Health Beyond Hospitals (Lecture for Ramathibodi Clinical Fellows)
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Health Beyond Hospitals (Lecture for Ramathibodi Clinical Fellows) Health Beyond Hospitals (Lecture for Ramathibodi Clinical Fellows) Presentation Transcript

  • Health Beyond Hospitals Nawanan Theera-Ampornpunt, M.D., Ph.D. Department of Community Medicine Faculty of Medicine Ramathibodi Hospital Mahidol University May 14, 2014
  • Introduction 2003 Doctor of Medicine (1st-Class Honors), Ramathibodi 2009 M.S. (Health Informatics), University of Minnesota 2011 Ph.D. (Health Informatics), University of Minnesota Currently • Lecturer, Department of Community Medicine • Deputy Executive Director for Informatics Chakri Naruebodindra Medical Institute Contacts nawanan.the@mahidol.ac.th SlideShare.net/Nawanan www.tc.umn.edu/~theer002 2
  • Outline • “Health” & Its Determinants • Health Systems & Healthcare Systems • Functions & Components • Characteristics of a Desirable Health System • Models of Healthcare Systems • Thailand’s Context • Major Issues in Health Care 3
  • “Health” & Its Determinants 4
  • Class Discussion: What Is Health? 5
  • Health • Health vs. Illness and Disease • Medical Model: Health = Absence of Illness or Disease • So what’s the problem with this model? 6
  • Problems with the Medical Model • Emphasis on treatment of illness/disease • Promotion and Prevention deemphasized • Not true sense of the word “Health” but rather just “Lack of ill health” • So what’s a better model of health? Shi & Singh (2004) 7
  • The WHO Model & Definition • “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” WHO Constitution (1948) • Also known as biopsychosocial model of health 8
  • Holistic Health • The well-being of every aspect of what makes a person whole and complete Shi & Singh (2004) Holistic Health Physical Mental Social Spiritual 9
  • 10 The Epidemiology Triangle 10 Host EnvironmentAgent Disease
  • 11 Determinants of Health 11 Individual Adapted from Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand Environment Health Healthcare Systems Biological - Genetics Psychologic al (KAP) - Knowledge - Attitudes - Practice (Behaviors/ Lifestyles) - Physical - Chemical - Biological - Social, cultural, economic, political, technological
  • 12 Natural History of Disease Adapted from Centers for Disease Control and Prevention. Principles of epidemiology, 2nd ed. Atlanta: U.S. Department of  Health and Human Services; 1992 (Cited in http://www.cdc.gov/osels/scientific_edu/ss1978/lesson1/Section9.html) Healthy Health Promotion Disease Prevention Early Detection Prompt Treatment Rehabilitation/ Limitation of Disability Primary Prevention (Preventing Disease) Secondary Prevention (Preventing Disability or Death) Tertiary Prevention (Preventing More Disability or Death) Stage of Susceptibility Stage of Subclinical Disease Stage of Clinical Disease Stage of Recovery, Disability or Death Exposure Pathologic Changes Onset of Symptoms Usual Time of Diagnosis
  • 13 Health Promotion Strategies: Ottawa Charter 13 WHO (1986)
  • 14 Social Determinants of Health • The circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. 14 WHO (2008)
  • 15 Social Determinants of Health 15 WHO (2008)
  • Health Systems & Healthcare Systems 16
  • Health Systems • A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. • Includes efforts to influence determinants of health as well as more direct health- improving activities. • More than the pyramid of publicly owned facilities that deliver personal health services. WHO (2007) 17
  • Health Systems • Includes • A mother caring for a sick child at home • Private providers • Behavior change program • Vector-control campaigns • Health insurance organizations • Occupational health and safety legislation. • Inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health. WHO (2007) 18
  • Health Care • Health care: Activities and services performed to improve a person’s health and well-being, through prevention and treatment of illness. • Similar terms • Healthcare services • Healthcare delivery Adapted from Shi & Singh (2004) 19
  • 20 Healthcare Systems • An organization that delivers healthcare • In general, healthcare systems • promote good health in populations • balance levels of actual care provided with the expectations of the population they serve • Narrower definition than WHO’s “Health Systems” 20 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • 21 Healthcare Systems • Different models of healthcare systems • Purely public (care conducted by the state) • Purely private (care conducted by independent, privately funded organizations) • Often a mixed model • In countries with state run healthcare system, a private system may coexist in parallel or offer services not available under the public system 21 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • 22 Healthcare Systems • Privately owned, commercial organizations may also act as healthcare systems • These organizations may serve a single area or multiple geographic locations • Private healthcare systems may be: • Not-for-profit organizations (governed by principle of non-distribution) or • For profit organizations (distribute surplus funds to shareholders or owners) 22 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • 23 Healthcare Systems • Healthcare systems can be measured using benchmarks • One framework for assessment: •Patient assessed value •Performance on clinical interventions •Efficiency 23 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • 24 Public Health 24 “is the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.“ (Winslow, C.E.A. 1920) Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).
  • What is Public Health? • Private Health • Clinicians, Health Practitioners • Treat Individual Health Problems • Action usually taken after illness/injury occurs • Public Health • Agencies • Treat/Maintain Health of Populations • Actions include Education, Policy, Research, Monitoring 25 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 7a).
  • Multiple Layers of “Health Systems”: A Health Systems Research Perspective 26 Hoffman et al. (2012)
  • 27 10 Great Public Health Achievements – US, 1900-1999 • Vaccination • Motor-vehicle safety • Safe workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water • Recognition of tobacco use as a health hazard 27 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).
  • 28 How Has Public Health Improved Healthcare? • Improvements in understanding disease • Epidemiology is considered the basic science of public health and is • a quantitative basic science • a method of causal reasoning based on developing and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality • a tool for public health action to promote and protect the public’s health 28 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).
  • 29 • An example of epidemiology at work: • In 1854: epidemic of cholera in London, England • Cholera is a bacterial disease • Lack of sanitation and overcrowding led to the spread of disease • Dr. John Snow linked the spread of disease to a contaminated public water pump • Snow’s hypothesis: cholera was spread by contaminated water 29 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b). How Has Public Health Improved Healthcare?
  • 30 • Improvements in data collection • Original methods of data collection were crude • progressive improvement in methodology led to the use of sophisticated scientific methods to collect data • cohort studies • randomized controlled trials 30 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b). How Has Public Health Improved Healthcare?
  • 31 • Improvements in data analysis (use of tools such as multivariate analysis and meta-analysis) • Improvement in disease surveillance • Example: the Real-Time Outbreak and Disease Surveillance (RODS) Laboratory at the University of Pittsburgh, Department of Biomedical Informatics 31 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b). How Has Public Health Improved Healthcare?
  • 32 • Improvement in training • Establishment of many schools of public health in the early 20th century • Professional degrees such as Master of Public Health (M.P.H.) • Improvements in infrastructure • Federal • State • Local health departments 32 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b). How Has Public Health Improved Healthcare?
  • Functions & Components of Health Systems 33
  • 34 Functions of Healthcare Systems 34 Healthcare Service Delivery Health Insurance Adapted from Shi & Singh (2004) by Theera‐Ampornpunt Healthcare Payment Healthcare Financing Access Funding Funding Claims & Reimbursements Governance, Policy & Administration
  • 35 Components of Health Systems 35 Cited in: Hoffman et al. (2012)
  • 36 Components of Health Systems 36 WHO (2009)
  • 37 Healthcare Delivery 37 • Healthcare is delivered in different places Inpatient facilities • Hospitals • Institutions for treating sick or injured people • Historically places for shelter, almshouses • Different types of hospitals • General medical and surgical hospitals • Specialty hospitals (orthopedic, pediatrics, women’s services, psychiatric, neurological, infectious disease) Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • 38 Healthcare Delivery • Hospitals may be publicly or privately owned • Patients can be admitted to a hospital through • Emergency room • An internal outpatient clinic • Directly admitted from an external physician’s office • Depends on local practices 38 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • 39 Healthcare Delivery • Nursing and residential care facilities • Can be short term facilities or long term facilities • Long term care classified by level of care • Nursing homes gradually shifted from being part of the welfare system to being a part of the healthcare system 39 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • 40 Healthcare Delivery Outpatient facilities • Hospitals in some countries provide ambulatory care through internal outpatient clinics • Physicians offices (also known as private clinics) • Primary care offices • Specialty care offices • Single specialty or multispecialty offices 40 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • 41 Healthcare Delivery • Dental offices • General dentists or specialists • Medical and diagnostic laboratories • Pharmacies • Internal pharmacies of hospitals • Private pharmacies • Community health centers • Other ambulatory health services 41 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • U.S. Healthcare Industry Industry segment Employment Establishments Total 100.0 100.0 Ambulatory healthcare services 42.6 87.3 Offices of physicians 17.0 36.0 Home healthcare services 7.2 3.7 Offices of dentists 6.2 20.4 Offices of other health practitioners 4.7 19.6 Outpatient care centers 4.0 3.6 Other ambulatory healthcare services 1.8 1.4 Medical and diagnostic laboratories 1.6 2.4 Hospitals 34.6 1.3 General medical and surgical hospitals 32.5 1.0 Other specialty hospitals 1.4 0.2 Psychiatric and substance abuse hospitals 0.7 0.1 Nursing and residential care facilities 22.8 11.4 Community care facilities for the elderly 5.2 3.5 Residential mental health facilities 4.1 4.0 Other residential care facilities 1.3 1.1 1.1 Table: Percent distribution of employment and establishments in health services by detailed industry sector, 2008. 42 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).
  • Characteristics of a Desirable Health System 43
  • 44 WHO Framework 44 WHO (2009)
  • 45 EQESAR Framework • E - Equity • Q - Quality • E - Efficiency • SA - Social Accountability • R - Relevancy 45 Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 46 Equity • Equal services for equal needs • Unequal services for unequal needs • Accessibility • Physical • Psychological • Financial • Information 46 Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • Quality • Safety • Timeliness • Effectiveness • Patient-centeredness Adapted from IOM (2001)
  • 48 Efficiency • Cost-effectiveness • Output or outcome versus cost • Technical/operational efficiency • Allocative efficiency 48 Adapted from Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 49 Social Accountability • Good governance • Adequate oversight and monitoring • Transparency 49 Adapted from Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 50 Relevancy • Relevant to issues/problems in the context of interest • Context-dependent 50 Adapted from Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • Models of Healthcare Systems 51
  • 52 Models of Healthcare Systems 52 Model Financing Provider Ownership Example of Countries Employer-based (market-based) private insurance Multipayer, voluntary Private United States National health insurance Single-payer (general taxes) Public/Private Canada National health system Single-pyaer (general taxes) Public United Kingdom Socialized health insurance Employer- employee, mandatory Private Germany Hybrid Multiple models Public/Private Thailand Adapted from Shi & Singh (2004)
  • Thailand’s Context 53
  • 54 Thailand’s Health Systems: Public • กระทรวงสาธารณสุข • สํานักงานรัฐมนตรี • สํานักงานปลัดกระทรวงสาธารณสุข (สป.) • สํานักงานคณะกรรมการอาหารและยา (อย.) • กรมการแพทย์ • กรมควบคุมโรค • กรมพัฒนาการแพทย์แผนไทยและการแพทย์ทางเลือก • กรมวิทยาศาสตร์การแพทย์ • กรมสนับสนุนบริการสุขภาพ • กรมสุขภาพจิต • กรมอนามัย 54
  • Thailand’s Health Systems: Public ราชการบริหารส่วนกลางใน สป. • สํานักบริหารกลาง • ศูนย์เทคโนโลยีสารสนเทศและการ สื่อสาร • สถาบันพระบรมราชชนก • สํานักการพยาบาล • สํานักตรวจและประเมินผล • สํานักนโยบายและยุทธศาสตร์ (สนย.) • สํานักบริหารการสาธารณสุข (สบรส.) ราชการบริหารส่วนภูมิภาคใน สป. • สํานักงานสาธารณสุขจังหวัด (สสจ.) • สํานักงานสาธารณสุขอําเภอ (สสอ.) • โรงพยาบาลส่งเสริมสุขภาพตําบล (รพ.สต.) 55
  • 56 Thailand’s Health Systems: Public • สถาบันวิจัยระบบสาธารณสุข (สวรส.) • สํานักงานกองทุนสนับสนุนการสร้างเสริมสุขภาพ (สสส.) • สํานักงานหลักประกันสุขภาพแห่งชาติ (สปสช.) • สํานักงานคณะกรรมการสุขภาพแห่งชาติ (สช.) • สถาบันรับรองคุณภาพสถานพยาบาล (สรพ.) • องค์การเภสัชกรรม • โรงพยาบาลบ้านแพ้ว (องค์การมหาชน) • โรงพยาบาลของรัฐนอกสังกัดกระทรวงสาธารณสุข 56
  • Thailand’s Health Systems: Public สภาวิชาชีพ • แพทยสภา • ทันตแพทยสภา • สภาการพยาบาล • สภาเภสัชกรรม • สภาเทคนิคการแพทย์ • สภากายภาพบําบัด • สภาการแพทย์แผนไทย • สภาการสาธารณสุขชุมชน คณะกรรมการการประกอบโรคศิลปะ • สาขาเทคโนโลยีหัวใจและทรวงอก • สาขาการแก้ไขความผิดปกติของการ สื่อความหมาย • สาขากายอุปกรณ์ • สาขาการแพทย์แผนจีน • สาขากิจกรรมบําบัด • สาขารังสีเทคนิค • สาขาจิตวิทยาคลินิก 57
  • 58 Thailand’s Health Systems: Public • กระทรวงศึกษาธิการ • กระทรวงแรงงาน • สํานักงานประกันสังคม (สปส.) • กรมสวัสดิการและคุ้มครองแรงงาน (occupational health & safety) • กระทรวงการคลัง • กรมบัญชีกลาง (สิทธิข้าราชการ) • กระทรวงการพัฒนาสังคมและความมั่นคงของมนุษย์ • กรมพัฒนาสังคมและสวัสดิการ • สํานักงานส่งเสริมสวัสดิภาพและพิทักษ์เด็ก เยาวชน ผู้ด้อยโอกาส คนพิการ และผู้สูงอายุ • สํานักงานส่งเสริมและพัฒนาคุณภาพชีวิตคนพิการแห่งชาติ 58
  • 59 Thailand’s Health Systems: Public • กระทรวงเกษตรและสหกรณ์ • กรมปศุสัตว์ (Zoonosis & control of outbreaks) • กระทรวงทรัพยากรธรรมชาติและสิ่งแวดล้อม • กรมควบคุมมลพิษ (Environmental health) • กระทรวงคมนาคม (เช่น เรื่องอุบัติเหตุจราจร) • กระทรวงการต่างประเทศ (เช่น นโยบายสุขภาพระหว่างประเทศ) • กระทรวงยุติธรรม (เช่น การฟื้นฟูสมรรถภาพผู้ติดยาเสพติด) • สํานักงานคณะกรรมการคุ้มครองผู้บริโภค (สคบ.) 59
  • 60 Thailand’s Health Systems: Private • For-profit hospitals • Non-profit hospitals • Private clinics • Pharmacies • Private laboratories • NGOs • Media • etc. 60
  • 61 Thailand’s Hospitals (2010) 61 Hospital Category Number of Hospitals Percentage of All Hospitals District hospitals (MOPH) 737 56.4% General hospitals (MOPH) 68 5.2% Regional hospitals (MOPH) 26 2.0% Other hospitals under MOPH* 50 3.8% Other public hospitals outside MOPH† 111 8.5% Private hospitals 315 24.1% Total 1307 100.0% *Including general and specialty hospitals under other departments within the Ministry of Public Health. †Including university hospitals, military hospitals, autonomous public hospitals, prison hospitals, hospitals of state enterprises, and public hospitals under local governments. MOPH = Ministry of Public Health Source: Bureau of Policy and Strategy, Ministry of Public Health (November 2010).
  • Major Issues in Health Care 62
  • 63 Major Issues in Health Care • Public Policy & Healthcare Reform • Universal Health Coverage • Cost Containment • Quality & Patient Safety • Innovative Models of Healthcare Delivery & Financing 63
  • 64 Major Issues in Health Care • Evidence-Based Practice • Increased Expectations & Patient Volumes • Prevention vs. Treatment • Rise of Aging Population & Chronic Diseases • Legal Issues (e.g. Malpractice) • Patient engagement • Workforce: Shortages, maldistributions & evolving competency requirements • Technological Advances 64
  • 65 Major Issues in Health Care • Globalization • Educated, engaged patients • Lifestyle changes • Challenges in control of disease outbreaks • Emerging field of “Global Health” 65
  • Paradigm Shifts in Medicine 66 • Physician-centric to patient-centric care • Individual to team-based care • Paper-based to electronic-based management of medical records • Provider-kept to personal health records Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  National Coordinator for Health Information Technology, U.S. Department of Health and Human  Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1c).
  • 67 Summary • Health  Health care • There are “Health” issues beyond hospitals • There are key players of “Health” beyond hospitals • Clinicians should learn to play collaborative roles with others within and outside hospitals for health of individuals and population. 67
  • References • Centers for Disease Control and Prevention (CDC). Ten great public health achievements--United States, 1900–1999. MMWR Morb Mortal Wkly Rep. 1999 Apr 2;48(12):241-3. • Hoffman SJ, Rottingen JA, Bennett S, Lavis JN, Edge JS, Frenk J. A review of conceptual barriers and opportunities facing health systems research to inform a strategy from the World Health Organization. Geneva, Switzerland: World Health Organization; 2012. Available from: http://www.who.int/alliance- hpsr/alliancehpsr_backgroundpaperconceptualbarriersopportunities.pdf • Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. 337 p. • McKee M. Measuring the efficiency of health systems. The world health report sets the agenda, but there’s still a long way to go. BMJ. 2001 Aug 11;323(7308):295-6. • Shi L, Singh DA. Delivering health care in America: a systems approach. 3rd ed. Sudbury (MA): Jones and Bartlett Publishers; 2004. 652 p. • Winslow CE. The untilled fields of public health. Science. 1920 Jan 9;51(1306):23-33. 68
  • References • World Health Organization, Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. Available from: http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf • Constitution of the World Health Organization. Geneva, Switzerland: World Health Organization; 1948. Available from: http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf • Everybody’s business. Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, Switzerland: World Health Organization; 2007. Available from: http://www.who.int/healthsystems/strategy/everybodys_business.pdf • Systems thinking for health systems strengthening. Geneva, Switzerland: World Health Organization; 2009. Available from: http://whqlibdoc.who.int/publications/2009/9789241563895_eng.pdf 69