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Czech doctors strike over pay and health system
AIM tackles health and poverty
Czech doctors strike over pay and health system
"Poor need
Last week’s doctors’ strike in the Czech Republic has raised issues of medical ethics. The original one-day action on Nov 1 was supported by both the radical Doctors’ Trade Union (LOK) and the more moderate Union of Czech Doctors (SCL). However, LOK chairman, Dr David Rath, then urged doctors to prolong their protest by "indefinite administrative action", which could include refusing to inform relatives about a patient’s condition. But SCL chairman Dr Petr Sucharda, rejected this idea and resigned from his post and membership of ’, the SCL council in protest. Response to Rath’s call has been patchy. His recommendation was at once criticised by Deputy Premier Jan Kalvoda. He said that the withholding of information from relatives is not only contrary to medical ethics, but also to the "moral conscience of society in a broader sense". : The strike was over two issues, one of them pay. The LOK is demanding a threefold pay rise for hospital doctors, but Health Minister Jan Strasky maintains that if this is granted, hospital managers ,’. would not have enough funds to meet other, essential costs. Health care, he reminded the doctors, is now financed not directly by the state budget, but by the new insurance schemes. He said that doctors salaries could be increased only grad,
ually, through
a
placed
1288
social process and social processes take time-that’s bad news for donors". Guerrero, formerly mayor of Cali, Colombia, and now advisor to the Pan American Health Organization, was speaking at an Action in International Medicine conference in London on Nov 3-4, jointly sponsored by WHO, calling for determined and concerted action to help reduce the ill-health consequences of poverty. Dr Niall Tierney, chief medical officer of Ireland, emphasised that the effects of poverty could not be eliminated without a total commitment of all social and economic sectors. One example that came up repeatedly was the tragic neglect of women’s education in many of the poorest countries. The conference expressed indignation that decades of talk had produced very little and called for urgent remedial action, in the first place from the 100 academic and professional bodies in over 30 countries that are members of AIM. In a formal declaration it recommended: that health and development workers should press their political leaders for
UK aid
projects provide
high-level commitments to reduce poverty and improve the health of their populations; that governments be lobbied to reduce their dependence on harmful activities (eg, the production and advertising of addictive substances such as nicotine and *
alcohol); that information on successful and failed interventions for tackling the causes and effects of poverty be systematically catalogued and disseminated; that the potential energy resource of poor people themselves be recognised, enhanced, and harnessed; that health resources be shifted to the district level of the health-care system; that intersectoral and interagency cooperation be fostered and coordinated, especially at district level; and that front-line health workers be given appropriate training and the ability to access and use relevant information. AIM also urged its members to convene "echo" conferences on health and poverty, to prepare action programmes in their own countries. *
AIM is at 125 6QA, UK.
The UK National Audit Office assessment overseas health and population aid programmes indicates how important it is to set clear, appropriate,
project-specific objectives at design stage. Other requirements for ensuring project success include the availability, at the outset, of baseline data, and the setting of measurable indicators of progress (Overseas Development Administration: Health and Population Overseas Aid, House of Commons Paper 782, HM Stationery Office). An important point made in the report is the need to set measurable indicators of progress towards the project’s objectives. Broad objectives-eg, improvements in health status-give project managers little guidance on how to monitor progress. Precise lower-level objectives more directly related to project activities are required. This issue has been addressed in the Overseas Development Administration’s Project Cycle Management approach introduced in 1993, which sets objectives at three levels-the wider goal to which the project contributes; the specific purpose that the project is intended to achieve; and the various outputs. Even with this kind of objective setting, there is the danger that project monitoring might focus too much on inputs (quality of raw material) and outputs (eg, number of clinics built), without assessment of whether the project might achieve its intended impact. Here the NAO found
High Holborn, London WC1V
Andrew Herxheimer
lessons in
systematic improvement of the country’s
in the health service, or with an injection of cash by the government. The latter, he said, would simply cause an overall increase in prices. : The second grievance is the new insurance system itself. According to one of the country’s leading human rights organisations, the Czech Helsinki group, the "insensitive and dogmatic" introduction of market principles (including insurance) into the health service, means that most . inhabitants of the republic no longer have . access to state-of-the-art forms of treatment. In a letter to Strasky, last week, the group said that the government must not stand aside and watch the health sector become destabilised. Comprehensive . reform is needed; the dismissal of health minister Ludek Rubas last month and his replacement by Strasky was not sufficient. : Ironically, the doctors’ action has come at the time when the health of the entire government is under scrutiny. 2 weeks ago, Trade Minister Vladimir Dlouhy was admitted to hospital with hepatitis. All the other members of the cabinet have been vaccinated against hepatitis and under a 50 days of medical supervision, including dietary restriction, reduced contact with the public, and a ban on sport and exercise. : Vera Rich
people don’t need gifts, they just opportunities", said Dr Rodrigo Guerrero, adding "Development is a
setting objectives
that formal mid-term reviews, focusing on whether project outputs were achieving the purpose as specified in the project framework, could be helpful. Targets for assessing progress have to be based on available baseline data. In the Zimbabwe Sexual Health project, there were, at the outset of the project, no reliable indicator levels for four of the six indicators for which targets were set. Another measure recommended for improving monitoring is the agreement, with the project manager, of a format for reporting progress. Otherwise, progress reports tended to include considerable detail but no ready summary of progress and/or an analysis of
expenditure against targets. When projects are not meeting their targets, remedial action may be required. The report points out that it would help, especially if management were contracted out, to define respective responsibilities for such action. Aid projects should
always consider sustainability, especially for projects not expected to produce an immediate impact. The difficulty here, the report acknowledges, is not just the availability of funds but also the commitment and management capacity of the recipient government. In one population project in Pakistan, 35 non-governmental organisations closed down after the project ended. recurrent
Vivien Choo
Czech doctors strike over pay and health system
"Poor need
Last week’s doctors’ strike in the Czech Republic has raised issues of medical ethics. The original one-day action on Nov 1 was supported by both the radical Doctors’ Trade Union (LOK) and the more moderate Union of Czech Doctors (SCL). However, LOK chairman, Dr David Rath, then urged doctors to prolong their protest by "indefinite administrative action", which could include refusing to inform relatives about a patient’s condition. But SCL chairman Dr Petr Sucharda, rejected this idea and resigned from his post and membership of ’, the SCL council in protest. Response to Rath’s call has been patchy. His recommendation was at once criticised by Deputy Premier Jan Kalvoda. He said that the withholding of information from relatives is not only contrary to medical ethics, but also to the "moral conscience of society in a broader sense". : The strike was over two issues, one of them pay. The LOK is demanding a threefold pay rise for hospital doctors, but Health Minister Jan Strasky maintains that if this is granted, hospital managers ,’. would not have enough funds to meet other, essential costs. Health care, he reminded the doctors, is now financed not directly by the state budget, but by the new insurance schemes. He said that doctors salaries could be increased only grad,
ually, through
a
placed
1288
social process and social processes take time-that’s bad news for donors". Guerrero, formerly mayor of Cali, Colombia, and now advisor to the Pan American Health Organization, was speaking at an Action in International Medicine conference in London on Nov 3-4, jointly sponsored by WHO, calling for determined and concerted action to help reduce the ill-health consequences of poverty. Dr Niall Tierney, chief medical officer of Ireland, emphasised that the effects of poverty could not be eliminated without a total commitment of all social and economic sectors. One example that came up repeatedly was the tragic neglect of women’s education in many of the poorest countries. The conference expressed indignation that decades of talk had produced very little and called for urgent remedial action, in the first place from the 100 academic and professional bodies in over 30 countries that are members of AIM. In a formal declaration it recommended: that health and development workers should press their political leaders for
UK aid
projects provide
high-level commitments to reduce poverty and improve the health of their populations; that governments be lobbied to reduce their dependence on harmful activities (eg, the production and advertising of addictive substances such as nicotine and *
alcohol); that information on successful and failed interventions for tackling the causes and effects of poverty be systematically catalogued and disseminated; that the potential energy resource of poor people themselves be recognised, enhanced, and harnessed; that health resources be shifted to the district level of the health-care system; that intersectoral and interagency cooperation be fostered and coordinated, especially at district level; and that front-line health workers be given appropriate training and the ability to access and use relevant information. AIM also urged its members to convene "echo" conferences on health and poverty, to prepare action programmes in their own countries. *
AIM is at 125 6QA, UK.
The UK National Audit Office assessment overseas health and population aid programmes indicates how important it is to set clear, appropriate,
project-specific objectives at design stage. Other requirements for ensuring project success include the availability, at the outset, of baseline data, and the setting of measurable indicators of progress (Overseas Development Administration: Health and Population Overseas Aid, House of Commons Paper 782, HM Stationery Office). An important point made in the report is the need to set measurable indicators of progress towards the project’s objectives. Broad objectives-eg, improvements in health status-give project managers little guidance on how to monitor progress. Precise lower-level objectives more directly related to project activities are required. This issue has been addressed in the Overseas Development Administration’s Project Cycle Management approach introduced in 1993, which sets objectives at three levels-the wider goal to which the project contributes; the specific purpose that the project is intended to achieve; and the various outputs. Even with this kind of objective setting, there is the danger that project monitoring might focus too much on inputs (quality of raw material) and outputs (eg, number of clinics built), without assessment of whether the project might achieve its intended impact. Here the NAO found
High Holborn, London WC1V
Andrew Herxheimer
lessons in
systematic improvement of the country’s
in the health service, or with an injection of cash by the government. The latter, he said, would simply cause an overall increase in prices. : The second grievance is the new insurance system itself. According to one of the country’s leading human rights organisations, the Czech Helsinki group, the "insensitive and dogmatic" introduction of market principles (including insurance) into the health service, means that most . inhabitants of the republic no longer have . access to state-of-the-art forms of treatment. In a letter to Strasky, last week, the group said that the government must not stand aside and watch the health sector become destabilised. Comprehensive . reform is needed; the dismissal of health minister Ludek Rubas last month and his replacement by Strasky was not sufficient. : Ironically, the doctors’ action has come at the time when the health of the entire government is under scrutiny. 2 weeks ago, Trade Minister Vladimir Dlouhy was admitted to hospital with hepatitis. All the other members of the cabinet have been vaccinated against hepatitis and under a 50 days of medical supervision, including dietary restriction, reduced contact with the public, and a ban on sport and exercise. : Vera Rich
people don’t need gifts, they just opportunities", said Dr Rodrigo Guerrero, adding "Development is a
setting objectives
that formal mid-term reviews, focusing on whether project outputs were achieving the purpose as specified in the project framework, could be helpful. Targets for assessing progress have to be based on available baseline data. In the Zimbabwe Sexual Health project, there were, at the outset of the project, no reliable indicator levels for four of the six indicators for which targets were set. Another measure recommended for improving monitoring is the agreement, with the project manager, of a format for reporting progress. Otherwise, progress reports tended to include considerable detail but no ready summary of progress and/or an analysis of
expenditure against targets. When projects are not meeting their targets, remedial action may be required. The report points out that it would help, especially if management were contracted out, to define respective responsibilities for such action. Aid projects should
always consider sustainability, especially for projects not expected to produce an immediate impact. The difficulty here, the report acknowledges, is not just the availability of funds but also the commitment and management capacity of the recipient government. In one population project in Pakistan, 35 non-governmental organisations closed down after the project ended. recurrent
Vivien Choo