The President’s opening speech: Jan STENCL
Acknowledgements to the local organizer: Annik CONZEMIUS.
Welcome to the new participants:
Assitan SY-SOW, Bouraïma MAIGA (SOMAGO of MALI).
UPIGO had the pleasure of being invited to the Italian Congress in TURIN in October 2008 and to the African Congress in Bamako in December of the same year. Our Secretary-General will give you many more details on this subject later.
As was decided at the General Assembly in Copenhagen last year, the fight against mortality in sub-Saharan Africa is, as you know, the top priority of our union, and I am counting on the collaboration of each delegation to see this action through to a successful conclusion.
Luxembourg, a special little country: Presentation by Dr Paul WIRTGEN, director of the Bohler Clinic.

The Secretary-General’s report: Guy SCHLAEDER
UPIGO had the pleasure of being invited to the Italian National Congress SIGO-AOGEI in TURIN. Guy SCHLAEDER presented an overview of the history of UPIGO and illustrated its place among the international organisations.
Jan STENCL explained in detail the aspects of maternal mortality in sub-Saharan Africa, its most important causes and the possibilities for improvement in co-operation with UPIGO.
Pier-Francesco TROPEA dealt with the growing increase in medico-legal proceedings, the situations most frequently concerned and the preventive recommendations.
In December 2008 Jan STENCL and Guy SCHLAEDER represented UPIGO at the very nice African Congress of the SAGO-SOMAGO (African Society of Gynaecology-Obstetrics / Malian Society of Gynaecology-Obstetrics) in Bamako (MALI)
Many contacts were made with the African societies of gynaecology-obstetrics. The objective now is to fight against maternal mortality, by uniting our efforts.
Furthermore, UPIGO is still very active in the European Council in STRASBOURG. We are in close relations with the Health Commission of the Parliamentary Assembly which covers the 47 countries of the “Great Europe”.
We are collaborating on a big report on prevention in matter of health with other INGOS enjoying participatory status like our Union. UPIGO has especially developed prevention of cervical and breast cancer from the public health point of view.
Apologies for absence: please see below.
The treasurer’s report: Raymond BELAICHE
Despite several late payments of the subscriptions from some delegations the accounts are balanced.
On 31st May 2008, the balance was 27, 816 euros.

ROUNDTABLE DISCUSSIONS WITH THE DELEGATIONS

DENMARK: Hans-Henrik WAGNER, Suzan LENZ
On January 1st 2007, the 13 counties of Denmark merged into 5 regions. The idea was that it would be easier and less expensive that way. So far we are in some kind of transition phase where it is very difficult to implement new modalities in health care because the government argues that the regions must be fully operative before they can give access to new things, so we work and wait.
We have a lack of doctors and this will go on for at least 10 years.
The regions have a plan to get different doctors, different specialities together in central units, they argue that it is more efficient but they also think that they can have more control with us.
There is now "cancer package" so we have to see a patient before 48 hours if the GP finds a patient suspect for cancer, there is also a guaranty for treatment for non cancers that must not exceed 1 month, in case it does, the patient can go to a private hospital for treatment and the public insurance will pay, there has been much discussion if patients can go to another country paid by the public insurance but this problem is at present unsolved. 
Because of the transition from 13 to 5 "centres for decision" there is a great change in hospitals and departments, instead of, in principal, 13 bigger central hospitals there will now be 5 extra big central hospitals with "satellite" hospitals spread out, this causes a lot of anger, fighting and frustration, it does not affect the private gynaecologists so much we are so far almost forgotten in that game

FRANCE : Raymond BELAICHE
French gyn-obs, of whom I am a representative, are facing a disastrous problem that endangers their own patrimony and their beneficiaries. Most of the insurance companies cover our potential disputes up to a limit between 3 to 6 millions of euros. But in some admittedly very rare case of serious disputes, judges have ordered indemnifications of about 7,5 millions euros. In time, limitation periods and procedures could lead to an obvious rise of those amounts. The ONIAM (the French office of national indemnification for medical accidents), which represents the national solidarity; refuses to insure, for unregulated-fees practitioners, what will not be taken charge of by the insurances. It will have to be paid by the practitioner or by his or her beneficiaries. This means a real patrimonial bankruptcy.

GREECE: Nicolas TSATSARIS
In Greece the health insurance system is neither uniform nor equalitarian. It costs a lot to the community and to the state. Rigid, bureaucratic and often inhuman, it covers very partially or not at all healthcare given in the private sector. The public sector is often archaic, uncomfortable, slow and bureaucratic. Number of Greek people, if they can afford it, get also in parallel a private health insurance in order to have a better coverage and access to private healthcare units in case of a serious health problem. All the attempts to create a unitary system failed because of the corporatist reactions of the diverse socio-professional groups.
The coverage of the follow up of pregnancy varies a lot depending on the public health insurance of the woman. The delivery expenses are not covered (yet the delivery is a natural event) and all public health insurance services offer a delivery bonus.
For the last thirty years Ob-Gyn have created very big private gynaeco-obsterical units in order to practice under good conditions. The majority of those big clinics are anonymous societies and some of them are listed on the Stock Exchange. Their big success has drawn the attention of big financial groups. They invested and took control of some major private gynaeco-obstetrical or medico-surgical units.
Recently the marketing service of a bank related to one of those financial groups has had the idea to propose to those who would open an account to pay a small annual contribution access freely or at very preferential rate to certain medical or paramedical acts in the units controlled by the group. The medical act or the analysis becoming thus a bonus related to the opening of a bank account... Very fast and even before the medical profession reacted this example was followed by other banks and more recently by the Diners Club...
Another point which worries us a lot it is the constant and very fast increase of cost insurance covering professional responsibility and the decrease of the number of companies accepting to cover this risk.
ITALY: Pier-Francesco TROPEA
In Italy, since several years, our speciality is facing two major problems: the medico legal issue, concerning mainly the obstetricians and the continuing medical education, especially of the OB-GYN. On the first matter, very high indemnifications ordered by the judges and consequently annual premium increase of the gynaecologists’ insurances have lead to “defensive medicine”. This has lead to an inflation of the number of Caesarean sections and a reduction of the number of young doctors registering for obstetrics.
As far as the second question is concerned, the education of the gynaecologist in Italy is currently not satisfactory. Academic speciality schools do not manage to offer a practical education to all the students. Because of the opposition of the heads of the university clinics, hospitals have not been able by law to create the “teaching hospital”. They are not authorized to educate specialists and award them a speciality degree.

LUXEMBURG: Annik CONZEMIUS
The minister of Health is trying to create structures and commissions for quality control.
Private practitioners (90% of the gynaecologists in Luxemburg) are resenting those measures for being restrictive.
The EFGM programme or the « breast field » are, for instance, interesting approaches. Unfortunately, they are highly time-consuming and are not paid, as far as the medical aspect is concerned, while meeting hours are included in the nurses’ work schedule.
Quality control also includes a record of incidents and faults. This is difficult to achieve in such a small country as Luxemburg, because even with data anonymisation, everything comes out in the end.
To pre-empt fear of legal actions, a solution could be the system of compensation without fault. The current government is studying this project.

MALI: Mariame DIAKITE
We have no health insurance. Insurance for professional liability is not compulsory for practitioners, even private ones. On the other hand, public servants are covered by the state in case of any problem. Maternal mortality is high in spite of the start of several strategies (creation of the reference-evacuation system, free Caesarean sections since June 2005, institutionalization of a national day against maternal mortality on June 8th, etc). The main cause of obstetrical death is postpartum haemorrhage. Its treatment is a difficult matter because of the shortage of blood and blood products. People are reluctant to give blood because they fear that they will be revealed HIV/AIDS positive or simply because they just don’t know they can donate blood. The evacuation of a parturient is often difficult, especially during the wet season when the roads are impracticable. Lastly, human resources are scarce and badly spread out. Rural areas suffer from poor means of communication. Our national society of gynaecology, the SOMAGO, is ready to cooperate with UPIGO in order to launch a pilot programme aiming for a better obstetrical safety in rural areas.

FEDERAL REPUBLIC OF GERMANY: Klaus KOENIG
Text not received

SLOVAKIA: Jan Stencl and Anna Bohacikova
The private sector has stabilized and the incomes of the practitioners are relatively high. On the other hand, in hospitals, the number of specialists is not always sufficient. There, doctors and midwives have low salaries. Doctors are going in the private sector or abroad. Private Doctors do not perform deliveries. We may soon have a problem with midwives: they would like to have the right to perform deliveries, but for the moment, only doctors have this right.

ANTICIPATING THE LEGAL RISK: Raymond BELAICHE
The majority of lawsuits are essentially the product of the same distinctive characteristics
Négligence
Absence of communication
Lack of knowledge of the procedures of expert reports and jurisdiction.
The expert medical report plays an important role in the legal proceedings because the magistrates generally refer to the expert medical report and their decisions rest on the proof of a causal relation between the wrong caused and the damage suffered.
When faced with a contentious action the practitioner’s behaviour must be exemplary, coherent and consensual.

UPIGO has set up a Medico-Legal committee, under the direction of Dr Raymond BELAICHE, expert to the French Courts, to carry out international medical expert reports and to help implicated colleagues to prepare a statement of defence.
The experience of a gynaecologist, an obstetrician and a jurist experienced in medical expert reports has already enabled numerous colleagues, little used to the judicial machinery, to avoid the difficulties of putting together a case which they would have come up against, even with the help of a lawyer, who, by definition, did not have the knowledge of practicing our speciality.

List of the delegations present in Luxemburg:
Germany: Klaus König (Vice-President) ;
Denmark: Suzan Lenz, Hans Henrik Wagner ;
France: Raymond Belaiche (Treasurer) Guy Schlaeder (Secretary-General); Italy: PierFrancesco Tropea;
Luxemburg: Annik Conzemius (Vice-President), Elisabeth Heisburg (in charge of mother and child service at the government) ;
Mali : Mariame Diakité (Vice-President), Mustapha Touré, Assitan SY-SOW, Bouraïma MAIGA ;
Slovakia: Jan Stencl (President), Anna Bohacikova.
Apologies for absence : Nicolas Tsatsaris (Greece), G.M. Cousin (France), A. Sepou (Central African Republic), E. Alihonou (Benin),
Hervé ILOKI (Guinea), Brigitte THIOMBIANO and Jean LANKOANDE (Burkina Faso), Giovanni ADINOLFI (Italy), Mamadou DIALLO (formerly from Mali, at present representing the United Nations in Eritrea), Stefan KONSTANTINOV (Bulgaria), Mario LITSCHGI (Switzerland), Milan KUDELA (Czech Republic)
and Aissata BAL-SALL (Mauritania).

Report written in September 2009 by Guy Schlaeder (UPIGO General Secretary)