Health Challenges in South Eastern Europe

Volume 10 Number 3-4, 2004 eurohealth

Health challenges in South Eastern Europe

Kosovo, 1999

Explaining regional differences in mortality in the Balkans

Access to health care for Roma in South Eastern Europe

Children in Serbia and Montenegro

The effectiveness of health impact assessment eurohealth Lest we forget LSE Health and Social Care, London School of No one could fail to be moved by the terrible and Economics and Political Science, Houghton Street, London WC2A 2AE, United Kingdom C tragic events in south east Asia at the turn of the tel: +44 (0)20 7955 6840 fax: +44 (0)20 7955 6803 year. The response of both governments and email: [email protected] individuals to an event with a truly global impact has website: www.lse.ac.uk/Depts/lsehsc

been unprecedented, and much more will be EDITORIAL

required for many years to come. The appointment EDITOR: of former US President Bill Clinton as the UN’s David McDaid: +44 (0)20 7955 6381 O email: [email protected] special tsunami relief envoy to push for GUEST EDITORS OF SPECIAL SECTION ON SEE reconstruction is to be applauded. Such events how- Bernd Rechel and Nina Schwalbe ever can understandably take the spotlight off other email: [email protected] areas of the globe, where much work is still needed SENIOR EDITORIAL ADVISER: Paul Belcher: +44 (0)7970 098 940 M to improve population health. email: [email protected] DESIGN EDITOR: Much of this double issue of Eurohealth is devoted Sarah Moncrieff: +44 (0)20 7834 3444 email: [email protected] to health in South Eastern Europe, an area that has EDITORIAL TEAM: been blighted by conflict as well as major economic Julian Le Grand, Josep Figueras, Walter Holland M and political upheaval over the last 15 years. As the Martin McKee, Elias Mossialos editors of this section, Bernd Rechel and Nina SUBSCRIPTIONS Schwalbe, note in their introductory article while Champa Heidbrink: +44 (0)20 7955 6840 Slovenia is already a member, and some other email: [email protected] countries are well on the road to joining the EU, the Published by LSE Health and Social Care and the European prospect for the others remains bleak. The path to Observatory on Health Systems and Policies, with the finan- E EU membership mirrors that of population health. cial support of Merck & Co and the European Observatory on Health Systems and Policies. News section compiled by The health of many in the region has been left Eurohealth with some additional input from EurohealthNet. behind, and a number of highly vulnerable groups in Eurohealth is a quarterly publication that provides a forum for policy-makers and experts to express their views on the region. These include the Roma, displaced health policy issues and so contribute to a constructive debate persons as well as victims of the sex and drug trades. on public health policy in Europe. N The views expressed in Eurohealth are those of the authors There is also evidence of emerging HIV/AIDS and alone and not necessarily those of LSE Health and Social tobacco epidemics. Care, EuroHealthNet or the European European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is Many health system reforms and initiatives have a partnership between the WHO Regional Office for Europe, the governments of Finland, Greece, Norway, Spain and been undertaken, with some success, but the Sweden, the European Investment Bank, the Open Society challenges remain great, compounded in many Institute, the World Bank, the London School of Economics T and Political Science and the London School of Hygiene & instances by discrimination and mutual distrust. The Tropical Medicine. international community, as urged by Rechel and Advisory Board Schwalbe must continue to play a part in addressing Dr Anders Anell; Professor David Banta; Mr Nick Boyd; these challenges. They argue that while much Professor Reinhard Busse; Professor Johan Calltorp; Professor Correia de Campos; Mr Graham Chambers; international aid has gone into the area little has been Professor Marie Christine Closon; Professor Mia Defever; Dr targeted to health care and that it continues to Giovanni Fattore; Dr Livio Garattini; Dr Unto Häkkinen; Professor Chris Ham; Dr Maria Höfmarcher; Professor remain a low priority for donors. More than ever at David Hunter; Professor Egon Jonsson; Dr Meri Koivusalo; this time of terrible tragedy, there is a need to ensure Professor Felix Lobo; Professor Guillem Lopez-Casasnovas; Dr Bernard Merkel; Dr Stipe Oreskovic; Dr Alexander that existing initiatives in regions such as South Preker; Dr Tessa Richards; Ms Heather Richmond;Professor Richard Saltman; Mr Gisbert Selke; Professor Igor Sheiman; Eastern Europe are not neglected. Professor JJ Sixma; Professor Aris Sissouras; Dr Hans Stein; Dr Jeffrey L Sturchio; Dr Miriam Wiley

David McDaid © LSE Health and Social Care 2004. No part of this publication may be copied, reproduced, stored in a retrieval sys- Editor tem or transmitted in any form without prior permission from LSE Health and Social Care.

Design and Production: Westminster European, email: [email protected]

Printing: Optichrome Limited

ISSN 1356-1030 Contents Volume 10 Number 3-4

European Health policy

3 Facing (uncomfortable) facts: The European dimensions of health services Philip C Berman and Petra Wilson

South Eastern Europe 6 Health in South Eastern Europe Bernd Rechel and Nina Schwalbe

7 The European Union, South Eastern Europe and the wider European neighbourhood Martin McKee, Bernd Rechel and Nina Schwalbe

10 Explaining regional differences in mortality in the Balkans: A first look at the evidence from aggregate data Arjan Gjonça

15 Access to health care for Roma in South Eastern Europe Ivan Ivanov

Health Impact Assessment 17 Treatment of drug addiction in South Eastern Europe: A country overview 41 The effectiveness of health impact Andrej Kastelic and Tatja Kostnapfel Rihtar assessment Matthias Wismar 20 Implementating a national TB control programme in minority communities: Challenges and accomplishments from Kosovo Alka Dev and Jennifer Mueller Family Care 44 Family care: A conceptual 25 TB control and DOTS implementation: clarification. Challenges for future A bridge between the countries of South Eastern Europe health policy and practice Lucica Ditiu Deirdre Beneken genaamd Kolmer, Inge Bongers, Henk Garretsen and 28 Reducing perinatal mortality in FYR Macedonia Agnes Tellings Dragan Gjorgjev and Fimka Tozija

30 Planning for health at county level: The Croatian experience Selma Sogoric Monitor 34 Access to health services for displaced persons in Serbia: 48 Web Watch Problems of income and status Ozren Tosic 49 New Publications

37 Children in Serbia and Montenegro: 50 European Union News Health status and access to basic health services by Eurohealth with input from Mary E Black, Oliver Petrovic, Vesna Bjegovic and Jelena EuroHealthNet Zajeganovic-Jakovljevic Contributors to this issue

Deirdre Beneken genaamd Kolmer is a Lucica Ditiu is TB Medical Officer, PhD student of Social Sciences at Tilburg World Health Organization, Office for University, The Netherlands. TB Control in the Balkans, Bucharest, Romania.

Philip C Berman is Director, European Henk Garretsen is Professor of Health Health Management Association. Care Policy at Tilburg University, The Netherlands.

Professor Vesna Bjegovic is Professor of Arjan Gjonça is Senior Lecturer in Public Health, Department of Social Demography, London School of Medicine, University of Belgrade. Economics and Political Science.

Dr Mary Black is Programme Dragan Gjorgjev MD PhD is Adviser Coordinator, Young People’s Health Coordinator, Republic Institute for Development and Participation Project Health Protection, Skopje, FYR Officer, UNICEF Belgrade. Macedonia.

Inge Bongers is Senior Research Fellow Ivan Ivanov is Staff Attorney, European of Health Care Policy at Tilburg Roma Rights Centre, Budapest, University, The Netherlands. Hungary.

Alka Dev is Programme Manager, Andrej Kastelic is based at the Centre for Doctors of the World – USA, New Treatment of Drug Addiction, Ljubljana, York. Slovenia.

1 eurohealth Vol 10 No 3–4 Dr Oliver Petrovic is Early Childhood Agnes Tellings is Senior Research Fellow Development Project Officer, Young of Philosophy of Education, University People’s Health Development and of Nijmegen, The Netherlands. Participation Project Officer, UNICEF Belgrade.

Tatja Kostnapfel Rihtar is based at The Fimka Tozija MD PhD is Head of the Sound of Reflection Foundation, Department for Injury and Violence Ljubljana, Slovenia Control and Prevention, Republic Institute for Health Protection, and Associate Professor Cathedra of Social Medicine, Medical School, Skopje, FYR Macedonia.

Martin McKee is Professor of European Public Health, London School of Ozren Tosic is a consultant in health pol- Hygiene and Tropical Medicine. icy, health management and financing, Belgrade, Serbia and Montenegro. He was Commissioner for Refugees in the Serbian Government from February 2003 to March 2004.

Jennifer Mueller is Consultant, Doctors Petra Wilson is Deputy Director, of the World – USA, New York. European Health Management Association.

Bernd Rechel is Research Fellow, Matthias Wismar is Health Policy European Centre on Health of Societies Analyst, European Observatory on in Transition London School of Hygiene Health Systems and Policies, Brussels. and Tropical Medicine.

Nina Schwalbe is Senior Fellow, Public Dr Jelena Zajeganovic-Jakovljevic is Health, Open Society Institute, New Young People’s Health Development and York Participation Project Officer, UNICEF Belgrade.

Selma Sogoric, MD, MPH, PhD is Senior Lecturer in public health, Andrija Stampar School of Public Health, Medical School, University of Zagreb, Croatia.

eurohealth Vol 10 No 3–4 2 EUROPEAN HEALTH POLICY Facing (uncomfortable) facts: The European dimensions of health services

At the May 17th ‘Open Forum’ of the tise, control and enthusiasm, the debate Philip C Berman European Health Forum – the was based on the written questions submit- and Petra Wilson Commission’s interface with civil society in ted by the audience after the presentations. health – one of the parallel sessions It was lively, diverse and illuminating, giv- explored the challenges of delivering high- ing a snapshot overview of the issues in EU quality health services in Europe from the health services policy which are currently perspectives of mobility of patients and exercising the minds of groups such as health care professionals, access to services EHTEL (European Health Telematics and safety of goods and services. Association) AIM (the Association of Mutuals), PCN (the Standing Committee The first thing to note is that the inclusion of Nurses) as well as other individuals who of the phrase “health services” in the title took part in the discussion. demonstrates a seismic shift in the percep- tion of European policy-makers. Since the time of the Maastricht Treaty it had been Issues raised during the debate axiomatic that “health services” and The discussion began from the perspective “Europe” could not be uttered in the same that, despite the year’s work on the High breath (at least in public) by any Level Process of Reflection, Ministers of Commission official aspiring to career pro- Health continue to be reluctant to accept gression. Article 152 TEC, after all, had any diminution in the principle of sub- clearly stated that “Community action in sidiarity when it comes to health services, the field of public health shall fully respect although probably all of them would readi- the responsibilities of the Member States ly accept that EU employment law, EU for the organisation and delivery of health data protection law and EU product safety services and medical care”. Yet here was legislation all have a significant impact on the Commission sponsoring and hosting an health service delivery. Certainly, they have event that implicitly recognised that acknowledged that as EU citizens increas- Europe does indeed have a role to play in ingly move from member state to member the delivery of health services. state, EU legislation on the free movement of goods, services and people clearly The session in question included presenta- applies to health services. tions from the European Health Management Association (EHMA), the The debate clearly acknowledged that the European Public Services Union (EPSU), provision of high-quality health services the Standing Committee of European and products in an enlarged Europe is an Doctors (CPME), the European Group issue of importance not only to health representing community pharmacists experts (whether in the guise of DG Health (PGEU), the European Social Insurance and Consumer Protection or Ministries of Partners (ESIP) and the Group of Health) but also to policy-makers for Pharmaceutical Wholesalers (GIRP). finance, trade, and employment (and others). These interlinked interests were de Given that all the presentations are on the facto recognised at the meetings of the European Health Forum website, this arti- High Level Reflection Process with the cle would do no great service in summaris- participation of the Commissioners for ing the presentations. Instead, it seeks to Health and Consumer Protection, capture the spirit of the debate which fol- Employment and Social Affairs, and lowed the presentations. Facilitated by Mel Internal Market. Yet it is questionable Read MEP with a powerful blend of exper- whether the presence of the three Commissioners signified a common Philip C Berman is Director, European Health Management Association. Commission perspective or policy on the E-mail: [email protected] delivery of high-quality health services, or whether sufficient communications exist Petra Wilson is Deputy Director, European Health Management Association. between similar ministries at national level. E-mail: [email protected] There are powerfully divergent interests at

3 eurohealth Vol 10 No 3–4 EUROPEAN HEALTH POLICY stake in the provision of health services play in ensuring that these principles were which cannot easily be resolved. One per- not lost. spective is that health services constitute an economic activity which should be regard- Drawing many health care strands ed as little different from any other eco- together nomic activity. A very different viewpoint The papers and the subsequent discussion would consider health care to be a public highlighted that it is becoming increasingly sector service which needs to be protected important to draw together the many from the growing influence of the commer- health care strands that have a European cial sector. perspective – most obviously pharmaceuti- Only rarely will there be real consensus cal products and services, e-Health (focus- within a country on the policy direction ing in particular on issues such as interop- which should be adopted in relation to the erable electronic health records), and the adoption of market principles to health, practical issues of increased mobility of and it is even less likely that there will be both patients and professionals. In the lat- “There are powerfully agreement at a European level. It is essen- ter case the focus was on the challenges tial, though, that the key actors should be posed by mutual recognition of qualifica- divergent interests at involved in the debate both at national and tions, transparency of professional discipli- European level. So long as the fiction is nary proceedings, as well as clinical refer- stake in the provision maintained that it is Ministers of Health ence centres. The discussion also looked at alone who hold the decision-making pow- the wider social perspective of health ser- of health services which vices delivery in the context of an aging ers in their own hands, it will be difficult to cannot easily be develop a dialogue that will enable any use- population. The need to develop better ful consensus to emerge. The same applies integrated services is a growing focus at resolved” at the European level. national level, and should equally be reflected at European level through greater Some considerable discussion focused upon collaboration between the Directorates new EU initiatives such as the draft General for Health (and Consumer Services Directive and concurred that it is Protection) and (Employment) and Social increasingly important that Member States Affairs. The Open Method of and the European Institutions should Coordination was highlighted as a means attempt to agree on policy directions rather to integrate these strands so that initiatives than allowing the European Court of are not developed in counter-productive Justice to formulate policy in the vacuum isolation but, rather, that the opportunity created by indecisiveness. Given the funda- for synergistic collaboration can be seized. mental issues regarding the market that are at stake, the danger is that minimal deci- During the course of the debate it became sions will be taken on the basis of lowest increasingly clear that there is a need for common denominators. Agreement will be greater clarity about the terms that are reached to do as little as possible for fear of used. What, for example, does the raising issues that might be difficult to Commission mean by ‘access’? It seems to resolve. These are symptoms of a leader- mean different things in different contexts. ship vacuum, with Ministers of Health fail- In the White Paper on Services of General ing to coalesce around a vision of the added Interest, ‘access’ is used to refer to the con- value that Europe can bring to its citizens. cept of “universal” access which although it Real concern was expressed at the Open is common-place in the networked indus- Forum session that the draft Services tries of water and electricity, does not carry Directive was in danger of destroying care- the same philosophical connotation as fully constructed health services, built up access in health care; the High Level over the last 100 years, because the Process of Reflection focused primarily on Commission had asked Member States to access in terms of the right to move from remove any health service measures that one member state to another for treatment; fail to comply with internal market regula- while the draft Directive on Services con- tions. Is it really the case that our citizens siders access primarily in terms of the right want health systems that comply with the of the individual to obtain reimbursement internal market, or do they regard the prin- for health care received outside the State of ciples of equity and solidarity as of greater residence. Such terminological confusion is value and importance? Certainly, the par- almost certainly not limited to ‘access’. ticipants at the Open Forum session were Greater clarity on other terms, such as strongly in favour of the latter, including ‘health services’, ‘markets’ and even ‘public the idea that the European Charter of health’ might be beneficial in easing the Fundamental Rights might have a role to policy-making process.

eurohealth Vol 10 No 3–4 4 EUROPEAN HEALTH POLICY

“Real concern was Finally, the increasing recognition that Safeguarding central principles of there is a significant European aspect to the European health care expressed that the draft delivery of health services needs to be On a personal note, the authors of this reflected in the composition of committees Services Directive was and in the consultative processes adopted report recognise that the European bound- by the Commission. While the involvement aries of health care have expanded very sig- in danger of destroying of senior civil servants from the Member nificantly in recent months, not merely as a result of the expansion of the Union from carefully constructed States might have been appropriate when the more limited definition of public health 15 Member States to 25, but particularly in health services” dominated the European agenda, it is now terms of the (reluctant) acceptance that important that, as the Commission begins health services issues have to be addressed to address health service issues, those in the context of Europe. The danger still responsible for delivering health services persists, however, that the initiative will be (and not only their Ministry officials) seized not by those who have primary should be involved in the consultative responsibility for health, but by others. process. While Ministry officials will con- Until recently, the vacuum was filled by tribute a governmental perspective, this can the judges in Luxembourg. Now it seems be very different to the perceptions of increasingly likely that those responsible those who are actually managing and deliv- for the internal market will take the initia- ering services, either in the acute sector or tive. This constitutes a grave risk, for while at primary or community levels. It is thus a the judges had some understanding of the real missed opportunity that the new High core principles of solidarity and equity, it is Level Group on Health Services and certainly questionable whether such values Medical Care will not enjoy the benefits would be shared by the champions of the that a well balanced representation of all internal market. History would judge our those involved in health services delivery health care leaders and politicians poorly if, could bring. It is unfortunate that the new in the rush to develop the internal market High Level Group will limit itself, for the as a consequence of globalisation, the cen- main, to civil servants. We can only tral principles of European health care were encourage the DG Health and Consumer abandoned in favour of a largely free mar- Protection and the Group to make good ket. This is the moment for Ministers of use of their capacity to call upon external Health and the Commission, and in partic- expertise and to ensure that this is done fre- ular the Commissioner with responsibility quently and from a wide range of profes- for health, to show real leadership in safe- sionals. guarding precious European values.

The health implications of an expanded EU: Threats or opportunities for the UK and Europe?

In conjunction with the Department of Health, Health Protection Agency On 1st May 2004 the European Union underwent an unprecedented expansion, and World Health Organization with the accession of ten new members, most of which had until recently been part of the Soviet bloc. British tabloid headlines predicted catastrophe for the UK, with Eastern Europeans “filling NHS beds” or spreading infectious disease. Thursday 10 March 2005 At the same time, health policy makers looked to the new member states as a solution to a looming shortage of healthcare professionals. This conference will at the Royal College of Physicians, attempt to discover the reality behind the rhetoric. 11 St Andrews Place, Regent’s Park, London NW1 The programme will include the impact on European health (especially the UK) from the expansion, the impact on healthcare professionals’ mobility, and the The programme and booking form importance and relevance of the new neighbourhood countries. Further debate are available on-line at will cover the economic implications of the changes and the potential for the www.rcplondon.ac.uk/calendar/2005 use of health as a tool of foreign policy. or from: Conference Department, Royal College of Physicians Audience: Public health specialists, infectious disease specialists, hospital Tel: 020 7935 1174 Ext. 436/300/252 Fax: 020 7224 0719 physicians, political analysts, health policy analysts, academic institutes, non- Email: [email protected] governmental organisations and policy research units.

5 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE Health in South Eastern Europe

Bernd Rechel and Much of South East Europe became known that the impact of transition and conflict as one the world’s worst trouble spots dur- has been substantial. ing the last 15 years. In addition to the eco- Nina Schwalbe The break-up of Yugoslavia left hundreds nomic and political challenges faced by all of thousands of people dead and millions transition countries in Central and Eastern became refugees and internally displaced Europe, many of the countries of this persons. The economies in the region region have suffered violent conflict on a plummeted, with a devastating effect on the scale unknown in Europe since the Second region’s health infrastructure. The regulato- World War. The length of the road ‘back to ry ability of states disappeared, corruption Europe’ is a good indicator of future politi- ran rampant, and many people were forced cal and economic prospects. The most eco- into poverty. In the post transition years, a nomically advanced country of the region, number of extremely vulnerable population Slovenia, was included in the first wave of groups have emerged, including victims of European Union enlargement in 2004, and trafficking and prostitution, refugees, inter- Bulgaria and Romania are expected to join “The business of nally displaced people and Roma. in 2007. Croatia and the Former Yugoslav improving health in Republic of Macedonia have submitted The governments in the region have their membership applications. While responded to this health crisis with a series South Eastern Europe Croatia looks firmly set on the path to of reforms and programmes. Health care accession, Serbia and Montenegro is lag- funding has been based on payroll contri- is unfinished” ging behind. But the prospects are bleak for butions, primary health care was strength- Bosnia and Herzegovina, which barely ened and more emphasis put on health pro- functions as a state, and a question mark motion. Effective systems for disease sur- hangs over the future status of Kosovo. veillance are now being established and Moldova, finally, has been designated one there is a push to reform mental health care of the European Union’s ‘new neighbours’, in all countries of the region. In spite of the with little hope of joining the Union any scale of the challenges, a number of suc- time soon. cessful projects and programmes have been implemented in recent years. How have wars and transition affected the health of the people of South East Europe But much more needs to be done. Health and how have governments responded? care financing must be reformed to ensure While the wars in the countries that equality of access, especially for vulnerable emerged from former Yugoslavia received populations. An emerging HIV/AIDS epi- wide media coverage, there is scant infor- demic must be stopped, a tobacco epidemic mation on the health of the people living in reversed, and greater emphasis given to this region. What is quite clear, however, is health promotion and public health infrastructure. The business of improving health External funding for health for South Eastern Europe in US $ (1997–2001) in South Eastern Europe is unfinished.

Albania 37,757,064 3,122,000 International donors have spent large sums of money on the region in the aftermath of Bosnia and Herzegovina 120,991,210 4,067,000 war, but almost none of the post-emer- Bulgaria 30,985,432 8,033,000 gency resources went to health care and the Croatia 22,265,354 4,446,000 issue remains a low priority for donors. Of the billions allocated for overall develop- Macedonia 34,115,676 2,035,000 ment aid, only a small fraction was dedicat- Moldova 16,120,119 4,276,000 ed to the health sector. In many countries it accounts for well below 1% of total exter- Romania 225,152,370 22,437,000 nal assistance. Serbia and Montenegro 34,979,528 8,600,000 Now that peace has returned and the Source: World Health Organization, Evidence and Information for Policy (EIP), 2004. world’s attention has shifted to Iraq, there is a danger that health in the region will Bernd Rechel is Research Fellow, European Centre on Health of Societies in again be neglected. Yet, a healthy popula- Transition London School of Hygiene and Tropical Medicine. tion will be crucial for economic growth E-mail: [email protected] and regional stability, and the international Nina Schwalbe is Senior Fellow, Public Health, Open Society Institute, New community must play its part in addressing York. these challenges.

eurohealth Vol 10 No 3–4 6 SOUTH EASTERN EUROPE The European Union, South Eastern Europe and the wider European neighbourhood

Martin McKee, The wider European neighbourhood nology that will catalyse economic The historic enlargement of the European progress. Union on 1st May 2004, bringing in eight Bernd Rechel and The EU’s priorities can best be assessed by central European and two Mediterranean examining the concrete actions it proposes. Nina Schwalbe countries, has inevitably raised the question Many of these have major implications for of “where next for the EU?” In March health. For example, the EU advocates 2003 the European Commission published broadening and deepening existing free- a Communication to the Council and the trade arrangements. Clearly this provides European Parliament, setting out a vision many opportunities for mutual benefit, yet for a “Wider Europe Neighbourhood”.1 an unintended consequence could be that The document became the basis for the European Neighbourhood Policy, directed increased trade would allow trans-national at the new eastern and southern neighbours tobacco companies to exploit their power- of the European Union (Box 1). The ful positions to subvert domestic tobacco “EU support for Communication was concerned with coun- control policies as they have already done tries that do not currently have the in many countries of the former Soviet 2 infectious disease prospect of EU membership, and the Union. Council and the European Parliament have Second, the EU advocates policies on surveillance systems in subsequently stressed that this policy migration that will facilitate movement by should be seen as separate from the ques- the new neighbours is “bona fide nationals […] who have legiti- tion of possible EU accession. mate and valid grounds for regularly cross- required” The document underlines the importance ing the border and do not propose any of working with these countries to pro- security threat.” Again, greater mobility mote their prosperity (Box 2). In particular can bring many benefits for the EU and its it identifies the need to develop an integrat- neighbours but the movement of people ed market with liberalised trading rules, and goods has always been accompanied by create a political framework that enhances the movement of infectious disease. the rule of law and bolsters economic activ- Strengthening the ability to detect, investi- ity, promote environmental protection that gate and contain cross border outbreaks is will support sustainable development, and key. This will require EU support for sur- develop co-operation in science and tech- veillance systems in the new neighbours.

Box 1 THE “NEW NEIGHBOURS” Box 2 THE EUROPEAN UNION’S OBJECTIVES FOR THE WIDER EUROPE NEIGHBOURHOOD Algeria Lebanon Armenia * Moldova Azerbaijan * Morocco • To work with the partners to reduce poverty and create an area of shared prosperity and values based on deeper economic integration, intensified Belarus Palestinian Authority political and cultural relations, enhanced cross-border cooperation, and Egypt Russia shared responsibility for conflict prevention between the EU and its Georgia.* Syria neighbours. Israel Tunisia Jordan Ukraine • To anchor the EU’s offer of concrete benefits and preferential relations within a differentiated framework which responds to progress made by * included in May 2004 the partner countries in political and economic reform

Martin McKee is Professor of European Public Health, London School of Hygiene and Tropical Medicine. Bernd Rechel is Research Fellow, European Centre on Health of Societies in Transition London School of Hygiene and Tropical Medicine. Nina Schwalbe is Senior Fellow, Public Health, Open Society Institute, New York.

7 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE

The new European Centre for Disease environmental policy, there are no dedicat- Prevention and Control can play a key ed experts on health. role, but it must have adequate resources. By launching its European Neighbourhood Third, it calls for the EU to play a greater Policy, the EU has accepted that it must role in crisis management, specifically in play a role in promoting peace and pros- facilitating the resolution of disputes in perity in the countries that surround it. The “It is essential that areas such as Palestine, the western Sahara, EU already contributes to the development and Transdnistria (a breakaway region of of policies that will promote health among health issues play a Moldova), which will have immediate its 385 million new neighbours, through effects on the health of the people living in mechanisms such as the Barents Euro- central role in the these areas. Other areas where health plays Arctic Council and the TACIS programme. a central role in the EU’s relations with its The challenge now is to bring these activi- Neighbourhood new neighbours range from enhanced ties to the forefront of its newly developing cooperation to tackle the trafficking of relationships in this region. Agreements, Action human beings and drugs, developing col- Plans, and Stabilisation laborative industry in science and technolo- South Eastern Europe gy, and promotion of human rights and Although the countries of South Eastern and Association Process environmental protection. Europe would seem by their geography to fall into the “new neighbour” category, this currently underway” The process is moving ahead rapidly and, has not proven to be the case. The reasons in May 2004, the mechanisms for co-opera- vary. Some of these countries are already tion were set out in detail.3 For each of the on their way to full integration with the new neighbours, the European Union European Union. Bulgaria and Romania envisages the drawing up of are in line for accession in 2007 and Croatia Neighbourhood Agreements, with detailed has been awarded candidate status and Action Plans and a timetable for the expressed its hope of joining the EU at the achievement of benchmarks. The jointly same time as Bulgaria and Romania. agreed Action Plans resemble the enlargement process in many ways. Thus, even For the countries of the Western Balkans though EU membership is not on offer, (Albania, Bosnia and Herzegovina, Croatia, these plans will be based on a commitment the former Yugoslav Republic of to shared values of human rights (including Macedonia and Serbia and Montenegro), in minority rights), the rule of law, good gov- 1997 the EU launched the Stabilisation and ernance, and neighbourly relations. They Association Process. This process offers will cover political dialogue, economic and these countries the prospect of full integra- social development policies (including tion into EU structures. The first hurdle involvement in EU programmes on educa- for accession is forming a Stabilisation and tion and research), trade, and justice. The Association Agreement with the European plans will be specific to each country, tak- Union. So far, only Croatia and the former ing into account their different stages of Yugoslav Republic of Macedonia have economic and political development. Figure Life expectancy at birth in the European Union and selected new The Agreements will be supported by a neighbours new financial mechanism, the European Neighbourhood Instrument, backed by €255 million for the years 2004–2006. However, the European Parliament noted European Union in November 2003 that the scale of funding Libya is probably inadequate to support new activities without impacting negatively on Syria existing ones and so should be reconsidered for 2007 and beyond.4 Algeria Given the integral relationship of health to Moldova many of the objectives being pursued, it would seem evident that Directorate Ukraine General (DG) Sanco and DG Social Affairs Egypt would need to participate actively in this process. Yet so far they have not. A Task Russia Force on Wider Europe has been established within DG External Relations and 50 55 60 65 70 75 80 years while it includes experts in areas such as the Source: WHO internal market, justice, transport, and

eurohealth Vol 10 No 3–4 8 SOUTH EASTERN EUROPE

signed such agreements. The former Commission on the wider European neigh- Yugoslav Republic of Macedonia, the first bourhood, Moldova’s (and Ukraine’s) country to sign, did so in April 2001, and membership aspirations were recognised, the agreement entered into force in April but it was also stated that the EU must 2004. In March of 2004, the country sub- await completion of the 2004 enlargement mitted its application for EU membership, and only then debate further enlargement. but it is unclear when it will achieve candi- Resolving the situation in Transdnistria date status, in view of its dire economic sit- will clearly be key to the discussion, as REFERENCES uation and continuing ethnic friction. Transdnistria was described in the 1. Commission of the Communication as a “magnet for organised The EU has stressed that its European European Communities. crime”6 which can destabilise the process Neighbourhood Policy does not apply to Wider-Europe Neighbourhood: of state-building, political consolidation the Western Balkans. Indeed, the prospect A New Framework for and sustainable development. During a visit of these countries of becoming members of Relations with our Eastern and to Moldova in December 2003, the EU was endorsed by the European Southern Neighbours. Commissioner Verheugen reassured the Council meetings in Feira in 2000 and Communication from the country that the New Neighbourhood Thessaloniki in June 2003 and has been Commission to the Council Policy and possible accession are two sepa- reaffirmed by the Communication from the and the European Parliament. rate processes, but also made clear that European Commission. However, while Brussels 11.3.03 COM(2003) accession of Moldova is not on the agenda the EU has maintained this formal commit- 104 final. for the moment. ment, it is still unclear when the remaining 2. Gilmore A, McKee M. countries and territories of the region Tobacco and transition: an Conclusion (Albania, Bosnia and Herzegovina, Serbia overview of industry invest- It is in the interests not only of their own and Montenegro, and Kosovo) will be able ments, impact and influence in citizens, but also of the EU, that the coun- to join the enlarged Union. For them there the former Soviet Union. tries in South Eastern Europe and the “new are few prospects for signing Stabilisation Tobacco Control neighbours” should be peaceful and pros- and Association Agreements with the 2004;13:136–42. perous. Yet it is clear that they face many European Union, not to speak of achieving problems, including in the area of health. 3. Commission of the the status of candidate countries. A study European Communities. published in 2003 demonstrates that, Projects such as the Commission on Beyond Enlargement: throughout this region, people can expect Macro-Economics and Health have provid- Commission Shifts European to live between five and ten years less than ed important new insights into the contri- Neighbourhood Policy into their neighbours inside the EU, infant mor- bution that good population health plays in Higher Gear. Press Release. tality is almost three times higher, many economic development, an argument that Brussels 12.05.04. children have high rates of iodine deficien- has proven more persuasive to many poli- 4. European Parliament. cy and anaemia, and there is widespread cy-makers than the equally important one 5 Report on Wider Europe – use of tobacco, illegal drugs and alcohol. that health should be a measure of progress in its own right. Neighbourhood: A New The only country from South Eastern Framework for Relations with Europe which has been included in the A healthy population is the basis for an our Eastern and Southern New Neighbour policy is Moldova, which effective workforce, not just because of Neighbours (COM(2003) 104 is by far the poorest “new neighbour“, reductions in sickness absence but also – 2003/2018(INI)). Committee with a per capita GDP of only €417.1 because the prospect of a long life is an on Foreign Affairs, Human Recently, Moldova has become a member incentive for individuals to invest in their Rights, Common Security and of the Stability Pact for South Eastern own future, through education and skills Defence Policy, Rapporteur: Europe, which was launched at the EU’s acquisition. A healthy population will also Pasqualina Napoletano. initiative in 1999, in the aftermath of the reduce the cost of health care, which will A5-0378/2003. Kosovo crisis. The Stability Pact is an ini- benefit not only the state directly but, more 5. Rechel B, McKee M. tiative of a number of international organi- importantly, the many families that would Healing the Crisis. A sations, including the EU, the G8, the otherwise use that money to invest in Prescription for Public Health OSCE, the Council of Europe, OECD and wealth creation. It is therefore essential that Action in South Eastern the UN. It aims to contribute to stability health issues play a central role in the Europe. Information Review. and development of the region, but is sepa- Neighbourhood Agreements, Action Plans London: London School of rate from the Stabilisation and Association and in the Stabilisation and Association Hygiene & Tropical Medicine, Process which is led by the EU and associ- Process currently underway. To both be a 2003. ated with integration into the European good neighbour and protect its own citi- Union. Moldova has expressed its wish to zens, the EU must help surrounding coun- 6. Commission of the be included in the Stabilisation and tries to tackle the burden of disease and European Communities. Association Process and in September 2003 premature death by investing significant European Neighbourhood presented a Concept for the Integration of financial and technical resources in the Policy. Country Report the Republic of Moldova into the “neighbourhood.” Moldova. Commission Staff European Union. Working Paper. Brussels, 12 May 2004, SEC(2004) 567. In the Communication of the European

9 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE Explaining regional differences in mortality in the Balkans: A first look at the evidence from aggregate data

Arjan Gjonça Introduction Balkans in 1990, but analyses trends and While studying mortality in Eastern patterns prior to and after 1990. European countries, scholars have often posed the question of why some of the Data description and methodology Balkan countries did not experience the The mortality of the populations studied same mortality crises in the 1980s as most here are generally well documented; regular of the former communist countries of censuses and more or less complete death Eastern Europe? Mesle1,2 points out that registration data are available for all Balkan countries such as Albania and Yugoslavia, countries from the early-twentieth century, which had the worst life expectancy at or even earlier in the case of Greece and birth in 1950, were among the leaders of Bulgaria. The detail and the quality of mor- Eastern European countries in 1990. Some tality data is of course somewhat varied, authors have tried to provide explanations and not all data are available classified by “Overall mortality of this different mortality trend by focus- region. The quality of mortality statistics ing on particular countries.3,4 This research for the Balkan countries is high, even in trends cannot be question is not just an important one to countries where doubts have been raised study, but it also highlights the fact that about the quality of mortality statistics, explained by changes in despite its diversity the Balkans still remain they are similar to those in most developed an area that should be studied as a unit. It is societies .2,5 infant mortality” obvious that there is a profound shortage Aggregate level data on mortality is used of, and urgent need for, comparative stud- here, taken from publications of national ies of mortality in the Balkans which statistical offices of the Balkan countries, as should not just detail but also try and find well as international publications. In order plausible explanations for mortality pat- to check the accuracy of these data, as well terns. In outlining the main mortality as to complete possible missing data, other changes before and after 1990 this paper international publications are also used, tries to explain the regional differences in such as the Demographic Yearbooks of the mortality in the Balkans. United Nations. Other data related to pos- The mortality of any population is deter- sible determinants of mortality patterns in mined by a complex set of factors. While the Balkans have also been collected by socioeconomic determinants, such as national and international publications. income or urban-rural status are often con- One important point to make here is that sidered, longer-standing cultural factors are individual level data that can explain the often hard to assess. Nevertheless, there are casual mechanism for mortality patterns are parts of the world where issues such as diet very difficult to find in the Balkans, conse- and life-style, often linked both to geogra- quently results are primarily based on phy and history, are important considera- aggregate level data, using life table functions for a full understanding of a populations and standardised indexes. tion’s health. One such region is the The analysis concentrates on the period Balkans. It is also important to recall that between the end of the 1980s and beginning an awareness of the past is an essential of the 1990s for two different reasons. component to any understanding of the First, most of the Balkan countries experi- present, or presumption for the future. enced the same social, political and eco- That is why this paper focuses not only on nomic systems as the rest of Eastern the regional mortality differences in the Europe until 1990. Second, after 1990 the Federal Republic of Yugoslavia disintegrat- ed, and the Balkans experienced the Arjan Gjonça is Senior Lecturer in Demography, London School of formation of the newly independent states Economics and Political Science. E-mail: [email protected] Bosnia and Herzegovina, Croatia, FYR

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Macedonia, Serbia and Montenegro and Results of mortality comparisons in Slovenia, with data on mortality trends the Balkans often missing or of problematic quality. The focus is on a national perspective, as Long-term changes well as sub-regions within national states Since the Second World War, mortality where data are available. It is important to rates in the Balkan countries, with the emphasise that focusing on sub-regions, the exception of Greece, have been converging. analysis of mortality patterns reveals simi- Directly after the Second World War, there larities or diversities not noticeable at a was a large difference between life national level. This is important in the expectancy at birth (see Figure 1). Balkans, which is home to at least twenty Excluding Greece, life expectancy at birth identifiable ethnic groups, ten languages, in 1950 varied by 7 years for men, and 12 three alphabets and three main religious years for women. The large variation in groups. Behaviour and life style factors are female life expectancy is attributable largely not always generalisable at the national to the situation in Albania, where it has level. They might be related to history, been argued that the traditional values of geography, climate and other factors that society put female infants at a are not confined by national borders. disadvantage.5 The mortality of these countries began converging after 1970, unlike Figure 1: Life expectancy at birth in years, both sexes combined what was happening elsewhere in Europe. In 1990 the variation in life expectancy at birth, again excluding Greece, was around 85 2.8 years for men and 2.3 years for women. The most substantial improvement during 80 this period occurred in Yugoslavia and Albania. Life expectancy at birth for 75 Yugoslavia and Albania improved respec-

70 tively by 14.6 and 16 years for men and 17.6 and 23 years for women. Improvement 65 in Romania has been slow compared to the other Balkan countries, while in Bulgaria 60 mortality has worsened since the 1970s, in particular for men. This experience was 55 also observed in other East European countries, where reductions in mortality 50 began stagnating from the 1970s onward.1,6 1950 1960 1970 1980 1990 2000 When different components of overall Greece Bulgaria Romania Former Yugoslavia Albania mortality are considered, a different picture Note: Data on Albania are corrected for the completeness of death registration. Data can be observed. Table 1 shows infant mor- for 2000 from the Former Yugoslavia refer to Serbia and Montenegro tality rates since 1950. Dramatic reductions Source: Country statistical and UN demographic yearbooks. in infant mortality rates occurred in all Balkan countries, but more so in Albania and Yugoslavia, where they had been exceptionally high in the 1950s. Contrary Table 1: Infant mortality rate per 1000 infants, both sexes combined to life expectancy at birth, infant mortality rates remain very diverse even in the 1990s. Thus, Albania and Romania, despite 1950 1960 1970 1980 1990 2000 improvements during this period, still in 2000 have very high infant mortality rates Albania 134.0 100.9 89.6 66.2 41.6 23.7 of approximately 23.7 and 21.9 deaths per thousand live births respectively. In con- Bulgaria 108.2 45.1 27.3 20.2 14.8 15.1 trast, Greece and Bulgaria have relatively low levels of infant mortality, at 6.4 and Romania 118.1 75.7 49.4 29.3 26.9 21.9 15.1 deaths per thousand respectively. As with life expectancy at birth, Greece has a Former much lower infant mortality trend. An 139.8 87.7 55.5 31.4 20.2 18.4 Yugoslavia interesting feature of these trends in infant mortality rates is that despite the high life Greece 43.6 40.1 29.6 17.9 9.7 6.4 expectancy at birth achieved by most of these countries in the 1990s, infant mortali- Source: Country statistical and UN demographic yearbooks. ty rates, including those for Greece as well,

11 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE remain high by the standards for developed Table 2: Life expectancy at age 15 in years, both sexes combined societies. Importantly, overall mortality trends seen 1950 1960 1970 1980 1990 2000 from the 1970s onwards among some of the Balkans cannot be explained by changes in Albania 53.7 58.5 60.0 60.2 60.6 62.4 infant mortality. Changes in adult mortality for those aged 15 from 1950 to 2000 are Bulgaria 58.7 58.7 58.0 57.9 58.0 shown in Table 2. Interestingly quite a large amount of variance in mortality in the Romania 56.7 57.4 56.9 57.3 57.8 Balkans may be due to variations in mortality for this group. Thus, in 1990, life Former 52.5 56.4 57.2 58.2 59.1 58.9 expectancy at age 15 varies from 57.3 years Yugoslavia in Romania to 60.6 years in Albania and 63.0 years in Greece. Another very distinc- Greece 58.8 60.1 60.6 63.0 63.5 tive feature is that instead of a convergence in mortality rates, what one can see is a Source: Country statistical and UN demographic yearbooks. divergence over time. The countries with the greatest improvements in life expectancy at age 15 with 6.6 years are Yugoslavia among adults, especially among males, and Albania with 6.9 years gained between since the late 1980s. Different authors 1950 and 1990. In Greece, life expectancy attribute this to a range of factors, includ- increased 4.7 years between 1960 and 2000, ing the effects of increased stress due to while in Bulgaria life expectancy at age 15 economic, political and social uncertainty was actually lower in 2000 than in 1960. and a rise in smoking and alcohol con- It is surprising to see a controversial pat- sumption. tern such as that in Albania, where the Figure 2 shows the differences in adult infant mortality rate has for some time mortality by region for all Balkan countries been among the highest in Europe, while for 1990 (although detailed regional infor- adult mortality rates are among the lowest. Previous research has found that this controversial pattern is due to the importance Figure 2 Sub-regional differences of adult mortality in the Balkans in 1990, of diet and life style factors.7,5 Could simi- measured by the probability of dying between ages 15 and 60 lar factors be at play in the other Balkan countries? Regional patterns of adult mortality In attempting to analyse patterns of adult mortality in Europe, scholars to date have focused on two major divisions in Europe. The first is the division between Northern and Southern Europe (or the Mediterranean), where the mortality rates of adults in the latter group are much lower. These differences are not just found between nation states, but also within particular countries. Thus, distinctive differences are found between northern and southern Italy, where mortality is much lower in the Mediterranean south compared to the more continental north. This north-south gradient of mortality differences is found also in other Mediterranean countries, such as France, Portugal and recently in Albania.7,5 Most of these differences are attributed to the effects of the Probability of dying (%) Mediterranean diet and life style. The sec- up to 8 10–12 14–16 ond dimension of difference in European adult mortality is that found between west- 8-–0 12–14 over 16 ern and eastern Europe.1,2,6,8 The collapse of communism in Eastern Europe has been accompanied by an increase in death rates Note: Data on Bulgaria refer to the whole country, not to regions

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mation is lacking for Bulgaria and has been shown that there is no relation- Romania). It clearly shows both gradients ship between regional differences in overall of mortality in Europe, the difference or adult mortality and the level of educa- between north and south as well as tion in Albania (education taken as an indi- between east and west. Thus the areas with cator of development). No relationship was the lowest adult mortality are the Greek also found between the level of urbanisa- regions of Crete, Peloponnesus, Central tion and industrialisation and mortality dif- Greece and Epirus. Then, south-west ferences.5 Albania and the Greek regions of Thessaly, Where socioeconomic differences cannot Macedonia and Athens do slightly worse, account for regional differences in mortali- but better than the rest of the Balkans. The ty, one has to turn to possible life-style fac- regions that follow are north-east Albania, tors. It has been established for a long time Greek Thrace, FYR of Macedonia, and that the low mortality in the Mediterranean Montenegro. The central Balkans follow countries can be attributed to the positive this group, Bulgaria and Serbia, while the effects of the Mediterranean diet. High worst adult mortality is found in the intakes of mono-unsaturated fats, low “Mortality differences extreme north-east, in Romania, and in the intakes of saturated fats and high consump- extreme north-west, in Croatia and are very much related tion of fresh fruit, vegetables and wine have Slovenia. Just looking at this map it is clear often been cited to account for the differ- that mortality differences in the Balkans are to geographical ences between northern and southern very much related to geographical position. position” European mortality. What are the factors shaping adult It is ironic that some of the first evidence mortality in the Balkans? supporting the positive effects of As noted, individual data on determinants Mediterranean diet and life style came from of mortality are missing, not just for the a study which involved some of the Balkans as a whole, but also for individual Mediterranean populations of the Balkans. countries and at the sub-regional level. In The ‘Seven Country’ study, which included such circumstances any effort to try and 16 cohorts from different populations and find a casual mechanism to identify the countries and followed them over the influence of different factors on mortality course of twenty years, included six patterns is limited. Discussion must be cohorts from Balkan populations. In based on existing evidence from aggregated Greece two cohorts of men aged 40–59 level data. were enrolled in the study, one cohort from Crete and the other from Corfu. In Different authors have studied the relation- former Yugoslavia, there were about four ship between socioeconomic development cohorts, two of them in Croatia (Dalmatia and levels of mortality. In the former and Slavonia), and two in Serbia (Velika Yugoslavia one can possibly relate the level Krsna and Zrenjanin).10,11 of development of different regions with the level of infant mortality. Kosovo and The authors found marked differences in FYR Macedonia had the highest rate of the 15 year death rates and coronary heart infant mortality in 1990, while being the disease rates for the Balkan cohorts in the most underdeveloped regions of study. Death rates were low in Corfu and Yugoslavia. However, it is impossible to Creete, most notably those for coronary find any correlation between the level of heart diseases. Another piece of interesting adult mortality in former Yugoslav regions evidence of this study is that the death rate and their level of social and economic for all causes and for coronary heart dis- development. Thus, Kosovo and FYR eases in Dalmatia are much lower than in Macedonia have comparatively low levels Slavonian Croatia. of adult and cardiovascular mortality. Also Apart from other factors, the authors Matsaganis found that there was no rela- looked at the relationship between the rates tionship between the social and economic of coronary heart disease and calorific development of Greek regions and their intake in diet from total fats, unsaturated levels of overall mortality.9 The two and saturated fats. The study showed a extreme regions, Athens as the wealthiest high correlation between the average per- and Thrace as the poorest, have very simi- centage of dietary energy from saturated lar mortality rates. fatty acids and the incidence and death Our own analysis of adult mortality found rates from coronary heart disease. The that, historically, these two regions have most important finding of this study for us the worst levels of adult mortality in is that, first, differences in mortality due to Greece. The case of Albania is similar. It coronary heart disease between Crete in

13 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE the south of Greece and Corfu in the north “Diet may be an important consideration in under- are explained by the use of olive oil in the two cohorts; and secondly, so are the dif- standing why some countries did not experience ferences between Dalmatia in the West Croatia and Slavonia in East Croatia. Thus, worsening mortality” most of the research coming from this study supports the positive effects of the Mediterranean diet in explaining the regional differences between these cohorts, which reflect the regional differences in adult mortality in the region. This evidence is also supported by the case of Albania. It was originally argued that the 2. Mesle F. Mortality in Eastern and low mortality found in Albania could be Western Europe: A Widening Gap. In: attributed to the traditional forms of Coleman D (ed). Europe’s Population in the Mediterranean diet in the country.4 But, 1990s Oxford: Oxford University Press, latterly it has been suggested that even the 1996. regional differences in Albania can be 3. Watson P. Explaining rising mortality explained by different regional dietary pat- among men in Eastern Europe. Social terns of the country.7 Thus, the north-east Science and Medicine 1995;41(7):923–34. having a more continental dietary pattern, where animal fats are widely used, has a 4. Gjonca A, Wilson C. Falkingham J. worse mortality than south-west Albania, Paradoxes of health transition in Europe’s where a Mediterranean dietary pattern, poorest country: Albania 1950–90. based on a large use of olive oil, fruits and Population and Development Review vegetables is predominant. 1997;23(3):585–609. 5. Gjonca A. Communism, Health and Conclusion Lifestyle: The Paradox of Mortality It was stated earlier in this paper that the Transition in Albania London and research reported here is only a first tenta- Westport: Greenwood Press, 2001. tive step towards a thorough comparative epidemiology of the Balkans. In order to 6. Bobak M, Marmot M. East West Health make further progress we need more con- Divide and potential explanations. In sistent and detailed aggregate information, Hertzman, Kelly and Bobak M (eds). East- including regional information on Bulgaria West Life Expectancy Gap in Europe, 1996 and Romania, as well as a greater body of NATO ASI Series, Vol 19. 1996. individual level data. Obtaining this infor- 7. Gjonca A, Bobak M. Albanian paradox, mation becomes even more problematic for another example of protective effect of the 1990s due to the conflicts that gripped Mediterranean lifestyle? Lancet 1997; the region. 350:1815–17. However, we can sketch out the beginnings 8. Bobak M, Marmot M. East-west mortality of a comparative analysis and advance a divide and its potential explanations: pro- hypothesis to form the basis of future posed research agenda. British Medical research: that diet does indeed play a major Journal 1995;312:421–25. role in determining regional mortality pat- 9. Matsaganis M. An Economic Approach terns. When considering trends over time, and Inter-Regional Mortality Variations diet may be an important consideration in with Special Reference to Greece Bristol: understanding why some South-East University of Bristol, Faculty of Social European countries, such as Albania and Sciences, PhD Thesis 1992. Yugoslavia, did not experience the worsening mortality during the 1970s and 1980s 10. Keys A. A Seven Country Study: A seen in many other communist countries of Multivariate Analysis of Death and Eastern Europe. However, this remains Coronary Heart Disease Cambridge, highly speculative. Massachusetts: Havard University Press, 1980. 11. Keys A, Menotti A, Karvonen M J, Aravanis C, Blackburn H, Buzina R, REFERENCES Djordjevic B S, Dontas A S, Fidanza F, Keys 1. Mesle F. La mortalité dans les pays MH. The diet and 15-year death rate in the d’Europe de l’Est. Population seven countries study. American Journal of 1991;3:599–650. Epidemiology 1986;124:903–15.

eurohealth Vol 10 No 3–4 14 SOUTH EASTERN EUROPE Access to health care for Roma in South Eastern Europe

Ivan Ivanov Introduction among the Roma is higher than that of When examining the state of health of a non-Roma and that they have lower access population it is necessary to examine both to health care. Poverty is the most power- the concept of ‘health’ and the population’s ful factor contributing to the worsening of access to health care. As a concept, health Roma health. Unemployment, poor living can be conceived of as: the capacity for conditions, illiteracy, lack of information each human being to identify and achieve and isolation negatively influence their his/her ambitions, satisfy his/her needs and health. be able to adapt to his/her environment Of particular importance is the extremely which should include decent housing, nor- high unemployment rate. In some Roma mal access to education, adequate food, a “For many years neighbourhoods in Bulgaria this is between stable job with regular income and suffi- 90 and 95%,3 with similar figures found in strategies addressing cient social protection.1 other countries in the region. (This may issues related to Roma Access to health care is a right and a pre- not however capture informal employment requisite for good health without which so actual unemployment rates may be health have been full participation in social, economic, and somewhat lower). The Roma cannot afford political life cannot be enjoyed.2 to pay doctors’ fees and buy prescription inadequate” Unfortunately many Roma people in South medicines. Transportation to hospitals and Eastern Europe face disadvantages in specialised medical centres is often beyond accessing housing, education, adequate their financial means. Roma settlements are food and a stable income, elements that usually located in isolated areas or on the contribute to overall health. In addition, outskirts of a town or village with limited access to health care for Roma in the region access to public services. They lack the nec- is generally more limited than for the non- essary infrastructure for normal living such Roma population. as sewage systems, indoor running water, power supplies and telephone networks. For many years the strategies addressing All these factors directly impact on the issues related to Roma health have been health in these settlements. The combina- inadequate. However, the situation has tion of physical, economic and informa- become particularly acute in the post com- tion-based barriers to preventative health munist period. Studies of health care care that many Roma face in their every reforms in the region have brought to light day life is a consequence of the inter-relat- very alarming tendencies, including low life ed effects of poverty, discrimination and expectancy, high premature mortality and lack of familiarity with health care institu- high levels of morbidity among the Roma tions. population. Although these tendencies pre- ceded the fall of communism, the Roma Discrimination in accessing health have encountered many additional difficulties with the privatisation of public services care and the transition towards a market econo- Discrimination and prejudicial attitudes are my in the last decade. Today, most Roma a pressing concern for Roma in all areas of in the region live in conditions of over- life, including the health care sector. whelming poverty, and permanent stress. Discriminatory treatment by health care Communities lack proper sanitary systems workers including physical and verbal and suffer from poor nutrition, leading to abuse and negligence in examinations deterioration in their health status. works further to alienate the Roma from the health care services. They are often Roma health denied medical care because of their ethnic Research shows that the rate of illness background. Romani women are dispro- portionately affected by such treatment given their generally higher interaction Ivan Ivanov is Staff Attorney, European Roma Rights Centre, P.O. Box with health services. As observed in Italy, 906/93, 1386 Budapest 62, Hungary. E-mail: [email protected] discriminatory behaviour on the part of

15 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE health care workers can also impact on the Without advice from a GP and lacking the rights of children to access health care ser- money to pay for non-subsidised treat- vices.* A recent survey conducted among ment, they have no access to medical tests fourth and fifth year students in Hungary or specialists. revealed that about 10% of future doctors are strongly and about 40% mildly preju- Conclusion diced against the Roma. Other studies have In order to achieve substantial improve- shown that many doctors, nurses and other ment in the health situation of Roma, the medical staff in South Eastern Europe feel governments in South Eastern Europe hostility towards the Roma, based on their should take a multi-sectoral approach to colour of skin, poverty or lack of educa- address discrimination, as well as problems tion. regarding access to social benefits, education, decent living conditions and housing. A number of Romani women have report- Governments should adopt comprehensive ed such discrimination to international anti-discrimination legislation expressly organisations. A Bulgarian woman told the prohibiting discrimination in access European Roma Rights Centre in Budapest to health care, accompanied by the estab- that she was refused specialised medical lishment of special bodies to monitor treatment after experiencing a miscarriage “Discrimination and implementation. It will be crucial that gov- because of her ethnicity. A specific example ernments also include the Roma in the prejudicial attitudes are of discrimination and negligence based on a strategic planning and implementation patient’s Roma origin is a case from process aimed at improving Roma health. a pressing concern for Elhovo, Bulgaria. In this case, a Romani woman who was seven months pregnant REFERENCES Roma in all areas of experienced pain and then examined by a 1. Toward a New Public Health. Ottawa local doctor. After discovering that the life” Conference. Geneva: World Health unborn child had died, the doctor sent his Organization, 1986. patient to the regional hospital, but the hospital’s doctors were very unfriendly and 2. European Monitoring Centre for Racism hostile with both the local doctor and the and Xenophobia. Breaking the Barriers – Romani woman. They informed him that Roma Women and Access to Public Health he should treat Roma patients locally and Care. Strasbourg: Council of Europe, 2003. not send them to the hospital. Following 3. Ensuring Minority Access to Health this argument, the pregnant woman was Profile – Sociological Survey, Bulgaria. left for more than two hours in the corri- Ref: BG 0006.08/LCR, 2003. dor and in the evening her condition deteriorated, and as a result she died. FURTHER READING Segregation in hospitals and maternity Ringold D, Orenstein MA, Wilkens E. wards is common practice, being the rule Roma in an Expanding Europe: Breaking the rather than the exception. Roma patients Poverty Cycle. Washington: World Bank, often stay in separate rooms, reserved for 2003. Available at http://lnweb18.world- the Roma. Many Roma have said that they bank.org/eca/ecshd.nsf/ECADocByUnid/ have been intentionally segregated by med- EDF5EC59184222F8C1256D4F0053DA41/ ical staff and believe that they receive lower $FILE/Full%20Report%20in%20English. quality medical treatment and less attention pdf than other patients. For instance Roma Zoon I. On the Margins. Roma and Public women from Bulgaria have said that they Services in Romania, Bulgaria and have been segregated in maternity wards, Macedonia. Templeton MN (ed). New with one woman and her new born baby York: Open Society Institute, 2001. placed in the hospital corridor while non- Available at http://www.soros.org/ Roma women were in separate rooms. The initiatives/roma/articles_publications/ Romani women also complained that doc- publications/marginsromania_20011201/ tors were rude to them and that cleaning romania_bulgaria_macedonia.pdf staff did not maintain standards of good hygiene in their rooms. Turnev I. Common Health Problems Among Roma – Nature, Consequences and Possible Furthermore, doctors in their capacity as Solutions. Sofia, Bulgaria: Open Society general practitioners (GPs) act selectively Institute, 2001. and refuse to enroll Roma patients on their patient lists, even though they have very limited rights for doing this. Refusal by * See for example UN Committee on the rights of the child, concluding GPs to accept Roma patients has a direct Observations: Italy. CRC/C/15 Add. 198. 18 March 2003, para 54; and effect on their access to health care. CRC/C.15/Add. 201, 18 March 2003, para 67.

eurohealth Vol 10 No 3–4 16 SOUTH EASTERN EUROPE Treatment of drug addiction in South Eastern Europe: A country overview

Andrej Kastelic and This article presents an overview of the methadone detoxification was piloted in treatment of drug addiction in south east- the Toxicological Clinic in Tirana, the eligi- Tatja Kostnapfel ern Europe and of the obstacles to compre- bility requirements are fairly restrictive and hensive treatment and advocacy efforts in in 18 months, only 68 patients were treated. Rihtar the region. It draws on the experience of The existing treatment infrastructure is the South Eastern European Adriatic clearly insufficient. For this reason, in 2004 Addiction Treatment Network (SEEAN). the non-governmental organisation SEEAN was established in Sarajevo in (NGO), Aksion Plus, will began a MMT October 2003. The network is an informal programme under the supervision of the organisation of experts on addiction Institute of Public Health, with the finan- treatment and harm reduction from the cial support of the International Harm countries of south eastern Europe and the Reduction Development Programme of the “Experts in the region Adriatic coast. It aims to give mutual sup- Open Society Institute (OSI) in New York. port in training and in developing substitu- Uniquely in the region it is the only MMT are not satisfied with tion treatment programmes in the region. A programme run by an NGO. progress made in most database of experts and institutions is under construction and a website has been Bosnia and Herzegovina of these countries” established (www.seea.net). The network A government-funded methadone detoxifi- has published a regional magazine cation programme was initiated in the can- (Odvisnosti-Ovisnosti-Zavisnosti-SEEA ton of Sarajevo in January 2002. MMT Addiction, available on the website of the began in July 2002 and in the first four network) and several regional conferences months 40 patients were treated. have been organised. Methadone is also used in other cantons of the country, but it is given only on ambula- A central focus of the article is the avail- tory basis. The Public Institute for ability of drug substitution treatments in Alcoholism and Substance Abuse of the the region, particularly methadone mainte- canton Sarajevo, however, plans to imple- nance treatment (MMT). The status of ment MMT in other large cities. available treatment varies widely from country to country. Bulgaria Recently in Bulgaria some substantial steps Albania have been taken towards extending the Since the early 1990s, Albania has recorded availability of treatment services to meet a steady increase in problems related to the growing demand. In the Bulgarian production, trafficking and use of illicit National Programme for Prevention, drugs. Between 2001 and 2004, an estimat- Treatment and Rehabilitation of Drug ed 4,500 drug addicts were in need of treat- Addiction 2001–2005 and the National ment. Young people between 20–24 years Strategy to Combat Drugs 2003–2008, of age were among the most vulnerable MMT is now considered a core interven- (54% of all treatment demanded), but tion for opiate dependence and a backbone equally alarming was the high number of of the future national system for addiction Andrej Kastelic is based at the those under 19 years of age (23% of treat- treatment. MMT is seen as the treatment Centre for Treatment of Drug ment demanded), a number rising rapidly option of choice, providing a quick profes- Addiction, Zalo_ka 29, 1000 in recent years, especially among members sional response to the majority of drug Ljubljana, Slovenia, E-mail: of the Roma minority. users seeking medical treatment. [email protected]. Tatja Kostnapfel Rihtar is Methadone has been registered in Albania The most important developments are the based at The Sound of since 2002, but its costs are not covered by opening of new substitution programmes Reflection Foundation, the state or any insurance agencies. At and an increase in the number of treatment Zalo_ka 29, 1000 Ljubljana, present, methadone is available only in one slots. By the end of 2005, the government Slovenia, E-mail: tatja.kost- licensed private pharmacy at a relatively plans to increase the number of MMT [email protected] high price. Although short-term programmes by a factor of three. Such

17 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE programme expansion provides hope for The former Yugoslav Republic of the development of a national methadone Macedonia treatment system in that it provides indi- In FYR Macedonia there is only one MMT viduals with direct programme experience, programme. It is located in a day hospital and thus positively influences attitudes and for prevention and treatment of drug activities at political, professional, and dependencies, Kisela Voda, part of the community levels. Psychiatric Hospital in Skopje. Although Attaining good quality care is an essential services are free of charge, the day hospital goal together with the establishment of a is housed in an old building in the suburbs network of accessible effective pro- of Skopje, unsuitable for such a health grammes. The key will be to provide new institution. Neither the institute staff nor programme staff with comprehensive train- philosophy of work meet the needs of the ing and to ensure that future methadone clients. The programme is expensive, cen- programmes are in tune with high stan- tralised, and lacking permanent and coordi- dards of quality clinical practice. This will nated support from other social agencies. necessitate adopting national standards for The number of clients who use methadone clinical quality and developing official intravenously is high. It has been estimated “More advocacy and methadone treatment guidelines. that 70 % of clients have been infected with Hepatitis C. There are no clear treatment capacity building is Croatia guidelines and to date, most psychiatrists needed” The first cases of heroin addiction in do not support or recognise the validity of Croatia were registered in the late 1960s MMT. and in 1971 the Sestre Milosrdnice Clinical Hospital in Zagreb opened the first Serbia and Montenegro Department for Addiction Treatment. According to the latest UNICEF study, Methadone was introduced in 1991 and there are about 70,000–100,000 drug users continues to be the only substitution med- in Serbia and Montenegro, including 40,000 ication covered by insurance. in Belgrade and 5,000 in Novi Sad. MMT is Buprenorphine is licensed but patients available in three cities, with a well func- must pay themselves. Inpatient treatment is tioning programme in Novi Sad. However, organised for short-term detoxification in there are currently only about 200 clients in the psychiatric departments of all general the whole country and substitution treat- hospitals and in four specialised centres. ment is entirely absent in Montenegro. Outpatient treatment is the main standard Since MMT was introduced in 1987, it has of care and is based on cooperation not fared well following the disintegration between centres for outpatient treatment of Yugoslavia and poor political and eco- and general practitioners; there are 15 out- nomic situation. Inclusion criteria for patient centres throughout the country. MMT in Belgrade are exceptionally nar- They are the focal point for all types of row. Clients must be at least 25 years old, treatment: drug-free, detoxification and have several years of dependence, several methadone maintenance. Centres typically failed attempts at therapy and be infected include a medical practitioner, nurse, psy- with HIV. Detoxification therapy is rarely chologist and social worker. Psychiatrists used, and maintenance therapy is the most are usually in charge of the centres, but frequent form of treatment. Although there they are often also run by other specialists are many factors that put Serbia and or GPs. Montenegro at risk of a significant expanded HIV epidemic, the number of drug users Although GPs are not allowed to begin with HIV infection seems to have methadone treatment or change therapy, decreased over the last years, and is now they have many other functions in addition estimated at only 1%. This has reduced the to prescribing and administering number of clients eligible for MMT. methadone. They see the patient every day in their offices, know his/her medical histo- Because of the marked absence of HIV pre- ry, social circumstances and family history vention services for vulnerable population and usually take part in treatment deci- groups in the region, the new project, ‘HIV sions. A well developed network of GPs Prevention among Vulnerable Population makes MMT available in "every village". Initiative (HPVPI)’ in Serbia, supported by Of 2,400 GPs in Croatia, more than 1,000 the UK Government, Imperial College have patients on MMT. There are no wait- London and the International Harm ing lists for treatment, no strict inclusion Reduction Development Programme of the criteria and treatment is practically free of OSI, might serve as a model for effective charge. HIV prevention strategies in south eastern

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FURTHER READING Europe. The programme also plans a coun- tants to the WHO, The Joint United Dickov A, Vucˇković N, Lajić try wide launch of MMT. Nations Programme on HIV/AIDS, the O, Jovisˇević O, Durović D. International Harm Reduction Attitudes and knowledge of Slovenia Development Programme of the OSI, and parents about drug abuse. There are between 10,000 and 12,000 intra- International Harm Reduction Association. Odvisnosti-Ovisnosti- venous drug users in Slovenia (correspond- They are also involved in developing treat- Zavisnosti-SEEA Addiction ing to 50–60/10,000 population). The shar- ment programmes in Central and Eastern 2003;4(1–2). ing of injection equipment (estimated to be Europe and in Central Asia. 80%) as well as unsafe sex are common and For the promotion of the treatment pro- Hasesˇić H, Mehić Basara N, increase the potential for the spread of grammes and their assistance, the Sound of Poktajac M. Methadone treat- HIV. National guidelines for the manage- Reflection Foundation (Odsev se slisˇi) was ment in Sarajevo. Odvisnosti- ment of drug users, including MMT, were established in 1998 by staff in charge of the Ovisnosti-Zavisnosti-SEEA adopted by the Ministry of Health in 1994. Centres for Prevention and Treatment of Addiction 2003;4(1–2). Since 1995, 18 regional Centres for the Drug Addictions. Training programmes Prevention and Treatment of Drug Ivancˇić Ante. Methadone treat- were organized in cooperation with the ment in Croatia. Odvisnosti- Addictions (CPTDA) have been estab- Foundation and numerous manuals for Ovisnosti-Zavisnosti-SEEA lished, providing far-reaching services experts, drug users and their families were Addiction 2003;4(1–2). including: prevention; individual, group published. and family therapy; counselling services for Kastelic A, Kostnapfel Rihtar drug users, relatives and community health T. Drug addiction treatment in services; substitution programmes; prepara- Conclusion the Republic of Slovenia. tion for inpatient treatment; rehabilitation Estimated coverage of substitution treat- Odvisnosti-Ovisnosti- and social reintegration; consultation with ment amongst problem drug users in Zavisnosti-SEEA Addiction health, social, education services and the Western European countries was between 2003;4(1–2). police; co-operation with NGOs, thera- 30 and 100 patients for 100,000 inhabitants Kastelic A, Kostnapfel Rihtar peutic communities and self-help groups; in 2001, compared with 0.6 in Estonia, 0.84 T. Integrating methadone treat- education; research and publishing. in Serbia and Montenegro and less than 10 ment in the Slovenian public in other Central and Eastern European Criteria for MMT are opiate addiction, pre- health system. Heroin countries. Coverage is higher in Croatia vious detoxification attempts, written con- Addiction and Related Clinical and Slovenia reaching 21.9 and 103.7 MMT sent, a minimum age of 16, permanent resi- Problems 1999;1(1):35–41. clients per 100,000 population respectively. dence in the region where a drug prevention Estonia, Poland and Slovenia are the only Kostnapfel Rihtar T, Kastelic and rehabilitation centre is located, agree- countries in Central and Eastern Europe A. Findings from the ment of GP and having health insurance. that provide MMT in prisons. Only a few methadone maintenance pro- Methadone guidelines (EuroMethwork) countries (including Slovenia and Croatia) gramme in the Republic of have been translated into Slovenian. use buprenorphine. Slovenia. Heroin Addiction and Substitution treatment is also regulated by a Related Clinical Problems Law for Prevention and Treatment of Drug The International Harm Reduction 1999;1(2):10–11. Addiction. The opening of the new Centre Programme of the Open Society Institute is strongly supporting substitution treatment Mitrić B, Tomcˇuk A. Drug for Treatment of Drug Addiction at the programmes in several countries in south abuse in Montenegro. Psychiatric Clinic, Ljubljana took place in eastern Europe. SEEAN makes it possible Odvisnosti-Ovisnosti- January 2003. Inpatient treatment is also to exchange knowledge and experience in Zavisnosti-SEEA Addiction provided for prisoners. the region. However, experts working in 2003;4(1–2). Several conferences have been held in the region are certainly not satisfied with Tulevski IG, Sekutkovska S. Slovenia: The 3rd European Methadone progress made in most of these countries. Drugs, drug use and drug treat- Conference 1997; 1999 Slovene Conference Much more advocacy and capacity building ment in the Republic of on Addiction; International Association are needed. Macedonia. Odvisnosti- Symposium on Addiction Medicine in Ovisnosti-Zavisnosti-SEEA 2001; Meeting of Central and Eastern ACKNOWLEDGEMENTS Addiction 2003;4(1–2). European Countries on Addiction We would like to express our gratitude to Treatment organised with the WHO in Erald Bekteshi (Tirane, Albania), Zihni Sulaj Substitution Therapy in south 2001; International Conference on the Tirane, Albania), Nermana Mehić-Basara eastern Europe, status report. Reduction of Drug Related Harm in 2002; (Sarajevo, Bosnia and Herzegovina), Harm Reduction News and the first Adriatic Southeast European Alexander Kantchelov (Sofia, Bulgaria), 2003;4(2). Countries Conference and Symposium on Georgy Vassilev (Sofia, Bulgaria), Ante Simon S. Launching a compre- Addiction Treatment organised jointly Ivancˇić (Porecˇ Croatia), Slavica Gajdadzis- hensive HIV prevention initia- with Croatia in 2003. Knezevicˇ (Skopje, Macedonia), Ivan G. tive. Harm Reduction News Establishing the network of centres for the Tulevski (Skopje, Macedonia), Nikola 2004;5(2). prevention and treatment of drug addiction Vucˇković (Novi Sad, Serbia and Verster A, Buning E. was cited as an example of successful prac- Montenegro), and Mira Kovacˇević Methadone guidelines tice in United Nations – Best Practice Case (Belgrade, Serbia and Montenegro) for Eurometh 2000. Studies. Slovenian experts act as consul- information contributed to this paper.

19 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE Implementing a national TB control programme in minority communities: Challenges and accomplishments from Kosovo

Alka Dev and Although exact figures of the population be assumed that Kosovo has one of the size in Kosovo are lacking, estimates of the highest levels of TB incidence in Europe, Jennifer Mueller resident population (persons living in with an average incidence rate estimated by Kosovo) range from 1.8 to 2.0 million peo- the World Health Organization to be ple. According to the Living Standards 77/100,000 in 1999. Measurement Survey of 2000 (carried out Given the volatile post-conflict environ- by the Statistical Office of Kosovo with the ment and the need to reconcile ethnic- assistance of the World Bank), 88% were based discrimination and disputes, the ethnic Kosovo Albanians. The ethnic international community began to provide Serbian population accounted for 7%, large amounts of assistance. In addition to while other ethnic groups together funding for the United Nations Interim accounted for approximately 5% of the Administration Mission in Kosovo total population. (UNMIK) and the Kosovo Force (KFOR), “Kosovo has one of the In early 1989, the Yugoslav government approximately $2.2 billion was poured into highest levels of TB abolished all autonomy for Kosovo and reconstruction efforts. However, no long- followed with the dismissal of all Albanians term commitment was made by the inter- incidence in Europe” working in areas such as administration, national community to work with the teaching, and health. The health situation Kosovo Provisional Institutions of Self- of Kosovars worsened considerably at this Governance (PISG) in order to bring about time and continued to worsen over the next sustained changes at the community level, decade due to the departure of qualified especially for the Serbian minority and Albanian health workers and a general dis- the Roma, Egyptian, and Ashkali (REA)1 trust of the Serbian-run health system by communities. the Albanian population. In response, the At present, TB health facilities and infra- Albanian community organised an infor- structure in Pristina and the larger provin- mal, volunteer, parallel health services cial towns are quite good. However, rural structure, primarily run from homes, which areas of Kosovo remain extremely poor, lacked adequate equipment, drugs, report- with few local facilities, and damaged infra- ing structures and supervision. structure. Rural communities remain isolat- This article analyses the process of integrated, especially during the harsh winters and ing minority areas into tuberculosis (TB) access to health care remains a challenge, control activities in Kosovo in the after- even more so for rural communities of math of the NATO offensive in 1999. At minorities. Within Kosovo itself there are that time, the health care situation was pre- approximately 22,000 internally displaced carious as 800,000 Albanians living in people, mainly Serbs and Roma, who are refugee camps in FYR Macedonia and displaced from their homes in Albanian Albania returned to find badly damaged majority areas, but also some Albanians infrastructure and health care facilities, displaced from their homes in the three including Anti-TB Dispensaries (ATDs), Serb-dominated provinces in northern laboratories, and Institute of Public Health Kosovo. (IPH) buildings. Alka Dev is Programme Manager and Jennifer Mueller According to the Epidemiology Consultant, Doctors of the Department at the Institute of Public 1. These ethnic identities are, for the most World –USA, 375 West Health in Pristina, registered cases of TB part, self-identified, and describe different Broadway, New York, NY increased dramatically from 413 in 1990 to parts of the community traditionally known 10012, USA. 883 in 1997. Although no reliable denomi- as ‘Roma.’ The distinctions are based on lan- E-mail: [email protected] nator for population size is available, it can guage, history and social structure.

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Prior to two days of riots in March 2004, cantly. UNMIK and the Kosovar govern- there had been some progress towards the ment are in the process of issuing a gradual integration of minority communi- ‘Charter of Patient Rights’ that would pro- “Most Serbs and ties into the Albanian social and political mote equal health care access for all and structure. However, the events in March integration of all minorities into the major- certain Roma may have a lasting impact in Kosovo, as ity health care system. As yet, however, 4,100 Serbs and Roma were displaced, and most Serbs and certain Roma communities communities do not many of their homes and public facilities, do not feel secure visiting Albanian health such as schools and health houses, were care facilities. feel secure visiting burnt or destroyed.2 There is an ongoing parallel health care structure in Kosovo, operating under the Albanian health care Background: health care services in auspices of medical authorities in Belgrade, facilities” minority communities in Kosovo which serves the Serb enclaves, with hospi- Access to general health care in minority tals in North Mitrovica and Gracanica. communities varies considerably, with Serbs from other enclaves seek primary some communities having relatively easy medical treatment in small, often inade- access to primary, secondary, and tertiary quately supplied health houses in their health care, while other enclave communi- communities (if available), and travel to ties have almost no regular access. Overall, Gracanica and North Mitrovica for sec- in terms of access to health care, some com- ondary and tertiary care. Certain Roma 3 4 munities, such as the Bosniaks, the Turks communities are also served by this parallel 5 and, to a lesser extent, the Goranis, have health care system. Rarely, Serbs may seek become almost fully integrated in, or have and receive emergency health care from good access to the Albanian system, while Albanian hospitals, sometimes on their others, such as Serb enclaves, remain isolat- own, and sometimes with KFOR or other 6 ed. international escorts. The situation of the REA communities is more complicated, with some communities Setting up tuberculosis facilities in having certain freedom to access services, minority areas others experiencing difficulties or discrimi- As part of its efforts to improve TB pre- nation by available providers, and others vention and treatment in Kosovo, Doctors having little or no access to services at all. of the World-USA (DOW) selected two The degree of access is linked to the lan- minority communities in which to set up or guage used by each community, as different rehabilitate TB facilities in 2000: Laplje groups use one or more of three languages: Selo and Strpce. These locations were iden- Albanian, Serbian, or Romani. tified on the basis of the degree of isolation, the high TB rates, the pre-existence of The groups most integrated with the some health care facilities, the presence of Albanian majority speak Albanian and are capable doctors, and the size of the com- identified as Ashkali or Egyptian. Roma munities. A key element of establishing communities speaking Serbian or Romani functioning TB treatment centres in these appear to have difficulties accessing health areas was the participation of local medical care in the majority areas, and in some staff. Local staff were instrumental in cases, in the Serb areas as well. On the local designing the facilities, and adapting them level, however, both Albanian and Serb to the needs and capacities of their commu- communities discriminate against all three nities. In addition, technical training was groups to a certain extent. undertaken by international consultants, Discrimination continues to reduce this who were perceived as being more neutral population’s access to health care signifi- than Kosovar trainers.

2. For further details of the violence, see Amnesty International report: Serbia and Montenegro (Kosovo/Kosova)--The March Violence: KFOR and UNMIK's failure to protect the rights of the minority communities, July 2004 3. Immigrants from Bosnia, Serbo-Croatian speakers, with close ties to Bosnia, and the health care system there. 4. Turkish speaking Kosovars, traditionally based only in the south, and in Pristina. 5. Slavic Muslims living in isolated mountainous communities in the southern-most tip of Kosovo, traditionally with ties to Serbia. 6. Serbs currently live in the three northern most municipalities Mitovica/ë, Leposavic/q and Zubin Potok, where they are in the majority, and in selected larger enclave communities in Albanian-majority municipalities, notably in Gracanica/Laplje Selo area in central Kosovo, and Strpce in the south, and in smaller more isolated enclaves in municipalities throughout Kosovo, such as in Obiliq, Gjilan, Novo Brdo, and Rahovac among others.

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The initial contacts with the medical staff in training of nurses to implement a patronage the Serb community were made and main- nursing system. The patronage nursing sys- tained by DOW’s TB Project Director. tem is a visiting nursing system in which These contacts were based on relationships nurses monitor TB outpatients in their that pre-dated the war, and the minority homes (with an aim to improve outpatient doctors’ subsequent moves to the minority treatment practices). Monitoring activities enclaves from facilities in Pristina. The pri- include inquiry into treatment lapses, over- mary contact was between the TB Project coming patient barriers to care, patient Director, and one Serbian pulmonologist, education about treatment and conse- who has since become the coordinator for quences of treatment failure, and family the minority areas. contact tracing. Communication and transportation, both A further element in the training was symptoms of the continued isolation of educating the nurses and the doctors in the minority areas, have been the causes of methods of accurate and consistent report- most ongoing challenges in minority inte- ing. In 2003, patronage nurses conducted gration into TB control. It remains difficult 433 home visits, and provided health for staff of the National Tuberculosis education to 1,841 TB patients and family Programme (NTP) and of DOW in members. They also assessed the possibility Pristina to communicate with minority of TB infection in 106 individuals who areas, and to oversee the implementation of came into contact with TB patients. the programme from Pristina. One major challenge in treating patients in A further challenge facing the doctors in these minority communities was the mobil- the minority areas is the difficulty they ity of the populations. Patients tend to be “One major challenge have in transporting sputum for testing. At mobile, travelling to Serbia for extended present, they do not feel secure using the periods, or migrating due to security in treating patients in labs in the Albanian areas. The difficulties concerns. Sometimes, unfortunately, these minority communities in transport have meant that not all patients migrations lead to the interruption of treat- are given a sputum test prior to receiving ment and record keeping. was population treatment, contrary to DOTS (Directly Observed Therapy, Short-course) recom- Health education mobility” mendations. Efforts to locate an appropri- Based on the results of two Knowledge, ate site for a lab in the minority areas have Attitudes and Practices (KAP) surveys, not yet been successful, and may be partly participating staff developed a health edu- stymied by a lack of political will on the cation programme aimed at reaching three part of minority health authorities. target groups: the patients, youth in schools, and the general public. Training minority doctors and nurses Health education about TB provided by in best practices nurses and doctors in TB hospitals has DOW trained doctors and nurses from all helped to increase knowledge among over Kosovo in DOT principles. The train- patients. The comparison of the results of ing, conducted by outside experts, included the first KAP survey (November 1999) training in standardised treatment regimens with the results of the second KAP survey and directly observed therapy for all spu- (August 2002) show that in 2002 patients tum smear-positive cases. Training was also had a much higher level of knowledge conducted in the standardised recording about TB. The number of patients not and reporting system to allow assessment knowing any symptoms of TB decreased of treatment results for each patient and of from 33.3% to 0%. The results of the first the performance of the overall TB control KAP survey of patients showed shame as a programme. major barrier to treatment with 12.9% of In addition to minority participants, DOW patients claiming that TB is a shameful dis- also included two Serb doctors and five ease. In the second KAP survey only 2% of Serb nurses practicing in the selected patients said that TB is a shameful disease, minority areas. It is of note that these med- indicating that the information campaign ical personnel considered themselves to be had decreased the stigma associated with under the Serbian health system (of Serbia the disease. and Montenegro), and felt they needed In order to target the patients, videotapes, ‘clearance’ from Serbian health authorities brochures, and handouts were developed, to attend training with other Kosovar which were to be used both in the hospital health care practitioners. setting and in home visits. Minority nurses An essential part of the programme was the were successfully trained in TB health

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education. The training was planned and of 80% and the intervention was also facilitated by both the Albanian and Serb followed by greater case finding. Case staff together, which was the first joint notification rates increased between 2001 exercise for minority health professionals. and 2002 by 16% (from 92/100,000 to Subsequently, these nurses returned to 107/100,000). their hospitals and were charged with train- The Minority TB programme is one of a ing other nurses involved in patient care. In handful of programmes in Kosovo where order to reach the minority communities, doctors and medical staff from minority Serb nurses were provided with materials areas are cooperating directly with the in Serbian for their patients. Almost all majority health care system. This achieve- patients (94%) reported in the second KAP ment should not be under-estimated; trust- survey to have received health education building activities, close cooperation, and information in the hospital and 100% of flexibility were essential. the patients said that education helped them to understand TB. The access of minority patients in Strpce, Laplje Selo, and neighboring Gracanica to A second approach to health education was TB treatment has been much improved by through workshops held in schools to help these interventions. The training of the educate young people about the disease. doctors and nurses, as well as the imple- DOW piloted this project in five schools, mentation of the patronage nursing system, and continued in regions with a high inci- has made it possible for patients to be cared dence of TB. Teachers who were trained at for and cured without strenuous and DOW sessions taught modules in schools, unsecured journeys to North Mitrovica or using brochures, a comic strip, and posters. Serbia, some of which patients would not “Doctors and medical Schools were partly chosen based on the have been able to complete. percentages of minority children attending staff from minority the school. The patronage nursing system in particular had a significant impact in the minority areas are cooperating Future goals areas. The minority clinician in Laplje Selo reported initial resistance from the patients directly with the The TB programme described above is in the final stages of being handed over to the to the treatment, but their confidence and majority health Institute of Public Health within the trust has been won through the visible suc- Ministry of Health based in Pristina. The cess of the programme in providing them care system. This handover includes parts of the minority with appropriate treatment, information programme, such as the health education and follow-up. The training received by the achievement component, although DOW will retain an doctors and nurses also appears to have had advisory capacity for minority concerns. In an impact on their relationships with their should not be 2005, DOW will continue to advise the patients. underestimated” NTP on strengthening the case detection The health education initiative appears to system in minority areas. have had a significant impact on the health and behaviour of patients. Patients report- Success factors and lessons learned ed feeling much more confident in their The interventions described above have treatment, and having a better understand- been successful in a number of ways: in ing of the importance of the drug regimen. establishing cooperation between majority The impact of health education has also and minority health care systems and contributed to patient confidence in dis- providers, lowering TB incidence rates in cussing TB with other individuals outside certain minority areas, improving health- the hospital and within their immediate related behaviours, increasing equality of family. This is important to note, as the access to TB treatment, and in lowering the stigma attached to TB patients remains stigmatisation of the disease amongst TB high in Kosovo and contributes to patients patients and their communities. hiding their disease. Since the initiation of activities in minority In terms of increased equality of access for areas for patients and providers, the TB minorities, the impact is not uniform across treatment success rate for minority com- all minority groups. As noted above, there munities has improved to parallel the suc- are three broad groups within the minority cess rates from majority areas. At the community. The first group includes beginning of the interventions, the minori- Bosniaks in the Peja and Prizren regions, ty area treatment success rates were at 62% the Turks in the Prizren region, and some as compared to the overall Kosovo rate of REA communities, primarily Albanian- 91%. By early 2003, minority areas were speaking Ashkali groups. While some com- reporting treatment success rates upwards munity members of these groups expressed

23 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE some feeling of insecurity or discrimination direct impact in those areas, links with when accessing health care in general, they other nearby minority communities are not had no specific complaints about the TB necessarily made without a great deal of health staff. conscious effort and deliberate programming. Efforts need to be made at a local The second group includes those minorities level on a community-by-community basis living primarily in enclaves whose access to to spread the success of specific regions “Continued success TB health care has been much improved by more widely. the facilities, the doctors, and the nurses in depends on sustained the TB clinics in Laplje Selo, Strpce, and Conclusion North Mitrovica. These groups include efforts to maintain and Minority communities in Kosovo are frag- mainly Serbs and Serbian-speaking Roma mented and often isolated and, with limited communities in Gracanica, Laplje Selo, and improve links with access to health care, are particularly vul- Strpce. nerable to TB. The continued ethnic ten- and among minority However, there is a third group of minori- sions throughout the region and political ties whose access to health care has not yet pressures from above have provided very communities” been affected by the minority programmes real challenges for the establishment of a of DOW. This group includes Serbs living TB programme for minorities that is inte- in enclaves in other regions of Kosovo, iso- grated into the national TB programme, lated REA communities, and REA commu- but still successfully addresses the needs of nities living within Serb enclaves who have those communities. difficulty in accessing health care through The DOW Minority TB Programme has the Serb parallel system. Patients are either tried to emphasise equality of access to sent to Vranya, in Serbia, or treated in the health care, tackling political and practical small health houses available in the com- obstacles to produce a locally run pro- munities themselves. This group also gramme that has been successful in lower- includes Roma communities in isolated ing TB incidence rates in minority commu- enclaves or internally displaced persons nities. The intervention was also followed (IDP) camps, that continue to be severely by a 16% improvement in case notification isolated, have little to no access to adequate rates over one year and an 18% increase in health-care, and are very vulnerable (for treatment success rates for minority areas. example, the four Roma IDP camps in Northern Mitrovica and Leposavic). This programme has been successful in a Training Roma nurses might be a way to number of other ways: it has established affect Roma access in the future, as with cooperation between majority and minori- Serb nurses in Serb areas. ty health care systems, increased equality of access to TB treatment, improved health- By approaching the problem of TB treat- related behaviours, and lowered the stigma- ment in minority communities as a collabo- tisation of the disease amongst the popula- rative problem to be solved by all parties, tion. rather than by imposing a solution from outside, the programme implementers were These results, however, are not static, and able to build a programme suitable for the continued success in the future depends on communities and to establish long-term sustained efforts to maintain and improve trust, essential for the sustainability of the links with and among minority communi- programme. ties through collaboration, cooperation, and a concerted outreach effort. Further, Another element of success was the empha- rigorous efforts to improve standards in sis on health education, particularly with operation, reporting, and training need to the patients themselves. This element con- be maintained in order to provide minority tributed directly to the success of the pro- communities with the same level of health gramme as it improved patients’ awareness care as enjoyed in the majority areas. levels, compliance and understanding. It Because many disparities affecting minority also contributed to a change in the communities are caused by factors beyond approach of health care workers and the control or scope of NGO and health- improved patient-doctor relationships and specific activities, political will and support nurses’ buy-in, as they saw the direct from state actors and structures is essential impact of their work. for gains to be sustainable and less vulnera- A final lesson is that although the establish- ble to future political upheaval. ment of TB clinics in certain areas has a

For further information please download the full case study report from www.dowusa.org. This case study was funded by The Child Survival Collaborations and Resources Group (The CORE Group).

eurohealth Vol 10 No 3–4 24 SOUTH EASTERN EUROPE TB control and DOTS implementation: A bridge between the countries of south eastern Europe

Lucica Ditiu Background information tries of South Eastern Europe fall into all In late 1999, the World Health three of the WHO defined categories for Organization (WHO) created the position TB burden (See Table).2 Romania belongs of Tuberculosis (TB) Medical Officer for to Group I, the group of countries with the Albania, FYR Macedonia and the UN- highest TB burden, with steadily increasing administered province of Kosovo* charged notification rates over the last 10 years, with the implementation of a project fund- reaching 133 per 100,000 population in ed by European Commission 2002. All others with the exception of Humanitarian Assistance Office (ECHO), Slovenia are in Group II, including Bosnia devoted to strengthening tuberculosis (TB) and Herzegovina where the trend is down- programmes and Directly Observed wards and Serbia and Montenegro where Treatment, Short-course (DOTS) imple- the notification rate is on the up. Special mentation. In May 2002 the office was mention should be made of Kosovo where enlarged to also cover:* Albania, Bosnia the notification rate has been increasing and Herzegovina, Bulgaria, Croatia, and in 2002 was 53 per 100,000 inhabitants. Romania, Serbia and Montenegro, Slovenia, TB control in most of the countries was and Turkey (from 2003). and is still vertically organised, conducted There are considerable health problems in through a single institution (National the countries of South Eastern Europe. The Institute or Hospital) with officially recog- consequences of war plus socioeconomic nised national authority for TB and lung transition have led to social insecurity, high diseases. Inpatient facilities are organised levels of poverty and deterioration in the through a system of hospitals (or depart- health care systems. All of these factors ments in large hospitals) devoted to have contributed to the spread of TB, a dis- patients with TB and other lung diseases. ease known to affect the poorest and most Patients are usually hospitalised for the vulnerable members of society.1 The coun- entire intensive phase of the treatment or until no longer smear positive. The average length of hospitalisation is between 40–60 Table TUBERCULOSIS NOTIFICATION RATES IN SOUTH EASTERN EUROPE days. The exception is Croatia, where the (most recent year reported) patients are hospitalised for a maximum of three weeks. Country Notification rate The outpatient system is organised in so- per 100,000 called ‘anti TB dispensaries’ where sec- Group I Romania 133 ondary level health care is provided through specialists in TB and lung diseases. Group II Bulgaria 42 There is usually one TB dispensary per dis- trict, so that the number in each of the Bosnia and Herzegovina 41 countries of the region varies (for example, Serbia and Montenegro 40 10 in Kosovo, 160 in Romania and 271 in Turkey). Outpatient facilities are in charge FYR Macedonia 33 of follow up and monitoring of patients Croatia 33 during the continuation phase (from 4–6 months) as well providing anti TB drugs. Turkey 26

Albania 20 * The UN administered province of Kosovo Group III Slovenia 17 will be referred to here as Kosovo ** The WHO office is called ”Office for TB Lucica Ditiu, is TB Medical Officer, World Health Organization, Office for Control in the Balkans” but includes all the TB Control in the Balkans, Bucharest, Romania. countries from South Eastern Europe, plus E-mail: [email protected] Turkey and without Moldova.

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There is moderate but increasing interac- Although governments have expressed tion between TB dispensaries and family their political commitment for DOTS doctors, evidenced mainly by the referral of implementation, funds have come from TB suspects to TB specialists. Sometimes, external donors. In Albania, Bosnia and family doctors are involved in follow up of Herzegovina, Kosovo and FYR Macedonia TB patients during the continuation phase. there has been extensive technical and In the former Yugoslavia a system of financial support from the World Health ‘patronage nurses’ was used for follow up Organization (WHO), European of patients. There are still areas, Kosovo, Commission and United States Agency for FYR Macedonia, and Serbia and International Development (USAID). Montenegro, where patronage nurses facili- Romania received support from the Open tate the direct observation of patients. Society Institute (OSI), USAID, WHO and However, the absolute number of patron- the World Bank. Limited external support age nurses is totally inadequate and, due to was offered to Bulgaria by the Swiss- health sector reforms, their future role is Bulgarian cooperation agency and to uncertain. Diagnosis is based on bacterio- Croatia by the OSI. No significant external “There are clear logical examination, X-ray and clinical financial support was forthcoming for examination. Bacteriological examination Serbia and Montenegro, Slovenia or indicators of includes both smear and culture examina- Turkey. demonstrated tions, often with inefficient use of resources TB proposals submitted to rounds 2, 3 and for sophisticated methods of culture. 4 of the Global Fund for AIDS, improvement in TB Tuberculosis and Malaria (GFATM) by Opportunities for and threats to Romania, Serbia and Montenegro and control programmes” tuberculosis control Kosovo were approved and significant WHO and the International Union against funding will now be available for TB Tuberculosis and Lung Diseases control programmes. Funds are mainly for (IUATLD) recommend DOTS as the main extensive staff training in TB management strategy for TB control. DOTS is known as (from lung diseases specialists to laboratory the most effective strategy, with cost technicians, family doctors, nurses and effectiveness ranging from US$5 to US$ 40 volunteers), procurement of equipment for per DALY (disability adjusted life year) bacteriological laboratories, improving gained.3 This strategy is a significant laboratory services, and strengthening opportunity for the region’s health care surveillance and monitoring. systems. There are clear indicators of demonstrated Most governments agree with the princi- improvement in TB control programmes. ples of the DOTS strategy, embarking on All countries are using WHO standardised implementation. One reason for the rapid case definitions, treatment regimens, and acceptance of DOTS was that in Bulgaria, forms and registers for recording and Romania and the countries of the former reporting, thus allowing for cross country Yugoslavia there already existed under analysis and comparison. In terms of data communism a system of strict supervision collection, computerised databases of treatment, very similar to recommended including individual information on all Directly Observed Treatment (DOT), one TB patients now exist in Albania (700 component of the DOTS package. There patients per year registered), Bosnia and was also a decreasing reliance on mass Herzegovina (1,700 per year), Kosovo screening by X-ray, with diagnosis includ- (1,500 per year), and Romania (35,000 per ing smear and culture tests in Romania, year – the largest individual data base, Bulgaria, and Croatia. available since 1994). All other countries use aggregate data for national reporting. Implementation began at different times through pilot projects: Bosnia and For bacteriological diagnosis, each country Herzegovina 1997; Romania, Serbia and and territory now has an established labo- Montenegro and Slovenia 1998; Bulgaria ratory network, with a National Reference 2000; Albania in 2001, Kosovo and FYR Laboratory coordinating activity and the Macedonia 2001; Turkey 2002. At end 2002 quality assurance system. It is important to Bosnia and Herzegovina, Kosovo and note that quality assurance thus far has Slovenia were reporting 100% DOTS cov- only been established in Croatia and erage, followed by Bulgaria 78%, Romania Slovenia, but is beginning in Albania, 54%, FYR Macedonia 50%, Serbia and Kosovo, FYR Macedonia, Romania, Serbia Montenegro 40% and Albania 30%. All and Montenegro. There have been no sig- have aimed for 100% coverage by end nificant national shortages of anti TB drugs 2005. during the last four years, although tempo-

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rary shortages (maximum two months) duced. Even so the number of MDR TB were seen in some areas of Bulgaria, cases appears to be decreasing, indicating Kosovo and Serbia and Montenegro. that TB control programmes are improving. Better survey information is needed Between 2000 and 2003, anti TB drugs for however to fully understand the situation. Albania, Bosnia and Herzegovina, Kosovo and FYR Macedonia were procured In terms of information, education and through different donors or international communication to the public very little has organisations. At the end of 2002, Bosnia, been done in the region. There is very low Kosovo and FYR Macedonia applied for public awareness on TB, with little if any drugs from the Global TB Drug Facility coverage in schools, or through public (GDF) and received a three-year grant. In education campaigns. Some projects have Romania, Croatia, Slovenia and Turkey been undertaken in Albania, Kosovo and drug procurement and distribution is FYR Macedonia, but not as part of a clear organised by governments and health national strategy. “The major threat insurance funds, with no shortages remains the recorded during the last four years. Most TB control as a bridge between remarkable has been the evolution of the southeast European countries sustainability of commitment towards TB control in What makes TB Control in South Eastern Albania, whose government from 2004 Europe unique is the collaboration between achievements” decided to purchase anti TB drugs with managers and staff of National national funds through the GDF direct Tuberculosis Programmes (NTP) of the procurement mechanism. different countries. It started in 2000, when Despite general success in eliminating the NTP and laboratory managers from shortages, the overall drug management Albania, FYR Macedonia, Kosovo, system still requires special attention. Bulgaria, Bosnia and Herzegovina and There is very little knowledge at central Romania gathered to form what is now level relating to consumptions, inventories, called ‘The Balkan initiative in TB existing stocks and expiry dates for anti TB Control’. The Initiative tries to increase drugs. Drugs are distributed to peripheral regional collaboration, to help solve the units based solely on the number of TB common problems faced by TB Control patients, without taking into account programmes, and addresses specific topics previous drugs received, used and left. of common interest. The first meeting, held in Romania, brought together people from Although HIV prevalence rates seem rela- countries in conflict with each other; pro- tively low, there is a possibility that these fessionals willing to work and collaborate are being under reported and/or under with colleagues from neighbouring coun- diagnosed.1 Furthermore, there are very tries in TB management and laboratory few reliable data on TB/HIV co-infection networking. and little initiative to improve collaboration between TB and HIV programmes. On their own initiative in 2002, a second However with HIV funds received by meeting was held in Romania, with the Bulgaria, Croatia, FYR Macedonia, participation of an even larger number Romania, Serbia and Montenegro and of countries, including Serbia and Turkey from GFATM proposals it is likely Montenegro, Croatia and Turkey. The that collaboration may begin soon. For meeting addressed fundraising possibilities example, in 2004, a joint HIV/TB frame- and introduced participants to the GDF work was developed and approved in and GFATM. A third meeting in 2003 in Romania Ohrid, FYR Macedonia had a record number of attendees, thirty from all countries There are no current data to show an epi- of South Eastern Europe, and tried to demic of multi drug resistant TB (MDR – familiarise the participants with the moni- TB caused by strains of TB bacteria resis- toring and evaluation of TB programmes, tant to at least isoniazid and rifampin) in as well as with recent updates on TB the region and the absolute number of control in children. MDR TB patients ranges between 5 per year in Albania to 400 per year in Romania. Apart from training and information shar- However, these figures should be regarded ing accomplished at these meetings, region- as underestimates, as few drug resistance al networking has clear benefits for all, surveys have been conducted (for example, especially for TB patients. It is not unusual in Croatia, Romania and Slovenia) and the to see TB patients going for the continua- system of quality assurance for bacteriolog- tion phase of treatment from Kosovo to ical laboratories has only just been intro- FYR Macedonia and Albania (or vice

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versa). Thanks to the use of common and the international community will be data forms and the existing collaborative critical, as the fragile achievements in TB network it is now very easy to follow up control still need external support. patients when they cross territorial boundaries. REFERENCES Conclusion 1. Rechel B, McKee M. Healing the Crisis: A There is strong momentum and potential Prescription for Public Health Action in for controlling TB in most of the countries South Eastern Europe. Information Review. in South Eastern Europe. Significant London: London School of Hygiene and achievements by TB programmes have Tropical Medicine, 2003. been obtained over the last four years, 2. Borgodoff M, Floyd K, Broekmans J including the training of large numbers of Interventions to reduce tuberculosis mortal- staff, equipping of laboratories, and ity and transmission in low and middle improved data collection and reporting. income countries. Bulletin of World Health The major threat remains the sustainability Organization 2000:80(3):217–27. of these achievements, the need to expand DOTS to areas not yet covered and the 3. WHO. DOTS expansion plan to stop TB integration of TB control programmes in the WHO European region 2002–2006. within an environment of changing health Copenhagen: World Health Organization, systems. Maintaining the interest of donors 2002:1–22.

Reducing perinatal mortality in FYR Macedonia

Dragan Gjorgjev Introduction than four changes of directors in the three Several years ago, the perinatal mortality main institutions involved took place and Fimka Tozija rate in FYR Macedonia was among the during the project, while there was also a highest in Europe. Between 1998–2001, the frequent change of Ministers of Health and Ministry of Health, supported by the a change of local directors in university World Bank, responded to this challenge clinics and medical centres. A second major by starting a project to reduce perinatal challenge was posed by the violent conflict mortality. It aimed to develop a national in the western part of FYR Macedonia in strategy for perinatal care, introduce an evi- 2001, resulting in a postponement of con- dence-based medical training programme sultant visits and a delayed development of and develop the national neonatal intensive education modules. A final challenge was care network. the initial failure to include obstetricians in the training provided and in overcoming Challenges faced the initial opposition of those neonatolo- The project faced three major challenges. gists who were not included in the training The high turnover of staff slowed down programme. implementation of some activities. More Project activities It is noteworthy that all project objectives were achieved despite numerous obstacles. Dragan Gjorgjev MD PhD is Adviser Coordinator, Republic Institute for Health Protection, Skopje, 50 Divizija 6 Skopje, FYR Macedonia. Project activities included: E-mail: [email protected]. – Meeting basic educational needs of neonatal providers at secondary and Fimka Tozija MD PhD is Head of the Department for Injury and Violence tertiary level, including both doctors Control and Prevention, Republic Institute for Health Protection, and and nurses. Associate Professor Cathedra of Social Medicine, Medical School, Skopje, FYR Macedonia. E-mail : [email protected] – Structural development of a tertiary care

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unit in the Clinic for Obstetrics and Major achievements Gynaecology, relocation of the tertiary An evaluation of the National Perinatal care unit in the Clinic for Paediatrics Programme was carried out in January and development of a neonatal transport 2002, exactly two years after education of service. trainees commenced. The evaluation aimed “The environment for to assess the outcomes of the National – Provision of equipment to secondary Perinatal Programme, including its organi- change is ripe but and tertiary care units and the transport sational framework, long term strategy and service, staged according to operating equipment. funding is needed for bed numbers and training programme. The evaluation compared the perinatal – Inclusion of neonatal rotations in paedi- further educational mortality rate in the three years before atric training and of basic neonatal intervention (1997–99) with the rate in the programmes” information in undergraduate medical two years after intervention (2000–01), training. covering 16 hospitals where more than – Introduction of advanced neonatal train- 93% of babies in the country are born. The ing for nurses and midwives. evaluation established an overall decrease – Establishment of a centre for continuous of 21% in the perinatal mortality rate and a medical education, development of an 8- decrease of 36% in early neonatal deaths of week training programme for doctors babies weighting more than 1,000g (7.7 and nurses, and training of ten educa- compared to 12.0 per 1,000 live births), tors. reflecting the postnatal thrust of the programme. – Establishment of a Perinatal Committee to guide and integrate perinatal care at The evaluation also assessed the quality of all levels of implementation. teaching at the Continuous Medical Education Centre. It concluded that the – Development of clinical protocols based educational programme was sustainable, on the best available evidence, including the methods based on evidence and that the the Cochrane database and Welsh data- teachers included a skilled team of doctors base of perinatal trials. and nurses, competent in delivering a cur- – Establishment of a Maternal, Perinatal riculum using modern, innovative teaching and Infant Mortality Committee to methods and multi-faceted assessment investigate all maternal, perinatal and techniques. infant deaths. The assessment of twelve maternity and – Development and implementation of two paediatric units found huge improve- standardised psychometric and neuro- ments in the practice of evidence-based logical testing for all high-risk neonates medicine. A significant number of medical and to provide audit data on long-term professionals underwent training. In total, morbidity and appropriate intervention 115 doctors and nurses were trained, con- into school age. stituting 50% of doctors and 25% of nurses who care for neonates in the country. A – Development of a strategy for perinatal survey of trainees indicated a high level of care in Macedonia acceptance of the educational curriculum and its teaching and assessment methods. Key success factors and lessons There were also major structural improve- learnt ments. Equipment was distributed, Key success factors included: installed and corresponding training pro- “all project objectives – Establishment of an organisational vided. The intensive care units of the framework for perinatal services Paediatric Obstetrics and Gynaecology were achieved despite Clinic in Skopje were reconstructed and a – Regionalisation of neonatal care, transfer newborn emergency transport service is of high risk mothers to the capital numerous obstacles” now operational. In addition, a national Skopje and establishment of a national database for perinatal and neonatal data transport service for sick neonates was developed, its users trained and soft- – Introduction of evidence-based educa- ware distributed to trainees. tion and practice In terms of management, an organisational A major lesson of the project was the framework for working groups in support importance of including obstetricians and of the central Perinatal Committee was midwives. Similar projects in the future completed and a long term National should aim to include these groups from Perinatal Strategy developed. the beginning.

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Take away message of the project REFERENCES This project can and should serve as a model for reforming other areas of health 1. World Bank Health Sector Transition care in FYR Macedonia, such as the nation- Project. Former Yugoslav Republic of al emergency service. The next milestone in Macedonia. Implementation Completion the reduction of perinatal mortality will be Report No. 25735, April 2003. to decrease the rate to less than 10 per 1000 2. Jeffery HE, Kocova M, Tozija F, Gjorgjev live births by 2005. This will require atten- D, Pop-Lazarova M, Foster K, Polverino J, tion to the obstetric/midwifery component Hill D. The impact of evidence-based educa- of perinatal health. The environment for tion on a perinatal capacity-building initia- change is ripe but funding is needed for tive in Macedonia. Medical Education 2004; further educational programmes and 38(4):435–47. should be considered a fundamental part of the National Health Strategy.

Planning for health at county level: The Croatian experience

Selma Sogoric The war and subsequent disintegration of The World Health Organization’s Urban the former Republic of Yugoslavia during Health/Healthy Cities Programme in the 1990s resulted in the creation of the Europe provided Croatia with an early independent nation-states of Croatia, FYR model for developing new social structures Macedonia, Slovenia, Bosnia and and organisational relationships to improve Herzegovina, and Serbia and Montenegro. local public health. The initiative recog- The recent history of armed conflict, politi- nised the importance of political will and cal turmoil and severe economic change has cross-sector alliances and strove to develop resulted in tremendous individual and soci- participatory mechanisms so that individu- etal stresses throughout the region.1–4 als, voluntary associations, and city govern- “A unique training ments in Europe could think about, under- In the case of Croatia, the transition to new stand, and make decisions together regard- programme Healty forms of government and economic sys- ing local public health issues.7–9 tems led to a deterioration of public health Counties was services.5,6 A process of decentralisation of Healthy counties the health sector, which started at the developed” In the summer of 1999, directors of the beginning of 2000 mandated that local Motovun Summer School of Health county governments assume public health Promotion convened a panel of 25 planning responsibilities. These responsi- Croatian public health experts to review bilities had formerly been centralised. existing public health policy and practice at This paper describes the evolution of a pro- the county level. The group used an assess- ject aimed at strengthening local public ment tool called the Local Public Health health planning capacity at the county level Practice Performance Measures of Croatia after decentralisation. Local self- Instrument, which had been developed by government and administration in Croatia the Public Health Practice Programme are organised into 20 counties and the City Office of the US Centers for Disease of Zagreb. Populations in the counties vary Control and Prevention (CDC).10 The from 90,000 to 450,000, while the City of Faculty from the Andrija Stampar School Zagreb has 800,000 inhabitants. of Public Health adapted the instrument to fit the Croatian context and translated it Selma Sogoric, MD, MPH, PhD is Senior Lecturer in public health, Andrija into the local language. The expert panel Stampar School of Public Health, Medical School, University of Zagreb identified the following as the weakest Rockefellerova 4, 10000 Zagreb, Croatia. points in existing public health policy and Phone: +385 1 45 66 996. Fax:+385 1 45 90 275. E-mail: [email protected]

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practice at the county level: Organisation of training – Priority setting and policy formulation Teams from three counties completed a cycle of four 4-day workshops conducted – Strategy formulation and comprehensive over a period of four months. Each county planning for solving priority issues team was composed of 9 to 10 representa- – Coalition building among community tives: at least three from the political and groups and other stakeholders executive component (County Councils – Policy assurance, an issue stemming and Departments for Health, Labour and from the lack of objectives and therefore Social Welfare), three from the technical component (County Institute of Public an inability to determine whether they Health departments, Centre for Social are achieved Welfare); and three from the community – Lack of analysis of existing health (NGOs, voluntary organisations and the resources. media). In order to maximise the participa- In 2001, the Open Society Institute, New tory nature of the workshops, the number York financially supported and facilitated of trainees at any given training activity the ongoing collaboration between the was limited to 30. Andrija Stampar School of Public Health Since mutual learning and exchange of and the CDC. The same autumn two facul- experience was an important part of the ty members from the Stampar School process, each cohort was composed of attended the CDC’s Management for three counties from different parts of International Public Health course Croatia with different levels of local gover- in Atlanta. Returning to Croatia they “A ‘learning-by-doing’ nance experience. The Ministries supported developed a unique training programme, the direct costs of training (training pack- training approach was Healthy Counties, aimed at assisting age development, teaching and staff counties assess population health needs in a expenses) and the counties covered the best tool for public participatory manner, select priorities, plan trainees’ lodging and travel expenses. A for health and, ultimately, assure provision different county hosted each workshop and health capacity of the right type and quality of services, provided the training venue. better tailored to population health needs. building” The programme incorporates a multi- Description of curriculum disciplinary and inter-sectoral approach, Each cohort of counties went through four permanent consultation with community days intensive training: (‘bottom-up’ approach) and use of qualita- Workshop 1 – Assessment tive analysis. The curriculum was devel- County team members reviewed the core oped as a blend of recognised management public health functions and practices, and tools, public health theory and practice and became familiar with participatory needs use of Healthy Plan-it™ material of the assessment approaches, methods and tools. Sustainable Management Development Each team developed a framework for Programme. The programme’s main goal county health needs assessment and decid- was to increase county-level capacities to ed on methods for involving citizens. conduct health planning and provide more Considerable attention was devoted to self- effective public health services. management and group management tech- After two months of consultations with niques, especially time management and stakeholders in the Ministry of Health, team development. Homework assigned to Ministry of Labour and Social Welfare, the county teams for completion prior to County Governors, National Institute of the next workshop involved creating a draft Public Health and the Andrija Stampar version of a County Health Profile. To School of Public Health, officials reached a accomplish this, the teams had to apply one consensus about the aims and content of or more methods of participatory needs the programme. A ‘learning-by-doing’ assessment, identify sources of information training approach appeared to be the best inside and outside the health sector, formu- tool for public health capacity building and late county health status indicators, and strengthening of collaboration between collect appropriate data. health policy stakeholders. All trainees Workshop 2 – Healthy Plan-it™ understood from the outset that training inputs were expected to yield measurable Through application of ‘Healthy Plan-it’, outputs within a few months. Each county an educational programme developed by team was expected to plan and conduct the CDC’s Sustainable Management assessments, and elaborate a County Development Programme, county teams Health Profile and a County Health Plan. were guided through a health planning

31 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE process. They were first introduced to month later. The assignment required the different techniques for selecting priorities teams to present results as well as describe among community health needs, then to the process used, including the participative problem-solving and decision-making tech- assessment of health status and needs, niques. Reaching consensus in groups that selection of priority areas, policies and were so diverse and new to one another programmes to address priority health was a potential problem. Consequently, the needs, implementation plans, monitoring trainers employed a variety of confidence and quality assurance mechanisms, and building exercises and consensus tech- evaluation plans. Teams had to present niques, which assisted in the achievement their County Health Profiles and Plans of desired team goals. locally to their own County Councils, and then nationally to other counties and Each team selected five county health ministries. priority areas on the second day of the workshop and began to develop plans for On-going follow-up addressing them. The teams learned how to A tutorial system of guidance and monitor- identify and analyse problems, find their ing was introduced after the fourth work- root causes and trace possibilities for shop to ensure that team members not lose solving problems inside complex, multi- their commitment and enthusiasm. County organisational systems. Prior to the next team coordinators met mentors monthly workshop, the teams had to identify coun- and follow-up workshops on county health ty ‘health stakeholders’ and conduct con- “A centralised ‘one- policy development were held every three sultations on selected priorities. Following months. Alumni from the first cohort were size-fits-all’ approach these meetings, each team revised priorities involved in training of the second and third and began drafting their County Health cohorts, providing new trainees with is no longer sufficient” Plans. practical advice and guidance from recent Workshop 3 – Policy development graduates of the programme. Expert help and support to the counties was provided This module began with an introduction to by the faculty on request throughout the the process of building constituencies. process of developing County Health Participants learned interpersonal Plans. communication, partnership, advocacy and negotiation skills. Collaboration with the By the beginning of September 2004, six media, public relations and social market- training cohorts had completed the ing were addressed. Homework assigned to Healthy Counties programme (15 county the county teams required them to convene teams and the city of Zagreb) and produced local expert panels in their respective coun- County Health Profiles and Health Plans ties to obtain advice on appropriate policies with prioritised health needs and specific and interventions to address priority health recommendations. Nine county councils issues. accepted and approved their own county strategic health documents, five of these Workshop 4 – Quality assurance guaranteed funding for project implemen- Skills developed in this module included tation in priority areas. planning change, building institutional Currently, training continues for a subset capacity for change, and conflict recogni- of those already trained. Participants con- tion and resolution. Another training sist of ‘troikas,’ groups of three in county objective was to familiarise participants leadership positions: one elected official, with methods for analysing the wider one professional civil servant from the environment. Presentations given by repre- county administration, and one profession- sentatives of the Ministry of Health, al from the county public health institute. Ministry of Labour and Social Welfare and The troikas liaise between their own coun- by the leader of the national health system ty team, other counties and trainers from reform project helped participants to view the Stampar School. During 2003/2004 their county projects from a larger, national troikas came together on several occasions perspective. Skills like resource planning and received additional training on evi- and management (both human and finan- dence based public health programmes for cial), implementation, quality assurance, early detection and treatment of breast can- monitoring and evaluation were also part cer (Mljet, October 2003), comprehensive of this training. (medical and social) care for the elderly Homework for this module was to finalise (Samobor, March 2004), and Total Quality the County Health Profiles and County Management for managers in the health Health Plans for public presentation six sector (Uvala Scott, May 2004).

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Discussion Education 1999;1:1–9. The shift from centrally planned economies 2. Lang S. Challenge of goodness: twelve to more representative governments and humanitarian proposals based on the experi- market-based economies is taking place ence of 1991–1995 wars in Croatia and rapidly throughout South Eastern Europe. Bosnia and Herzegovina. Croatian Medical The simultaneous process of decentralisa- Journal 1998;39:72–6. tion and health sector reform has resulted in significant pressures on local govern- 3. Lang S. Challenge of goodness II: new ments to better plan and manage their pub- humanitarian technology, developed in lic responsibilities. As local governments Croatia and Bosnia and Herzegovina in are faced with this new challenge, they are 1991–1995, and applied and evaluated in also presented with greater freedom in Kosovo 1999. Croatian Medical Journal selecting priorities, allocating resources, 1999;40:438–45. and satisfying local health needs. These 4. Beaglehole R, Bonita R. Public health at opportunities require increased capacity the crossroads: which way forward? Lancet locally to identify and prioritise needs, 1998;351:590–92 plan, implement and evaluate interventions. 5. Bozicevic I, Oreskovic S, Stevanovic R, The Healthy Counties programme in Rodin U, Nolte E, McKee M. What is hap- Croatia has built county level capacity to pening to the health of the Croatian popula- assess public health needs in a participatory tion? Croatian Medical Journal manner, to plan for health and assure pro- 2001;42:601–5. vision of services tailored to local health 6. Lang S, Kovacic L, Sogoric S, Brborovic needs. The programme’s benefits in Croatia O. Challenge of goodness III: public health are extending both below and above the facing war. Croatian Medical Journal county level. The project serves to provide 2002;43:156–65. support for the more localised Healthy 7. World Health Organization Regional Cities projects, as well facilitate a paradigm Office for Europe. Centre for Urban health. shift in the national ministries’ mindset that Strategic Plan. Urban Health/Healthy Cities a centralised ‘one-size-fits-all’ approach is Programme (1998–2002). Phase III of the no longer sufficient. WHO healthy Cities project. Copenhagen: 7 The project has successfully engaged stake- June 1998. holders from political, executive, and tech- 8. World Health Organization. City Health nical arenas and involved a variety of com- Profiles: How to Report on Health in Your munity groups (young and older people, City. 2nd edit. Copenhagen: WHO, 1997. the unemployed, farmers, islanders, urban families etc.), local politicians, and institu- 9. Sogoric S. Application of the modified tions in the needs assessment, prioritising method of “rapid appraisal to assess com- and planning for health cycle. munity health needs” for making rapid city health profiles and city action plans for County Health Plans are accepted political- health. Croatian Medical Journal ly (by County Councils), professionally 1998;39:267–75. and publicly. Proposed interventions for health improvements rest on local organisa- 10. Richards T B, Rogers J J, Christenson tional and human resources and are G.M et al. Assessing public health practice: (presently in five counties) financially sup- Application of ten core function measures of ported through county budgets. With the community health in six states. American experience gained through this programme, Journal of Preventive Medicine the Faculty of the Andrija Stampar School 1995;11(Suppl 2):36–40. is extending its assistance to neighbouring countries with similar political and economic histories. The first one to try out and test nationally the training model (beginning in June 2003) is FYR Macedonia and Serbia and Montenegro will begin a similar programme in 2005.

REFERENCES 1. Levett J. On the humanitarian disaster in the Balkans from a public health perspective. The Internet Journal of Public Health

33 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE Access to health services for displaced persons in Serbia*: Problems of income and status

Ozren Tosic As a result of inter-ethnic conflicts in the growth of the private sector and the lack of former Yugoslavia and the consequent accountability of service providers. Local break-up into five independent countries, population health deteriorated in the 1990s refugees and internally displaced persons as a result of the cumulative effects of polit- (IDPs) ** started to arrive in the Republic ical, economic and social collapse. Income of Serbia in 1991. It is estimated that has become the major obstacle to access to refugees and IDPs now represent nearly 10 health services, with displaced populations per cent of the Serbian population. In 1995 suffering the most. there were 700,000 refugees and since 1999 around 230,000 IDPs have arrived from Financing Kosovo. 120,000 refugees have returned to Health care services for employees and their countries of origin while another their families are paid by the Health 50,000 have emigrated to a third country. Insurance Fund (HIF), which is the major Of 110,000 who acquired Serbian citizen- purchaser of health services, financed “Refugees, IDPs and ship, some also obtained citizenship in their through monthly salary contributions. country of origin and/or, at the same time, There is a tradition of universal health cov- local residents share maintained refugee status in Serbia. erage inherited from the former difficulties stemming Currently there are around 270,000 Yugoslavia, including solidarity in the refugees registered with the Serbian financing of health care where those with from an inefficient Commissioner for Refugees. However, higher incomes pay a proportionally higher these data are not precise as there is still a contribution to the Health Insurance Fund. health care system” spontaneous (unregistered) return of Health care for the small proportion of refugees to countries of origin, free cross- uninsured (between 5 and 7%) legally ing of the border with Bosnia and should be financed through the Ministry of Herzegovina, a different definition of the Health. Refugees have the same (tax based) status of returnees to Croatia and no offi- source of funding as uninsured citizens, cial way to register deceased refugees in this time through the Serbian Serbia.1 In any case, the number of IDPs Commissioner for Refugees. has not changed significantly since 1999, From 1989 to 2000, state allocations for due to the absence of security and other health (including health insurance and bud- conditions for a return to Kosovo. getary funding) in absolute terms per capita As with most other countries, available decreased each year. In 2001, they started data from Serbia do not indicate major dif- to rise again. Per capita spending for health ferences in the physical health of refugees in Serbia, however, is still lower than in and IDPs compared with the local popula- 1989. The salary contributions of insured tion. However the Serbian Institute of citizens are not sufficient to pay for their Public Health has noted that 13% of IDPs own health services, let alone to cover have serious medical problems: with high malnutrition among IDPs and refugees in collective centres and displacement serious- * Serbia in this article refers only to the ly affecting mental health. Refugees, IDPs Republic of Serbia, one of the two republics and the local resident population share dif- along with the UN administered province of ficulties stemming from an inefficient Kosovo that constitute the country of Serbia health care system, the uncontrolled and Montenegro. ** Displaced persons are defined as refugees when they have found refuge in another Ozren Tosic is a consultant in health policy, health management and financ- country and as IDPs when they were forced ing, Belgrade, Serbia and Montenegro. He was Commissioner for Refugees in to leave their home but stayed within their the Serbian Government from February 2003 to March 2004. country of origin.

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uninsured citizens, include refugees and a exhausted by a failing economy. large proportion of IDPs. As a result, the It is estimated that over 120 000 or around health care of uninsured citizens has never 25% of refugees and IDPs are living below been adequately financed and until 2003, the poverty line. This is twice the propor- health care for refugees had no specific tion of the poor in the resident allocation in the Serbian budget. At pre- population.3 As with the rest of the coun- sent, the state owes more than €30million try’s inhabitants, this reflects low income, to public health service providers for health but also other dimensions of poverty such care provided to refugees over the past 12 as inadequate access to health services. This years; a debt that is probably never going situation is exacerbated in the least devel- to be repaid. It is also worth noting that, oped areas with the highest concentration due to inadequate funding for health ser- of IDPs (southern Serbia). vices in general, the state owes many times more to health care institutions for services Ethnic and gender issues among the delivered to the overall population. “120,000 refugees or refugee and IDP populations Roma are the poorest and most vulnerable Solidarity displaced persons live population group, in particular where they In practice, health services for the unin- belong to the displaced. Some estimates sured, refugees and a large proportion of below the poverty line” suggest that there may be as many as IDPs were financed in Serbia mainly from 500,000 Roma in the country. A large num- employees’ contributions to the Health ber live in slums with inadequate housing Insurance Fund and out of pocket. Over and it is estimated that these poor living the last 15 years, out of pocket payments conditions, contribute to a considerably for health services have become a signifi- shorter life expectancy compared with the cant source of health care funding; with overall population. Displacement aggra- estimates of up to 40% of total health care vates problems faced by this population expenditure. These payments are made for group. There are no precise data on the drugs, and private services as well as infor- total number of Roma or of the proportion mal payments to employees of public of Roma among refugees, but within the health facilities. As refugees and IDPs are IDP population more than one tenth are poorer than the resident population, the Roma.4 The lack of a fixed address and reg- impact of displacement on income is a istration with municipal authorities are predominant issue in access to health and major obstacles for access to services. These other public services. This pattern has been problems are perhaps best illustrated by the observed throughout Eastern Europe and recent case of a Roma IDP, none of whose 2 Central Asia. seven children possessed a birth certificate. 2003 was the first year a significant alloca- Consequently, none of the children have tion from tax sources was made in the bud- been able to gain access to health care and get for refugees. However, per capita, it is education. more than three times less than the amount Other vulnerable population groups recorded by health providers as spent on include women, children, and households the health care of refugees. IDPs do not with older people or located in rural areas, have a special line item within the govern- all of which have a higher risk of poverty ment budget for health care, although their than the average population. Women, for social, economic and formal status within example, have on average wages that are the country represents a significant obstacle 15% lower than the wages of men. Women to the utilisation of health services. belonging to vulnerable populations, such as Roma, refugees and IDPs, face a double Social status disadvantage and have the highest risk of 1995 (refugee exodus from Croatia) and poverty, with consequent difficulties in 1999 (IDPs from Kosovo) brought a sharp accessing health services. Women and chil- rise in the already numerous displaced dren living in ‘collective centres’ for dis- population in Serbia, on both occasions placed persons are additionally affected by more than 200,000 people sought refuge. their unfavourable living environment. They left their property, jobs and social networks were shattered. Refugees and Access to health services IDPs shot to the top of the list of the most Legally, IDPs and refugees have the same vulnerable and poorest populations, with rights as local citizens to access health ser- the Roma among them being the worst off. vices free of charge at the point of delivery. This was also a damaging financial blow to Moreover, they do not have to pay official the public services and a population already co-payments (the so-called ‘participation’)

35 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE for medical services or medicines, which Conclusion “Funding should are mandatory for all except vulnerable The large number of refugees and IDPs population groups. The only precondition temporarily residing in Serbia makes for a be available for all is that they are registered with the Serbian large financial burden on both taxpayers Commissioner for Refugees and present and the overextended Serbian health bud- citizens regardless of their registration card. This has somewhat get. However, this problem will not be alle- socioeconomic status” inflated the number of people registered as viated in the near future, as there is little IDPs and refugees, some of whom may chance that refugees and IDPs will soon have returned to Croatia and Bosnia and return to their place of origin. Those who Herzegovina or may never have left came as children are sometimes now par- Kosovo. They usually seek treatment in ents whose offspring do not have any emo- Serbian hospitals, when it is more difficult tional links to their parent’s country of ori- to access these services in their local place gin. For many Serbs from Croatia, their of residence. possessions have been largely destroyed or may be out of reach because of bureaucrat- Refugees and IDPs share the difficulties of ic obstacles. Property in Bosnia and the largely inefficient health care system Herzegovina is being returned, but the fail- with the local population. State spending ing Bosnian economy does not offer much on health care is not sufficient; providers incentive for return. Serbs from Kosovo, are largely unaccountable to public scruti- many of whom have had their property ny, professional or state control, while pri- destroyed or sold, cannot return for securi- vate health services, out of reach for the ty and other reasons. poorest segments of population, are completely self-regulated. However, additional It is more than 13 years since refugees and difficulties are experienced by displaced later IDPs started to settle in Serbia. Due to persons due to poverty levels that are dou- the inefficiency of governmental adminis- ble those of the local population, rendering tration and/or for quasi-political reasons, them unable to pay for private services or 500,000 of these people are still registered pay “under the counter” in public facilities. as displaced, officially not belonging in the They are not within the social networks place where they now live. The political needed to navigate through the highly inef- and economic situation in Serbia, Croatia ficient health system, although after five or and Bosnia and Herzegovina are strongly more years of displacement these networks linked to the economic wellbeing of these are being created. individuals, their access to public services (including health) and, ultimately, their Distance to service and the poor outreach health status. Although refugees and IDPs of services to the 14,000 refugees and IDPs share the problems of local residents in (3% of total) living in collective centres is coping with the highly inefficient, underfi- another difficulty. Collective centres are nanced and unaccountable health services, usually situated on the outskirts of urban the additional burden of poverty, unclear areas, relatively far from secondary and ter- arrangements for health care financing for REFERENCES tiary hospitals that provide the majority of the displaced, their undefined status and health services. Residents of collective cen- 1. Commissioner for Refugees the lack of developed social networks tres are usually the poorest within the of the Republic of Serbia. makes for a nightmarish scenario. refugee/IDP population. Another problem Annual Report, 26 December is the practice by primary health care facili- In 2003 the government adopted a Poverty 2003. ties of not registering IDPs and refugees, Reduction Strategy Paper (PRSP) that 2. World Bank. Living in preventing adequate medical follow up. included the National Strategy for Limbo, Conflict-induced dis- Refugees and Displaced Persons adopted in There is also a lack of funds allocated to placement in Europe and 2002. The PRSP’s objective in the health refugee health services. Regions with large Central Asia. Washington: sector includes the reduction of inequalities IDP and refugee population have not been World Bank, 2004. for vulnerable groups, with an emphasis on given adequate financial means to face the 3. Government of the Republic equal access to basic health services. additional costs. This financial burden for of Serbia. Poverty Reduction Funding should be available from the public health care provision to IDPs and Strategy Paper for Serbia, 2003. Health Insurance Fund for the insured and refugees has also severely affected the from the state budget for all other citizens 4. 10.5% according to: United capacity of those Health Insurance Fund regardless of their socioeconomic status, Nations High Commissioner Regional Offices covering the municipali- including refugees and IDPs. In the chang- for Refugees, Commissioner ties where IDPs are registered as temporary ing political environment, Serbia will need for Refugees of the Republic of residents. This impacts on the provision of a continuous political commitment by the Serbia, Registration of care to other vulnerable groups as well as government to finance the provision of Internally Displaced Persons health insurance contributors. accessible and quality services for these from Kosovo and Metohija, under served populations. 2000.

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Children in Serbia and Montenegro:* Health status and access to basic health services

Mary E Black, Introduction Montenegro, constituting 20% of the pop- This paper reviews the health status of chil- ulation. The country faces a demographic Oliver Petrovic, dren (0–18 years old) in Serbia and challenge with an ageing population, falling Montenegro and their access to basic health birth rate (though high in some minority Vesna Bjegovic and services. An additional topic is dealt with in population groups), continuing migration some depth – birth registration, which is and brain drain. Some 25–30% of the pop- Jelena Zajeganovic- the key to access to many basic services. ulation live below or close to the poverty 1 Jakovljevic The paper closes with an update on the line, including over a third of children. Plans of Action for Children in Serbia and Already burdened with the consequences Montenegro and the opportunity this may of conflict and sanctions, economic col- represent for the first concerted policy lapse and migration, Serbia and approach to children in the country. (Much Montenegro faces additional challenges in of the thinking and research work for this making the transition to democracy and a was completed during discussions in market economy. GDP has fallen by 50% UNICEF with staff and counterparts in since 1990, public debt is rising and esti- 2003 and 2004). mated to exceed 7 billion USD by 2005, The opinions expressed in Serbia and Montenegro has good prospects and the weak economic base is constraining this publication are those of meeting many of the Millennium public spending. Investment in health and of the authors and do not Development Goals (MDGs) at national education per child has more than halved necessarily reflect the poli- level, such as further reductions in infant over the last ten years.2 It will be important cies or views of UNICEF and child mortality, high immunisation that children are set high on the political rates and universal primary education. agenda as development in early childhood However, there are wide and increasing is an essential first step for combating geographical and ethnic disparities in sur- poverty. vival, poverty, health status and educational level of children. Health of children The infant and under five mortality rate is Both Serbia and Montenegro have Poverty decreasing but children from marginalised Reduction Strategy processes (PRSPs) in population groups are still dying from pre- place, which offer a framework for future ventable diseases and 75% of infant mortal- development. The UN resident and non- ity happens in the perinatal period. More resident agencies have agreed with the gov- premature children survive but the number ernment a development assistance frame- of cases with multiple disabilities is also work (UNDAF) for the period of increasing. Few women die in childbirth; 2005–2009 with three main areas: institu- however the quality of services is low, tional and public administration reform, authoritarian, medically driven and service- rule of law and sustainable development. centred and offers little or no choice or Building on the work towards the MDGs, participation for families. Attitudes to the PRSP and the UNDAF, Plans of mothers are also in need of change as ser- Action for Children have been developed vices lack a client friendly approach. in both Serbia and Montenegro. Exclusive and continued breastfeeding rates There are 1,663,000 children in Serbia and are low at 10% at four months, although 70% of maternity units have acquired Baby Friendly Hospital status. However, practices remain poor even in some of the Dr Mary Black is Programme Coordinator, Dr Oliver Petrovic, Early country's top referral units. Although chil- Childhood Development Project Officer, and Dr Jelena Zajeganovic- dren in the majority of families are tradi- Jakovljevic, Young People’s Health Development and Participation Project Officer, UNICEF Belgrade. Svetozara Markovica 58, 11000 Belgrade, Serbia & Montenegro. Professor Vesna Bjegovic is Professor of Public Health, Department of Social Medicine, University of Belgrade. * Excluding the UN administered province E-mail: [email protected]; Phone: +381 11 36 02 100 of Kosovo.

37 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE tionally put first, information on actual epidemic is still in an early stage but the care practices and family choices in differ- current situation (e.g. needle sharing among ent parts of the country is missing. Only intravenous drug users, risky sexual behav- 22% of children receive preschool educa- iour) suggests a rapid increase in the next tion. Pre-school education is particularly 3–5 years. inaccessible for children in greatest need The government has taken some steps to (covering 0.5% of Roma and children with prepare. Republican AIDS Committees special needs) and those from underdevel- were formed in Serbia and Montenegro in oped areas. 2002 and HIV/AIDS strategies are under Immunisation coverage is high nationally at development. All drugs for AIDS are on 92%, although there are regional variations the list of medicines available in the coun- from 70–100%. Immunisation is particular- try and are funded by the health insurance ly low among poor and Roma children, fund. There is as yet no national register or although little data has been recorded in national surveillance for HIV/AIDS. this regard. UNICEF in 2003 found 16,000 Pregnant women are not routinely tested, “Investment in health thus there is no data on the percentage of un-immunised children, mostly Roma, in and education per child nine out of 23 regions in Serbia. The gov- pregnant women who are HIV positive. ernment procures needed vaccines for chil- Testing for pregnant women is only pro- has more than halved dren. Locally produced are BCG (the vac- vided if the woman is at particular risk and cine against childhood tuberculosis), DPT only one woman has tested positive during over ten years” (protects against Diphtheria, Pertussis and pregnancy so far. However at least 14 chil- Tetanus), OPV (protects against polio) and dren have contracted HIV by mother-to- MMR (protects against measles, mumps child transmission. There have been some and rubella). Although there is a national initial efforts to strengthen the prevention policy for immunisation of all newborn of mother-to-child transmission and offer children against Hepatitis B, a complete HIV testing to all pregnant women. The national budget has not been allocated to official recommendation is that HIV posi- this and immunisation rates are around tive pregnant women receive up-to-date 20%. There is no information available on anti-retroviral treatment and care. Vitamin A deficiency among children in The Belgrade AIDS clinic reports 31 chil- Serbia and Montenegro. However, high dren living with HIV/AIDS. Most children levels have been reported elsewhere in the living with HIV/AIDS stay within extend- region, making it possible that there is a ed families, even when their parents die. problem. National immunisation legisla- There is no special support provided to tion exists but could be strengthened by them, except medical treatment when need- intersectoral immunisation committees and ed. Few children living with HIV are new long term immunisation plans in each involved in the regular school system and republic. According to international stan- those who have, have been exposed to dis- dards, iodine deficiency has been eliminat- crimination and hysterical reactions by pared, but work still remains to maintain this. ents and school personnel. A major prob- Almost one third of children under five and lem is a lack of information and awareness women of reproductive age are anaemic. in the general population about practical Knowledge of the HIV/AIDS epidemic in aspects of HIV/AIDS in everyday life. the country is based on patchy data. The HIV/AIDS prevention needs to begin dur- reported countrywide numbers of AIDS ing primary school and targeted at vulnera- cases are 1,250, cumulative to December ble groups, but information and pro- 2003, (in Serbia around 1,200, in grammes on safer sex or the risks of needle Montenegro 50) with the majority of cases sharing are poorly developed, tending to occurring in people aged 20–39 years. rely on old-fashioned lectures and talks. Including the time it takes to develop the Newer programmes include peer-to-peer education. Programmes are largely intro- virus, this means that they were infected duced informally by non governmental when they were 15–24 years old. There is organisations (NGOs), although the only passive reporting of HIV/AIDS cases, Ministry of Education in Serbia has now which in 2002 totaled 43 new HIV cases introduced health education as part of its being reported in Belgrade alone.3 reform of the curriculum. Voluntary confidential counselling and testing is still only available in a few centres Young people face notable risks during the and the numbers tested are very low. The current transition process. The impact of rate of 1.5 people tested for HIV per 1,000 conflict, poverty and high unemployment, population (excluding voluntary blood the legacy of isolation, deteriorating eco- donors) is one of the lowest in Europe. The nomic conditions, a decline in the provision

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“Few children living of basic services and a breakdown of soci- Access of children to basic health etal and cultural norms together with gen- services with HIV are in the der stereotyping have resulted in the pres- The health care system in Serbia and ence of increased risky behaviour amongst Montenegro is still in a poor condition as a school system” young people. Despite satisfactory knowl- result of the unfavourable events in the eco- edge of HIV/AIDS and the link with nomic, political and social sphere to which unsafe sex, young people frequently prac- the population was exposed in the 1990s.2 tice unprotected sex. Some groups are more There are other underlying causes including susceptible, and in one study, hardly any discriminatory attitudes of health staff, reg- 4 Roma used condoms. Moreover, youth istration issues, formal and informal co- friendly health services throughout the payments, insufficient financing and infra- country are quite sporadic, particularly in structural shortcomings, problems with the 5 the area of reproductive health. Condoms accessibility of health care and low motiva- € are available and cost 0.5 each, although tion among health care professionals. cost remains a factor for some poor people. Though basic health care is formally free of There has been an increase in drug use charge at the point of utilisation, an among young people (cannabis and syn- increasing number of people are faced with 6 thetic drugs). Drug use and risky sexual out-of-pocket charges even for primary behaviour are often related. Sex in return care services. Figure 1 shows that in Serbia for money or some other benefit has in 2002, payment for general practitioners increased in the last decade. This has been was unrelated to economic status, and reported among girls as well as boys. Cases reported by around 30% of respondents in of violence and rape have been reported the survey. Reported payments are even and levels of domestic violence are high. more frequent for paediatricians, affecting An increase in human trafficking, with 50% of those who are poor. Similar results around 10% of victims under 18, may act were found regarding the utilisation of lab- as a regional pathway for the spread of the oratory, radiology or other support ser- 7 epidemic. Particularly vulnerable young vices in health care. Though poorer popula- people such as sex workers, drug users and tion groups reported visits to physicians, men having sex with men (MSM) are at utilisation of these additional services was particular risk of contracting HIV. much lower (24%) in comparison to According to one survey, 57.1% of intra- respondents living above the poverty line. venous drug users share needles, and only Private health care services are still not reg- 60.3% of sex workers and 41.5% of MSM ulated and no official data exist on their use condoms regularly. Targeted and out- use. They form an important stop-gap for reach services for these populations do not those who can afford to pay. exist and they experience discriminatory attitudes in accessing regular services.6 For poor families in Serbia, the most commonly cited reasons for not using health care services are a lack of financial resources (64%), followed by remoteness Figure 1 Payment for visit to physicians according to income level of health care facilities (13%), which is very typical for rural areas.8 A survey in 2002 painted a similar picture. People living in Other poverty who did not use health care ser- specialists vices despite being in poor health provided the following reasons: Gyneacologgist 1. No health insurance – 39% 2. Minor disorder self treated – 34% Paediatrician 3. Health care services too expensive – 16% General 4. Minor disorder not requiring treatment Practitioner – 9% 0 10203040506070 5. Too great a distance to health care % of those who paid services – 2% Poverty group (Source: PRS Survey database 2002) Below 4,400 din Below 5,500 din Above 5,500 din In rural areas children must face large geographical distances and inadequate trans- Source: PRS Survey, 2002. portation, a shortage of physicians and

39 eurohealth Vol 10 No 3–4 SOUTH EASTERN EUROPE other health care providers, a lack of health Plans of action for children care facilities, lack of health prevention As part of the implementation of the interventions, low motivation of health Convention on the Rights of the Child, professionals, difficulties in getting formal National Action Plans for Children in health insurance, and different forms of Serbia and Montenegro have been formally informal payments.8 adopted by their respective governments. This represents a first attempt in the coun- Roma children face particular barriers. try at a concerted policy approach for chil- Lack of health insurance is common,8 and dren. Both plans are based on the four in some cases families are not even aware of foundation principles that underpin the how to obtain a health insurance card or Convention: non-discrimination, best register a birth, nor are there any state out- interests of the child, right to life, survival reach services to help them do so. Several and development, and participation. They NGOs have received funding from interna- define goals and targets to be achieved by REFERENCES tional donors to support minority, dis- the years 2010 and 2015, as well as a set of placed and poor people with this complex 1. World Bank. Living indicators to measure progress achieved. issue of registration. During interviews and Standards Measurement The major priorities of the Serbian Action focus group discussions, Roma as well as Survey in Serbia and Plan for Children are: others living in poverty, often mention the Montenegro 2003. Belgrade: poor quality of health care services, includ- • Poverty reduction for children World Bank, 2003. ing the inadequate behaviour of health pro- • Quality education for all children 2. United Nations Country fessionals and long waiting times. Health Team. Common Country strategies were adopted by the parliaments • Better health for all children Asssessment for Serbia and of Serbia and Montenegro in 2004 and 2003 • Having a strategy for protecting the Montenegro. Belgrade, 2003. respectively, with a focus in both in partic- rights of children with special needs http://unpan1.un.org/intradoc/ ular on people living in poverty, those fac- groups/public/documents/UN ing exclusion from service provision or • Protecting the rights of children without TC/UNPAN012897.pdf those at risk of human rights abuses.9 parental care 3. Report on the Work on • Protecting children from neglect, vio- AIDS Counselling of Belgrade Registration of births lence and abuse IPH in 2002. Belgrade: The right of children to a name and nation- Belgrade IPH, December 2002. ality is set out in the UN Convention on • Building the country’s capacity for solv- the Rights of the Child to which Serbia and ing children and youth problems 4. Oxfam. Survey of Roma Montenegro is a signatory. Birth registra- Attitudes to Contraception. The major priorities of the Montenegro Oxford: Oxfam, 2002. tion is mandatory, and there are financial Plan of Action are: incentives to register a child; €1,000 for the 5. Homans H. Assessment of first child and higher amounts for subse- • Protect all children from inequality Reproductive Health Services quent children. There is however no sys- • Ensure that all children receive a good for Young People in Serbia. tematic way of checking if this has been quality basic education Prepared for UNICEF 2003 done for each child and some are not regis- • Assure a healthy life for girls and boys 6. Cucic V. Rapid Assessment tered. Birth certificates must be renewed and Response on HIV/AIDS regularly at the municipal office where the • Protect the environment for children Among Especially Vulnerable child was registered, and a fee must be paid • Ensure that all children are full citizens Young People in Serbia. each time. This is not the case in many Belgrade: UNICEF, 2002. European countries where the original birth A model project is underway in five munic- 7. Limanowska B. Trafficking certificate remains valid for life. There are ipalities to develop local Action Plans for in Human Beings in South also other financial barriers. While the first Children, bringing together key stakehold- Eastern Europe. UNDP, 2003. copy of the birth certificate is free of charge, ers from all sectors, including civil society subsequent copies may or may not be, representatives, and preparing data collec- 8. UNICEF. The Many Faces depending on the purpose for which they tion of key indicators that can be used to of Poverty. Research on are needed. For school enrolment purposes inform decision making at local level. Children Poverty in Serbia. copies are still free but copies to obtain citi- Combined with plans for decentralisation Belgrade: UNICEF Belgrade zenship require a mandatory payment. of key services, including health services, 2004. Parents have to pay from their own this may offer the best chance for improv- 9. Ministry of Health Republic resources and must obtain documents from ing services for children at the local level. It of Serbia, Ministry of Health the municipality where the child was born, also offers an opportunity for participation Republic of Montenegro. making this difficult for the poor, those and improved public information on key (Cited 2004, July 20) .Available internally displaced from Kosovo and issues. So far access to health and education at URL: refugees. A child without registration finds has not become an election issue in the http://www.zdravlje.sr.gov.yu/ it difficult, if not impossible, to get access to country, but it could well do so in future as and education, health and social services, and is the transition takes hold and disparities http://www.gom.cg.yu/eng/mi lost from official statistical data. increase. nzdr/

eurohealth Vol 10 No 3–4 40 HEALTH IMPACT ASSESSMENT The effectiveness of health impact assessment

Matthias Wismar In recent years health impact assessment ing all determinants of health, tackling (HIA) has attracted a lot of attention inequities, and providing a new impetus for amongst the public health community participation and empowerment in health. across Europe. HIA has received political Its capacity to influence the decision mak- support from various European governing process is linked to its prospective char- ments, some of whom made their commit- acter. A widely used definition describes ment explicit putting HIA on the political health impact assessment (HIA) “as any agenda. HIA was included in official policy combination of procedures or methods by papers and pilots and projects were funded. which a proposed policy or program may At an international level, HIA also received be judged as to the effects it may have on support. The European Commision includ- the health of a population’2 There are many “HIA opens up ed aspects of human health in its directive other definition of HIA,3 still, most on environmental impact assessment. An researchers would agree on two central fea- opportunities for the attempt to integrate health in all tures of HIA:3 Community policies is under way. For the – It attempts to predict the health conse- proactive management purpose EU policy development a generic quences of different options. HIA methodology has been developed.1 of inequalities in The World Health Organization has sup- – It is intended to influence and assist decision makers. health” ported HIA too, in the European Region including it in the HEALTH21 policy. This means, HIA is always prospective and Additionally, various programmes and cen- geared towards the decision making tres work in support of the development process. Decision-makers would not neces- and implementation of HIA. sarily follow the recommendation of the Scientifically, a lot of progress has been HIA, but they would need to justify why made too. The international literature on they put up with the potential negative HIA has been growing rapidly. health effects of their decision. The trade Theoretical, methodological and conceptu- off between a healthy public policy and al progress has been accompanied by fully other considerations would become explic- fledged HIA reports and case studies. it. HIA is a thoroughly inter-sectoral activ- Many countries and sub-national entities ity since it focuses on the so-called deter- have developed resources for HIA and minants of health. They include housing, embarked on capacity building. Guidelines, agriculture and food production, educa- tools and instruments have been devised, tion, work-environment, water and sanita- websites containing HIA-databases, docu- tion. HIA analyses the potential impact of ments and tools are now online. Successful a policy, programme and project on the HIA-training courses have been developed determinants and in turn how the determi- in some countries and dedicated HIA units, nants impact on the health of the popula- affiliated with or integrated into academic tion. departments, have emerged. Equally explicit HIA addresses the distribution of potential health gains and losses HIA as a key element of inter- among subgroups of the affected popula- sectoral health policy tion. This may allow potential health These developments reflect an enthusiasm inequalities to be brought to the attention linked to the potential of HIA. It is consid- of policy makers, the affected population ered as a major opportunity to integrate and the public before damage is done. In health into all policies. It has been so fact, HIA opens up opportunities for the attractive because HIA promises to influ- proactive management of inequalities in ence the decision making process, address- health. Participation plays an important role in HIA too. The significance and integration of lay knowledge,4 the creation of Matthias Wismar is Health Policy Analyst, European Observatory on Health ownership and of course the empowerment Systems and Policies, Brussels. E-mail: [email protected] of the affected population are issues that

41 eurohealth Vol 10 No 3–4 HEALTH IMPACT ASSESSMENT are frequently raised in the context of HIA. tiveness of HIA in terms of influencing the “the evidence on the decision-making process is available. After Defining effectiveness all, anecdotal evidence and selected studies effectiveness of HIA is No wonder that HIA has generated a lot of from England, Sweden and The enthusiasm, but there is a lot of scepticism Netherlands seem to suggest that HIA may more than sketchy” too. This scepticism is linked to the crucial work. Yet it remains unclear if these are but still unanswered question, does HIA exceptional success stories. It is also unclear work? This simple question is still unan- if these specific successes are linked to spe- swered because of a number of highly com- cific contextual conditions that may exist in plex methodological issues surrounding the one country but not in another. In plain evaluation of HIA. Outcome evaluation of terms, the question is not only does HIA a given HIA focusing on health gain or loss work, but also what works and in what for an affected population is difficult if not context? If we are to develop appropriate impossible to conduct.5 In many cases the solutions for inter-sectoral health that long latency of the health effects of the match the diversity of European countries intervention initiated by the decision at and sub-national entities it will be of the stake would require that the evaluation utmost importance to find adequate cover a period of more than a decade. We answers to this question. need answers sooner than that, and of course, over this long period the composi- Research into the effectiveness of HIA tion of the population group affected by In order to address these issues in August the intervention would inevitably have the European Observatory on Health changed exacerbating the complexity of Systems and Policies launched a three year outcome evaluation. In addition, any inter- multi country project on the effectiveness vention initiated by the decision at stake of HIA, co-funded by the European may not remain stable. It is in the very Commission under the Public Health nature of complex social interventions like Work Programme (Grant No 2003101). policies, programmes or projects that they Currently there are 17 partners from 14 change over time. They get amended, Member States as well as observer partners adjusted and may change direction. As with from 4 countries in the project. (See Box). many public health interventions, factors other than the intervention in question that European Observatory on Health Systems and Policies, WHO European influence health outcomes are rather Centre for Health Policy (project leader) uncontrollable. Unrealistically long periods EuroHealthNet, Belgium of time, vague boundaries of the population Health Development Agency (HDA), England group affected and shaky interventions call Institute of Public Health in Ireland for other forms of evaluation.6 Institut za varovanje zdravja Republike Slovenije, Slovenia An alternative and feasible strategy to assess the effectiveness of HIA is not to Jagiellonian University - Institute of Public Health, Poland choose health gain or health loss as the Landesinstitut für den Öffentlichen Gesundheitsdienst NRW, Germany endpoint of the evaluation but instead the National Institute of Public Health, Sweden influence on the decision making process. 7 Semmelweis University Budapest Health Services Management Training There are three ways in which HIA might Centre influence the decision making process:2 STAKES, National Research and Development Centre for Welfare and – raising awareness among decision mak- Health, Finland ers; Técnicas de Salud SA, Spain – helping decision makers identify and TNO Prevention and Health, The Netherlands assess possible health consequences; Institute of Hygiene, Catholic University of the Sacred Heart, Rome – helping those affected to contribute to University of Southern Denmark decision making. Wales Centre for Health, Wales If this constitutes a yardstick for assessing WHO Collaborating Centre on Health and Psychosocial factors, Belgium the effectiveness of a HIA, then the link between knowledge production and deci- Trnava University – Faculty of Healthcare and Epidemiology, Slovak sion making will be of fundamental impor- Republic tance. Directorate-General of Health, Portugal Unfortunately, despite the rapid growth of Institute of Health Economics and Management, Switzerland (Observer) the literature on HIA, the evidence on the Kaunas Medical University, Lithuania (Observer) effectiveness of HIA is more than sketchy. Ministry of Health Malta (Observer) No systematic knowledge about the effec-

eurohealth Vol 10 No 3–4 42 HEALTH IMPACT ASSESSMENT

The overall aim is to map the use of HIA, REFERENCES evaluate its effectiveness and identify the 1. Abrahams D, den Broeder L, Doyle C, determinants for its successful implementa- Fehr R, Haigh F, Mekel O, Metcalfe O, tion. Effectiveness in the context of the Pennington A, Scott-Samuel A. EPHIA - project refers to the capacity to influence European Policy Health Impact Assessment: the decision making process and be taken A Guide. Liverpool: IMPACT, University into account adequately by the decision of Liverpool, 2004 www.ihia.org.uk/docu- makers. Five specific objectives are derived ment/ephia.pdf from this overall aim: 2. Health Impact Assessment: main concepts – To map the use of health impact assess- and suggested approach. Gothenburg con- ment in Member States; sensus paper, December 1999. In: Diwan V, “a systematic mapping – To map the use of other impact assess- Douglas M, Karlberg I, Letho J, Magnússon ment methodologies that have taken up G, Ritsatakis A (eds). Health Impact of HIA configuration health; Assesment: From Theory to Practice. Göteborg: Nordic School of Public Health, – To develop a set of indicators to mea- 2001:89–103. throughout Europe is sure the implementation of HIA; 3. Kemm J, Parry J. What is HIA? overdue” – To assess the factors that enable or hin- Introduction and overview. In: Kemm J, der the implementation of HIA includ- Parry J, Palmer S (eds). Health Impact ing the institutional, organisational and Assessment. Oxford: Oxford University cultural contexts as well as the decision Press, 2004:1–13. making process; 4. Elliott E, Williams G, Rolfe B. The role of – To disseminate the findings to improve lay knowledge in HIA. In: Kemm J, Parry J, the use of HIA in the decision making Palmer S (eds). Health Impact Assessment. process in the Member States; Oxford: Oxford University Press, The research into HIA has already brought 2004:81–90. to light a vast heterogeneity of models. [8] 5. Kemm J. Perspectives on health impact This shows that there is not a ‘one-size- assessment. Bulletin of the World Health fits-all’ solution in HIA. This diversity in Organization 2003;81(6):387. the development of HIA across Europe may reflect the differences in the purpose 6. Øvretveit J. Action Evaluation of Health of HIA and in the contextual conditions in Programmes and Changes. Oxford: various countries. This diversity has often Radcliffe Medical Press, 2002. been formulated in terms of bipolarities: 7. Quigley RJ, Taylor LC. Evaluation as a quantitative versus qualitative methods, key part of health impact assessment: the health versus disease oriented, participant English experience. Bulletin of the World versus expert driven, rapid versus in-depth Health Organization 2003;81(6):415–19. assessment, separate versus integrated in 8. Letho J, Ritsatakis A. Health impact other assessments.9 Therefore, a systematic assessment as a tool for intersectoral health mapping of HIA configuration throughout policy. In: Diwan V, Douglas M, Karlberg I, Europe is overdue. This mapping can build Letho J, Magnússon G, Ritsatakis A (eds). on previous studies in the field.10 Part of Health Impact Assessment: From Theory to this mapping is to understand specific Practice. Göteborg: The Nordic School of inter-sectoral policy related traditions. It Public Health, 2001:23–87. has been argued that in some countries other processes exist which resemble some 9. Parry J, Kemm J. Future directions for features of HIA,11 and in fact, in some HIA. In: Kemm J, Parry J, Palmer S (eds). countries the term HIA does not exist at Health Impact Assessment. Oxford, Oxford all. University Press, 2004:411–17. In addition to mapping HIA-configura- 10. The Welsh Assembly Government, tions across Europe an in-depth analysis on EuroHealthNet. Health Impact Assessment the influence of HIA will be carried out. and Government Policymaking in European This in-depth analysis will focus on how Countries: A Position Report. Cardiff: Public HIA has influenced (or not influenced) the Health Strategy Division, Office of the decision making process. The analysis will Chief Medical Officer, Welsh Assembly take into account specific HIA-configura- Government, 2003. tion and its interaction with contextual fac- 11. Gulis G. Health impact assessment in tors. Both the mapping and the in-depth CEE region: case of the former analysis will contribute to the understand- Czechoslovakia. Environmental Impact ing of what works in what context. Assessment Review 2004;24(2):169–75.

43 eurohealth Vol 10 No 3–4 FAMILY CARE Family care: a conceptual clarification Challenges for future health policy and practice

Deirdre Beneken The healthcare problems of individuals are care”.5 This definition differs from often solved without the intervention of another6 that describes family care as a genaamd Kolmer, professionals through family caregiving. form of homecare. “With family care help Population ageing, a shortage of profes- is given to those in need of care by one or Inge Bongers, sionals and cost-control in the healthcare more members of his social environment. sector1, increase the importance of family This seems to point to a hierarchy in care- Henk Garretsen, caregiving in most west-European coun- giving. When it becomes impossible to take and tries, where comparative research has care of oneself, care could be given by shown that national governments no longer members of the family, neighbours and Agnes Tellings take full responsibility for care services.2 friends (in this order)”. This emphasises the The involvement of family caregivers, social relationship between patient and however, is not without problems. Family family caregiver. In the previous quote, this caregivers can experience problems while social link isn’t mentioned, implying that providing care and while realising their family care could also be provided, for need to fully participate in society.3,4 One example, by a volunteer who has no social cause of those problems involves the differ- relationship with the patient. ent conceptions of ‘family care’ that are in The National Council for Public Health use, which has meant that the position of (NRV)7 stresses the social link between the family care compared with other types of “family care has been family caregiver and the patient in its care is not clear. Moreover, the plurality of description of family care, adding that care definitions of family care is not beneficial defined in different is not given professionally and thus often for fine-tuning between policy and prac- becomes invisible. “It is the care which is ways” tice. For the healthcare sector to function not given from a professional point of view properly, such fine-tuning is indispensable. to a patient by one or more members of his This article proposes a definition of family direct social environment, this care directly care, based on analysis of several concep- springing from the social relation”. This tions of family care described in Dutch lit- definition is also used by others including erature. This definition is meant to form within the Institute for Advice Research the basis for positioning family care relative and Development, the Institute for Care to other types of care, as well as theorising and Wellbeing (NIZW) and the and outlining policy. Finally, we deal with Department of Public Healthcare, the consequences for Dutch policy and Wellbeing and Sport. The latter adds that practice resulting from the proposed defini- family care is about unstructured, long- tion. term care (from three months onwards) going beyond the day-to-day duties of a Family care and its definitions family caregiver. Several definitions empha- Since the introduction of the word ‘family sise that family care is unpaid, and not pro- care’ in the Netherlands, it has been vided within a professional framework. defined in different ways, for example as However, since the implementation of “complementary, non-vocational care to individual budgets for patients, family care- the elderly, patients, and others in need of givers may receive some compensation for their ‘unprofessional’ help, as help may otherwise be obtained at a healthcare insti- DM Beneken genaamd Kolmer is a PhD student of Social Sciences, IMB tute or, individually, from a professional Bongers is Senior Research Fellow of Health Care Policy, and HFL Garretsen caregiver. is Professor of Health Care Policy at Tilburg University, The Netherlands. A Tellings is Senior Research Fellow of Philosophy of Education, University of An expansive view is that family care Nijmegen, The Netherlands. improves both the quality of caregiving and reduces costs.8 In this view family care is E-mail and corrrespondence to: DM Beneken genaamd Kolmer, Tilburg defined as “care provision which is shared University, PO Box 90153, 5000 LE Tilburg, The Netherlands, by the members of the social environment Tel.: +31 13 4663164; Fax: +31 13 4668068, E-mail: [email protected] on a basis of voluntary reciprocity.

eurohealth Vol 10 No 3–4 44 FAMILY CARE

Essential for this type of care is personal relationship with the patient. involvement, dedication and concern of all Some of the other features of definitions of those involved. This type of care is always family care could be seen as being clus- of an emotional nature”.8 The core of this tered: the patient’s willingness to recipro- description is the social environment of cate and the emotional nature of the care which ‘social relationship’ described earlier both involve the social link between care- is one part. What distinguishes this defini- giver and patient. Two other characteristics tion from others is the emphasis on the of care not provided within the framework emotional nature of care coloured by the of professional social care and family care, use of terms such as dedication, involve- and delivery of care in a non-organised set- “the long duration of ment and concern. Another distinction is ting, are also connected with the fact that reciprocity, what the caregiver receives family care springs from the social link family care contributes from the patient. between caregiver and patient. Therefore, it to problems faced by While the NRV definition is generally seems sufficient to put emphasis on this accepted, several definitions are currently social relationship in a future definition caregivers” in use. One characteristic in particular that of family care, while it is also relevant to features in most is the social relationship note that family care is provided for long between family caregiver and patient. periods of time. Authors writing about ‘family care’ seem to view this as a necessary condition for One of the reasons policy with respect to using the phrase ‘family care’ appropriate- family care is needed is the long duration of ly. Other characteristics of family care that family care, which contributes to problems can be deduced from the definitions given faced by family caregivers. The last feature above are the following: provided outside to include in a future definition of family the framework of professional social care; care concerns the fact that family care tran- given over a long time period; not provided scends ‘the way things are normally run’ in an organised setting; over and above with regard to both duration and intensity. normal care in both duration and intensity; Family care is in that respect a form of 9 given on the basis of the patient’s willing- intense care that often leads to problems. ness to reciprocate; emotional; unpaid; Based on the above analysis the following complementary; invisible and delivered in a definition of family care can be proposed: home setting. ‘intense and long-term care given by laymen from the patient’s direct social envi- Analysis of characteristics ronment, springing from the social link In order to arrive at a more adequate defin- between the patient and the family care- ition of family care, an analysis of these giver, not coming from an organised setting characteristics is necessary. Four features and not provided within the framework of no longer seem appropriate. Family care as professional social care’. a form of unpaid care has become obsolete ever since the introduction of the individ- The positioning of family care with ual care budgets in the Netherlands, which regard to other types of care allow non-professional caregivers to be In order to determine the position of fami- paid. Secondly, it is imprudent to indicate ly care defined above relative to other types that a feature of care is its complementary of care, a distinction should be made nature, as this is a major point of discus- between professional care on one hand and sion: should family care complement informal care on the other. Professional professional care, or should it be the other care is seen as organised care provided by 9 way around? paid professionals. Assistance can be A third feature best left out is the so-called offered in residential settings or on an out- ‘invisibility’ of family care. Indeed, care patient care basis. In general, professional given by people who have social relation- care is granted following a needs assess- ships with patients has become increasingly ment and reimbursed through social insur- visible in recent years in the Netherlands ance. The reciprocity between the profes- because of the help that the government, sional and the patient lies in the financial support centres, and home help agencies reward paid to the professional for services now provide for these people. The final rendered. Such care can be both of short- feature to abandon is the notion that family term and long-term duration. A person care is only provided in the home. One with learning disabilities who is cared for recent study10 indicates that in both the during a five-day stay in a residential home family home and in nursing homes care is every week will receive long-term profes- provided by individuals having a social sional care whereas for a client in need of

45 eurohealth Vol 10 No 3–4 FAMILY CARE advice from a general practitioner a seven provided professionally: family care, vol- minute consultation might suffice. unteer work and contact with patient groups. Family care is here defined similar- Characteristically, professional care is ly as in the definition of the NRV7 and vol- organised and paid-for care, involving unteer work is described as ‘a voluntary trained social workers. Family care, by offer of help in an organised context, by contrast, is not organised nor provided individuals without any form of pay- within the framework of professional social ment’.12 Finally, contact with other indi- care. Moreover, family care is provided on viduals and patients with the same condi- a long-term basis and can complement pro- tion is seen as ‘group-orientated, organised fessional care in daily practice. as a series of one-to-one exchanges aimed It is more difficult to define informal care at solving shared problems. Those involved (or informal help), but essentially this may give help in both ways, without any profes- be done in three ways. Firstly to view sional guidance through a mutual exchange “Mutual care should informal care as family care only,4 as help of lived experiences’.12 Family care, volun- that is instrumental in the patient’s daily teer work and mutual patient support share be appreciated by functioning and which is offered voluntari- their informality, but they can also be dis- ly and free to people from the social net- tinguished from one another. society” work of the caregiver who have serious The principal differences between family physical and/or psychological problems. care and volunteer work are that family Care provided by volunteers lies outside care, in contrast to volunteer work, takes this definition because volunteer work isn’t place between people who already have a necessarily given to individuals from their social link with each other before the need own social environment. The social link of care arose. Volunteer work is provided between patient and caregiver is important within an organised setting, the work does in distinguishing informal care (in this case, not have to be intense or long term, and is family care) from volunteer work. provided freely without obligation in order Govaart and Morée’s11 definition of infor- to help others on social grounds. mal care, by contrast, includes both family When comparing family care and mutual care and volunteer work. Informal care patient contacts, the following points stand consists of a continuum with intensive out: that mutual patient contacts take place forms of family care to which the social in an organised setting, consisting mainly link is vital on the one hand and traditional of efforts to better the situation through volunteer work where people provide care discussion of common experiences, and based on their commitment to an organisa- participation in such contact groups is a tion on the other. ‘Help to neighbours and matter of choice, which may not be the case friends can also be placed on this same con- for family care. tinuum: although this help is offered from an existing relationship it doesn’t have The three forms of care discussed each have either the intensity or effort characteristic their own niche in the field of informal care of family care’ .11 On the continuum a wide and are complementary. For example vol- variety of forms can be placed, with some unteers can help to alleviate family caregivers’ burden by offering social support of them containing more features of family and practical help. “Volunteers can take care while others are more similar to volun- over certain activities of family caregivers teer work. Again, the social link turns out when asked, they can prevent or decrease to be the defining feature to distinguish professional care as well as provide infor- family care from volunteer work, although mation on professional or other activities in both do fall, within this definition, in the the field of care and welfare”.4 The features “a custom-made policy category of ‘informal care’. of the proposed definition of family care would lead to a better The third description of informal care is are of help in distinguishing family care more elaborate. Provincial policy on infor- from other types of informal care such as adjustment of policy mal care in the Netherlands12 defines this volunteer work and mutual patient contact as ‘care offered by laymen to (elderly) groups. and practice” patients with (chronic) diseases and disabilities who cannot function completely on Reflections their own without this care. This help The fine-tuning of policy and practice includes household tasks and activities of regarding family care, which is needed if daily living and is offered on a short-term public health care is to function efficiently, or long-term basis’. In Dutch policy on is hampered by great diversity in current informal care, this third definition is used definitions of family care. A clear-cut defi- to describe collectively all forms of care not nition of family care will contribute to a

eurohealth Vol 10 No 3–4 46 FAMILY CARE fine-tuning of policy and practice. care, but where this is received instead from a family caregiver. If the government By comparing different definitions of fami- would agree with this definition, it would ly care and by analysing the features result- be legitimate to suggest that family care- ing from such a comparison, a more ade- givers are entitled to the status of employ- quate definition of family care has been 3. Bakker H. Ontspoorde ees, as they perform tasks normally under- proposed. Although this definition, zorg. Overbelasting en taken by professionals. Thus, the use of the ‘intense and long-term care given by lay- ontsporing in mantelzorg voor proposed definition certainly has conse- men from the patient’s direct social envi- ouderen. Utrecht: Nederlands quences for health care policy, among other ronment, springing from the social link Instituut voor Zorg en things. between the patient and the family caregiv- Welzijn, 2001. er, not coming from an organized setting Using the proposed definition in practice 4. Tweede Kamer. Zorg Nabij: and not provided within the framework of decreases the number of family caregivers notitie over mantelzorgonders- professional social care’, recognises all rele- entitled to family care support. It is vital to teuning, 27401, nr. 65, vant features of family care, some aspects note though that people who look after a 2000–01. remain opaque. relative in need but do not fall into the pro- 5. Van Dale Groot posed category, still retain their social Characteristics that could be interpreted in Woordenboek der Nederlandse importance. Occasionally taking care of a different ways, should be inspected in clos- Taal. Utrecht: Van Dale lexi- relative in need is a form of solidarity er detail, including two features in particu- cografie, 1999. which society requires. Mutual care should lar: the long-term character and the intensi- be appreciated. Looking after an ill relative 6. Van der Doef M. ty of family care. What ultimately is meant occasionally, however, differs from intense Mantelzorg tegen betaling? by taking care of someone close on a long- and long-term caregiving. There is more Meningen van mensen uit term and intensive basis? The Dutch risk of experiencing social exclusion, of Tilburg. Medisch Contact National Organisation of family caregivers feeling exhausted and of caregiving becom- 1991;46(25):798-800. (LOT) and the Organisation of Voluntary ing disjointed.9 Home Care and the Assessment Boards 7. Nationale Raad voor de have determined the dividing-line between A third consequence of using the proposed Volksgezondheid. occasional care and long-term family care definition has to do with positioning family Ondersteuning Mantelzorg. at three months,4 on the assumption that care in relation to other types of care. By Zoetermeer, 1991. family caregivers usually experience social, regarding family care, in addition to volun- 8. Hattinga Verschure JCM. physical and emotional problems only after teer work and mutual patient support Het verschijnsel zorg: een inlei- a three-month period. Whether or not the groups, as being a part of informal care, ding tot de zorgkunde. family caregiver actually has these prob- family care’s position in relation to other Lochem: De Tijdstroom, 1981. lems does not determine if someone is a types of care is clarified. Confusing the 9. Beneken genaamd Kolmer long-term family caregiver, so the critical notions of family care and informal care is DM, Bongers IMB. argument runs. For example, someone who prevented. Distinguishing family care, vol- Ondersteuning, erkenning en takes care of a relative in need every day for unteer work and mutual patient support welzijn van mantelzorgers: a long time and who has no problems is a groups from each other will diminish the verslag van een verkennende long-term family caregiver. Yet whether or risk of informal care becoming a kind of studie naar de positie van man- not problems are encountered does say ‘one size fits all’ notion. telzorgers in Nederland. something about the burden of caregiving. Governmental policy regarding family care Tilburg: Universiteit van This always has both an objective and a might in particular focus on those family Tilburg, 2002. subjective element. A valid argument for caregivers who meet the criteria of the pro- choosing a three-month period is the incip- 10. Swinkels M. De zorg gaat posed definition. This policy could take ient structural character of family care. door! Participatie van mantel- into account any problems arising from zorgers. Tilburg: Instituut voor Besides being long-term, family care also within this group. In other words: a cus- advies, onderzoek en ontwik- should be intense, so that the family care- tom-made policy aimed at a particular tar- keling in Noord-Brabant giver offers help going beyond day-to-day get-group would lead to a better adjust- (PON), 2001. activities. Situations are often characterised ment of policy and practice. by a collision between duties to society and 11. Govaart MM, Morée M. the personal preferences of the family care- Georganiseerde naastenliefde. giver. Intense family care, for example, is Contradictie of wenkend per- spectief? In: Hortulanus RP, provided to family members who are REFERENCES chronically ill or who have physical or Machielse JEM, editors. Wie is mental disabilities. Consequently, cleaning 1. Rostgaard T, Fridberg T. Caring for mijn naaste? Het Sociaal up the house occasionally for an unwell sis- Children and Older People – A Comparison Debat Deel 2. ‘s-Gravenhage: ter is not intense family care. Intense family of European Policies and Practices. Elsevier bedrijfsinformatie, care seems to begin with the patient’s need Copenhagen: The Danish National Institute 2000. for professional care, with this need being of Social Research, 1998. 12. Provinciaal Beleid. filled by someone with whom the patient 2. Walker A, Maltby T. Ageing Europe. Studiemiddag Informele zorg. has a social link. In this definition, family Buckingham/ Philadelphia: Open University Provincie Noord-Brabant, care is more or less a need for professional Press, 1997. 2001.

47 eurohealth Vol 10 No 3–4 E-mail [email protected] to suggest websites WEBwatch for inclusion in future issues.

Luxembourg Presidency News, information and publications from the Luxembourg Presidency of the European Union. www.eu2005.lu/en

Open Society Institute The OSI, founded by investor and philanthropist George Soros in 1993, is a private operating and (OSI) and grantmaking foundation based in New York City and Budapest that serves as the hub of the Soros Soros Foundations foundations network, a group of autonomous foundations and organisations in more than 50 coun- Network tries. OSI and the network implement a range of initiatives that aim to promote open societies by shaping government policy and supporting education, media, public health, and human and www.soros.org women’s rights, as well as social, legal, and economic reform. The website can be searched by regions where the OSI operates, including central and eastern Europe, providing an enormous amount of information on activities and links to Soros foundations in the region. One programme focuses on issues related to the Roma in central and eastern Europe and the former Soviet Union. The programmes’ Roma-related efforts, are aimed primarily at improving the social, political, and economic situation of Romani populations. Information on a number of public health programmes and initiatives in the region is also provided.

European Disability EDF is a European umbrella organisation representing more than 50 million disabled people in Forum (EDFF) Europe. Its mission is to ensure disabled citizens’ full access to fundamental human rights through their active involvement in policy development and implementation in the EU. The website www.edf-feph.org (English and French) provides information on the latest news and developments across Europe, together with updates on forthcoming events and publications. A monthly news bulletin in English and French updates readers on activities and views of the EDF and EU policy developments.

Mental Disability MDAC is an international non-governmental organisation based in Budapest that promotes and Advocacy Centre protects the human rights of people with mental health problems and intellectual disabilities across (MDAC) central and eastern Europe and central Asia. MDAC works to improve the quality of life for people with mental disabilities through litigation, research and international advocacy. A database www.mdac.info with country specific information is provided on the website (in both English and Russian).

Implementing Mental IMHPA aims to support the development and implementation of mental health promotion and Health Promotion mental disorder prevention action across Europe. With partners across 28 European countries, Action (IMHPA) IMHPA is developing a set of tools, for health professionals, practitioners and policy makers, to support implementation and dissemination at national and regional levels. The network aims to www.imhpa.net develop and disseminate evidence-based mental health promotion and mental disorder prevention strategies across Europe and to facilitate their integration into countries’ policies, programmes and health care professionals’ daily clinical work. Since April 2003, IMHPA has been engaged in developing three strands of products to be dissemi- nated, implemented and tested across European countries. These include the development of a standardised internet database of evidence-based mental health promotion and mental disorder prevention programmes and policies; a training manual for primary health care professionals to include mental health promotion in daily clinical practice; and a European policy action plan for mental health promotion and mental disorder prevention.

Personal Social The PSSRU’s mission is to conduct high quality research on social and health care to inform and Services Research influence policy, practice and theory. It was established at the University of Kent at Canterbury in Unit (PSSRU) 1974, with new branches opening at the London School of Economics and Political Science and at the University of Manchester in 1996. PSSRU researchers come from a wide range of disciplines www.pssru.ac.uk and backgrounds, including the caring professions. The Unit’s work has had an important influence on theory, and policy development and reform in several countries: for instance, in care-managed community care of older people and the study of costs and the costs of outcomes. In addition to contact details and information on current research activities the website provides access to a searchable database of reports and other publications.

eurohealth Vol 10 No 3–4 48 NEW PUBLICATIONS Eurohealth aims to provide information on new publications that may be of interest to readers. Contact David McDaid [email protected] if you wish to submit a publication for potential inclusion in a future issue.

Implementing Change This concise and sharply written book by Professor Michael Harrison of Bar-Ilan University, in Health Systems. Israel and Senior Research Scientist at the US Agency for Healthcare Research and Quality Market Reform in the looks at the implementation in the United Kingdom, Sweden and the Netherlands of market United Kingdom, reforms in the health care sector through the 1980s to the late 1990s. Reforms in various guises over this time period were intended to improve efficiency, contain costs and promote quality. In Sweden and the all three countries reforms included initiatives to encourage managed competition between Netherlands health care providers and/or insurers. After describing the historical and institutional contexts for health care systems in all three countries, and their experiences in implementing reform, the Michael I. Harrison book goes on to analyse what the potential contribution of market-orientated reforms for efficiency and quality in publicly funded and regulated health care systems may be, and also what can be learnt more generally from these three case studies to aid in the implementation of public London: Sage policy. Publications, 2004. One key observation is that in all three countries competitive reform encountered serious tech- ISBN 0-7619-6175-5 nical, organisational and political obstacles, but nevertheless reforms still helped instigate both 240 pages. system and health policy change. The book concludes with a short set of guidelines for ‘a decen- tralised, learning-focused approach to implementing health system change’. Cloth £60 Paperback £21.99 Contents: Health system reform and policy implementation; Market reforms in the United Kingdom; Outcomes of market reform in the United Kingdom and Labour’s new health policies; Market experimentation within the Swedish health system reform; Reform outcomes in Sweden and the emerging mix of public and private care; Regulated competition in the Netherlands; Reform outcomes and new policy trends in the Netherlands.

Promoting Health: This book edited by Angela Scriven and Sebastian Garman, both from Brunel University, UK, Global Perspectives critically examines a range of issues argued to be central to informing the promotion of health in the global arena. The overarching theme of the book is the interconnectedness of the world we live in, where boundaries between individuals and societies are being eroded, with consequent Edited by Angela Scriven implications for global health. Chapters offer insights into the key determinants of health and Sebastian Garman between and within countries; how effective health promotion is in achieving health gain at a global level and the significant health challenges to be faced in the twenty-first century. Case Basingstoke: Palgrave studies on strategies for promoting health in different parts of the globe are presented. Macmillan, 2005 Contributors include representatives from the World Health Organization, The International Union of Health Promotion and Education and the World Bank. ISBN 1-4039-2137-7 Contents: Promoting Health: A Global Context and Rationale, Angela Scriven; Key Global 297 pages. Health Concerns for the 21st Century, Basiro Davey; Inequalities in Health: International Hardback £52.50 Patterns and Trends, David McDaid and Adam Oliver; Global Health Promotion: Challenges Paperback £18.99 and Opportunities, Maurice Mittelmark; The Social Context of Health Promotion in a Globalising World, Sebastian Garman; Globalisation and Noncommunicable Diseases, DerekYach, Robert Beaglehole and Corinna Hawkes; Food, Health and Globalisation: Is Health Promotion Still Relevant? Martin Caraher, John Coveney and Tim Lang; Tobacco: The Global Challenge for Health Promotion, Samira Asma, Prakash Gupta and Charles Warren; HIV/AIDS: Lessons For and From Health Promotion, Peter Aggleton; Global Environment Change and Health, Paul Wilkinson; Promoting Health in Low and Middle Income Countries: Achievements and Challenges, John Hubley; Trends and Factors in the Development of Health Promotion in Africa, 1973-2003, David Nyamwaya; Health Promotion in Latin America, Hiram Arroyo; A Public Health and System Approach To Health Protection and Health Promotion in Hong Kong, Sophia Chan and Gabriel Leung; Public Health in the Former Soviet Union, Joana Godinho; Health Promotion Development in Europe: Barriers and New Opportunities, Erio Ziglio, Spencer Haggard and Chris Brown; Health Promotion in Australia and New Zealand: The Struggle for Equity, Shane Hearn, Hine Martin, Louise Signal and Marilyn Wise; Health Promotion in Canada: Back to the Past or Towards a Promising Future? Ann Pederson, Irving Rootman and Michel O'Neill; Health Promotion in the USA: Building a Science Based Health Promotion Policy, Debra Lightsey, David McQueen and Laurie Anderson.

49 eurohealth Vol 10 No 3–4–4 Press releases and other suggested information for future inclusion can be e-mailed to the editor David McDaid [email protected] EUCOMPILEDn BY EUROHEALTHews WITH ADDITIONAL INPUT FROM EUROHEALTHNET

COUNCIL OF EUROPE MARKS 50 YEARS OF HEALTH ACTION CRITICAL MID-TERM REVIEW In Strasbourg on 16 November the cies, noting that “cooperation with OF THE LISBON PROCESS Council of Europe’s European the World Health Organization has In Lisbon, in 2000, the heads of Health Committee (CDSP) marked led to a pioneering type of joint States and Governments of the 50 years of work with the launch of a assistance programme - the South- EU-15 decided to start an eco- book Health, Ethics and Human East Europe Health Network” and nomic and social reform process Rights – The Council of Europe that “in this connection that the with the ultimate aim of becoming Meeting the Challenge. Deputy Council of Europe is prepared to co- by 2010 “the most dynamic and Ambassador of the Netherlands, organise the second Health Ministers competitive knowledge-based Cees Meeuwis, symbolically handed Forum on ‘Health and Economic economy in the world capable of over the first copy of the book to Development’ in 2005 to mark the sustainable economic growth with Council of Europe Deputy Secretary transition of this successful joint more and better jobs and greater General, Maud de Boer Buquicchio, activity to full regional ownership social cohesion, and respect for at the beginning of the meeting held and sustainability.” The European the environment”. at the Palais de l’Europe. The book Network of Health Promoting A mid-term review chaired by details the development of half a cen- Schools organised in conjunction former Dutch Prime Minister, tury of work on health, including with the WHO and the European Wim Kok, is critical about the milestones such as the development Union was also held up as a signifi- process achieved so far and doubts of international standards in blood cant achievement. She also referred whether the goals can be reached transfusion, action on organ dona- to the many challenges which Europe must face including ageing by 2010. Mr Kok believes there is tion and transplantation and the a risk that the Lisbon strategy will campaign to promote and protect the societies, medical and patient migration and the application of genetics. become “a synonym for missed human rights of people with objectives and failed promises” HIV/AIDS. Ms de Boer-Buquicchio concluding with a hope that one day “ the words and that “progress to date has Ms de Boer-Buquicchio said “When “human rights” will conjure up in been inadequate largely due to we speak about human rights, in our our minds images not of courtrooms lack of commitment and political mind’s eye we see, quite stereotypi- and prisons alone, but of a cohesive will.” The report focuses mainly cally, images of courtroom delibera- society where everyone enjoys equal on the lack of competitiveness of tions or people in prison cells, or rights, also of access to state-of-the- the European economy, and puts images of people abused by the art medical care and protection of forward a recommendation on police, or maybe images of demon- their health, which would pave the healthy ageing. European institu- strations and public leaders speaking way for harmonious living.” tions will debate this in the period in opposition to the government. We leading to the Spring Council The full text of the Deputy Secretary rarely think about people being meeting. General’s speech is available at treated in hospitals and clinics, visit- Latest updates on the Lisbon strat- http://www.coe.int/t/e/SG/SGA/doc ed by doctors and nurses, or resting egy can be found at http://europa. uments/speeches/2004/ZZP_2004_% in homes for senior citizens. Yet, the eu.int/comm/lisbon_strategy 2016%20Nov_Strasbourg.asp ever-evolving concept of human rights and our understanding of it have been constantly enlarging their scope over recent decades. Through ENGLAND: WHITE PAPER ON PUBLIC HEALTH SETS OUT NEW this evolution in our thinking and MOVES ON SMOKING, OBESITY AND SEXUAL HEALTH vision, we have come to realise that Health Secretary John Reid pub- smoking could be banned progres- the right to good health and its pro- lished ‘Choosing Health – the sively by the end of 2008 in work- tection is as much a human right as Government’s White Paper on places and establishments where other commonly recognised rights improving public health in food is served across England. and freedoms. It could hardly be England’. The document aims to The White Paper can be accessed at otherwise: health is an issue at the make it easier for people to change http://www.dh.gov.uk/Publications their lifestyle so they eat more core of our existence. Good health is AndStatistics/Publications/Publicati healthily, exercise more and smoke the gateway to life and to the enjoy- onsPolicyAndGuidance/Publication less. It also sets out moves to ment of all human rights.” sPolicyAndGuidanceArticle/fs/en? improve sexual health, encourage CONTENT_ID=4094550&chk=a She also acknowledged the impor- sensible drinking and improve N5Cor tant contribution made by coopera- mental well-being. It proposes that tion with other international agen-

eurohealth Vol 10 No 3–4 50 REPORT ON PRIORITY MEDICINES FOR EUROPE AND THE WORLD CALL TO ENHANCE THE SOCIAL PILLAR OF THE On 18 November WHO released elderly and adolescents; Priority Medicines for Europe and LISBON STRATEGY Diseases for which biomarkers are the World. Commissioned by the absent: Alzheimer’s disease; On 20 October, the Social Dutch Government under their EU osteoarthritis; Platform published two major Presidency, and discussed at a high position papers, their proposals level conference in The Hague, it Diseases for which basic and applied for the next Social Policy Agenda identifies a priority list of medicines research is required: cancer; acute 2006–2010, and their mid-term taking into account Europe’s ageing stroke; evaluation of the Lisbon strategy population, the increasing burden of Neglected diseases or areas: tubercu- preceding the official report of the non-communicable illnesses in losis; malaria and other tropical High Level Expert Group chaired developing countries and diseases infectious diseases; by Wim Kok. which persist in spite of the availability of effective treatments. The Diseases for which prevention is par- The Social Policy Agenda 2006– report looks at the gaps in research ticularly effective: chronic obstruc- 2010 provides detailed and practi- and innovation for these medicines tive pulmonary disease including cal proposals for the next five and provides specific policy recom- smoking cessation; alcohol use disor- years to create a European social mendations on creating incentives ders: alcoholic liver diseases and policy based upon fundamental and closing those gaps. alcohol dependency. rights. It covers many areas of social policy and draws upon the It also identifies gaps for diseases for The report suggests that Europe can expertise of Platform’s members which treatments do not exist, are and should play a global leadership in a wide range of social sectors. inadequate or are not reaching role in public health. The problems patients. Threats to public health now experienced in many developing The Evaluation of the Lisbon such as antibacterial resistance or countries are similar to those seen in Strategy assesses the extent to pandemic influenza, for which pre- Europe. Efforts to shorten the medi- which the EU is currently meeting sent treatments or preventive mea- cine development process without the goals it set – particularly the sures are unlikely to be effective in compromising patient safety would social goals – at Lisbon in 2000. It the future, also require immediate greatly assist in promoting pharma- provides a clear assessment from action. In total 17 priority conditions ceutical innovation. The report calls social NGOs in the form of a were identified: for the EU to help create and sup- short question and answer paper, port a broad research agenda for a outlining the challenges in stark Future public health threats: infec- critical review of regulatory require- terms. tions due to antibacterial resistance; ments within the medicine develop- pandemic influenza; The two papers can be accessed at: ment process looking at their rele- Diseases for which better formula- vance, costing, and predictive value. www.socialplatform.org/module/ tions are required: cardiovascular FileLib/SocialPolicyAgenda2006- The report can be accessed at disease (secondary prevention); dia- 2010_Final_EN.pdf http://mednet3.who.int/ betes; postpartum haemorrhage, pae- prioritymeds/report/index.htm www.socialplatform.org/module/ diatric HIV/AIDS, depression in the FileLib/ENSPEvaluationLisbon20 05final.pdf RIGHT WORK-LIFE BALANCE IS A WIN-WIN SITUATION FOR ALL The European Foundation for the Indeed, a future shortage of work- YOUNG PEOPLE’S LIFESTYLE Improvement of Living and ers and skills is likely to force our Working Conditions Forum on economy to adopt successful work- AND THE ROLE OF SPORTS Living to work – working to live, life balance policies”, warned The European Commission has Tomorrow's work-life balance in Ireland's Taoiseach, Bertie Ahern. published four studies on sports in Europe took place in Dublin in Acting Director of the Foundation, the EU. On of them, entitled “Study November. Established as a plat- Willy Buschak, called for fresh on young people’s lifestyles and the form for top-level debate, the thinking to deal with what he role of sport in the context of educa- Forum is a biennial event, bringing called ‘obstacles to our attempts to tion and as a means of restoring the together international policymak- meet the Lisbon targets’. Particular balance”, deals with the sedentary ers, government leaders, social challenges include the ageing of the lifestyle and lack of exercise of partners, researchers and other EU workforce, the need to develop young people. The European Year high-level actors to exchange expe- a knowledge-based society and to of Education Through Sports ended riences. “A better work-life balance improve productivity. in December. An evaluation report leads to reduced stress for workers will be published later in 2005. and increased productivity. It is not More information available at just an issue of importance to the http://www.eurofound.eu.int/ More information at individual, it is also of strategic newsroom/archive_pressrelease/ http://europa.eu.int/comm/sport/ importance to our economy. pressrel_041104.htm whatsup/index_en.html

51 eurohealth Vol 10 No 3–4 NEW COMMISSION FINALLY IN OUTGOING COMMISSIONER BYRNE BECOMES SPECIAL ENVOY TO PLACE WORLD HEALTH ORGANIZATION The new Barroso team finally Former Commissioner for Health of internationally accepted rules on received approval from the European and Consumer Protection, David communicable diseases. Next time Parliament and took office on 22 Byrne, took up a new role as the there is a SARS outbreak there will November. In October President WHO Special Envoy on the revi- be rules. This is deadly important " Barroso chose not to submit his team sion of the International Health to a vote in the Plenary after two Officials from WHO's 192 Regulations from 1 November. The Commissioners were rejected by Member States came together from International Health Regulations their respective Parliamentary 1 - 12 November to negotiate a are the main piece of international Committees, the original Italian revised draft of the Regulations. A law governing the control of infec- nominee for Justice and Home final draft will be presented to the tious diseases. They were first Affairs Rocco Buttiglione was reject- World Health Assembly in May, adopted in 1969 for a small number ed by the Committee on Civil 2005. Mr Byrne's role is to facilitate of diseases and with minor amend- Liberties, Justice and Home Affairs, this process of negotiation between ments have remained largely while Laszlo Kovacs, from Hungary the Member States. He is working unchanged since then. The revision was considered not to have the nec- with the Member States and with of the Regulations to broaden their essary expertise for the job of the WHO Director-General to scope has been under way for sev- Energy Commissioner. Latvian resolve outstanding difficulties and eral years and is now approaching a nominee, Ingrida Udre, also came to build support for the solutions crucial decision point. The revision under pressure after questions about proposed. has become more urgent in light of her involvement in an ongoing inves- the recent outbreaks of SARS and More information on the tigation into funding irregularities avian influenza. David Byrne said International Health Regulations within her political party. Both on taking up his appointment that can be found at Buttiglione and Udre resigned to be “the revision of the International http://www.who.int/gb/ghs/e/ replaced by Franco Frattini and Health Regulations is a cornerstone index.html Andris Piebalgs. Lazlo Kovacs was then moved to the Taxation and Customs Union portfolio with Piebalgs taking the job of Energy NEW REPORT ON ACTIONS AGAINST DEPRESSION Commissioner. Details of the full new Commission A new report Actions against people with depression commit team are available at depression. Improving mental suicide. http://europa.eu.int/comm/ health and well-being by combat- The report builds on a whole range commission_barroso/index_en.htm ing the adverse health, social and of past and current mental health- Details of Health and Consumer economic consequences of depres- related activities under the Protection Commissioner sion has been prepared for the Programme of Community action Kyprianou’s new cabinet are Commission DG for Health and in the field of public health (2003- available at Consumer Protection. Depression 2008). They focus on better infor- http://www.europa.eu.int/comm/ and depression-related problems mation about the mental health of commission_barroso/kyprianou/ are today among the most pressing the population as well as on the cabinet_en.htm public health concerns. Estimates promotion of good mental health for total disease burden quoted in and the prevention of mental dis- this report indicate that they ease. It describes the illness of THE SITUATION OF ROMA IN account for more than 7% of all depression, highlights economic AN ENLARGED EUROPE estimated ill health and premature and social consequences, and pre- mortality in Europe, only exceeded A new report published by DG sents the evidence base and areas by ischaemic heart disease (10.5%) Employment and Social Affairs for effective interventions. It also and cancer (11.5%). Moreover examines the conditions Roma, identifies some of the challenges in there are other burdens caused by Gypsies and Travellers face in developing promotion and preven- depression, beyond the health sys- education, employment, housing tion strategies and possible solu- tems: These include the loss of and healthcare (among others). It tions. Finally, it presents conclu- quality of life for the affected and sets out both good and bad prac- sions and suggestions for the way their families, a loss of productivity tice in policies and programmes forward. for firms and an increased risk of for Roma, as well as recommenda- unemployment for individuals. The full report is available at tions on how to improve existing Depression can mean that people http://europa.eu.int/comm/health/ policies in order to tackle the withdraw from family life, social ph_determinants/life_style/ widespread discrimination and life and work, and far too many mental/depression_en.htm social exclusion which Roma, Gypsies and Travellers face.

eurohealth Vol 10 No 3–4 52 START OF THE LUXEMBOURG NEW EXECUTIVE AGENCY UK: REPORT ON HEALTHCARE PRESIDENCY FOR PUBLIC HEALTH IN A RURAL SETTING Luxembourg holds the Presidency PROGRAMME of the European Union from 1 In this report, by the British January until 30 of June 2005. Mars The European Commission has Medical Association, the key areas di Bartolomeo, Minister of Health created an “Executive Agency for of medical education and training, and Social Security has set out prior- the Public Health Programme” recruitment and retention, and ities in the field of public health, for the management of accessibility and sustainability of these include work on the service Community action in the field of healthcare are examined in the directive; humanitarian support to public health. The agency was rural context, with a focus on pri- victims of the Tsunami in South established on 1 January 2005 mary care. UK and international East Asia in the field of health and until the end of 2010 and based in examples of good practice are reconstruction; promoting healthy Luxembourg. The Commission included and recommendations lifestyles; young people’s health remains responsible for the pro- for action made. The report is (including mental health); the fight ject programming stage while the aimed at all healthcare profession- against obesity and smoking; the new agency will be responsible als and organisations that can European Regulation on Nutrition for the project implementation respond and improve healthcare in and Health Claims; the European stage: managing all the phases in rural areas Regulation on Medicine for the lifetime of specific projects, Rural areas make up four-fifths of Children; International Health carrying out all the operations the UK landmass and include up Regulation; coordination of national necessary for the execution of the to a quarter of the population. The social security systems. budget and for the management proportion of older people living of the programme, and providing On the services directive, Mr di in rural settings is higher than in logistical, scientific and technical the general UK population there- Bartolomeo said that there is noth- support. ing as precious as one’s health: fore doctors may have to deal ‘Health is one’s unique and irre- More information at with more cases of chronic disease placeable capital” that should not be http://europa.eu.int/eur-lex/lex/ such as heart disease, stroke and sacrificed for the sake of competi- LexUriServ/site/en/oj/2004/ mental illness. tion and that issues of access and l_369/l_36920041216en00730075. Despite the image of the ‘rural quality should not be forsaken. The pdf idyll’ there are poor people expe- Luxembourg Presidency will organ- riencing disadvantage throughout ise conferences on patients’ security, rural areas and they often live near e-health, rare diseases, access to people with very different circum- TOBACCO CONTROL MOVES health care in the Internal Market, stances. This results in pockets of and long term care for elderly IN SCOTLAND AND MALTA deprivation existing alongside rel- people. On 10 November the First Minister ative affluence. Deprivation and More information at of the devolved Scottish poverty are important determi- http://www.eu2005.lu Government announced to the nants of health and disease. Scottish Parliament the cabinet’s Commenting on the report, Dr decision to bring forward legislation Vivienne Nathanson, the BMA’s for a comprehensive ban of smoking Head of Ethics and Science, said: HEALTH COUNCIL PLEADS in all enclosed public places in “The UK needs to learn from FOR A LONG-TERM SUPPORT Scotland. The decision-making countries like Australia, the USA AFTER THE TSUNAMI process included public consultation and Canada which have developed and more than 52,000 individuals Meeting in an extraordinary ses- innovative solutions to the prob- and 1,000 groups and businesses lems affecting rural healthcare.” sion on 7 January 2005, the EU's responded. The target date for full Foreign Affairs, Development and implementation is Spring 2006. She added: “A major problem is Health ministers have agreed that the myth of the ‘rural idyll’. humanitarian aid should be the More information at Deprivation in rural communities main focus of tsunami relief http://www.scotland.gov.uk/Topics/ has been ignored for a long time. efforts at this point. The Council Health/health/smoking There is a real case of the haves highlighted the importance of Meanwhile in Malta legislation was and the have-nots. There are those actions to prevent the emergence passed in September 2004 that bans with private transport who can of epidemics and protect human smoking in any enclosed private or access services, while those with lives by ensuring food supply and public premises which are open to lower incomes have limited access access to drinking water, medi- the public except for designated and choice.” cines and vaccines. smoking rooms”. The ban includes The report is available at http://ue.eu.int/uedocs/cms_Data/ bars and restaurants, and is accom- www.bma.org.uk/ap.nsf/Content/ docs/pressdata/fr/gena/83322.pdf panied by a guide on how smoking healthcarerural/$file/rural.pdf rooms should be constructed

53 eurohealth Vol 10 No 3–4 COMMISSIONER KYPRIANOU CALLS FOR MORE ACTION TO PROMOTE POSITIVE MENTAL HEALTH

Speaking at the European Ministerial for mental health promotion, mental health promotion together Conference on Mental Health embedded in mental health strate- with the prevention of mental disor- "Facing the Challenges, Building gies, can make a valuable contribu- ders. The new European Health Solutions" organised by the WHO, tion towards pursuing this objec- Strategy will be one vehicle for this, and co-sponsored by the European tive.” and there will also be a Commission Commission, Council of Europe and Communication on Mental Health Speaking on the need to strengthen Government of Finland to Member States and Parliament partnerships, the Commissioner Commissioner Kyprianou called for with the objective of “being to pave stressed that “the health sector more action to be taken to promote the way for actions by the should engage in partnerships with positive mental health in Europe. He Commission on mental health in a other policy fields and relevant outlined three areas, the need to later phase and to present options to stakeholders, such as educational invest more in the promotion of policy makers and other stakehold- institutions and employers in order good mental health and the preven- ers. It will cover different areas: the to advise them and to co-ordinate tion of mental disorders, the need place of mental health in a broad action.” One sector highlighted by for the health sector to engage in health policy context and the need to the Commissioner where co-opera- partnerships with other policy areas mainstream mental health in other tion can be strengthened is that of and stakeholders, and finally dis- policies, the rights of mentally ill employment, as “a high level of cussed the Commission’s agenda to people, the creation of partnerships mental health of the work force is in address these issues. with the relevant actors and the the interest of employers. It sup- launch of a dialogue with EU The Commissioner said “We should ports productivity; it supports inno- Member States to identify and invest more in the promotion of vation; and it helps keep rates of address health inequalities.” A third good mental health and the preven- absenteeism low.” activity will be the presentation in tion of mental disorders. Indeed, one The human rights of those with late 2005 of a Working Paper on co- of the main, and well-known, chal- mental health problems were also ordinated actions to reduce alcohol- lenges for public health policies is highlighted during the speech, both related harm. not only to improve the availability within health, social care and crimi- of treatments of illnesses but also to The full text of the Commissioner’s nal justice systems. Concluding his ensure the effective promotion of speech is available at speech the Commissioner outlined good health: these are two sides of http://europa.eu.int/comm/health/ two areas of action where the the same coin. In such a context, the ph_determinants/life_style/mental/ Commission will concentrate activi- promotion of mental health should ev_20050112_en.htm ties: mental health information and seek to strengthen the abilities of people, as soon as possible in their life, to avoid the development of mental illness.” HOW MOTHERS TREAT THEIR BABIES IS KEY TO MENTAL HEALTH IN LATER LIFE The Commissioner emphasised the link between mental health and key Early findings from a five-country sionals, primary health care policy objectives of the European study on early intervention in providers working with general Union saying that “Mental health is childhood indicate that investing a practitioners (such as health visitors a central dimension of human health small amount in training profes- and nurses) are given specialised but and that it supports quality of life, sionals in the community to sup- inexpensive training in supporting economic growth, innovation and port mothers with new babies mothers with newborn babies and social cohesion. These constitute key makes a difference to young peo- intervening early if problems are policy objectives of the European ple's mental health. Mental health in detected. Compared to a group Union. A high level of mental health children and adolescents was one of without this training for providers, is needed for the transition of the the topics under discussion at the the mothers and babies in the inter- European Union into a dynamic WHO European Ministerial vention group were found to have a knowledge society.” Conference on Mental Health, held better relationship. The mothers on 12-15 January 2005, in Helsinki, were more involved and facilitative, An important aspect of the Finland. and less controlling and punitive. Commissioner’s address to the The research has been coordinated Conference was his emphasis on The European Early Promotion by Professor John Tsiantis of the positive mental health rather than Project, taking place in Cyprus, Athens Medical School, Greece and seeking to alleviate the burden of Finland, Greece, Serbia and Professor Hilton Davis of the South poor mental health alone. He noted Montenegro and the United London and Maudsley Trust, that “we should try to improve the Kingdom, is an early intervention United Kingdom. mental health of the population as a to help children, underway for four matter of priority rather than only years. With expert back-up from More at http://www.who.dk/ seek to reduce the burden of a men- experienced mental health profes- mediacentre/PR/2005/20050111_1 tal disease when it is overt. Measures

eurohealth Vol 10 No 3–4 54 WANLESS REVIEW OF SOCIAL CARE FOR OLDER PEOPLE IN ENGLAND UNDERWAY

The King's Fund has commissioned the Spring of 2006, will consider social care. Our task is to set out the former NatWest Group chief execu- three issues. He will examine the key factors driving demand for social tive Sir Derek Wanless to carry out a demographic, economic, social, care, and the likely costs over the fundamental review into the long health, and other relevant trends next 20 years. We will then have to term demand for and supply of over the next 20 years that are likely consider the resources required and social care for older people in to affect the demand for and nature how they should be paid for” England. of social care for older people aged King's Fund chief executive Niall 65 and over in England. Secondly he This report will follow the two inde- Dickson said: “A serious, long-term will look at the financial and other pendent reviews Sir Derek conduct- analysis of how we fund social care resources required to ensure that ed for the government on future is overdue. It was the missing piece older people who need social care are health care spending in the UK and in the original Wanless jigsaw and it able to secure comprehensive, high on public health in England. remains one of the big unanswered quality care that reflects the prefer- Although the social care review will policy questions. We believe this ences of individuals receiving care, focus on older people, the King’s review should have a major impact and finally will consider how such Fund hopes to move into other areas on the way care and support for social care might be funded of adult social care, such as mental older people is delivered in this illness and learning disabilities once Sir Derek said: "Now is the right country.” Julien Forder, senior this review is complete. time to conduct a comprehensive research fellow and deputy director review of the provision of social care of LSE Health and Social Care, of Sir Derek, who is expected to report for older people to find a sustainable, which the Personal Social Services back the findings of his review by long-term financial settlement for Research Uni is a part, is being sec- onded to the review as project manager. BILL AND MELINDA GATES FOUNDATION CALLS FOR PROPOSALS More information at TO PROMOTE EUROPEAN SUPPORT FOR GLOBAL HEALTH http://www.kingsfund.org.uk/ healthpolicy/wanless.html The Bill & Melinda Gates ing activities among the Core Foundation invites proposals to Members and other organisations build the capacity of non-govern- working on related efforts. THIRD HIGH LEVEL MINISTERIAL mental organisations working Optionally, a seventh organisation within Europe to advocate in sup- could serve the role as Network CONFERENCE ON EHEALTH port of achieving the three Coordinator that would not have The Norwegian government, in Millennium Development Goals responsibility for any jurisdiction- conjunction with the Luxembourg related to global health. This would specific activities. Funding will be Presidency of the European Union be accomplished through a new provided for up to five years. The and the European Commission, will European Global Health Network size of the grant award will be host this conference to be held on comprised of six Core Members determined according to the on 23–24 May 2005 in Tromsø. The based in the United Kingdom, approach and budget identified in conference is organised in close col- France, Germany, Italy, Spain, and the successful proposal, but will laboration with the Norwegian Brussels (for the European Union). not exceed $2 million per year for a Directorate of Health and Social total of $10 million. Through the Network, Core Affairs and the Norwegian Centre Members would receive funding to More information at for Telemedicine and focuses on increase their advocacy efforts http://www.gatesfoundation.org/ important health issues, and the way within these six jurisdictions, and nr/downloads/globalhealth/ in which they can be supported by one of them (serving as Network Grantseekers/RFPs/GHA-05- eHealth, to make major advances Coordinator) would receive addi- 02EuropeFinal.pdf that benefit the people of Europe. tional funding to support network- Norwegian Minister of Health and Care Services, Ansgar Gabrielsen has said that “Health policy-makers in all countries have a clear responsi- THE SOCIAL SITUATION IN THE EUROPEAN UNION 2004 bility to pursue the needed orienta- The report provides an overview of population trends, living conditions and tion in relation to eHealth: We can't social coherence in the European Union. It seeks to portray the social dimen- all be captains of all ships, but the sion of the enlarged Union, looking at both social trends and emerging policy conference can provide all those challenges. The complete report is available only in English. A summary is involved with the lighthouses with available other languages. incentives, initiatives, and ideas.” The report is available at http://europa.eu.int/comm/employment_social/ More information on the conference publications/2004/keap04001_en.html and programme can be found at http://www.ehealth2005.no

55 eurohealth Vol 10 No 3–4 News in Brief

Primary health care: detection, EC Report on young people and Director named for new EU management and outcome of drugs health agency depression The European Commission has The Management Board of the Depression is a common healthcare launched a report on young people European Centre for Disease problem, largely managed in primary and drugs in the European Union. Prevention and Control (ECDC) has care, with little or no specialist input This survey was requested by nominated Mrs Zsuzsanna Jakab, a from secondary care services. The Directorate General “Justice and senior public health official from quality of care is often low, with Home Affairs” and coordinated by Hungary, to be the Centre’s first poor recognition of the condition, Directorate General Press and Director. inadequate prescription, poor com- Communication. pliance with medication and poor Markos Kyrpianou, Commissioner Key themes include: Exposure to provision and uptake of psychologi- for Health and Consumer Protection drugs; Why do young Europeans cal interventions. So states Simon welcomed the decision saying that experiment with drugs?; Difficulties Gilbody from the University of “Mrs Jakab has an impressive track in stopping drug use; The conse- Leeds in a new report prepared for record in international public health quences of consuming drugs; Ways the Health Evidence Network. cooperation. I am sure she will pro- of tackling drug-related problems; vide the ECDC with the leadership The report indicates that a substan- Sources of information on drugs; it needs to start up its activities and tial evidence base exists to support The danger of drugs; The opinion of establish its reputation”. the effectiveness of collaborative young people on various drug-relat- care, case management and stepped ed issues. She will appear in front of a care in improving patient adherence European Parliament committee in The report is available at with treatment and improved clinical early 2005 before her appointment. http://europa.eu.int/comm/health/ outcomes. Clinician education and Once the appointment is confirmed ph_determinants/life_style/pub_drug guidelines, when offered on their the Director can begin recruiting _en.htm own, are largely ineffective strate- staff for the Centre and establishing gies. Improved outcomes will its Europe-wide network of disease Smoking ban comes into law in require a greater allocation of control experts. resources to primary mental health Italy The new legislation came into effect More information at care than is currently the case in http://www.europa.eu.int/comm/ many health care systems from January 2005 and banned smoking in most indoor spaces, health/ph_overview/strategy/ecdc/ The report is available at although smoking rooms are permit- director_ecdc_en.htm http://www.euro.who.int/eprise/ ted in completely enclosed areas main/WHO/Progs/HEN/Syntheses/ with a good ventilation system. Both Obesity roundtable – workshop capdepr/20041208_2 smokers and proprietors who flout on best practice the ban can be fined. The ban had The European Commission organ- World Aids Day 2004 been delayed by one month to give ised a round table on Obesity in late EU Commissioners Markos businesses more preparation time. October. The workshop enhanced Kyprianou and Louis Michel spoke the role of nutrition labelling, the about EU actions to tackle the Nordic countries to fight importance of education through HIV/AIDS epidemic on the occasion alcohol policy as a block campaigns, examined the range of of World AIDS Day 2004, which The health ministers of Finland, products that are reduced in energy, was dedicated to “Women, girls and Sweden, Norway, Iceland and fat, sugar and salt, and debated on HIV and AIDS”. Denmark have agreed for the first the advertising regulation especially Speaking at the European time to align their alcohol policies in for children. Parliament, Commissioner order to reduce alcohol consump- The agenda, different contributions, Kyprianou re-stated that “the tion. conclusions and follow up can be Commission is addressing the The Nordic system – high prices and found at: HIV/AIDS issue both within and low consumption – is under pressure http://europa.eu.int/comm/health/ outside the EU. Together with the from the EU’s internal market which ph_determinants/life_style/ Member States the EU is the biggest allows private consumers to buy nutrition/ev_20041029_en.htm contributor to the Global Fund, low-taxed liquor in other countries. which is the main financial instru- Norway, Sweden and Iceland, who ment in the struggle against the charge the highest prices for alcohol, HIV/AIDS epidemic globally”. He are also among the five nations in also emphasised the importance of EuroHealthNet Europe with the lowest annual con- issues such as prevention, informa- sumption of pure alcohol per person. 6 Philippe Le Bon, Brussels tion, access to treatment, stigma and Tel: + 32 2 235 03 20 discrimination. Commissioner More information at Fax: + 32 2 235 03 39 Michel affirmed a commitment to http://www.euobserver.com/ Email: [email protected] education and prevention. ?sid=9&aid=17557

eurohealth Vol 10 No 3–4 56 Photograph copyright of Beka Vuco

ISSN 1356-1030 leaflet 21/12/04 5:25 pm Page 1

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TT KK HH UU RR EE EE A A H TT H SS TT OO RR RR OO O FF OPP IEESS PPOORRTTUUNNIITTI ONE DAY CONFERENCE

Thursday 10 March 2005

At the Royal College of Physicians, 11 St Andrews Place, Regent’s Park, London NW1

Organised in conjuction with Department of Health, Health Protection Agency and World Health Organization leaflet 21/12/04 5:25 pm Page 2

S ON TI EU: On 1st May 2004 the European Union underwent an unprecedented A ED C ND expansion, with the accession of 10 new members, most of which had

I A

L P ? until recently been part of the Soviet bloc. British tabloid headlines

P X E M E P I predicted catastrophe for the UK, with Eastern Europeans “filling NHS

N O beds” or spreading infectious disease. At the same time, health policy H A R

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L U makers looked to the new member states as a solution to a looming O E A shortage of healthcare professionals yet, in the first 3 months after

E D

H the enlargement, only 53 nurses had moved to the UK.This conference N

A will attempt to discover the reality behind the rhetoric. H

K T U The conference has been designed to discuss several different areas E related to the expansion of Europe.These include the impact on H T European health (especially the UK) from the expansion, as well as the R O impact on healthcare professionals’ mobility, and finally the F S importance and relevance of the new neighbourhood countries. IE Further debate will cover the economic implications of the changes IT N and the potential for the use of health as a tool of foreign policy. U RT TH PO REATS OR OP Audience: Public health specialists, infectious disease specialists, hospital physicians, political analysts, health policy analysts, academic institutes, non-governmental organisations and policy research units.

Conference organiser: Dr Michael Pelly, Associate Director, International Office, Royal College of Physicians and Chelsea and Westminster Hospital, London.

PROGRAMME 09.00 Registration and coffee 09.30 Welcome and introduction Professor Carol Black CBE, Royal College of Physicians BACKGROUND Chair: Professor Roger Williams CBE, Director, International Office, Royal College of Physicians 09.40 EU enlargement and health: an introduction and overview Professor Martin McKee, European Centre on Health of Societies in Transition, London School of Tropical Medicine and Hygiene 10.00 Discussion 10.10 A cordon sanitaire: micro-organisms do not respect borders Professor Peter Borriello, Interim Director, Centre for Infection, Health Protection Agency 10.30 Discussion 10.40 Perspectives on the trends in non-communicable diseases Dr Imogen Sharp, Head, Health Improvement and Prevention, Department of Health 11.00 Discussion 11.10 Coffee IMPACT Chair: Professor Pat Troop, Chief Executive, Health Protection Agency 11.30 Impact of healthcare mobilisation: challenges for some, opportunities for others Professor James Buchan, Queen Margaret University College, Edinburgh 11.50 Discussion 12.00 Closing the gap; health and wealth in a divided Europe Professor Witold Zatonski, Maria Sklodowska-Curie Memorial Cancer Center,Warsaw 12.20 Discussion 12.30 Health as a tool of foreign policy now and in the future and the economic implications of expansion and healthcare/population movement Speaker tbc, Foreign and Commonwealth Office 12.50 Discussion 13.00 Lunch leaflet 21/12/04 5:25 pm Page 3

INITIATIVES CURRENTLY UNDERWAY Chair: Dr John Martin, Director,World Health Organization Office at the European Union, Brussels 14.00 Health Protection Agency: response to communicable disease threats Professor Angus Nicoll, Director, Communicable Disease Surveillance Centre, Health Protection Agency 14.20 Discussion 14.30 Prevention of obesity and smoking. Lessons from initiatives for healthy living Professor Peter Kopelman, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London 14.50 Discussion 15.00 HIV/AIDS and TB in Europe: a World Health Organization perspective Dr Gudjón Magnusson, Director Technical Support,World Health Organization Regional Office for Europe, Copenhagen 15.20 Discussion 15.30 Tea CONCLUSIONS Chair: Dr David Harper, Chief Scientist, Head of the Health Protectorate, International Health and Scientific Development Directorate, Department of Health 15.50 European Commission perspective on health: objectives and current priorities Dr Bernard Merkel, Head of Unit, Health and Consumer Protection and Directorate-General, European Commission 16.10 Discussion 16.20 Department of Health perspective on the opportunities and challenges of an enlarged Europe for health policy Mr Nick Boyd, Head of International Affairs, Department of Health 16.40 Discussion 16.50 Panel discussion 17.20 Closing remarks and summary 17.30 MILROY LECTURE Winners and losers: the health effects of political transition in Eastern Europe Professor Martin McKee, European Centre on Health of Societies in Transition, London School of Tropical Medicine and Hygiene

18.30 Close of conference and reception ✁

ROYAL COLLEGE OF PHYSICIANS THE HEALTH IMPLICATIONS OF AN EXPANDED EU: THREATS OR OPPORTUNITIES FOR THE UK AND EUROPE? Thursday 10 March 2005

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THE HEALTH IMPLICATIONS OF AN EXPANDED EU: THREATS OR OPPORTUNITIES FOR THE UK AND EUROPE? Thursday 10 March 2005

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