00 vol43_4_FINAL.ai - International Hospital Federation

2007 Volume 43 Number 4
International Hospital Federation | Fédération Internationale des Hôpitaux | Federación Internacional de Hospitales
World Hospitals and Health Services
The Official Journal of the International Hospital Federation
www.ihf-fih.org
Includes papers
delivered at the 35th
World Hospital
Congress in Korea
Editorial
IHF Newsletter
International Hospital Federation news
Calendar
IHF interview: Climate change and human health
Country profile
Uganda health care
Policy
Global health diplomacy: Training across disciplines
Vision and strategy for ubiquitous health care:
The end of business as we know it
Please tick your box and pass this on:
■ CEO
■ Medical director
■ Nursing director
■ Head of radiology
■ Head of physiotherapy
■ Senior pharmacist
■ Head of IS/IT
■ Laboratory director
■ Head of purchasing
■ Facility manager
Management
Korean Hospital Design, State of the Art
Creating competent health-care specialists: The Swiss
School of Public Health
Clincial care
The importance of militaries from developing countries
in global infectious disease surveillance
e-health supplement
Sharing and management of EHR data through a
national archive: Experiences from Finland
Opinion matters
War-scarred Iraqis face health burdens in foreign lands

CONTENTS
World Hospitals and Health Services
2007 Volume 43 Number 4
The Official Journal of the International Hospital Federation
Contents
03
Editorial Professor Per-Gunnar Svensson
IHF IHF NEWSLETTER Newsletter
04 International Hospital Federation news
08
09
10
13
International news
Conference and event calendar
IHF interview: Climate change and human health
Carlos Corvalan
COUNTRY PROFILE
Uganda health care
ARTICLES
Policy
16 Global health diplomacy: Training across disciplines
Arnold D Kaluzny, PhD
20
23
29
32
38
Vision and strategy for ubiquitous health care: The end of
business as we know it Arnold D Kaluzny, PhD
Management
Korean hospital design, state of the art
Professor Chang-Ho Moon
Creating competent health-care specialists: The Swiss School of
Public Health Ursula A Ackermann-Liebrich, Sandra Nocera
and Sonja Merten
Clinical care
The importance of militaries from developing countries in global
infectious disease surveillance Jean-Paul Chretien, David L
Blazes, Rodney L Coldren, Michael D Lewis, Jariyanart
Gaywee, Khunakorn Kana, Narongrid Sirisopana, Victor
Vallejos, Carmen C Mundaca, Silvia Montano, Gregory J
Martinb and Joel C Gaydosa
E-HEALTH SUPPLEMENT
Sharing and management of EHR data through a national
archive: Experiences from Finland Pekka Ruotsalainen,
Persephone Doupi, Päivi Hämäläinen
REFERENCE
42 Abstract translations in French and Spanish
45
Directory of IHF professional and industry members
OPINION MATTERS
48 War-scarred Iraqis face health burdens in foreign lands
EDITORIAL STAFF
Executive Editor:
Professor Per-Gunnar Svensson
Desk Editor:
Sheila Anazonwu, BA(Hons), MSc
EDITORIAL BOARD
Dr René Peters
Dutch Hospital Association
Norberto Larroca
Camara Argentina de Empresas de Salud
Dr Harry McConnell
ISHED
Dr Persephone Doupi
STAKES
EDITORIAL OFFICE
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01210 Ferney Voltaire, France
Email: info@ihf-fih.org
Internet: www.ihf-fih.org
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ISSN: 0512-3135
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World Hospitals and Health Services is published
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World Hospitals and Health Services is listed in Hospital Literature
Index, the single most comprehensive index to English language
articles on healthcare policy, planning and administration.
The index is produced by the American Hospital Association
in co-operation with the National Library of Medicine. Articles
published in World Hospitals and Health Services are selectively
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The International Hospital Federation is an independent,
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in the planning and management of hospitals and health services.
The opinions expressed in this journal are not necessarily those
of the Federation or Pro-Brook Publishing Limited.
Vol. 43 No. 4 WORLD | World hospitals Hospitals and and health Health services Services | 13| 01

EDITORIAL
Fresh insights
from Seoul
PROFESSOR PER-GUNNAR SVENSSON
DIRECTOR GENERAL, INTERNATIONAL HOSPITAL FEDERATION
In this edition of World Hospital and Health Services we
carry a couple of papers delivered at the IHF Congress in
Seoul, Korea, held in November 2007. One of these
papers is addresses the “Vision and strategy for ubiquitous
health care; The end of business as we know it”. The author
claims that health services and clinical enterprises have
entered a new era involving an increasing amount of
economic, service and research activity across rather than
within the boundaries of traditionally defined organizations.
This is, of course, true considering the number of alliances
and networks that are developing, for example, in order to
integrate different types of services, such as rehabilitation
and acute care.
Another presentation made in Seoul focused on current
thinking in Korean hospital design. This article illustrates the
global perspective adopted in the design and architecture of
modern Korean health-care facilities and how they have
adapted evidenced-based design to the cultural and social
context of Korea.
In another paper, the health burden of the war in Iraq is
discussed, including the plight of the estimated two million
people who have fled the war-torn country. Estimates from
scientific journals tell us that the death toll of the war is
between 100,000 and 300,000. These estimates based on
sample data and should be interpreted as such. But the
message is clear: a human-made disaster is a fact.
Further, and on a more positive note, another article
shows how the military have a significant role to play in
infectious disease surveillance in developing countries. This
is illustrated by experience from Thailand and Peru where
military health organizations, in partnership with the US
military, use their laboratory, epidemiological,
communication and logistical resources to support civilian
ministry of health efforts.
In another article one of the most expensive health-care
systems in the world, the Swiss, is described and analyzed.
It is said that although there are some differences between
the Swiss cantons in their policies, legislation and structure,
efficiency can be improved. In the article it is said that some
improvement may be possible if health economics and
public health were better coordinated and interrelated; and
also if the leadership, that is presently dominated by lawyers
and business economists, was more oriented towards health
needs and reducing inequities in access and health.
Finally, we have some experiences on national archiving of
health and welfare data reported from Finland. In this
article, digital archiving is discussed and analyzed from
different perspectives, for example, regarding citizens’ access
and ways to improve the system. ❑
London, December 2007
Per-Gunnar Svensson
Director General of IHF
Vol. 43 No. 4 WORLD | World hospitals Hospitals and and health Health services Services | 13| 03

IHF NEWSLETTER
International Hospital Federation news
World Hospital Congress in Korea proves huge success
THE INTERNATIONAL HOSPITAL FEDERATION’S 35TH
INTERNATIONAL WORLD HOSPITAL CONGRESS held in
Seoul, Korea from 5-9 November 2007 was very well attended
and received. Dwight Moe, the IHF Project and Event Manager
gives his reflections of that busy event here.
The core mission of the IHF is contained in the opening of
our vision statement –
“Our goal is to develop and maintain a spirit of cooperation and
communication among our members, with the primary goal of
improving patient safety and of promoting health in underserved
communities.“ Our vision is to become a world leader in facilitating
the exchange of knowledge and experience in health sector
management. Through the dissemination of evidence-based
information, IHF will help improve patient care quality around the
globe.”
All of us are so busy
with the day to day
challenges that face us
and our organisations
that we sometimes
hesitate to travel to
Chul Soo Kim, President, Korean
Hospital Association
events because there
does not seem to be
enough time to cope with the tasks already before us. Allow me
to suggest that meeting face to face with colleagues from around
the world who face the same or similar challenges as we do is a
vital tool to help us meet our challenges at home.
In the case of the 35th IHF World Hospital Congress 2500
delegates of which 600 were from countries other than Korea
representing over 60 countries met and laid the groundwork
for future collaboration and exchanges. For example I
witnessed colleagues from Finland speaking about possible
solutions with colleagues from Nigeria a synergy that would
have been extraordinarily unlikely, but for their attendance in
Seoul.
Even when we seem to be overwhelmed by the mass of work
piling up on our desks we need to invest the time to look
beyond our borders. The challenges facing our health-care
systems are too great to face alone. We know that we must
work together and to take collaborative approaches. In a world
of emails, voicemail and SMS there is still no better way to
pursue our goal of international cooperation than meeting face
to face with colleagues from around the world.
The Korean Hospital Federation should be praised for
producing a flawless and engaging event with a level of
organization, hospitality and warmth that was truly impressive.
I look forward to seeing you at other IHF events and especially
in two years time at the 36th IHF World Hospital Congress in
Rio de Janeiro, Brazil from November 10-12, 2009.
IHF President Gérard Vincent (centre) speaking with Jae Hoon
Choi (right), CEO of Ezmedicom, a Korean company
pioneering the very latest computer technology to increase
the efficiency of hospital management through the use of an
innovative IT platform for e-Procurement and e-Logistics for
“Zero Inventory Management”.
Inter-professional training seminar on infection control in South Africa.
HEALTH CARE WORKERS SAFETY IN THE CONTEXT OF
DRUG RESISTANT TB in low and middle-income countries.
The International Council of Nurses (ICN), the International
Hospital Federation (IHF) and the International Federation
of Red Cross and Red Crescent Societies (IFRC)/South
African Red Cross Society and the World Medical
Association (WMA), members of the Lilly MDRTB
Partnership, initiated together a workshop in Cape Town,
South Africa, on health care worker safety and infection
control in the context of drug-resistant TB in low and middle
income countries. The 2-day workshop,12-13. November
2007, brought together South African community support
workers, hospital managers, nurses and physicians working
in the context of drug-resistant TB, to jointly examine and
04 | World Hospitals and Health Services | Vol. 43 No. 4

IHF NEWSLETTER
address these issues. This
common seminar for all four
health care professions was
the first one held in South
Africa. Given the already
critical shortage of health
providers and the generally
weak health systems in the
regions most affected by XDR-
TB and MDR-TB, particularly
in southern Africa, anxiety
about safety in the health
care environment runs high
and can dissuade health
providers from accepting
assignments in these settings.
The workshop programme, therefore addressed
administrative, environmental and personal respiratory
protection with the objective of identifying good practices
and challenges to the implementation of joint
recommendations for facilities and health workers It
Scenes from the Inter-professional training seminar
drew up recommendations for implementing guidelines
in their hospitals and suggested establishing a common
working group with a plan of action to communicate the
identified practices and recommendations.
IHF launches a new hospital benchmarking service
at the 35th World Hospital Congress
IHF DIRECTOR GENERAL PROFESSOR PER-GUNNAR
SVENSSON in his plenary speech unveiled the latest
initiative from the IHF to help improve the management
and quality of hospitals: a web-based benchmarking
service created specifically for IHF members.
The IHF Hospital Benchmarking Service will allow hospitals
to monitor their processes and compare performance with
other facilities in their own countries or around the world.
Data is entered into an easy-to-use web interface manually or
automatically. The same interface then provides narrative and
graphic information about performance, cost and quality of
care in as much detail as required.
The data from the IHF Hospital Benchmarking Service
will be used to create global standards in health care and
the measures which
are necessary for
better hospitals.
The technology
Benchmarking results displayed
behind this service is
provided by a leading Scandinavian medical IT company
and subscriptions to the service are being managed by Pro-
Brook Publishing on behalf of the IHF.
For further information contact: benchmark@ihffih.org
or telephone Trevor Brooker on +44 1394 446
006 or visit www.ihf-fih.org and click the IHF Hospital
Benchmarking Service banner.
Governing Council member profile Professor Helen Lapsley
PROFESSOR HELEN MADELEINE
LAPSLEY is a health economist
nominated to the International
Hospital Federation by the Australian
Healthcare Association, on which she
is a Council member. She was born
and educated in New Zealand, but has
lived in Sydney, Australia, since 1975.
She holds professorial appointments in the Faculty of
Medicine at the University of New South Wales, and in the
Centre of National Research on Disability and
Rehabilitation Medicine at the University of Queensland.
She has undertaken consultancies for the Australian
Government, the World Health Organization and the
World Bank on economic issues and policies relating to
health-care financing, the medical workforce, governance
of health service providers, and the costs of tobacco,
alcohol and illicit drug use.
She is an author and co-author of more than 100
publications, including books, monographs and papers in
scholarly journals.
In 2004 she was awarded the Sidney Sax Medal for
outstanding contributions to the Australian Healthcare
Industry in the field of health services policy, organization,
delivery and research.
She is currently a member of the Pharmaceutical Benefits
Remuneration Tribunal and is a Ministerial appointee to
the New South Wales Medical Board.
Vol. 43 No. 4 | World Hospitals and Health Services | 05

IHF NEWSLETTER
International news
round up
AFRICA
Kigali hosts regional workshop on patient safety
MORE THAN 50 PARTICIPANTS FROM 21 COUNTRIES
took part in the first African regional workshop on patient
safety which was held from 10 to 12 December 2007 in Kigali,
Rwanda.
The three-day workshop provided a forum for the
participants to exchange experiences and strategize on how
patient safety can be improved in the region. Participants were
provided with guidelines and tools to facilitate
implementation of safer care in their respective countries. In
the African region, there is a lack of comprehensive data on
the nature and extent of patient harm attributable to health
care. This dearth of information is compounded by weak
health systems, a severe health workforce shortage, crumbling
infrastructure and weak management capacity.
In spite of these challenges, the WHO African Region is
currently focusing on patient safety as a major health system
performance and quality management indicator. This is being
done through:
➜ the creation of an over-aching strategy and development
of action plans to address patient safety issues ;
➜ the establishment of a regional network for patient safety;
➜ The organization of inter-country workshops and regional
meetings and training sessions to raise awareness on
patient safety .
Participants in the Kigali workshop came from Angola,
Botswana, South Africa, Rwanda, Kenya, Zambia, Seychelles,
Mauritius, Zimbabwe, Sierra Leone, The Gambia, Ghana,
Swaziland, Lesotho, Mozambique, Uganda, Nigeria, Liberia,
Malawi, Ethiopia and, Namibia.
For more information contact: Sam Ajibola, Brazzaville,
Republic of Congo; Tel.: + 47 241 39378; E-mail
ajibolas@afro.who.int
AMERICAS
Nearly one in five Americans say they can’t afford needed health care
NEARLY ONE IN FIVE US ADULTS – more than 40 million
people – report they do not have adequate access to the health
care they need, according to the annual report on the nation’s
health released today by the Centers for Disease Control and
Prevention (CDC). The report, “Health, United States, 2007,”
is a compilation of more than 150 health tables prepared by
CDC’s National Center for Health Statistics
Other major findings of the report include:
➜ Young adults 18-24 years of age were more likely than
children or older adults to lack a usual source of care and
to be uninsured
➜ One in 10 adults ages 45-64 years did not have a usual
source of health care, and more than 5% of adults in this
age group who had diagnosed high blood pressure, serious
heart conditions, or diabetes reported not having a usual
source of medical care.
➜ In 2005, one out of five people under the age of 65
reported being uninsured for at least part of the 12
months prior to being interviewed. The majority of this
group reported being uninsured for more than 12 months.
➜ One in 10 women aged 45-64 years with income below
the poverty level reported delaying medical care due to
lack of transportation.
➜ About one-third of all children living below the poverty
level did not have a recent dental visit in 2005, compared
with less than one-fifth of children with higher income.
The full Health, United States: 2007 is available at
http://www.cdc.gov/nchs/. For more information visit
www.hhs.gov/everyamericaninsured.
08 | World Hospitals and Health Services | Vol. 43 No. 4

IHF NEWSLETTER
Conference and
event calendar
IHF EVENTS
2008
10-14 March
International Comparative Programme in Hospital Management
Gulf of Tigullio, the Italian Riviera of Camogli and Portofino, Italy
Domenico.salvatore@unobocconi.it / paolo.tedeschi@unibocconi.it / Dwight@ihf-fih.org
www.sdabocconi.it/icphm / http://www.ihf-fih.org
8-10 September
MCC Hospital World
Berlin, Germany
Dwight@ihf-fih.org http://www.ihf-fih.org / www.hospitalworld.info
2009 2011
10-12 November 37th World Hospital Congress *
36th World Hospital Congress *
Dubai, Unites Arab Emirates
Rio de Janeiro, Brazil
Dwight@ihf-fih.org
Dwight@ihf-fih.org
http://www.ihf-fih.org
http://www.ihf-fih.org / http://ihfrio2009.com/
COLLABORATIVE EVENTS
2008
25-28 May
Geneva Forum: Towards Global Access to Health
The “Geneva Forum: Towards Global Access to Health” will host its second edition in May 2008. Theme of this edition is:
‘Strengthening Health Systems and the Global Health Workforce’. International Conference Centre of Geneva, Switzerland
Geneva Health Forum Secretariat. Tel: +41 22 372 96 72 / 58; E-mail: info.genevahealthforum@hcuge.ch Internet:
www.genevahealthforum.org / http://www.ihf-fih.org Register on-line: http://genevahealthforum.hugge.ch/registration/information_on_line_registration.html
Submit an abstract: http://genevahealthforum.hugge.ch/abstract_themes.html
Apply for a travel grant: http://genevahealthforum.hug-ge.ch/registration/travel_grants_2008.html
Find out about the Marketplace: http://genevahealthforum.hug-ge.ch/marketplace_general_information.html
21-24 September
Sixth Conference on Quality Health Care for Culturally Diverse Populations
Minneapolis, Minnesota, US
Improving the delivery of health services to migrant, refugee and indigenous patients: This conference features model
programmes, policies and issue debates from health professionals, policymakers, researchers and advocates. We extend a
special invitation to international participants to discuss country-specific examples and the potential for global collaboration.
rcchc@aol.com; sheila@ihf-fih.org
http://www.diversityrxconference.org; http://www.ihf-fih.org
Call for Presentation Proposals
Main conference website
Submit an abstract: http://www.diversityrxconference.org/Call-For-Proposals/64/
Events marked * are interpreted into English, French and Spanish. All other events will be
in English/host country language only. IHF members will automatically receive brochures
and registration forms on all the above events approximately 6 months before the start
date. IHF members will be entitled to a discount on IHF Congresses, pan-regional
conferences and field study courses.
For further details contact the: IHF Project & Event Manager, International Hospital
Federation, Immeuble JB Say, 13 Chemin du Levant, 01210 Ferney Voltaire, France;
E-Mail: Dwight@ihf-fih.org Or visit the IHF website: http://www.ihf-fih.org
Vol. 43 No. 4 | World Hospitals and Health Services | 09

IHF INTERVIEW
Climate change and
human health
CARLOS CORVALAN
IS AN ENVIRONMENTAL EPIDEMIOLOGIST AND COORDINATOR OF THE INTERVENTIONS
FOR HEALTHY ENVIRONMENTS UNIT AT WHO IN GENEVA
Protecting health against the effects of climate change will
be next year’s theme for World Health Day (7 April
2008) and WHO’s 60th anniversary celebrations.
Carlos Corvalan talks about WHO’s work with countries to
help them tackle those effects and how climate change affects
people’s health.
Q: Are there any effective initiatives that have helped countries
adapt to the negative impact of climate change on people’s health?
A: Many. We have been working with countries to assist in
the identification of vulnerabilities and of adaptation options
for climate change. For example, WHO helps countries set up
early warning systems for heatwaves, to be informed and
prepared for vector-borne diseases in areas where increases are
expected from warming, or the safe use of wastewater in
water-scarce areas. But this is only the tip of the iceberg of
what needs to be done. We must deal with climate change
from the point of view of health security, and address water
security, food security and energy security among others.
Q: There has been a very lively public debate about climate
change yet health is rarely mentioned. Has WHO been slow to get
involved?
A: WHO has been quite proactive in this area but in spite
of this, the health argument has not been used to its full
extent when discussing global action, such as in the
conferences of the United Nations Framework Convention
on Climate Change (UNFCCC). Many of the global climate
change key players have not known enough about what
WHO is doing. Up to very recently, WHO has not been
sitting at the key tables, with the appropriate level of
representation. All this is changing very fast, and you can
now see WHO taking a key leadership role on climate change
globally. Climate change is on the health agenda of Director-
General Dr Margaret Chan, and this will have an enormous
positive impact on protecting people’s health.
Q: Will we ever completely understand how climate change
affects peoples’ health?
A: There are many unknowns, but we know enough to
take action to protect health. Let’s consider the simplest
case, heatwaves. They kill people, and more such extreme
events are expected as a result of climate change. After the
heatwave in Europe in 2003, which killed tens of thousands
of people, early warning systems are being set up, and lives
are being saved. So action is possible. Early warning
mechanisms are also being put in place to warn of the
increasing risk of hurricanes in the Caribbean and glacier lake
outburst floods – a consequence of melting glaciers due to
warming. We also know that malaria and other vector-borne
diseases are highly sensitive to climatic conditions, and that
warming shifts the distribution of vectors. Diarrhoeal diseases
increase with rising temperature among the least developed
countries. Perhaps one of the greatest concerns is the impact
of climate change on the land, leading to changes in
production of food, in particular for subsistence farmers.
Increasing temperatures and changes in water availability
could be disastrous to the livelihoods of millions of people,
with clear implications for health. The same can be said
about the millions who depend on mountain water for
drinking and irrigation, from the seasonal melting of snow
and glaciers. So although we do not have a complete
evidence base the current evidence cannot be ignored, and
neither should the projections and models which are a clear
warning, and a call to action now.
Q: Is there concern about how climate change affects animal
health and the repercussions for human health?
A: Certainly. For example, we know that many countries,
particularly in Africa, are very concerned about the effect of
climate change, and particularly droughts, on livestock. If it
becomes impossible for livestock to graze, then you take
away the economic support and the whole way of life for
some populations, which in turn impacts on their health.
More research is needed in the area of animal health and its
repercussions for humans, and the role of other factors
besides climate, such as changes in land use, water stress,
and human alteration of ecosystems. But the potential for
major health impacts from animal health remains large.
There has been some debate about whether there is a
connection between climate change and avian influenza. No
links have been established, although it is known that
climate change could alter the timing and geographical
pattern of bird reproduction and migration. We do not
understand the impacts of small ecological changes
sufficiently to either accept or reject the possibility that birds
or other animals could spread new emerging diseases to
other animals and potentially also to humans. The
construction of scenarios in cases like this – to separate what
is plausible from possible or likely – is a useful way to
analyse levels of risk versus levels of impact and to look for
intervention options in each case.
10 | World Hospitals and Health Services | Vol. 43 No. 4

IHF INTERVIEW
Q: How reliable are the available data on the effect of climate
change on health?
A: Economic interests can be the hidden variables in the
pursuit of evidence and can delay action. How reliable were
the data on smoking and lung cancer in the 1950s? What
about the evidence on stratospheric ozone depletion in the
1970s? With smoking we had a huge industry trying to
convince the public that there was no risk to health. With the
increase in ultraviolet radiation from stratospheric ozone
depletion, actions by governments and industry to remove
ozone-depleting substances from products came at a price.
For the health sector, and for individuals, protection was less
expensive: avoid the sun, wear a hat, use sun screen.
Countries took action to reduce and eliminate ozonedepleting
substances and the health sector took action to
protect public health. Given what we know today about
climate change and its likely consequences on ecosystems and
on human well-being, globally we should be taking much
stronger action. Yes, we need more data, more studies, but
current data are reliable enough to make us very concerned
and we should act before matters get worse.
Q: How many people in the world are suffering from adverse
health effects of climate change?
A: A few years ago, as part of WHO’s Comparative Risk
Assessment study, we estimated the health impacts of climate
change, in terms of mortality and healthy life years lost, based
on data for the year 2000. The study was very selective in
terms of the diseases we included, and was, in our view, a
large underestimate. In all, just over 150 000 deaths globally
in that year were attributed to the observed increases in
temperature by 2000. In terms of healthy life years lost, it was
on a par with outdoor air pollution, which is a well-studied
risk factor. The most severe impacts (overall, not just on
health) were expected to occur in vulnerable populations,
among the poor, and particularly in Africa. The WHO study
clearly showed that the impacts investigated occurred
predominantly among young children in Africa.
Q: Did the Intergovernmental Panel on Climate Change (IPCC)
reports give adequate attention to the ill effects on people’s health
caused by climate change?
A: The IPCC brings together hundreds of the best scientists
and WHO has contributed and participated in its work since
1993. Its strength is in climate science, distilling information
and accumulated knowledge from the best institutions
globally, and carefully assessing an increasing number of
studies and a detailed understanding of the uncertainties. Its
most recent report states that the warming of the climate
system is unequivocal. “Health” is given the space of one
chapter among 40 or more in the three main IPCC volumes
released this year. So while one can say that IPCC does give
adequate attention to health, it provides a compact summary
of current knowledge. What we know today is not much more
than what we learned in previous IPCC reports, or even in the
first WHO report in 1990: Potential health effects of climate
change. But we are making great progress in the amount of
evidence available, which will improve confidence in the
statements made. The IPCC provides probability estimates as
“confidence levels” for decision-makers. So, for example, the
health chapter states with “very high confidence” that the
health effects of climate change will increase in all countries
and regions; and it concludes with “high confidence” that
there will be an increase in malnutrition and in the number of
people affected by climate related events. So, from a public
health perspective the IPCC reports constitute a
comprehensive assessment of the most recent literature and
are a very valuable synthesis of the latest evidence available.
Q: Governments are increasingly expressing concern about
climate change and its effect on health. Is this just rhetoric or are
governments starting to act?
A: WHO has been addressing this topic since the late
1980s and we have observed a slow but increasing level of
concern in the health sector in various countries. This seems
to have exploded in the last couple of years. I think the Al
Gore film, An Inconvenient Truth, impressed a lot of people,
and caused increased public demand for information and
action. The Stern review report on the economics of climate
change made clear that although action to stabilize the climate
would be costly, inaction would be significantly more
expensive. And now the Nobel Peace Prize. People are looking
at what action they can take, as individuals or as members of
a community or organization to reduce their impact on the
environment. When it comes to governments we need to see
their concern matched with resources, by investing in cleaner
technologies, for example, and by investing in interventions
where changes are inevitable. Action is falling very short of
what is truly needed, and this applies to the health sector as
well.
Q: What is WHO itself doing to mitigate the negative impact of
climate change on health?
A: WHO, like many international organizations, produces
lots of greenhouse gases. If you think of travel alone, each of
us is far from being climate neutral. A return trip from Europe
to Asia already puts us well over of what is acceptable as a low
carbon emission quota for one person for a whole year. So
there is already a lot that WHO staff could achieve just by
reducing air travel. But we can do more. We can also make
clear to individuals, to communities and to countries that
many of the actions that are necessary to cut greenhouse gas
emissions can also be good for your health. For example,
shifting to cleaner energy sources, or to more sustainable
urban planning and transport systems, cuts carbon dioxide
emissions which in addition to reducing the impact on
climate would also help reduce the 800 000 deaths per year
from air pollution, the 1.9 million deaths per year from
physical inactivity and the 1.2 million deaths per year from
road traffic accidents. We can fight climate change and get
healthier in the process. ? ❑
Published with the kind permission of the World Health
Organization: WHO Source: Bulletin of the World Health
Organization: volume 85, Number 11, November 2007, p21-900.
Vol. 43 No. 4 | World Hospitals and Health Services | 11

COUNTRY PROFILE: UGANDA
Uganda
health care
The vision of the health sector is to make a contribution
to the wellbeing of the people, that is to say, expanded
economic growth, increased social development and
poverty eradication. The overall development goal remains the
“attainment of a good standard of health by all people in
Uganda”.
The overall goal of the health sector is, therefore, the
attainment of a good standard of health by all the people in
Uganda, in order to promote a health and productive life,
with the specific objective to reduce morbidity and mortality
from the major cause of ill-health and the disparities therein,
as a contribution to poverty eradication and economic and
social development of the people. The Ministry of Health’s
strategic objectives for the achievement of the mission
statement include:
➜ To establish policies, guidelines and health care package
in the districts and at national Level.
➜ To co-ordinate and facilitate all stakeholders in the health
sector to achieve the national goals for health.
➜ To provide sufficient referral and tertiary health care
services so that the patients who cannot be successfully
treated at district level can receive appropriate attention.
➜ To develop health information and quality assurance
systems that, facilitate districts and national planning and
policy implementation, monitoring and evaluation.
Between 1988 and 2002 considerable effort was made to
restore the functional capacity of the health sector, reactivate
disease control programmes and re-orient services to Primary
Health Care. The positive impact of these measures was
evidenced by the fall in infant mortality rates and the rising
utilization of services. However the steady improvement was
overshadowed by several factors such as:
➜ the high prevalence of preventable communicable
diseases;
➜ the rising incidence of non-communicable diseases;
➜ the rapidly increasing demand for services due to
population growth and effects of HIV/AIDS;
➜ the resource constraints.
The diseases responsible for the largest proportion of
morbidity and mortality continue to be: Malaria, Acute
Respiratory Infections, HIV/AIDS, Tuberculosis, Malnutrition,
Maternal and Perinatal Conditions, cardiovascular conditions,
and Trauma/accidents.
For the Financial Year 2005/06 (FY2005/06), the health
sector was funded to the level of Ushs (Ugandan Shillings)
226.62 Billion through Medium Term Expenditure
Framework (MTEF) funding mechanisms (Government of
Uganda (GoU) budget and donor projects) presenting a GoU
E
ssou
Kisangani
anga
RWANDA
Kigali
Bujumbura
Uganda
Kalemi
Juba
Gulu
UGANDA
Kampala
BURUNDI
Tabora
Eldoret
Kisumu
TANZANIA
KENYA
Nairobi
Tanga
Mom
Dar
funding at Ushs 9065/= per capita. This represents 10% of
the GoU budget, far below the Abuja declaration of 15% of
the commitment of African heads of state to spend on health.
The sector priorities remain reproductive health, provision
of medicines and other medical supplies, human resources,
health infrastructure development and enhancing publicprivate
partnership. Social health insurance will be a central
understanding of the health sector for the next five years
starting from 2007. This will be undertaken collaboratively
with other stakeholders.
Background: Situational analysis of the health sector
Prior to the upheavals which beset Uganda for two decades
during the 1970s-1980s, the country had the best health
indices in the sub-region. The period of decline led to the
collapse of the Sector and to a reversal so that Uganda’s health
indices now, are probably the worst inb the sub-region.
Uganda did experience significant economic growth for
over a decade with poverty decreasing substantially.
Expansion in the agriculture, construction and
communications sectors fuelled growth, which averaged 7%
for much of the 1990s. It nevertheless, remains one of the
poorest countries in the world with 31% of the population
living below the poverty line and a per capita income of
around $300 per annum. Within the region, however,
Uganda has been a leader in the fight against HIV and AIDS
with prevalence dropping from 18% to 6% during the past
decade.
The advent of the National Resistance Movement (NRM)
Government in 1986 opened the way to new thinking and to
new effort which culminated in the development of the
National Health Policy and Sector Strategic Plan (NHPSSP).
Vol. 43 No. 4 | World Hospitals and Health Services | 13

COUNTRY PROFILE: UGANDA
The Health Policy Review Commission set up in 1987 led to
the development of the Three Year Rolling Plans with priorities
identified as consolidation of existing health services and reorientation
of services to Primary Health Care.
While these interventions resulted in some tangible
progress, there remains much to be accomplished in the
development of the health system to acceptable levels.
Accessibility to basis health services, measured as population
living within five kilometres of a health facility, is estimated to
be 49% countrywide and only 42.7% parishes having any
type of health facility, with wide variations between rural and
urban areas and between different districts (Health Facilities
Inventory 2000).
Under the Government policy on decentralisation and
liberalisation, roles both at the centre and at local government
level have changed. In addition, the role of the private sector
and its interaction with the public sector, have become more
prominent.
The Health Sector Strategic Plan (HSSP – 2000/1-
2004/5)
The Health Sector Strategic Plan was developed as a
collaborative undertaking of the Ministry of Health, related
ministries, the development partners and other stakeholders.
The plan was prepared within the framework of the Poverty
Eradication Action Plan (PEAP) and health sector policy.
The principal aims of the Health Sector Strategic Plan
(HSSP) are to:
➜ Improve access of the population to the Uganda National
Minimum Health Care Package (UNMHCP), special
attention will be placed on increasing effective access for
the poor, the difficult to reach and the otherwise
disadvantaged.
➜ Improve the quality of delivery of the package and
➜ Reduce inequalities between various segments of the
population in accessing quality services.
Particular attention being paid to:
➜ training, recruitment, rational deployment, motivation
and retention of qualified staff across the country;
➜ rehabilitation and improvement in the performance of
existing facilities while providing new facilities to
identified underserved populations;
➜ social mobilisation for community empowerment and
participation in the management and monitoring of
health services; and
➜ better co-ordination and management of resources
through ensuring that all stakeholders adhere to the
Sector-Wide Approaches code of conduct.
Health infrastructure
Service outlets comprise 1,738 facilities, of which 1,226
belong to government, 465 belong to NGOs and 47 belong
to the private sector. The facilities include 104 hospitals (57
government, 44 NGO and 3 Private), 250 health centres (179
government, 68 NGO and 3 private), palliative care 2
(government 1, NGO 1) and others (989 government, 352
NGO and 41 private).
Government hospitals
These are in three categories; namely national referral,
regional referral and district/rural hospitals. Among the
government hospitals, there are those which are institutional.
National referral hospitals are also teaching hospitals. The
Regional referral hospitals are both teaching hospitals and
resource centres to the regions they are situated in.
District/rural hospitals, manned by general doctors, comprise
all other government hospitals not included in the above
mentioned categories.
Non-Government hospitals
Some of these hospitals have specialists, like Nsambya,
Rubaga, Mengo (Kampla district), Lacor (Gulu district), and
Matany (Moroto district).
Health centre grades
The facilities are further graded as HC II, HC III and HC IV.
The grading depends on the administrative zone served by the
facility; parish, sub-county and health sub-district. These
provide different types of services, however, a unit can work
as HC II and III or IV. If a facility has more than one grade, the
highest is considered.
HC II stands for Health Centre Grade II and serves a parish.
It provides outpatient care, ante-natal care, immunisation and
outreach and is manned by one enrolled nurse, one enrolled
midwife and two nursing assistants (the enrolled nurse and
enrolled midwife may be replaced by one comprehensive
nurse should this level of cadre become available).
HC III stands for Health Centre Grade III and serves a subcounty.
It provides all the services of Health centre Grade II,
plus inpatient care and environmental health. It works as a
HC II for the parish where it is situated, and is manned by one
clinical officer, one enrolled nurse, two enrolled midwives and
one nursing assistant, one health assistant, one laboratory
assistant and a Records Officer.
HC IV stands for Health Centre Grade IV, which serves a
health sub-district and acts as the headquarters of the health
sub-district. It provides all the services of Health Centre III,
plus surgery, supervises the lower level units HC IIs and IIIs,
collects and analyses data on health, and plans for the health
sub-district. It has at least one medical officer, two clinical
officers, one registered midwife, one enrolled nurse, one
enrolled midwife, one comprehensive nurse, two nursing
assistants, one laboratory technician, one laboratory assistant,
one health inspector, one dispenser, one public health dental
assistant, one Anaesthetic Officer, one Assistant Health
Educator, one Records Assistant, one Accounts Assistant and
two support staff.
Training institutions
There are 41 training schools (30 government, 11 NGOs).
They offer 34 types of courses, ranging from certificate to
degree courses. Research institutions are under an umbrella
body known as the Uganda National Health Research
Organisation (UNHRO), the functions of which are to create
sustainable science culture in which health research plays a
significant role in guiding policy formulation and action to
14 | World Hospitals and Health Services | Vol. 43 No. 4

COUNTRY PROFILE: UGANDA
improve the health and development of the people in
Uganda.
UNHRO is responsible for the administration and guidance
of the following research institutions:
➜ Uganda Virus Research Institute
➜ Uganda Cancer Institute
➜ Uganda Tuberculosis Investigation Centre
➜ Natural Chemotherapeutics Research Institute
➜ Central Public Health Laboratory
➜ Uganda Trypanosomiasis Research Organisation
➜ Uganda Joint Clinical Research centre (research on
HIV/AIDS/STD)
➜ Uganda Heart Institute
Professional Councils
The four statutory professional councils, that constitute
corporate bodies, with the role of ensuirng good professional
practice and quality of care, are as follows:
➜ Medical and Dental Practitioners Council
➜ Nurses and Midwives Council
➜ Allied Health Professional Council
➜ Pharmaceutical Council
Other health delivery institutions are the
➜ Health Services Commission
➜ Uganda AIDS Commission
➜ National Drug Authority
➜ National Medical Stores
➜ Uganda Blood Transfusion Services
➜ Equipment Workshops
➜ Orthopaedic Workshops
➜ Public Health Laboratory
The number here given is not conclusive as there are many
unreported private facilities especially in the urban areas.
Others include dispensaries, maternity units, sub-dispensaries
and dispensary-maternity units (DMU).
Public-Private Partnership in Health (PPPH):
The Public Private Partnership in Health project was initiated
in 1997 by the Ministry of Health. The implementation of the
project commenced in July 2000 and is jointly funded by the
Government of Uganda and the Government of Italy.
The objective of the partnership is to establish a functional
integration and a sustained operation of a pluralistic health
care delivery system by optimizing the equitable use of the
available resources and investing in comparative advantages of
the partners.
Areas of Partnership
➜ Policy formulation and development
➜ Co-ordination and planning
➜ Financial resource mobilization and allocation
➜ Human resource for Health management
➜ Monitoring and evaluation of health care delivery outputs
➜ Service delivery /Health Sub-District management
The Public Private Partnership in Health Working Group
appointed by the Health Policy Advisory Committee (HPAC)
is responsible for the implementation of the activities in the
workplan. The PPPH Working Group is divided into three
sub-working groups to representing the three main subsectors
of the private sector in health.
Sub-Working Group 1: Private Not For Profit (PNFP)
This category of providers is motivated by concern for the
welfare of the population. The PNFP comprise of agencies
that provide health services from an established static health
unit/facility to the population and those that work with
communities and other counterparts to provide non facilitybased
health services.
The facility-based PNFP have a large infrastructure base
comprising of a network of hospitals and health centres
accounting for 42% of the 99 hospitals, and 28% of the 1,617
lower level units in the country with a considerable
percentage of these units located in rural areas. They provide
health services and train health workers.
Sub-Working Group 2: Private Health Practitioners
(PHP)
Presently the sector encompasses all cadres of health
professionals in the Clinical, Dental, Diagnostics, Medical,
Midwifery, Nursing, Pharmacy and Public Health categories
who provide private health services outside the Public, PNFP
and the Traditional and Complementary Medicine
establishment. The Private health practitioners provide mainly
primary level services and limited secondary level services. A
few urban units offer tertiary and specialist care.
Sub-Working Group 3: Traditional and
Complementary Medicine Practitioners
The practitioners include all types of traditional healers: i.e.
Herbalists, Spiritual healers, Bone Setters, Traditional Birth
Attendants, Hydrotherapists, Traditional Dentists, etc. It does
not include people who engage in harmful practices, casting
of spells and child sacrifice. There are several associations with
registered members at the sub-county and district levels,
coordinated by Cultural Officers. Many though remains
unaffiliated to any association. A large number of non-
Ugandan Traditional Medicine Systems have recently been
introduced into the country. These include the Chinese and
Ayurvedic practised from China and India respectively. Other
systems like Reiki, Chiropractice, Homeopathy and
Reflexology are among later practices introduced into the
country. ❑
SOURCES:
Ministry of Health – Uganda
http://www.health.go.ug/index.htm
http://www.health.go.ug/docs/abstract2001.pdf
Mulago Hospital Complex
http://www.health.go.ug/mulago.htm
World Health Organization, Regional Office for Africa
Country Health System Fact Sheet 2006 Uganda
http://www.afro.who.int/home/countries/fact_sheets/
uganda.pdf
Vol. 43 No. 4 | World Hospitals and Health Services | 15

POLICY: UBIQUITOUS HEALTH CARE
Vision and strategy for ubiquitous
health care: The end of business
as we know it
ARNOLD D KALUZNY, PhD,
PROFESSOR EMERITUS OF HEALTH POLICY AND ADMINISTRATION, SCHOOL OF PUBLIC
HEALTH AND SENIOR FELLOW, CECIL G SHEPS CENTER FOR HEALTH SERVICES
RESEARCH, UNIVERSITY OF NORTH CAROLINA, CHAPEL HILL, USA
Abstract
Health services and the clinical enterprise have entered a new era involving an increasing amount of economic,
service and research activity across rather than within the boundaries of traditionally defined organizations. These
new inter-organizational arrangements present unprecedented challenges and opportunities. How they are
designed and managed will have profound consequences on the quality, safety and cost of health care. Building on
knowledge gained from ongoing activities within health services as well as other sectors, but recognizing the unique
challenges in the provision of health care, guidelines are presented that may be of benefit to those involved in
emerging partnerships, networks and alliances.
As is often said, “The opportunities are at the
intersection.” Health services and the clinical
enterprise have entered a new era involving an
increasing amount of economic, service and research activity
across, rather than within, the boundaries of traditionally
defined organizations. While well recognized in the
industrial literature and nicely described by Rosebeth Moss
Kanter (1989) in her pioneering work When Giants Learn to
Dance, this represents a significant departure within the
provision of health services. A departure from the prevailing
intra organizational focus requires managers, clinicians and
researchers to learn to work as partners in an exceedingly
complex and dynamic environment. In short… the end of
business as we know it.
The opportunity and challenges of interorganizational
arrangements
Emerging inter-organizational arrangements have taken
many forms and are described using a variety of terms such
as partnerships, networks, alliances, etc. Regardless of the
name, these arrangements involve existing organizations and
are designed and managed to achieve some long-term
purpose not possible by any single organization. How these
new organizational forms are designed and managed will
have profound consequences on the quality, safety,
effectiveness and cost of health care.
Building on knowledge gained from ongoing activities
within health services as well as other sectors, but
recognizing the unique challenges in the provision of health
services, effective management of these various forms of
inter-organizational arrangements involves;
➜ Defining the development and management of these
various forms of inter-organizational arrangements as a
process involving specific stages of collaboration
influenced by various factor having consequence on the
operations of the participating organizations as well as
the emerging inter-organizational arrangement.
➜ Understanding that the underlying dynamic of the
newly formed inter-organizational arrangement is not
“command and control” but one that is better described
as one of trust, commitment and synergy.
➜ Recognition that the success of the newly formed interorganizational
arrangement is a function of various
behavioural factors of those involved as well as the role
of executive and middle management and the prevailing
incentives within the participating organizations.
Inter-organizational arrangements as a process
The development of the various forms of inter-organizational
arrangements involves a process that occurs over a period of
time. As illustrated in Figure 1, this process involves a
number of distinct collaborative stages; Emergence,
Transition, Maturity and Crossroads. Since these are
fundamentally fairly unstable organizational forms at each
stage the arrangement is at risk of imploding or
disintegrating. Each stage is influenced by a set of
precipitating factors and each stage involves a number of
major managerial tasks that affect the ability of the network
or alliance to move to the next stage of development. For
example the major driving force for the emergence of a
16 | World Hospitals and Health Services | Vol. 43 No. 4

POLICY: UBIQUITOUS HEALTH CARE
Factors
Common
Problem
Dependability
Sustainability
Stages Emergence Transition Maturity Crossroads
Mgr
task
Define
Purpose
Figure 1: Stages of collaboration
Dev Strategy
Coordination/
Commitment
Funding
Achieve
Objectives
Sustain
Commitment
hospital alliance is the identification of a common problem,
a problem that can’t be adequately addressed or managed by
a single organization. In the case of a hospital alliance this
could involve the benefits of joint purchasing agreements or
an attempt to expand market share within a given
community. At this stage the managerial challenge is to
define the purpose of the network/alliance assuring that the
participating organizations have a clear understanding of
what is attempting to be achieved by the network/alliance
arrangement. Experience suggests that this is not an easy
task.
Once there is agreement on the purpose to be achieved,
the arrangement moves to the next phase of collaboration:
transition. Here the major challenge is to insure
dependability in what is to be accomplished by the
organizational form created. As with the prior stage, the
emerging inter-organizational arrangement faces a number of
managerial tasks such as developing a strategy and
operational mechanisms for collaboration that facilitate
commitment and funding. The third stage of collaboration is
maturity where the need is to assure sustainability over time.
At this stage the managerial tasks involve the continued
ability to achieve objectives, meet expectations and maintain
commitment of those involved.
At some point the particular network or alliance arrives at
a crossroads where it either continues as a mature interorganizational
arrangement or disbanded in that it has
accomplished its objective or the participating organizations
realize that there is nothing being gained by the
collaboration. At each stage failure to adequately address the
driving factors may result in an abrupt termination of the
developmental process.
Adapted from Zajac, D’Aunno and Burns, 2006
respective resources and expertise to
resolve a common problem that can’t be
addressed by any single organization.
The challenge is to recognize the unique
character of the inter-organizational
arrangements and develop appropriate
strategies to ensure their effective
management and expected outcomes
(Savitz, 2007). Ohmae’s (1989)
characterization of good partnerships
(also appropriate to networks and
alliances) in his classic study of
industrial global alliances is very
applicable to the managerial challenges
involving inter-organizational
arrangements within a healthcare
setting:
Good partnerships, like good marriages, don’t work on the basis
of ownership or control. It takes effort and commitment and
enthusiasm from both sides if either is to realize the hoped for
benefits. You cannot own a successful partner any more than you
can own a husband or a wife.
The importance of individuals and behavioural factors
Jim Collins (2001) in Good to Great vividly describes the
need to “get the right people on the bus.” While he was
describing the management of organizations, this is clearly
the case in the management of inter-organizational
arrangements such as clinical networks, or hospital alliances
as they evolve through the various stages of collaboration.
Who are the “right people” is always a challenge and this is
a function of the purposes to be achieved. Unfortunately
within health care the disciplinary bias tends to exclude
critical individuals necessary to achieve sustainability. For
example networks designed to achieve some clinical
objective exclude critical managerial personnel. Similarly
networks or alliances designed to achieve some
organizational objectives exclude critical clinical personnel.
Clinicians such as physicians and nurses as well as
managerial personnel from the participating organizations
need to be involved to fully realize the potential of the
emerging inter organizational arrangement. Failure to fully
involve executive and middle management from the
participating organization is risking the ability to address the
managerial challenges at the various stages of the
collaboration. As well described by Deming (1986):
“The problems are with the system and the system belongs to
management.”
Commitment not control
Despite lip service to the virtues of quality improvement and
the role of participatory decision making, traditional
management paradigms prevail which are perhaps best
characterized as “command and control.” Command and
control while amenable to a hierarchal structure, is
inappropriate for inter organizational arrangements
described as lateral and often “loosely coupled”. In these
arrangements each participating organization brings their
Managing emerging inter-organizational
arrangements
Achieving a level of understanding is necessary but not
sufficient to assure effective management of the emerging
inter-organizational arrangements. Management and others
involved in these arrangements are best served by strategies
that are aligned with the nature of the participating
organizations and the purpose to be achieved. While
tempting to extrapolate from the business sector to health
Vol. 43 No. 4 | World Hospitals and Health Services | 17

POLICY: UBIQUITOUS HEALTH CARE
Cancer Research Network (CRN)
http://crn.cancer.gov/
National Community Cancer Centers Program
(NCCCP)
http://ncccp.cancer.gov/
Early Detection Research Network
http://edrn.nci.nih.gov/
Primary Care Practice-Based Research Network
(PBRN)
http://www.ahrq.gov/research/pbrn/pbrninit.htm
Center for Health Management Research (CHMR)
http://www.hret.org/hret/programs/chmr/
Community Clinical Oncology Program (CCOP)
http://prevention.cancer.gov/programsresources/programs/ccop
Figure 2: Illustrative network/alliance arrangements
services there is growing evidence that considerable
adaptation is necessary. As stated by Jim Collins (2005) in a
supplement to his classic book Good to Great assessing
success in the social sector:
“We must reject the idea--well intentioned, but dead wrong –
that the primary path to greatness in the social sectors (health
care) is to become ‘more like a business.”
With that in mind, and recognizing that the
“opportunities are at the intersection,” inter-organizational
arrangements are necessary to address the substantive issues
of quality, cost, safety, etc. Increased attention is being given
to the study of these arrangements involving hospitals,
public health departments, primary care practices,
governmental agencies and the university community.
Figure 2 presents an illustrative list of collaborative
arrangements involving various kinds of organizations.
While many of these have undergone evaluation, the
Community Clinical Oncology Program, as a pioneering
effort of the National Cancer Institute, National Institutes of
Health, provides a prototype from which other emerging
networks can benefit.
The community clinical oncology programme: A brief
description and guidelines
The Community Clinical Oncology Program (CCOP) is an
alliance involving National Cancer Institute, thirteen clinical
cooperative groups and cancer centres (termed research
bases) and presently sixty three community hospitals and
their physicians (termed CCOPs). The program was initially
launched in 1981 to conduct treatment and cancer
prevention and control trials in the community and through
that process (a) improve community practice patterns, (b)
diffuse state of the art cancer management to community
hospitals where eighty percent of cancer care is provided
and (c) conduct cancer treatment, prevention and control
trials within a community setting.
Extensive evaluation and monitoring of the overall
program over time (Kaluzny, Warnecke and Associates,
2001, Weiner, McKinney and Carpenter, 2006) provides the
principles and lessons that others might find helpful in the
development and management of inter-organizational
arrangements. At the minimum it provides an opportunity
to identify actions to be avoided – perhaps described as
“fatal flaws.” Three are worthy of specific mention.
➜ Underestimate the amount of time involved in (a)
managing the inter-organizational arrangement through
the various stages of collaboration, (b) addressing the
various managerial tasks at a level of effectiveness to
achieve its objective.
➜ Attempting too complicated/ambitious projects at the
initial stages of collaboration.
➜ Failure to spend sufficient time at the initial stage of the
collaboration process and thus missing the opportunity
to build trust and mutual understanding among the
participants.
The CCOP experience in addition to identifying “fatal
flaws” suggests some guidelines for the management of
inter-organizational forms including:
➜ The development of an explicit participation strategy
that is understood and accepted by all participants.
➜ Sequential implementation of projects such that initial
activities have a reasonable chance of success thereby
giving support to future more complex projects as well
as attracting new participants over time (Weick,1984).
➜ Explicit and sustained effort to build a consensus
among the participants concerning mission, goals,
objectives and relevant metrics, etc.
➜ Aligning incentives with the goals of the particular
partnership/network/alliance.
➜ Accepting realistic time expectations.
➜ Early identification of “idea champions” - individuals
who are strongly committed to the collaborative effort
and devote time and energy to the enterprise.
➜ Maintaining dialogue involving both managers
…particularly upper and middle level managers……
and relevant clinicians.
The ability to successfully function within a
partnership/network or alliance arrangement provides the
opportunity of achieving objectives not possible by any
single organization. Within health services the evolving
technology requires that managers, clinicians and the
research community understand the value of these interorganizational
forms and develop the skills necessary for
their effective operations in order to provide quality, safe,
cost effective health care to the population we serve. ❑
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POLICY: UBIQUITOUS HEALTH CARE
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1.
Collins, Jim (2001). Good to Great. HarperCollins Publishers Inc.
2.
Collins, Jim Good to Great and the Social Sectors, HarperCollins Publisher Inc,
2005
3.
Deming, W. Edwards (1986). Out of the Crisis. MIT Press
4.
Kaluzny, AD, Warnecke, RB and Associates, Managing a Health Care Alliance, San
Francisco: Jossey-Bass, 1996 (Reprinted Beard Books, Washington DC, 2001)
5.
Kanter, Rosabeth M. When Giants Learn to Dance, New York: Simon & Ohmae
K: The global logic of alliances . Harv Bus Rev 89:143-154, Mar.-Apr.1989
6.
Savitz, L.A., Managing effective participator research partnership. Jr Comm J Qual
Patient Saf 33(suppl):7-15, Dec.2007
7.
Weick K: Small wins:Redefining the scale of social problems. Am Psychol
39(1):40-49, 1984
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Weiner, B.J., McKinney, M.M., Carpenter, W.R. Adapting clinical trials networks
to promote cancer prevention prevention and control research. Cancer,
Jan1.2006:106(1):180-187
9.
Zajac, E.J., D’Aunno, T. A., and L.R. Burns, Managing Strategic Alliances, in S.
M. Shortell and A. D. Kaluzny, Health Care Management: Organization Design and
Behavior, 5th Edition, Thomson Delmar Learning, Clifton Park, NY, 2006
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Vol. 43 42 No. 41 | World Hospitals and Health Services | 33 19

POLICY: HEALTH DIPLOMACY
Global health diplomacy:
Training across disciplines
ILONA KICKBUSCH,
GRADUATE INSTITUTE FOR INTERNATIONAL STUDIES, GENEVA, SWITZERLAND
THOMAS E NOVOTNY,
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, UNITED STATES OF AMERICA
NICO DRAGER,
DEPARTMENT OF ETHICS, TRADE, HUMAN RIGHTS AND LAW, WORLD HEALTH ORGANIZATION,
GENEVA, SWITZERLAND
GAUDENZ SILBERSCHMIDT
SWISS FEDERAL OFFICE OF PUBLIC HEALTH, BERN, SWITZERLAND
SANTIAGO ALCAZAR
MINISTRY OF HEALTH FOR INTERNATIONAL AFFAIRS, BRASILIA, BRAZIL.
Abstract
Global health diplomacy is an emerging discipline where health is incorporated into traditional diplomacy as a
foreign policy tool. As, with any new area, there is a need for training. This article sets out what global health policy
involves and the current academic response to providing training for it.
In the March 2007 issue of the World Health
Organization’s Bulletin, cross-cutting issues involving
health and foreign policy were examined from a broad
range of perspectives: conceptual, educational, military,
trade, development and humanitarian aid, national and
human security, migration, analytic, environmental and
human rights. David Fidler, an expert in international law,
reflected that there might in fact be a revolution under way
in health and foreign policy, 1 though the transformation is
not completely understood and still relies on governments
to see health as a key function of foreign policy.
Nevertheless, the changing landscape of health and foreign
policy now involves so many new actors, approaches and
funding opportunities that there is an inevitable sense of
chaos accompanied by excitement about the opportunities
ahead.
Some governments have taken purposeful strides to
incorporate health as a foreign policy tool. Perhaps, however,
it is the other way around: foreign policy is now being driven
substantially by health to protect national security, free trade
and economic advancement. We offer a few examples of this
changing field of health and foreign policy as background to
our academic response:The United Kingdom is attempting
to establish policy coherence with the development of a
central governmental global health strategy based on health
as a human right and global public good. Rooted in the
recognition of globalization and its effects on health, this
new effort will bring together the United Kingdom’s foreign
relations, international development, trade and investment
policies that can affect global health. 2 Switzerland has
prioritized health in foreign policy by emphasizing policy
coherence through mapping global health across all
government sectors. 3 Through the Departments of Interior
(Public Health) and Foreign Affairs, an agreement on the
objectives of international health policy was submitted to
the Swiss Federal Council to assure coordinated
development assistance, trade policies and national health
policies that serve global health. Brazil has demonstrated
policy coherence through its assertion of health as key to its
own development and as a basis for south-to-south
cooperation. In particular, Brazil’s role in asserting flexibility
in the Trade-Related Aspects of Intellectual Property Rights
(TRIPS) agreement to support the health concerns of
sovereign nations set the stage for an integrated, rights-based
approach to trade policy. Today, Brazilian diplomats serve
key roles in health and other ministries to assure policy
coherence across the government; they have also provided
leadership in key multinational health negotiations such as
the Framework Convention on Tobacco Control. The Global
Health Security Initiative (GHSI) is an international
partnership to strengthen health preparedness and response
globally to biological, chemical, radio-nuclear and pandemic
influenza threats. Launched in November 2001 by Canada,
the European Commission, France, Germany, Italy, Japan,
20 | World Hospitals and Health Services | Vol. 43 No. 4

POLICY: HEALTH DIPLOMACY
Mexico, the United Kingdom and the United States of
America, WHO provides technical support to the initiative
(available at: http://www.ghsi.ca/english/index.asp). The
ministers of foreign affairs of Brazil, France, Indonesia,
Norway, Senegal, South Africa and Thailand established an
initiative on Global Health and Foreign Policy in 2006, with
an Oslo Ministerial Declaration in 2007 that recognized the
need for new forms of governance to support development,
equity, peace and security. 4 The issue of health and foreign
policy has not escaped the attention of multinational
organizations such as the Organisation for Economic Cooperation
and Development (OECD), the World Trade
Organization (WTO) and others. 5 WHO has formed the
Intergovernmental Working Group on Intellectual Property,
Innovation and Public Health to find new ways to deal with
access to health care and medicine. Director-General
Margaret Chan has made it clear that health and foreign
policy are inextricably linked and that the Member States are
challenged to support this linkage. The interface between
trade and health is, in fact, on the cutting edge of health
diplomacy. Health professionals need to understand this
interaction to assure rational trade agreements, informed by
health needs and supported through progressive foreign
policy. 6 However, global health governance is a mixed bag of
unclear accountability and exciting opportunity. The
infusion of large, new funding sources from philanthropy
and the unprecedented attention provided by celebrities,
former presidents, development economists, multinational
banks and others has stimulated the field of global health
into a huge, complex and unwieldy discipline, in need of
careful study and consideration of new forms of governance
and improved knowledge of the interaction between health
and foreign policy.
The academic response
Academia has begun to shape global health training
programmes to inform health professionals through crossdisciplinary
didactic and experiential learning. Global health
programmes have proliferated across both north and south,
with curriculum content spanning research skills, cultural
studies, social sciences and basic sciences. 7 We have
identified an additional need for training that brings health
and foreign policy professionals together to define the field
of health diplomacy within global health. Initially, we
designed this as an executive training course for mid-career
and senior professionals who could share their experiences
and perspectives in a focused, one-week intensive
programme. We believe that it may also be incorporated into
more mainstream global health educational programmes.
During 18–22 June 2007, the Graduate Institute of
International Studies, Geneva (HEI), welcomed 18
participants, with professional backgrounds in both
diplomacy and health and representing ten countries, to the
first Summer Programme on Global Health Diplomacy
(available at: http://hei.unige.ch/summer/healthindex.html).
During this intensive programme, the participants were able
to engage with a faculty of health professionals and
diplomats to share views and professional experiences from
their work. The initial group of participants was recruited on
the basis of their current involvement in policy, international
health negotiations, private-sector, nongovernmental
organization and multinational organization work. We
sought to include a balance of various disciplines and
geographic areas in those accepted to the programme
through the institute’s web site. The goals of the course were
to: focus on health diplomacy as it relates to health issues
that cross national boundaries and are global in nature; and
discuss the challenges facing health diplomacy and how
they have been addressed by different groups and at
different levels of governance. The programme addressed the
goals of global health diplomacy, the changing interface of
foreign policy and health, and the attempts to create policy
coherence between development partners and across
ministries. A special focus was put on understanding the
negotiation process – in particular, the interface between
technical and political issues that arise in global health
agreements. Practical exercises and role-playing represented
recent negotiations on the International Health Regulations,
the Framework Convention on Tobacco Control,
Resolutions on Trade and Health, and the 2007 World
Health Assembly resolutions dealing with sharing of
biological materials. The ethical and human rights
dimensions of global health diplomacy were also
considered.
The course discussions benefited from the diverse
backgrounds of the participants, including those from
ministries of foreign affairs and health, from international
organizations, diplomatic missions, development agencies,
nongovernmental organizations and the private sector. At
the end of the course, the participants created a global
health diplomacy discussion community on the WHO
Knowledge Management for Public Health (KM4PH)
discussion portal to engage in continuous exchange as part
of an Academy of Global Health Diplomats (available at:
http://ezcollab.who.int/KM4PH/OpenForumGHD/GHD20
07/).
This first Summer Programme on Global Health
Diplomacy was co-organized with WHO, the Oswaldo Cruz
Foundation (Fiocruz) of Brazil, the Swiss Federal Office of
Public Health, the Swiss Agency for Cooperation and
Development, the University of California San Francisco
Global Health Sciences programme and the Gulbenkian
Foundation. The enthusiasm generated among the
participants in this inaugural course illustrates the
diplomatic and health sectors’ growing interest in such
short-term executive education.
For the future, our partnership between HEI, the
University of California and Fiocruz is planning to extend
these executive training programmes to Brazil and the
United States of America. Academia may have a very
important role to play in shaping the governmental and
nongovernmental emphasis on health in international
relations in our troubled world. In addition, we have
obtained funding to design a pilot health diplomacy
curriculum for academic global health educational
programmes. Health sciences students in these programmes
Vol. 43 No. 4 | World Hospitals and Health Services | 21

POLICY: HEALTH DIPLOMACY
who seek careers in global health may benefit greatly from
the content material presented in our model executive
training programme. They will assume leadership roles in
global health that need grounding in diplomacy as well as in
the health sciences. We also plan to develop a more formal
compendium of case studies and historical reviews on
health diplomacy for use in such professional and graduate
school programmes.
Conclusion
Global health diplomacy is a field in the making, with a need
for both conceptual development and practical training
programmes. The HEI programme described here is the first
attempt to bring together diplomatic and health
professionals to understand their common interests in
health as foreign policy. Alternatively, foreign policy may
utilize health concerns to achieve national goals. It may not
matter which takes preference, but it is clear that the
growing concern for multilateral cooperation on critical
global health problems requires purposeful engagement in
learning across these two sectors. In addition, there is a need
to include nongovernmental actors, philanthropy and the
private sector in this exciting new field of study. The
landscape of global health and foreign relations has changed,
and thus a new lens through which to view this landscape is
needed. Joint training such as that described here may help
the focus of that lens. The lessons learned from this
executive training programme may be quite valuable as an
additional focus of study for preprofessional students in
schools of public health, global health sciences or other
health professional schools. ? ❑
References
1.
Fidler DP. Reflections on the revolution in health and foreign policy. Bull World
Health Organ 2007; 85: 243-4.
2.
Donaldson L. Health is global: proposals for a UK Government-wide strategy.
Lancet 2007; 369: 857-61.
3.
Kickbusch I, Silberschmidt G, Buss P. Global health diplomacy: the need for new
perspectives, strategic approaches and skills in global health. Bull World Health
Organ 2007; 85: 243-4.
4.
Ministers of Foreign Affairs of Brazil. France, Indonesia, Norway, Senegal, South
Africa and Thailand. Oslo Ministerial Declaration – global health: a pressing
foreign policy issue of our time. Lancet 2007; 369: 1373-8.
5.
Drager N, Fidler DP. Foreign policy, trade, and health: at the cutting edge of
global health diplomacy. Bull World Health Organ 2007; 85: 162.
6.
Novotny TE. Global health education and careers. In: Markle W, Fisher M, Smego
R, eds. Understanding Global Health. New York: McGraw-Hill; 2007.
7.
Garrett L. The challenge of global health. Foreign Aff 2007; 86: 1-17.
22 | World Hospitals and Health Services | Vol. 43 No. 4

MANAGEMENT: HOSPITAL DESIGN
Korean hospital design,
state of the art
PROFESSOR CHANG-HO MOON
DEPARTMENT OF ARCHITECTURE AND BUILDING ENGINEERING, KUNSAN NATIONAL
UNIVERSITY, KOREA
Abstract
This paper analyzes the architectural characteristics and trends and suggests some tasks for better hospitals.
Hospital design has been improved qualitatively in architectural form and interior. Although overall forms of most
buildings have a vertical concept, horizontal concept hospitals have been attempted. In ward plan, various shapes
have appeared and interior space has been more dynamic. Special clinics and centres have been established and
operated to meet the high level of patients’ demand. Suggestions for better hospital could be the increase of private
rooms, decreasing the size of the nursing unit, the use of the horizontal concept, supplement of safety-privacyhygiene,
and some sensory factors.
This paper is going to review the national health system
and the present situation of Korean hospitals, to
analyze the architectural characteristics and design
trends of Korean new/remodeled hospitals in the last 10
years, and to suggest some tasks for better hospital in the
future.
Major discussion points about the architectural
characteristics and trends of the hospital consist of overall
form of the building, hospital size and floor area, shape and
plan of ward, and trends of hospital design and
management.
Present situation of national health and hospitals
Owing to the rapid development of Korean economy (Figure
1) and industry and the introduction and expansion of
national the health insurance system since 1976, more
diversified and higher level of medical services have been
demanded, and so many hospital buildings have been
recently constructed and remodeled.
Compared with some OECD countries the number of
acute care beds per 1,000 people in Korea could be regarded
as enough in quantitative terms (Figure 2). But the quality
of acute care facilities in Korea has plenty of room for
improvement. There are still very few beds for long-term
care facilities and so special measures for their expansion
should be immediately considered. Therefore, Korea should
consider not only quantitative expansion of long-term care
facilities but also qualitative approaches for acute care
facilities.
Architectural characteristics and trends of
hospitals
Overall form of the building
Most Korean hospitals have been designed with a vertical
concept such as “tower on podium” or “monolith” type
(Figure 3). To compensate the weak points of compactness
in the vertical concept hospital, light-courts and/or hospital
streets with an atrium have been sometimes brought in. And
also accent elements such as decorative exterior staircase
and architecturally unique forms are often adopted to relieve
18000
14
US$
16000
14000
12000
10000
8000
6000
4000
2000
12
10
8
Bed
6
4
2
Korea
Japan
England
USA
0
1970 1975 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005
Year
0
1990 1995 2000 2001 2002 2003
Year
Figure 1: Per capita GNI in Korea (1970-2005)
Figure 2: Number of acute care beds per 1,000 people
Vol. 43 No. 4 | World Hospitals and Health Services | 23

MANAGEMENT: HOSPITAL DESIGN
Figure 3: The vertical concept: New Yonsei Severance Hospital
the visual boredom.
Recently another new example with the horizontal
concept has appeared in hospital design (Figure 4). For this
hospital with a spacious site and excellent natural
surroundings, a horizontal concept was used for easy growth
and change and has continued to successful development
without any severe problems.
Hospital size and floor area
Many Korean hospitals have increased not only hospital size
(the number of beds) but also total floor area. In the case of
university hospitals, they usually have more than 500 beds.
Total floor area per bed has been over doubled from 40-50_≥
in 1980s to 100-120_≥ in 2000s.
There are many reasons for this: the establishment of
various special clinics and centres which can carry out the
new diagnostic/treatment functions and the extension of
public space such as lobby and patients’ rest area for a better
healing environment.
Shape and plan of ward
The majority of Korean hospital wards had a strictly
rectangular shape for function-oriented purposes and
minimum public space. For the type of floor plan, the
double corridor type with shorter traffic distance is most
popular, but has the defects of some rooms without natural
light and ventilation.
Lately, instead of the rectangular shaped floor plan,
Figure 4: The horizontal concept: Chonnam National University
Hwasun Hospital
various shapes such as triangular, “W”, pinwheel, curved
rectangular, “T” of ward plan have been designed, together
with the consideration of spacious public areas like the
patient dining room and day/rest room (Figure 5). Such
unique and high-rise shapes of wards sometimes performs a
role as the landmark for the local area.
In case of a hospital constructed on a suburban large site
with good natural surroundings, the ward was planned as a
single corridor type with the advantages of natural light and
ventilation and a “T” shape standard ward (template) for
easy expansion.
The number of beds per nursing unit for some referred
hospitals is 40-60 beds. Comparing that with advanced
countries, it still looks too many. Looking over the kinds of
bed-rooms in nursing units, 1, 2, 3, 5 and 6 bed-rooms are
shown. The ratio of multiple (3-6) bed-rooms in a nursing
unit reaches the 59-100% (average 80%), which is also too
high.
Trends of hospital design and management
Large-sized and large-scaled building in university hospitals
has been generalized, and architectural form has been
changed from simple to symbolic and aesthetic. Not only
exterior form but also interior design has been upgraded
through a dynamic and comfortable atmosphere by selecting
the elements of a light-court, inner garden, atrium, hospital
street, artworks and curved walls.
An example of hospital architecture with the horizontal
concept has been completed and coping well with growth
and change (Figure 6). OPD and D and T block were
horizontally connected with standard ward blocks. When
the new function of a cancer centre was required, a standard
ward shape was added and there is still enough space for
Figure 5: Various shapes of floor plan
Figure 6: Master Plan: Chonnam National University Hwasun
Hospital
24 | World Hospitals and Health Services | Vol. 43 No. 4

MANAGEMENT: HOSPITAL DESIGN
more horizontal growth. The power plant and funeral
parlour at the site’s edge were connected with the main
hospital building in the centre by an underground common
duct, they could not be any obstacles for main hospital
building to grow. And medical school and research
laboratory have a plan to connect horizontally with main
hospital building. Therefore this hospital complex has been
successfully developed with a master plan for the whole site.
In most large-scaled hospitals, the OPD block is separated
from D&T block by hospital street or big light-court. This
could be analyzed as an intention to secure a better healing
space for patients’ rest and enhance a sense of orientation
for the visitors’ travel.
To meet the higher level of patients’ medical demands,
most large-sized hospitals have sought specialization.
Various special clinics and centres were established and are
in operation. Especially the cancer centre, the emergency
centre, children centre and elderly healthcare centre are
almost self-supporting with their own building.
Improvement of nursing unit is also in progress. In the
case of multiple bed-room, there were over six beds a room
without a toilet, but nowadays most popular multiple bedroom
have maximum five beds in a room with their own
toilet. Sometimes the ward dining room is planned for
inpatients’ convenience and used for multipurpose.
Tasks and suggestions for better hospital in Korea
The decrease of multiple bed-rooms and the increase of
private and semi-private rooms are needed for inpatient’s
privacy and convenience in hospital planning. And
downsizing the number of beds per nursing unit is also
required to upgrade nursing quality as well.
The vertical concept which has been uncritically accepted
in Korean hospital design needs to be reconsidered depending
on the size and location of site. Sometimes the horizontal
concept hospital can be desirable for a certain site because it
has such advantages such as easy response for growth and
change, harmonizing with the surrounding environment, and
close arrangement of relational function units.
Consideration of users’ safety (separation of car and
pedestrian outside the building, various indoor safety
facilities), protection of patients’ privacy, and ensuring
hygiene standards through strict management of clean and
dirty materials, which are still unsatisfactory in Korean
hospitals, need to be supplemented.
To create better healing environments, sensory elements
like landscaped gardens inside and outside the building,
scientific and functional planning of lighting/colouring,
arrangement of various art works, and space of diverse
exhibition and performance should be positively considered.
Conclusion
Korea has sufficient acute care facilities, which need to be
upgraded, but very little long-term care beds, which should
be expanded. Korean hospital design has been improved
qualitatively in architectural form and interior space.
Though overall forms of most buildings are still the vertical
concept, horizontal concept hospital also has been
attempted.
Most hospitals have increased the number of beds and
total floor area. In ward plan, various shapes of floor plan
have appeared and floor areas have been expanded. Special
clinics and centres have been established and operated to
meet the high level of patients’ demand.
Suggestions for better hospital could be summarized as
following:
➜ increase of private and semi-private rooms;
➜ decreasing the number of beds per nursing unit,
realization of horizontal concept hospital;
➜ supplement of safety-privacy-hygiene, and
➜ consideration of some sensory elements for healing
environment.
After Kwanghyewon, the first western style Korean
hospital in 1885, a lot of hospitals have been constructed
and remodeled owing to rapid development of economy and
industry and health insurance system. Now is the time to
concentrate more on the design of fundamental contents
rather than architectural form in hospitals. ❑
References
1.
English Homepage, Ministry of Health and Welfare (http://english.mohw.go.kr/).
2.
Chang-Ho Moon, A Study on the Architectural Characteristics and Trends of
General Hospital in Europe, Journal of the Korea Institute of Healthcare
Architecture, Vol. 1 No. 1, 1995.12
3.
Shin-Ho Lee and Soo-Kyung Park, Basic Study on the Optimization of Bed
Resources, Korea Health Industry Development Institute, 2004.12
4.
Kwang-Seok Choi, A Study on the Design Trends of Hospital Architecture by
Analyzing Block Plans of Korean Hospitals: Journal of the Korea Institute of
Healthcare Architecture, Vol. 13 No. 2, 2007.5
5.
Ka-Young Jeong, Nae-Won Yang and Han-Seung Lee, A Study on the
Architectural Planning of Specialized Care Center in the Korean General
Hospital: Journal of the Korea Institute of Healthcare Architecture, Vol. 13 No. 3,
2007.8
Vol. 43 No. 4 | World Hospitals and Health Services | 25

MANAGEMENT: TRAINING
Creating competent health-care
specialists: The Swiss School of
Public Health
URSULA A ACKERMANN-LIEBRICH, SANDRA NOCERA AND SONJA MERTEN,
SWISS SCHOOL OF PUBLIC HEALTH+, ZURICH, SWITZERLAND
Abstract
The Swiss health-care system (the second most expensive worldwide) is fragmented into 26 cantonal authorities for
a population of 7.5 million. Cantons differ in policy, legislation and structure. Health insurance is compulsory
although contributions vary greatly between cantons. A recent report by the Organisation for Economic Cooperation
and Development (OECD) pointed out that weak governance has led to a system in which “efficiency can
be improved”, “a broader legal framework for health promotion and disease prevention is overdue” and “equity is
not guaranteed”. 1 To a certain extent, this situation is due to the scarcity of specialists who know how to judge and
respond to health needs and who also understand the complexities of financial flows and the effect of policy
interventions in complex systems. As in most countries, health economics and public health have developed
independent training programmes, mostly without any coordination or cooperation. Health services therefore are
often managed by lawyers or business economists who apply free-market instruments to this regulated system. In
the Swiss context, this leads to ever-increasing costs and inequalities without evaluation of potential health gains. 2,3
The Swiss government and six major universities
proposed a new initiative to respond to this
situation. In July 2005, the Universities of Basel,
Bern, Geneva, Lausanne, Lugano and Zurich signed an
agreement of cooperation for the creation of the Swiss
School of Public Health+ (SSPH+) (Figure 1). The
purpose of the SSPH+ is to coordinate and improve the
existing postgraduate training programmes in public health
and health economics and to stimulate the creation of new
collaborative programmes (Table 1). The “+” in the name
symbolizes the strong emphasis on collaboration between
the two fields, promising to open new possibilities for
training professionals competent in both public health and
health economics.The SSPH+ has stimulated close
collaboration between the leaders of its different
programmes through regular exchange and discussions.
The following objectives have been launched so far and are
detailed in Table 1 overleaf.
Future perspectives
Due to the European Bologna Reform, Swiss universities
have introduced a two-step study system offering
bachelor’s and master’s degrees. The medical faculties are
adapting to this process by reorganizing their study
programmes. Public health, which today can only be
studied at the post-master’s level, might become a
discipline at the master’s level, which will then lead
University
of Geneva
University of Basel
University of Berne
University of Lausanne
University of Zurich
University
of Lugano
Figure 1: Swiss School of Public Health+: collaboration
between six universities
directly to the doctoral level. In this context, doctoral
programmes have become particularly important. In order
to provide a high-quality public health education, it is
crucial that public health research at an internationally
compatible level is firmly consolidated in Switzerland itself,
otherwise the limited training and career opportunities will
lead to a brain drain of the best-qualified teachers.
Internationally recognized doctoral training offered by
Swiss universities through SSPH+ is indispensable. PhD
training opportunities in public health complement the
Vol. 43 No. 4 | World Hospitals and Health Services | 29

MANAGEMENT: TRAINING
MAS programme
Interuniversity Master of Advanced Studies
in Public Health
Organizer
Universities of Basel, Bern and Zurich
Programme’s language
German
Enrolled students
200
Master of Advanced Studies in Public Health
University of Geneva
French
24
Master of Advanced Studies in International
Health
Swiss Tropical Institute Basel
English
60
Master of Advanced Studies in Health
Economics and Management
University of Lausanne
French
40
Master of Advanced Studies in Health
Economics and Management
University of Lugano
Italian
20
Master of Advanced Studies in
Pharmaceutical Economics and Policy
University of Lausanne
English
4
Master of Advanced Studies in Occupational
Health
University of Lausanne and the Swiss
Federal Institute of Technology Zurich
German, French and English
20
MAS, Master of Advanced Studies.a In addition, the SSPH+ supports and develops doctoral courses in health economics and in different
sciences of public health. Approximately 80 students are enrolled in these courses. The SSPH+ also supports different certificate programmes
for approximately 100 students (more information available at: http://www.ssphplus.ch).
Table 1: Postgraduate courses supported by the Swiss School of Public Health+ in 2007 a
Master of Advanced Studies (MAS) programmes, such as
Master of Public Health or Health Economics, which are
not primarily research-oriented. They offer thorough
scientific competencies at the highest level and are partly
engaged in international collaboration. The national
collaborations between universities and disciplines in the
SSPH+ also allow students to obtain a broad and
transdisciplinary vision of public health. In combination
with thorough research experience, this is certainly a
desirable asset for managers of our health services.
Nevertheless, the need for interdisciplinary training of
experienced professionals from different fields, who want
to change professional orientation and thus need further
advanced studies, will still create a demand for MAS
programmes. These programmes should be more
integrative between health economics and public health
because future leaders of our health services need both
competences. The tendency to have managerial training
without respecting the field in which it will be applied
should be discouraged in health care.
Evaluation
Our hypothesis is that the training of health professionals
with competencies in health economics and in public
health will eventually make a difference to the organization
of the Swiss health-care system. When postgraduate
training in public health and health economics started in
the 1990s, three or four cantonal physicians (who act as
medical advisors to the government and are responsible for
health surveillance in the canton) had a degree in either of
the two specialities. This is reflected in the cantonal public
health politics and planning. Until recently, only a few
cantons had a binding policy addressing prevention and
health promotion; they were notably those with a close
collaboration with university institutes of social and
preventive medicine. In the 1980s, a proposed national
law on health protection and prevention was turned down
by the cantons, mainly on the advice of cantonal
physicians who feared intervention by national authorities.
By 2007, the number of cantonal physicians with
postgraduate qualifications in public health and health
economics had increased to about 30%. The same is true
for professionals in cantonal health departments, where we
now find employees with a degree in public health working
directly with a cantonal physician in at least five cantons.
Does this have an impact on population health?
The cantons that employed competent persons for
health promotion certainly have developed better
programmes and increased government awareness of
population needs. The first canton with such a person was
St Gallen, followed by Ticino and Aargau. In the Frenchand
Italian-speaking areas, there are now organized
programmes for breast cancer screening, resulting in
decreasing breast cancer mortality rates when compared to
the cantons without screening. 4 St Gallen will be the first
canton to introduce it in the German-speaking part in
2008.
Cantons with competent advisors (16 out of 26 cantons)
were able to increase the national sample of the Swiss
health interview survey to produce a report for their
respective populations. 5 It is not by chance that Vaud was
the first canton to introduce Diagnosis Related Groups
(DRG) for financing of hospitals. 6 There is close
collaboration between the leading Institute of Health
Economics and the Institute for Social and Preventive
Medicine (the public health institute in the medical
faculty), both located at Lausanne University in Vaud.
DRG is a system that allows comparisons between
caseloads of different hospitals and thus provides the
means to limit or even control excessive costs. This system
will now be introduced in all cantons. At the national level,
a new law on health promotion and prevention is now
under discussion without resistance from the cantons.
Evaluating the impact of training on the changes in
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MANAGEMENT: TRAINING
health services ought to be a subject for research within
our doctoral programmes and could well be developed
with international collaboration. ❑
Published with the kind permission of the World Health
Organization: WHO Source: Bulletin of the World Health
Organization: Volume 85, Number 12, December 2007, 974-976
References
1.
OECD reviews of health systems - Switzerland. Organisation for Economic Co-operation
and Development (OEDC) and WHO; 2006 (ISBN: 92-64-02582-0).
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World health report 2004: changing history. Geneva: WHO; 2004 (ISBN-13: 978-
9241562652).
3.
Spoerri A, Zwahlen M, Egger M, Gutzwiller F, Minder C, Bopp M. Educational
inequalities in life expectancies in German-speaking part of Switzerland 1990-1997.
Swiss Med Wkly 2006; 136: 145-8.
4.
Bulliard JL, La Vecchia C, Levi F. Diverging trends in breast cancer mortality within
Switzerland. Ann Oncol 2006; 17: 57-9.
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Calmonte R, Galatai-Petrecca M, Lieberherr R, Neuhaus M, Kahlmeier S. Gesundheit
und Gesundheitsverhalten in der Schweiz 1992-2002 [Swiss Health Interview survey].
Bundesamt für Statistik: Neuchâtel; 2005 (ISBN: 3-303-14090-1).
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Ruffieux C, Marazzi A, Paccaud F. Exploring models for the length of stay
distribution. Soz Praventivmed 1993; 38: 77-82.
Vol. 43 No. 4 | World Hospitals and Health Services | 31

CLINICAL CARE: INFECTIOUS DISEASE
The importance of militaries from
developing countries in global
infectious disease surveillance
JEAN-PAUL CHRETIEN,
DEPARTMENT OF DEFENSE - GLOBAL EMERGING
INFECTIONS SURVEILLANCE AND RESPONSE SYSTEM,
SILVER SPRING, USA
DAVID L BLAZES,
UNITED STATES NAVAL MEDICAL RESEARCH CENTER
DETACHMENT, LIMA, PERU
RODNEY L COLDREN,
ARMED FORCES RESEARCH INSTITUTE OF MEDICAL
SCIENCES, BANGKOK, THAILAND
MICHAEL D LEWIS,
UNIFORMED SERVICES UNIVERSITY OF HEALTH
SCIENCES, BETHESDA, MD, USA
JARIYANART GAYWEE,
ARMED FORCES RESEARCH INSTITUTE OF MEDICAL
SCIENCES, BANGKOK, THAILAND
KHUNAKORN KANA,
ARMED FORCES RESEARCH INSTITUTE OF MEDICAL
SCIENCES, BANGKOK, THAILAND
NARONGRID SIRISOPANA,
ARMED FORCES RESEARCH INSTITUTE OF MEDICAL
SCIENCES, BANGKOK, THAILAND
VICTOR VALLEJOS,
UNITED STATES NAVAL MEDICAL RESEARCH CENTER
DETACHMENT, LIMA, PERU
CARMEN C MUNDACA,
UNITED STATES NAVAL MEDICAL RESEARCH CENTER
DETACHMENT, LIMA, PERU
SILVIA MONTANO,
UNITED STATES NAVAL MEDICAL RESEARCH CENTER
DETACHMENT, LIMA, PERU
GREGORY J MARTIN
UNITED STATES NAVAL MEDICAL RESEARCH CENTER
DETACHMENT, LIMA, PERU
JOEL C GAYDOS
DEPARTMENT OF DEFENSE, GLOBAL EMERGING
INFECTIONS SURVEILLANCE AND RESPONSE SYSTEM,
SILVER SPRING, USA
Abstract
Military forces from developing countries have become increasingly important as facilitators of their government’s
foreign policy, taking part in peacekeeping operations, military exercises and humanitarian relief missions.
Deployment of these forces presents both challenges and opportunities for infectious disease surveillance and
control. Troop movements may cause or extend epidemics by introducing novel agents to susceptible populations.
Conversely, military units with disease surveillance and response capabilities can extend those capabilities to
civilian populations not served by civilian public health programmes, such as those in remote or post-disaster
settings. In Peru and Thailand, military health organizations in partnership with the military of the United States use
their laboratory, epidemiological, communications and logistical resources to support civilian ministry of health
efforts. As their role in international affairs expands, surveillance capabilities of militaries from developing
countries should be enhanced, perhaps through partnerships with militaries from high-income countries. Militaryto-military
and military-to-civilian partnerships, with the support of national and international civilian health
organizations, could also greatly strengthen global infectious disease surveillance, particularly in remote and postdisaster
areas where military forces are present.
Militaries maintain public health programmes to
monitor, prevent and treat infections that could
reduce the operational effectiveness of their forces.
To advance mission objectives or broader national goals,
military forces may extend their public health capabilities to
civilian populations not adequately served by civilian public
health programmes – for example, groups experiencing
humanitarian emergencies or people in remote areas beyond
the reach of ministries of health. However, the mobility that
facilitates such operations can also allow military forces to
carry infectious agents to susceptible civilian populations. 1
In many developing countries (that is, low- or middle-
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CLINICAL CARE: INFECTIOUS DISEASE
income economies as classified by the World Bank) 2 the
pursuit of foreign policy goals may involve use of military
forces to participate in peacekeeping operations, military
exercises and humanitarian relief missions, or to carry out
more traditional military tasks such as the securing of
borders.
Here, we consider the growing importance of developing
country militaries in global affairs, and the threats and
opportunities this growth presents for infectious disease
surveillance and control in civilian populations. We use
examples from Peru and Thailand to show how militaries in
developing countries can strengthen surveillance
programmes run by ministries of heath.
Militaries in developing countries: new and
traditional missions
During the 1990s, military forces in developing countries
comprised an increasing proportion of the global total
military as the United States and other high-income
countries made significant reductions in force size. 3
According to one set of troop strength estimates, militaries
in developing countries currently comprise 17 of the 25
largest active duty forces worldwide, with a combined total
of 10.5 million of the 14.3 million personnel in these 25
forces. 4
Currently, military forces from developing countries are
deployed to participate in many multinational operations
(Box 1). Increasing engagement abroad is evident in UN
peacekeeping operations. Between 2001 and 2006, the
number of high-income countries contributing military
forces to UN peacekeeping operations decreased slightly
from 24 to 23, and the number of military personnel
contributed by high-income countries fell from about 8000
to 2000. During the same period, the number of developing
countries contributing military forces increased from 53 to
73, and the number of personnel contributed nearly tripled,
from about 22,000 to about 63,000. 5
Developing countries also supply forces to non-UN
multinational missions. The African Union Mission in Sudan
draws its approximately 7000 military personnel from Chad,
Egypt, Gabon, the Gambia, Kenya, Nigeria, Rwanda,
Senegal, South Africa and Zambia. 6 The Multinational Force
and Observers in the Sinai Peninsula includes about 800
military personnel from Colombia, Fiji and Uruguay, in
addition to contingents from Canada, European countries,
New Zealand and the United States. 7 As of January 2007,
stability operations in Iraq included forces from 22
developing countries. 8
Military personnel from developing countries are frequent
participants in multinational military exercises to improve
collaboration and practice tactical plans with allies. For
example, military forces and observers from 18 countries,
including several in central and south America, exercise
plans every year for defending the Panama Canal. 9
Following the 11 September 2001 terror attacks, the
United States military established the Combined Joint Task
Force – Horn of Africa in Djibouti to assist countries in
eastern African in combating terrorism. In a recent exercise
led by Combined Joint Task Force - Horn of Africa, military
forces from Kenya, Uganda, the United Republic of Tanzania
and the United States practiced a coordinated response to
humanitarian emergencies. 10
Disaster relief missions also draw on military forces from
developing countries. These forces made a significant
contribution to the multinational response to the December
2004 Indian Ocean earthquake and tsunami. Militaries from
Bangladesh, India, Indonesia, Malaysia, Pakistan, Sri Lanka
and Thailand, among others, contributed medical, logistical
and engineering personnel, as well as aeroplanes, helicopters
and ships. 11
Military deployments and transnational epidemics
Increasing deployment of militaries from developing
countries could help spread infections across borders.
Historians believe that forces from the United States were
instrumental in the rapid spread of the 1918–1919
influenza pandemic during World War I. 12 Crowded berthing
and training environments probably facilitated transmission
among troops, while troop movements within the United
States and to Europe introduced the virus to new
populations. Recently, influenza outbreaks on United States
Navy ships following port calls (despite high crew
vaccination rates) have raised the possibility of port-to-port
spread. 13 Military forces also have carried adenoviruses 14 and
Mycobacterium tuberculosis 15 between populations.
Transmission of vector-borne diseases between military
and civilian populations can occur when infected troops
travel to areas with competent vectors. A large malaria
outbreak occurred in California in 1952 when a soldier
United Nations peacekeeping operations (current)
➜ United Nations Organization Mission in the Democratic
Republic of the Congo; 18 473 military personnel.
➜ United Nations Mission in Liberia; 15 638 military
personnel.
➜ 14 other current operations.
Other multinational peacekeeping or security operations
(current)
➜ African Union Mission in Sudan; 7000 military personnel.
➜ Multinational Force and Observers, Sinai Peninsula; 1500
military personnel.
➜ Operation Iraqi Freedom and Operation Enduring Freedom.
Joint military exercises with the United States
➜ Panamax 2006: 18 countries; Panama Canal defence.
➜ Cobra Gold, 2006, with Indonesia, Japan, Singapore,
Thailand; various scenarios.
➜ Natural Fire, 2006, with Kenya, Uganda, the United
Republic of Tanzania; humanitarian response coordination.
Humanitarian relief operation
➜ Indian Ocean tsunami response, 2004–05; militaries from
about 20 countries.
Box 1: Types and recent examples of multinational military
operations with significant participation by developing
countries
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CLINICAL CARE: INFECTIOUS DISEASE
Department of affected naval base
Iquitos (north east, in Amazon jungle region)
Tumbes (north)
Piura (north)
Lima (west)
Ica (south west)
Disease or syndrome
P. vivax malaria, dengue fever, diarrhoeal disease
Dengue fever, diarrhoeal disease
Diarrhoeal disease
Cyclospora cayetanensis (multiple outbreaks),
diarrhoeal disease (multiple outbreaks)
Diarrhoeal disease
Table 1: Selected infectious disease outbreaks in Peruvian naval forces detected by Alerta, 2004–2005
infected with Plasmodium vivax malaria during service in
the Korean War camped, while parasitaemic, in a popular
park. 16 A rapid public health response may have prevented
local dengue transmission when infected Australian soldiers
returned from service in East Timor. 17 Local transmission
was theoretically possible following return of Soviet forces
infected with P. vivax from Afghanistan, 18 and of United
States forces infected with dengue from Haiti 19 and
Somalia. 20
Deployed forces may encounter antimicrobial-resistant
pathogens that are not common in their home countries. For
example, in 1997 Minnesota National Guardsmen returned
from training in Greece with ciprofloxacinresistant
Campylobacter jejuni diarrhoea. 21 Nosocomial transmission
of drug-resistant Acinetobacter baumannii, which has
caused wound infection and colonization in United States
forces serving in Afghanistan, Iraq and Kuwait 22 occurred in
at least one United States military hospital. 23
Multinational military operations pose an additional risk
of deployment facilitated spread, since forces may have
different exposure histories, and screening and vaccination
requirements. 24 To reduce the risk of introducing human
immunodeficiency virus (HIV) into host country
populations, the UN requires that countries offer uniformed
peacekeepers voluntary pre-deployment HIV testing and
counselling. 25 There are few data to make a causal link
between multinational peacekeeping operations and local
outbreaks.
Military surveillance contributions to civilian health
authorities
In humanitarian emergencies, well-equipped militaries may
use their logistical, communication, organizational,
epidemiological and mobile laboratory resources to establish
surveillance for populations vulnerable to epidemics. 26,27
Following the Indian Ocean tsunami in 2004, a United
States Department of Defense overseas laboratory, United
States Naval Medical Research Unit-2 (NAMRU-2, in
Jakarta), established a field laboratory in the heavily affected
Indonesian city of Banda Aceh with the Indonesian
government and WHO. 28 The laboratory provided reference
services that confirmed some epidemics, thus facilitating
timely intervention for some outbreaks and allaying
concerns about other infectious diseases. After several
months, NAMRU-2 turned the laboratory over to the
Indonesian government who continued to use the facility.
Some militaries that maintain advanced laboratory and
epidemiological capabilities to protect the health of their
forces share these assets with civilian health organizations to
respond to epidemics. 29 For example, German and United
States military medical organizations are partners in the
Global Outbreak Alert and Response Network, a WHO-led
technical collaboration of institutions and networks that
pool human and technical resources for the rapid
identification, confirmation and response to outbreaks of
international importance. Three United States Department
of Defense overseas laboratories – NAMRU-2, the Navy
Medical Research Unit-3 (NAMRU-3, in Cairo) and the
Armed Forces Research Institute of Medical Sciences
(AFRIMS, in Bangkok) – are WHO Collaborating Centres
and frequently assist ministries of health and WHO in the
surveillance of and response to epidemics.
Developing country militaries might not possess
sophisticated public health capabilities, but if they maintain
awareness for unusual disease occurrences, they may
provide valuable early warning for epidemics of global
importance. Within some developing countries, militaries
already support civilian health authorities by providing
health services for civilians in remote areas and reporting
military surveillance data to the ministry of health. When
forces collaborate with civilians to conduct military and
civilian infectious disease surveillance, these partnerships
enable compliance with the International Health
Regulations (2005), 30 which require that WHO be rapidly
notified of infections that may constitute a public health
emergency of international concern – irrespective of whether
the infections are in civilian of military populations.
Later in this paper, we describe surveillance systems
operated by developing country militaries that, in various
ways, support epidemic preparedness of the ministry of
health in the host country. These systems are collaborative
efforts of the host country military and the United States
Department of Defense through its overseas laboratories,
long-standing facilities that conduct research on infectious
diseases of bilateral importance. 31 As part of the United
States Department of Defense – Global Emerging
Infections Surveillance and Response System, established
by Presidential directive in 1997 to confront emerging
infections as a national security threat, 32 they also develop
regional capacity to detect and respond to epidemics. 33
Two of the five United States Department of Defense
overseas laboratories are hosted by foreign militaries – the
Peruvian Navy hosts the United States Naval Medical
Research Center Detachment (NMRCD), established in
1983; and the Royal Thai Army (RTA) hosts AFRIMS,
established in 1961.
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CLINICAL CARE: INFECTIOUS DISEASE
Peru
Peru has a population of over 27 million people living in
tropical, sub-tropical and temperate regions. The Peruvian
military comprises the Army, Navy, Air Force and National
Police and includes more than 200,000 personnel. The
Navy maintains dozens of training facilities, ports and other
bases across the country – from modern facilities in the
capital city Lima to remote bases in border areas. Crowded
living conditions and difficulties in maintaining hygiene
(with which most militaries must contend) contribute to
outbreaks of respiratory and diarrhoeal diseases among Navy
personnel. In tropical areas, Navy units are at risk of malaria,
yellow fever, dengue and other vector-borne diseases.
Outbreaks of infectious disease have had a significant effect
on the Peruvian Navy’s ability to carry out missions.
In Peru, as in many countries, the military complies with
disease reporting policies established by civilian health
authorities. The Peruvian Ministry of Health has identified
45 nationally reportable infectious and non-infectious
diseases. The Navy monitors these diseases in its active duty
personnel (about 25,000 people) and their family members
(about 100,000), and reports surveillance data to the
Ministry of Health. With many units in remote locations,
the Navy provides the Peruvian Ministry of Health with
information on disease burden and outbreaks in areas where
there is little civilian public health infrastructure.
Before 2002, however, the Peruvian Navy relied on a
paper-based reporting system that did not facilitate rapid
detection and control of infectious disease outbreaks,
especially in remote locations. Mailed reports could take
weeks to reach Lima from the border areas, by which time
outbreaks often were well advanced or over. After several
unexpected deaths – probably the result of infectious
diseases – in units in the Amazon jungle region drew
attention to surveillance deficiencies, the Peruvian Navy and
NMRCD developed Alerta, an electronic disease surveillance
system that at modest cost has transformed public health
surveillance and response in the Peruvian Navy.
Alerta allows reporting and tabulation of the nationally
reportable diseases, as well as others important in military
populations, such as influenza-like illness and training
injuries. Units report to the surveillance hub at NMRCD by
Internet, telephone or radio-relay. The Navy has assigned an
officer to the hub to facilitate communication with
surveillance sites. Alerta covers over 95% of Navy forces and
family members in all Navy regions. The system has
identified 31 disease outbreaks (some of which are shown in
Table 1), including Peru’s first confirmed cyclosporiasis
epidemic, 34 and has frequently allowed rapid epidemiologic
investigation and control to take place.
Another collaborative surveillance activity of NMRCD and
the Peruvian military is focused on peacekeepers. Since June
2005, Peru has deployed groups of about 200 troops for six
month tours with the UN Stabilization Mission in Haiti
(MINUSTAH).
To assess the risk of infectious disease exposure in Haiti
and importation back to Peru, the Ministry of Defense and
NMRCD developed a serological surveillance programme.
With funding from the United States Military HIV
Programme, the Ministry of Defense collects serum from
peacekeepers before and after deployment, which NMRCD
tests for exposure to HIV, hepatitis B and hepatitis C viruses,
human T-cell lymphotropic virus 1 and 2, syphilis, dengue
and malaria. Each peacekeeper also completes a
questionnaire on insect, animal and sexual contacts while
deployed.
As with Alerta, the military uses this programme primarily
to monitor infectious disease risks in its forces. But through
data sharing with the Peruvian Ministry of Health, civilian
authorities will be made aware of infectious diseases
imported by returning forces that could be transmitted to
civilian populations in Peru.
Thailand
During the late 1980s, Thailand experienced a sharp rise in
HIV prevalence. 35 The Thai government launched a
countrywide HIV/AIDS education campaign and made
condoms available to commercial sex workers and their
clients, since commercial sex was considered a major route
of HIV transmission. 36 The Thai Ministry of Public Health
initiated HIV surveillance in sentinel populations, including
commercial sex workers and intravenous drug users, to track
the epidemic and assess the effectiveness of control
measures in high-risk groups. In 1989, the RTA initiated
HIV screening for all incoming recruits, who were
conscripted by lottery from every district in Thailand (50
000–60,000 men aged between 18 and 22 years annually,
with exemptions given to certain groups; 36 currently, the
RTA does not use conscription). With technical assistance
from the United States Army Component of AFRIMS, the
RTA also gathers socio-demographic information from
recruits when they are admitted to the RTA.
By allowing the Thai Government to monitor the HIV
epidemic in a large, national sample of young men, the RTA
HIV screening programme has proven a useful complement
to the Ministry of Public Health HIV surveillance
programmes. The Ministry of Public Health and RTA staff,
often in collaboration with university researchers, used the
RTA HIV surveillance database to assess the national effect
of government control measures in young men, 36,37 identify
areas of Thailand with high HIV incidence, 38,39 define risk
factors for HIV infection, 40,41 and describe the natural history
of HIV infection. 42 To support future epidemiological studies
of other infectious diseases, scientists from the RTA and
United States Army maintain a repository for serum that is
left after HIV testing at the RTA Institute of Pathology.
Another collaboration between the RTA and United States
Army addresses a similar challenge to the one facing the
Peruvian Navy – conducting timely infectious disease
surveillance in remote areas. Many RTA personnel are
assigned to areas near borders with Cambodia, the Lao
People’s Democratic Republic and Myanmar where they
deter and defend against external and internal security
threats. Public health resources and communications are
limited in these places, making timely epidemic detection
and control in RTA forces difficult. In border areas
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CLINICAL CARE: INFECTIOUS DISEASE
inaccessible to the Ministry of Public Health, the RTA
provides public health services for both civilian and military
populations.
RTA and United States Army collaborators developed the
unit-based surveillance system in 2002 to improve
surveillance along the Thai-Cambodian and Thai-Lao
People’s Democratic Republic borders. The system allows
data to be collected by RTA soldiers who do not have
medical training (since few RTA medical officers serve in
such areas), with analysis and interpretation carried out in
Bangkok. Participating military units collect syndromic
information daily on local populations and report the data to
higher headquarters by radio or fax (syndromes under
surveillance include constitutional, respiratory and
gastrointestinal). At headquarters, data are recorded into a
Microsoft Access-based program and transmitted through an
internet-based system to the AFRIMS main frame at least
twice a week. If analysts at AFRIMS identify a possible
outbreak, medical authorities from the Ministry of Public
Health and the RTA are notified and they may initiate
control measures.
Building on the partnership that created the unit-based
surveillance system, the RTA and United States Army
medical personnel are currently refining the system for
surveillance of influenza-like illness and initiating laboratorybased
influenza surveillance at remote RTA facilities that
serve civilian and military populations.
Discussion
Military-to-military partnerships, in which militaries with
advanced public health capabilities commit to helping other
militaries develop laboratory and epidemiologic capacity, are
one way of improving surveillance in developing country
militaries. There are other successful military-to-military
partnerships besides the ones presented here. For example,
the French Forces Institute of Tropical Medicine (IMTSSA),
a WHO Collaborating Centre, partnered with the
Vietnamese Army Health Corps to control malaria in Viet
Nam. 43 The French military also supported the Gabonese
military and Global Outbreak Alert and Response Network
partners in responding to an Ebola epidemic in 2001. 44
As the global involvement of military forces from
developing countries rises, the importance of effective
surveillance in these populations increases – not only for the
protection of military units but also for civilians.
Higherincome countries, and their militaries with advanced
epidemiologic and laboratory resources, should seek
opportunities to partner with militaries from developing
countries to improve surveillance capabilities. Militaries of
all countries should seek civilian-military partnerships when
located in domestic or foreign areas where their surveillance
capabilities could improve the local civilian public health
infrastructure. These collaborations could provide mutual
benefit, alerting each population to infectious disease risks
in both groups and providing early warning of epidemics
with potential global significance.
Neutral international health organizations, such as WHO,
can facilitate partnerships between military organizations
through leadership that remains independent of the
interests of any one country. Both military and civilian
health agencies may be reluctant to fully engage in health
partnerships with militaries without the broad legitimacy
that such organizations can provide.
In the United States military experience with influenza
surveillance, close relations with WHO have facilitated
international partnerships. The United States Department of
Defense – Global Emerging Infections Surveillance and
Response System coordinates global influenza surveillance
for the United States military through the Military Health
System and the Department of Defense overseas
laboratories, which conduct influenza surveillance with
many partner countries and contribute to the WHO Global
Influenza Surveillance network. Assuring potential partners
that surveillance will support WHO efforts has been
especially important in certain regions. For example,
NAMRU-3, a WHO regional reference laboratory for
influenza, has helped countries throughout the Middle East
and north Africa to develop national influenza laboratories.
In 2003, the Russian Academy of Medical Sciences,
WHO, the North Atlantic Treaty Organization, and the
United States Department of Defense – Global Emerging
Infections Surveillance and Response System hosted civilian
and military public health leaders from 18 countries in St
Petersburg, the Russian Federation, to discuss ways of
enhancing influenza pandemic preparedness through
civilian–military cooperation. 45 Participants established
lasting collaborations with groups in their home and other
countries, and agreed that WHO leadership and continued
work was needed to bridge gaps between civilian and
military efforts. In the future, multilateral civilian–military
public health forums involving international organizations
and developing and high-income countries could establish
and sustain partnerships to address those gaps.
Finally, there is a need for critical examination of the
expanding role of militaries in post-disaster assistance,
global infectious disease surveillance and other activities
that extend military public health capabilities to civilian
populations in need. Research should draw on lessons
learned from recent 46 and ongoing missions to identify
appropriate applications and methods of civilian–military
public health cooperation. ❑
Acknowledgements
We thank the peer reviewers for thoughtful comments that
strengthened this paper. Competing interests: None
declared.
Published with the kind permission of the World Health
Organization: WHO Source: Bulletin of the World Health
Organization: 2007; 85:174-180
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CLINICAL CARE: INFECTIOUS DISEASE
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Vol. 43 No. 4 | World Hospitals and Health Services | 37

E-HEALTH SUPPLEMENT: EHR
Sharing and management of EHR
data through a national archive:
Experiences from Finland
PEKKA RUOTSALAINEN, PERSEPHONE DOUPI AND PÄIVI HÄMÄLÄINEN
STAKES UNIT FOR EHEALTH AND EWELFARE, STAKES - NATIONAL R&D CENTRE FOR WELFARE AND
HEALTH, HELSINKI, FINLAND
Abstract
The management of Electronic Health Records is a complex business ranging beyond just digital archiving. This
article looks at the challenges involved, the different models for EHR data archiving and the impact on health-care
provider systems, aswell as expected benefits. Particular attention is paid to the Finnish system and its
experiences.
Digital archiving is not a health-care specific question.
Digital Libraries and many other organizations are
developing both the necessary technology and
requirements for digital archiving. However, based on the
unique nature of health-care information, certain health-care
specific questions remain to be solved (see Box 1).
Archiving is much more than just a simple preservation of
papers, microfilms or bits. Archiving is a combination of:
➜ data reception management;
➜ data preservation and accessing management;
➜ security and privacy protection management;
➜ records management;
➜ information description methods, and
➜ storage media technology.
In health care an archive is defined as an organization that
intends to preserve health records for access and use by an
identified group of clients for a regulated period of time.
Traditionally, health-care archives have been storages of
paper documents and pictures. In many cases, even when
the service provider is using an Electronic Health Record
(EHR) system, it has been common practice to print the
content of digital records in paper or film format for long-
➜ Very long preservation time of health information
(up to 100+ years)
➜ Dynamic nature of health care data objects and documents
➜ Sensitive data content, requiring high degree of security,
confidentiality and privacy protection
➜ Strong legal and regulatory framework specifying who can
access what, when and for what purpose
➜ Context-, purpose- and sensitivity-based access and
disclosure rules for data objects
Box 1: Specific requirements of health-care archiving
term preservation purposes.
An electronic archive (eArchive) preserves information in
digital format. The differences between paper and digital
preservation are marked. Digital archiving is strongly
dependent on software. New file formats, software, and
platforms succeed each other rapidly and digital material
requires constant maintenance in order to remain usable. In
the case of digital archiving there is the risk that not only the
functionality, but also the structure of the record and the
context of archived bits and data streams may be lost after
hardware and software migrations.
An eArchive has the responsibility of making information
available in a correct and independently understandable
form even after a long time. It is therefore necessary to know
what each data object is and what it is meant to do. Data
should also be undamaged and complete, and there must be
proof of its authenticity: that it is what we believe it to be.
As a result, eArchives store not only data, but also metainformation
(e.g. representation, description, content and
context information of the data, links between components,
and required preservation information).
Alternative models of EHR data archiving
Different types of archives exist. An independent archive is a
closed system aimed only for designated users. Co-operated
archives have common standardized submission and
dissemination methods, but no common retrieval tools (e.g.
no link repositories). Federated archives are based on the
fact that different organizations have interest in the
maintenance of several archives. As the motive is to share
some expensive resources, federated archives are systems
with shared functional areas.
In practice, an eArchive system can be a separate archive
(“a secondary storage”) or an EHR-system can manage all
archiving functions without a technically separate eArchive.
38 | World Hospitals and Health Services | Vol. 43 No. 4

E-HEALTH SUPPLEMENT: EHR
Independent of which combination is
used, the purposes of the eArchive and
• Service providers
the EHR-system are different.
The eArchiving process is a long-term
HPC
EHR
undertaking. During this process patient
Data
information is moved between the EHR-
extract
systems, the eArchive and customers/
recipients.
There are differences between
Cross - Border
countries in how the eArchiving process
communication
is defined.
In its most basic form, archiving can
External
eHealth
take place through storage in local EHR
services
systems and connectivity is ensured
through a centralized link repository.
However, it is questionable whether this
practice truly constitutes archiving.
In some cases, as for example in
Finland, the eArchiving process starts
when the EHR is originally created by
the EHR-system of the local service provider during the care
process, and ends when the regulated preservation time is
reached and the record is disposed by the archive. This
means that the service provider organisation should manage
at the same time both active records inside its own system,
as well as the eArchiving process.
On the other hand, there are countries where the
eArchiving process starts by a selection of records for
permanent preservation and EHRs are stored by a specific
archiving organization.
In the UK for example archives are records appraised for
permanent preservation and the term archiving is used in
connection to the permanent preservation of records in the
Place of Deposit. The NHS definition for records
management covers the creation, storage, management and
disposal of records. The NHS code of good practice is based
on national requirements.
The Japanese model for eArchiving of health records is
based on the use of the Open Archiving Information System
Reference Model (ISO 14721). The eArchiving process
covers only occurrences inside the eArchive.
• Regional EPR -systems
Background to the current solutions and practices
in Finland
The Strategy for the Utilization of Information and
Communication Technologies in Welfare and Health was
first established by the Ministry of Social Affairs and Health
in 1996. The strategy was built around the principle of
citizen-centred, seamless service structures. Among the
main targets of the strategy were the horizontal integration
of services (social, primary, and secondary care) and the
development of shared, coordinated services. The strategy
was updated in 1998, placing specific emphasis on the
adoption of digital patient and client records in all levels of
care, combined with nation-wide interoperability between
distributed legacy systems, and supported by a high level of
security and privacy protection.
The legislation on Experiments with Seamless Service
Relationship
Certificate
Consent
HL7/CDA R2
/XML documents
Secure communication network
Rule
engine
CA
services
AI
Term and
code
server
WEB -Services
Registration
of EHRs
Statistical services
Quality monitoring
Figure 1: The Finnish national EHR archiving architecture
-sensors
Consent
management -
ment
Citizen patient
Citizen portal
Searching and
access services
eArchive
management
E - prescriptions
Chains in Social Welfare and Health Care Services was
adopted in 2000 (Act 811/2000). The main focus of the
legislation was to support the development of regional
cooperation for seamless services, promote continuity
of care, and advance the building of regional
information service systems and adapters between
existing legacy systems. Pilot-projects in accordance to
the seamless service chains legislation were started. The
participating regions started building reference
databases to enable true usability of patient data across
organisational boundaries.
During the implementation phase of the experimental
legislation, a new initiative was started to improve the health
care system of Finland. The Decision-in-Principle by the
Council of State on securing the future of health care was
given on 11 April 2002. The document states that
“nationwide electronic patient records will be introduced by
the end of 2007”. The National Health Project Programme
was launched and the electronic patient record project was
included in the programme.
Every health-care organization in Finland has the
responsibility to manage and archive health records. Inside
the provider organisation the health record is personal and
life-long. Based on current national regulations, health
records shall be archived up to 100 years (images up to 20
years). According to the 2006 national survey, 95% of
hospital districts (20 out of 21 in total) were using an
Electronic Patient Record (EPR) for narrative texts with high
rates of utilization. Progress has been truly rapid, since only
two years earlier just 13 out of 21 hospital districts were
EPR-users. High uptake of EPR systems within organizations
has also impacted positively the regional exchange of
information. Exchange of laboratory and radiological data
has been commonplace already for sometime, but recently
also eReferrals and eDischarge letters sent directly from one
EPR-system to another have increased.
By the end of this year (2007) all hospitals should have an
EPR system in use.
EHRs
Vol. 43 No. 4 | World Hospitals and Health Services | 39

E-HEALTH SUPPLEMENT: EHR
EHR
Data
entering
-Structured
data
- common terms
Extract
Semantic
mapping/
parsing
Data
viewer
and manager
Metadata
HL7 CDA R2
BODY
Metadata
HL7 CDA R2
BODY
National
eArchive
Figure 2: Data exchange process between a local EHR-system
and the eArchive
The Finnish choice – centralized archiving
On the basis of the experience gained in the aforementioned
pilot projects, permanent legislation on both ePrescription
and eArchving came in effect in 2007. The legislation on
handling electronic patient information covers centralized
archive services, encryption and certification services, and
the patient’s access to the data. The law makes mandatory
the incorporation of all public health care units into the
electronic archiving system, as well as of those private health
care units that do not use paper-based archives. The
transition period is four years.
The creation of a centralized archiving system was chosen
for the following main reasons:
➜ Cost reduction.
➜ Simplicity of the necessary architecture, which allows
for:
• one point for EHR disclosure;
• one centralised consent- and opt-out management
service;
• possibility to use HL7 CDA messages between EHRsystems
and the eArchive;
• single entry point for patients and citizens (eg to
access audit-logs and own EHRs).
The new national communication architecture (Figure 1)
aims to support both technical and semantic interoperability
of EHRs and provide a solution to the problem of their long
term availability and usability. Security services are also one
of the key functions of the platform.
The Web-service platform acts as an integration machine.
Information between legacy systems and common services
is transferred in the form of documents. Technical
interoperability is achieved by using standardized messages
(at present HL7CDA R2 and DICOM). A basic level of
semantic interoperability is achieved by making mandatory
the use of the national core data set, selected classifications
and EHR-headings. All necessary terms and classifications
are available for download and use through the term and
code server.
Key common national services are the registration of
EHRs, eArchive, consent management, the certification
service and the aforementioned code server. The registering
service is the key tool for tracing the location of EHRs and
managing their actual status.
Citizens and patients will be able to connect to the
national eArchive as of 2011, via secure Web services
utilizing the citizen smart card and certification services.
Impact on hospital and other health-care provider
systems
The construction of the national communication platform is
financed both by the Ministry of Social Affairs and Health
and public and private provider organizations. Its services
will be launched in spring 2008 and it should be fully
operational by the end of 2011.
The new legislation of July 2007 states that all EHR
systems storing digitized EHRs shall use the national
services after 2011. At present, most EHR systems are
typically based on relational database technology and are not
intended to function as trusted long-term archiving systems.
Therefore, before health-care service provider
organizations are accepted to join the national services a
number of new functionalities and services must be
implemented into existing legacy systems, which will
subsequently have to be certified against specific criteria for
functionality, interoperability and security.
Health-care service providers will need to bear the costs of
updating their own systems, as well as the maintenance
costs of the platform after 2011 through the usage fees that
will then come into effect.
From a technical point of view, the transfer of data from
the organizational EHR system to the eArchive and,
reversely, the possibility to retrieve from the archive and view
both own records, but also other existing records of a certain
patient requires the development and implementation of the
following applications and functionalities (see Figure 2):
➜ Data entry interface which supports common headings,
terms, classifications and the EHR core data set.
➜ Creation of patient consent document and physicianpatient
relationship credential.
➜ Capturing data from the local database.
➜ Generation of HL7CDA and DICOM messages.
➜ Generation of the preservation and access requests
which are sent to the eArchive.
➜ Viewing of received EHR-messages.
➜ Generation of audit logs.
➜ New services ensuring access of citizens to their own
data and to the respective local and national audit logs.
In addition to the above mentioned basic development
requirements, there are also some future challenges to be
addressed:
➜ achieving true semantic interoperability will necessitate
further development in the structure, terminology and
vocabulary of the EHR;
➜ selecting the optimal distribution of intelligence
between legacy systems and the eArchive;
➜ developing user-friendly retrieval tools for professionals;
➜ ensuring the usability of systems and their successful
integration into personnel workflows.
Finally, the overall future of the present local/regional EHR
systems poses an interesting question, since technologically
40 | World Hospitals and Health Services | Vol. 43 No. 4

E-HEALTH SUPPLEMENT: EHR
it will be possible to utilize the eArchive as online storage, so
that locally there is only an application utilizing centralized
Web services.
The update of organisational systems will certainly also
affect the work processes of healthcare professionals, who
will need to modify their data entry practices but will also
gain much wider access to their patients’ existing data,
allowing them to provide better quality care. At this point
however it is too early to predict what the end balance
will be.
Expected benefits
The creation of a common archiving system is expected to
promote patient and client care quality and confidentiality,
as well as increase the efficiency of health-care services.
Through using the national archive it will be possible to
create, on the basis of patient consent, one virtual, life-long,
personal health record for every citizen. Theoretically, that
record can then be utilized for profiling, proactive
prevention and prediction of future health status and risks.
From an organisational point of view, it is envisioned that by
2015 it will be possible to have available statistical and
process management information based on real-time data. ❑
References
1.
Ruotsalainen P., Regional EHR systems and eArchives in Finland, In: Bryden JS,
De Lusignan S, Blobel B, Petrove_ki M (Editors). Medical Informatics in
Enlarged Europe. Proceedings of the European Federation for Medical
Informatics, Special Topic Conference, May 30-June 1 2007, Brijuni, Croatia.
IOS Press/AKA, p. 174-179.
2.
Records Management, NHS Code of Practice, Part 1 and Part 2, Department of
Health, London, 2006.
3.
ISO/DIS 14721 Reference Model for Open Archiving Information Systems
(OAIS). ISO, 2003.
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Sosiaali- ja terveydenhuollon tietoteknologian hyödyntämisstrategia. Sosiaali- ja
terveysministeriön työryhmämuistioita 1995:27. [Strategy for utilising
information technology in the field of social welfare and health care in Finland]
(In Finnish).
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Sosiaali- ja terveysministeriö. Sosiaali- ja terveydenhuollon tietoteknologian
hyödyntäminen; saumaton hoito- ja palveluketju, asiakaskortti. Sosiaali- ja
terveysministeriön työryhmämuistioita 1998:8. (In Finnish only, published
Ministry of Social Affairs and Health working group document on ICT in social
and health care)
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Hämäläinen P, Tenhunen E, Hyppönen H, Pajukoski M. Experiences on
Implementation of the Act on Experiments with Seamless Service Chains in
Social Welfare and Health Care Service. Discussion Papers 5/2005. Stakes.
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Decision in Principle by the Council of State on securing the future of health
care. Brochures of the Ministry of Social Affairs and Health 2002:6.
www.terveyshanke.fi/eng.pdf
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Ministry of Social Affairs and Helath press release (in Finnish only) Tiedote
234/2006.
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Finland Fact Sheet. In: eHealth priorities and strategies in European countries.
eHealth ERA report - March 2007. Towards the Establishment of a European
eHealth Research Area. European Commission. Information Society and Media
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http://sty.stakes.fi/FI/koodistopalvelu/koodisto.htm
Vol. 43 No. 4 | World Hospitals and Health Services | 41

REFERENCE
World Hospitals and Health Services 2007 Volume 43 Number 4
Résumés en Français
VISION ET STRATEGIE DE SERVICES DE SANTE
SANS MURS: FIN DE L’ENTREPRISE D’ANTAN
(VISION AND STRATEGY FOR UBIQUITOUS
HEALTHCARE: THE END OF BUSINESS AS WE KNOW
IT)
Les services de santé et l’entreprise clinique sont entrés dans
une ère nouvelle qui connaît de plus en plus d’activités
économiques, de services et de recherches embrassant les
organisations traditionnellement définies sans y être
enfermés. Ces nouveaux dispositifs inter-entreprises
présentent à la fois des défis et des opportunités sans
précédent. Leur conception et leur gestion auront des
conséquences profondes sur la qualité, la sécurité et les
coûts des soins de santé. Les auteurs s’appuient sur les
connaissances acquises dans le cadre d’activités au sein des
services de santé et dans d’autres secteurs, tout en
reconnaissant les difficultés particulières aux prestations de
santé présentent des lignes directrices qui peuvent aider
ceux qui s’intéressent aux partenariats, aux réseaux et aux
alliances.
CONCEPTION HOSPITALIERE COREENNE DANS
L’ETAT ACTUEL DES CONNAISSANCES
(KOREAN HOSPITAL DESIGN, STATE OF THE ART)
Cet article analyse les caractéristiques et tendances
architecturales et suggère quelques tâches pour améliorer les
hôpitaux. La conception des hôpitaux a été qualitativement
améliorée en termes d’architecture intérieure et extérieure.
Bien que la forme globale de la plupart des bâtiments soit de
conception verticale, un hôpital de conception horizontale a
été tenté. Sur le plan des salles, des formes variées sont
apparues et l’espace intérieur est plus dynamique. Des
cliniques et centres spécialisés ont été créés et mis en service
pour répondre aux exigences élevées des patients. Les
suggestions avancées pour améliorer les hôpitaux sont
l’augmentation du nombre de chambres privées, la
diminution de la taille des unités de soins, la réalisation du
concept horizontal, l’amélioration de la sécurité, de
l’hygiène et de la vie privée, et certains facteurs sensoriels.
UNE SOLUTION POUR OBTENIR DES SPECIALISTES
DE SANTE COMPETENTS : L’ECOLE SUISSE DE
SANTE PUBLIQUE
(A SOLUTION FOR CREATING COMPETENT HEALTH-
CARE SPECIALISTS: THE SWISS SCHOOL OF PUBLIC
HEALTH)
Le système de santé suisse (qui vient en second parmi les
plus chers du monde) est divisé en 26 autorités cantonales
pour une population de 7,5 millions. Les cantons diffèrent
du point de vue politique, législation et structure.
L’assurance médicale est obligatoire, mais les contributions
varient considérablement entre les cantons. Un récent
rapport de l’OCDE (Organisation de Coopération et de
Développement Economiques) a relevé que le manque de
gouvernance avait abouti à un système dans lequel
“l’efficacité pouvait être améliorée”, “il était plus que temps
d’élargir le paysage juridique de la promotion de la santé et
de la prévention des maladies” et que “l’égalité n’était pas
garantie”.1 Dans une certaine mesure, cet état de chose est
imputable au manque de spécialistes capables d’évaluer et
de répondre aux besoins de santé et également de
comprendre les complexités des flux financiers et l’effet des
interventions de politique dans les systèmes complexes.
Comme dans la plupart des pays, le système économique de
santé et la santé publique ont créé des programmes de
formation indépendants, le plus souvent sans la moindre
coordination ou coopération. Les services de santé sont
donc souvent gérés par des juristes ou des économistes
d’entreprise qui appliquent des instruments du marché libre
à ce système réglementé. Dans le contexte suisse, ceci
aboutit à des coûts et à des inégalités sans cesse croissants
sans évaluation des avantages de santé possibles.
IMPORTANCE DU PERSONNEL MILITAIRE DES PAYS
EN DEVELOPPEMENT DANS LA SURVEILLANCE
MONDIALE DES MALADIES INFECTIEUSES
(THE IMPORTANCE OF MILITARIES FROM
DEVELOPING COUNTRIES IN GLOBAL INFECTIOUS
DISEASE SURVEILLANCE)
Les forces militaires des pays en développement participent
de plus en plus à l’application de la politique étrangère de
leur gouvernement, en prenant part aux opérations de
maintien de la paix, aux exercices militaires et aux missions
de secours humanitaire. Le déploiement de ces forces génère
à la fois d’importants problèmes et des opportunités pour la
surveillance des maladies infectieuses et pour la lutte contre
ces maladies. Les mouvements de troupes peuvent être à
l’origine de l’apparition ou de la propagation d’épidémies à
travers l’introduction de nouveaux agents parmi des
populations sensibles. A l’inverse, les unités militaires
disposant de capacités pour surveiller les maladies et
organiser une riposte peuvent transmettre ces capacités à des
populations civiles ne bénéficiant pas de programmes de
santé publique civils, comme dans les régions isolées ou
venant d’être frappées par une catastrophe. Au Pérou et en
Thaïlande, les organisations sanitaires militaires, en
partenariat avec les forces militaires des Etats-Unis
d’Amérique, soutiennent les efforts du Ministère de la santé
civil en faisant bénéficier celui-ci de leurs ressources en
matière de laboratoires, d’étude épidémiologique, de
communications et de logistique. Compte tenu de leur rôle
grandissant dans les affaires internationales, il faudrait que
les capacités de surveillance des forces militaires des pays en
développement soient renforcées, éventuellement par un
partenariat avec le secteur militaire de pays à haut revenu.
Avec l’aide d’organisations nationales et internationales
civiles ayant une mission sanitaire, des partenariats de types
militaire/militaire ou militaire/civil pourraient aussi conduire
à un renforcement substantiel de la surveillance des
maladies infectieuses dans le monde, notamment dans les
42 | World Hospitals and Health Services | Vol. 43 No. 4

REFERENCE
régions isolées ou venant de subir une catastrophe, où des
forces militaires sont présentes.
PARTAGE ET GESTION DES DONNEES DE DOSSIER
DE SANTE INFORMATISE (EHR) PAR ARCHIVAGE
NATIONAL : L’EXPERIENCE DE LA FINLANDE
(SHARING AND MANAGEMENT OF EHR DATA
THROUGH A NATIONAL ARCHIVE: EXPERIENCES
FROM FINLAND)
L’archivage numérique n’est nullement l’apanage des
services de santé. Les bibliothèques numériques et bien
d’autres organisations sont en passe de mettre en place la
technologie et les conditions requises à l’archivage
numérique.
En Finlande, la Stratégie d’utilisation des technologies de
l’information et des communications en matière de bien-être
et de santé avait été initialement créée en 1996 par le
Ministère de la Santé et des Affaires Sociales. Cette stratégie
reposait sur le principe de structures de service homogènes
centrées sur le citoyen. Parmi les principaux objectifs de la
stratégie figuraient l’intégration horizontale des services
(services sociaux, soins primaires et secondaires) et
l’élaboration de services partagés et coordonnés.
La création d’un système d’archivage centralisé avait été
essentiellement choisie pour les raisons suivantes:
➜ Diminution des coûts
➜ Simplicité de l’architecture nécessaire, qui permet :
- un seul point de divulgation d’EHR
- un seul service de gestion centralisée des
consentement et des refus
- la possibilité d’utiliser les messages HL7 CDA entre
systèmes EHR et eArchive
- un point unique d’entrée pour les patients et citoyens
(pour avoir accès aux journaux d’audit et à ses
propres EHR).
Toutefois, en raison de la nature exceptionnelle des
informations de santé, il faut résoudre certaines questions
spécifiques à la santé, et c’est ce que cet article examine.
PROBLEMES DE SANTE POUR LES IRAQUIENS QUI
PARTENT A L’ETRANGER POUR FUIR LA GUERRE
(WAR-SCARRED IRAQIS FACE HEALTH BURDENS IN
FOREIGN LANDS)
Plus de 2 millions d’Iraquiens ont fui leur pays ravagé par la
guerre depuis 2003, la plupart de réfugiant dans les pays
voisins comme la Jordanie et la République arabe de Syrie.
Une récente consultation régionale de l’OMS a souligné les
nouvelles difficultés auxquelles se heurtent beaucoup des
personnes déplacées, entre autre l’accès limité aux services
de santé dans leur pays hôte.
World Hospitals and Health Services 2007 Volume 43 Number 4 Resumen en Español
VISION Y ESTRATEGIA PARA LA OMNIPRESENTE
ATENCION DE LA SALUD: EL FIN DE ESTA
ACTIVIDAD COMERCIAL TAL Y COMO SE LA CONOCIA
HASTA AHORA
(VISION AND STRATEGY FOR UBIQUITOUS
HEALTHCARE: THE END OF BUSINESS AS WE KNOW IT)
Los servicios de salud y las empresas clínicas han iniciado
una nueva época que implica una cantidad cada vez mayor
de actividades económicas y un mayor número de servicios
y de investigación que, en lugar de mantenerse dentro de los
límites de las organizaciones tradicionalmente definidas
traspasan esa frontera. Estos nuevos convenios entre
organizaciones representan unos retos y oportunidades sin
precedentes. La manera en la que se proyecten y gestionen
tendrá unas consecuencias sumamente profundas sobre la
calidad, la seguridad y el coste de la atención de la salud.
Basándose en los conocimientos adquiridos de las
actividades en curso en el seno de los cuidados de salud, así
como las de otros sectores, aunque teniendo siempre en
cuenta las dificultades excepcionales de la prestación de los
servicios de salud, se ofrecen una serie de pautas que
pueden resultar de utilidad para todas aquellas asociaciones,
sistemas y alianzas en vías de desarrollo.
DISEÑO ARQUITECTONICO DEL HOSPITAL
COREANO, LA TECNICA MAS MODERNA
(KOREAN HOSPITAL DESIGN, STATE OF THE ART)
Este artículo estudia las características arquitectónicas y las
nuevas tendencias y hace una serie de sugerencias para la
construcción de un hospital mejor. Bajo el aspecto
cualitativo, el diseño hospitalario ha mejorado tanto desde el
punto de vista arquitectónico como en lo que respecta a su
interior. Si bien el modelo global de la mayoría de los
edificios tiene un aspecto vertical, se ha intentado introducir
el concepto del hospital horizontal. En los planos de salas
hospitalarias han surgido diferentes formas con un espacio
interior más dinámico. Por otro lado, se han abierto y puesto
en funcionamiento diversas clínicas y centros especiales para
hacer frente al elevado nivel de demanda de los pacientes.
Entre las sugerencias para un hospital mejor cabe citar un
aumento de salas privadas, una reducción del tamaño del
departamento de enfermería, una realización del concepto
horizontal, un aumento del margen de seguridad, privacidad
e higiene, además de algunas ayudas sensoriales.
UNA SOLUCION PARA LA FORMACION DE
ESPECIALISTAS COMPETENTES EN LA ATENCION
DE LA SALUD: LA ESCUELA SUIZA DE SALUD
PUBLICA
(A SOLUTION FOR CREATING COMPETENT HEALTH-
CARE SPECIALISTS: THE SWISS SCHOOL OF PUBLIC
HEALTH)
El sistema suizo de atención de salud (el segundo más
costoso a nivel mundial) se divide en 26 autoridades
cantonales que cubren a una población de 7.5 millones de
personas. Los cantones son bastante distintos en cuestión de
Vol. 43 No. 4 | World Hospitals and Health Services | 43

REFERENCE
política, legislación y estructura. El seguro de enfermedad es
obligatorio si bien las cotizaciones varían en gran manera de
un cantón a otro. Un informe reciente de la Organización de
Cooperación y Desarrollo Económico (OCDE), ponía de
manifiesto que una administración deficiente ha dado lugar a
un sistema en el que “la eficacia puede mejorarse”, “un
sistema legal más amplio para la promoción de la salud y la
prevención de las enfermedades debió haberse puesto en
práctica hace tiempo” y “la equidad no está garantizada”. En
cierta medida, esta situación se debe a la carencia de
especialistas que sepan como juzgar y reaccionar ante los
requisitos de salud y que comprendan las complejidades de
los flujos financieros y el efecto de las intervenciones políticas
en sistemas complejos. Al igual que en la mayoría de los
países, la economía sanitaria y la salud pública han puesto en
marcha programas de capacitación independientes, en su
mayoría sin ninguna coordinación o cooperación. Por tanto,
muy frecuentemente los servicios de salud están controlados
por abogados o economistas comerciales que recurren a
instrumentos de mercado para este sistema regulado. En el
marco suizo, esta situación da lugar a unos costos cada vez
más elevados y unas desigualdades sin evaluar las posibles
ganancias en materia de salud.
IMPORTANCIA DE LOS MILITARES DE LOS PAISES
EN DESARROLLO EN LA VIGILANCIA MUNDIAL DE
LAS ENFERMEDADES INFECCIOSAS
(THE IMPORTANCE OF MILITARIES FROM
DEVELOPING COUNTRIES IN GLOBAL INFECTIOUS
DISEASE SURVEILLANCE)
Las fuerzas militares de los países en desarrollo han cobrado
una creciente importancia como facilitadores de la política
exterior de sus gobiernos, participando en las operaciones
de mantenimiento de la paz y en ejercicios militares y
misiones de socorro humanitario. El despliegue de esas
fuerzas plantea tanto retos como oportunidades para la
vigilancia y el control de las enfermedades infecciosas. Los
movimientos de tropas pueden causar o propagar epidemias
al introducir agentes nuevos en poblaciones vulnerables. Y a
la inversa, las unidades militares con capacidad de vigilancia
de las enfermedades y de respuesta pueden hacer extensiva
esa capacidad a las poblaciones civiles no atendidas por los
programas civiles de salud pública, como las que viven en
zonas remotas o han sufrido desastres. En el Perú y
Tailandia, organizaciones sanitarias militares en colaboración
con militares de los Estados Unidos de América utilizan sus
recursos de laboratorio, epidemiología, comunicaciones y
logística para secundar los esfuerzos realizados por personal
civil del Ministerio de Salud. Conforme aumenta su
implicación en los asuntos internacionales, debería
mejorarse la capacidad de vigilancia de los militares de los
países en desarrollo, tal vez mediante fórmulas de
colaboración con militares de los países de ingresos altos. La
colaboración militares-militares y militares-civiles, con el
apoyo de organizaciones sanitarias civiles internacionales,
también podría contribuir a potenciar considerablemente la
vigilancia mundial de las enfermedades infecciosas, sobre
todo en las zonas remotas y posdesastre donde se hayan
desplegado fuerzas militares.
LA DISTRIBUCION Y GESTION DE DATOS DEL
REGISTRO ELECTRONICO DE SALUD (EN INGLES
EHR) POR MEDIO DE UN ARCHIVO NACIONAL: LA
EXPERIENCIA DE FINLANDIA
(SHARING AND MANAGEMENT OF EHR DATA
THROUGH A NATIONAL ARCHIVE: EXPERIENCES
FROM FINLAND)
Los archivos digitales no son un asunto exclusivo de la
atención de la salud. Tanto las bibliotecas digitales como
numerosos otros organismos se están dotando de la
tecnología y los aparatos necesarios para poner en marcha
un archivo digital.
En Finlandia, el primero en introducir el uso de la
información y las tecnologías de la comunicación en la
asistencia social fue el Ministerio de Asuntos Sociales y
Sanidad en 1996. Esta estrategia se elaboró en base al
principio de un servicio sin fisuras, centrado en el
ciudadano. Entre sus objetivos principales cabe citar la
integración horizontal de los servicios (desde el punto de
vista social, y la atención primaria y secundaria) y la creación
de unos servicios compartidos y coordinados.
La creación de un sistema de archivos centralizado se eligió
por los motivos siguientes:
➜ La reducción de costos
➜ La simplicidad de la arquitectura imprescindible que
tenga en cuenta lo siguiente:
- un lugar para la inclusión del registro electrónico de
salud
- un servicio de gestión centralizado basado en el
consentimiento o la exclusión
- la posibilidad de hacer uso de los mensajes HL7 CDA
Entre los
- distintos sistemas de EHR y los archivos electrónicos
- un lugar de acceso único para los pacientes y
ciudadanos (p. ej. con el fin de acceder a los registros
y EHR personales)
No obstante, debido al carácter tan excepcional de la
información relativa a los cuidados de la salud, todavía
quedan por resolver algunos problemas específicos que son
los que se examinan en este informe.
LOS IRAQUIS MARCADOS POR LA GUERRA HACEN
FRENTE A PROBLEMAS DE SALUD EN TIERRAS DEL
EXTRANJERO
(WAR-SCARRED IRAQIS FACE HEALTH BURDENS IN
FOREIGN LANDS)
Desde 2003 más de dos millones de iraquíes han
abandonado su país destrozado por la guerra y la mayoría se
han refugiado en el vecino Jordán y la República Arabe Siria.
En una conferencia regional auspiciada por la OMS, se
pusieron de manifiesto los numerosos problemas con los
que se enfrentan muchas de las personas desplazadas, entre
ellos el acceso limitado a los cuidados de salud que tienen
en el país anfitrión en cuestión.
44 | World Hospitals and Health Services | Vol. 43 No. 4

REFERENCE
Directory of IHF professional
and industry members
The International Hospital Federation is grafeful to its “D” members (listed
below) who support the world wide activities of the IHF through their
membership. The IHF recommends that you give consideration to their
products and services.
AUSTRALIA
Mr Harry McConnell
Director
INSTITUTE FOR SUSTAINABLE HEALTH
EDUCATION AND DEVELOPMENT (ISHED)
JTA International
GPO Box 1080
Brisbane, QLD 4001
Australia
Tel: +617 311 44615
Fax: +617 321 02161
Email: harry@ihn.info
Internet: www.ished.org
BARBADOS
Mr Jeremy A.N. Voss
Chief Architect
TVA CONSULTANTS LTD
Grosvenor House
Harts Gap
Hastings
Christ Church
Barbados
Tel: +246 426 4696
Fax: +246 429 3014
Email: tvabgi@sunbeach.net
BELGIUM
Ms Brigitte Baten
AGFA GEVAERT NV
Septestraat 27
B-2650 Mortsel
Belgium
Tel: +32 3 444 2111
Fax: +32 3 444 7908
Email: brigitte.baten @agfa.com
Internet : www.agfa.com
Mr Hugo Schellens
CEO
ULTRAGENDA NV/SA
Antwerpsesteenweg 19
9080 Lochristi
Belgium
Tel: +32 9 230 2020
Fax: +32 9 230 0202
Dr Tamara Kunert-Latus
TERUMO EUROPE NV
Research Park Zone 2
Haasrode
Interleuvenlaan 40
B-3001 Leuven
Belgium
Tel: +32 16 38 1222
Fax: +32 16 400 249
Email: tamara.kunert_latus@terumo-europe.com
Mr Frederic Petit
FHP VILEDA PROFESSIONAL DIVISION
Avenue Andre Ernst 3-B
Verviers
Belgium
Tel: +32 87 322 137
Fax: +32 87 322 158
Email: Frederic.petit@fhp-ww.com
Internet: www.vileda.com
BRAZIL
Waleska Santos, M.D.
Waleska Santos, M.D.
HOSPITALAR FEIRAS CONGRESSOS E
EMPREENDIMENTOS LTDA
Padre João Manuel, 923, 6th Floor
01411-001 São Paulo –SP
BRAZIL
Tel: +55 11 3897 6199;
Fax: +55 11 3897 6191
Email: waleskasantos@hospitalar.com.br
Website: www.hospitalar.com.br
DENMARK
Mr Stefan Bjork
Senior Adviser
NOVO NORDISK A/S
Novo Alle
2880 Bagsvaerd
Denmark
Tel: +45 44 448 888
Fax: +45 44 490 555
Email: stbj@novonordisk.com
Internet: www.novonordisk.com
FINLAND
Mr Sami Aromaa
Director Global
Communications
INSTRUMENTARIUM 0YJ
P O Box 900
31 Datex - Ohmeda
Finland
Tel: +358 10 394 11
Fax: +358 9 146 3310
Email: anni.toivakainen@datexohmeda.com
Internet: www.datex-engstrom.com
FRANCE
Lynda E. Mikalauskas
Associate Director, Europe
JOINT COMMISSION
INTERNATIONAL
13 Chemin du Levant
Batiment JB SAY - 4th Floor
01210 Ferney Voltaire
France Métropolitaine
Tel: +33 450 42 60 82
Fax: +33 450 42 48 82
Email:
lmikalauskasg@jcrinc.com
Internet: www.jcrinc.com
INTERNATIONAL ASSOCIATION OF INFANT
FOOD MANUFACTURERS(IFM)
194 Rue de Rivoli
75001 Paris
FRANCE MÉTROPOLITAINE
Internet: www.ifm.net
GERMANY
Managing Direktor
Architect and Engineers
FAUST CONSULT GmbH
Biebricher Allee 36
D-65187
Wiesbaden
Germany
Tel: +49 611 890 410
Fax: +49 611 890 4199
Email: faust@faust-consult.de
Internet: www.faust-consult.de
Mr Hardy Low
CEO
MCC-MANAGEMENT CENTER
OF COMPETENCE
Scharnhorststrasse 67a
D-52351, Duren
Germany
Tel: +49 2421 121 77 11
Fax: +49 2421 121 77 27
Email: loew@mcc-seminare.de
Internet: www. mcc-seminare.de
Herr H. Hassenpflug
Director of Communications
SYSMEX EUROPE GmbH
Bornbach 1, 22848 Norderstedt
Germany
Email: hassenpflug@sysmex-europe.com
Internet: www.sysmex-europe.com
Dr Daniel Zeidler
Head of Medical Marketing
PENTAX EUROPE GmbH
Julius-Vosseler-Strasse 104
22527 Hamburg
Germany
Tel: +49 40 561 92
Fax: +49 40 559 45
Email: zeidler.daniel@pentax.de
Internet: www.pentax.de
Mr H Giesen
Project Director
MESSE DUESSELDORF GmbH
Messeplatz, 1
D-40474, Duesseldorf
Germany
Tel: +49 211 456 001
Fax: +49 211 456 0668
Email: giesenh@messeduesseldorf.de
Internet: www.messe.dusseldorf.de
Mr Martin Rudmann
Commercial Director
SOLVAY GmbH
Hans-Boeckler Allee 20
30173 Hannover, Germany
Tel: +49 511 857-0
Internet: www.solvay.com
HONG KONG
Alfred Sit Wing-Hang
Health Sector Manager
HKSAR GOVERNMENT
ELECTRICAL & MECHANICAL
SERVICE DEPARTMENT
3 Kai Shing Street
Kowloon, Hong Kong (Special administrative
Region: China)
Tel: +852 2808 3562
Fax: +852 2870 0074
Email: lslai@emsd.gov.hk
Internet: www.emsd.gov.hk
INDIA
Dr Shyama S Nagarajan
Manager
ICRA
4th Floor, Kailash Building 26 Kasturba Gandhi
Marg, 110001, New Delhi, India
Tel: +91 11 233 57940
Vol. 43 No. WORLD 4 | World hospitals Hospitals and and health Health services Services | 13| 45

REFERENCE
Fax: +91 11 233 55239
Email: shyama@icraindia.com
Internet: www.icraindia.com
IRAN
MH Adabi, MD
Chief Executive Officer
KARAMED
No 11, Khordad alley
Paknejad Blvd, Shahrake Qods
Tehran 48446
IRAN
Tel: +982 1 88368774
Fax: +982 1 88365287
Email: mhadabi@hotmail.com /
info@karamed.com
Internet: www.karamed.com
ISRAEL
Dr M.Modai
President & CEO
SAREL SUPPLIES & SERVICES FOR MEDICI
ISRAEL
Sarel House, Hagavish St.
Industrial Zone
42504, South Nethanya
Israel
Tel: +97 298 922 089
Fax: +97 298 922 147
Email: joshua@sarel.co.il
Internet: www.sarel.co.il
KOREA
Mr Jae Hoon Choi
Chief Executive Officer
Ezmedicom Co. Ltd.
JinSuk Building
1536-26 Seocho-dong, Seocho-gu,
Seoul, 137-073
KOREA
Tel: +82 2 3016 7701
Fax:+82 2 3616 8802
Email: jhchoi@ezmedicom.com
Internet: www.ezmedicom.com
LEBANON
Dr Faouzi Adaimi
President
FEDERATION DES HOPITAUX ARABES
Autoroute Jounieh
Immeuble Bouza Bashir
1er Etage
BP 2914, Journieh
Lebanon
Tel: +961 990 0110
Fax: +961 990 0111
Email: hndl@terra.net.lb
LUXEMBOURG
Mr Rene Christensen
Senior Economist
EUROPEAN INVESTMENT
BANK
100 Boulevard Konrad
Adenauer
2950
Luxembourg
Tel: +352 43 798 540
Fax: +352 43 798 827
Email: r.christensen@eib.org
Internet: www.eib.org
PHILIPPINES
Mr Ashok K. Nath
Chairman
OPTIONS INFORMATION
COMPANY
# 10 Garcia Villa Street Lorenzo Village
1223 Makati City
Philippines
Tel: +632 813 0711
Fax: +632 819 3752
Email: ashok@optionsinfo.com
Internet: www.optionsinfo.com
SOUTH AFRICA
Dr Susan Chalmers
Managing Director
WOUND CARE (PTY) LTD
PO Box 2763
7129 Somerset West
South Africa
Tel: +27 21 852 8655
Fax: +27 21 852 8656
824364385
Email: info@chemspunge.co.za
Internet: www.woundcare.co.za
SWEDEN
ANOTO
Emdalavägen 18
22369 Lund
SWEDEN
Tel: +46 46-540 12 00
Fax: +46 46-540 12 02
Internet: www.anoto.com
H Josefsson
Partner/Architect
WHITE ARKITEKTER AB
Post Box 2502, S-40317, Goteborg
Sweden
Tel: +46 31 608 600
Fax: +46 31 608 610
Email: hakan.josefsson@white.se
Internet: www.white.se
Prof Gunnar Németh, MD, PhD, MBA
Senior Vice-President / Chief Medical Officer
CAPIO AB
Gullbergstrandgata 9, PO Box 1064, S-405 22
Goteborg, Sweden
Tel: +46 31 732 40 00
Fax: +46 31 732 40 99
Email: gunnar.nemeth2@capio.com
Internet: www.capio.com
John Hansson
GETINGE INTERNATIONAL AB
P O Box 69, SE-31044 Getinge
Sweden
Tel: +46 3515 5500
Email: john.hansson@getinge.com
Internet: www.getinge.com
Vice President, Marketing
BOULE MEDICAL AB
P O Box 42056, SE-12613 Stockholm
Sweden
Tel: +46 8 744 77 00
Fax: +46 8 744 77 20
Email: info@boule.se
Internet: www.boule.se
SWITZERLAND
Mr Hans Strobel
Marketing Director
JOHNSON & JOHNSON
ADVANCED STERILIZATION PRODUCTS
Rotzenbuehlstrasse 55, Ch 8957 Spreltenbach
Switzerland
Tel: +41 56 417 3363
Fax: +41 56 417 3333
Email: hstrobel@cscch.jnj.com
UNITED ARAB EMIRATES
Mr Thumbay Moideen
President
GULF MEDICAL COLLEGE HOSPITAL AND
RESEARCH CENTRE
PO Box 4184, Ajman
United Arab Emirates
Email: gmcajman@emirates.net.ae
Internet: www.gmcajman.com
INDEX CONFERENCES & EXHIBITION EST
Dubai Health Care City Block B, Office No 303
PO Box 13636
Dubai, United Arab Emirates
Tel: +971 4 265 1585
Fax: +971 4 265 1581
Email: index@emirates.net.ae
Internet: www.indexexhibitions.com
UNITED KINGDOM
Mr S Robert Wendin
MARSH EUROPE
Tower Place East Tower, EC3R 5BU, London
UK – England
Tel: +44 207 357 1000
Fax: +44 207 929 2705
Email: robert.wendin@marsh.com
Internet: www.marsh.com
Mr David Selwyn
Secretary
ASSOCIATION OF PRIMARY CARE
GROUPS & TRUSTS (APCGT)
5-8 Brigstock Parade, London Road, Thornton
Heath , Surrey CR7 7HW
UK - England
Tel: +44 208 665 1138
Fax: +44 208 665 1118
Email: info@apcgt.org
Internet: www.apcgt.co.uk
Mr Philip Emsley
Mobile Data Management
EXTENDED SYSTEMS LIMITED
10 Queen Square
Bristol BS1 4NT
UK – England
Tel: +44 117 333 9000
Fax: +44 117 333 9001
Email: philip.emsley@extendedsystems.co.uk
Internet: www.extendedsystems.com
Maggie Smock
Manager
REGENT MEDICAL LIMITED
Two Omega Drive Irlam
Manchester M44 5BJ
UK – England
Tel: +44 161 777 2600
Fax: +44 161 777 2601
Email: maggie.smock@regentmedical.com
Internet: www.regentmedical.com
The Directors
PRO-BOOK PUBLISHING LTD
Alpha House
100 Borough High Street
London SE1 1LB
UK – England
Tel: +44 207 863 3350
Fax: +44 207 863 3351
Email: info@probrook.com
Internet: www.pro-brook.com
Mr Nicholas Shapland
Managing Director
JONATHAN BAILEY
ASSOCIATES (UK) LIMITED
2nd floor, 13 Park Street
London SE1 9EA
UK – England
Tel: +44 20 7323 4578
Fax: +44 20 7637 9350
Email:
nickshapland@jonathanbailey.com
Internet: www.jonathanbailey.com
Mr Witney M. King
Managing Director
INTERNATIONAL HOSPITALS GROUP LIMITED
The Manor House Park Road,
Stoke Poges SL2 4PG
Bucks
UK – England
Tel: +44 1753 784 777
Fax: +44 1753 784 784
Email: wmk@ihg.co.uk
Internet: www.ihg.co.uk
Mr Bryan Pearson,
Managing Director
FSG COMMUNICATIONS LTD
Vine House, Fair Green, Cambridge CB5 0JD
UK – England
Tel: +44 1638 743 633
Fax: +44 1638 743 998
Email: bryan@fsg.co.uk
Internet: www.fsg.co.uk
UNITED STATES OF AMERICA
Mr Markus E. Zettner
Director, Global Network Development
46 | World Hospitals and Health Services | Vol. 43 No. 4

REFERENCE
CIGNA - INTERNATIONAL EXPATRIATE
BENEFITS, 590 Naamans Road
Claymont, 19703, DE, USA
Tel: +1 302 797 3494
Fax: +1 302 797 3055
Email: Markus.zettner @cigna.com
Internet: www.cigna.com/expatriates
Mr Ahmed Ahsan
President & CEO
HORIZON STAFFING SERVICES
Corporate Headquaters
1169 Main Street, Suite 350
East Hartford, 06108, CT, USA
Tel: +1 860 282 6124
Fax: +1 860 610 0078
Email: ahmed@horizonstaff.com
Internet: www.horizonstaff.com
Sherry Hayes
Director
ERNST & YOUNG LLP
1225 Connecticut Avenue, NW
20036, Washington DC
USA
Tel: +1 202 327 7480
Fax: +1 202 327 7893
Email: sherry.hayes@ey.com
Internet: www.ey.com
Dr Christos A.
Papatheodorou, MPH, FACS
INTERACTIVE HEALTH MANAGEMENT
SOLUTIONS LLS
1200 South Federal Highway Suite 202
Boynton Beach, 33435, FL
USA
Tel: +1 561 731 5881
Fax: +1 561 731 5877
Mr John R. Schlosser
Senior Director
SPENCER STUART
10900 Wilshire Boulevard Suite 800
Los Angeles, 90024, CA
USA
Tel: +1 310 209 0610
Fax: +1 310 209 0912
Email: jschlosser@spencerstuart.com
Internet: www.spenserstuart.com
Patricia A Schneider
Vice President
GLOBAL MED-NET INC
A Goeken Group Company
1751 Diehl Road
Suite 400, Naperville, 60653
IL
USA
Tel: +1 630 717 6700
Fax: +1 630 717 6066
Email: pas81@aol.com
Internet: www.globalmednet.net
Anthony M. Montville
HealthTek Solutions, inc
Dominion Tower
999 Waterside Drive
Suite 1910
Norfolk
23510
VA
USA
Tel: +1 804 757 625 0800
Fax: +1 804 757 625 2957
Email: solutions@healthtek.com
Internet: www.healthtek.com
Mr W Davenhall
Health & Human Services Solutions Manager
ESRI
380 New York Street
Redlands
92373
CA
USA
Tel: +1 909 793 2853
Fax: +1 909 307 3039
Email: bdavenhall@esri.com
Internet: www.esri.com
Jeff Fadler
Executive Vice-President &
Chief Operating Officer
MEDIFAX EDI INC
1283 Murfreesboro Road
Nashville
37217
Tennessee
USA
Tel: +1 615 843 2500
Ext. 2103
Fax: +1 615 843 2539
Email: jeff.fadler@medifax.com
Internet: www.medifax.com
The President
MEDICAL SERVICES
INTERNATIONAL, INC
20770 Highway, 281 No
Suite 108 # 184
San Antonio
78258-7500
Texas
USA
Tel: +1 210 497 0243
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WORLD hospitals and health services | 13

OPINION MATTERS
War-scarred Iraqis face health
burdens in foreign lands
More than 2 million Iraqis have fled their war-ravaged
country since 2003, with most taking refuge in
neighbouring Jordan and the Syrian Arab Republic.
A recent WHO-hosted regional consultation highlighted the
new troubles faced by many of those displaced, including
limited access to health care in their host countries.
But the 45-year-old’s problems didn’t stop once he arrived
in the Jordanian capital of Amman in December 2006. “We
sold the family car and we’ve been living off of that money,
but it is running out”, Abdel Jabar told us. “I have another
problem though, a huge problem. I was diagnosed with
bladder cancer in Jordan and although I have undergone
several operations the doctor says it is not completely
removed.”
Like many other Iraqis who have sought refuge in Jordan,
Abdel Jabar is unemployed and cannot pay for needed
health care. Many Iraqis in Jordan and the Syrian Arab
Republic suffer from chronic diseases such as high blood
pressure, cardiovascular disease and diabetes, said Dr Ala
Alwan, WHO Assistant Director-General.
Iraqis receive no special discount or consideration at staterun
Jordanian health facilities, paying the same as any
Jordanian or other foreigner in the kingdom. “Iraqis in
Jordan are provided with the same medical care as
Jordanians who do not have insurance”, said chief Jordanian
government spokesman Nasser Judeh.
Demands for health care and other services needed by
displaced Iraqis in neighbouring countries are placing huge
strains on their host states. A WHO-organized conference
held 29–30 July in the Syrian capital, Damascus, discussed
these issues and sought ways to improve access to services.
The meeting was attended by health and foreign affairs
officials from Iraq, Egypt, Jordan and the Syrian Arab
Republic, the latter three countries hosting the bulk of more
than 2 million Iraqis who have fled their homeland since the
war began in 2003. Representatives of UN agencies, and the
Red Crescent Societies of Jordan and the Syrian Arab
Republic also attended.
The host nations agreed that displaced Iraqis should have
the same access to health services as their own populations.
Alwan said this was a major commitment that required extra
resources for the health sector. Participants agreed to seek
additional funding from the international community and
the Iraqi government, which has already promised its
support.
Alwan said the most urgent priority is to ensure access to
primary health care, including preventive and curative
treatment; maternal and childhood medical services;
emergency care; and provision of essential drugs and
medical supplies.
“All displaced Iraqis living outside Iraq should be able to
freely and safely return to Iraq in due course, so the strategy
for meeting their health-care needs in host countries should
be seen as a temporary one”, Alwan, a former Iraqi minister
of health, told the Bulletin. “Meanwhile, the international
humanitarian community and Iraqi government must
support countries like Jordan and the Syrian Arab Republic
to enable their health systems to address the increasing
burden of providing health services for displaced Iraqis.”
The Iraqi Red Crescent office in Amman said the
governments of Jordan and other host countries are waiting
for Baghdad to pay the US$ 25 million pledge it promised
to assist displaced Iraqi civilians, particularly in health.
Jordanian spokesman Judeh said the presence of some
750 000 displaced Iraqis was straining the kingdom’s
infrastructure. Another 1.4 million Iraqis have moved to the
Syrian Arab Republic since 2003, with substantial numbers
arriving in Egypt, Islamic Republic of Iran, Lebanon and
Turkey. More than 50 000 Iraqis continue to leave their
homeland monthly, mainly to Jordan and the Syrian Arab
Republic, according to the United Nations High
Commissioner for Refugees (UNHCR).
“This has put an incredible burden on the Jordanian
economy in terms of health, food, medicine, education,
infrastructure and resources”, Judeh said.
Abdel Jabar has spent most of his money on
chemotherapy and needs additional treatment, including
complicated surgery. International Catholic relief agency
Caritas provided financial support for his initial treatment,
but the Iraqi said he needed 6000 to 8000 Jordanian dinars
(US$ 8470 to US$ 11 290) for further treatment. “This is
beyond my capability and Caritas cannot fund it”, he said.
“I am praying that the UNHCR can help.”
Caritas worker Hania Bisharat said her agency only helps
Iraqis living on under US$ 80 per month. Last year, Caritas
provided some 3000 displaced Iraqis with medical
treatment and has helped a similar number so far this year.
Other governmental and nongovernmental aid agencies,
such as the Iraqi and Jordanian Red Crescent Societies,
Medicines Sans Frontiéres and Care International, provide
additional medical services and other assistance to Iraq’s
displaced. ❑
Published with the kind permission of the World Health
Organization: WHO Source: Bulletin of the World Health
Organization: Volume 85, Number 9, September 2007, 649-732
48 | World Hospitals and Health Services | Vol. 43 No. 4