PUBLIC HEALTH SERVICES PROVISION OPTIONS A review of the international practice
I. INTRODUCTION What is the Public health? Over the past two centuries, public health has achieved great successes, illustrated by the remarkable reductions in deaths and disability from many infectious diseases (Bernd, McKee, 2014). For instance, a child born in 1955 had an average life expectancy at birth of only 48 years (WHO, 1988). By 2000, the life expectancy at birth had increased to 66 years, and it is expected that it will rise to 73 years by 2025 (WHO,1988). These improvements “have resulted from improved living conditions overall, advances in medical science, and a number of population-level interventions” (CDC, 2011).
The “understandings of public health vary among different countries in Europe and the term is difficult to translate into some other European languages”. (Bernd,McKee, 2014). In 1988 the Institute of Medicine (IOM) provided a definition of public health in their work “The Future of Public Health”. The IOM report define public health mission as “fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM, 1988). This definition “directs attention to the many conditions that influence health and wellness, underscoring the broad scope of public health and legitimizing its interest in social, environmental, economic, political, and medical care factors that affect health and illness” (Turnock, 2012). The definition of IOM also reflected in Winslow’s definition which is used in concept paper of the WHO European Region concluded in 2011. Winslow’s definition of public health is “the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society…” (Winslow, 1920). The phrases, “science and art,” “organized community effort,” and “birthright of health and longevity” capture the substance and aims of public health (Turnock, 2012). Therefore, public health can have different images depending of the perception of general public. For instance, public health could be perceived as 1) the system and social enterprise, 2) the profession, 3) the methods (knowledge and techniques), 4) governmental services (especially medical care), 5) the health for public (Turnock, 2012).
Viewing public health as a system gives an understanding how interconnected components interact. “Health systems are one of key instruments created by human societies to help achieve improved health outcomes as they [health systems] raise and channel recourses and create and manage the service delivery mechanisms.”1 The countries of the former Soviet Union (FSU) over the last 20 years have experienced an transformation.2 Most countries of FSU inherited major features of Semashko model of health care, despite its achievements in ensuring universal coverage, “this system also characterized by a poor quality, inefficiency and lack of responsiveness”3. In early years, the specialists from so-called Sanitary Epidemiological (San-Epid) Service were responsible for “maintaining preventive and routine sanitary and epidemiological surveillance to ensure safe working conditions in enterprises, public facilities and institutions”4. “The san-epid service initially made a significant progress in fighting communicable diseases, establishing comprehensive childhood vaccination
1 http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627- 1095698140167/ImprovingDeliveryofHealthServicesFINAL.pdf 2http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet- countries.pdf 3 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet- countries.pdf 4 http://www.euro.who.int/__data/assets/pdf_file/0010/96418/E84927.pdf
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. programs and contributing to the decline of many communicable diseases, it was much less effective in the areas of noncommunicable disease, occupational health and environmental health”5.
The FSU countries experienced the reform of san-epid service differently. “Since 1990, these systems have undergone varying degrees of reform in all the countries. In each country, the structures for and provision of public health system has evolved over the years according to different decisions made by governments and ministries of health”6. For instance, such countries as Armenia, Belarus, the Russian Federation, and Ukraine “have largely preserved the Soviet san-epid structure. Meanwhile, some countries such as Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan have built additional structures; and others, Georgia and the Republic of Moldova, abandoned the san-epid service and set up new public health infrastructures”7.
Despite of other countries, the san-epid service in Ukraine was administered in a hierarchical fashion with services at the national, regional (oblast/city) and district level8. In Ukraine, the san-epid service underwent major reforms in 2011– 2012. “Its status was upgraded from a structure within the Ministry of Health to a central executive body under the Cabinet of Ministers and its emphasis was shifted from administrative services to health promotion and education”9. Moreover, “the reform expanded the tasks of the service to include the prevention of tobacco use, reduced the number and frequency of planned inspections and simplified licensing procedures”10.
In all countries in Europe, different actors are involved in public health activities and their integration can be challenging”11. The poor integration of separate vertical public health structures and primary health care has been identified as a challenge in a number of countries, including Azerbaijan (Ibrahimov et al., 2010), Belarus (Richardson et al., 2013), Kazakhstan (Katsaga et al., 2012), Tajikistan (Khodjamurodov & Rechel, 2010) and Ukraine12. So, to manage effectively public health activity the central state authority is needed.
Overview of 10 essential public health services, WHO: Useful link: http://www.euro.who.int/__data/assets/pdf_file/0010/172729/Review-of-public-health-capacities- and-services-in-the-European-Region.pdf?ua=1 Public health systems are commonly defined as “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.” 13 The “essential public health services” were described by different agencies in the world (Bernd,McKee, 2014). An adaptation of these “essential public health functions” has been developed by the WHO Regional Office for Europe in the form of 10 essential public health operations (EPHO)14:
5 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet-countries.pdf 6 http://www.euro.who.int/__data/assets/pdf_file/0016/125206/e94398.pdf 7 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet-countries.pdf 8 http://www.euro.who.int/__data/assets/pdf_file/0010/96418/E84927.pdf 9 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet-countries.pdf 10 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet-countries.pdf 11 http://www.eurohex.eu/bibliography/pdf/2444834988/Rechel_2013_Lancet.pdf 12http://www.euro.who.int/__data/assets/pdf_file/0010/96418/E84927.pdf 13 https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html 14 http://www.euro.who.int/en/health-topics/Health-systems/public-health-services/policy/the-10-essential-public-health-operations
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1. Surveillance of population health and wellbeing 2. Monitoring and response to health hazards and emergencies 3. Health protection including environmental occupational, food, safety and others 4. Health promotion including action to address social determinants and health inequity 5. Disease prevention, including early detection of illness 6. Ensuring governance for health and wellbeing 7. Assuring a sufficient and competent health workforce 8. Assuring sustainable organizational structures and financing 9. Advocacy communication and social mobilization for health 10. Advancing public health research to inform policy and practice
Those 10 Essential Public Health Operations (EPHOs), which can be applied to capacity building, planning and delivery of services 15. In addition, these public health operations have the benefit of identifying horizontal activities across the whole political and administrative spectrum of policy- making, rather than focusing on the activities of specific institutions (Koppel, Leventhal et al. ,2009). The operations 1 to 5 of public health can be viewed as core public health operations, while operations 6-10 are overarching operations that enable the delivery of public health activities 16.
The development of effective public health system is a priority in health care reform in Ukraine1718. The development of public health system will be in line with European action plan for Strengthening Public Health Capacities and Services 19 (EPHOs).
15 http://www.euro.who.int/en/health-topics/Health-systems/public-health-services/policy 16 http://www.euro.who.int/__data/assets/pdf_file/0003/271074/Facets-of-Public-Health-in-Europe.pdf?ua=1 17 https://www.kmu.gov.ua/ua/npas/249618799 18 http://moz.gov.ua/uploads/0/691-strategiya.pdf 19 http://www.euro.who.int/en/health-topics/Health-systems/public-health-services/publications/2012/european-action-plan-for-strengthening- public-health-capacities-and-services
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. II. PUBLIC HEALTH SERVICES AT THE PRIMARY HEALTH CARE LEVEL
In Europe, and worldwide, there is a debate on where public health ends and health care begins20. “Since the conception of public health, there has been controversy surrounding the clinical versus the social domain of medicine.21” “In contrast to isolated clinical practice, primary health care focuses on health and prevention, health promotion, continuous and comprehensive care, team approaches, intersectoral collaboration, and community participation.”22 Therefore, the basic pillars of public health which include disease prevention, health protection and health promotion and health systems provide these services23.
In addition, the terms ‘primary health care’ (PHC) and ‘public health’ (PH) may carry different meanings depending on the context and perspective24. For instance, PHC could be defined as: • Health or medical care that begins at time of first contact between a physician or other health professional and a person seeking advice or treatment for an illness or an injury. • First-contact, accessible, continued, comprehensive and coordinated care. First- contact care is accessible at the time of need; ongoing care focuses on the long-term health of a person rather than the short duration of the disease; comprehensive care is a range of services appropriate to the common problems in the respective population and coordination is the role by which primary care acts to coordinate other specialists that the patient may need25 The first definition is “profession-centered” and emphasize on the integral role of clinician and WHO definition focuses on the ‘health system as a whole and recognizes the need to involve communities in their health”26. In the Alma-Ata Declaration of 1978 emerged as major milestone of the 20th century in the field of public health, and it defined primary health care as the hey to the attained of the goals of Health for All. The “primary health care sector is the setting of key public health functions, such as the provision of immunizations and, increasingly, health promotion and education”27. “Primary health care systems can be strengthened by building stronger collaborations between primary care and public health. Stronger collaborations can lead to more integrated systems, universal coverage, improved access to care, and ultimately improved health outcomes28”.
20 http://www.euro.who.int/__data/assets/pdf_file/0009/389844/Designed-report-2.pdf?ua=1 21 https://www.jabfm.org/content/22/3/242.long 22 https://www.jabfm.org/content/22/3/242.long 23 http://www.euro.who.int/__data/assets/pdf_file/0009/389844/Designed-report-2.pdf?ua=1 24 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588212/ 25 https://apps.who.int/iris/bitstream/handle/10665/108066/E58474.pdf?sequence=1 26 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588212/#B23 27 28 Strengthening primary health care through primary care and public health collaboration: the influence of intrapersonal and interpersonal factors
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. One of the approaches of health system integration is social-ecological model (SE model). It describes the relationship between individual, relationship, community, societal, and global influences. To address integrate the health care and public health in all these levels is critical to develop strategies which will guide the development of PH and PHC strategies (Table 129). Table 1. Strategic alignment of policy and services across the continuum of health needs
According to the scoping literature review of collaboration between primary care and public health, it was identified framework that includes systemic, organizational and interactional determinants for collaboration (Table 230).
Table 2. Primary Care and Public Health Collaborative Framework
“All former Soviet countries have embarked to varying degrees on attempts to strengthen primary health care and thus use resources more efficiently31”. In Ukraine “the primary health care receives about 10% of health care financing, and the major share of costs goes to highly specialized care”32. The retraining of specialist physicians as general practitioners (GPs) was a major feature of attempts to strengthen primary health care in almost all countries of the region33. “However, few countries have trained more than a small proportion of physicians working in primary health care. In Ukraine in 2010, GPs accounted for 32·9% of all physicians working in primary care, and 70% of GPs worked
29 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588212/#B40 30 Ruth Martin-Misener, Ruta Valaitis, Sabrina T. Wong, Marjorie MacDonald et all (2012): “A scoping literature review of collaboration between primary care and public health” 31 http://www.eurohex.eu/bibliography/pdf/2444834988/Rechel_2013_Lancet.pdf 32 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260664/#CR15 33 http://www.eurohex.eu/bibliography/pdf/2444834988/Rechel_2013_Lancet.pdf
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. in rural areas34. “Common problems are the low salaries and prestige of GPs, insufficient training, and little public support for the new role35”.
“The changes in the organization of the system of service provision require to reorganize also the area of management and control over the financial resources. The Ukrainian government has taken intensive action to achieve this goal. In 2018 the works started to implement new organizational scheme with the main focus on the central body, the National Health Service of Ukraine (NSHU)36”. The new institution is supposed to perform a role of public agency responsible for contracting health service providers. Meanwhile, “the process of implementation of a new financing scheme has been initiated, in the first place at the level of primary health care37”. “Except for the change of money flows, the reform allows also private providers to be contracted by public payer. The use of new financial mechanisms is planned to come into force in the area of specialist treatment in 2019, whereas in 2020 the implementation of solutions for guaranteed access to services is supposed to take place38. “Some ad hoc investment are also being applied to improve the supply of medicines and vaccines, as well to ensure general improvement of the infrastructure of service provision (Ministry of Health of Ukraine, 2018)”39.
References (Chapter I, II. III)
Centers for Disease Control and Prevention. (2011). Ten great public health achievements-- worldwide, 2001-2010. MMWR. Morbidity and mortality weekly report, 60(24), 814. Retrieved from:https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6024a4.htm
Bueno-de-Mesquita, H. B. (2015). Noncommunicable diseases of major public health interest and prevention. Asia Pacific Journal of Public Health, 27(8_suppl), 110S-115S.
Rechel, B., In McKee, M., & European Observatory on Health Systems and Policies,. (2014). Facets of public health in Europe. Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0003/271074/Facets-of-Public-Health-in- Europe.pdf?ua=1
World Health Organization.(1998) The world health report 1998-life in the 21st century: a vision for all. Geneva, Switzerland. Retrieved from: https://www.who.int/whr/1998/en/whr98_en.pdf
Winslow CEA. The untilled field of public health. Mod Med. 1920; 2: 183–191.
34 http://www.euro.who.int/__data/assets/pdf_file/0018/280701/UkraineHiT.pdf?ua=1 35 http://www.eurohex.eu/bibliography/pdf/2444834988/Rechel_2013_Lancet.pdf 36 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260664/#CR15 37 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260664/#CR15 38 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260664/#CR15 39 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260664/#CR15
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. Institute of Medicine, National Academy of Sciences.(1988). The Future of Public Health. Washington, DC:National Academy Press;. Retrieved from: https://www.jstor.org/stable/3342895?read-now=1&seq=2#metadata_info_tab_contents https://www.who.int/docs/default-source/primary-health/vision.pdf http://www.euro.who.int/en/health-topics/Health-systems/public-health- services/publications/2018/ensuring-collaboration-between-primary-health-care-and-public-health- services-2018
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. III. CHALLENGES IN PUBLIC HEALTH IN UKRAINE Ukraine has one of the worst health profiles in European region which is characterized by low life expectancy, disability rates and morbidity (Table 3). According to the latest data published by WHO, the life expectancy in Ukraine is 72.5 Comparing to other European countries the life expectancy in Ukraine is ranked low40. Moreover, the life expectancy in Ukraine has the high gender gap. The life expectancy for men is 67.6 years and for female is 77.1 years. The years of potential life lost for Ukrainian men is more than twice as high as that of women. For each case of death in the average of 30-69 years, an average of 10.3 years of potential life is lost41. The main risks contributing to of disability-adjusted years (DALYs) in 2017 are behavioral (dietary risks, tobacco and alcohol use, low physical activity), metabolic (high blood pressure, high LDL, high body mass index, high fasting plasma glucose, impaired kidney function) and environmental risks (air pollution).42 Those risk factors are responsible for majority of non- communicable diseases and could be largely modifiable and preventable. The risks which are related to lifestyle such as smoking, alcohol consumption, diet, physical activity are key contributors to the many diseases. “These causes of chronic diseases are expressed through common chronic conditions such as high blood pressure, high blood glucose levels, high cholesterol and overweight/obesity”43. Table 3. Life expectancy and causes of death (2017) Key Health Indicators Top 10 causes of death44 Life expectancy at birth:72.5 years Ischemic heart diseases (44.88%) (EU average 80.6245 ): Stroke (12.67 %) • 67.6 years for male (EU – 78.646) Alzheimer’s disease (5.06%) • 77.1 years or female (EU-83.3647) Cirrhosis (2.91%) Cardiomyopathy and myocadiac (2.32%) Lung cancer (2.27 %) Self-harm (1.98%) Colorectal cancer (1.91 %) COPD (1.51%) Stomach cancer (1.34%) Alcohol use disorder (1.2%) ______Prevalence of key risk factors: Tobacco. Tobacco use is a major preventable cause of premature death killing 7 million people a year globally48. In addition,” worldwide, tobacco use is the single greatest avoidable risk factor for
40 https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=UA 41 https://www.ncbi.nlm.nih.gov/pubmed/29783257 and full version http://wl.medlist.org/03b-2018-23/ 42 http://www.healthdata.org/ukraine 43http://documents.banquemondiale.org/curated/en/281511468143401258/pdf/713010WP0Prich00Box370065B00PUBLIC0.pdf 44 https://vizhub.healthdata.org/gbd-compare/ 45 https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=EU 46 https://data.worldbank.org/indicator/SP.DYN.LE00.MA.IN?locations=EU 47 https://data.worldbank.org/indicator/SP.DYN.LE00.FE.IN?locations=EU 48 http://www.euro.who.int/__data/assets/pdf_file/0007/347632/UKR_GATS_2017_ES_17Aug2017_Final.pdf
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. cancer mortality and kills approximately 6 million people each year, from cancer and other diseases. Tobacco smoke has more than 7000 chemicals, at least 250 are known to be harmful and more than 50 are known to cause cancer”49. According to “Global Adult Tobacco Survey” (GATS) in Ukraine (2017), 23.0 % (8.2 million) of adults in Ukraine reported current tobacco use in any forms (40.1 % of males, 8.9 % of females). Overall, 22.8 % of adults currently smoked tobacco (39.7% among males and 8.8% among females). Among daily cigarette smokers (7.2 millions), 90.5 % smoked 10 or more cigarettes. Almost two in five (39.2 %) tobacco smokers had attempted to quit smoking last 12 month. Among tobacco smokers who visited a health care provider in the past 12 months, 49.2% were asked by health care provided if they smoked, and 39.4% were advised by health care provider to quit smoking50. Ukrainian government and public institutions working towards combat smoking epidemics51. Hower, the smoking rate in Ukraine is still high and smoking cessation services should be a priority on the primary healthcare level as” most tobacco users try to quit multiple times, and repeated intervention is necessary to support this iterative process.52” In Ukraine the first national smoking-cessation service was launched in June 201753. Alcohol consumption. WHO estimates that alcohol consumption in the post-Soviet countries remains higher than in any other region of the world 54. ” The harmful use of alcohol causes a large disease, social and economic burden in societies. In 2012, about 3.3 million net deaths, or 5.9% of all global deaths, were attributable to alcohol consumption”55. Ukraine is second in the world when it comes to alcohol-related death56. Epidemiological studies show that for every ten deaths in working-age men, between four and six are caused by heavy or hazardous drinking (such drinking causes about a third of deaths in working-age women).57 58 ” Alcohol-related harm is determined by the volume of alcohol consumed, the pattern of drinking, and, on rare occasions, the quality of alcohol consumed59”. Alcohol per capita (APC) consumption for Ukrainians over 15 years old is 13.9 liters (as compared to the global average of 6.2)60. In Ukraine the prevalence of heavy episodic drinkers 61among population was 22.6 % (35.2% among males and 12.1% among females)62. The
49 https://www.who.int/cancer/prevention/en/ 50 http://www.euro.who.int/__data/assets/pdf_file/0007/347632/UKR_GATS_2017_ES_17Aug2017_Final.pdf 51 http://www.euro.who.int/__data/assets/pdf_file/0007/233368/Tobacco-Control-in-Practice-Article-6.pdf 52 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494968/ 53 http://www.euro.who.int/__data/assets/pdf_file/0004/385078/ukr-leaflet-hr-eng.pdf?ua=1 54 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet- countries.pdf 55 https://www.who.int/substance_abuse/facts/alcohol/en/ 56 Tobacco and alcohol consumption in Post-Soviet Ukraine: qualitative ...journals.uran.ua/tcphee/article/download/27519/83310 57 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1890567/ 58 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275563/ 59 https://www.who.int/substance_abuse/facts/alcohol/en/ 60 Tobacco and alcohol consumption in Post-Soviet Ukraine: qualitative ...journals.uran.ua/tcphee/article/download/27519/83310 61 consumed at least 60 grams or more of pure alcohol on at least one occasion in the past 30 days.
62 https://www.who.int/substance_abuse/publications/global_alcohol_report/profiles/ukr.pdf?ua=1
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. health consequences form alcohol use and as a result alcohol-related death are alcohol poisoning, pneumonia, injuries, suicide, and cardiovascular diseases.63 “Ukraine also has one of top 10 suicide rates in the world, and suicide is associated with both depression and alcohol use disorder.64” More information about alcohol consumption: https://www.demogr.mpg.de/papers/working/wp-2009-017.pdf http://www.euro.who.int/en/health-topics/disease-prevention/alcohol-use/data-and- statistics/infographic-the-risk-of-dying-from-an-alcohol-attributable-cause https://openknowledge.worldbank.org/bitstream/handle/10986/28834/120767-WP-Revised- WBGUkraineMentalHealthFINALwebvpdfnov.pdf?sequence=1&isAllowed=y Obesity. “Intercountry comparable overweight and obesity estimates from 2008 show that 53.5% of the adult population (> 20 years old) in Ukraine were overweight and 21.3% were obese. The prevalence of overweight was lower among men (50.5%) than women (56.0%). The proportion of men and women that were obese was 15.9% and 25.7%, respectively. It is estimated that adulthood obesity prevalence predicts that in 2020, 32% of men and 10% of women will be obese. By 2030, the model predicts that 49% of men and 6% of women will be obese”65. The obesity has significant implications for diabetes and cardiovascular disease. Raised blood pressure/hypertension/high blood pressure. “High blood pressure has serious health implications for society as it is a major risk factor for serious cardiovascular events”66. It is estimated that half of the cardiovascular disease events are attributed to hypertension67. In Ukraine, in 2015, raised blood pressure (adults aged 18+) had 32 % of population (35 % for men, 30% for female).68 High-blood pressure is responsible for 42 % of total death and compared to other European countries like France - 15%, Bulgaria - 41 %, in Ukraine this percentage is the highest69. Thus, it is highly important to prevent, treat and control hypertension in order to reduce the cases of cardiovascular diseases. More information about HBP: http://documents.worldbank.org/curated/ru/525041547230842315/pdf/133691-WP-PUBLIC-ADD-SERIES- HypertensioninUkrainePolicybriefENGLFINAL.pdf
63 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2972439/ 64 https://openknowledge.worldbank.org/bitstream/handle/10986/28834/120767-WP-Revised- WBGUkraineMentalHealthFINALwebvpdfnov.pdf?sequence=1&isAllowed=y 65 Text is taken from http://www.euro.who.int/__data/assets/pdf_file/0019/243334/Ukraine-WHO-Country-Profile.pdf?ua=1 66 http://www.euro.who.int/__data/assets/pdf_file/0008/185903/e96816.pdf 67 https://www.sciencedirect.com/science/article/pii/S0140673608606558 68 https://www.who.int/nmh/countries/ukr_en.pdf?ua=1 69 http://vizhub.healthdata.org/gbd-compare and http://documents.worldbank.org/curated/ru/525041547230842315/Hypertension-Care-in- Ukraine-Breakpoints-and-Implications-for-Action
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. Non-communicable diseases
Useful link (country profile on main patterns of NCDs, graphics: https://apps.who.int/iris/bitstream/handle/10665/128038/9789241507509_eng.pdf?sequence=1) NCDs are the main cause of mortality in Ukraine with contributing behavioral factors such as alcohol use, tobacco consumption and unhealthy lifestyles. For instance, four main types of NCD (cardiovascular diseases, cancer, diabetes and chronic respiratory diseases) account 38 million deaths worldwide annually70 (Table 4). NCD epidemic is increasing in the world and it is expected that in will increase by increase to >23.6 million death per year by 203071 (currently it is 17.3 million death per year). NCDs are responsible for 91% of all deaths in Ukraine (578 200 cases of death in 2016). “While comparing the likelihood of dying at the age of 30-69 from four main NCD in the countries of the world, it turns out that in Ukraine this index is one of the worst72. On July 26, 2018 the Cabinet of Ministers of Ukraine approved the National Action Plan for Non-Communicable Diseases (available in Ukrainian), prepared by the Ministry of Health of Ukraine. Table 4. Proportional mortality from NCDs in Ukraine (201673)
Cardiovascular diseases. For instance, in 2017, ischemic heart disease is responsible for almost 44.8 % of total death (1.400 per 100,000)74. Meanwhile, stroke causes 12.67 % of total death in Ukraine. Cancer. According to the National Cancer registry of Ukraine (2016) there were registered 135714 new cases of cancer (375.6 cases per 100,000 population)75. The incidence of many cancers is
70 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561645/ 71 https://www.scholars.northwestern.edu/en/publications/heart-disease-and-stroke-statistics-2016-update-a-report-from-the 72 http://wl.medlist.org/03b-2018-23/ 73 https://www.who.int/nmh/countries/ukr_en.pdf?ua=1 74 http://www.healthdata.org/ukraine 75 http://www.ncru.inf.ua/publications/BULL_19/PDF/03-06-vstup.pdf
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. increasing as a result of lifestyle and environmental factors and an increasingly aged population76. In 2017, the prevalence of cancer is approximately 950 000 cases. The most common cancers among men are non-melanoma of skin (21.4%), prostate cancer (11.3%), and bladder (7.3%). Among women - breast cancer (23.0%), non-melanoma of skin (17.5%), and uterine corpus cancer (12.1%)77. Between 30-50% of all cancer cases are preventable78. During the general medical examinations there were diagnosed 28.0 % of cancer patients. Moreover, only 48 % of breast cancer cases were detected among women79. Diabetes.80 The prevalence of diabetes is 9.1 % (approximately 1.2 million people81) (8.3 % for men, 9.7% for women) in 201682. People who have type I Diabetes account 6.5%. Links to check: https://www.who.int/diabetes/country-profiles/ukr_en.pdf https://www.ncbi.nlm.nih.gov/pubmed/27717926 Other Public Health Challenges. HIV/AIDS and TB could be nominated as a critical infectious agents causes of deaths in Ukraine. Both TB and HIV/AIDS epidemics demand a sustainable funding and service provision models improvements. Prevalence of mental health disorders are underestimated but in the last decade come more and more visible for health care system and funding model as well as option provision need to be streamlined. The injuries, including traffic- related ones, should be considered as well as huge impact on healthcare system exists and preventive services need to be strengthened. Useful recourses for the chapter on “Challenges in PH in Ukraine”: http://www.healthdata.org/ukraine http://www.euro.who.int/en/about-us/partners/observatory/publications/studies http://www.euro.who.int/__data/assets/pdf_file/0003/387534/online-appendix-hps-51-eng.pdf?ua=1 http://documents.worldbank.org/curated/en/953751468250295078/pdf/781850WP0P11980onsolidat ed0complete.pdf
(2007, DHS): https://dhsprogram.com/pubs/pdf/FR210/FR210.pdf http://www.euro.who.int/__data/assets/pdf_file/0007/233368/Tobacco-Control-in-Practice-Article- 6.
76 https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(15)00205-3/fulltext 77 http://www.ncru.inf.ua/publications/BULL_19/PDF_E/9-str_kont.pdf 78 https://www.who.int/cancer/prevention/en/ 79 http://www.ncru.inf.ua/publications/BULL_19/PDF/03-06-vstup.pdf 80 statistics аналіз поширеності та захворюваності на діабет та його ускладнення Ткаченко
81 http://moz.gov.ua/article/health/vsesvitnij-den-borotbi-z-diabetom-scho-treba-znati-pro-hvorobu 82 https://www.who.int/diabetes/country-profiles/ukr_en.pdf
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. IV. PUBLIC HEALTH SERVICES
a. Public health services providers
Benefits of Integration (PH & PHC) As mentioned above, there have been few formal analyses of the efficacy of primary care and public health integration. However, evidence indicates that some advantages can be realized through integration. A recent literature review of primary care and public health collaborations conducted in Canada found that these efforts resulted in improved health outcomes, improved workforce outcomes, and benefits at the patient and population levels (Martin-Misener et al., 2009), but that these examples are not widespread. Lasker and the Committee on Medicine and Public Health (1997) conducted a review of more than 400 instances of medicine and public health collaboration and noted a number of benefits that arose from such endeavors. Specifically, the authors found that collaboration benefited clinicians by providing population-based information relevant to their practices, enhancing their capacity to address behaviors and the underlying causes of illness, and generating better quality assurance standards and performance measures. Public health entities received support for their role
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. in carrying out population-based strategies, including the collection of individual-level data for surveillance purposes, the dissemination of health education and key health promotion messages, and cooperation for the assurance of quality medical care for all members of a community. Beyond the benefits to providers and public health entities, it stands to reason that society gains from integration as well. Integration can improve the efficiencies and harness the capabilities of primary care and public health and their respective workforces to focus on common problems. By joining forces, primary care and public health are better able to meet the nation’s goal of improved population health. Unfortunately, however, integration is no easy task. Challenges of Integration Aligning primary care and public health to work together and with other partners in pursuit of the shared goal of improved population health is challenging. ….
Provision of public health services Germany While the specific tasks of the public health services and the levels at which they are carried out differ from Land to Land, they generally include activities linked both to the Land’s sovereign rights and the care provided for selected groups, such as: • surveillance of communicable diseases; • health reporting; • supervision of hygiene in hospitals and among hospital staff, and since 2000 of office-based physicians and non-physician health professionals; • supervision of commercial activities involving food, pharmaceuticals and drugs; • overseeing certain areas of environmental hygiene; • physical examinations of schoolchildren and certain other groups; • diagnostic and – in exceptional circumstances – therapeutic services for people with specific communicable diseases including sexually transmittable diseases and tuberculosis; • provision of community-oriented psychiatric services; • health education and promotion; and • cooperation with and advice to other public agencies. These services are provided by roughly 350 public health offices across Germany, which vary widely in size, structure and tasks. In the first decades of the Federal Republic’s history, the Länder defended their responsibility for public health services against several attempts by the federal government to extend its influence in this sector. Originally, immunizations, mass screening for tuberculosis and other diseases, as well as health education and counselling, were in the hands of the public health services. Since the 1970s, however, many of these individual preventive services have been transferred to physicians in private practice, combined with an expansion of the SHI benefits package. Before 1970, only antenatal care was included in the benefits package. Since 1971, however, screening for cancer has become a benefit for women over 20 years and men over 45 years. At the same time, regular check-ups for children under 4 years of age were introduced (and extended to children under 6 years of age in 1989 and to adolescents in 1997). Also in 1989, group dental preventive care for children under 12 years and individual dental preventive care for those aged 12–20 years became SHI benefits; individual preventive care was extended to those
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. aged 6–20 years in 1993. Regular health check-ups, such as screening for cardiovascular and renal diseases and diabetes, for sickness fund members over 35 years were also introduced in 1989. Primary prevention and health promotion were made mandatory for sickness funds in 1989, eliminated in 1996 and reintroduced in modified form in 2000. With §§ 20 and 20a SGB V, the Act to Strengthen Competition in SHI expanded the scope of the sickness funds’ activities yet further to include occupational health promotion as a standard SHI benefit as of 2007. The sickness funds are given a benchmark of €2.78 per insured individual for primary prevention measures and occupational health promotion. In 2010, the sickness funds spent approximately €300 million on primary prevention and occupational health promotion. Between 2000 and 2010, spending on primary prevention increased from €1.10 to €4.33 per person covered by SHI. In 2010, around 12 million people – many more than in the previous year – received preventive and health promoting activities from their sickness funds. In particular, setting-based measures were expanded: In 2010, more than 30 000 institutions (up from 14 000 in 2007) – especially kindergardens, schools and vocational schools – were supported by targeted activities in the areas of exercise and healthy eating, thereby reaching 9 million people. Individual courses have also been increased; utilization of these increased steadily between 2002 and 2009, with a slight decrease in 2010. With 52%, exercise courses have remained most popular (Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen, 2012). Since 2003, the existing cancer-screening benefits covered by SHI (women: cervix/genital, breast, skin, rectum/colon; men: skin, rectum/colon, prostate) have been extended to include colonoscopy (two tests, at the ages of 55 and 65 years) as an alternative to stool testing and a systematic mammography screening programme for women aged 50 to 69 years. The expansion of the SHI benefits package to include screening and early detection services means that private-practice physicians are obliged to deliver these services as part of the regional budgets negotiated by the regional associations of SHI physicians and the sickness funds. For some other services, such as immunizations, the physicians negotiate with the sickness funds and arrange separate fees that are not part of the regional budgets. Consequently, preventive services are now delivered within the same legal framework as curative services, meaning their exact definition is subject to negotiations at the federal level between the sickness funds and the physicians. The current directive of the Federal Joint Committee on preventive services includes clinical and laboratory services for screening and information about test results and prognosis; health education, however, is still given low priority in the reimbursement and documentation requirements. Since 2000, the functions of public health services in controlling communicable diseases have been reorganized according to the Infection Protection Act (Infektionsschutzgesetz). The surveillance procedures were streamlined and essentially centralized at the Robert Koch Institute to better evaluate and inform the public about infectious diseases and to cooperate with European disease-control agencies. Besides supervising hygienic standards in hospitals, public health offices also check hygienic standards in practices of ambulatory care physicians, dentists and other health professionals. Hospitals and ambulatory surgery facilities are now required to report nosocomial infections and multiresistant microbes, with recommendations for improving the situation. Since the introduction of the Infection Protection Act in 2000, well-proved voluntary and educational standards for HIV have been applied to all sexually transmittable diseases, and the former stricter regulations have been abolished. Public
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. health offices have been required to strengthen their counselling services and to provide diagnostic services and treatment in certain cases, including for example non-compliant patients with tuberculosis. The Federal Centre for Health Education, an agency of the Federal Ministry of Health, is responsible for population-wide campaigns for lifestyle-oriented primary prevention of chronic diseases, including initiatives to prevent HIV; sex education and family planning; and initiatives to prevent addiction, increase exercise, improve nutrition and help people to cope better with stress. It also operates campaigns to encourage organ and tissue donation. The Centre also operates a database on projects that aim at reducing inequalities in health by particularly targeting the socially disadvantaged. Currently, the database provides information on more than 1700 projects directed at improving the health of socially disadvantaged people or groups.
Spain One area that has seen significant developments over the last decade is Public Health policies. Some advances include the General Law (33/2011) on Public Health and new taxes on tobacco and alcohol – introduced in 2013. In addition, the introduction of population-based screening for colorectal cancer is notably increasing overall coverage, while also slowly reducing regional inequalities in uptake. Although there have been new developments in the national regulation of public health (see below), no major novelties in the provision of public health services have been experienced in Spain since 2010. Competences on public health local planning and provision were transferred to all 17 ACs between 1979 and 1981. Although with some variation, public health within ACs (Autonomous Community) has a dedicated structure where a health authority, usually a general directorate, ensures the enforcement of the regulations passed to support public health policies, throughout the workforce of public health inspectors, and holds the executive planning role for public health services and the provision of public health surveillance and monitoring activities (health status, health determinants and health risks). The health authority also acts as the regional hub of the national network for epidemics surveillance and those care settings that provide population-based screening programmes. Finally, the health authority supports non-health-care providers in the development of prevention and health promotion programmes mediated by schools or nongovernmental organizations. In coordination with the regional health authorities, municipalities are critical public health agents in sanitation and environmental issues and, in larger villages, in food safety control, slaughter of animals, and in local health promotion programmes. Interestingly, core public health agents in the SNS are primary care doctors and nurses. The bulk of preventive medicine and health promotion activities (for example, infant and older people vaccination programmes, primary and secondary prevention of noncommunicable diseases, opportunistic screening activities, health education activities) are integrated as part of their normal activity. Besides the public health activities developed at regional level, the Spanish Ministry of Health (MSSSI), through the General Directorate of Public Health, has responsibility for certain public health tasks, such as international health activities (for instance, control and surveillance of risks derived from international movement of commodities and passengers), food safety regulation, the system of alerts for health emergencies and, notably, the coordination of the 17 public health regional Departments of Health and INGESA. As in many SNS instances, public health policies are coordinated in the context
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. of the Interterritorial Council, and particularly, throughout the working groups that compose the Commission for Public Health, including: (a) the committee on environmental health; (b) the working group on epidemiological surveillance; (c) the working group on occupational health; (d) the working group on health promotion; and (e) the committee on vaccination programmes. Nationwide, public health efforts since 2010 have been on developing regulatory provisions (see Section 6.1.6, Reforms on public health) and providing guidance aimed at addressing health determinants. Some notable actions include: the Ministry of Health issued Law 42/2010 on tobacco consumption and market regulation, expanding the provisions of the previous “anti-tobacco” 2005 Law (Law 28/2005), increasing the protection of minors and nonsmokers and prompting health institutions, particularly primary health care, to implement smoking cessation programmes (see Section 1.4, Health status and Section 6.1.6, Reforms on public health); the working group on the NAOS strategy (AECOSAN, 2017) (in Spanish, Strategy on nutrition, physical activity and obesity prevention), consolidated by Law 17/2011, has been working on the elaboration of indicators for the assessment of the NAOS strategy (AECOSAN, 2011), the monitoring of child obesity (AECOSAN, 2016) and the development of accreditation criteria for those schools interested in the implementation of health 94 Health Systems in Transition promotion activities on nutrition, physical activity and obesity prevention (AECOSAN, 2015); in the context of the local development of the strategy for health promotion and prevention approved in 2013 (MSSSI, 2014c), the SNS Interterritorial Council approved in January 2015 the Guide for the local implementation of the SNS Strategy on Health Promotion and Prevention (MSSSI, 2015f ) whose main pillars are the leadership of municipalities and their intersectoral action; the Ministry of Health also chartered a new regulation (RD 843/2011) to define requirements and quality criteria for the providers of preventive services in the context of occupational health; the Ministry of Finance has implemented two reforms on taxation affecting alcohol and tobacco products – through the first reform in 2013, taxation increased 10% for alcohol (with the exception of wine and beer) and 3% for a pack of cigarettes; the second wave, implemented in 2017, implies 5% increase in alcoholic beverages, 2.5% increase for a pack of cigarettes and 6.8% increase in rolling tobacco; finally, Law 33/2011 on Public Health issued the principles and actions to include “Health in All Policies” in the institutional action on health, and sought to update and upgrade the coordination mechanisms among the 17 health authorities and INGESA, essentially in terms of epidemic surveillance and control, and the provision of common benefits (for example, common vaccination calendar, common neonatal screening tests or colorectal cancer screening).
Croatia The provision of public health services is organized through a network of public health institutes, with one national institute and 21 county institutes. A number of national programmes are currently in place. The Mandatory Vaccination Programme, in place since 1948, is the most important and most successful preventive health programme in the country. The Early Cervical Cancer Detection Programme, launched in late 2012, is one of the most recent national public health programmes. The CNIPH is responsible for the collection, analysis and publication of public health statistics (e.g. information on disease incidence or mortality) and epidemiological data, and for health promotion
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. and health education at the national level. It also maintains a number of public health registers, such as the Croatian Cancer Register, Croatian Register for Psychoses and Register of Suicides, Register of HIV/AIDS, Register of Health Care Workers and others. CNIPH’s Department of Epidemiology is the centre for disease control and prevention in Croatia. It maintains the central information system for reporting and monitoring the incidence of infectious diseases, and proposes and supervises the implementation of key preventive and anti-epidemic measures by various actors in the health care system, from family doctors to clinical hospitals, including specially trained and equipped epidemiology service units within the county institutes of public health. The Department also supervises compulsory immunizations and pest control; monitors environmental pollution and waste management; sets standards; and tests food and drinking water safety. The county public health institutes provide services (for their respective populations) in the following areas: epidemiology and quarantine of communicable diseases; epidemiology of noncommunicable diseases; water, food and air safety services; immunizations (including overseeing the compulsory immunization programmes); mental health care (prevention and out-of-hospital treatment of addictions); sanitation; health statistics; and health promotion. Compulsory immunization programmes are carried out by primary care doctors (family doctors and primary care paediatricians) and the school medical service (affiliated with the county institutes of public health) for school-age children. Non-compulsory vaccination programmes are delivered through family doctors or county institutes of public health. Some of the non-compulsory vaccinations, recommended by the CNIPH for certain high-risk populations are free of charge for these populations (e.g. influenza vaccine for older people and patients with chronic diseases). Physicians may also offer opportunistic screening (e.g. cervical smear tests or mammograms) to patients attending for something else. The Mandatory Vaccination Programme (also called the Childhood Vaccination Programme), which started in 1948, is the most important and most successful preventive health programme in the country. It covers the following vaccines: BCG (against tuberculosis) (administered with hepatitis B); DTaP/ IPV/Hib (combination vaccine against diptheria, tetanus, pertussis, polio and Hib disease) (administered with hepatitis B); measles, mumps and rubella; diphtheria, tetanus and pertussis (combination vaccine); polio; and tetanus for people over 60 years old. Participation in this programme is obligatory for the target population, for doctors responsible for administering the vaccinations, and for the bodies responsible for its organization and funding (CHIF and CNIPH). The programme is improved every year on the basis of best practice evidence. The programme and other public health activities, such as surveillance and early response system, have been successful in keeping infectious diseases under control. Diseases preventable through vaccination have either totally disappeared (diphtheria, poliomyelitis) or their incidence has been drastically reduced.
Table. Public Health programmes in Croatia
Mandatory Vaccination Program 1948 (ongoing) Breastfeeding Promotion Programme 1992 (ongoing) National Programme for Roma 2003 (ongoing) National Plan for Preparedness for Flu Pandemic 2005 (ongoing) National Programme for Prevention and Early Detection of Breast Cancer 2006 (ongoing)
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. National Programme for Prevention and Early Detection of Colorectal 2007 (ongoing) Cancer Programme of Psych0-social Aid at Children’s Oncology Wards 2007 (ongoing) National Programme of Health Care of Person with Diabetes 2007 (ongoing) Programme of Protection Against Domestic Violence 2009 (ongoing) National Programme for Control of Antibiotic Resistance of Bacteria 2009-2014 System of Prevention and Treating Addictions and Mental Health in 2009 (ongoing) County Institutes of Public Health Prevention of Injuries in Children 2010 (ongoing) Prevention of Obesity (Action Plan) 2010-2012 National Program for Prevention of HIV/AIDS 2011-2015 Prevention of Suicide in Children and Youth 2011-2013 National Programme of Prevention and Early Detection of Cervical 2012 (ongoing) Cancer
The National Programme for the Early Detection of Breast Cancer, established in 2006, was the first national programme for the early detection of malignant diseases in Croatia. The programme encompasses a mammography examination every two years for all women aged 50–69. In addition, women aged 20–40 are recommended to undergo a clinical breast examination every three years, and women over 40 annually. The National Programme for the Early Detection of Colorectal Cancer was started in 2007 and includes an occult blood test for all persons over the age of 50. The Early Cervical Cancer Detection Programme was launched in December 2012 and will include a Pap smear every three years for women aged 25–64. A later phase of the programme foresees the introduction of new technologies, such as liquid-based cytology and human papilloma virus (HPV) testing. No evaluation of these programmes is yet available. Occupational health services are provided through occupational medicine specialists, mainly working in private primary care practices or county health centres. Until 2011, all registered employers were required to register their companies and employees with the Croatian Institute for Health Insurance of Health Protection at Work, which was established at the end of 2007 and which directed them, on the basis of location, to occupational medicine specialists for periodic examinations (Lalić, 2008). In 2011, this Institute was annexed to the CHIF and no longer exists as an independent entity. The National Centre for Addiction Prevention is part of the CNIPH and is responsible for the monitoring of addictions, and planning and evaluation of preventive measures. The National Register of Treated Psychoactive Drug Addicts was established in 1978 and is maintained by the National Centre for Addiction Prevention. Since 2003, county centres for addiction prevention form a part of the county institutes of public health. In 2010, the National Strategy against Disorders caused by Excessive Consumption of Alcohol for 2011–2016 was passed. It targets prevention of alcohol abuse, and treatment and rehabilitation of persons with alcohol-related problems, as well as promoting a socially engaged approach to the problems of excessive alcohol consumption. Operational plans for the Strategy are yet to be elaborated and adopted.
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. V. FINANCING OPTIONS FOR PUBLIC HEALTH SERVICES PROVISION i. Financing mechanisms for prevention services a. Immunization In Croatia, the national vaccination programme is completely covered by the Health Insurance Institute 83. In contrast, the Netherlands, which like Germany largely relies on health insurance to pay for curative health services, funds major prevention programmes from general taxation84. A mix of public financing sources seems to be common, such as in the Czech Republic, where preventive services provided by GPs (vaccinations and screening) are covered by the benefit package of the health insurance fund, while the Ministry of Health provides direct, tax-based funding for public health services, such as specialized health programmes85. Austria also relies on a mix of financing sources; the two-thirds of the budget for vaccines is from the federal government, and a sixth each is paid each by the Länder (regions) and the social health insurance institutions86. In south-eastern Europe, funding for core public health functions, such as vaccination, typically comes directly from central government87. In Finland, for example, municipalities are responsible for funding immunizations88. In Denmark, vaccination programmes are also financed by the regions89, while in Belgium two thirds of vaccination costs are borne by the federal government and one third by the communities90. Poland has introduced co-funding from the local government91. The “Öffentliche Gesundheitsdienst” in Germany is a state-run system of public health offices run and funded by cities and municipalities. b. Primary and secondary prevention of communicable diseases (HIV/AIDS, TB, STI), Screening programs and Other preventive measures (Iodination of salt, Fluoridation, iron fortification, ets.) In Germany, most preventive measures aimed at individuals, such as immunizations, screening programmes and health check-ups are carried out by office-based physicians and paid from the sickness funds’ benefit package, while population-based health promotion activities are also paid for by the sickness funds (Busse & Blümel, 2014).
83 WHO, Evaluation of Public Health Services in South-eastern Europe. Croatia. Draft National Report, 2007, World Health Organization Regional Office for Europe: Copenhagen. 84 Schäfer, W., et al., The Netherlands: Health System Review. Health Systems in Transition, 2010. 12(1). 85 Bryndova, L., et al., Czech Republic: Health system review. Health Systems in Transition, 2009. 11(1): p. 1-122 86 Hofmarcher, M. and H.-M. Rack, Austria: Health system review. Health Systems in Transition, 2006. 8(3): p. 1–247 87 WHO, Evaluation of public health services in south-eastern Europe, 2009, World Health Organization Regional Office for Europe: Copenhagen. 88 Vuorenkoski, L., P. Mladovsky, and E. Mossialos, Finland: Health system review. Health Systems in Transition, 2008. 10(4): p. 1-168. 89 Strandberg-Larsen, M., et al., Denmark: Health system review. Health Systems in Transition, 2007. 9(6): p. 1-164. 90 Gerkens, S. and S. Merkur, Belgium: Health system review. Health Systems in Transition, 2010. 12(5): p. 1–266. 91 Gotsadze, G., et al., Reforming sanitary-epidemiological service in Central and Eastern Europe and the former Soviet Union: an exploratory study. BMC Public Health, 2010. 10(440).
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001.
In the Republic of Moldova the Ministry of Health is in charge of planning and executing the state budget in the health sector, taking into account the needs of its subordinated institutions and national programmes. Once the budget has been approved by Parliament, the Ministry of Health reallocates the resources based on current priorities or emerging needs. Public health institutions also generate their own revenues from providing services such as laboratory services and sanitary testing, amounting to approximately 25–30% of their budgets. Annually, resources for prevention measures are also allocated from mandatory health insurance funds (managed by the National Health Insurance Company). These resources are used for the procurement of vaccines, the implementation of screening programmes and some health promotion activities coordinated and managed by the National Health Insurance Company. The government contributes to total health financing both by allocating a certain percentage (not less than 12.1%) of the total government budget to the National Health Insurance Fund and by directly financing public health services as well as national public health and special programmes. The public health programmes (e.g. the National Alcohol Control Programme; the National Tobacco Control Programme; the National Food and Nutrition Programme; the National TB Control Programme; the National HIV/AIDS Control Programme) have mixed sources of funding. They are funded from the national state budget, mandatory health insurance funds, and some programme activities are covered by external donors. As each programme involves other sectors (agriculture, industry and enterprises, financing and taxation, education, youth and sport, public order etc.), each of these sectors plan and allocate resources from their own budgets for financing and implementing activities within those national programmes for which these are responsible (Ciobanu et al., 2018). ii. Financing mechanisms for health promotion services and programmes Spain. Individual-oriented health promotion and preventive medicine services are mostly integrated as part of the primary care package of benefits; for example, medical counselling, tobacco and alcohol control, hypertension or diabetes control, secondary prevention where applicable. Those services are funded as part of the primary care payment mechanisms. In turn, population-oriented services such as vaccination campaigns or population screening programmes (breast, colorectal or cervical cancer) are funded via earmarked budgets. As a consequence of those programmes, for example, surgical or medical treatments are again funded as part of the corresponding payment mechanisms, depending on whether follow up is performed in primary, specialized or hospital care. Lastly, ACs’ health departments award grants to municipalities and not-for-profit organizations (foundations, associations or charities) to complement public health programmes on drug abuse, health education in schools, secondary prevention in mental health, occupational risks, health promotion on population minorities, etc. Financing health promotion The challenge of putting health promotion activities on a sustainable financial basis has been noted in several countries. The problem is particularly acute where funding mechanisms are not linked to
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. health financing as a whole, but rather ad hoc or based on external funding9293. Several countries, including Austria and Switzerland, have established foundations for health promotion9495. Both foundations pursue co-financing, which may have increased health promotion expenditure from other sectors96. Some of the most successful health promotion activities have been implemented in the Nordic countries97, such as the oftencited North Karelia project in Finland98. In Central and Eastern Europe, health promotion was underdeveloped in the Soviet period99 and health promotion tends remain in many countries one of the most underdeveloped and underfinanced domains of public health100. The Austrian Health Promotion Foundation, for example, has since 2009 offered full financing to projects by small- and medium-sized companies, as these were perceived to be most affected by the economic crisis101. iii. Financing mechanisms for health protection, surveillance and services related to monitoring and response to health hazards and emergencies Croatia. Public health services provided by the county public health institutes (e.g. epidemiology) are financed from the CHIF’s budget. Other public health services (e.g. services provided within public health programmes) are financed mainly from the State and county budgets and paid for depending on activity or programme. Some services are charged directly to users. Personnel working in county public health institutes are paid a salary. Some services, such as educating employers on preventive health measures and the monitoring of environmental safety standards and food safety, are paid on a FFS basis and charged directly to users.
92 WHO, Evaluation of public health services in south-eastern Europe, 2009, World Health Organization Regional Office for Europe: Copenhagen 93 Bayarsaikhan, D. and J. Muiser, Financing health promotion, 2007, World Health Organization: Geneva. 94 Saltman, R., et al., Assessing health reform trends in Europe, in Health Systems, Health, Wealth and Societal Well- being, J. Figueras and M. McKee, Editors. 2012, Open University Press: Maidenhead. p. 209-246. 95 Schang, L., K. Czabanowska, and V. Lin, Securing funds for health promotion: lessons from health promotion foundations based on experiences from Austria, Australia, Germany, Hungary and Switzerland. Health Promot Int, 2011. 96 Schang, L., K. Czabanowska, and V. Lin, Securing funds for health promotion: lessons from health promotion foundations based on experiences from Austria, Australia, Germany, Hungary and Switzerland. Health Promot Int, 2011. 97 Glenngård, A., et al., Health Systems in Transition: Sweden, 2005, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies: Copenhagen. 98 Vuorenkoski, L., P. Mladovsky, and E. Mossialos, Finland: Health system review. Health Systems in Transition, 2008. 10(4): p. 1-168. 99 Saltman, R., et al., Assessing health reform trends in Europe, in Health Systems, Health, Wealth and Societal Well- being, J. Figueras and M. McKee, Editors. 2012, Open University Press: Maidenhead. p. 209-246. 100 Maier, C., et al., The reform of public health and the role of the sanitary-epidemiolgical services (sanepid) in the newly independent states. Meeting report, Bishkek, Kyrgyzstan, 10– 12 November 2008, 2009, World Health Organization Regional Office for Europe: Copenhagen. 101 Schang, L., K. Czabanowska, and V. Lin, Securing funds for health promotion: lessons from health promotion foundations based on experiences from Austria, Australia, Germany, Hungary and Switzerland. Health Promot Int, 2011.
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. iv. Mechanisms for reimbursing providers (primary health care) in Croatia, Compulsory immunizations are usually carried out by primary care doctors and school medicine services and are paid by way of capitation. In Sweden for example, some county councils use a small performance-based element of payment (2-3% of the total payment), that is partly dependent on the provision of preventive services102. In South East Europe, several countries have adopted such combined payment systems103. In Montenegro, 10% of earnings of primary health care teams are directly related to implementing prevention programmes104. This framework allocates extra funds to general practices if they meet a range of criteria, some of which relate to disease prevention105. In Estonia, GPs receive specific incentives to offer preventive services, including counselling patients on medical and behavioural risks106 107. While in some countries, personal preventive services are covered by the main public financing body, as in Estonia by the national health insurance fund108, in others, such as Armenia109, there are no incentives for physicians to engage in prevention. NCD programmes During previous century, interventions such as contributed to a major shift in major causes of death: noncommunicable diseases and health conditions are expected to account for an estimate 75 % of all deaths worldwide by 2030[3]. Non-communicable diseases (NCDs), mainly “cancer, cardiovascular diseases, diabetes, and chronic respiratory diseases, are now responsible for more than 35 million deaths per year in the world; more than 80% of these deaths occur in low- and middle-income countries” (Bueno-de-Mesquita, 2015). According to the Global Burden of Disease Study (2010) ischaemic heart disease was the leading cause of death in all parts of Europe in 2010 (Lozano, Naghavi et al. 2012) and the leading cause of disability-adjusted life years (DALY) in central Europe, eastern Europe and central Asia, coming second in western Europe to lower back pain (Murray, Vos et al. 2012). Public health measures, such as tobacco control, improved diets and physical activity, and reduction in hazardous alcohol drinking, are among the key actions that could help to achieve the reduction of NCDs, both in Europe and beyond (Beaglehole, Bonita et al. 2011). There is a evidence
102 Anell, A., A. Glenngård, and S. Merkur, Sweden: Health system review. Health Systems in Transition, 2012. 14(5): p. 1-159. 103 Rechel, B., J. Bozikov, and W. Bartlett, Lessons from Two Decades of Health Reforms in South East Europe, in Health Reforms in South East Europe, W. Bartlett, J. Bozikov, and B. Rechel, Editors. 2012, Palgrave Macmillan: Houndmills. p. 229-239. 104 Ostojic, D. and R. Andric, Reforms of the Organization and Financing of Primary Health Care in Montenegro, in Health Reforms in South East Europe, W. Bartlett, J. Bozikov, and B. Rechel, Editors. 2012, Palgrave Macmillan: Houndmills. p. 207-217 105 Boyle, S., United Kingdom (England): Health system review. Health Systems in Transition, 2011. 13(1): p. 1-486. 106Koppel, A., et al., Estonia: Health system review. Health Systems in Transition, 2008. 10(1): p. 1-230. 107 Koppel, A., A. Leventhal, and M. Sedgley, eds. Public health in Estonia 2008. An analysis of public health operations, services and activities. 2009, World Health Organization Regional Office for Europe: Copenhagen. 108 Koppel, A., A. Leventhal, and M. Sedgley, eds. Public health in Estonia 2008. An analysis of public health operations, services and activities. 2009, World Health Organization Regional Office for Europe: Copenhagen. 109 Armenian, H.K., et al., Analysis of public health services in Armenia, 2009, American University of Armenia: Yerevan.
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. that suggests that many of these “interventions are cost-effective and of major long- term benefit to societies” (McDaid, Suhrcke 2012). The strategies of Italy and Spain do not include specific budgets. In Italy, some of the activities are financed through funds allocated by the Ministry of Health for the national NCD strategy (Gaining health) and the national prevention plan. Some of the resources earmarked for objectives of the national sanitary plan for 2006–2008 were transferred to the regions to promote action consistent with the goals of the national NCD strategy. Moreover, partners and stakeholders have themselves financed some of their activities within the strategy (such as those related to the promotion of healthy food or food reformulation). In Spain, the health authorities at the national and regional levels share the responsibility of financing the numerous actions and projects on the implementation of the national strategies. Montenegro has included financial planning in its action plan, but, in the absence of an evaluation of the first phase (2009–2013), it is difficult to judge the extent to which it has been implemented. Through strictly controlled and transparent targets aimed at the whole of society, the Tajik NCD strategy offers ways of increasing the resources required to achieve the outcomes of its mid-term and long-term action plans, and defines the responsibilities of the different government agencies in this respect. One of the activities listed in the Azerbaijani operational plan defines the roles and responsibilities of the focal point (the operational and overall coordination body/secretariat) for the implementation of the current strategy and aims at establishing a functioning NCD prevention and control unit with adequate funding. Whether it will be possible to secure the funding once the strategy receives government approval remains to be seen. Ear-marked taxes Some countries have started to ear-mark the revenue derived from taxes on products detrimental to health for public health activities. An example is Austria, where revenue from tobacco tax has to be used for preventive check-ups and health promotion measures110. Bulgaria has committed to devoting 1% of resources received in the national budget from excise duties on tobacco and alcoholic beverages are used for programmes addressing these risk factors and illicit drugs111. With the exception of taxes on tobacco and alcohol, however, the use of fiscal instruments for public health is not yet widespread112 .
5.1 Primary care and essential public health functions as the core of integrated health services The delivery of quality health services that respond to the needs and preferences of people, at both the population and individual level, is the first component of PHC. Services cover the full continuum from health promotion and disease prevention to treatment, rehabilitation, and palliative care and are delivered at individual or population level, as appropriate. Populatio Continuity Continuity of care
110 Hofmarcher, M. and H.-M. Rack, Austria: Health system review. Health Systems in Transition, 2006. 8(3): p. 1–247. 111 WHO, Evaluation of public health services in south-eastern Europe, 2009, World Health Organization Regional Office for Europe: Copenhagen. 112 Breda, J., et al., Food security and healthier foods, in Facets of public health (in press), B. Rechel and M. McKee, Editors. 2013, World Health Organization, on behalf of the European Observatory on Health Systems and Policies: Copenhagen
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. results from the delivery of seamless coherent person-focused care over time across different care encounters and transitions of care (69). Primary care is based on a commitment by health professionals and individuals to a long-term relationship based on mutual trust that facilitates continuity (relational continuity) and is further supported by evidencebased pathways of care (management continuity) and integrated information systems (informational continuity). Continuity has been linked to lower mortality, fewer emergency department visits and admissions, shorter hospital stays, lower health care costs, and improved patient satisfaction; it can also enhance accountability (70,71). Access and continuity should both be promoted. Achieving both will require more effective use of resources as demand for health services increases. Coordination One of the essential functions of primary care is to coordinate service delivery across the whole spectrum of health and social care services, including mental health services, long-term and social care, through integrated, functional, and mutually supportive arrangements (including referral systems) for transitions and informationsharing along evidence-based care pathways. Coordination decreases the wellknown risks at transition points (from home to clinic and from hospital to clinic) (72). It should also ensure seamless transitions between the public and private sectors – both profit and non-profit – as necessary. Person-centredness Effective primary care is centred on the whole person, in health and in sickness, taking into consideration the full physical, mental, and social circumstances rather than focusing on a specific organ, stage of life, or subpopulation. The person-centred nature of effective primary care aligns with the central role of people in PHC and supports the use of patient- centred measures in its evaluation (62,73). Because primary care is comprehensive, coordinated and personcentred, it is ideally suited to respond to the challenges of multimorbidity. 14 For many people, herbal medicine, traditional treatments, and traditional practitioners are the main sources of health care. Appropriate integration of evidence-based, safe and effective traditional medicine as part of primary care can lead to better health outcomes and economic advantages (74,75). Traditional medicine draws on and enhances societal knowledge of health preservation and management, supporting the vision of a knowledge-based healthy society equipped for self-care (76,77). In many countries, traditional medicine has been effectively integrated with allopathic interventions. Traditional medicine has been shown to be effective in areas such as NCD management, palliative care, rehabilitation, several neglected tropical diseases, mental health and the care of the elderly (78,79,80,81). B. Population-based services Population-based services employ a public health approach to improve health and well-being on a large scale. The public health functions specifically relevant to a PHC approach and closely linked to primary care are health protection, health promotion, and disease prevention (service delivery), surveillance and response, and emergency preparedness (intelligence) (82). Health protection Health protection includes risk assessment, and supervision of enforcement and control of activities for minimizing exposure to health hazards in order to protect the population, by ensuring environmental, toxicological, road and food safety. It overlaps with health care delivery through patient safety, and with self-care through consumer safety. Health protection shapes the physical and social environment to allow people to live healthy lives. Health promotion While health protection guards against potential threats to good health, health promotion enables people to have more control over their own h Emergency preparedness Emergency preparedness aims to address unforeseen and catastrophic circumstances that create a surge of demand for health services and strain resources and infrastructure. This function is important in both well-established systems and those that are precarious or known to be at risk of disruption, for example by
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. environmental disasters or conflict. A strong and well trained PHC workforce is needed during emergencies to ensure that the health system is responsive and adaptable, and to help with planning, thus helping to avoid the rapid and uncontrolled depletion of health resources. In PHC-oriented systems, public health functions may be delivered as separate national or subnational programmes (e.g. disease prevention may include a school-based immunization programme) or through primary care services (such as cervical cancer screening in some countries), according to what is most appropriate in the particular setting. In both cases, public health functions should be coordinated and integrated with each other and with primary care, in a coherent PHC approach with integrated policies, adequate resources, aligned leadership, and effective communication. Better integration of public health and primary care has been associated with improvements in health behaviour, a range of health outcomes including reduced rates of chronic disease and maternal and child health, improved access to health services and health literacy (83, 84).
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113 https://www.who.int/docs/default-source/primary-health/vision.pdf
This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001.