From totalitarianism to pluralism in Poland: Problems of transformation on the health scene

An analysis of the social ramifications of the proposed healthcare reforms in Poland Is presented. Poland's health care systemis undergoing profound change. The consequences of these changesmay not be fully appreciated by the government, its representative,or the public at large. Health care has long been the victimof political ideology in Poland and it seems that it still is.For example, decentralization and privatization are seen asthe solutions to all problems, in large measure because nationaland local budgets are not sufficient to cover the costs of care.However, most citizens cannot afford the cost burden and believethat all citizens should have a minimum level of social protectionand that certain vulnerable groups (e.g. children, handicappedpersons, the elderly) should not be required to pay for services.The new reforms must go hand in hand with changes in infrastructureand need to consider social attitudes towards personal responsibilityfor health.     

Building public health associations in the transition countries of south-eastern Europe: the example of Albania

The Albanian Forum of Public Health (AFPH), an umbrella organization including different public health associations operating in Albania, was established in March 2004 with the support of the European Public Health Association (EUPHA) and the Open Society Institute (OSI). Ever since its establishment the AFPH has been an open arena wherein opinions and options for rational health policies comprising all relevant issues of the New Public Health are discussed, formulated, and documented near the Albanian Ministry of Health. Notwithstanding the laudable mission of the AFPH, there is an emerging need to establish a regional Public Health Forum in south-east Europe as a basic prerequisite for sustainable development of public health in these countries. Most conveniently, this regional umbrella organization should have a supporting Secretariat based in one of the south-east European countries. Nevertheless, there is a clear call for international funding with participation of different agencies and bodies (OSI, EUPHA, Canadian International Development Agency, and the Stability Pact). A regional association in the south-east Europe would enable the organization of annual conferences in the most renowned institutions in the region. Also, a regional collaboration among public health associations would be a suitable start for the development of research in south-east Europe. Furthermore, the existence of a regional public health association would make feasible the establishment of a scientific public health journal for south-east Europe in the English language.     

Population health and the health system: a comparative analysis of avoidable mortality in three nations and their world cities

BACKGROUND: Access to timely and effective medical services can reduce rates of premature mortality attributed to certain conditions. We investigate rates of total and avoidable mortality (AM) and the percentage of avoidable deaths in France, England and Wales and the United States, three wealthy nations with different health systems, and in the urban cores of their world cities, Paris, Inner London and Manhattan. We examine the association between AM and an income-related variable among neighbourhoods of the three cities. METHODS: We obtained mortality data from vital statistics sources for each geographic area. For two time-periods, 1988-90 and 1998-2000, we assess the correlation between area of residence and age- and gender-adjusted total and AM rates. In our comparison of world cities, regression models are employed to analyse the association of a neighbourhood income-related variable with AM. RESULTS: France has the lowest mortality rates. The US exhibits higher total, but similar AM rates compared to England and Wales. Rates of AM are lowest in Paris and highest in London. Avoidable mortality rates are higher in poor neighbourhoods of all three cities; only in Manhattan is there a correlation between the percentage of deaths that are avoidable and an income related variable. CONCLUSIONS: Beyond the well-known association of income and mortality, persistent disparities in AM exist, particularly in Manhattan and Inner London. These disparities are disturbing and should receive greater attention from policy makers.     

中国东、中、西部地区农村老人健康状况及影响因素分析

目的通过对中国东、中、西部地区农村老人健康状况差异调查及相关影响因素分析,为国家平衡推进不同地区健康老龄化提供参考。方法于2014年3—5月采取立意抽样方法对江苏省海安县、河南省南乐县、青海省大通县抽取的3 053名≥60岁农村老人进行问卷调查。结果东、中、西部地区农村老人在经济水平、养老需求、患病情况、医疗服务利用等多方面存在差异;农村老人最常见的慢性病患病率依次为高血压38.78%(1 184/3 053)、关节炎29.97%(915/3 053)、心脏病16.80%(513/3 053);高血压中部患病率48.73%(497/1 020)>东部34.33%(344/1 002)>西部33.27%(343/1 031),关节炎西部患病率42.48%(438/1 031)>中部24.61%(251/1 020)>东部22.55%(226/1 002),心脏病西部患病率25.90%(267/1 031)>中部13.53%(138/1 020)>东部10.78%(108/1 002),糖尿病东部患病率8.68%(87/1 002)>西部6.30%(65/1 031)>中部5.49%(56/1 020);中、西部地区患有≥2种慢性病的老人明显高于东部地区,差异有统计学意义(P<0.01)。结论农村老人健康状况存在地区差异,东部地区老人健康状况好于中、西部地区;地区、年龄、性别、家庭结构及平时的生活方式与老人健康状况相关。     

Lessons for health strategies in Europe: The evaluation of a national health strategy in England

Objectives: To determine the impact of the national health strategyfor England, ‘Health of the Nation’ (HOTN) at thelocal level; the mechanisms by which this was achieved; andto provide lessons for the new strategy, ‘Saving lives:our healthier nation’. Design: Case studies. Semi-structuredInterviews with key actors across a range of organisations (n=133),analysis of documents (n=189), and analysis of expenditure forthe period 1991/1992 – 1996/1997. Setting: Eight randomlyselected English health authorities. Main outcome measures:Perceptions and documentary evidence of the impact of HOTN onlocal policy and changes In expenditure. Results: Three modelsof implementation were Identified: strategies based directlyon HOTN; HOTN plus additional elements (‘HOTN plus’);and strategies under another label such as healthy cities orurban regeneration. There was clear commitment to Intersectoralwork and some support for joint appointments of directors ofpublic health by health and local authorities. HOTN was seenas failing to address underlying determinants of health, reducingcredibility with key partners. Views were divided on whetherto adopt a population- or disease-based model. Consistency incentral government policies and communication of the strategywere criticised. HOTN was universally perceived as increasinghealth promotion activities, particularly in the key areas.HOTN received few mentions in corporate contracts and generalpractice reports. Expenditure on health promotion activitiesIncreased slightly then declined, and HOTN appears to have hadonly limited influence on resource allocation. Conclusions:Central government, In England, should enable rather than prescribestrategy implementation. It should ensure appropriate structuresare in place and that national polices are consistent with thestrategy. There is a debate about where the responsibility forhealth strategy should lie, whether with the NHS or local authorities.The new strategy should address different audiences: local government;the NHS; the voluntary sector; the private sector; and the public.One model is the matrix approach of the European Commissionhealth promotion programme. HOTN failed to engage three groups:the public, primary care, and the private sector. This studyhas important implications for the monitoring of the new strategy.It needs to be firmly embedded in the work of those who mustimplement it. It should be incorporated into the NHS performancemanagement framework. The current financial reporting mechanismspreclude monitoring expenditure on a health strategy. Ring-fencingsome resources for the new strategy should be considered, ifonly to give it the high priority it requires. This study, bothin terms of the methods used to evaluate the strategy and thelessons learned, could be used by other European countries developingand evaluating their own health strategies.     

Managing the transitions: a Western European View of Health Care Development in Eastern Europe

The health care systems of Eastern Europe are undergoing rapidchange. Ministries of Health in the Eastern countries are turningto the West for solutions. This paper offers an overview ofthe health systems of four Eastern European countries, the catalystsof reform in those countries, and possible strategies for managingthe transitions. The objectives of health care reform are outlinedas well as the key issues and obstacles facing Eastern governmentsas they attempt to change both the structure and function ofhealth care systems.     

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.     

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.     

Differences in prevalence of overweight and stunting in 11-year olds across Europe: The Pro Children Study

OBJECTIVES: To assess country differences in prevalence of overweight, obesity, underweight and stunting in the Pro Children Survey. METHODS: A cross-sectional study conducted in a random sample of schools in nine European countries in 2003. The subjects were 8317 11-year-old children from Austria, Belgium, Denmark, Iceland, The Netherlands, Norway, Portugal, Spain and Sweden. Parents reported height and weight of the children, and BMI values were analysed using the US Centers of Disease Control and Prevention and the International Obesity Task Force reference populations. Continuous variables were compared with one-way analysis of variance (ANOVA) with Games-Howell post hoc tests. Categorical variables were analysed using chi-square tests. RESULTS: The prevalence of overweight + obesity varied between the countries from 8.6% to 30.6% and 5.9% to 26.5%, respectively, depending on the reference population, with the lowest prevalence in Dutch girls, the highest in Portuguese boys. Obesity prevalence varied from 1.1% (Dutch and Danish girls) to 10.7% (Portuguese boys) and from 0.3% (Dutch girls) to 6.2% (Portuguese boys), respectively. Portugal and Spain had the highest prevalence of overweight and obesity for both genders. The ranking of the countries according to overweight and obesity prevalence was roughly the same, independent of reference population. The prevalence of underweight varied from 2.3% (Swedish boys) to 12.3% (Belgian boys), using the American reference population. The proportion of stunted children was highest in Portugal, Spain and Belgium. CONCLUSIONS: The highest levels of overweight, obesity and stunting in the pro children material are found in Portugal and Spain.     

Access to health care for induced abortions: analysis by means of a French national survey

BACKGROUND: With an incidence of 15 per thousand, abortion is a common reproductive event in France. This study describes conditions of access to health care for abortions based on women's reports, taking into account the woman's background and the influence of the first professional contacted. METHODS: A representative sample of 2,863 women, aged 18 to 44, was interviewed by telephone between September 2000 and January 2001. Of these women, 480 had an abortion in the last 10 years. MAIN RESULTS: The choice of first professional depended on women's background, as we found differences according to age, educational level or past induced abortion. This choice affected subsequent access conditions, in terms of time delay or complexity of patterns of care to access abortion services. Women who first contacted a private gynaecologist, which is the most frequent situation in France, had more direct and shorter patterns of care. Conversely, general practitioners were associated with longer and more indirect patterns of care, especially when women were less well educated. CONCLUSION: This study reveals the heterogeneous nature of patterns of access to an abortion in France. It also raises questions concerning the training of general practitioners, who seem to be less well prepared to take charge of a request for an abortion than other professionals. Efforts must be made to better inform women and these professionals about the process required for abortions.     

Unemployment and health in Spain: The influence of socio-economic environment

We present the results of a study on the association betweenunemployment and health and the use of health services, exploringthe influence of the socio-economic environment on these relationships.With this aim, data from the Spanish National Health Survey(SNHS) were used. Health was measured by subjective health status,presence of chronic illnesses and psychological symptoms. Theuse of health services was measured by drug consumption (overthe counter and/or prescribed drugs), doctor consultation, hospitaladmission and casualty attendance. A total of 13,344 individualsaged between 16 and 65 years were included. Results were analysedfor all of Spain and for 3 regions with different socio-economiclevels: Andalusia, Catalonia and the Basque Country. Althoughin Spain as a whole there was a relationship between unemployment,ill health and more use of health services, this relationshipvaried for the selected regions. Thus, in Catalonia and theBasque Country, where unemployment rates have dramatically increasedin recent years, this relationship was maintained, while inAndalusia, where high unemployment rates have been a long-standingphenomenon, the relationship was less clear. It is suggestedthat the economic and social environment might be critical indetermining the relationship between unemployment and health.     

Purchasing for health gain: The problems and prospects for purchasing for health gain in the "managed markets" of the NHS and other European health systems

"Purchasing for health gain" a phrase used to describe a strategicrole for purchasing bodies which were established in 1990 aspart of the UK NHS reforms. Is it an empty phrase, serving tohide the reality of purchaser's main task of controlling expenditure?Will the operational difficulties encountered in the first twoyears of the reforms continue to stand in the way of a strategicrole for public purchasing bodies? Is a strategic role impossiblein an "managed market" for health care? This paper considersthe concept of health gain and the difficulties encounteredby NHS purchasers. It is argued that 1) the term "internal market"is inadequate to describe the different frameworks and combinationsof features in different public health care systems with managedcompetition; 2) purchasing for health gain is more difficultin some types of "managed market" than in other types; 3) theway the UK market is developing may increase, rather than reducethe difficulties; 4) there is no evidence as yet that primarycare purchasers cannot purchase for health gain if they areorganized and rewarded for doing so; 4) performance assessmentof purchasers and purchaser competition would reduce their costsand increase their effectiveness in purchasing to improve thehealth status of their populations; 5) value choices are integralto purchasing for health gain and new processes and institutionsare needed to decide priorities and to introduce explicit rationing.The prospects, some solutions, and the implications for othercountries introducing similar changes are discussed.     

世行贷款卫生项目与中央卫生专项资金项目管理模式比较研究

文章从项目规划立项、项目执行和监测评价等方面对世行贷款卫生项目和中央卫生专项资金项目进行比较研究,旨在总结世行贷款卫生项目与中央卫生专项资金项目基本管理模式的基础上,促进两种资源的统筹利用,优势互补,改进项目管理水平,进一步提高卫生财政资金的使用效率。     

A framework and toolkit for capturing the communicable disease programmes within health systems: tuberculosis control as an illustrative example

The frameworks and methods used for analysis, monitoring and evaluation of communicable disease control vary greatly. Although a number of manuals exist instruments for a detailed analysis of wider health system context are lacking. This is surprising given that the success of vertical programmes is often determined by the constraints of health systems. The importance of the context and the health system in determining the successful implementation of national tuberculosis programmes is well recognized by the WHO, which recommends analysis of national tuberculosis programmes within the context of health care system, health reform and the economic status of the country. However, current approaches inadequately capture intelligence on the health systems variables impacting on programme efficacy, limiting the ability of policy makers to draw lessons for wider use. A recent WHO report highlights the major systemic constraints to DOTS implementation and recommends a comprehensive and multi-sectoral approach to tuberculosis control. This obviates the need for tools that take into account health systems issues as well as focusing on a particular vertical programme but no such comprehensive tool exists. This paper outlines the conceptual basis for a model and a toolkit for rapid assessment, monitoring, and evaluation of the context, the elements of the health system and vertical communicable disease programme. It describes the framework, the potential strengths and weaknesses, approach and piloting of the toolkit and its two elements: first for 'horizontal assessment' of the health system within which the programme is embedded and second for 'vertical assessment' of the infectious disease-specific programme.     

大连市集中空调场所军团菌污染及人群健康状况影响调查

目的调查大连市集中空调场所冷却塔水军团菌污染状况及暴露人群中军团菌隐性感染状况,研究军团菌对人群健康的影响因素。方法2005年8～9月,随机采集大连市使用集中空调的32所公共场所集中空调冷却塔水,采用分离病原培养法进行军团菌检测;随机抽取使用集中空调场所的工作人员血样,采用微量凝集试验法,进行血清军团菌抗体检测。结果大连市公共场所集中空调冷却塔水军团菌检测的场所阳性率为53.13%,军团菌血清型分别为嗜肺军团菌(Legionella pneumophila,Lp)Lp7、Lp8、Lp9和Lp10型。其中,Lp9型28株,占总菌株的77.78%,为优势菌株。人群血清学抗体检测显示,使用集中空调的公共场所人群Lp10感染率较高。结论大连市使用集中空调的场所存在军团菌污染,人群中存在军团菌隐性感染。     

Welfare state regimes and differences in self-perceived health in Europe: a multilevel analysis

The aim of this study was to determine the degree to which welfare state regime characteristics explained the proportional variation of self-perceived health between European countries, when individual and regional variation was accounted for, by undertaking a multilevel analysis of the European Social Survey (2002 and 2004). A total of 65,065 individuals, from 218 regions and 21 countries, aged 25 years and above were included in the analysis. The health outcomes related to people's own mental and physical health, in general. The study showed that almost 90% of the variation in health was attributable to the individual-level, while approximately 10% was associated with national welfare state characteristics. The variation across regions within countries was not significant. Type of welfare state regime appeared to account for approximately half of the national-level variation of health inequalities between European countries. People in countries with Scandinavian and Anglo-Saxon welfare regimes were observed to have better self-perceived general health in comparison to Southern and East European welfare regimes.     

Health consumer and patients' organizations in Europe: towards a comparative analysis

Despite the rise of health consumer and patients’ organizations (HCPOs) in modern health‐care systems, studies are few and far between. In particular there is a lack of comparative research across Europe and at the pan‐European level. In an effort to address this gap, an expert workshop was held in Vienna in February 2006. This involved 22 delegates from 10 European Countries and was funded by the European Science Foundation (ESF). The workshop reviewed the development of HCPOs in Europe and their role in the policy process in order to establish a platform for further research in this field. It found evidence of an increase in HCPOs across European countries, increased engagement with policy makers and political institutions, and the creation of alliance organizations bringing together HCPOs across the sector. However, variations between countries were observed, relating to different political, cultural and health system contexts. There was no consensus on whether the rise of HCPOs constituted a new social movement. An increase in HCPO activity at the pan‐European level was noted, reflecting the increased interest of EU institutions in health policy. At both domestic and European levels, concerns about the representativeness and legitimacy of HCPOs were raised as well as questions about their independence (notably with regard to the drugs industry). HCPOs face a number of obstacles including: lack of capacity and resources, fragmentation and the power of more established interests within the health‐care system. The workshop concluded that further research is needed in this field, in the form of a comparative study of HCPOs in European countries and an analysis of their activities at the pan‐European level.     

Trends in cancer mortality in central European countries: The effect of age, birth cohort and time-period

An analysis of changes in mortality from major cancer sitesand all cancer sites combined in 6 central European countries,considered as a Western group of countries [Germany (the formerFRG), Switzerland and Austria) and an Eastern group of countries(Poland, Czechoslovakia and Hungary) is presented. Cancer mortalityand population data have been obtained from the World HealthOrganization Mortality Database and are available over at least20 years. They have been analysed using age-period-cohort modelsand birth-cohort and time-period effects are presented graphically.The group of Eastern countries shows consistent and continuingincreases in male lung cancer risk in contrast to the patternin the group of Western countries, where after increases inolder cohorts, the risk has stabilized or gone down in malecohorts born after around 1910. Steady and continuous increaseshave been, in general, observed for women In both groups ofcountries. All tobacco- and alcohol-related cancers considereddemonstrate very similar patterns in men: an initial decreaseIn mortality by birth cohort with a subsequent Increase In morerecently born cohorts. While all the countries considered demonstratecontinuing decreases in stomach cancer risk for both sexes,cohort-based increases have been observed In Eastern countriesfor colorectal cancer, prostate cancer and female breast cancer.These results demonstrate the magnitude of the increasing mortalityfrom tobacco- and alcohol-related cancers In the countries consideredand emphasize the importance and potential of public healthmeasures In preventing such increases continuing in the future.