AFEW-Tajikistan Has Unique HIV Rapid Testing Point in the Country

Tajikistan is among the countries where HIV prevalence has increased by more than 25% over the last 10 years. In Tajikistan the number of sterile needles and other commodities for people who inject drugs per year is still very low. 
AFEW-Tajikistan is the only NGO in the country that has HIV voluntary counselling and rapid testing

Olesya picture

By Olesya Kravchuk

Communications Officer at AFEW (AIDS Foundation East-West) International

AFEWTajikistan Has Unique HIV Rapid Testing Point in the Country


HIV voluntary counselling and rapid testing point opened on December 1, 2016 in Qurghonteppa, Tajikistan. Testing point is situated in the representative office of RPO “AFEW-Tajikistan” in Khatlon region. The activity is conducted within “Bridging the Gaps: Health and rights of key populations” funded by the Ministry of Foreign Affairs of the Netherlands.

HTC center 2HTC center

Tajikistan is among the countries where HIV prevalence has increased by more than 25% over the last 10 years. The country is at the early stage of an HIV/AIDS epidemic, with an estimated 16,000 people living with HIV at the end of 2015. Although the proportion of new HIV cases diagnosed among people who inject drugs (PWID) seems to have fallen dramatically over time (down to 22.4% in 2015), PWID still bear a disproportionate number of HIV infections. In Tajikistan the number of sterile needles and other commodities for PWID per year is still very low.

HTC center 3IMG_9944

AFEW-Tajikistan” is the only NGO in the country that has HIV voluntary counselling and rapid testing. “We chose Qurghonteppa for providing these services because our second office is situated there. Besides, one of the main routes of Afghan drug traffic goes through Khatlon region and that is why drug addiction level in the region is high,” director of AFEW-Tajikistan Ikram Ibragimov says. “People who use drugs are the main target audience for us. As a rule, donors and partners work in the capital and on the North of the country. We decided to go South.”


People find out about the testing point from AFEW’s website, media and business-cards that organization disseminates among population, get information from the clients who visit the center themselves. Mostly, the visitors of the center are representatives of key populations.

“HIV is one of the most serious public health problems of our region. It is very good that AFEW-Tajikistan obtained the opportunity to open such point in its branch and this will allow AFEW together with еру regional AIDS center of Khatlon to fulfill the goals of UNAIDS Global Strategy,” says the director of regional AIDS Center of Khtalon region Akram Davlatov.

Starting from December 1 and up until March 16, there were 69 people tested for HIV. Two positive cases of HIV were detected and clients already started the antiretroviral treatment. The total number of HIV-infected people in Tajikistan is 8750. This is the officially registered cumulative HIV cases as of the 1st of January 2017.



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Public-private Partnership Paradox: the Case of Gavi and Health System Strengthening

The WHO model for Health System Strengthening (HSS) includes improving its six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes.... It appears that Gavi maintains a very different interpretation of HSS....vhere the interconnectedness between the building blocks is hardly taken into account

Rènee de Jong

By Renée de Jong

Junior Global Health Advocate at Wemos Foundation  

Public-private Partnership Paradox: the Case of Gavi and Health System Strengthening


Public-private partnerships claim to have saved millions of lives since 20001, but despite their efforts, the Millennium Development Goals on health were not reached. It remains questionable if the achieved results can be sustained without well-functioning health systems2.

The World Health Organization (WHO) states that failing health systems are the root cause for low health outcomes and inequalities3. It hampers the right to health, as a rights-based approach to health requires accessible, affordable and high quality care4. Also with the Sustainable Development Goals in mind, we might have to rethink our current approaches. In this article, I take a close look at the functioning of the Global Vaccine Alliance, known as Gavi. Public-private partnerships such as Gavi have often been criticised for being too disease-focused; Gavi focuses on vaccinating children. These disease-specific approaches contradict with earlier agreements made by the international community like the Alma Ata Declaration for strong primary healthcare and the Paris Agreement on Aid Effectives from 20055. Moreover, the WHO stresses the need for Health System Strengthening (HSS) in its Framework for Action: strengthening health systems to improve health outcomes3.

Contribution to health systems?

Currently, public-private partnerships, such as Gavi develop programs with the aim to strengthen health systems. However, it is questionable whether those programs positively contribute to health systems in low income countries. HSS programs are criticised as ‘old wine in new bottles’ and when badly executed it could become a meaningless container concept6.

Gavi’s primary aim is to provide more equitable vaccination coverage in low-income countries7, but hits a roof where health systems are not functioning. To overcome these ‘system barriers’ or ‘bottlenecks’, Gavi invests in programs labelled as ‘health system strengthening’. However, Gavi’s approach is criticised for not truly strengthening health systems but rather strengthening the power of Global Health Initiatives8. The approach of public-private partnerships has moved the debate around health systems from the political debate to a technical debate8.

The doubt about the effects of HSS programs is alarming. Therefore, I compared the approach to HSS suggested by the WHO with the practical investments by Gavi at country level. My aim was to understand how the approaches differ and why. Below I present the main findings from my qualitative study based on programs labelled as HSS by Gavi, literature and expert interviews.

What is Health Systems Strengthening?  

To explain HSS, WHO refers to their building block model for health systems (see figure below). HSS is defined by WHO as: “improving these six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes. It requires both technical and political knowledge and action”3. The building block model from WHO should assist everyone who wants to address a health system.

R DeJ ong Figure 1

In practice, it appears that Gavi maintains a very different interpretation of HSS. The building blocks are used to justify their HSS approach, which is meant to strengthen results in vaccination. HSS is mainly done via investment in local resources: cars, boats, bikes, kits for community health workers and cold chain equipment. Most of their actions are related to service delivery, human resources and information, and usually at local or district level9–11. It appears that the interconnectedness between the building blocks is hardly taken into account. Poorly designed programmes with a disease specific approach still risk unwanted effects and fragmentation of the system12. At the same time positive effects may lag behind, as system barriers remain.

Let me give two practical explanations I was given during my interviews. They show how HSS programs can interfere negatively with the health system.

Vaccinations and trust

Gavi funds a programme labelled as ‘health system strengthening’ in Kenya, with the aim to convince the population to vaccinate its children (demand generation). However, local health systems are sometimes left unable to meet the need for vaccinations while people need to travel sometimes far to reach the clinic. When Gavi has created demand before all vaccinations can be supplied, some patients are left with an unmet need. If the demand for vaccinations increases while in practice it remains challenging to vaccinate children, the trust in the health system could be harmed.

Even when immunisation services are improved, but not general care at health clinics such as treating an abscess or diabetes, this could decrease trust in the health system by the population. For example when people visit the clinic for general care, but this need cannot be met. Because of the decrease in trust, people would be less eager to return to the clinic to vaccinate their children. This is not only an issue actually for vaccines. One expert mentioned that women would not return to a local clinic to give birth because when they saw the clinic, they assumed that care at the clinic would be hardly better than at home.

Only if health systems meet the needs of the local population, trust in the health system can grow. This is why the concept of the ‘responsiveness’ of a health system is so important and requires good leadership besides financial investment.

Why does Gavi still have a disease-specific approach?

Based on the HSS programmes by Gavi, literature and interviews, I found the following reasons why the environment which supports the continuing of disease-specific approaches remain.

First, indicators play a strong role. They create a drive for short-term success. Gavi aims for “the biggest bangs for the bucks” based on their primary goals. As a consequence, progress in ‘Health System Strengthening’ is measured by vaccination follow up rates and other indicators directly related to vaccination13. This has two disadvantages. Their indicators do not measure the possible adverse effects for the health system like the above mentioned examples show. Moreover, long-term effects on the health system can easily be overlooked. However, it is these lasting effects, whether positive or negative, which are important to understand. The positive long-term effects of actions cannot easily be translated into ‘lives saved’, in a relatively short term period.

Second, for Gavi as a Public-Private Partnership the advanced market commitment is stated as their business model14. Their aim is to create a market for vaccines to reach their goal: to provide more equitable vaccination coverage in low-income countries7. This short term commitment to the market resembles a neo-liberal approach and misses out on long-term sustainable solutions which would contribute to a rights based approach. The ambition to build a market for vaccines could be conflicting with the ambition to build a responsive health system. However, the ‘saving lives’ story attracts investment and donations and could undermine investment in alternatives which cannot be easily translated into ‘saved lives’15 such as system investments. Again, this might undermine a shift to a systems approach.

Third, there is an imbalance in power between Gavi and the recipient low income countries. Gavi calls its program ‘country driven’ as governments write the proposals. Nonetheless, Gavi has the power to deny proposals due to which countries have to adjust and resubmit the proposals according to Gavi’s criteria. This process is time consuming and burdens the ministries of health.

While I only included Gavi’s HSS programme in my research, other research has shown similar results. An example is the study by Cavalli16, who showed comparable effects by an HSS programme focused on neglected tropical diseases. This is probably the case for many global health initiatives. Besides, if all other development organizations demand that health system strengthening programs are in accordance of their own short-term disease-specific goals (like vaccination in Gavi’s case), there is only limited space for countries to truly invest in the long-term needs of the population (e.g. primary healthcare). Therefore, the gravity of the problem should not be underestimated.

How about the WHO? Although WHO mentions that one of its objectives is to steer Global Health Initiatives to a less vertical approach, it is in a relatively weak position compared to public-private partnerships, mainly due to its financial situation17. So far WHO appears unable to correct the misuse of the building block model.

How to move towards responsive health systems?

As long as countries do not have an adequate system to raise funds for their health system (e.g. insurance or taxes) they will remain dependent on big donors such as Gavi. In practice, Gavi hardly focuses on the financing of health systems. Nevertheless, Gavi aspires that countries buy all vaccinations themselves in the future. Here it shows the need for countries to make progress in Universal Health Coverage to become able to fund their own health system, as is a goal for the sustainable development goals.

In my research I also questioned issues that were left unproblematic in the HSS discussion. I have seen that a label of ‘health system strengthening’ on a programme surely does not mean that the programme actually strengthens the health system. For now my conclusion is that there is an urgent need for more systems thinking in programmes, financial independency for low income countries, better governance for health and suitable indicators to monitor health system programmes.

We should remain critical to programs addressing health systems, in order to ensure that all programmes truly strengthen health systems. In the end of the day, badly functioning health systems imply that people cannot reach, afford or receive the care they need.

About the Author: This article is based on the Master thesis of Renée de Jong. She works for the Wemos Foundation as a Junior Global Health Advocate. The study was executed to support the Health Systems Advocacy Partnership which includes the following organisations: ACHEST, Amref, HAI and Wemos.  The full thesis can be requested, and questions can be sent to


  1. Gavi. Half a billion children vaccinated and seven million lives saved thanks to Gavi partners. Accessed March 23, 2017.
  2. Ooms G, Van Damme W, Baker BK, Zeitz P, Schrecker T. The “diagonal” approach to Global Fund financing: a cure for the broader malaise of health systems? Global Health. 2008;4(1):6. doi:10.1186/1744-8603-4-6.
  3. World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. 2007:1-56.
  4. Ooms G, Marten R, Waris A, Hammonds R, Mulumba M, Friedman EA. Great expectations for the World Health Organization: A Framework Convention on Global Health to achieve universal health coverage. Public Health. 2014;128(2):173-178. doi:10.1016/j.puhe.2013.06.006.
  5. Hafner T, Shiffman J. The emergence of global attention to health systems strengthening. Health Policy Plan. 2013;28(1):41-50. doi:10.1093/heapol/czs023.
  6. Marchal B, Cavalli A, Kegels G. Global health actors claim to support health system strengthening – Is this reality or rhetoric? PLoS Med. 2009;6(4):1-5. doi:10.1371/journal.pmed.1000059.
  7. Gavi. Gavi’s mission – Gavi, the Vaccine Alliance. Published 2017. Accessed March 15, 2017.
  8. Storeng KT. The GAVI Alliance and the “Gates approach” to health system strengthening. Glob Public Health. 2014;9(8):865-879. doi:10.1080/17441692.2014.940362.
  9. Republic of Kenya Ministry of Health. Proposal for Health Systems Support.; 2006.
  10. The Government of the Republic of Zambia. GAVI Alliance Health Systems Strengthening (HSS) Applications.; 2007.
  11. Republic of Uganda. GAVI Alliance Health System Strengthening ( HSS ).; 2007.
  12. Savigny D de, Adam T. Systems Thinking for Health Systems Strengthening.; 2009. doi:10.1155/2010/268925.
  13. Gavi. Health systems goal indicators. Published 2017. Accessed March 22, 2017.
  14. Gavi. Gavi’s business model – Gavi, the Vaccine Alliance. Published 2017. Accessed March 15, 2017.
  15. McCoy D, Jensen N, Kranzer K, Ferrand RA, Korenromp EL. Methodological and Policy Limitations of Quantifying the Saving of Lives: A Case Study of the Global Fund’s Approach. PLoS Med. 2013;10(10). doi:10.1371/journal.pmed.1001522.
  16. Cavalli A, Bamba SI, Traore MN, et al. Interactions between global health initiatives and country health systems: The case of a neglected tropical diseases control program in Mali. PLoS Negl Trop Dis. 2010;4(8):1-7. doi:10.1371/journal.pntd.0000798.
  17. Kickbusch I, Reddy KS. Global health governance – the next political revolution. Public Health. 2015;129(7):838-842. doi:10.1016/j.puhe.2015.04.014.

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Inclusive Communication as a Mechanism to Improve Equity of Access in Health Systems

A really equitable health system is that that ensures that people with special needs also have fair access to healthcare. This is especially relevant for people with communication needs, who may experience more barriers of access to healthcare services. 

Inclusive communication is an approach to communication in which information and its understanding are made accessible to everyone

Alex Henriquez

By  Alex Henriquez

Research Analyst at Healthcare Improvement Scotland / Scottish Health Council

Inclusive Communication as a Mechanism to Improve Equity of Access in Health Systems


Equity in Health Systems means that everyone should receive a fair treatment independently of their economic or physical conditions. It is very easy to link equity in health systems with fair access of those of us who do not have either a physical or learning disability. However, a really equitable health system is that that ensures that people with special needs also have fair access to healthcare. This is especially relevant for people with communication needs, who may experience more barriers of access to healthcare services. Here is where the approach of inclusive communication represents a powerful tool for health systems and global health practitioners to ensure that those who experience more barriers of access to healthcare, can receive the attention they need.

Inclusive communication is an approach to communication in which information and its understanding are made accessible to everyone (Mander, 2015). To make information accessible to every person it is necessary to recognise that people have different levels of understanding and specific communication support needs that must be taken into consideration (Hartley Kean, 2016). This includes people with a learning disability, autistic spectrum disorders, dementia, neurological illness, stroke, cancer, head or brain injury, visual impairment, people who are deaf or blind or who have a dual sensory impairment, as well as those who have aphasia, autism, motor neurone, cerebral palsy and mental illness (Scottish_Government, 2015).

Research suggests that people with learning and physical disabilities face serious health inequalities compared to the rest of the population. For instance, they are three times as likely to die early than the general population (Turner and Robinson, 2010). Moreover, their prospects to experience poor general health or to have high levels of unmet physical and mental health needs are greater than the rest of the population (Turner and Robinson, 2010).

Some of the key determinants of these inequalities include exposure to social determinants of ill health such as poor housing, unemployment, poverty and disconnectedness (Emerson and Baines, 2010). However, and in addition to these, communication difficulties and poor health literacy are also considered a key determinant, one that can be challenged by health services providers (Turner and Robinson, 2010).

Within the healthcare system, the provision of accessible information is regarded as a key component of quality healthcare and the promotion of wellbeing (Jarrett et al., 2015). Therefore, serious investment in producing resources that meet people’s communication needs; training and supporting staff; and fashioning the delivery of health services to enable people with disabilities to make informed choices are regarded as essential to ensure they experience fair services and enjoy a better health (Jarrett et al., 2015).

In the 21st century it is important for healthcare practitioners to consider that people with special communication needs can improve their access to healthcare, if the communication barriers they experience are tackled wholly from a those systems approach in which accessible information is constantly promoted.

Evidence on Inclusive Communication

The availability of primary research into inclusive communication practice and its impact on people with communication support needs is limited. Existing research into inclusive communication can be organised into three main categories; first, studies that focus on communication resources, second, studies that focus on the implementation of specific resources among a specific social sub-group; third, studies that analyse the processes involved in the delivery of inclusive communication materials.

Within the first category, two studies have been reviewed (Shiose et al., 2009, Geiger, 2010). These concluded that the use of inclusive resources and the inclusion of people with disabilities in the design and implementation of information resources help to promote awareness and social participation. Shiose et al. (2009) investigated the effects of inclusive communication as a mean to raise awareness of people’s different communication needs. They found that the implementation of inclusive communication resources and the inclusion of elderly and disabled people in the design process of educational materials can help to improve social awareness. Likewise, Geiger (2010) highlights the efficacy of culturally specific non-verbal communication and contextual elements as a mean to enable the communicative participation of young children with severe disabilities.

Within the second category, Jones et al. (2007) investigated the impact of using a picture book about cancer to meet the information needs of cancer patients with learning disabilities. They found that while the resource allowed patients to receive cancer information, there were knowledge and information gaps between doctors, learning disability staff and carers that prevented patients from having a deeper understanding about their condition and treatment options (Jones et al., 2007). Similarly, Calculator (2009) analysed the role of Augmentative and Alternative Communication (AAC) as a mean to successfully promote the inclusion of students with severe disabilities in general education. He concluded by stating that integration of AAC can be used as a tool to promote everyone’s access to information and participation and not only those in need of it. However, he highlights that the sole existence of AAC and other forms of inclusive technology will not guarantee inclusion and participation unless there are clear processes and practices in which teachers, learning disabilities staff and all students engage in order to consider the communication support needs of those with learning disabilities (Calculator, 2009). If these processes are not taken into account, people with communication support needs will continue facing barriers to access information and services despite the existence of inclusive information resources and technology (Calculator, 2009).

Within the third category, Mander (2015) investigated the experience of accessible information between the British National Health Service staff and service users with learning disabilities. She found that while the practice of producing accessible resources has become more widespread and advanced, the same cannot be said about the practice of delivering them, which varies across service providers (Mander, 2015). Whilst she observed a degree of engagement with service users within specialist services, there was limited evidence to suggest cross-service engagement in inclusive communication (Mander, 2015).

In a following study, Mander (2016) investigated the delivery of health-related accessible information for adults with learning disabilities. She found that the delivery of accessible information allowed for personalisation and appeared to support understanding; however, this was mediated by the skills of those delivering it. The author concludes by highlighting the necessity to shift focus away from the resources-research and to focus on the processes to deliver accessible information (Mander, 2016).

Similar conclusions were reached by Jarrett et al. (2015) after assessing the use of accessible information material in the provision of healthcare for people with learning disabilities in the NHS Scottish health board of Ayrshire and Arran. They added that the understanding of inclusive communication varied across services, with staff within the learning disabilities and mental health services showing a significantly greater knowledge on resources and delivery of accessible information than those in Primary Care (Jarrett et al., 2015). Just like Mander (2016), Jarrett et al. (2015) reflect on the importance to move beyond the resources and concentrate on the practice of understanding how people recognise, promote, understand and support the delivery of accessible information (Jarrett et al., 2015).

A successful practice in this case is that of the ‘Stroke Voices’ programme from Chest Heart & Stroke Scotland. This is a fully inclusive communication and public involvement training and support resource for people who experience aphasia and cognitive problems after a stroke (Mackellaig et al., 2014).  By putting a strong emphasis on public engagement, inclusive training delivery methods and inclusive resource development, the ‘Stroke Voices’ programme has successfully demonstrated that it is possible to support people who have had a stroke to present their views for service development and have a say in their healthcare and treatment options (Mackellaig et al., 2014).

To summarise, research on inclusive communication indicates that the way in which accessible information resources are employed is as important as their availability. Moreover, the effective use of accessible information is determined by the interplay of different factors, such as, a positive attitude of the provider, accurate recognition of service user’s communication needs, the provider’s knowledge of which communication strategy to use, the provider’s skill in using AAC strategies and lastly, the availability of inclusive communication resources ready to match the service user’s communication needs (Hartley Kean, 2016). While existing literature supports the development and use of inclusive communication resources, these are not enough to ensure inclusion and participation. It is necessary to establish clear, effective processes that enable the implementation and delivery of accessible information. The case of ‘Stroke Voices’ shows that it is possible to fully integrate an inclusive communication approach towards the development of stroke services within NHS Scotland.

A considerable property of the delivery of healthcare is the existence of information asymmetries between users and providers which prevent users from accessing the essential information about their health and treatment options, causing costly inefficiencies in the health system (Cruz and Kini, 2012). People with special communication support needs face even greater barriers to access information. As observed by Turner and Robinson (2010) these barriers lead to the widening of health inequalities experienced by them.

While health systems globally strive to improve equity of coverage and access to health services, it is necessary for public health practitioners to make an extra-effort and consider the needs of those with communication support needs. As indicated by the evidence, the availability of accessible informative resources is not enough, it is important to focus on the processes in which information is delivered.

The Scottish Case: Inclusive Communication in Scotland

In 2007 the Scottish Government commissioned a literature review to describe the lived experience of people with communication support needs (Law et al., 2007).The review concluded that in comparison with the general population, people with Communication support needs are more likely to experience negative communication and barriers of access to education, healthcare, criminal justice and other public services (Law et al., 2007). Moreover, they do not receive the necessary information required to utilise services, tend to be misjudged in terms of cognitive and education level, be unemployed and/or employed at low level and live in socially deprived areas (Law et al., 2007). The review concludes by emphasising that service providers must engage with the concept of ‘person centred care’ in order to effectively adapt and respond to the specific communication needs of people with learning and physical disabilities (Law et al., 2007).

Following this, the Scottish Government released in 2010 the Healthcare Quality Strategy which highlights the necessity for services to be person-centred (Scottish_Government, 2010). The Quality Strategy builds on three foundations; people’s views will be gathered and listened in order to improve care; it is about making the right thing for every person, every time and by making continuous measurable improvements in the aspect of quality of care of patients, their families and carers (Scottish_Government, 2011). The strategy also highlights the importance to have clear communication and explanation about conditions and treatments; therefore, for services to be fully person-centred, service providers need to communicate with users in ways that work for them (Scottish_Government, 2011, Hartley Kean, 2016).

In addition to this, between 2010-2014 the Scottish Government commissioned the Communication Forum Scotland to carry out the Civic Participation Network Project for people with communication support needs (Money, 2016). The project lead to the coproduction of the Talk for Scotland Toolkit, which sets out the national principles for inclusive communication. The six principles for inclusive communication will help health and social care services providers to deliver services more effectively and support people with communication support needs. These principles are linked to performance indicators and they operate at national, local and individual level.  The principles are as follows:

  1. Communication accessibility and physical accessibility are equally important
  2. Every community or group will include people with different communication support needs
  3. Communication is a two-way process of understanding others and expressing yourself
  4. Be flexible on the way your service is provided
  5. Effective user involvement will include the participation of people with different communication support needs
  6. Keep trying (Scottish_Government, 2011).

While the principles have been valued at national and local level, an examination of their implementation commissioned by the Scottish government, ‘The Joe Report’, indicated that simply having these principles was not enough and that further actions needed be taken in order to properly implement an inclusive communication practice (Money, 2016).

The report indicated that in order to effectively mainstream inclusive communication practice throughout public services it was necessary to have senior staff leading the agenda; to share, evidence-based definitions of quality inclusive communication practice; to make realistic and sustained investment and to have a means of regulating inclusive communication practice (Money, 2016).

Building on these recommendations and on the 2007 United Nations Convention on the Rights for People with Disabilities, in late 2015, the Scottish Government published a consultation on its 2016-20 delivery plan to implement the Convention and realising the vision to become an inclusive communication nation (Scottish_Government, 2015).

In its delivery plan, the Scottish Government wants disabled people to have equal and inclusive access to:

  • The physical and cultural environment, transport and suitable, affordable housing
  • Healthcare provision and support for independent living. Disabled people will have control over the best use of resources. There will be good quality support for disabled children.
  • Education, paid employment and an appropriate income and support whether in or out of work
  • The justice system without fear of being unfairly judged or punished, and with protection of personal and private rights.

Lastly, the government emphasises that in order to achieve these outcomes, three ways of working must be adopted by service providers as follows:

  1. Ensure that disabled people are empowered to participate fully
  2. Communication is inclusive and is accessible
  3. The barriers facing disabled people are known, understood and addressed

To Conclude

People with physical and learning disabilities still face barriers of access to health and social care services that contribute to the widening of health inequalities between them and the general population. Inclusive communication represents an opportunity to reduce such barriers and ensure that disabled people not only access the services they need, but also understand their health conditions, treatment options and have a say on these. Evidence indicates that the availability of resources is not enough to achieve this. While resources are important, it is more important to strengthen the processes through which people interact, that is, ensuring that all staff are aware of people’s communication needs, understand them and act upon these. Scotland is on the path to become an inclusive communication nation, while this is a challenging process, it also represents a rich opportunity to move closer towards the goal of achieving equity of access to health services.


CALCULATOR, S. N. 2009. Augmentative and alternative communication (AAC) and inclusive education for students with the most severe disabilities. International Journal of Inclusive Education, 13, 93-113.

D’CRUZ, N & KINI, R. 2012. The effect of information assymetry on consumer driven health plans.

EMERSON, E. & BAINES, S. 2010. Health Inequalities and People with Learning disabilities in the UK. In: HEALTH, D. O. (ed.). Learning Disabilities Observatory

GEIGER, M. 2010. Using cultural resources to build an inclusive environment for children with severe communication disabilities: a case study from Botswana. Children’s Geographies, 8, 51-63.

HARTLEY KEAN, K. 2016. Realising the vision of communication inclusion. Tizard Learning Disability Review, 21, 24-29.

JARRETT, D., MACGREGOR, S. & TERRAS, M. 2015. The use of accessible information in the healthcare of people with learning disabilities In: SCOTLAND, U. O. T. W. O. (ed.). Ayrshire and Arran University of the West of Scotland_NHS Ayrshire and Arran

JONES, A., TUFFREY-WIJNE, I., BERNAL, J., BUTLER, G. & HOLLINS, S. 2007. Meeting the cancer information needs of people with learning disabilities: experiences of paid carers. British Journal of Learning Disabilities 35, 12-18.

LAW, J., VAN DER GAAG, A., HARDCASTLE, B., BECK, J., MACGREGOR, A. & PLUNKETT, C. 2007. Commnication Support Needs: A Review of the Literature In: RESEARCH, S. E. S. (ed.). Edinburgh Scottish Government

MACKELLAIG, J., COTTER, N., PEARDON, L. & BERTIN, D. 2014. Empowering stroke patients to have their say in a person-centred NHS in Scotland Service Development 10, 87-93.

MANDER, C. 2015. First-hand experience of accessible information. Tizard Learning Disability Review, 20, 80-87.

MANDER, C. 2016. An investigation of the delivery of health-related accessible information for adults with learning disabilities. Tizard Learning Disability Review, 21, 15-23.

MONEY, D. 2016. Inclusive Communication and the role of speech and language therapy In: THERAPISTS, R. C. O. S. A. L. (ed.) Position Paper. London

SCOTTISH_GOVERNMENT 2010. The Healthcare Quality Strategy for NHS Scotland In: GOVERNMENT, S. (ed.) Healthier Scotland Edinburgh

SCOTTISH_GOVERNMENT 2011. Scottish Government Principles of Inclusive Communication Edinburgh

SCOTTISH_GOVERNMENT 2015. UNCRPD The Scottish Government’s Draft Delivery Plan 2016-2020. In: GOVERNMENT, S. (ed.). Edinburgh

SHIOSE, T., KAGIYAMA, Y., TODA, K., KAWAKAMI, H. & KATAI, O. 2009. Expanding awareness by inclusive communication design. Ai & Society, 25, 225-231.

TURNER, S. & ROBINSON, C. 2010. Health Inequalities and People with Learning Disabilities in the UK: 2010 implications and actions for comissioner In: HEALTH, D. O. (ed.) Improving Health and Lives: Learning Disabilities Observatory



Creating and Maintaining Fair, Trustworthy and Sustainable Research Collaborations

The Research Fairness Initiative (RFI) responds to the increasing understanding of the importance of partnerships and SDG 17 by ensuring that institutions around the world can have access to an evidence-base on how to create and maintain fair, trustworthy and equitable partnerships in research and innovation

Lauranne Botti

By Lauranne Botti, Manager


and Carel Ijsselmuiden, Executive Director

COHRED’s Research Fairness Initiative (RFI)

The Council on Health Research for Development-COHRED Group Geneva, Switzerland

Creating and Maintaining Fair, Trustworthy and Sustainable Research Collaborations


The recognition of the benefits that international research and innovation collaborations bring to sustainable development, especially for low- and middle-income countries, is becoming more widely recognized. The UK Department for International Development (DFID) have recently increased expenditure on research, making it clear that there is a growing concern and intention to provide means for capacity building through research collaborations.[1] In addition, the positive impacts brought on by collaborations are emphasized by the fact that Goal 17 of the UN Sustainable Development Goals (SDGs) is on Partnerships, encouraging the creation of inclusive collaborations where partners share goals, values and principles.[2] SDG 17 is a direct result of international development aid reaching new heights – in 2014, a total of $135.2 billion was spent on international cooperation for development, setting a historical record.[3]

The Research Fairness Initiative (RFI) responds to the increasing understanding of the importance of partnerships and SDG 17 by ensuring that institutions around the world can have access to an evidence-base on how to create and maintain fair, trustworthy and equitable partnerships in research and innovation.

What is the RFI?

The RFI is a reporting mechanism for research programmes, institutions and nations that fosters the use and compliance with existing best practice guidelines. As a global learning platform, the RFI will raise awareness of the tools and information that stimulates the development of fair, sustainable research systems and institutional policies and practices. The RFI was conceptualized by the Council on Health Research for Development (COHRED) and was developed in global collaboration with institutions of various sectors since 2015.

How does the RFI create and maintain fair research collaborations?

The RFI raises awareness on many documents and guides that stand as best practice standards, such as the Commission for Research Partnerships with Developing Countries’ (KFPE) Guide for Transboundary Research Partnerships.[4] The tool implements these standards by encouraging institutions to report on 15 guidelines that inspire fairness, research competitiveness, partner efficiency and guides RFI Reporting Organisations (RROs) to adopt these principles within their institutional policies and practices for sustainable development.[5] The RFI also benefits its member organisations by acting as a global learning platform, leading institutions to address obstacles that can be encountered while collaborating with other partners, such as addressing capacity building, ethics standards, transparency in financial systems and fair sharing of benefits, costs and outcomes.

Who is adopting the RFI?

The RFI is in its implementation stage and is ready to engage with institutions around the world. Several institutions from government ministries, national research centres, universities, donors and businesses from Austria, Brazil, Colombia, Costa Rica, Germany, Kenya, the Philippines, Senegal, South Africa and Spain, for example, have demonstrated clear interest to implement the RFI in its first year.

The Initiative has also received a significant amount of support and backing by CAAST-Net Plus,[6] a European Union-funded project that is a network of 26 organisations, which enhances European Union and Sub-Saharan African research and innovation collaborations. As a result, the potential adoption of the RFI as a grant-assessing tool for the EU for the food security and sustainable agriculture sector is being discussed, largely expanding the reach of the global tool to areas other than the Health field. Though the tool was originally created and shaped to address issues encountered in research collaborations for health, the RFI guidelines effectively apply to international partnerships from all research and innovation sectors.

As one can see, the interest and uptake of the RFI is growing in 2017 at a time when togetherness and shared perspectives, principles and goals are more crucial to secure joint forces for sustainable development between civil society, governments and the scientific community. Successful international collaborations are central to generating high quality research, high-level competitiveness and capacity building in low- and middle-income countries.[7] All in all, the RFI is a timely intervention that will provide guidance as a key source to understand, access and put into practice standards addressing fairness, trust and sustainability in research partnerships as an innovative compliance tool that provides solutions to problems that are found in collaborations from all areas of the globe.


[1] Overseas Development Institute (2005). North-South Research Partnerships: A Guidance Note on the Partnering Process. Available at: (Accessed: 7 March 2017).

[2] United Nations Sustainable Development Goals (2015) Global partnerships – United Nations sustainable development. Available at:

[3] ibid

[4] Swiss Commission for Research Partnerships with Developing Countries (KFPE) (2012). A Guide for Transboundary Research Partnerships: 11 Principles, 7 Questions. Available at:

[5] Research Fairness Initiative (2017). ‘RFI evidence-base.’ Available at:

[6] CAAST-Net Plus:

[7] Nature (2015). ‘Nature Index 2015: Collaborations.’ Nature. Vol 527, Issue No. 7577 (November 12, 2015). Macmillan Publishers: London.

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From Animosity to Murder: the Spectrum of Workplace Violence against Physicians

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From Animosity to Murder: the Spectrum of Workplace Violence against Physicians

The observed increase in violence against physicians is a clear trend, supplemented by no end of anecdotal stories of physician disrespect; spitting, verbal, and physical assault, online harassment. Many of these would be criminal if done against a transit operator, but such behaviour seems to be increasingly tacitly accepted as part of a doctor’s craft

Lawrence Loh

By Lawrence C. Loh

Dalla Lana School of Public Health, University of Toronto, and Director of Programs at The 53rd Week Ltd

From Animosity to Murder: the Spectrum of Workplace Violence against Physicians


A warm August evening, and after a long day at work, I had just finished bedtime with my kid and was unwinding in the kitchen with my wife. We were preparing for dinner; grilled chicken, and I was about to wander out on the patio with my beer and fire up the grill.

A message came in from an old friend – an internist in Ohio – saying simply “we need to talk tonight.” Focused on my plans for the evening, I simply responded that I had a number of competing deadlines before midnight, and that if he let me know what was going on, I could try to connect.

He called me, and dropped a thunderbolt: Dr. Guillermo Martinez, Mexican-born urologist practicing in Slovenia, devoted husband and father of two children, friend, and former International Federation of Medical Students Associations (IFMSA) Secretary General—dead at 36. Gunned down at his hospital by a disgruntled patient. (1)


One certainly doesn’t have to look very far to note that public perception of medical professionals seems to be worsening. In the midst of provincial contract disputes here in Canada, animosity around patient satisfaction scores and litigation in the U.S., and healthcare systems worldwide under strain as industrialized populations age beyond capacity, patient respect for physicians seems to be at a nadir.

Some argue that this is simply the changing physician-patient relationship, where physicians need to adapt from being unquestionably revered as teachers and healers to a new, more patient-focused normal, where service is expected and entitled. That does not, however, excuse or explain the far more disturbing trend that should not be tolerated in any circumstance: violence against physicians. Most recently, statistics from the United States Centers for Disease Control found rates of workplace violence against physicians, while traditionally low, doubled over a two year period from 2012-2014. (2)

In 2010, I returned to Toronto after a year of graduate studies in Baltimore, and watched the shooting of a spinal surgeon at Johns Hopkins unfold in live images of streets familiar to me. The first concern—being America—was terrorism, especially in Baltimore, a stone’s throw away from DC. The story that did emerge, however, was more personally disturbing. This wasn’t terrorism at all. Instead, a disgruntled family member, unhappy with an update on his mother’s care, had shot the treating physician – and soon after, perhaps realising what he had done, took his and his mother’s lives as well. A tragedy in almost every regard, with the silver lining being that the surgeon survived. (3)

Fast forward to this past summer, where residency was already a distant memory, and my ten-year med school reunion was slated for the fall. My classmates were now staff physicians building careers and families. As a public health physician, I had left full-time clinical practice behind, but often recounted to my learners how fun it was getting a consult back from an old friend. It acted, in many ways, as an indirect check-in: “good to see you’re out there, friend – and presumably doing well.” Having participated in the IFMSA as a student, I also enjoyed hearing from friends around the world that were going through similar transitions, even if our staying in touch relied increasingly on social media instead of in-person meet-ups that, the latter made increasingly difficult by distance and life pressures.

Six years on, I had long forgotten the Hopkins shooting. After all, while hitting metaphorically close to home, that whole scenario seemed so surreal and seemingly illogical. I should have recognized, however, that as my contemporaries became productive front line physicians, the unthinkable would perhaps become imperceptibly more likely.

That’s what made the news I received that August evening somewhat more poignant. In the days after Memo’s murder, the news spread throughout the IFMSA community to practicing physicians the world over. Shock abounded, as in addition to being just an all-round good guy, Guillermo was well known as an excellent surgeon who cared deeply about his patients. Initially murky details came into sharper focus: unhappy with the prognosis and the time it was taking for him to access treatment, one of his patients decided the best way to address this would be to shoot his treating physician. In turn, that patient himself was shot and killed by police while trying to escape the hospital grounds.

The months since have seen a return to daily life, though there was a London-based reunion that saw many of us who knew Guillermo reunite, reminisce, and drink a tequila toast in his honour. That he left Mexico, one of the most violent countries on earth, only to be gunned down in a hospital in Central Europe gave me pause. He had gone to work expecting to save lives; not to lose his own. How had it come to this?


Data suggests there are other professions that face relatively higher risks of violence in their dealings with the general public: taxi drivers, liquor store and gas station employees, and police officers. (4) The cynic in me felt that perhaps these workers be better prepared than physicians around workplace violence. After all, I rationalised, it might be a matter of expectations, that those engaged in these occupations recognize the risk of violence inherent in their work. Certainly, while a trainee on an emergency rotation might have a story or two, I felt that physicians for the most part naively believe that they are shielded by a purported public respect for the profession. The idea seemingly that patients understand that physicians are there to help, and are trying their best to do right by them.

But in thinking again on the shift towards patient-centred care and service, I began to wonder if our risk was ultimately all that different from other professions that also deal with cross-sections of the public. Add to that the fact that one’s health is so highly valued, and that patients might be in extremely vulnerable states, ready to lash out, and my wonderings became even more unsettled. The observed increase in violence against physicians is a clear trend, supplemented by no end of anecdotal stories of physician disrespect; spitting, verbal, and physical assault, online harassment. Many of these would be criminal if done against a transit operator, but such behaviour seems to be increasingly tacitly accepted as part of a doctor’s craft.

Now, in fairness, there are a minority of physicians who themselves fail to treat patients and families with respect. But so many others go in with the intention of helping their patients each and every single day, and work on conditions for which the outcome is not fully within our control. When patient expectations fail to align with reality, and things take a turn for the worse, where does that leave the treating physician as a potential punching bag, or worse?

Compounding this is the fact that physicians, once revered as infallible and God-like, are now seen as cogs in a healthcare wheel. Cogs that are singularly responsible for achieving unrealistic outcome targets in an increasingly complicated world. Surely this is the pendulum swinging a bit too far, and perception needs to return to the pragmatic middle: physicians as human; determined to do their best in situations of great complexity; trying to work with rather than for patients. Humans with fallibilities, to be sure, but also with feelings, families, and friends. Family and friends who love them, support them, and ultimately pick up the pieces when violence visits.


While I myself have largely left clinical practice, I often think of my many friends both in Canada and around the world who still see patients. There are many patients who are suffering, and I know for a fact that the vast majority of their practitioners work their hardest to restore and optimise health within the constraints imposed by the context and system to the very best of their skills and ability.

After Guillermo’s passing, though, I sense that many of us who knew him—or who have heard the story—recognise the circumstances behind his tragic, senseless death, and perhaps see elements of those circumstances in their own interactions with certain patients. Surely, at some point in the future, one of us will be in a standoff with an angry patient around antibiotics for a cold, or an opioid refill or a decidedly unnecessary request for referral, and maybe, just maybe, doubt will creep in: “Is this it..? Is this the one that’s going to do it?”

A wise preceptor of mine once said that anger is simply unmet expectations. A fair statement, to be sure; but it does not characterize the expectations, which might very well be unrealistic or misplaced. Are we a new generation of physicians that will simply accept that we are practicing in a riskier, colder, less kind world? Or can we better shape these expectations and address this growing trend of animosity and violence towards physicians before it consumes more lives—for the sake of not only ourselves, but our patients, our communities, and our loved ones?

Dedicated to the memory of Dr. Luis Guillermo Martinez Bustamante (1980-2016)


(1) Spry E. Luis Guillermo Martinez Bustamante [obituary] BMJ 2016;354 doi:http//

(2) Gomaa AE, Tapp LC, Luckhaupt SE, Vanoli K, Sarmiento RF, Raudabaugh WM, Nowlin S, Sprigg SM. Occupational traumatic injuries among workers in health care facilities – United States, 2012-2014. MMWR Morb Mortal Wkly Rep. 2015 Apr 24;64(15):405-10.

(3) ABC News. Johns Hopkins Hospital: Gunman Shoots Doctor, Then Kills Self and Mother. [news story] Accessed online on November 27, 2016 from

(4) Hendricks, S.A., Jenkins, E.L., and Anderson, K.R. Trends in workplace homicides in the U.S., 1993–2002: a decade of decline. Am J Ind Med. 2007; 50: 316–325 DOI:

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Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings


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