The challenges to public health in Hungary in the twenty-first century

The creation of a new school of public health in Hungary offersan opportunity to reassess existing approaches to postgraduatetraining in public health. This paper describes the philosophybehind the training programme that will be offered by the school.It seeks to equip this new generation with the skills to assessthe health needs of the Hungarian population and to design andimplement effective policies to meet these needs. The task ofthe school will not be easy. It will have to confront strongvested interests. This is illustrated in the paper by a discussionof the activities of the tobacco industry. Finally, they mustbe able to base their activities on up-to-date, research-basedevidence. The wide diversity of skills that will be needed toaddress the health needs of the Hungarian population justifiesthis new, multidisciplinary approach in which alliances willbe forged with all agencies that have the power to contributeto improving health.     

Child public health: A new basis for child health workers

To treat and alleviate diseases in children is an importanttask that demands extensive knowledge, skills and training.It forms the basis of our understanding of sick children andtheir needs, and its quality is a measure of the efforts ofsociety to care for its citizens. With the health of children,however, a much broader view must be taken, including otheraspects of children's well-being than their diseases and theirmedical care. To reach the goals set by international organizationsand national governments for the populations' health, policiesbased on public health ideas and functions must be vigorouslypursued. Although these actions are valid for the whole population,there are major reasons why children should be seen as particularlyimportant. Merging the broad aspects of health and public healthfunctions with children's special needs creates child publichealth, which aims to place the health of children and adolescentsin its full social, economic and political context. It is nota new speciality; rather it is a counterbalance towards thefullness of health. Its activities - in teaching, research andservice - should be practical and relevant and include knowledgeand experience from many professions and sciences. With sucha broad competence, child public health is fit to take on awide range of child health issues, be it healthy public policyfor children and adolescents, support for vulnerable groups,education and training or creating centres of relevance forresearch and surveillance of children's and adolescents' health.     

Adapting and disseminating effective public health interventions in another country: towards a systematic approach

BACKGROUND: Public health interventions that have proven effective in one country, are often adapted and disseminated in other countries. However, the process by which effective interventions are chosen for adaptation and dissemination in another country is often not conducted systematically. METHODS: We propose a more systematic approach and describe the main steps that have to be taken in the assessment of the usefulness of effective interventions in another national context. RESULTS: The following steps are proposed. Step 0: Point out the most relevant areas in public health (this is a collaborative effort by policy makers, scientists and practitioners). Step 1: Identification of potentially effective interventions (through systematic literature searches). Step 2: Assessing the levels of evidence and grades of recommendation for adoption. Step 3: Can the results of the trials be generalized to the national situation? Step 4: Can the intervention be implemented in the national situation? CONCLUSION: A more systematic approach to the adaptation and dissemination can be adopted. The basic steps described should be worked out in more detail before they can be used in practice.     

Parental economic stress: evidence of an overlooked public health risk among Swedish families

BACKGROUND: Studies have demonstrated that when parents shoulder considerable financial responsibilities, adverse health outcomes may occur. The present study assesses the association between economic stress and self-rated health in a sample of Swedish parents, and especially how this relation is affected by foreign origin and employment status. METHODS: A questionnaire was sent to a random sample of 5,600 individuals between the ages of 21 and 81 in Malm?, Sweden. The total response rate was 69%. Among the respondents, 824 were parents having at least one child living at home. The main exposures were such sociodemographic variables as country of origin and employment status, and economic stress. The outcome variable was self-rated health. RESULTS: Of the parents in the study, the 34.7% coded as exposed to economic stress showed a significantly increased odds ratio for poor self-rated health (OR=3.12, 95% CI: 2.01-4.84) adjusted for age and sex. After controlling for foreign origin and unemployment, the odds ratio remained statistically significant regarding exposure to economic stress (OR=1.94; 1.16-3.23). In the multivariate model, foreign origin and unemployment were also strongly associated with poor self-rated health (OR=1.78, 95% CI: 1.12-2.88; OR=1.67, 95% CI: 1.01-2.75, respectively). The adjusted population-attributable risk for poor self-rated health was estimated to be 27.4% for economic stress, 26.6% for foreign origin, and 16.7% for unemployment. CONCLUSIONS: Parental economic stress was associated with low self-rated health to a statistically significant degree, even when accounting for employment status and foreign origin. It, therefore, deserves to be seriously considered as an potential public health risk factor among Swedish families.     

Health maximization rejected: The view of Swedish politicians

The meaning of the equity target in Swedish public health policyand its relationship to efficiency is investigated. Three interpretationsof the relationship are analysed and the support given to eachof them by 449 Swedish politicians is investigated in a postalquestionnaire. The common health economics interpretation thatequity is embodied in the health maximization principle, whichimplies that distribution is unimportant, is rejected by approximately70%. The results also refute the lexicograhpical interpretation,since support for the equity target depends upon the magnitudeof the efficiency sacrificed. The third interpretation couldbe labelled plural targets or trade-off, implying that achievementsin respect of 1 target must be weighed against losses in respectof some other target. Approximately 70% of the respondents wereprepared to sacrifice health benefits in exchange for equityof health. However, support for the different interpretationsof equity are strongly associated with sex and political affiliation.Men and representatives of the Conservative Party have muchgreater sympathy for the health maximization principle.     

Health profiles, lifestyles and use of health resources by the immigrant population resident in Spain

BACKGROUND: Our study aimed at describing the health profiles, life styles and use of health resources by the immigrant population resident in Spain. METHODS: Cross-sectional, epidemiological study from the Spanish National Health Survey (NHS) in 2003. We analysed 1506 subjects of both sexes, aged > or =16 years, resident in Spain. RESULTS: The immigrant population present diseases that are similar to those of the autochthonous population. The autochthonous population had significantly higher values for alcohol consumption and smoking (60.8 and 39.6%) than immigrants (39.6 and 27.5%). The percentage of immigrants hospitalized in the preceding 12 months was observed to be higher than that of the Spanish population (11.4 vs. 8.2%, P < 0.05). The immigrant population consumed fewer medical drugs than the Spanish population (42.6 and 49.9%, respectively). CONCLUSIONS: Immigrants in Spain display better lifestyle-related parameters, in that they consume less alcohol and smoke less than the autochthonous population. As for the use of health-care resources, while immigrants register higher percentages of hospitalization compared with the Spanish population, there is no evidence of excessive and inappropriate use of other health-care resources.     

The health of homeless people in Britain: A review

Housing has long been identified as a prerequisite for goodhealth. In Britain not all members of the population have accessto housing. The homeless population may be divided into thosewho are officially accepted as homeless and the unofficial homelesspopulation. The official homeless population is dominated byfamilies with children whilst the unofficial homeless populationincludes a range of circumstances from those living in squatsto those literally living on the streets. In Britain the numberof official homeless tripled between 1978 and 1992 and is currently143,500 households (approximately 330,500 people). It is estimatedthat there are a further 6, 000 people living on the streetsand 50,000 in hostels giving a total estimated homeless populationof 386, 050. Demographic data indicate that there are importantdifferences in the composition of the official and unofficialhomeless populations. The official homeless group consists almostexclusively of young families, usually headed by a lone female.The unofficial homeless group is predominantly male and older.The official homeless population report higher prevalences ofchronic health problems and general psychiatric problems thanthe general population whilst the unofficial group are characterizedby elevated rates of psychiatric disturbance and alcohol consumption.These data indicate that homeless people are not a homogeneoussocial group but present a variety of different health needswhich require the provision of appropriate services.     

European regulatory policies on medicines and public health needs

The establishment of the EMEA has been a revolutionary step in the European pharmaceutical system. The 15 Member States of the European Union now share a common system for the evaluation of new medicinal products entering the European market. The decisions taken apply to the whole EU, with important implications for both industry and patients who may benefit from new therapies. The main immediate consequences of this system are: i) the time and effort saved by Member States in the evaluation of new drug applications; ii) more consistent and quicker availability of medicines in EU countries; iii) the establishment of a homogeneous regulatory policy throughout the EU. Public health has been presented as the fundamental concern of the EMEA, the mission statement of which is 'to promote the protection of human health ... and of consumers of medicinal products'. However, we note that there are some inconsistencies with this objective and the current system, such as those regarding drug trial requirements and the institutional location and financing of the EMEA. In this paper, some aspects of the new system are reviewed and consideration given as to how they relate to public health needs. Proposals are made for debate alternatives and improvements to the present system that would better respond to patients' health needs.     

Heroin-assisted treatment as a response to the public health problem of opiate dependence

Injection drug use (involving the injection of illicit opiates) poses serious public health problems in many countries. Research has indicated that injection drug users are at higher risk for morbidity in the form of HIV/AIDS and Hepatitis B and C, and drug-related mortality, as well as increased criminal activity. Methadone maintenance treatment is the most prominent form of pharmacotherapy treatment for illicit opiate dependence in several countries, and its application varies internationally with respect to treatment regulations and delivery modes. In order to effectively treat those patients who have previously been resistant to methadone maintenance treatment, several countries have been studying and/or considering heroin-assisted treatment as a complementary form of opiate pharmacotherapy treatment. This paper provides an overview of the prevalence of injection drug use and the opiate dependence problem internationally, the current opiate dependence treatment landscape in several countries, and the status of ongoing or planned heroin-assisted treatment trials in Australia, Canada and certain European countries.     

To integrate or deintegrate?: Fitting public health into New Zealand's reforming health system

The relationship between public health and clinical medicinehas been the subject of international debate. In New Zealandsuccessive restructurings of the health sector have seen significantchanges in this relationship and the status of public health.The paper traces these changes over a decade of public sectorrestructuring (1984–1993) and shows how public healthpolicy and the purchasing and delivery of public health serviceshave been subject to integration, deintegration and reintegrationwith clinical and treatment services. Some advantages flowedfrom integrating policy, purchasing and delivery, includinga comprehensive approach to tackling problems through nationalhealth goals and targets. On the other hand, there is evidencethat public health was financially disadvantaged by this association.A separate public health structure, set up in 1992 and led byan independent Public Health Commission, brought some benefits.These included a specific budget and a high profile for publichealth. It also created tensions between competing policy agencies,a fragmented purchasing system for public health and exposedpublic health to political interference. This led to the abolitionof the Commission in 1995 and the reintegration of policy makingat the national level and purchasing at the regional level.At the end of 1996 a new coalition government formally abandonedthe commercial elements of its predecessor's health reforms.The new policy requires the main providers of hospital and relatedservices, which continue to include public health, to focuson health gains for their defined populations. With the integrationof policy and purchasing this should lead to the promotion ofbetter integration at the service delivery level.     

The sociodemographic patterning of health in Estonia, Latvia, Lithuania and Finland

BACKGROUND: Public health problems in the Baltic countries are typical of Eastern European transition economies. A common assumption is that the economic transition has been particularly difficult for previously disadvantaged groups, and comparative research on the health differences between sociodemographic groups in the Baltic countries is therefore needed. This study compared associations of health with gender, age, education, level of urbanization and marital status in three Baltic countries and Finland. METHODS: The data were gathered from cross-sectional postal surveys conducted in 1994, 1996, 1998 and 2000 on adult populations (aged 20-64 years) in Estonia (n = 5052), Latvia (n = 4290), Lithuania (n = 7945) and Finland (n = 12796). Three self-reported health indicators were used: (i) perceived health, (ii) diagnosed diseases and (iii) symptoms. RESULTS: The prevalence of less-than-good perceived health (average, rather poor or poor) was higher in the Baltic countries (men 66-56%, women 68-64%) than in Finland (men 35%, women 31%). The odds ratios (with 95% confidence intervals) of less-than-good perceived health among the low educated compared to the highly educated in Estonia, Latvia, Lithuania and Finland were 2.03 (1.49-2.77), 2.00 (1.45-2.76), 2.27 (1.78-2.89) and 1.89 (1.61-2.20) among men, and 3.32 (2.43-4.55), 2.77 (2.04-3.77), 2.07 (1.61-2.66) and 1.89 (1.63-2.20) among women, respectively. Diseases and symptoms were also more common among the lower educated men and women in all four countries. However, urbanization and marital status were not consistently related to the health indicators. CONCLUSIONS: The Baltic countries share a similar sociodemographic patterning of health with most European countries, i.e. the lower educated have worse health. The methodological considerations of this study point out, however, that further research is needed to support public health policies aimed at the most vulnerable population groups.     

Factors associated with self-rated health in Greece: a population-based postal survey

BACKGROUND: Self-rated health (SRH), as an indicator of population health, is a concept useful both for research and planning. This study reports SRH, and factors related to it, in Greece. METHODS: Population-based postal survey, using World Health Organisation (WHO) questionnaires with a sample of randomly selected geographically stratified individuals. Response rate reached 41%. RESULTS: As expected, age, income and education were related to SRH, but accounted for only 20% of the variance. CONCLUSIONS: SRH in Greece is related to sociodemographic factors, but perhaps not as strongly as in other populations. Other explanatory variables will require further research.     

Managing the gap between demand and publicly affordable health care in an ethical way

A major health policy challenge of the 1990s is to manage thegap between the demand for health care and our ability to payfor care and to do so in an ethical way. This paper describesEuropean responses to the gap, which have been to do nothing,to do more with the same or less resources, to do more withmore resources, to change behaviour and attitudes and to definehealth needs more narrowly. These responses have not reducedthe gap and cannot prevent it from widening in the future. Rationingand prioritizing are other responses, which will have an increasinglyimportant role. This paper proposes that the survival of publichealth care systems depends on recognizing and ‘managing’the gaps and doing so in an ethical way. Conventional responseshave ethical problems equal to or more serious than those involvedin rationing and prioritizing. The paper proposes that rationingand prioritizing must become more central methods for managingthe gap between resources and demand in the future, but thatsuch approaches will need to be more explicit and ethical ifthey are to gain public support.     

History of public health research in Estonia: A review

The University of Tartu (which was founded In 1632) and itsDepartment of Public Health (Hygiene) have been the centre ofpublic health research in Estonia. Environmental factors suchas living conditions, water, soil, air and food have been thetraditional topics. The study on blind people and people sufferingfrom eye diseases among the rural population of Livonia conductedby Professor Himmelstiern in 1856–1859 proved to be thefirst epidemlological study in Russia. Professor Körber,a supporter of a statistical approach in research, founded thelocal school of demographers in 1890s. Professor Khlopin's stayin Tartu (1895–1903) was a very fruitful period. He andhis students paid much attention to communal hygiene. ProfessorRammul, the head of the department in 1920–1940, initiatedand supervised an extensive medicogeographical study of overallEstonia. The Second World War and post-war years caused a standstillin research. A revival occurred in the end of 1950s when ProfessorKask returned to the department. After his death (1968), AssociateProfessor Ulbo and Professor Jannus continued his work. Theirmain study areas were concerned with public health aspects ofthe water supply, nutrition of pre-school children and theirprovision with vitamins, work conditions and health risks ofsome occupations. During resent years the area of research hasenlarged to comprise health risks due to lifestyle factors,health economics and health care management topics. After thewar special medical research institutes were established. Theyhave made a considerable contribution to public health researchin Estonia.     

European training in public health: A practical experience

Development of public health in Europe requires the human resourcesnecessary for planning and managing programmes with a European,intersectoral and multidisciplinary approach, based on the ‘healthfor all’ strategy. In this paper the European TrainingConsortium in Public Health (ETC-PH) presents the experienceof 4 years of developing educational activities and materialwith these approaches. Participants from different countriesand 5 institutions concerned with training in public healthhave been involved. Evaluation is positive both for studentsand teachers and an ETC network and project register have beencreated as a way for communication to continue and for the consortiumto offer ongoing support to all participants.     

Access to health care for asylum seekers in the European Union--a comparative study of country policies

BACKGROUND: The aim of our article is to characterise and compare current standards of health care provision for asylum seekers in the 25 European Union (EU) countries in order to identify the needs and potential for improving access to health care for asylum seekers. METHODS: The study is based on an e-mail survey performed between April and June 2004. The questionnaire was concerned with asylum seekers' access to medical screening upon arrival, and their general access to health care services on April 1, 2004. The questionnaire was sent to ministries and NGOs responsible for asylum seekers' health care in the 25 EU countries. A total of 60% of the ministries and 20% of the NGOs responded. We received answers from 24 out of the 25 countries. RESULTS: Medical screening was provided to asylum seekers upon arrival in all EU countries but Greece. The content of screening programs, however, varied as well as whether they were voluntary or not. We found legal restrictions in access to health care in 10 countries. Asylum seekers were only entitled to emergency care in these countries. A number of practical barriers were also identified. Legal access to health care changed during the asylum procedure in some countries. Access to specialised treatment for traumatised asylum seekers existed in most countries. CONCLUSION: Health policies towards asylum seekers differ significantly between the EU countries and may result in the fact that the health needs of asylum seekers are not always adequately met.     

Struggle for control: General practitioners in the Swedish health care system

This paper reports on findings on the perspectives of generalpractitioners (GPs) in Sweden since the introduction of theStockholm model. The research design was exploratory with theintention of discovering several perspectives shared by doctors.The subjects were asked to describe their work, how long theyhad been working and to describe whether they were familiarwith the Stockholm model. Questions also focused on professionalautonomy, the use of diagnostic related groups (DRGs), the Isolationof work and the possible impact on patient care. While previousresearch suggests that doctors may be losing autonomy, the experiencein Sweden, in particular, as it relates to GPs, may be different.Most of the doctors interviewed reported that the Stockholmmodel had increased productivity and efficiency, that economicincentives influenced their medical decisions and that medicaltreatment appears more patient focused than before. GPs reportedan enhanced social and economic status within the medical professionsince the introduction of the Stockholm model.     

Public Health Renaissance and the Role of Schools of Public Health

In these turbulent times of political, social and economic changesin Europe public health is again coming into focus. Schoolsof public health, for long the basis for education of publichealth leaders will also in the future play a key role in promotingthe ‘new’ public health agenda. Based on ecologicalawareness and public involvement in health their teaching, researchand policy development should make them be seen as Centres ofRelevance and not only as Centres of Excellence, thus gearingtheir activities to the needs of new generations of practitionerswho can be both activists and advocates for health. If trainingand research are made relevant for practice and community service,then schools will be in the centre of public health insteadof in the periphery of medicine. Elements of a strategy to achievethese objectives are discussed.