +(31 43) 367 0708;E-mail: [email protected] Wide Web: http://www.the-network.org)

World Federation for Medical Education(Dr Hans Karle, President);Faculty of Health Sciences;University of Copenhagen;The Panum Institute; Blegdamsvej 3;2200 Copenhagen N, Denmark(Telephone: +(45) 35 32 70 68;Fax: +(45) 32 32 70 70;E-mail: [email protected])

World Medical AssociationDr Delon Human, Chief Executive Officer,WMA Secretariat; B.P. 63; 01212 Ferney-Voltaire, France (Telephone: +33 450 407575; Fax: +33 450 40 5937;E-mail: [email protected])

World Organization of Family Doctors(WONCA)

(Dr W.E. Fabb, Chief Executive Officer);World Organization of Family Doctors;Locked Bag 11; Collins Street East PostOffice; Melbourne Victoria 8003, Australia(Telephone: +(61) 3 9650 0235;Fax: +(61) 3 9650 0236;E-mail: [email protected])

Centro Colaborador de la OrganizacionMundial de la Salud para la Formaciónde Recursos Humanos

Facultad de Medicina; UniversidadNacional Autónoma de México; Edificio“B” Primer Piso; Apartado Postal 70-443;México, DF 04510, Mexico(Telephone: +(52 5) 616 1162; 623 2401/2402;Fax: +(52 5) 616 1616;E-mail: [email protected])

WHO Collaborating Centre for HealthManpower Development

Office for International Relations; Facultyof Medicine; Rijksuniversiteit Limburg;Postbus 616; 6200 MD Maastricht,Netherlands(Telex: 56880 fg rl nl;Telephone: +(3143) 881 520;Fax: +(3143) 670 708)

WHO Collaborating Centre for Researchin Health Manpower Development;Community-Based Educational Systems(COBES) Programme

Faculty of Health Sciences; University ofIlorin; PMB 1515; Ilorin, Nigeria(Telex: 33144 unilon ng;Telephone: +(23431) 221 844)

WHO Collaborating Centre for Researchand Training in EducationalDevelopment of Health Personnel

Department of Medical Education (DME),College of Physicians and Surgeons, 7thCentral Street, Defence Housing Authority,Karachi 75500, Pakistan(Telephone: +(92 21) 588 7111/588 3285;Fax: +(92 21) 589 3062)

WHO Collaborating Centre for Qualityof Care

Medical University of Southern Africa,Box 203 Medunsa 0204,Republic of South Africa(Telex: 32 0580 sa;Telephone: +(27 12) 529 4669;Fax: +(27 12) 560 0274)

WHO Collaborating Centre for HealthCare Professionals Development

Institut d'Estudis de la Salut; Balmes 132–136; 08010 Barcelona; Spain(Telephone: +(3493) 238 6900;Fax: +(3493) 238 6910;E-mail: [email protected];Web: http://www.iesalut.es)

WHO Collaborating Centre for Researchand Training in EducationalDevelopment

Educational Development Centre; Facultyof Medicine; University of Gezira; P.O.Box 20; Wad Medani; Sudan

WHO Collaborating Centre for MedicalEducation

Faculty of Medicine; ChulalongkornUniversity; Rama IV Road; Bangkok10330; Thailand(Telephone: +(662) 252 7859;Fax: +(662) 254 1931)

Centre collaborateur de l’OMS pour laRecherche et la Formation en matièrede Développement de la Formation desPersonnels de Santé

Centre National de Formation Pédagogiquedes Cadres de la Santé; 67, boulevardHedi Saidi; Bab Saadoun; Tunis 1005,Tunisia

WHO Collaborating Centre for PrimaryHealth Care/Public Health Education

School of Public Health; Loma LindaUniversity; Loma Linda 92350; California;USA

WHO Collaborating Centre for Leader-ship Development for Health for All

School of Public Health; University ofHawaii; 1960 East-West Road;Honolulu; Hawaii 96822; USA(Telephone: +(1808) 956 7486;Fax: +(1808) 956 5286)

WHO Collaborating Centre forEducational Development of HealthProfessionals and Health Care Systems

Department of Medical Education(M/C 591); University of Illinois College ofMedicine at Chicago; Box 6998; Chicago,Illinois 60680, USA(Telephone: +(1312) 996 3590;Fax: +(1312) 413 2048)

WHO Collaborating Centre forEducational Development of HealthProfessionals and Health Care Systems

University of Illinois College of Medicine atRockford; 1601 Parkview Avenue;Rockford, Illinois 61107-1897, USA(Telephone: +(1815) 395 5600;Fax: +(1815) 395 5887;E-mail: [email protected] [email protected])

WHO Collaborating Centre forPostgraduate Public Health Educationand Research

School of Hygiene and Public Health;Johns Hopkins University;615 North Wolfe Street; Baltimore,Maryland 21205-2179, USA(Telephone: +(1410) 955 3540;Fax: +(1410) 955 0121)

WHO Collaborating Centre for theDissemination of Community-oriented,Problem-based Learning

Primary Care Curriculum; Social MedicineProgram; Department of Family andCommunity Medicine; School of Medicine;University of New Mexico; 2400 TuckerAvenue, NE; Albuquerque; New Mexico87131-5241, USA(Telex: 660 461;Telephone: +(1505) 277 2165;Fax: +(1505) 277 0657)

ADDRESSES


Towards UnityFor HealthThe newsletter Towards Unity for Health isissued in April and October by the WorldHealth Organization, Geneva, Switzerland. Itaims to provide a forum for reflection oninitiatives worldwide to foster coordinatedchanges in health services organization andhealth professions practice and education. Itis also intended to help create a climate ofsolidarity among health authorities,academics, health professionals andrepresentatives of the community toencourage more appropriate approaches topursuing relevance, quality, cost-effectiveness and equity in health services.

© World Health Organization, October 2001

This document is not a formal publication ofthe World Health Organization (WHO), andall rights are reserved by the Organization.The document may, however, be freelyreviewed, abstracted, reproduced ortranslated, in part or in whole, but not forsale or for use in conjunction withcommercial purposes.

The views expressed in documents bynamed authors are solely the responsibilityof those authors.

The designations employed and thepresentation of material on maps in thisdocument do not imply the expression ofany opinion whatsoever on the part of theWorld Health Organization concerning thelegal status of any country, territory, city orarea or of its authorities, or concerning thedelimitation of its frontiers or boundaries.Dotted lines represent approximate borderlines for which there may not yet be fullagreement.

Comments are invited from individuals andinstitutions interested in health systemsdevelopment and health services delivery.Contributions of short articles (less than 800words long) are particularly welcome. Pleaseaddress comments and contributions to:

Dr Charles BoelenDepartment of Health Service ProvisionWorld Health Organization1211 Geneva 27, SWITZERLAND(telephone: +41 22 791 2510fax: +41 22 791 4747e-mail: [email protected])

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