The challenge of public health transition in South Eastern Europe

The transition countries in the region of South Eastern Europe (SEE) share the historical burden of communism and four centuries of Ottoman dominance. In spite of deep, inherited rifts, they are going to develop multilateral collaboration as expressed in the Dubrovnik Declaration of 2001. Recently, a common public health strategy was drafted and a regional Forum for Public Health agreed upon. This special issue of the Journal of Public Health provides an overview of relevant developments in SEE with reference to new schools of public health and national public health associations.     

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.     

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.     

National health interview surveys in Europe: an overview.

In order to study the value of national health interview surveys for national and international research and policy activities, this paper examines the existence and content of recent and future health interview surveys in the 15 member states of the European Union (EU), Norway, Iceland and Switzerland. National health interview surveys are performed in most countries, but not in Greece (only regional surveys), Luxembourg, Ireland and Iceland (only multi-purpose surveys). The health interview surveys in the other 14 countries provide regular data on the main health topics. Of the 14 health topics that are examined in this inventory seven are measured in all countries. Questions on health status (e.g. self-assessed health, long-term physical disability, and height and weight) and medical consumption (e.g. consultations with the general practitioner, GP) are often included. Lifestyle topics are less often included, except smoking habits, information about which is sought in all countries. Topics like diet and drugs/narcotics are more often included in special surveys than in general health interview surveys. Despite differences in the content, frequency and methodology of national health interview surveys in different countries, these surveys are a valuable source of information on the health of Europeans.     

Resources for development of training in public health and health managment in Eastern Europe: the Kaunas experience

The aim of this paper is to review the resources and steps required for development and evaluation of training in public health and management of public health as experienced in Kaunas University of Medicine, Lithuania. The transition from Departments of Social Medicine and Hygiene to a Faculty of Public Health of international standards requires a process of adaptation and development of human resources more than physical facilities. After restoration of independence in 1990, rapid development of training in public health was started in Lithuania. Great support was provided by the international projects Baltic Rim Partnership for Public Health (BRIMHEALTH) and European Union Trans-European Mobility Scheme for University Students (TEMPUS). Undergraduate and postgraduate training programs were successfully implemented in the Faculty of Public Health, Kaunas University of Medicine. Lithuanian experience could serve as an example of success and pitfalls in training a critical mass of professionals who should act as powerful advocates for health, promoting analysis, continuity and success of public health interventions, and health care reforms in countries in transition.     

The international community and the reconstruction of health care in South Eastern Europe

Today, with the aid of the international community [European Union (EU), World Bank (WB), World Health Organisation (WHO), United Nations Children's Fund (UNICEF), nongovernmental organisations (NGOs), Global Fund (GF), Stability Pact, etc.] the ministries of health in transitional countries in the South Eastern Europe (SEE) region are in the process of expanding the capacities and skills of the health workforce in order to achieve successful health care reform and accomplish necessary steps for EU integration. The aim of this paper is to review international community support to reconstruction of the health care in SEE countries, with main focus on the EU and WB donors and projects. Review was done on the basis of existing donor reports, Internet search (search of official Web sites and electronic databases, check of references from selected documents, and use of a generic Internet search engine) and authors’ experience from different health projects. The governments of SEE countries, in order to create an effective and efficient health system, overcame a period of transition and soon or later became ready for the process of EU integration, and began working on the following issues: rehabilitation, reconstruction and equipping of health facilities; developing a health strategy and policy documents; legislation and financing framework; building institutional, human resource and management capacity; health care sector reform; support to public health development and restructuring of the pharmaceutical sector. In many SEE countries, the capacity of the Ministry of Health and Health Insurance Fund was strengthened, and policy and strategy documents were drafted to guide reorganisation and reorientation of health care services. The public health system was strengthened. A family medicine model was introduced and developed in most countries. Development of enabling legislation mostly followed proposed changes in the health system. Although progress on several important fronts in achieving transition and progress in the rehabilitation health sector in SEE countries is significant, a lot remains to be done. Experience in some countries can be used to stimulate, motivate and encourage professionals throughout the civil service to grasp with both hands the opportunities for positive change.     

Eastern Europe and the former Union of Soviet Socialist Republics: animal health systems in transition

The economic transition in Eastern Europe and the former Union of Soviet Socialist Republics (USSR) during the last decade has profoundly changed the agricultural sector and the well-being of people in rural areas. Farm ownership changed; selected farm assets, including livestock, were transferred to farm workers or others, and the social and service structures of rural society are in a state of uncertainty. The transition has, in general, led to the deterioration of rural services. Animal health services have also deteriorated. This decline is associated with the contraction of the livestock inventory, the fragmentation of farms, higher transaction costs for service providers, and the overall decline of the rural economy which has, so far, lowered the demand for animal health services. There are considerable differences in the way that these countries are coping with the economic transition and its aftermath. Among the determining factors in the former USSR are, as follows: the speed of recovery from the legacies of large State-controlled farming and a centrally planned animal health system, the efforts made to address poverty reduction, the choice on whether to become a Member of the World Trade Organization and the requirements of such membership, the ability to provide low-cost services to a fragmented and unskilled livestock production sector. In Eastern Europe, the requirements for joining the European Union (EU) are an additional and important determining factor. In the short term, the choice of a veterinary system to serve the livestock sector may differ from country to country, depending on the legacies of the past, the status of reforms and the proximity of Western markets. Lower-income countries with an oversupply of veterinarians may support labour-intensive, low-cost systems which focus on food security and public health. The better-endowed EU accession countries may focus rather on improved disease surveillance, production enhancement, quality assurance and increased food safety. Such choices may also determine the investment made by these countries in upgrading their State system, laboratories and veterinary education facilities.     

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.     

Heatwaves and public health in Europe

Public health measures need to be implemented to prevent heat-related illness and mortality in the community and in institutions that care for elderly or vulnerable people. Heat health warning systems (HHWS) link public health actions to meteorological forecasts of dangerous weather. Such systems are being implemented in Europe in the absence of strong evidence of the effectiveness of specific measures in reducing heatwave mortality or morbidity. Passive dissemination of heat avoidance advice is likely to be ineffective given the current knowledge of high-risk groups. HHWS should be linked to the active identification and care of high-risk individuals. The systems require clear lines of responsibility for the multiple agencies involved (including the weather service, and the local health and social care agencies). Other health interventions are necessary in relation to improved housing, and the care of the elderly at home and vulnerable people in institutions. European countries need to learn from each other how to prepare for and effectively cope with heatwaves in the future. Including evaluation criteria in the design of heatwave early warning systems will help ensure effective and efficient system operation.     

Developing schools of public health in countries of Eastern Europe and the Commonwealth of Independent States

Countries of Eastern Europe and the Commonwealth of Independent States are facing a combination of difficulties in health including high rates of mortality from preventable diseases, and pressures for reform of their health care systems. The development of schools of public health is an important priority for international aid and for national government attention. This provides a challenge of integrating experience from many countries in the industrialized world and academic centers of excellence in the field of public health. Traditional departments of social hygiene within medical academies need to evolve to educate new generations of doctors to cope with challenges facing the health systems in these countries. Development of post-graduate centers of training will also be needed as independent schools of public health within single or multi-faculty universities to train health workers in a New Public Health. This paper outlines the mission of a school of public health (SPH), and the steps needed to achieve its objectives, with examples of several schools at relatively advanced and moderate levels of development. The purpose is to provide guidelines for those SPHs under development that are seeking international support and resources.