Choice and solidarity: the health sector in Eastern Europe and proposals for reform

The citizens of Eastern Europe have witnessed an unprecedented social and economic transformation during the past decade of transition from socialism to market-based economies. We describe the legacy of socialism and summarize the current state of the health sector in ten Eastern European countries, including financing, delivery, purchasing, physician incomes and the widespread phenomenon of under-the-table payments. The proposals for reform, derived from explicit guiding principles, are based on organized public financing for basic care, private financing for supplementary care, pluralistic delivery of services, and managed competition, with attention to incentives and regulation to impose a constraint on overall health spending.     

Dilemmas of health promotion and political changes in Eastern Europe

Mortality and morbidity trends in the Western and the Easternparts of Europe have differed considerably during the past threedecades. The ‘socialist’ political regimes havebeen largely responsible for the deterioration of health ofthe population. The main features of this unfavourable situationcan be summarized as follows: low value set on man, on humanlife and health; extreme tensions between depressed living standards,aspirations and their gratification; negative effects of thereproduction of the social structure; chronic lack of genuinehuman communities, human relationships and social support, disordersof the value system. The author presents in case study the dilemmasthe Hungarian health promotion programme has to face. In the1990s in Eastern Europe health promotion has to face the followingchallenges: How is it possible to carry out effective preventiveactivities under circumstances of economic crisis, lack of resourcesand the population's declining living standards? What will bethe new responsibilities in prevention related to poverty, deprivationand unemployment? What will the new health care system be like?How should health be promoted in reorganizing local societies,communities? In the Eastern Europe of today, there is a greaterneed than ever before for health promotion.     

Regional collaboration in public health training and research among countries of South Eastern Europe

It is argued that each country of South Eastern Europe should have its own school of public health. However, a basic prerequisite of modern public health training is the comprehensiveness of the programme and a worldview approach. Most of the countries of South Eastern Europe face the same difficulties to adapt their inherited communist structures of public health training to Western standards. A regional collaboration would facilitate the process of establishing schools of public health in all countries of the region and support the training of public health professionals at all levels. KEY POINTS: South East Europe includes Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Macedonia, Moldavia, Romania, Serbia and Montenegro, and Slovenia. Public health institutions in South East Europe face similar difficulties to adapt their inherited teaching structures to Western standards. Public health institutions in South East Europe should make a joint effort towards establishing regional training programmes. A regional approach in public health training would enable an efficient use of resources in countries of South East Europe.     

Health behaviour, risk awareness and emotional well-being in students from Eastern Europe and Western Europe.

Life expectancy and other indices of health have deteriorated markedly in the former socialist countries of Eastern Europe over recent decades. The possible roles of lifestyles, knowledge about health and behaviour, emotional wellbeing and perceptions of control were assessed in a cross-sectional survey of young adults of similar educational status in Eastern and Western Europe. As part of the European Health and Behaviour Survey, data were collected in 1989-1991 from 4170 university students aged 18-30 years from Austria, Belgium, the Federal Republic of Germany, the Netherlands and Switzerland, and from 2293 students from the German Democratic Republic, Hungary and Poland. Measures were obtained of health behaviours, awareness of the role of lifestyle factors in health, depression, social support, health locus of control, and the value placed on health. After adjustment for age and sex, East European students had less healthy lifestyles than Western Europeans according to a composite index of 11 health behaviours, with significant differences for seven activities: regular exercise, drinking alcohol, avoiding dietary fat, eating fibre, adding salt to food, wearing a seat-belt, and using sunscreen protection. East European students were less likely to be aware of the relationship between lifestyle factors (smoking, exercise, fat and salt consumption) and cardiovascular disease risk. In addition, they were more depressed (adjusted odds of elevated scores on the Beck Depression Inventory of 2.46, 95% C.I. 1.95-3.09), reported lower social support, and had higher beliefs in the "chance" and "powerful others" locus of control. Internal locus of control levels did not differ across regions, and Eastern Europeans placed a higher valuation on their health. Unhealthy lifestyles associated with lack of information about health and behaviour, greater beliefs in uncontrollable influences, and diminished emotional well-being, may contribute to poor health status in Eastern Europe.     

Future Scenarios for Public Health in Europe

The public health task is determined by a combination of demography,patterns of ill-health and the availability of policies andinterventions which can make an impact on health outcomes. Thechanging political and administrative environment provides bothopportunities and threats for the public health enterprise inEurope. If we are to optimize our contribution public healthpractitioners must acquire a strategic overview of the issueswhich need to be addressed. There are tools available whichcan help in the process of strategic analysis which come fromthe world of business. Such tools may not seem initially attractiveto those working in the public sector, however, they shouldbe judged by their utility in generating understanding and indicatingappropriate policy directions. The application of some suchtools would seem to indicate a mismatch and a tension betweenthe old and new public health agendas and the institutionalarrangements which support them. This paper is intended to stimulatea debate about the most effective way forward whereby a widerange of energies can achieve the greatest synergy.     

The development of medical sociology in Eastern Europe, 1965-1990

The article primarily analyses factors which stimulated thedevelopment of medical sociology in Eastern Europe and presentsboth the differences and similarities in countries of the Easternblock. The dominant political ideology and its changes whichtook place between 1965 and 1990, constitute a general contextof considerations. Among other analysed factors is the strengthand tradition of local sociologies in particular countries aswell as specific demands constrained by medicine. The articlefurther presents the main theoretical inspirations and researchproblems undertaken by medical sociology in Poland, where theaccomplishments of this discipline are relatively high.     

我部医疗保健工作的管理

为了以一流的标准做好重点对象医疗保健工作，本介绍了该部开展医疗保健工作的体会。一是强化组织领导，强化保健意识，强化措施到位，强化激励机制，强化硬件建设；二是强化管理，从健全完善制度，加强能级管理，周密科学安排，严格质量把关等方面入手，按万无一失地要求落实保健工作。三是优质服务，通过加强窗口建设，狠抓学习提高，鼓励技术创新，重视保健教育等手段，以一流的标准完成保健工作。     

Homosexuality and HIV/AIDS prevention: the challenge of transferring lessons learned from Western Europe to Central and Eastern European Countries

In order to stem the rapidly growing HIV/AIDS epidemics in Eastern Europe a transfer of prevention know-how and experience from Western European countries is necessary. The success of such a transfer is contingent on addressing a number of challenging issues. Monolithic ideas of East/West difference need to give way to the growing empirical evidence which not only shows a tremendous diversity but also many similarities among the 51 countries within the WHO European region. These include similarities regarding sexual attitudes and HIV prevention needs. Western constructs such as a gay identity need to be de-emphasized however, when it comes to promoting human rights (and thus improving HIV prevention for men who have sex with men) in Central and Eastern Europe. In asking the question of what should be transferred from Western Europe to other countries, both the strengths and weaknesses of the last 20 years of prevention need to be considered. In terms of Western European research the strength lies in identifying the social structural causes of HIV transmission. In terms of practice, the successes of instituting country-level structures while also working within the gay community are to be emphasized. Short-comings are evident in terms of reaching men of lower socio-economic status, cultural minorities and sex workers. On such questions, the expertise of Europe as a whole is needed in order to find new answers.     

Treatment targets in patients with type 2 diabetes set by primary care physicians from Central and Eastern Europe

Background: Primary care physicians have an important role in the care of patients with Type 2 diabetes but little is known about this issue in Central and Eastern European countries.

Objectives: To investigate the treatment goals of patients with type 2 diabetes mellitus (type 2 DM) set by primary care physicians in Central and Eastern European countries and illustrate inter-country variation.

Methods: A cross-sectional survey of primary care physicians randomly chosen in nine countries. A validated questionnaire was used. Physicians reported treatment goals for patients with type 2 DM.

Results: A total of 44.1% of physicians, reported the acceptance of HbA1c < 6.5% (48 mmol/mol) as a treatment goal, whilst 40% chose lower levels (< 6.1%; 43 mmol/mol). In all countries, 62% of physicians set FPG at a level of < 6.0 mmol/l. Most respondents set low BP levels as a goal of therapy (47% of physicians in all countries: BP < 130/80 mmHg and 48% < 120/80 mmHg). A TC level < 4.5 mmol/l and a LDL-C level < 2.5 mmol/l were reported as the targets for patients with diabetes by 51% and 69% of all respondents, respectively. The overall differences between all the countries were statistically significant (P < 0.01).

Conclusion: For patients with diabetes approximately half of physicians set treatment goals at levels that were recommended within the international guidelines. Most of them set treatment goals for HbA1c and BP at very low levels. Educational efforts to raise awareness about new treatment goals are needed.     

Air pollution and mortality in Central and Eastern Europe: An estimate of the impact

Air pollution is severe in some areas of Central and EasternEurope but the quality and representativeness of measurementsare not consistent. Studies in the Czech Republic and Polandhave shown an impact of air pollution on overall mortality,post-neonatal mortality and lung cancer. Estimates in this papersuggest that air pollution may cause up to 3% of all-cause,all-age mortality in the Czech Republic, which is some 9% ofthe mortality gap between this country and Western Europe. Theimpact in other countries of Central and Eastern Europe is probablysmaller.     

Towards a common public health strategy for the region of South Eastern Europe

Aim

A seminar organised in the framework of the Public Health Collaboration in South Eastern Europe programme (PH-SEE), Belgrade, Serbia and Montenegro, 23–28 August 2004, aimed to answer the question: Is there a real need for a regional public health policy framework in South Eastern Europe (SEE)? The answer is probably yes because the specific situation in the SEE region has to be taken into account for the development of relevant and realistic public health goals.

Methods

To evaluate the current situation in the SEE region, Strengths, Weaknesses, Opportunities and Threats (SWOT) methodology was applied. A set of key messages and recommendations have been formulated. Based on the priorities identified and agreed upon, PH-SEE experts formulated five goals.

Results

The result of very intensive work was a framework for a regional SEE public health strategy being drafted during the seminar. An initial 5-year term was established beginning in 2005. This framework represents only a first step towards an officially agreed upon regional strategy framework.

Conclusions

The purpose of that exercise was to demonstrate the benefits of regional collaboration by using the technical competence and experience of public health professionals in the region. Moreover, the harmonisation with European Union (EU) public health standards and policies must be considered in health policy development in the region.     

Towards a stakeholders' consensus on patient payment policy: the views of health‐care consumers,providers, insurers and policy makers in six Central and Eastern European countries

Background

Although patient charges for health‐care services may contribute to a more sustainable health‐care financing, they often raise public opposition, which impedes their introduction. Thus, a consensus among the main stakeholders on the presence and role of patient charges should be worked out to assure their successful implementation.

Aim

To analyse the acceptability of formal patient charges for health‐care services in a basic package among different health‐care system stakeholders in six Central and Eastern European countries (Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine).

Methods

Qualitative data were collected in 2009 via focus group discussions and in‐depth interviews with health‐care consumers, providers, policy makers and insurers. The same participants were asked to fill in a self‐administrative questionnaire. Qualitative and quantitative data are analysed separately to outline similarities and differences in the opinions between the stakeholder groups and across countries.

Results

There is a rather weak consensus on patient charges in the countries. Health policy makers and insurers strongly advocate patient charges. Health‐care providers overall support charges but their financial profits from the system strongly affects their approval. Consumers are against paying for services, mostly due to poor quality and access to health‐care services and inability to pay.

Conclusions

To build consensus on patient charges, the payment policy should be responsive to consumers'' needs with regard to quality and equity. Transparency and accountability in the health‐care system should be improved to enhance public trust and acceptance of patient payments.     

Health indicators in the European regions--ISARE II

BACKGROUND: Most comparisons of health data in Europe take place at the national level. However, there is increased interest in looking at health data at a sub-national level. This is because of the increased importance in many European countries, of regions and devolved powers to them. This study aimed to establish the availability of health data at a regional level and to construct an experimental database. METHODS: Using a network of country correspondents, data were collected on a series of topics from all the regions of that country. In addition, a supplementary list of data was collected from one region of each country. RESULTS: Out of the then 15 Member States of the European Union (EU), 14 countries participated in the study. Thirteen countries were able to supply data. Where data were available, using the criteria we developed, these were of relatively good quality. Data on mortality was most readily available, but data on the important public health topics such as obesity was much more difficult to obtain, and absent in many cases. CONCLUSIONS: It is possible to construct a database and a resultant set of indicators for relevant sub-national areas of Member States in the EU. This is not likely to be achieved through current routine data collection systems unless significant changes are made to the data collection processes such as those undertaken by Eurostat. There is, also, an urgent need to introduce comprehensive sub-national data collections on important public health topics such as obesity and smoking.     

Private practice in Slovenia after the health care reform.

BACKGROUND: Slovenia is one of the many post-socialist countries which started its reorientation of the health care system in the early 1990s. One of the aspects of the reform was the introduction of independent practice, which is performed either as a purely private practice on the basis of out of pocket payment or through contract with the National Health Insurance. A combination of both is also possible. In 1992 and 1993 the first physicians started to work in that way. The physicians that took this opportunity belonged to three main groups: dentists, primary health care physicians and secondary care specialists. The groups differ regarding their style of work and possibilities for running a profitable service. No studies have been done to evaluate the success of their decision. OBJECTIVES: The aim of the study was to evaluate the motives for leaving salaried posts, practice organization, perceived improvements and satisfaction with their choice of the practitioners who started to work independently in Slovenia in 1992 and 1993. METHODS: An anonymous questionnaire was sent to all self-employed physicians that started their independent practice in 1992 and 1993. A 54.5% response rate was achieved. The analysis of non-responders has shown that they did not differ significantly according to sex, location of practice, speciality or method of payment, from the responders. RESULTS: The analysis shows that the reported reasons for choosing independent practice are not different across the groups. Possibility for greater income was not reported as a major reason for leaving public service. There are important differences in organization of work: general practitioners reported spending more time on patient contacts and administration than the other two groups; they also work exclusively for the National Health Insurance, which is not the case for the other two groups. The perceived areas of improvement differ substantially. Regardless, the overall satisfaction with their choice is high (over 90% would make the same decision again), the general practitioners are the most dissatisfied group. CONCLUSIONS: The analysis shows that self-employed physicians in Slovenia represent three different groups with different positions regarding how they earn their money. Their expectations have largely been met, since they claim that the doctor/patient relationship is better, as well as some conditions for the patients. A follow-up study that would take into account the long-term effects of privatization, and analysis of economic functioning and patient satisfaction would be necessary in order to verify these claims.     

基层医疗保健机构孕产妇保健服务利用现状与相关因素分析

目的 探究影响孕产妇利用保健服务的相关因素,并结合地区实际,提出了相关建议和措施.方法 对在我院进行保健服务的1558名孕产妇进行调查分析,结合实际情况用SPSS 18.0统计学软件进行系统分析.结果 文化程度、家庭年收入水平、居住地距离、职业和医保等因素对孕产妇保健服务利用影响较大;同时,在1 558名受访者中,接受孕前保健指导的比率相对较低,早孕检查、5次以上产检率和住院分娩率结果相对较高,说明近几年来孕产妇对保健服务利用的意识有所提高,但产后访视比例仅为21.76％,比例较低.结论 针对当前现状,研究认为,个人、基层医疗保健机构及卫生管理部门等各方应当分别在提高认识水平、提高服务水平及加强基层系统建设等方面进行改善,以提高孕产妇保健服务的利用,提高优生优育水平.     

Public health training in Europe. Development of European masters degrees in public health.

BACKGROUND: Changing political and economic relations in Europe mean that there are new challenges for public health and public health training. There have been several attempts to develop training at the master's level in public health which is focused on meeting the new needs. These have failed due to being too inflexible to allow participation by schools of public health. METHODS: A project funded by the European Union involving public health trainers has developed a new approach which allows participating schools to retain their national differences and work within local rules and traditions, but which aims to introduce the European dimension into public health training. This paper reports the conclusions of this project. CONCLUSIONS: A network of schools wishing to develop European Master's degrees is being established and other schools offering good quality programmes will be able to join.     

Antenatal HIV screening in Europe: a review of policies

BACKGROUND: The increased prevalence of HIV infection in women is leading to a rising number of children born to HIV-infected mothers. As therapeutic possibilities for HIV/AIDS increase, the detection of undiagnosed HIV infections in pregnant women, followed by adequate management, is of crucial interest. Therapeutic protocols are being updated and increasingly applied in most European countries, but there is no structured information on policies and strategies with regard to antenatal HIV screening as such. METHODS: In order to identify national policies with regard to antenatal HIV screening, a structured questionnaire was sent to key-informants within the ministries of health and national institutes for public health in each of the 25 EU Member States. RESULTS: Information was obtained from all EU Member States with the exception of Cyprus and Luxembourg. Eighteen countries issued a national policy with regard to antenatal HIV screening, 16 opted for a system in which HIV testing is offered to all women attending antenatal services while only two opted for selective screening. None of the 18 countries with a national policy supports a mandatory screening strategy. The voluntary testing strategies are of two types: opting in versus opting out. In almost all EU countries with antenatal HIV screening policies, screening conditions are defined. CONCLUSION: Policies are in place in most EU countries. Nevertheless, there is a need for more integrated European policies and region-specific recommendations on the performance of antenatal HIV screening as an opportunity for comprehensive HIV/AIDS service delivery. This would enable the different aspects of prevention to be linked and also address both the needs of pregnant women and mothers as well as that of their infants.     

Clinical and psychosocial service needs of children and families affected by human immunodeficiency virus in Europe

Background: Although human immunodeficiency virus (HIV)-infectedchildren have specific service needs, uninfected children bornto HIV-infected mothers are also likely to be profoundly affectedby HIV. However, there has been little systematic documentationof services available for families with HIV infection in Europeor any investigation into service use by families and theirsatisfaction with current provision. Methods: A two-part surveywas carried out: interviews with service-providers in 15 paediatricHIV centres in Europe were carried out to obtain informationon current provision of clinical and psychosocial services.This was followed by an anonymous, self-completed questionnairesurvey of parents and carers of children attending ten of these15 centres. Results: Most (nine out of 15) centres had weeklycase-loads of more than ten HIV-infected and -affected children.Three-quarters (138 out of 182) of the families surveyed includedat least one HIV-infected child. In most (13 out of 15) clinicsa psychosocial professional was routinely available, in additionto paediatricians. Service users reported general satisfactionwith clinic organization, such as medical appointment schedules,continuity of in-and out-patient care and coordination of adultand child appointments. The level of information provided wasconsidered satisfactory by most service users, although parentstended to be less satisfied than alternative carers. Sick parentsand unemployed respondents had the highest level of serviceuse and three-quarters of service users reported unmet serviceneeds. Conclusion: The range of services provided was remarkablysimilar across countries, which may reflect the fact that allcentres were referral centres. However, the challenge of meetingthe outstanding service needs of certain families remains.