Strategic Leadership. Implementation of the Healthy City Project in Horki, Belarus Andrei Famenka,1 Sviatlana Bezzubenka,2 Natalya Karobkina,2 Raisa Prudnikova3

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SHORT COMMUNICATION

Cross-sectoral health processes: strategic leadership. implementation of the healthy city project in Horki, Belarus Andrei Famenka,1 Sviatlana Bezzubenka,2 Natalya Karobkina,2 Raisa Prudnikova3

1 WHO Country Office, Minsk, Belarus

2 Horki Central District Hospital, Horki, Mogilev Region, Belarus

3 Horki District Centre for Hygiene and Epidemiology, Horki, Mogilev Region, Belarus

Corresponding author: Andrei Famenka (email: [email protected]) ABSTRACT

This article describes the implementation of the Healthy City project in combat noncommunicable diseases (NCDs) and promote a healthy lifestyle1 the small town of Horki, Belarus. Particular attention is paid to the role were adapted to local conditions and more flexible strategies were adopted of strategic leadership in cross-sectoral health collaboration. Factors to implement the main areas of these programmes. The experience gained contributing to the successful implementation of the project included the so far from the Horki – Healthy City project shows that the leadership of local interest of the local authorities, technical and advisory support from the governments has facilitated the harmonious and coordinated work of various WHO European Healthy Cities Network, and the financial independence of the sectors in accordance with WHO’s research-based recommendations for local authorities. A special feature of the Horki – Healthy City project is that improving public health and achieving health equity at the local level. the goals and objectives of the nationwide cross-sectoral programmes to

Keywords: WHO, HEALTHY CITIES, BELARUS, CROSS-SECTORAL HEALTH COLLABORATION, NONCOMMUNICABLE DISEASES

INTRODUCTION modernization of the state health-care system without any drastic changes or reforms (5). In Belarus, the right to health protection and universal access to medical care, including free care at state health- During the period of perestroika from the late 1980s to the care institutions, is enshrined in the constitution and early 1990s, migration and urbanization trends intensified in national law (1, 2). Ensuring that people have equal access to Belarusian society and socioeconomic conditions changed, medical care and taking measures to preserve and promote which affected the structural and functional features of the health is a key factor in the development, implementation health-care system as well as public health indicators. In the and evaluation of the appropriate public policy (3). Belarus period from 1991 to 2010, the difference in life expectancy provides its population with a high level of medical services, between the urban and rural population of Belarus was as with limited out-of-pocket household payments and a high high as five years at certain points, and in rural areas men level of protection against the financial risks associated with were expected to live seven years less than women (6). At this the provision of medical care (4). At present, Belarus has time, the incidence of certain noncommunicable diseases achieved significant success in ensuring affordable universal among the rural population and residents of small Belarusian health coverage for its population. The country has achieved towns was 10–24% higher than the corresponding incidence stability in the provision of health services and has maintained among the urban population (7). In addition, there was a high level of health-care coverage throughout the gradual a higher prevalence of risk factors for NCDs among the rural population and residents of small towns as well as a low level of adherence to medical recommendations for the effective use and administration of medication, especially among men (8). 1 The state programme entitled People’s Health and Demographic Security in the Republic of Belarus for 2016–2020.

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The need for comprehensive measures to improve the health administrative centre of the Horki District, in collaboration of people living in rural areas and small towns has been with the WHO European Healthy Cities Network. The town reflected in national programme documents, such as the State has a population of 33 000 people, features well-developed Programme for Rural Development and Revival (for 2005–2010 industry and transport links with neighbouring regions of the and 2011–2015), the Health-Care Development Programme of Republic of Belarus and the Russian Federation, and is home the Republic of Belarus (for 2006–2010 and 2011–2015) and the to the oldest agricultural university in Europe, the Belarusian National Demographic Security Programme of the Republic State Academy of Agriculture, where 5607 students study of Belarus (for 2007–2010 and 2011–2015). In political terms, fulltime. The academy employs 602 instructors, including the recognition of the role of cross-sectoral collaboration 41 doctors of science and professors and 295 candidates of in the development of policies and the implementation sciences and associate professors. Overall, the students make of measures to improve public health while taking local up roughly 20% of the district’s total working population. Due conditions into account have been key (9). The current state to the unique landscape of the area and its vast park areas, the programme, People’s Health and Demographic Security in city is sometimes referred to as “little Switzerland.” the Republic of Belarus for 2016–2020, clearly outlines the goal of improving the availability and quality of health care The major factors that led to the decision to implement for the rural population and residents of small towns, as the project included the interest of local authorities in the well as a shift in emphasis towards the prevention of NCDs initiative, the existence of favourable administrative factors and the promotion of a healthy lifestyle for all age groups. (such as the local budget resulting from the generation of In addition, the programme pays particular attention to the a high level of taxes and fees) and the financial independence needs of vulnerable groups (10). In 2015 Belarus launched of local authorities. The WHO Regional Office for Europe the international technical assistance project Prevention of provided significant advisory support at the preparation stage Noncommunicable Diseases, Promotion of a Healthy Lifestyle in terms of formulating the goals and objectives as well as the and Support for the Modernization of the Health-Care System core aspects of the work in accordance with the programme in the Republic of Belarus (BELMED)2, which is funded by documents of the WHO European Healthy Cities Network the European Union (EU) and implemented by the United and the European Health for All strategy (12). Before the Nations Development Programme (UNDP), the World Health project was launched in Horki, a publicity campaign was Organization (WHO), the United Nations Children’s Fund carried out in the media to disseminate information about (UNICEF) and the United Nations Population Fund (UNFPA), the project among the district’s residents. In addition, an in cooperation with the Ministry of Health of the Republic awareness raising campaign about the goals, objectives and of Belarus. One of the objectives of the project is to provide tools of the project was carried out among the heads of local support for the modernization of the health-care system with enterprises and employees of regional organizations. From a particular focus on primary health care in the Republic of the very start of the project, the local authorities (the Horki Belarus, which pilots new models of patient-centred care and District Council of Deputies and the Horki District Executive the integration of public health measures in primary health Committee) assumed responsibility for coordinating the care in order to achieve better results in the fight against NCDs activities of various organizations and groups involved in and their risk factors (11). the implementation of the project. The primary role in the execution of the project is played by the coordinating council, which includes representatives of health-care institutions COORDINATION OF CROSS- (Horki Central District Hospital and Horki District Centre SECTORAL COLLABORATION for Hygiene and Epidemiology), education, sports, tourism, the editorial board of the local newspaper Gorki News3 and AT THE LOCAL LEVEL representatives of the Belarusian Orthodox Church (13).

As part of systematic measures to improve the health of the A town’s/ city’s residents are the main source of information rural population and residents of small towns, the Ministry when it comes to the identification of the structural and of Health of the Republic of Belarus had already adopted an functional changes that need to be made to the local initiative in December 2012 to introduce the Healthy City environment, the changes that need to be made to health, pilot project in the small town of Horki, Mogilev Region, the educational and cultural institutions and industrial facilities,

2 Further in the paper referred to as EU-UN BELMED project. 3 http://www.gorkiv.by/

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as well as to what constitutes the vision of the image of a healthy representatives of the Ministry of Emergency Situations and city. Therefore, the Centre for Hygiene and Epidemiology the Ministry of Internal Affairs. carried out a survey among residents and organized a number of public opinion polls. In addition, virtual voting was The Sports and Tourism Department of the Horki District conducted on the websites of the Horki District Executive Executive Committee serves as a patron for the programme Committee and Gorki News. More than 3000 residents took and thereby regularly renovates the equipment in the part in the polls and voting over the course of the project (14). outdoor exercise area along the so-called Environmental Furthermore, representatives of organizations and enterprises Path (a specially equipped pedestrian path), and an initiative are able to submit their proposals to the project secretariat group conducts Nordic walking classes for residents of all throughout the year as they arise. ages. The interest of business leaders in supporting the health of their employees should also be commended. A number of All obtained information is arranged by the project secretariat comprehensive measures have been introduced in conjunction and presented at quarterly meetings of the coordinating with the Horki Central District Hospital to improve the quality council, where current issues concerning the project are and accessibility of medical care. Such measures include discussed and new proposals and adjustments are made to the mobile health-care groups travelling to companies (to carry implementation of the action plan for the current year. Every out check-up examinations and measure health indicators), six months, the results of the project monitoring activities and the allocation of an additional day at the district clinic each priority issues for implementation are reviewed at a meeting of month to conduct medical examinations of managers and the Horki Executive Committee. At the end of each year, the employees of organizations in the region (the first and third coordinating council holds a meeting to approve the work plan Saturday of each month) and the training of volunteers from and budget for the next year. For example, in 2019 there are various organizations in self-help and mutual assistance skills. plans to build a roller skiing track and workout sites in all the The Horki Central District Hospital has been participating town’s residential areas, hold outdoor fitness classes, organize in the EU–UN BELMED project since 2016, introducing a cross country run in the autumn and set up mental well-being pilot measures to provide patient-centred care and integrate rooms at educational institutions, among other activities. public health measures into primary health care as part of the Support for the Modernization of the Health-Care System with a Particular Focus on Primary Health Care in the Republic of LOCAL CROSS-SECTORAL Belarus programme (15). ACTIONS FOR HEALTH The municipal clinic runs the Trust Youth Centre in order to During the project’s implementation, all the town’s residents, provide friendly assistance to adolescents, with individual and regardless of age or income, including people with disabilities, group conversations held with students of the State Academy of were given access to modern sports facilities and the Agriculture as well as high school students. The Centre trains opportunity to systematically engage in physical education volunteers, organizes participation in community actions and sports based on their preferences, level of physical fitness and distributes booklets, leaflets and hand-outs on a variety and health. All sports facilities were equipped with modern of healthy lifestyle issues. As part of a cooperation agreement equipment and fitness machines. between the Republic of Belarus and the Belarusian Orthodox Church, a prayer room was opened at the admissions unit of An awareness raising campaign has been carried out to the Central District Hospital. Each month, representatives encourage all aspects of healthy eating in the local population. of the Belarusian Orthodox Church visit hospital wards and Horki food enterprises have learned how to produce dietary hold discussions about leading a healthy lifestyle, family and high-fibre baked and confectionery goods and have begun values, preventing stress and mental health. As part of the producing fermented milk beverages, whey protein-enriched Horki – Healthy City project, the state educational institution milk as well as milk containing vitamins A and C. The Horki Centre for Corrective Development Education and Department of Education is implementing several preventive Rehabilitation holds sporting events to develop physical activity projects including Healthy Class, Healthy School and Healthy among children with disabilities. Specialists from the Horki Lifestyle – That’s Good! Furthermore, an educational mini- Children’s and Youth Sports School promote equestrian sports centre for students has opened at the University Preparatory and talk about the benefits of interaction with horses (16). School No. 1 that offers classes on life safety, traffic rules and first aid. The mini-centre employs health professionals and

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Over the course of the implementation of the Horki – Healthy Acknowledgments: the authors would like to express their City project, the overall occupancy ratio of sports facilities has gratitude to the donors and participants of the EU-UN increased from 35% to 82%; the length of the city’s bike path BELMED project, without whom the publication of this article network has increased from 4 km to 14 km; two neighbourhood would not have been possible. The project is funded by the outdoor mini-exercise areas have been built; and the share of European Union and is being implemented by the Ministry preventive hand-out informational and educational materials of Health of the Republic of Belarus in collaboration with in the overall circulation of printed materials has increased the WHO, the United Nations Development Programme, from 11.2% in 2014 to 27.9% in 2018. the United Nations Children’s Fund and the United Nations Population Fund. Despite the fact that it is difficult at present to assess the specific contribution of the project to improvements in public Sources of funding: none stated. health, as the project’s activities are being implemented simultaneously with the large-scale measures of the People’s Conflict of interests: none stated. Health and Demographic Security in the Republic of Belarus for 2016–2020 state programme and the EU–UN BELMED Disclaimer: the authors are solely responsible for the project, the following positive trends can be seen in terms of opinions expressed in this publication, which do not improvements to the demographic situation in the town and necessarily represent the decisions or policies of the World the region over this period: Health Organization.

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