Project Database Project Steering Group Third Meeting Brussels, Belgium 21 April 2008

Reference DPSG 3/5/Info 1 Title Database project interim implementation report – Part 1, Narrative Report Submitted by Secretariat Summary / Note This part of the interim report includes the main part as well as seven annexes: Annex 1: NDPHS e-Newsletter 1/2007 Annex 2: NDPHS e-Newsletter 2/2007 Annex 3: Database Project WP 5 Expert final report Annex 4: NDPHS HIV/AIDS Expert Group thematic report Annex 5: NDPHS Primary Health Care Expert Group thematic report Annex 6: NDPHS Prison Health Expert Group thematic report Annex 7: NDPHS SILHWA Expert Group thematic report

NB. Unless requested by other participants in the DPSG 3 Meeting, the Secretariat does not intend to discuss the above annexes during the meeting. Consequently, the participants may wish to consider the need to print them.

This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. Requested action For reference

DPSG_3-5-Info_1__Database_project_interim_narrative_report 1

A Database on Public Health Projects in North Eastern Europe and its neighbouring countries (NDPHSProjectDatabase)

Project No. 2006310

INTERIM REPORT (Period covered: February 2007 – January 2008)

Part 1, Narrative Report

This report has been developed for the Public Health Executive Agency (PHEA) by the NDPHS Secretariat at the Secretariat of the Council of the Baltic Sea States. It consists in two parts: Part 1: Narrative Report and Part 2: Financial Report

Stockholm, Sweden, 26 March 2008

DPSG_3-5-Info_1__Database_project_interim_narrative_report 2 TABLE OF CONTENTS

1. Executive summary...... 4 2. Introductory information...... 5 2.1. Name of the project...... 5 2.2. Organization receiving the subsidy and project coordinator...... 5 2.3. Overall aim and specific aims of the project...... 5 2.4. Project structure...... 6 2.5. Project timeline ...... 6 3. Implementation of the project ...... 6 3.1. WP 1 – Coordination of the project ...... 6 3.2. WP 2 – Dissemination of the results ...... 8 3.3. WP 3 – Evaluation of the project ...... 10 3.4. WP 4 – Database Development...... 11 3.5. WP 5 – Information Provision on Specific Health Areas ...... 13 3.6. WP 6 – Thematic Reports, Network Creation and Stakeholder Analysis...... 14 3.7. WP 7 – Project Pipeline ...... 15 4. Further information ...... 17

Annexes:

Annex 1: NDPHS e-Newsletter 1/2007 Annex 2: NDPHS e-Newsletter 2/2007 Annex 3: Database Project WP 5 Expert final report Annex 4: NDPHS HIV/AIDS Expert Group thematic report Annex 5: NDPHS Primary Health Care Expert Group thematic report Annex 6: NDPHS Prison Health Expert Group thematic report Annex 7: NDPHS SILHWA Expert Group thematic report

DPSG_3-5-Info_1__Database_project_interim_narrative_report 3 1. EXECUTIVE SUMMARY

This document is a narrative part of the first interim report developed by the Northern Dimension Partnership in Public Health and Social Well-being (NDPHS) Secretariat for the Public Health Executive Agency (PHEA).1 It has been developed in accordance with the reporting requirements set out in Annex III to the Grant Agreement and outlines progress made by project “A Database on Public Health Projects in North Eastern Europe and its neighboring countries” during the first year of its implementation, i.e. from 1 February 2007 to 31 January 2008. Short description of the activities planned to be implemented in the near future is also included, as required.

The project commenced on 1 February 2007 and will continue until 31 January 2009. It is run by the NDPHS (formally, only ten of its Partners). The NDPHS Secretariat (which is a unit hosted by the CBSS Secretariat) acts as the project management unit. The project is co-funded by the European Commission (represented by the PHEA) as well as ten NDPHS Partners and the NDPHS Secretariat.

The overall aim of the project is to contribute to the regional efforts aimed at reducing the serious health and social problems in the Northern Dimension area, which risk having a negative impact on health development in the EU in general. The strategic objective of this project is to achieve a coordinated policy and project approach in actions against HIV/AIDS and lifestyle-related diseases and for healthy and socially rewarding lifestyles. In order to achieve the above objective, the project is structured in seven work packages designed to address each of these goals in a coordinated and integrated manner.

As regards the progress made during the first year, 12 months after the commencement of the project, all of the Project Work Packages have been advanced at least as far as was foreseen in the initial timetable. Additionally, it should be stressed that the project has thus far provided considerably more deliverables than originally planned for. This interim narrative report provides brief information about the progress in each of the seven work packages. Further details can be obtained from the project implementation unit (see item 2.2 Organization receiving the subsidy and project coordinator).

1 The interim report is broken into two parts: a narrative part (this file) and a financial part.

DPSG_3-5-Info_1__Database_project_interim_narrative_report 4 2. INTRODUCTORY INFORMATION

2.1. Name of the project

“A Database on Public Health Projects in North Eastern Europe and its neighbouring countries”

2.2. Organization receiving the subsidy and project coordinator

Full legal name Secretariat of the Council of the Baltic Sea States (on behalf of the Northern Dimension Partnership in Public Health and Social Well-Being (NDPHS) Secretariat) Abbreviated legal name CBSS Secretariat Legal status International Secretariat Department/Unit NDPHS Postal address: P.O. Box 2010 Street and street number Strömsborg Post code and town / city 103 11 Stockholm Country Sweden Family and first name of Family name: Maciejowski coordinator First name: Marek

Qualities of the coordinator Head of the NDPHS Secretariat

VAT number 502052-4616 Telephone (including country +46 8 4401938 and area code) Fax number (including country + 46 8 440 1944 and area code) E-mail [email protected] Internet www.cbss.org and http://www.ndphs.org

2.3. Overall aim and specific aims of the project

The overall aim of the project is to contribute to the regional efforts aimed at reducing the serious health and social problems in the Northern Dimension area, which risk having a negative impact on health development in the EU in general. The strategic objective of this project is to achieve a coordinated policy and project approach in actions against HIV/AIDS and lifestyle-related diseases and for healthy and socially rewarding lifestyles. The specific aims to be achieved are: (i) network creation and new project proposals for the purpose of more coordinated project and policy efforts in this area; (ii) developing innovative database and project pipeline embedded in a web-site specially developed for hosting them;

DPSG_3-5-Info_1__Database_project_interim_narrative_report 5 (iii) collecting information on projects and processes on HIV/AIDS, lifestyle related diseases, prison health, etc. with existing relevant data, policies, research, best practice, etc. (also from other existing databases); (iv) developing a series of thematic reports featuring integrated analyses in specific health and geographical areas as well as proposing policy recommendations and project-based actions to be carried out; (v) creating efficient organisational and expert networks in these areas; (vi) producing and disseminating information resulting from the project.

2.4. Project structure

In order to achieve the above objectives, the project has been structured in seven work packages designed to address each of these goals in a coordinated and integrated manner:

WP 1 – Coordination of the project; WP 2 – Dissemination of the results; WP 3 – Evaluation of the project; WP 4 – Database Development; WP 5 – Information Provision on Specific Health Areas; WP 6 – Thematic Reports and Network Creation; WP 7 – Project Pipeline.

2.5. Project timeline

The project commenced on 1 February 2007 (retroactively, as the permission to start the project on that date was granted by PHEA on 19 February 2007). It will continue until 31 January 2009. Short description of the activities planned to be implemented in the near future is also included in accordance with the reporting requirements set out in Annex III to the Grant Agreement.

3. IMPLEMENTATION OF THE PROJECT

In the following part of the narrative interim report progress by work package has been presented.

3.1. WP 1 – Coordination of the project

Status: ongoing

3.1.1. Work Package objectives as spelled out in the Grant Agreement

The main objectives of this WP are the over all management of the project, agreements with partners, the organization and moderation of steering committee meetings, the coordination and contracting of project experts, tenders and the coordination of sub-contracts, the coordination of partners input, financial management and reporting to EU and project steering meetings.

DPSG_3-5-Info_1__Database_project_interim_narrative_report 6 3.1.2. Progress made during the reported period

The project was and is managed by the NDPHS Secretariat, a unit within the Council of the Baltic Sea States (CBSS) Secretariat. The overall responsible project manager is Mr. Marek Maciejowski, Head of the NDPHS Secretariat. The CBSS Administration Team is supporting him in the financial management. The project manager is also supported in his work by another employee at the NDPHS Secretariat, Mr. Bernd Treichel, as well as by the Project Main Expert – Mr. Redas Laukys (during June – August 2007) who, as from October 2007 was replaced by Ms. Agne Marudinaite. Also, the NDPHS Expert Group Chairs and International Technical Advisors (ITAs) supported the implementation of this WP.

All activities, which are foreseen in the project work plan for the first year of the WP 1 implementation, were implemented on time and there was no deviation from the initial work program set out in Annex I to the Grant Agreement except for the employment of the Project Main Expert. Instead of 220 work days, this position provided only 46 days of work during the first year of the project implementation. This has been compensated by a considerably higher involvement of the NDPHS Secretariat (262.83 work days) than envisaged in the project proposal (25 work days).

The Project Partners, through the Database Project Steering Group members, were receiving all necessary information and were kept up to date about the developments within the project. They were also taking decisions, as necessary. There were two Steering Groups meetings in 2007 (DPSG 1 – 27 March 2007 in Warsaw, Poland (cf. http://www.ndphs.org/?mtgs,dpsg_1,_warsaw) and DPSG 2 – 15 October 2007 in Kaliningrad, Russia (cf. http://www.ndphs.org/?mtgs,dpsg_2_kaliningrad).

Further, the NDPHS Secretariat attended 3 meetings of the NDPHS Expert Group Chairs and ITAs as well as 3 meetings of the NDPHS Expert Group on HIV/AIDS, 4 meetings of the NDPHS Expert Group on Prison Health, 2 meetings of the Expert Group on Primary Health Care and 4 meetings of the Expert Group on Social Inclusion, Healthy Lifestyles and Work Ability (SIHLWA) (the links to the meeting documents pages for each of them can be found at http://www.ndphs.org/?mtgs;4). During each of these meetings the Secretariat provided comprehensive information about the Database Project, progress in its implementation as well as the role of these groups in the project implementation (for example, see documents: EG Chairs and ITAs 4: http://www.ndphs.org/?download,460,EG_Chairs_and_ITAs_4-4.1- Info_2_List_of_issues_for_EGs_successful_launch_of_Project.pdf, EG Chairs and ITAs 5: http://www.ndphs.org/?download,1052,EG_Chairs_and_ITAs_5-3- 1__Database_Projectprogress__future_activities.pdf and EG Chairs and ITAs 6: http://www.ndphs.org/?download,1793,EG_Chairs_and_ITAs_6-4-1__Database_Project- progress_and_future_activities.pdf).

Considering that the project is implemented within the framework of the NDPHS, also the countries and organizations who are not Project Partners were kept informed about the progress at regular intervals and, when appropriate, were invited to contribute with their expertise to the project and support its implementation.

The work program planned for the following period is in line with the initial work program set out in Annex I to the Grant Agreement. Most notably the third meeting of the Database Project Steering Group (DPSG) is scheduled to take place on 21 April 2008, in

DPSG_3-5-Info_1__Database_project_interim_narrative_report 7 Brussels, Belgium and will be hosted by the European Commission (further details will be posted in early April at http://www.ndphs.org/?mtgs,dpsg_3__brussels).

3.2. WP 2 – Dissemination of the results

Status: ongoing

3.2.1. Work Package objectives as spelled out in the Grant Agreement

The objectives of this WP are to gain the widest support of information providers to database as possible, and the widest use and uptake of database tool and analytical reports/network creation as possible.

3.2.2. Progress made during the reported period

All activities, which are foreseen in the project work plan for the first year of the WP 2 implementation, were implemented on time and there was no deviation from the initial work program set out in Annex I to the Grant Agreement.

The following is the list of main actions taken until 31 January 2008:

• The Secretariat developed text for the new NDPHS website (in coordination with the Chairs and ITAs of the NDPHS Expert Groups / Associated Expert Groups as regards sections concerning their own EGs). This was preceded by the development of a new web engine and a new visual design by a service provider (selected through an open tender in February 2007, it developed the engine during March to mid-April 2007, although a number of additional pieces of work were done later on to further develop the website). The website was officially launched on 29 May 2007. The engine of the website has a number of mechanisms embedded into it (some of them are mentioned below). The new website is regularly updated (e.g. the calendar of events) and new pieces of information are added to it. It is available in English, Polish and Russian languages and can be considered a gateway to information about public health and social well-being in Northern Europe (cf. http://www.ndphs.org). The total number of hits at the website since its launch was: 100,854; • The Secretariat set up electronic mailing lists (as a part of the NDPHS website engine). The number of persons included in these lists is as follows: over 14,000 e- mail addresses for NDPHS e-news, over 110 e-mail addresses for NDPHS press releases and over 650 e-mail addresses for the NDPHS e-Newsletter (cf. http://www.ndphs.org/?e-news; http://www.ndphs.org/?press-releases and http://www.ndphs.org/?e-newsletter as well as http://www.ndphs.org/?subscribe- unsubscribe); • The Secretariat set up a Northern Dimension Public Health and Social Well-being News on-line service and encouraged various organizations to submit news to it (cf. the front page of the NDPHS website and http://www.ndphs.org/?nd-news; NB. Only the most recent three news pieces are visible); • The Secretariat developed and announced a new MS PowerPoint presentation about the NDPHS and the Database Project (available in English and Russian) (cf. http://www.ndphs.org/?presentations); • The Secretariat developed (with input from current and previous CSR Chairs, the

DPSG_3-5-Info_1__Database_project_interim_narrative_report 8 Chairs of the NDPHS Expert Groups and the NDPHS’ SIHLWA OSH Sub-group) and announced through the NDPHS e-news service two pieces of the NDPHS e- Newsletter (cf. Annex 1 and Annex 2; also available at http://www.ndphs.org/?e- newsletter). As regards an indicator included in Annex 1 to the Grant Agreement, i.e. the Number of e-Newsletters sent during the project Æ the figure is 2; • The Secretariat wrote an article about the NDPHS and the Database Project to the Barents Newsletter on Occupational Health and Safety, issue No. 2/2007 (cf. http://www.ttl.fi/Internet/English/Information/Electronic+journals/Barents+Newsletter /); • The Secretariat included links on the NDPHS website to numerous relevant institutions and organizations. Especially one page of the NDPHS website is dedicated to providing links to other website, namely Useful Links page at http://www.ndphs.org/?link,useful_links. Indicator included in Annex 1 to the Grant Agreement: Number of Linkages created to other databases. It is estimated that the website (not counting the Database) contains more than 130 links to external pages. Further, the Secretariat approached many organizations and institutions with a request to place a link to the NDPHS website on their own websites (in some cases the Secretariat also provided a draft text proposed for including on a foreign website). As a result of these efforts, the link to the NDPHS website, in some cases coupled with information about the NDPHS (e.g. see http://ec.europa.eu/health/ph_international/ndphs_en.htm) have been posted on many foreign websites. • Five pieces of NDPHS e-news were produced and distributed, three of which as part of the Database Project that featured the following titles: (i) “A new information gateway to public health and social well-being. The NDPHS is launching its new website;” (ii) “Following the recent launch of its website, the NDPHS now opens two new information channels. The first issue of the NDPHS e-Newsletter and a presentation now available at the NDPHS website;” (iii) “NDPHS e-Newsletter 2/2007 now available, Polish added as the third language on the NDPHS website” (cf. http://www.ndphs.org/?e-news); • Three complementary press-releases were distributed on same topics (cf. http://www.ndphs.org/?press-releases); • Results of the project were also disseminated to the participants of two main NDPHS events that took place in the meantime, i.e. the Partnership Annual Conference (PAC) held at the ministerial level (NB. during which the Database and the Project Pipeline were formally launched), as well as the Committee of Senior Representatives (CSR) meeting (both events were held in autumn 2007); • There were many meetings of the NDPHS Expert Groups, through which results were disseminated (cf. the list provided in section regarding WP 1). • The Secretariat worked together with NCM’s St. Petersburg Office staff assigned to the Database Project on the NDPHS outreach to the North-West Russia, which is in line with the objectives of the Database Project; • Various NDPHS representatives advocated and publicized the NDPHS Database Project during non-NDPHS meetings they attended, including during meetings such the Northern Dimension Steering Group and Northern Dimension Senior Official Meetings held in June and November 2007, respectively; • Work was initiated and continued to develop a brochure and a flyer about the NDPHS and its Database project.

DPSG_3-5-Info_1__Database_project_interim_narrative_report 9 The work program planned for the following period is in line with the initial work program set out in Annex I to the Grant Agreement. Most notably the NDPHS folder and info-sheets will be produced heavily focusing on the results of the Database Project such as the thematic reports, the database and the project pipeline. Also, efforts will continue to: (i) identify further target persons and groups who should receive information about the NDPHS, the Database project, the Database, the Project pipeline, as well as the thematic reports (donors, national ministries, local/regional bodies, IGOs, NGOs, IFIs, institutions, key individuals, etc.); (ii) publicize the above-mentioned three deliverables through other information channels (such as presentations during events, etc.); (iii) keep the website and the database up to date. Finally, results of the project will continue to be also disseminated to the participants of the NDPHS events: CSR meeting in April and October 2008 and PAC in November 2008, as well as to the participants of the NDHSP Expert Group meetings and other events during the rest of 2008.

3.3. WP 3 – Evaluation of the project

Status: ongoing

3.3.1. Work Package objectives as spelled out in the Grant Agreement

The main objectives of this WP are to ensure that project fulfils its objectives in actually providing relevant information to target groups. Additional objectives are to possibly transfer of general project idea also to other health / geographical areas and to identify the level and way of continuing the project after the end of EU financing by NDPHS sources.

3.3.2. Progress made during the reported period

All activities, which are foreseen in the project work plan for the first year of the WP 3 implementation, were implemented on time and there was no deviation from the initial work program set out in Annex I to the Grant Agreement. Evaluation of the project was regularly made by the NDPHS Secretariat. The Secretariat developed a brief progress report highlighting, inter alia, critical areas for each Database Project Steering Group (DPSG) meeting (cf. documents for DPSG 1: http://www.ndphs.org/?download,550,DPSG_1-4.8- 1_NDPHS_Pipeline--progress_so_far_and_next_steps.pdf and http://www.ndphs.org/?download,545,DPSG_1-4.1- Info_2_List_of_issues_for_successful_launch_of_Project_Database.doc as well as for DPSG 2: http://www.ndphs.org/?download,1245,DPSG_2-4.1-Info_1__Database_Project-- progress_and_future_activities.pdf). Further, additional information was orally presented by the Secretariat to the DPSG during meetings, as well as by e-mail correspondence between meetings, for consideration and decision, as appropriate. Based on the outcomes of these considerations relevant actions were taken in the course of the project implementation.

The work program planned for the following period is in line with the initial work program set out in Annex I to the Grant Agreement. The Secretariat is developing a brief progress report highlighting, inter alia, critical areas for the 3rd meeting of the DPSG to be held on 21 April 2008 (cf. http://www.ndphs.org/?mtgs,dpsg_3__brussels). Further, it is planned that the interim narrative and financial reports for PHEA will be discussed at length during the DPSG 3 Meeting.

DPSG_3-5-Info_1__Database_project_interim_narrative_report 10 3.4. WP 4 – Database Development

Status: ongoing

3.4.1. Work Package objectives as spelled out in the Grant Agreement

The objective of this WP is to prepare an analysis of existing databases, to take a decision on the technology of choice, define the database fields, carry out the technical development of the database, as well as the creation of linkages with other databases, and a pilot test phase for database users.

3.4.2. Progress made during the reported period

All activities, which are foreseen in the project work plan for the first year of the WP 4 implementation, were implemented on time and there was no deviation from the initial work program set out in Annex I to the Grant Agreement.

The following is the list of main actions taken until 31 January 2008:

• The Secretariat analyzed the existing databases of relevance to the NDPHS Database and, based on this analysis, developed an outline of the Database sections and their data fields. It then ran an approval procedure of its concept with the Members (April- May 2007); • Following the above approval the Secretariat ran an open tender to select a company to develop the database engine to be integrated with the new NDPHS website (June 2007); • The engine of the database was developed during the period July – October 2007 (originally three sections were developed: Projects, Organizations and Persons as well as five external databases were connected); • The Secretariat developed so-called “white-pages” describing the database; • The NDPHS Partners and Associated Partners as well as the NDPHS Expert Groups were invited to test the database (31 October 2007); • The NDPHS Database was officially launched following decision of the 4th Partnership Annual Conference on 15 November 2007 (cf. http://www.ndphs.org/?database). E-news and a press-release was distributed on this occasion announcing this launch (cf. section regarding WP 2); • From 1 November 2007 intense efforts were taken to screen all the records obtained from external databases and correct misleading, incorrect or incomplete information as well as to hide the records for which complete information could not be found. These efforts continued until January 2008 (cf. Work Package 5); • Three more databases were connected to the NDPHS Database after the launch, increasing the total amount of the linked databases to 8 (cf. http://www.ndphs.org/?database,page,external_databases); • Following decision of the DPSG 2 Meeting (on 15 October 2007, in Kaliningrad, Russia), a fourth section (Papers) was developed in January 2008.

Currently the database consists in four mutually integrated sections: Projects, Organizations, Persons and Papers. Visitors (common users) can perform two different types of actions: (i) search and sort information; and (ii) add, edit and delete their own information. Easy to use guidelines for users are available at http://www.ndphs.org/?database,page,about.

DPSG_3-5-Info_1__Database_project_interim_narrative_report 11

The following verifiable and quantifiable indicators were used for the database tool itself:2

Projects section:

• Total number of projects in the database: 495 • Number of data fields in one record: 27 • Number of projects obtained from external databases: 485 • Number of projects obtained from the NDPHS Project Pipeline: 4 • Number of projects inserted manually: 6 • Number of searching options: 12 • Number of sorting options: 6

Organizations section:

• Total number of organizations in the database: 219 • Number of data fields in one record: 21 • Number of organizations obtained from external databases: 108 • Number of organizations inserted manually: 111 • Number of searching options: 5 • Number of sorting options: 5

Persons section:

• Total number of persons in the database: 185 • Number of data fields in one record: 18 • Number of persons obtained from external databases: 130 • Number of persons inserted manually: 55 • Number of searching options: 5 • Number of sorting options: 4

Papers section:

• Total number of papers in the database: 12 • Number of data fields in one record: 20 • Number of papers obtained from external databases: 0 • Number of papers inserted manually: 12 • Number of searching options: 5 • Number of sorting options: 4

General indicators:

• Number of links created to other databases: 8

2 All figures were taken from the database and calculated on 20 March 2008 i.e. when this interim report was being finalized.

DPSG_3-5-Info_1__Database_project_interim_narrative_report 12 • Approximate number of links in the database to external websites: 485 (projects) + 95 (organizations) + 1 (person) + 9 (papers) • Number of links made to the database from other sources: at least 6; • Number of health areas/themes covered: 23; • Number of geographical areas covered: 23; • Number of Daily/Weekly New Information Entries: 15 records added per day, i.e. 105 records per week, i.e. 445 records per month (all figures are averages); • Number of daily hits: 453 (on average)

The work program planned for the following period is in line with the initial work program set out in Annex I to the Grant Agreement. Efforts will continue to (i) publicize the database especially to the target persons and groups, as mentioned in sections regarding WP 2 and WP 5 (donors, national ministries, local/regional bodies, IGOs, NGOs, IFIs, institutions, key individuals, etc.); (ii) keep the database up to date; (iii) review newly added records and approve them for public display (quality assurance efforts); (iv) add 1-2 more external databases.

3.5. WP 5 – Information Provision on Specific Health Areas

Status: ongoing

3.5.1. Work Package objectives as spelled out in the Grant Agreement

The objectives of this WP are the identification of information providers/data sources, necessary data groups, gaps and possible analyses derived from data, network meetings in the specific four health areas covered: 1) communicable diseases 2) lifestyle related diseases 3) prison health and 4) primary health care Æ continuous facilitation and the control of data input.

3.5.2. Progress made during the reported period

All activities, which are foreseen in the project work plan for the first year of the WP 5 implementation, were implemented on time and there was no deviation from the initial work program set out in Annex I to the Grant Agreement.

The following is the list of main actions taken until 31 January 2008:

• An Expert (Ms. Marina Wetzer-Karlsson) was employed by the Finnish Ministry of Social Affairs and Health to support the implementation of this Work Package (30 working days during November – December 2007) (cf. Ms. Wetzer-Karlsson’s report attached as Annex 3); • All data originally harvested from the external databases was record-by-record checked for quality and corrections were made where necessary and possible, and records were hidden when corrections were not possible (November 2007 – January 2008); • Many potential information providers and potential information users were identified and contacted and their data was entered into the database; • NDPHS Expert Groups were several times approached by the NDPHS Secretariat with request to, inter alia, (i) help publicize the Database, and (ii) identify the above

DPSG_3-5-Info_1__Database_project_interim_narrative_report 13 mentioned information providers and users. Further, they were encouraged to start/continue uploading information about projects, organizations, persons and papers, e.g. thematic reports, into the database), which they started to do; • NDPHS Expert Groups discussed during their meetings the concept and, subsequently through e-mail contacts, the contents of the thematic reports. Experts employed to assist them in the development of the thematic reports identified necessary data groups, and gaps and made analyses, inter alia, based on those data; • As regards network meetings in the specific four health areas covered: (i) communicable diseases; (ii) lifestyle related diseases; (iii) prison health and (iv) primary health care – as mentioned in the section describing WP 1 – during the first year of the project implementation there were held 3 meetings of the NDPHS Expert Group Chairs and ITAs as well as 3 meetings of the NDPHS Expert Group on HIV/AIDS, 4 meetings of the NDPHS Expert Group on Prison Health, 2 meetings of the Expert Group on Primary Health Care and 4 meetings of the Expert Group on Social Inclusion, Healthy Lifestyles and Work Ability (SIHLWA). During each of these meetings the Database Project issues were one main part on their agenda including, but not limited to the WP 5 issues.

The work program planned for the following period is in line with the initial work program set out in Annex I to the Grant Agreement. As mentioned in sections regarding WP 2 and WP 4, efforts will continue to identify target persons and groups (such as donors, national ministries, local/regional bodies, IGOs, NGOs, IFIs, institutions, key individuals, etc.). Further, the Database Project will continue to be one main issue on the agendas of the Expert Group meetings (the nearest one will be held on 3-4 April 2008 in Tallinn, Estonia, cf. http://www.ndphs.org/?mtgs,hiv/aids_8__tallinn).

3.6. WP 6 – Thematic Reports, Network Creation and Stakeholder Analysis

Status: ongoing

3.6.1. Work Package objectives as spelled out in the Grant Agreement

The objective of this WP is to show the use of the database tool in terms of developing a concrete series of reports on analyses, project gaps, policy gaps, institutional gaps, etc. and resulting recommendations to national and international responsible authorities. The objective also includes the organization of "real" network meetings (workshops) resulting into further online discussions for certain health areas and geographical areas.

3.6.2. Progress made during the reported period

All activities, which are foreseen in the project work plan for the first year of the WP 6 implementation, were implemented on time and there was no deviation from the initial work program set out in Annex I to the Grant Agreement.

The following is the list of main actions taken until 31 January 2008:

• Each NDPHS Expert Groups was approached with information about the need to develop a thematic report (early 2007). This was followed by a set of instructions as to

DPSG_3-5-Info_1__Database_project_interim_narrative_report 14 what these thematic reports should contain and the amount of funding available (mid 2007); • Thematic reports as an issue was included on the agendas of all Expert Group meetings held during the first year of the project implementation (the links to meeting documents pages are provided in section regarding WP 1). During these meetings the Experts Groups agreed on the specific topics to be covered by their own thematic reports; • In late 2007 and January 2008, the Expert Groups developed the following thematic reports (they subsequently, started “polishing” them): o HIV/AIDS Expert Group: “HIV/AIDS in the Baltic Sea Region and Northwest Russia” (this report has already been uploaded to the Database and is available at: http://www.ndphs.org/?database,view,paper,20, however final revisions and “polishing” will be done by the Expert Group during its forthcoming meeting on 3-4 April 2008 in Tallinn, Estonia) (cf. Annex 4); o PHC Expert Group: “Primary Health Care in the Northern Dimension Countries” (final revisions and “polishing” will be done by the Expert Group during its forthcoming PHC Expert Group meeting and Seminar "Primary health care in Northern Dimension Countries" to be held in Vilnius, Lithuania on 22 and 23 May 2008, respectively) (this report has already been uploaded to the Database and is available at: http://www.ndphs.org/?database,view,paper,21) (cf. Annex 5); o PH Expert Group: “Women’s Health in Prison in the Northern Dimension Countries” (this report has already been uploaded to the Database and is available at: http://www.ndphs.org/?database,view,paper,19) (cf. Annex 6); o SIHLWA Expert Group: “Country Reports on Occupational Safety and Health in the Northern Dimension Area” (this report has already been uploaded to the Database and is available at: http://www.ndphs.org/?database,view,paper,22) (cf. Annex 7).

Indicator included in Annex 1 to the Grant Agreement: Number of Thematic Reports produced – the figure is: 4.

The work program planned for the following period is in line with the initial work program set out in Annex I to the Grant Agreement. Final revisions and “polishing” will be performed by the Expert Groups. The reports will subsequently be translated to Russian and printed in both English and (funds permitting) Russian language versions. Also, it is planned that all thematic reports will be presented to the CSR 14 Meeting in autumn 2008. Finally, based on the outcome of the thematic reports the Expert Groups will develop a series of project-based interventions as well as short and concise lists of policy recommendations for presentation at a political level, which were already broadly outlined in their thematic reports.

3.7. WP 7 – Project Pipeline

Status: ongoing

3.7.1. Work Package objectives as spelled out in the Grant Agreement

In parallel to the general analyses, recommendations and networks a specific "Project pipeline" facility will be created which shall enable project review, development of topics and

DPSG_3-5-Info_1__Database_project_interim_narrative_report 15 project networks. Included in the process are the implementing organizations, partners and donors.

3.7.2. Progress made during the reported period

All activities, which are foreseen in the project work plan for the first year of the WP 7 implementation, were implemented. However, a delay and deviations from the initial work program set out in Annex I to the Grant Agreement occurred as explained below.

The following is the list of main actions taken until 31 January 2008:

• Norway, which agreed to assume the role of the WP 7 Lead Partner, developed an initial concept of the NDPHS Project Pipeline (already before the commencement of the project); • A pipeline prototype had been developed and, after revisions and amendments, was finalized in May 2007 (in accordance with the project work plan, the pipeline should have been ready and on-line in April 2007); • Considering that the prototype did not meet the pipeline technical requirements, the Secretariat, as the Project Main Partner, in agreement with the NDPHS CSR Chair and the WP 7 Lead Partner, changed the service provider. The PHEA was informed of this deviation from the initial work program in an email sent to it by the NDPHS Secretariat on 15 July 2007; • A new project pipeline (engine and “white pages”) was developed (August – 10 September 2007); • The Secretariat was in regular dialogue with the Norwegian Ministry of Health and Care Services to encourage it to channel at least part of its funding for (relevant to the NDPHS) projects through the NDPHS Project Pipeline. The pipeline was fine-tuned to make it suit the voiced Norwegian requirements and preferences; • The Secretariat identified financial agencies / funding opportunities which could not, at least for the time being) offer funding through the pipeline, but which were worth being mentioned in the pipeline (cf. below) (August – November 2007); • The NDPHS Expert Groups were invited to test the project pipeline (14 September 2007). On the same day, during the EG Chairs and ITAs 5 Meeting, the NDPHS Secretariat discussed with them the thematic and geographical areas to be included in the pipeline (and, later on, in the NDPHS Database); • The NDPHS Partners and Associated Partners were invited to test the project pipeline (31 October 2007); • The Secretariat met with the Finnish Ministry for Foreign Affairs to encourage it to channel at least part of its funding for (relevant to the NDPHS) projects through the NDPHS Project Pipeline (6 November 2007); • The NDPHS Project Pipeline was officially launched following decision of the 4th Partnership Annual Conference on 15 November 2007 (cf. http://www.ndphs.org/?pipeline). During the PAC Finland announced that it would put through the NDPHS Project Pipeline EUR 1.5 million for projects of relevance to the NDPHS. E-news and a press-release was distributed on this occasion announcing, inter alia, this launch and the Finnish pledge (cf. section regarding WP 2); • Following Finland’s announcement to allocate funds for projects through the pipeline, the Secretariat jointly with Finnish MFA fine-tuned the pipeline to make it suit the Finnish requirements and preferences (January 2008) before it was opened for project proposals (on 1 February 2008).

DPSG_3-5-Info_1__Database_project_interim_narrative_report 16

The pipeline provides information both about the funding opportunities in the pipeline (cf. http://www.ndphs.org/?pipeline,page,funding_opportunities) as well as funding opportunities outside the pipeline (http://www.ndphs.org/?pipeline,page,non-pipeline_agencies).

The work program planned for the following period is in line with the initial work program set out in Annex I to the Grant Agreement. The following actions were taken during February – March 2008:

• Finnish Ministry for Foreign Affairs’ grant funding of EUR 1.5 million available through the NDPHS Project Pipeline was announced through the NDPHS e-news on 1 February 2008; • Until 20 March 2008 there had been 7 project proposals submitted of which 4 were approved for funding (the latter can be viewed in the NDPHS Database at: http://www.ndphs.org/?database,db,ndphs_pipeline). Indicators included in Annex 1 to the Grant Agreement, which are related to the NDPHS Project Pipeline are as follows: o Number of submitted / accepted project proposals in project pipeline – the figures on 21 March 2008 are: submitted 7 / accepted 4 (0/0 on 31 January 2008); o Number of joint/transnational projects created – the figures on 21 March 2008 a is: at least 4; • A new page was developed in the pipeline which offers graphical presentation of funding put through the pipeline (cf. http://www.ndphs.org/?pipeline,charts).

Regarding further future, efforts will continue to: (i) encourage the Norwegian Ministry of Health and Care Services to channel at least part of its funding for (relevant to the NDPHS) projects through the NDPHS Project Pipeline; (ii) encourage other donors to do likewise; (iii) publicize the database especially to the target persons and groups, as mentioned in sections regarding WP 2, WP 4 and WP 5 (donors, national ministries, local/regional bodies, IGOs, NGOs, IFIs, institutions, key individuals, etc.); (iv) identify potential project proponents (organizations and people) and encourage them to use the pipeline.

4. FURTHER INFORMATION

Further information is available from the Project Main Partner, i.e. the NDPHS Secretariat (see item 2.2 Organization receiving the subsidy and project coordinator). Contact details are also available at: http://www.ndphs.org/?secretariat.

DPSG_3-5-Info_1__Database_project_interim_narrative_report 17 Northern Dimension Partnership in Public Health A partnership committed to and Social Well-being achieving tangible results

e-Newsletter Issue 1/2007

Contents Dear Reader… A unique Partnership 1 The Northern Dimension Partnership in Public Health and Social Well-being The Northern Dimension – a policy (NDPHS) is pleased to present the first issue of the bi-annual NDPHS e-Newsletter. concept 1 This newsletter is produced as a part of the NDPHS Database project, which we will Dedicated expertise 2 provide up-to-date information about in each issue (see page 3). We will also be Expert Group on HIV/AIDS 2 presenting progress and achievements in other areas of the NDPHS’ work. However, on Expert Group on Prison Health 2 the occasion of publishing this first issue, we would like to provide you exclusively with Expert Group on Primary an in-depth overview of the Northern Dimension concept, the NDPHS and its Expert Health Care 2 Groups, as well as the NDPHS Database project. Expert Group on Social Inclusion, All readers are invited to contribute articles to future issues of the NDPHS Healthy Lifestyles and Work Ability 3 e-Newsletter (read more in the info boxes on page 4). Associated Expert Groups 3 We hope that you will find the NDPHS e-Newsletter both informative and Delivering tangible results – a NDPHS interesting! Database project 3 NDPHS Secretariat

The Northern Dimension – a policy A unique Partnership concept Founded in 2003 in Norway, the NDPHS works to The NDPHS is one of the two partnerships established with- improve the quality of life and the demographic situ- in the framework of the Northern Dimension policy. As many ation in Northern Europe, and foremost in North-West other political concepts, the Northern Dimension (ND) policy is Russia. Thirteen governments and eight intergovern- terminologically complex. In short, it can be understood as an mental organisations constitute the Partnership, and umbrella concept for activities that promote stability, enhance utilise it as a platform to: well-being and sustainable development in the ND area, while it Discuss and agree upon priorities in policy- also serves as a common platform for promoting dialogue and making through increased cooperation in the concrete cooperation. It involves four partners, which are the spheres covered by the NDPHS, and European Union, Iceland, Norway and Russia, and covers a fairly Enhance the coordination of international large area ranging from the European Arctic and Sub-Arctic to activities aimed at narrowing social and eco- the southern shores of the Baltic Sea encompassing the coun- nomic disparities and improving peoples’ tries in its vicinity, as well as the North West Russia in the East to health and social well-being. Iceland and Greenland in the West (see the map below). 2 The Partnership focuses on two main priority areas: Reduction of major communicable diseases and the prevention of lifestyle related noncommunicable diseases, and; Enhancement and promotion of healthy and socially rewarding lifestyles. The NDPHS aims to contribute to the above by intensifying cooperation, assisting the Partners and participants in capacity building, and by enhancing coordination between international activities within the Northern Dimension area. In doing so, it builds on and supports existing national and international activities within its area of focus, and also promotes eﬀorts addressing issues that are not yet covered by its existing activities. Currently, Lithuania holds the Northern Dimension area rotating chairmanship of the Partnership. 2

Northern Dimension Partnership in Public Health and Social Well-being The Northern Dimension... Dedicated expertise 1 A number of other actors are in- Four Expert Groups and two Associated Expert Groups provide professional volved in the ND as well. They include, input to the preparation and implementation of joint activities and work pro- but are not limited to the four region- grammes within the NDPHS. The expert groups consist of high level experts from al councils in the Northern Europe national ministries, agencies of Partner Countries, Partner Organisations, research (AC, BEAC, CBSS, NCM), several Inter- institutions, hospitals, NGOs and other relevant bodies. national Financial Institutions, as well as other European Union institutions Expert Group on HIV/AIDS and bodies and those of the other Northern Dimension partners. HIV/AIDS and other sexually transmitted infections (STIs) Six priority sectors have been are rapidly spreading in Eastern Europe and are on the rise in agreed upon for the ND, which cover Western Europe. Peoples’ health and social conditions within the following issues: economic coop- the Northern Dimension area still vary signiﬁcantly. The need eration, freedom, security and justice; to share experiences and expertise in prevention plans, health external security; research, education education, case management and testing is considerable. and culture; environment, nuclear The Expert Group on HIV/AIDS endeavours to prevent the safety and natural resources as well as spread of HIV/AIDS and other STIs by strengthening the col- social welfare and health care (includ- laborative and coordinating work in the region. It also works Mr Pauli Leinikki ing the prevention of communicable towards the inclusion of policies that emphasize HIV/AIDS as Chair of the HIV/AIDS diseases and life-style related diseases a priority issue on the political agenda in all Partner Coun- Expert Group and the promotion of cooperation be- tries and as a major issue in the work of all Partner Organisa- tween health and social services). The tions. The Group develops and supports regional projects and networks aimed at latter is dealt with by the Northern Di- the prevention of HIV/AIDS and cross-border cooperation. mension Partnership in Public Health Read more about HIV/AIDS EG, including its past, ongoing and planned future and Social Well-being. activities at www.ndphs.org/?hiv-aids_eg. Visit our website and learn more about the Northern Dimension at Expert Group on Prison Health www.ndphs.org/?about_nd. The penal system presents a section of the society where major health problems are concentrated. The spread A unique Partnership of communicable diseases occurs predominantly within the 1 marginalised groups that live under harsh socio-economic Four Expert Groups have been circumstances, of which many members may subsequently established within the NDPHS, enter the penal system. There are also obvious connections which deal with challenges relat- between social disparities, mental disorders, drug use, in- ed to HIV/AIDS, Prison Health, Pri- fectious diseases, crime and imprisonment. mary Health Care as well as Social Inclusion, Healthy Lifestyles and Work The Expert Group on Prison Health focuses on commu- Ms Ingrid Lycke Ellingsen Ability (SIHLWA). These Expert Groups nicable diseases, drug and social rehabilitation, care for Chair of the PH Expert have an advisory role and provide pro- inmates with mental disorders and other special needs, Group fessional input to joint NDPHS activi- as well as inmates’ living conditions or educational pro- ties (cf. article “Dedicated expertise”). grammes. It seeks to contribute to the improvement of health in prison and to As regards cross-cutting activities, the communicate collective knowledge in this field. It supports coordinated and NDPHS is currently involved in two collaborative efforts to further prison reforms and in developing relevant na- major eﬀorts, namely preparations for tional policies. Read more about PH at www.ndphs.org/?ph_eg. the forthcoming Partnership Annual Conference (PAC) organised at the Expert Group on Primary Health Care ministerial level, as well as the implementation of a regional multi-compo- With the Alma-Ata Conference in 1978 organised by nent project. Concerning the former, the World Health Organisation (WHO) and UNICEF, primary it will be held on 16 November 2007 health care came into existence as a new approach to health in Vilnius, Lithuania, and will focus on policy. Within the Northern Dimension area, certain social occupational safety and health (but and economic problems continue to result in high mortality with a broad health content and title). rates, the prevalence of cardiovascular diseases, violence, al- Regarding the latter, it has already de- cohol and drug abuse and the spreading of infectious diseas- livered a new website and will in the es such as tuberculosis and HIV/AIDS. Health systems need Mr Carl-Eric Thors near future provide further tangible to be improved, particularly the provision and delivery of pri- Chair of the PHC Expert results such as a Project Pipeline, a mary health care. To that end, the Expert Group on Primary Group Project Database and a series of the- Health Care focuses on modern primary health care systems matic reports (read more on page 3). and human resource development. 3

2 Northern Dimension Partnership in Public Health and Social Well-being 2 Delivering tangible results – a NDPHS It supports health promotion and disease prevention and works for the improvement Database project of health service systems and health sector The NDPHS encourages and promotes cooperation at various levels reforms. ranging from the implementation of projects that involve stakeholders Read more about PHC EG, including its from the local level to policy development at the national level and high- past, ongoing and planned future activities level dialogue at the ministerial level. All of them aim at achieving tangi- at www.ndphs.org/?phc_eg. ble results and making progress towards the agreed goals. One example of such efforts is the NDPHS Database project. It is a Expert Group on Social Inclusion, cross-cutting activity involving various NDPHS bodies, and is contained Healthy Lifestyles and Work in seven components, or “work packages” (WP): Ability (SIHLWA) WP 1 – Coordination of the project “A healthy lifestyle WP 2 – Dissemination of the results adds years to life and life WP 3 – Evaluation of the project to years,” states the World WP 4 – Database Development Health Organisation WP 5 – Information Provision on Specific Health Areas (WHO). Socio-economic WP 6 – Thematic Reports and Network Creation conditions determine the WP 7 – Project Pipeline lifestyle of people and The project is coordinated by the NDPHS Secretariat and financially they still differ dramati- supported by the European Union within the framework of the Public cally in the Northern Di- Mr Mikko Vienonen Health Programme and ten NDPHS Partners. It was launched in February mension Area. This results Coordinating Chair of the 2007 and will continue for 24 months. in high mortality rates SIHLWA Expert Group Good progress has been made during the first months of the project’s often caused by suicide, implementation. The new NDPHS website (www.ndphs.org) is one tangi- violence, alcohol and drug abuse or the spread- ble outcome. Soon, the NDPHS Project Pipeline (WP 7) will be integrated ing of infectious diseases. Greater accessibility into it, followed at the end of 2007 by the NDPHS Project Database (WP to healthy physical and social environments 4). These two components will operate as useful tools for the Partnership is needed to help people to develop and to pursue one of its main goals, namely, the enhanced coordination of strengthen basic skills to live healthier life- international activities in the Northern Dimension area aimed at narrow- styles. This demands an integrated approach ing social and economic differences and improving peoples’ health and to public health challenges to be taken by social well-being. health, social, education and other relevant Until now, there was no existing comprehensive mechanism in place sectors. With that in mind, the SIHLWA Ex- to coordinate the provision of funding for projects on public health and pert Group assists in coordinating and further social well-being by several different agencies in the Northern Dimension developing the Partnership’s cooperation in area. The NDPHS decided to address this shortcoming and has now devel- areas related to alcohol, periodic drinking, oped a prototype of the NDPHS Project Pipeline. As soon as the pipeline youth lifestyles as well as occupational safety is adjusted to donor agencies’ requirements, the NDPHS Partners individ- and health. The Expert Group consists of three ually and the Partnership collectively (e.g. through its Expert Groups), on sub-groups of which each focuses on a set the one hand, and project proponents, on the other hand, will be able to of specific issue areas, namely: Alcohol (ALC benefit from and support various processes facilitated and streamlined sub-group), Adolescent Health and Socially thanks to this pipeline. This multifaceted characteristics of the pipeline Rewarding Lifestyles (ADO sub-group), and will enable the NDPHS to take a strategic position of a project catalyst in Occupational Safety and Health (OSH sub- the Northern Dimension area. group). Read more about SIHLWA EG, includ- Further, the NDPHS Project Pipeline will help, e.g., better coordinate ing its past, ongoing and planned future ac- concrete ideas for health improvement emerging from the grassroots level, tivities at www.ndphs.org/?sihlwa_eg. and support groups active in the NDPHS area in identifying suitable donors. The value gained by submitting a project via the pipeline will be that Associated Expert Groups a project applicant will need to submit a project proposal only once. The There are two Associated Expert Groups proposal will then be immediately forwarded to all relevant donors who in the NDPHS: will be linked to the pipeline. More specifically, based on the thematic and geographical characteristics of the project, the pipeline will automatically The Baltic Sea Network on Occupa- categorize the project and select the donor(s) who have a potential inter- tional Health and Safety (BSN), and est in funding a project featuring such a characteristics. A possibility of co- The Council if the Baltic Sea States funding projects by several donors has been foreseen, too. (CBSS) Working Group for Coopera- During a spring 2007 test-run of the pipeline, a 2 million EUR grant tion on Children at Risk. for health-related projects was channelled through it by the Norwegian Read more about these two groups on Ministry of Health and Care Services. Based on the experiences gained the NDPHS website at www.ndphs.org/ by Norway the pipeline will be further improved in the near future and ?associated_egs. displayed on the NDPHS website. 4

Northern Dimension Partnership in Public Health and Social Well-being 3 Delivering tangible results... 3 As far as the Project Database is concerned, the Partnership decided to develop it, on the one hand, having in mind that there have been and will be many interesting projects on public health and social well-being implemented in the Northern Dimension area. On the other hand, the Partners were concerned that despite the fact that there is much to learn from those projects, valuable knowledge and experience accumulated by them is sometimes lost with projects being shelved soon after they are completed. The database will help prevent the latter from occurring and will also encourage people to disseminate the results of their work so that others can benefit from it. It will be a tool for funding agencies to use when designing their funding programmes, as it will provide a comprehensive picture about the implemented and ongoing projects. In this respect, it will help coordinate work of the Partnership, collectively, and between Partners, individually. To ensure that the information presented in the database is complete and up-to-date, data will come from The new NDPHS website offers a clear structure, user friendly navigational tools and menus, improved search functions, and different sources – other existing data- easy-to-access web-pages bases, the NDPHS Project Pipeline and from manually registered projects. The relevant information on persons of recommendations to national and in- WP 5, Information Provision on Specific with technical expertise related ternational bodies. Health Areas, will help the NDPHS iden- to a given project. Within the framework of WP 2, Dis- tify proper sources of information and All of these sections will be linked to- semination of the results, the delivera- interesting contents to be included in gether, taking and feeding information bles such as the Project Pipeline and the the NDPHS Database. The NDPHS data- to and from each other. Visitors will be Project Database, as well as the wealth base structure will be divided into three able to use an advanced search engine of information developed within the sections which will interact with each to find information. Currently, there is no described NDPHS project will be widely other: one database available that would offer distributed through several information A “projects’ section” which gath- so comprehensive, yet fairly detailed in- channels created by the project. These ers and presents information formation about implemented and on- channels include, but are not limited to about relevant projects; going projects in the Northern Dimen- the new NDPHS web site, e-news, press- An “organisations’ section” which sion area. releases and this e-Newsletter. links a given project to the As regards the Thematic reports Persons, organisations and individu- organisation(s) which fund, imple- which belong to WP 6, the NDPHS plans als interested in participating in the ment or assist in a given project; to produce a series of publications where NDPHS Database project are warmly A “people’s section” which con- certain health and geographical areas welcome to contact the NDPHS Secre- tains addresses and additional will be further analysed resulting in a set tariat (see the contact details below).

The NDPHS e-Newsletter is published by the Northern Dimension Partnership in Public We plan to publish the next issue in late We encourage readers to disseminate Health and Social Well-being (NDPHS) Secretariat in Stockholm, Sweden. It is published 2007. You are invited contribute to it. the contents of the NDPHS e-Newsletter. bi-annually and is available only in electronic format through direct mailing to subscrib- For further details - please contact us at: It may be freely reproduced and reprinted, ers and on the NDPHS website, where you can also subscribe to it (www.ndphs.org). NDPHS Secretariat provided that the source is cited. Strömsborg Developed by: P.O. Box 2010 Marek Maciejowski, The NDPHS e-Newsletter arises from the project “NDPHS Project Database” which has SE-103 11 Stockholm, Sweden Bernd Treichel and received funding from the European Union, in the framework of the Public Health Pro- Tel: +46 8 440 1920 Maxi Nachtigall gramme. The sole responsibility for that document lies with the NDPHS Secretariat. The Fax: +46 8 440 1944 Proofreading: Asha Davis Public Health Executive Agency is not responsible for any use that may be made of the E-mail: [email protected] information contained herein. Website: www.ndphs.org Layout: Studio TCM

4 Northern Dimension Partnership in Public Health and Social Well-being Northern Dimension Partnership in Public Health A partnership committed to and Social Well-being achieving tangible results

e-Newsletter Issue 2/2007

Contents Dear Reader… Partnership holds a ministerial The Northern Dimension Partnership in Public Health and Social Well-being is conference 1 pleased to present the second issue of its bi-annual e-Newsletter. Looking back at the en- Lithuania completes its chairmanship 2 tire year of 2007, it is fair to say that the Partnership lived up to the motto written above, Polish added as the third language and delivered numerous tangible results aimed to benefit not only its own Partners but on the NDPHS website 2 also various stakeholders in our region. Some of these achievements have been described Norway takes on the NDPHS helm 3 in this issue of our e-Newsletter, and more can be read about on the NDPHS website. NDPHS adopts a Strategy on Health While thanking all the Partners and other supporters of the NDPHS for their commit- at Work 3 ment to the Partnership’s goals and their efforts during this year, we would like to wish all NDPHS Database and Project Pipeline of them and the readers of this e-Newsletter a peaceful holiday season as well as prosper- launched 4 ous and successful year 2008! NDPHS Secretariat

Partnership holds a ministerial conference Every second year the NDPHS holds its Partnership An- Partners’ activities during the past two years and praised the nual Conference (PAC) on a ministerial level. This year’s PAC, NDPHS, and particularly the Chair Country and the Secretariat, undoubtedly the crowning event for the Lithuanian Chair- on an effective and successful management of the coopera- manship, was attended by ministers of health and/or social tion. A detailed description of the Partnership’s achievements affairs and other high-level representatives of Partners, as well during 2007 can be found in the above-mentioned NDPHS as Portugal in its capacity as the EU Presidency. The main is- Progress Report. As regards the future, the adopted NDPHS sues on the agenda were the adoption of the NDPHS Strat- Work Plan for 2008, which is not less ambitious than the one egy on Health at Work (read page 3), the launch of the NDPHS for 2007, sets targets, defines action lines and specifies activi- Database and Project Pipeline (read page 4), the approval ties to be carried out at the various levels of the Partnership. of the NDPHS Progress Report for 2007 and the adoption of Both the Progress Report and the Work Plan include and build the NDPHS Work Plan for 2008. Finally, the event culminated on NDPHS Expert Groups’ reports and plans. with the handing over of the NDPHS chairmanship to Norway, The PAC was preceded by the NDPHS Forum “Healthy Life which now holds the NDPHS helm, and Russia, which assumed - Healthy Work,” which, on its part, was the culmination of the Co-Chair position (read more on pages 2 and 3). months of hard work to prepare the above mentioned NDPHS Many good words Strategy on Health at were said about the Work. Partnership and its For further details progress during the con- and to download the ference, such as that the above mentioned doc- NDPHS is not only a well uments, please visit functioning initiative of the PAC 4 webpage East-West cooperation at http://www.ndphs. within the Northern org/?mtgs,pac_4__viln- Dimension, but it also ius and read the press- serves as a valuable fo- release about this event rum for sharing experi- at http://www.ndphs. ences gained by various org/?press-releases. The countries and networks, Forum’s webpage can be and a reference model viewed at www.ndphs. for other European re- org/?mtgs,healthy_life- gions. The participants healthy_work. noted and praised sig- Hosted by Lithuania, this year’s Partnership Annual Conference was held in Vilnius nificant progress in NDPHS Secretariat

Northern Dimension Partnership in Public Health and Social Well-being Lithuania completes its chairmanship It takes two years of intense work for a country that assumes the honoured position of the Partnership’s Chair, before it passes over the helm during a NDPHS’ main event: a ministerial-level Partnership Annual Conference (PAC). At the end of 2005, Lithuania took the chairmanship of the Partnership together with Norway as the Co-Chair, to only recently hand it over to the latter upon successful completion of its term. At the same time Russia assumed the Co-Chair position, thereby continuing the tradition of a joined East-West leadership in the NDPHS. The endorsement of the Northern Dimension (ND) Policy Framework Document, adopted by the EU, Iceland, Norway and Russia opened up a new sustainable pathway for the ND cooperation. The inclusion of the social welfare and health care among the ND policy’s six priority sectors and the explicit mentioning of the NDPHS have anchored the Partnership as one of the key players in Northern Dimension cooperation. During the Lithuanian Chairmanship, the NDPHS “We hope that the Partnership Strategy was able to develop and implement a broad array of will be one component to help realising activities aimed to benefit both the Partners and vari- the occupational safety and health strat- ous stakeholders in the area. These included, but were egies of the WHO, the ILO and the Euro- not limited to new tools such as a new website, a da- pean Union. The systematic approach tabase as well as a project pipeline (the latter being an of the strategy, developing policies, pro- innovative financing mechanism to support project grammes and systems for health at work initiatives on public health and social well-being in the and linking the public health and occu- ND area). Lithuania also hosted several NDPHS events, pational health systems will harness the HE Rimvydas Turčinskas, Lithu- among them the PAC and the NDPHS Forum, and en- resources of both systems for a coherent and effective delivery of health services anian Minister of Health opens sured the participation of Lithuanian experts in Expert the NDPHS Forum Group meetings. It also took care of many organisa- for the working age population.” tional and administrative aspects of the NDPHS. The highlight of the last two years of the Lithuanian Chairmanship was the recently held, and chaired by HE Minister Rim- vydas Turčinskas, the Partnership Annual Conference, which, inter alia, adopted the NDPHS Strategy on “Healthy Life – Healthy Work”. This strategy, the first of its kind in the Partnership, is embodying the core mission of the Partnership: intensifying cooperation between Partner Countries, assisting in capacity building and enhancing coordination between international activities in the Northern Dimension area. All Partners welcomed and unanimously adopted the strategy (read more on next page).

“Some of the Partnership’s achievements during the The Partners considered the Lithua- Lithuanian Chairmanship have been important for nian Chairmanship very successful, its successful work during the coming years: estab- with tangible results delivered through lishing a competent secretariat and a broad network a wide array of concrete activities. This of Expert Groups and delivering vital elements of the would not have been possible without Partnership’s Financing and Coordinating Mecha- a solid commitment demonstrated on nism. There were, however, some areas such as se- many occasions by the Partners and the curing financing and ensuring appropriate partici- Secretariat, for which Lithuania would pation in Expert Groups, where the results were only like to once more express its gratitude. satisfactory. The progress of the Partnership was, to a large degree, made possible thanks to human and I am confident that with its foundations firmly established and the dedicated Dr. Viktoras Meižis, previous Chair financial resources provided by the Partners, particu- of the NDPHS CSR larly Finland, Norway and Sweden. I am truly grate- Norwegian Chairmanship at the helm, ful to my many colleagues in the NDPHS, both across the Partnership’s future is bright. the country and from abroad, for the support they rendered to me during my chairmanship and for our Dr. Viktoras Meižis Head of Foreign Affairs friendly cooperation.” Lithuanian Ministry of Health

Polish added as the third language on the NDPHS website We are pleased to announce that the NDPHS website (including the Database and Project Pipeline) is now also available in the Polish language. This was possible thanks to the much appreciated support of the Polish Office for Foreign Aid Pro- grammes in Health Care. Offering a website in three languages is very unique among networks such as the NPDHS and is a clear demonstration of the Partnership’s efforts to reach out to as many people and stakeholders in the region as possible. By doing this, the Partnership aims to not only disseminate information among them, but also to encourage them to become involved in activities to improve public health and social well-being.

2 Northern Dimension Partnership in Public Health and Social Well-being Norway takes on the NDPHS helm NDPHS adopts a Strategy on Health It has been a busy autumn for the at Work Partnership, with the Partnership An- Poor working conditions, occupational accidents and nual Conference at ministerial level, occupational diseases cause a great deal of suffering. They Senior Officials meeting in Kalinin- cost countries in the Northern Dimension area an estimat- grad, several meetings of all the Expert ed 4% of the Gross Domestic Product and a loss of EUR 225 Groups, progress in projects, launching billion every year. Great variations in working conditions of new tools and development of new and, in some areas, lack of or insufficient access to preven- plans and strategies. There is a strong Ms Toril Roscher- tive occupational health services are sources of enormous momentum in the Partnership now. The Nielsen, the Chair of the NDPHS CSR inequities in health. These discrepancies are not in line Partners seem more committed than with the objectives of the NDPHS, and are counterproduc- ever, the Expert Groups are all active, the pipeline and da- tive to the sustainable and productive development of the tabase are up and running. Health is steadily becoming individual countries and the region as a whole. Therefore, more important in international politics, and the Northern the SIHLWA Ex- Dimension has become more visible in European politics. pert Group (Sub- It is a very favourable moment for Norway and Russia to group on OSH) take the lead in the Partnership. It is important to keep and the Baltic Sea this momentum, as we must remember that the Partner- Network (BSN), ship is a Partnership only, totally dependent on the activi- with the sup- ties of its Partners. port of national Among the central issues on our agenda now is the and international further consolidating of the Expert Groups, including experts, devel- developing their role into one where they stimulate con- oped a strategy crete projects. Project implementing agencies should take to address these the initiative to present their projects and ideas to the Ex- challenges. Their pert Groups, and may in return get useful advice, quality final effort was improvement, contacts and approval. The Expert Groups the NDPHS Fo- are about to publish thematic reports in their fields of re- rum "Healthy Life The Author of the article and Ms Anne Degrand-Guillaud sponsibility. It will be interesting to follow the use of these of the European Commission chatting during a coffee - Healthy Work," break during the NDPHS Forum reports. which was held Last year, we have seen a stronger interest in the Part- in Vilnius the day before the 4th Partnership Annual Con- nership from Russia and the European Commission, a fact ference. It gathered many highly respected experts from that can be attributed not only to the renewed Northern Di- WHO, ILO, EU and other organisations, who discussed the mension, but also to better performance of the Partnership. ways to address the challenges and, finally, approved the The EC has now initiated a meeting between the South East Strategy for submission to the PAC (read more at www. Europe Health Network and the Partnership. It is likely that ndphs.org/?mtgs,healthy_life-healthy_work). these two regional cooperation structures can learn from While discussing the above and adopting the Strategy, each other. the PAC recognised that occupational health services have a Stronger involvement of the Partners would lift the great, but unused potential for promoting healthy lifestyles Partnership even further. In practical terms, this would im- in a holistic way, and that primary health care and occupa- ply that more Partners connect to the Pipeline, make use of tional health services can improve the efficiency by increas- their representation in the Expert Groups, see the increased ing collaboration and links with one another. importance of the Northern Dimension in foreign policy It is exactly to that end, that the Strategy aims at draw- and the Partnership’s role in that, and link other on-going ing up national occupational safety and health (OSH) pro- relevant activities to the Partnership. Further involvement files, policies and programmes, defining high-risk sectors of the international organisations would also be welcome, to eliminate health hazards at work and, finally, organising as it is as a win-win situation: WHO’s Health in Prisons seminars, information and awareness campaigns with the Project is successfully cooperating with the Prison Health help of ILO, WHO and the European Agency for Safety and Group, and the ILO has played a lead role in developing the Health at Work. NDPHS Strategy on Health at Work. An overall review of the implementation of the Strategy Next year, we hope to provide a permanent legal basis will be done in 2011 by the SIHLWA Expert Group. to the Secretariat. We will also have an evaluation of the The Strategy is available for download at http://www. Partnership. It will give all Partners a good possibility to ex- ndphs.org/?mtgs,pac_4__vilnius. press their views and expectations, and to get an external feedback on the Partnership’s role and activities. Mr Wiking Husberg Senior OSH Specialist Ms Toril Roscher-Nielsen International Labour Organisation Director General Chair of the NDPHS SIHLWA‘s OSH Subgroup Norwegian Ministry of Health and Care Services

Northern Dimension Partnership in Public Health and Social Well-being 3 NDPHS Database and Project Pipeline launched On 16 November 2007, during the The NDPHS Project Pipeline is an- ture is that expert groups and individual 4th Partnership Annual Conference other unique tool, the first of its kind in experts can be invited to review and ap- (PAC), the NDPHS officially launched the region. It has been designed to help praise project proposals. Once a project its Database and Project Pipeline. Both coordinate financing agencies’ funding is approved, it will also be displayed in these internet-based tools are open for activities, and enable project propo- the NDPHS Database. the public use and have been conven- nents to easily identify suitable funding As an additional service, the Pipeline iently integrated into the NDPHS web- opportunities and submit one com- also hosts a growing list of financing site at www.ndphs.org. They aim to help bined form matching donors’ individual agencies that can fund projects in the better coordinate and streamline efforts requirements.Information about fund- Northern Dimension area, but are not striving to improve public health and ing offered by the participating finan- connected to the Pipeline. social well-being in Northern Europe. cial agencies is conveniently displayed During the recent PAC Finland an- through three templates (by thematic Currently, the NDPHS Database nounced that it would contribute EUR areas, by geographical areas and the features three sections that contain in- 1.5 million for projects, which would be formation about projects (currently ca. combination of these two). 500), organisations (currently ca. 250) and persons (experts, project managers, etc.; currently ca. 280). In January 2008 a new section will be added containing papers, publications, reports, etc. All sections have been integrated with each other, i.e. project information is linked with information about organisation(s) that implemented and/ or financed this project and its project manager(s), and vice versa. Anyone may search for and sort information included in the Database, as well as add, edit and delete own information (NB. for quality assurance reason, each piece of information has to be approved by the Web- site Management Team before it is put for public display). Information is collected from three sources, i.e., through manual input, from the Project Pipeline, and automatically Database – search for and submit information about projects, organisations and persons Project Pipeline – check for funding opportunities and submit your project proposal from other databases available on the web. So far, eight external databases have An application needs to be written channelled through the Pipeline. The next been linked to the NDPHS Database, but only once, but can be sent to several call for proposals of the Norwegian Min- their number will grow in the near future. relevant financing agencies at the same istry of Health and Care Services, which It is hoped that the Database will be- time. Hence, the Pipeline can be seen as is planned to be opened in April 2008, come a useful tool helping people and a market place for project proponents will also be made through the NDPHS organisations collect and disseminate and donors to meet together and get Project Pipeline. Other donors will, hope- information, share best practices, find project ideas transformed to project ap- fully, follow in the future. To that effect, partners, e.g., for joint projects, etc. To plications and, finally, funded projects. the NDPHS takes concerted efforts to put it simply – no matter if you want To encourage and coordinate co-fi- encourage other donor countries as well to gain an overview of health-related nancing of projects a user-friendly inte- as financing agencies to joint the Project project activities in North West Rus- grated mechanism has been designed, Pipeline and, by this, further increase sia, or you are looking for a consultant which allows a project proponent and their own visibility and outreach. who has been working in Karelia on the agencies s/he applied to, to stay HIV/AIDS issues, the NDPHS Database is informed about each others requests, NDPHS Secretariat the place which you should visit. submissions, etc. Another helpful fea-

The NDPHS e-Newsletter is published by the Northern Dimension Partnership in Public We encourage readers to disseminate the Developed by: Health and Social Well-being (NDPHS) Secretariat in Stockholm, Sweden. It is published contents of the NDPHS e-Newsletter. NDPHS Secretariat bi-annually and is available only in electronic format through direct mailing to subscrib- It may be freely reproduced and reprinted, Strömsborg ers and on the NDPHS website, where you can also subscribe to it (www.ndphs.org). provided that the source is cited. P.O. Box 2010 We plan to publish the next issue in early SE-103 11 Stockholm, Sweden summer 2008. You are invited to contribute Tel: +46 8 440 1920 The NDPHS e-Newsletter arises from the project “NDPHS Project Database” which has to it. For further details - please contact us at Fax: +46 8 440 1944 received funding from the European Union, in the framework of the Public Health Pro- the NDPHS Secretariat. E-mail: [email protected] gramme. The sole responsibility for it lies with the NDPHS Secretariat. The Public Health Website: www.ndphs.org Executive Agency is not responsible for any use that may be made of the information contained herein.

4 Northern Dimension Partnership in Public Health and Social Well-being Summary Report of the WP 5 in EU project NDPHS Project Database

Information provision on specific Health Areas

Health Information expert Marina Wetzer-Karlsson

This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

Table of contents

1. Introduction ...... 4 2. Background ...... 4 2.1 Overall concept and aim of the NDPHS database...... 4 2.2 Objectives the task ...... 6 2.3 Tasks identified for the consultant ...... 6 3. Overview of the work done...... 6 3.1 Identification of possible information providers/sources ...... 6 3.2 Identification of possible information/data users...... 7 3.3 Evaluation of other possible information/data needed in the database ...... 7 3.4 Checking and testing the database of its consistency, and informational aspects...... 8 3.5 Other findings, proposals and comments ...... 10 4. Discussion and Conclusion ...... 10

ABBREVIATIONS

HR Human Resources ITA International Technical Advisor ND Area Northern Dimension Area NDPHS Northern Dimension Partnership in Public Health and Social Well-being NDPHS EG Northern Dimension Partnership in Public Health and Social Well-being Expert Group NGO Non Governmental Organisation PH EG Prison Health Expert Group PHC EG Primary Health Care Expert Group SIHLWA EG Social Inclusion, Healthy Lifestyles and Work Ability Expert Group WP Work Package

1. Introduction This report contains a description of the task and a summary of the comments and proposals made regarding Work Package 5 (WP 5) in the NDPHS Project Database.

It was agreed with the Head of the NDPHS Secretariat that the implementation of the task will be done in continuous proposals “as we go along”; therefore reference is made in the text to the documents/proposals sent to the NDPHS Secretariat separately. Also continuous discussions with the relevant stakeholders have been undergone during the entire task.

Furthermore, in the discussion and conclusion paragraph estimation on the future need of Human Resources (HR) for the maintenance and updating of the database is given.

2. Background There are several databases and information sources available in the Northern Dimension area. However, this data /information is scattered around in different settings and is not easily accessible nor it is easily comparable with each other. The data provided in the area in terms of projects, their field of activities, implementers and funding is presented in many different ways. This also means that there is lack of coordination and there is a risk of duplication of projects or lack in some health areas of projects. At the moment no database is available, which combines information/data on projects, epidemiological data, organisations, experts, funding, policy, research, best practises, target groups etc. into one database or web portal (DPSG 2/4. 1/Info 2).

A database can be a very powerful tool in analysing current trends and in emerging issues. It is also a very good way to increase networking among the actors within a specific field or organisations involved in implementation as in this case the implementation of health and social related development projects within the ND area. A database can also function as an important tool in capacity building and can be seen as a tool in knowledge management.

Knowledge sharing is one of the key issues in a database at least in this type of information database, where a wide range of information is provided for many different actors (policy makers, project implementers and experts in different fields) from different levels of development work (political to grass-root level).

2.1 Overall concept and aim of the NDPHS database

The text below is from the NDPHS Database at www.ndphs.org/?database and has been the base for this task in identification of information and data sources and providers and also in the other issues within this task.

Information included in the NDPHS Database is collected from several sources to ensure as comprehensive and complete overview as possible. These sources include the following:

• Other relevant external databases (directly linked to the NDPHS Database); • NDPHS Project Pipeline; This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

• Information inserted manually through forms provided in the NDPHS Database.

As regards the first source, every effort was taken by the NDPHS to identify and connect external databases containing information relevant to its own database. Unless otherwise stated, external databases are linked to the NDPHS Database through an automatic feed or a parsing mechanism . These databases have been linked to the NDPHS Database through an automatic feed or a parsing mechanism (the NDPHS Database runs a fully automated routine, which contacts the linked source databases on a regular basis to update new project information). The aim is to increase the reach of information and allow to more widely disseminate information contained in the linked databases, and to do so seamlessly and effortlessly. At the same time the visibility of these databases is also increased as each piece of information in the NDPHS Database, which comes from them, is properly tagged with the source name.

Concerning information originating from the NDPHS Project Pipeline, only the projects, which have been granted the (entire) requested funding and whose implementation is, therefore, guaranteed, are automatically included in the NDPHS Database.

Finally, NDPHS Database enables information to be inserted manually. This solution makes it possible for organisations and individuals to share the information about their own projects and organisations and increase their visibility. It also allows individuals (such as project leaders and experts) to include in the database information about themselves or their co-operants. While all actors active in the Northern Dimension area and dealing with issues related to public health and social well-being are encouraged to submit information to the NDPHS Database, it should be noted that each piece of information submitted manually has to be approved by the NDPHS Database Management Team before it becomes visible to the public.

A carefully structured and accurate database mechanism has been developed for the NDPHS Database allowing for storing of the above-named three groups of information in an integrated way. This mechanism allows for information to be both added and edited as well as searched for, sorted and deleted in an effortless and user-friendly way. (http://www.ndphs.org/?database,page,about)

The NDPHS Database is a joint effort of the NDPHS Partner Countries and Organisations and one of the main elements of the Partnership’s Coordinating and Financing Mechanism. Its ultimate goal is to help better coordinate and streamline efforts aimed at the improvement of public health and social well-being in Northern Europe. More specifically, its aim is to bring information closer to people, institutions and organisations at various levels, and to help them, for example, in:

• Monitoring and coordinating activities in the Northern Dimension area; • Designing funding programmes (financing agencies); • Searching for other organisations and/or individuals with an aim of involving them in one’s own activities, on the one hand, and introducing own organisation and/or person as a potential partner in activities of other organisations (networking and developing partnerships with other people, institutions and organisations); • Increasing expertise and knowledge as well as facilitating know-how transfer; • Developing policy, research and other papers; • Sharing best practices and lessons learnt; • Preparing information (e.g. for lectures, training activities, awareness raising campaigns, etc.).

The above include, on the one hand, fact-finding activities and, on the other hand, presenting and disseminating information about one’s own activities. (http://www.ndphs.org/?database)

2.2 Objectives of the task The objectives of the WP 5 task are the identification of information provider/data sources, necessary data groups, gaps and possible analyses derived from data, network meetings in the specific four health areas: 1) communicable diseases, 2) lifestyle related diseases, 3) prison health and 4) primary health care → continuous facilitation and control of data input.

2.3 Tasks identified for the consultant • To identify possible information providers/sources, so that it will be possible for the NDPHS Secretariat to contact these.

• To identify information and data users

• Evaluate other possible information/data needed in the database, such as a “new” section e.g. publications/papers

• Check/test the database pilot program of its consistency, and informational aspects 3. Overview of the work done

At first the database was checked/tested. This part of the task was time-consuming and took 10 days. This task is discussed in more detail in paragraph 3.4.

Secondly, the identification of possible information and data providers/sources were identified in terms of larger organisations, foundations and institutions. The identified organisations, foundations and institutions could also be considered to be joined to the NDPHS pipeline. See more detailed description in paragraph 3.1.

Thirdly, information of NGOs and other institutions where gathered, these may be seen as both information and data providers/sources and users of the database. See description in paragraphs 3.1 and 3.2 for more information.

Fourthly, list of persons as possible providers/sources and users of the database have been prepared. See paragraph 3.2.

The last task preformed was evaluation of other possible information/data needed in the database. A new section of general social and health information was proposed. See paragraph 3.3.

Furthermore, the task has been implemented through consistent discussions and e-mail correspondence with the relevant stakeholder within the project.

3.1 Identification of possible information providers/sources The identification of possible information providers/sources has been done in cooperation with the NDPHS Expert Groups (EGs), HIV/AIDS, Prison Health (PH), Primary Health Care (PHC), Social inclusion, healthy life styles and work ability (SIHLWA). The views and opinions of the Expert Groups

were asked in what kind of providers/sources and users would in their view be the most relevant. Unfortunately, only few of the experts answered or notified their views and opinions. However, several discussions with the International Technical Advisor (ITA) of the HIV/AIDS EG have taken place and also the Chair of SIHLWA has been consulted on the issues of possible information providers/sources.

The information providers/sources have been categorised into two categories: 1) Possible funders for the pipeline with existing databases and activities in the ND area, 2) Health related information and data providers/sources. Proposals and Information/data have been sent in separate documents to the NDPHS Secretariat on the 20th November 2007, 3rd of December 2007 and 4th of December 2007 (Annex 1, 2 and 3).

3.2 Identification of possible information/data users The field of Non Governmental Organisation (NGO) work done within the ND area (both geographical and priority areas of health and social well-being) is extensive and the information of the projects is seldom in any of the “larger” databases, therefore the NGO sector is seen as one of the important information users and also providers (at least in the project section of the database). A proposal/document of these has been sent to the NDPHS Secretariat on the 3rd of December 2007 (Annex 2).

It is suggested that these organisation would be contacted as has already been done for the organisations listed in the database. Some of the organisations have been already contacted (they are marked in the list). However, this list is not totally complete, because the NGOs change and data corrections are continuously deemed necessary as the development work/aid changes etc. Therefore, it is suggested that the work would be continued in identifying new organisations working in the field and would be done regularly in the future. The organisations could be contacted at regular intervals as a sort of reminder of checking and encouraging them to join the database.

The list also includes other types of organisations e.g. web-based magazines and NGO support facilities. These are a good way of channelling information of the database to other NGOs engaged in development work within the area.

A list of persons who would be possible information/data providers (in terms of their expertise) and users of the database has been sent to the NDPHS Secretariat on the 4th of December 2007 (Annex 3).

3.3 Evaluation of other possible information/data needed in the database

To increase networking and in order to be able to provide all the below mentioned issues, a general social and health information section to be added to the database was proposed.

• Sharing best practices and lessons learnt; • Preparing information (e.g. for lectures, training activities, awareness raising campaigns, etc.).

A general proposal (overview) of such a section was sent to the NDPHS Secretariat on the 7th of December 2007 (Annex 4). In further discussions and comments of the proposal with the Secretariat amendments were made (sent on the 18th of December 2007) (Annex 5). Also a proposal of search field and categories was done (sent on the 19th of December 2007) (Annex 6). The EGs were further consulted for advice in this matter. However, their response was vague and only one comment was received. Therefore, it was suggested that the NDPHS Secretariat would continue the development of a general information section in the database in cooperation with the EGs.

3.4 Checking and testing the database on its consistency, and informational aspects It was agreed that the work of this task would be started from the checking/testing and this was also a very good way of getting to know and understand the way the database works. This gave the consultant a very good base (information/data) for the other assigned tasks.

The checking and testing of the database was done manually, by searching, sorting and adding, deleting the information inserted in the database during its pilot phase and before the public launch.

Proposals of changes and corrections were made during the process with the relevant project team members. Some comments and proposals have been sent in writing and some have been discussed over the telephone and by e-mail correspondence. This phase was done between 9th of November and 19th of November 2007.

The main issues, which have arisen during the checking and testing and some other are listed in more detail in the proposal/document sent to the NDPHS Secretariat on the 13th of November 2007 (Annex 7) are presented below.

There were several inconsistencies in the data inserted in the database, mainly in terms of the external databases and their automatic “communication”. Efforts are taken to increase and improve the coding system between the different databases. However, it is recognised that the external databases do not include all the information, which is contained in the NDPHS database and therefore the automatic coding cannot be totally complete. The manual correction is very time-consuming and therefore, action has been taken already in contacting the organisations and persons in encouraging them to check and correct their information in the database. Furthermore, it was agreed that the Project Main Expert continues systematically to do the corrections of the information/data of database as the first priority. Once the corrections are made the Project Main Expert should move to the next stages, being the contacting of new organisations and persons in order to “market” the database.

3.4.1 Projects section Inconsistencies that have occurred in the projects section of the database are the following: • Within the different external databases the most common problem has been the identification of the thematic area and target audience. • An other issue has been the coding of the financier in some cases (mainly BEAC) the automatic data input has inserted the data in the wrong category (as lead partner), but action was taken immediately to correct this.

Proposal for the future: In terms of developing the coding system and “communication” between the databases in the case of thematic area may not be possible. Therefore, it is suggested that a systematic way of checking the thematic area and target audience would be assured. For example, depending on how often the communication between the databases is done, then also at the same time a manual check of the updated information/data would be done at least for the main issues, such as thematic area, summary and financier (if available).

Also the encouragement of organisations and persons implementing projects continuously may be a good way of keeping the database up to date. However, this will need reassuring of the future human resources in NDPHS Secretariat.

Informational aspects of this section The informational parts of this section are adequate and no proposal for changes has been made nor seen as necessary.

3.4.2 Organisation section At the checking/testing and reviewing phase of this section it was recognised that this section was still in terms of information fairly incomplete (as also informed by the Head of the NDPHS Secretariat). A list of information of the organisations inserted in the database was sent to the Secretariat. The list mainly contained web sites of the organisations and some other comments were also included.

There is a concern over the updating of this section in the future; it will need HR of the NDPHS Secretariat to activate the organisations in checking and updating their own information. The Project Main Expert has started this work already.

Informational aspects of this section Proposals of some changes and comments of the informational aspects of the organisations section have been made in the proposal/document sent to the NDPHS Secretariat on the 13th of November 2007 (Annex 7).

3.4.3 Persons section At the checking and testing phase the persons section of the database was still very incomplete (inconsistency for instance in the order of first name and last name and very little data was available) and the data inserted to the persons section was mainly by the external databases and measures were taken to do corrections and amendments to this section immediately by the Project Main Expert and the consultant. This work still continues.

The only concern with this section is the future updating, if it will not be possible to activate the persons themselves to keep their information correct it will lead to either a lot of work for the NDPHS Database Management Team or then a lot of incorrect information. For example, all these persons are mainly linked to projects and they may not be acting anymore in the same organisation as at the time of the project in question.

Proposal for the future: It is suggested that all the persons inserted (external or NDPHS manually inserted) would be systematically checked and contacted and encouraged to check their data. A notification/reminder could be sent in the future at regular intervals (e.g. once in six months) from the NDPHS Secretariat.

Informational aspects of this section The information provided in this section is relevant and no proposal for changes is neither made nor seen as necessary.

3.5 Other findings, proposals and comments One of the things in terms of the thematic area was that HIV/AIDS and TB were set under the same thematic area and it was important that they be divided into two separate ones. The importance of having these two separate is that being two very large scale diseases under the same thematic area would have decreased the informational value of this area and may also have created a lot of extra work in the future to split them up. Actions to split these two were taken immediately and the Project Main Expert has been doing the necessary changes in the database.

In the discussions with ITA of HIV/AIDS EG the issue of possibly having an automatic notification system for the ITAs when a new project in their field is inserted in the database would be useful. This should be possible if the ITAs can be linked to the NDPHS Secretariat’s Database Management Team. In this way the ITA would get information of a new project in his/her field of expertise and would be able to take action if needed.

4. Discussion and Conclusion In order for this type of database with many different levels of information and data to be useful, (effective and attractive) for the users, it is very important that most complete and accurate information/data is provided. Therefore, it is of the utmost importance that maintenance and updating is ensured for the future. In terms of the maintenance of the database it is important to bear in mind that the technical parts of the database will also be updated regularly (servers and the external database information/data “pick ups” and the “speed” of the database will be updated in terms of when the use of the database increases, it will need to be responsive and accessible.

It is estimated that future HR needed for ensuring the sustainability (and provision of accurate information/data) of the database would be to employ one full time person for the maintenance (not including the technical aspects), marketing and updating of the database.

Annex 1

Title of Project NDPHS Project Database

Work Package No. 5 Information Provision on Specific Health Areas

Name of Paper Identification of possible information and data providers/sources to be connected to the NDPHS database and pipeline

Summary -

By/date Health Information Expert/20.11.2007

Identification of possible information and data providers/sources to be connected to the NDPHS database and pipeline

In order to increase the usage and commitment to use the project-database in terms of NGOs and other implementing organisations it is seen important to be able to provide concrete “benefits/incentives”. Therefore, it is proposed that the following information and data providers/sources may also be seen and considered to be eligible partners for the NDPHS project-pipeline.

In this list the organisations and their priority areas, geographical coverage are presented shortly and their contact details are given.

Bill and Melinda Gates Foundation

Website: http://www.gatesfoundation.org/default.htm

Priority Areas:

Infectios diseases (other than STDs and HIV/AIDS) Acute Diarrheal Illness: The foundation is funding work aimed at preventing and treating infectious diarrhea, which contributes to the deaths of 2 million to 3 million young children each year. Malaria: The foundation's grantees are working in many areas to reduce the burden of malaria on the world's poorest countries. Their work includes the development of vaccines to prevent the disease and large-scale efforts to control malaria by making better use of existing tools. Chronic diseases Acute Lower Respiratory Infections: The foundation aids efforts to improve diagnosis and develop better vaccines against these common infections. Child Health Child Health is one of the foundations priority, much of the work on specific diseases supported by the foundation is aimed at child diseases. HIV/AIDS and TB HIV/AIDS: The foundation supports the development of vaccines and other tools and strategies with the potential to prevent tens of millions of infections and deaths. They also fund comprehensive initiatives that include both prevention and treatment. TB: The foundation supports work in the prevention and treatment of TB, including the search for improved vaccines, better tools for diagnosis, and new drugs to treat active TB. Poor Nutrition

The foundation assists efforts to improve nutrition, including developing foods and crops that are high in essential vitamins and minerals, and ensuring that healthy foods get to those who need them most. Reproductive and Maternal Health To improve the health of women in the developing world, the foundation supports efforts to reduce deaths and illnesses related to pregnancy and prevent unintended pregnancies.

Information source: http://www.gatesfoundation.org/GlobalHealth/Pri_Diseases/default.htm

Geographical area:

Bill and Melinda Gates Foundation support activities in over 100 countries also within the priority area of Northern Dimension.

Project database

The foundation does not have a project database as such but a list of accepted funding is available at: http://www.gatesfoundation.org/GlobalHealth/Grants/default.htm?showYear=2007

Contact Details:

Bill & Melinda Gates Foundation PO Box 23350 Seattle, WA 98102

Phone: (206) 709-3100 (Reception)

(206) 709-3140 (Grant Inquiries)

Email: [email protected]

EEA Financial Mechanism

Website: http://www.eeagrants.org/ngos

The Financial Mechanism’s aim is to reduce social and economic disparities within the European Economic Area (EEA), and to enable all EEA countries to participate fully in the Internal Market.

Through the EEA Financial Mechanism, the three EEA-EFTA states Iceland, Liechtenstein This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

and Norway will make a total €600 million available to the 10 countries that joined the EU and the EEA in May 2004, as well as to Greece, Portugal and Spain. Through the Norwegian Financial Mechanism, Norway will make an additional €567 million available to the 10 countries that joined the EU and the EEA in 2004. Both mechanisms run over a five- year period until 2009. Norway, as the largest of the three donors, will contribute with close to €1.14 billion.

Information source: http://www.eeagrants.org/financialmechanisms

Priority areas: • Protection of the environment • Sustainable development • Conservation of European cultural heritage • Development of human resources

Health and childcare The Norwegian Financial Mechanism will also make funding available for: • Implementation of legislation in the field of internal security and border control, such as support for ‘Schengen’ action plans • Environment, i. a. with emphasis on strengthening the administrative capacity to implement relevant acquis and investments in infrastructure and technology with priority given to municipal waste management, • Regional policy and cross-border activities • Implementation of aquis communitaire through technical assistance

Academic research within the priority sectors of both mechanisms may also be eligible for funding. Information source: http://www.eeagrants.org/prioritysectors

Project database

The EEA has a good and relevant database of the projects implemented thru this financial mechanism. http://www.eeagrants.org/projects

Contact Details:

Financial Mechanism Office Postal address: 12-16 Rue Joseph II 1000 Brussels, Belgium

Visiting address: 47-48, Boulevard du Régent 1000 Brussels, Belgium

Tel: +32 (0) 2 286 1701 Fax: +32 (0) 2 286 1789 Email: [email protected]

Nordic Council of Ministers

NCM has several funding mechanisms/programmes within the ND area and is also a member of the NDPHS, so therefore it is suggested that discussion/negotiations would be initiated if not already done.

An example of one of the programmes NCM has provided funding opportunities is:

The NGO Programme. Information can be found at: http://www.norden.org/russland/uk/stotte.asp.

The website also contains a list of projects which have received funding, but no actual database is available.

Annex 2

Title of Project NDPHS Project Database

Work Package No. 5 Information Provision on Specific Health Areas

Name of Paper Identification of possible information and data providers/sources and users to be connected to the NDPHS database1

Summary -

By/date Health Information Expert/3.12.2007

1 (In addition to those sent to the Secretariat on the 20.11.2007)

Governmental and International organisations to be included in the database

The Canadian International Development Agency (CIDA) CIDA is Canada’s lead agency for development assistance. It has a mandate to support sustainable development in developing countries in order to reduce poverty and to contribute to a more secure, equitable, and prosperous world. CIDA has many projects in Russia and has also a good database of projects. Therefore, it may be good to conduct discussions with them in terms of having them as an external database. CIDA may also be a good candidate for the NDPHS pipeline, because they also fund development projects and Canada is a part of the NDPHS partnership. (Sent also by e-mail to the Head of Secretariat on the 26.11.2007)

Website: http://www.acdi-cida.gc.ca/cidaweb/acdicida.nsf/En/Home

Programme/project database: http://www.acdicida.gc.ca/CIDAWEB/acdicida.nsf/En/JUD-112911223-LTK?OpenDocument

Eurasian Harm Reduction Network (EHRN)

The mission of EHRN is to support, develop and advocate for harm reduction approaches in the field of drugs, HIV, public health and social exclusion by following the principles of humanism, tolerance, partnership and respect for human rights and freedoms.

EHRN is a flexible body, which shares a unified ideology and employs a diversity of policies and approaches. Function of the Network in the field of coordination lies in support of efforts of regional and topic-driven sub-networks to address urgent issues. Activists and member organisations as well as the Steering Committee and the Secretariat of the Network provide with ideas, urgent information, mechanisms, and methodologies that meet demands and increase work efficiency of member organizations in the region and within the sub-networks.

In line with its mission, EHRN initiates and supports changes aimed at implementation of more effective drug policies and integration of topics related to the work conducted in the field of drugs. As a result, EHRN sees reduction of criminal and socially unwelcome factors related to drug use as well as enhanced appreciation by the society of the value of harm reduction activities. This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

More information of the EHRN activities, networking and projects can be found at http://www.harm-reduction.org/?ItemId=15926

Website: http://www.ceehrn.org/

Contact details:

EHRN Secretariat contacts: Siauliu Str. 5/1-21, Vilnius 01133 Lithuania Tel. +370 5 269 1600 Fax. + 370 5 269 1601 E-mail: [email protected]

Finnish NGO sector information already distributed of the NDPHS and its database and pipeline

KEHYS ry is the abbreviation for the Finnish NGDO Platform to the EU. It is a registered organisation that offers services to the non-governmental organisations on issues concerning development cooperation of the EU. It provides information about EU development policy and about opportunities for Finnish NGO's to receive EU funding. It also provides support for organisations to influence EU policy, training, consultancy and information. KEHYS ry promotes collaboration and networking between Finnish and European NGO's which deal with development cooperation and development education. It also promotes debate in Finland and in the EU about development policy.

First contact to KEHYS ry was by telephone (16.11.07) to their Information Officer Ms. Anna Pollari and then by e-mail to her. The information sent has been passed forward to the Project Advisors within the organisation and they will distribute it further to the member organisations.

The information sent via Kehys ry to the Finnish NGO sector is the websites of NDPHS (main page), pipeline, database and the press release on the 26th of November 2007.

KEPA, or the Service Centre for Development Cooperation, is a service base for Finnish NGOs interested in development work and global issues. Over 250 such organisations belong to KEPA. These organisations vary greatly in character - large and small, local and national, professional and ideological. KEPA itself is a politically

and ideologically non-aligned organisation that operates with funding from the Finnish foreign ministry.

The information was sent to the Communications Manager Mr Mika Railo. The information sent via Kepa to the Finnish NGO sector is the websites of NDPHS (main page), pipeline, database and the press release on the 26th of November 2007.

FinnChurchAid (FCA)

FinnChurchAid (FCA) is one of the major international NGO's in Finland. It carries out development, relief and interchurch aid on behalf of the Evangelical Lutheran Church in Finland and its congregations.

FCA channels funds mainly through the Lutheran World Federation (LWF), the World Council of Churches (WCC) and ACT (Action by Churches Together). Assistance is given irrespective of the recipient's political orientation, religion, ethnic background or nationality.

FinnChurchAid does advocacy work on behalf of the world’s poorest people for life’s basic human rights and dignity. All our programs emphasize the individual’s responsibility.

Cooperation in the ND area

Cooperation continues with Estonian and Ingrian Lutheran churches. With regard to content, the most important challenge was support for education in the Ingrian church.

FinnChurchAid also supported the work of the Russian Orthodox Church among marginalized people in society, particularly among children. It also supported the work of the Interchurch Council for Diaconic Work in St. Petersburg, which strengthened its role in the churches’ HIV/AIDS work in Russia.

• Main program countries: The Balkans, Estonia, Russia • Main programs: Reconstruction, interchurch aid • Total Development assistance 2.1 million Euros • Development assistance 15% • Emergency and refugee assistance 22% • Interchurch aid 63% Human rights and peace <1%

Website: http://www.kua.fi/english/front_page/?id=51

Contact details:

FinnChurchAid P.O. Box 185 (Street name: Luotsikatu 1 A) FIN-00161 Helsinki

Tel: (-358-9) 18021 Fax: (-358-9) 1802 207 Email: [email protected] or Internet: http://www.kua.fi

Finnish Lung Health Association (Filha ry)

Filha is a non-governmental public health organisation (NGO) fighting against lung diseases by implementing prevention and treatment programmes, educating health care professionals and enhancing networking of experts. Filha acts nationally in Finland but also in its neighbouring areas and in areas of less developed health care infrastructure. Filha was founded in 1907 and is thus one of the oldest public health organisations in Finland.

Contacted on Friday the 23rd of November 2007, 2 of the project advisors at Filha ry and one of them had already on the 26th updated information and opened an account.

Swedish NGO sector information could be distributed of the NDPHS and its database and pipeline

Forum Syd gathers two hundred Swedish organisations working with international development assistance and the forming of opinion on global issues. Member organisations consist of major popular movements such as Save the Children Sweden and the Swedish Society for Nature Conservation, as well as small societies run entirely on a voluntary basis. Forum Syd also works with a large number of organisations and networks worldwide. Our common aim is global justice.

Contact details: Main Office Forum Syd Box 15407 S-104 65 Stockholm, Sweden This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

visit: Katarinavägen 20, Telephone: +46 8 506 370 00 Telefax +46 8 506 370 99 [email protected] http://www.forumsyd.org

Russian NGO sector

The Centre for the Development of Non-Governmental Organisations The Centre for the Development of Non-Governmental Organisations (NGOs) is a resource centre for non-commercial organisations in the North-West Region of Russia, working in the areas of social protection, ecology, education, learning, culture, art, human rights protection and other socially beneficial causes. The Centre's work is focused on the development of civil society in Russia, furthering its role in the community with the aim of promoting the regions' ongoing development and improvement of a stable quality of life.

Website: http://old.crno.ru/english/e_index.html Contact details: 87, office 300 Ligovsky pr. St. Petersburg 191040 Russia Telephone/Fax: + 7 812 118 3794

Stellit

Regional Non-Governmental organization of social projects in sphere of population's well-being "Stellit" began its work in 1996, and registered as an official NGO in February 2002.

Working in the society requires holding on to your beliefs and trusting in your fortune. This idea guided the selection of a name for our organization. "Stellit" (from the Latin word "stella" meaning "a star"), which is a harm-resistant alloy of metals.

Stellit's founders are professional sociologists and psychologists with extensive research experience in deviant behaviour research with the Sociological Institute of the Russian Academy of Sciences.

Stellit was conceived and registered as in independent NGO that that would provide services, policy recommendations and serve as a centre for continued research and public education.

Already as an organisation in the project database, but should be contacted in order to encourage adding other their projects in the database.

Website: http://www.ngostellit.ru/eng/

Contact details: 190020, Russia, St.Petersburg, Bumazhnaja str., 9 – 617 Tel. /fax: +7 (812) 445 2893, 445 2894 “Hot-line” (department “Social work”): +7 (812) 970 1308 (from 10 to 18 o’clock workweek days) Tel. in Moscow: +7 (926) 534 9463

Nochlezkha “Night Shelter”, St. Petersburg Regional Humanitarian Organisation for the Homeless The organisation "Nochlezhka" (Night Shelter) adheres to the founding principle that every human life is valuable and that everyone in Russia has the right to live a life in dignity and safety, independent of social status. Nochlezhka carries out programmes directed at social and psychological rehabilitation and defence of homeless people's rights, primarily in the North-Western Region of Russia

Website: http://homeless.ru/index.php?lang=en

Contact details: 112-B, Borovaya str., St. Petersburg 192007, Russia Tel: +7 812 974 84 42 +7 812 380 50 44 www.homeless.ru E-mail: [email protected]

St. Petersburg Regional Non-governmental Organisation for Work with Children and Youth – Centre Innovations

The goal of the organisation is preparation and implementation of programmes that develop innovative methods in the social sphere. The work is aimed at children and adolescents of social risk groups.

Conceptual bases of the activity:

1. Work with the complete spectrum of problems in the area of family and childhood – from developing and implementing practical projects that aid “street” children to work in schools with programmes to prevent drug addiction among children and adolescents, in order to track not only progress in solving problems, but also the interrelations between the origins of these problems;

2. A multifaceted approach, which takes into account the social, educational, psychological, and ethical problems that we try to resolve;

3. Successive work on the problem which proceeds in stages: creating innovative model projects; working out a methodological basis while simultaneously collecting statistical data; developing and systematising the information obtained; propagating methods and approaches on the basis of acquired experience with the aim of introducing them into governmental structures.

Website: http://www.innovations.spb.ru

Contact Details:

Russia, 191011, St. Petersburg Ul. Dumskaya 1/3 Tel. / fax: (007-812) 315 48 25 E-mail: [email protected]

Open Health Institute (OHI) OHI is a Russian non-governmental organisation and is one of the largest NGOs in Russia in the sphere of public health. OHI was founded in 2003. OHI activities include: Infectious disease control aiming at HIV/AIDS prevention, fighting combine HIV/AIDS and TB epidemics; non-infectious disease control such as, improvement of tobacco and alcohol control policies and professional development of public health and medical personnel according to the principles of evidence-based medicine. OHI works together with both international and Russian organisations and academic institutions.

Website: http://www.ohi.ru/e_aboutohi.php

Contacted via e-mail on the 26th of November the organisations is visible in the database but no information is available.

Karelian regional public-youth organization "Balance" The charitable organization known as "Balance", occupied with adaptation orphan children of Karelia was founded in Petrozavodsk in 1999. Balance has already achieved great results in five years of its being in existence. Today the Balance organization provides assistance and support to ten orphan institutions of Petrozavodsk in different fields.

Website: http://www.balance.sampo.ru/eng.html or http://balance.metakultura.ru

Contact details:

Adress: 183035, Russia, Karelia, Petrozavodsk, Krupskaya St., 12, KROMO "Ravnovesie" Phone/Fax: +7 (8142) 76-54-82 URL: e-mail: gezalov(at)yandex.ru

Russian Cancer Society

The Russian Cancer Society (RCS) is the nationwide voluntary health organization dedicated to eliminating cancer as a major health problem in Russia by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service. Particular emphasis is placed on professional and public education.

To meet its objectives, the RCS creates and carries out programs in collaboration with 58 regional divisions. The Society cooperates with other organizations, societies, and governmental bodies engaged in promoting cancer control and research.

RCS creates a focused endeavor to unite multidisciplinary approach in cancer control and establish a formal two-way communication with cancer treatment facilities and other health care providers. RCS activities aim to influence Russian policy issues which affect the death rates from avoidable or controllable cancer.

Website: http://www.pror.ru/pror_rcs.shtml

Contact details:

RCS Secretariat

Address: Kashirskoye shosse 24,115478 Moscow, Russia

Main numbers: Tel. +7 (495) 324 1640 Tel. +7 (495) 324 1470 Fax +7 (495) 324 1205 E-mail: [email protected]

Russian NGO support organisation and web based magazine

Foundation for the development of non-governmental organizations NGO SCHOOL - professional support of civic initiatives

The NGO School Foundation is the largest resource centre in Russia providing comprehensive counselling support to organizations which develop civic initiatives. The key objective of the Foundation is to disseminate key knowledge on the legal, financial, and management aspects of non-profit activity and create platforms for exchange of experience and further development of the Russian non-profit sector.

The NGO School Foundation was established in 1997 by Charities Aid Foundation UK under the name of Consultations for Associations and Foundations, an autonomous non-profit organization. After five years of successful operation it was reorganized into the NGO School Foundation.

The mission of the Foundation is to ensure professional development of non-profit organizations and provide support to civic initiatives. Over the years, more than 3000 non-profit leaders from 63 regions of Russia have taken part in educational programs of the Foundation. The NGO School has also been implementing large projects, many of which aim at encouraging children, youth and adults to actively participate in the efforts to improve the quality of life in cities and villages. During the ten years the Foundation has been providing consultancy services which help non-profit organizations to cope with the legal and financial issues they face daily.

This organisation may be a good way of promoting and distributing information of the database and the general activities within health and social well-being issues in the ND area

Website: http://www.ngoschool.org/

Contact: details:

24/2 Tverskaya St., Building 1, Entrance 2, Floor 5. 103050 Moscow, Russia

Annex 3

Title of Project NDPHS Project Database

Work Package No. 5 Information Provision on Specific Health Areas

Name of Paper Identification of possible information and data providers/sources and users to be connected to the NDPHS database (Persons)

Summary -

By/date Health Information Expert/4.12.2007

List of persons to be contacted and possible inserted in the database The persons listed below are all involved in health and social issues in terms of projects and position of work. These may also be included (if not already) in the Newsletter mailing list. Some of the persons are already in the database, but this list offers some more information of those persons.

Mr. Bengt Sibbmark [email protected]

Ms. Carina Strand [email protected]

Mr. Claus Sømod [email protected]

Ms. Eva Pedersen [email protected]

Ms. Grethe Fenger Møller [email protected]

Ms. Gunilla Malmborg [email protected]

Mr. Gunnar Tveiten [email protected]

Ms. Helgi Már Arthursson [email protected]

Ms. Helle Engslund Krarup [email protected]

Mr. Jan Simonsen [email protected]

Mr. Kristian Birk [email protected]

Ms. Lena Valentin [email protected]

Ms. Maria Waltari [email protected]

Ms. Marianne Kristensen [email protected]

Ms. Maria-Pia de Palo [email protected]

Ms. Mikaela Dahlblom [email protected]

Ms. Monica Norrman) [email protected]

Mr. Ole T. Andersen [email protected]

Ms. Rebecka Wallin Kucer [email protected]

Mr. Risto Pomoell [email protected]

Ms. Siw Ellefsen [email protected]

Ms. Synnöve Jordas [email protected]

Mr. Søren Rendal [email protected]

Mr. Thor Thorarinsson [email protected]

Ms. Unni Rörslett [email protected]

Ms. Viveca Arrhenius [email protected]

Ms. Tatjana Smolskaja [email protected]

Ms. Inna Rozhkova [email protected]

Ms. Vera Utjugova [email protected]

Mr. Mikhail Murashko [email protected], [email protected]

Mr. Vladimir Kostrov [email protected]

Dr. Anders Blaxhult, MD Fax: +47 22 24 27 74 Deputy State Epidemiologist E-Mail: [email protected] Swedish Institute for Infectious Disease Control

171 82 Solna, Sweden Mr. Arnt Uchermann Tel. +46 8 457 2379 Health enterprise of Northern Norway E-Mail: [email protected] Leader Barents Office

Health Enterprice of Northern Norway Dr. Hans Blystad P.O.Box 410 Senior medical epidemiologist N-9915 Kirkenes Norwegian Institute of Public Health NORWAY (NIPH) Tel: +47 913 27 321 Department of Infectious Disease Fax: +47 7897 3169 Epidemiology E-Mail: arnt.uchermann@helse- PO Box 4404 Nydalen finnmark.no N-0403 OSLO

NORWAY Phone: +47 22042404 Mr. Thor Robertsen Fax: +47 22042513 Special Adviser E-Mail: [email protected] Finnmark County Administration Tel. +47 78 96 20 88 Fax +47 78 96 23 70 Mr. Olav Berstad E-Mail: [email protected] Ambassador Ministry of Foreign Affairs, Oslo Mr. Roald Røkeberg P.O Box 8114 Assistant County Counsellor Dep 0032 Oslo, Norway Finnmark County Administration Tel: +47 2224 3101 Tel. +47 77 78 81 84 Fax: +47 2224 3570 Fax +47 77 78 83 64 E-Mail: [email protected] E-Mail: roald.rokeberg@troms- f.kommune.no

Ms. Hildur Odland Mr. Sigbjørn Eriksen Adviser Special Adviser Ministry of Foreign Affairs Nordland County Administration P.O Box 8114 Dep 0032 Oslo Tel. +47 756 506 05 Tel: +47 22 24 32 34 Fax +47 756 506 01

E-Mail: [email protected] in Russian North-West Federal District Mr. Svyatoslav Prokofyevich St. Petersburg State Medical Academy Lukyanenko 195 067 St. Petersburg, Deputy Head of the Department for Piskarevsky, pr.47 Legal Tel:+7 812 543 50 14, - 543 14 73, and International Activities -543 59 18, Ministry of Foreign Affairs Fax: +7 812 740 15 24 Ministry of Health and Social E-Mail: [email protected], Development of the Russian [email protected] Federation Tel. +7 095 925 11 40 Ms Klara Shevchenko Fax + 7 095 692 42 17 Head of the Social Development E-Mail: [email protected] Department Administration of the Karelian Ms. Ekaterina Kuznetsova Governor Project assistant in International Affairs 19, Lenin Avenue, Petrozavodsk Public Health Care Committee Republic of Karelia St. Petersburg Tel: +7 814 2 790 339 Russia Fax: +7 814 2 792 191 E-Mail: [email protected] E-Mail: [email protected]

Ms Marina Pavlovna Shevyreva Ms Irina Mihailovna Turnovskaya Head of Department for Vice Minister Pharmaceutic Activities, Human Ministry of Health, Social Development Wellbeing, Science and Education and Sport of the Republic of Karelia Ministry of Health and Social Lenin av. 6, Development of Russian Federation 185 035 Petrozavodsk Rahmanovsky street 3/25 Tel: +7 814 2 79 29 03; +7 814 2 792900 127994 Moscow Fax: +7 814 2 78 28 19 Tel: +7 495 692 07 75 E-Mail: [email protected] Communicator: + 7 495 628 44 53

Fax: +7 495 692 42 17 Mr. Lev Volikovski E-Mail: [email protected] Head of Karelia AIDS Centre Mr. Alexander Shabrov [email protected] Professor Representative of the Ministry of Mr. Khidishian Ervand Arutunovich Health This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

Deputy Minister, Ministry of Health, NGO”Rassvet”, Archangelsk Karelia [email protected] [email protected] Fax: +7-8142-782819 Mr. Narkevich Mikhail Ivanovich Fond ”Zdorovie” Mr. Mikhail Murashko E-mail: [email protected] Minister Ministry of Health of the Republic of Mr. Roman Buzinov Komi Head of the Territorial Administration Lenin str. 73, 167000 Siktivkar, Russia of Federal Service for the Consumers’ Tel: +7 8212 44 07 77; +7 8212 44 20 52 Rights Protection Surveillance and Fax: + 7 8212 44 13 25 Human Wellbeing in the Arkhangelsk [email protected] Region [email protected] Tel: +7 182 20 05 69 E-mail: [email protected] Mr. Konstantin Anatolyevich Sazhin Vice Minister of Labour and Social Ms. Irina Menshutkina Development Health Care Department, Unit of Adult Ministry of Labour and Social Development Health Care 167000 Syktyvkar Arkhangelsk Region Administration Komi Republic Tel: +7 182 20 2156 Tel. +7 212 24 15 01 (secr.), +7 212 24 E-mail: [email protected] 64 51 Fax +7 212 20 37 27 (Remember to mention that fax is for Sazhin) Mr. Alexander Gavrilov E-mail: [email protected]; Press secretary Health Care Department Arkhangelsk Region Administration 163004 49, Troitskiy pr., Arkhangelsk, Dr. Vera Utyugova Russia Chief Doctor AIDS Center in the Arkhangelsk Region

20 Chumbarova Luchinskogo street, 163061 Arkhangelsk, Russia Tel: +8-8182 65 42 11 Fax: +8 8182 65 42 11 Mr. Leonid Rozavskiy, E-mail: [email protected] Director Medical Information Analytical Centre, Ms. Ermolina Elena Ivanovna

Health Care Department of St.Petersburg State Medical Arkhangelsk region administration Academy named after 163004 49, Troitskiy pr., Arkhangelsk, I.L.Mechnikov Head Infectionist of Saint - Russia Petersburg and Leningrad Tel. +7 8182 21 05 75, Fax. +7 8182 20 region 83 99 St. Petersburg State Medical Email: [email protected] Academy, Mechnikov Academy Ms. Veronika Vorobieva Tel:+7 – 812 – 277 2707, mobile: - International Unit, Medical Information 7- 812 - 941- 65 - 54 Fax: +7 - 812 - 140 1524 Analytical Centre, E-mail: [email protected], home Health Care Department of e-mail: [email protected] Arkhangelsk region administration Tel./Fax. +7 8182 20 83 99 Email: [email protected] / [email protected] Ms. Hotenova Nataliya Nikolaevana Director Mr. Yury Sumarokov Centre for Medical Information and Vice Rector on International Statistics Collaboration Tel: +7 812 22 57 46 Northern State Medical University Tel: +7 182 28 57 59 Mr. Aleksei Kovelenov E-mail: [email protected] Chief Doctor AIDS Centre of the Leningrad Oblast Mr. Vladimir Agafonov (name abbreviated) Head of the Infectious Disease ul. Professora Popova, 15-17 Department 197376 St. Petersburg Northern State Medical University E-Mail: [email protected] Tel: +7 182 28 57 91; +7 182 22 95 27 Mr. Sergei Emmanuilov E-mail: [email protected] Director

Health Care Department of Mr. Mikhail Stanislalovich Nechaev Arhangelsk Region Head of the Health Administration 49 Troitsky prospect, 163 004 Fax +7 818 53 427 40, +7 818 53 428 58 Arkhankelsk E-mail: [email protected] Tel. +7 8182 215 584 Fax: +7 8182 215 710 Dr Tamara Vasilyevna Sologub E-mail: [email protected] Professor, Head of Infection Contact e-mail: Disease Department of the [email protected]

Committee for Labour and Social Protection Mrs. Olga Shabalina in Murmansk Region Senior expert St. Polarnye Zory 46a, Murmansk Department of Heath Care 183025 49 Troitsky prospect, 163 004 Tel: +7 – 815 – 2 – 446 058 Arkhankelsk Fax: + 7 8152 444 553 Tel: + 7 8182 215685 Fax: + 7 8182 215710 E-Mail: [email protected] E-mail: [email protected] Mr. Leonid Mostovoy Youth Committee of Murmansk Mr. Viktor Pavlovitš Terekhov Tel: + 7 8152 44 14 22 Head of Social Welfare Department of Mobile: + 7 921 2755524 Arhangelsk Region Novgorodskiy 160 Dr. Svetlana Eduardovna Presnova Tel. +7 8182 286 193 Chef Physician Fax +7 8182 215 964 Murmansk Tuberculosis Dispensary E-mail: [email protected] Tel: +7 8 152 45 19 29 GSM: +7 921 7342211 Mr. Arkadi Dmitrijevits Rubin E-Mail: [email protected] Vice Chair of the Health Care Mr. Michail Stanislalovich Nechaev Committee in Head of the Health the Murmansk Area Administration, Nenets Ministry Murmansk Region Administration of Health Health Committee in the Murmansk Nents Autonomous Okrug Area Health Administration, Nenets Profsoyuzov St. 20 Ministry of Health Fax +7 818 53 427 40, +7 818 53 428 58 183 038 Murmansk E-mail: [email protected] Tel: +78152 45 65 76 Fax: +78152 47 64 26 E-Mail: [email protected]; Ms Margarita Zaitseva [email protected] Head of the Committee on Social Protection Ms. Elena Evgenjevna Viktorova Committee on Social Protection Vice Chair of the Committee for Smidovtsha 20 Social Naryan-Mar Protection in Murmansk Region Tel. +7 818 53 40 504 Fax +7 818 53 422 69 This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

E-mail: [email protected] University of Lapland Project "Well- Being" Ms. Merja Saarinen Tel: +358 400 969 Ministerial Adviser Fax: + 358 16 3950 PO BOX 33, FIN-00023 GOVERNMENT E-mail: [email protected] Tel: +358 9 160 74030 GSM: +358 50 5634796 Ms. Pia Skaffari E-mail: [email protected] Researcher Project "Well- Being" Tel: + 358 16 341 3944; + 358 400 780 Mr. Pekka Tuomola 864 Physician

Helsinki Deaconess Institute Ms. Marja-Leena Kärkkäinen Munkkisaarenkatu 16, Helsinki County Administrative Board Oulu Tel: + 358 50 351 3885 Fax +358 (0)2051 78481, -78726 Fax: + 358 9 775 4057 E-mail: marja- E-mail: [email protected] [email protected]

Ms. Paula Karppinen Mr. Ilpo Tapaninen Consul (Social Affairs and Health Planning Officer Care) Council of Oulu Region Tel. +358 8 321 4000 Tel: +7 812 331 76 00 Fax +358 8 321 4455 Fax +7 812 331 76 12 E-mail: ilpo.tapaninen@pohjois- Mobile: +7 812 904 88 28 pohjanmaa.fi E-Mail: [email protected]

Consulate General of Finland Preobrazhenskaya pl. 4 Ms Ritva Kauhanen 191028 St. Petersburg Provincial Planner Regional Council of Lapland Dr. Riitta Pöllänen Fax +358 16 318 705 Provincial Medical Officer E-mail: [email protected] State Provincial Office of Lapland Tel. +358 02051 77725 Fax +358 02051 77730 E-mail: [email protected] Mr Hannu Leskinen Ms. Katja Sukuvaara General Secretary Project co-ordinator The Regional Council of Kainuu This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

FINLAND E-mail: Tel: +358 8 7171 25/+358 50 65 376 [email protected] Fax: +3588 7171 260 u E-Mail: [email protected] Mr Atle Staalesen Advisor Ms. Helena Ödmark Norwegian Barents Secretariat Ambassador Ministry for Foreign Affairs PB 276, 9915 Kirkenes Fax +46 8 723 1176 Tel. +47 78977051 E-Mail: Fax +47 78977055 [email protected] E-mail: [email protected]

Mr. Janove Sehlin Professor Ms Anna Prakhova County of Västerbotten Chairperson Umeå University Working Group of Indigenous Peoples Department of histology and cell in the BEAR (WGIP) biology 13 Sportivnaya Streer, Office 124 B SE 90187 UMEÅ 183 010 Murmansk Tel: +46 90 786 5209 Russia Mobile: + 46 70 522 4893 Tel: +7 8152 45 21 40 Fax: +46 90 786 6696 Fax: +7 8152 45 21 40 E-Mail: [email protected] E-Mail: [email protected]

Dr. Ali Arsalo Mr. Alf E. Nystad [email protected] Adviser Norwegian Barents Secretariat in Mr. Dadi Einarsson Kirkenes [email protected] Wiullsgt. 3/5 N-9901 Kirkenes Ms. Valentina Chaplinskaya Tel. +47 789 77050 European Commission Delegation in Fax +47 789 77055 Russia, Moscow Office Mobile: +47 950 31969 Tel: +7 495 721 20 34 E-Mail: [email protected] Fax: + 7 495 721 20 40 Mr. Murdo Bijl Advisor Europe Office

IAVI-International Aids Vaccine Tel: +45 33 96 02 91 Inititative Fax +45 33 93 58 18 P.O Box 15788 E-Mail: [email protected] 1001 NG Amsterdam

The Netherlands E-Mail: [email protected] Ms. Maija Rusakova

Director Mr. Leonid Mostovoi NGO Stellit Director Murmansk Region Youth Pietari Administration E-mail: [email protected] Karla Marxa 25 a str, 183025 Murmansk. Mr. Jan Lindgren puh. +7-8152-44 14 22, Secretary General GSM: +7 921 27 55 524 Finnish Lung Health Association, Filha E-Mail: [email protected] tai [email protected] ry Tel: +358 9 4542 1220 Mr. Ane Kofod Petersen Fax: +358 9 4542 1210 Advisor E-Mail: [email protected] Nordic Council of Ministers Tel: +45 33 96 02 05

E-Mail: [email protected] Mr. William P. Amoss

Executive Director Ms. Kristina Larsen Vishnevskaya-Rostropovich Coordinator Foundation Nordic Council of Ministers E-Mail: [email protected] Store Strandstræde 18

DK-1255 København K Dr. Corina Reinicke Telefone: +45 3396 0285 WHO Russia Fax: + 45 3393 2047 Tel. +7 095 787 21 49 E-Mail: [email protected] Fax: + 7 495 787 21 19

E-Mail: [email protected] Mr. Mats Holmström Information Officer in Social and Mr. Bertil Lindblad Health Sector UNAIDS, Moskova Nordic Council of Ministers Secretariat Tel: + 7 495 232 92 45 Store Strandstræde 18 E-Mail: [email protected] DK-1255 København K

Ms Ingrid Lycke Ellingsen Styrmoes v 13 NO-3043 Drammen NORWAY Phone: +47 32 83 23 70 E-Mail: [email protected]

Mr. Pål Christian Bergstrøm Senior Adviser Regional Office for Children, Youth and Family affairs (Bufetat), Northern Norway Tel: +47 78481124/ +47 91147848 E-Mail: [email protected]

Ms. Olga Fedulova Murmansk Regional Medical Information and Analytical Centre Head of International Department Tel: + 7 815 2 47 62 50 Mobile: +7 921 1588714 Fax: + 7 815 2 45 14 27 E-mail: [email protected] [email protected]

Annex 4

NDPHS Project Database

Work Package No. 5 Information Provision on Specific Health Areas

Name of Paper Information providers/sources in terms of general info not project information/data and proposal of an additional section for the NDPHS database

Summary -

By/date Health Information Expert/7.12.2007

Information providers/sources in terms of general info not project information/data and proposal of an additional section for the NDPHS database

Introduction

In terms of achieving the aims and goals of the database it is suggested that also general health and social information would be provided as a separate section of the database.

This would support knowledge management theories, approaches and techniques where overall knowledge sharing and practical activities are gathered in one place.

The documents sent earlier to the Secretariat contain suggestions of information and data sources/providers and users, which have focused on projects, organisations and persons. This document focuses on the possibility of providing a general health and social information section in the NDPHS database. E.g. information based on general health indicators used globally (using existing health and social indicator databases – as links or external), general information on the most relevant strategies and policies in health and social sector and a field of “Best Practicies”. This document gives an example of “what” and “how” this section may be “built” and what to include (also some contact details are given).

This approach has also been proposed by the NDPHS Secretariat earlier in a slightly different way.

Further, the Secretariat recalled the idea of three sections of the NDPHS database: Projects, Organizations, and People. The Secretariat proposed considering possible further extension of the NDPHS Database, e.g., including of a publications section and/or an indicators section. It continued to explain the idea of inserting an indicator section in the NDPHS database. Such a section could include indicators which cover the health status of the ND area and which could be used to highlight crucial areas for further work and activities for the NDPHS. The Secretariat provided a draft list of possible indicators in its e-mail sent to the meeting participants on 11 September 2007. Indicator data can be taken from other databases, inserted manually based on available publications and other sources of information. Data and indicators in the indicator section of the NDPHS database could be helpful to develop reports on the health status of the region and can, on the other hand, document improvements and tangible results achieved thanks to the work of the Partners. One should, however, keep in mind that the availability and reliability of indicator data is a challenge, and the work with indicators requires both time and money. Finally, the Secretariat proposed that a mechanism be developed within the database which would allow for generation of statistical graphs and charts. It gave information about what

data is available and could be displayed in a graphical format (Marek Maciejowksi at EG Chairs and ITAs, Fifth Meeting, Vilnius, Lithuania, 14 September 2007)

Search section of the NDPHS database

In the database the search field could be as follows:

Database search Simple text search (include more than 3 letters): Search projects Search organisations Search persons

* Search general information on health and social issues (may be here as a separate search option)

The layout of the general information section could be set as presented below

Would include links to external health and social Indicators field indicator databases (see paragraph Health and Social indicator databases possible to be included into

Would include the most relevant strategies and Strategies and policies within the priority areas of NDPHS (see Publications paragraph Information providers of Strategies and fi ld policies possibly to be included into NDPHS database)

Would include e.g. postings of best practices of Best Practices field activities and strategies within NDPHS priorities and the ND area (see paragraph”Best practices” field in the information section of the NDPHS database)

The different fields proposed and their information to be included is presented below in the text as different paragraphs.

Health and Social indicator databases possible to be included into

In this field few generally well known indicator databases could be included such as;

• NOMESCO and NOCOSCO health indicators database includes indicators concerning social and health statistics is based on data collected for the annual statistical publications of NOMESCO and NOSOSCO – Health Statistics in the Nordic Countries and Social Protection in the Nordic Countries. http://www.nom- nos.dk/Database/Indicators.htm

The database gives the users the opportunity to make their own analyses and presentation of the data. This database is already in the useful links section of the NDPHS website.

Contact details: Questions may be directed at [email protected] Or contact Johannes Nielsen by phone + 45 72 22 76 25 concerning the content of the database. For technical questions concerning use contact Jesper Marcussen, phone: + 45 7222 7626. Responsible for content of database: Johannes Nielsen

• WHO EURO “Health for All database” link would be available they also have reproductive health indicator database (http://www.who.int/reproductive- health/global_monitoring/RHRxmls/RHRmainpage.htm ). From this database it is easy and clear to obtain information in the field of reproductive health.

• National health indicators available at: http://www.euro.who.int/healthinfo/products/20020514_2

However, there are some limitations to bear in mind when, using indicator databases where the information is provided by the countries/different establishments themselves. E.g. information provided is collected differently in different countries and some variations in the use of terms may occur. For example,

some data may not be totally comparable with each other but will anyway provide a general overview.

The World Health Organization Regional Office for Europe Contacts: In Copenhagen: Liuba Negru, Tel: (+45) 3917 13 44 [email protected] In Brussels: Albena Arnaudova, Tel: (+32) 25064658 ext. 2205 [email protected]

• World Bank may also have some good reliable indicator databases e.g. http://econ.worldbank.org/WBSITE/EXTERNAL/EXTDEC/0,,menuPK:476823~pagePK:6 4165236~piPK:64165141~theSitePK:469372,00.html

Contact details for the World Bank issues:

In Moscow: Marina Vassilieva, tel: (7-495) 745-7000 ext. 2045 [email protected]

In Washington: Ivelina Taushanova, tel: 202 47 39 277, EU cell +359 889 59 00 99 [email protected]

Information providers of Strategies and policies possibly to be included into

In this field some of the already existing links of the NDPHS website may also be seen here, as well as in the useful links section. In this way it would be possible to obtain more complete data when developing an overall picture of the health and social well-being situation and activities in the Northern Dimension area. The links section of the NDPHS website is comprehensive and good. However, its content may not became at its best use in being only presented in the useful links section. E.g. one could assume that a person searching for information of projects and general health issues in the region would not necessary go to the links section at all, because there are too many sites to “scroll” through. (E.g. first do a project search, then see projects and, then back to NDPHS main

page, and then useful links section. If the general information would be provided at the database one would not have to “leave” the database at all.)

Examples of such links are in the useful-links of the NDPHS website at the below presented headings at http://www.ndphs.org/?link,useful_links#Global_Initiatives ;

• Global Initiatives and Strategies on Public Health and Social Well-being • Regional Initiatives and Strategies on Public Health and Social Well-being • Regional Networks on Public Health and Social Well-being • National Initiatives and Strategies on Public Health and Social Well-being

”Best practices” field in the information section of the NDPHS database

“Best practice” is a widely used term and many definitions of it are used. In NDPHS database it could be seen as a technique, where knowledge, good practices and outcomes in the development work within health and social well-being is distributed in ND area. It could also be seen as a technique of finding new innovative ways of doing development work in the area.

This field could be a “posting” place for organisations, other institutions and persons of “best practices” e.g. evaluation documents of projects and programmes, research studies of various health and social issues within the ND area and guidelines could be provided in this field.

Discussion and conclusion

At the NDPHS database site the following is mentioned (http://www.ndphs.org/?database):

Its ultimate goal is to help better coordinate and streamline efforts aimed at the improvement of public health and social well-being in Northern Europe. More specifically, its aim is to bring information closer to people, institutions and organisations at various levels, and to help them, for example, in:

• Monitoring and coordinating activities in the Northern Dimension area; • Designing funding programmes (financing agencies);

• Searching for other organisations and/or individuals with an aim of involving them in one’s own activities, on the one hand, and introducing own organisation and/or person as a potential partner in activities of other organisations (networking and developing partnerships with other people, institutions and organisations); • Increasing expertise and knowledge as well as facilitating know-how transfer; • Developing policy, research and other papers; • Sharing best practices and lessons learnt; • Preparing information (e.g. for lectures, training activities, awareness raising campaigns, etc.).

To be able to achieve the above mentioned, especially those highlighted with italics and bold, it is seen necessary to include an informational section in the database.

It is important to provide evidence based reliable information and data. Therefore, it is suggested that sources of information and data providers, which are well established organisations and institutions would be used. They have regular updating systems and relevant quality management of the information and data they provide.

This way of presenting information and data will not increase largely the need of human resources at the NDPHS Secretariat, if the information and data is provided as direct links (or external) to the organisations and institutions.

It is also suggested that the information and data providers should be kept to few (some) reliable and well known and not to include a lot of information and data providers. Otherwise it may lead to an information and data “jungle”, which does not serve anyone.

Furthermore, by adding this kind of information section to the database it may attract many different types of users not only those who are implementing projects or otherwise involved in the development work. It is seen probable that also media, commercial agencies/establishments and students would be attracted to use the database.

This proposal of an information section was discussed with SIHLWA EG Chair Mr. Mikko Vienonen and HIV/AIDS ITA Ms. Outi Karvonen. The idea was welcomed and also seen needed. Many thanks to Mr. Mikko Vienonen and Ms. Outi Karvonen of providing their time and views in this issue. Also a lot of good contacts and aspects to take into consideration have been obtained from them. Otherwise the response from the EGs has been vague and therefore, only the opinions and proposals of SIHLWA and HIV/AIDS EGs have been notified here.

Annex 5

NDPHS Project Database

Work Package No. 5 Information Provision on Specific Health Areas

Name of Paper Amendments to Annex 4: Information providers/sources in terms of general info not project information/data and proposal of an additional section for the NDPHS database

Summary -

By/date Health Information Expert/December.2007

This paper is an amendment to the proposal sent to the NDPHS Secretariat on the 7th of December 2007, Information providers/sources in terms of general info not project information/data and proposal of and additional section for the NDPHS database

Introduction and justification

In this paper examples and views of steps to take, maintenance and advantages are given. In terms of achieving the aims and goals of the database it is suggested that also general health and social information would be provided as a separate section of the database.

At the NDPHS database site the following is mentioned (http://www.ndphs.org/?database):

To be able to achieve the above mentioned, especially those highlighted with italics and bold, it is seen necessary to include such a section also in the database.

It is important to provide also general health and social information and data, which is evidence based and reliable. Therefore, it is suggested that sources of information and data providers, which are well established organisations and institutions would be used. They have regular updating systems and relevant quality management of the information and data they provide. Furthermore, in order to be able to implement WP 6 of the NDPHS project Database a ready “posting” place for these would be provided.

The elements, lay out and practical arrangements needed and advantages of the proposal for a General Health and Social information/data section

Would include links to external health and social Indicators field indicator databases.

Strategies and Would include the most relevant initiatives and Publications strategies within the priority areas of NDPHS fi ld

Would include e.g. postings of best practices of Best Practices activities and strategies within NDPHS priorities and the field ND area (E.g. evaluation documents, Thematic Reports ifi hlth

Overview of the information section

Indicators field

Steps to take

• Links to be included, first step is to agree the links to include (examples of some are given below and in the report on the 7th of December 2007, contact details are included)

• Provide a shortened indicator list in the sector of each of the expert groups (see comment below, it is suggested that the Secretariat would continue the development of this in cooperation with the EGs)

SIHLWA EG Chair Mikko Vienonen comment on the 17th of December 2007:

“This may be too premature to think, but we might give a try to a selective shortened indicator list in the sector of each of the expert groups. A working title could be "selected top 20 (or 10) indicators for ..." e.g. SIHLWA: indicators for social inclusion healthy lifestyles and work ability [SIHLWA.1: Adolescent health & socially rewarding lifestyles, SIHLWA.2: Alcohol, and SIHLWA .3: Occupational safety and

health. Using these indicators and common aseessment criteria could give more objectivity to our thematic papers and assessments.”

Maintenance

• Database management team responsible for the updating of the existing links of the external indicator databases

• Expert Group ITA, check the relevance of the indicators selected to 20 (or 10) list at regular intervals, to be agreed upon with EGs

Advantages

• Give more objectivity to the thematic papers and assessments, which will be produced in the future

• Gives a good/relevant overall overview of the social and health situation in the area of ND

• Attracts different types of users, not only project implementers but also media, students (studying in the field)

• Brings information and data closer to “people” (easy access, user friendliness)

Indicators By “clicking” on indicator field direct links to different indicator databases/ banks would appear as the below examples

NOMESCO and NOCOSCO health indicators database includes indicators concerning social and health statistics is based on data collected for the annual statistical publications of NOMESCO and NOSOSCO– Health Statistics in the Nordic Countriesand Social Protection in the Nordic Countries. http:/ / www.nom-nos.dk/ Database/ Indicators.htm

WHO EURO “Health for All database” link would be available they also have reproductive health indicator database (http:/ / www.who.int/ reproductive- health/global_monitoring/ RHRxmls/ RHRmainpage.htm ). From this database it is easy and clear to obtain information in the field of reproductive health.

National health indicators available at: http:/ / www.euro.who.int/ healthinfo/ products/ 20020514_2

Strategies and Publications

Steps to take in Strategies and publications field

• Suggestion that the EGs would be consulted in publications to include (see comment below of SIHLWA EG Chair Mikko Vienonen)

“BEING SELECTIVE is very important. "Less is better than more". From the users' point of view it is essential that one can find in the data base the latest and most important strategy and policy documents of international organizations such as WHO, ILO, WB, NDPHS, EC, EU, NCM, etc. It would also be good (but not always easy to update and have in English or Russian) the strategy and policy documents of member states (e.g. Finland, Sweden, Russia, etc.). Even if it would not be complete, I would suggest giving it a try. The Expert Groups could do a lot to help on this.”

Maintenance

• The field could be maintained as the useful links section by the NDPHS Secretariat (possibly the Database Management team), because most of the documents and publications can be found also there

Advantages This document arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

• Provides comprehensive overall picture of the existing and relevant publications, policy papers and strategies within the ND area for all levels working in the area of health and social well-being

• Assists the EGs in the production of Thematic Papers

• Attracts different users from different levels of development work and other actors interested in social and health issues

Strategies and Publications field

By “clicking” on strategies and publication field, the following sub fields (options) would appear as the examples below

HIV/ AIDS (contains links to publications in the mentioned Publications Pr i son Healt h PHC field )

Social Inclusion, Healthy Lifestyles and Work Ability Global Initiatives and Strategies on Public Health Initiatives and and Social Well-being (contains links to these as on the useful links section at St r at e gi e s NDPHS website)

Regional Initiatives and Strategies on Public Health and Social Well-being (contains links to these as on the useful links section at NDPHS website)

National Initiatives and Strategies on Public Health and So c i a l We l l - b e i n g (contains links to these as on the useful links section at NDPHS website)

Best Practices

Steps to take

• First step is to define “best practice”. It is suggested that the term is defined as it appears (as it is understood) in the NDPHS Database project document Annex 1, Description of Action and at http://www.ndphs.org/?database.

• Second step to map the already existing evaluations of projects in the database. It is suggested that the EGs would be consulted and that the ITAs would gather them to be posted on the evaluations field.

• In terms of the Evaluations field the responsibility of ITAs would be to be aware of the evaluations done of the projects in his/her field and also to review that the evaluations are relevant to be posted in the database (in the future)

• Thematic Reports are to be further developed in the WP 6 of the NDPHS Project Database (see below quote from the project document Annex 1, Description of Action, 5.6 WP 6 Thematic Reports and Network Creation, 5.6.2 Objectives). Once the WP 6 is in action and reports are being produced a “ready posting” place is available.

“The objective of this Work Package to show the use of the database tool in terms of developing a concrete series of reports on analyses, project gaps, policy gaps, institutional gaps etc. and resulting recommendations to national and international authorities...”

Maintenance

• ITAs and EG Chairs responsible of the production of documents (agreed in their ToRs already?)

Advantages

• Possibility to share knowledge and lessons learnt

• Later (in the future) also the possibility to include networks and arrange network meetings

Best Pract ices

Evaluations

These would be the responsibility of the ITAs to check that they are relevant and Thematic Reports may be posted in the database.

Other to be decided by the need of the different groups

This document arises from the project “ NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Secretariat. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

Overall issues in the maintenance of the information section

By presenting the information and data mostly as direct links it is estimated that it will not increase largely the need of human resources at the NDPHS Secretariat.

As the information and data is provided as direct links (or external) to the organisations, institutions, databanks and publications their own quality management systems takes care of the information and data quality assurance.

Possible increase of the users of the database

Furthermore, by adding this kind of information section to the database it may attract many different types of users not only those who are implementing projects or otherwise

involved in the development work. It is seen probable that also media, commercial agencies/establishments and students would be attracted to use the database.

Comment

It is suggested that in terms of content issues and decision of the general information section of the database the NDPHS Secretariat would kindly consult the EGs further. The response of the EGs has been limited during this task and only few comments were obtained of the EGs.

Annex 6

NDPHS Project Database Workpackage No 5 Information Provision on Specific Health Areas Name of Paper General information section in the NDPHS database, datafields and categories in the publication section Summary - By/date Health Information Expert/19.12.2007

Proposal on search options

Publications

Data field Categories Search query: Free word search (any words in the publication) Word search (all words) phrase

Title: All words Any words

Author: Name (All or any first name/lastname or organisation)

Language: Would at this point suggest to only have english and russian

Date: As in the project, organisation, persons search

Publication type: All Global initiatives Global strategies/policies Regional initiatives Regional strategies/policies National initiatives National strategies/policies Evaluations Thematic reports Best Practices

Thematic area: Same thematic areas as in project, organisation, persons search

Geographical area: Same as in project, organisation, persons search

Title of Project NDPHS Project Database

Work Package No. 5 Information Provision on Specific Health Areas

Name of Paper Draft Report of the informational aspects of the organisations section and consistency check of the information inserted in this section

Summary Firstly, in this report the informational aspects of the organisations section and the consistency of the information are analysed. The informational aspects of the data fields are viewed from; layout and informational value aspects.

Secondly, the actual content has been checked and a list of information and comments of the information/data is provided.

Annex 1. Contains information of the Federal Ministries in the Russian Federation

Annex 2. Contains information of governments on the World Wide Web

By/date Health Information Expert/13.11.2007

Annex 7

Informational aspects of the data fields in the organisations section of NDPHS database

The data fields in the organisations section of the database is very comprehensive and gives in general a relevant overall picture of the organisations. However, once being this comprehensive it may cause inconvenience in the future maintenance of this section.

In terms of layout and in order to increase the level of information retrieved at “a glance” it is suggested that the layout would be changed to e.g. as presented in the table below.

With the present layout the viewer needs to “scroll” up-down to view the primary/substance information.

By organising the organisations primary/substance informational data fields together in the beginning it will enable the viewer to retrieve the primary/substance information at once in the visual field.

The secondary information (see table) needs to be clarified. Firstly, do these fields contain information of the organisation in question or secondly, does this information link to the persons who are either leader’s in projects run by the organisation or have been manually added by the organisation? At the moment there is information in these fields containing both. Thirdly, it also contains in some cases information of the financing agency. However, it is recognised that these are problems mainly caused by the ongoing development of the external database - NDPHS database “communication”. Therefore, this note is only for reminder.

Suggestion is also made in terms of the data field; Persons who are either leader’s in projects run by the organisation or have been manually added by the organisation itself to consider its informational value. If the purpose of this section is to attain information of experts in different fields, is the informational value high and should be kept as a data field. This data field is at the moment very closely linked to the above mentioned fields (contact details), and the challenges in them.

The layout/order of data fields currently Suggestion of new layout/order of data fields

Organisation name Organisation name Primary/substance information Database Organisation website Once the window opens Type of organisation Type of organisation of the organisation view section, this information Organisation website Fields of expertise would show in the visual field of the viewer and no Street and number Geographical coverage “scrolling” would be P.O.Box Working languages needed

ZIP/Postal Code Street and number Secondary information

Annex 7

City P.O.Box If organisations website is available all this Country ZIP/Postal Code information can be found there. Phone number/ City If no website available Internet telpone ID for the organisation this section is very important. Fax Country

E-mail: Phone number/

Internet telpone ID

Fields of Expertise Fax

Geographical coverage E-mail:

Working languages Further information

Electronic newsletters Database

Persons who are either Persons who are either Need of consideration of leaders in projects run by leaders in projects run by the informational value of the organisation or have the organisation or have this data field. been manually added by been manually added the organisation itself by the organisation itself

Further information

Content of the organisations section of the NDPHS database

After reviewing approximately 90 organisations in the database it is recognised, (as also informed by the Head of Secretariat), that for now the inserted information is still fairly incomplete.

Therefore, in the following pages information of the organisations inserted in the database is given in a list format. The websites of the organisations are provided. Furthermore, some comments have been added were seen necessary. The organisations are listed in the chronological order as they are in the NDPHS database (by ID).

Information of few organisations was not possible to attain and they are not presented here nor are the organisations, which information was fairly complete.

Annex 7

List of organisations and their websites as they appear in the NDPHS database, sorted by ID number

ID No. 14 Norwegian Institute of Public Health

Web: http://www.fhi.no/eway/?pid=238

ID No. 15 Troms Red Cross

Web: http://www.redcross.no/distriktforside.asp?Did=30

ID No. 16 Ungdomshuset Tvibit

Web: http://www.tvibit.net/

ID No. 19 Norweigan People’s Aid

Web: http://www.npaid.org/

ID No. 22 Christian Interchurch Diaconal Council

Web: http://cidc.ru/activ/a008e.html

ID No. 24 Institute of Community Medicine, University of Tromso

Web: http://uit.no/samfmed/4810?Language=en

ID No. 25 Arkhangelsk Region Administration

The Arkhangelsk Region Administration is the main executive body. It organizes and administers the region, draws up and implements the budget and development programs representing the interests of the population, works to solve existing problems, and concerns itself with the prospects for regional development.

See annex 2.

ID No. 26 ECAD representation in St Petersburg

Web: http://www.ecad.ru/

ID No. 27 ECAD European Cities Against Drugs

Web: http://www.ecad.net/

ID No. 29 NGO "Volunteer Centre"

Web: information can be found at: http://www.civilsoc.org/nisorgs/russwest/moscow/volnteer.htm

Annex 7

(Not the NGOs own pages)

ID No. 30 The Stockholm Institute of Social Education

Web: http://www.lhs.se/LHS/Templates/Page____178.aspx

ID No. 31 Early Intervention Institute St Petersburg

Web: http://www.eii.ru/

ID No. 36 Hiv Norge

Web: http://www.hivnorge.no/id/27.0

ID No. 37 Umeå University

Web: http://www.umu.se/umu/index_eng.html

ID No. 38 Umeå University, Epidemiology dept of Public Health and Clinic Medicine

Web: http://www.umu.se/medfak/institutioner/folkh_med_eng.html

Comment: Name of department incorrect in the database

ID No. 40 SOS-barnebyer Norway

Web: http://www.e-fadder.no/cgi- bin/sos/jsp/retrieve.do?lang=no&site=NO&nav=6.2&BV_SessionID=@@@@1391577080.1194 938937@@@@&BV_EngineID=cccfaddmhflddfkcfngcfkmdhkhdffj.0

ID No. 45 The Ministry of Health and Social Development of the Republic of Karelia

Web: http://www.gov.karelia.ru/Power/Ministry/Health/index_e.html

Comment: Incorrect name in the database

ID No. 46 The Global Fund to Fight Aids, Tuberculosis and Malaria

Web: http://www.theglobalfund.org/en/

ID No. 48 Open Health Institute

Web: http://www.ohi.ru/concurs.html

Comment: Russian only

ID No. 50 Swedish International Development Co-operation Agency (SIDA)

Web: http://web.mit.edu/urbanupgrading/upgrading/resources/organizations/Sida.html

ID No. 52 The Russian Ministry of Health

Annex 7

See annex 1 or 2 to this document

Comment: name incomplete

ID No. 53 The Russian Ministry of Justice

See annex 1 or 2 to this document

Comment: name incomplete

ID No. 54 Northern State Medical University

Web: http://www.nsmu.ru/english/

ID No. 55 The Elton John AIDS Foundation

Web: http://www.ejaf.org/

ID No. 56 County Council Västernorrland

Web: http://www.y.lst.se/english/aboutthecountyofvasternorrland.4.17431b9f544f8dca97fff1734. html

ID No. 58 Luleå County Administration, Social Department

See annex 2.

ID No. 60 HEDEC/STAKES

Web: http://idc.stakes.fi/EN/index.htm

Comment: Name of organization incorrect, the correct name is International Development at STAKES

ID No. 61 Örnsköldsvik Municipality

See annex 2.

ID No. 62 Municipality of Archangelsk

See annex 2. Link from Archanelsk Regional Adimistration pages

ID No. 65 Klinikk Hammerfest

Web: http://www.helse-finnmark.no/category921.html

ID No. 66 Ministry of Social Affairs and Health of Finland

Web: www.stm.fi

Annex 7

ID No. 67 World Health Organization Regional Office for Europe, Copenhagen

Web: http://www.euro.who.int/

ID No. 68 Archangel State Medical Academy

The same university in organization ID 54 (Northern State Medical University)

ID No. 70 Länsstyrelsen i Norrbottens län

See annex 2.

Comment: In English County of Norrbotten

ID No. 71 Republican Centre of Medical Prophylactic

Web: http://www.gov.karelia.ru/gov/Power/Ministry/Health/Center/index_e.html

ID No. 72 Physical Training and Sport Medicine, Karelia

Same as in ID 72, is in the same unit in The Republic of Karelia

ID No. 73 Ullevål University Hospital

Web: http://www.ulleval.no/modules/module_123/proxy.asp?C=54&I=2826&D=2

ID No. 76 Ministry of Health of Karelia

Web: http://www.gov.karelia.ru/gov/Power/Ministry/Health/index_e.html

Complete name of the Ministry: Ministry of Health and Social Development of Republic of Karelia and is already in the database ID 45.

ID No. 79 SEEC North

Web: http://www.seec.org.uk/

ID No. 80 Norwegian Church Aid

Web: http://english.nca.no/article/archive/449/

ID No. 81 Association "Christian Interchurch Diaconal Council", St.-Petersburg.

Same organisation as in ID 22

ID No. 84 Social Transformation Programme of the Netherlands Ministry of Foreign Affairs (MATRA)

Annex 7

Web: http://www.netherlandsembassy.ee/index.php?matra

ID No. 86 UNAIDS

Web: http://www.unaids.org/en/

ID No. 87 UNODC (United Nations Office on Drugs and Crime)

Web: http://www.unodc.org/unodc/index.html

ID No. 88 The Russian Harm Reduction Network

Web: http://www.ceehrn.org/

Comment: Current name of the organization: the Central and Eastern European Harm Reduction Network (CEEHRN) changed its name to the Eurasian Harm Reduction Network (EHRN) of which the Russian Harm Reduction Network is probably a part of.

ID No. 89 International Antiviral Therapy Evaluation Centre (IATEC)

Web: http://www.iatec.com/

ID No. 90 PharmAccess International

Web: http://www.pharmaccess.org/RunScript.asp?p=ASP\Pg0.asp

ID No. 91 Research Centre of Obstetrics, Gynaecology and Perinatology

Web: http://www.pregnancy.ru/

ID No. 92 WHO

Web: http://www.who.int/en/

ID No. 93 Dutch Postcode Lottery / Nederlands Postcode Loterij

Web: http://www.postcodeloterij.nl/

ID No. 94 Dutch AIDS Fund

Web: http://www.aidsfonds.nl/

ID No. 96 Partners in Health

Web: http://www.pih.org/home.html

Annex 7

Annex 1.

Federal Ministries of the Russian Federation

Ministry of the Russian Federation for Atomic Energy http://www.x-atom.ru/minatom/minatom.html

Ministry of the Russian Federation for Anti-monopoly Policy and the Support of Entrepreneurship http://www.maprus.ru/

Ministry of Culture of the Russian Federation http://www.mincult.isf.ru/

Ministry of Defense of Russia http://old.rian.ru/mo/

Ministry of Labour and Social Development of the Russian Federation http://www.mintrud.ru/ (broken link)

Ministry of Transport of the Russian Federation http://www.mintrans.ru/

Ministry of Energy of the Russian Federation http://www.mte.gov.ru

Ministry of Justice of the Russian Federation http://www.scli.ru

Ministry of the Russian Federation for Taxes and Duties http://www.nalog.ru

Ministry of Foreign Affairs of the Russian Federation: http://www.mid.ru/

Ministry of Education of the Russian Federation: http://www.ed.gov.ru/

Ministry for Economic Development and Trade of the Russian Federation http://www.economy.gov.ru

Ministry of Finance of the Russian Federation http://www.minfin.ru

Ministry of Health of the Russian Federation http://www.mednet.ru/

Annex 7

Ministry of the Russian Federation for Communications and Informatization http://www.ptti.gov.ru/

Ministry of Industry, Science and Technology http://www.minprom.ru/

Ministry of Internal Affairs of the Russian Federation http://www.mvd.ru/

Ministry for Natural Resources of the Russian Federation http://www.fcgs.rssi.ru/rus/mepnr/index.htm (dead link)

Ministry of Agriculture and Foodstuffs of the Russian Federation: http://www.aris.ru/

Ministry of the Russian Federation for Civil Defence, Emergency Situations and Disasters http://www.emercom.gov.ru/

Ministry of the Russian Federation for the Press, Television and Radio Broadcasting, and Mass Communications http://www.tvradio.ru/

Ministry of Property Relations of the Russian Federation http://www.mgi.ru/

Ministry of the Russian Federation for Physical Fitness, Sport and Tourism http://www.infosport.ru/minsport/index.htm

Ministry of Railways of the Russian Federation http://www.css-mps.ru/

Annex 7

Annex 2.

Governments on the World Wide Web (some examples more country information can be found at: http://www.gksoft.com)

Norway: http://www.gksoft.com/govt/en/no.html

Russian Federation: http://www.gksoft.com/govt/en/ru.html

Here can also be found most of the Regional Administrations in the Russian Federation

Sweden: http://www.gksoft.com/govt/en/se.html

Ukraine: http://www.gksoft.com/govt/en/ua.html

Attention: These links need to be checked some of them may be dead or broken links.

Northern Dimension Partnership in Public Health and Social Well-being

NDPHS Expert Group on HIV/AIDS

Thematic Report

HIV/AIDS in the Baltic Sea Region and Northwest Russia

NDPHS Series No. 2/2008

Northern Dimension Partnership in Public Health and Social Well-being (NDPHS)

NDPHS thematic report: HIV/AIDS in the Baltic Sea Region and Northwest Russia

The views reflected in this paper are those of the members of the NDPHS Expert Group on HIV/AIDS who have developed it and should not, therefore, be interpreted otherwise. If specific country data are not available in this report, this is because the authors were either unable to obtain it or did not receive permission to publish this data.

Editor: Pauli Leinikki Authors of annexes: Marja Anttila, Simo Mannila

This paper may be freely reproduced and reprinted, provided that the source is cited.

It is also available on-line in the Papers’ section of the NDPHS Database at www.ndphs.org/?database,view,paper,20

View our website at www.ndphs.org and keep an eye on policy developments and explore the world of the NDPHS – a partnership committed to achieving tangible results!

Further information:

NDPHS Secretariat Strömsborg P.O. Box 2010 103 11 Stockholm, SWEDEN Phone (switchboard): +46 8 440 1920 Fax: +46 8 440 1944 E-mail: [email protected]

The paper arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Expert Group on HIV/AIDS. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

Thematic report

HIV and AIDS in the Baltic Sea Region and Northwest Russia

Contents

1. Introduction ...... 4 2. Recent epidemiological development in some countries ...... 4 2.1. Northwest Russia...... 4 2.2. The Baltic Countries...... 5 2.3. Nordic Countries ...... 6 3. Social and political impact, future...... 7 4. Regional collaboration and the role of the expert group on HIV/AIDS of NDPHS...... 8 4. 1. Surveillance...... 8 4.2. General awareness, policy development ...... 9 4.3. Development of legislation and national policies ...... 10 4. 4. Prevention...... 11 4.5. Treatment, care and support ...... 12 5. Gaps and problem areas ...... 13 6. Recommendations for project based activities...... 16 6.1. Priorities of project-based activities for the near future. Examples:...... 17

Annexes

Annex 1 Mother-to-child transmission of HIV Annex 2 Immigrants and HIV/AIDS in the Baltic Sea region and NW Russia

1. Introduction

The HIV epidemic continues to spread through injecting drug use but increasingly the infection is also spreading to other parts of the population. Significant change has taken place through the possibility to widely implement highly active antiretroviral treatment (ART) not only improving the situation of those infected but also by enhancing prevention efforts and reducing the stigma and discrimination known to drive the epidemic further. The future of the epidemic in the region is markedly shaped by the ability to use ART so that all vulnerable groups, injecting drug users (IDUs) and their partners in particular, can be reached. At the same time, the message of the importance of prevention should be kept renewable and fresh so that new generations are aware of the risks and empowered to make the correct choices for their future.

2. Recent epidemiological development in some countries

2.1. Northwest Russia

Northwest federal district of Russian Federation (NWFD) includes seven oblasts (Archangelsk, Vologda, Kaliningrad, Leningrad, Novgorod, Pskow) two republics (Komi and Karelia), Nenets national district and the city of St. Petersburg.

First case of HIV-infection in the region was registered in 1987. As of the 31 December 2006, 56,742 cases have been registered, of them 4,618 have died, 679 from AIDS. The dynamics of the epidemic is showed in table 1.

The epidemic is still driven by infections among injecting drug users although increasingly infections are also reported from people (often women) who report heterosexual transmission. The number of children born to HIV-infected mothers is quite high reflecting the high prevalence among pregnant women. The number of pregnant women receiving antiretroviral treatment has risen significantly during recent years thus reducing the number of children born with the infection (see annex 1).

Table 1: Number of reported new HIV cases in NW Russia in 1997-2007 (Source: Northwest District AIDS Centre, St Petersburg)

Region 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 St. Petersburg 70 73 387 3,735 10,119 5,757 3,961 3,689 4,045 4,459 4,548 Leningrad region 6 4 49 842 2,191 1,572 1,134 1,009 1,094 973 1,165 Kaliningrad reg. 1,095 583 423 363 484 394 340 397 414 454 501 Murmansk reg. 10 19 38 69 469 318 206 163 241 371 416 Rep. of Komi 7 14 14 51 126 196 116 114 135 147 134 Novgorod region 5 5 5 42 239 166 93 93 77 96 134 Vologda region 5 4 9 57 318 182 119 125 119 134 133 Rep. of Karelia 3 4 8 50 65 51 39 61 81 55 92 Archangelsk reg. 3 6 7 8 43 61 40 38 49 62 62 Pskov region 7 5 11 16 66 46 30 39 30 46 44 Nenetsk aut.dist. ------1 2 2 4 Total 1,211 717 951 5,233 14,120 8,743 6,078 5,729 6,287 6,799 7,233

National or even regional statistics may not give the best possible picture of the current situation. Only part of the infections is registered (estimates vary from 30 to 60 per cent, WHO 2006). Another important issue is the geographic diversity. While in some cities and centres the rise may have levelled off indicating a stabile situation, other cities may witness explosive epidemics.

Kaliningrad, one of the first cities and regions to show a severe epidemic among the drug users in the region, is still marred by a rapidly spreading epidemic. The rate of new cases reported annually has remained high after the peak in the 1990s with a prevalence among the highest in the region (400/100,000 at the end of the year 2005).

The recent response to counteract the epidemic in Russia has significantly intensified. In 2008, 30,000 patients are estimated to become recruited to sustained antiretroviral treatment. In 2007, 6,239 pregnant HIV-positive women received full course of preventive medication. In addition, new preventive measures sponsored by the federal government were implemented including those targeted at vulnerable groups. Also the capacity of the laboratories, AIDS centers, sexually transmitted infection (STI) centers and other centers providing service to people infected or at risk for HIV, has been improved by state initiatives, supported by the Global Fund and the World Bank.

2.2. The Baltic Countries

The Baltic countries have shown different dynamics in their HIV epidemics. In Lithuania, the overall figures have remained relatively low, a major outbreak within a prison indicated that also there injecting drug users are a major risk group. In Latvia, the epidemic, also driven by drug use, started already in the 1990s. Comparatively, more cases are in advanced stages than in other countries. Estonia, having the highest number of infected persons demonstrates the greatest variation between different parts of the country. In the eastern region, and in particular in Narva city the prevalence and incidence is very high, possibly the highest in Europe, while some other regions are practically free of the disease. Reasons for this difference may include failures in prevention among Russian speaking population, links with high-endemic Leningrad region across the border and social conditions with high unemployment rate.

Very often injecting drug users contract the infection at a young age. Figure 1 demonstrates the difference in the distribution of transmission categories between the Baltic countries and the Nordic countries.

Figure 1. Difference in the transmission routes between the Baltic and the Nordic countries (Source: Personal communication, Gedris Likatavicius, EuroHIV, 2006)

Reported HIV cases by transmission mode in Nordic countries and Baltic States, 2005 Nordic Countries Baltic States

N=330 MTCT MTCT MSM N=708 cases 2% 0.6% 5%

MSM Hetero 36% 35% 56% from persons originating from Hetero subsaharian 54% Africa or South East Asia

IDU Transfusion IDU 59% 0% 8%

Transfusion 0.3%

EuroHIV MTCT- mother to child transmission, Bordic countries: Denmark, Sweden, Finland; Baltic states: Latvia, Lithuania Cases with unknown transmission mode excluded

In all Baltic countries ART is available and through the assistance of the Global Fund a universal and non-discriminating access to treatment has been developed. Harm reduction aiming at a reduction of risk behaviour and thus vulnerability to HIV among drug users and their partners is gradually being implemented. In Latvia, low-threshold centres and outreach work is being developed providing counselling, needle exchange, and other necessary material, medical and social support and help in assistance for seeking treatment for drug addiction. In Estonia, similar structures are under development, while in Lithuania main focus has been on educational approaches (although outreach is available in many cities there, also). Methadone and buprenorphine (Subutex) as part of harm reduction is widely available in Estonia and Latvia through prescription of doctors. In Lithuania the attitudes towards maintenance therapy are more conservative.

2.3. Nordic Countries

Nordic countries have had a stabile situation for many years now. Since the local outbreak among injecting drug users in Finland in the late 1990s significant outbreaks have not been observed. However, a continuous, if slow, rise in the annual numbers of reported cases is seen in all Nordic countries. Main risk factor seems to be increasing number of infections among men who have sex with men (MSM) but containment of spread among drug addicts needs continuous vigilance.

As in many European countries, the number of cases among individuals moving from endemic countries to the Nordic countries has increased. In most cases the infection has been acquired before immigration but prevention among migrant population calls for special attention and focused and culture-sensitive interventions. 6

3. Social and political impact, future

The political and social impact of HIV is and will be much more severe on the Southern and Eastern side of the Baltic Sea. If the HIV-prevalence is related to the purchasing power of the national domestic gross income (GNP) the difference is almost a hundred fold (table 2). The World Bank predicts a drop in GNP of 3-10% in the next couple of years (Source: UNAIDS: 2006 AIDS Epidemic Update. Eastern Europe and Central Asia).

Table 2

HIV-prevalence in some countries and regions in NW-Europe (Leinikki, SLL 2007)

Country/region HIV-prevalence * HIV-prevalence in proportion with the GNP** St.Petersburg 667 23,8

Leningrad oblast 452 16,1 Kaliningrad 402 14,3 Estonia 376 8,4 Murmansk 165 5,9 Latvia 144 3,6 Karjala 50 1,8 Lithuania 29 0,7 Sweden 27 0,26 Finland 25 0,25

Pauli Leinikki/Tampere 7.9 2007

*Cumulative number of reported HIV- cases /100 000 inhabitants, source: national and regional AIDS centres (2005) **GNP adjusted with purchasing power. (Leinikki, Journal of Finnish Medical Association, 2007)

With the introduction of ART treatment, not only the quality of life but also life expectancy of those infected will improve dramatically. In order to achieve these benefits, a system to provide life-long drug therapy along with strong social support must be set up. In order to adjust to this, the national health policies may need to be revised frequently and social and health care will consume much more resources than what used to be the case only 5-10 years ago. Also, approaches that are used in other countries may not be appropriate. All this is a challenge not only to the health policies but to the entire political structure. Providing equal opportunities to infected people and avoiding discrimination will need political courage and advocacy.

Most experts believe that the future demographic development will be affected by HIV in the worst hit countries in the region. The disease may cause reduction in the population, reduce the working power and directly and indirectly snap off from the GNP several percent units. Since the infection is hitting hardest certain vulnerable groups, not often prioritised in the political dialogue, attention and advocacy is needed to reach necessary efficiency in the prevention and treatment. Special programmes for vulnerable groups such as prisoners and ex-prisoners, migrant populations, injecting drug users and socially marginalised young people are necessary to complement the services of the national health and social policies.

Recent increase in the infection rate among women in many countries reveals special problems; women may be vulnerable not only due to injecting drug use by themselves, but also as sexual 7

partners of men who use intravenous drugs and during commercial sex work. More often than men women are not able to use the available preventive and social interventions due to power imbalance within relationships and within society. In NW Russia the number of women learning about their HIV infection only when delivering a baby is strikingly high (WHO, Smolskaya et al, 2007).

Legal obstacles for effective prevention must be removed and all sectors of the society recruited to the work. Since the picture will change considerably in the forthcoming years with more individuals with more advanced disease, their life depending on successful implementation of continuous medication, the national AIDS policies must be regularly updated and receive sufficient political attention.

4. Regional collaboration and the role of the expert group on HIV/AIDS of NDPHS

Under the Northern Dimension Partnership on Health and Social issues (NDPHS) an Expert Group on HIV/AIDS has been working for several years (previously as part of the Task Force for Communicable diseases under the Council of Baltic Sea States and before that, as an unofficial “All- Baltic Union against AIDS”). National/Partner representatives in the group (EG) are senior experts participating actively in the shaping and implementation of national AIDS policies in their own countries. In its policy paper the EG has identified five priority areas:

1. Surveillance, 2. General awareness and policy development, 3. Legislation, 4. Prevention, 5. Treatment and care.

For each priority area, key recommendations for actions are given.

4. 1. Surveillance

Surveillance is a key for adequate response. Information to politicians and lay people about the dynamics of the epidemic as well as the dynamics of the underlying risk factors and impact of interventions are necessary for making correct decisions. Good surveillance needs access to groups at high risk of infection. When dealing with HIV, they are often difficult to reach through traditional methods used in public health.

Ideally, surveillance should be linked with preventive interventions that are targeted to particular groups at risk such as injecting drug users (IDUs), commercial sex workers (CSW), migrant populations, certain young people and women. As an example, the rapidly growing rate of HIV- positive women giving birth to children in Russia who have not had contact with the health care during pregnancy and therefore not had admission to prophylactic treatment (WHO, 2006 AIDS Epidemic Update), should be mentioned.

Underreporting may also grow as many patients seek treatment in private clinics. Monitoring changes in the risk behaviour patterns that are associated with HIV spread (second generation surveillance) will become more and more important indicators for the development of the epidemic. Methodological challenges of risk behaviour monitoring in hard to reach and hidden population 8

subgroups include changes of the sample composition of surveyed populations over time. Significant improvements in the surveillance of sexually transmitted infections are also needed in almost all of the countries. In many instances, legal obstacles and discrimination are posing challenges to good surveillance. More extensive use of sentinel surveillance could in many instances provide the missing data and indicate trends.

Availability of effective treatment for HIV infection as well as for drug dependence could increase the willingness of people to seek for testing and other contacts with health care providers, improving the surveillance. Voluntary Counselling and Testing (VCT) is an important instrument, utilization of which should be enhanced by applying approaches that promotes reaching of vulnerable groups. One way to do this is through low-threshold service centres (LTSC) that are currently used for drug users and for commercial sex workers. Such centres can provide anonymous and free of charge access to medical and social support and essential means for prevention such as condoms and clean injecting equipment. Use of rapid tests also helps, repeated visits will not be needed to learn the result and waiting for the result is optimal time for counselling and advice. Epidemiological information can be obtained using non-invasive sample collection such as saliva samples.

Wide use of ART will bring along the problem of monitoring the efficacy and compliance among people receiving medication. This should become part of the basic surveillance of the epidemic. Data collection linked to outreach programs is feasible for second-generation surveillance.

Recommendations:

• Promote effective VCT with special emphasis on reaching the vulnerable groups. (low threshold centres, outreach approaches, anonymous testing, use of rapid tests)

• Target groups with special emphasis should include IDUs, CSWs and their clients, prisoners, ethnic minorities, foreign students, migrant populations, and adolescents. Special efforts have to be made not to overlook potential hidden epidemics e.g. among MSM, which may be difficult to detect with traditional surveillance methods due to the very strong social stigmatization of MSM in the region.

• Second generation surveillance according to standards set by UNAIDS and WHO should be promoted to receive relevant information about changes in risk behaviour.

4.2. General awareness, policy development

The World Bank and national authorities project significant economic, demographic and political consequences following the current level of HIV epidemic in some countries in the region. The impact will be hardest in Russia’s most affected regions, some of which border EU and the Northern countries. The possible outcomes to the Baltic countries have not yet been analysed in detail but will probably be as severe in Estonia and Latvia. Modelling of the outcome of HIV-epidemic in the Baltic region could be a fruitful field of international collaboration including NDPHS. Other, less pessimistic forecasts have also been published. Careful evaluation of the situation at regular intervals is warranted.

National policies should recognize the severity of the threat and raise the general political awareness of the situation. Measures to eliminate discrimination must be implemented, be it people living with the infection or people who need help because their behavioural patterns puts them at particular risk for the infection. National policies should also ensure that all people at risk get adequate information 9

about the risks and access to means to avoid it. HIV should also become an issue in all policies in order to create the necessary human and financial resources that are needed to change the course of the epidemic.

Human rights of people living with HIV/AIDS should be equal to those of non-infected people. People are more vulnerable to the effects of HIV infection when they do not have the respect and support of their community. Discrimination due to sexual orientation, drug abuse, ethnic background etc. make people also vulnerable to infection.

Recommendations:

• Promote general awareness about the impact of the emerging threat and available measures to control the situation on individual and societal level.

• Emphasize the importance of eliminating discrimination, and of providing adequate information about the risks and how to avoid them.

• Include HIV/AIDS in all sectors of national policies (labour, education, national security, economics, health, social support, foreign policy) to support effective planning and implementation of national response.

• Keep the issue of human rights high in the national agenda.

4.3. Development of legislation and national policies

Legislation should support the participation of the entire society in the fight against HIV. Preventive work is more effective if the authorities get full support from civil organisations (NGOs) and self help groups including people with the infection. Private business might have a significant role by reaching their employees in situations useful for preventive interventions. Employers also bear important responsibility in preventing discrimination in workplaces. Prisons are becoming more and more important in contributing to the national public health in general. Prisoners and ex-prisoners comprise a significant part of the national disease burden for many chronic diseases such as HIV, viral hepatitis and tuberculosis.

Modelling studies demonstrate that focusing preventive measures to IDUs in an epidemiological situation like present day NW Russia is the most effective way to prevent the infections at the entire population level also (Long, E.F. et al. AIDS, 20, 2207-2215, 2006). Scientific studies show that harm reduction is an essential element in effective HIV prevention among IDUs (WHO, Policy Brief: Reduction of HIV transmission through drug-dependence treatment. Geneva 2004). Legislation should not prevent effective, evidence-based prevention strategies. It should ensure equal and non- discriminating access to free, voluntary, anonymous or confidential HIV/AIDS counselling and testing, treatment and care to all members of the society including prisoners. Legislation should also ensure necessary education concerning prevention of sexually transmitted diseases and infections linked with drug use at all levels of education.

Recommendations:

• Develop legislation to promote partnership between NGOs, civil societies, private business and governmental agencies in their fight against HIV. 10

• Remove legal obstacles to ensure universal, non-discriminating access to anti-retroviral drug treatment to all infected people.

• Remove legal obstacles to develop policies that allow implementation of evidence-based prevention strategies among vulnerable groups such as drug users, other socially excluded groups, sexual minorities etc. The policies should combine harm reduction programs with medical and social rehabilitation.

4. 4. Prevention

HIV-prevention must be a joint effort shared by various sectors of administration such as education, health, justice, economy, defence and internal security. Politicians and the public administration are responsible for successful recruitment of NGOs and the civil society to work side by side with public bodies. Most affected countries need to scale-up their national HIV/AIDS prevention efforts to allow much broader coverage of at risk populations and other preventive measures to stop the epidemic.

Targeted interventions are necessary to initiate behavioural changes and diminish the risks for transmission. In vulnerable groups efforts should be focused as much to those already infected as those not yet infected. ART should be seen as an integral part of prevention. Extended case management should include elements such as early case finding, appropriate primary and secondary prevention and monitoring of compliance and treatment outcome. Involvement of members from the target population is essential for success. The ability to reach the target populations should be monitored carefully; it may take some time before an intervention becomes sufficiently accepted by the target population to achieve its goal.

Basic education at schools should give sufficient information and life skills to average children to be able to avoid HIV-infection. This means that the curricula at schools should be re-evaluated and restructured; also teachers need training to be able to communicate the necessary messages effectively. HIV must be integrated into a broader sexual health agenda. Young people themselves should participate in designing and delivering educational activities. A big challenge is to reach young people who are particularly vulnerable to HIV for various reasons.

Prevention of other sexually and parenterally transmissible diseases should be closely linked with HIV prevention. STI control projects should be able to reduce the rate of new infections in particular among young people. Proper surveillance of chlamydial infections based on proper laboratory diagnostics is a good indicator of the spread of STI:s among the population.

Several minority groups are often left outside proper information concerning HIV. This may be due to language problems but also to social marginalization. The status and needs should be investigated and appropriate intervention programs developed. Representatives of target populations should participate in the planning and deliverance of interventions.

Reduction of mother-to child transmission (MTCT) to very low levels is possible today with the help of ART. All infected pregnant women should have the possibility to get proper treatment free of charge. This should be integrated into comprehensive and non-discriminating antenatal services linked with necessary social and economic support. HIV infected women should have the same right to take reproductive choices as uninfected women. Projects to develop best practices and proper surveillance of this particular problem should be encouraged.

Overcrowded prisons pose a significant threat for the spread of communicable diseases in the region. Both behavioural risks (sexual and parenteral infections) and risks due to crowding (tuberculosis, other respiratory infections) contribute. At the same time prisons should also be seen as potential sites for successful preventive work both for HIV and for drug abuse. HIV testing should be made readily accessible to inmates of all prisons, discreetly and at their own request; it should always be voluntary and accompanied by counselling also in the case of negative test results. Needle exchange programs can be useful and integral parts of a general approach to drug and health services in prisons. They should be integrated into other health promotion measures, counselling and social rehabilitation. Continuation of medical treatment, preventive work and support after the inmates return to the civil society must be properly organised.

Recommendations for actions/priorities):

• Promote networks of “low-threshold centres” (easy access sites for medical and social support) and outreach activities for hard-to-reach target groups.

• Work towards the acceptance of school education programs, with the main aim to increase knowledge, to encourage healthy attitudes, to develop essential life skills and to support non- risk-taking behaviour.

• “Youth clinics” supporting the development of important life skills to lessen the vulnerability of young people to HIV should be supported or equivalent services provided by other means.

• Enhance STI prevention and care in particular with reference to certain risk factors such as sex between men, work related migration, and international travel.

• Develop proper preventive programmes for ethnic minorities and migrants and monitor their ability to reach the target populations and induce behavioural change

• Prevent mother-to-child transmissions applying concrete national targets approaching zero transmission rate.

• Implement harm reduction strategies in prisons, including support and rehabilitation programmes for those having completed their sentence.

• Promote frequent and interactive evaluations of current interventions. Peer reviewing using international experts could be applied through the NDPHS.

4.5. Treatment, care and support

Anti-retroviral treatment has the promise to significantly enhance HIV prevention but it may also fail. Widespread unregulated access to anti-retroviral drugs could lead to rapid emergence and spread of resistant virus strains. To be successful, a universal and non-discriminating access to treatment based only to objective medical criteria is essential. Lowering the price for medicines, technical improvements for simpler dosage and development of new antiviral drugs through research are all necessary ingredients for future success.

Adherence to treatment seems to be the most important element for success. Delivery of ART should be linked with proper medical and social support organised in such a way that normal life is possible 12

(“one-door delivery”). Since the need is life-long, it may become necessary to arrange the service outside the normal health services. When necessary, the services should also include harm reduction measures to keep the patients attached to the treatment. Monitoring should include among other things compliance and possible emergence of drug resistance.

Education of health care workers (HCW) in counselling and care of HIV infected people and AIDS patients become even more important in the future. Well-informed HCW will also help disseminate information and promote anti-discriminatory attitude into the society.

National recommendations for case management should , in addition to guidelines for medical care and treatment, include elements from early case detection and primary prevention to secondary prevention, harm reduction, social care and support to home care and terminal care. It is a challenge to regional collaboration to harmonise the national guidelines as much as feasible.

Recommendations for actions/priorities):

• Create national case management guidelines based on scientific evidence.

• Develop a network of properly equipped diagnostic laboratories to enable monitoring of disease progression, evaluation of treatment success and resistance testing in case of treatment failure.

• Strengthen local health care services and NGOs in their role in supporting care and clinical management of infected persons.

• Establish and develop effective education of health care workers in counselling and care of HIV-infected people and AIDS patients.

5. Gaps and problem areas

HIV/AIDS prevention has been pushed up high in national agendas for health promotion due to the severity of the threat: so far attempts to stop the epidemic have been successful in reducing the rate of new infections, but the number of infected individuals in all countries is still growing. New developments in treatment have led to some improvement in the quality of life of those infected but at the same time put pressure on developing proper life-long treatment services for growing number of individuals.

In the region, injecting drug use is the driving force for the epidemic accompanied by secondary spread through unprotected sexual contacts, mostly commercial. Most vulnerable people are socially and politically not prioritized in any way, they often suffer from severe discrimination and social exclusion that not only worsen their own life but also promotes spread of the infection among them and into the wider population.

Migrant populations, be it immigrants or people moving around in their own countries due to occupation or other reasons are also vulnerable to HIV in part because proper “culture-sensitive” information and preventive means are not always available.

Examples of other groups that need special attention are pregnant women. Today proper treatment can prevent transmission to the offspring very effectively but if such a treatment cannot be arranged, children with infection continue to be born in the region. Also, gender issue is relevant regionally,

empowerment of women would certainly lead to more systematic use of condoms and thus slowing the spread of the epidemic. Another example is men who have sex with men (MSM). In Western countries MSM are a group highly vulnerable by HIV due to social and lifestyle factors. This has not been as visible in the Baltic countries or NW Russia but at the same time reliable information is difficult to obtain due to the harsh stigmatisation.

Even if particular target-specific preventive actions have been promoted in all countries, they still lack proper privilege in national priority evaluations. This has, in part, been supported by international organisations whose main focus has been in Africa, where optimal prevention strategies are different from those that are best in the Baltic Region. Recently, significant resources have been provided by the Global Fund in Estonia, and Russia is developing a large-scale programme to enhance health promotion.

In many countries, in particular in the Nordic countries, the role of NGOs in implementing important components of national AIDS policies has been very useful. However, in the Baltic countries and in Russia NGOs have not had similar resources or working environment leading to suboptimal performance. This is a pity, since their role in areas which are most difficult to official health and social care delivery, such as prevention among ex-prisoners, injecting drug users and like would be very pivotal.

Every country is updating their national AIDS-policies regularly instructed by UNAIDS. This process has also brought along some common goals and implementing structures such as national committees etc. In these policies the national gaps are evaluated and assessed and actions prioritised according to the resources that are available.

The following areas can be regarded as gaps common or characteristic to the countries in the region:

1. Lack of precise and up-to date information about the dynamics of the spread of the disease and the underlying risk factors. National figures, collected in a structured way give an understanding of the overall situation in the country, but actually the epidemic may follow very different courses and have different underlying risk factors in various parts of the country. In particular when injecting drug use is the main risk factor, local epidemics may be very explosive, which, after fading out, leaves a high number of people carrying the infection into the local society. Therefore it would be of great importance to take necessary steps in the right places in the right time.

Measures that should be prioritised are listed in section 4.1. Surveillance.

2. HIV is one disease among other diseases and must compete for resources and public attention not only when developing national policies for health care but also in people’s minds. Since the forecasts concerning the development of HIV in the countries have been and will remain uncertain, there has been some reluctance to accept forecasts of possible economic or political consequences. Another issue is that HIV has been often regarded as a separate health policy issue not included in other sectors of administration such as labour, economics, education etc. Inclusion of HIV “in all policies” would certainly make necessary adjustments easier and also contribute in diminishing discrimination, still an important risk factor not only for those infected but also to those who are at increased risk for transmission.

Measures that should be prioritised are listed in section 4.2. General awareness, policy development.

3. Legislative measures must not make optimal prevention and treatment unfeasible. Legal framework differs from one country to the next making proper comparison of outcomes very 14

difficult. This may also account for the lack of academic research in this field. Often representatives of certain vulnerable groups provide the information about the actual situation of diseased people or people at risk and universal indicators are not available. International collaboration in this field is an important tool to keep the dialogue open and make initiatives for necessary changes and adjustments. The big challenge of today is the provision of proper prevention and treatment to certain vulnerable groups such as injecting drug users. Harm reduction measures including substitution therapy has proven effective in many studies but implementation is still controversial in some countries of the region.

Measures that should be prioritised are listed in section 4.3. Development of legislation and national policies.

4. Success in prevention is a key to be able to stabilise the HIV situation in the region. Several formats have been applied and there is evidence that special prevention measures that include easy access, provision of social and medical support along with positive incentives such as rapid testing and that are tailored to specific target populations are successful. They have not been applied but in a limited number of places in the Baltic countries and NW Russia. By extending this to an interactive regional network of adequate resources members would bring significant added value in terms of experience, data and optimal use of resources.

Measures that should be prioritised are listed in section 4.4. Prevention.

5. Treatment and care is today able to improve quality of life for those infected, decrease the risk of spread of the infection and provide a positive incentive for prevention. Regional exchange of best practises, training visits etc. could enhance development of good practices. A common view of national guidelines and necessary practical steps would also eliminate the threat posed by infected people moving from one country to another in order to achieve, what they believe, better treatment than what is available at home.

Measures that should be prioritised are listed in section 4.5. Treatment, care and support.

6. Recommendations for project based activities

The projects should bring added value due to the regional aspect of the activity, they should support national policies and enhance available resources in critical and underdeveloped areas. Here are topics that should be covered by project based activities:

1. Regional coordination of activities with common goals. An example is the Barents HIV initiative which brings together various stakeholders and financing sources.

2. Joint cross border activities between two neighbouring areas/cities with similar epidemiological situation and risk factors. An example is the project between Narva and Ivangorod to develop preventive interventions towards injecting drug users which is currently under development. Similar “twinning projects” could be created elsewhere.

3. Projects to implement best practise that are ongoing in some places or countries but less developed in some others. “Low-threshold centres” for drug users in Murmansk with the support of experts in Finland, which is now being copied into new locations in Russia provide an example.

4. Prevention of mother-to-child transmissions.

5. Collaboration between expert laboratories to implement monitoring of molecular typing and drug resistance.

6. Development of common guidelines and monitoring criteria for extended case management covering aspects from early diagnosis and prevention through medical and social support and care to terminal care and family support. Development of a database for this.

7. Management of HAART

8. Support to primary health care to identify and care of HIV-infected people.

9. Early detection of HIV cases in genitourinary medicine, antenatal care, pulmonary medicine and other relevant fields of medicine.

10. HIV prevention, care and treatment of infections in prison settings

11. Enhancement of surveillance of HIV/TB interactions in the region by creating a network of implementing agents including relevant NGO:s. The Baltic countries and NW Russia both have high prevalence and incidence of HIV and tuberculosis, including multiresistant strains. Projects should not only facilitate laboratory diagnostics but also focus on reliable and representative epidemiological investigation and sampling.

12. Development of criteria that could be applied in all countries in the region for evaluating economic and social impact of current HIV epidemic.

13. Regional collaborative projects for prevention and surveillance among MSM.

14. Comparison of national AIDS-policies and measures to harmonise them in appropriate issues.

15. Supporting activities of NGOs that are working along the recommendations described in section “Regional collaboration and the role of the expert group on HIV/AIDS of NDPHS.”

16. Development and evaluation of information material that take into account the mobility of people and cultural similarities of the region.

6.1. Priorities of project-based activities for the near future

Examples:

• Regional coordination programmes to enhance multisectoral and multilateral collaboration.

• Development and networking of “low-threshold service centres” for drug users and other hard-to reach risk groups.

• Subregional/local collaborative and twinning projects between partners with similar epidemiological situation and risk factors.

• Surveillance and analysis of risk factors.

• Projects involving people with HIV.

• Development of common regional standards for case management.

• Integration of social and health care for HIV-infected individuals

• Support to primary health care to enhance early detection of HIV cases and proper case management.

• Services for HIV-infected people with other medical conditions (mental, infections, malignancies etc)

• Pregnant women and HIV. Particular emphasis is access to women in risk groups.

• Gay men, surveillance of infections, risk behaviour and preventive interventions.

• Reducing stigma in work places or among general population.

• Prevention of social exclusion of PLWHA and their families.

• Collaboration with and training of media in HIV prevention and social impacts.

• HIV and risk behaviour surveillance in prisons with special emphasis on Tb/HIV interactions.

• HIV prevention in prisons.

• Specific training courses for “HIV-specialists”, i.e. for medical doctors, e.g. internists, dermatologists, neurologists, psychiatrists etc., who need special skills in meeting and caring of HIV-infected people.

• Links with teen-age sexual health projects and interventions. 17

• Promotion of early diagnosis of HIV

• Laboratory projects to support state-of-the art monitoring of drug resistance and molecular epidemiology of HIV.

• Care of families with HIV

Annexes

Annex 1 Mother-to-child transmission of HIV Annex 2 Immigrants and HIV/AIDS in the Baltic Sea region and NW Russia

Annex 1

Mother-to-child transmission of HIV Dr Marja Anttila, Senior Expert, International Development Collaboration at STAKES

1. General background

Pregnant women living with HIV are at high risk of transmitting HIV to their infants during pregnancy, during birth or through breastfeeding. Globally, over 90 % of new HIV-infections among infants and young children occur through mother-to-child transmission (MTCT). Without any interventions, 20% to 45% of infants of HIV-positive mothers may become infected, with an estimated risk of 5-10 % during pregnancy, 10-20 % during labour and delivery, and 5-20 % through breastfeeding. The overall risk of transmission can be reduced to less than 2 % by an evidence-based package of interventions. This package is now the standard of care in most high-income countries, where its implementation has led to the virtual elimination of new HIV cases among children.

Prevention of mother-to-child transmission of HIV (PMTCT) requires a comprehensive set of interventions that include preventing primary HIV-infection in women of childbearing age, preventing unintended pregnancies in women living with HIV, preventing HIV transmission from a woman living with HIV to her infant, and providing care, treatment and support to women living with HIV and their children and families. Health systems need to be strengthened and resources allocated so that these services can be provided.

A comprehensive national response to tackle MTCT includes:

1. Improved availability, quality and use of maternal, newborn and child health (MNCH) services. Functioning and adequate MNCH services are the foundation for any intervention to prevent MTCT. 2. Voluntary counselling and testing (VCT) for HIV. In order to avoid or minimize negative consequences, HIV testing during pregnancy must be voluntary and confidential and be accompanied by quality counselling and subsequent referral to adequate delivery options and care. VCT is an important entry point to prevention and care services and a critical component to MTCT interventions as women have to know their HIV status to access to and benefit from these interventions. 3. Antiretroviral therapy. The administration of antiretroviral drugs during pregnancy and at the time of delivery has proved to significantly reduce the risk of MTCT. 4. Infant feeding options. Avoiding breastfeeding has proved to be an effective way to prevent postnatal MTCT. Mothers need advice and adequate resources to provide formula feeding for their infants, especially in resource-constrained communities. 5. Caesarean section. Elective caesarean section has been demonstrated to have a more protective effect against MTCT than vaginal delivery. However, the procedure must be performed in an adequately resourced health facility by skilled and experienced staff. There seems to be no additional benefit of caesarean section, if the viral load of the mother around birth is below the limit of detection. 6. Care and support. It is utmost important to provide care and support for mothers to help them maintain their health − both for their own and their children's benefit. Identifying the available referral and support systems for the follow-up of both the mother and her infant 19

contributes to meeting the long-term prevention, care and support needs of the HIV-infected mother, her partner and their baby.

All countries in the world have committed, as part of the UNGASS 2001 declaration on HIV/AIDS, to "reduce the proportion of infants infected with HIV by 20 % by 2005 and 50 % by 2010". This is achieved by ensuring that at least 80 % of pregnant women accessing antenatal care have information, counselling and other HIV-prevention services available to them, increasing the availability of and providing access for HIV-infected women and babies to effective treatment to reduce MTCT, as well as through effective interventions for HIV-infected women.

In July 2005, G81 leaders made a commitment to “develop and implement a package for a comprehensive HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all people who need it by 2010.” This promise was made global at the UN World Summit in September 2005, and in June 2006 all UN member states endorsed a commitment to “universal access to comprehensive prevention programmes, treatment, care and support by 2010”.

According to a survey performed by UNICEF in 63 countries2, in 2004 only about 11 % of all pregnant women received PMTCT counselling through established PMTCT services − in most cases it was provided as an integral part of MNCH services. HIV-testing was done to 4.5 % of pregnant women living in Asia and to 14.3 % of those living in Southern Africa, whereas 65.4 % of all pregnant women living in Eastern Europe were tested. About two third of HIV-positive pregnant women identified through PMTCT programmes received antiretroviral (ARV) prophylaxis. In Central and Eastern Europe 40 % of countries provided ARV prophylaxis to more than 60 % of HIV- infected pregnant women.

Globally, there is still a lot to be done to achieve the universal access to comprehensive prevention programmes, including PMTCT services. UNICEF and WHO have, together with an Interagency Task Team comprising of representatives from various UN and international nongovernmental organisations, developed a guidance document for scaling up the PMTCT services3. The document lists ten guiding principles for the adaptation and implementation of PMTCT programmes at the global, regional and country levels, e.g. the importance of family-centred longitudinal care and the importance of male involvement. The document also highlights the need for demonstrated government leadership, commitment and accountability and the necessity of the link between delivery of PMTCT and of sexual and reproductive health care. In addition, the importance of the active participation of people living with HIV in the implementation of policies is discussed, as well as policies and programmatic approaches to minimize the HIV-related domestic violence, stigma and discrimination in the context of PMTCT and HIV care for children.

2. MTCT in the Russian Federation

On the brink of generalised epidemic

Russia faces one of the world's fastest growing HIV epidemics. The cumulative number of officially registered HIV cases was 417,715 (1 January 1987 through 31 December 2007). In 2006 Russian

1 The “Group of Eight” or G8, is an international forum composed of 8 country members – Canada, France, Germany, Italy, Japan, Russian Federation, United Kingdom and the United States. A representative from the European Commission also participates. Together, these countries represent approximately 65% of the world’s economy. 2 PMTCT Report card 2005. 3 Guidance on Global Scale-up of the Prevention of Mother-to-Child Transmission of HIV. WHO 2007. 20

authorities reported over 39,000 new HIV cases and in 2007 the number is over 43,000.4 However, the real number of PLWHA is higher than official statistics suggest.

In Russia, young people (aged 15-24) are disproportionately affected by HIV epidemic, constituting 53 % of the cumulative reported HIV cases. Overall, majority of PLWHA in Russia are between ages 18 to 35 years. The epidemic predominantly affects intravenous drug users (IDUs), sex workers (who are often also IDUs), and bridging populations. Among the newly reported HIV cases with an identified route of transmission 65% were infected through injecting drug use.5

The HIV epidemic in Russia is at the concentrated stage (HIV prevalence rate among one or more high-risk populations is higher than 5 %, but does not exceed 1 % among pregnant women in urban areas). However, in the last four years Russia has seen an increase in the percentage of HIV cases resulting from sexual contact; the majority of new infections among women of reproductive age are now sexually transmitted. This has resulted in the increasing numbers of HIV-positive pregnant women. Up to 30 % of HIV-positive women become pregnant and most HIV tests are done and most HIV cases discovered when women seek antenatal care. HIV is spreading fastest in the country's economically developed regions. In 2005 the epidemic became generalised (HIV prevalence rate among pregnant women is consistently higher than 1 %) in five Russian regions: St. Petersburg, Samara, Sverdlovsk, Ulyanovsk and Chelyabinsk. Between 1 % and 1.8 % of all pregnant women in these regions are HIV positive. Furthermore, ten other regions are on the brink of a generalised epidemic, among them Kaliningrad and the city of Moscow.6

Policy and registration of MTCT in Russia

There are several specific characteristics in the issue of HIV-infection and pregnancy. First, the woman may not be aware of her HIV status prior the pregnancy, either because she does not think she is at risk of getting the infection from her partner, or she ignores the risk of the infection deliberately or she is unaware of these risks. Secondly, although the woman knows her risky behaviour (as an IDU or sex worker), she and her partner ignore the possibility of pregnancy. Thirdly, an HIV-positive woman may want to have a child and is seeking advice and prophylaxis to avoid MTCT and to get treatment and support for herself in order to take care of her offspring. All this makes PMTCT a complex issue, starting from the services targeted to prevent HIV-infection generally among young people and provision of youth-friendly reproductive health services, and ending to provision of individual medical and social support to the HIV-positive mother, her child and her family. PMTCT also includes adequate reproductive health services provided to PLWHA and, especially, to IDUs and sex workers.

Medical and social care for mothers and children in the Russian Federation is regulated through several laws, orders and decrees relating to general health protection and provision of medical care and to prevention of HIV-infection. Among these are Government Decree on providing free HIV medication to outpatients in Federal Specialised Medical Institutions, the Executive Order of the Ministry of Health on prevention and chemoprophylaxis of MTCT, and the Ministry of Health Directives on the standards of PMTCT and standards for medical care of children with HIV. These give health professionals detailed guidance on PMTCT in different situations.

4 Data obtained from http://www.afew.org/english/statistics/HIVdata-RF.htm 5 Data obtained from http://www.euro.who.int/aids/ctryinfo/overview/20060118_36 6 The Provision of Medical and Social Care for HIV-positive Pregnant Women and Their Infants. Policy Briefing Paper. Ministry of Health and Social Development of the Russian Federation. 2007 21

A policy briefing paper, published in 20077, lists the following as the key PMTCT measures in Russia: • Improving guidelines on HIV prevention among women, on provision of medical and social care for HIV-positive pregnant women, on strengthening professional skills of staff that provides medical and social care for HIV-positive women and children, on integration of HIV/AIDS prevention into the regular obstetric, paediatric and social services, on improving family planning services for PLWHA, and on placing children with HIV into residential care; • Applying medical care standards; • Providing counselling to all pregnant women and informed voluntary HIV testing twice during pregnancy; • Increasing triple HIV therapy coverage of HIV-positive pregnant women (during pregnancy and delivery and postpartum treatment of infants); • Using optimum methods of delivery; • Providing HIV-positive mothers with family planning advice; • Introduction of modern approaches to outpatient monitoring of children born to HIV-positive mothers and to early diagnosis of newborns; • Providing comprehensive medical examinations for HIV-positive women and children and providing full courses of treatment, including HAART, to those requiring it; • Implementing birth certification system, which encourages early registration of pregnancies; • Improving HIV epidemiological surveillance through good quality reporting and monitoring of HIV-positive pregnant women; • Evaluating the reach and quality of PMTCT at both regional and national levels; • Improving collaboration between agencies involved in epidemiological surveillance of HIV.

At present, antenatal and postpartum care for HIV-positive women and their infants, including ARV therapy, is provided by obstetric and paediatric services. Regional AIDS and infectious diseases centres provide specialised medical care (counselling, diagnostic, treatment and prevention services). However, pregnant mothers and young children are sometimes unable to access these services, either because of their far-out location or due to other factors, such as the health status of the mother during pregnancy. The reason for not using the PMTCT services might also be the unwillingness of the pregnant woman to attend regular MNCH services, or the late HIV diagnosis, or the lack of ARV drugs at these centres.

Since the beginning of 2004, registration of children, born to HIV-infected mothers is being conducted by the Russian Clinical Hospital of Infectious Diseases − Scientific and Practical Centre on Assistance Provision to HIV-infected Women and Children, in St. Petersburg. The registration is three-fold: 1. Report on a new-born child, born to HIV-infected mother; 2. Report on taking the child, born to HIV-infected mother, off the register; 3. Report on confirmation on the diagnosis of a child, born to HIV-infected mother.

The Centre also registers if any chemoprophylaxis against MTCT during pregnancy, in labour and to new-borns has been given. Also, data on mode of delivery (caesarean section), feeding of the child (breast-feeding or formula-feeding) and the amount of abandoned children is collected.

7 Policy Briefing Paper, MOHSD,Moscow 2007. 22

The reality of HIV-positive women in Russia

A recent study among the HIV-positive women in the Leningrad region surveyed the experiences and needs for psychological and social support of 63 women living with HIV8. The experiences on stigmatization and needs for family planning, as well as the knowledge and attitudes of 120 health professionals, who work with HIV-positive women, were also surveyed.

The HIV-positive women were mostly young, with secondary or lower level of education, and most of them were married or cohabiting. The women had a relatively high level of HIV awareness, but they still demonstrated a limited tolerance towards other PLWHA. Only 27.4% of those who were married had revealed her HIV-positive status to her partner. Drug experience was common; 56 % had used drugs during the year before the study.

Nearly two thirds of the respondents had been pregnant when the HIV-infection diagnosis was made. At the time of the survey, 27.4 % were currently planning to have a child. The respondents, however, talked about childbirth as one of the most problematic issues for HIV-positive women.

On average, the women were rather dissatisfied with the health care offered at non-specialised medical and preventive institutions; there had been experiences of negative attitudes and betrayal of confidence. About 42 % of women had been refused medical examination and/or necessary treatment at non-specialised medical and preventive institutions at least once in their life. The respondents, however, expressed their satisfaction with the medical care at specialised medical and preventive institutions, attitudes among doctors being better than those of nurses.

About 57 % of women reported to have received ARV therapy to prevent MTCT during pregnancy and 39 % had received ARV therapy during labour.

A considerable part of the medical staff respondents believed that all medical care for HIV-positive people should be provided at a specialised medical institution. The study also revealed that there is low awareness on how the pre- and post-test counselling should be conducted. The medical staff, despite their high general awareness of HIV-infection, demonstrated a limited tolerance towards PLWHA.

The study recommends that new forms of work with HIV-positive people should be implemented, e.g. self-help groups, meeting on "neutral territory" i.e. outside the specialised medical institutions, organising less formal type of support in the places of residence of HIV-positive women etc. Also training of medical and prevention staff in the methods of work with PLWHA is needed.

Another survey, conducted during 2004-2006 in five high prevalence areas (St. Petersburg, Kaliningrad, Yekaterinburg, Irkutsk and Tver) among 758 HIV-positive pregnant women, aimed at investigating behavioural risks among these women before and after HIV diagnosis9. The surveyed women were all diagnosed HIV-positive for the first time during the study period and sought antenatal care at medical facilities.

The study found that female vulnerability to HIV varied geographically: in St. Petersburg, Yekaterinburg and Kaliningrad HIV risks were present in the behaviour of women at the moment of diagnosis (e.g. drug use), whereas in Irkutsk and Tver much lower number of women reported practising risk behaviours. There was a link between reproductive behaviour and behavioural HIV

8 Assessment of Social and Psychological Support Needs of HIV-positive Women. Survey results report. 2007 9 Risk Factors Impacting on the Spread of HIV among Pregnant Women in the Russian Federation. 2007 23

risks; the proportion of planned pregnancies as well as antenatal care was lower in Kaliningrad and St. Petersburg; in St. Petersburg 50 % of the HIV cases were not diagnosed until delivery.

Majority of the women (86 %) were pregnant when the HIV diagnosis was made. The pregnancies that were ongoing during HIV diagnosis resulted in childbirth in 55.6 % as an average for all five study sites, whereas this was the case for 77.3 % in St. Petersburg and 32.8 % in Kaliningrad.

HIV was diagnosed most frequently at antenatal clinics (54 %) followed by AIDS Centres (16%). St. Petersburg was an exception from this; 46 % of the HIV diagnoses were done at the AIDS Centre. As an average in all five study sites, 37.2 % of respondents received pre- and post-test counselling. The number of women receiving no counselling was higher in St.Petersburg, reflecting the late reporting to antenatal services.

The percentage receiving ARV therapy was in the same order as in the study from Leningrad region: 55.7 % received therapy during pregnancy, 60.1 % during delivery and 60.3 % after delivery.

The study has shown the need for more accurate epidemiological history in newly infected HIV cases, as well as the need for regular screening and monitoring of the behaviour in general population in order to follow the epidemic patterns and ensure timely responses to any changes. The study results support the importance of informing the HIV-infected women about the attendance in reproductive health services in order to receive full prevention treatment. As important is to inform young women of reproductive age on the risks of HIV-infection and the benefits of voluntary testing even before planning their pregnancy.

MTCT statistics

The number of HIV-positive pregnant women in the Russian Federation is rising; there has been an almost 600-fold increase in the rate of new HIV diagnoses among pregnant women from 1995 to 2002.

In 2005, 12,836 pregnant women out of a total of 2.9 million were registered as HIV positive (0.44%) and more than half of all pregnancies among HIV-positive women resulted in births10. Around 5,000 children are born to HIV-positive mothers annually. According to data at the end of 200611, the cumulative number of children born to HIV-positive mothers was 22,901 in the whole country.

In NW Russia regions, the cumulative numbers of children with verified HIV-infection at the end of 2006 were: St.Petersburg - 136; Leningrad region - 67; Kaliningrad region - 41;Vologda region - 10; Murmansk region - 7; Novgorod region - 6; Republic of Komi - 3; Archangelsk region - 2; and Republic of Karelia - 1. In Pskov region and Nenets autonomous district, no HIV-postive children have been registered.12

Table 1 presents the detailed figures of those children born in 2004 and 2005 to HIV-positive mothers in Russian Federation. The figures also show that the percentage of pregnant woman and new-born children receiving ARV prophylaxis is slowly increasing. Also, the registration and data collection on MTCT and its prevention has improved with significant decrease in the "no data"

10 Policy Briefing Paper, MOHSD, Moscow. 2007 11 Data received from North West District AIDS Centre, St.Petersburg, on January 2008 12 HIV-infection in North-West Federal District of Russaian Federation in 2006; St-Petersburg. 2007 24

figures. In Table 2, the increase in percentage of those receiving ARV is also visible for the North West regions of the Russian Federation.

HIV-infection of a woman is very often diagnosed only when she becomes pregnant: in 2005 63 % of HIV-positive women who gave birth had been diagnosed HIV during pregnancy, while the remaining 37 % had been diagnosed in the preceding two to four years. The two studies cited in the previous chapter verify this. They also highlight the importance of antenatal services as the main entry point to HIV-diagnosis and − subsequently − to PMTCT services such as counselling, treatment, secondary prevention, family planning, child care, and psychological support.

Each year approximately 20 % of HIV-positive pregnant women do not register for antenatal care and by the time they attend a maternity facility, they are already in labour. This causes delays in the administration of ARV prophylaxis and puts the infant in increased danger of getting the infection during labour and through breastfeeding.

Table 1. Data on HIV-positive pregnant women and their infants in the Russian Federation, 2004-2005 (Source: Information Bulletin. Children born to HIV-infected mothers in 2004-2005. Prevention of MTCT of HIV in the territories of the Russian Federation. St. Petersburg 2007)

2004 2005 2004-2005 Registered HIV+ pregnant women 9,926 no antenatal care 2,044 under medical observation 7,104 no data 778 Chemoprophylaxis during pregnancy and labour not carried out, % 17.3 14.4 carried out, % 70.0 82.6 no data, % 12.7 3.0 Children born to HIV+ women, annual numbers 5,148 4,847 9,995 Chemoprophylaxis to newborns not conducted, % 8.8 7.1 conducted, % 79.9 88.7 no data, % 11.3 4.2

Children born to HIV+ mothers 2004-05 born in 2004 born in 2005 taken off the register, % 62 78 with confirmed diagnosis, % 6 2 under medical observation, % 32 20

NB: Moscow city on-line data is not sent to Russian Clinical Hospital of Infectious Diseases

Table 2. Data on HIV and PMTCT in North West Russia and Moscow region (Source: Information Bulletin. Children born to HIV-infected mothers in 2004-2005. Prevention of MTCT of HIV in the territories of the Russian Federation. St. Petersburg 2007)

Territory Cumulative HIV+ pregnant Children Percentage of Percentage of no. of HIV+ women, tot. born to HIV+ mothers newborns cases number and % HIV+ given ARV given ARV 1.1.87 - under medical mothers prophylaxis, prophylaxis, 31.10.07 observation 2004-05 2004 / 2005 2004 / 2005 2004-05

St. Petersburg 35,315 248* (79%) 906 89 / 89 92 / 94 Moscow Oblast 30,619 484 (69%) 488 52 / 65 52 / 63 Leningrad Oblast 12,293 409 (69%) 411 71 / 92 83 / 94 Kaliningrad Oblast 5,791 106 (66%) 108 87 / 87 87 / 90 Murmansk Oblast 2,243 67 (90%) 68 88 / 91 94 / 94 Komi Republic 962 23 (70%) 23 69 / 86 81 / 100 Novgorod Oblast 917 41 (78%) 41 81 / 80 76 / 95 Karelia Republic 438 13 (54%) 13 25 / 100 25 / 100 Pskov Oblast 354 16 (63%) 18 71 / 67 86 / 91 Arkhangelsk Oblast 256 5 (80%) 5 100 / 67 100 / 67 * note the discrepancy between the registered no. of HIV+ mothers and registered children born to HIV+ mothers

3. MTCT in the Baltic Countries

In Estonia, there was a drastic rise in the number of new HIV cases from the second half of 2000, continuing also during 2001. Starting from 2002, the number of officially registered cases has decreased, but Estonia still has the second highest estimated prevalence of HIV in Europe, over 1 % of the adult population. By the end of 2006, 5,731 people have been diagnosed HIV-positive. The epidemic is concentrated in Tallinn and the surrounding Harjumaa County and in Ida-Virumaa County in the North-Eastern Estonia.

Since 2000, the infection has been mainly transmitted through the sharing of contaminated syringes. Although the data is incomplete, increased HIV spread through heterosexual intercourse has been detected since 2002. Thus, according to the AIDS counselling cabinets IDUs accounted for 90% of HIV-infected people, 66% in 2003 and only 48% in 2006. Although this data is not based on all new HIV-cases, it still may be claimed that the infection has started to spread from IDUs to other young people through sexual encounters.

The first childbirth with HIV-positive mother in Estonia took place in 1999. During 2000-2006 a total of 175,176 pregnant women have been tested; out of these 631 were HIV-positive. By the end of 2006, the total number of known childbirths to HIV-positive mothers has been 376. Altogether 23 HIV-positive children and 353 HIV-negative children have been born from HIV-positive mothers.13

The number of HIV-positive pregnant women in Estonia has remained stable in past years. All pregnant women in Estonia are covered by health insurance from the 12th pregnancy week and thus are guaranteed all health services free of charge (including prophylactic ARV treatment). All women who register their pregnancies are recommended already during their first visit to take the HIV-

13 Data from Tervise Arengu Institute (National Institute for Health Development), accesed on 4.2.2008 from http://www.tai.ee/?id=4043 26

infection test in addition to other tests. The corresponding test is also recommended to all women who decide to have an abortion. Problems related to MTCT start when the risk group women are not aware of their rights or their interests are limited only to a short-term economic income. Dealing with this vulnerable group the cooperation of local level specialists based on the case management principle is essential.

The HIV-epidemic in Latvia has followed the trends and patterns of other Eastern European countries. At an early stage the epidemic showed similarities with the initial epidemic in most Northern European countries with MSM as the major transmission route, but the rapid increase of IDUs since the end of 1990s increased also HIV-infection among drug users. As in Estonia, the HIV- incidence among IDUs peaked in 2001; since 2004 the reported number of newly diagnosed cases has been relatively stable. By the end of 2006, Latvia reported a cumulative total of 3,631 HIV cases.

The "feminisation" of the HIV epidemic has also increased the number of HIV-positive pregnant mothers. At the end of 2005 the number of registered HIV-positive women was 901 and HIV- positive pregnant women 17114. At the end of November 2007, altogether 24 MTCT cases have been registered15. As in Estonia, it is obligatory for the maternity services to offer VCT to all women during the 12th and 29/30th weeks of pregnancy and preventive ARV treatment is free of charge. In 2006 there were five and in 2007 seven new MTCT cases, showing that although preventive programmes are in place, the PMTCT services do not reach all who are in need of these services.

By the end of 2007, Lithuania has reported a cumulative total of 1,306 HIV cases and only one case of mother-to-child transmission16. The HIV epidemic among IDUs peaked in 2002, about a year later than in Estonia and Latvia. In 2006, 77 % of the new cases were among IDUs. HIV testing is systematically offered to all pregnant women.

4. MTCT in Europe

Initially large numbers of paediatric HIV cases in Western Europe significantly decreased after 1995 with the large scale introduction of prevention techniques. The overall mother-to-child transmission rate was around 15 % before 1994, 7.9 % during 1994 to 1999 and in the past years the transmission rates have been 1.6 %.

But despite the knowledge of how to prevent MTCT, rapidly growing numbers of HIV-infected women in East European and CIS countries have caused sharp increase of MTCT since 1996. In the past five years the transmission rates have been 6.7 % in Eastern Europe. Most of the MTCT cases have been recorded in Ukraine and Russian Federation.

HIV-testing of all pregnant women is performed in most of the European countries. EuroHIV survey 2006 reports the situation in the 53 countries participating in regular surveillance of HIV-epidemic17. In 37 countries (84 %), HIV testing is routinely offered to pregnant women by health care providers. Estimates of the percentage of pregnant women routinely tested for HIV infection were provided by 23 countries (Figure), of which 11 estimated that more than 90 % were tested, nine estimated that between 50 % and 90 % were tested and three countries estimated that less than 50 % were tested.

14 The Latvian National Report 2006 on Monitoring the Follow-up to the Declaration of Commitment on HIV/AIDS. 2005. 15 Data from Latvian AIDS Prevention Centre, accessed on 4.2.2008 from http://www.sva.gov.lv/aids/statistic/kum_tr_gr.php 16 Data from Lithuania AIDS Centre, accessed on 4.2.2008 from http://www.aids.lt/stats.lt.php?gr=3 17 EuroHIV 2006 Survey on HIV and AIDS Surveillance in the WHO European Region. 27

In most European countries, HIV testing is accompanied by counselling (pre- and/or post-) when testing is initiated either by the provider or by the patient. In many health-care settings, an "opt-out" approach (consent is inferred unless the patient declines testing) for routine HIV testing may be proposed. Post-test counselling is still considered as an integral component of the HIV testing process in Europe and is viewed as essential for both those who test HIV-negative (prevention) and HIV-positive persons (psychosocial support). Counselling is important especially for young women in the countries with high prevalence among the young, since information on the ways to avoid MTCT is the only way of preventing unnecessary HIV-infection in infants. Naturally, after counselling, the health system needs to be able to provide the young woman the needed PMTCT treatment and care.

Information on MTCT in some WHO EURO Member States, as of December 2007 (Data obtained from http://www.euro.who.int/aids/surveillance/20051114_1 on 29.1.2008.

Country Cumulative total Cumulative No. of infants No. of MTCT MTCT as % of of reported HIV No. of MTCT, born to HIV+ cases in 2006 known trans- cases end of 2006 mothers in 2006 mission routes Austria 3,705 0.3 % Belarus 7,747 19 Belgium 18,890 5 3 % Bulgaria 689 0.9 % Cyprus 518 < 1 % Czech Republic 920 4 9 0 Estonia 5,731 105 4 Finland 2,082 14 13 1 France* 20,677 180 1,500 34 Georgia 1,156 6 1.6 % Germany 29,017 177 250-300 14 Greece 8,164 53 3 Hungary 1,366 5 0 Ireland 4,419 37 115 2 Israel 4,999 144 13 3 % Italy 57,375 77 450 9 Kazakhstan 7,402 37 < 1 % Kyrgyzstan 1.070 4 2 Latvia 3,631 17 5 Luxembourg 770 2 Moldova 3,464 42 14 Netherlands 7,188 142 7 Norway 3,496 45 5 Poland 103 14 Portugal 30,366 96 7 Romania 6,613 9 0 9 % Serbia 2,104 9 0 Slovenia 316 5 0 Sweden 7,477 107 6 2 % Switzerland 29,353 160 1 FYR Macedonia 96 5 0 5 % Turkey 2,544 45 2 Ukraine 91,057** 1,367 2,822 168 United Kingdom 84,816 1,504 91 Uzbekistan 10,015 53 31 * Reporting from 2003 onwards only ** Excluding MTCT

References:

Reversing the Epidemic. Facts and Policy Options. HIV/AIDS in Eastern Europe and the Commonwealth of Independence States. UNDP. Bratislava 2004.

Guidance on Global Scale-up of the Prevention of Mother-to-Child Transmission of HIV. Towards universal access for women, infants and young children and eliminating HIV and AIDS among children. WHO and UNICEF with the Interagency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Children. ISBN 978 92 4 159601 5.WHO 2007.

PMTCT Report Card 2005. Monitoring Progress on the Implementation of Programs to Prevent Mother to Child Transmission of HIV. UNICEF. December 2005. Accessed on 29.1.2008 at http://www.uniteforchildren.org/knowmore/knowmore_28922.htm .

Assessment of Social and Psychological Support Needs of HIV-positive Women. Survey results report. Leningrad Oblast Centre for Prevention and Relief of AIDS and other Infectious Diseases, Regional Public Organisation of social projects in the sphere of population's well-being "Stellit", and International Development Collaboration at STAKES. 2007.

Risk Factors Impacting on the Spread of HIV among Pregnant Women in the Russian Federation. WHO EURO, Sexually transmitted infections/HIV/AIDS programme. 2007.

The Provision of Medical and Social Care for HIV-positive Pregnant Women and their Infants. Policy Briefing Paper. Ministry of Health and Social Development of the Russian Federation. Moscow 2007. Accessed on 31.1.2008 at http://www.unicef.org/russia/media_4913.html .

Information Bulletin. Children born to HIV-infected mothers in 2004-2005. Prevention of MTCT of HIV in the territories of the Russian Federation. Ministry of Health and Social Development; Republican Clinical Hospital of Infectious Diseases - Scientific and Practical Centre on Assistance Provision for HIV-infected Pregnant Women and Children. St. Petersburg 2007. Accessed on 31.1.2008 at http://www.unicef.org/russia/media_4913.html .

The Latvian National Report 2006 on Monitoring the Follow-up to the Declaration of Commitment on HIV/AIDS. Coordination Committee on Limiting Spread of STD and HIV Infection. Riga 2005.

Kristi Rüütel and Liilia Lõhmus: HIV and AIDS in Figures 2006. Version 05022007. National Institute for Health Development. Accessed on 4.2.2008 from http://www.tai.ee/?id=4950 .

EuroHIV 2006 Survey on HIV and AIDS Surveillance in the WHO European Region. European Commission, UNAIDS, WHO, the French Institute for Public Health Surveillance. Accessed on 4.2.2008 from http://www.eurohiv.org/

Annex 2 30

Migration and HIV/AIDS in the Baltic Sea Region and NW Russia

Simo Mannila, Senior Expert IDC at STAKES

1. Background

This paper summarizes some discourses and findings relevant when considering migration and HIV/AIDS in the Baltic Sea Region and NW Russia. Firstly, migrant populations are not homogeneous; they consist of many different ethnic groups and migration can be based on very varying motivations. Nevertheless, there are some general findings which can be used as a starting point when looking at immigration in the Baltic Sea Region and North-Western Russia and HIV/AIDS. Secondly, when we speak of emigrants vs. immigrants, we usually look at migrant flows between countries. Nevertheless, internal migration may also be relevant: in many countries such as the Russian Federation and Estonia, there seems to be wide regional variation in the prevalence of HIV/AIDS, and internal migration inside the Russian Federation could be of major importance also for the potential spread of HIV/AIDS. Finally, there may be national minorities, who by living conditions and life style may differ from the basic population as much or more than migrants. There may also be differentiation by health, and the minorities may be more vulnerable to ill-health incl. HIV/AIDS. These are some comments to define the subject matter of this paper. Internal migration and the status of ethnic minorities in relationship to HIV/AIDS are, however, not a key focus here.

In general, people who emigrate are healthier than those in the country of origin. This is called the healthy migrant -hypothesis, and there is extensive, even if rather variable evidence for it (e.g. McKay & al. 2003). The hypothesis says that there is a health-based selection in migration: those who emigrate tend to be healthier than those who stay. One of the most dramatic findings in Finland in compliance with this hypothesis tells us that Russian and Estonian male immigrants in Finland are healthier than Finnish men. This result is based on the comparison of the findings of a separate survey to the results of the Finnish Health 2000 Study (Liebkind & al. 2004): a very unexpected finding knowing Russian men's tendency to "die too young" (World Bank 2004). The healthy migrant -hypothesis is often supplemented or equaled to the "salmon" -hypothesis: this refers to the fact that migration with all that goes with it requires somehow going upstream, and unsuccessful migrants tend to return more often than successful ones. There is less research into the salmon hypothesis - an epidemiologically interesting idea considering that migration may transmit health problems - than into healthy migrant hypothesis or immigrant health in general (cf. Abraido-Lanza & al. 1999).

Healthy migrant- hypothesis refers, thus, to a selection into emigration rather than directly to the health status of immigrants, but it can explain some of surprising findings among immigrants. Nevertheless, the reasons to emigrate vary, which bears direct implications to immigrant health. We may say that there are two main reasons to emigrate vs. immigrate, sometimes combined with each other: poverty and persecution. Firstly a most typical form of migration is search for work or better life: health is an asset in the search for work and in order to go abroad for this a minimum of health is required. Secondly, major population movements are also caused by wars, various catastrophes or persecution, all leading to large-scale vulnerability and migration. Persons immigrating on these grounds - even if the healthy migrant hypothesis might be true for them as compared to those who will stay - may suffer from ill-health due to their life course. This is acerbated by the fact that countries vulnerable to wars, catastrophes and political turmoil, leading to emigration waves, usually have considerably higher morbidity and mortality than other countries. When looking at health of migrants, a key factor in hypothesizing health is the reason for migration.

An interesting case is constituted by some other emigration vs. immigration grounds such as that of ethnic origin. Some countries have built their immigration policy at least partly on ethnic favouritism giving a special status for some ethnic groups: these countries include in the European Union e.g. Germany (returning immigrants from Eastern Europe and CIS), Greece (Pontic Greeks) and Finland (Ingrian and other Russian Finns). How does this selection criterion potentially influence the health profile of immigrants? It is probable that the immigration into these countries has been more based on search for welfare than any ethnic factors: this interpretation is supported by e.g. the finding supporting healthy migrant -hypothesis referred to above. Ethnic origin as a reason for migration becomes important when there is a possibility to have a better life referring to it. However, there may be other background factors bearing an impact on the findings from persons migrating for ethnic reasons. There has been, for instance, higher morbidity of the Finnish minority in Estonia as compared to that of Estonians, interpreted as the lagged impact of repression during childhood and which may be presumed also among some persons of this group who immigrate to Finland (e.g. Katus & al. 2003).

The comparison of health between the basic population and immigrants may be complicated because the profiles of health and illness may be very different. Some forms of illness may be very common in the countries of origin, and uncommon in the target countries. This may lead into problems in diagnostics and inadequate health care for immigrants, if their health problems are not well recognized or their access to health care for various reasons (culture, finances) is limited. This may also lead into unfounded prejudices concerning the disease burden of immigrants. A key example here is HIV/AIDS, which is a major public health problem in many Sub-Saharan countries, with a prevalence of over 10 % or more, while in all European countries the prevalence is much lower.

2. Basic factors bearing an impact on HIV/AIDS spread by migration

In sum, the basic factors bearing an impact on HIV/ AIDS spread on a certain region via internal or external migration could be defined as follows:

• Prevalence of HIV/ AIDS in the countries of the region and other countries

• Migration flows inside the region and between the region and other parts of the world

• Lifestyles of the people linked directly to transmission modes, and

• Schemes of early intervention and health care related to HIV AIDS in the region

In the case of Baltic Sea Region and NW Russia we see major differences between the countries as to the prevalence of HIV-infection; migration flows (who; from where; flow sizes), and also as to the lifestyles and schemes to address HIV/AIDS in the region. The country-specific information is, however, very variable, and below we address the above topics on the basis of this information, some country cases and draw some more general conclusions. The key information sources are various websites of international organizations and the Barents HIV/AIDS Programme documents collecting a great deal of statistics and some individual country-specific studies. The point of the paper is to describe HIV/AIDS discourse in the Baltic Sea region and NW Russia in the context of the above general factors and what we know about them from our countries of interest.

3. Prevalence of HIV/ AIDS in the countries of the region and other countries

There are major differences in the prevalence and incidence figures of HIV-infection between the countries in the Baltic Sea region and in the NW Russia. However the information base varies by country: a good example of this is the number of tested persons. Administrative statistics very commonly reported in the HIV/AIDS discourse never cover the whole picture. The coverage is presumably better in the countries with high awareness concerning HIV/AIDS and well developed services including access to proper care, and worse in countries with less awareness of the problem and less developed care. This means that in the former case the administrative statistics capture a larger share of the whole picture. On the basis of project work carried out in NW Russia we may conclude, that Russian administrative statistics, in particular, are downwards biased, while the situation in the Nordic countries is better. There are estimates that the prevalence of HIV/AIDS in Russia could be at least 1 %, while the registered cases cover around 370,000. If the prevalence estimates are true - and they are done by the best qualified international organizations, the difference here is alarmingly over one million cases - some of them unaware of their health problem, some others maybe discouraged by the lack of information, lack of services and a possibility of discrimination.

Other countries such as Poland and the Baltic States may be placed between these two extremes in the Baltic Sea region and NW Russia. The Estonian case is, however, interesting: the statistics show particularly high rates of testing among the population, i.e. there is a probability that the Estonian statistics will capture HIV/AIDS in rather real terms. The result is reflected in the record-high prevalence of HIV/AIDS found in Estonia.

Table 1 shows the estimated incidence of HIV cases in the Baltic Sea Region and Russia in 2004. This may serve as an illustration of the very variable situation in the countries of our interest.

Table 1. Incidence of HIV in various countries of the Baltic Sea Region and Russia and prevalence by cases by the end of 2006 (Salminen 2007; EuroHiv 2007).

Country New cases per million, 2004 All cases, 2006 Sweden 48 7,477 Finland 25 2,082 Denmark 54 4,746 Norway n/a 3,496 Germany 24 29,017* Poland 17 10,555 Lithuania 39 1,200 Latvia 141 3,631 Estonia 568 5,731 Russian Federation 239 369,187 * since 1993

The incidence data show the latest development of the problem, not its size. We see that in 2004 there were two groups of countries, the first one with a very high prevalence including Estonia, Russian Federation and Latvia, and the second one including all other countries. Measured by the absolute number of cases the end of 2006 there were almost 370,000 reported HIV cases in the Russian Federation, 3,631 cases in Latvia and 5,731 cases in Estonia. The absolute number of reported cases in Poland and Germany is also very high, over 10,000 vs. almost 30,000. Taking into account the abovementioned gap, the increase of registered cases may be also positive: it may also mean that the health care and other public services increasingly recognize the problem and are able to tackle with it. In any case, this also indicates that migration - and also commuting and tourism, since 33

sometimes these can hardly be separated from migration - will bear an impact on the HIV-infection spread through migration between these countries. In any cases, when looking at prevalence or incidence data solely, we should focus on population movements between the three high incidence countries Estonia, Latvia and the Russian Federation, and other countries of our interest as a potential risk source.

It is also interesting to compare the HIV figures of various regions in NW Russia. In 2007 the prevalence per 100,000 in the Russian Federation was 268 according to statistics gathered for the Barents HIV/ AIDS programme. The situation of the NW Russian regions as compared to this average was as follows (Table 2).

Table 2. The prevalence per 100 000 and registered cases in the NW Russian regions until 11/ 2007 (comparison figure: Russian average). (Information from AIDS Foundation, East-West 2007, www.afew.org/English/countries/Russia.php , accessed in January 2008)

Region Prevalence/100,000 Registered cases Saint Petersburg 736 35,315 Leningrad region 727 12,293 Republic of Karelia 63 438 Murmansk region 253 2,243 Archangelsk region 19 256 Pskov region 45 354 Kaliningrad region 460 5,791 Nenets autonomous district 225 1,284 Republic of Komi 90 936

Russian Federation 268 403,100

The table shows major variation inside the NW Russia. Saint Petersburg is hit worst, and it is also on the top of the problem list by the number of cases: there are over 35,000 registered HIV cases in Saint Petersburg. Leningrad region, which surrounds Saint Petersburg is by relative indicators almost at the same level, which is three times above the Russian average. Kaliningrad, Murmansk and Nenets autonomous district belong to the middle range of the regions. A great deal of transport industry and links with export business is concentrated in all these regions (Murmansk: shipping, military, Nenets: various raw materials) and Kaliningrad is one of the largest harbours in the Russian Federation, at the crossroads between Poland and Lithuania, and the region where the epidemic spread first. HIV prevalence is considerably lower in Karelia, Pskov and Komi - the two first regions being rather marginal in the Russian economic geography, while Komi similarly to e.g. Nenets today has major natural resources and figures quite high on the list of Russian gross regional product champions.

The Russian figures show considerable regional variation in the HIV prevalence inside the country. Considering the high figures of Saint Petersburg and Leningrad Oblast, we should not worry for Russian internal migration: the HIV prevalence in the NW Russia can hardly become higher because of that. Other, much smaller countries and regions show also considerable regional variation. Estonia is also here a typical example: the problem is concentrated in the Northeast Estonia and to a certain extent in Tallinn, while the prevalence of HIV in the Southern and Western parts of the country is very low. This may be related to accumulation of social problems as well as the links between the NE Estonia and high prevalence regions of Saint Petersburg and Leningrad oblast. In Finland, too, as probably in most countries, the capital region is worst hit, but the spread does not seem to be as concentrated as it is in Estonia or in the Russian Federation (Salminen 2007). In the Finnish case, the 34

geographical difference is hardly related to the accumulation of social problems, but it may be related to international links and the concentration of some ethnic minorities more typical of the capital region than other regions.

There are estimates that in all European scale Estonia and the Russian Federation may be worst hit by the HIV epidemic, and there are rather gloomy prognoses concerning the future impact of HIV on the demographic and economic development of these countries (Leinikki 2007; Plavinski & Baranova 2005). There are also estimations of more general character pointing out the detrimental impact of ill- health on the Russian economic development not including the potential impact of HIV/AIDS epidemic and pointing out very positive results of any improvement in health (Suhrcke & al. 2007). According to most recent information concerning e.g. the whole Russian Federation and Saint Petersburg, the gross national vs. regional product is developing very positively and the negative demographic development seems to be at least slowing down (e.g. BOFIT 2008). The economic development in Estonia has lately been less favourable than in the booming years some ten years ago, but we cannot speak about major problems.

> Theoretically, problems in economic and human development - potentially also related to HIV/AIDS - would mean an increasing impetus for emigration in search for better life from vulnerable regions or countries to other countries. However, we must bear in mind the selection into migration, and the variation between the groups of migrants. Labour migration in search for better life, supports the healthy migrant hypothesis, relevant also for the spread of HIV/AIDS.

4. Migration flows influencing the Baltic Sea region and NW Russia

Migration consists always of immigration and emigration, and as a result of these flows we have the migration balance. The countries of the Baltic Sea region showed e.g. in 2005 varying profiles (e.g. www.migrationinformation.org ). While the migration balance was positive for Germany (1.2), Sweden (2.7), Norway (4.7), Denmark (1.4) and Finland (1.7), it was negative for Poland (-0.3), Estonia (-0.3), Latvia (-0.5) and Lithuania (-3.0). There is extensive discussion concerning the emigration of labour force from the new EU Member States to the old ones plus Norway: in the Baltic Sea region all Baltic countries and Poland are hit, while the Scandinavian countries and Germany receive immigrants. In Finland the labour immigration is somewhat lagged due to the fact that the restrictions in the Finnish labour market until May 2007. The profile of NW Russia may be rather close to a zero balance: while Saint Petersburg keeps attracting people from all Russia, many other regions such as the rural Leningrad and Arkhangelsk oblasts have a negative immigration balance (Zubarevich 2007). These figures show the main outlines of migration profiles in the Baltic Sea Region and NW Russia.

The population movements in the European Union are caused by the establishment of one labour market. There seem to be rather rough estimates concerning the size of this phenomenon, but it has been estimated, for instance, that in there are over 2 million Polish citizens in the UK only, plus some hundreds of thousands in Ireland. In general, the above migration balance coefficients make major changes in absolute numbers in all Baltic countries as well as in Poland. Inside the European Union/EEA there may, however, be other cases, where besides migration commuting and even tourism must be considered with a keener eye, since it is so easy both geographically and linguistically. This may be valid, for instance, for the relationship between Greater Helsinki Area and Estonia/Tallinn, due to the geographical proximity and difference in the living standards as well as in the HIV rate of the two regions. According to Rüütel (2007) the HIV incidence figure for Estonia 2005, referring to EuroHiv data, was 461, while the corresponding figure for Finland was 26 and for Sweden 43. Similar cases hardly exist between other countries in the Baltic Sea region: for instance, between some parts of Denmark and Sweden's Skåne district there is a very high level of cross- 35

border commuting and migration, but the difference in the living standard and HIV rate is insignificant (Sweden: 43, Denmark 53; Rüütel 2007). However, healthy migrant -hypothesis is as valid for commuting as it is for migration. There is hardly reason to believe that persons looking for work or working in the neighbouring country would suffer from major ill-health.

There is also extensive legal and illegal migration into the Baltic Sea region and NW Russia from outside this region, which is may be of paramount interest for the spread of HIV-infection. There are, for instance, estimates that there are 5-15 million illegal immigrants in the Russian Federation, some of them in NW Russia. Although many of these persons may be Russians who have migrated from some parts of the previous Soviet Union (e.g. from Central Asian countries, Caucasus), there is still a large number of other people. If all immigrants in the Russian Federation should be of those countries of origin which are typical of legal immigrants, the immigrants would be from Ukraine and other CIS countries as well as from some Asian countries such as China and Vietnam. The prevalence of HIV by EuroHiv (2007) in these countries of origin is not higher than that in e.g. Estonia or the Russian Federation. On the basis of the healthy migrant -hypothesis, there is, again, no reason to believe that the immigration from these countries would be a major risk for the spread of HIV-infection. However, in some cases a drug connection may be a confounding factor, as discussed in the next chapter.

Major immigration flows come also to the Baltic Sea region countries from non-European countries. This is, more valid for Nordic countries and Germany than Poland, the Baltic states and NW Russia. The immigrants from the countries of Sub-Saharan Africa, in particular, are here of special interest, since the prevalence of HIV in these countries surpasses any European figures and we may speak about a genuine epidemic. Also the character of the illness is different in these cases: it cannot be directly linked to any life styles or life style minorities as is the case in many European countries, the HIV prevalence rates can be up to 10-40% of population in certain regions of the worst hit Sub- Saharan African countries.

Where do the immigrants come from, and what is the size of immigration from outside the European Union to the Baltic Sea region? The German data of rather recent years show a surplus balance of approximately 50,000 immigrants from the non-EU European countries (as compared to the number emigrants). In Finland, persons from Russia and Estonia are the key immigrant groups, amounting presently to a minority of approximately 50,000 Russian-speakers in Finland (e.g. Liebkind & al. 2004). Otherwise, the immigration to Finland consists of various groups and includes e.g. Somalis, Albanian-speakers (mainly from Kosovo), Arabic-speakers and Vietnamese (Jasinskaja-Lahti & al. 2002). In Sweden, the largest immigrant group consists of Finns (almost 200,000 by the country of origin). The following immigrant groups in Sweden in the order of size are persons from (ex) Jugoslavia, Irak, Bosnia-Herzegovina, Iran and Norway. These immigrant profiles would, in general, indicate that the major immigrant groups usually come from the neighbouring countries or as refugees and asylum-seekers (e.g. persons from Kosovo, Vietnamese to Finland, Bosnia- Herzegovina, Irak to several countries). The immigration flows from Sub-Saharan Africa into any of the Baltic Sea region countries are modest. The main target of this immigration may be Germany, with approximately 32,000 Sub-Saharan African immigrants yearly, but with a net immigration balance of only 7,000. The immigration from e.g. Asian and South-Asian countries is considerably larger by size in Germany: there are over 100,000 immigrants from Asian countries yearly, with a positive immigration balance of over 30,000 (Marcus 2007). However, for instance, the list of 20 main immigrant groups to e.g. Sweden does not include immigrants from any South Asian countries (www.immi.se). The volume of immigration to any of the Baltic countries is modest as compared to the emigration figures.

The HIV estimates (Marcus 2007) for migrants from non-EU European countries do not show an alarming difference as compared to the German figures. This is in compliance with the healthy 36

migrant hypothesis. The key difference is between Sub-Saharan African immigrant and basic population (estimated incidence 3% vs. 0.1%), and also between South-East Asian and basic population (0.6% vs. 0.1%). In the overwhelming majority of the cases the HIV-infection has − according to information available − not been transmitted in the target country i.e. it was there before the immigration.

> We may state that considering population movements, the HIV problem in the Baltic Sea region is acerbated by the health status of immigrants from those regions of the world where the HIV epidemic is very common. This means, in particular, Sub-Saharan Africa. Considering the risks of social exclusion typical of many immigrant groups, potential cultural difference between the countries of origin and the target countries, as reflected in the understanding of health, demand for health services and cultural sensitivity of health services, this makes a major challenge to the combat against HIV/AIDS and functioning of health systems.

The information concerning e.g. immigrants (HIV-infection rates, transmission) in Finland is in compliance with this conclusion (e.g. Salminen 2007).

According to international information there are reasons to believe that the spread of HIV-infection in the Russian Federation has not been contained, and it entails an increasing risk to the whole Russian population. Does this risk spread to the countries of the Baltic Sea region?

> There does not seem to be adequate information to support this hypothesis, and additional research is needed here. The reasons for the fact that the hypothesis is presently hardly supported may be multifarious, e.g. EU visa policy, healthy migrant effect, also culturally induced scarcity of contacts between some neighbouring countries.

5. Lifestyles of the people linked directly to transmission modes

In the previous chapters we have discussed the spread of HIV-infection in the Baltic Sea region and NW Russia, with some comments concerning the situation in other parts of the world; we have also discussed the migration patterns inside the region of our interest as well as immigration into the Baltic Sea region and NW Russia. Here we highlight some lifestyle factors, which, according to our information concerning the transmission channels, bear a very important influence on the HIV epidemic and its development.

Looking at the HIV statistics based on administrative data from various countries collected in the Barents HIV/AIDS Programme and showing the channels of transmission we may see major differences between country profiles indicating that HIV is related to different life styles or life style problems in different countries of the Baltic Sea region and the NW Russia. Two most remarkable findings, based on the expert papers of the Barents HIV/AIDS Programme (e.g. Marcus 2007; Salminen 2007) are as follows:

• In the Baltic countries the problem seems to be largely related to drug abuse; • In the Nordic countries and in Germany, the problem is still largely related to men having sex with men.

In all countries there is an awareness of the potential threat meaning that HIV-epidemic will become generalized so that it will be a sexually transmitted illness not contained in any of the minority segments of the population. There are various indications that this process is underway for instance in the Russian Federation and even Nordic countries (e.g. Blystad 2007). According to the administrative data, the problem in NW Russia has also continued to be related to drugs, but we may 37

state this with a certain reservation, due to the large difference between the registered HIV cases (350,000 cases by the end of 2005, presently over 400,000) and the estimated prevalence (up to 1.1% for the whole country by UNAIDS 2006). When speculating on the real significance of the gap between the registered cases and estimated prevalence, we must bear in mind that also drug abuse is rather wide spread, and its links with more traditional Russian problems such as alcohol abuse are still widely unknown. This means, we do not know what the overlap between different social problems is and we have no clear picture to which extent the problem still is concentrated on persons with some special lifestyle. In fact, any increase in the registered number of HIV cases in the Russian Federation should at present be welcomed, since it would not necessarily indicate increased prevalence: it would most probably indicate that the diagnostic system, cure and care start to function. This said presuming that the internationally estimated HIV prevalence in the Russian Federation is not faulted. We must point out that the prevalence estimates are not very accurate: for 2006 the international estimate for Russia was between 560,000 and 1,600,000 (EFS 2006).

In addition to the issues of drug addiction and men having sex with men, we must pay special attention to prostitution and trafficking as key elements in the HIV transmission, also internationally. The information concerning this is rather scarce, and additional research would be needed. Major work in the field of trafficking is carried out by the International Organization of Migration, but the HIV problems are not a key focus (http://iom.fi/content/view/89/98). In the press there is also conflicting information concerning the input of foreigners (immigrants or tourists) in the sex business of the Baltic Sea region, and the significance of trafficking as a transnational social problem.

This means, related to migration, that the HIV risks related to migration are also related to the lifestyles of men having sex with men (cf. WHO 2007a), to the relationship of drug use, prostitution and trafficking with migration - taking into account the Schengen borders and their impact on the dissemination of drugs and more intense cross-border relations. In the present HIV policies, it is not clear that these factors of key importance have been addressed to an adequate extent, and it is clear that additional research would be needed.

> We see that a twin-track approach, focusing on both the general population and the special risk groups and their lifestyles is here needed - this goes for research as well as policy design. Any epidemiological models of general character must remain inaccurate, if the significance of the special factors - no doubt requiring targeted research, since the phenomena cannot be described by standard population surveys or administrative statistics, which can be considered socially constructed - is neglected.

As far as the immigrants from non-European countries are concerned, the issue of the abovementioned lifestyles is still valid and special attention must be paid on more general cultural issues. Medical anthropological knowledge accumulated in other countries may be here very useful. However, when HIV-infection is wide-spread in the general population, persons with no special lifestyle or no major social problems may suffer from the infection, which has not been diagnosed due to e.g. inadequate health services in the country of origin. This means that additional sensitivity is required in the health care of the target countries to understand the complexities of immigrant health.

> There is also a need of anti-discrimination approach in all HIV policies. It is important, in particular, to pay attention to the potential discrimination on the basis of ethnic origin: foreign nationals may be considered dangerous because of their origin, which is based on a misguided idea concerning what HIV/AIDS is and what it is not.

European Union attempts to fight discrimination by means of two directives (Racial Directive 2000/43/EC, and Employment Directive 200/78/EC), but it is clear that their implementation varies 38

by country. As far as the Russian Federation is concerned, there is evidence of xenophobic tendencies in the civil service and misguided understanding of HIV-infection as an illness (e.g. WHO 2007b), which may cause difficulties in designing and implementing effective HIV/AIDS policy (e.g. Open Society Institute 2007).

6. Schemes of early intervention and health care related to HIV AIDS in the region

The schemes of early intervention and health care related to HIV/AIDS, and their variation by countries, may be an intermediate factor looking at the link between migration and HIV/AIDS. There are differences between societies concerning the extent how HIV-infection is diagnosed, treated, and how the victims of the illness are supported by public or other (mainly NGO) services. This difference exists also between the countries of the Baltic Sea region and NW Russia, as well as between all countries of our interest and other countries of the world. We could think that the better the awareness and services available are, the higher the healthy migration effect; however, there is hardly any indication that there would be migration between countries induced by the difference in the treatment and services available for persons with HIV/AIDS.

As far as ethnic minorities are considered, some of them may be considered new, some traditional: at some point of history the difference between these two may become blurred. There is information from e.g. Canada, showing increased vulnerability of some traditional ethnic populations to HIV (e.g. Boulos 2007).

> This means that a special sensitivity of the public services (health care, social care, law enforcement) is needed towards the needs of vulnerable ethnic minorities, both old and new. Their access to e.g. health services is often not equal that of the basic population, and there may be socio- cultural barriers from both sides in help-seeking and help-offering behaviour as well as in the understanding of the severity of the HIV/AIDS problem. This is still another reason for a twin-track approach: the combat against HIV/AIDS may also be considered a strand in more general social inclusion and equal opportunity policies.

Thus, in the awareness raising concerning HIV & AIDS and designing and providing the public services we must pay attention to the cultural minorities and their special needs. This request is relevant to all countries of the Baltic Sea region and NW Russia. Risks of social exclusion, also related to and potentially caused by ethnic discrimination, vary by country and ethnic groups, and we must not increase them or let them accumulate by insensitive policies. Promotion of equal opportunities for all and diversity management in public service - integral in some countries with multicultural population, such as Canada - must be included in the repertoire of combat against HIV and AIDS for the rights of the illness victims.

7. Summary of challenges and recommendations prepared by the HIV/AIDS Expert Group submitted to Lisbon Meeting

Presented in the EU meeting "HIV and migrant populations", Lisbon, Oct 13 2007

Background – Immigration and xenophobia are linked – Immigration often linked with legal ”irregularities” – poor access to health and social services – Immigration linked with secularism – cultural communication problems - counselling – Immigration linked with ”different” disease patterns compared to main population – Immigration linked with ”different” disease patterns compared to main population – Inaccurate surveillance and poor knowledge about the actual dynamics of HIV within migrant communities – Poor understanding of the risk factors Challenges – Can we provide proper counselling and treatment in a cultural-sensitive way? – Do we know what is actually going on? (”hidden populations”, different groups) – Can we handle the situation among illegal immigrants? (Cave discrimination!) – How to meet challenges like xenophobia among the general population? – Which strategy? 1.Integration 2. Separate services > "Twin-track approach"?

Recommendations • Better definitions, more research and information is needed to fully understand the HIV problem among non-native populations, • Legal and economic restrictions and obstacles vary from one EU-country to another, a need for ”Ombudsman” at EU level • Emphasis should be on human rights, and their practical implementation; access to proper cARV-treatment is a useful criterion • In training, target populations must be involved in the implementation of training

References

Abraido-Lanza A F, Dohrenwend B P, Ng Mak D S & Turner J B (1999) The Latino mortality paradox, a test of the salmon bias and healthy migrant hypotheses. American J of Public Health 10, 1543-1548.

BOFIT - Bank of Finland, Institute of Transition (2008) BOFIT Forecast for Russia 2008-10. www.bofit.fi/bofit_en/seuranta/ennuste/208/bve108.htm .

Boulos D (2007) Second Generation HIV Surveillance in Canada. 7th Meeting of the Northern Dimension Partnership in Public Health and Social Well-being HIV/ AIDS Expert Working Group Meeting in Porto Oct 9-10 2007.

Blystad H (2007) HIV-infection in Northern Europe. The challenge of HIV and TB Co-infection. Norwegian Institute of Public Health, Paper prepared for the Barents HIV/ AIDS Programme, Oslo 1 March 2007.

EFS - Epidemiological Fact Sheets (2006) Russia Update November 2006. UNAIDS, UNICEF, WHO.

EuroHiv (2007) HIV/ AIDS Surveillance in Europe. End-Year Report 2006. www.eurohiv.org .

Jasinskaja-Lahti I, Liebkind K & Vesala T (2002) Rasismi ja syrjintä Suomessa. Gaudeamus, Helsinki.

Katus K, Puur A & Poldma A (2003) Demographic development of the Ingrian National Minority in Estonia. Yearbook of Population Research in Finland XXXIX, 141-170. The Population Research Institute, Helsinki.

Leinikki P (2007) HIV-epidemia lähialueillamme. Pääkirjoitus. Suomen Lääkärilehti 8/ 2007, 736.

Liebkind K, Mannila S (2004) Liebkind K, Mannila S, Jasinskaja-Lahti I, Jaakkola M, Kyntäjä E & Reuter A. Venäläinen, virolainen, suomalainen. Kolmen maahanmuuttajaryhmän kotoutuminen Suomeen. Helsinki: Gaudeamus, 2004, 153.

Marcus U (2007) HIV and Migration in Germany. 7th Meeting of the Northern Dimension Partnership in Public Health and Social Well-being HIV/ AIDS Expert Working Group Meeting in Porto Oct 9-10 2007.

McKay L, Macintyre S & Ellaway A (2003) Migration and Health: A Review of the International Literature. MRC Social & Public Health Sciences Unit, Occasional Paper No 12. January 2003.Glasgow.

Plavinski S L & Barinova A N (2005) A sexually transmitted HIV/ AIDS epidemic in Russia? Aaltonen U & Mannila S (eds.) What Are We Doing There? Experiences and lessons learned from the development cooperation in health care and social welfare, 227-243. STAKES, Helsinki.

Open Society Institute (2007) Monitoring the Moscow Metro for Ethnic Profiling by the Police. www.justiceinitiative.org/ .

Rüütel K (2007) HIV/ AIDS Burden in Estonia. Northern Dimension Partnership in Public Health and Social Well-being HIV/ AIDS Expert Working Group Meeting in Porto Oct 9-10 2007.

Salminen (2007) HIV/ AIDS tilanne Suomessa - ulkomaalaiset ryhmässä ja tulevaisuuden haasteet. National Institute of Public Health, INFE/ HIV Unit.

Suhrcke M, Rocco L, McKee M, Mazzuco S, Urban D & Steinherr A (2007) Economic Consequences of Noncommunicable Diseases and Injuries in the Russian Federation. WHO on behalf of the European Observatory of Health Systems and Policies, Wilts.

UNAIDS (2006) Country Profile: Russian Federation. www.unaids.org/en/CountryResponses/Countries/russian_federation.asp .

WHO (2007a) HIV Prevalence and Risks among Men Having Sex with Men in Moscow and Saint Petersburg. WHO Regional Office for Europe, Copenhagen.

WHO (2007b) Risk Factors Impacting on the Spread of HIV among Pregnant Women in the Russian Federation. WHO Regional Office for Europe, Copenhagen.

The World Bank (2004) Dying Too Young. Addressing Premature Mortality and Ill-Health Due to Non- Communicable Diseases and Injuries in the Russian Federation. http://siteresources.worldbank.org/INTECA/Resources/DTY-Final.pdf .

Zubarevich N (2007) Human Development and Millennium Development Goal in, Russia and Russian Regions. Lecture at the Alexander Institute of Helsinki University, August 2007.

Northern Dimension Partnership in Public Health and Social Well-being

NDPHS Expert Group on Primary Health Care

Thematic Report DRAFT

Primary Health Care in

the Northern Dimension Countries

NDPHS Series No. 4/2008

1 Northern Dimension Partnership in Public Health and Social Well-being (NDPHS)

NDPHS thematic report: Primary Health Care in the Northern Dimension Countries

The views reflected in this paper are those of the members of the NDPHS Expert Group on Primary Health Care who have developed it and should not, therefore, be interpreted otherwise. If specific country data are not available in this report, this is because the authors were either unable to obtain it or did not receive permission to publish this data.

Editors: Arnoldas Jurgutis, Valentin Rusovich and Michail Dotsenko

Reference Group for the preparation of the report: Goran Carlsson, Sweden Toralf Hasvold, Norway Simo Kokko, Finland Zbigniew Krol, Poland Ursel Kedars, Estonia Leif Persson Sweden Carl-Eric Thors, Sweden

Pictures: Arnoldas Jurgutis, Valentin Rusovich

This paper may be freely reproduced and reprinted, provided that the source is cited.

It is also available on-line in the Papers’ section of the NDPHS Database at: www.ndphs.org/?database,view,paper,21

View our website at www.ndphs.org and keep an eye on policy developments and explore the world of the NDPHS – a partnership committed to achieving tangible results!

Further information:

NDPHS Secretariat Strömsborg P.O. Box 2010 103 11 Stockholm, SWEDEN Phone (switchboard): +46 8 440 1920 Fax: +46 8 440 1944 E-mail: [email protected]

2 Agency is not responsible for any use that may be made of the information contained therein.

ACRONYMS 4 Chapter 1 Introduction 5 1.1 Background 5 1.2 Scope of differences in development of primary health care among 6 Northern Dimension Countries 1.3 Data sources and methods 7 Chapter 2 Basic public health and primary health care indicators 7 Chapter 3 Organization of primary health care in Northern Dimension Countries 12 3.1 Primary health care practices and physicians 12 3.2 Other primary care team members 17 3.3 Primary health care team and community. Home care 18 3.4 Cooperation with secondary health care specialists 21 3.5 Equipment and informational technologies 22 3.6 Workload indicators 24 3.7 Tasks of general practitioners 26 3.8 The role of professional associations 28 Chapter 4 Education of PHC doctors and nurses 29 4.1 Introduction 29 4.2 Undergraduate education 30 4.3 Postgraduate education and licensing 31 4.3.1 Internship 31 4.3.2 Specialty training/vocational training in general practice/family 32 medicine 4.3.3 Licensing 34 4.3.4 Continuing medical education/continuing professional 35 development (СPD) 4.4 Nurse training 35 4.4.1 Nurse training in ND Countries 35 4.4.2 Conclusions 38 Chapter 5 Purchasing and remuneration of primary health care 39 5.1 Introduction 39 5.2 Purchasing of health care in Northern Dimension Countries 39 5.3 Provider reimbursement 40 5.4 Co-payments for primary health care services 42 Chapter 6 Conclusions 46 Chapter 7 Gaps in the primary care systems in ND Countries. Recommendations 47 for project-based activities References 50 Annex 1 51

4 ACRONYMS

PHC Primary Health Care

GP General Practitioner

ND Northern Dimension

NDPHS Northern Dimension Partnership in Public Health and Social Well-being

NDPHS EG Northern Dimension Partnership in Public Health and Social Well-being Expert Group

PHC EG Primary Health Care Expert Group

SIHLWA EG Social Inclusion, Healthy Lifestyles and Work Ability Expert Group

ITA International Technical Advisor

TM Task Managers

WHO Word Health Organization

WONCA World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians

EURACT European Academy of Teachers in General Practice

5 Chapter 1 Introduction

The report is a one of thematic primary health care reports in the Northern Dimension Countries within the framework activities of the Northern Dimension Partnership in Public Health and Social Well-being (NDPHS). The countries covered in the report include Sweden, Finland, Denmark, Norway, Poland, Lithuania, Latvia, Estonia, Iceland and Russia. The data from Germany and Belarus is also presented in the report as these countries have collaborative relations with the Northern Dimension PHC expert network.

1.1 Background

Within the Northern Dimension area, large differences exist in health condition among population groups. Large population groups enjoy good health to an extent second to none in the world, while underprivileged ones suffer from high disease prevalence and premature mortality. Contributing causes to these differences include social and economic problems associated with high morbidity rates from cardiovascular diseases, violence, alcohol and drugs abuse and spread of infectious diseases such as TB and HIV/AIDS.

The mission of the Northern Dimension Partnership in Public Health and Social Well-being is to promote sustainable development of the Northern Dimension area by improving peoples' health and social well-being. It aims to contribute to this process by intensifying cooperation, assisting the Partners and Participants in capacity building, and by enhancing coordination between international activities within the Northern Dimension area.

The priority objectives of the ND PHS include the prevention of lifestyle related to noncommunicable diseases (e.g. type 2 diabetes, metabolic syndrome, many cardiovascular and pulmonary diseases, as well as several cancer diseases) and the reduction of major communicable diseases. The enhancement and promotion of healthy lifestyles through modern public health strategies by involving community members from different public sectors and shifting responsibility for health from health care to other relevant public health sectors has been considered as the most important strategies for reaching these objectives.

The role of the community and other non-health care sectors in improving the public health have been for the first time emphasised 30 years ago at the WHO Alma-Ata Conference. At the conference and released afterwards Alma-Ata Declaration the role of primary health care had been referred to as a basis of the overall health care system, where continuous, comprehensive care should be provided to distinct population. Since that time, a number of international studies comparing different countries have revealed that countries which have stronger focus on primary health care, based on family medicine, succeeded more cost-efficiency for public health improvement and better satisfaction with overall health care. Hence, the organisation and delivery of primary health care with a societal perspective should be particularly emphasised. Northern Dimension Partnership recognises that health systems must be appropriately strengthened so that primary health care could be used as efficient tool for health promotion and disease prevention. Following these recognitions, the ND PHS Primary Health Care expert group was established in September 2004.

The NDPHS PHC Expert Group (EG), at its third meeting in Kraków in February 2007, formulated the overall objective of its work as improved public health through developing primary health and social care services, responding appropriately and equally to the needs of the people. Situation analysis of the primary health care in the Northern Dimension Countries and production of thematic reports have been defined as one of four working areas of the PHC EG. Objective of this report is to describe situation of primary health care emphasising possible gaps, differences and to provide support for planning, implementation and monitoring of the projects or other initiatives that contribute to the development of Primary Health Care in the Northern Dimension Region.

6 Furthermore, this report provides input to the NDPHS Database project, co-financed by the EU Commission.

1.2 Scope of differences in development of primary health care among Northern Dimension Countries

The Northern Dimension Countries show a high diversity in the way health care in general and primary health care in particular are organized. On the one hand the Nordic countries like (Denmark, Finland, Iceland, Norway, Sweden) have well known traditions of the general practice oriented model of primary health care. On the other side the countries like Poland, Lithuania, Latvia, Estonia, Russia, Belarus experiencing the different stages of the primary care transition from the "Semashko system" of policlinics with district pediatricians and internists working together with number of specialists , like gynecologists, surgeons, otolaringologists, as the first contact doctors to more comprehensive and efficient model of family medicine. These countries only 10 - 15 years ago have started primary health care reforms by developing new concepts of primary health care, and training new professionals like family doctors. The community nurses with more autonomous functions have been introduced in the primary health care systems. The most countries in transition are still missing clear definition and understanding of the role of primary health care in the system. These countries are also not homogeneous and could be divided into two groups:

- the Baltic States and Poland where the tempo of the reforms is higher, primary health care to some extend is separated from secondary and tertial health care and more steps are done in strengthening the medical specialties relevant for primary health care like family medicine/general practice and family nurses/community nurses.

- Russia and Belarus where only first steps are made towards a GP oriented model of primary health care.

Differences in overall development of primary health care emerge when comparison of these three groups of countries is made. To some extent differences exist between all countries when compare:

- the organization of primary health care facilities (solo/group practices/health care centres/policlinics)

- the legal status of the practices (private/public municipality owned/state owned)

- the number of the population attached to the practice

- requirements for the competence (education, specialization, license) of primary health care providers both doctors and nurses

- the principle of listing (obligatory or free choice of the patient), to particular practice or/and doctor

- the core functions (sick leaves issuing/curative care/prevention activities).

- The position of the primary health care specialties like family medicine/general practice, community nursing in comparison with compare with other medical specialties

Remuneration systems for primary health care are also quite different, having impact on the workload, task profiles and quality of health care from country to country.

1.3 Data sources and methods

1. All countries of the Northern Dimension have been actively reforming their primary health care systems during the last decade. In "North-West Dimension countries" the main strategies of the reforms in primary care included more efficient use of the resources through purchasing and 7 giving more financial tools on the level of the PHC, substitution specialist health care services by PHC professionals including GPs and trained nurses (nurse practitioners).1,2

In the North-East countries there have been big steps taken in the development of the new specialty and training of GPs and the introduction of the new forms of organization in primary care, including private practices. However, not so much research has been carried out investigating recent changes of primary health care in Northern Dimension Countries. The available data used in this comparative report are mainly based on research carried out and published in the late 1990s. Considering the dynamic reforms in the ND Countries some of these data was updated using available national sources of information. There were also inputs made by the local experts who reviewed and updated the available data during the preparation of this report.

Important source of information was the country profiles of the European Observatory on Health Care Systems, known as HITs (Health care in transition), with the systematic review of the health care systems in the Countries of the WHO European region3

In the relevant chapters of the report the health system and rating practice characteristics developed by Professor Barbara Starfield were used applying to the of PHC systems to the ND Countries.

Chapter 2 Basic public health and primary health care indicators

If we compare the core public health indicators like life expectancy at birth, infant mortality, years lost due premature death before 65, etc. in the countries of Northern Dimension Partnership it is obvious that the gap between two groups – the Nordic countries and Germany from one side and Baltic States, Belarus, Russia from other is increasing since the 1970s. Indicators of Poland lie in between of these two groups. (Diagrams 1 – 3).

The differences in socio-economic development could be one of the main reasons of these differences in public health situation between two groups of countries. Countries with poorer public health situation are experiencing worse socioeconomic development. Moreover these countries devote less resources to health care to compare with the GDP (Diagrams 4 and 5). Nevertheless the share of the domestic national product spent on a country's health system cannot be taken solely as a proof of a society's commitment to the Alma-Ata Conference statement: "the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector".

Diagram 1: Life expectancy at birth, in years

Diagram 2: Reduction of life expectancy through death before 65 years

Many premature deaths in countries with poorer public health indicators could be explained by higher prevalence of lifestyle related risk factors, e.g. smoking accounts for around 30% of socioeconomic inequalities in mortality and around 15% of socioeconomic inequalities in morbidity among European man4. Equity oriented approach in reduction of socioeconomic inequalities could lead to improved public health. The differences in life expectancy could be improved by 3.96 years merely by means of better education when compare those with at least upper secondary education to those with lower levels of education. Experience of Sweden, where regression of children mortality occurred during several decades, proved, that most important role in this process was Community intervention programs (targeted to parents' education). Health care system is defined as important, but it never played the main role in reducing the children mortality. Parental education was important supportive strategy indicating a shift in focus of responsibility from health care to family and community.

Diagram 3: Total health expenditure as % of Gross Domestic Product (GDP)

There is international evidence to prove that structural features of a national health system impact on the cost-effectiveness and the equity effects of the health system. Maybe the most obvious example of this is the health system of the United States, consuming some 15% of the GDP, at the same time leaving more than 15% of the population without qualified health care.

Many developed countries due to improved medical technology and increased specialization, unequal accessibility of health care services and dramatically increasing expenses during 6-7 decade of last century for the first time experienced crisis in health care system. Shain and Roemer were the first who in 1957 proved the hypothesis that increased health care resources increase consumption of health care services. Supplier induced demand today is widely investigated problem faced by all developed countries. More and more evidence recently is found that increased access to specialized services in developed countries correlate with higher expenses for health care, but no correlation found with improved public health indicators5. On the other hand increased access to family doctor (general practitioner) leads to reduction of premature mortality rates attributed to certain conditions6.

More problems with inefficiency of the health care system meet the countries with ill defined role of primary health care and poor coordinated opened access to specialized care. Soviet Union was one of such countries who overestimated role of specialized health care for increasing population health. The main investment aiming to improve population health was done by the means of building more hospitals and increasing number of doctors and particularly narrow specialists. When comparing Northern Dimension Countries on how many doctors and hospital beds are available former Soviet Union countries still have leading positions (Diagrams 6 and 7).

Diagram 4: Total health expenditure, PPP$ per capita

Diagram 5: Hospital beds per 100,000

Diagram 6: Physicians per 100,000

During seventieth well-known centralized program of dispensarization" increased accessibility to specialized care and made obligatory visits to different specialists for preventive check-ups. The program of dispensarization in the 1980s implied that every adult patient (for children there was another special program) should be on regular basis examined by means of the laboratory, instrumental examinations (small scale X-ray of longs, ECG for all patients older than 40) with the subsequent consultations of the relevant specialists (usually neurologist, otolaringologist, surgeon and ophthalmologists and gynecologist). Patients with chronic conditions should undergo some other relevant examinations dependant on the condition (gastroscopy, ultrasound, etc.). People do not understood real benefit of such preventive interventions. The check-ups were carried out in a very formal way and had been more specialists driven than meet the "real needs of the community". So these countries inherited from Soviet time dominance of medical professionals in decision making regarding health related questions and limited responsibility for health of the community and other sectors.

Table 1: Expenditure on health as a % of GDP in the ND Region (Source: WHO Regional Office for Europe health for all database) Total expenditure on health as a % of GDP in % growth (1999-2002) the ND the ND Region Countries 1999 2002 2004 Germany 10.6 10.9 10.6 2.83 Norway 8.9 (1998) 9.1 9.7 (9.6) 2.24 EU average 8.6 (1998) 8.7 9.0 1.16 Sweden 8.4 (1998) 9.2 9.1 9.52 Iceland 8.4 9.9 9.9 17.85 Denmark 8.3 8.8 8.6 6.02 Finland 6.9 (1998) 7.3 7.4 5.79 Estonia 6.9 5.1 5.23 -26.08 Poland 6,3 6,1 6.2 -3,17 Lithuania 5.3 (1998) 5.7 6.5 (5.9) 7.54 Belarus 4.5 4.9 6.2 (6.4) 8.89 Latvia 4.4 5.0 7.1 (5.1) 13.63 Russian 2.2 (1995) 2.9 6.0 (6.2) 31.81 Federation

12 Chapter 3 Organization of primary health care in Northern Dimension Countries

3.1 Primary health care practices and physicians

The first comprehensive definition of the primary care was given at the WHO Alma-Ata Declaration in 1978. "Primary health care forms an integral part both of the country's health system, of which it is the central function and main focus, and the overall social and economical development of the community. It is the first level of contact of individuals, the family and the community with the national health care as close as possible to where people live and work and constitutes the first element of a continuing health care process." 7(WHO, Alma-Ata Declaration, 1978)

After the Alma-Ata Declaration there were other definitions of the primary care dependant on the purposes of the policy documents. For practical reasons most recent definitions of primary health care concentrate on the health care system issues rather than intersectional approach including economical and social issues whatever important they could be. So in the recent European primary health care policy documents primary care could be defined in the following ways: as referring to the level of care between the hospital and specialist sector and the informal care8. Anyhow the concept of primary care highlighted in the report include the main health care system components as the facilities with general practitioners or other primary care doctors, community nurses, the other PHC staff and home care networks in the Northern Dimension Countries.

Type of regulation and the ownership of the primary care facilities determine to large extend the equitability in distribution of the primary health care facilities. If there is no strong commitment of the governments to promote the equitable distribution of the primary care than the big geographical differences in availability of primary health care premises are unavoidable resulting in the "inverse care law". It means that the group of the population that needs more care receive it less because of the absence of the staff and facilities, and on the other hand, the population that is well-off and comparatively have less health care problems receive more medical care.9 According to the scoring of the health care characteristic by Barbara Starfield "the regulated primary care or public health centres are considered to have highest commitment to primary care. Regulated primary care implies that national policies influence the location of physician practice so that they are distributed throughout the population rather than concentrated in certain geographical areas". 10 (See Annex 1: Component 1 – Regulation).

Referring to the North Dimension Countries we could find all spectrum of the type of regulation for establishment of the new primary care practices. In the majority of the ND Countries there is a high control on the distribution of the primary care practices although the mechanisms of regulations are different. In Sweden, it is up to each county council to decide how to deliver primary care to the population for which it is responsible. Even if primary care is mainly publicly provided, there are also private providers at this level. In addition to local health centres and family-physician surgeries, private physicians and physiotherapists, district-nurse clinics and clinics for child and maternity health care provide primary care. Private health centres and practitioners are relatively common in the big cities.11 The number of primary care facilities and GP practices is regulated by the different levels of local governments (district, provincial or county councils), professional associations (Germany). On the opposite side with no overall primary care regulations are countries that stick to the "open market" approach like Germany. Most countries score intermediate including the "post-Semashko" countries following the transition path from over- regulated governmental health care system to inventing other incentives for more equal distribution of primary health care facilities. Lithuanian experience is a good example of such changes – from centralized, highly regulated mainly hospital care towards introducing elements of free market in primary care. In 1997 when primary health care was separated from secondary health care, local government (municipalities) has to regulate primary health care distribution. Primary health care development plan should be developed by health care department and approved by municipal council. Objective of such plan was to indicate places where improvement of primary health care was needed and new primary health care facilities should be opened for getting better accessibility and equity. So it was avoided that private independent contractors will open their practices in neighbourhood of others in prestige areas, but not were it really needed. That requirement worked

13 only for seven years. In 2006 these regulations were abandoned as contradicting to the free market law.

The ownership of primary health care practices varies within the countries of Northern Dimension. Only three counties (Denmark 100%, Germany 100%, Norway 58%) have a high prevalence of self-employed (privately owned) GP practices. In the other of the ND Countries the majority of GPs are employees. In the countries with highly regulated and controlled primary care like Sweden, Finland in Western part and Belarus, Russia in Eastern part the local authority (governments) on the community or district level own the most of primary care facilities. There is, however a considerable increase in the number of the private practices in the Baltic States during the last decade. In all Baltic Countries during primary health care reform priority was given to private-independent contractors. Estonia was the first who started with family doctors as independent contractors from very beginning of the primary health care reform. Family doctors as independent contractors in Estonia demonstrate the dominant model of primary health care. In Lithuania, implementation of health care system with private independent contractors has started since year 1999, when EU PHARE project for the support of the PHC reform process announced competition for family doctors to establish private practices (Vignette 3.1).

14 Vignette 3.1: Spreading GP offices private – independent contractors in Lithuania

Aim of one of the components of the EU PHARE Project “Support to the Continued Reform Process and the Development of Primary Health Care in Lithuania” was to improve accessibility of primary health care services for the population with the technical support for establishment of private - independent contractors GP offices. Until that time only state-owned PHC practices delivered PHC services under the contract with Mandatory Health Insurance Fund. Private PHC practices have got support with basic equipment under condition that successful business plan is presented and they own or rent premises. Another requirement was that premises and services for the population should be located in the area where PHC offices needed (negotiated with municipalities). More than 100 applications have been presented and 56 practices have got support from the project in year 2000t. Number of the private practices since that time was growing and in 2007 there were 53% private institutions (218 private institutions out of 412). Still at the beginning of the process there were serious problems of management of the private practices, because owners - general practitioners - haven't got any education neither during their training years in the universities, nor during the project running period about basic management, finances running, planning, staff recruiting skills. Yet the establishment of private primary health care within the National Health Care System was declared as priority, unequal functioning conditions, more favorable for municipal institutions and less for private practices were existing for more then 10 years and some still exists until now. Thus some of the first private practices had suffered from financial and existentional problems. Survivors have developed skills for efficient functioning; have increased numbers of listed patients and prestige among other professionals. Successful examples of private practicing influenced rapid growth of new private family doctors offices and stimulated municipal primary health care centers for competitive services. Overall the example of emerging of the private sector within National Health care system serves as a good example of restructuring the health care in countries with limited resources.

Unfortunately the available WHO database on the primary health care system resources does not provide reliable instrument for international comparison. Partly it is because of the differences in the estimation and definition about the primary care staff and units. Some basic information regarding the premises and staff is presented in Tables 3.1 and 3.2.

Table 3.1: Primary health care practices, PHC physicians and other staff in PHC practices per 100,000 of population. WHO database, last available, updated by ND PHC EG members for Belaorus, Lithuania, Poland, Estonia Country The body, The number of Number of Number of Number of regulating the the primary GPs per midwifes per pharmacis establishment health care 100,000 100,000 ts per of primary units per population population 100,000 health care 100,000 population facilities. Belarus Local 67 32 (including 18 29 authorities all PHC doctors: therapists and pediatricians, and GPs) Denmark Municipalities N/A 77 17 65 Estonia County 60 65 26 62 governments, local municipalities and EHIF Finland Municipalities 4 66 32 155 Germany Insurance, N/A 102 16 58 associations Iceland Municipalities 40 77 50 101 Latvia N/A 22 53 Lithuania Local 105 82 30 70 authorities Norway Municipalities 29 71 39 61 Poland Community 60 49 15 58 Council Russia Local 11 22 41 8 authorities Sweden County council 12 N/A NA 59

In some countries only GP practices are included in the primary care units (Finland, Norway, Sweden), in Russia, Belarus, Latvia all primary care facilities are included (policlinics, feldsher posts and rural doctor's ambulatories). In Russia, Belarus all primary care doctors are included in the database (district internists, district pediatricians and GPs). The available data about the number of the primary health care nurses is absent. The WHO database monitor the total number of the nurses per 100,000 and the percentage of the nurses working in the hospitals. That make relevant further international comparison research of the number of nurses in primary care taken into consideration the important role that nurses play in the PHC team.

The primary health care doctors are the major actors in the primary care system. The Nordic countries have the long term traditions of the general practitioners as the main providers of primary care. The terms "primary health care doctors and specialists" that are used in the relevant publications and further in the report for the sake of simplicity are not quite correct since in the majority of the ND Countries general practitioner is a trained specialist in field of primary care with the same qualification and training requirements as any other specialists. Following recommendations of the WHO, WONCA, EURACT requirement for the primary health care 16 specialists is increasing. Special knowledge and skills for working in primary health care are needed, they are different from these of specialists who are working in hospitals and are trained in hospitals. Sustainable evidence proves that if care is provided by specially trained family doctors, efficiency of overall health care and indicators of public health are better.12, 13 During the last decade GPs replaced the district internists and district pediatricians in Baltic States. However even after the intensive retraining programs these retrained family doctors are missing some clinical and communication skills essential for family medicine. In Estonia primary health care is provided only by family doctors, while in other two Baltic States district internists and district pediatricians are still working in the primary care. District internists and district pediatricians. In Lithuania, at the end of 2006 primary health care was provided by 1837 family doctors (66 % out of all drs), 475 district internists (17%) and 490 (17%) district pediatricians. At the end of 2006 21% of population still has been listed to district internists and district pediatricians. In Poland, 10 000 GPs are working and another 20 000 need to be retrained as GPs . This shortage is still covered by the former primary care physicians: district internists, district pediatricians and gynecologists)14 . In Germany, Russia and Belarus primary care doctors are represented by community therapists or internists, community pediatricians and general practitioners. In the recognized instrument for international comparison of the primary care systems according to Barbara Starfield the emphasis is given to the following PHC features regarding the primary care doctors: general practitioners or family doctors make higher scores in terms of continuity and better knowing of the family context, the gate-keeping function of the GPs and the system of patients lists. General pediatricians and general internists are considered as "intermediate" primary health care practitioners because their training has a major sub-specialty focus. Other specialists are not considered primary care physicians because their training is focused on sub-specialty issues (Annex 2 – component 3)

Table 3.2: GP gate-keeping position, listing, employment status, age and gender. (Boerma W. G. W., Fleming D. M., 1998), updated by ND PHC EG members for Estonia, Lithuania. Country Patients Gatekeeping Patient Self employed Solo Female per GP function lists (private) (%) (%) (%) Belarus 1600 no Yes/catch 0 53 90 ment area Denmark 1609 Yes Yes 100 29 16 Estonia 1600 Yes Yes 100% (95%) 24 94 Finland 1582 No Yes, since 2 8 54 2003 Germany 2110 No Yes 100 67 16 Iceland 1594 Yes Yes 25 15 12 Latvia N/A Partial Yes N/A 17 77 Lithuania N/A Partial Yes N/A 29 89 Norway 1360 Yes Yes 58 25 25 Poland 2000 Yes Yes 40-100% 40 55 dependant on the region A Russia No Catchment N/A n/a n/a area Sweden 2870 No yes 1 2 35

Two characteristics out of this table could be used for scoring as proposed by B. Starfield for rating practice (1) and system (2) characteristics : (1) first contact (gatekeeping): first contact implies that decisions about the need for secondary health care services are made after consulting the primary care physician. Requirements for access to specialists via referral from primary care are considered most consistent with the first contact aspect of primary care. The ability of patients to self refer to specialists is considered conducive to a specialty– oriented health system. Where the are incentives to reduce direct access to specialists but no requirement for referral, an intermediate score is assigned; (2) patient lists highest scores are assigned where there are system requirements for personal lists. Intermediate scores are assigned where there are group lists 17 and/or where the existence of such lists is de facto rather than required. The lowest score is assigned where neither is present.17 (See Annex 1).

The average number of population per one GP varies from country to country with the lowest – 1360 – in Norway and reaching 2870 in Sweden. In Russia, Belarus and to less extend the Baltic States and Germany primary care doctors are not only GPs. In Belarus, and Russia most PHC doctors are district pediatricians (one for 800 children), district internists (one for 1800 adults) and GPs working in rural areas.

The key functions of the GP or primary care doctor is coordination of the health care to the patients. There are only three of the ND Countries where GPs have strong gate-keeping functions. The Baltic States introduced by legislation gate-keeping function in the early 2000s. In countries like Germany, Poland, Russia and Belarus there are no gate-keeping function of the primary care doctors. Just in some counties of Russia (e.g. Kaliningrad oblast) new primary health care funding schemes since 2003 were introduced together with gate-keeping function and partly fund-holding for family doctors.

Another general characteristic of the PHC is the number of primary care doctors working in the same practice. In Germany and Belarus, more than a half (67% and 53%, respectively) the practices are solo. Other countries report a high prevalence of duo or group practices or health care centres. The number of solo practices in the Nordic countries like Sweden and Finland is very low: 2% and 8%, respectively.

There are considerable differences in the gender of the primary care doctors within the ND Countries. The countries of the former Soviet Union and the Baltic States report that well over half the GPs are female. The percentage of female GP or primary care doctors in these countries is in Belarus 90%, Estonia 94%, Latvia 77% and Lithuania 89%. Primary care was traditionally seen as a low status medical work in the countries of the former USSR with a substantial drain of male doctors to specialists and the hospital sector.

The universal challenge for all primary care systems of the ND Countries is how to make PHC attractive for qualified staff in general and how to promote a uniform distribution of primary care staff in the rural areas and economically deprived territories. The evidence says that if there is no strong commitment of the national governments for even distribution of the human resources, then the so-called "inverse care law" is working. It means that the group of the population that needs more care receives less because of the absence of the staff and facilities and on the other hand the population that is well – off and comparatively have less health care problems receive more medical care.

Every country of the ND region has its own strategy to pursue this goal. In Sweden, the PHC doctors are eligible for extra allowances for working in the distant areas. In Finland, more financial tools were given to the municipalities that are more flexible with setting the salary level of the primary care physicians.1 In Norway all professionals (including GPs) with higher academic education get their state education loans reduced by 15% every year they work in the northernmost areas. The privatization in Baltic States of the primary care practices especially successful in Estonia is one of the strong incentives for young GPs to choose for the primary care.15 In Belarus, there has been adopted a law of the obligatory 2 year placement of the young doctors in the primary care after receiving the medical diploma. In Russia, the 2005 health reform included a substantial increase of the basic salary to all primary care doctors.

It is common knowledge that the utilization of specialist health services is higher among privileged population groups. In most countries PHC serves to counteract this unequal service utilization. However, this is not applicable for Sweden.

18 3.2 Other primary care team members

. Nurses, midwifes, feldshers (in ex-Soviet Union countries), physiotherapists, pharmacist and social workers are the most important professional medical staff of the primary care. In the Scandinavian countries community nurses or public health care nurses and home visitors play an ever-growing role in the care for elderly and chronically ill patients.

There is a clear trend of growing autonomy of the nursing profession in the Nordic countries. For instance, district nurses play a special role, as many first contacts with the health care system are their responsibility. Often, they make a first assessment of patients and, if necessary, refer them either to the health centre's general practitioners or to the hospital. They are also involved in home care, and regularly make home visits, especially to the elderly. District nurses have limited rights to prescribe pharmaceuticals. However, they do not have sole medical responsibility, but act, instead, under the supervision of physicians.16 In Norway there are no district nurses but there are public health nurses in all municipalities with the number of autonomous functions.

In contrast nurses in Russia, Belarus are still seen only as the doctor's help with a lot of pure secretarial and administrative work in the primary care. Ten years ago in Baltic States it has been introduced new training programs for primary health care nurses and special license requirements. Further development of the community nursing is hindered by lacking of the proper remuneration schemes with more incentives for independent activities of nurses (e.g. Lithuania). To high extend profile of primary health care nurses have been changed during primary health care reform in Poland. They are allowed to create their own list of patients. In most the ND Countries family midwifes are also members of the PHC team.

In Russia and Belarus feldsher posts in the remote rural areas are still numerous and an important resource of the primary care. Long distances, the resistance of doctors to practice in the rural areas, and a growing number of elderly people living in the countryside justify the existence of the network of feldsher posts. Feldsher posts are in a very strong position to provide preventive services including immunizations and home care to people close to their living place. As a rule feldsher posts are supervised by the rural doctor's (GP) practice.

Rehabilitation staffs – physiotherapists and occupational therapists – are now seen as core professional staff in PHC centres in the Nordic countries. They play a major role in the rehabilitation of diseased elderly, but are also important for children with functional impairments and for adults in need of training and environmental adaptation.

3.3 Primary health care team and community. Home care

Primary health care activity should be targeted to improve health of a distinct population. Therefore primary health care professionals should be able to recognize health needs of the community and to empower community and other sectors to deal with the relevant health problems. That's why teamwork and cooperation with other sectors is crucial to achieve proper contribution from community and other sectors.

The entire ND Countries region face the same social trends in their societies: increasing number of the elderly population, reduction of the informal care possibilities to the elderly family members due to the smaller family size, high proportion of the single stayed elderly people and increased female participation in the labour market. The other aspect of the importance of the structured home care is the demand of the health care management for more efficient use of the hospital sector and reducing of the hospital stay by substitution of the care that used to be done at the hospitals. Each country of the ND Countries is tackling the same problem with its own approach transforming the available facilities and resources to the new community's needs17.

Primary care doctors and community nurses could be acting within the same or different organization structures or facilities. There is the growing interest to improve the team work within the primary care sector including primary care doctors, community nurses (feldshers), social 19 workers, the staff of the elderly houses, nursing houses and with representatives of other sectors when it needed in each ND country. Interface of care and cure in the primary care requires good cooperation within the primary care sector even when community nurses and primary care doctors work from their own small premises like in Denmark and Norway. In countries like Sweden, Finland and partly Russia and Belarus with the traditions of the somewhat larger health centres with the numerous staff under one roof" there are more possibilities for the team work and better coordination of primary care yet the implementation of the teamwork is always the challenge. Long traditions of hierarchic administrative structure, "top down" approach, in countries like Russia, Belarus and to some extend in Baltic States and Poland are obstacles for introduction of teamwork model. Tasks of primary health care nurse in these countries were very limited mainly to be just doctor's assistant working in the same room with the doctor and doing some paper work. Another area of her work was making injections, immunizations and other procedures in the office and at patient's home following doctors prescriptions. Strengthening the role of primary health care nurse and increasing responsibility of community and other sectors for health was important component of the reforms in all East Europe countries (vignette 3.2).

20 Vignette 3.2: Experience of implementation of Primary health care teamwork training program in Lithuania

Training of trainers program for Primary health care teamwork training have been developed and implemented in the frame of EU PHARE project “Support to the Continued Reform Process and the Development of Primary Health Care in Lithuania” with the objective to strengthen focus of primary health care team towards community care, by implementing more efficient based on teamwork primary health care model and involving community in health promotion activities (Support of the EU PHARE project “Support to the continuous process of health care reform in Lithuania” . Participants of this multidisciplinary training course were family doctors, community nurses, other nurses and social workers (representing social care sector). 24 trainers have been trained representing four universities in Lithuania and around 200 primary health care professionals have been trained during the project period. Two weeks training course provided trainees with proper attitude on priorities of based on teamwork PHC organizational model; essential knowledge and basic skills for effective teambuilding and leadership in solving family and community health problems; basic knowledge on methods used in community health need assessment and sound motivation to develop community health intervention projects. Analysis of the priority health problem and development of the community health project was part of the training. Part of the training course was devoted for the meeting with the representatives of the community and working together to analyze priority problem and to develop community action plan for solving it. Outcome of this project was raised responsibility and motivation of the community to take active role, leadership for solving health care problems. In some places as an output appears new NGO active in development and implementing of health problems. Lack of financial incentives for community nurses and better meeting the community's health care needs by PHC providers are major obstacles for implementing the teamwork training. Patients' problems and lack of incentives for community nursing.

There are variations in defining of the community served by the primary care facilities. In most of the countries of Nordic countries and Germany, since recently the Baltic States there is a combination of free choice of the patient and the geographical limitations of availability of the primary care provider. In countries like Russia and Belarus there is mostly a compulsory system of catchment area of the community according to the registration of the person.

The capacities of the home care (including nursing homes) are different within the ND Countries. Nordic countries have better defined network of facilities for the elderly people while Baltic States, Russia and Belarus are only moving from the traditional family with two or three generations living in the same flat with high expectations from the society of informal care for the elderly. This applies even when the condition of the elderly patient is very complicated (demented or requiring high professional nursing).

The growing number of elderly patients and the need to provide both social and medical care is another feature of the primary care in the ND Countries. The main implications of this trend are the growing number of nursing hospitals and elderly homes in the Nordic countries and the increasing demand for home care. In Russia and Belarus it is still common that PHC practices in the rural distant areas have also number of beds for the elderly and chronically ill patients who are not (temporally) able to stay on their own in their houses. Finland has a large number of nursing home like beds in the health centre hospitals. The capacity of actual nursing homes has been strongly reduced since 1995 to give room to "special assisted housing" or to "intensified assisted housing", 21 which means that there is 24 hours a day staff presence. In Finland, the hospital beds under the administration of Primary Care are not constricted to the rural areas. They primary care beds have a strong position in the urban centres, too. About 55-60 % of the care is short term care (short hospitalization, rehabilitation, post-operative care), and the rest is long-term nursing home type care, very much for patients with advance dementia. The fact that health centre hospitals are in operation and are often a natural sequence in the care of the patient, especially and older patient, explain much of the high rate of hospitalization. This is because using the acute specialist hospital and the health centre hospital leads statistically to two admissions, instead of the usual one admission.

Community orientation and family centreness are the other two criteria used for the scoring instrument for the primary care systems. Community orientation high rating is given where practitioners use community data in planning for services or for the identification of problems. Intermediate values are assigned where clinical data derived from analysis of data from the practice is used to identify priorities for care. Low ratings are assigned when there is little or no attempt to use data to plan or organize services. Family centreness high ratings are given to explicit assumption of responsibility for family-centred care.17

3.4 Cooperation with secondary health care specialists

The development of new medical technologies, ageing of the population and the increase of co- morbidity require good coordination between the primary care and secondary care. Gate-keeping functions of the GPs are among the essential features of strong primary care. The available evidence shows the advantages of the gate-keeping function of the GPs for cost containment and better coordination of care.18 Although the ND Countries are different in regard of the gate-keeping function of the GP they have all to cope with the specific problems of cooperation between the primary and secondary care. The health care systems more driven from the needs of specialist care as a rule have no or very limited gate-keeping function of the GPs. In countries like Russia, Belarus there are regulations promoting annual health "preventive" check-ups of the patients even without complaints by main specialists of the policlinic (neurologist, ear nose throat, surgeon, ophthalmologist and gynecologist) for "early detection" of the possible diseases "in the latent phase".

Table 3.3: Number of out-patient visits to primary care versus secondary care, referral rate to the specialists and hospital admissions WHO database, last available. Data for Norway have been updated by PHC Expert group members Number of out- Referral rates to Admissions to patient contacts per specialists hospitals per one person to 100 population primary care Belarus 12.5 30-40% (estimated)28.1 Denmark 4.08 N/A 22 Estonia 6.8 N/A 19 Finland 4.2 5% of all contacts 25 in PHC (HIT 2002) Germany 7.3 N/A 22 Iceland 4.1 N/A 16 Latvia 5.2 N/A 22 Lithuania 6.7 30% 23 Norway N/A 7% (T. Hasfold 19 2008) Poland 6 >10% 17 Russia 8.9 30-40% estimated 22 Sweden 2.8 N/A 15

22 The differences in the number of out-patient contacts are striking within the ND Countries as well as the available referral rates to the specialists.

High number of the out-patient contacts in primary care and referral rates in Belarus (12.5) and Russia (8.9) could be explained by the tradition of involving narrow specialists in the so-called preventive health check-ups. A lot of out-patient contacts in these countries are made due to the current regulations on the sick leave issuing implying that the patient should attend the primary care doctor from the first day of the sickness and every other day thereafter until the patient is capable to work.

In respect to the hospitalization rates the highest rates are in Belarus (28 per 100) population per year, Finland (25), Denmark (22), Lithuania (22), Russia (22) and Germany (22). The lowest hospitalization rates are in Iceland (16) and Sweden (15).

Splitting of medical professions due to the development of technologies and specialization resulted in the rapid increase of the number of physicians and nurses working in the hospital and specialist sector. The proportion and the status of the primary care doctors dropped considerably in most of the ND Countries. Yet understanding the growing gap in coordination and patient satisfaction due to overspecialization have led to the policy of increasing the number of primary care doctors and improving their training. The possibility of collecting all relevant health and social information about the patient (including the results of the previous secondary care specialist treatments), continuity and coordination of care are the major advantages of a well functioning health care system.

The adequate information exchange between specialist sector and primary care needs proper regulations or guidelines on communication between the primary care doctors, nurses and specialists. Where this is present for only certain aspects of care (such as long term care), intermediate ratings are given. Low ratings reflect the general absence of guidelines for the transfer of information about the patients.

See attachment Practice characteristics scores. 19Starfield B. "Health Policy and Primary Health Care" 1998, p.338 -339

3.5 Equipment and informational technologies

Availability of essential, relevant to primary health care equipment of the primary care doctor is one of the indicators of the quality infrastructure of the primary care system. Out of the comparative study of the Profiles of GPs in Europe a list of essential 25 items was developed to compare the outfit of the primary care practices in Europe.

Table 3.4: List of the essential medical equipment of the GP (primary care) practice Item Laboratory 1. Haemoglobinometer 2. Blood glucose test 3. Cholesterol meter 4. Blood cell counter Imaging 5. Ophthalmoscope 6. Proctoscope 7. Otoscope 8. Gastroscope 9. Sigmoidoscope 10. X-ray machine 11. Microscope 12. Ultrasound Functional measurements 13. Audiometer 14. Bicycle ergometer 15. Eye tonometer 16. Peakflow meter 23 17. Spirograph 18. Electrocardiograph 19. Sphygmomanometer Other medical equipment 20. Urine catheter 21. Coagulometer 22. Minor surgery set 23. Suture set 24. Defibrillator 25. Disposable syringes

Table 3.5: Use of medical equipment and computers (data from Boerma W. G. W., Fleming D. M., 1998, updated with new figures for Poland and Belarus) Country Average number of items of % GPs using computers for patient diagnostic equipment (25 items) records () (the items list must be attached) Belarus 12.1 0 (no regulations on e-documents in health care) Denmark 13.6 Close to 100% Estonia 9.5 60% Finland 20.5 100% Germany 13.9 Close to 100% Iceland 17.2 Close to 100% Latvia 9.7 3 Lithuania 12.8 0 Norway 16.1 Close to 100% Poland 14 Close to 100% (for reporting to the National Health Fund activities) Russia N/A Less than 1% Sweden 15.7 Close to 100%

Equipment is an essential part of the quality infrastructure for the primary health care facilities. According to the survey the better-equipped practices are in the Nordic countries. According to the research from the 25 essential items of the equipment of the GP practice in Finland there were 20.5 items available, in Iceland there were 17.2 items, Norway – 16.1 and Sweden – 15.7 items 24 available. The less equipped practices were in Estonia (9.5), Russia and Belarus (12.1). In Finland, many GP practices are equipped with ultrasound, in striking contrast to GP practices in other the ND Countries. Similar tendencies could be found (availability of ultrasound) in some primary health care practices in Russia where there is still a very dominant biomedical approach toward patient problems and an overestimated role of technology in primary health care. (I added because my experience in Kaliningrad).

(Use of computers in GP practices increases the quality and continuity of care for the patients and could serve as another important indicator of the quality of infrastructure of the primary health care. There is a striking contrast in the use of the computers within the ND Countries. Like the situation with the other equipment Nordic countries show a high level of computer use for the patient charts that is close to 100%. In Belarus, Lithuania, Latvia, and Russia computers are basically not used for the patient's electronic charts. In Lithuania, an ongoing e-health project is going to introduce during 2008 software for primary health care practices in two out of ten counties.

3.6 Workload indicators

Some workload indicators of the PHC practices from the international survey are represented in Table 3.6.

Table 3.6: Average number of patient contacts per day in the surgery, and home visits per week ((Boerma W. G. W., Fleming D. M., 1998) Country Consultati Home Phone contacts Average length of % of GPs ons in the visits per per day consultations, making practice week minutes hospital visits per day Belarus 21 25 N/A 12 - Denmark 24 6 16 13 7 Estonia 16 16 4 16 11 Finland 19 3 6 18 38 Germany 50 34 11 13 19 Iceland 17 4 15 17 37 Latvia 13 15 4 21 7 Lithuania 17 15 3 16 14 Norway 19 6 11 19 N/A Poland 30 10 2 22 25 Russia N/A N/A N/A 12 N/A Sweden 16 2 7 25 9

The workload indicators reflect differences in organizing the primary care in the ND Countries. The highest number of consultations per day in the practice is reported in Germany (50), in Poland (30) and Denmark (24). Fewer patients per day are seen in Latvia (13), Estonia (16) and Sweden (16). On the opposite, the average length of the consultation is shortest in Belarus (12 min), Germany and Denmark (13 minutes) and longest in Sweden (25 min) and Latvia (21). Poland reports a considerably long average consultation (22 minutes) with a high workload of consultations in the practice.

Home visits are made very frequently in Germany with a number of home visits per week of 34. There are also a lot of home visits done in the Baltic States (Estonia 16, Latvia 15, and Lithuania 15), and Belarus 22. In the Nordic countries, home visits are quite few (Sweden 2 per week, Finland 3, Iceland 4, Denmark and Norway 6 visits per week). The trend for these countries during the last years is that number of home visits has dropped to near zero. For instance in Finland the only setting, where home visits are formally expected is the initiation of care planning/assessment for a very dependent chronic home care patient. The differences in the number of home visits could also be partly explained by different regulations within the ND Countries. The regulations in 25 Belarus, Russia and the Baltic States demand an obligatory visit to the doctor or calling a PHC doctor at home for issuing a sick-leave certificate, resulting in a high number of home visits in these countries. On the other hand, the largest proportion of home visits is done by the public nurses and home visitors.

Telephone consultations are quite popular in the Nordic countries. Denmark reports 16 telephone contacts with the patients per day, Iceland 15 and Norway 11. No telephone calls is reported in the official statistics in Belarus and quite few telephone contacts take place in the Baltic States (Lithuania 4 per day, Latvia 3) and Russia.

The last activity that is represented in the workload indicators deals with the percentage of GPs involved in visiting patients at the hospital. Only Finland and Iceland report a high proportion of GPs who make visits at the hospital (Finland 38%, Iceland 37%).

Preventive services and health promotion are essential parts of the task profile of the primary health care and general practitioners.

Table 3.7: Involvement in preventive services: routinely assessing blood pressure and blood cholesterol level; child surveillance and immunization (possible scores 0 to 2) and family planning. (Boerma W. G. W., Fleming D. M., 1998) Country Blood pressure Blood Child Involved in family (%) cholesterol (%) surveillance/immuniz planning (%) ation score Belarus* 96 23 1.8 18 Denmark 71 29 2.0 99 Estonia 88 22 1.1 24 Finland 54 44 1.4 83 Germany 91 79 1.6 86 Iceland 60 33 2.0 94 Latvia 92 24 0.6 33 Lithuania 91 39 0.4 14 Norway 46 35 1.5 31 Poland 92 35 1.5 31 Russia 95 N/A N/A N/A Sweden 40 33 1.8 35

The results of the survey on the preventive services in primary health care revealed some differences within the ND Countries. In the Baltic States, Poland, Belarus and Russia routine assessment of blood pressure is more than 90 % and Nordic countries average less than 60% (Finland 54%, Norway 46% and Sweden 40%). Measuring of blood pressure in the Nordic countries is performed not during every contact with any adult patient but it takes place in all cases according to a guideline tailored different types of patients. On the other side Nordic GPs are much more involved in family planning, with more than 80% of the GPs involved (Denmark 99%, Finland 83%, Germany 86%, Iceland 94%, Norway 90%). GPs in the Baltic States, Poland, Russia and Belarus are less actively involved in the family planning issues, averaging less than 35%. Child surveillance and immunization activities are done by more than half the GPs in Denmark, Finland, Germany, Iceland, Poland and Sweden. In the Nordic countries, the vaccination is delegated to the nurses and has close to 100% coverage of children with the immunization programmes. In Latvia and Lithuania these activities scored less than 1.0. It is most likely that other primary health care specialists like pediatricians carry out these activities.

* Matra report on Belarus in 2005. 26

3.7 Tasks of general practitioners

According to the definition of general practitioner one of the important functions of a GP is to be a doctor of the first contact with the patient irrespective of age, sex and nature of the problem. In a survey the responding GPs answered about their involvement in briefly described cases and situations. The results are given in table 3.7.

Table 3.8: The role of general practitioners in the first contact with health problems (possible scores range from 1 to 4) (Boerma W. G. W., Fleming D. M., 1998) Country Total Children Women's problems Psychosocial Acute score problems problems problems Belarus N/A N/A N/A N/A N/A Denmark 3.5 3.6 3.7 3.6 3.3 Estonia 2.1 2.1 1.8 1.9 2.5 Finland 3.0 3.2 3.1 2.7 3.3 Germany 2.8 2.8 2.4 3.0 3.3 Iceland 3.1 3.4 3.1 2.9 3.3 Latvia 2.0 1.7 1.8 2.0 2.4 Lithuania 1.7 1.5 1.6 1.6 2.3 Norway 3.3 3.3 3.6 3.0 3.4 Poland 2.3 2.3 2.0 2.1 3.1 Russia N/A N/A N/A N/A N/A Sweden 2.8 3.0 2.7 2.8 3.0

The GPs from Denmark, Finland, Iceland and Norway scored more than 3.0 with the total score, showing on average high involvement in solving of the health problems of children, women, psychosocial problems and acute care. GPs from Estonia, Latvia, Lithuania and Poland are less involved in children care, women problems and psychosocial conditions. They also score less than 2.5 in the acute care. Belarus and Russia didn't take part in the survey and comparative data does not exist. Countries in transition still are in early stage of the development of family medicine and community nursing so less comprehensiveness in health problem solving could be found in primary health care in these countries. Yet due to the rapid changes going on in these countries in each ND country "centres of excellence" could be found serving as models for all the Northern Dimension Countries. (Vignette 3.4 and 3.5). 27 Quality improvement activities differ evidently in Poland, Baltic States, Russia, Belarus and Nordic countries. Projects for introducing quality tools would be as priority for these countries. Quality assurance mainly represented in the form of the external control (audit) in , Baltic States, Russia, Belarus contrasts with internal audit experience in the Nordic countries. Internal audit tools based on the demand for improvement of personal performance motivate primary care staff to act better without fear of being externally controlled. First trials to introduce internal audit tools as APO audit were very successful in Vologda, Kaliningrad, Lithuania. Participation of Lithuania and Kaliningrad in EU financed project HAPPY AUDIT together with Sweden, Denmark and other countries will demonstrate possibilities to change attitudes of GPs towards respiratory infections treatment with antibiotics and serve as an example of international cooperation for quality improvement.

Vignette 3.4: Matra projects "Primary Care Development in Minsk and Vitebsk Regions"

In the period from 1999 to 2005, two successive Matra projects supported by the Dutch Ministry of Foreign Affairs and implemented by NIVEL (the Netherlands Institute of Health Service Researche) were carried out in Belarus with the general aim to strengthen primary care and general practice development in Minsk and Vitebsk Regions.

The activities realized covered the essential directions of the primary care improvements in two out of the six Regions of the country. The working conditions in 30 rural practices were improved by purchasing of the basic GP equipment, computers and implementation of the statistical health care software. The activities on quality improvement included the structured workshops on improving medical-, nursing- and communicational skills with the participating GPs and nurses. The methods of peer review and mutual practice visits were introduced within two groups of the GPs. Four guidelines were developed during the project and published (Otitis media, low back pain, fever in children and chronic heart failure). Education and training of GPs and nurses where improved by curriculum inputs from the Dutch experts and during the "train the trainer" workshops as well as during study tour to the Netherlands of the GP teachers. The support of the patient education was realized by developing of the set of informational leaflets for the patients on the 20 relevant health care topics (including smoking cessation, problem drinking, overweight, low back pain, otitis media and other). During the project the professional association of GPs was founded and in 2004 entered WONCA as the Association in collaborative relation). Two National surveys among GPs and the patients were carried out during the project. In collaboration with the Ministry of health a policy advising papers were prepared on the future primary health care development in the country.

Vignette 3.5: Building up a sustainable development of Primary Health Care in Kaliningrad region in cooperation with local and national resources

There is project with the three lateral participation of Sweden, represented by Blekinge Institute for research and development, Lithuania, represented by Klaipeda University Public health department and Kaliningrad, represented by the Regional Administration was started in 2002 with an aim to participate in training family doctors, improve performance, skills and attitudes of already working doctors, present an international primary care perspective for family physicians, chief physicians, administrators and politicians from Kaliningrad region. Lithuanian experience from the period of transferring from previous soviet health care system to family medicine 28 based system is emphasized, the Russian language skills for effective communication are effectively used and 10 twin based practices for doctor and nurses team work and practical skills training were established The educational

3.8 The role of professional associations

Involvement of the professional associations in the activities of professional training, development of the professional guidelines for the GPs, participating in defining the policy and financing of the primary care are necessary conditions for the stronger primary care. Nordic countries and Germany have long traditions of the medical associations in general and associations of GPs dating from the 1970s. The countries of Eastern Europe with the traditional hierarchical approach were lacking the professional medical associations till the beginning of the 1990s.

Apart from articulation of the professional interests in the countries professional associations of GPs play important roles in the processes of recertification of GPs (Denmark, Estonia) and activities of the quality assurance in the primary care. In the last 15 years associations are highly involved in the development of the professional guidelines for the primary care physicians. According to the available evidence all the ND Countries developed sets of official guidelines for the primary care physicians. Other activities of the professional associations aim to improve the performance of the PHC doctors are small group education, peer review activities and practice visits. 20

Still a lot remains to be done for the further development of the newly founded GPs associations in the countries in transition.

Chapter 4 Education of PHC doctors and nurses

4.1 Introduction 29 Staff training is of paramount importance for the life and performance of the whole healthcare system. Primary care's leading role was highlighted in the Alma-Ata Conference Principles with the implication that training of the primary health care staff is one of the most important issues in medical training.

General Practitioner is recognized to be a PHC central figure. Therefore, GP education and training is a very serious issue. So, how do educational policies of Northern Dimension Countries reflect that?

First of all, this attitude leads to setting up Family Medicine Departments practically in all the ND Countries. In 2002 a EURACT work group prepared a report titled The European Definition of General Practice/Family Medicine that presents a new view on Family Medicine as a profession. The report states that in addition to being a clinical profession and having common European educational standards, general practice is also an academic and scientific discipline. Here, the word "academic" has a deep meaning by equating this profession with others that are taught in medical universities and by making it mandatory for the undergraduate curricula. In a EURACT Review of problems in teaching family medicine in Europe (Dr Igor Švab, General Practice Teaching at the Undergraduate Level in Europe, EURACT at the RCGP Spring meeting – April 1999) the availability of Family Medicine Departments was used as an assessment criterion of the development in teaching family medicine. Published less than 10 years ago, the criterion is still relevant yet Family Medicine departments operate practically in all the ND Countries. This applies not only to Sweden, Finland, Norway and Denmark, Germany, Iceland with their dozens of years of family medicine history but to Baltic States (Poland, Estonia, Latvia and Lithuania) as well as Russia and Belarus where family medicine has been developing for the last fifteen years. Thus, family medicine can be considered as having achieved an academic independence in the ND Countries and that setting up Family Medicine departments effectively means creating organs to coordinate training of FM staff at undergraduate, postgraduate and continuous education levels.

In fact, the way how FM departments were established to a certain degree reflect goals and objectives set for the PHC development. Most often such departments were organized at Public Health Faculties (Sweden, Lithuania) which reflects the community-oriented principle. In some other countries (Russia, Belarus) the departments were set at already existing internal medicine departments thus reflecting the disease-oriented principle. That was later followed by including patient-oriented aspect, prevention and healthy lifestyle issues,, etc. into the training curricula.

Problem-based learning became a common teaching principle practically in all countries. In modern education, the paradigm of "teaching it all" was replaced by an emphasis on "learning to learn". This approach tries to train students to become self-directed, independent learners who, in their professional careers, should recognize when they are in need of acquiring new knowledge.

30 4.2 Undergraduate education

A WHO and WONCA forum issued a number of recommendations on training general practitioners. These guidelines emphasise the importance of the basic (undergraduate) medical education which must ensure an "adequate foundation for the following specialized training". They also state that the subject of family medicine shall be taught in every medical school and provide the balance between the general and specialized training (WHO-WONCA. Making Medical Practice and Education More Relevant to People's Need's: The contribution of the Family Doctor. WHO-WONCA Conference in Ontario, Canada WHO-WONCA, 1994).

A basic undergraduate medical training in the ND Countries traditionally takes about 6 years. Up until recently the undergraduate studies were a little longer in Denmark (6.5 years) with an attempt to cut it to 6 yeas or can be shorter (5.5 years in Sweden).

The selection of students to study at medical faculties is also of a certain interest. While the majority of the ND Countries do not request a special high school training to enter medical universities, in Sweden an entrant must graduate from secondary school with subjects that include natural science. Of course, such an early vocational guidance should help to further specialist development. However, nobody attempted to prove the assumption. Some countries (Denmark and Norway) have no entrance examinations enrolling students based on their school scores, though entrance examinations are a more common practice.

In most the ND Countries the education is free and the state fully provides for the studies. The education accessibility to everybody regardless of his/her social status proclaimed by Norway seems very progressive. A small percentage of students are taught in private universities (Germany) but this figure is insignificant and does not shape the general tendency. A recent study shows that tuition fees are charged in about half of the member states of the European Union and tend to be very small as compared to those charged by the national universities in Japan or by state universities in the United States. The proportion of students receiving grants and loans to cover living expenses varies among EU countries from less than 5 percent to more than 90 percent (Ulrich Teichler. German Higher Education in a European Context. INTERNATIONAL HIGHER EDUCATION. The Boston College Centre for International Higher Education. Number 30. Winter 2003). We can speak of a small but gradually growing quota of Russian students who pay for their education. However, this is rather initiated by universities trying to keep their financial equilibrium being underfinanced by the state budget and having low-salaried teachers. The Estonian University of Tartu and the Faculty of Medicine can admit additional students for medical training who pay for their own education. These students have the right to continue their training in publicly funded positions if some become available during the course of their studies. The University of Tartu has used this option for up to 10% of the total number of admitted students and has also admitted up to 20 students (20%) from abroad (mainly Finland).

Comparing educational curricula in different countries is quite difficult because undergraduate programs can vary even within one country between universities in different cities. However, an emphasis on an independent problem-based learning becomes a growing general tendency in ND undergraduate medical programs.

The input made by the undergraduate education into the foundation of further special training in family medicine could be assessed by several factors: 1. The scope of studies in general practice for undergraduates; 2. The time spent at a GP to learn about GP functions and an early vocational guidance; 3. Practical skills acquired by undergraduates.

However, the most important aspect of the basic medical education rests in acquiring decision making skills.

There are several key tendencies in teaching family medicine for undergraduates. The major one is teaching undergraduates without emphasising the family medicine principles followed by a professional training for postgraduates (Germany). In autumn 2003 in Germany the ordinance was 31 completely changed, with the political aim of facilitating profound innovations in favour of bedside teaching, community-based teaching, problem-solving skills and the integration of basic science and clinical subjects.

The other tendency is to have a relatively short, introductive family medicine course for senior students (Estonia, Latvia, Russia and Belarus). Sweden provides an example of a country which introduces medical students to general practice throughout their studies under the principles of problem-based learning. In a number of Swedish universities students are included into family medicine since being freshmen. For instance the curriculum of the youngest university in Linkoping allocates significantly more hours for general practice and almost every semester students visit Health Centres. Most universities define three periods of training in general practice at the undergraduate level: during the first two years with the universities students visit general practices (health centres) where they accompany general practitioners for two days and perform minor errands (for about one week at each semester); as third-year students during the transfer between pre-clinical and clinical years of their education they spend about two weeks at a health centre where a GP will introduce them to consultation techniques, physical examination and record keeping; at their last year and at the end of the clinical period students are usually assigned to a health centre for 2-3 weeks. As a rule training in family medicine is a part of the community medicine. The weeks at health centres students spend working with their tutors, at seminars, lectures and watching videos. Very often this period also includes oral and written exams.

Table 4.1: GPs or primary care doctors who finish their postgraduate training out of total medical graduates per year. (R. Saltman et al. Primary care in the driver's seat. 2006, EURACT 2004).

Total annual medical graduates GP annual graduates (% of total) Belarus 1900 15% Denmark 600 30% Estonia 85 21% Finland 500 18% Germany 10000 18% Iceland N/A N/A Latvia N/A N/A Lithuania 650 31% Norway 550 36% Poland 2500 40% Russia N/A N/A Sweden 600 17%

4.3 Postgraduate education and licensing

Traditionally postgraduate studies have been the basis for forging a General Practitioner in all the ND Countries. There is an EU Standard for General Practitioner Training which defines the postgraduate curricular content and the minimal duration of GP professional education that is 3 years. However, the duration of postgraduate studies varies across the ND Countries from 2 – 3 years (in , Lithuania, Estonia, Russia and Latvia) to 4 years in Poland and up to 5 years and above (Sweden, Denmark, Norway, Finland and Iceland). In Germany, the duration of specialization in general medicine was increased from three to five years in 1998 in order to strengthen the quality and professional status of future family practitioners. The above provides a certain reference point with regard to the duration of family doctor training.

32 4.3.1 Internship

Virtually all the ND Countries have internships that start once the basic medical education is complete. The internship can last from 1 to 2 years. The status of internship graduates slightly varies from country to country. However, in general, residents have a right to register and work as a doctor. Norway has the most strict internship rules. The Norwegian internship continues for 18 months. The Norwegian Registration Authority for Health Personnel is responsible for the administration of the intern service. The 18-month internship period consists of six months in a medical ward, six months in a surgical ward and a final six months in general practice. Norwegian and foreign students with the basic medical education from a Norwegian or foreign university and those with a medical license from a number of countries outside the European Union also need to complete the internship period in Norway in order to receive a Norwegian physician license. The internship period for physicians in Norway has traditionally been an important regional policy tool. The intern positions have been concentrated in rural areas. A similar case of solving rural understaffing can be observed in Belarus where each university graduate must work as an intern (who is called a "general practitioner") for 2 years in a rural area. Interestingly enough, a medical university graduate in Belarus is already called "general practitioners", which refers not to the specialization in general practice but rather to the obtained general medical training.

Under the Swedish modus of GP postgraduate training every university graduate shall complete an 18-month internship which will allow him to register and certify as a doctor. These 18 months are divided into 6 months of studying internal diseases, 6 months of studying general practice, 3 months of psychiatry and 3 months for a discipline of an intern's choice. The mandatory 6-month training in family medicine for any medical doctor is good for raising the doctor's competence plus it will also foster a fruitful cooperation between the GP and the narrow specialist in the future. Being adopted in many ND Countries such internship system when all future specialists must work for some time in general practice has a high practical value. The same format is used in Denmark (6 month of therapy + 6 months of surgery + 6 month in general practice), in Iceland, where graduation is followed by a 12-month compulsory training program that includes 9 clinical months in the required fields: internal medicine for 4 months, surgery for 2 months and general practice for 3 months. The applicant can choose between several clinics for the remaining 3 months. After successful completion of this program, the Ministry of Health and Social Security grants the doctor a license to practice (full registration). One year of mandatory clinical practice after university graduation is a rule for all graduates in Lithuania. In Russia, a university graduate must also spend 1 year in internship to be allowed to work independently like internist. However, the time allocated for the training in general practice does not exceed 2 months (18% of the total training time) and is not mandatory for any medical professional.

Two extremes with regard to internship are observed in Germany and in Finland. In Germany, having graduated health care professionals are eligible for registration at the Lдnder ministries responsible for health. A regulation that medical graduates receive a full state recognition only after having worked in clinical practice for 18 months was abolished in 2004. In Finland, two years of practical work and training are required, both in hospitals and in health centres, to obtain a license to practice independently. Part of this training may be completed in the private health care sector, depending on the approval of the medical faculty, or by doing research. After obtaining a license, doctors may continue working at a health centre, specialize in one of the numerous medical specialties or establish a private practice.

4.3.2 Specialty training/vocational training in general practice/family medicine

Europe has run extensive researches to develop a new general practice (family medicine) concept that would be consistent with the new political and socio-economic facts of the 21st century Europe. In 2002 experts of the European Chapter of the World Organization of Family Doctors developed new definitions for the General Practice/Family Medicine profession, its fundamental attributes and a new definition of the general practitioner/family doctor and determined requirements to the scope of primary healthcare delivered by family doctors (The European definition of general practice/family medicine. 2002. – WONCA EUROPE.- 48 p.) 33 The World Federation for Medical Education developed Global Standards for Improving the Quality of Medical Postgraduate Education (2003). The Council of the European Academy of Teachers in General Practice generated Guidelines for Compiling a Training Program for General Practice/Family Medicine Specialists which were approved by the Amsterdam European Regional Conference in 2004. The use of the above mentioned organizational and methodology documents create a unified approach to training and to arranging professional activities of general practitioners. Therefore, key differences in GP professional training observed across the ND Countries are rather found in the training duration and main formats, than in the content.

The shortest residency training courses are in the Russian Federation (2 years) and in Estonia, Latvia, Lithuania (3 years). In Iceland the training lasts for 4.5 years. The most common duration is 5 years (Denmark, Germany, Norway and Sweden). The longest is in Finland where specialization in general medicine (i.e. family medicine) takes six years of training. This includes a specified period working in a hospital and a health centre, a specified number of theoretical courses and successful completion of a national examination organized by medical faculties. As already said earlier, Germany has increased the duration of the studies from 3 to 5 years. The shorter residency program in Russia and Baltic States can be explained by an acute understaffing in general practice when primary health care went through reforms. Besides, if in Russia a resident doctor has a student status and receives the scholarship that equals to about 20% of a young doctor's salary, Scandinavian residents receive doctor's salary which provides sufficient finances to go on improving one's qualification for 5 years. Obviously some arrangements are still needed to resolve the issue.

There is no sense in considering a short, 6-month re-training for doctors used in former Soviet republics as a means of staffing the reforming primary health care. Having analyzed Western experiences of family medicine development one can conclude that an abridged training policy shall be a short-term option good for urgent situations only.9

The Norwegian system is a popular model for postgraduate training of family medicine professionals. The system is noted for being logical and friendly (there is no examination – but maybe not "friendly" towards the patients (Richards T. Recertifying general practitioners//BMJ. – 1995. – Vol. 310.- P.1348-1349.) To obtain the general practice professional status a graduate having completed the internship shall continue studying for 4 more years while working in general practice plus 1 more year while working at hospital. This model has been applied in Norway since 1985. The system seems flexible and includes practice, training in hospital, a theory course and a program for group work as well as teaching practical skills. Unlike other countries' training systems the Norwegian one has no mandatory exams or tests for verifying the knowledge. And it is linked to and explained by the methodology of postgraduate studies. The Specialist's Diploma is issued by the Association of General Practitioners. Thus, the postgraduate studies include 4 year work in general practice and one year in hospital. For 2 years the work in general practice is combined with training in groups that includes 4 base courses 30 hours each (120 hours), 280 hours of elective studies, i.e. training at courses; visits to practices, hospitals, Mother and Child Centres, vaccination; curatorship of medical students; research; peer visits to practices (mandatory); 110 hours are reserved for mandatory clinical courses; a program for training practical skills; at least 40 duties of 24 and 12 hours within 5 years.

We have reviewed the Norwegian training program in such a detail because this flexible program ensures the best conditions for specialist training. The studies in small groups are recognized to be the most efficient learning method. A program for decentralized educational groups has been part of the training program for GP specialists in Norway since 1985. The vision is that young GPs become more competent by sharing experience and clinical knowledge with direct reference to clinical practice. The groups are supervised by experienced GPs formally trained as group facilitators. The typical group has 6-10 participants.

Swedish vocational postgraduate studies last for 5 years and do not adhere to a mandatory curriculum. The studies are guided by the problem-oriented approach whereat the resident improves his/her competence by resolving real medical and social issues of his/her patients. At the

34 start of the vocational training a trainee and his tutor/supervisor sign an individual contract. According to the guidelines the majority of the time (about three years) the postgraduate spends at general practice and for two years he/she stays with a hospital (studying internal diseases, surgical disciplines, pediatrics, oto-rhinolaryngology, etc). The choice of hospital specialization will depend on one's previous training and on the field which the tutor wants to focus at.

A new model for Residency Program in Family Medicine was created in Stockholm to reach a better education through increased participation in and responsibility for the education. The residents are geographically divided into seven ST-forums. The forums are further divided into base groups of 8-18 persons. Each forum is coordinated by a leadership consisting of residents and the directors of studies. The main part of the program in the forums is meetings in the base groups one afternoon per week. Examples of program in these meeting are: lectures or seminars on medical topics, study visit, discussions about family medicine and current work- and education matters. Increased responsibility for planning and execution of the residency now lies with the resident himself. Positive outcomes is an education based on the individuals own experiences, skills, interests and needs, which brings greater responsibility for his/her own professional growth (Martin Forseth et al. ST-Forum: A new model creating better residency program in family medicine in Stockholm. Abstracts of 15th Nordic Congress of General Practice, 13-16 June, 2007, Reykjavik, Iceland. P.48)

Specialist training in general practice in Denmark entails 2.5 years in a general practice and 2.5 years in five different specialties in hospital. While at hospital, return days once a month are planned back to the practice to which the trainee has been attached.

4.3.3 Licensing

Virtually all countries allow family medicine professionals to start practice having completed their professional resident training. However, there are some country specifics when it comes to permitting working as doctors. As it was mentioned earlier Germany has even cancelled 18-month postgraduate internship. Starting 2004 a university graduate receives a full state recognition. It can be a testimony to a high assessment of German undergraduate studies. Since 2004, continuing education has been made obligatory for all health professionals; evidence of appropriate professional development has to be presented every five years. In the case of SHI-affiliated physicians, lack of adequate evidence may lead to a reduction of reimbursement. For other physicians, psychologists, dentists and pharmacists the responsibility of regulating, promoting and supervising continuing education lies with the professional chambers.

Some countries grant 5 year licenses with mandatory re-licensing having completed a training cycle of at least 144 hours (Russia, Belarus, Latvia and Estonia). In Lithuania, according to the Medical Practice Law adopted in 1996, licensing of all medical professionals has been initiated. In parallel to the licensing process a complete register of health care professionals is being developed. A special Ministry of Health Commission is in charge of licensing health professionals working both in public and private sectors. Duration of initial licenses for private providers is two years. Foreigners who have received a permit for temporary residence in Lithuania are eligible for licensing as well. However the duration of the license is up to three months and the work is permitted only for charity or specialist training activities. In Poland, re-licensing is every 4 years and is controlled by the Doctor's Chamber.

In Sweden, the National Board of Health and Social Welfare has a supervisory function with respect to all health care personnel. The Board is also the licensing authority for physicians, dentists and other health-service staff. The license is given for an unlimited period of time, i.e. once health care professionals have been given the right to practice they do not have to apply to keep that right. However, in cases of malpractice, licenses can be withdrawn. The National Board is also the designated authority, under EU directives for the mutual recognition of diplomas concerning health professions.

4.3.4 Continuing medical education/continuing professional development (СPD)

35 Continuous vocational education is among the most acute personnel problems. Health care was always known for the high importance, it is attached to continuous post-diploma education with the understanding that any medical doctor shall constantly improve his special medical knowledge and skills and that patients have a fundamental right to get the most effective treatment resorting to the knowledge and skills of a highly qualified doctor. Today's continuous education includes more than just continuous training and attitude development. Education that is not limited by a determined duration or school/clinic walls is becoming the life style and the prerequisite of one's development while he/she is socially active.

Medical practice specifics are that the scope of information required to deliver a comprehensive care to patients is always growing. And this is a fact of doctor's life throughout his/her professional career. Most European countries approach the improvement of their medical staff via Continuing Professional Development (CPD). Some countries have formalized their requirements to post- diploma studies tying them up to doctor re-certification (Germany, Latvia, Estonia, Lithuania, Russia) while others introduced an organized system of courses and other learning formats that is not coupled with exams to retain the specialist's certificate. Denmark uses Personal Learning Plans to ensure continuous professional development. The Norwegian СPD is considered the best organized and can give a good example to the UK, the country where general practice had originated (Richards T. Recertifying general practitioners//BMJ. – 1995. – Vol. 310.- P.1348-1349.). The Norwegian CPD has no exam and hence its peculiarity since the professional growth is not linked to doctors' fears of the exam where, if failed, they may loose their right to professional practice. A doctor who failed to meet the requirements of renewing his family medicine specialist status will not loose a right to practice. However, he/she will loose the right to receive an extra wage made of regular tariffs. And this provides the stimulus. The Norwegian CPD principles are as follows: 1) A right to improve one's qualification: each doctor's individual contract and an agreement with municipality provide for the time which can be used for CPD. This is usually 2 weeks per annum, about 60 training hours; 2) The professional development system has no exam; 3) Clinical practice is a mandatory condition to retain one's doctor status and at least one year out of 5 years of professional activities that must be worked as a GP; 4) Updating one's clinical knowledge and job skills by working at a hospital or attending courses for 100 hours; 5) other learning formats which can be measured in hours (assignments related to quality improvement and self-evaluation; peer reviews,, etc.).

Being a key aspect financing is provided by the state or through professional associations thus avoiding the participation of pharmaceutical companies in post-diploma training of doctors. In Iceland the state recognizes the importance of continuing medical education by granting every medical doctor it employs up to a 15-day paid leave per year for studies within his or her specialty, with full per diem allowances if the doctor goes abroad to study, as most do. Denmark has a negative experience of using financial support of a pharmaceutical company that later lead to an attempt to amend the course curriculum and to influence general practitioners in their selection of antibiotics (Friis H., Mabeck C. E., Vejlsgaard R. Changing in prescription of antibiotics in general practice in relation to different strategies for drug information//Dan Med Bull.- 1991.- Vol. 153.- P. 380-382.). A study to assess sources of CPD financing employed in different ND Countries can help to rule out such situations.

4.4 Nurse training

4.4.1 Nurse training in ND Countries

In Denmark basic nurse training takes three and a half years and is situated at a number of schools of nursing run by the counties and linked to county hospitals. Postgraduate training programmes for nurses are carried out at the Danish Nursing High Schools in Århus and Copenhagen, in collaboration with the University of Århus. A shorter general education for health and social care assistants has been established to provide training for basic nursing care functions in hospitals and nursing homes.

36 In Norway the standard minimum requirement for the nursing education is to have reached general study competence (which normally means that the student has completed three years of tertiary education). The Competence Reform has made it possible for people over 25 without general study competence, but with extended work experience in the health care sector, to be admitted into nursing education. Basic nurse education lasts for three years. Half of this time, 60 weeks, is devoted to practical work, of which between 32 and 42 weeks are spent in health care institutions. The further education programmes leading to specialist nursing degrees normally require some clinical work experience and take from one to two years to complete. It is common for students attending the full-time further education programmes to be paid an allowance by the employer during their studies. In exchange they commit themselves to work for that employer for an agreed number of years after finishing their specialist education. Many of the nursing education institutions have programmes for distance learning. These programmes make it possible for people to acquire nursing education if they cannot easily attend classes, for example because of family commitments. The development of communication technology has made this easier to organize. Those attending these courses often have work experience from the health care sector, and their employers sponsor parts of the courses. Nursing science is established as an academic discipline, with masters' degrees and PhDs. The Ministry of Education and Research regulates nursing education according to a framework plan. The Ministry of Health and Care Services pays the university colleges to compensate for any expenses incurred due to students' practice period. Auxiliary nurse education in Norway takes place at the tertiary education level, and is organized by the counties. Traditionally, it attracts mostly women over the age of 20. It also introduces a system whereby people can be assessed based on their earlier work experience, and based on this ‘real competence' they may qualify for authorization directly or they may be required to take some courses. As a part of the health personnel recruitment plan the government intends to target resources to enable existing unqualified personnel to be authorized as auxiliary nurses. The most important impact of the Competence Reform has probably been to strengthen the recruitment into the auxiliary nurse profession.

In Lithuania, there are six colleges for the training of nurses (paramedical personnel). Applicants must have completed 12 years of general school education, must pass an entrance examination and attend an interview. Students are trained as nurses and midwives as well as social workers. Training of feldshers stopped in 1998. There are a number of ongoing changes in nurses' training. These changes stress health promotion activities and community care. There are also curriculum changes towards gaining more practical skills and increasing the role of qualified nurses in training. Nurses are increasingly promoted as semi-independent health practitioners and formal training lasts 3.5 years. There is also a university degree program at Kaunas Medical University, Faculty of Health Sciences of Klaipeda University and Vilnius University. There is a nurses' retraining centre in Vilnius with a few local branches throughout the country. Training used to be free (except textbooks and partially subsidized accommodation) for all students but since 1995 some students started to pay for medical residencies.

In Sweden, nurses are educated at approximately 30 universities, university colleges and Independent program providers spread throughout the country. The study programme for nurses consists of three years of basic education, followed by specialist training. Nurses can choose to train in midwifery or intensive care, anaesthesia, community nursing or child nursing; this part of the training lasts from 40 to 60 weeks. Training in occupational health nursing lasts for 10 weeks after a general nursing education and two years of post-certification experience. Special postgraduate training is highly important for a nurse. Having graduated as a nurse, the prospective district nurse gets an additional 1,5 year specialist training in primary health care, including a 6- month training at a child health centre. Alternatively, the graduated nurse can have the same duration pediatric training at a pediatric hospital and a child health clinic. Then she can work only with children either in children hospital or at child health centre or within school health care.

Estonia's three nursing schools (in Tallinn, Tartu and Kohtla-Jarve) are recognized as vocational higher education institutions for basic and special training for nurses and midwives. They also offer a health protection programme and train other lower- and mid-level health specialists. Nursing schools and their curricula have been developed to meet the standards of vocational high school 37 and a bachelor's degree. Besides basic nursing training, Estonian medical schools also offer higher vocational training for midwives, optometrists, pharmacists, mid-level health protection specialists, radiology technicians, physiotherapists, dental technicians and lab technicians, as well as vocational-level training for long-term nursing specialists. Such training generally takes three and a half years (four and half years for midwives).

In Finland, the training of nurses and other health care personnel such as physiotherapists, laboratory personnel and others takes place at polytechnics by municipalities under the guidance and financial support of the Ministry of Education. Now the general and specialization programmes have been combined: students have common training in general nursing, complemented with training from a speciality of their choice: (i) nursing for surgery and internal medicine, (ii) paediatric nursing, (iii) anaesthetic and operating theatre nursing, (iv) psychiatric nursing. The training programme for public health nurses lasts three and a half years and that for midwives four and a half years. Assistant nurses used to be trained in a one-year programme, but this programme has been abolished. Instead, a new two and a half-year programme in basic care provision has been launched in both the health and the social services. Finland has always had the highest number of nurses among the Nordic countries. One reason for this may be that in the past the number of doctors was very low and therefore more nurses were needed for various tasks, particularly as care was rather inpatient-oriented. Second, a large number of public health nurses are needed for the various roles in public health care, especially maternal and child health care, school health care, occupational health care, home nursing,, etc. During the last 5-10 years, the roles and tasks of nurses in the clinical care have expanded, both in the areas of acute problems and also chronic diseases. The training of nurses has traditionally been oriented to preventive services. Now the future shows growing needs in clinical care and home nursing. This had lead to new planning of the contents and orientations in the training of nurses.

In Germany, the recent reforms of nurse training (2002), child nursing (2002) and elderly care- taking (2001) include modernized curricula and enhanced elements of preventive and psychosocial care and community-based practice. The traditionally strong emphasis on social work has been complemented by more training in nursing skills and sickness-related knowledge, although experience in geronto-psychiatric nursing has still not become an obligatory part of elderly caretakers' training. Despite initiatives to unify the nursing professions, the traditional profound dichotomy between them has been preserved by the recent reforms of primary professional training. The training was recently broadened by introducing obligatory rotation and modernized to account for changes in patient information, practice management and information technologies. The responsibility for financing nursing schools at hospitals used to be the state governments', but was shifted largely to sickness funds in 2000. Neither a system for monitoring nurses on the basis of professional qualifications and job positions nor a systematic planning of human resources according to future needs is in place.

Latvia has a three-year programme, which begins after twelve years of schooling. The number of students in nursing schools is less than planned, as a career in nursing offers a low income. A nursing faculty was established in the Latvian Medical Academy in 1990 and offers a four-year degree course in nursing. It is intended that these university-educated nurses work as head nurses in hospitals and specialized wards. There is a nine-month training course leading to a qualification for auxiliary nurses (nursing assistants).

Nursing in Iceland is, by law, a self-governing profession. A Department of Nursing was established in 1973 within the Faculty of Medicine at the University of Iceland. In the summer of 2000, it became an independent Faculty of Nursing. The Icelandic School of Nursing was closed in 1986, and all nursing education is now at the university level. Approximately 100 nursing students graduate each year. After basic nursing education, which currently leads to a B.Sc. degree, nurses become registered nurses (RNs). A university degree in nursing is needed to enter the two-year midwifery education programme, a restricted intake programme that began in 1996 within the Faculty of Nursing at the University of Iceland. Before that time, midwives were educated in a school of midwifery at one of the hospitals. Practical nurses (qualified auxiliary nurses or associate

38 nurses) have been educated in Iceland since 1965. They now receive their education in a 3-year programme offered by a number of higher secondary comprehensive schools.

In Russia, basic nurse training takes three years for students who had completed secondary education. Nursing faculties was established in different Medical Academies and offer a four-year degree course in nursing.

In Belarus, since 2003 there is a three years basic nurse training programmes replacing the previous 2-year basic nurse training. Basic nurse training however is separate from the first study year for the following directions: feldsher, midwife, laboratory nurse, pharmacist nurse and general nurse with the subsequent short term specialization in the relevant field dependant on the employment place. Postgraduate specialization of nurses takes place at the State college for the nurse continuous medical education.

In Poland, nurses used to be trained in a five-year vocational secondary school course. In 1991, nursing training was upgraded to a 2.5-year programme (later 3 years) for students who had completed secondary education. Midwifery and nursing are taught in separate courses in over 200 schools of nursing and about 60 schools of midwifery. Nursing faculties have opened in five university schools of medicine, and additional postgraduate training is available in midwifery, pediatric nursing, and psychiatric nursing and other specialties. Qualified nurses can go on to obtain university nursing degrees and masters level credentials and a doctoral degree in nursing.

Nurses must register for a license to practice with the voivodship (province level) nurses and midwives chamber. According to a law on nursing (passed in 1935 and still in force) only qualified persons have the right to use the title and to practice as nurses. The development of their own professional and educational structures has made nurses more autonomous in some respects although they mostly remain subordinate to doctors in the practice of their work. Nurses in Poland carry less responsibility than nurses in most western European health systems, however, and undertake tasks that in cost-effective terms should be performed by support staff.

4.4.2 Conclusions

A success of GP team performance to a large extent depends on the nurse efficiency. High performance of Nordic primary health care – first of all in Finland and Sweden – was significantly determined by a clear understanding of this important condition. Among all the ND Countries these two have the highest ratio of medical nurses to doctors. Being principal workers when it comes to caring about chronic disease patients, elderly and general prevention medical nurses ensure effective operation of general practices. Countries where medical nurses have a low social status and professional prestige (Russia, Belarus, Latvia and Lithuania) – and thus experiencing shortages of nurses – face additional difficulties in achieving objectives, in treatment and in prevention. The recruitment of nurses is currently the most serious staffing problem in the Danish health sector. The lack of nurses is mainly due to low salary levels and a heavy workload.

In a situation of constantly overloaded general practices resolving an issue of nurses may play an important role in optimizing the way general practices work. Evidently, if reinforced, the nursing workforce in some of the ND Countries can take up a number of organizational issues thus reducing the doctor's workload and considerably improving the quality of primary health care services.

Chapter 5 Purchasing and remuneration of primary health care

5.1 Introduction

39 Improving efficiency and financial structures has a beneficial effect on quality of care. As it was stated in the joint WHO – WONCA conference in November 1994, "Effective financing policies must be put in place which reward providers for improving health of individuals and populations and place premium on cost effectiveness".

The Northern Dimension PHC Expert Group members in their meetings (2005-2007) have raised existing problems in primary health care in the ND Countries. Many defined problems are to some extent related with financing of primary health care and remuneration, e.g. poor incentives to work in PHC for health care professionals (Finland, Latvia, Lithuania, Poland) or decreasing budgets for PHC (Poland, Estonia, Lithuania). Collecting information into thematic reports on remuneration schemes in different the ND Countries and how they stimulate preventive work in the community, influence vulnerable groups, affect utilization from gender and social perspectives and overall lead to higher health care quality were considered as very actual.

5. 2 Purchasing of health care in Northern Dimension Countries

All countries reforming their health care systems are trying to find the best way how to improve systems performance. Strategic purchasing is one key components for improvement of the performance of health care system so that to achieve better public health and more equity within the health system. Between Northern Dimension Countries there are differences in terms of who acts as purchaser (municipalities, regional government, central government or health insurance funds), in terms of funding sources (tax based, social insurance private insurance) and of course on payment methods used for reimbursement of primary health care and secondary and tertiary health care.

Quite different experiences of reforming health care and finding solutions for purchasing and payment of health care could be found in former socialist countries. All of them during the soviet era had connected purchaser and provider of health care services. Administration of hospitals played a key role in distributing the money among providers. All providers including primary health care were connected into one centralised organisation managed by a chief hospital physician. That's why primary health care being on the end of hierarchic chain suffered from low payment and low status. Payment method used in soviet countries was based on budget which was formatted not dependent on performance and "outputs" but more on "inputs" such as having number of doctors or hospital beds. Medical staff was paid on time based salary which was very low.

After the end of Soviet period all independent countries except for Belarus have performed a purchaser provider split. The selected purchasing method was different between the countries. Lithuania and Estonia are examples of a centralised purchasing method – they have a single health insurance fund, although the fund has five regional funds in Lithuania. Estonia has started with establishing 22 independent regional health insurance funds in 1992. A revenue sharing arrangement between them was planned, but did not work in practice. A central health insurance fund has been established in 1994 with the purpose of coordinating and controlling. In 2000, health insurance have got more autonomy by establishment of Estonian Health Insurance fund with some centralisation at regional level from 22, later 17 into 4 regional departments. In both Lithuania and Estonia the national level is responsible for regulation and developing the purchasing strategy, while the regional level is responsible for contracting decisions and reimbursement.

In the Russian Federation, the compulsory health insurance system introduced in 1993 created a purchaser-provider split through the establishment of a federal fund and 89 territorial funds on the oblast level. Every territorial fund collect 3,6% payroll tax on employers and regional government contributions for the nonworking population and can introduce their own way of purchasing of health care services through health insurance companies or territorial MHIF branches.

Scoring of Health System Characteristic proposed by Barbara Starfield financing: tax based systems are given the highest score, because they are generally more progressive in financing than other forms of financing. Social security based systems are given an intermediate score, because the percentage for employee contributions are not generally tied to level of income. Financing primarily through private insurance agencies is given the lowest score.17 (See Annex 1). 40 5. 3 Provider reimbursement

The Northern Dimension Countries vary in the way primary health care providers are reimbursed. In many countries reimbursement methods vary within the country, when different regions/counties are compared (Sweden, Russia), or depending on type of health insurance (Denmark, Germany).

Still it is lack of evidence which payment method is best for purchasing primary health care services. There was some evidence that primary care physicians provide a greater quantity of primary care services under fee for service payment compared with capitation and salary, although long-term effects are unclear. There was no evidence, however, concerning other important outcomes such as patient health status, or comparing the relative impact of salary versus capitation payment.34 Experience of some countries in transition indicated that 100% capitation models of payment have been shown to decrease utilization of preventive services.25 That's why many countries have introduced fee for service and bonus add-on to the capitation model. Lithuania having six years of 100% capitation fee model it has revealed decrease of preventive activities on cervical cancer screening and it leaded to increased mortality due to cervical cancer.

The Baltic States when reforming their health care systems from former Semashko system have made different choices.

Latvia has started with fee for service method of reimbursement which later, due to increased financial risks for mandatory health insurance fund, has been changed to "mixed capitation" system: involving a combination of capitation and general practitioner fund holding. GP pays for the services of specialists to whom the patient has been referred. Certain specialists (such as psychiatrists, endocrinologists, dentists,, etc. who do not require a referral from a GP) are allocated separate resources for their respective payments. Another model exist in town Kuldiga, so call "Kurzemes" model, based on capitation fee with main emphasis in development institution of family doctors, responsible for effective disease prevention and health promotion.(HIT LATVIA 2004) Since 1995 primary health care are paid 50% in a form of capitation and 50% in accordance with number of visits as fee-for-service.

Estonia from the very beginning of the reform has introduced combined method of payment for primary heath care. The capitation payment is weighted according to the age structure of patients list, with different amounts paid for children younger than 2, people aged 2 to 70 and those aged 70 and older. Fees-for-service can be earned for a maximum of 18.4% of the capitation payment. The procedures reimbursed by fees-for-service are agreed upon by the EHIF and the Association of Family Doctors and included in the price list 21. Third component – a basic monthly allowance is provided to cover the costs of investment in the practice, and additional payments are made to compensate family doctors who work more than a specified distance from the nearest hospital, to reward doctors with a diploma in family medicine and to ensure continuing education. A family doctor's income depends not only on the size of his or her patient list but also on performance, so that any money spent on unnecessary analyses and procedures will diminish his or her income.

In Lithuania, from the beginning of introduction of Mandatory Health Insurance fund it was agreed that primary health care should be reimbursed by mixed payment scheme. Lithuania has started in 1997 with 100% capitation fee for primary health care providers. Payment was differentiated according to the age structure of a patient list and some extra payment for rural inhabitants. The Ministry of Health and the State Sickness Fund have agreed to introduce gradually certain explicit financial incentives in the form of special bonus and fee for service payments. First bonus payment for diagnostic of early stages of cancer has been introduced in 200322 . Development and accessibility of primary health care at the beginning of the reform was different when different municipalities are compared. Capitation fee has limited initiatives to strengthen primary health care and even some model primary health care institutions had to decrease the workload and preventive activities in the community.23 Number of out-patient visits in secondary health care have increased, which initiated MoH and State Sickness Fund to get back and to decrease capitation fee for primary health care in year 2000. Situation have changed since 2003 when initiative payments schemes have been introduced gradually for different preventive and nursing activities and in year 2007 it makes around 20 % of total sum. Primary Health Care is getting additional 41 payment for screening of cervical cancer and prostate cancer, nursing at home of chronically ill patients, for the care of pregnant women and immunization of children.

In Norway and Denmark, the biggest proportion of combined payment scheme makes payment on fee for service basis while in Finland and Sweden GPs are salaried or paid more on capitation basis. In Norway GPs are paid by fee-for-service from the National Insurance Scheme, out-of- pocket payments and capitation from the municipalities. In Sweden, payment schemes varies between different countries. Some of the counties traditionally have contracts with health centres based on global budget. Most of the counties introduced capitation fee for family doctors when in 1993– 1994 the law relating to family doctors was introduced. Taking into consideration burden of chronically ill patients and increasing co morbidity some counties in Sweden started to investigate possibilities to introduce payment schemes when capitation fee weighted according different level of morbidity of population. Johns Hopkins ACG methodology usually is applied for adjustment for co morbidity and grouping the population in different resource utilisation bands.

Since 1994, in some of the counties very intensively private general practice offices started to replace traditional Swedish primary health care canters where PHC team and especially district nurses play important role in determined responsibility areas. County councils have different type of contracts with private GP offices, but most common payment scheme is based on a monthly fixed fee (capitation) per listed individual, and partly on a fee-for-service basis.

In municipal primary health centres of Finland most of employees are salaried. In some health centres the personal doctor system has been introduced and doctors are paid by a combination of a basic salary (approximately 60%), capitation payment (20%), fee-for-service payment (15%) and local allowances (5%). The personal doctor payment is thought to give better incentives for cost– efficiency than the monthly salary payment.24 Most of health centres employees are salaried 100%. In health centres where the personal doctor system has been introduced basic salary approximately 60%, and local allowances (5%).

In Poland, family physicians and internists working in primary health care are paid based on capitation fee. The amount reimbursed per patient, however, is extremely low (about $2 dollars per person per month) and the fee also covers lab tests. As a result, physicians over refer patients to specialists for care when possible, contributing, of course, to the bottleneck at the specialist and hospital levels. The proportion of health care expenditures spent on the PHC level has remained below 20%. In year 2007 for primary health care it was devoted 11% of whole budget of National Health Care.

In Germany, SHI-affiliated family physicians receive their income from the regional physicians' associations (for SHI-insured), private health insurers and other sources mainly on a fee-for- service basis although elements of per-capita and case-fee payments have been increased in recent years.

In Russia, every county has their own Mandatory Health Insurance fund and is able to develop their own model of purchasing of health care services and to introduce different payments schemes. Since (2007?) out of totally 89 regions 19 pilot regions have been selected where new payment schemes exist or will be introduced. Five different components of purchasing and payment are piloted and counties can select how many of these mechanisms they are implementing : (1) capitation based payment with partly fundholding, (2) one channel payment (only through Mandatory Health Insurance fund, while other regions still have payment from budget additionally to the payments from MHI fund. (3) New quality control system according to developed standards, (4) salaries not any more based on special normative, but flexible, special initiative payment schemes are introduced (up to 30% of salary), (5) salary of administrators not more than 3x higher than average.

As an example for other pilot regions payment scheme based on capitation with partly fundholding introduced in 2005 by Kaliningrad Mandatory health insurance is presented. In this pilot funding scheme (until 2008) only these primary health care physicians who have certificate of family medicine/general practice and have the list of their served population could participate. Contract 42 was made with the head of institution and fee per capita was revised every month and confirmed by steering committee of MHIF. Fee per capita in 2007 was around 140 roubles. Institutions have to cover their own expenses (salaries to their staff according to normative, medicine, other expenses) and to pay for secondary heath care services. Ambulance services, dispensers of tuberculosis, oncology were not included in the scheme. Saved amount, so call "residual profit" could be added to salary fund of the institution , but at first special committee evaluates performance of family doctors. So call "economical sanctions" were used for not fulfilled FD services or mistakes, e.g.:

¾ Not full dispensarization of chronically ill and no proved activity of diabetes, asthma, hypertension schools ( minus 5% of residual profit)

¾ Not fully provided prevention activities: fluorography, immunization, health education (minus 5%)

¾ Ambulance call rate in the district is higher than average (318 calls per 1000 inhabitants annually or 26 calls per 1000 per month in year 2007) (minus 5%)

¾ Late diagnostics of oncologic diseases, due FD felt (for every case minus 10%)

¾ Late diagnostics of tuberculosis, due FD felt (for every case minus 10%)

¾ Late hospitalization which was cause of worsening of patient's status, complications of the disease (-50% )

¾ Death due to mistake of family doctor (minus 100%)

¾ Other, like reasonable complain of the patients, not qualitative patients' records or bad sanitary hygiene status in health care institution proved after control of hygienic centre, not fulfilling the orders of MoH of Russian Federation, MoH of Kaliningrad oblast, chief doctor of Central regional hospital (minus 5-20%)

Withhold money were still kept within health care institution but could be used only for improvement of facilities and quality of primary health care. As the consequence of new funding scheme was pronounced increase of salaries of these family doctors who showed better results in their clinical and preventive activities. Still not so evident increase was of those family doctors who were working in central regional hospitals (in the same institution secondary health care specialists).

5.4 Co-payments for primary health care services

One of main principles of primary health care is accessibility of services. One of very important dimensions of accessibility is equal financial accessibility – services should be available for all population not depended on their income and social status. Most health care analysts consider that cost sharing is a weak instrument for achieving the objectives of efficiency and equity in allocation of health care recourses (Ray Robinson User charges for health care)24 The RAND Health Insurance experience provided in US during the 1970th showed that cost sharing is associated with marked reduction in the probability of medical use and outpatient visits among lower income groups. Effects were strongest in relation to services for pure children. Further studies showed that cost sharing reduce utilization of out-patient services and adversely affect health of unemployed, homeless, and lower income people (Rubin and Mendelson 1995).

Still many countries trying to regulate increasing demand of health care services by introducing co-payments to health care services. Sweden is one of such countries where exist uniform charges irrespective of income. For individuals who reached particular amount of services become free of charge through the high cost protection scheme. That means that many services, including secondary health care, are free of charge for many chronically ill patients when they reaching maximum amount. That scheme of co-payment is considered between different political groups.24 43 In Finland, amount of co-payments varies between different municipalities. In Denmark only 2% of population who choose to have direct access to general practitioners and specialists have to pay for the consultations.

East Europe countries during transition period have increased reliance on out-of– pocket payments. Still formal co-payments are not very common in primary health care of North East Countries. Co-payments were introduced in Latvia. Following Swedish model it was introduced limitation of annual co-payments up to 160 US $. No co-payments for primary health care services, with exception for some preventive check-up e.g. for driving license, employment, etc. exist in Lithuania, Latvia, Poland, Russia and Belarus. Due to very high home visits rate (common feature of all North East Europe Countries) co-payments for home visits made by GP was introduced in Estonia. Recently this issue to high degree is under political debates in Lithuania.

Informal payments for health care services were very common and still to some extend exist in North East Europe Countries. Free choice of primary health care, active listing and increasing variety of primary health care providers has limited informal payments for primary health care. From other hand it was noticeable in all countries in transition increased waiting time to secondary health care services. These services become unequally accessible – these who had ability to pay (formally or informally) use expensive health care recourses not appropriately to real needs and so increasing waiting times to these services.

According to data from European Observatory on Latvia (HIT Latvia 2003) informal payments have declined. It is argued that disadvantaged groups do not have enough money for even essential needs and therefore use medical services mostly for emergency care while on the other hand those who are more prosperous have the option to consult privately. On the other hand there is a general feeling among the population that informal payments have increased, particularly in the larger cities.35

Informal payments have not been common in Estonia and continue to be relatively rare. In 1998 a representative survey commissioned by the health insurance fund found that 1% of those it covered had paid the doctor extra in cash. An 2002 survey financed by the Organization for Economic Cooperation and Development (OECD) found that fewer than 1% of health service users had made an unofficial payment, and then mainly on the patient's own initiative. The mean value of the payments was €122 (EEK 1903) and the median value was €16 (EEK 250). Those who were more likely to make unofficial payments were people who spoke Russian as their first language and people who wanted to bypass the family doctor gate-keeping system.36

Co-payment is one of health system characteristics proposed by Barbara Starfield to use to characterize accessibility of PHC – formal cost sharing for primary health care services: "The highest scores are assigned where there are none or very low requirements for co-payment. Intermediate scores are assigned where required co-payments are low and/or where there is no ceiling on the level of payments. Low scores are assigned where co-payments are substantial and/or there is no ceiling" 17

44 Table 11: Comparison of reimbursement methods for primary health care providers in the ND Countries Country Main payment method Additional Co- Fundholding payments payments by patient Belarus 80 – 90% salary partly 10-20% None No depends on the number of bonus for the population in catchments reaching of area selected performance indicators Estonia Capitation fee 80% Basic No, except No (2004, HIT) adjusted for three age groups monthly for home (0-7, 7-70, over 70). Up to allowance visits 18,4% fee for service (for premises) and additional payment for distance Finland Most of health centres model 2: Municipalities No (2002, HIT) employees are salaried local set payments (model 1) allowances for services 5% they provide Mixed payment schee where – either an personal doctor's system annual (model 2) payment of 16,8 Euro or charges per consultation Norway Mixed payment scheme

Iceland Mixed payment scheme

Denmark Mixed payment system

Sweden Different models: Co-payments No (maybe (2005, HIT) (1)Global budget. of 60-140 some (2)Capitation became SEK, rates payment common in many counties determined schemes 1993– 1994 when the law by include partly related to family doctors was municipalities fundhoding introduced . for private Maximum of GP offices??) (3) For private general €100 45 practice offices payments user charges from the county councils for outpatient partly based on a monthly care in fixed fee (capitation) per each 12- listed individual, and partly on month a fee-for-service basis period. Two different models: Additional YES Partly payments for Latvia (1) capitation payment compensatio (2000, HIT) based on the number of listed n of the patients and the patient age general structure. A portion practitioner in of this payment constitutes a general practitioner low density remuneration; and a portion area and for is general a fixed payment for practitioner remuneration of the primary certification. health care nurse,

(2) "Kurzemes model", 50% accordance with the number of patients family drs practice and 50% in accordance with number of visits as fee-for- service Russia Varies between counties No. Health In some insurance counties schemes does not include cost sharing co- payments Lithuania Capitation fee is about 80% Bonus No and fee for service payments payment for is for preventive services like the results: screening of prostate cancer, diagnostics cervical cancer, care of of early pregnant, preventive check- stages of up of children, nursing at cancer (since home of chronically ill 2003) and patients since 2008 it is planned more bonuses for quality of care of chronically ill patients Poland Capitation fee as a basic No Not in payment (rest is not present but obligatory) + fee per case for were very preventive activities + 24 successful hours services trials in the past

46 Chapter 6 Conclusions

Available in the international databases research data on primary health care situation in Northern Dimension Countries are very limited and not represent recent situation. Appropriate strategies needed to be implemented for updating most actual data about primary health care situation.

The general health indicators report worse health conditions of the countries in transition. Low life expectancy and unhealthy life styles including smoking, excessive drinking and spreading of HIV and tuberculoses are the major health concerns in these countries.

Countries in transition have lower responsibility of their community for health. These countries inherited from Soviet time dominance of medical professionals and passive role of the community and other sectors in decision making regarding health related questions. Primary health care professional could play very important role for shifting responsibility for health towards community and other sectors.

The percentage of resources spend in health care sector is lower in the countries in transition. However in most of the countries the health expenditures have been rising during the last 5 years.

There is a great range of diversity in the organization of the primary health care in the Northern Dimension Countries. The organization and the context of the primary care is unique for any ND country yet the distinction North-West and North-East is still to some extent existing in the structure and the way primary health care is organized. North East countries especially Russia and Belarus still missing clear understanding the crucial role of primary health care as the basis for overall health care system. Family medicine as an essential medical specialty in primary health care still is in very early stage of development in countries in transition.

Nordic countries (Denmark, Finland, Norway, Iceland, Sweden) scored highest in the issues of the infrastructure of the PHC facilities. The PHC premises are better equipped, the computers and informational technologies are used to keep the patient records providing higher continuity and quality of health information. In these countries GPs are playing the central role in the primary care with the evident processes of professional emancipation of the nurses towards more autonomy in the PHC. GPs as a rule are working in PHC centres or group practices and they have quite distinctive gate-keeping functions.

The Baltic Sates, Russia and Belarus scored less in the availability of the essential practice equipment with rare use of informational technologies in primary care. In some countries like Russia and Belarus the GP model is confined to the rural health care. The position of the GPs is much weaker and the gate-keeping function is low. In the Baltic States (except for Estonia), Russia and Belarus the network of the feldsher posts in the distant rural communities remain a main resource of the primary care together with the network of GP rural practices (ambulatories or doctorates).

The workload of the GPs in the ND Countries is highest in the countries with self-employed GPs (Germany, Denmark, Poland) and with a high proportion of the fee-for-service remuneration of the PHC doctors. In Nordic countries GPs visit their patients less frequently and have by far more telephone contacts with the patients.

The high proportion of home visits and low number of telephone consultations in the Baltic States, Poland, Russia and Belarus could be the consequence of other regulations of sick-leaves certificate issuing (requirement to be seen by the doctor from the first day of sickness), no possibilities for delegation of home visits to the elderly and chronic patients to the community nurse and to some extent due to the medical traditions denying telephone consultations as reliable contacts with the patients.

The growing number of the elderly people requires broadening of the capacities for self-care, nursing and social care at patients home and appropriate long term care like nursing hospitals,

47 elderly houses, the number of community nurses and home care. Increasing elderly population and population with several chronic conditions to high extend increase usage of health care recourses.

GPs in the Nordic countries provide more comprehensive preventive and curative services to their patients including children and women. GPs in the Baltic States, Germany, Russia and Belarus provide comparatively fewer services to children and women. In many ways it is due to the traditional division of functions between other professions who are also active as the first contact doctors (pediatricians and gynecologists).

Development of primary health care varies between different practices in countries in transition. Due to different initiatives and support from West countries in all North East countries could be found "centres of excellence" which could be used as example of good primary health care for all Northern Dimension Countries.

All the ND Countries have the challenge to recruit and keep more qualified doctors in the primary care in general and in the rural and deprived areas in particular. Financial incentives, possibilities for privatization, and working in group practices are better strategies to make work in primary care and particularly in disadvantaged areas more attractive to the health care staff.

Chapter 7 Gaps in the primary care systems in ND Countries. Recommendations for project- based activities

The main objective of the comparative report on the primary care in the ND Countries is to identify the gaps in the primary care systems and to propose the project based activities using the best practice expertise from the other countries of the Northern Dimension Partnership. It is worth mentioning that the fact of implementing international projects in primary care will have the positive impact on the status of the primary care system in the involved countries. It is especially relevant in the East European countries with the long traditions of the specialist's driven health care systems.

Equitable distribution of the primary care personal and resources is a big challenge for all the ND Countries. Defining the mechanisms for promoting an equitably distributed primary care system could be the activity on the policy level in the countries with the more pronounced uneven distribution of the primary care (Poland, Baltic States, Russia, and Belarus). The activities on the managerial level could be supplemented with the pilot project regions of the countries.

Unhealthy life styles and risk behaviour is a big burden of the countries in transition in the ND partnership (Poland, Baltic States, Russia, Belarus). The last two decades are considered to have brought a certain breakthrough in the role of the primary care doctors (and nurses) for the professional advice on life style issues. In the countries in transition the knowledge on the proper brief interventions by primary care doctors is sporadic or absent. The educational activities on proper motivational counselling in the primary care settings and support of the modern informational materials on smoking cessation, nicotine replacement treatment, cutting down alcohol, diet and exercise would be very important.

Training of the primary care specialists – GPs and especially primary care nurses – is another big area for the possible cooperation and joint activities within the partnership. There is an evident gap in the requirements for professional training of the primary care doctors ranging from absent postgraduate training (Russia, Belarus for therapists) to 3 years in the countries of the EU and 5 years in Norway and Sweden. In the countries experiencing transition from policlinic system there is a burning problem of the shortage of the teaching practices for the practice based GP training. This goes mostly for the countries in the beginning of the primary care reform to GP oriented model (Russia, Belarus). Even the countries with the substantial progress during the last decade in the establishment of professional training for GPs and nurses will benefit from the possible cooperation in the running of the teaching primary care practices (the Baltic States). The gap in the status of the registered nurses in the Nordic countries and nurses in the Baltic States, Poland, Russia and

48 Belarus is big. There is a need for improving the professional training of the nurses to achieve more autonomy of the profession in these countries.

The ND Countries show big variations in the activities of the primary care staff. While telephone consultations by the GPs and 24-hours consultations lines by registered nurses (Sweden) are common practice in the Nordic countries, these services in the other countries are either underdeveloped (The Baltic States, Poland) or even prohibited and considered inappropriate by the current regulations (Belarus, Russia). Introduction of telephone consultation lines by doctors or trained nurses, development of guidelines for the professional triage and handling of the presented problems by telephone could improve certain aspects of the accessibility of the primary care in the latter countries. More appropriate use of the resources and reduction of the unnecessary ambulance visits could be the additional advantage for the health managers for implementing of these activities.

Effective financing and remuneration systems for the primary care staff attract the attention of the health care managers in the ND Countries. Partnerships and pilot projects in this area could be very useful in finding the balance between the needs of the patients and the communities and effective work of the primary care system. Payment schemes with the incentives to increase health promotion and disease prevention activities would be very relevant for most the ND Countries. Sharing of the experiences in this field and lessons learnt from the mistakes would be appreciated by the majority of the health care decision makers of the ND Countries.

New strategies are needed, especially in North East countries to improve cooperation between primary health care and secondary health care. More equitable and adequate to real needs accessibility to secondary health care resources should be guaranteed for all population in North East Countries. Appropriate strategies are needed to weight different needs according to the different level of morbidity of population and to limit unnecessary use of expensive health care technologies. Population with several chronic conditions (high morbidity) are high users of health care resources, so guidelines of care of population with high co-morbidity would be very relevant for countries in transition.

The professional infrastructure of the primary care like professional associations of GPs and nurses differs considerably in the ND Countries. The project-based activities between the professional associations like development of professional guidelines on the relevant topics, and peer review activities could promote professional emancipation of the primary care doctors and nurses. Introducing evidence based guidelines for the primary care and avoiding obsolete, ineffective or potentially hazardous practices could positively impact the quality of the primary care in the countries in transition.

Quality improvement activities differ evidently in Poland, Baltic States, Russia, Belarus and Nordic countries. Projects for introducing quality tools would be as priority for these countries. The quality mainly presented as external control (audit) in Poland, Baltic States, Russia and Belarus contrasts with internal audit experience in the Nordic countries. Internal audit tools based on the demand for improvement of personal performance motivate primary care staff to act better without fear of being externally controlled.

The report identifies the need to bridge the gap in the availability and the quality of home care and other forms of institutional care for the elderly people (nursing homes, shelters, elderly houses). Activities on catalyzing and introducing new forms of care for the elderly people in the primary care will have double benefit for countries with little experience in the field: better meeting the needs of the communities with the ageing population and reduction of unnecessary hospital admissions with substantial financial benefits. Projects supporting professional home care for the elderly and chronically ill patients are very welcome in the Baltic States, Russia and Belarus.

Appropriate strategies needed in all Northern Dimension Countries for empowerment of the community and other sectors to play active role in community health need assessment and solving of priority problems. Especially it is actual for North East Countries. Primary health care team should play active role in shifting responsibility for health from medical professional towards 49 community. Cooperation between primary health care and other sectors should be improved in all countries in transition. Proper attitudes and skills needed for primary health care professionals for teamwork, leadership and for getting contribution from community in health promotion activities.

The available data reveal the differences in the use of IT technologies in the primary care. There are countries with 100% use of the electronic patient chart (Nordic countries) and countries with blank patches in what regards use of computers in the primary care. Sharing experiences and defining guidelines for the information registered in the electronic patient charts will be very helpful both for the countries who will face the need to switch to electronic charts and for the countries with the already developed IT products to find the common grounds for comparing key statistical data on GPs' performance.

There are evident gaps in the research possibilities in primary care in the ND Countries. No doubt that all the above-mentioned areas for possible project-based activities will stimulate data collection and researches in the relevant fields. Approving general practice research, research in the nurse sector will be highly appreciated in the countries in transition.

50 References

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ANNEX 1

Comparison of Primary Health Care Score Components following methodology proposed by Barbara Starfield from:

Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res 2003; 38(3): 831-865.

Starfield, B. (1998). Primary Care. Balancing Health Needs, services, and Technology. New York/Oxford: Oxford University Press.

1. Component : Regulation

Country Indicator: Do specific national policies exist that Scoring regulate the distribution of primary care providers 0 = no overall primary care and facilities? regulation 1= limited (only Rationale: These policies are intended to improve some regions of populations) equity in distribution of primary care services 2=entire system regulated 52

Belarus Primary care is completely controlled and owned by the state. The 1 distribution and regulation of all primary health care is regulated by the local health care authorities at district and regional levels. However the system faces the uneven distribution of the doctors and nurses in the rural areas versus the cities. Even in the cities there is a constant shortage of the primary care doctors who prefer specialist career. There is a policy that aimed at the 2-year obligatory work as a primary care doctor for the medical graduates from the University. Denmark Since all training of authorized health professionals is public, the state does 2 exert control over the supply of health professionals, provided there are applicants for all places, which is not always the case for nurses. The counties can influence the extent of the provision of health care. First, they have the authority to regulate the number of private practitioners entitled to reimbursement by the NHSS, which is financed by county taxes. Second, the counties’ negotiations with the professional organizations are a key means of controlling the activities of private practitioners. Thanks to the NHSS and the fact that Denmark trains many doctors, there is an even distribution of doctors across the country, with very little variation between counties in the number of inhabitants per general practitioner. In this way the Danish health care system has succeeded in achieving short distances to general practitioners and reasonable equity in access to general practitioner services. Estonia Primary care services are equitably distributed across the country, with 2 financial incentives in place to encourage family doctors to work in rural areas. Finland Decisions on the planning and organization of health care are made by the 2 health committee, the municipal council and the municipal executive board. Everyone in Finland has the right to health services regardless of ability to pay or place of residence. The constitution states that public authorities shall guarantee for everyone, as provided in more detail by an Act of Parliament, adequate social, health and medical services and promotion of the health of the population. The Finnish health care system is very decentralized. The population in Finland is dispersed and local decision making has always been regarded as important. Germany 0 Iceland A health care centre is provided for each designated area of the country, 2 and all inhabitants are entitled to seek medical assistance at the health care centre or clinic most easily accessible to them at any given time. A 1998 study by the University of Iceland (19) showed that people in general have good access to primary care in acute and subacute cases. A total of 95% of the population lived less than 20 km from the nearest health care centre, and 94% reported that they were able to reach it within 20 minutes. Latvia According to research, patients in rural areas complain about the 0 difficulties with primary health care accessibility. With regard to equity in access, a disproportionate number of publicly provided services are available in Riga and other large urban centres. Many of these services are not available for the rural population, thus detracting from the achievement of equity in access to services. Lithuania Municipalities are responisible for primary health care development and 1 appropriate distribution of primary health care units for better accessibility. Nevertheless t was stoped with requirement that new place of primary health care unit should fit to primary health care development plan. Financial incentives in place to encourage family doctors to work in rural areas.

Norway The organizational structure of the Norwegian health care system is built 1 on the principle of equal access to services: all inhabitants should have the same opportunities to access health services, regardless of social or economic status and geographic location. In Norway there is long tradition that the government regulates the physicians’labour market. The purpose of the regulation has been to make it easier to recruit physicians in rural areas and to ensure that there is an adequate number of educational positions within each specialty. It has always been more difficult to recruit physicians to positions in rural areas than in urban areas. There are also differences among the specialties. The rate of unoccupied positions has been especially high for GPs and for positions in less popular specialties such as psychiatry and community medicine Poland Resources still follow facilities and equalization mechanisms have not been 0 developed to redistribute resources across geographic areas and across social groups. Russian The form of “tripartite agreements” between the 1 Federation Ministry of Health, the federal Medical Health Insurance Fund (MHIF) and regional health authorities, setting the Guaranteed Package Programme as a mechanism to balance commitments to free health care and available resources. The Guaranteed Package Programme determines the minimum types and volumes of care that are to be provided free of charge by the regions of the Federation, and is a planning tool on two counts. It is intended to facilitate a restructuring process away from inpatient care and toward increased outpatient care and moreover, it attempts to match free service provision with the total amount of funds available for this purpose. Sweden Health care is considered a public responsibility in Sweden, and the county 2 councils play a dominant role in the provision of health care services. According to the Health and Medical Services Act of 1982, “every county council shall offer good health and medical services to persons living within its boundaries”, and “promote the health of all residents”.During the 1980s, responsibility for health care planning was decentralized from the national level to the county councils. According to the 1982 Health and Medical Services Act, the county councils are required to provide for and promote the health of their residents and to offer equal access to health care. They also need to plan the development and organization of health care according to the needs of their population and the resources given. An important part of the objective of assuring that the entire population receives good health care on equal terms is that the health sector provides care within the limits of its economic resources. Municipalities are responsible for the care of elderly people and people with disabilities living in special accommodation. However, the county council is always responsible for care provided by doctors.

2. Component : Financing

Indicator: What is the method of financing health Scoring Country care for the majority of the population? 0= primarily private Rationale: Scored by level of progressivity, tax-based 1= social systems are considered most progressive. security 2= primarily tax-based

Belarus Almost all financial resources are collected as the tax revenues. As a new 2 tendency of the last 5 years there is a growth in number of the private medical clinics in the big cities where some popular specialists are concentrated (gynecologists, urologists, dentists) that operate on the fee- for-service basis providing better services to the patients (no queues, better service and attitude etc.). There is no private primary care facilities and the number of the private medical centers is almost negligent comparing to the public health care system. Denmark The main sources of finance in the Danish health care system are state, 2 county and municipal taxes. Other sources of finance include out-of-pocket payments for some health goods and services and voluntary health insurance taken out to cover part of these out-of-pocket payments. Estonia Health care in Estonia is largely financed publicly. Since 1992, earmarked 21 payroll taxes have been the main source of health care finance, accounting for approximately 66% of total expenditure on health care over the last five years. Other public sources of health care finance include state and municipal budgets, accounting for approximately 8% and 2% of total health care expenditure respectively. The Estonian Health Insurance Fund (EHIF) covered 94% of the population. Most health care resources – about 70% of total expenditure on health – are channelled through the EHIF. The state budget has funded approximately 8% of care, mostly through the Ministry of Social Affairs. Finland The health care system in Finland is mainly tax-financed. Both the state 2 and the municipalities have the right to levy taxes Germany Statutory health insurance is the major source of financing 1 health care, covering nearly 88% of the population in 2003. Iceland The Icelandic health care system can be described as universal, 2 comprehensive and mostly financed by general taxation Latvia Whereas Latvia has established an organizational structure consisting of a 1 central sickness fund (the State Compulsory Health Insurance Agency) with its regional satellites, health care services continue to be financed through a national, tax-funded system. About 79% of resources for health care are financed through taxation revenues Lithuania State Compulsory Health Insurance Fund with five regional satellites. Most 1 of the recourses are collected through taxation revenue. Norway The Norwegian health system is predominantly tax based and is built on 2 the principle of providing all inhabitants with equality of access to services, regardless of their social status, location and income. Public sector spending on health accounted for about 84% of the total. Poland Polish health care in the 1990s has been largely financed by government 1 sources through budget allocations Russian Main sources of finance are: Regional health budgets -- 44.7%; Mandatory 1 Federation health insurance (contributions for working population) – 15.9; Private contributions to voluntary health insurance --3.5. Sweden The health system is primarily funded through taxation. Both the county 2 councils and the municipalities levy proportional income taxes on the population to cover for the services that they provide. The county councils and the municipalities also generate income through state grants and user charges.

3. Component : Primary care provider

Indicator: What is the predominant type of primary Scoring Country

0= majority are specialists 1= majority are pediatricians , internist 2= majority are generalists Belarus The majority of primary care is still provided by paediatricians and internists, 1 who work in the policlinics in the cities covering about 85% of the population. Since 1996 the profession of General practitioner appeared as a new clinical speciality. At the moment general practice is confined to the rural areas covering about 15% of the population. However there are also some pilot GP practices operating in the distant living areas of the cities running by the state as a pilot project. Denmark Primary health care in Denmark is provided by private practitioners and 2 municipal health services Estonia In Estonia general medical care is provided only by physicians qualified as 2 family physicians (=general practitioners). General medical care means outpatient health care services which are provided by family physicians and health care professionals (=nurses) working together with them. A family physician is a specialist who practices on the basis of a certain list of patients (=practice list). There are 803 practice lists opened at the current moment in Estonia. The majority of general medical care is provided by private companies founded by general practitioners. General practitioner may also practice as sole proprietors (private legal persons in private law). 100 % of population of Estonia is served by general practitioners (there isn’t any district internists and district pediatricians). All general practitioners have a financing contract with EHIF.

Finland The doctors working in health centres are mainly general practitioners. 2 Around a half of all doctors working in health centres have specialized in general medicine (six years of postgraduate training). Germany Despite efforts by the federal government to improve the status of family 1 practice in the ambulatory care sector, the number of office-based specialists has increased more rapidly than that of general practitioners over the past few decades, so that GPs dropped to less than 35% of all office-based physicians in 2002. Since 2004, hospitals have been granted additional competencies to provide care to outpatients that require highly specialized care on a regular basis. Also, participation in integrated care models offers new opportunities to become active in ambulatory care. The share of hospitals offering pre-inpatient or post-inpatient care has increased steadily, to 71% in 2002, since their introduction in 1993 . More hospitals in the eastern part (89%) than in the western part (68%) offered this kind of care in 2002 Iceland It is an exemption from the health authorities’ general policy that the first 2 contact with the health services should be through GPs. Most specialist outpatient care is provided by private practitioners working on their own or rented premises, sometimes in group practice. The private practitioners are the most rapidly growing part of the health care sector regarding volume. There are three types of health care centres: category H2, employing at least two physicians (not counting other staff members); category H1, employing one physician; and category H0, employing a nurse or a midwife with facilities for regular consultations by a physician. Latvia At the present time, patients may make their first contact with the health 1 services in various outpatient institutions: polyclinics, hospital emergency clinics or ambulatory emergency clinics, doctorates, feldsher points, and health points. At the end of 1999, 42% of primary care physicians were general practitioners, compared to 25% in 1998. Lithuania 71% of population is served by family doctors, other by district internists and 1 district paediatricians. Norway GPs are central to the primary care system, and the most common practice 2 structures comprise teams of two to six physicians. They also have auxiliary personnel. Most GPs specialize in general/family medicine 56

Poland Until recently, there was no concept of a family physician or general 1 practitioner. Primary care physicians were mainly specialists in internal medicine, obstetrics–gynaecology or paediatrics. Russian The majority of primary care is still provided by internists and paediatricians, 1 Federatio who work in the policlinics. General practitioners cannot realistically set up single-handed practices in the public sector, and the conversion of polyclinics n into group practices has taken place only in experimental pilot projects. Sweden According to a government decision in 1995, all physicians in primary care 2 must be specialists in general practice. General practitioners provide treatment, advice and prevention. Others directly employed at this level are nurses, midwives, physiotherapists and gynecologists, welfare officers and occupational therapists who also constitute part of the health-centre staff.

4. Component : Financial access Indicator: What is the level of cost-sharing for Scoring Country primary care visits? 0= high copayment Rationale: High primary care copayments are 1= moderate considered to be a barrier to access 2= none or very low Belarus There is no any payment for the primary health care in Belarus. However 2 the high accessibility of the primary care is competed with the problems of availability because of the shortage of primary health care doctors. High number of vacancies in the primary care, long queues to get to the doctor influence the physical accessibility of the primary health care. Denmark Access to general practitioners is free at the point of utilization for all 2 Danish residents. General practitioners act as gatekeepers to hospitals, specialists and physiotherapists (although no referral is necessary for visits to ENT specialists and ophthalmologists. However, individuals without referral, have to pay a small co-payment (paid to the general practitioner or specialist). Estonia Since 2002 the cost-sharing requirements for outpatient care are as follows: 21 there are no co-payments for visits to a family doctor in the office, although family doctors can charge a maximum fee of €3.20 (EEK 50) for home visits, which are common in Estonia and could be estimated as a very low co-payment. EHIF-contracted providers of ambulatory specialist care can charge a maximum fee of €3.20 (EEK 50) but there is no fee if the patient has been referred within the same institution or to another doctor in the same specialty. From August 2004, children under two years of age and pregnant women from the 12th week of pregnancy are exempt from co- payments for primary care home visits and specialist ambulatory visits. Finland According to “ Social Insurance Institution, 2001” out-of-pocket payments by 1 patients was in 1999 about 20% of total expenditure on health care Municipalities may choose from two alternative ways of charging for a visit to a health centre doctor: Fmk 120 (€ 20) to cover all visits during the following 12 months, or a Fmk 60 (€ 10) payment per visit for the first three visits, with all further visits being free for one calendar year. Children under 15 years are not charged. Laboratory and X-ray examinations are included in the fees. Germany Co-payments of €10 per quarter now also apply to the first contact at a 1 physician’s (not necessarily a GP) or dentist’s office and when other physicians are seen without referral during the same quarter. According to studies of differing methodologies, the number of people fully exempt from co-payments tripled between 1993 and 2000 from 10% to about 30% of the population. In 2001, 47% of prescriptions were exempted from co- payments .

Iceland That portion of health care services that are not tax financed, answering 1 to 17.1% of the total, is almost exclusively financed by direct household payments, primarily the private partial payment of specialist consultations, outpatient operations and dental care, as well as co-payments for pharmaceuticals. From 1993 the patient was charged ISK 600–700 for a GP consultation during normal working hours. However, for old age pensioners, the disabled and children less than 16 (children less than 18 since 1999), the charge was only a third of this amount. Outside normal working hours, the ordinary charge was ISK 1000; for old age pensioners, disabled people and children the charge was ISK 400. This admission charge was regarded as a patient contribution to the operating costs of the health care centres. The charge for home visits within normal working hours by one’s own physician is normally ISK 1000; for old age pensioners and disabled people allowance the charge is ISK 400. Outside normal working hours, the ordinary charge for home visits is ISK 1500, while for old age pensioners and disabled people it is ISK 600. Latvia In the outpatient clinics co-payments are LVL 0.50 for adults and LVL 0.20 1 for children per day. The payment for a physician’s home visit is LVL 1.00. In 1997, the percentage of the Basic Care Programme costs that were to be covered by out-of-pocket payments was reduced to 20%, consisting of 15% co-payment and 5% patient fee. A maximum limit of LVL 80.00 is set for the total amount per year that a household may pay on health care. The average unofficial payment made per visit amounted to LVL 29 (roughly equal to US $47 according to year-end 2000 exchange rates). Lithuania No co-payments for primary health care 2 Norway According to the OECD Health Database the share of out-of-pocket 1 expenditures in the health care system is about 15%. For a prosperous country like Norway a co-payment limited upwards to NKr 1615 (2006) a year for adults does not seem to be a major barrier to people in need of medical services. Poland According to a study estimating health care expenditures in Poland for 1 1994, informal payments by patients to physicians contribute to as much as double of the physician’s salary (Chawla et al., 1998). Out-of-pocket payments for health care increased to around 30% of revenue in the mid 1990s Russian Excessive state commitments for available funding did not allow them to be 1 Federation fulfilled, and resulted in widespread illegal out-of-pocket payments, often for the full cost of treatment, and hence in an irrational use of private resources (compared to cost-sharing). Free health care was in fact an illusion, as patients frequently had to make payments to doctors and nurses in order to receive care. This practice was reinforced by the very low levels of salaries prevailing in the health sector, making the underground payments seem morally justifiable. It is not possible to accurately estimate the size of this black economy but according to one study in the late 1980s it amounted to one seventh of the total budget for health care. This is a key factor which is thought to have compromised equity in access to services. Sweden Out-of-pocket payments. In 2004, the fee for consulting a physician in 1 primary health care varied from SKr 100 to SKr 150 (approximately €11– 17) among the county councils. The Government’s ceiling for out-of-pocket payments means that an individual’s total charges on health care for a period of 12 months, i.e. for visits to physicians, district nurses, physiotherapists, etc., cannot exceed SKr 900 (€100), not including inpatient care. After this ceiling has been reached, the patient pays no further charges for the remainder of the 12-month period, which is calculated from the date of the patient’s first visit to a physician. The exemption scheme is included in national health insurance, financed by the Swedish Social Insurance Board and administered by the county councils.

5. Component : Longitudinality

Indicator: Are individual patient lists required for all Scoring Country

0= never required 1= limited use (of group lists only) 2= mandatory and ubiquitous Belarus The implication of the Semashko health care system in Belarus is that 2 primary health care doctor is responsible for all the patients living in the attached geographical area. Each primary health care doctor is automatically responsible for the patients according to their address registration. The patient lists are updated once per year. Denmark A data system covering general practitioners, specialists, pharmacies and 2 hospitals is currently under development. It is already in use for administrative purposes such as electronic transferral of patient records, prescriptions, orders and payment. The long-term aim is to build clinical databases, which will extend the existing possibilities for health care evaluation and research across different provider levels and institutions. Estonia The patient list (=list of patients = practice list) is mandatory for every 2 family physician irrespective of the legal form of practicing. Every family physician has only one practice list.

Finland Moderate. Choice of physicians is limited but possible. Getting better 1 because of list is increasing Germany Should be specified 0 Iceland Should be specified Latvia Should be specified Lithuania Patient list is required for every primary health care institution and for 2 every doctors within PHC institution Norway At present 99% of the population is registered on the regular GP scheme, a 2 list system, which aims to strengthen the patient–physician relationship by giving the patient the right to choose a regular general practitioner. In 1997, each municipality was given the responsibility to provide a named physician for every citizen according to a patients’ list system. Poland Primary health care is organized on a geographic basis, with each internal 2 medicine specialist covering a population of between 1200 and 2500 patients. Each primary care paediatrician is responsible for about 800 to 1000 children. Russian Primary health care doctor is responsible for all the patients living in the 2 Federation attached geographical area (district). Each primary health care doctor is automatically responsible for the patients according to their address registration. Sweden There is a need for integration between hospital care, primary care and 0 institutional care, especially in the provision of services for the elderly, and for those with disabilities or mental illnesses.

6. Component : First contact Indicator: Is there a requirement that primary care Scoring Country practitioners serve as gatekeepers to other levels of 0= never required care? 1= required but not Rationale: First contact is essential if primary care enforced of required for is to attend to the majority of health problems. limited population only 2= always required

Belarus Primary care doctors in Belarus traditionally had never had gatekeeping 0 role. Moreover even the name of the primary care specialist as “community internist (therapeft)” or “community paediatrician” imply the responsibility for treating mostly the internal diseases in the attached population. There is still the number of outdated not evidence- based preventive activities stimulating the direct application for specialists consultations like annual complex check ups and dispancerazation by narrow specialists (surgeon, neurologist, ear nose throat specialist, ophthalmologist) even without any complaint. Denmark General practitioners play a key role in the Danish health care system as 2 the first point of contact and as gatekeepers to hospitals, specialists and physiotherapists. Since 1973 Danish residents over the age of 16 have been able to choose from two general practitioner options known as Group 1 and Group 2. Individuals in Group 1 are registered with a general practitioner practicing within 10 km of their home (5 km in the Copenhagen area), giving them free access to general preventive, diagnostic and curative services. Children must register separately (that is, they are considered as independent subjects). Patients may consult an ear, nose and throat specialist or an ophthalmologist without referral, but they must be referred by their general practitioner to gain access to all other specialist and hospital treatment. Group 1 patients seeking specialist care without a general practitioner’s referral are liable to pay the full fee. Individuals in Group 2 are free to visit any general practitioner and any specialist without referral, but they must pay for all services except hospital treatment. Very few people choose this second option (only 1.7% of the population), partly due to general satisfaction with the referral system and partly because it is more expensive than the first option. Estonia The new system is intended to support the family doctors’ gate-keeping 1 role and ensure continuity of care. Primary care is organized as the first level of contact with the health system. Family doctors control most access to specialist care. Patients need a family doctor’s referral in order to see most specialists and to be admitted as a non-emergency inpatient. However, patients are able to access the following specialists directly, without a family doctor’s referral: ophthalmologists, dermato- venereologists, gynaecologists, psychiatrists, dentists and, in case of trauma, traumatologists and surgeons. Most patients have timely access to EHIF-contracted family doctors, and few patients would be willing or able to pay for primary care after the government introduced regulations concerning specialist visits without family doctor referral. Patients now have to pay out of pocket for any visits to specialists made without referral from their family doctor. The system of partial gatekeeping is not yet well accepted by the population: only 41% of patients prefer to be referred to a specialist by their family doctor, while almost 37% of patients want to be able to visit specialists directly (although the number of such patients has decreased by 6%), and 21% prefer to find the specialist themselves. Finland The doctors working in health centres are mainly general practitioners. 1 However, it is not obligatory to be a specialist in general medicine to work as a physician in a health centre. Germany Ambulatory health care is mainly provided by private for-profit 0 providers, including physicians, dentists, pharmacists, physiotherapists, speech and language therapists, occupational therapists, podologists, and technical professions. Family practitioners (about half of ambulatory physicians) are no gatekeepers in Germany, although their coordinating competencies have been strengthened in recent years. Iceland It has not recommended that a GP referral should be required in order to 0 consult a specialist, as has been tried in the past. The preferred situation would be a system with higher financial rewards for the specialist and lower co-payments for the patient when the patient is referred by a GP. It is also declared that people should have the right to go directly to the service providers of their choice. Others have pointed out that the number and activities of specialists are relatively uncontrolled, and that patients have almost unlimited access to specialist care since GPs have no gatekeeper role.

Latvia Primary care physicians (general practitioners, internists and paediatricans) have a gatekeeper role. The patient needs a referral from a primary care physician to receive specialist or secondary level care. Without a referral the patient must pay out-of-pocket or through private health insurance. Exceptions to the requirement of a referral include the following: dentists for children, psychiatrists, tuberculosis specialists, venereal disease specialists, gynaecologists, endocrinologists for diabetics, and specialists for emergencies (these specialists can be visited without a referral). Lithuania Yes, referral to secondary health care is needed from primary health care physician. Direct access is possible to dermatologist as well to any specialists if patient pays out of pocket to secondary health care 1 institution or if patient is on the list as chronically ill patient. Norway The GP acts as gatekeeper and agent for the patient with regard to the 2 provision of health services. Normally the patients’ first contact is with the regular general practitioner. Referral to the specialist health care service is conducted by the physician based on medical reasons. The physicians at the municipalities level (the patient’s regular GP and the emergency wards GP) have a gatekeeping role for the specialist health care. Poland Primary care doctors are the first point of contact with health services and 1 are meant to act as gatekeepers to the rest of the system. In rural areas, primary care is provided through small polyclinics or outpatient centres staffed by an internal medicine specialist, Russian Gatekeeping was part of the Soviet system of primary care, but it did not 1 Federation work in practice. However, there are some rayons in the Russian Federation where it is partly functional today; these include the Samara oblast, St. Petersburg, Chuvashia, Kemerovo, Tula, and Tver. Sweden The general practitioner usually provides the first health service contact 0 for adults or elderly people who have mainly physical health problems or minor mental health problems. Normally, a patient’s first health care contact is with a general practitioner at a local health centre, but patients can seek care at private clinics as well. Patients can also seek care directly at hospital outpatient departments. Most often a referran from a general practiontioner is required for specialized care. Nursers have to a limited right to prescribe pharmaceuticals, and midwives have a limited right to prescribe contraceptives. The first contact for old people can also be the municipal health care. Furthermore the first contact can be the child welfare centre, the antenatal clinic, and the school health service. A national telephone service with care advice is financed by the county councils.

7. Component : Comprehensiveness Scoring Country Indicator: Is a full range of primary care services 0= not comprehensive and procedures available for all age groups? (some services offered only in Rationale: Specific list of services includes: specialty care) 1= somewhat prevention, mental health, minor surgery, and (all offered but routine obstetric care. not in every primary care unit) 2= comprehensive (all offered in most locations)

Belarus In Belarus most of the essential basic health care services and procedures 1 are available for all age groups at the level of primary care. Immunization cover is very high 96% and effective. Minor surgery is done at the level of the policlinic in collaboration with the surgeon (specialist level) and routine obstetric care (except for the labour deliveries carried out in the hospital) is carried out in a team work with the midwifes. Denmark A full range of primary care services and procedures available for all age 2 groups. Estonia The main services provided by family doctors include diagnostic 1 procedures, treatment of general illnesses, health counselling, health promotion and disease prevention. However, patients are able to access the following specialists directly, without a family doctor’s referral: ophthalmologists, dermato-venereologists, gynaecologists, psychiatrists, dentists and, in case of trauma, traumatologists and surgeons. Finland The main work of health centre doctors is to provide office-based general 2 medical care to patients of all ages. They are also involved in maternal and child health care, occupational health care, family planning, inpatient care, home nursing (home visits by general practitioners are not very common; these are more often done by nurses), consultation at a municipal home for the elderly,etc. Germany Should be specified 0 Iceland Should be specified Latvia General practitioners provide general health care for children, adults and elderly people, and including outpatient surgical manipulations, rehabilitation, pregnancy care, perinatal care, and emergency care; they prescribe medications, ensure 24-hour availability, and also carry out preventive work (immunization) and health promotion. The range of services is determined in the Basic Care Programme, which includes care of acute and chronic diseases, preventive care, child and maternity care. Lithuania According to the job description of family physician it should be 1 guaranteed full range of services. Perfomance of family doctors in reality is limited (especially in preventive services, minor surgery, gynecologicl investigation) because of relatively low capitation fee. Norway A full range of primary care services and procedures is available for all 2 age groups Poland Should be specified Russian Should be specified Federation Sweden The primary care services include both basic curative care and preventive 1 services delivered through the local primary health care centres. In many cases, the general practitioner also provides the first health-service contact for children, although this function is shared with paediatricians and district nurses. Specifically female health problems are mostly covered by obstetricians, gynaecologists, district nurses or midwives.

8. Component : Coordination

Indicator: Are guidelines for the transfer of information between Scoring Country primary care and other levels available and required? 0= no Rationale: Data transfer (either through electronic means of through guidelines client-held records) is essential for coordinating care between levels. present 1= guidelines present but not widely used 2= guidelines present and required

Belarus There is a good transfer of information between the primary care and 2 specialist care in Belarus. Reports are required to be sent in to the primary care doctor in case of hospital admission or specialist’s consultation. After referral, general practitioners have no further influence on the 1 Denmark treatment and care of the patient, although hospitals or specialists are required to inform general practitioners when their patients are discharged. During the patient’s stay, general practitioners hand over responsibility to doctors employed by the hospital, although they are notified when a patient is discharged. Many hospitals are trying to improve relations with general practitioners by selecting a general practitioner to act as a contact person between the hospital and local general practitioners. Estonia Should be specified In Estonia after referral general practitioner as 1 physicians of other specialties and hospitals are required to inform each other by sending compendium of the case and medical record. All general practitioners use electronic patient records but some information is kept on paper record. Laboratory analysis results are sent to general practitioner in electronic way but integration of different systems and administrative systems is yet poor. Although separate health care providers have their own electronic medical record systems a standardized electronic health record system is under development coordinated by Ministry of Social Affairs. The transition from paper patient records to electronic applications is often not complete. Primary and secondary level health care are not always very well coordinated.

Finland Primary and secondary care are not always very well coordinated. Health 1 centres do not always get sufficient information about the treatment of patients after their referral to hospital. It has been suggested that one person, for example the personal doctor, should have a better overall view of patients when they are treated at different levels of the health system. The issue of continuity of care as well as the importance of the personal doctor have been raised in various national health policy documents. Continuity of care is also a central issue in the health care 2000 development project. Germany Should be specified 0 Iceland Electronic health record systems have been introduced to the Icelandic 2 health care system. All health care centres use the same software, and efforts have been made to harmonize electronic records in hospitals and health care centres. The main advantages of electronic health records are the increased possibilities for continuous treatment, easier access to information and speedier information mediation, increased data security, and more efficient use of funds, equipment and human resources. The collection, handling and mediation of information from various institutions must be standardized for electronic medical records to have an advantage over present methods. The Ministry of Health and Social Security has defined the standards that all electronic health records will have to meet. Latvia Cooperation between primary, secondary and tertiary health care 0 is inadequate. Lithuania Cooperation between family doctors and secondary health care specialists 1 is moderate Norway All GPs use electronic patient records (EPRs) today. Integration between 1 clinical systems, laboratory systems and administrative systems today is often poor. The transition from paper patient records to electronic applications is often not complete. The goal of the government strategy S@mspill 2007 (English name: Te@mwork 2007), is to expand the use of the National Health Network, and to include more participants in the network. The primary aim is for this strategy to contribute to improved teamwork between municipal health and social services, specialist health care and general practitioner services. Poland

Russian The links between primary and secondary care in polyclinics and 1 Federation hospitals were also problematic. Whereas the structure of the system was appropriate for the development of such links, in practice it did not occur. Ambulatory care was offered through the polyclinic, in isolation from the provision of inpatient care in hospitals. This meant that patients admitted from a polyclinic to a hospital and then discharged back to the outpatient clinic often experienced a lack of continuity of care. The varying criteria used by doctors in the different settings and the failure to communicate also allowed inappropriate referrals to take place, while poor coordination encouraged the duplication of services in both parts of the system. But, in the pilot projects efforts have been made to strengthen continuity of care; protocols have been introduced to improve the links between primary and secondary care. Sweden The referral process varies across the county councils: in some counties 1 the general practitioners have a “gatekeeping” role Normally, the general practitioner either makes an appointment for an appropriate caregiver for the patient, (i.e. with a specialist, a diagnostic centre, a laboratory or a hospital) or provides the patient with a referral letter so that he/she can make the appointment.

9. Component : Family-centered

Indicator: Is there a requirement that client Scoring Country records be organized by family as opposed to by 0= never required individual? 1= required Rationale: Indicator, that primary care considers for only some patient’s family environment in diagnosis and regions or populations treatment 2= generally required Belarus There is no general requirement to organize the patient’s records by 1 family. Moreover traditional splitting of the population care into separate facets as adult care and children care discourages family centredness of care. However for some categories of the patients (tuberculoses, infection diseases) there are special procedures developed to inform primary health care providers about the infection diseases in the family. High. Cildren assigned to the same general practitioner as adults 2 Denmark Estonia Shoud be specified In Estonia patients have a right to choose the same 1 family physician as their close relatives have. There isn't requirement for general practitioner to organize the patient’s records by family.

Finland Shoud be specified 0 Germany Shoud be specified 0 Iceland Shoud be specified Latvia Shoud be specified Lithuania Shoud be specified Norway Shoud be specified 2 Poland Shoud be specified Russian There isn’t a requirement that client records be organized by family as 0 Federation opposed to by individual Sweden Good list size includes family members 2

10. Component : Community-oriented 64

Indicator : Is there a policy that requires use of Scorin community-based data and/or presence of g community members in primary care management 0= never required of priority-setting? 1= required Rationale: Primary care is more effective when it for limited treats patients in their larger social context populati on only 2=gener ally required Belarus There is a on going practice in Belarus of the collecting and analysing of 2 the community-based data on the district level and in primary are in particular. There are no community members in primary care management or priority setting.

Denmark Should be specified 1 Estonia Should be specified The family physician in cooperation with family 1 nurse has a task to promote the health of all persons in the practice list and advise them on healthy lifestyle, activities and other issues to prevent diseases, injuries and bad influences on health. General practitioners participate in several short-term prevention projects. There isn't a policy that requires use of community-based data by general practitioner but there exist different policies to promote the health of community and whole population.

Finland Most health centres are now moving towards the principle of population 2 responsibility. In some municipalities the size of the population covered is so small that the principle of population responsibility already exists. At present, about 55% of the population receive primary care services according to the “population responsibility” principle, either by being covered by the scheme or by living in a small municipality with fewer than about 2500 inhabitants. Germany Should be specified Iceland Should be specified Latvia Should be specified Lithuania Should be specified Norway Should be specified Poland Should be specified Russian Should be specified Federation Sweden Preventive and population-oriented health care has 1 been integrated into primary health care. Special health education programs on tobacco, diet and/or alcohol are all functions generally carried out by general practitioners. General practitioners are also involved in providing some diagnostic services, in immunizing children and in paediatric surveillance. Some programmes, especially with regard to women’s health (cervical cancer and breast cancer screening), are usually organized by the county councils and are centrally planned. Midwives, district nurses and general practitioners provide family-planning services.

Northern Dimension Partnership in Public Health and Social Well-being

NDPHS Expert Group on Prison Health

Thematic Report

Women’s Health in Prison in the Northern Dimension Area

NDPHS Series No. 3/2008

Northern Dimension Partnership in Public Health and Social Well-being (NDPHS)

NDPHS thematic report: Women’s Health in Prison in the Northern Dimension Area

The views reflected in this paper are those of the members of the NDPHS Expert Group on Prison Health who have developed it and should not, therefore, be interpreted otherwise. If specific country data are not available in this report, this is because the authors were either unable to obtain it or did not receive permission to publish this data.

Editors: Ingrid Lycke Ellingsen, Elo Kocys and Maxi Nachtigall Pictures: Juerg Christandl, Amy Allock Maps: NDPHS, Nordic Council of Ministers

This paper may be freely reproduced and reprinted, provided that the source is cited.

It is also available on-line in the Papers’ section of the NDPHS Database at http://www.ndphs.org/?database,view,paper,19

View our website at www.ndphs.org and keep an eye on policy developments and explore the world of the NDPHS – a partnership committed to achieving tangible results!

Further information:

NDPHS Secretariat Strömsborg P.O. Box 2010 103 11 Stockholm, SWEDEN Phone (switchboard): +46 8 440 1920 Fax: +46 8 440 1944 E-mail: [email protected]

The paper arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Expert Group on Prison Health. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

1 CONTENTS

I. Executive Summary

1. INTRODUCTION………………………………………………………………………05 1.1 Women in Prison - a vulnerable group………………………………………….09 1.2 Background………………………………………………………………………...10 1.3 Gender Equality in Prison Health……………………………………………...... 10 1.4 Report guidelines………………………………………………………………….11 1.5 Expected outcomes…………………………………………………………….....13

2. LEGAL BACKGROUND...... 15 2.1 Legal background of health services in prisons………………………………..15 2.2 Regulations on women’s health in prison……………………………………....19 2.3 Regulations on work and education in prisons………………………………...23

3. WOMEN’S HEALTH IN PRISON IN THE NORTHERN DIMENSION AREA…..26 3.1 The prison health situation in the ND area………………….………………….26 3.2 Female prisoners in the ND area………………….………………………….....29 3.2.1 Age……………………………………………………………………....31 3.2.2 Organization of medical service within penitentiaries in the ND area…………….…………..……….………………………………32 3.2.3 In practice within the ND area: General Health...…..…………….…32 3.3 Main health problems encountered by women in ND area prisons ………....33 3.3.1 HIV/AIDS………………………………………………………………...34 3.3.2 HIV positive pregnant women in prison.……………………..………37 3.3.3 In practice within the ND area..……………………………………….38 3.4 Tuberculosis (TB)………………………………………………………………….41 3.4.1 In Practice within the ND area: TBC/ HIV...………………………….42

4. PREGNANT WOMEN AND MOTHERS IN PRISON……………………………….44 4.1 Pregnant women in custody……………………………………………………...45 4.1.1 Women in prison who are accompanied by their children ……………..47 4.1.2 In practice within the ND area...…………………………..……………….49 4.2 Women with children outside the prison – social well-being and prevention measures…………………………………………………………………………...53 4.2.1 In practice within the ND area..……………………………………….57 4.3 Criminal behaviour of youths………..………………………………………...... 58

5. SOCIAL REHABILITATION AND PRE-RELEASE TRAINING…………………...62 5.1 Background…………..…………………………………………………………….62 5.2 In practice within the ND area: Estonia – a case study...…………….…….....66 5.2.1 Individual Sentence Plan……………………………………………....66 5.2.2 Employment……………………………………………………………..67 5.2.3 Education in prison……………………………………………………..67 5.2.4 Rehabilitation Programmes…………………………………………....68 5.2.5 Preparation for release………………………………………………...70 5.2.6 Anger management…………………………………………………….71 5.3 VINN (WINNING) a good practice in social rehabilitation from Norway....….73 5.4 NGO’s involvement………………………………………………………………..75 5.4.1 In practice within the ND area..………………………………….……75 5.5 Alternative measures to prisons for non-violent offences:…………………….79 5.5.1 In practice within the ND the area...…………………………………..79

6. RECOMMENDATIONS………………………………………………………………...81

Appendix I List of references……………………………………………………………...84

Appendix II Questionnaire………………………………………………………………….95

Appendix III Index of Tables and Maps……………………………………………………98

3 I. EXECUTIVE SUMMARY

In the countries of the Northern Dimension (ND) area, the penal system presents a section of the society where major health problems are concentrated. For those who have to spend a shorter or longer time, or even a life-time, in prison, aspects of prevention and treatment for many complicated health problems become as crucial as the provision of rehabilitation and reintegration programmes for inmates, which are intended to help them ease back in society after their release. The spread of communicable diseases occurs predominantly between persons from marginalised groups who that live under harsh socio-economic circumstances, and consequently, many of which enter the penal system.

There are also obvious connections between social disparities, mental health problems, drug use, infectious diseases, crime and imprisonment. Thus, it is necessary to extend the scope of joint work concerning penal systems in the Northern Dimension area to cover not only communicable diseases but also prevention and the better treatment of psychiatric disorders, the treatment and rehabilitation of drug addicts, improved custodial conditions for inmates, training for prison staff and strengthened co-operation between the prison system and the civil and social services in general. Female prisoners, and among them, women who are pregnant or caring for small children, constitute an extremely vulnerable group within the prison population. Therefore, this Thematic Report will focus especially on challenges faced by this group.

Taking the health issues of women in prison into account, this Thematic Report developed by the Northern Dimension Partnership in Public Health and Social Well- being (NDPHS) Expert Group on Prison Health (PH EG) will examine how women’s health in prison is organized and whether health care and social well-being in prison is being adequately adjusted to women’s needs. It seeks to give recommendations to implement gender equality in the field of prison, including in the approach and assessment of prison health services.

CHAPTER 1

INTRODUCTION

Photo by Juerg Christandl

“It is a fundamental human right of everyone, including prisoners to the enjoyment of the highest attainable standard of physical and mental health. The state has a particular responsibility towards prisoners, as their loss of liberty means that the primary responsibility for their health then falls on the prison administration. Not only do prison authorities have a responsibility to provide medical care, they must also establish conditions which promote the well-being of prisoners and staff. Prisoners should not leave prison in a worse condition than when they entered.” (OHCHR 2006)

In the countries of the Northern Dimension (ND) area, as in all other countries, the penal system presents a section of the society where major health problems are concentrated. “The obvious purpose of a prison sentence is to punish the offender and to prevent her/ him from re-offending” (NDPHS Working Plan 2007-2008). However many former prisoners return to committing crimes after being released, creating a vicious circle of punishment and re-offence. For those who have to spend a shorter or longer time, or even a lifetime, in prison, aspects of prevention and treatment for many complicated health problems become as crucial as the provision of rehabilitation and reintegration programmes for inmates, which are intended to help them ease back into society after their release. The spread of communicable diseases occurs predominantly between persons from marginalised groups who live under harsh socio-economic circumstances, and consequently, many of which enter the penal system. There are also obvious connections between social disparities, mental health problems, drug use, infectious diseases, crime and imprisonment. Thus, it is necessary to extend the scope of joint work concerning penal systems in the Northern Dimension area to cover not only communicable diseases but also the prevention and better treatment of psychiatric disorders, the treatment and rehabilitation of drug addicts, improved custodial conditions for inmates, the training of prison staff, as well as the strengthened co-operation between the prison system and the civil and social services.

“With an ever increasing inmate population, prisoners are typically classified by security level or medical and psychiatric needs. Gender is another key category” (Desrosier & Senter 2007:7). Nearly all international instruments relating to the rules and standards of imprisonment (see chapter 2) refer to female prisoners as a minority group whose special needs are to a large degree ignored by all states, and accordingly, also by the states within the Northern Dimension area. Therefore, the issue of gender equality also needs to be raised in terms of female imprisonment, in order to fight gender discrimination within prison regimes. There is also a need to make positive adjustments to conditions for women detainees in terms of staff, accommodation, education and training, and last but not least, in terms of health.

In general, people who are in prison need a high level of health and social care (Hayton 2007, 18-19). Women are a minority in prisons but they are one of the most vulnerable groups when it comes to health issues and healthcare settings. As males comprise the majority within the prison population, women’s special needs are often neglected. Their rights as prisoners are for the most part ignored or badly implemented. But many health and social issues relating to imprisoned women could be solved by properly implementing rights and regulations that already exist (Kurtén-Vartio 2007).

The majority of the women in prison are first time offenders and many of them are never sentenced, but are rather kept on remand for a short period of time. Furthermore, most of female detainees are not accused for violent offences but mainly for the non-payment of fines, theft, prostitution and drug-related offences.1

Women are mainly accused of crimes leading to convictions that are short in duration or only kept in pre-trial detention for a limited amount of time. As a consequence, they might often be suddenly and unexpectedly released. Therefore, they cannot profit from any health or social rehabilitation programmes, as those programmes are mainly created for prisoners whose prison sentences are longer than one year. Meanwhile, a considerably higher number of women than men in custody have substance abuse problems, which will require long-term treatment.

The Quaker Council of European Affairs states that: “Unlike most male prisoners women do not have someone on the outside holding onto the family home and possessions and caring for their children. Women suffer disproportionately from being held far from their families and being separated from their children, receiving fewer visitors than men. Women are often lone-carers and we are concerned about what happens to children and elderly relatives in need of care. We notice the poverty in most prisoners’ families and that poverty usually increase with imprisonment” (http://www.quaker.org/qcea/prison/index.html). Many babies and children are separated from their mothers due to the imprisonment of the mother. The United Nations Office on Drugs and Crime (UNODC) estimates that around 100, 000 women are detained in prisons across Europe: “The Howard League for Penal reform, a non-governmental organisation estimated that around 10,000 babies and children aged under two are affected by the this situation (UNODC 2007a:14)”.

1 Anti-social behaviour among females that often leads to minor, non-violent crime is typically the result of past trauma, such as physical and emotional abuse, poverty, and childhood brutality, neglect or victimization. Therefore, it should be recommended that every woman who is entering prison for the first time receive a social background screening.

“Due to their small numbers women often have less access to services than men. Their security regimes are often disproportionately harsher than men’s because there are not enough women to make up separate blocks. Women’s health care needs such as antenatal care are often overlooked, as are their needs to combat drug-addiction and treat mental health problems. Female prisoners have a higher rate of mental illness and are more likely to have been victims of physical and sexual abuse than the general population. Women have high rates of suicide and self-harm in prison” (http://www.quaker.org/qcea/prison/index.html). An exceptionally vulnerable group in prisons includes pregnant detainees and female detainees who are accompanied by their children.

Women who are detained in prison over long periods of time will have a greater demand for health services. Their medical problems are more complex and the fact that females have particular health issues should also be taken into account. Imprisoned women place heavy demands on staff, requiring frequent and at least regular meetings with doctors/nurses. Still, female detainees cannot be characterised on the whole as being sicker than male prisoners are. Having access to regular professional healthcare, females utilise this resource more frequently than their male counterparts. Additionally, women are sometimes looking for health treatment and social care programmes in order to keep or regain the custody of their child/ children, or their right to visit their child and extended family. Women who are sentenced to prison have in many cases neglected their own health in the past, and thus, their general health conditions are often very poor. Prison might be the only place – and imprisonment the only occasion – in which these particular women are encouraged to accept health examinations and given treatment. Consequently, “prisons can contribute to the health of the communities by helping to improve the health of some of the most disadvantaged people in society” (Fraser 2007:25).

Prison is a microcosm of society in general. It houses however an aggregation of vulnerable individuals most of whom have rather traumatic backgrounds. This is especially the case for females in prison. Compared to male detainees, female inmates are three times more likely to have a history of personal trauma. In this respect, corrective treatment programs should target previous traumatic experiences, including physical, emotional and sexual abuse during both childhood and adult years. Studies have also shown that different forms of abuse early in life lead to self-harming behaviours and/or suicide later in life.

Studies e.g. by the Canadian NGO “Voices for children”2 and the international study on women’s imprisonment by the University of Greifswald (Duenckel at. al. 2005) show that most imprisoned women are coming from broken families or grew up in non-traditional settings such as in orphanages. They subsequently experienced difficulty in leading

2 Unlike men, the criminal behaviours of women are typically understood to be part of an overall coping strategy that often have their roots in childhood abuse or neglect, followed by leaving home early, dropping out of school, and substance abuse (as a coping mechanism). Perhaps as a direct consequence, women who are violating laws typically lead lives characterized by poverty, inadequate housing, abusive or exploitative partners, and general instability. Many women in prison left school before graduating, had their first child as a teenager, and have a history of unemployment. They may have few specialized job skills and rely on welfare, low-paying jobs, or criminal sources of income. Even compared to men in prison, women have high rates of serious drug addiction and women with mental health crises can find themselves in prison rather than in more appropriate residential placement. http://www.voicesforchildren.ca/.

7 normal, healthy lives, securing employment, finding a permanent place to live, and building up healthy social networks. It is therefore not difficult to understand why many female prisoners suffer from anxiety, depression, bipolar- and eating disorders, and self- mutilation. Being in custody may cause further stress and generate psychological trauma, especially when women are separated from their partners, children and families. Health care for women in prison must also take into account the negative effects that imprisonment has on any detained individuals. Women, as compared to men, are more prone to self-inflicted harm (also repeatedly).

The withdraw that drug-addicts experience when suddenly brought into custody can lead to acts of self-harm, impulsive, volatile and unpredictable behaviours. Many women face mental health problems, which are often re-enforced by drug dependency.3 An effective treatment for this kind of problem must therefore be a multi-disciplinary, involving psychiatrists, psychologists, social workers and counsellors. This kind of approach “should also include expertise from other non-prison based or community-based organisations with skills and expertise in these areas. This would provide a high level of ongoing support during and after a woman leaves the prison. In particular, groups with expertise in assisting and supporting women who have experienced sexual assault need to be a part of the team” (Anti Discrimination Commission 2006:89). Many of imprisoned women are non-violent offenders and do not pose a threat to society. They are mainly only a threat to themselves. For the most part, they do not need imprisonment, but rather adequate treatment for their drug and alcohol additions, trauma recovery, education, healthcare, parenting skills and simply better living conditions.4

Special attention must be paid to females’ gynaecological issues, including pre- or postnatal care as well as such care to women with small children. The tasks of prison health staff cannot be limited to treating sick patients only. They must also supervise hygiene conditions (especially for female needs) for catering arrangements; ensure healthy nutrition and diet, and the general living environment in prison.

Taking health issues for women in prison into account, this Thematic Report developed by the NDPHS Expert Group on Prison Health will look at how women’s health in prison is organized and whether healthcare and social well-being in prison is being adequately adjusted to women’s needs. It seeks to offer recommendations to implement gender equality in the field of prison health, including in the approach and assessment of prison health services. Human rights and basic decency should serve as the basis for the

3 The WHO publication “Health in Prison. A WHO Guide for the Essentials in Prison Health describes the typical female drug user arriving in prison as being between the ages of 17-30 and having been detained for 7-10 days. These female detainees are often heroin or methadone users, while crack, cocaine, cannabis, alcohol and cigarettes are also abused. These women have a history of drug addiction usually for up to nine years or even longer. Most intravenous drug users are hepatitis C positive, suffer from deep vein thrombosis, abscesses or sexually transmitted infections. They face a lack of information about these diseases. Their partners are mostly also imprisoned;, and their children, if they have any, are placed in extended family care or external care. Many of these women have been subject to a vicious circle of drug addiction and withdrawal, also substituting alcohol or cigarettes for drugs, leading to additional health problems. 4 Some women may have had the possibility to enter into a treatment programme but could not remain in such a programme due to the fact that they are often the only caretakers for one or more children, face inadequate social support systems, and lack the financial resources needed to complete treatment. The judicial system must take these complex issues into account when deciding on the appropriate length of sentences for women. (Anti Discrimination Commission Queensland 2006).

8 promotion of health, because they emphasise all aspects of prison life, especially for vulnerable groups.

1.1 Women in prison - a vulnerable group

As already emphasised, women constitute one of the most vulnerable groups when it comes to health issues and healthcare frameworks:

• There is however a lack of data and information regarding issues on women in prison in general, particularly in health. • Women have often been exposed to additional negative experiences such as mobbing, trafficking, prostitution or abuse. • There are few all-female prisons, which means that women have more challenges to face than men do while in prison. For example, they are often detained far away from their homes and suffer a loss of family ties. They can be victim of social exclusion, unsuitable security classifications, and at risk for cohabitation with male inmates. • There are several minority groups within female prison groups such as juveniles, ethnic minorities, and elderly women, each whose needs are difficult to address. • Women’s healthcare and requirements for social well-being differ from those of men. • Women are at higher risk for self-inflicted harm and suicide.

“Principle 5 (2) of the Body of Principles emphasises in particular that: “Measures applied under the law and designed solely to protect the rights and special status of women, especially pregnant women and nursing mothers, children and juveniles, aged, sick or handicapped persons shall not be deemed to be discriminatory. The need for, and the application of, such measures shall always be subject to review by a judicial or other authority” (Penal Reform International 2001: 94).

On the one hand, the issue of female imprisonment cannot be seen as a highly public issue as imprisonment in general is not broadly discussed in public either. Imprisonment seems to be a sensitive matter for the national authorities in every country. Being active in prison issues or working within the prison regime tends to have a low reputation in the public’s view. One indicator for the rather low relevance of imprisonment in public in general, and of female imprisonment in particular, is the availability of and accessibility to quantitative and qualitative data on issues. But there are differences. Qualitative studies, including field studies and interviews with staff and prisoners are much easier to find than disaggregated statistics on women imprisonment in a certain year or a certain region. On the other hand, it is a strong conviction in the NDPHS Expert Group on Prison Health that the issue of female imprisonment is highly overlooked, mainly in terms of health and social well-being. Far more research should be conducted and published on the living conditions of women in prison in general and their health and social-well being status in particular.

Taking the special situation of women in prison into account, the PH EG is focusing particularly on how prison health for women is organized and how health care in prison is adequately adjusted to women’s needs. As it is important to focus on diseases that affect both genders, there is also a common need to find differences, as to why, for

9 example, certain diseases/problems are more prevalent among women. In order to achieve gender equality among inmates, a comprehensive approach is needed towards prison reform, including the prioritisation of implementing basic human rights. This Thematic Report on women’s health in prison seeks to give recommendations for the implementation of gender equality in the approach to prison health and the assessment of prison health services.

1.2 Background

The Expert Group on Prison Health consists of high-level experts composed by a variety of individuals who are representing different fields of the penal system such as doctors, jurists, social workers and individuals with practical knowledge of working in prisons. They all have considerable experience in working on issues involving communicable diseases and epidemiology, drug abuse and mental disorders.

The PH EG’s overall objective is to promote sustainable development within the penal systems of the Northern Dimension area through improving health and social well-being (NDPHS PH EG 2004). Furthermore, the PH EG aims to:

• Raise awareness and foster commitment from the public regarding health in prisons, in particular for most vulnerable groups such as women, young people, and children. • Work towards the development of positive attitudes towards issues related to health in prison. • Promote networking and partnership-building among relevant stakeholders. • Support coordinated and collaborative efforts to further prison reforms and the development of national policies. • Work towards improving health in prisons in the Northern Dimension area and communicating collective knowledge in the field. • Propose topics and issues for new projects on prison health.

Understanding that good prison health is also good primary health, the Expert Group promotes the standards and rules for good primary health care in prisons and takes this as the foundation of all prison health services.

1.3 Gender Equality in Prison Health

Female prisoners are a minority but a non-deniable group in all national prison regimes. This requires equal opportunities and females’ equal access to social, economic and cultural rights. Up until today, female prisoners have been at a disadvantage in obtaining information about their rights as prisoners, gaining access to vocational and educational training, and adequate health care in prisons. A comprehensive approach to prison is needed that includes elements of implementing of the following basic human rights:

1. Social rights; 2. Economic rights; 3. Cultural rights.

10 “As prison sentences have been designed for men and by men, women are always an exception. It is a challenge to find special solutions to meet the needs of imprisoned women” (Sonja Kurten-Vartio, 2007). Women in prison settings are considered to be more difficult to deal with than men. Women face more severe moral punishment from society than male prisoners do, meaning that their sense of punishment does not necessarily end after they are released. Instead, their sense of punishment often continues in form of social isolation as well in private and occupational areas of life. On the other hand, searching for health care and social treatment when in prison can be highly valued among inmates. Drug rehabilitation might be an ideal first step in changing detainees’ lives and to give women a perspective for their future outside the prison.

Gender is more than a determinant of health that stands alone, but rather it cuts across all other determinants, namely income and social status, employment, education, social environment, physical environment, healthy child development, personal health practices and culture. The interaction aspects of gender and health can be seen in such factors as poverty, violence, sexually transmitted diseases, mental health, substance abuse, nutrition, health care delivery and reproductive health. Keeping this in mind, the Thematic Report will be based on the notion of gender equality, the process of treating both women and men fairly. “To ensure fairness, measures must be available to compensate for historical and social disadvantages that prevent women and men from otherwise operating on a ‘level playing field’” (Medical Women’s International Organisation 2002:11).5 Gender equality also means that health needs, which are specific to each gender, receive appropriate resources (e.g. reproductive health needs): “Research on women’s pathway into crime clearly suggests that gender matters in the forces that propel women into criminal behaviour and therefore, gender must be taken into account” (Charon Schwartz 2001).

1.4 Report guidelines

During their 3rd Expert Group meeting in Paris in June 2007 and the 5th EG Chairs and ITAs meeting in Vilnius in 2007, the PH EG agreed on the publication of a Thematic Report on women’s health in prison. The topic is also of relevance to a planned conference on women’s health in prison, organized by the World Health Organization (WHO) Europe “Health in Prison Project” (HIPP) in 2008 and a planned publication by WHO on women’s health in prison.

This Thematic Report focuses on the unique situation of women in prisons within in the Northern Dimension area of Europe. It will give a general overview on these women’s situations and will in detail analyse some of their health issues in prison, as “women prisoners physical, mental and emotional needs differ from those of men. Women can have different needs relating to problems such as substance addiction, mental health, anger management and a history of different kinds of abuse” (QCEA 2007:5). This report will pay particular attention to women as a vulnerable and “forgotten” group in prison.

Healthcare in prison must be based upon comprehensive primary healthcare, as “good prison health is good public health” (WHO Europe 2007:2). Therefore this report

5 An example of gender inequality is when inmates whose sentences are longer than one year are eligible substance detoxification. This policy is discriminatory towards women as most of the female offenders in need of treatment are generally serving shorter sentences in prison than men.

11 researches the question of how to provide meaningful primary health care for women in prisons. Primary health care is the foundation of prison health services as it is the “most effective and efficient element of health care in any public health system” (WHO Almaty Declaration 1978). It should be characterised by a balance of disease prevention and health promotion.

As stated by the WHO in its publication “A guide for essentials in prison health” (WHO Europe 2007:26), prison health care services must be able to address four major priorities:

1. Primary care; 2. Mental health; 3. Infections, Tuberculosis (TB), blood borne viruses, including HIV and skin conditions; 4. Dependence, especially on alcohol and drugs.

This Thematic Report framework is based on the following documents:

1. NDPHS PH EG Terms of Reference; 2. Moscow Declaration on Prison Health as a Part of Public Health (WHO Regional Office, 2003); 3. European Prison Rules, revised 2006 by the Committee of Ministers of the Council of Europe (EPR); 4. Standard Minimum Rules for Treatment of Prisoners; 5. Other general international regulations on Prison Health/ Recommendations of relevance; 6. Health in prisons, A WHO guide to the essentials in prison health, 2007; 7. Recommendations of the World conference on women Beijing report 1995; 8. NDPHS founding document, the Oslo Declaration concerning the establishment of a Northern Dimension Partnership in Public Health and Social Well-being.

These documents refer to the obligations of prison authorities to safeguard the health of all prisoners and the “need for prison medical services to be organized in close relationship with the general public health administration” (Coyle 2007:11).

Furthermore, the report will enforce aspects of gender equality within the area of prison health.6 As stated in the WHO Gender policy 2002, “In health, gender analysis contributes to the understanding of differentials between women and men in, for example, risk factors and exposures; manifestations, frequency and severity of disease and social responses to it; access to resources to protect health; and distribution of power and responsibilities in health care.” An underlying theme within the report is a gender approach seeking to deal with the distinct health characteristics of female detainees.

6 Mainstreaming gender is "...the process of assessing the implications for women and men of any planned action, including legislation, policies or programmes, in any area and at all levels. It is a strategy for making women's as well as men's concerns and experiences an integral dimension in the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and social spheres, such that inequality between men and women is not perpetuated. The ultimate goal is to achieve gender equality” (WHO Gender Policy 2002).

12 Accordingly to the Expert Group’s Action plan for 2008, this Thematic Report can form a basis for: • Supporting initiatives for reorienting prison systems to improve the implementation and status of health care; • Revealing gaps in research and action regarding prison health, as well as proposing topics and issues for new project proposals in the field; • Formulating criteria for future support for projects in the field of prison health (this should include the application of a Logical Framework Approach (LFA)); • Increasing the work and visibility of the NDPHS partnership and providing expert input to the preparation and implementation of joint activities carried out within the Partnership framework.

Furthermore, the report has five major objectives. It seeks to:

1. Generate interest from the public in the issue of women in prison; 2. Encourage national authorities, NGOs and national and international organisations to develop projects, and programmes to get involved and active in women’s health in prison; 3. Prompt donor organisations to fund and implement projects in this field; 4. Contribute to the NDPHS database project; 5. Provide a guideline of gender equal treatment in prison health.

Regarding its mandate, the PH EG will research and compile good practice models from prisons across the Northern Dimension Area, addressing the major challenges of women in prison. The report will compile information on policies, projects and programmes as well as recent and ongoing reforms within the prison health area.

This Thematic Report includes results from the PH EG questionnaire, developed by the Editorial Expert Group and disseminated and responded to by some of the members of the Expert Group on Prison Health of each NDPHS member country. As another item, the report gives an overview of the major national and international regulations and written standards concerning prison health in general and women’s health in particular.

The compilation of the report was undertaken by desktop research and the study of publications available on the Internet, from libraries and in archives. Additional input was given by all members of the Expert Group based on their experiences working with women in prison and/or their own studies.

1.5 Expected outcomes

The major outcome of the EG Prison Health Thematic Report will be an outline of the status and recommendations regarding improvement of health and social well-being of women in prison. It will provide good practice models and measurements of good health care for women in prison in the Northern Dimension area. It might serve as a guideline to be of use for authorities and decision-makers in the field of prison health, especially concerning women’s health in prisons. The recommendations should also be used to define core working areas regarding the implementation of the PH EG’s own Work Plan for 2008 and the overall NDPHS Working Plan for 2008 and to identify new project and research areas.

The Thematic Report will be distributed to major stakeholders, decision-makers and members of the NDPHS. It will also be made available to the public on the NDPHS website and broadly disseminated via other NDPHS communication tools.

Chapter 2

LEGAL BACKGROUND

Photo by Amy Allock

2.1 Legal background of health services in prison

The majority of penal institutions resemble organised medical services. The structure, organisation and content vary from country to country as well as what authorities are in charge of the prison medical services. In some countries services are placed under the authority of the Minister of Justice, while in other countries they are under the Minister of Health and Social Affairs. As a third option, there can be joint responsibility over health care in prison. Irrespective of which authorities are responsible for prison health services, they should, if possible, follow the recommendations and guidelines that have been agreed to in principle within international foray.

Such recommendations could include the Moscow Declaration, which was adopted at the joint World Health Organisation/Russian Federation International Meeting on Prison Health and Public Health in October 2003. This Declaration recommends that:

“Member governments [should] develop close working links between the Ministry of Health and the ministry responsible for the penitentiary system so as to ensure high standards of treatment for detainees, protection for personnel, joint training of professionals in modern standards of disease control, high levels of

15 professionalism amongst penitentiary medical personnel, continuity of treatment between the penitentiary and outside society, and unification of statistics.

Member governments are recommended to ensure that all necessary health care for those deprived of their liberty is provided to everyone free of charge.”

Several principal treaties, guidelines and recommendations govern the organisation and content of the prison medical services. An in-depth presentation and overview are to be found in WHO Health in prisons. A WHO guide to the essentials in prison health, which was published in the autumn of 2007. Several prominent authors contributed and the publication offers an almost complete description of different aspects of prison health care. In addition, several chapters contain practical information and advice on how to promote good health in prisons.

This Thematic Report will refrain from re-iterating too many of the facts that have already been discussed in the above mentioned document, however it will concentrate on some important aspects concerning the provision of health care for imprisoned women.

At the outset, some key points which have been expressed by Professor Andrew Coyle in the WHO guidelines: chapter 2, Standards in prison health: the prisoner as a patient should be emphasized:

• People who are in prison have the same right to health care as everyone else; • Prison administrations have a responsibility to ensure that prisoners receive proper health care and that prison conditions promote the well-being of both prisoners and prison staff; • Health care staff must deal with prisoners primarily as patients and not prisoners. • Health care staff must have the same professional independence as their professional colleagues who work in the community; • Health policy in prisons should be integrated into national health policy, and the administration of public health should be closely linked to the health services administered in prisons (this applies to all health matters but is particularly important for communicable diseases).

Documents of particular relevance to prison health care services are The Standard Minimum Rules for the Treatment of Prisoners and the revised version of the European Prison Rules. The latter was adopted in 2006 and contains an elaborated section on prison health care, including information on organisational aspects, medical health care personnel, the duties of medical practitioners, mental health and other matters (Rules 39 – 48):

• Rule 39 states that the authorities’ duty “to provide adequate prison medical services.” Further, that “Prison authorities shall safeguard the health of all prisoners in their care.” • Rule 40.1 states that “Medical services in prison shall be organised in close relation with the general health administration of the community or nation.”

This is consistent with the accepted principle of the Equivalence of care.

16 The Quaker Council for European Affairs – Women in prison project – has in its document The European Prison Rules: A Gender Critique proposed additions to some of the rules. 7

The European Prison Rules address of course both genders; however a few rules that are of special interest for the medical treatment of women are cited as follows:

• Rule 40.5 states that “All necessary medical, surgical and psychiatric services including those available in the community shall be provided to the prisoner for that purpose.” 8

• Rule 41 states that “Every prison shall have the services of at least one qualified general medical practitioner”9

The Council of Europe’s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (The CPT) gives in the Committees 3rd General report (CPT/Inf (93) 12) several recommendations of importance for prison medical services. These recommendations are also published in The CPT standards (www.cpt.coe.int).

The CPT points to the fact that “a well-functioning prison health care service can play an important role in combating the infliction of ill-treatment and make a positive impact on the quality of life in the prisons within it operates. On the other hand can an inadequate level of health care rapidly lead to situations falling within the scope of the term “inhuman and degrading treatment.”

The CPT emphasizes several points that are valid for administrating a well-functioning health care service in prisons:

• Access to a doctor • Equivalence of care • Patient’s consent and confidentiality • Preventive health care • Humanitarian assistance • Professional independence • Professional competence

7 Rule 40: “Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation” and “Prisoners shall have the same choice of health care as the general population.” 8 The Quaker Council proposes an addition to this Rule: “All substance abusers shall have access to a rehabilitation programme. Psychiatric services and drug rehabilitation services should be gender-sensitive, e.g. offering women-only therapy groups.” They also propose a new rule, namely: “Prisoners should have adequate access to information regarding their health and health care choices, particularly surrounding addiction and sexual health; female prisoners should have access to information surrounding women’s health issues.” 9 The Quaker Council proposes that Rule 41.1 has the additional wording: “Such a practitioner should have knowledge of women’s physical and health, eating disorders and the psychiatric implications of abuse and domestic violence when employed in prisons where female prisoners are held. General practitioners should understand these implications if they transfer from a male prison to a female or mixed prison.” This is further to Rule 41.5 that “Women prisoners should have the option to see a female doctor on request; they should not have to give reasons for such a request.”

In the section “Humanitarian assistance”, the CPT mentions certain specific categories of particularly vulnerable prisoners, among them mothers and children. The Committee is of the opinion that special attention should be paid to the needs of these vulnerable groups.

The CPT also recommends several measures concerning ante natal and post natal care which needs to be in place in order to provide satisfactory services to pregnant women and those who are accompanied by their newborn children (published in the 10th General report (CPT/Inf (2000) 13)).

It is important to emphasise once again that prisoners are entitled to the same level of medical care as persons living in the community at large, as this is an inherent, fundamental right of individuals. The CPT has frequently received complaints that states cannot provide adequate health care for prisoners because of a shortage of resources. The Committee however has stressed that even in times of economic difficulty the state governments have obligations to prisoners:

“The CPT is aware that in periods of economic difficulties […] sacrifices have to be made, including in penitentiary establishments. However, regardless of the difficulties faced at any given time, the act of depriving a person of his liberty always entails a duty of care that calls for effective methods of prevention, screening, and treatment. Compliance with this duty by public authorities is all the more important when it s a question of care required to treat life-threatening diseases.”

This Thematic Report does not cover all health issues connected to women in prison but focuses especially on:

• Pregnant women and women accompanied by their children. • Matters of social rehabilitation and training.

The following section in this chapter will present some general regulations and recommendations regarding the major topics addressed in this Thematic Report. Regardless gender issues, it should be kept in mind that a number of principles should be kept in place, which women can rely on when requesting health and social care in prison.

One such principle includes Principle 1 of the United Nations Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment: “Health personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as it is afforded to those who are not imprisoned or detained.”

2.2 Regulations on women’s health in prisons

This Thematic Report is based on major national and international instruments and guidelines, which regulate the conditions for women and infants in prison. The report therefore mentions legislation, regulations and recommendations, which particularly address the health of these vulnerable groups in prison:

• The European Convention on Human Rights; • The United Nations Convention on the Rights of the Child; • The United Nations Convention on the Elimination of All forms of Discrimination Against Women; • The United Nations Body of Principles for the Protection of All Persons Under Any Form of Detention or Imprisonment; • The International Covenant on Civil and Political Rights; • The Standard Minimum Rules for the Treatment of Prisoners; • The European Prison Rules, revised version (2006); • Recommendation 1469 (2000) on Mothers and Babies in Prison, adopted by the Council of Europe’s Parliamentary Assembly; • The Council of Europe’s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment – The CPT standards.

Even if the conventions and treaties – for instance the UN Conventions and the European Prison rules – are not legally binding in the signatory states, they have to be treated as important recommendations. However, the Standard Minimum rules and the European Prison rules codify the legal and appropriate implementation measures in national prison regimes, in addition to national rules and regulations. They are especially important to countries in which these regulations are not yet in place, or are pending implementation. The international study on imprisonment of women by Frider Duenckel therefore questions the use of these international standards in the face of heterogeneous prison regimes and legal systems in different countries. On the other hand, his study points out that in spite of socio-cultural and socio-economic disparities, the general conditions and challenges faced by female prisoners are similar: “They are merely a small minority of the total prisoner population that the prison system is not geared up for. Against this background internationally accepted minimum standards are important – even when they are not legally binding by international law, they can develop moral authority, and can be used in international collaboration as a common basis for legal reforms and for further training programmes, etc” (Duenckel, 2005:9).

The following documents outline rules, regulations and recommendations for pregnant and child-bearing women, as well as for women in detention who are accompanied by their children:

a. The Convention on the Rights of the Child (1989) is a universally agreed set of non-negotiable standards and obligations. The Convention sets out the children’s rights in 54 articles and two Optional Protocols. The Convention is child-centric and deals with the children’s specific needs and rights.

19 • Article 2.2: “States Parties shall take all appropriate measures to ensure that the child is protected against all forms of discrimination or punishment on the basis of the status…of the child’s parents…”

• Article 3.1: “In all actions concerning children, whether undertaken by public or private social welfare institutions, court of law, administrative authorities or legislative bodies, the best interest of the child shall be a primary consideration.”

• Article 9.1 and 4: “States Parties shall ensure that a child shall not be separated from his or her parents against their will, except when competent authorities subject to judicial review determine, in accordance with applicable law and procedures, that such separation is necessary for the best interests of the child…Where such separation results from any action initiated by a State Party, such as the detention, imprisonment…of one or both parents or of the child, stat State Party shall, upon request, provide the parents, the child or, if appropriate, another member of the family with the essential information concerning the whereabouts of the absent member(s) of the family unless the provision of the information would be detrimental to the well-being of the child…”

• Article 16: “No child shall be subjected to arbitrary or unlawful interference with his or her privacy, family, home or correspondence…”

• Article 18.1: “States Parties shall use their best efforts to ensure recognition of the principle that both parents have common responsibilities for the upbringing and development of the child. Parents or, as the case may be, legal guardians, have the primary responsibility for the upbringing and development of the child The best interest of the child will be their basic concern.”

b. The United Nations Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment.

• Principle 19: “A detained or imprisoned person shall have the right to be visited by and to correspond with, in particular, members of his family and shall be given adequate opportunity to communicate with the outside world, subject to reasonable conditions and restrictions as specified by law or lawful regulations.”

c. The European Convention on Human Rights

• Article 8, Right to respect for private and family life: “Everyone has the right to respect for his private and family life, his home and his correspondence.

The convention recommends that “there shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interest of national security, public safety or the

20 economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.”

d. The Standard Minimum Rules for the Treatment of Prisoners

• Article 23.1 and 2: “In women’s institutions there shall be special accommodation for all necessary pre-natal and post-natal care and treatment. Arrangements shall be made wherever practicable for children to be born in a hospital outside the institution. If a child is born in prison, this fact shall not be mentioned in the birth certificate.”

The Standard minimum rules further recommend that: “where nursing infants are allowed to remain in the institution with their mothers, provision shall be made for a nursery staffed by qualified persons, where the infants shall be placed when they are not in the care of their mothers.”

The European Prison Rules from 1987 were recently revised (2006). Of special relevance to this Thematic Report are a new section on women and a section on infants.

a. Rule 34: “In addition to the specific provisions in these rules dealing with women prisoners, the authorities shall pay particular attention to the requirement of women such as their physical, vocational, social and psychological needs when making decisions that affect any aspect of their detention.

b. Particular efforts shall be made to give access to special services for women prisoners who have needs as referred to in Rule 25.4 (Particular attention shall be paid to the needs of prisoners who have experienced physical, mental or sexual abuse).

c. Prisoners shall be allowed to give birth outside prison, but where a child is born in prison the authorities shall provide all necessary support and facilities.”

d. Rule 36: “Infants may stay in prison with a parent only when it is in the best interest of the infants concerned. They shall not be treated as prisoners.

e. Where such infants are allowed to stay in prison with a parent special provision shall be made for a nursery, staffed by qualified persons, where the infants shall be placed when the parent is involved in activities where the infant cannot be present.

f. Special accommodation shall be set aside to protect the welfare of such infants.”

21 e. The Parliamentary Assembly made in 2000 the following comments and recommendations about Mothers and Babies in Prison:

“Experts agree that early maternal separation causes long-term difficulties, including impairment of attachments to others, emotional maladjustment and personality disorders. It is also recognised that the development of young babies is retarded by restricted access to varied stimuli in closed prisons.

In view of the adverse effects of imprisonment of mothers on babies the Assembly recommends that the Committee of Ministers invite member states:

i. to develop and use community-based penalties for mothers of young children and to avoid the use of prison custody; ii. to develop education programmes for criminal justice professionals on the issue of mothers and young children, using the United Nations Convention on the Rights of the Child and the European Convention on Human Rights; iii. to recognise that custody for pregnant women and mothers of young children should only ever be used as a last resort for those women convicted of the most serious offences and who represent a danger to the community; iv. to develop small scale secure and semi-secure units with social services support for the small number of mothers who do require such custody, where children can be cared for in a child-friendly environment and where the best interests of the child will be paramount, whilst guaranteeing public security; v. to ensure that fathers have more flexible visiting rights so that the child may spend a little time with its parents; vi. to ensure that staff have appropriate training in child care; vii. to develop appropriate guidelines for courts whereby they would only consider custodial sentences for pregnant women and nursing mothers when the offence was serious and violent and the woman represented a continuing danger; viii. to report back on the progress made by the year 2005.” f. The CPT states in its 10th General Report (2000) about Women deprived of their liberty:

“It is axiomatic that babies should not be born in prison, and the usual practice in Council of Europe member States seems to be, at an appropriate moment, to transfer pregnant women prisoners to outside hospitals.

Many women in prison are primary carers for children or others, whose welfare may be adversely affected by their imprisonment (cf. also Recommendation 1469 (2000) of the Parliamentary Assembly of the Council of Europe on the subject of mothers and babies in prison).

22 In the view of the CPT, the governing principle in all cases must be the welfare of the child. This implies in particular that any ante and post-natal care provided in custody should be equivalent to that available in the outside community. Where babies and young children are held in custodial settings, their treatment should be supervised by specialists in the areas of social work and child development. The goal should be to produce a child-centred environment, free from the visible trappings of incarceration, such as uniforms and jangling keys.”

The second major set of issues addressed in this Thematic Report concerns work, social rehabilitation and pre-release training in prisons, especially for female prisoners. National and international documents and guidelines set rules in place and offer recommendations that are meant to impact the standards enjoyed by men as well as women. However, insofar as such rules and regulations pertain to women, they are often ignored by prison authorities and not properly implemented within prison regimes.

2.3 Regulations on work and education in prisons

Several principal treaties, guidelines and recommendations point to the fact that prison authorities shall provide all prisoners with work and education. The following documents are of special relevance to this issue:

• The European Prison Rules – revised version 2006; • Recommendation Rec(2006)2 of the Committee of Ministers to member states on the European Prison Rules concerning work and education in prisons; • Recommendation by the Quaker Council of European Affairs. The European Prison Rules. A Gender Critique (2006); • The Standard Minimum Rules for the Treatment of Prisoners; • The Council of Europe’s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment – The CPT standards; • A Human Rights Approach to Prison Management – Handbook for prison staff. Andrew Coyle, International Centre for Prison Studies 2002. a. The European Prison Rules – revised version 2006.

Several articles in this document particularly deal with work and education. The following articles are of special importance: • “Prison work shall be approached as a positive element of the prison regime • Prison authorities shall strive to provide sufficient work of a useful nature […] • As far as possible, the work provided shall be such as will maintain or increase prisoners’ ability to earn a living after release […] • […] there shall be no discrimination on the basis of gender in the type of work provided.” 10

10 The Quaker Council of European Affairs wants the addition of: “Whilst taking into account the physical differences of men and women. All employment shall accord with equal opportunities, laws and policies. Care shall be taken that female prisoners in a mixed prison do not take on a disproportionate share of domestic work within the prison.”

23 • “The organisation and methods of work in the institutions shall resemble as closely as possible those of similar work in the community in order to prepare prisoners for the conditions of normal occupational life. • In all instances there shall be equitable remuneration of the work of prisoners. • As far as possible, prisoners who work shall be included in national social security systems.”11

The European Prison rules pay special attention to education in some of its articles, such as by stating that:

• “Every prison shall seek to provide all prisoners with access to educational programmes which are as comprehensive as possible and which meet their individual needs while taking into account their aspirations.

• Priority shall be given to prisoners with literacy and numeric needs and those who lack basic or vocational education.

• Education shall have no less a status than work within the prison regime and prisoners shall not be disadvantaged financially or otherwise by taking part in education.”

The rules also point to the necessity of libraries in the prison wherever possible, which can be organised in co-operation with community library services. Furthermore, the rules state that as far as practicable, education shall:

• “Be integrated with the educational and vocational training system of the country so that after their release they may continue their education and vocational training without difficulty”12 b. Recommendation Rec(2006)2 of the Committee of Ministers to member states on the European Prison Rules concerning work and education in prisons

Of particular importance in this case is the rule stating that:

“There shall be no discrimination on the basis of gender in the type of work provided.”

Further, the rule mentions that prison work shall be approached as a positive element within the prison regime, that authorities shall provide sufficient work of a useful nature, and that the work shall be intended to maintain or increase prisoners’ abilities to earn a living after their release. Moreover, the organisation and type of work shall “[…] resemble as closely as possible those of similar work in the community in order to prepare prisoners for the conditions of normal occupational life.”

11 The Quakers also want to add: “Maternity leave shall be granted prisoners according to the practices/ laws of the general population. Prisoners caring for children should be allowed the free option of continuing with work or of caring for their children.” 12 The Quakers would like to add that: “Prisoners caring for children should be allowed the free option of continuing in education or of caring for their children full time.”

24 “In all instances there shall be equitable remuneration of the work of prisoners.

Education shall have no less a status than work within the prison regime and prisoners shall not be disadvantaged financially or otherwise by taking part in education.”

3. Recommendations by the Quaker Council of European Affairs follow the same line, namely that:

“Member states ensure that women are given equal access to education, training and work opportunities as male prisoners.

Member states ensure that women are given jobs and training which will provide them with skills that they can use on release. Jobs and training should not be allocated to prisoners on the basis of gender.”

4. The Standard Minimum Rules for the Treatment of Prisoners

Several rules deal with work in the prison context. Some of the subparagraphs are quoted as follows:

Rule 71. (3): “Sufficient work of a useful nature shall be provided to keep prisoners actively employed for a normal working day.”

Rule 72. (1): “The organization and methods of work in the institutions shall resemble as closely as possible those of similar work outside institutions, so as to prepare prisoners for the conditions of normal occupational life.”

Rule 72. (4): “So far as possible the work provided shall be such as will maintain or increase the prisoners’ ability to earn an honest living after release.”

Rule 76. (1): “There shall be a system of equitable remuneration of the work of prisoners.”

Rule 77 is dealing with education and recreation:

“Provision shall be made for the further education of all prisoners capable of profiting thereby, including religious instruction in the countries where this is possible. The education of illiterates and young prisoners shall be compulsory and special attention shall be paid to it by the administration. So far as practicable, the education of prisoners shall be integrated with the educational system of the country so that after their release they may continue their education without difficulty.”

5. The CPT states in its 2nd General report (1992):

“A satisfactory programme of activities (work, education, sport, etc.) is of crucial importance for the well-being of prisoners.”

Chapter 3

WOMEN’S HEALTH IN PRISON IN THE NORTHERN DIMENSION AREA

3.1 The prison health situation in the ND area

Well-functioning medical services are of utmost importance for male and female detainees with shorter or longer prison sentences time, and even life-time sentences, in order to ensure the prevention and treatment of many health problems, as well as to offer programmes for rehabilitation and their reintegration into society.

The majority of penitentiaries do have some semblance of a health care system in place. The quantity and quality of the services however vary considerably, and a number of problems remain unsolved. Experience shows that people from the poorest and most marginalized sections of society make up the bulk of prison detainees. This means that the prison population mainly consists of persons with poor somatic health, persons infected with various transmissible diseases, chronic untreated conditions, vulnerable persons with psychological/psychiatric problems, and those who engage in at-risk behaviours such as intravenous drugs use and prostitution. The most considerable challenges for medical services are to treat and prevent the spread of communicable diseases such as HIV/AIDS and other sexually transmissible diseases, Hepatitis and Tuberculosis as well as to care for prisoners with mental disorders and drug addicts.

Over nine million people detained in penal institutions around the world. However, the figures for prison populations vary considerably between different regions of the world, and between different parts of the same continent. In Europe, close to 2 million prisoners are detained in various penal establishments (pre-trial institutions, correctional facilities, colonies, prisons, juvenile detention centres etc.) The highest number are to be found in the Russian Federation, which in July 2007 had 889,598 detainees, of which 7,1 % were women and 2,5 % children and minors. The median rate of prisoners per 100 000 of the national population for European countries is 184. A study for the Northern Dimension Partnership in Public Health and Social well-being Progress report 2007 reveals that the rate per 100 000 of the national population varies from 628 in the Russian Federation, to 237 in Poland, 85 in France, and between 66-82 in the Scandinavian countries. Surprisingly high is the number of prisoners per 100 000 of the national population in Estonia (268), Latvia (292) and Lithuania (235) (NDPHS 2007: Annex 3).

A considerable number of penal institutions are located within the ND area. The institutions differ enormously in terms of living conditions, medical services and social programmes. Many challenges are cross-cutting, ranging from general somatic diseases, communicable and sexually transmitted diseases to severe mental health disorders. The NDPHS Expert Group on Prison Health focuses on prison health challenges related to HIV/AIDS, Tuberculosis and Hepatitis (B/C), drug addiction, alcohol and tobacco abuse and their consequences for somatic and mental health. The Expert Group pays particular attention to social rehabilitation as well as to vocational and educational training programmes. It is aiming to establish common and widely accepted recommendations and solutions for disease prevention, the improvement of health care and social work in prisons, drug and alcohol rehabilitation, social inclusion programmes and the improvement of mental health.

On their website, the non-governmental organisation Penal Reform International (PRI) informs about the situation of women in prison globally. It states that around half a million women and girls are imprisoned in different types of institutions worldwide. Countries with the largest population of detained women are the United States (183,000), China (71,280), the Russian federation (55,400) and Thailand (28,450).13 Compared to statistics on male detainees, women constitute a rather small group in prison, however also a growing one.

Women are usually imprisoned for minor offences, non-violent crimes, drug violations and criminal activity related to the purchase of narcotics, such as prostitution and burglary. Many of these women have ethnic, linguistic or indigenous minority backgrounds. In large part, they have dysfunctional social backgrounds and are also responsible for taking care of children and/or other family members. “Women, especially mothers, in prison have special physical, vocational, social and psychological needs. Yet, they often face problems with maintaining contact with family and the outside world, as well as difficulty in assessing education, training, work programmes, and health care while in prison. They are also vulnerable to abuse and violence including rape, inappropriate surveillance and strip searches. Women in prison have higher levels of depression, anxiety, phobias, neuroses, and self-mutilation, and suicide compared to the general population and male prisoners.”14

13 International centre for prison studies, 2006 world female imprisonment list. 14 http://www.penalreform.org/women-in-prison.html

A major challenge to this study has been to find useful data on women in prison and their special needs. Exact data on prisons and imprisonment in general is difficult to find and it is even more difficult as concerns female prisoners. Many countries simply do not disaggregate data and cannot provide statistical information for male and female prisoners separately (which is a major problem because the general situation for female prisoners is different from their male counterparts as described above). The collection of data and statistical information on female prisoners is needed in order to advise and develop appropriate measures to meet their special needs. When countries do provide statistical information on female prisoners, their approaches to data collection differ widely across Europe. Many countries have no comparable definitions as to what constitutes a female inmate and what a women’s prison actually is. Sometimes there is statistical data available for pre-trial institutions for women, but not for closed institutions or vice-versa. Also, the methodology for collecting information and analysing statistical data on female prisoners differs between the countries. Some collect data on prisoners in general and estimate the number of female prisoners using different timeframes (e.g., average number for one specific day, estimated total number of female prisoners over a whole year, and percentage of the total prison population). International comparison of prison population rates cannot be viewed as being unproblematic either and should also be kept in mind. The categories included in the number of prisoners vary from country to country. Therefore, it is not possible to compare national data without reservations, as it is not necessarily apparent that different countries present information based on the same categories.

In order to compare data between countries and thereby make it possible to also compare penal systems for female prisoners across Europe, it will be important to develop general measures on how to collect statistical data. As already mentioned, exact figures on women as well as on other vulnerable/minority groups in prison are extremely hard to come by. In depth work and research in the social sciences field on these particular issues is very limited and remains far too general. The NDPHS PH EG appreciates the latest publication of the WHO Europe Office, Health in prisons – A WHO guide to the essentials in prison health. It provides as much information as possible (and as much as is available) on the conditions of women in prison. The Expert Group strongly recommends that further project-based activities that collect better and complete statistical data on women and other minority groups in prison be undertaken. Thereby, health indicators for imprisoned women have to be developed in order to be able to compare the health situation of female prisoners across the region and to develop general guidelines for a Gender Sensitive Prison Management and a comprehensive gender equal approach to prisons.

The point has often been made that it is very costly for states to organise separate detainment facilities for women and to provide them with specialised and focused health care. The result is that women are often held in institutions that are well-suited to their special needs, as such institutions are mainly designed for men in terms of their living conditions, education and training, leisure activities and health services. Gender inequality therefore runs rampant in terms of overall trends in imprisonment and particularly in the area of prison health: “In these circumstances, particular care is required to ensure that women deprived from their liberty are held in a safe and decent custodial environment” (www.cpt.coe.int/en/annual/rep-10.htm). The CPT has recommended a number of measures in order to minimize the risk to the physical and/or psychological integrity of women deprived of their liberty.

Some of these important measures are:

• Mixed gender staffing in prisons and especially in the health care sector; • Separate accommodation for women if they are imprisoned with men in the same building; • Equality of access to activities, as well leisure time as educational. Hereby the particular critic of the CPT on activities for women in prison should be highlighted: “all too often encounter women inmates being offered activities which have been deemed “appropriate” for them, such as sewing or handicrafts, whilst male prisoners are offered training of a far more vocational nature.” (www.cpt.coe.int/en/annual/rep-10.htm). This issue will be further discussed in chapter 5: Social rehabilitation and pre-release training. The PH EG believes that rehabilitation and pre-release training is an essential part of inmates’ social-well being and significantly contributes to a more successful reintegration into society after their release from prison (and is thus a major stepping stone to successful social rehabilitation).

According to the CPT, particular women’s hygiene needs should be addressed in an adequate manner. Access to sanitary and washing facilities as well as hygienic equipment should be available upon request. Furthermore, the CPT points to the need for ante natal and post natal care for pregnant women and those with newborn babies. Health care in prisons should be provided in accordance with the health care available to society at large. Prisoners (both female and male) should not be at a disadvantage in the case of access to adequate medical services.

This Thematic Report is based on statistical data and information from the Quaker Council for European Affairs, PRI, IPS and the CPT, as well as a questionnaire developed by the NDPHS Expert Group on Prison Health (attached as an Appendix to this study). The questionnaire was circulated to all members of the Expert Group during early November 2007 for the purpose of collecting the latest statistical information on women in prison in the northern Dimension Area. Information was also compiled on transmissible diseases, Tuberculosis, access to substitution and psychological treatment, and on the number of pregnant women and mothers in prison. The questionnaire was also designed to generate an overview of how the number of female prisons the ND area, where they are located, and how the health systems within these institutions are organized.

3.2 Female prisoners in the ND area

Female prisoners represent between two and ten percent of the total prison population in the world. During the last ten years, the number and percentage of female prisoners has remained relatively stable in the ND area within countries like Denmark, Latvia, Norway and Sweden. The number of female prisoners has increased in Estonia and Finland. In some other countries overall trends in the numbers and percentages of female prisoners are more complex, such as in Germany and Poland, where the numbers of female

29 prisoners have increased while the percentage of the total prison population has remained consistent.15

On average, five percent of the total prison population in the Nordic countries consists of women. In general, “Women have been particularly effected by increasingly though anti- drug laws in some countries which have led to a much faster rate of imprisoned women” (European society of criminology 2007:13).

Latvia 418 (2007) Lithuania 341 (2007)

Es tonia 209

Sw eden 293 (Oct.2006)

4.061 Germany Poland 2.720

Iceland 6

Finland 245

2.144 France

170 Denmark

211 Norw ay Russ ia 60.668 (2008)

Table 1: Female population in prison – total numbers/ percentage of total prison population by 1 September 2006, if not indicated differently, also including pre-trial detainees.

15 There has been an increase of the total number of persons who have been imprisoned in the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) over the period of 2001 to 2005 with 19%. For Finland, the increase has been 24%, for Denmark and Sweden 23%, and for Norway 15%. Iceland has had a stable prison population after 2003. (Nordisk statistikk for kriminalomsorgen i Danmark, Finland, Island, Norge og Sverige 2001-2005, Rapport 1/2007 fra Kriminalomsorgen). The number of persons on remand in the Nordic countries has been relatively consistent.

1 Latvia

5 Lithuania

3 Es tonia Sw eden 5 Germany 7

22 Poland

1 Iceland 8 Finland

France 55

4 Denmark 9 Norw ay 45 Russia

Map 1: Number of women’s prisons and prisons with women units in countries in the ND region

3.2.1 Age

The PH EG has no information on the age groups of female prisoners in the ND area. Statistics from other European countries have been presented in a survey published in 2005. It indicates the age of female prisoners, as some of the countries to a certain degree are comparable. In most countries female prisoners are fairly young. “Those under 18 years old vary from less than 1% in France to less than 3% in England and Wales. Statistics from Hungary indicate that women under 19 years old represent 2% of all inmates; in Germany juveniles less than 18 years old represented 2% of women inmates. Of the data reported in all countries, more than one-quarter of adult women inmates are under 30 years of age. The figures for women ages 18 (19) to 29 years are very important in England and Wales (50%), and to a lesser extent, in France (42%). This age group is less important in Germany (32%), Hungary (31%) and Italy (29%). In these 3 countries, there are more women who are between 30 and 39 years old. Also, in these 3 countries, the percentage of women over 40 years of age is more important (33% in Germany, 35% in Italy and 37% in Hungary) than in England and Wales (18%) or even in France (29%). Nevertheless in all countries, more than 60% of adult women inmates are under 40 years of age and are therefore fairly young."16

16 European Commission, DG Research EC, 2005: Women, Integration and Prison. An analysis of the processes of socio-labour integration of women prisoners in Europe - MIP PROJECT. http://cordis.europa.eu/documents/documentlibrary/2746EN.pdf

3.2.2 Organisation of medical service within penitentiaries in the ND area

The legal responsibility for the provision of medical services in prisons differs from country to country. Prison administrations often face a dilemma in terms of balancing security requirements and public health requirements (for example to prevent the spread of blood-borne viruses or other infectious diseases in the society as well as within prisons). It has therefore been recommended the links between prison and public services be tightened, resulting a greater responsibility for the ministries of public health in several countries to provide health services.

In the Northern Dimension area the responsibility for the provision of health services in prison falls under different authorities. In those countries where the provision of prison medical services is placed under the authority of the Minister of Justice, a greater participation of the Ministry of Health would help to ensure optimum health care for prisoners as well as implement the general principle equivalent health care in prison to the outside community.

The organisation of medical services within female prisons varies from prison to prison, especially when it comes to the health care for special vulnerable groups such as women, juveniles and the elderly. Several important recommendations have been made by the CPT “Health care services in prison” which are published as an extract from the 3rd General Report (CPT/Inf (93)12). These recommendations are applicable to both male and female prisons.

3.2.3 In practice within the ND area: General Health

Prisons for women in Latvia and Estonia have their own medical departments and mother and child units. They have also their own prison hospitals, which are located close to a public hospital, operating in cooperation with the prison.

Sweden/Latvia: Cooperation between women’s prisons in Sweden and the Baltic countries (SIDA evaluation, 03/11/). The Ilguciema Colony for Women and the KVM Hinseberg Prison for Women in Sweden are two female establishments participating in twinning programmes.17 The report emphasises significant changes in the attitudes and behaviours of staff members towards one another, and between staff members and prisoners. The positive use material support given by the Swedes, e.g., school equipment and furniture, computers, laundry equipment, kitchen equipment and

17 Twinning - Twinning is considered to offer enhanced possibilities for organisational learning and sustainable capacity building, in contrast to traditional technical assistance, e.g. the use of short- or long- term experts. However the institutions describe the twinning in other terms. They regard twinning as the process of building mutual trust and understanding of a long-term character. They generally claim twinning has been most helpful, and we agree that it has worked well. We also find the decision to concentrate initially on building up professional understanding, mutual trust, and friendship as justified. Investments must be made in creating the relationships upon which activities can be further built and changes viably implemented. It has often been the case that trust and personal relationships have contributed to practical policy changes within prisons. Frequent topics addressed by such cooperation are staff-inmate relations; dealing with violent prisoners; staff “debriefing”; health (TB and HIV/AIDS) and hygiene; drug awareness and rehabilitation; work and vocational training; security and control; psychology and social work; preparation for release; probation service; teaching methods and programmes; and others related area of focus.

32 workshop equipment etc, was observed. In terms of direct results, the 12-step programme for alcohol and drug addicts was highlighted as one of the most beneficial outcomes of the twinning. Staff members were trained by Swedes and the Prison Fellowship International (http://www.pfi.org/) helped to restore a venue in which the course could take place. There have also been direct developments in education, vocational courses, and in particular, computers (which were also provided for the staff).

Norway/Russia: The Twin Prison Project started at the end of the 1990s as a humanitarian measure. Lorries with clothes, hygienic tools and other related items were sent to Russia. At the same time, the female prison Bredtveit started co-operation with a twin prison in the Mozhaisk female colony. The colony houses from 1,000 to 1,200 inmates in addition to approximately 100 children who are between the ages of 1 month to 3 years old.

Gradually it developed into a project for providing money to improve the living conditions, and especially the bathrooms, in the prisons. A delivery-room was renovated and the Bredtveit prison partly financed a mother-and-child unit where women detainees can stay with their children. The mother-and-child unit was completed in 2007. Financial contributions have also been made to the prison hospital and the prison church.

The Twin Prison Project had a dual focus. On the one hand, it focused on provided financial support for renovations, on the other hand, to develop professional co-operation in regards to the implementation of the VINN-program (see Chapter 5). Money has not been transferred after 2006. Another female prison in Norway, Ravneberget prison, and Bredtveit prison are working close together to implement the project in Russia.

Another professional project between the two female prisons in Norway and the Mordovia region of Russia with 3,000 female prisoners has taken place. The cooperation is only professional, focusing on training for program facilitators.

All prisons are concerned about the children who live on their premises. They can stay together with their mothers for up to three years. The women show interest in learning about the role as parents. Overall, the number of inmates in Russian prisons has increased. Alternatives to imprisonment have been discussed, and the prison authorities in the Mordovia region have displayed and interest in learning about the Norwegian approach to alternatives. A seminar focusing on alternative measures is planned to take place during 2008.

3.3 Main health problems encountered by women in ND area prisons

There is no question that male and female prisoners shall have access to the same medical services. The standard of health care shall be at least equal to the best health care provided in general or available to the average members of the larger community. Women seem, however, to have greater needs for health care, both in the community and in prison. A survey from the National Institute of Corrections in Washington, DC has shown that 20-35% of women enter prison while already sick compared to 7-10% of men. Even if figures from prisons in the ND region cannot be documented, there is little doubt that female prisoners need more medical attention than men.

33 Women’s health problems can roughly be divided into four main categories: somatic diseases, including transmissible diseases (TB, HIV/AIDS, hepatitis etc.) and dependency-related diseases; mental health problems/disorders such as depression, anxiety, stress, psychosis, personality disorders, self-harm, suicide attempts/suicide, drug-induced disorders, ADHD and PTSD; women-specific health-related problems/diseases; other problems, for instance the consequences of having been victims of exploitation, physical/emotional abuse, human trafficking. This Thematic Report will focus especially on HIV/AIDS, Tuberculosis and what we refer to as Women- specific health-related problems/diseases.

“Delays in health care treatment, such as scans during pregnancy and screening for cervical cancer and breast cancer, may adversely affect women in prison and choices they can make surrounding their health. A break in receiving the contraceptive pill heightens women’s risk of unintended pregnancy. Women should be able to see a female nurse and doctor on request; failure to do so may result in certain medical problems not being reported. As prisons often have only one prison doctor this may be more difficult to provide than in a normal clinic/doctor’s’ surgery.

The small number of women prisoners may mean prisons are more likely to employ male medical staff. Women need adequate toiletries, such as a choice of feminine hygiene products, soap that is suitable for sensitive skin and enough shampoo to wash long hair. In many prisons, hygiene provisions for women are inadequate and access to showers may be severely limited. Women need different health as men e.g. information on sexual and reproductive health, breast cancer, osteoporosis and hormonal problems. Women going through the menopause need information in order to make choices about how to manage this period of their lives and may need dietary supplements. (In Denmark, nutritional supplements may not be brought into prison, thus women will need prescription supplements). Appropriate health information is particularly important for psycho-social illnesses such as eating disorders, self-harm and some mental health problems” (Quaker Council of European Affairs 2007: 46ff).

3.3.1 HIV/AIDS

The best overview of the HIV-situation is provided by a report from the Penal Reform International, Briefing nr 2: In most countries, the prevalence of HIV infection in prisons is significantly higher than within the population outside prison. In Poland, 20 per cent of the country’s 7,000 infected people have spent time in prison or pre-trial detention facilities during their lives. Similarly, in Latvia, one-fifth of the HIV cases concern people in prison (UNDP, 2004). Current indicators suggest that HIV prevalence is increasing at a dramatic rate. The former Soviet states have experienced a particularly rapid increase in HIV prevalence in prisons. In Russia, the number of prisoners living with HIV increased from seven in 1994 to 36,850 in 2002 – an increase in the prevalence rate from 0.008 per 1,000 inmates to 41.1 per 1,000 inmates (UNDP, 2004). Similarly, in Ukraine, admissions of prisoners with HIV increased from 11 in 1994 to 2,939 in 1997 (WHO Europe, 2001). In Lithuania, an HIV outbreak in Alythus prison in 2002 resulted in 263 prisoners testing positive for HIV within just a few months. Prior to this, there were only 18 known HIV infections within the entire prison system and 300 people living with HIV in the country as a whole (Jurgens, 2002). HIV prevalence is compounded by the high rates of hepatitis C (HCV) and tuberculosis (TB) infections in prisons. TB is the main cause of death for people living with HIV/AIDS and as such presents a serious risk

34 to those infected with the virus. TB infection rates in prison can be between five and ten times the national average (Farmer & Yang, 2004); in some cases, this can increase to as much as 100 times the prevalence rate found outside prison (Reyes, 2007). The prevalence of multi-drug resistant strains of TB (MDR-TB) and extreme drug resistant (XDR) strains are also higher in prisons than the rest of the population. “These trends culminate in high TB mortality rates in prison. In some prisons in Russia, TB accounts for up to 80 per cent of inmate deaths” (Farmer & Yang, 2004).

“In Russia for example, petty drug offences account for 75 per cent of female prisoners” (Wolfe, 2004). “Prison sentences are the norm for arrested drug users rather than diversion into drug treatment or rehabilitative programmes” (Walcher, 2005). “The consequences of punitive drug policies are high rates of imprisonment and a high concentration of injecting drug users in prison, which in turn drive the HIV epidemic and contribute to prison overcrowding” (Penal Reform International 2007).

Women are more at risk of contracting HIV from sexual activities than men are, due to a number of factors: The main groups at risk are young women engaging in at-risk sexual behaviour with multiple partners, engaging in intravenous drug-use, have a history of drug-related offences and are involved in prostitution. Women may enter prison pregnant but unaware of their pregnancy status due to their unconventional living conditions. Such women may even become pregnant while prison on the account of visitations by their partner(s). Vulval and vaginal inflammation can increase the likelihood of acquiring HIV infection. Thus, sexually transmitted diseases can increase the likelihood of eventual HIV infection, especially if the sexually transmitted infection (STI) is not detected and properly treated.

Many female prisoners have problematic social and criminal backgrounds. “Prisons could provide a forum for a last chance of reaching marginalized and often confused women […] will be most at risk of contracting HIV” (Reyes 2001). A prison can often be the only place where a sick woman has the time and the resources to receive treatment from doctors or gynaecologists, as well as a diagnosis, treatment and potential cure for whatever disease they have contracted. “STI monitoring may therefore offer a useful indicator of change in sexual behaviour” (Reyes 2001: 195). Gender inequality, the lack of education, unemployment, poverty, prostitution, physical abuse, and forced unprotected sex render women at higher risk to be infected by HIV. Many women have a long history drug addiction and intravenous drug use, which also places them at higher risk for hepatitis and HIV infection.

According to official figures, approximately 35,384 of Russian inmates are HIV positive, with this figure rapidly increasing. The number of HIV positive people entering the prison system is rising by an average of 15 to –20 percent each year. There exists a combination of risk factors such as tattooing with shared needles, sexual activity in prisons, and intravenous drug use (with shared needles). Approximately 96,915 inmates are reported to be drug addicted, with 61,579 being dependent on alcohol, and one-third suffering from various psychological and psychiatric disorders. About 100 convicts with AIDS are imprisoned (CPT 2003/ 89).

In Latvian prisons in 2006, “prisoners contributed to 16 percent of all new cases, which used to be 30-33 percent during 2000-2003 respectively. A decline in the share of new HIV positive cases found in penitentiary system can be attributed to the declining number of individuals who are tested by the prisons. If in 2000 the prison system tested

35 8,722 individuals, this number declined to 2,600 in 2006 (new entries per year approximately 3.000). Since 2000, due to lack of financial resources and outdated infrastructure, the number of HIV tests has been reduced. The incidence of HIV in prison is ten-fold higher than in within the greater community. Therefore, the situation within penitentiary system remains to be a problem and still poses a risk for the spread of HIV. Such a risk is due to the fact that approximately 6.1 percent of prison population (December 31, 2006) is HIV positive (UNGASS 2008a: 10).

In Estonian prisons “in 2000, 80 inmates who were HIV positive were detected and formed 20% of all new HIV cases. In the years that followed, the proportion of inmates who are HIV positive has increased. In 2003, 266 people were detained in a penal institution upon the moment of HIV detection, accounting for 32% of all new cases. In 2004 the inmates formed 21% (155 people) of all new HIV positive cases. The majority (89%) of inmates infected with HIV are men between the ages of 15 and 24. Approximately 12-13% of all inmates in Estonian prisons were infected with the HIV as of 2004. Since 2004 the proportion of prisoners among new HIV cases decreased to 19% (118 people) in 2005. Most prisoners are infected before the actually enter the prison. There have been seven cases (according to the data from the Ministry of Justice) of HIV transmission in the prison (one trough tattooing, five through sharing contaminated syringes, and one unknown)” (Estonian Ministry of Social Affairs 2008:7).

As already mentioned, prisoners are at an exceptional risk of HIV infection because of the connection between intravenous drug use and imprisonment. HIV infection is currently a serious problem in juvenile prisons. It is feared that a second phase of the HIV epidemic will be characterised by heterosexual transmission, which would further aggravate the situation. Women prisoners who have engaged in prostitution are at an additional risk.

The two first HIV cases among IDUs in Estonia were diagnosed in 1997. From September 2000 onwards, the number of HIV positive persons increased rapidly. HIV infections are primarily seen among IDUs. The first HIV positive person detected in prison was diagnosed in May 2000. By October 2001, 464 HIV positive persons had been detected, among them 47 women and 65 minors, and all of them drug users. Newly arrived prisoners are examined at the Central prison hospital in Tallinn. Previously, testing was conducted mainly among risk groups such as IDUs, sex workers, homosexuals and patients with hepatitis B or C due to lack of resources. More funds have however now been available. Testing is voluntary.

In order to purchase drugs, many women earn money by way of prostitution or engage in at-risk sexual activities while under the influence of drugs. There is often uncertainty about their partners, and the protection offered by condoms is compromised by violent sexual intercourse or sexual abuse. These factors increase the risk of being infected with sexual transmitted diseases or bloodbound viruses such as HIV. “Health services in women’s prisons need to be resourced to take account of this particularly high demand” (WHO 2007:166). As the HIV virus is not only found in semen or blood but also in breast milk and vaginal fluid, prisons must be equipped to meet the needs of female prisoners, especially vulnerable or minority groups including pregnant prisoners or homosexual women (Curtis 2006). The correct use of condoms should be basic practice in relation to all types of sexual activity, whether vaginal, anal or oral, as it can greatly reduce the risk of acquiring or transmitting STIs such as HIV. The WHO Health in prison guide suggests the following components for comprehensive HIV treatments in prison:

• Providing easy access to voluntary HIV counselling and testing; • Conducting surveillance of HIV and AIDS; • Mitigating social impact by undertaking measures to counter HIV-related stigma and discrimination; • Mitigating HIV-related diseases by providing appropriate care, treatment […] and support for HIV and related diseases; • Preventing new infections through: reducing sexual transmission by providing life skills […], providing easy and anonymous access to condoms and lubricants, controlling sexually transmitted infections, notifying partners and implementing measures aimed at reducing sexual abuse and rape; • Ensuring blood safety by testing transfused blood for HIV, reducing the number of non-vital blood transfusions and enrolling donors at lower risk; • Reducing the incidence of transmission through sharing contaminated injection equipment, needle and syringe programmes, substitution therapy and peer based education [including special education for minority groups as e.g. women having sex with women].

As documented by several researchers, heterosexual relations are becoming the leading risk factor for females within a certain age group for being infected with HIV. With the increasing transmission of HIV/AIDS and its specific manifestations in women, this also becomes an issue for the prison environment, which complicates the treatment and care of female prisoners, especially for pregnant women. On the other hand, being HIV positive and going through the prison system also provides a unique opportunity for receiving treatment, education and counselling on HIV/AIDS issues. In most countries and institutions in the ND region, women have the possibility to receive antiretroviral treatment.

HIV treatment in prison has mainly been focused on male inmates, as the female prison population is always comparably smaller. Consequently, women’s specific needs are often neglected. The prison environment does not always take into account the specific needs of women, such as accessibility to regular showers, the greater need for hygiene products due to menstruation, the need to make sanitary napkins available and to dispose of them properly, and adequate nutrition for pregnant women as well as women who are infected with diseases such as HIV/AIDS.

3.3.2 HIV positive pregnant women in prison

“The transmission of HIV from a pregnant mother to her unborn child is the most common source of HIV infection among children. The most effective interventions that can help to reduce this transmission depend upon a pregnant woman first knowing her HIV status. Therefore it is recommended that information, counselling during pregnancy as well as around the time of and after delivery, and any voluntary testing service should be available to women prisoners” (Reyes 2001). Furthermore, the possibility of terminating the pregnancy should be an option, taking into account the legislation of the country. “Pretest counselling should be provided by trained medical staff, such as midwives trained in HIV education” (Reyes 2001).

37 Another way that pregnant women transmit HIV to their children is through breastfeeding (as the virus can be present in breast milk). The report states that this predicament has not undergone sufficient research and the extent to which viral loads in the blood and maternal milk are correlated should be further researched. However, “all preventive measures for HIV should be available for pregnant women in prison who have family visits, and proper counselling provided about HIV infection. Whenever relevant, the use of condoms during pregnancy specifically to avoid possible HIV infection should be explained and encouraged. Condoms should be available to all prisoners without undergoing embarrassing situation as to having specifically asked for it. Further research has shown that the possibility of HIV transmission is significantly higher when the mother is infected during pregnancy or when breast-feeding, if she is in an advanced stage of the disease (AIDS) or has a high viral load (shortly after infection)” (Reyes 2001).

Furthermore, transmission of the HIV virus from the mother to her child occurs during childbirth, when the foetus passes through birth canal. In order to minimise the risk of infection, C-sections are often (and should be) preformed on HIV-infected women in childbirth (equivalence of care). C-sections should also be an option for every pregnant female prison detainee and performed by specially trained personnel. Postpartum care should be similar for women with and without HIV infections. Mothers should be provided with information and training as to on how they can safely handle bloodstained sanitary pads and material used after delivery.

“In Latvia for example, annually ~30 HIV positive pregnant women are detected. As of December 31, 2007 there were 25 HIV infected children born to HIV infected mother in Latvia. Out of all HIV cases, among pregnant women 49.3% are reported due to sexual transmission and in 25.9%, the women have a history of drug injecting7. HIV cases among pregnant women in Latvia are mostly found among mothers that avoided adequate prenatal care as well. This may suggest that pregnant IDUs are not adequately reached by HIV testing during pre-natal care services in Latvia” (UNGASS 2008a: 11).

It would be favourable to have more NGOs involved in prisons that face HIV-related challenges and reproductive health issues. It is no doubt that women should be the first group to receive interventions concerning measures to curb at-risk behaviours and treat their health-related consequences. Of course it is also important to involve men such prevention and treatment processes.18

3.3.3 In practice within the ND area

All countries within the ND region have the experience of establishing special measures for prisoners who are infected with HIV. The following includes some examples which might be of interest to other penal establishments.

Estonia: WHO Health in Prisons Project - Best Practice Award 2007

18 “The global experience shows that prisoners as well as other groups at risk are best served when external agencies (governmental and NGOs) are involved in delivering HIV prevention and curative services. Therefore states’ agencies (PHA, LIC, SATLD, RCPAD) that receive funding from budget have to deliver HIV/AIDS, TB, hepatitis, STI testing, prevention services and care in prisons. Such involvement of respective agencies and NGOs should be aimed at developing and delivering confidential, competent and coordinated prevention, treatment and support to those in the places of detention” (UNGASS 2008:30).

38 Best Practice Award 2007 in Category 1 went to Tartu Prison in Estonia. The category includes any aspect of the clinical care provided to prisoners by doctors, nurses or other healthcare professionals.

HIV prevention and care in Tartu prison

The aim of this project was to improve the accessibility of voluntary counselling and testing (VCT) and antiretroviral treatment (ARV), increase distribution of information to prisoners and prison staff. The target groups were prisoners and prison staff members who were in close contact with prisoners as both guards and contact persons.

The rapid spread of HIV/AIDS has been the most serious health problem in Estonia since August 2000. The epidemic escalated very quickly. The main source of the epidemic was IDU (intravenous drug users). A considerable number of drug users are admitted to the prison. Prison staff plays a prominent role in educating prisoners on how to minimise virus transmission, how to reduce at-risk behaviour and harm reduction. Increased knowledge of HIV/AIDS will reduce discrimination against those who are infected. The entire medical staffs of Tartu prison and specialists from the community hospitals have been involved in the program.

The aim of the project is to build up a system that provides constant VCT, ARV treatments and care, and reduces at-risk behaviour on the part of prisoners. In order to achieve the goals of the project, the following activities are carried out:

• Voluntary testing and/or re-testing if needed; • Pre-and post-test counselling; • Timely access to medical care; • Access to HIV specialists; • Regular HIV education for prisoners and members of the prison staff, including medical staff.

This project began in 2002 and is still active. Over 8000 inmates have participated in the Project between 2002 and 2006.

There is voluntary HIV testing for every incoming detainee to Tartu prison. According to the Quakers’ observations, medical staff tries to persuade as many prisoners as possible to undergo testing, and to receive counselling and advice. HIV positive prisoners are not kept separately from the other prisoners, and treatment and supervision is confidential. If a woman is HIV positive it is left up to her who she will share information with concerning her HIV status. Also, testing for STIs upon arrival is voluntary. The QECA reports that for many women it will be the first time they take part in a gynaecological examination for STI and or see a gynaecologist. This situation is mainly the result of women’s poor social, educational and economic backgrounds. Homosexuality among women is more or less ignored, while the prison does not provide female inmates with condoms (these are only provided to male inmates. However, the medical facilities for female treatments are considered to be of an excellent quality by the QCEA observer and by the CPT. Pregnant women do not have to leave the prison for pre-natal ultrasound scans and female prisoners have the option to be examined and treated by female medical staff (Quaker Council of European Affairs 2006, part II country report Estonia).

Estonia: NGO Convictus originated in Sweden and was started in Estonian prisons during the end of 2002. It has now 25 employees of whom 50% are ex-clients. They have received funding from different sources. Since September 2007, the Estonian Ministry of Justice finances the support group service in prisons. According to the terms of the contract between the Ministry of Justice and Convictus, they provide:

• Support groups for HIV positives within prisons in Estonia; • Counselling; • Education for prison personnel and prisoners.

Besides these, they also provide within the community:

• A support group for ex-prisoners; • A support group for women engaging in intravenous drug use and for those who are HIV positive; • Community-based needle exchange and counselling programmes.

Convictus representatives visit prisons throughout Estonia, including the Harku female prison, weekly. As far as possible, they meet with groups of six to eight prisoners. They provide advice on health care and harm reduction services for drug- and alcohol addicts, and offer links to community services in order to provide through-care services. They also have a contract with the Family Planning Programme, which has been seeing around ten prisoners in each of their group meetings (with two groups per week over the last six to twelve months.) The groups are offered both in the Estonian and in the Russian languages. Prisoners learn about the Convictus groups from each other and must submit an application to join the group. Convictus also holds information days in order to reach out to more prisoners at any one time, which is also important for those serving shorter sentences and are eager to join the group meetings. Convictus staff also has a valuable role in training prison staff members and making them aware of the needs of prisoners who are addicted to drugs or who are HIV positive.

Convictus offers expertise and support to prisoners who may not feel that they are able to seek contacts elsewhere, due to concerns about being judged or not being treated humanely.

The government in Estonia now acknowledges them as an important part of the rehabilitation of prisoners, and they will therefore continue to receive state funding until 2015.

Russia: “In 1999 PRI implemented an 18-month HIV prevention project within the penal establishments of Nizhniy Novgorod. The aims of the project were to raise awareness about HIV infection and prevention among the prison population, improve the living conditions and treatment of HIV positive prisoners, and provide materials to aid the prevention of HIV transmission. Activities included the provision of training and relevant educational resources, organising study visits, researching prisoners’ attitudes and knowledge about HIV/AIDS and facilitating bleach distribution within the prisons. The project resulted in significant improvements in the living conditions and provision of activities for prisoners with HIV or tuberculosis. This included enabling them to have greater access to their families. The improved awareness of HIV/AIDS among both

40 prison staff and prisoners served to abate fears and reduce the stigma attached to the virus. The project also led to the initiation of a peer learning programme within the prisons” (Penal Reform International 2007).19

3.4 Tuberculosis (TB)

The spread of Tuberculosis (and other transmissible diseases) is a big concern of several of the countries in the ND region. It has become an enormous problem for the prison authorities and for many penitentiaries. A news flash which was disseminated via the Council of Europe in 2003 emphasised that “Tuberculosis and AIDS rule in Russia’s overflowing prisons” and also described that more than 86,000 of almost 900,000 inmates – around one in 10 – were infected with the respiratory disease, and some 30% of ill inmates were infected with the resistant form of Tuberculosis.

In 2003 the Russian authorities reported however that the spread of TB in detention centres and prisons had halted. A drop of 27% of TB cases had been seen in 2002. It was said that at the moment there were no problems curing any of the disease’s forms and they were fully supplied with medicines and medical equipment for identifying TB. According to the authorities there had been over 100,000 TB cases in penal institutions in 2001 whereas in 2003 the figure was at 77,000.

WHO has reported that TB is up to 100 times more common in prisons than in the civilian population and its spread is exacerbated by late diagnoses, late treatment, poor prison conditions and overcrowding. HIV infection dramatically increases the risk of developing active Tuberculosis. The Baltic countries and the Russian Federation have the highest figures of MDR-TB in the world. New HIV cases in Eastern Europe consist of 75% IDUs, 77% men, and 84% are under 30 years old.

Even if the PH EG cannot point to exact numbers of TB-infected prisoners in the ND- countries, in 2007, there was sufficient documentation to show that TB in prisons still constitutes a very big problem to which it has to be paid much attention.

Tuberculosis affects the most vulnerable groups in society, including prisoners. Prisoners live mainly under poor conditions of health that result in the increasing problem of communicable diseases in prisons, especially as concerns Tuberculosis. Overcrowding, a lack of proper nutrition and poor hygienic conditions has led to an increase in the number of prisoners infected with Tuberculosis. Mainly the new member states of the European Union (EU) and Russia were affected by the spread of TB in the early 1990s when social and economic transformations in these countries resulted in larger vulnerable groups within the general population, including socially marginalised individuals who suffered from disease, malnutrition, weak immune systems and drug addictions (in which case many people were also infected with HIV/AIDS).

To combat the spread of TB from prisons into the society at large, the following is needed:

19 Further information: Reyes & Bollini (2000) Evaluation of the implementation of the project of HIV prevention and management activities in the prison system of Nizhniy Novgorod oblast, Russian Federation. Available in English and Russian

• Hygienic and general conditions in prisons must be improved; • Treatment against TB must continue after release; • All relevant actors and services including health care services, social services, the judicial system, media and NGOs must try to combat the spread of communicable diseases. They can also play an important role in the prevention of such infections within prisons society at large.

The CPT recommends that: “For control of the transmissible diseases to be effective, all the ministries and agencies working in this field in a given country must ensure that they coordinate their efforts in the best possible way. In this respect the CPT wishes to stress that the continuation of treatment after release from prison must be guaranteed.”

3.4.1 In practice within the ND area: TB/ HIV

Estonia: Activities to contain the spread of TB within prisons are an integrated part of the National Tuberculosis Programme (NTP) in Estonia. The reporting/recording system in the prisons has been part of the National TB Registry since 1999 when the DOTS strategy was introduced into the prison system. The main idea of the project is to establish a well-functioning data exchange system between the NTP Registry and the prison hospital.

One of the weak sides of this process is the collection of the screening-data when convicts enter the prison and throughout their stay. The follow-up activities vis-à-vis prisoners with TB who are released from the Prison hospital are another problematic process. This is connected to the problem of data exchange between the civil society and the prison system. According to data from the NTP Registry, many of the released prisoners do not continue their treatment after being released.

The adequate and timely information exchange between the prison system and the civil society as well as within the prison system will increase the possibility of improving the management of TB and the MDR-TB problem in Estonia. Strengthening data collection and data management will help to improve TB containment activities within the prison system as well as in civil society. This is of crucial importance because of the MDR-TB and the increasing problem of HIV/AIDS within general society and the prison system. According to data from the NTP Registry, the prison system contributes approximately five percent to annual national statistics. 20

Norway: The “Task Force on Communicable Disease Control in the Baltic Sea Region” has invested quite a lot of financial resources in various projects during the 1990s and over the first years of the new millennium to combat communicable diseases. In 2002 a small expert group visited prisons in Estonia and Lithuania in order to assess their situations concerning transmissible diseases. The assessment and results of the project included the issuance of recommendations to prison authorities in the two countries and

20 “There are 5 separate TB departments in Estonia with 230 beds including 30 beds for compulsory treatment. There is one separate department for prison system (40 beds)” (Ministry of Social Affairs 2008:22).

42 as well as to the Task Force. These were published and can be found within the NDPHS project database.21

Finland: The Finnish organisation FILHA has several projects in Russia. More information can be found within the NDPHS project database.

21 Based on information from the Norwegian Bredtveit prison there are no known cases of TB. All prisoners are screened at the entrance to prison.

43 Chapter 4

PREGNANT WOMEN AND MOTHERS IN PRISON

Photo by Juerg Christandl

Women who are pregnant or caring for small children constitute an extremely vulnerable group within the prison population. This has been well documented by the Quaker United Nations office in the publications “Women in Prison and Children of Imprisoned Mothers” (2004) and “Pre-Trial Detention of Women and their Children” (2006). “There is little public awareness of conditions in prison in which pregnant women and new mothers are held” (Kitzinger 1997).

The University of Greifswald conducted an international study on female prisoners which shows that out of the overall number of women interviewed, 70,2% in Poland, 68,7% in Lithuania, 67,8% in Germany, 63,5% in Russia and 57,7% in Denmark were mothers.22

“The imprisonment of a woman who is a mother can lead to the violation not only of her rights but also the rights of her child(ren). When a mother is imprisoned, her baby or child(ren) may stay with her in prison or be separated from her and left on the ‘outside’. Both situations can put the child at risk” (QCEA 2007: 5).

22 Cited by the Quaker report 2006.

4.1 Pregnant women in custody

In general, “Pregnant women and women with young children should not be imprisoned unless absolutely necessary” (UNODC 2007a: 50). Alternative, non- custodial measures should be taken into account. In cases where it is absolutely necessary to send a pregnant woman or a woman who has just recently given birth to prison, authorities should consider alternatives to pre-trial detention for mothers of babies and dependent children. This includes measures clarifying how, when and by whom the existence of such children is ascertained and taking into consideration whether pre-trial detention is necessary (Townhead 2006:18). Furthermore, “the state takes on the responsibility to provide adequate care for the women and their babies” (UNODC 2007: 50). Prisons are for the most part not adequately equipped to offer pregnant prisoners or imprisoned women accompanied by children with sufficiently good living conditions. Pregnancy in prison is an exceptional circumstance. It is hard to get enough sleep, stay relaxed before going into labour and enjoy adequately hygienic conditions.

In some cases the psychological burden is quite heavy on pregnant women in prison, on the account that they have been accused of committing a crime and sentenced, and therefore are separated from their relatives or partner/husband. Instead, they live in a cell with other women, where noise is constant noisy and privacy is restricted. “Pregnant prisoners have “dietary requirements, medical needs and specialised exercise regimes…it maybe difficult to arrange for prisoners to have health care checks and scans, ante natal classes, birth preparation classes and post-natal care” (Townhead 206:46). Access to medical staff 24 hours a day can seldom be provided by the prison regime. Other prisoners might exercise aggression towards a pregnant detainee, as she may receive better care and more resources than her non-pregnant counterparts. This can result in physical abuse or bullying, which may lead to additional stress for the pregnant prisoner.

Pregnant women need specific care during their imprisonment. As mentioned in Chapter 1, a considerable number of women in prison are drug addicts and often have suffered from their addictions for many years. As drug addiction can lead to amenorrhea, it can in fact happen that a pregnancy goes unnoticed until the detainee is tested in connection with beginning substitution treatment. Therefore, it is not only important that a pregnancy is handled in a clinically correct way but also that the mother-to-be has access to psychological support in order help her ease into the new situation of being pregnant and in prison. The pregnant detainee must have the possibility to decide how she wants to handle her pregnancy. The prison should be prepared for treating and counselling pregnant women who wish to go through with childbirth but also to provide them with the option to terminate the pregnancy, if legal.

Another situation arises if a female inmate has suffered a miscarriage before arriving in prison or shortly thereafter, probably caused by withdrawal from previous drug use.

All pregnant women in prison must receive the same kind of pre-natal check-ups as given to pregnant women within the outside community. They must also receive special dietary nutrition which suits their condition. It should be possible for pregnant women to regularly see a nurse/midwife and/or a doctor, and preferably a gynaecologist. Special attention should be given to pregnancy-related health complications such as high blood

45 pressure, diabetes or iron deficiency. The prison should provide whatever medical support is needed to save the lives of the mother and her child.

Transport to the nearest hospital to the prison must be secured – a long journey to a local hospital by way of inadequate transportation is not acceptable and can compromise the health of both the mother and her child. Childbearing women should not need to be left alone during delivery and instead be given the possibility to decide who should be with them during her period of labour. Speedy authorization is to be provided by the prison regime without subjecting the pregnant detainee to bureaucratic or embarrassing procedures. Mothers-to-be in prison should also have the possibility to be accompanied by companions during childbirth. These measures aim to make childbirth in prison comfortable for the detainee as possible. This is important for the child’s future development and for the social rehabilitation of the mother. As prisons usually cannot provide and comply with such measures, the national justice systems should avoid subjecting pregnant women to childbirth in prison this kind of situation. The prison system is often simply not capable of meeting the needs of a pregnant women in terms of both allocating resources as well as providing moral support.

UNODC lists some major rules and regulations that should be followed when pregnant women are imprisoned:

• Women should be transferred to hospitals outside the prison to give birth to a child; • Shackling or any other kind of restraining are inadequate and condemned as inhuman; • Security measures should be limited to the absolutely lowest level needed; • The child should be officially registered right after birth as any other child. The condition of being born while the imprisonment of the mother should not be mentioned in any birth certificate or official document. The child should not have any disadvantages by being born by an imprisoned woman; • The women should receive adequate pre- and post-natal care and that the child profits from the same regular postnatal checkups and participates in e.g. vaccinations plans if applicable; • Breast-feeding should be possible in prison in an adequate environment under clean, silent and relaxed conditions. The prison regimes should be adjusted accordingly.

Many women suffer from anxiety and depression prior to, but more often, after delivery. Therefore, women must have the possibility to see a psychologist/psychiatrist when needed and receive adequate treatment. Children and mothers should have a room where they can live undisturbed by other prisoners and in an environment that is appropriate for babies and small children.

As emphasized by UNODC the mother, not the child, is the prisoner, and accordingly the child should be treated in an appropriate way, having the possibility to play, make social contacts and socialise with other children inside and outside the prison. They should also receive health care, be supervised in terms of their physical and mental development, and receive sufficient support to learn and grow. The mother should have the possibility to be together with her child as much as possible. In situations where the mother cannot be with her child (for some reason connected to the prison regime), the

46 prison must take responsibility for ensuring that other care-givers are in place. It should be possible for relatives to keep in touch with the mother and her child as often as possible. This means that visitation rights should be more flexible and subject to less bureaucracy in these cases.

4.1.1 Women in prison who are accompanied by their children

There are different approaches to the national justice systems on how to deal with the issues of women giving birth or being accompanied by a child while in prison. The most common solution is the creation of a mother and baby unit (MBU).

2 RUSSIA 1 LATVIA 1 FINLAND 1 ESTONIA

8 GERMANY

POLA ND 50

Table 2: Number of MBUs in countries in the ND region (Townhead 2006:48, NDPHS questionnaire)

“There is no agreeing optimum time to separate children from their mothers” (Townhead 2006:69). However long a time the prison authorities allow a child to stay with their mother in prison depends on their assessment as to what is best for the child. The prison authorities can easily end up in a moral dilemma when they have to decide what the best solution is for the individual mother and her child. To be separated from the mother will always be traumatic. A crucial question that is often not adequately addressed is a matter of “when does it become more harmful to the child to stay in prison rather than to suffer separation from the mother?” Both the rights of the child as well as the rights of the mother have to be taken into account. However, many children and mothers do not face separation as the latter are mainly sentenced for minor offences and are therefore out of prison after short time. The separation of a mother from her baby should however be avoided when it is not absolutely necessary. “Allowing babies but not older children to

47 reside in prison is based on the premise that the separation of mother and baby causes emotional problems on both sides. But to keep a young child in the limited confines of a prison hampers their educational and social development and thus they should be removed from the prison at a certain age” (Townhead 2006:48).

Germany 3 Latvia 4

3 Denmark

Lithuania 3

2-3 Finland

4 Es tonia 3 Poland Sw eden 1

Table 3: Maximum number of years that children can stay with their mothers in prison (Duenckel et.al 2005).23

23 Norway: no babies allowed

4.1.2 In practice within the ND area

Poland: There are two „Houses for mother and child”; one in Lubliniec providing places for 15, the other in Grudziądz providing places for 35 mothers. Pregnant women are sent to special maternity ward institution within the regular prison which is situated next to the mother and child unit. On mother's request, she is taken to the mother and child unit with her child, where the baby can stay up to the age of 3 years. If there exist any educational or health reasons the doctor or psychologist can send a written opinion to the special division of the court. As a result court can make this period longer or shorter. While living in the house women are provided with clothes and shoes for babies, cleaning and caring equipment, bedclothes, pillow and duvet for children, blankets, etc. (own research).

There is special staff on site including: a paediatrician, psychologist, nurse, dietician and social case manager. As each mother and child house is situated next to a prison, the house is staffed by personnel from that same prison. If the father of the child has the legal right to decide on the fate of the child (shared custody), he has to agree that he or she can be taken to the mother and child unit. The equipment within the house has to be similar to that found in “normal” housing for small children. The house is equipped with bedrooms for the mothers and their children, providing the minimum private sphere, adequate furnishings for a baby, a shared living room, kitchen, and bath facilities. There are separate rooms for the personnel and medical staff.

Sweden: In 2005, five children were accommodated together with their mothers in prisons in Sweden. The children can stay with their mothers up to the age of 12 months old. Services and care are provided individually, offering the best solution for the child. The average time for children to stay in prison was five months. Prison authorities want to keep the child’s stay in prison as short as possible.

Russia: Prison Health conditions in Russia differ in general quite a lot from other countries in the Northern Dimension area. Eighty percent of convicted women in Russia are mothers. The average prison sentence is 5,5 years. Only a very small percentage of detainees (one percent) become pregnant while in jail. “As long as the mother is in pre- trial detention facility, she has the baby with her, but as soon as she is moved to a colony, the baby is taken away from her and put into a ‘home for mother and child’, in fact an orphanage which mothers can visit for a couple of hours a day” (Alpern 2002). There are ten colonies in Russia where women are detained “together” with their children, but only one where women actually live together with their children.

The colony no 12 for women in the village of Zaozernyi is situated approximately 15 kilometres from the city of Khabarovsks. It is a general regime establishment for sentenced women with a capacity of 1207 places. A majority of the detainees come from the Khabarovsk area, around 40%. According to the report CPT/ Inf (2003) 30, the colony is the only prison in this region of the country that accommodates female prisoners together with their children. Children can stay up to the age of 3 years. The colony has a baby unit located in a separate building located one kilometre outside the colony with space for 40 children. Accommodation is given in three different sections divided by the children’s ages. There are several playrooms; the units have their own kitchen, garden and a small farm. The children are taken care of by a team of 36 persons, including 3 doctors; 2 of them are pediatricians, nurses, educators and

49 orderlies. There is possibility for breastfeeding mothers to stay together with their child and to be employed in the unit. All babies are born outside the colony in nearby city hospitals.

The CPT reported after a visit to the colony in 2001 that members of the prison staff are present in the hospital room during delivery. In some cases women were not taken to city hospitals but gave birth in the prison hospital. Female inmates who were interviewed by the CPT reported that they were separated from their children after birth and not allowed breastfeeding due to different reasons (syphilis, smoking, long sentences). Alpern reported that escorted visits to the children who were placed in the children’s unit varied from two to three times a week, up to two months of separation. Alpern writes in her article that women who are in the “lucky position” of giving birth outside the prison are separated from their children and escorted back to their cells “only two hours after delivery” as the prison cannot afford to keep the staff away from the prison in the accompaniment of a birth-giving mother. It was also reported that women were not allowed to breast-feed. In addition, “the workers involved in care taking of the children of imprisoned mothers are convinced that convicted mothers do not deserve to be called mothers and should not be cared about” (Alpern 2002).

Latvia: Ilguciema prison (near Riga) is the only women’s prison in Latvia. Women stay together with their children in separate rooms in the mother and child unit until the child is one year old. Later on, childcare is organised by the prison personnel of the mother and child department, which is joint effort of the doctor, nurses and a teacher. Children of the ages one to four are visited by their mothers twice daily, and in total not less than three hours a day.

Children stay in the MBU whereas their mothers live in prison cells. Pregnant women have the opportunity to be scanned in prison. These procedures are monitored by a guard, while no other security measures are taken. They give birth to their children outside the prison. Also, abortion can be arranged up to the legal week and is freely available. Mothers with babies live in a special mothers and babies unit, which is specially equipped for keeping babies up to the age of one year. The unit has space for 6 mothers with up to 20 children. The QCEA observer reported that the facilities in the unit were very good, with enough space for all mothers, individually painted bedrooms with adequate furniture, even curtains and table cloths. The mothers could bring personal belongings, and there are toys and baby equipment at their disposal. From a medical point of view, the unit provides a nurse and a female doctor 24 hours a day and there is also a room reserved for medical treatment. New mothers are kept separately from the others in the unit and have the possibility to learn how to properly take care of their child. The mothers of older children are requested to go to work and to visit their children regularly. Older children have a separate dormitory with additional equipment such as toys and furniture. The unit is run by an American church group that also teaches Montessori-based rules. A garden providing space for play is also a part of the unit. Nurses ensure that the older children receive proper nutrition. The unit is drug-free (QCEA 2005, fact finding visit to Ilguciema).

Denmark: Horserød prison is the second biggest in Denmark with 221 female inmates. The QCEA observer reported the following: “The prison provides a family unit with fourteen beds for parents with children of less than three years of age and for married couples where both parents are sentenced. There is one cell for a couple with children, consisting of one cell for the parents and one connected room for the child. Before

50 coming to prison the sentenced parent receives a letter when to arrive in prison so that they have the opportunity to make arrangements for children and thereby having more influence in who will take care of the child during their imprisonment. Mothers have the choice to bring their babies if they wish to. The family unit is strictly separated from the other prison units in order to provide security for the child and to keep the unit drug-free. Mothers are not obliged to work when they are accompanied by their child, but if they wish to work, the child has the possibility to go to kindergarten. Children have the possibility to see family and friends outside the prison upon request. Mothers can take their children out of the unit and visit other prisoners with their child. There is no qualified childminder or a nurse, the effect of prison on children is not further monitored by any measures and a trade-of appears if the mother wishes to undergo special drug treatment in a separate unit as the child has not access to this unit” (QCEA 2006, part II, country report Denmark).

Estonia: According to QECA “the only mother and baby unit in the country is in Harku women’s prison and pregnant women and imprisoned mothers with children are transferred to Harku” (QCEA 2006, part II country report Estonia). Consequently separation is poses a problem to maintaining family ties because of the long distances between the prison and the sentenced mother’s home.

The unit was established in 2001, and is located in the same building as the medical department. The facilities consist of three rooms, a kitchen, two bathrooms and two toilets which are modern, renovated and furnished according to the needs of small children. At the moment there is a space for up to four mothers accompanied by their children. Age and gender differences of children will be kept in mind when housing them.

This unit also functions as a facility for pregnant women. Pregnant women are transferred to civilian hospitals for childbirth. After birth, mothers can keep their babies with them 24 hours a day, to be able to breastfeed and care for them generally. Mothers who are in prison can live together with their children until the child reaches the age of four. This guarantees the children with a living environment that will cause them the least amount of harm and will promote their normal development. There is a playground on within the prison for detainees’ children.

There are certain benefits for mothers who are living separately from other prisoners, such as access to more comfortable living conditions, possibilities to cook, etc. Mothers, who live in this unit, receive foodstuffs have to prepare meals for themselves and for their children. They receive advice from the prison medical staff and social workers. Mothers are guided by a social worker who ensures that the activities which they engage in with their children are in accordance with their needs and appropriate for the child’s development. Necessary equipment for children is provided by the prison, for example: books, means for handed and kinetic activities etc. Besides that, mothers also have the option to buy equipment and clothes for their children.

Older children have a possibility to go to the local kindergarten outside of the prison, where they will play and communicate with other children who are their own age. Mothers will escort their children to and from kindergarten daily.

Fathers are able to meet with their families during short and/or long-term visitations in accordance with the regulations of the Estonian Imprisonment Act.

51 All children in Estonia, regardless where they live have medical insurance from the Estonian Health Insurance Fund.

Estonia: Tartu prison does not have a mother and baby unit. Sometimes pregnant women in need of special antenatal care are kept on remand in Tartu prison. They can give birth in a civilian hospital. However, before the time of birth, the pregnant female prisoners “do not usually have to leave the prison for external medical appointments as there is an ultrasound suite in the prison medical department” (QCEA 2006, fact finding visit to Tartu prison). Near the time of the birth the medical department makes preparations for the prisoner to go to the civilian hospital. A social worker assists the pregnant woman, for example in cases where the mother has a long sentence and the child must therefore go to an orphanage. It is a general rule that the child’s birth certificate has no note from the prison.

Lithuania: In 1994 Panevezys Correction House opened an Infant Section. Accommodation is provided for women with babies born while their mothers were kept in pre-trial detention or in the Correction House during the imprisonment. Since 2003 this applies to mothers who gave birth to their babies before conviction. The children can stay together with their mothers if this is in the best interest of the child, and the child can stay until the age of three. The mother can afterwards choose either to place the child with her family or to keep the child in the Correction House. There are double rooms for mother and child in the unit as well as playroom and commonly used living conditions.

United Kingdom: In England a small charity group carried out the so-called “Doula project”, which consists of a small group of teachers and student teachers who accompany a woman during her pregnancy in prison. They can even support her during her delivery in prison if she wants them to. These projects provide a contact person outside the prison for the sentenced woman who helps her to stay in contact with the outside world and supports her in any matters regarding pre-release training; they can be with the prisoner during the pre- and postnatal visits and assists her with all postnatal care. A similar project of the charity group works on the basis of birth companions who give support to women who undergo childbirth while in prison. The charity has e.g. a small group of part time devotees going to prisons in order to visit and support the women in pre- and postnatal care. They draw up birth plans and help young mothers adjust to their new role as mothers. The setting up of birth companionship can be a good practical example from outside the Northern Dimension area, which might be worth adopting for female prisons in the ND area.

4.2 Women with children outside the prison – social well-being and prevention measures

In most of the ND countries, the legal custody of a child is with the mother. The children of imprisoned men mostly live with their mothers who are maintaining the relationship between the father and child and other family members. The average imprisoned women is single and has to take care of her child by herself, either by taking he or she into custody or by finding a care-giver for her duration of imprisonment. Due to a lack of close ties to family members of friends, the child is in danger of ending up in the care of foster families or foster homes. In an international study on women’s imprisonment (Duenckel 2005), it was shown that (out of the sample chosen) children of imprisoned women mainly stayed with their grandparents for the duration of their mothers prison sentences.

50 47,6%

45,2%

37,3%

32,2%

30 Mean Lithuania Poland Rus sia Germany

Table 4: Percentage of children who are staying with their grandparents while their mothers are in prison (Duenckel et.al 2005).

The rather low percentage in Germany is caused by a high percentage of children staying with their fathers when their mother is in prison. This was the case for 37,3%, compared to only 8,6% in Russia. An alternative to staying with the father or a grandparent is the possibility of staying at children’s homes.

53 30

25,7%

15,3%

9,5% 10

5,1%

0 Mean Lithuania Poland Russ ia Germany

Table 5: Percentage of children who stay in children’s homes. (Duenckel et.al 2005).

It is important to mention that in Russia only 2,9% of the children of imprisoned women stay within the care of their families. Instead, most are placed in children’s homes, however in Lithuania 18,6% of the children stayed in care of their families. This number was even higher than the number of children staying in children’s homes and with their fathers.

Out of the 2000 imprisoned women in the Northern Dimension area, 60 have children under the age of 18. Ten percent were kept together with the mother in prison depending on the age of the child (mostly very small children stay with the mother during her imprisonment). Forty-five percent of the children stayed with relatives other than their fathers. Five percent were taken care of by the father himself and an additional 20% were placed in foster homes or in the care of others. The imprisonment of the mother poses a challenge to the child’s life structure as well as to their social and personal development.

Children suffer from being separated from their mothers and from the social structures that they are accustomed to. Many of these children are present at the time of their mother’s arrest and often cannot comprehend the situation. Many have experienced being separated from their family members in the past, resulting in feelings loss, betrayal and insecurity. Depending upon their age and when they live in the ND area, a child may understand and deal with the situation of having the mother in prison differently.

During their first year of life a child is not expected to react to the situation of their mother being in prison. This is why the childbirth in prison is widely accepted in the national prison systems throughout the ND area. However, during its first months of life, a child develops a certain connection to its mother. He or she learns to trust her and to communicate its needs to her. As reported in the American study on children in prison: “if a primary caregiver ‘disappears’ by going to prison it will seriously interfere with the

54 development of trust” (www.fcnetwork.org, CLP 301) of the child. The child can sense that a parent, especially its mother is not present or even inconsistently present. Very young children develop a sense of being betrayed in terms of their opportunities to develop a close connection to the mother, as it is not really possible to substitute this special relationship with other care-givers.

Children between the ages of 1-2 years (toddler) want to grow even closer to their parents, and especially to their mothers. However it is also during this time that they begin to show tendencies towards independence. Their verbal and motor skills begin to develop, as does their desire to explore their worlds. At this time, they still of course need to be taken care of and are still highly dependent upon their mothers for this care. Children who are testing the limitations of parental control need guidance but also need to be said “NO” to. If this type of guidance and structure cannot take place on the account that the mother is in prison, “caregivers of children of prisoners pour emotional and physical resources into managing life in the criminal system and have little left for coping with a toddler’s extreme upsets and shifting mood”(www.fcnetwork.org, CLP 101).

It often happens, mostly to children at a certain age, that they feel somehow responsible for the fact that their mother is in prison. This is similar to the way in which children of divorced parents often believe that they themselves are the cause of the separation. Such feelings of guilt and/or shame result in an additional psychological burden for children of imprisoned mothers, and no doubt hinders their ability to develop in a normal, healthy way. This problematic tendency will be addressed later on in this Thematic Report, in the on chapter focusing on criminal behaviour among juveniles.

“Research from many countries has revealed that when fathers are imprisoned, generally the mother continues to care for the children. However, when a mother is imprisoned, the family will often break up, resulting in large numbers of children being institutionalized, in state care” (UNODC 2007:13).

“There are different traditions in respect to the contact that prisoners are allowed with other family members.”24 Children who are given visitation rights should have the possibility to freely move around in the visitors’ rooms, apartments and playgrounds on the prison grounds. They should also have the possibility to see how their mothers live, which includes being able to visit their mothers’ room/cell. It is known that children develop their own ideas about what their mothers’ lives are like inside a prison, especially when they are at a certain stage of their own development. Many children experience feelings of worry as to whether their parents are badly treated or suffer physically or psychologically while living in prison. Having the possibility to visit them and participate in their lives even while they are serving their sentences helps the children of detained parents to overcome their fears and better cope with the situation.

Children are allowed to visit their mothers in prisons within Denmark, Finland, Germany, Norway, Poland, and Sweden. In most of the countries, prisons have special visiting rooms and/or small apartments for overnight stays. Prisons make special arrangements for allowing extended visits and also provide visiting children with toys and books (Poland, Sweden, Norway, Finland, and Denmark). Only in Germany are more frequent visits by children allowed, however overnight stays or extended visits on weekends are

24 European Society of Criminology, newsletter April 2007, page 12.

55 not permitted. Countries like Estonia and Latvia do not have special arrangements for children visiting their mothers in prison.

When it comes to family visitation, a balanced approach should be taken to assessing what is best the child of an inmate. Some women are serving prison terms for committing crimes against family members, in which case they should not be allowed visitation by their child/children. These women need special therapy, which requires the involvement of care-givers, social services and well-educated staff members who are able to handle detainees with mental health issues. “Visits present logistical and security challenges for prisons, particularly in terms of staff time. This is increased for special visits such as family days” (QCEA 2007, part 1). The justice system and prison regime face many different challenges if children are to be allowed to visit prisons. Mothers can refuse to see their child if they think that it may be too disturbing for the child or because they will need additional security measures. Children may not have the developmental ability to understand what prison is and why their mother is being detained, which can negatively impact the way that her or she interacts with his or her mother during visitation. There may not have access to visitation rooms or such rooms may not be suitable to host children for longer-term visits. Their visits to prison may also require long periods of travel, making overnight stay a necessity in which they also need to be accompanied and supported by an adult. Certain aspects of prisoners’ social rehabilitation and reintegration, and their connection to family visitation will be outlined in Chapter 5.

Most women have legal custody of their children until they reach the age of 18. This creates additional stress for mothers at the time of their arrest, because they must also find appropriate care-givers for their children, who are both trustworthy and capable. During their imprisonment, women are often worried about their children. Therefore it is of utmost importance that the mother is given the possibility to remain in contact with their child/children, for example by ensuring regular visitation and guidance on how to keep family ties intact. Many women worry about the future of their child, and suffer from feelings of guilt and/or shame on the account of being in prison. This is a major issue addressed during prisoner rehabilitation. Measures should be taken to avoid a situation in which the child follows on their own feelings of separation and guilt, to later engage in juvenile criminal behaviours. Many studies demonstrate that the female prisoners with a child living outside the prison endure a particularly high level of stress. This stress stems from feelings of loss and guilt, because they have not managed to act as a stable force in their children’s lives, and because they are not able to participate in the every day life of their child. They also may blame themselves for the stress and anxiety felt by their child. Therefore, it is important that imprisoned mothers have the chance to participate in their children’s lives so that they may continue to be a part of it. Such an arrangement guarantees better social rehabilitation on the part of the prisoner, as she will have a life of caring for her child to look forward to upon being released. While still in prison, it should be possible for the mothers to participate in important events of their child’s life, such as birthdays parties, their first day at school or parent-teacher meetings. Otherwise, feelings of guilt and shame will put a successful rehabilitation and reintegration at risk.

It must be possible for the detained mother influence the decision on who is going to take care of her child while she is in prison. She will need to receive regular proof that her child is in good care, either by having the opportunity to examine their well-being during visitation or by receiving updates from visitors who they trust. As a minimum, she

56 should be entitled to regular contact with her child via mail and telephone. Many prisoners who have children experience difficulty in explaining to their child where they are, and why they cannot be “at home” with them. On of the reasons why it is so crucial to ensure regular contact and visitation between the mother and her child is to avoid a situation in which the child believes that his or her mother is missing or even deceased. Several studies illustrated that it is best for the child if the mother is able to explain on her own why she is in prison, in order to foster feelings of trust and security vis-à-vis her child. If the child learns about his/her mother’s imprisonment through a second or third source (i.e., by relatives or the media), there is a chance that mother-child trust might be compromised.

It is important that imprisoned women who have children are able to continue being mothers – this family role should not be taken away on the account of her imprisonment.

Having the possibility to see the child regularly can also produce stress for a mother in prison. Some studies show that these women suffer from depression and anxiety following their child’s visit, as it is during that time that they experience a heightened sense of loss and guilt/shame. They may feel a loss of being able to see their child growing up, and that they have ruined the possibility of enjoying a close relationship with their child. They may also blame themselves for not being good mothers, and thereby, experience feelings of being inadequate women and having low self-esteem. Such feelings led to depression and self-hatred, which can further result in self-inflicted harm and even thoughts of committing suicide. Many women are stigmatised for being criminals and for also abandoning their responsibilities to their children and families. This double-stigma of being criminals and “bad mothers’ may make it even more difficult for convicted women to reintegrate into society than their male counterparts.

One outcome of the depression, low self-esteem, feelings of loss, and stigmas that mothers in prison suffer from is their heightened aggression towards officials both inside and outside the prison. Many women have a distinct need to talk about their problems and feelings however, any productive communication requires time and specially educated staff (which most prisons do not have). The prison regime must take women’s approaches to conflict-management into account when arranging for psychological treatment. This is also because female conflict-management differs from men’s, especially when it comes to dealing with family problems and social stress.

4.2.1 In practice within the ND area

Eastern European Countries: “In general, it can be said that the Eastern European countries have the most human approach, where sentenced prisoners may receive private visits from their spouses, partners, and families at a regular basis, for a period of up to three days. These visits take place in small flats within the prison and visitors bring sufficient food with them for the period. There are usually communal sitting, cooking, and children’s play areas and up to a dozen separate bedrooms for prisoners and their [relatives]”.25

25 European Society of Criminology 2007:12.

57 Estonia: At the women’s prison in Harku long-term stays for children and family members are possible for up to three days every six months. These longer visits can take place with the spouse, parent, child or other closer relatives. Young children have the right to physical contact with their mothers.

Norway: At Bredtveit prison in Oslo – the biggest prison for women in Norway with 59 places –a visiting apartment is available where a mother and her child can spend time together. Overnight stays are possible. The mother and child must receive permission before spending time in the apartment, and must have already had visits together in a visitation room. The prison staff makes sure that the relations between the mother and her child are acceptable. The mother must also participate in a course on parent counselling. The apartment is equipped with kitchen, two bedrooms, a living room, and a bath. The purpose of the facility is to give the mother and child an opportunity to live a “normal” life together, and share ordinary experiences like preparing their own food, etc.

4.3 Criminal behaviour of youths

“Research has also indicated that the children of imprisoned mothers may be at greater risk of future incarceration themselves” (UNODC 2007: 13).

As recognized by Greene, Haney & Hurtado 2000:3f “children are profoundly affected by their mothers´ incarceration. Many will suffer feelings of fear, guilt, rejection, shame and loneliness. Studies have identified poor school performance and aggressive behaviour in children of incarcerated parents. In addition to the loss and instability that the incarceration of their mothers brings, many children may be vulnerable because of the risk factors to which their families´ difficult life circumstances have exposed them. Many of them may have experienced the very criminogenic factors that contributed to their mothers´ incarceration, giving rise to a cycle of criminality.”

Any report concerning pregnant women and women in prison accompanied by children should not only deal with this issue in terms of health (mainly) from the mother’s perspective, but should also take into account the social-well being of the child. In giving credit to the children and involving them in health and social well-being plans for their detained mothers, the justice system and prison regimes contribute to prevention, thus saving them from similar patterns of criminal behaviour. Just because their mothers are in prison, does not mean that the children of detained females will follow in the same pattern in life. On the contrary, the justice system and prison regimes can play a major role in working against this social bias and stigma. It is indeed an unfortunate case that the children of imprisoned women are often the forgotten victims of their mothers’ crime(s).

The experience of having a mother in prison can result trauma, however it can also come as a relief for children that their parents can no longer hurt themselves or others. However, data on children in prison and the influence of having an imprisoned mother has not been thoroughly analysed. The Quaker Council Europe recommends that, “States should keep and provide disaggregated data on women and girls in prison and pre-trial detention […]. States should systematically collect age and gender disaggregated data on babies and dependent children of all persons held in detention or in prison […]” (QCEA, part 1 2007:19).

58 Sentencing may result in the limitation of certain rights, but it should not impact the rights of the offenders’ children. These rights are often not considered when dealing with offenders. “The application of the principle of the best interests of the child seems, in fact, to be far from incorporated in the decision-making process regarding children of persons deprived of their liberty…In addition, the frequent dilemma between the rights of adults and children, in particular between the rights of women and the rights of the child, seems often to remain unaddressed and unresolved” (QUNO 2005: 48).

According to the Quaker Council of European Affairs the imprisonment of the mother can have affects on young children. When looking at the social background of juvenile prisoners, there are a number of factors that make some young people more likely to end up in prison than others. These factors are:

• A range of psychological problems such as depression, hyperactivity, aggressive behaviour, social withdrawal, regression and general delinquency, clinging/needy behaviour, sleep and eating disorders, truancy, poor academic performance and attempts to run away from home; • Symptoms including feelings of desertion, abandonment, and rejection on the account that their parent(s) are not present; • Financial desperation due to a loss of family income resulting from the imprisonment of the mother.

The following are additional risk factors for the children of inmates that can come about as a result of their incarceration (www.fcnetwork.org, CLP 301):

• Abuse • Poverty • Racism • Substandard schooling • Alcoholism • Drug addiction • Deteriorating/ uninhabitable housing • Gang involvement • Crime-victimization or criminal activity • Trauma • Parental neglect • Low nutrition • Inferior medical care • Mental illness • Physically or emotionally unavailable parents • Marital distress/divorce • Single parenthood • Lack of social support and role models • Deprivation of social relationships and/or activities • Profound repeated loss

It is imperative that both the parents as well as the children are protected against these risk factors during and after incarceration. Also, child-care givers must ensure that measures are taken to protect the child from any of the risks listed above. Having an

59 imprisoned mother can result in various serious consequences for children, both socially and psychologically.

As children might possibly be present when the mothers were arrested, and perhaps even witnessed violence during the arrest, they sometimes experience feelings of being powerless. They perhaps have the impression that representatives of law enforcement are indifferent to their interests and security, which can lead to post-traumatic stress, attention deficit disorders and attachment disorders. After their mothers’ arrest, children who cannot be cared for by their fathers or their close family members might be forced to enter foster homes. Foster arrangement can also entail multiple placements for the child, increasing the risk of abuse. Such scenarios are often considered to form the basis for criminal behaviour during adulthood.

”For many prisoners parents’ rage, depression and addiction is and has been a part of life followed by the criminal activity and own addiction” (www.fcnetwork.org/ CPL 301). The Canadian NGO “Voices for children” http://www.voicesforchildren.ca/ conducted a study, supporting this Thematic Report’s position on children as the “invisible victims” of an imprisoned parent. They listed factors that play a role in how parental incarceration – especially in the case if the mother – impacts the physical development of a child and contributes to the likelihood that they become later imprisoned (probably also having their own children outside or inside the prison):

• Unhealthy coping strategies. Coping strategies in general help children of all ages deal with hurtful situations. Children who have a mother in prison experience disruption, anxiety over the future, shame, and other difficulties such as violence or poverty.

• Rationalization is a particular coping strategy which children use to preserve their image of mom as a good person. They tell themselves that people who say bad things about her must be wrong or confused or malicious. Children might even begin to see crime as necessary and noble in some circumstances

• Living in poverty is an extreme strain on children whose mothers are imprisoned. They are affected by the stresses and strains of life in disadvantaged neighborhoods, subsidized housing complexes with high crime rates, poor nutrition and an ever-present sense of want.

• Freedom from adult supervision and guidance is another factor that may lead to criminal behavior in young people whose mother is in prison. Whether they choose to accept it or not, adult guidance allows adolescents to grow and develop within a safe environment.

• Stereotyping by decision-makers within the justice system is also a problem if children are pre-judged based on the criminal involvement of their family members, which might lead into a situation of self-fulfilling prophecy, where the child is expected to become a criminal and final just fulfills the expectations if the society.

60 The imprisonment of women, and especially mothers, should be avoided in order to break the vicious circle of the multi-imprisonment of several generations within the same family.

Chapter 5

SOCIAL REHABILITATION AND PRE-RELEASE TRAINING

Photo by Juerg Christandl

5.1 Background

“It is essential for inmates who have become a vulnerable population that they should be educated, treated and empowered”.26 In the international study on women in prison conducted by the University of Greifswald in 2005, the authors point to the fact that access to activities, especially education and vocational training is a major challenge for female prisoners. This type of access should not be restricted by the fact that women are not detained separately from men, but rather they are in male prison “annexes”. Furthermore, as argued in Chapter 2, education and activities should not force women into typical female work, but be gender equal, appropriate, and for the good of the prisoner’s (male or female) reintegration: “[…] cleaning, kitchen duties and handiwork” (Duenckel 2005: 11) is therefore not acceptable work or training for detained women.

Observatoire Internationale des Prisons (OIP)27 demonstrates that a high percentage of prisoners are illiterate or have received only very basic education. Many women come from marginalized families and socio-economic sectors, and have thus suffered from discrimination and poverty. Most of them committed their first offence because of their

26http://www.steppingstonesfeedback.org/downloads/Using_SteppingStones_in_an_Indian_Prison.pdf). 27 http://www.oip.org/.

62 poverty-stricken situation. Several women in prison have a history of abuse and have been unable to change their living situations due to lack of financial/material resources. In many countries, girls are still not offered access to education to the same extend that boys are.

A survey conducted in 2002-2003 by Christine Friestad and Inger Lise Skog Hansen in Norwegian prisons reveals28 that the most common living conditions before imprisonment (for men and women) include:

• Lack of a social contact (no prison visits in the last 3 months); • Unemployment (was not employed during the time of conviction); • Health problems (has a chronic disease which negatively impacts their quality of daily life); • Lack of education (only attended elementary school); • Problems with housing; • Economical problems.

Thirty percent of the women and men surveyed had none of the problems listed above. Thirty-five percent had two or more of the problems. There was a tendency for women to have a heavier concentration of problems than men. Three times as many women as men had three or more of the above listed problems.

Among the selected persons surveyed, it was found that in the case of women:

• Almost all of the women were unemployed at the time of conviction which makes them especially vulnerable in the labour market;

• Around 50% had an insufficient level of education (only elementary school as the longest completed level). In the general society, this figure sits at 10%;

• Between 40% to 50% suffered from health problems In general society this figure sits at around 25%;

• More than one-third had problems with housing. There are big differences between the statistics for inmates and persons in general society in relation to their respective levels of education, with completely diverging tendencies. Most of the prisoners surveyed had:

• Elementary school as their longest completed level of education. Four out of ten had only completed junior secondary school and very few had any education beyond advanced secondary school. • Difficulty reading and/or writing. • No occupation or an occupation that did not require any education. • Employment not extending beyond one year. Only three out of ten were employed at the time of their imprisonment.

28 Friestad, C. & Hansen, I.L.S. (2004) Levekår blant innsatte. Fafo-rapport 429. Oslo: Forskningsstiftelsen Fafo

63 And again, three times as many women as men had three or more of these problems. Also, two-thirds of the inmates had an adolescence marked by one or more of the above-mentioned problems.

The majority of the inmates indicated that the main source of their income was derived from the social security system and criminal offences such as petty theft. Taking this into account, the European prison rules clearly state that there should be education and employment for women in prison in order to guarantee their successful rehabilitation and re-integration into society after release: “Women must have access to diverse types of jobs, and true choices should not be limited to jobs which are traditionally considered feminine.”

The UNODC warns that typical female education programmes “impose the role models on women, which exist in society, thereby failing to help them overcome the restrictions imposed by stereotypical perceptions” (UNODC 2007: 34). This means that rehabilitation and vocational training must follow a gender equal approach, aiming at increasing women’s opportunities in the job market after release from prison. Programmes should support female detainees in becoming able to make a living based on their new professions or their new skills, thereby ensuring their successful reintegration into society and helping them to regain self-confidence.

UNODC suggests the following types of vocational training:

• Administrative skills as bookkeeping, computer skills; • Creative skills including painting, decorating, hairdressing, dressmaking; • Gardening, horticulture, electro technology; • Women’s health and childcare.

Another issue is the unequal payment for work inside the prison and a noticeable gap in salary levels for female and male prisoners. This should be avoided and gender equal measures should be taken into account. Otherwise, work in prison may result in the loss of self-esteem in the case that detainees see that they are not remunerated at the same level for the same work. When women are detained in the same prison as men are, they should receive access to separate educational and work facilities and special gender- tailored programmes.

Successful social rehabilitation depends upon the type and quality of the prisoners’ activities and programmes, as well as the extent of the prisoner’s access to them. UNODC points out that, “Activities and programmes should first of all prevent recidivism.” Furthermore, education and vocational training make it possible to establish close working relations with organisations from outside the prison system such as NGOs. Many countries and prison regimes, e.g. in Russia, do not always react positively to the work of NGOs in prisons. But NGOs can make a difference in the quality of social rehabilitation where authorities do not have the resources to provide adequate programmes.

Another solution to the general problem of a lack of resources is peer education. In this case, selected, educated prisoners organise self-learning and educational classes for their fellow inmates. The prisoners who are leading such peer education sessions gain teaching experience and enjoy the feeling of being somehow useful to the prison

64 community. Prisoners who are taught by other inmates gain knowledge and skills (i.e. literacy skills) and enjoy comfortable learning “among equals.” Establishing peer self- help group in prison under the supervision of an NGO volunteer or a social worker can encourage prisoners to become active in educational/vocational programmes, overcome low self-esteem, and develop their own programmes tailored to women’s needs. The latter is especially important as these women are in touch with their needs to an extent that most people are not.

In general, UNODC suggests that prisons should offer programmes:

• To build confidence and life skills; • Parenting programmes; • Psycho-social support, therapeutic programmes, self-help and consultation for cases of drug-abuse, trauma, and violence.

“Prison administration should make every effort to involve local civilian agencies and NGOs in providing activities for women prisoners” (UNODC 2007:7) and furthermore it has to be taken into account that “Programmes that stress rehabilitation, allows the offender an opportunity to re-enter society as a responsible and productive citizen. [If there is no possibility for education and personal development in the prison, inmates] are released back into the same environment from which they came from, without any skills or education to change their situation” (Schwartz 2001).

“Illiteracy in prison is an overlooked issue. The number of illiterate people within the imprisoned population is usually quite high.” (www.educationinprison.org/regionalnetwork/offenders.php).

Education should be seen as being part of social well-being and a key factor in successful social rehabilitation. The family of the detainee should be included in their education and rehabilitation activities as well. Education in prison.org suggests the following measures to include the family of the detainee in educational interventions:

• Preventive psychological work focusing on family (probably in connection with different forms of abuse that appeared in the family); • Promotion of family participation in the detainees activities inside the prison (that requires that the prisoner is placed in a prison close to the family home); • Counselled interventions on the family level right after the release of the prisoner to help the process of reintegration of the prisoner; • As most rehabilitation programmes are tailored for prison contexts not for family community contexts that are not sustainable after release, new measures for this scenario should be found; • Special arrangements should be found for cases were several family members are imprisoned.

In a comparative study from Belgium and Portugal, its author Claudia Resende (Resende 2006) develops a chain of rehabilitation steps in prison, starting from individual rehabilitation to social rehabilitation to re-adaptation. In the first stage, the individual rehabilitation, the following types of competence have to be developed:

65 • Endogenous competence: self-control, assertiveness, resistance to frustration, and a sense of responsibility. • Technical competence: reading, fluent language and trainings. • Social competence: inter-personal skills, conflict management, and respect for others. • Competence towards risk behaviour designed for different risk groups as drug addicts, HIV/Aids infected. • Cognitive behaviour.

During the second phase of social rehabilitation, prisoners must learn how to reconnect with their families and the labour market. The prisoner must have e.g. the possibility to prepare for employment interviews, establish contact with the outside social-cultural dimension of life outside prison. This grants them access to sport facilities, literature, theatre performances, music and exhibitions. The prisoner might also establish contact with communities outside the prison, which aids their reintegration to society after their release.

These two concepts will lead to the re-adaptation of social skills, which should result in their successful reintegration in society. Managing life outside the prison does not only depend on what kind of individual resources and living conditions are available – it has also depends on what kind of conditions society can offer. Reintegration is only possible if the efforts offered inside the prison are met by a healthy the structure in society at large.

5.2 In practice within the ND area – Estonia, a case study

This chapter will take a closer look at education, social rehabilitation programmes and best practices based on experiences from Harku female prison in Estonia.

5.2.1 Individual Sentence Plan29

In order to evaluate the social-economic situation and the dangerousness of prisoners, a re-offending risk and needs assessment instrument has been developed and implemented. The instrument is common for prison and probation. Outcome of the risk assessment will provide input to the individual sentence plan (ISP).

The purpose of the ISP is to plan how to work with the individual detainee: to determine the chances to reduce his/her risk of recidivism (the need for education, ability to work, professional skills, etc.) and to draw up a timetable for implementing these measures.

29 Estonia implemented this system from Canada. Canada is seen of having one of the most progressive correction systems in the world. Concerning female prisoners, Canada has six houses for women in prison complexes, also offering a healing lodge for Native American women, non-traditional job training off-site, a trade school which is certifying educational trainings and prison tattoo parlours in order to control the spread of communicable diseases. According to the Canadian prison strategy, there must be a correction plan individually developed for every woman coming to prison. This plan includes education, addiction and medical treatment, parenting classes and finally the last three months of training in non-traditional jobs. Prisons additionally offer regular classes in anger management, behaviour modification, cognitive therapy and domestic violence prevention. www.drug-rehabs.com/female-inmates.htm.

66 The ISP is reviewed once a year (once in six months in case of young detainees) and changed if necessary. The ISP is the basis for the prison and the prison department to decide in which prison the detainee will be placed. The ISP is developed for every inmate who is sentenced longer than one-year period.

5.2.2 Employment

According the Imprisonment Act, all convicted prisoners under the age of 64, who do not have any medical contraindications, are obliged to work. Prisoners who are acquiring education and prisoners who are raising a child of less than three years of age are also released from mandatory work.

Working prisoners are divided into two categories: prisoners engaged in the maintenance work of prison – support staff, cleaners, kitchen helpers etc.; and prisoners engaged in production.

In 2001 a state company - Public Limited Company Estonian Prison Industries – was established in order to increase the employment of prisoners, competitiveness of the production and to decrease the expenses of prisons. The Company organises prisoners’ engagement in production works. The Company provides three main jobs for female inmates: sewing, completion and packing of goods. Currently, about 90% of women in Harku prison are working.

5.2.3 Education in prison

The aim of providing education is to prepare the prisoner for release by supporting the comprehensive development of personality and increasing the ability to cope. The development of the organisation of studies is based on the Recommendation of the Eu- ropean Council “Education in Prison”. Education in prison is organised by the Ministry of Education and Research.

There is a possibility to obtain basic and upper secondary education and vocational education in Estonian as well as in Russian language. The most common areas of vocational training are metal- and woodwork and sewing. Prisoners who are acquiring education are released from mandatory work. Prisoner may also apply for a permit to study outside the prison. With the aim to integrate non-Estonians into the Estonian society, prisons organise courses of official language and citizenship studies. The study work is supported by the prison’s library.

With the purpose to improve co-operation between the prison and the school as well as counsel the prisoners in the education-related questions, a position of education organiser has been created in all prisons. Hobby-oriented education and cultural and sporting events in prisons are arranged by free-time counsellors.

General education

Education in prison is part of the state education system that provides:

• General basic education • Upper secondary level education • Vocational education • Short-term vocational skills courses • Estonian language courses for foreigners

On September 1, 2007, scholarships for prisoners to study became available. Currently the system offers Estonian language courses. In 2008/2009 it will include additional categories as well. The changes are already visible, and the participation in courses has increased and become more stable. The quality of education has improved after prisons have started to outsource the service.

During 2006/2007, 23 students began general education and 70,5% of them completed studies in Harku prison. During 2007/2008, 25 inmates started general education.

Vocational training

Vocational training is one possible means of re-socialisation. The completion of studies may ensure work in the prison and within the general society after release. During 2006/2007, 18 inmates participated in a sewing course. Out of these participants, 81% completed their studies. Two students completed the whole course and the rest partly completed the. During 2007/2008, 12 inmates started vocational training.

The vocational training system in prison is quite flexible and based on the needs of the prisoners. Prisoners themselves may choose whether they want to take a whole course or study only individual topics which they consider necessary. Prisoners, who receive allowance for their studies have displayed more interest towards improving their education. Participation in courses has overall become more stable.

5.2.4 Rehabilitation Programmes

Lifestyle training

The general objective of the Programme is to reverse the habit of using addictive substances. The maximum objective of the Programme is to cure addictions to substances and/or gambling. The minimum objective is to gain control over its use and/or gambling.

The Programme is designed for prisoners who abuse or are addicted to substances (incl. narcotics, alcohol, tobacco, prescription drugs) and gamblers whose addiction to gambling causes unlawful behaviour. The Programme can be adjusted according to the mental health welfare system, probation supervision, and to penitentiary institutions.

During the Programme:

• The motivation levels of the participants are increased; • The harm caused by addiction and the benefits of overcoming it are shown; • The correlations between the use of addictive substances and unlawful behaviour are analysed; • A training plan is drawn up and self-control training is held; • Participants learn how to cope with addiction and social pressures; • Participants learn how to avoid relapses and how to cope with them.

Way of Life Training may be carried out individually or as group work. In the case of individual work, it consists of six to eight one-hour meetings once a week and in case of group work, it consists of eight to ten meetings once a week, lasting 1.5 hours. In case of group work, the group leaders should meet the participants individually four or five times to discuss homework.

Social Skills Training

The Programme is designed for offenders who have difficulties expressing themselves, and analysing their thoughts or behaviours in their everyday life.

All of the offenders need to develop their social skills. Neither the form of punishment, type of crime, nor the length of the punishment is decisive as whether they should participate in the Programme or not. It is important that the participants do not have psychiatric problems or drug or alcohol addiction. It is equally important that all the group members speak the same language and are in the same age group.

Training may be held both in open and closed groups. In case of open training, the participants may join the group at any time. In closed groups, all the participants take part in all the meetings from the beginning. The length of the Social Skills Training is ten hours during two months. Each meeting lasts 1.5 to 2 hours depending on the number of participants.

During the Training, the participants learn to:

• Listen • Start a conversation • Communicate with authorities • Say no • Control their anger • Respond to anger • Stand up for themselves • Cope with conflict situations • Make choices and negotiate • Express criticism • Receive criticism • Present themselves • Express recognition • Respond to recognition

69 It is not possible to teach social skills academically. This learning can only be based on life situations and experience, applying methods of active learning: narration’s of the teacher, conversations, discussions, brainstorms, role-plays, dramatisations, imagination tasks, decision games, case studies, self-analysis, teaching peers etc.

5.2.5 Preparation for release

This Programme is targeted at inmates who will be released within the next six months and have not received the skills and knowledge which are necessary in order to cope with the life outside the prison.

The purpose of the Programme is to give the inmate the knowledge and practical skills for how to independently find a job and a place to live, as well as how to face other social challenges. Lectures are given once a week during a two-month period. After that, short-term field trips will take place.

The main idea behind this course is that the representatives from The Social Care Centre, the specialists from The Labour Market Board, and the local administration will give presentations to the inmates in order to enhance co-operation with the various prison institutions and to guarantee pre-release consultation to prisoners.

The lesson learned during the Programme will be fixed through short-term field trips along with a social worker. Other prison departments will co-operate with each other in selecting those inmates. They must have participated in the Programme beforehand. The plan for the field trips will be based on the notion of replacing the theoretically acquired “know-how” with practical skills. To give an example of such a trip, the following activities could be carried out:

• Using public transport; • Visiting a bank (opening a personal account, introduction to using an ATM); • Visiting the Tallinn Labour Market Board, getting acquainted with the necessary documentation; • visiting a cafe (behaviour in a public place); • Getting an ID card; • Museum visits; • Summaries, suggestions for independent activities.

Feedback

A questionnaire was compiled in 2004 to get feedback from the Programme participants. The answers showed that all of the participants wanted to take part in similar courses in the future. The respondents found that these kinds of consultations and the presentations by guest lecturers gave them the self-confidence to manage with their release and for becoming competitive in the labour.

The inmates also received information about who to approach if there would be problems in finding a domicile. A very important aspect was considered to be the understanding attitude of the lecturers towards the inmates by treating them as human beings and not as inmates. The course was rated positively by the inmates and they

70 believed that everyone scheduled to be released from prison should complete the Programme. The respondents could not find anything negative about the course. Among the positive results was also the fact that the co-operation with the different institutions led to a change in their attitudes towards the prison and its inmates.

The Programme leader believed that the Programme’s general goal was achieved and the course was a success, thus inspiring further thoughts about, for example, engaging the inmate as quickly as possible after their incarceration. The first part of the program should focus on motivating the participants to change their behaviour and later focus on the skills for helping the participants to cope in freedom.

Leaving Prison

Release from the prison after completing a sentence must be carefully planned and prepared for. UNODC suggests pre-release preparation for resettlement in the society should begin one to two months before the actual release and continue after release for a certain period of time (depending on the individual case). During the pre- release period, the prisoner should follow a certain “programme of assistance to prepare for release to ensure that the social, psychological and medical support needs of the offender are met and will continue uninterrupted after prison “(UNODC 2007:47). Families should be involved in any reintegration programme.

Another approach is the establishment of transit houses/open prisons or half-way houses for women and their children who are released from detention: “These transit houses should be kept distinct from safe houses for victims of violence” (Townhead 2006:5). Institutions should help to built-up relations with the families and re-establish contacts with society and the world outside in general. Also, they should protect the recently released women from returned to their “old,” destructive circumstances or associated communities, including violent men, unemployment or homelessness. Here, the prison regime should cooperate with NGOs, social welfare institutions and social services in order to minimise the obstacles and their intensity encountered in the post- release reintegration of women.

5.2.6 Anger management

This Programme is imported from Finland and has been implemented in male and juvenile prisons in Estonia since 2001. At the beginning it was implemented in Harku Prison as well; however it was interrupted after some years when the trainers left. Since 2008 it is being re-implemented in this prison.

Anger management is targeted towards inmates who display tendencies towards impulsive and aggressive behaviours. The goal of the Programme is to improve their knowledge on what happens to them when they become angry, to explain to them why anger management tools are useful, and to give the participants a chance to manage their anger through role-play. In addition, it is also important to get experience with group work and to direct the participants to monitor and analyse their own behaviour, as well as to create and increase their interest in self-development.

The main topics of the sessions (in the progressing order of difficulty and time):

71 • Recognising situations that cause anger; • Managing one’s body language; • Soothing thoughts; • Relaxation; • Pragmatic, assertive style of interaction; • Coping with criticism and insults; • Coping with peer pressure; • Identifying efforts to anger oneself; • Avoiding resignation, self-motivation.

Anger management is a short cognitive-behavioural course where the participants work on their thinking and behaviour through: lectures; watching sample situations; playing role-play games; conducting discussions; and doing their homework. The course consists of nine meetings, each session lasting for a maximum of two hours. For a less successful group, one topic may have to be discussed over two sessions, which doubles the length of the course.

It is important to show the participants that it is possible to avoid stereotype-based thinking and behaviours. In presenting real life situations, the most suitable moment is to implement new skills and knowledge through training. The inmates get more opportunities for self-expression, including through role-playing.

Feedback

The studies in male prisons have revealed that participants have been active and motivated to take part in anger management. As feedback, the participants have mostly reported that the group offered a friendly and trusting environment, which fosters the participant’s openness and opportunity for self-analyses. However it has also been reported that the course is too short, and could be longer or go deeper into covering the topic within the same group. Many claim to have used the knowledge and skills gained from the course in real life, including in quarrels and during conflicts, which they learned to prevent. The participants have reported positively about their experience, finding valuable abilities in themselves and learning how to better connect with other people.

It is well advised to design the programmes based on local needs and by local specialists. Programmes that are already known from other countries/institutions as well functioning could be adjusted according to the appropriate requirements and implemented.

Lithuania: In 1978 Panevezys Vocational Training Scholl No. 5 started training qualified dress-makers for their main enterprise, i.e. Panevezys Correction House (a penal institution for women). In 1998 the school was made into Panevevezys Vocational Training Centre Branch Office that could offer more opportunities for vocational training. Qualifications can be acquired to become a dress-maker, hairdresser and cook.

In 1978 a general education school with the staff of 12 experienced teachers was opened in the female prison. The inmates can receive primary, secondary and high school education, and can also enrol in the non-formal educational courses in English, German or Lithuanian languages, computer, and healthy lifestyle and art crafts.

72 The Training Centre at Panevezys Labour Market is implementing the following educational programs:

• Basics of computing • Needlework • Planting specialists • Florists • Dress-makers • Environmental managers • Cane weawers.

Different Psychological Programs are available such as Psychological Adaptation Programs:

1. Anxiety and stress release, management of negative emotions; 2. Emotional support; 3. Getting to know oneself (making use of inner resources and reinforcement of one’s self-assurance).

Reintegration Programs:

1. Motivation of inmates to be released for professional activities; 2. Psychological interventions and probationary program.

Reform Programs:

1. Non-adaptive behaviour program; 2. Possibilities for use of inner resources and reinforcement of one’s capabilities.

5.3 VINN (WINNING)30 a good practice in social rehabilitation from Norway

VINN is a flexible and focused support-group program with an array of topics specially adopted according to women's needs.

The primary objective of the program is to build women's ability to make wiser choices that will lead to a better life e.g. without substance- or alcohol- abuse and without criminal activity and violence. Another objective is to increase the women's awareness about the interrelations between drug abuse/addiction, violence and crime.

The purpose: Women can overcome their alcohol- or drug addictions, and tap into alternatives lifestyles to crime. They can learn to develop a better relationship with their children, learn about raising children, and become able to create boundaries that keep violent partners out of their lives.

30 This chapter is based on various documents including: The Handbook/Manual for facilitators/group leaders, the Evaluation report, personal communication with Torunn Højdahl 2008 and reading of some literature on Cognitive Behavioral Therapy.

73 The theoretical background: The content of VINN reflects the basic humanistic approach to psychology, implying that people do have the ability to change. Pedagogically, the program based on the principles of Motivational Interviewing (Miller & Rollnick 2002) and the theory of the going through different stages in a process of change, originally developed by Prochaska, DiClemente and Norcross (1992). These theories correspond to a model that describes how motional change is possible and how the process of change should be supported by a facilitator. The VINN program has been developed by the Correctional Service of Norway Staff Academy by the Senior Advisor/Assistant Director Torunn Højdahl. A special Handbook/Manual for facilitators/group leaders and an Exercise Booklet for participants have been published and are used in the course of the program.

The target group of VINN: The program can be used in the correctional service, in probation, in centres for battered women and detox-institutions. VINN may suit women kept or serving sentences in colonies/prisons, who are HIV-infected, abuse alcohol, medicines or drugs have a criminal lifestyle or have been battered.

The role of the facilitator/group leader: Facilitators work with a view to enabling solutions. Their goal is to elicit and support natural processes of change and also to explore ambivalence. It is important to explore women's personal resources and the strong character traits that women can use to overcome their own problems.

Different topics that cover several aspects of women’s lives can be chosen:

• Identity and self-esteem • Openness and communication • Change and choice • Substance abuse and dependency • Grief and loss • Boundaries in relationships • Anger • Violence • Children • Network and relationship

The programme is built on group sessions that take place two to three times a week with each session lasting two 2 hours. It is recommended that the program lasts for a period of five to twelve weeks. The VINN program has so far been used in several penitentiaries in Norway, some prisons in Sweden, and in one colony in Russia.

Evaluation: The VINN program was evaluated in 2007 by Dr. psychol. Per Kristian Granheim, on the basis of a questionnaire completed by participants from Swedish and Norwegian prisons, as well as from the Probation service of Akershus in Norway. The participants have in general a high score in regards to all of the topics of VINN, which indicates that they have benefited greatly from the program.

Conclusion: "Processes of change take time and support group do not solve all problems but it can give opportunities for reflection and learning, thus initiating a process of change leading to an improved quality of life" (Torunn Højdahl 2008).

5.4 NGOs’ involvement

Non-governmental organisations can play a central role in all national prison systems, especially when it comes to social-rehabilitation and pre-release training, education and vocational programmes. In many countries in the Northern Dimension area, NGOs have developed close relationships to the prison authorities in order to provide services which the national prison regime may not be able to offer in an appropriate extent. In the following section, the report will give some examples from the region concerning NGOs’ involvement in the social rehabilitation of prisoners before and after release.

5.4.1 In practice within the ND area

Estonian NGO Tallinna Hoolekande Keskus: This NGO provides various forms of support for people who experience difficulty in managing their lives after they have been released from prison and/or are homeless. People are expected to come if they are in need of:

• ID card • Residence or working permit • Help in searching for job • Help in applying for pension • Psychological counselling • Social skills training group for people released from prison • Shower • Second-hand clothes.

This rehabilitation centre has a day-care and an accommodation centre. A homeless night-shelter which has 30 beds and separate sections for men and woman is open every day from 21.00 - 09.00 hrs.

In the day- care centre, the following services are offered free of charge:

• Social counselling • Psychological counselling • Social skills training groups for people released from prison • Food • Shower • Razors, soap, used clothes, etc • Books, newspapers, magazines, TV • Internet & e-mail access • Sewing machine.

Ex-prisoners who have no permanent living quarters have the possibility to enjoy accommodation in the rehabilitation centre under the terms of an agreement.

France: GENEPI National student organisation for teaching prisoners (Groupement Étudiant National d’Enseignement aux Personnes Incarcérées) is a French student organisation which bases its work on 1300 volunteers who will work inside prisons in

75 France. GENEPI works together with other organisations such as the Red Cross, Penal Reform International and Observatoire International des Prisons (OIP). The idea behind GENEPI is that students voluntarily joint the NGO and support the imprisoned fellow citizens, and in that way execute their civic duty. The volunteer organisation organises and participates in prison rehabilitation programmes, giving educational support to prisoners and promoting cultural activities in prison. The group itself cooperates with other grassroots organisations.

The NGO splits its work into activities inside and outside the prison. Inside, they provide general school education as mathematics, physics, French and other languages. Furthermore, they provide high-level classes where inmates can study law, philosophy and economics. The idea behind this is to spark interest among inmates in certain subject areas or support their interest in particular fields. Of course the other intention is to make general school education available to those who do not have a school degree or have not received basic education (due to e.g. early school drop out). Inmates are preparing for studying for a degree, and thereby, to improve their chances of employment after their release. This project also aims to increase literacy in prison and in the French society in general. Thereby, the student organisation offers mainly language classes in French for French-born prisoners, but also French as a second language (francais langue etrangére).

Students organise and conduct socio-cultural events and activities with and for inmates such as theatre, dancing classes, arts and crafts classes. There is also a possibility to read the newspapers and other press together and to discuss current political and social issues.

All activities aim to support the social rehabilitation and reintegration of prisoners into society after their release.

Outside, GENEPI organises information- and awareness-raising events for the general public. Thereby, the NGO works to prevent and reverse biases and prejudices existing in the general public about prison inmates. GENEPI organise events in schools for students and undergraduates, in the general public with exhibitions, conferences, concerts and workshops.

Russia: The UVENTA foundation is working on the same level with a group of students offering philosophy and psychology classes to prisoners.

Russia: In camp 14 in the republic of Mordovia, the prison regime works on the basis of an adaptation system developed in Norway, and tested in the settlements of the rehabilitation centre. All prisoners spend their first three months of their sentence in a so- called adaptation group, and six months before the release they gather in a pre-release group preparing for release.

Sweden/Russia: The Swedish Development Agency SIDA supports a project that is called: Development of the organisation “CRIMINALS RETURN INTO SOCIETY” in St Petersburg region.31 The project started in 2006 and will continue until 2009. SIDA will support a project regarding the start-up of two organisational branches of the NGO

31 Decision no: 2006-001984, Swedish part: RIKSKRIS, SIDA contribution: SEK 3 000 000.

76 “Criminals Return Into Society” (C.R.I.S. in Leningrad Region). The branches will be of assistance to discharged prisoners during their first period of freedom. The support will consist of various measures for the target group, such as competence development and information activities directed towards prisons, authorities and schools.

C.R.I.S. was formed in 1997. The association consists of more than 3,900 (January 2003) former criminals. Most of them had been addicted to drugs or alcohol and are now living drug-free and law-abiding lives. There are also about 900 supporting members from all classes of society, including the Royal King of Sweden. They try to be of assistance to discharged prisoners during their first period of freedom, attempting to make life meaningful for them. The idea is that people who have experienced addiction, crime and correctional treatment, and now live a life free from drugs from and without criminal activities, constitute the backbone of the association and support those who have just been released from prison and need positive reinforcement. Before their date of release, prisoners establish contacts with new acquaintances that they came to know during their prison term.

In order to give a prisoner an honest alternative to a life of crime, C.R.I.S. contacts inmates while still incarcerated. The contacts are intensified during the period just upon release. At the date of release, a number of C.R.I.S. members meet the prisoner outside. An important feature of C.R.I.S. is that its work pools supervisors. Older members of the association are meant to serve as an integrating link between new members and society and its authorities on the other hand. The idea is that the recently released member should be able to get in touch with his/her “godfather” or “godmother” by phone or personally, in order to get direct help and support in difficult situations. The godfather or godmother has experienced the same practical everyday problems that are difficult for an outsider to understand. The godfather and the godmother are reachable 24 hours a day and are equipped with a mobile phone that may also be issued to the released member as well. The godfather and godmother activities are developed in collaboration with probation officers, in order for godfathers and godmothers to receive future status as layman probation officers (http://www.kris.a.se/akutinfo.htm).

Latvia: The State Probation Service was established in October 2003. It is a national institution within the Ministry of Justice with a mission “to care about public safety through rehabilitation of offenders and supervision of offenders in society”. The national service is cooperating with correctional institutions in preparing inmates for release into society, provides assistance to recently released offenders, develops programmes for the correction of social behaviour of offenders, organises meditation between offenders and victims, and organises community work service. The service has 28 regional offices all across the country. The service aims to overcome the lack of social programmes for offenders before and after release, the lack of half way housing and the fight of social problems leading to imprisonment or coming up right after release as poverty, unemployment and alcohol addiction.

The activities are based on the initiative of the European Commission “Equal project,” offering new solutions to promote the employment of ex-prisoners” during in the years 2005-2007. Its main task is to develop a framework for rehabilitation, education and employment of prisoners and ex-prisoner system. The outcome of the project in Latvia is the establishment of centres for social rehabilitation as a component of the prison administration. They have established the prison’s social rehabilitation centres (PSRC)

77 in four prisons, one of them at Ilguciema prison for women. Four centres for social rehabilitation for ex-prisoners (SRC) have set up a plan for general and vocational training and have established a special unit for the coordination of the work practices. Project activities have included establishing of places for work, improving the general and vocational education programmes in prisons, and developing and piloting programmes for social rehabilitation. The project has published a handbook for officers in prisons, and has also developed and disseminated information material for ex- prisoners, informing them about the access the social rehabilitation programme’s services in the SRC’s. An additional step was to involve and inform potential employers about the possibilities for cooperation and the employment of prisoners. Based on the project, the state probation service compiled recommendations in order to improve the employment and vocational training situation for prisoners in Latvia.32

Lithuania: In 1997 alcoholics Anonymous group was established in Panevezys Correction House for women. In 2002 another group, Drug Addicts Anonymous group was created. Their activities are based on the 12-Steps Program. Two centers for dependence diseases treatment and psychological rehabilitation are functioning in the penal institution. Around 30 inmates are undergoing treatment for dependencies according to the Minnesota Program.

Poland: The Polish NGO MONAR was already established in 1978 and is working with social re-adaptation programs. Since 1993 the NGO is organising a regular assistance programme for e.g. ex-prisoners, providing half-way housing and first shelter in residential housing, and thereby actively offers help and assistance to people released from custody.

In general, giving educational and vocational programmes to prisoners with longer sentences only is counterproductive. Shorter sentences, alternative measures and education and rehabilitation programmes are adequate measures to fight criminality, poverty, marginalisation and health risks. Those should also be available to prisoners with short sentences, and mainly to women who are released after a short time (as they accordingly need specially tailored guidance).

Norway: Prison Visitor is a non-governmental association. It offers services to all prisons in Norway, including within female prisons. It has functioned for several years and is well known by the inmates who can enjoy their services on a voluntary basis.

The Norwegian Red Cross established in 2005 a “Net-work co-operation” with prisons in Norway. The female prison Bredtveit has since the beginning of 2006 enjoyed this service. Voluntary members from the Red Cross are in contact with individual prisoners as long as they are serving their sentences in prisons and remain in touch with them for up to two years after they have been released. The purpose is to develop a social network without drugs and criminality. The “Net-work co-operation” has no other function than to offer a social framework in which a pleasant time can be had together with the prisoner. The Red Cross-member can meet the prisoner either in the prison or during a leave. Red Cross can also invite for a trip or organise happenings. The “Net-work cooperation” organised in 2006 and 2007 a one-week trip to the seaside of Norway. The

32 For more information on the European Commission initiative Equal – new approaches to the resettlement of (Ex)offenders see http://ec.europe.eu/employment_social/equal/.

78 “Net-work co-operation” is looked upon very positively and is well appreciated by the inmates and the prison authorities. It will be developed into a national project.

The Crisis Centre in Oslo is a non-governmental organisation that helps and supports women who have been victims of violence and abuse or have suffered from other bad experiences. Similar Centres are located in many different places in Norway. Bredtveidt prison and the Correctional Service Region East have established co-operation with the Crisis Centre in Oslo. The Centre has created dialogue-groups for women and can also provide individual conversations with female prisoners, either in the prison or in the Crisis Centre’s own facilities outside the prison.

5.5 Alternative measures to prisons for non-violent offences

Alternative sentencing is often seen as being more cost-effective than incarceration for non-violent offenders. Instead of incarceration, it could be more successful to provide these offenders with community-based programmes, where the prisoners themselves support the greater society/community/public service. Thereby, a sentenced woman could maintain a job or be in job-training, which could give her new skills to making-a- living after her sentence is complete, for benefit for the society. Charon Schwartz (2001) suggests community services as being very beneficial to the social rehabilitation of female non-violent offenders: “Why not allow them to spend time to soothing the cries of a baby born addicted to drugs, or let them read stories to children in hospitals dying of cancer, let them feed the hungry or homeless […]” (Schwartz 2001). A more holistic approach, as Schwartz calls it, would demonstrate to women the ways in which they can regain self-respect and rebuild their self-esteem.

In cases where female offenders do not pose a risk to the public, their rehabilitation needs, parental status and the harmful impact of imprisonment should be taken into account. The Tokyo Rules, as pointed out by the UNODC (2007:68) give some guidelines for alternative sentencing for women:

• Verbal sanctions • Conditional discharge • Status penalties • Economic sanctions, monetary penalties • Confiscation or expropriation order • Restitution to the victim or compensation order • Suspend or differed sentence • Probation, judicial supervision • Community service order • Referral to an attendance center • House-arrest • Combinations of measures listed above

5.5.1 In practice within the ND area

Russia: A sentence can be postponed, reduced or cancelled for pregnant women or women having a child who is younger than 14 years old, with the exception of those who

79 have a sentence of more than five years (Criminal code of Russian Federation, Article 82).

Finland: In Finland the view on prisoners has changed over the last years. The Finnish state and the society were questioning the sense of punishment and the actual impact that imprisonment had on society in general and the individual in particular. The debate generated the idea of opting for imprisonment less and instead opting for more rehabilitation programmes, open prisons, electronic bracelets and trial period as alternative measures. More than one-third of Finnish prisoners serve sentences of less than one year and less than 8% of the penalties are sentences for more than ten years, according to the prisoners’ organization Ban Public (http://www.prison.eu.org/).

Canada: Canada developed the so-called private family visit programs during the late 1980s. Canadian Programs for private family visiting for successful social rehabilitation are currently representing the best ways of preserving social, family and conjugal ties between incarcerated individuals and their intimates (http://champpenal.revues.org/).

Prisoners sentenced to two years or more should have the possibility of rehabilitation for social life. To do so, a number of programmes have been set up and developed to meet the potential social and psychological needs of imprisoned individuals. In addition to these special programmes, the Canadian custodial institutions give the possibility of lengthy private family visiting (PFV). The intention of this programme is to maintain the social family and conjugal ties between the prisoners and families and friends and at the same time: “to reduce the punishment inflicted on families of offenders” (http://champpenal.revues.org/). As stated as objectives of its mission, the correctional service Canada works to “assisting the rehabilitation of offenders and their reintegration into the community” (http://champpenal.revues.org/). Prolonged visits of members of the community and from outside the prison should preserve the social and family unit, inasmuch as possible, as well as to reinforce the offender’s role and status as citizen and parent.” These are to be seen as stabilizing factors of the later release and the successful reintegration into society. The report quotes that “in addition, statistics show that if an inmate’s family is still intact and ready to accept the inmate upon release, the inmate’s chance of leading an honest life are greatly enhanced.”

Possible visitors are not only family members but can also be close friends and relatives. The private family visitation programme is open to all inmates. Some exceptions might occur in cases where there is an acute threat to the family or certain members of the family by the prisoner, or because the inmate has access to other programmes. Private family visits last 72 hours at most and may occur every two months. They take place in a special area, separated from the rest of the prison where the families have the possibility to stay on their own, have cooking and sleeping facilities, structures in furnished apartments, also providing some space outside, like a courtyard. During the visit, the staff must maintain contact to the prisoner; food and personal belongings are checked before the visitors are entering the prison. These checks are to be done prior the visits to keep the privacy during the stay of the family members. Champ pénal concludes about the long term private stays: “one must never lose sight of the fact that the offender will return to the community some day and that everything possible must be done to achieve the best possible […] rehabilitation, but also that mutual support between incarcerated persons and their intimates is an indispensable factor both for survival in detention and for enabling those outside to cope with that absence” (http://champpenal.revues.org/).

Chapter 6

RECOMMENDATIONS

Photo by Amy Allock

Based on the findings presented in this Thematic Report on women’s health in prison, the NDPHS Expert Group on Prison Health puts forward the following set of project- based recommendations:

1. Social-economic background screening: It is recommended that social background screenings of every woman entering the prison for the first time are consistently and thoroughly conducted. This includes setting up a standardized questionnaire/template to collect useful data regarding the women’s social and economic backgrounds, also covering their health status. One purpose of such information collection would be to facilitate a comparative study on the social and economic backgrounds of women in prison, and to sufficiently meet their particular health care needs.

2. Gender Equality: As this Thematic Report emphasises the importance of gender equality and its accompanying principles, the Expert Group recommends that a project be undertaken which will analyse the implementation of basic human rights, specifically in relation to social rights, economic rights and cultural rights for both genders, also incorporating the right to access to health care services. The project should cover the implementation of these basic rights in prisons,

81 taking into account that detained women are still discriminated against in social, economic and cultural terms. As stated earlier, discriminatory attitudes and behaviors, including stereotyping, is very present with prison environment. Such biases have to be overcome.

3. Reform in Prison Health: The Expert Group deems it important to carry out a project that will analyse health-related prison reforms underway in prison systems found in different countries of the ND area. Such a project should provide an overview of the various types of ongoing and planned projects in any of the ND countries, as well as describe and define the different type of reform steps/measures. Furthermore, a comparative study could analyse quantitative and qualitative differences among health care services provided - if any - within the ND countries, depending on what actors are responsible for overseeing prison health services.

4. Living conditions: The Expert Groups sees great potential for a project that will serve as a study on the living conditions of female prisoners in general and the organisation of health care services for imprisoned women in particular. Again, this study should be comparative, using qualitative as well as quantitative, and primary and secondary data (according to what is available).

5. Birth: A fifth recommendation includes the idea to undertake a project on birth companions, based on the British good practice model. In this way, it is recommended to transfer this project idea to the ND area and to initiate a “pilot project” which sets up the system of birth companionship in female prisons in with different countries of the ND area, possibly in cooperation with the relevant British NGO.

6. Children: In terms of female prisoners accompanied by children, another recommendation for a project could include taking a closer look into the influences on and consequences for the child’s development. Circumstances for analytical consideration could be: :

a. if the child accompanies the mother in prison for the first years of her sentence and b. if the child is outside the prison but regularly visits the mother in prison.

7. Data collection: A further recommendation stems from some of the comments presented in the introductory chapter concerning a lack of data on women in prison. It is therefore recommended that a quantitative study across the Northern Dimension Area and beyond be conducted, in order to collect quantitative data on women’s living conditions and their health status in prisons. A standardized questionnaire should be developed and issued to each female prison in the area, also taking into account pre-trial as well as closed prisons. In developing a standardized questionnaire, there should be common understanding of which indicators and parameters should be measured in order to monitor and asses the performance of a given prison and the national health system.

8. Education and social rehabilitation: the Expert Group suggests that a project which examines different models of peer education taking place in countries such as France and Estonia be initiated. In addition, we recommend that a project be

82 developed to establish and/or strengthen the links between prison authorities, including medical health services, the community health services and various NGOs. Cooperation on issues such as HIV and TB prevention and care, drug- rehabilitation, pre-release training and education, and post-release activities would be of particular importance.

9. Post-release: A final recommendation is to establish a post-release study/project that mainly serves as a follow-up on women’s rehabilitation after their release from prison, and especially the provision of health care and treatment initiated while in prison. This should also include monitoring the measures that were taken to successfully reintegrate women into society, even if they were in prison for only a short period of time. Post-release studies could also cover women´s housing possibilities following their release, focusing espeically on the provision of half-way houses and other possibilities for accomodation after release.

83 Appendix I List of references

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Appendix II Questionnaire

NDPHS Expert Group on Prison Health Thematic Report 2007: Women’s Health in Prison

+ + + Questionnaire + + +

In general, people who are in prison need a high level of health and social care. Women are a minority in prison but they are one of the most vulnerable groups when it comes to health issues and health care settings. As the majority of the prison population consists of male detainees, women’s special needs are often neglected. However, over the past years, the number of female offenders has risen at a greater rate than of their male counterparts in a number of countries in Europe.

As decided at PH EG 3rd Expert Group meeting in Paris in June 2007 and further discussed at the 4th PH EG meeting in Copenhagen in October 2007, the PH EG will publish a Thematic Report33 on women’s health in prison.

The PH EG Thematic Report 2007 concerns how prison health for women is organized and how health care in prison is adequately adjusted to women’s needs. In finding good practice examples from the ND region, the report focuses on two main issues, with additional one sub-issue each:

1. Women accompanied by children and pregnant women a. HIV/AIDS infected women

2. Post release reintegration and social rehabilitation a. The role of NGO’s during imprisonment and after release of women

Since October 2007, an External Expert is working on the Thematic Report. Following the given PH EG Terms of Reference for Thematic Report, an Editorial Group was also established, which held its first meeting during the end of November.

The PH EG’s Thematic Report topic is also of relevance to a planned conference on women’s health in prisons, organized and hosted by the WHO Europe “Health in Prison Project” (HIPP) in 2008 and a planned publication on women’s health in prison.

In order to collect current data on the health status of women in prison, in the ND area, the Editorial Group of the EG Prison Health needs the help of the NDPHS member countries and its representatives. We would like to kindly ask you to provide answers to the following questions listed in the questionnaire below. The answers will be used to compile the first chapter of the Thematic Report, giving a geographical overview on the

33 Following the NDPHS and EG PH Terms of Reference, the production of Thematic Reports builds one partnership approach supporting coordinated and collaborative efforts to further prison reforms, develop relevant national policies and to promote networking and partnership-building among all relevant stakeholders in the field of interest.

95 location of different categories of women’s prison and describing the general health situation/ issues of imprisoned women in the ND area and NDPHS member states.

The first table asked for information on the country and the contact details of the person providing the information to the PH EG. In the second table, we would like to ask you to give your answers numerically, in percentages or short notes in the “answer” column. If you have remarks or any additional information to the questions, please type them in the column “additions”. If you cannot give an answer to a question, please leave the field blank. Please feel free to choose a separate document or to create additional tables, if necessary. Indicate the question to your answer by marking them with the number of the question. Please attach additional documents to the questionnaire in the same file.

A Contact information Country

Last Name: First Name:

Position/ Title: E-mail:

Phone: Fax:

No. Question Answer Remarks 1 Number of female prisons of any type in the country, (or divided by categories e.g. pre-trial, short- term, long-term etc.) 2 Names and locations of women’s prison of any type in the country (or divided by categories e.g. pre-trial, short-term, long-term etc.) 3 Distance in kilometres between the prison or any other establishments and the next hospital/prison hospital 4 Total number of imprisoned women in the country in any type of prison (or divided by categories e.g. pre-trial, short- term, long-term etc.) 5a How is the medical service in female prisons organized (please specify for the different categories of establishments, if possible) 5b What kind of staff is available in the women’s prison?

96 5c How often is it possible to see A doctor: A nurse: Other medical staff (please specify): 6 Latest estimated number of women in prison infected with Tuberculosis 7a Latest estimated number of women in prison infected with HIV/AIDS 7b Is there a possibility for female prisoners to receive antiretroviral treatment? 8 Is substitution treatment available for all female prisoners upon request? 9a Latest number of cases of self- harm of women reported for any kind of prison 9b Latest number of cases of suicide of women reported for any kind of prison

10 Latest number of imprisoned women undergoing psychological intervention in any kind of prison 11a Is there a possibility for women to be with their children during imprisonment? 11b If yes, until what age is the child allowed being together with the mother in prison? 11c If yes, how is childcare in prison organised in your country (please specify by different categories of imprisonment, if possible)

Please send your compiled answers, saved within this file by electronic mail to: Ms Maxi Nachtigall (External Expert, Expert Group on Prison Health, Thematic Report 2007): [email protected]

Please return the completed questionnaire at your earliest convenience but not later than 21 December 2007. The information provided and sources referred to will be cited according to general regulations.

Appendix III Index of Tables and Maps

Table 1: Female population in prison – total numbers/ percentage of total prison population by 1 September 2006, if not indicated differently, also including pre-trial detainees.

Map 1: Number of women’s prisons and prisons with women units in countries in the ND region

Table 2: Number of MBUs in countries in the ND region (Townhead 2006:48, NDPHS questionnaire)

Table 3: Maximum number of years that children can stay with their mothers in prison (Duenckel et.al 2005).

Table 4: Percentage of children who are staying with their grandparents while their mothers are in prison (Duenckel et.al 2005).

Table5: Percentage of children who stay in children’s homes. (Duenckel et.al 2005).

Northern Dimension Partnership in Public Health and Social Well-being

NDPHS Expert Group on Social Inclusion, Healthy Lifestyles and Work Ability (SIHLWA)

Thematic Report

Country Reports on

Occupational Safety and Health in the Northern Dimension Area

NDPHS Series No. 1/2008

Northern Dimension Partnership in Public Health and Social Well-being (NDPHS)

NDPHS thematic report: Country Reports on Occupational Safety and Health in the Northern Dimension Area

The views reflected in this paper are those of the members of the Occupational Safety and Health sub group of the NDPHS Expert Group on Social Inclusion, Healthy Lifestyles and Work Ability (SIHLWA) who have developed it and should not, therefore, be interpreted otherwise. If specific country data are not available in this report, this is because the authors were either unable to obtain it or did not receive permission to publish this data.

Editors: Timo Leino and Suvi Lehtinen

This paper may be freely reproduced and reprinted, provided that the source is cited.

It is also available on-line in the Papers’ section of the NDPHS Database at http://www.ndphs.org/?database,view,paper,21

View our website at www.ndphs.org and keep an eye on policy developments and explore the world of the NDPHS – a partnership committed to achieving tangible results!

Further information:

NDPHS Secretariat Strömsborg P.O. Box 2010 103 11 Stockholm, SWEDEN Phone (switchboard): +46 8 440 1920 Fax: +46 8 440 1944 E-mail: [email protected]

The paper arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS SIHLWA Expert Group. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

List of authors

Estonia Ms. Irma Nool, Occupational Health Board and Ester Rünkla, Labour Policy Information and Analysis Department, Ministry of Social Affairs, Tallinn

Finland Dr. Timo Leino and Ms. Suvi Lehtinen, Finnish Institute of Occupational Health, and Dr. Matti Lamberg and Ms. Ritva Partinen, Ministry of Social Affairs and Health, Helsinki

Latvia Professor Maija Eglite and Dr. Ivars Vanadzins, Institute of Occupational and Enivronmental Health, Riga

Lithuania Dr. Remigijus Jankauskas, Institute of Hygiene, Vilnius

Norway Dr. Arve Lie and Dr. Tore Tynes, National Institute of Occupational Health (STAMI) and Mr. Axel Wannag, Directorate of Labour Inspection, Trondheim

The Russian Federation Dr. Mikhail Mikheev, St. Petersburg and Mr Roman Litvyakov, ILO, Moscow Professor Nikolay Izmerov, Dr. Evgeny Kovalevskiy and Dr. Galina Tikchonova, Research Institute of Occupational Health of Russian Academy of Medical Sciences, Moscow

3 Contents

1. Introduction

2. Country reports Estonia Finland Latvia Lithuania Norway The Russian Federation

3. Conclusions

Annex: Population and health indicators

4 1. Introduction

In spite of positive developments in safety and health at work during the past 20 years, the traditional safety and health hazards still constitute a substantial risk for worker's safety, health and work ability. A total of 22 to 47% of EU workers are exposed to traditional physical, chemical or ergonomic hazards. 5,000 EU workers die annually as a consequence of occupational accidents and high numbers of occupational diseases are caused by unhealthy conditions of work.

Poor working conditions, occupational accidents, and occupational diseases cause a great deal of human suffering and exclude people from work. In addition, they cost countries in the Northern Dimension area an estimated 4% of the Gross Domestic Product: a loss of up to EUR 225 billion every year.

In addition to the traditional burdens for safety and health, several new risks related to the rapid change of work life, the introduction of new working methods, new technologies, new materials and substances, and new work organizations bring new challenges to the field of safety, health and well-being. However, new technologies also provide good opportunities for better safety and health at work. An important background factor is the globalization process and associated growing competition. According to Dublin Foundation surveys, 23–60% of EU workers are exposed to psycho-social hazards such as high pace of work, time pressure, tight deadlines, stress and fatigue. In addition, insecurity of employment and short-term and precarious work contracts constitute a stress factor for a substantial part of the workforce.

Life style related health issues are a growing concern to work ability and employability. The European Health Report 2005 of the World Health Organization, using the Disability Adjusted Life-Years (DALYs) as a measure, found the most important causes of the burden of disease in the WHO European Region to be non-communicable diseases (NCDs – 77% of the total), external causes of injury and poisoning (14%) and communicable diseases (9%). Seven leading conditions – ischaemic heart disease, unipolar depressive disorders, cerebrovascular disease, alcohol use disorders, chronic pulmonary disease, lung cancer and road traffic injuries – account for 34% of the DALYs in the Region. Seven leading risk factors – tobacco, alcohol, high blood pressure, high cholesterol, overweight, low fruit and vegetable intake, and physical inactivity – account for 60% of DALYs.

The European Strategy for Health and Safety at Work 2007–2012 emphasizes a comprehensive approach in safety and health at work when aiming at the achievement of the Lisbon Strategy objectives of high quality of work. The development of adequate infrastructures is called upon to cover, in addition to the traditional occupational safety and health hazards, the problems and challenges of "new work life", including social and psychological risks, age and gender factors, and to promote health and well-being at work. The EU will also work on mainstreaming health and safety at work in other Community policies. The Strategy calls for the development of coverage and content of multidisciplinary preventive and protective services, and the promotion of safety, health and work ability constitutes an important element in the Strategy implementation. The Second EU Programme of Community Action in the Field of Health 2008–2013 deals with health aspects, including occupational health. The Luxembourg Declaration on Health Promotion emphasizes the role of the workplace as a forum for the promotion of health and work ability of the working-aged people. Workplace Health Promotion (WHP) is the combined efforts of employers, employees and the society to improve the health and well-being of people at work. This can be achieved through a combination of improving the work organization and the work environment, promoting active participation, and encouraging personal development.

New EU Member states strongly support the development of mechanisms for regional networking of stakeholders whose tasks could be, inter alia, generating information for evidence-based policy making, monitoring and evaluation as well as collaboration on the establishment of norms and standards for the health workforce, including internationally agreed definitions, classification systems and indicators. 5

Keeping in mind the above mentioned background the Northern Dimension Partnership in Public Health and Social Well-being (NDPHS) decided – through its Occupational Health and Safety sub group of the Expert Group on Social Inclusion, Healthy Lifestyles and Work Ability (SIHLWA) – to review the OHS situation in the NDPHS countries in collaboration with the Baltic Sea Network on Occupational Health and Safety (BSN) in November 2006.

The aim of this study was to analyse the status of occupational health and safety and responses to the current and forthcoming needs and demands for policy considerations and for further actions.

At this stage, six of the thirteen NDPHS countries participated in the study, which was based on systematic data collection and involving several experts and authorities in each participation countries. The reports have been reviewed in NDPHS SHILWA OHS sub group and BSN meetings.

6 2. Country reports

Estonia

1. Geography and demography

Area

The capital city is Tallinn (400,946 habitants), and the official language is Estonian. The country is divided into 15 counties and 205 municipalities. Estonia has been an independent republic since 24 February 1918, and regained its independence on 20 August 1991. The area of Estonia is 45,227.6 km2 (population density 30.3 per km2).

Population

The population of Estonia on 1 January 2007 was 1.3424 million.

Table 1. Population by age groups, in 2006

Age Total population Men Women 0–14 202.7 104.1 98.6 15–74 1049.2 490.1 559.1 75– 92.9 25.2 67.7 Total 1344.8 619.4 725.4

Source: ILO labour force survey

Labour force

According to Statistical Office of Estonia (31.12.2006 ) there were: - 65 000 employers and - 627 000 employees. 7

Table 2. Labour force, employment and unemployment rate by sex, in 2006

Age 15-74 Men Women Labour force, thousands 344.2 342.6 Employment rate, % 65.9 57.8 Unemployment rate, % 6.2 5.6

Source: ILO labour force survey

2. Economy

According to the Ministry of Finance macroeconomic forecast, in 2007 and 2008 Estonian economy will grow 8.1% and 7.3%, respectively. Economic growth is based on domestic demand and exports, although their growth rates will decelerate.

Table 3. Gross domestic product at market prices

At current prices At reference year 2000 prices

€/per capita €/per capita 200 4 456 4 456 0 200 8 327 6 743 5 200 9 851 7 512 6

Source: Statistics Estonia

3. E-policies and Digital Opportunity Index

The Government of Estonia approved the Estonian Information Society Strategy 2013 on 30 November 2006. It is a sectoral development plan, setting out the general framework, objectives and respective action fields for the broad employment of ICT in the development of knowledge-based economy and society in Estonia in 2007-2013. The Strategy comprises three objectives: Development of citizen-centred and inclusive society, which means broadening technological access to digital information and improving skills and widening opportunities for participation; Development of knowledge- based economy which means promotion of ICT uptake by enterprises and Increasing the competitiveness of the Estonian ICT sector; and development of citizen-centred, transparent and efficient public administration which means in practice improving the efficiency of the public sector as well as provision of user-friendly public sector e- services.

Table 4. The Digital Opportunity Index of Estonia

Opportunity Infrastructure Utilization DOI 2005/06 2005/06 2005/06 2005/06 Estonia 0.99 0.50 0.45 0.65

Source: World Information Society Report 2007

4. OHS legislation and actors

The Ministry of Social Affairs is the responsible body on occupational safety and health. The policies, strategies, and development programmes for occupational health and safety are discussed in the Advisory Committee of Working Environment, in which in addition to the representatives of the Ministry sits representatives from the trade unions and the employers' associations (Figure 1).

Ministry of Social Affairs

Working Life Development Health Health Care Board Labour Inspection Department Department Occupational Health Departmet 15 Regional Inspectorates - legislation - consultations - enforcement - directions - monitoring - inspection - analysis - statistics .- register of OH - registers specialists

Occupational health Working environment services specialist WORKPLACE - risk assessment Working environment First aid specialist Employer - health examination representative Employee Working environment council

Social partners Research and advisory support Estonian Employers' Confederation of - Labour Policy Information and Analysis Department Ministry of Confederation Estonian Trade Social Affairs - Advisory Committee of Working Environment - National Institute for Health Development - consultations - agreements - Tartu University - training - information - Tallinn Technical University - Estonian University of Life Sciences - Training Centres - Measurement laboratories

- education - analysis - implementation - research - assessments - expert services - development - advice - measurements-

Figure 1. Occupational health and safety system in Estonia (1)

The policies on the development of OH&S in Estonia are aiming at: 1. Decreasing the number of occupational accidents and occupational diseases

9 2. Increasing the work ability and the employability of workers 3. Reducing human and economic losses due to health and safety hazards in the work environment 4. Promoting physical and psychosocial health and welfare at work.

A National Programme for the Development of Occupational Health, 2005 and 2010 has been set for achieving the aims for occupational health and safety. By 2010 the coverage of occupational health service should be 35–40 % of Estonian employees, and the occurrence of work-related diseases decreased by 15%.

The area of working environment is regulated by the Occupational Health and Safety Act. (1998). The basic principle in the act is the employer's responsibility to ensure safe and healthy working conditions. National enforcement of this act and the requirements prescribed in legislation based on this act is carried out by the Labour Inspectorate.

Figure 2 illustrates the health and safety activities and resources in Estonian companies based on evaluation of 7277 companies in 2000-2003. Seventy-eight percent of the companies had a safety manager and 63% had also a safety representative of the employees. Some 30% had a contract with an OH service, and in 39% had carried out rik assessment.

Figure 2. Health and safety activities and resources in Estonian companies

Source: Labour Inspectorate

5. Occupational accidents and occupational diseases

Even though a great deal of development and improvements of occupational health and safety legislation has taken place, Estonia still has no formal system of state insurance for occupational accidents and diseases. This has been one of the most important issues in the debate for promoting occupational health and safety. (5)

According to the Action Plan for Growth and Jobs 2005–2007, one of the key activities is improving the working environment through a more effective implementation of occupational safety requirements and developing the accident at work and occupational

10 disease insurance system, as well as a system for preventing accidents at work and occupational diseases. (6)

Occupational accidents

The number of reported occupational accidents has been decreasing (Tabe 5), and was according to the Labour Inspectorate (Tööinspektsioon) only 564 per 100 000 employees in 2005. It is unlikely that the reduction is caused by better implementation and monitoring of safety requirements since the number of lost working days due to occupational accidents remains high, totalling 145 000 days in 2004. The most serious accidents and fatalities occurred in construction, agriculture and forestry, transport and industry.

Table 5. Reported occupational accidents in Estonia 2000-2006

2000 2001 2002 2003 2004 2005 2006 Fatal accidents 26 30 35 31 34 24 28 Fatal accidents /100000 workers 4,5 5,2 6,0 5,2 5,7 4,0 4,3 All accidents 2428 2421 3115 3230 3326 3300 3651 accidents /100000 workers 518 570 689 637 558 564 558

Source: Labour Inspectorate

In Estonia occupational accidents and occupational diseases are reported by employers. The number of accidents is clearly under-reported. Next graph (Figure 3) illustrates the statistics problem of Estonian reporting system of occupational accidents.

4500

4000

3500

3000 3221

2500 EU-15 Estonia 2000

1500

1000 689 570 637 439 567 518 558 564 558 350 349 384 500

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Figure 3. Occupational accidents per 100 000 workers in Estonia and EU-15

Source: Labour Inspectorate and Eurostat

The low registered number of accidents is partially due to the fact that accidents of the self-employed persons have been registered as domestic accidents. From January 2007 accidents affecting the self-employed while working together with other employees are

11 registered as occupational accidents. The change of law is expected to increase the total number of accidents by 10%. (5)

Compared to the previous year, 2006 brought an increase in the number of fatal occupational accidents in Estonia. However, the year-to-year variation is quite big due to the generally low number of fatal accidents partly related to the relative small size of work force in Estonia (Figure 4).

6 EU-15 5 5,7 Estonia

4 4,5 4,0 3

2 2,5 1

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Figure 4. Fatal accidents per 100 000 workers in Estonia and EU-15

Source: Labour Inspectorate and Eurostat

The decrease in the figures since 2003 does not reflect an improvement in the situation, but rather stems from amendments to the law, according to which accidents happening on the way to or from work are since 1 July no longer considered occupational accidents.

The number of registered occupational accidents and workdays lost due to occupational accidents increased until 2002 (Table 6). This growth was caused by neglect of safety requirements, improved registration of accidents and an amendment to the law, according to which the benefit for temporary incapacity for work in the extent of 100% of average income is since 1999 paid for all occupational accidents (previously only for occupational accidents caused through the employer's fault).

Table 6. Number of workdays lost due to occupational accidents

2000 2001 2002 2003 2004 2005 2006 number of workdays lost 157 051 149 564 171 850 146 411 118 941 125 314 131 508 due to occupational accident Percentage of total number of 3,1 3,2 3,7 3,0 2,2 2,3 2,3 sick –leave days

Source: Estonian Sickness Fund

Occupational diseases

Diagnosis of occupational diseases is aggravated by several factors: proving the presence of links between the disease and the risk factors in the working environment is particularly problematic. This indicator is also influenced by the availability of occupational health care services (incl. the insufficient number of occupational health physicians in the county). Next graph (Figure 5) gives the time series of occupational diseases per 100 000 workers in 1993-2006 in Estonia.

60 58 58 50 49 40 42

30 31

20 25 22 22 18 18 17 17 16 10 12

0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Figure 5. Occupational diseases per 100 000 workers in Estonia

Source: Labour Inspection

The number of reported occupational diseases is low, as seen from the table 7. One reason is the insufficient number of trained occupational health physicians at the outpatient clinics. More complicated cases can be diagnosed at the Clinic of Occupational Diseases in Tallinn.

Table 7. Reported occupational diseases in Estonia

Main diagnosis 2000 2001 2002 2003 2004 2005 2006

Vibration disease 137 117 45 15 30 12 10 Hearing disorder 60 42 22 21 20 17 18 Repetitive strain injuries 128 97 48 55 66 61 79 Other occupational diseases 30 25 15 11 16 7 10 Total 355 281 129 102 132 97 117

Source: Labour Inspection

On the first place are muscular-skeletal disorders, followed by vibration disease, noise- induced hearing loss and erysipelas among the meat processing workers. Hazardous substances, like asbestos, are still in use, but only incidental cases of asbestosis have been diagnosed. The socio-economic situation is the reason of the spreading of infectious diseases, like tuberculosis, which has been registered among medical personnel. There

13 are also evidence of increasing psycho-social stress caused by harassment and threat of violence at work. Among the cases diagnosed in recent years, the number of vibration syndromes has decreased and the number of repetitive strain injuries (caused by handling loads, incorrect working posture, and forced posture) has risen. While the vibration syndrome cases formed 39% of all diagnosed occupational diseases in 2000 and 23% in 2004, the proportion of repetitive strain injuries in the same years was 36% and 49% respectively.

6. Occupational health services

Occupational health services are organised on a free market basis. Bigger companies run their own clinics. Some private occupational health clinics also offer their services to enterprises. Government do not subside the costs of service in any way.

The coverage of service is low, an estimate is 30%. Postgraduate specialisation training for physician and nurses has been organised. Estonian occupational health and safety experts have also received postgraduate and upgrading training through several bi- and multilateral projects funded by EU, Finland and other countries.

7. Resources

The numbers of experts in various categories is described in Table 8.

Table 8. Occupational health and safety experts by category

Professional group No. involved Value indicator Unit including part-time workers Occupational health 42 0.07 /1,000 physicians employed Occupational health 20 0.03 /1,000 nurses employed Occupational 2 0.003 /1,000 hygienists employed Labour safety 90 0.15 /1,000 inspectors employed

8. Main problems on OHS

- low priority of occupational safety and health in politics - no centre of excellence - low coverage of service - occupational accident and diseases insurance system not existing

9. Main priorities for the next 5 years

- raising awareness of the importance of occupational health and safety among employers and employees, and among general public - starting new dialogue between the government and social partners on occupational health and safety (activating tripartite Advisory Committee on Working Environment) - strengthening legislative base (Law on Occupational Health Services, Law on Occupational Accidents and Diseases Insurance system) 14 - competence building of occupational health service experts

References

1. Kaadu T, Tammaru E, Rünkla E. Contry profile: Estonia. In: Rantanen J, Kauppinen T, Lehtinen S, Mattila M, Toikkanen J, Kurppa K, Leino T (eds.) Work and health country profiles of twenty-two European Countries. People and Work Research Reports 52. Finnish Institute of Occupational Health, Helsinki 2002:103–20. http://www.ttl.fi/NR/rdonlyres/CD02E563-0717-4A3C-B97A- 90FFBFA7306C/0/estonia.pdf, accessed on 20 October 2007. 2. ILO. Labour force survey 2006. 3. http://web.worldbank.org 4. World Information Society Report 2007. http://www.itu.int/osg/spu/publications/worldinformationsociety/2007/report.html, accessed on 20 October 2007. 5. Karu M, Roosaar L. Quality of work - Estonia. http://www.eurofound.europa.eu/ewco/studies/tn0612036s/ee0612039q.htm, accessed on 20 October 2007. 6. Action Plan for Growth and Jobs 2005–2007. For implementation of the Lisbon Strategy, Republic of Estonia. Tallinn. 2005.

15 Finland

1. Geography and demography

Area

Finland has been an independent republic since 6 December 1917. Its area covers 338,000 km2 (population density 15 per km2). The capital city is Helsinki (540,000 habitants), and the official languages are Finnish (spoken by 93% of the population) and Swedish (6%). The country is divided into five provinces and some 400 municipalities.

Population

The population of Finland was 5.277 million in 2007. Sixty-three percent of the population lives in urban areas.

Table 1. Population by age groups, in 2006, in thousands

Age Total population Men Women 0–14 901 460 441 15–74 3972 1986 1986 75– 404 138 266 Total 5277 2584 2693

Source: ILO labour force survey

Labour force

Table 2. Key indicators in the labour force survey by sex 2007/09 - 2006/09

Year/Month Change

2007/09 2007/08 2006/09 2007/09 - 2006/09 Per cent (% Per cent (% Per cent (% Percentage points (% ) ) ) ) Indicator Sex Both 69.3 71.5 68.7 0.6 Employment rate sexes (population aged 15-64) Males 70.7 74.1 70.7 0.0 Females 67.9 69.0 66.7 1.1 Both 6.4 5.9 6.8 -0.5 sexes Unemployment rate Males 6.0 5.3 6.2 -0.2 Females 6.8 6.6 7.5 -0.8 Both 66.3 68.3 66.0 0.3 Labour force participation sexes rate Males 68.3 71.4 68.2 0.2 Females 64.2 65.1 63.8 0.4

Source: Labour force survey 2007, September. Statistics Finland

2. Economy

Table 3. Gross domestic product at market prices

At reference year 2000 At current prices prices € billion €/inhabitant € billion 2000 132,3 25 555 132,3 2005 157,2 29 964 149,9 * 2006 167,1 31 723 157,4 * * preliminary data

Source: Statistics Finland, National Accounts

3. E-policies and Digital Opportunity Index

The Government will promote the development of the information society by: • ensuring that citizens have access to fast broadband connections, • improving citizens’ information society skills, 17 • promoting confidence in information society services, • reforming operating models and structures, developing Government services and administration and putting them on an electronic basis, • promoting similar developments in local authorities and the business sector, • taking educational policy measures, • investing in research and product development, • supporting other actors in the information society, • participating in important projects promoting the information society, and • issuing relevant legislative measures.

The Information Society Programme consists of seven sub-sectors: • telecommunication infrastructure and digital television • citizens' ability to utilise the information society and security • training, working life, research and development • utilisation of ICT in public administration • electronic commerce and digital contents • legislative measures • international dimension.

Table 4. The Digital Opportunity Index of Finland

Opportunity Infrastructure Utilization DOI 2005/06 2005/06 2005/06 2005/06 Estonia 0.99 0.65 0.44 0.69

Source: World Information Society Report 2007

4. OSH legislation and actors

The leading occupational safety and health authority is the Ministry of Social Affairs and Health. It is responsible for policy making of occupational health and safety. The coordination of policies and activities at the national level takes place in ministerial groups at the government level: the ministers of neighbouring sectors coordinate their policy making. The OSH Department of the Ministry coordinates its activities mostly in negotiations with the other ministries and social partners, first of all in the Advisory Committees which constitute a broad consultative mechanism with social partners and other relevant stakeholders. The coordination mechanisms cover the whole OSH sector described in Figure 1. The workplace is considered to be the main focus and arena of the OSH activity.

Figure 1. OH&S system in Finland (6)

5. Occupational accidents and occupational diseases

Occupational accidents

The statistics on occupational accidents are collected into the official statistics of Finland from notifications made by the employers to the accident insurance institutions on the basis of legislation, from the Farmers' Social Security Institution and from Statistics Finland's own labour force surveys. The Federation of Accident Insurance Institutions (FAII) collects its own statistics on the basis of notifications made by employers as stipulated by law.

All accidents that happen at work, in traffic work and in commuting traffic of all sectors of the economy, including industries, services, the private and public sectors, and the self-employed and entrepreneurs are registered. This results in higher absolute and relative figures than in many other countries, where only the accidents that happen at work may be registered. (Annex 1)

According to claims statistics filed by the FAII the total number of accidents was 128 000 and the accident rate 28.3 accidents per million hours worked in 2005. Sever injuries account for 10% of total. On average, five employees in every hundred were injured in occupational accidents. About 70% of all occupational accidents and diseases occur to men.

19 The registration of minor accidents leading to less than 3 days of disability explains about 30% of the total injury burden, commuting accidents about 13%, and the accidents of the self-employed and farmers about 7% of the total number of accidents. Thus, if only the accidents of wage earners at work, leading to an absence of 3 days or more, were to be registered, the figures would be almost 50% less than they are at present.

The total number of occupational accidents has declined substantially after the mid-70s. The total number of fatal accidents has fallen in the past 10-year period 43% and the rate 45%, respectively.

The risk occupations are in construction, food industry, wood working, machine and metal workshops, pulp and paper production, agriculture, road traffic, rubber and plastics product work, packing and storehouse work and stevedoring, which all show twice as high a risk for occupational accident as the average of all occupations.

Occupational diseases

The Act 1343/1988 on Occupational Diseases defines an occupational disease as a disease caused by physical, chemical or biological factor at work or by physical overload and poor ergonomics (e.g. repetitive strain). The statistics on occupational diseases is collected by the Finnish Institute of Occupational Health and FAII.

The number of new and suspected occupational disease cases compensated was 5311 in 2005. The frequency of compensated occupational disease was at 1.4 paid claims per million hours worked. On average, 20 cases per 10 000 workers occurred in 2005. Both the number and the frequency of occupational disease claims paid out have declined 50% in the past 20 year's time.

Repetitive strain injuries, hearing loss, dermatoses, respiratory allergies, and asbestos- related diseases comprise 80% of all occupational morbidity. The risk occupations are food workers, construction workers, farmers, forestry workers and fishers, metal foundry and engineering shop workers, wood workers, chemical industry workers, pulp and paper workers, who have three to six-times higher risk than on average among all occupations.

Altogether 152 claims for fatal occupational accidents and diseases were compensated in 2004. Most of the deaths (110) were caused by asbestos exposure in shipyards or on construction sites during the 1960s and 1970s. The fatality risk figure for men in occupational accident or illness was 14 deaths per 100 000 employees. The risk for men to have a fatal work accident was 13 times bigger than that of women.

6. Occupational health services

The occupational health services in Finland are based on four main laws: the Occupational Health Care Act (1383/2001), the Occupational Safety and Health Act (738/2002), the Act on Occupational Safety and Health Administration (16/1993) and the Act on the Supervision of Occupational Safety and Health (44/2006). In addition, the Sickness Insurance Act (1113/2005) provides detailed regulations on reimbursement and follow-up of occupational health services.

The purpose of the Occupational Health Care Act is to ensure a safe and healthy work environment, the prevention of work-related diseases and accidents, the promotion of the work ability and functional capacity of employees, and the provision of preventive occupational health services for the employees. The implementation of the Act is guided by the Government Decree 1484/2001, which gives more detailed requirements for the conditions of operation and for the content of services.

20 The current OH service has the following key elements: • comprehensive services covering physical, medical, psychological and social aspects of work • multidisciplinarity • prevention and promotion • quality-oriented and evidence-based • integrated with other activities of the company • collaborating with other services of the enterprise and those outside the company • based on the principle of participation of workers and employers.

Each employer is obligated to organize services for his/her employees. The organization and content of services need to be based on a prioritized safety and health needs assessment, a company-wide occupational health action plan, and in the case of external service providers, on a formal contract between the employer and the service provider.

According to the Work and Health study, in 2006, employers had organized occupational health services for 92% of employees, for whom 93% also had medical treatment included in the service. The coverage of occupational health services is much lower in small companies (55%). The coverage among agricultural entrepreneurs (63%), and among other entrepreneurs and the self-employed (37% in 2006) is also quite low, but for them OH services are voluntary.

The model of service provision can be chosen by the employer in consultation with the workers (Figure 2). Municipal health care centres are responsible for providing occupational health services to employers who request them. Employers may also organize occupational health services themselves, or through private service providers. The farmers and most of the entrepreneurs are served by municipal health care centers. The trend among bigger companies is moving away from self-organized services to occupational health services organized by private providers.

The compliance of the employer is inspected by the OSH Authorities, whereas the content of the contract, as well as competence and activities of the health personnel are supervised by the health authorities.

The Social Insurance Institution reimburses employers 60% of the costs of preventive services and 50% of the expenses of medical care.

The content of the services stipulated in the legislation and the Government Ordinance is mainly preventive. Curative activities and the provision of general practitioner-level health services may also be included. The tasks of occupational health professionals in the provision of services include: • Surveillance of the work environment • Initiatives and advice on the control of hazards at work • Surveillance of the health of employees including vulnerable groups • Monitoring and provision of rehabilitation advice for handicapped workers • Planning and follow-up of measures for maintaining the employees' work ability • Adaptation of work and the work environment to the worker • Organization of first aid and emergency response • Health education and health promotion • Collection of information on workers’ health • Provision of curative services for occupational diseases • Provision of general health care services

Enterprise Enterprise

Self-employed Municipal health Farmers 2004 (2000) care centre Enterprises 64% (61%) Employees 37% (37%) OHS units 33% (31%) Enterprise

Enterprise Enterprises 1% (2%) Employees 18% (25%) OHS units 31% (38%) OHS Enterprise unit

Enterprise

Enterprise Enterprises 3% (4%) Employees 6% (6%) OHS units 7% (7%) Joint model OHS unit

Enterprise

Enterprise Enterprise

Enterprises 32% (33%) Employees 39% (32%) OHS units 29% (24%) Private medical centre Enterprise

Figure 2. Organizational models of OHS in Finland

22 For improving the quality of service the Ministry of Social Affairs and Health and the Finnish Institute of Occupational Health produced the guide on 'Good Occupational Health Practice' for the first time in 1997. The new edition was published in 2007, and was distributed to all 1000 OHS units in the country. It was boosted with a promotional tour and its content is incorporated in the training programmes of OH experts. At the same time a ' Quality Key' -tool for self-assessment of OHS was published and is now in use. The FIOH continues to produce the evidence based OHS practice guides and will coordinate the Cochrane Occupational Health Field and production of systematic reviews (www.cohf.fi).

7. Resources

The numbers of experts in various categories is described in Table 5.

Table 5. Occupational health and safety experts by category

Professional group N involved incl. part- Value indicator Unit time workers Occupational health 2,461 1.04 /1,000 physicians employed Occupational health 2,615 1.10 /1,000 nurses employed Occupational 837 0.35 /1,000 physiotherapists employed Occupational 343 0.15 /1,000 psychologists employed Occupational 150 0.06 /1,000 hygienists employed Labour safety 360 0.15 /1,000 inspectors employed

8. Main problems on OSH

The Finnish workforce is ageing rapidly making the work ability problems more prevalent. Differences in health according to education, occupation and income are large in Finland. Differences in mortality are growing especially fast. When the life expectancy of a 35- year-old male manual worker today is 74 years, can a same aged man in a leading position expect to live until 80.

New substances, new technologies and new work organizations are being introduced, and new flexible work time schedules are being implemented. Problems of light work ergonomics, psychological stress and information work load burden a growing number of workers. New biological hazards and organic materials are arising due to the growing mobility and from new biotechnology products.

At the national level, the enterprises are fragmented, work contracts are shortened, and the continuity of care from a single workplace may disappear. Surveillance of the work environment and of workers' health, assessment of their exposures and risks are becoming more cumbersome and demanding. Today more and more people are self- employed. Such challenges differ substantially from those of the traditional manufacturing industries for which occupational health services were originally designed.

The Finnish OHS model which is based on a wide societal consensus, special legislation, a well-established service infrastructure which to some extent is also a part of the municipal primary health care infrastructure, has good possibilities to adapt to the new conditions. 23

But much still remains to be done to tackle both the traditional and new problems of OHS. The substantive content and the methods, as well as the competence of the OHS staff need to be continuously evaluated and renewed.

New service models are needed to provide services for the increasingly fragmented work life, the micro-enterprises, the self-employed, distant and teleworkers and other home workers. Experiments are going on concerning several optional models at local and regional levels. The projects will be evaluated, and choices will be made on the basis of the experiences learned in the development projects.

9. Main priorities for the next 5 years

Within the working-age population there are still considerable health gaps between the different socioeconomic groups. The health gaps among the employed population are based - not only on factors related to work - but also on health behaviour. Apart from improving work, work environments and workplace organisation it is also important to focus on tackling health risks related to lifestyles. In occupational health care measures should be increasingly aimed at branches and occupations in which employees are most vulnerable to risks at work.

The main aim of Finnish healthcare policy is to prolong people's health and the lifespan of their functional ability. It aims to safeguard the possibility for everyone to enjoy a good quality of life, diminish health differences between population groups and reduce the rate of premature death. This demands that attention is paid to the health factor of all societal decision making. Health is integral to social policy.

The Programme of Prime Minister Matti Vanhanen’s second Cabinet includes three cross- sectoral policy programmes: 1) The policy programme for health promotion; 2) The policy programme for employment, entrepreneurship and worklife; and 3) The policy programme for the wellbeing of children, young people and families. All these policy programmes include elements that have to do with work life and wellbeing at work. The objectives of the policy programme on health promotion are to improve the general state of health of the population and to narrow the health gaps between individuals. The policy programme continues the development work along the lines of our “Health in All Policies” thinking – meaning that it cuts across the traditional boundaries between administrative sectors.

Occupational Health 2015 – Development Lines

The Government Resolution on Occupational Health 2015 came in force in 2004. It lines the development of occupational health care up to 2015. The Resolution was prepared by the tripartite Advisory Committee on Occupational Health Cares under the Ministry of Social Affairs and Health. The ten development lines are:

Development line 1. Legislation The Ministry of Social Affairs and Health is responsible for the preparation and development of legislation on occupational health cares in collaboration with the labour market organizations and other partners important for occupational health cares.

Development line 2. Content of occupational health care The Ministry of Social Affairs and Health, the Finnish Institute of Occupational Health, and the expert organizations in collaboration with the occupational health service units will develop the content of occupational health care and high-quality procedures to ensure good occupational health practice, taking different types of employment relationship into account.

24 A good deal of emphasis in occupational health care will be placed on activities at the workplace, and on strengthening cooperation between occupational health care and the workplace.

Practical methods will be developed, evaluated and verified, and training will be provided to support their adoption. Good evidence-based practices in occupational health care will be evaluated and developed.

Development line 3. The occupational health service system The Ministry of Social Affairs and Health, the State Provincial Offices, the municipalities, the Occupational Safety and Health Inspectorates, the Finnish Institute of Occupational Health, occupational health service units, and other actors in the field of health care will collaborate to ensure that occupational health services are comprehensive and easily accessible for employers, employees, entrepreneurs, and self-employed persons.

Regional cooperation projects between municipalities and service providers will be launched within the occupational health service system.

When occupational diseases are suspected, access to examination will be guaranteed independent of industrial sector, trade or profession, or locality.

The support services needed to implement occupational health services will be of high quality and produced throughout the country on a comprehensive regional basis, using the network of the Finnish Institute of Occupational Health and other networks and partners that operate regionally.

Development line 4. A funding and compensation system for occupational health care The Ministry of Social Affairs and Health and the Social Insurance Institution will collaborate with the labour market organizations to develop a funding and compensation system to promote the effectiveness of occupational health services in the workplace. The compensation side will be developed so that it supports a flexible provision of services.

Development line 5. Human resources in occupational health care The extent of the range of services will be supported in collaboration with the Finnish Institute of Occupational Health, the universities and polytechnics, and other partners. Training programmes will be drawn up for all the experts required by the Act on Occupational Health Care.

The quality of the training and the qualification of the persons trained will be ensured by overhauling the training programmes, and by examinations and certificates. The training for instructors in the sector will be improved.

The Ministry of Social Affairs and Health and the Ministry of Education in collaboration with other partners will take care that the human resources for occupational health care are sufficient. They will also ensure that there is sufficient funding for occupational health service training so that occupational health services can be implemented according to good occupational health practice.

The professional skills of occupational health service personnel will be supported in accordance with the instructions on further education issued by the Ministry of Social Affairs and Health.

Development line 6. Ethics of occupational health care The Ministry of Social Affairs and Health, the Finnish Institute of Occupational Health, the Finnish Association of Occupational Health Physicians, the Finnish Association of Occupational Health Nurses, and expert organizations in the field of occupational health

25 services will cooperate with the labour market organizations to increase the effectiveness of continuous education on ethical issues and the dissemination of information.

The guidelines on professional ethics for occupational health service professionals and experts will be overhauled. There are provisions in the legislation on the use of information on the health of employees and on passing it on to another party. Instructions on the implementation of these provisions are now being drawn up. Although information on the health of private persons is protected, it will also be made available for use in occupational health services, if necessary. The right of employers to obtain information and the responsibility to provide information on health and on health hazards in the workplace will be secured in such a way that the privacy of the individual will not be endangered. The right of the employee to be made aware of the risks associated with occupational health and safety and the right to information on his/her own health will be guaranteed.

Development line 7. Cooperation The Ministry of Social Affairs and Health, the Finnish Institute of Occupational Health, the State Provincial Offices and the Occupational Safety and Health Authorities in collaboration with the health services will support cooperation as required by the Act on Occupational Health Care.

Workplaces and occupational health service units will incorporate cooperation as a part of planning, and it will be taken into account in the assessment of operations. Cooperation between occupational health services and other health care providers, the labour administration, the education administration, the social insurance system, the social services and the Occupational Safety and Health Authorities will be made to collaborate more closely and more effectively.

Cooperation models will be developed for joint occupational health services in workplaces.

Development line 8. Information management systems in occupational health care The Ministry of Social Affairs and Health will coordinate the development of information systems in collaboration with the institutions in the sector.

Information systems and tools to assist in the planning, implementing and monitoring operations will be introduced in occupational health services. Registration and the use of statistical material and databases in the sector will be promoted by increasing user- friendliness and cooperation in maintaining registers. Linking occupational health services with information technology and Internet projects in the social and health care sector will be supported. External expert services and information services that support occupational health care will be further developed as Internet services to be used by experts and workplaces.

Development line 9. Research and development in occupational health care The Finnish Institute of Occupational Health, the Ministry of Social Affairs and Health, and the Social Insurance Institution in cooperation with the universities and other research institutes and key stakeholders will continue research and development work on occupational health care and agree on joint research programmes and cooperation with other programmes.

Research-supported experiments will be launched to develop occupational health services for special groups, small workplaces and self-employed persons. The impact of occupational health care on well-being at work and on remaining longer at work will be examined in an evaluation study. The economic impact of occupational health services will also be studied. The service system will be developed continuously with the aid of research interventions.

26 Development line 10. Monitoring and supervision The Ministry of Social Affairs and Health will be responsible for monitoring the implementation of the development strategy in occupational health care.

The Finnish Institute of Occupational Health will produce information on more detailed monitoring of the Act on Occupational Health Care and the development strategy using the 'Work and health in Finland' and the 'Occupational health services in Finland' surveys, and research and statistics on work life and working conditions. The Social Insurance Institution will produce information on the operation of occupational health care using data obtained through the compensation system.

Wellbeing at work and remaining at work longer than before requires a sufficient supply of occupational health care professionals and experts and improvement of training, the occupational health care service system and occupational health care content so as to make sufficient high-quality occupational health care services available to all employees, entrepreneurs and other self-employed persons. It is also important to maintain the health and working capacity of the unemployed to help them find employment.

These targets require an increase in allocations from the State budget and investments on the part of occupational health care service providers in the development of the content and functioning of their services. The effectiveness and functioning of occupational health care require employers and employees to commit to a healthy and safe working life.

References

1. Ministry of Social Affairs and Health; Safety at work http://www.stm.fi/Resource.phx/eng/subjt/safet/index.htx 2. ILO. Labour force survey 2006. 3. Worldbank http://web.worldbank.org 4. World Information Society Report 2007. http://www.itu.int/osg/spu/publications/worldinformationsociety/2007/report.html, accessed on 20 October 2007. 5. Lehto A-M. Quality of work and employment - Finland. http://www.eurofound.europa.eu/ewco/studies/tn0612036s/fi0612039q.htm, accessed on 21 October 2007. 6. National Occupational Safety and Health Profile of Finland. http://www.stm.fi/Resource.phx/publishing/store/2006/05/aa1155885585766/pass thru.pdf, accessed on 21 October 2007. 7. Occupational accidents and diseases in Finland. Review of trends in 1996-2004. Federation of Accident Insurance Institutions, Helsinki, 2007. www.tvl.fi

27 Latvia

1. Geography and demography

Area

The capital city is Riga (760,000 habitants), and the official language is Latvian (spoken by 56% of the population). The country is divided into 26 regions and 473 municipalities. Latvia has been an independent republic since 18 November 1918, it regained independence on 4 May 1991. The area of Latvia is 65,589 km2 (population density 38.1 per km2).

Population

The population of Latvia was 2.4 million in 2007, and 68.1% of the population lives in urban areas.

Table 1. Population by age groups, in 2006

Age Total population Men Women 0–14 328.6 168.1 160.5 15–74 1809.8 848.5 961.3 75– 156.5 40.9 115.6 Total 2294.9 1057.5 1237.4

Source: ILO labour force survey 2006

28 Labour force

Table 2. Rates of economic activity, employment and unemployment in percentage, in 2006

Rate of economically active Rate of employed to the Rate of unemployed to the population to the total total population economically active population population TOTAL Males Females TOTAL Males Females TOTAL Males Females 15- 71.3 76.2 66.6 66.3 70.5 62.3 7.0 7.4 6.5 64

Source: Central Statistical Bureau of Latvia

2. Economy

Table 3. Selected economic indicators of Latvia

2000 2005 Gross national product per 2,846 6,770 capita, USD Gross domestic product 2,835 (GDP) per capita, purchasing power parity, USD

3. E-policies and Digital Opportunity Index

The National Information Society Strategy in Latvia has been prepared 'e-Latvia 2005– 2009' (http://ec.europa.eu/idabc/servlets/Doc?id=23412). The main priorities are e- Government, e-Learning, e-Business and welfare, e-Health, Broadband and access to services, and Security. According to the EU Policy Brief, which is available and accessible at http://www.litta.lv/documents/konferences /05/mikelsons-niedra_brief_latvia.pdf, the key challenge for Latvia to expand the use of e-Government services is related to improved access for citizens to Internet. On-going investment in public internet access points is one obvious solution.

The Latvian Information Technology and Telecommunications Association, LIKTA, is a professional association, founded in 1998, that regroups over 60 important ITTE product and service providers and educational institutions, as well as over 150 individual professional members of the ITTE industry sector in Latvia (computer hardware and software, electronics, telecommunications infrastructure, and service providers). LIKTA member organizations employ over 15,000 people. The principal objective of LIKTA is to promote and further the development of Information Society in Latvia, so that all citizens may be given the opportunity to benefit from ICT and contribute to the Knowledge-based economy.

According to LIKTA, Latvia wholly endorses the objectives of e-Europe and intends to become a full partner of the knowledge-based global economy. It has elaborated its own e-Latvia strategy, as well as an e-government model. Crucial prerequisites for this mission are a knowledgeable, ITT-literate population and a well developed ITTE industry. http://www.litta.lv/en/about/.

LIKTA has taken the initiative of licensing and setting up the European Computer Driving License (ECDL) certification programme in Latvia and the development of applied informatics courses for schools, compatible with ECDL requirements.

This will improve the level of knowledge among the general population about information technologies, increase their computer and Internet usage skills, and enable people to benefit from modern technologies. All these activities are crucial from the point of view of the successful development of electronic information services in the country.

There is no single strategic policy document called "National e-Inclusion Strategy". The Latvian e-Inclusion policy is being implemented and will be developed in accordance with several policy planning documents, including: • Concept paper "The Growth Model for Latvia: People First", based on human- oriented growth scenario approach (2005) • Latvian National Development Plan for 2007-2013, aimed at promotion of balanced and sustainable development and competitiveness of the country (2006) • Information Society Development Guidelines for 2006-2013 (2006) • Lifelong Learning Policy Guidelines for 2007–2013 (2006) • Education Development Guidelines for 2006–2013 (2006) • State Culture Policy Guidelines for 2006-2015 (2006) • The Concept "e-Health in Latvia" (2005) • Broadband Development Strategy for 2006-2012 (2005) • Latvian e-Government Conception (2002) • E-Government Development Programme for 2005 – 2009 (2005) • Conception for e-Procurement System (2006) • State Unified Library Information System Conception (2001) • Policy Guidelines for Reduction of Disability and it’s Consequences • Conception on eServices Development (in drafting).

Table 4. The Digital Opportunity Index of Latvia

Opportunity Infrastructure Utilization DOI 2005/06 2005/06 2005/06 2005/06 Latvia 0.98 0.42 0.23 0.54

Source: World Information Society Report 2007

30 4. OHS legislation and actors

The organizational structure of state authorities and services, responsible for occupational health and safety in Latvia is described in Figure 1.

Figure 1. Occupational health and safety system in Latvia

The Ministry of Welfare is a state administration institution that creates and coordinates the social security policy of the State. The purpose of Ministry of Welfare is to develop a democratic, stable, responsible, and viable social security system that would enable the possibility to protect the social and economical rights of every person. Under the supervision of the Ministry are the areas of social assistance, social insurance, labor and gender equality. In order to achieve the goal set, the Ministry solves the following issues using political, economical, and legal means: • Issues of social insurance, social care, and social assistance; • Problems related to labour and labour protection, employment, and unemployment; • Issues related to ensuring and implementation of principles of gender equality. The Ministry of Welfare operates in accordance with the Law on Institution of Ministries and the Rules of Ministry of Welfare. The political priorities of operation of the Ministry are being set in accordance with the Declaration on the proposed activities of Cabinet of Ministers, and policy planning documents developed by the Ministry. The central apparatus of the Ministry of Welfare comprises nine departments, as well as two independent departments.

The State Labour Inspectorate (SLI) is a state administrative and supervisory institution. Its activity is determined by the “State Labour Inspectorate Law”. The following persons and institutions are subjected to the supervision and control of the SLI: entrepreneurs, the state and municipal institutions, religious and nongovernmental organizations, employers and their representatives according to the mandate and responsibilities delivered to them, dangerous equipment and their owners, as well as workplaces and other places at the enterprises available for the employees during their work process. The main task of SLI is to take measures to ensure effective 31 implementation of State policy in the field of labour legal relations, labour protection and the technical supervision of dangerous equipment. In implementing the above mentioned task, officials of the SLI perform the following functions: • Control equipment at the work places, the usage of individual and collective protective means, the usage of dangerous and harmful substances, as well as the compliance of technological processes with the requirements of regulatory enactments. • Control the fulfilment of obligations of employers and employees determined by employment contracts and collective agreements. • Promote cooperation between employers and employees, as well as to take measures to facilitate the prevention of differences of opinion between the employers and employees. • Deal with the matters of labour legal relations, labour protection and technical supervision of the dangerous equipment, as well as provide free consultations regarding the above mentioned issues. • Carry out investigation and registration of occupational accidents, as well as participate in the investigation of occupational diseases. • Control equipment and facilities at work places, utilisation of individual and personal protective means in conformity with regulatory enactments. • Register the dangerous equipment, issue permits for the commencement of operation of such equipment, as well as investigate accidents with dangerous equipment in accordance with the procedures prescribed by the Cabinet. • Issue licences and carry out repeated registration of certificates, extend the term of their validity or annul these certificates in the cases when entrepreneurs have intended to perform the following activities: industrial blasting, pyrotechnic services, production or maintenance of electronic shocking devices, storage of pyrotechnic products, explosive substances, detonators or their accessories in order to perform the previously mentioned activities or to provide services.

The Institute of Occupational and Environmental Health (IOEH) is a structural part of the Riga Stradiņš University. The main purpose of the IOEH can shortly be defined as generation and dissemination of information on the interaction of working and general environment and human health as well as provision of training in the field of occupational and environmental health. Its main purpose is to promote practical implementation of generated information in order to create healthier and safer working environment for everyone. Such goal certainly requires a wide range of activities in the field of Occupational and Environmental Health.

5. Occupational accidents and occupational diseases

Accidents at work

The State Labour Inspectorate (Valsts Darba Inspekcija, VDI), which is the state supervisory and control institution responsible for labour protection in Latvia, reports that both the number of workplace accidents and deaths arising from workplace accidents, have increased over the past few years.

According to the annual report of VDI, some 1,568 workers out of a total of 1.048 million employed people were victims of workplace accidents in 2005; some 56 of these persons died and 275 were seriously injured. In 2004, 1,402 workers were victims of occupational accidents, 61 of whom died and 254 of whom were seriously injured

The table 5 below outlines the number of workplace accidents per 100,000 workers; these findings are also drawn from the VDI Annual Report 2006, which the inspectorate prepares for the International Labour Organization (ILO). If one compares the number of casualties per 100 000 workers given in the table with the data in the aforementioned paragraph, an obvious discrepancy emerges, despite the fact that both data come from 32 official sources. This discrepancy can be explained by the fact that different data sources were used to compile the workplace accident statistics.

Table 5. Occupational accidents per 100 000 workers, in 1995–2006

Occupational accidents per 100 000 workers, in 1995–2006 199 199 199 199 199 200 200 200 200 200 Year 2005 2006 5 6 7 8 9 0 1 2 3 4 No 173 163 136 135 137 146 140 150 145 136 169 177

Source: VDI, Annual Report 2006, p.5

Table 6. Breakdown of accident victims by sectors according to NACE classifier

Sectors Including Total Serious Fatal 2005 2006 2005 2006 2005 2006 A Agriculture, hunting and 82 78 19 20 3 8 forestry B Fishery 4 3 0 2 1 0 C Mining and quarrying 9 10 5 1 0 1 D Processing industry 534 587 83 86 9 16 E Electric energy, gas and water 40 36 6 3 6 1 supply F Construction 172 217 67 65 15 10 G Wholesale trade and retail trade; 107 147 15 21 2 0 repair of cars, motor-cycles, personal and household goods H Hotels and restaurants 20 13 1 0 0 1 I Transport, storage and 261 285 39 33 10 8 communication J Financial intermediation 9 1 2 0 1 0 K Real estate transactions, renting, computer 24 24 1 7 1 3 services, science and other commercial services

Total 1582 1716 276 286 56 53

Source: VDI, Annual Report 2006, p.5

Occupational diseases

Number of occupational diseases and patients revealed for the first time during a year, has been gradually increasing since 1993 until 2004. In 2005 there was a slight decrease in occupational diseases and patients registered for the first time. Number of first time patients in 2004 exceeded that of 1993 by 9.5 times, but number of first time diagnosis – by 14.5 times.

In Latvia 184.5 new cases per 100,000 employees were registered in 2004 and 162.7 cases in 2005, while in 2000 occupational morbidity rate was 83.6 cases per 100,000 employees

250

184.5 200 156.2 162.7

150 121.9 Total 95.4 83.6 Men 100 Women 47.5 35.1 50 20.4 26.3

0 199 199 199 199 200 200 200 200 200 200 Number of diseases 6 7 8 9 0 1 2 3 4 5 Year

Figure 2. Dynamics of occupational diseases annually registered for the first time in Latvia per 100,000 employees, 1996 - 2005 (figures indicate total numbers).

Table 7. Number of occupational patients revealed for the first time during a year

Number of occupational patients revealed for the first time during a year Total Men Women Year Per 100 000 Per 100 000 Absolute Per 100 000 Absolute employed Absolute employed numbers employees numbers men numbers women 1993 82 - 43 - 39 - 1994 185 - 72 - 113 - 1995 174 - 96 - 78 - 1996 109 11,5 55 11,1 54 11,9 1997 118 11,9 77 15,2 41 8,5 1998 149 15,1 75 14,6 74 15,6 1999 211 21,8 108 21,5 103 22,1 2000 232 24,7 105 21,9 127 27,5 2001 332 34,5 150 30,9 182 38,2 2002 433 43,8 181 35,8 252 52,1 2003 554 55,0 235 45,5 319 65,1 2004 786 77,2 343 65,7 443 89,3 2005 782 75,2 370 69,2 412 82,0 2006 589 61,0 - - - - Total 4147 1910 2237

Source: State register of occupational diseases

Table 8. Number of occupational diseases revealed for the first time during a year

Number of occupational diseases revealed for the first time during a year Total Men Women Year Per 100 000 Per 100 000 Absolute Per 100 000 Absolute employed Absolute employed numbers employees numbers men numbers women 1993 127 - 76 - 51 - 1994 284 - 110 - 174 - 1995 311 - 180 - 131 - 1996 194 20.4 94 19.0 100 22.0 1997 260 26.3 179 35.2 81 16.8 1998 346 35.1 196 38.3 150 31.6 1999 434 44.8 223 44.3 211 45.3 2000 760 80.8 344 71.7 416 90.2 2001 891 92.6 392 80.7 499 104.8 2002 1150 116.3 483 95.6 667 137.8 2003 1520 150.9 601 116.2 919 187.6 2004 1847 181.4 750 143.7 1097 221.2 2005 1693 163.4 734 137.4 959 191.0 2006 1111 115.0 - - - - Total 9817 4362 5455

Source: State register of occupational diseases

Similarly to situation worldwide, structure of occupational diseases in Latvia has changed during 1993-2005. Since 1999 there was a dramatic increase in morbidity of diseases caused by physical overloads, such as musculoskeletal and connective tissue disorders, as well as carpal tunnel syndrome, but occurrence of occupational diseases caused by chemical substances and dust has decreased.

The Latvian State Register of Occupational Disease Patients and People Exposed to Ionising Radiation due to Chernobyl NPP Accident mainly contain chronic forms of occupational diseases, which have developed within many years and do not correlate with exposure duration. Therefore, it can be assumed that increase of occupational morbidity in Latvia is more related to other factors than effects of working conditions. Following other factors could be mentioned: • Many years occupational morbidity in Latvia was lower than that of other EU states, therefore, it is probable that due to improved diagnosis and registration of occupational diseases number of cases registered for the first time will still grow. However, considering amendments in legislation, it is hard to forecast onset and speed of such increase in future, • Employees become more aware of occupational risks and signs of occupational diseases; more and more employees are informed on possibilities of receiving financial support in case of occupational diseases (for example, knowledge on occupational risk factors has increased among health care professionals by 7.1%, compared to 2002 (Vanadzinš, 2003), • Number of certified occupational physicians has increased (see Figure 38), and most probably knowledge of physicians has improved as well (for example, duration of training courses for occupational physicians has increased from 50 hours in 1998 to 300 hours in 2006), • In spite that implementation of compulsory health examinations seems to be unsatisfactory number of examinations carried out most probably has increased. Unfortunately, there are no reliable data on this issue.

6. Occupational health services

At present, the leading role in the operation of the occupational safety and health protection system is played by the Ministry of Welfare responsible for development, planning and co-ordination of the labour protection system and policy and by the State Labour Inspectorate, which is the main supervisory and control institution in the field of labour protection, under the supervision of the Ministry.

In order to promote co-operation with social partners (social dialogue) in the field of occupational safety and health, the National Tripartite Co-operation Council– Tripartite Co-operation Sub-Council for Labour Affairs (TCSLA) – was established covering issues of both labour legal relations and labour protection. The Sub-Council comprises representatives of the Ministry of Welfare, Ministry of Justice, State Labour Inspectorate, Latvian Free Trade Union Confederation (LFTUC) and Latvian Employers’ Confederation (LEC).

The structure of the institutional system of occupational safety and health is presented in Figure 3.

MiMiniMi Social partners

Figure 3. Institutional system of occupational safety and health in Latvia

37 7. Resources

The numbers of experts in various categories is described in Table 6.

Table 9. Occupational health and safety experts by category

Professional group No involved including Value indicator Unit part-time workers Occupational health 410 0.41 /1,000 physicians employed Occupational health 50 0.05 /1,000 nurses employed Occupational hygienists 40 0.04 /1,000 employed Labour safety inspectors 139 0.14 /1,000 employed

8. Main problems on OHS

In general, motivational levels are very low and, because organised labour is almost non-existent in small and medium sized enterprises (SMEs), collective agreements rarely cover occupational health and safety issues. VDI has been unable to promote social dialogue in these companies. In addition, economic incentives for employers to invest in occupational health and safety issues simply do not exist.

Decrease in number of first time occupational diseases in 2005 could be explained by amendments in legislation regarding compulsory medical examinations. Cabinet Regulation No 86 “On compulsory medical examination and training in providing first aid” (adopted on 3 April 1997) defined that only a certified occupational physician is authorised to issue final conclusion, whether health status of an employee corresponds to respective working conditions, but Cabinet Regulation No 527 “Procedure for carrying out compulsory medical examination” (adopted on 8 June 2004) establishes that such a conclusion can be issued by both a certified occupational physician and a family physician. Incompetence of family physicians could be one of the reasons leading towards decrease of occupational diseases diagnosed for the first time in 2005 compared to 2004.

Another essential factor pointed out by experts is insufficient capacity of the Centre of Occupational and Radiation Medicine of P.Stradins Clinical Hospital, which is an obstacle for larger number of occupational patients to be wholesomely examined. Calculations show that Commission of Occupational Physicians of the Centre of Occupational and Radiation Medicine, which is working only once a week, is able to examine only 15-30 patients in one session. Thus, patients have to be listed in a queue. Moreover, the Centre of Occupational and Radiation Medicine of P.Stradins Clinical Hospital even lacks a secretary, who would compile and process data and documents of all those patients.

It shall be noted that present costs are mostly related to fighting the consequences (treatment of people suffering from workplace accidents and occupational diseases) rather than preventive measures and rehabilitation (medical, social and professional rehabilitation, which would return employees to labour market after retraining). To improve labour market, the focus shall be switched from treatment to rehabilitation. Early diagnosis of occupational diseases is essential, for example, during compulsory medical examinations. This would increase efficacy of treatment and rehabilitation measures and, thus, prevent cases of disability. This, in its turn,

38 will reduce necessity for long-term compensations from the Special Budget for workplace accidents to be paid in case of permanent loss of work ability.

9. Main priorities for the next 5 years

The Ministry of Welfare (Labklājības ministrija, LM) decided in 2006 of developing a National Action Plan (NAP) for the occupational health and safety strategy, strengthening of institutions in the field of occupational health and safety at work, capacity building of the State Labour Inspectorate and enhancing social dialogue.

Experts from the German Federal Ministry of Economics and Labour (Bundesministerium für Arbeit und Soziales, BMAS) and the Finnish Institute of Occupational Health (FIOH), as well as from Latvian organisations, namely the VDI, the Work and Environmental Health Institute of Rīga Stradiņš University (Rīgas Stradiņa universitātes Darba un vides veselības institūts), the Latvian Employers’ Confederation (Latvijas Darba Devēju konfederācija, LDDK) and the Free Trade Union Confederation of Latvia (Latvijas Brīvo Arodbiedrību savienība, LBAS) have been involved in the planning process (7).

Development of the National Action Plan

The objective of the NAP on occupational health and safety is to facilitate the implementation of the national strategy on occupational health and safety. The main quantitative targets are to reduce the number of accidents at work by 3% a year, as of 2009, along with the occupational sickness rate by 3% starting from 2012.

The Ministry of Welfare has issued two important strategy documents outlining the ‘Conception of the development of labour protection from 2007–2013’ and ‘The programme for development of labour protection from 2007–2010. The panel of experts has recommended several improvements for the existing legislation, especially with regard to clarifying the functions of the public organisations involved and the introduction of a new instrument – namely, the standard of the labour protection practice. The latter practice encompasses a labour protection model created on the basis of the existing legislation. This has been deemed a necessary step in order to help employers and labour protection specialists interpret and apply labour protection legislation, while at the same time not forcing them to commit to anything more concrete.

Strengthening current institutional setting

In an effort to strengthen the current institutional arrangements, the panel of experts has suggested reorganising the Work and Environmental Health Institute into a National Institute for the Working Environment. This institute would serve the state information strategy in the field of labour protection.

Capacity building of State Labour Inspectorate

Capacity building of VDI includes introducing new training models for companies and workers, as well as the implementation of a client’s oriented and sectoral approach.

Enhancing social dialogue

Enhancing social dialogue at company level and in the field of labour protection is necessary, especially in small and medium-sized enterprises (SMEs). A curricula for

39 a training programme for SMEs' on occupational health and safety and training aids were prepared, and 16 national trainers were trained to run this programme.

In March 2007, VDI organised seminars on ‘Social dialogue – gain for all’ in three Latvian cities. In these seminars, international experts reported on the economic impact of an efficient labour protection strategy and the benefit of social dialogue in companies. Linda Matisane presented the results of the study on ‘Working conditions and risks in Latvia’. This study is one of the research projects from the labour market research programme, subsidised by the EU Social Fund.

References

1. Eglite M, Vanadzins I, Matisane L. Country profile: Latvia. In: Rantanen J, Kauppinen T, Lehtinen S, Mattila M, Toikkanen J, Kurppa K, Leino T (eds.) Work and health country profiles of twenty-two European Countries. People and Work Research Reports 52. Finnish Institute of Occupational Health, Helsinki 2002:239–56. http://www.ttl.fi/NR/rdonlyres/ADA80A10-E5FD-4187- 8D9E-F52A183EB70B/0/latvia.pdf, accessed on 19 October 2007 2. ILO. Labour force survey 2006. 3. http://web.worldbank.org 4. World Information Society Report 2007. http://www.itu.int/osg/spu/publications/worldinformationsociety/2007/report. html, accessed on 20 October 2007. 5. http://countryprofiles.wikispaces.com/Latvia, accessed on 19 October 2007. 6. Karnite R. Quality in work and employment - Latvia. http://www.eurofound.europa.eu/ewco/studies/tn0612036s/lv0612039q.htm, accessed on 21 October 2007. 7. Brueckner, B., Twinning project: Occupational health and safety strategy (further development) (314Kb PPT), Presentation of project results, 27 March 2007. Information in Latvian about the project, available at: http://www.lm.gov.lv/index.php?sadala=723&id=3480

40 Lithuania

1. Geography and demography

Area

The capital city is Vilnius (550,000 inhabitants), and the official language is Lithuanian. Lithuania has been an independent republic since 16 February 1918 till the soviet occupation in 1940. Lithuania regained its independence on 11 March 1990. The country is divided into 10 districts and 60 local administrations. The area is 65,300 km2 (population density 52 per km2).

Population

According to statistical data of 2006, the population of Lithuania was 3.40 million people, and 66.47% of the population live in urban areas. The population is composed of Lithuanians (84.6%), Russians (5.1%), Poles (6.3%) and people of other origin (4%).

Table 1. Population by age groups, in 2006

Age Total population Men Women 0–14 560.3 287.4 (51.3%) 273.0 (48.7%) 15–74 2621.9 1235.7 (47.1%) 1386.1 (52.9%) 75– 220.9 63.6 (28.8%) 157.3 (71.2%) Total 3403.1 1586.7 (46.6%) 1816.4 (53.4%)

Source: ILO labour force survey 2006

41 Labour force

The labour force is 1.5883 million people, of which 1.4990 million are employed. The gender distribution is 70.5% men and 64.6% women. The unemployment rate has decreased from 17.4% in 2001 to 5.6% in 2006.

Sources: Department of Statistics to the Government of the Republic of Lithuania (Statistics Lithuania) http://www.stat.gov.lt/en/)

2. Economy

The expansion of the Lithuanian economy is very dynamic with growth rates being among the highest ones in Europe. In 2006, the GDP went up by 7.5% as compared to the year 2005.

The real GDP per capita amounted to EUR 6,996 in 2006, by purchasing power standards GDP per capita amounted to EUR 15300.

Table 2. Selected economic indicators of Lithuania

1998/2000 2005 Gross national product per 2,886 7,210 capita, USD, in 2005 Gross domestic product 3,227 (GDP) per capita, purchasing power parity, USD

Source:

3. E-policies and Digital Opportunity Index

According to a study (Digital Lithuania 2001) carried out in 2001, 73.8% of Lithuanian citizens related the future of Lithuania to the need for an information society, almost as many (72.3%) expected a better life in relation to the development of the information society. Among the barriers to the spread of Internet, according to the respondents, were the high costs and difficulties related to access. A total of 69.2% of the respondents thought that the government was not paying the necessary attention to the issues of the development of information society.

Since then, Lithuania has made a considerable progress in the area of the Information Society and Knowledge Economy development. Many important legal acts regulating and stimulating processes of the Information society were passed, and institutions responsible for coordination of this sector were established.

State’s investments in the information and knowledge society sector have been gradually growing. In 2001 state investments in information society development projects amounted to LTL 80.5 million; 2002 – LTL 90.5 million; 2003 – LTL 99.2 million; 2004 – LTL 114 million; 2005 – LTL 137.5 million. Additional EU funds allotted to these projects in 2002 totalled LTL 9.8 million, 2003 – LTL 47.5 million, 2004 – LTL 61.7 million, 2005 – LTL 63.7 million. In 2006, planned state investments in information society development projects amount to LTL 124.6 million, additional EU funds – LTL 30.7 million. Since 2002, the establishment of public Internet access points has been implemented under the private business initiative Window to the Future. Public Internet access points were established in

42 the most frequented places: libraries, recreation centres, ward offices, community centres and similar. It was aimed at ensuring the maximum distance of 8 to 10 km of the nearest public Internet access point for the rural population.

Table 3. The Digital Opportunity Index of Lithuania

Opportunity Infrastructure Utilization DOI 2005/06 2005/06 2005/06 2005/06 Lithuania 0.99 0.46 0.38 0.61

Source: World Information Society Report 2007

4. OHS legislation and actors

The organizational structure of state authorities and services, responsible for occupational health and safety in Lithuania is described in Figure 1.

LITHUANIAN GOVERNMENT

Lithuanian Safety at Work (tripartite) Council

MINISTRY OF SOCIAL MINISTRY OF HEALTH SECURITY AND LABOUR

Safety at Work (tripartite) Commission

Occupational health institutions Occupational safety institutions

• Occupational Medicine Centre • State Labour Inspectorate • Central Occupational Medicine • Labour Market Training Expertise Commission Authority • Technical Supervision Service • Institute of Labour and Social Research

Figure 1. Occupational health and safety system in Lithuania

Public institutions and establishments, implementing the state policy in the field of occupational safety and health

Ministry of Social Security and Labour within its competency implements the state policy in the field of occupational safety and health (together with Ministry of Health), following provisions of Constitution of the Republic of Lithuania, laws, Governmental resolutions and other standard acts. Minister of Social Security and Labour (on his/her own or in conjunction with other minister or ministers) approves relevant standard acts on occupational safety and health, establishes the procedure of their enforcement and application, represents interests of the Republic of Lithuania in the field of occupational safety and health in other countries and international organizations.

State Labour Inspectorate under Ministry of Social Security and Labour controls compliance with requirements of standard acts on occupational safety and health, other labour relations legislation in enterprises. It also provides consultations to employees, trade unions, employers, safety services in enterprises on issues of safety, occupational hygiene, and compliance with labour laws, also collective agreements and contracts, as well as labour disputes.

The State Labour Inspectorate investigates accidents at work, occupational diseases, applications and requests of employees, participates in investigation of industrial accidents, attestation of employees on issues of occupational safety and health. It also controls the compliance with procedure and terms of inspection of technical status of potentially dangerous equipment as well as performance of permanent supervision, organizes drafting of standard acts on supervision of equipment, performs the functions of the institution responsible for maintenance of state register of potentially dangerous equipment. In addition, it also approves occupational safety and health rules and standard instructions and provides consultations to employers, employees on issues of application of labour laws and prevention of accidents at work and occupational diseases.

Lithuanian Labour Market Training Authority under Ministry of Social Security and Labour performs functions of labour market vocational training, orientation and consultations management and implements state policy in these fields. It organizes development and approval of training programmes of labour market vocational training, including issues of occupational safety and health. Performs expertise of material training basis in enterprises, organizations, educational establishments and submits recommendations to the Ministry of Education and Science on issuance of permits (licences) to provide labour market vocational training.

Technical Supervision Service is a control institution for inspection of various potentially dangerous equipment, accredited by the Lithuanian National Accreditation Bureau in November 2000, following the requirements of the standard LST EN 45004.

Institute of Labour and Social Research is a research institution founded by the Ministry of Social Security and Labour undertaking both theoretical and applied research on the issues of labour and social policy formation and implementation.

Ministry of Health - within its competency implements the state policy in the field of occupational safety and health (together with Ministry of Social Security and Labour) and analyses the population’s health needs, state of health and its

44 forecasts, health care resources, acceptability, accessibility as well as suitability of health care and plans health promotion activities on the state level.

Occupational Medicine Centre of Institute of Hygiene carries out scientific research, upgrading and requalification of occupational health specialists, expert research of environmental impact upon human health and compiles relevant information, develops criteria for diagnosing of occupational diseases, manages state register of occupational diseases.

Central Occupational Medicine Expertise Commission deals with expertise of complicated cases when establishing the diagnosis of occupational diseases.

Institutions of safety and health management at the regional level

County administration Delegates are representatives of municipalities to the regional occupational safety and health commission.

Council of municipalities (administration) On the consent of enterprises, has the right to develop and approve joint occupational safety and health improvement programmes or measures and commit funds for their implementation. Has the right to establish a vacancy of municipal inspector-consultant on safety and health in compliance with Model regulations on municipal safety at work inspector - consultant (approved by the Ministry of Public Administration Reforms and Municipal Affairs and the Ministry of Social Security and Labour, Decree No. 31/84, 8 July 1996).

Regional occupational safety and health commissions in counties (Their Regulations are approved by the Decree No. 137/573 of 29 October 2001 of the Minister of Social Security and Labour) Following the principles of tripartite cooperation of social partners of state, employees and employers participate in delivery of state policy on occupational safety and health.

Safety and health at work in enterprises, institutions and organizations

Occupational safety and health services at enterprises Carry out prevention of industrial injuries and occupational diseases, supervision and control of safety and health at work, provide consultations to employees on issues of occupational safety and health following provisions of Model regulations on safety at work services in enterprises (approved on 10 June 2002; No. 77/262, Official Gazette 2002, No. 69-2850).

Occupational safety and health committees in enterprises Analyse and evaluate activities of employers, units of the enterprise, services in the field of occupational safety and health, develop measures to improve safety and health at work, proposals to collective agreements, analyse causes and circumstances of accidents at work and occupational diseases, following the provisions of General regulations on occupational safety and health committees in enterprises (approved by the protocol of Occupational Safety and Health Commission No. 65; 11 March 2002).

System of tripartite institutions

Safety and Health Commission of the Republic of Lithuania adjusts interests of state, employees and employers in the field of safety and health on the tripartite cooperation principle of social partners. Safety and Health Commission of the

45 Republic of Lithuania – established in 1994 – implements the provisions of the then-in-force Law on Safety and Health at Work. The Commission participates in the formulation and delivery of safety at work policy; analyses status of safety at work and proposes improvement measures, develops relevant recommendations and draft measures; discusses and submits proposals regarding laws and other standard acts on issues of safety at work, etc. The Commission is made up of 15 equal members: 5 representatives of employees, employers and public administration institutions. The Commission is headed by chairman, elected from members of the Commission following the principle of rotation.

The system of tripartite institutions in Lithuania is made up of a group of tripartite structures, majority of which are specialised. Majority of these institutions function on the national level, some – in regions.

The Tripartite Council of the Republic of Lithuania (hereinafter – Tripartite Council) has been functioning since 1995. It discusses at the national level topical labour, social and related economic issues. Four standing specialised commissions function under the Tripartite Council. Many other specialised tripartite structures are functioning in Lithuania: State Social Insurance Fund Board, Employment Council under the Ministry of Social Security and Labour, Safety at Work Commission of the Republic of Lithuania, Guarantee Fund Board, Lithuanian Vocational Training Council, Tripartite Commission under National Labour Exchange (National Commission), and Board of Experts under the Lithuanian Labour Market Training Authority.

Organisations of social partners

Trade unions and their organisations Lithuanian laws provide for only one legitimate form of organised workers’ representation – trade unions. Four trade unions function on the national level in Lithuania:

Lithuanian Workers Union – formed as a branch of the grass-root movement "Lietuvos atgimimo sąjūdis". The first group of Workers Union was established in 1988 in Kaunas, and in summer 1989 the first congress was held, during which political and economic requirements were raised. After reestablishment of independence of the Republic of Lithuania, during the congress held on 1 July 1990 the political objectives were renounced and Lithuanian Workers Union was declared to be an organisation of trade unions. Currently Lithuanian Workers Union unites 25 towns/regions, i.e., regional workers unions and 12 industrial – trade federations and in total has about 52,000 members;

Lithuanian Labour Federation – was functioning from 1919 till 1941. Its activities were re-established in 1991. Lithuanian Labour Federation in 1995 merged with Lithuanian Association of Trade Unions, and in 1997 joined the Lithuanian Federation of Regional Trade Unions. Currently the Labour Federation unites 10 branch trade unions, functioning on different production, industry and regional levels and has more than 20 thousand members. Since 1996, the Lithuanian Labour Federation is a full-pledged member of the World Labour Confederation;

Lithuanian Centre of Trade Unions – established on 23 March 1993 and unites 14 branch trade unions with more than 90 thousand members. This organisation actively participates in the activities of the Baltic (Lithuanian, Latvian, Estonian) Board of Trade Unions and strives to establish cooperation with trade unions of other European countries and the Baltic Sea Region states. As the other three above mentioned trade unions, Lithuanian Centre of Trade Unions actively

46 participates in the process of drafting laws and tripartite dialogue in formulation of labour and social policy;

Lithuanian Confederation of Trade Unions – a confederation of trade unions, uniting 11 independent branch trade unions. Lithuanian Amalgamation of Trade Unions was established in 20 February 1992 on the agreement of free trade unions and is a constituent part of Lithuanian movement of trade unions. In 1994 this organisation of trade unions joined the International Confederation of Free Trade Unions (ICFTU), and in 1998 became an associated member of European Confederation of Trade Unions (ETUC). It also maintains relations with trade unions in Sweden, Denmark, Finland, Germany and other countries.

Employers' organisations Two large confederations of employers are functioning on the national level: Lithuanian Confederation of Industrialists; and Lithuanian Confederation of Business Employers These confederations unite smaller branch and regional associations and separate enterprises.

5. Occupational accidents and occupational diseases

Accidents at work

Accidents at work in the undertakings of Lithuania in 2005: • 112 fatal, • 216 serious, and • 3,003 minor labour-related accidents at work.

There were 17.7 serious and 9.2 fatal accidents at work per 100,000 employees. The numbers of both serious and fatal accidents at work have been increasing during the period of 2001-2005. In 2005, the majority of fatal (23%) and serious (17%) accidents at work occurred as a result of traffic offences, while the majority of minor accidents at work (46%) were as a result of violations of safety and health legislation.

In 2005, the majority of serious accidents at work occurred in construction undertakings, viz. 83.9 accidents per 100,000 employees. The number of serious accidents at work was also high in undertakings engaged in forestry, production of construction materials, chemical industry, transport and agriculture, viz. approx. 40 accidents per 100,000 employees. In 2005, the highest number of fatal accidents at work occurred in forestry undertakings, viz. 55.2 accidents per 100,000 employees. The number of fatal accidents at work per 100,000 employees was high in undertakings engaged in the production of construction materials (40), chemical industry (38.2) and construction (37.9).

Occupational diseases

In Lithuania occupational diseases are registered in the National Registry of Occupational Diseases at the Institute of Hygiene Occupational Medicine Centre. During the period 1995-2006 the number of the registered occupational diseases increased from 370 to 1447 cases (Figure 2). Morbidity of occupational diseases is almost twice higher in Lithuania than in the old European Union countries. Contrary to the EU, most of occupational diseases are diagnosed in the employees of pre- retirement age (55-64 years of age) and in young workers (25-34 years of age) they are nearly not diagnosed at all.

47 1600

1400

1200

1000

800

600

400

200

0 95 96 97 98 99 0 1 2 3 4 5 6

number of occupational diseases

Figure 2. Occupational diseases in Lithuania in 1995-2006

Up to 2003, the structure of occupational diseases in Lithuania was dominated by vibration disease and occupational hearing impairment, which made 70-80% of all registered occupational diseases annually (Figure 3). From 2004 the registration of separate syndromes has been introduced instead of vibration disease, therefore the number of occupational musculoskeletal disorders and nervous diseases augmented. The structure of occupational diseases in the EU countries is also dominated by occupational musculoskeletal disorders, but differently from Lithuania, the number of diagnosed occupational respiratory, cutaneous and tumorous diseases is considerably higher. Not a single case of occupational cancer was registered over the period 1995-2006.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 969798990123456

vibration disease hearing impairment musculoskeletal disorders nervous diseases respiratory diseases other diseases

Figure 3. Changes in the structure of occupational diseases in 1995-2006

6. Occupational health services

Occupational safety and health comprises all preventative measures aimed at protecting functional capacity, health and life of employees at work which are used or planned at all operational stages of the company to protect employees from occupational risks or minimize these risks.

Every employee must be provided with secure and healthy working environment irrespective of the activities of the company, type of employment contract, number of employees, profitability of the company, work place, working environment, nature of work, duration of the working day or shift, citizenship, race, nationality, gender, sexual orientation, age, social background, political or religious beliefs of the employee. Creation of secure and healthy working conditions in all work-related aspects is the duty of the employer. Occupational safety and health measures in the company are funded by the employer.

The state of occupational safety and health in companies is measured to the extent that work equipment and working conditions in the company and its units meet occupational safety and health requirements laid down in legal acts. Measurement of the state of occupational safety and health involves assessment of the occupational risks, i.e. the likelihood of injury or any other deterioration of the employee’s health due to the impact of the harmful and/or hazardous work environment factor(s).

Occupational risks must be assessed in every company. The procedure for occupational risk assessment in companies is established in the Occupational Risk Assessment Regulations. Occupational risk assessment is carried out with the help of the occupational safety and health service of the company, bodies measuring the risk factors certified by the State Public Health Service and licensed occupational safety and health experts. The assessment includes measurement of risks to employees posed by every factor (chemical, physic, biological, ergonomic, psychosocial, physical) of the work environment. When the risks are assessed, Occupational Risk Assessment Cards are completed for each risk assessment object. Information in the Occupational Risk Assessment Cards must be summarised and the Document of Occupational Safety and Health Status in the Company must be completed in the established form. When the occupational risks are assessed, the company has to draw up a risk elimination and mitigation action plan which is used for implementation of risk prevention measures.

Key indicators of the occupational safety and health status are the number of accidents at work and incidence of occupational diseases.

From 2006, the companies may receive funds from the State social insurance fund budget for implementation of risk prevention measures.

In Lithuania, the companies’ in-plant services (integrated model) is used for occupational health services:

Enterprise

OHS Enterprise unit

Figure 4. Occupational health service model in Lithuania

49 7. Resources

The competent occupational health and safety personnel is important for the implementation of the National occupational safety and health programmes and strategies, and for the provision of occupational health and safety services to the workplaces. The further development of the multidisciplinary approach is also crucial.

The numbers of experts in various categories (2001) is described in Table 4.

Table 4. Occupational health and safety experts by category (1)

Professional group No. involved including Value indicator Unit part-time workers Occupational health 22 0.015 /1,000 physicians employed Occupational health 349 0.24 /1,000 nurses employed Occupational hygienists 32 0.02 /1,000 employed Labour safety inspectors 162 0.11 /1,000 employed

8. Main problems on OHS

During the recent years the number of occupational diseases and traumas has increased as well as the number of deaths at workplaces. However, only a small part of occupational diseases is diagnosed, preventive medical examinations of workers are inefficient, recognition procedure of occupational diseases is very complicated, there are no diagnostic criteria for the use of general practitioners. In order to satisfy better the occupational safety and health needs in the country, it is firstly necessary to develop institutional capacities and to ensure appropriate training for all participants of this sector. Besides, it is necessary to restructure the health care system, changing the structure of provided services and strengthening the components of primary health care. Moreover, an important problem is the implementation of non-governmental occupational safety and health function.

In Lithuania there is a lack of occupational medicine services; they are available only in big companies. Then again, there is no legislation regulating the activities of occupational health services for small and medium-size enterprises. Currently, the regulations for occupational health services inside enterprises establish that occupational medicine doctors, general practitioners as well as public health and nursing professionals licensed for this type of activity shall work in the enterprises. However, the enterprises lack a lot such professionals (occupational medicine doctors in particular).

Both material and human resources are insufficient too. Complex measures as well as complex funding are necessary.

9. Main priorities for the next 5 years

The main aim of Lithuanian healthcare policy is to prolong people's health and the lifespan of their functional ability. It aims to safeguard the possibility for everyone to enjoy a good quality of life, diminish health differences between population groups and reduce the rate of premature deaths.

Directions for strengthening of occupational health: - coordination of occupational health activities (legalisation of a coordinating authority and creation of occupational health services network); - strengthening of occupational health services and development of human resources (setting of competence requirements for occupational health professionals and their continuous training).

Strategic research activity priorities are: - research on the efficiency of implementation of the occupational health policy; and - creation of the national occupational health information network.

This priority is based on the experience of Occupational Medicine Centre (OMC) gained through the participation in the Northern Dimension Partnership project, coordinated by the Ministry of Health, the aim of which is to enhance occupational health services both in Lithuania and other countries of the region, as well as its contribution to the creation of the telematic information network of the Baltic Sea Region.

- Research on the effects of asbestos and other carcinogens in working environment and on the impact of psychosocial risk factors.

This priority is based on the competence of the OMC and Laboratory of Chemical Hazards Investigation of Institute in carrying out research on the effects of asbestos and stress on workers’ health as well as implementing the measures planned in the Government’s Annual Programme for 2006-2008.

- Research on the prevalence of occupational diseases and elaboration of diagnostic criteria.

This priority is based on the data and the experience of the National Register of Occupational Diseases at OMC in research and plans to participate in the elaboration of diagnostic criteria.

- Research and assessment of occupational risks due to chemical and physical factors in working environment.

This priority is based on the experience and expertise of the OMC Laboratory of Chemical Hazards Investigation of the Institute in performing expert tests for companies, institutions and organisations in compliance with the requirements set forth in the Rules for Occupational Risk Assessment.

References

1. Jankauskas R, Einikiene A, Gaizauskiene A, Peciulka S. Country profile: Lithuania. In: Rantanen J, Kauppinen T, Lehtinen S, Mattila M, Toikkanen J, Kurppa K, Leino T (eds.) Work and health country profiles of twenty-two European Countries. People and Work Research Reports 52. Finnish Institute of Occupational Health, Helsinki 2002:257–73. http://www.ttl.fi/Internet/partner/tf13/Occupational+health+and+safety+prof iles/Country+Profiles/Lithuania.htm, accessed on 11 October 2007 2. ILO. Labour force survey 2006.

51 3. Šaulauskas MP. Digital Lithuania 2001. [English summary of Skaitmeninė Lietuva 2001] Vilnius: Vilnius University, 2001. ISBN 9986-19-431-8. Free. Full report in Lithuanian available at http://www.fsf.vu.lt/filk/mps/sl2001.zip 4. Augustinaitis A. Review of: Saulauskas MP. Digital Lithuania 2001. [English summary of Skaitmeninė Lietuva 2001] Vilnius: Vilnius University, 2001. Information Research 2002;8(1), review no. R071. Available at: http://informationr.net/ir/reviews/revs071.html 5. World Information Society Report 2007. http://www.itu.int/osg/spu/publications/worldinformationsociety/2007/report. html Accessed on 11 October 2007. 6. http://web.worldbank.org 7. http://www.urm.lt/index.php?-466405799 8. Information Society Development Committee under the Government of the Republic of Lithuania. Sustainable development of knowledge society in Lithuania. http://ec.europa.eu/enterprise/e- bsn/statistics/figures/nationallevel/documents/word/lithuaniasustainabledevel opment.doc. Accessed on 18 October 2007. 9. Blaziene I. Quality in work and employment - Lithuania. http://www.eurofound.europa.eu/ewco/studies/tn0612036s/lt0612039q.htm, accessed on 21 October 2007. 10. Law on Safety and Health at Work, No.VII-2063, Art.2, par.1.; Official Gazette, 2000, No. 95-2698.

52 Norway

1. Geography and demography

Area

The area of Norway is 385,155 km2 (population density 12 per km2). 63% of the population lives in urban areas. The capital city is Oslo (500,000 habitants), and the official language is Norwegian.

Population

The population of Norway was 4.681 million 01. January 2007.

Table 1. Population by age groups, in 2006

Age Total population Men Women 0–14 906 464 442 15–74 3419 1727 1692 75– 356 135 221 Total 4681 2326 2355

Source: ILO labour force survey 2006

Labour force

The labour force was 2,501 million in August 2007. The unemployment rate stood at 2.5 per cent.

Source: Statistics Norway, 2007

53 2. Economy

Table 2. Selected economic indicators of Norway

2000 2005 Gross national product per 76750 capita, USD Gross domestic product 85585 (GDP) per capita, purchasing (1.7.2007) power parity, USD

Source: Statistic Norway, 2007

3. E-policies and Digital Opportunity Index

The e-policy is built on justice and community. The public welfare will be renewed and developed further and differences in the society will be reduced. The public responsibility and role regarding health, care and education shall be strengthened. • Full coverage of kindergartens. • Reinforce building of roads and railways. Improved maintenance. • Steps to reduce poverty, increase integration and including of the immigrant population. • Educational policy measures • Better public health and reduced social differences. • Improved the economy in the hospital sector • Restructuring of the energy and the environmental profile • Investments in the Northern areas. • More to cultural activities • Priority of research and development • A policy in favor of regional and local area development • Reduced crime and more safety

Table 3. The Digital Opportunity Index of Norway

Opportunity Infrastructure Utilization DOI 2005/06 2005/06 2005/06 2005/06 Norway 1.00 0.66 0.41 0.69

Source: World Information Society Report 2007

4. OHS legislation and actors

The occupational safety and health is based on Work Environment Act from 1977 amended in 2005. Although no formal tripartite body exists, all-important labour matters are discussed between social partners. There is no National Program on the promotion of safety and health. Improving the health and work ability of working people in Norway is mentioned in the National Health Plan for 2007-2010.

The Ministry of Labour and Social Inclusion The leading occupational safety and health authority is the Ministry of Labour and Social Inclusion. It is responsible for policy making. The coordination of policies and activities at the national level takes place in ministerial groups at the government level: the ministers of neighbouring sectors often coordinate their policymaking. The Working Environment and Safety Department of the Ministry coordinates its

54 activities mostly in ad hoc negotiations with the other ministries and social partners. The coordination mechanisms cover the whole occupational safety and health sector described in Figure 1. The workplace is considered to be the main focus and arena of the occupational health and safety activity.

Working environment and safety work is organized under the Working Environment and Safety Department in the Ministry of Labour and Social Inclusion. The operative supervisory authority rests with the Labour Inspection Authority and the Petroleum Safety Authority.

The National Institute of Occupational Health (STAMI) The Institute and the Department of Occupational Medicine Institute of Public Health at the University of Bergen and five regional departments of occupational medicine at the main hospitals are an integral part of the national system for protection of workers. The Institute collaborates with government agencies, workers’ and employers’ organizations and directly with enterprises.

55 Figure 1. Occupational health and safety system in Norway

Ministry of Labour and Social Ministry of Health Ministry of Care Services Education and Inclusion • legislation • legislation Research

Labour Petroleum Regional Hospital University of

Inspection Safety Organisations (5) Bergen Directorate Authority • regulation • regulation • guidelines • guidelines • information • information Research and • monitoring • monitoring Advisory Support

• enforcement • inspection Department of

• enforcement Occupational

Regional Medicine, Institute Inspections (7) of Public Health

• information Departments of • inspection Occupational • enforcement Medicine at Major Hospitals (6)

National Institute of Occupational

Health, STAMI

• research Local Health and Safety • diagnostics of Ombodsman occupational diseases • training Employer WORKPLACE Employees • information • advise OHS Committee • monitoring • interventions • services

Occupational Health Social Partners Services, OHS Secretariate • in-plant of OHS at • group service STAMI Trade Employers' • private OHS Unions Confede- • advice rations • guidelines • collective agreements • special agreements

5. Occupational accidents and occupational diseases

Occupational accidents

Occupational accidents are reported by the employers to the Norwegian Labour and Welfare Organization (NAV) and forwarded to the Labour Inspection (Arbeidstilsynet), the Petroleum Safety Authority and other inspecting bodies.

The department for National Surveillance of Work Environment and Occupational Health (NOA) at National Institute of Occupational Health has estimated the number of occupational accidents leading to sick-leave of one day or more to 78 000. However, only some 25 000 were reported. Agriculture, forestry and building and construction were the top three most accident-prone industries. The number of fatal accidents at work was on average 58 cases per year in the 1990s, 87 in 2000 falling to 62 in 2005 (Figure 2) In 2000-2005, fisheries had the relative highest risk of fatal accidents, followed by sea transport, energy and mining, and agriculture and forestry (Figure 2) Almost all fatal accidents occurred to men.

Land-based activity Fishery Sea transport Continental shelf 90 80 70 60 50 40 30 20 No. fatal of accidents 10 0 2000 2001 2002 2003 2004 2005 Calendar year

Figure 2.The number of fatal occupational accidents per year in 2003-2005

Source: Statistics Norway, 2007

Occupational diseases and work related disorders

The Work Environment Law obliges every doctor to report work related disorders to the Labor Inspection and the other inspection Authorities. However, there is a huge under reporting. Thus the register is not suitable for common analysis.

In 2006, the number of reported work related disorders was 3392. The four largest diagnostic groups were noise-induced hearing loss (1987), diseases of respiratory organs (398), skin diseases (239) and musculoskeletal disorders (210).

In order to qualify for compensation a disease must, as the main rule, fall within the legal definition of an occupational disease. The compensation systems are run by NAV and insurance companies. It should be noted that occupational musculoskeletal and psychological diseases legally are exempted from compensation.

In Figure 3 is presented the compensated occupational diseases in 2005:

Headache

Diseases of nervous system

Diseases of hearing organs

Skin diseases

Diseases of respiratory organs

Injuries, poisonings, violence

All other diagnoses

Undefined diagnoses

Total

0 200 400 600 800 1000 1200 Number

Figure 3. Compensated cases of occupational diseases by diagnostic group in 2005

Source: National Institute of Occupational Health/NOA

6. Occupational health services

There are several different ways in which occupational health services are organized at the enterprise level. Some large companies have their own private in- company service. Another type of arrangement is that several companies have a joint arrangement and establish an occupational health services company, which then service the group. A third type of arrangement is an independent occupational health service enterprise selling their services in the market. Certain industries/trades are deemed by the government to have greater health and safety risks than others, and are required by law to hire the assistance of an occupational health service. These industries/trades are specified in a separate regulation. About 40% of the occupational health services’ volume is internal services in the enterprises, the rest are external services of which about 50% are owned by the enterprises and 50% privately owned. The coverage of service is approximately 60% (1.2 million) of the work force.

There is no official registration, but it is estimated that some 400-500 occupational health service units are in operation. The content of the assistance from the occupational health service is based on the risk assessments and needs of the enterprise. Enterprises are in a specific regulation informed on how they should use the assistance of the occupational health service. The occupational health service legally has a purely advisory role. The responsibility for the health and safety situation in the enterprise rests solely with the management. The regulation inform the enterprises to ask for preventive and advisory services from the occupational health service, but, to some extent, also other health concerns of employees might be attended to. The occupational health services are encouraged to follow good

58 occupational practice guidelines, which are just recently renewed. There are yet no formal governmental post-graduate qualification requirements for medical and other personnel occupied in occupational health service.

The average cost of occupational health service amounts to 150 Euros per employee per year, a total cost of 180 million Euros per year. The amounts of services purchased by the enterprises are highly variable, from less than 50 Euros up to more than 1000 Euro per employee per year. The government is not compensating the costs of occupational health services.

7. Resources

The estimated numbers of experts in various categories is described in Table 4.

Table 4. Occupational health and safety experts by category in Norway

Professional group N involved incl. part- Value indicator Unit time workers, 2007 Occupational health 355 /1,000 physicians employed Occupational health 670 /1,000 nurses employed Occupational 340 /1,000 physiotherapists employed /ergotherapists Occupational hygienists 390 /1,000 /safety engineers employed Psychologists 30 /1,000 employed Administrative personnel 470 and other Total 2295

Source: Secretariat for the Occupational Health services, National Institute of Occupational Health

8. Main problems on Occupational Health Service

The following problems can be mentioned: • The occupational health service has been little backed by government, but through law and regulations. The services have been left to survive in the market as best they can. • There are gaps in coverage, especially in small and medium sized enterprises. Too many enterprises obliged to associate occupational health service have not done so. • Too many enterprises do not properly ask for preventive and advisory services from the occupational health services. • Quality of service from the occupational health services varies too much. • Competence of the service providers varies too much. • Occupational health services might be more adjusted to and focused on the customers' needs. • The statistics regarding occupational accidents and occupational diseases could be improved.

9. Main priorities for the next 5 years

Getting all enterprises under the regulation to associate occupational health service.

Getting all enterprises to use the assistance of the occupational heath service in accordance with the regulation.

Directing the development of occupational health services so that the structure and contents are in line with the health and social policy objectives; renewing regulations (A possible regulation on Occupational Health Service)

Meeting the challenges of the aging work force, health inequities and exclusion from the workforce, the reduction of sickness absence and early retirement and promotion of early return to work and the employment of functionally disabled (The National Campaign on Inclusive Working Life).

Improving collaboration between occupational health services and enterprises; micro companies and SMEs, in particular.

Improving the quality of occupational health service; a mandatory certification and quality control system for occupational health service and personnel is needed.

Establishing a good quality national surveillance system for work environment and – health.

References

1. Eklund T. Country profile: Norway. In: Rantanen J, Kauppinen T, Lehtinen S, Mattila M, Toikkanen J, Kurppa K, Leino T (eds.) Work and health country profiles of twenty-two European Countries. People and Work Research Reports 52. Finnish Institute of Occupational Health, Helsinki 2002:296–311. 2. ILO. Labour force survey 2006. 3. http://web.worldbank.org 4. World Information Society Report 2007. http://www.itu.int/osg/spu/publications/worldinformationsociety/2007/report. html, accessed on 20 October 2007. 5. Aasnass S. Quality of work and employment - Norway. http://www.eurofound.europa.eu/ewco/studies/tn0612036s/no0612039q.htm , accessed on 21 October 2007. 6. Mehlum I, Kjuus H, Veiersted K, Wergeland E. Self-reported work-related health problems from the Oslo Health Study. Occupational Medicine 2006 56(6):371-379. http://occmed.oxfordjournals.org/cgi/content/full/56/6/371 7. Oystein Saksvik P, Torvatn H, Nytro K. Systematic occupational health and safety work in Norway: a decade of implementation. Safety Science, Volume 41, Number 9, November 2003, pp. 721-738(18) 8. National Health Plan for Norway (2007–2010) http://www.regjeringen.no/en/dep/hod/Whats-new/News/2007/National- Health-Plan.html?id=449316 9. Lie, A and Bjørnstad, O. Occupational health services in Norway - legislative framework, trends, developments and future perspectives. Policy and Practice in Health and Safety, Issue 1 Supplement , pp. 103-109(7), 2007. Institution of Occupational Safety and Health

61 The Russian Federation

1. Geography and demography

Area

From 1991 Russia is a federative presidential republic with two chambers parliament. Council of Ministers is chaired by the Prime Minister.

The area of the country is 17,075,400 km2 (population density 8.5 per km2). The capital city is Moscow (8,546,000 habitants), and the official language is Russian. The country accounts 89 administrative areas and 1,865 regions.

Population

The population of the Russian Federation was 144 964 million in 2003 and 142 200 million in 2007. About 73% of population is concentrated in urban areas. 80% of the population are Russians, 4% Tatars, 2% Ukrainians, and in addition there are more than 100 ethnic minority groups. The population growth rate from the year 1992 has a well seen negative character due to high rate of mortality, which is for working population related to unnatural causes of premature death and it is as 2,5 higher than in developed countries. During last years birth rate was growing, mortality rate was diminishing year by year. However life expectancy for men is still low and it is about 60 years. Life expectancy for women is 71 year. It is still very big gap between men and women life expectancy.

Table 1. Population by age groups, in 2006

Age Total population Men Women 0–14 21,063 10,783 10,280 15–72 112,000 52,661 59,339 73– 9,424 2,562 6,862 Total 142,487 66,006 76,481

Source: ILO labour force survey

Labour force

The labour force was approximately 73 million in 2005. According data of Rosstat the working population in 2006 was about 68,7 million. The standardized unemployment rate was 7.5% in 2006. Unemployment is highest among women and young people.

Table 2. Labour force in 2006

Number (2006) % Economically active and employed 74 261 000

Standard and Full-time 63 425 000 92,3% regular Part-time 1 308 000 1,9% Non-standard or irregular No data ______% Self-employed 3 986 000 5,8% Unemployed 7,5% from number of 5 542 000 economically active population (74 261 000) Should-be-non-employed but employed – child No data ______% labour Total Population by Employment 68 719 000 100,0%

2. Economy

Russia has a market economy. The new conception of the industry development forms the main three groups. In the first group the following branches of economy are included: oil and gas industry, forestry and wood felling, mining and energy production. Aviation and space, atomic industry, all branches of the military industry, machine-tool construction, biotechnology, wood processing industry, cellulose and paper production industry are included into the second group. The third group consists of cars production industry, light industry, food industry, agriculture and machinery for agriculture.

Table 3. Selected economic indicators of the Russian Federation

1999 2005 Gross national product per capita, USD NA Gross domestic product (GDP) per capita, 6,912 12,420

63 purchasing power parity, USD

3. E-policies and Digital Opportunity Index

Table 4. The Digital Opportunity Index of Russian Federation

Opportunity Infrastructure Utilization DOI 2005/06 2005/06 2005/06 2005/06 Russian 0.97 0.37 0.23 0.52 Federation

Source: World Information Society Report 2007

4. OHS legislation and actors

The right on healthy work is constitutional. Article 37 of the new Constitution of the Russian Federation says that every citizen has a right to work under conditions which meet demands of safety and hygiene.

Constitutional rights are further developed by Labour code which is a comprehensive legislative document and it includes occupational safety and health, work organization and other aspects related to this subject. Article 154 of this code prescribes obligatory preliminary and periodical medical examination and defines category of workers and type of industry which is under these conditions. Federal law on Obligatory social insurance from accidents and occupational diseases was approved in 1998. In accordance with this law employer should insure his employees and pay in full.

Special attention should be given to two recently approved laws: “Sanitary- epidemiological well being of the population” (№ 52-ФЗ, approved on 30 March 1999) and “Basics of Occupational Safety and Health in Russian Federation” (№181-ФЗ, approved on 17 July 1999).

The law on Sanitary-epidemiological well being of the population describes the major activities of the Federal Service for Surveillance in the Field of Consumer Rights' Protection and Human Well-being (“Rospotrebnadzor”), which also includes occupational safety and health. This law covers all kinds of occupational hazards including potentially toxic chemicals and biologically active substances, which can be used after the state registration in the Federal Registry of potentially toxic and biologically active substances (Article 14). Article 22 of this law deals with toxic wastes and article 25, 26 and 27 deal with occupational health and prescribing hygienic standards, norms and rules. If the hygienic or technical safety requirements are not met this law gives permission to Chief Sanitary Officer or Labour Inspector to stop production or other activity, or to punish responsible person financially or administratively or to bring the matter to the court.

The law “Basics of Occupational Safety and Health in Russian Federation” defines what kind of health and safety services should be provided for people at work. It requires that in the company with more than 100 employees specialist with appropriate background and experience in Occupational Safety and Health should be in the staff. In company with less 100 employees employer himself makes decision to employ an appropriate specialist or to have an agreement with specialist or with company, available in the market, which provides Occupational Safety and Health service. In the companies with more than 10 employees committee or

64 commission dealing with health and safety should be created. Thus the law on Sanitary-epidemiological well being of the population relates mainly to health but another law mentioned above defines the basic requirements of occupational safety. According these laws employers are responsible for occupational safety and health matters. Three partite approach is required by this law. Collective agreement is one the main instruments of Occupational Safety and Health practice.

Alone the same line the system of Occupational Safety Standards is being developed by All Russia Institute for Standardization. As an example GOST R 12.0.006-2002 “General demands for Occupational Safety and Health in the Organization” could be given. This standard was harmonized with international standard OHSAS 18001-99 developed by International Standardization Organization.

Federal Service for Surveillance in the Field of Consumer Rights' Protection and Human Well-being (“Rospotrebnadzor”) of Ministry of Public Health and Social Development of the Russian Federation (before 2004 – Department of State Sanitary and Epidemiological Surveillance of Ministry of Public health of Russian Federation – “Gossanepidnadzor”) is mainly responsible for providing of safety regulations and control of preventive measures realization. Until 2002 practically all documents contained regulations concerning safety and health in the use of harmful and dangerous substances were worked out by “Gossanepidnadzor”, justified by Ministry of Justice and were obligatory for execution. After adopting in 2002 of Federal Law No. 184-FZ “About technical regulation” only general safety requirements adopted as federal laws (“Special Technical Reglament”) became obligatory, other regulations worked only as recommendations. In 2007 this law was corrected and questions of occupational health and safety was moving out from the Law No. 184-FZ area.

Economically active population is exposed to different type of occupational health hazards. Therefore, the functions of the preventive health service is seen as to control of occupational hazards, minimize exposure to them, health protection and promotion, prevention of occupational diseases and other illnesses. There is an administrative structure to deal with this task. In Russia Hygienic standards and norms are established for most of occupational hazards. National Commission on Occupational Exposure Limits of the MHSD has sections dealing with certain occupational hazard. Commission consists of leading specialists in the area. Accepted by Commission the proposed by research Institutions value of Occupational Exposure Limit is to be presented to the MHSD for approval. As far as toxic chemicals concerned there is Maximum Allowable Concentrations (MAC) for more than two thousand hazardous substances (chemical and biological) in the air at workplace. For those substances which are highly accumulative the Time Weighted Average (TWA) concentrations is to be established. Carcinogens, allergens and substances with other specific effects are marked in the list of MACs or TWAs.

Carcinogenic substances are listed in special document which has been developed by commission on carcinogenic factors at MHSD. This list of substances, products, technological processes carcinogenic for the human being is based on the list published by International Agency for Research on Cancer. Enterprises which are defined as carcinogenic are under special observation. On the basis of toxicity indicators including MAC values chemicals are divided into four classes. An appropriate safety measures are defined for each class. These standards and norms are quite often lower than in other countries therefore process of MACs harmonization is going on.

65 Hygienic standards “Maximum permissible concentrations of harmful substances in the ambient air” GN 2.1.6.1338-03; “Approximately safe levels of exposure to contaminants in the ambient air” GN 2.1.6.1339-03 (for substances that have no thresholds established on the strong scientific data); “Maximum permissible concentrations of harmful substances in the working zone air” GN 2.2.5.1313-03; “Approximately safe levels of exposure to contaminants in the working zone air” GN 2.2.5.1314-03 (for substances that have no thresholds established on the strong scientific data) are established as federal law.

State centres of occupational medicine are in charge of occupational health in Russia. They provide OHS both in state and private sectors of economy. They can be divided into the municipal located on the basis of regional and interregional hospitals. Those are located on the basis of specialized research institutes. The latter are designed for occupational medical aid to the workers of different administrative territories. These OH centres differ in their functions and structure. Coordination is done by the Center of Occupational Medicine of the Ministry of Health of the Russian Federation that has a great volume of expertise. Only centres of occupational medicine have the right to diagnose work-related and occupational diseases in Russia. Centres of occupational health have been developed lately. Some of them are designed to give occupational health services to the workers and their family members at big enterprises. The example of such a centre is the Centre of occupational health at Volzhskiy Automobile Plant. No private curative occupational health centres exist in Russia.

Due to economic problems in the country high percentage of working population still work under conditions which do not comply with national safety and health standards, norms and rules particularly in the industries which difficult to regulate. Unfavourable situation is observed in the coal mining, ferrous and nonferrous metallurgy, cellulose and paper production industry and energy generation. In 2005 22.2% of all employees and 14.3% of working women and in the beginning of 2006 – 20,8% of all employees in basic industries (mining and milling; manufacturing industries; production and distribution of energy, gas, water; construction; transport; communication) were working under conditions which did not meet the Occupational Health and Safety national standards and regulations. In the year 2003 these indicators were 19.9 and 13.2 accordingly. The annual economic losses caused by poor working conditions, are estimated in 407,8 billion roubles.

5. Occupational accidents and occupational diseases

From the beginning of current century annually about 200,000 workers are injured, more than 10 thousand cases of occupational diseases are detected, and more than 14 thousand workers become invalids owing to occupational accidents and diseases. During last years the situation in occupational safety and health has been slowly improving as can be seen from the health indicators given below.

Frequency rate of occupational injuries in 2005 was 3.1 per 1000 workers. In 2001 it was 5.0 and was decreased significantly. Occupational morbidity was 1.61 per 10 000 workers both in years 2005 and 2006. 1.59 cases of occupational diseases and 0.02 per 10 000 of occupational intoxications were reported in 2005.

Of the registered occupational illnesses in 2005 were 98.41% (98.42% in 2006) chronic; 0.17% (0.14% in 2006) acute; 0.95% (1.45% in 2006) acute intoxications; and 0.50% chronic intoxications

66 Occupational diseases by cause in 2006 were as follows: (numbers in 2005 in brackets): 39.0% (38.6%) caused by physical factors; 19.7% (18.2%) caused by overload and repetitive stress; 7.7% (8.1%) caused by chemical factor; 5.2% (6.3%) causes by biological factor; 3.3% (1.4%) caused by allergic diseases; and 0.6% (0.4%) caused by tumors.

69.1% of chronic occupational diseases were revealed in medical periodical examinations.

In 2006 26.05% of total registered occupational diseases in the country were coming from coal mining, 21.52% from aviation transport, 13.3% from nonferrous metallurgy, 7.83% from ferrous metallurgy, and 6.58% from machine-building.

The number of fatal cases has decreased from 6194 cases in 2001 to 4604 cases in 2005.

Persons of economically active age are 0,57 million from total 1,8 million established in 2005 cases of disablement (it is 32% higher than in 2004). 11,6 thousands cases of disablement were compensated as occupational injures or diseases. This can be an indicator of pure quality of early diagnostics of occupational diseases.

The premature deaths and diseases due to occupational exposure impact are seriously diminishing Russian working population and adding to the imbalance of the demographic structure.

6. Occupational health services

Until year 2005 occupational health was under the responsibility of Ministry of Health, and occupational safety under the Ministry of Labour and Social Development. In the 2005 reform these two Ministries were merged into a new Ministry of Health and Social Development (MHSD) with the following federal functions: - development of the state policy and legal regulations in the public health - social development; - labour and consumers' right protection including medical prevention aspects as well as prevention of infectious diseases such as HIV\AIDS; - medical service and medical rehabilitation; - pharmaceuticals and drugs quality; - sanitary and epidemiological wellbeing; - quality of life and population income; - policy on demography; - health services provision for each branch of economy with dangerous conditions of work; - risk assessment related to the noxious occupational factors of physical and chemical nature; - health resorts; - labour payment; - provision of pension and social insurance; - conditions of work and labour safety; - social partnership;

67 - employment and unemployment; - labour migration; and - social defense of population, family, women and children.

Many of the above listed functions of MHSD have direct or indirect relationship to Occupational Health and Safety.

MHSD works through three Federal services and three Federal agencies: - Federal service on supervision in the sphere of consumers' right protection and wellbeing of human being; - Federal service on supervision in the sphere of public health and social development; - Federal service on labour and employment (Labour inspection is attached to this service); - Federal agency on public health and social development; and - Federal medicine and biology agency.

The frame of work is defined for each Federal service and each Federal agency (see an appropriate cite: www.government.ru). Occupational Safety and Health department at MHSD is located within Federal service on supervision in the sphere of consumers' right protection and wellbeing of human being. Each administrative region (they are 89) has territorial Centre of Federal service on supervision in the sphere of consumers' right protection and wellbeing of human being. Each such Centre has an Occupational Safety and Health department covering the whole country.

In addition, every sector of economy has department of occupational safety and health, which has coordinating and controlling functions. It also develops statistics and works in collaboration mainly with Federal service on labour and employment or with other appropriate service or agency of the MHSD if necessary. There is a Committee of Labour and Social Development in the local government of each administrative territory which also deals with occupational health and employment.

Occupational health and safety in Russia is very much the component of public health. However, absence of national specialized agency makes occupational safety and health less visible and less efficient in the development of national policy and strategy in this important area.

MHSD has its own mechanism and vertical structure for control of occupational safety and health legislation and standards, norms, rules and other regulations implementation into practice. MHSD with its territorial centers provides preventive and curative occupational health services. Department of Occupational Health at the Federal Territorial Centre is responsible for these services. This department has a net of scientific institutions (centers) reporting to it. These institutions make also research in Occupational health, and develop hygienic standards, norms and rules. Inspection of the working conditions, compliance with the above mentioned hygienic standards, norms and rules is carried out by the net of territorial centers (Rocpotrebnadzor). These centers have equipped laboratories and properly trained staff. They report to the occupational health department at the MHSD.

The structure of occupational health services in Russia have changed during the recent years together with the changes in economy and public health. Now it is not as strict as it was before 1990s.

According to active legislation employer is responsible for preventive measures implementation, organization and funding of current control of dangerous and

68 hazardous factors at the enterprise, organization and funding of preliminary and periodical medical examinations of workers if necessary, under supervising and control of federal and regional competent authorities.

The first level is health monitoring of the employees of the hazardous enterprises. According to the Governmental Decree there are compulsory pre-employment and periodical medical examinations. The medical examination of the employees can be carried out either by municipal or private medical institutions. Such kind of examination is paid by the employer directly or through insurance company. Periodical medical examination of the employees also can be carried out in the medical unit of the enterprise itself. Some of the biggest plants still have their own well-equipped medical centers that can provide all kinds of examination and treatment. After working in hazardous conditions for 5 years the employee has to pass through in-depth physical examination at the specialized Occupational Medicine Center. It can be rather difficult because many regions and cities have no such centers.

Occupational Medicine Center is the second level of occupational health services. It is the only institution that has the right to decide on the occupational origin of the disease. If the physician in the course of periodical medical examination suspects occupational origin of a disease he has to inform the surveillance center (Rospotrebnadzor) and the employer. The surveillance center investigates the work place and fills the “Sanitary-hygienic Characteristic of the Work Place”. With this document the patient goes to the Occupational Medicine Center where after in- depth examination the commission of the physicians decides if occupational hazards led to occupational disease development in this patient. Another function of the Occupational Medicine centers is to summarize the results of all periodical medical examinations and reveal the problems of occupational health in their regions. There are several occupational medicine research institutes in the country, they have their own clinics and carry out both scientific and practical tasks.

In 2006 started mass health examination of all employees of the state and municipal institutions, including educational, cultural, sporting etc. This work is financed by the Social Insurance Fund and is the part of the national project “Health” and it was directed by the special Decree of the Government.

Medical service for big enterprises is provided by its own occupational physician or medical department, which may have outpatient department and hospital. Medium size and small enterprises are covered by territorial medical centres (policlinic). There is occupational physician responsible for workers health. Usually occupational physician of this department provides medical service to the group of such enterprises. Recently the concept on healthy company as a new approach, recommended by the World Health Organization has been considered for implementation into practice. According to this concept the company itself should develop program on health and safety and health education including healthy lifestyle. This concept foresees that the produced product should be safe for human being and for the environment.

In accordance with decree N12 workplace attestation (comprehensive assessment of potential workplace hazards) is obligatory in every five years. On the basis of the results of workplaces attestation conditions of work are classified as optimal, allowable, dangerous, or extreme. Results of attestation are used for the development of preventive measures and also by insurance companies.

Preliminary and periodical medical examination are carried out following the requirements of the Decree N90, which defines what type of specialists should be involved in this process. Depending on the health risk this decree defines periodicity

69 of medical examination and what kind of laboratory investigation should be done. There is also a list of common contraindications and list of occupational diseases. The list of occupational diseases is open and diagnosis of occupational disease is established and registered if the relationship between clinical picture and conditions of work is proven. Diagnosis of occupational disease can be established only by a specialized clinic or as it was mentioned above by center of occupational pathology. Diagnostic criteria of occupational diseases are described in great details in handbooks. The main objectives of occupational safety and health services is defined as improvement of working conditions, strengthening of workers health through the improvement of health protection and health promotion

7. Resources

There is no comprehensive national statistics on the numbers of all experts of various categories in occupational health services in Russia. However, since occupational health is under the responsibility of the Federal Centers of Hygiene and Epidemiology (Rospotrebnadzor), which cover all territories of the country, some numbers can be given. According to the annual report of 2006 the numbers of various specialists working in these Centers were: - total number of staff (working) 50654, of which: - physicians 14834; - another type of specialists with high level of education 2234; and - nurses, assistants etc. 29550.

8. Main problems on OHS

Today the state is granting compensation on occupational accidents (employers are involved indirectly by centralized insurance system). Indemnification is given on the fact of a labour mutilation, an occupational trauma of the suffered worker, instead of owing to presence guilty. Such scheme leads to absence of economic interest of the involved parties to carry out preventive actions to improve working conditions, health protection and social protection.

The introduction of the country into WTO is connected with the obligations to reduce norms and standards which are not in conformity with the international rules of management and safety of work. If the Russian enterprises are not prepared to change their ways when there is a risk that they will be finally superseded in the market by foreign competitors.

The occupational safety and health system operating now is constructed on the principles of reaction to insurance cases, instead of the principle of prevention.

The normative base, including the order of carrying out attestation of workplaces, recommendations on planning actions for occupational safety, systems of accreditation and certification, the order of occupational safety and health training, is also not adapted for small and medium-sized enterprises.

Planning of special advanced measures in occupational diseases prevention is under responsibility of Ministry of Health and “Rospotrebnadzor” on the base of annual survey named “State report on sanitary-epidemiological situation in Russian Federation” (this survey made by Federal Centre on Hygiene and Epidemiology and contain analysis of data collected from regional departments of “Rospotrebnadzor”, included occupational and environmental hygienic measurements data).

In 2006 “Rospotrebnadzor” provided complex of proposals in different areas:

70 - changes in “Labor Code of Russian Federation” for legislative limitation of maximum period of work in conditions of exposure to dangerous or harmful occupational factors based on risk assessment in different occupations, - developing of economical measures for employers motivation to provide safety measures, - education programs for workers and responsible persons, - renewal of legislative documents (in areas of medical examinations of workers, list of occupational diseases, risk assessment, occupational diseases statistics, etc).

9. Main priorities for the next 5 years

A Safe Work Program has been proposed to the Ministry of Health and Social Development of Russian Federation aimed at improving occupational safety and health.

The program is planned to be realized in five phases: First step (2008-2010), second step (2011-2015), third step (2016-2025).

The overall objective of the Program is to protect health of the worker and to provide safety of work by introduction of professional risks control system at each workplace and involving in management of these risks of the basic parties of social partnership — employers and workers.

The primary goal of a new occupational safety and health system is transition from reaction to insurance cases to management of occupational risks.

The main tasks are the following: - to lower risks of occupational accidents and occupational diseases; - to raise quality of workplaces and working conditions; - to lower death rate; - to increase life expectancy and to improve health of the working population; - to give special attention to health promotion component at work; - to develop programme on HIV/AIDS prevention at workplace.

The basic directions are the following: - Modernization of legal basis on occupational safety and health; - Perfection of the organization of occupational safety and health systems, creation of a professional risks management system; - Information-technical support; - Strengthening of a role of social partnership; - Modernization of system of social insurance; - Propagation of healthy and safe work; - Corporative programs on occupational safety and health.

As a result the programme aims at reaching the safety and health level of the EU countries - to lower quantity of workplaces with harmful and dangerous working conditions to 3-5 %, and to reduce serious occupational accidents and fatalities to a level of no more than 0,05-0,08.

The costs of the reform could be drawn from several resources: 1. The budget of Social insurance Foundation (2007 - 497 860 thousand RUR; 2008 - 532 710 thousand RUR; 2009 - 567 336 thousand RUR). 2. Federal and regional budgets;

71 3. Budgets of State foundations; 4. Municipal budgets; and 5. International funding.

References

1. Basics of the Occupational Safety and Health of the Russian Federation. Federal low. Moscow, 1999, (in Russian). 2. Izmerov N, Suvorov GA, Subbotin VV, Denisov EI, Zhavoronok LG, Radionova GK, Novokhatskaya EA, Tikhonova GI,. Golovkova NP, Leskina LM, Mikhailova NS, Yakovleva TP, Matiukhin VV, Shardakova EF, Yushkova, E.G.Yampolskaya OI. Country profile: The Russian Federation. In: Rantanen J, Kauppinen T, Lehtinen S, Mattila M, Toikkanen J, Kurppa K, Leino T (eds.) Work and health country profiles of twenty-two European Countries. People and Work Research Reports 52. Finnish Institute of Occupational Health, Helsinki 2002:328–47. http://www.ttl.fi/NR/rdonlyres/68FB524C-E6D4-49A0-9F7E- 0F19A5A9553C/0/the_russian_federation.pdf, accessed on 22 October 2007. 3. ILO. Labour force survey 2006. 4. Federal law on sanitary epidemiological wellbeing of population. Approved by Duma, 12 March, 1999. Moscow, Os’89, 1999 (in Russian). 5. Mikheev M., Shlyakhetsky N., Retnev V. Occupational Health in the Russian Federation. 6. Occupational Health in Industrializing Сountries. State of the art reviews. Edited by Joseph LaDou.. Vol. 17, Number 3, Hanley & Belfus, July- September 2002, 469-478 7. The World Bank http://web.worldbank.org 8. World Information Society Report 2007. http://www.itu.int/osg/spu/publications/worldinformationsociety/2007/report. html, 9. www.government.ru 10. Annual sourcebook on statistics for Russian Federation for the year 2006. Rosstat. Moscow, 2007. 11. “State report on sanitary-epidemiological situation in Russian Federation in 2006”/ Federal Centre on Hygiene and Epidemiology, 2007. http://www.rospotrebnadzor.ru/docs/doclad/

72 3. Conclusions

The Northern Dimension Partnership in Public Health and Social Well-being has – through its Occupational Health and Safety sub group of the Expert Group on Social Inclusion, Healthy Lifestyles and Work Ability (SIHLWA) – reviewed the situation in six NDPHS countries and found great variations in health status, working conditions and access to preventive occupational health services. This situation is detrimental to the health and wellbeing of the citizens and unfavourable to the economies of the NDPHS countries. Immediate actions are needed to turn around the negative trend of polarization of health.

Many NDPHS countries seem to focus more on population at risk instead of a more holistic approach. It seems, however, that the strategies are gradually moving towards promotion of health and work ability, and reducing consequences of bad life style and risks and strains at work simultaneously.

National actions plans on OHS are existing in some of the NDPHS countries. Unfortunately these plans are not always implemented very effectively. Part of the problem is the lack of reliable statistics and surveys, and follow-up indicators making it difficult to show the effects. There is a need to improve statistics and do more surveys to guide health policy actions.

Awareness and knowledge of occupational health and safety issues among employers and employees as well as among general public is still in many respect low. The governments leading role in raising public awareness of OSH and setting national targets and resources for corrective and preventive actions at workplaces and generally is recognized. However, streamlining labour unions' and third sector preventive health organisations' actions are needed, too.

A focus on small and medium size enterprises (SMEs) is crucial, as they are the main job creators and have only limited resources to deal with OSH issues compared to big enterprises. The OHS systems are not well equipped to serve micro-companies and SMEs. New, simple and inexpensive methods in risk management are needed.

The relevance and quality of OSH services is an issue in all NDPHS countries. Better integration of OSH into the work place management systems and primary health care is in order. This should be backed with a large scale training of staff in OHS, primary health care clinics, safety inspection services and in work place safety organization.

At the multi-national level, EU, ILO, and WHO should cooperate to support the initiatives taken by the Northern Dimension Partnership in Public Health and Social Well-being and the Baltic Sea Network on Occupational Health and Safety in their efforts to implement their OSH strategies consistently, effectively and efficiently. The national OSH profiles and programs will form a part of the NDPHS data base and will be produced so that they are usable for the ILO and WHO data bases on OSH.

The importance of OSH as part of public health and workplace as an arena for workers' health promotion is gaining ground in Europe. Functional basic and advanced level occupational health services are asked for and seen as an investment not only for health, safety and well-being but also for stable labour markets, better productivity, and improved quality of services and products.

73 ANNEX

Population and health indicators

EST FIN LAT LIT POL NOR RUS

Population (million) in 2003 1.454 5.213 2.325 3.454 38.195 144.964 4.564

Labour force (% of 47.9 50.6 47.9 47.0 44.3 73.2 51.9 population) in 2002 (2005)

Unemployment rate ( % of 4.5 8.8 7.5 19.0 7.6 4.5 civilian labour force) in (2006) (2006) (2006) 2005 male 8.8 18.2 5.0 female 8.9 19.9 4.0

Life expectancy at birth in 71.78 78.72 70.95 72.24 74.74 64.8 79.71 years in 2003 male 66.18 75.25 65.73 66.51 70.53 58.55 77.16 female 77.22 82.05 75.97 77.90 78.91 71.84 82.17

Live births per 1000 9.63 10.86 9.02 8.86 9.19 10.92 12.37 population in 2003 (2006)

Deaths per 1000 13.41 9.41 13.95 11.87 9.56 16.04 9.32 population in 2003 (2006)

New cases of occupational 11 231 61 35 16 115 diseases per 100 000 in (2005) 2003

Injured in work-related 239 2226* 57 77 211 523 accidents per 100 000 in (2004) 2003

Deaths due to work-related 2.29 2.47 1.68 3.27 1.37 1.07 accidents per 100 000 in (2005) 2003

% of population self- 35.87 54.70 32.48 43.50 - - - assessing health as good in 2002 male 34.60 52.99 40.21 47.50 - - - female 36.59 56.07 28.62 40.20 - - - source: data collected from several international databases and publications * causing over four days absence from work