PUBLIC HEALTH SERVICES PROVISION OPTIONS A review of the international practice I. INTRODUCTION What is the Public health? Over the past two centuries, public health has achieved great successes, illustrated by the remarkable reductions in deaths and disability from many infectious diseases (Bernd, McKee, 2014). For instance, a child born in 1955 had an average life expectancy at birth of only 48 years (WHO, 1988). By 2000, the life expectancy at birth had increased to 66 years, and it is expected that it will rise to 73 years by 2025 (WHO,1988). These improvements “have resulted from improved living conditions overall, advances in medical science, and a number of population-level interventions” (CDC, 2011). The “understandings of public health vary among different countries in Europe and the term is difficult to translate into some other European languages”. (Bernd,McKee, 2014). In 1988 the Institute of Medicine (IOM) provided a definition of public health in their work “The Future of Public Health”. The IOM report define public health mission as “fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM, 1988). This definition “directs attention to the many conditions that influence health and wellness, underscoring the broad scope of public health and legitimizing its interest in social, environmental, economic, political, and medical care factors that affect health and illness” (Turnock, 2012). The definition of IOM also reflected in Winslow’s definition which is used in concept paper of the WHO European Region concluded in 2011. Winslow’s definition of public health is “the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society…” (Winslow, 1920). The phrases, “science and art,” “organized community effort,” and “birthright of health and longevity” capture the substance and aims of public health (Turnock, 2012). Therefore, public health can have different images depending of the perception of general public. For instance, public health could be perceived as 1) the system and social enterprise, 2) the profession, 3) the methods (knowledge and techniques), 4) governmental services (especially medical care), 5) the health for public (Turnock, 2012). Viewing public health as a system gives an understanding how interconnected components interact. “Health systems are one of key instruments created by human societies to help achieve improved health outcomes as they [health systems] raise and channel recourses and create and manage the service delivery mechanisms.”1 The countries of the former Soviet Union (FSU) over the last 20 years have experienced an transformation.2 Most countries of FSU inherited major features of Semashko model of health care, despite its achievements in ensuring universal coverage, “this system also characterized by a poor quality, inefficiency and lack of responsiveness”3. In early years, the specialists from so-called Sanitary Epidemiological (San-Epid) Service were responsible for “maintaining preventive and routine sanitary and epidemiological surveillance to ensure safe working conditions in enterprises, public facilities and institutions”4. “The san-epid service initially made a significant progress in fighting communicable diseases, establishing comprehensive childhood vaccination 1 http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627- 1095698140167/ImprovingDeliveryofHealthServicesFINAL.pdf 2http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet- countries.pdf 3 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet- countries.pdf 4 http://www.euro.who.int/__data/assets/pdf_file/0010/96418/E84927.pdf This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. programs and contributing to the decline of many communicable diseases, it was much less effective in the areas of noncommunicable disease, occupational health and environmental health”5. The FSU countries experienced the reform of san-epid service differently. “Since 1990, these systems have undergone varying degrees of reform in all the countries. In each country, the structures for and provision of public health system has evolved over the years according to different decisions made by governments and ministries of health”6. For instance, such countries as Armenia, Belarus, the Russian Federation, and Ukraine “have largely preserved the Soviet san-epid structure. Meanwhile, some countries such as Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan have built additional structures; and others, Georgia and the Republic of Moldova, abandoned the san-epid service and set up new public health infrastructures”7. Despite of other countries, the san-epid service in Ukraine was administered in a hierarchical fashion with services at the national, regional (oblast/city) and district level8. In Ukraine, the san-epid service underwent major reforms in 2011– 2012. “Its status was upgraded from a structure within the Ministry of Health to a central executive body under the Cabinet of Ministers and its emphasis was shifted from administrative services to health promotion and education”9. Moreover, “the reform expanded the tasks of the service to include the prevention of tobacco use, reduced the number and frequency of planned inspections and simplified licensing procedures”10. In all countries in Europe, different actors are involved in public health activities and their integration can be challenging”11. The poor integration of separate vertical public health structures and primary health care has been identified as a challenge in a number of countries, including Azerbaijan (Ibrahimov et al., 2010), Belarus (Richardson et al., 2013), Kazakhstan (Katsaga et al., 2012), Tajikistan (Khodjamurodov & Rechel, 2010) and Ukraine12. So, to manage effectively public health activity the central state authority is needed. Overview of 10 essential public health services, WHO: Useful link: http://www.euro.who.int/__data/assets/pdf_file/0010/172729/Review-of-public-health-capacities- and-services-in-the-European-Region.pdf?ua=1 Public health systems are commonly defined as “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.” 13 The “essential public health services” were described by different agencies in the world (Bernd,McKee, 2014). An adaptation of these “essential public health functions” has been developed by the WHO Regional Office for Europe in the form of 10 essential public health operations (EPHO)14: 5 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet-countries.pdf 6 http://www.euro.who.int/__data/assets/pdf_file/0016/125206/e94398.pdf 7 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet-countries.pdf 8 http://www.euro.who.int/__data/assets/pdf_file/0010/96418/E84927.pdf 9 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet-countries.pdf 10 http://www.euro.who.int/__data/assets/pdf_file/0019/261271/Trends-in-health-systems-in-the-former-Soviet-countries.pdf 11 http://www.eurohex.eu/bibliography/pdf/2444834988/Rechel_2013_Lancet.pdf 12http://www.euro.who.int/__data/assets/pdf_file/0010/96418/E84927.pdf 13 https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html 14 http://www.euro.who.int/en/health-topics/Health-systems/public-health-services/policy/the-10-essential-public-health-operations This document is made possible by the support of the American and British People through the United States Agency for International Development (USAID) and through the UK Good Governance Fund/UK Government (UK aid). The contents of this document are the sole responsibility of Deloitte Consulting, LLP and do not necessarily reflect the views of USAID, the United States Government, UK aid, or the UK government’s official policies. This document was prepared under Contract Number 72012118C00001. 1. Surveillance of population health and wellbeing 2. Monitoring and response to health hazards and emergencies 3. Health protection including environmental occupational, food, safety and others 4. Health promotion including action to address social determinants and health inequity 5. Disease prevention, including early detection of illness 6. Ensuring governance for health and wellbeing 7. Assuring a sufficient and competent health workforce 8. Assuring sustainable organizational structures and financing 9. Advocacy communication and social mobilization for health 10. Advancing public health research to inform policy and practice Those 10 Essential Public Health Operations (EPHOs), which can be applied to capacity building, planning and delivery of services 15. In addition, these public health operations have the benefit of identifying horizontal activities across the whole political and administrative spectrum of policy- making, rather than focusing on