Preventive Health Care Systems in the Russian Federation
Preventive Health Care Systems in the Russian Federation
Progress Report N3.
Volume II
ANNEXES
May 1999
|Content |
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| page number |
|7.1 |COMPONENT 1: POLICY | |
|7.1.1 |Program and a list of participants. Round Table “ Development of public health policy and health| |
| |promotion in Russia”, April 16 1999 | |
| |Draft Concept on Health Protection of the population of the Russian Federation in the period of | |
| |economic and social transition | |
| |Resolution of the Round Table “ Development of public health policy and health promotion in | |
| |Russia”, April 16 1999 | |
|7.1.4 |Reports on relations between federal regional and local legislation on HP & DP ( in Russian) | |
|7.1.5 |Analysis of 8 federal and regional legislative papers on HP & DP ( in Russian) | |
|7.1.6 |Analysis of the draft Federal Health Care Law ( EU expert review) | |
|7.1.7 |Analysis of the federal draft Law on Smoking Restriction | |
|7.1.8 |Program of the Conference “ Health promotion and disease prevention in Russia”, 25- 27 May 1999 | |
| |( in Russian) | |
|7.1.9. |Materials on the seminar “ Financial analysis and reimbursement system in primary health care”, | |
| |May 1999, Vologda oblast | |
|7.1.10. |Preliminary report on financial analysis in Electrostal city and Vologda oblast | |
|7.1.11. |Preliminary analysis of regional target programs in Vologda oblast | |
|7.1.12. |Program “ Work place health promotion and disease prevention among municipal employees in the | |
| |city of Electrostal” ( final version) | |
| | | |
|7.2 COMPONENT 2: NETWORKS AND TRAINING |
| |
|7.2.1 |Materials of the 4th ToT Seminar, March, 1999 ( in Russian) | |
| |Proposal on the introduction of Public health Schools in the Russian Federation | |
| |Materials of the Round Table on Sexually- Transmitted Diseases, March 1999 | |
| |Draft working papers on training on HP & DP ( in Russian) | |
| | | |
|7.3 |COMPONENT 3: MONITORING AND INFORMATION | |
| | | |
| |Program and materials of the Training course on survey methodology | |
| |Materials of the meetings of the monitoring group, April- May 1999 | |
| |Report “ Monitoring on the level of primary care in Holland” | |
| |Report “ Youth health care and life- style monitoring in Holland” | |
| |Report on health system in Finland and the role of data registers and health surveys | |
| |Process evaluation ( CINDI handbook) of the health promotion practice in Vologda oblast ( | |
| |preliminary joined report) | |
| |Program of the seminar “ Subjective and objective indicators of health” | |
| |Preliminary report on the Public Health Survey in Vologda oblast ( in Russian) | |
|7.3. 9. |3rd & a special Issue of the Information Bullitine ” Express profilactica” ( in Russian) | |
|7.3.10. |Article ” First steps in realization of the Tacis Russia Preventive Health Care project” ( in | |
| |Russian) | |
|7.3.11. |Health education leaflets ( in Russian) | |
| | | |
|7.4 |COMPONENT 4: PRIMARY HEALTH CARE | |
|7.4.1. |Materials of seminars on non- pharmaceutical treatment of hypertension, Vologda oblast | |
|7.4.2. |Report on the implementation of the Program “ Non- Pharmaceutical Treatment of Hypertension” , | |
| |Vologda oblast | |
| |( in Russian) | |
|7.5 |STUDY TOURS | |
| | | |
| |Summary Table on study tours, March- May 1999 | |
| |Report on the Study Tour “ Teaching in HP & DP” to the Netherlands, 20 March- 2 April, 1999 | |
| |Report on the Study Tour “ Establishing the Information Center on Health Promotion” to Finland, | |
| |11- 18 April 1999 | |
|7.5.4. |Report on the Study Tour on regional health policies development to Wales ( United Kingdom), 18-| |
| |23 April 1999 | |
|7.5.5. |Report on the Study Tour “ Teaching HP & DP in schools” to Finland, 17- 23 May, 1999 | |
| |Report on the Study Tour “ International Walk Test Leader Course” to Finland, 19- 24 May 1999 | |
|7.5.6. |Report on the study tour to the Congress of Atherosclerosis society, Greece, 26- 30 May 1999 | |
| | | |
|7.5.7. |OTHER ANNEXES | |
| | | |
| | | |
| | | |
|7.6.1. |Agreed plan of activities in Tchelabinsk oblast | |
|7.6.2. |Agreed plan of activities in Orenburg city | |
| | | |
| | | |
ANNEX 7.1
POLICY, LEGISLATION AND FINANCING
ANNEX 7.1.1
Program and a list of participants. Round Table “ Development of public health policy and health promotion in Russia”, April 16 1999
Ministry of Health of the Russian Federation
The Tacis Russia Preventive Health Care Project
Round Table
The Development of Public Health Policy & Health Promotion in Russia
Friday, April 16 1999
Objectives:
• To discuss the draft Concept on protection of health of the population of
the Russian Federation in the transition period
• To assist in the development of federal and regional public health and health promotion policies
• To promote the establishment of co- operative links between various actors in public health.
• To discuss opportunities and threats for the new public health policies.
Participants:
• Members of the Steering Committee and Executive Board of the
Tacis Project
• Officials of the Ministry of Health and other Ministries of Russia
• Regional Authorities
• Russian scientists and researchers
• Non- governmental organizations
• EU Tacis, EC and WHO experts
Other International Agencies
10:30-10:50 Registration of the participants
Round Table Discussion
Chairman: Gennady G. Onischenko /First Deputy Minister of Health, Russian Federation
| | |
|11:00-11:15 |Opening of the Round Table Discussion |
| |Gennady G. Onischenko |
|11:15-11:30 | Implementation of the Tacis Russia Preventive Health Care Project Nikolay V. Shestopalov |
|11:30-11:45 |Draft Concept on Health Protection of the population of the Russian Federation during the |
| |period of economic and social transition |
| |Rafael G. Oganov |
| | |
| |European public health policy in the XXI century |
|11:45-12:15 |Irina Sokolova- Snegir |
| |Pauliina Aarva |
|12:15- 12:45 |WHO Health for All strategy in the XXI century |
| |B.Serdar Savas |
|12:45-13:00 |Coffee- break |
|13:00-13:30 |Discussion |
|13:30-14:00 |Comments on the draft Concept on Health Protection of the population from the federal and |
| |regional perspectives |
| | |
| |Oleg P. Schepin |
| |Ivan А. Pozdnjakov |
| | |
| |Valery I. Ljuschin |
| | |
|14:00-14:30 Discussion |
|14:30-15:00 Lunch |
| |
|Steps of the Tacis Russia Preventive Health Care Project to support the development of public health and health |
|promotion policies in Russia |
|Chairman: Nikolay V. Shestopalov / Deputy Head, Sanitary and Epidemiology Department, Ministry of Health, Russian |
|Federation. |
| | |
| |Legislation and financing |
| | |
| |Review of the federal legislation on health promotion in Russia. Valentina S. Tsarkova |
|15:00-15:15 | |
|15:15-15:30 |The importance of financial analysis for the development of health policies. Example of the |
| |city of Electrostal. |
| |Ilkka Vohlonen |
| |Ljudmila M. Pestun |
| |Networking and training. |
| | |
|15:30- 15:45 |The improvement of professional training in health promotion and disease prevention. |
| |Anna M. Kalinina |
| |Emilia G. Volkova |
|15:45-16:00 |Coffee- break |
| |Monitoring and information systems |
| | |
|16:00-16:15 |The use of the process evaluation of preventive practice. Example of the study in Vologda |
| |oblast. |
| |Vladimir.B.Filatov |
| |Tatjana A. Kamardina |
| | |
|16:15-16:30 |The use of population surveys in the development of public health policies. Example of the |
| |Public Health Survey in Vologda oblast |
| |Vladimir A. Iljin |
|16:30-16:45 |Proposals for the improvement of the medical statistical data collection. |
| |Tamara M. Maximova |
| | |
| | |
| |Demonstration projects |
|16:45-17:00 |Demonstration projects in Vologda oblast: school health promotion programs, pilot out- |
| |patient clinics programs and public awareness campaign |
| |Alexander I. Popugaev |
|17:00-17:40 |Discussion |
|17:40-18:00 |Future perspectives of the Tacis Russia Preventive Health Care Project in the development |
| |and implementation of health promotion policies in Russia |
| |Pauliina Aarva |
| | |
| |Closing of the Round Table Discussion |
|List of participants: |
|The Steering Committee, Tacis Russia Preventive Health Care Project |
|Chairman | |
|Onischenko, Gennady G. |First Deputy Minister of Health, Russian Federation |
|Gerasimenko, Nikolay F. |Chairman, Health Committee, State Duma, Russian Federation |
|Kolinko, Alexander A. |Head, Health Authority, Vologda region |
|Komarov, Youri M. |Director, Research Institute “Medsoceconominform”, Ministry of |
| |Health, Russian Federation |
|Kulagin, Stanislav M. |Adviser, President Administration, Russian Federation |
|Ljabin, Vasily V. |Head, Health Authority, Deputy Head, Administration, Moscow |
| |region |
|Luschin, Valery I. |First Deputy Head, City Administration, Electrostal |
|Naigovzina, Nelly B. |Assistant to the First Vice- Prime Minister, Russian Federation|
|Oganov, Rafael G. |Director, Research Institute of Preventive Medicine, Ministry |
| |of Health, Russian Federation |
|Paltsev, Mikhail A |Rector, Moscow Sechenov Medical Academy, Ministry of Health, |
| |Russian Federation |
|Pozdnjakov, Ivan A. |First Deputy Head, Regional Administration, Vologda region |
|Schepin, Oleg P. |Director, Research Institute of Social Hygiene and Management, |
| |Ministry of Health, Russian Federation |
|Surovov, Mikhail V. |Deputy Head, Research department, Ministry of Education, |
| |Russian Federation |
|Tegay, Nina D. |Head, Organization department, Mandatory Health Insurance Fund |
|Vshanov, Nikolay I. |Deputy Head, Family, women and children department, Ministry of|
| |Labor and Social Affairs |
| |
|The Expert Advisory Board, Tacis Russia Preventive Health Care Project |
| | |
|Chairman |Deputy Head, Department of the Sanitary and Epidemiology, |
|Shestopalov, Nikolay A. |Ministry of Health, Russian Federation |
|Glazunov,Igor S. |Head, department of formulation of policy of prevention of non-|
| |communicable diseases, Research Institute of Preventive |
| |Medicine, Ministry of Health, Russian Federation |
|Filatov, Vadim B. |Head, Department of methodology of the |
| |development of health promotion, Semashko Institute of social |
| |hygiene, economics and management |
|Kalinina, Anna M. |Head, Prevention department, Research Institute of Preventive |
| |Medicine, Ministry of Health, Russian Federation |
|Maximova, Tamara M. |Head, department of research on social and hygiene monitoring |
| |of public health , Semashko Institute of social hygiene, |
| |economics and management |
|Selin, Youri M. |Head, department of training of medical and pharmaceutical |
| |staff, Research and academic institutions unit. |
|Tsarkova, Valentina S. |Health Committee, State Duma, Russian Federation |
|Vyalkova, Galina M. |Deputy Head, department of organization of health facilities, |
| |Federal Mandatory Health Insurance Fund organizational unit |
|Other participants: | |
|Russian: | |
|Avvakumov, Grigory A. |Head, Health education department, Sanitary and Epidemiology |
| |Committee |
|Denisov, Igor N. |Deputy rector, Sechenov Moscow Medical Academy |
|Dartau, Ljudmila A. |Head, population research section, Trapeznikov Institute of |
| |management, Russian Academy of Science |
|Iljin, Vladimir A. |Director, Vologda, Research co- ordination center, Russian |
| |Academy of Science |
| | |
|Kalev, Oleg F. |Deputy Rector, Treatment activities, State Medical Academy, |
| |Tcheljabinsk |
|Kamardina, Tatjana V. |Chief specialist, Research Institute of Preventive Medicine, |
| |Ministry of Health, Russian Federation |
|Kasimov, Riza A. |Chairman, Management Board, Center for prevention of cardio- |
| |vascular diseases, Vologda |
|Kucherenko, Vladimir Z. |Head, Health care management department, Moscow Sechenov |
| |Medical Academy, Ministry of Health, Russian Federation |
|Lebedkova, Svetlana E. |Head of the department, Medical Academy, Orenburg |
| | |
|Lindenbraten, Alexander L. |Deputy Director, Semashko Institute of social hygiene, |
| |economics and management |
|Marchenko, Tatjana |Co- ordination unit for technical assistance of EC countries |
|Melnikova, Ljubov S. |Head, department of the Ministry of Health, Russian Federation |
|Nechaev, Vasily S. |Long- term expert, The Tacis Russia Preventive Health Care |
| |Project |
|Ovcharov, Vladimir K. |Deputy Director, Semashko Institute of social hygiene, |
| |economics and management |
|Pestun, Ljudmila M. |Deputy Chief Doctor, District Medical Unit, Electrostal city |
|Potapchik, Elena |EU Tacis Health Care Management Project |
|Potemkina, Rimma A. |Deputy Head, department of formulation of policy on prevention |
| |of non- communicable diseases, Research Institute of Preventive|
| |Medicine, Ministry of Health |
|Popugaev, Alexander I. |Deputy Head, Regional Health Authority, |
| |Vologda Oblast |
|Pristyazhnjuk, Valentina I. |Member of Parliament, Moscow Duma |
|Salakhoutdinova, Sevil |EU Tacis Health Care Management Project |
|Shabunova, Alexandra A. |Head, group of sociological information and socio- economic |
| |research, Russian Academy of Science |
|Shevtchenko, Klara I. |Deputy Minister of Health, the Republic of Karelia |
|Shishkin, Sergey |EU Tacis Health Care Management Project |
|Semivelichenko, Tamara N. |Head, Health authority, Orenburg city |
|Solovjeva, Olga G. |Chief specialist, Curative services department, Ministry of |
| |Health, Russian Federation |
|Syrtsova, Ludmila E. |Head, department for medical professional training, Ministry of|
| |Health, Russian Federation |
|Tkatchenko, Elena V. |Long- term expert, The Tacis Russia Preventive Health Care |
| |Project |
|Tcherniavski, Valery E. |EUROHEALTH programme, World Health Organization, Regional |
| |Office for Europe |
|Volkova, Emilija G. |Deputy Rector, Postgraduate Medical Academy, Tcheljabinsk |
| | |
|Volodin, Nikolai N. |Deputy Head, department for medical research institutions, |
| |Ministry of Health, Russian Federation |
|Yurishev, Yury A. |Tacis Monitoring Programme, Russian Federation |
|Zhukovsky, Georgy S. |Deputy Director, Research Institute of Preventive Medicine, |
| |Ministry of Health, Russian Federation |
|International: | |
|Aarva, Pauliina |Project manager, The Tacis Russia Preventive Health Care |
| |Project |
|Alderslade, Richard |Regional Adviser, Partnership in Health and Emergency |
| |Assistance |
| |World Health Organization, Regional Office for Europe |
|Axelsson, Runo |Team Leader, The Tacis Project “ Governance of Social Security”|
| | |
|Brinkman, Nico |The Netherlands School of Public Health |
|Harper, Jonathan |The Tacis Health Care Management Project |
| | |
| |EU expert, The Tacis Project “ Governance of Social Security” |
|Fotaki, Marianne | |
|Lindroos, Mauno |EU expert, Tacis Russia Preventive Health Care Project |
|Milen, Anneli |Co- director, The Tacis Russia Preventive Health Care Project |
|McLure, Douglas |Tacis Monitoring Programme, Russian Federation |
|Savas, Serdar |Director, Programme Management, |
| |World Health Organization, Regional Office for Europe |
|Siegel, Paul Z. |Medical epidemiologist. Center for Disease Control. Atlanta USA|
|Siem, Harald |Special Representative of the Director- General in Moscow |
| |World Health Organization |
|Sokolova- Snegir, Irina |Acting Head, Department for Human Resources, Tacis sector, |
| |Delegation of the European Commission in Russia |
|Thielman, Klaus |EU Tacis Health Care Management Project |
|Vohlonen, Ilkka |Long- term expert, The Tacis Russia Preventive Health Care |
| |Project |
ANNEX 7.1.2.
Draft Concept on Health Protection of the population of the Russian Federation in the period of economic and social transition.
Draft, March 1999
Prepared by the Research Institute of Preventive Medicine of the Ministry of Health of the Russian Federation.
Major health problems of the population of Russia.
The social and economic changes in Russia within the past ten years were accompanied by the deterioration in health of the population. Crude mortality rates in Russia is on an average 1.5 times higher than in other economically developed countries. The differences are the most prominent in death rates from diseases of the Circulatory system ( 2 times as higher), accidents, poisonings and traumas ( 2- 3 times as higher), and infectious diseases, largely in males ( 2- 4 times as higher). Infant mortality in Russia is 2-3 times as higher than in other countries. This is largely related to the complications during pregnancy and birth as well as perinatal pathology. The most dangerous diseases in the society at present are tuberculosis, HIV and other STDs, and drug addiction, particularly among adolescents. High mortality rates contributed to the low compare to other economically developed countries, life expectancy at birth, especially among male population ( 10 years less).
The main determinants of the mortality rate and its trends are various risk factors. They include behavior and lifestyle ( smoking, heavy drinking, unhealthy diet, low physical activity and others); environment ( psycho- social stress, unsafe physical environment, and poor living and working conditions); and human biology which is a cumulative result of genetic factors and behavioral and environmental factors
( higher level of blood pressure, lipids and blood lipoproteins, excessive weight and others).
A significant increase in mortality in 1992- 1994, might be linked to the psychosocial stress resulted from the social and economic changes combined with the effect of the major risk factors existing within the past several decades.
A decrease in mortality in 1995- 1998 might be related to the adaptation of the population to the social and economic effects of the reforms, and thus psychosocial stress, as well as reducing of several risk factors such as excessive weight, dislipidemy and ecological factors. Another explanation is the natural selection when the weakest part of the population with major chronicle diseases died in 1992- 1994.
However, despite the trend to reducing in mortality and increasing of life expectancy at birth, the indicators are much worse than in other economically developed countries. The prevalence of the major risk factors is still very high. In the situation of additional psychosocial stress which might happen due to the worsening of economic and social conditions, there is a possibility of an increase in mortality rates and decrease in life expectancy at birth. To prevent these negative trends and promote a further decrease in mortality, the implementation of urgent preventive measures in the transition period is needed.
The major efforts should be concentrated on the risk factors that can be removed, and which are related to the lifestyle and physical environment. They include:
• to reduce the prevalence of smoking;
• to improve the type and quality of diet;
• to increase physical activity;
• to prevent or reduce the effect of psychosocial factors;
• to reduce alcohol consumption;
• to prevent drug addiction;
• to prevent HIV and other STDs;
• to prevent the negative effect of ecological factors and improve physical environment;
• to encourage vaccination programs;
The priorities and strategies at the regional and local levels may differ significantly depending on the situation and capacities available.
The improvement of the situation in relation to the risk factors particularly lifestyles will lead to reducing mortality from cardio- vascular diseases, external causes ( accidents, poisonings, traumas), mobidity and mortality from infectious diseases which are the major contributors to the premature deaths in Russia.
For instance, the calculations of the expected mortality indicators by major risk factors which were done based on the multifactoral models, showed that if the effect of four risk factors ( smoking, hypertension, high cholesterol level and excessive weight) are reduced by 15 % in the working population groups, the mortality rate including mortality from cardio- vascular diseases will decrease by 10 %.
The development of the comprehensive concept of the protection and promotion of health of the population of Russia in the period of social and economic reforms is needed.
Aim of the Concept: to encourage positive trends in the health status of the population of Russia by reducing the number of premature deaths.
Objectives:
• to change behavior of the population and promote healthy lifestyles;
• to improve social and physical environment;
• to promote preventive practices eithin health care services;
• to encourage intersectoral co- operation;
Major principals of the implementation of the Concept.
To ensure the successful implementation of the Concept, the following principals should be followed:
➢ Integrated approach. Because the risk factors are common for most chronicle diseases, the efforts to identify and reduce them should be unified.
➢ Intersectoral co- operation. Health care is unable to implement complex health promotion and disease prevention programs using exclusively its own resources. The extent of the co- operation will depend on a particular problem and preventive interventions.
➢ Encouragement of international co- operation to find the most effective approaches to address the problems.
➢ Support of research and involvement of scientists to the development and implementation of health promotion programs.
➢ Use of two preventive approaches, population and high risk groups. These approaches should not contradict each other as their combination leads to the maximum effect.
➢ Implementation of health promotion programs at the federal, regional and local levels. Two later levels should be prioritized.
➢ The priority population groups for preventive activities should include children, adolescents, women of fertile age and working population.
Strategies.
Encouragement of health promotion policies. By policy we understand the achievement of consensus with legislative and executive bodies of power regarding priorities, approaches and strategies of health promotion and disease prevention.
The policy should be implemented at the federal, regional and local levels. The change of health policies at different levels is effective to promote changes in individual behavior and creating the basis for promotion of health in the society. Because the determinants of health are linked to the every day life of the people, two main approaches in the implementation of the policy are essential:
1. to promote and support the intention of people to change their lifestyle
2. to create safe and healthy physical and social environment which would support these changes( “to make a healthy choice easy”).
A number of policy papers which cover various aspects of health promotion were developed in Russia within the past five years. They include “ Concept of the development of health care and medical science in the Russian Federation”;
“ To Healthy Russia. Policy of health promotion and disease prevention with the priority on non- communicable diseases.”, “ Concept of protection and promotion of health of the population of the Russian Federation by the methods of health education”, “ Concept of the public policy on healthy diet of the population of the Russian Federation until the year 2005”. At present based on the above documents a comprehensive Concept on protection and promotion of health in the Russian Federation in the period of social and economic changes should be developed.
Encouragement of intersectoral approach. Health Care system alone can not solve the health problems resulted from the impact of various factors including political, economic, social, environmental and other determinants. To improve the health of the population at any level there should be involvement of different actors in the society, medical, non- medical and the population.
Intersectoral co- operation for health promotion and disease prevention suggests building a network between various sectors of the society. The partners of the health care include legislative and political structures, regional administrators, education, social, culture and sports sectors, mass media, police, food industry, agriculture, various international agencies and programs.
The achievement of consensus is a process which requires time, negotiations and co- ordination at any level, nation, regional or local. It requires the establishment of federal, regional and local intersectoral co- ordination structures of the highest administrative level with the involvement of legislative and executive powers and other sectors of the society. To implement intersectoral co- operation and achieve the agreement of the principals and strategies for health promotion, regular conferences and meetings should be organized. The type of the partners involved to the co- operation depends on a particular problem and approaches to its solution.
Improvement of legislation. Article 2 of the Basics of the legislation on health protection and promotion of the population says that prioritizing of preventive activities is one of the principals of health promotion of the population. However, this declaration is formal, as neither mechanisms of its implementation nor control mechanisms and sanctions were determined.
To ensure the legislative basis for health promotion, the development of legislation on health promotion should be strategically planned. This work should involve representatives of various sectors, both medical and non- medical. Some responsibilities to develop legislation can be forwarded to the regions according to the Agreement on the division of responsibilities between federal and regional authorities.
There should be the following types of laws and regulations. They would vary according to the urgency of the problem, types of strategies, level of responsibility, schedule and forms of implementation:
• federal laws
• federal government policies/regulations
• sector/institution policies/decrees
• regional laws
• regional government policies/regulations/decrees
• local government policies/regulations/decrees
• organizational policies/regulations
The following areas of legislation should be developed:
▪ financial policy to support health promotion and disease prevention;
▪ legislation on promotion of the appropriate physical and social environment for healthy behavior and lifestyles;
▪ legislation on reconsidering the structures and functions within health care services;
▪ regulations to promote complex and intersectoral approaches and co- ordination of the activities of various Ministries and sectors;
▪ encouragement of health care authorities to support the development of the regional legislation.
The priority should be given to the development of the legislation on tobacco and antismoking, antialcohol policies and health care system.
Assurance of financial and other resources. The cost of preventive programs are much lower than the cost of treatment and social support of people with disabilities.
Even a minor reduction of the effect of the risk factors result in the decrease in mortality and mobidity. For instance, the decrease of the level of cholesterol by 1 % or blood pressure by 1 mm mc will result in the decrease of the risk of cardio- vascular diseases in the population by 2-3 %.
The main approach to assure the financial resources to support health promotion programs is the intersectoral co- operation. Health is the responsibility of the whole society. It is largely determined by social and economic factors. Health problems can not be solved by the health care sector alone without the involvement of other sectors of the society. This principals should be understood by the Parliament, by the government, by the whole population and every individual person. Searching for resources primarily suggests searching for partners, building a coalition which will allow to increase both financial and human resources.
Health care system itself has a potential to allocate resources to health promotion. Funding for preventive activities should be separated from the whole health care funding. Within this funding priorities should be clearly defined. In the situation of the deficiency of financial resources, preventive demonstration programs should be primarily funded. This will show in practice what and how can be done as well as prove effectiveness and efficiency of preventive programs.
To develop preventive practices, financial resources should be reallocated within the health care sector. A per capita principal of funding should substitute for financing per a number of hospital beds. This process is starting in Russia. A part of resources allocated to the Primary Health Care ( PHC) should be increased. There should be funding for preventive activities within the PHC. One of the sources of funding of preventive activities in PHC is Health Insurance resources. Another important source of funding of preventive programs is an earmarked tax on tobacco and alcohol, financial sanctions on those who violate health protection laws and regulations and private contributions.
Strengthening preventive practices within health care services. Strengthening preventive practices within health care requires the development of structures which implement health promotion and prevention activities at the federal, regional and local levels.
These structures in the health care system are health institutions, Preventive medicine centers, Family planning centers, HIV/AIDS prevention centers, sanitary and epidemiology ( Sanepid) facilities. It is enough to have the existing structures to organize the work on health promotion and disease prevention. However, their activities should be co- ordinated and integrated both within the health care sector and with other social services, non- governmental organizations ( NGOs) and the mass media.
Health care services should be reoriented from treatment into prevention of diseases. Preventive strategies should be focused on primary prevention and health promotion at the population level. This strategy requires to change structures and functions of health care services and establish public health service and public health professionals. These professionals are trained in Public Health schools and included both medical and non- medical staff.
Primary health care services should identify people with high risk and implement secondary prevention at the community level. In the transition period the prior attention should be given to the diseases which significantly effect the health status of the whole society and where effective methods of screening and treatment exist. They include an early detection of
▪ hypertension by systematic measuring of blood pressure to all the patients presenting to a health facility;
▪ tuberculosis by mandatory photoroentgenography of people in 14- 60 age group;
▪ breast cancer and cervical cancer by a regular mammography and cervical smear test.
The patients with the symptoms should have access to preventive activities and treatment.
An important task of doctors of all specialties should be prevention of smoking, particularly among children, adolescents and pregnant women and providing help, including medical help to those who decided to quit. To implement this, special rooms can be set up in health facilities. These rooms would be self- financed.
Professional training in health promotion and disease prevention should be developed both on the undergraduate and postgraduate levels. A system of continuing training in health promotion and disease prevention should be set up within the existing system of training of health professionals.
Health education and involvement of population to health promotion activities. No preventive program will have an effect if the population is not involved to its planning and implementation. An important step in the planning of a preventive program is the assessment of needs of the population it is developed for. The assessment would help to estimate priorities, resources, the level of knowledge of the population and capacity to change values and standards accepted in the society as well as the demand of the society for health promotion and disease prevention.
A health education strategy is one of the most important in health promotion development. The level of knowledge and competence in health issues determines the attitude towards preventive interventions and the extent of participation in them. Health education should be based on differentiated information programs addressed and adapted to the particular groups of the population and depend on age, education level, social status and other variables.
A very important source of health information is the mass media. A health education strategy is crucial for the development of health promotion and should be considered as a separate project based on the following principals:
▪ principal of social marketing;
▪ any health education program should focus on particular risk factors or a particular disease, and not on the lifestyle in general;
▪ a health education campaign should be addressed to a particular social and demographic group.
The development of comprehensive education strategies both on the population/ community and individual/group levels requires the legislative, administrative and financial support of the State.
The improvement of the information system. The system of monitoring of the health status of the population should be improved. The only reliable information that can be taken at present from the routine state statistics is the data on mortality and the life expectancy at birth. The monitoring of the main health indicators should be based on representative randomized samples selected on the national or local principals. This will allow to receive quick and reliable information, predict the situation and respond to the needs of the society.
The database to manage health of the population should be extended. In addition to mortality indicators, the indicators of biological and behavioral risk factors which to a large extent determine mortality and mobidity should be included to the monitoring structure.
A primary task is the establishment of unifying monitoring techniques which will be used in planning, management and evaluation of effectiveness of prevention programs. It would also help to forecast the health status of the population for future years.
Increasing the role of research on health promotion and disease prevention. The following areas of research should be prioritized:
▪ development of new economically efficient methods to reduce risk factors which effect the health of the population;
▪ development, planning, management and evaluation of the demonstration regional and local programs of health promotion and disease prevention;
▪ reducing the gap between scientific results and their practical implementation;
▪ use of scientific evidence in the formulation of health promotion and disease prevention policies at all levels;
Different sectors and organizations should be involved to the implementation of this Concept. They include the Ministry of Health, Russian Academy of Medical Science, Mandatory Health Insurance Fund, the mass media, State Committee for Ecology, Ministry of Science, Ministry of Economics, Ministry of Labor, Ministry of Education, Ministry for Sports, Ministry of Defense, and others as well as regional authorities, community authorities, and NGOs. The implementation of the Concept strategies should be co- ordinated by the Government of Russia. The Intersectoral Commission for Health Promotion is a responsible body within the Government. The responsibilities of the Commission should be extended sufficiently to ensure the successful implementation of the Concept.
The Concept was translated from Russian
by Elena V. Tkatchenko, MPH, DLSHTM.
ANNEX 7.1.3.
Resolution of the Round Table “ Development of public health policy and health promotion in Russia”, April 16 1999, Moscow.
The Round Table Discussion “ Development of public health policy and health promotion in Russia” was held in Moscow on the 16th of April 1999. The objective of the meeting was to discuss the Draft Concept on health protection of the population of the Russian Federation in the period of economic and social transition as well as the progress in the implementation of the Tacis Russia Preventive Health Care project.
The members of the Steering Committee and the Expert Advisory Board of the Tacis Russia Preventive Health Care Project, officials of the Ministry of Health and other Ministries of the Russian Federation, representatives of the regional and local authorities, scientists and researchers, non- governmental organizations, experts of the European Commission, the World Health Organization and other international agencies participated in the discussion.
Having discussed the draft Concept and the experience of the the Tacis Russia Preventive Health Care Project participants of the Round Table agreed upon the following:
1. The content of the Concept of protection of health of the population of the Russian Federation in the period of economic and social transition has been approved in general.
While developing the final version of the Concept of protection of health of the population of the Russian Federation the following comments are recommended to be taken into account:
• to formulate the main aims, principals and strategies of the state policy in health protection, health issues need to be considered from a broader perspective with the emphasis on the impact of socio- economic conditions
• we recommend that the document takes into account the basic principals of the WHO Health for All Strategy
• prevention issues need to be prioritized in health protection policies, and the implementation mechanisms should be considered
• we recommend that the period of the implementation is clearly indicated, and the system of the control for the implementation is developed.
2. We recommend that further activities on the development of the Concept should
be coordinated by the working group that will include professionals and
organisations involved to health promotion in Russia as well as international
experts.
3. Activities implemented by the Tacis Russia Preventive health care project so far
as well as planned for the next period have been approved.
4. The work of the Round Table was useful and constructive, and it would be
desirable to conduct similar meetings on an average once a year.
ANNEX 7.1.4.
Reports on relations between federal regional and local legislation on HP & DP.
The Annex was prepared in Russian and is presented in the Russian version of the Report.
ANNEX 7.1.5
Analysis of 8 federal and regional legislative papers on HP & DP.
The Annex was prepared in Russian and is presented in the Russian version of the Report.
ANNEX 7.1.6
Analysis of the draft Federal Health Care Law.
Mauno Lindroos
18.5.1999
Draft Federal Law on the Health System of the Russian Federation
These comments have been prepared from a practical viewpoint by a person who has drafted similar legislation. To a large extent the comments focus on issues that might be described as technical, in order to make the law clearer and easier to understand. If I have not understood something it may also be due to lack of understanding of the Russian legal culture or translation problems. The actual substance of the law, that is what kind of health system Russia should have, is exclusively for the Government and State Duma to decide.
GENERAL COMMENTS
1. Background
If and when approved, the proposal will become the most comprehensive law on the health system of the Russian Federation. The existing Basic legislation of the Russian Federation on Health Protection is incorporated into the present draft and is going to be deleted. It is clear that such a fundamental law should not be drafted and adopted with only one or two years in sight, but at least ten years or more so that the system can be thoroughly implemented. This means that, before passing the legislation, enough time must be allowed for discussions on alternative solutions. The articles must technically be very carefully prepared, in order to reach a sustainable legislation.
2. Some general principles
2.1. Economic basis
It is true that the economic resources for health care have declined during the last years. This is, however, nothing unique for Russia, but happens in most countries in times of economic recession. A declining financing basis gives rise to numerous reflections:
▪ There is no objectively defined “sufficient” level of resources for health care. One can say that the resources in any given country are never sufficient, because the needs always grove beyond the resources.
▪ It is not relevant to define financing of health care as a certain percentage of the GDP. The GDP varies considerably and there is no general figure to express a “sufficient” percentage.
▪ No law makes money. If Government policy on one hand does not create a favorable situation for investments, production and trade, raised productivity and efficient taxation, then no single branch of that Government could successfully demand more resources. Resources in a national economy are only created through production and trade.
▪ Before demanding more resources, the health system should look at itself and ask whether it makes the best possible use of the existing resources today. Is the system managed and operating efficiently and without unnecessary costs? Are only necessary facilities used and the rest closed down? Are only necessary human resources used and the rest directed to other tasks? Before you demand more money, you should try to cut the existing costs. This is a difficult task, but without the slightest doubt it has to be dealt with, sooner or later.
▪ The explanatory notes to the draft law do not contain any economic estimates. Only such measures should be prepared and adopted for which financing is secured.
2.2. Basis of organization
The draft law is based on the assumption that a decentralized health system has negative implications. Therefore this law will create a centralized system, where even minor issues would have to be decided by the Federal Ministry of Health. The fact is, however, that almost all countries with a federal government structure (for instance Canada, Germany and the USA), have given the main responsibility concerning health care to the regional and local level, in order to have decisions made as close to the citizens as possible. Responsibility here means not only operating the system, but also managing it and deciding on strategic issues. In order to guarantee sufficient accessibility and equality there must be some general principles and rules, which are implemented alike in all parts of the country. Most decisions can, however, be made at regional or local level, where the needs of the population are best known. The draft law gives a possibility for this in Article 14, which makes it possible to conclude agreements between the federal and regional level.
2.3. Ethical basis
The above mentioned economic and organizational questions also have an ethical dimension. It is unethical to adopt legislation without a sound financial basis if there is a risk that it cannot be properly implemented. Of course all countries know so called symbolic legislation, where the political intention is only to show a reaction to some problem and then forget it, without actually trying to solve it.
This law affects every citizen of the Russian Federation. Therefore it should be written as clearly, simply and transparently as possible and limited to an extent where it is still possible for interested citizens to read it through and even get some useful information. This draft contains 156 articles and that is really very much.
The principles and priorities of health promotion and disease prevention, as well as healthy life-styles are stressed in Article 4. The draft does not, however, say anything about the personal responsibility of the individual for his health. To a certain degree it is ethical to require that also the individuals are interested in their own health and try to adopt favorable lifestyles. Of course this is a change that will take a long time, but perhaps the law should contain a principal statement to this effect.
On the border of ethical and legal principles are the treaties and recommendations adopted by the Council of Europe, of which Russia is member. The most important documents are the Treaty on Human and Civil Rights, the Social Charter and the Convention on Social and Medical Assistance. All these documents put certain requirements also on the health system of a Member State
2.4. The general role of health promotion and disease prevention
This draft law is not aimed specifically at promoting health promotion and disease prevention, although these activities by the definition in Article 2 are seen as part of medical care. They are also included among the main principles in Article 4. Article 35 states that health budgets of all levels (federal, regional, local) shall contain a “certain, defined share of funds” for health promotion and disease prevention. There is no specification of the amount of this share or how it is to be defined. The same provision says that the employers shall pay for medical examinations and screenings of their personnel. Articles 45 and 46 deal with the procedures governing health promotion and disease prevention and Article 48 specifically states that primary health care also includes health promotion and disease prevention. Articles 15, 16 and 17 regulate the issue of programs. Articles 99 and 100 refer to the specific legislation concerning sanitary-epidemiological surveillance and finally Articles 122 – 133 regulate the position of various vulnerable population groups, like families, minors, elderly and handicapped.
As can be seen from the description above, this draft law contains quite a few provisions related to health promotion and disease prevention. They seem sufficient for a law like this and there is probably no need for more detailed provisions.
3. Technical principles
The legal order, that is the totality of the laws in force in a society at a given time, gives the framework for every new draft law, and should be taken into account properly. This means several things:
▪ The draft law may not be in contradiction with existing laws, neither the Constitution nor other laws. If the lawmaker wants to change something that is already in force, he shall change that provision in question and not issue a new, contradictory one.
▪ The same issue is to be regulated only once. There is no need to repeat what is already stated in some other law. If some provisions, for instance, are already included in the Health Insurance Law they need not be repeated in the Law on the Health System of the Russian Federation. If it is important to notify the reader of such a provision in another law, it is made by an explicit referral to that very provision. General referrals to various laws are better made in one single article at the beginning of the draft law. In this draft the referral technique is not very good, as the referrals are too general and the reader does not know where to find the provision referred to.
▪ Another aspect of the same thing is that the legislator should honor the division of work between different branches of legislation. Provisions about economic for-profit activities and the founding and operating of business companies are to be found in the Civil Code, provisions about crime and punishment in the Criminal Code and so on.
▪ Legislation is the State’s most valuable tool for strong messages to the population about how or not to behave. Therefore it should not be used for self-evident purposes. You do not have to state, for instance, that a patient has the right to examination and treatment (Article 135).
DETAILED COMMENTS
CHAPTER 2
Article 10; Foreign Economic Activities in the Area of Health
This is a strange provision to be included in a health care Act. Normally issues on trade would be found in the Civil Code. Obviously that is not the case in Russia.
If it is absolutely necessary to regulate questions on foreign trade in this law, perhaps it could be made with a general statement. Each oblast could then decide on the practical operations, since reality probably varies a lot between various regions.
The referrals “under procedures established by laws of the Russian Federation” are too general. How is the reader of this law, who is not a lawyer, supposed to know what laws he should look for?
If “federal body of executive authority in the area of health” means the Ministry of Health, why not write it out? The Federal Ministry of Finance is mentioned clearly in Article 34.
CHAPTER 4
Article 23; Health Care Quality Standards
Naturally the idea behind this provision is to raise the quality of health care in the Russian Federation and that is understandable. The provision itself is, however, very rigid. It demands that all health institutions, regardless of their present standard and resources, shall comply under the threat of suspension of license. Both the preparation of such standards and the control of their implementation require a lot of resources. Perhaps it would be wise to start in a smaller scale in order not to lose credibility by lack of proper implementation.
Again the referral to “procedures established by laws of the Russian Federation” is too general.
Article 24; Licensing of defined Health and Pharmaceutical Services
At the beginning of the provision there is a referral to “relevant laws of the Russian Federation”. It would be better to state exactly what laws are meant. On the other hand, if there is specific legislation on licensing in the area of health care, would it not be better also to have these provisions there?
Article 25; Certification of Health Services
This provision must be seen in connection with Article 23 on health care standards. The idea might be good, but it should be adopted only if it is possible to implement it in practice. Certification is both resource and time consuming.
CHAPTER 6
Part III of the law is devoted to Financing. This is good, but all provisions on financing should be in this part of the law and not spread to other parts of it.
Article 35; Financing of disease prevention
Section 4 states that programs specified in Article 43 shall be financed in accordance with “relevant Russian laws”. Article 43 Section 5 again stipulates that something happens in accordance with “relevant legislation of the Russian Federation”. This provision and its referrals do not actually give any information whatsoever to the reader.
CHAPTER 7
Article 40; Financing of the Health System
This is one of the most important provisions in the whole law. Perhaps due to language difficulties it is not easy to understand what criteria actually shall determine the rate of financing and resource allocation. In most European countries the government in the State budget makes a yearly overall decision as to how much of the taxpayers’ money is going to each sector of society, for instance health. This decision is purely political and normally strongly influenced by the Ministry of Finance. After that the regional allocation of the overall resources can be made in many different ways, but some kind of per capita basis with higher coefficients for very young and very old people is often used. Also morbidity factors as well as regional features are involved. Then expenses have to be adjusted to the resources available and not the other way around. In the proposal the main principle seems to be that the level of financing should be determined by health programs approved by the Government. In practice, however, the actual level of financing will depend on resources available in the State budget. This means that the health programs should be prepared and also adopted in co-ordination with the State budget. As had been said earlier it is not appropriate to state that the financing shall be “sufficient to cover all necessary expenses”. It is always open for discussion which expenses are necessary.
CHAPTER 8
Articles 42 and 43; Extrabudgetary and additional financing of health care
These both Articles deal with the same question, creating “extra” resources from outside the budget. Due to the general shortage of resources it is understandable that the proposal offers a great variety of possibilities for health care institutions to raise funds. Everything that is not clearly criminal is allowed and recommended. The open question is how these possible extra resources are taken into account in the federal and regional budgeting process. Do the budgets include a target amount, which is to be achieved by external financing or is the question left open, which also may mean that there are no plans about how to spend this possible extra money.
Article 44; Mandatory Health Insurance
There is a separate Russian law on Health Insurance. It would seem natural to regulate all issues concerning health insurance in that law.
CHAPTER 9
Article 47; Guarantees regarding access to health care
Section 1: The corresponding provision in some Western countries would state that health care shall be provided “to the extent permitted by economic resources”. There is never a sufficient level of health care in any society.
Section 4: The strongest possible way to say something by way of legislation is to state it in the Constitution. It goes without doubt that also health professionals shall follow the Constitution and there is no need to state it again here.
Section 5: Part III of the law is all about financing. Therefore you should not actually have financial provisions in other articles, where they are not easy to find.
Articles 48 – 57; different kinds of health care
The various classification systems described in these Articles only seem confusing and it is not easy to see why they are needed. They also contain financial provisions, which belong to Part III of the law.
CHAPTER 11
Article 67
This is a very important provision as it states what actually is planned be done within the area of health. Since all activities cost, the list should be exclusive, stating that “according to this law, the following are activities in the area of health care”.
Articles 68-70; subjects of the health system and health institutions
These articles are drafted in such a general form and with such general referrals that they contain very little information for the reader.
Article 72; medical institutions
What is the relationship between this provision and Article 69 concerning health institutions?
Article 73; Ethics Committees
The provision is not requiring compulsory ethical committees. Several international regulations and recommendations, however, require that ethical committees shall be established, especially to assess applications for medical research on human beings, fetuses or embryos. In several European countries there is either a separate law on medical research or the relevant provisions are included in the Law on Patient’s Rights.
CHAPTER 12
Article 80; right to carry out revenue-generating activities
What is the relationship between this Article and Article 43 on additional financing of health institutions? Sections 3 and 4 of Article 80 contain strict provisions on liability, but no such provisions are included in Article 43.
Article 82; provision of private health services
Problems normally develop when public non-profit organizations start doing business “on the side”. Very naturally they tend to become more interested in their paying customers than in public patients. In order to prevent this, the draft provision puts very strict conditions on how and when private health care may be provided. The problem is that such conditions are difficult to supervise in practice.
If Russia’s Consumers’ Union is a NGO, the law should not include it as an official supervisory body and to this respect, as part of Government.
Article 84; Contractual liability
As stated in the Article, the question of contractual liability is probably already regulated in the Civil Code. In that case this provision is not needed.
CHAPTER 13
Article 87; private medical practice
The same provision is included earlier in Article 24 and does not have to be repeated.
CHAPTER 14
Article 94; admission to hospital care
This provision is important as part of the general patient’s right to receive good health care within the limits of resources available. It is important for a patient who is ill to know that there are clear rules on hospitalization and on the other hand the patient must be protected against discretionary hospitalization. The draft provision only says that the Ministry will decide later and that there is federal legislation, which regulates hospitalization against the will of the patient. As such it does not contain any information.
Article 95; registration of patients
This Article is also very generally drafted and does not provide exact information on the rules for registration and use of patient information.
CHAPTER 16
Articles 99, 100; sanitary provisions
Since there is a specific law on sanitary – epidemiological issues, these provisions don’t seem necessary.
CHAPTER 22
Article 117; the right to be employed by health institutions
The draft law contains three articles with a very similar content: Article 24 about licensing health and pharmaceutical services, Article 71 about the right to work in the field of health and then this Article 117 about the right to be employed by health institutions. All three provisions could be combined into Article 117.
CHAPTER 25
Article 134; voluntary health insurance
The normal procedure is that insurance provisions are found in special insurance legislation. This article is not about health care, but about insurance and would fit better in a general insurance law or alternatively the Health Insurance Law.
Article 135; patients’ rights
Provisions on patients’ rights form an important part of modern health legislation. Their function is normally to safeguard and specify the civil rights given to each individual in the Constitution. Among these are the rights to integrity, self-determination, information etc. and they should be upheld also in the environment of health care, where the initial position of the individual is weak. Detailed provisions on how to arrange the actual health care of patients are normally not included in the patients’ rights. A Law on patients’ rights could include the following provisions:
▪ A right to good health care and proper treatment. This provision would make a general statement that each patient has the right to good health care within the limits of the financial resources available. Each patient must be treated with respect for his human rights, his beliefs and his privacy. It might also be stated that, if a person cannot be treated immediately, he must be informed about the reasons for the delay.
▪ A right to information. The patient must receive sufficient information about his health situation, the planned treatment, alternative solutions, dangers and possible side-effects. Information shall no be given against the will of the patient or if the information could pose a danger to the health of the patient.
▪ A right to self-determination. The patient has the right to decide about treatment and also to refuse it.
▪ Confidentiality. All patient journals and other material about the patient are confidential and must not be disclosed. The police, prosecutor or judge has no general right to obtain this information, but only when investigating serious crimes (with a maximum penalty of several years in prison).
▪ Ombudsman. In several countries every medical institution has to appoint a special patients’ ombudsman to take care of the rights of the patient and help him to defend them. The ombudsman might belong to the personnel of the institution.
▪ Complaint. Health care treatment cannot normally be compared to actual administrative decision-making, where it is easy to have an appeal procedure. It is not practically possible to have the ordinary courts trying to solve disputes concerning the provision or non-provision of health care, nor disputes on how the treatment was actually carried out. Therefore there exists a possibility to complaint to the director of the medical institution in question. If that brings no result the patient can sue for compensation or punishment of the personnel etc.
As concerns the provisions of Article 135, many of the above mentioned principles are included. A lot of other issues have, however, also been included, and they would not generally qualify as patients’ rights. They partly concern details of arranging the health care treatment and partly specific practical questions, like the right to have a lawyer, receive visitors, meet the priest, worship, keep own items, have a possibility to get education while in hospital, receive and send mail and use the telephone, which would normally be considered self-evident and not needing inclusion among patients’ rights. The thing is that if you mix very small details and fundamental principles in the same provision you diminish the value of the latter ones.
Article 139; refusal to obtain health care
This provision is in accordance with the patient’s right to self-determination. In practice a refusal is normally based on religious or philosophical beliefs. The Jehova’s witnesses do not, for instance, approve of blood transfusion as a mean of treatment. In some countries there is a provision for cases like these, saying that the doctor and patient together shall try to find alternative treatment.
So called health care testaments are becoming increasingly common. A person can, even long before he gets ill, prescribe that he does not want his treatment to be prolonged artificially or that he is willing to donate organs or let his body be used for teaching and research purposes after his death.
Article 140; health care without the consent of the patient
It is unclear what are such “socially dangerous” crimes, which give the right to treatment against the will of the patient and what kind of “health care” is foreseen for such a case. Without detailed information it is not possible to determine whether such provisions comply with the Regulations of the Council of Europe.
Article 145; prohibition of euthanasia
The provision prohibits both active and passive euthanasia. Active euthanasia is very rarely permitted anywhere in the world. In many countries, however, the patient’s right to self-determination means that he has the right to refuse prolonged, artificial treatment. Because the patient, at the actual moment when the decision about the discontinuation of treatment must be made, normally is not in the state to make it, so called health care testaments have been developed, as was described above under Article 139.
Since that Article states that a patient has a right to demand discontinuation of health care, it is contradictory to say in Article 145 that discontinuation of life maintenance activities is forbidden. One solution or the other should be chosen.
Article 149; appeal
As said above in connection with Article 135, it is not common to give the right to appeal to civil courts about matters of providing health care. Regular courts have neither the skills nor the capacity for dealing with such cases, which to some extent might be unfounded. Of course this only concerns cases, where the dispute is about how specific health care measures should have been performed. When dealing with claims for damages or criminal cases, the courts are appropriate.
Article 154; criminal charges
There is a contradiction here, because Article 152 also has a provision on criminal charges, although the Article actually should be dealing with administrative liability only.
Article 156; liability for financing
This provision is difficult to understand. Actually it does not deal with liability at all, but with responsibility for financing at various levels. If at all needed, this article should be placed within Part III of the draft law.
ANNEX 7.1.7
Analysis of the draft Law on Smoking Restriction, May 27, 1999.
The Tacis Russia Preventive Health Care Project
Mauno Lindroos
19.5.1999
The Federal Draft Law on “Restrictions on Smoking”
1. Introduction
The epidemiological evidence of the negative health effects of tobacco use (lung cancer, cardiovascular diseases) can be considered indisputable. Equally clear are the negative effects of passive smoking. The issue is not so simple in the court trials that have been raised in various countries. The litigant has to be able to prove many other things in addition to the epidemiological relationship. A tobacco case normally concerns one person only, and it must be proved that the illness and/or death of this specific person was caused by tobacco use. The causality requirements are very strict. Also it must be proved that this person was not sufficiently informed about the health hazards of tobacco in order to make an informed decision on whether to smoke or not. Tobacco, after all, is legally on the market. And of course it must be shown that the manufacturer was aware of these hazards, but did not provide sufficient information. The first trials did not succeed, but clearly the trend is changing, above all in America. Sooner or later Russian lawyers will start the first tobacco trial here too.
The perspective of future court cases on tobacco does not as such require the State to do anything. Court cases are always tried on the basis of the legislation in force. The enacting of anti-tobacco legislation emanates from reasons of health policy and economy.
2. General comments
Anti-smoking legislation consists of several elements, which can be grouped into a) restrictions, b) orders, c) encouragement, d) signal effect and e) education.
Every law has a signal or symbolic effect, as it shows that the State thinks a certain problem is so important that it deserves its own law. The signal effect is better achieved by a separate law than by spreading the provisions over various different laws. Of course similar provisions in other laws must be deleted if this draft law is adopted.
The educational effect is achieved by moving gradually from modest provisions to stricter ones, so that the public opinion is able to follow.
Tobacco legislation is not extremely expensive to implement. On the contrary, it gives possibilities to raise more funds through taxation. Anyway, both the income and expenditure side should be considered with the Ministry of Finance before passing the law. This is the reason why legislation in Western countries normally is prepared and proposed by the Government and not the members of Parliament.
3. Detailed comments
3.1. Restrictions
▪ Nicotine and tar content is restricted in the law. The requirements in Article 3 (1,1 mg of nicotine and 12 mg of tar) are strict and therefore the Russian manufacturers have been given a transitional period until 2002. This is a realistic approach. The alternative would be to regulate the maximum content in a by-law, which is easier to change and then gradually lower it.
▪ Restrictions on advertising are already in force and working. In the draft law the advertising restrictions are extended. If the law is passed there will effectively be a total ban on tobacco advertising in Russia. This is an approach favored by several countries as well as the European Union and the WHO. The problem when implementing the ban on advertising is the existence of indirect advertising in the name of clothes (Marlboro Classics), watches and so on. It could be added in Article 5 of the draft law that also indirect advertising is forbidden. Broadcasting of international sports events (Formula 1) presents another problem, which is difficult to solve nationally.
▪ The ban on selling tobacco products to persons under 18 years in Article 4 is common for several countries. In order to be credible, this provision needs some resources for surveillance. If no age restrictions are in force in Russia at this moment, it might be wiser to start with a lower age, for instance 15 years, which is easier to control.
▪ Legislation is effective only when it does not move too far ahead of the public opinion. That is why tobacco legislation is often developed gradually from a rather modest start towards stricter rules, thus educating the views of the public along the way. This should be kept in mind when imposing restrictions on where to allow smoking The general level of consciousness can be assessed by a simple test: If ordinary people with children do not generally smoke at home or in their car, the opinion is getting favorable for imposing legal restrictions. Article 6 of the draft law forbids smoking in a large variety of premises. This kind of provision exists for instance in the Finnish legislation today, but Finland got its first anti-smoking law as early as 1976. If it is probable that the public opinion will find this provision too severe, it should perhaps be modified, especially as concerns smoking in sport facilities, marketplace and work place. It might also be hard for employers to arrange a special smoking room with ventilation if the State does not support the change financially, for instance through tax deductions.
3.2. Orders
▪ The provision in Article 3 that each pack of cigarettes or tobacco shall tell the contents of tar and nicotine as well as have a warning about the health hazards of tobacco is normal in this type of legislation. The Russian draft states that the size of the warning shall be at least 25% of the front side of the package. This is a very big percentage, as compared with other countries and the present situation in Russia.
▪ Taxation is perhaps the most efficient method to influence smoking. Most Western countries put taxes on tobacco much exceeding their production costs. The price of tobacco should deliberately be raised as high as possible, almost but not so high as to create a favorable market for smuggling. Better than the consumer tax foreseen in Article 8 of the draft law might be to introduce a special tobacco tax.
3.3. Encouragement
Anti-smoking activities are foreseen in Article 8 of the draft law. They are to be financed from federal and regional budgets. Another way is to “earmark” part of the revenue from tobacco taxation for these purposes. In some countries 0,5% of the revenue is put to the disposal of the Ministry for Health for these activities.
The idea in Western countries is that you have to fight tobacco with its own weapons like advertising campaigns in movie theaters and on TV. Part of the money is best spent by non-governmental organizations, who arrange their own campaigns. Naturally children and young persons are the main target groups.
In a market economy media is supposed to be independent. It is normally against the Constitution to state by law what the media should or should not write. Therefore Article 7 of the draft law should be changed accordingly.
3.4. Other issues
Section 4 of Article 6 proposes that the employer could pay lower wages (bonuses) to smokers. This kind of provision is not acceptable. Smoking in itself is perfectly legal and there is no right to punish a person who smokes. Otherwise the employers could also pay lower wages to those who drink too much, eat high-fat food or pollute the air by driving a car.
The reason for including Article 2 in the draft is not clear. Are the relevant provisions of the laws mentioned there to be implemented beside the provisions in the anti-smoking law? In that case that could be stated explicitly.
Article 9 requires that the President and the Government bring “their norms” in accordance with the anti-smoking law. Perhaps it could be specified in the draft law, which these norms are.
ANNEX 7.1.8.
Program of the Conference ” Health promotion and disease prevention in Russia”, 25- 27 May 1999, Ministry of Health, Moscow.
The Annex was prepared and enclosed to the report in Russian
ANNEX 7.1.9.
Materials on the seminar “ Financial analysis and reimbursement system in primary health care”, May 1999, Vologda oblast.
25.5.1999/IV
SEMINAR IN VOLOGDA 7.5.1999 by Ilkka Vohlonen
FINANCIAL INCENTIVES IN PRIMARY HEALTH CARE:
Basic principles of capitation reimbursement of doctors
1. Research, experience and various international organizations have concluded that the reimbursement of doctors in primary care (i.e. policlinics) is best done by capitation. Timely salary and fee-for-service are not as beneficial.
2. Objectives of capitation usually are the following: to increase the productivity in the provision of curative services (i.e. to improve technical efficiency) , to reduce the indirect costs of curative services (e.g., the laboratory, x-ray and referrals to hospitals), to facilitate the better quality of provision of services, and to increase the primary care activities in disease prevention and health promotion (i.e. to improve allocative efficiency).
3. Capitation assumes that: the doctors are paid mainly according to the number and types of citizens enrolled annually for each doctor’s responsibility, the citizens agree to seek for the same doctor repeatedly and the doctors agree not to serve the citizens enrolled for another doctor, the doctors commit themselves to fast and appropriate quality of provision, and the reimbursement of the doctors depends on the annual contract about the price of a basic unit of accountability between the doctors and the employer/financier of services.
4. In most countries, the capitation reimbursement system does not exist in its pure format but rather it consists of various elements of reimbursement (e.g., BASIC ALLOWANCE, CAPITATION ALLOWANCE AND FEE-FOR-SEREVICE ALLOWANCE)
5. In Finland, BASIC ALLOWANCE attributes to about 30 % of reimbursement, CAPITATION ALLOWANCE attributes to about 60 % of reimbursement, and FEE-FOR-SERVICE ALLOWANCE attributes to about 10 % of reimbursement.
6. BASIC ALLOWANCE consists of a basic lump sum for being a medical graduate, additional sum for any extra education, additional sum for extra ordinary area or environment and additional sum for seniority or administrative responsibilities.
7. CAPITATION ALLOWANCE consists of number of citizens enrolled to the doctor (a price for an unit, usually adults between 18 and 64 without differentiation for gender), coefficients of age (usually newborn, school age, adults, retired, and old), and coefficients of gender (usually different except for adults 18 to 64). The contract negotiations concern both the unit price and the coefficients and are based on a very detailed analysis of the morbidity of the population.
8. FEE-FOR-SERVICE ALLOWANCE consists of fees of every first visit per patient per month. This allowance is to take into account various influenzas, environmental factors and the demand of primary care services. The purpose is, that the doctors are not able to generate income by referring patients to themselves or their collegues.
9. In the long term, in order for the doctor to have less demand for the curative services, it is the benefit to activate disease prevention and health promotion among the enrolled population. The less demand for the services, the more freedom the doctor has – irrespective of the size and the conditions of the reimbursement. The doctor is reimbursed even though the curative services are not demanded. In some countries, the doctors also have indirect financial incentives (e.g., funds).
10. In order for the capitation reimbursement system to work, it is extremely important that the doctors’ sources of income do not consist of any other alternatives with respect to the responsibilities to be carried out within the employment concerning the enrolled population. The most frequent dysfunction of the system appears when the doctors, nevertheless, are generating income and the financer of the primary care ends up with increased costs rather than decreased costs.
List of Participants in the Seminar 7.05.99
Place: City Hospital #3, Conference Hall
Time: 10.00
1. Kolinko Alexandr Andreevich – Chief of Health Care Department of Vologda Region Administration
2. Popugaev Alexandr Ivanovich – First Deputy of the Chief of Health Care Department of Vologda Region Administration.
3. Banshikov Gennadi Trofimovich – Main Therapist of Health Care Department of Vologda Region.
4. Smirnov alexandr Vitalyevich – Deputy Chairman of Health Care Committee of Legislative Assembly.
5. Duganov Mikhail Davidovich – Chief of Planning and Financial Department of Health Care Department of Vologda Region
6. Simkina Irina Borisovna – Deputy Director of Territory Fund of Mandatory Health Insurance.
7. Chumakov Mikhail Vladimirovich – Chairman of Licensing Commission of Health Care Department of Vologda Region.
8. Zolotilov Victor Vassilyevich – Chief of Health Care Department of Vologda City.
9. Solovyov Anatoliy Youryevich – Chief Physician of Policlinic #4
10. Sokolov Nickolai Vladimirovich – Chief Physician of City Policlinic #3
11. Podzigun Zinoviy Vladimirovich – Economist of City Policlinic #3
12. Volkova Tatyana Nickolayevna – Economist of City Hospital #1
13. Kudrin Sergei Vassilyevich – Chief Physician of City Hospital #3
14. Sinayeva Alevtina Yakovlevna – City Hospital #3
15. Nevzorov Alexandr Stanislavovich – City Hospital #3
16. Lukina Natalia Alexandrovna – Policlinic #3
17. Chekina Tatiana Pavlovna – Policlinic #3
18. Ovcharova Marina Yuryevna – Policlinic #3
19. Gulyaeva Irina Vladimirovna – Director of Policlinic #1
20. Pomelova Raissa Petrovna – Policlinic #2
21. Popugaeva Tatiana Vassilyevna – Policlinic #2
22. Sheverdova Olga Vassilyevna – Policlinic #4
ANNEX 7.1.10.
Preliminary report on financial analysis in Electrostal city and Vologda oblast.
25.5.1999/IV
BACKGROUND
Most of the financial problems in Russia are related to the adequate resourcing of the curative health care. From the point of view of the development of the health of the population by the long term policies, the role of the financial incentives is to facilitate healthy lifestyles by positive re-enforcement, and the role of the legislative actions is to facilitate healthy lifestyles by restricting unhealthy lifestyles.
In the implementation of health policies on the prevention of diseases and health promotion at the federal, regional and local levels the administrative strategies can be divided into two general approaches: the positive or the negative approaches in behaviour modification. The positive enforcement of appropriate behaviour usually is done by various types of financial incentives, and the negative enforcement is done by legislation in order to restrict inappropriate behaviour. As in an automobile, there is a pedal for the accelerator (to speed up), another one for the break (to slow down), and one decision-maker (the driver) to apply these tools.
The first component of the project includes the development of both of these strategies in disease prevention and health promotion - the development of legislative tools and the development of financial tools in disease prevention and health promotion.
The purpose of either financial or legislative actions is to balance the institutional (or individual) responsibilities for the occurrence and the consequences of preventable diseases. The assumption is, for example, if the occurrence of the otherwise preventable diseases leads to the increased demand of public expenditure in some curative health services, the public authorities should also have the increased responsibility (and right) for financial and/or legislative strategies in disease prevention and health promotion. Economic surplus and economic loss should be governed by the same institutional decision-making. The successful driving of an automobile hardly could be done by two persons – one in charge of speeding (accelerating) and another in charge of slowing down (breaking).
Until now, it seems obvious that the expertism in the area of health economics and financial analyses concerning health issues is not well developed in the Russian federal expert institutions.
GENERAL OBJECTIVES
The general objectives of the potential financial analyses in the project can be described as follows:
A. MACROANALYSIS AT FEDERAL LEVEL:
1) To analyze and to make proposals about the institutional balancing of financial accountability between the causes of preventable diseases (e.g., tobacco industry) and the coverage of economic losses (e.g., income substitutions for invalidity by public authorities).
B. MACROANALYSIS AT MUNICIPAL and/or REGIONAL LEVEL
2) To analyze and to make proposals within public budget about the balancing of municipal and/or regional financial accountability between the disease prevention and health promotion activities (e.g., financing of public awareness programs) and the coverage of economic consequences of preventable diseases (e.g., curative treatment of lung cancer)
C. MICROANALYSIS AT PROGRAM LEVEL
3) To analyze and to make proposals about the disease specific prevention and health promotion programs (e.g., screening of hypertension) within the municipal and/or regional budgets.
The application of the results of the fist macro analysis might be difficult in the Russian Federation. For example, in the United States these discrepancies usually are solved by means of lawsuits. These triggering mechanisms might not exist in the Russian Federation, yet. The application of the results of the second macro analysis pre-assumes the availability of appropriate data, which might introduce practical problems in the achievement of the project objectives. The purpose of the micro analysis is to provide knowledge about the overall costing of a program for disease prevention or health promotion.
APPLICATION OF FINANCIAL INCENTIVES
The application of financial incentives requires at least the following: the financial data, the knowledge of financial theory, and the capacity to perform analyses of alternate financial solutions. It should be noted that the application of financial incentives in the improvement of the health of the population usually always requires intentional public policy in the beginning of the application. The purpose of the public policy is to co-ordinate the responsibilities for financing of disease prevention and health promotion with the responsibilities for the monetary losses due to the preventable diseases. If successful, the results of the public actions often will be transformed into actions which appear under market forces, e.g., smoke free flights, suger-free drinks and low-fat margarines. Even publicly organized weight reduction programs might become successful businesses.
In order to develop commonly applicable financial tools for the implementation of disease prevention and health promotion at the federal, regional and municipal levels, the project pilot activities currently include a macro financial analysis in Elektrostal municipality and a micro financial analysis in Vologda regional level.
In Elektrostal, the macro financial analysis focuses on the development and demonstration of an economic tool for municipal decision-making about the role of disease prevention and health promotion in the municipal budget. In Vologda, the micro financial analysis focuses on the development and demonstration of an economic tool for regional decision-making about the launching of a disease prevention or health promotion program in the regional (oblast) budget.
If the analyses can be performed successfully, they should be able to provide a transparent view about some potential discrepancies. For example, discrepancies between the roles of public authorities in the governance of disease prevention and health promotion and in the responsibilities for various types of social losses – for example, the financing of curative services for the treatment of preventable diseases. Another example would be the discrepancy between the focuses of the current municipal health expenditure and the causes of the economic losses of the society due to the unnecessarily early and preventable deaths.
The steps of the project work include:
a) the collection and processing of necessary financial data about the current public expenditure according to the source of finance and about the current social monetary losses according to the loosing institution (or individuals),
b) the development of logistic protocol for comparison of monetary expenses and social losses in monetary units, and
c) the formulation of municipal strategy in allocation of resources with respect to the preventive and curative health care as well as the actions in health promotion with respect to the municipal losses.
d) It will be later decided whether also the expenses and losses (direct and indirect) outside the municipal budget will also be included in the demonstration.
e) The result of the project pilot activities in Elektrostal will be a replicable model of macro financial tool for decision maker00s either at the municipal or regional level.
f) In Vologda region, the steps of the project work are similar to those in Elektrostal, however, the financial analysis will focus on a regional (or municipal) program of disease prevention or/and health promotion.
g) The financial analyses will produce: a) preliminary models of macro and micro financial analyses, b) examples of decision-making on the bases of the financial analyses, and c) basis for the development of further legislative proposals in disease prevention and health promotion with respect to balancing of responsibilities and consequences.
Elektrostal pilot: Financial macroanalysis
Objectives
The financial macroanalysis in Elektrostal municipality attempts to describe the needs for balancing of the preventable social losses (lost production capacity) of the Elektrostal municipal population and the current health expenditures (preventive and curative health care costs).
Methodolody
The current health care costs are calculated for all polyclinic and inpatient care which are allocated from the Elektrostal municipal budget. The expenditures of enterprises are estimated on the basis of the proportional municipal population which is not serviced by the municipality. The expenditures from other sources (e.g., federal, oblast or out-of-pocket) will be calculated and added at a later stage.
The preventable social losses are calculated on the basis of the potential years of life lost (PYLL) and the monetary value of these years (multiplied by Gross Domestic per Capita Annual Production).
Analysis
The comparison of the death rates (diagnosis specific/ ICD-9 causes of death), the diagnosis specific health care expenditures and the diagnosis specific social losses will provide an opportunity: to estimate the financial rationality of Elektrostal municipality in its policies to allocate public resources in most cost effective manner (in terms of investing in the municipal human capital), to estimate the amount of lost public investments (short and long term) in the promotion of the health of the municipal population, and to derive a set of optimal alternatives for investments in the health of the municipal population.
Schedule
The financial macroanalysis was started in November 1998. Until now the diagnosis specific mortality rates and the diagnosis specific curative health care expenditures have been calculated. The next step concerns the calculation of estimated preventable social losses. This is done by multiplication of diagnosis specific PYLL by the annual per capita production (in monetary terms). These calculations will be done in the end of April 1999.
In the beginning of May a seminar will be arranged in the Shemasko Institute with the federal financial expert group to review the collection of data and the assumptions done. After the necessary corrections of data, the statistical modeling of existing investments and the potential benefits will be done, and these will be reported to the Elektrostal municipal administration before summer 1999.
Preliminary Results from Elektrostal Analysis
In Elektrostal, all project work has been divided among three partners: the Elektrostal staff, the EU expert and the Russian experts. The Elektrostal staff has until now analysed the causes of death (according to ICD-9) in 1997. The cumulative diagnosis specific statistics are summarized according to the major groups of diseases in the following table in the rank order.
Table 1. Causes of Deaths in Elektrostal in 1997 in Rank Order
-----------------------------------------------------------------------------------------------------------------
• Circulatory system diseases 54.5 1170
• Neoplasm 11.2 240
• Injuries, poisoning and suicides 9.1 195
• Diseases of digestive system 2.2 48
• Metabolism and immune system disorders 1.9 40
Respiratory diseases 1.1 23
• Infectious and parasitic diseases 1.0 20
•
• Diseases of nervous system and perception organs 0.0 0
• Complication of prenatal and postnatal periods 0.0 0
• Diseases of sex-urinary system 0.0 0
• Diseases of bones, muscles and connective tissues 0.0 0
• Skin diseases 0.0 0
• Abnormalities, presented in perinatal period 0.0 0
• Mental disturbances 0.0 0
• Blood and organs hematogenetic diseases 0.0 0
•
• Other diseases 19.1 411
-------------------------------------------------------------------------------------------------------
Total 100.0 2147
The above described summary table is further analyzed according ICD-9 diagnosis specific rates and combinations of various diagnoses according to ICD-9 classifications.
The current health care expenses have also been analysed. In this analysis, the all policlinic and hospital expenditures of Elektrostal municipal health care were recalculated for 1997 according to the ICD-9 classification. A detailed description of the methodology applied in these calculations is being prepared. As in any other country, also in Elektrostal these calculations were not readily available. After the collection and aggregation of all expenditure data, all expenditures were recalculated according to the various diagnoses. Some of these statistics are shown in the following two tables.
Table 2. Causes of Health Care Expenditure in Elektrostal in 1997 in
Rank Order According to ICD-9 Diagnosis Group Classification
ICD-9 DIAGNOSIS GROUP % Rbls x 10K
-----------------------------------------------------------------------------------------------------------------
Respiratory diseases 16.3 47.0
• Circulatory system diseases 11.9 34.4
• Diseases of digestive system 11.0 31.8
• Diseases of nervous system and perception organs 8.7 25.1
• Complication of prenatal and postnatal periods 8.6 24.8
• Injuries, poisoning and suicides 7.4 21.2
• Diseases of sex-urinary system 4.1 11.7
• Neoplasm 3.3 9.6
• Diseases of bones, muscles and connective tissues 2.7 7.8
• Metabolism and immune system disorders 2.1 6.0
• Skin diseases 1.2 3.4
• Abnormalities, presented in perinatal period 1.1 3.3
• Infectious and parasitic diseases 0.8 2.3
• Mental disturbances 0.3 0.8
• Blood and organs hematogenetic diseases 0.2 0.7
• Other diseases 20.0 57.6
-------------------------------------------------------------------------------------------------------
Total costs for all classes of diseases 100.0 288.4
Table 3. Causes of Health Care Expenditure in Elektrostal in 1997 in
Rank Order According to ICD-9 Diagnosis Specific Classification
ICD-9 DIAGNOSIS % Rbls x 10K
465 3.9 11.3
460 3.2 9.2
650 3.1 9.0
480 2.6 7.6
413 2.0 5.7
401 1.9 5.3
850 1.8 5.1
532 1.7 4.9
487 1.6 4.8
414 1.6 4.7
362 1.5 4.4
575 1.5 4.3
535 1.5 4.2
470 1.4 4.1
410 1.3 3.7
490 1.3 3.7
493 1.2 3.6
721 1.2 3.5
.
.
.
.
852 0.2 0.1
Other 20.0 5.7
TOTAL 100.0 288.4
Currently, the first models of expenditure and death rates are being prepared by the Elektrostal authorities and the EU and Russian experts. These models describe the relationships between priorities of spending and the major causes of death, i.e. what is the rationality of setting priorities for current expenditure in health care ? These types of questions can be answered by e.g., cross-tabulations of the two types of rates. The first analysis will consist of two dimensional scattergrams, as described in the following.
Table 4. CROSS-TABLUATION OF CAUSES OF DEATHS AND CAUSES OF
HEALTH CARE EXPENDITURE IN ELEKTROSTAL IN 1997
ACCORDING TO RANK ORDERS
Y-axis =
Causes
of Death
in Rank Order
1 * = cardiovascular diseases
2 * = neoplasm
3 *= injuries and poisonings
4 *= diseases of digestive system
5*=metabolism and immune disorders
6 *= respiratory diseases
7*= infectious and parasitic diseases
8 * = diseases of nervous and perception organs
9 *= diseases of bones, muscles and connective tissues
10 *= diseases of sex and urinary systems
*= pre- and postnatal complications
10 9 8 7 6 5 4 3 2 1 X-axis=
Causes of Health Care Expenditure
The scattergram of the causes of death and the causes of health care expenditure shows that the frequent causes of death are also the frequent causes of health care expenditure. In addition, most of these frequent ones are largely preventable. Therefore, if health promotion and disease prevention were successful, the needs for financing of health care can be reduced and the existing resources can be used to generate more benefit to the population, patients and the various professionals.
The Elektrostal analysis will be continued by calculation of the PYLL rates and the corresponding monetary losses. After these calculations, the estimates of monetary losses and assumed short and long term investment scenarios and accountabilities will be performed.
Organization of activities
The collection and recalculation of financial information has been done by the Elektrostal health care administration under the supervision of Tacis Long Term Expert Ilkka Vohlonen. It is assumed that also the statistical modeling of revised data will be done by the Elektrostal authorities. This will require additional training which will be provided by the federal financial expert group and the Long Term expert.
Outcomes
The protocol of financial macro analysis will be reported by the Elektrostal authorities in collaboration with the federal financial expert group and the Tacis experts. It is assumed that in addition to providing the Elektrostal municipal administration with a new tool and information for decision-making, the protocol will be replicable in other Russian municipalities. If feasible, the protocol will be further developed for oblast administration.
Vologda pilot: Financial microanalysis
Objectives
The financial microanalysis in Vologda oblast attempts to describe the need for improvement of financial accountability in the treatment of hypertension. The treatment can be assessed in terms of the current pharmaceutical patterns of physicians and the patients and the assumed improvement in the non-pharmaceutical approaches.
Methodology
The economic consequences of current treatment patterns are calculated for a group of patients who have been diagnosed with hypertension a while ago. Possibly a retrospective cohort of patients will be analysed with respect to the various costs related to the treatment of the hypertension (e.g., physician visits, pharmaceuticals, hospitalizations, etc.). In the preliminary development of the analysis, the indirect cost items are not included (e.g., absentisms from work, invalidity, pensions, etc.). The direct cost items will be calculated cumulatively for the patients’ lifetimes, e.g., for the next 15 – 25 years after the diagnosis of hypertension.
The cost items will also be calculated for the patients who are treated by the non-pharmaceutical approach. Although some cost items might be higher, some cost items will be lower, and the assumption is that the overall costs will be lower for the non-pharmaceutical approach. After the calculation of the cost items and the overall costs within the two alternative approaches in the treatment, the cost items are classified according to the responsible financiers of the expenditures (e.g., the municipal, oblast, federal tax budgets, the mandatory insurance, the out-of-pocket payments, various foundations, etc.). By comparison of the demand of finance (i.e. the determinants of costs by items) and the supply of the finance (i.e. the accountable sources of monetary resources), the financial strategies can be developed for the more efficient use of existing resources in the secondary prevention and the treatment of hypertension.
Analysis
The comparison of the two alternate approaches will be done first with a small group of patients who represent the current pattern of treatment of hypertension in few Vologda policlinics. Because there is no readily available data on the lifetime costs of the treatment of hypertension by cost items and there is no readily available data on the relationship between the demand (determinants of costs) and the supply of finance by various sources, a special protocol will be developed for the data collection. This will include the collection of data by various methods from various sources.
Schedule
The financial microanalysis started in Vologda in the beginning of May 1999 and the plan for the pilot data collection is prepared by the beginning of June.
RESULTS OF PROJECT ACTIVITIES
Essential to both financial analyses is to demonstrate by a logical approach the relationships (or lack of relationships) between the financial responsibilities for arrangement of disease prevention or/and health promotion and the economic consequences (losses) due to the preventable diseases. Once these relationships (or lacks) are identified according to various actors and diseases, it is assumed that improved justifications for the financing of disease prevention and health promotion can take place. This will also improve the development of legislative actions.
level decision-making in Vologda pilot.
The financial macro- and microanalyses will be reported in ways which allow for the replication of the protocols in various pilot areas and other areas of the Russian Federation. It is planned preliminarily, that in the beginning of the September a Dissemination Workshop will arranged in Moscow in order to train Russian authorities in various approaches of financial analyses and to demonstrate the results and conclusions of the analyses already done within the Tacis Russia Preventive Health Care Project.
ANNEX 7.1.11.
Preliminary analysis of regional target programs in Vologda oblast.
1. Introduction
At present seven target programs haven been adopted by the Regional Duma in Vologda oblast: “Diabetes”, “Vaccination”, “Fighting tuberculosis”, “Prevention of HIV infection”, “Safe motherhood”, “Prevention and treatment of arteriosclerosis and hypertension” and “Effective and safe X-ray diagnostics”. Most programs have an implementation period of four to five years. The year 1999 is the third or fourth year of implementation for the majority of the programs. The present programs might continue the life of similar earlier programs. However, there is no certain information about it at the moment.
According to the description, the vaccination program terminated 1998. The head of the program has confirmed that the program was extended to 1999, but there are no documents confirming it, except that resources for this program are allocated in the regional health care budget for 1999. There is an edict of the Governor of the regions to extend the program “ Safe motherhood” for 1999. Neither the list of the activities within the program not the estimate of expenses are included.
2. Program structure and activities
All programs follow the same structure: 1) Introduction, 2) some epidemiological data on the problem, 3) goals, 4) objectives and strategies, 5) expected outcome. and 6) the budget. The number of interventions for each program is large, on an average 20 to 30 strategies in various categories, including both treatment and prevention.
Most of the regional programs correspond to the respective federal programs, although this is not an official requirement. Each region can adopt those programs, which are most important seen from their perspective. It is unclear whether the Vologda programs which correspond to federal ones are real priorities for the region or simply used as an opportunity to get additional funding from the federal budget.
Concerning the actual activities on the basis of the programs, official documents have only been received from the arteriosclerosis program. The issue was further clarified by interviews with specialists of different programs. The interviews showed that the activities were strongly focused on purchasing: medicines, vaccines, diagnostics and treatment equipment. For instance in 1998, all the resources of the diabetes program were spent on insulin, of the vaccination program on vaccines, of the HIV prevention program on testing equipment and tests, of the Safe Motherhood program on equipment for prenatal diagnostics, ultrasound scanners and biochemical analyzers.
3. Financing
The program budget is estimated in rubles in the year of adoption. This causes at least two problems: Firstly, the costs of the programs adopted before 1998 were estimated in non denominated rubles, but the real funding in 1998 in denominated rubles. Secondly, the programs do not give any information on whether the costs are calculated including inflation, and if yes, which inflation rate is used. The answers of the specialists differed considerably.
The interviews also showed that the estimation of program costs is a purely fictive exercise. The real figure is the amount allocated for prevention programs in the annual regional health care budget. This figure is usually significantly different from the one in the program. According to the programs more than 37 200 000 rubles (without counting for inflation) were to be spent in 1998. The regional health care budget for 1998 allocated 18 % of that or 6 812 000 rubles for programs. At the end of the day the programs actually received 86% of that amount or about 5 862 600 rubles.
The proportion of funding between different programs has shifted during these years. According to the programs in 1997, the funding on diabetes and tuberculosis was to be more or less equal in 1999, that is about 24% of the whole funding of prevention programs for each. However, the budget for 1999 allocated 64 % for diabetes and only 0.3 % for tuberculosis. There are other similar examples. This means that the interrelations between the program planning and the annual budget preparation are unclear.
It would also be important to find out how the priorities for funding are determined. We have not found any comparison between the programs based on their effectiveness or their costs per unit of preventive effect ( DALY, QALY, PYLL etc.). If epidemiological data are taken into account, the change in proportional funding allocated to the programs in 1997 and1999 is difficult to explain. Prevalence of diabetes in 1998 increased by 5% from 1997. The number of HIV- patients has increased from 5 to 14 ( about 300%) between 1996 and 1998. Of course, it is understandable if 17000 patients with diabetes seem more significant than 14 infected with HIV.
The table below shows the funding for 1998 according to the programs and according to actual spending from the regional budget. There is no data about the funds planned for each of the programs in the 1998 health budget.
|Program |Funding planned in the programs |Actual funding in 1998 |% of the funding planned |
| |for 1998 ( denominated rubles, | | |
| |prices of the year of the | | |
| |program adoption without | | |
| |counting for an inflation) | | |
|Diabetes( 1997- 2000). |10 432 500 |5 163 000 |50% |
|Combating tuberculosis ( 1997- |About 10 000 000 |203 000 |2% |
|2000) |( there’s no division of | | |
| |financing per year) | | |
|Vaccination ( 1994- 1998) |250 100 |473 600 |189% |
|HIV prevention ( 1997- 2000) |3 302 500 |23 000 |0.7% |
|Safe Motherhood ( 1998) |3 000 000 |0 |0 |
| | | | |
|Prevention of arteriosclerosis |214 100 |0 |0 |
|and hypertension ( 1998- 2000) | | | |
|Effective and safe ray |10 000 000 |0 |0 |
|diagnostics ( 1998- 2000) | | | |
As can be seen from the table, only the vaccination program was funded with 189% of what was planned. This might be explained by the significant change in the price of vaccines between 1994 and 1998. Despite the inflation, other programs were given between 0.7% and 50% of what was originally estimated. Three programs were not funded at all. For all three programs the year 1998 was the first year of implementation. To make more precise conclusions, the data from 1996 and 1997 must be analyzed. If similar results are obtained, it may be concluded that financial realities are not taken into account when developing the programs. None of the programs have received any funding from the regional budget by April 01, 1999.
Most programs have several sources of finance. Among these are the federal budget (diabetes, vaccination, tuberculosis, HIV prevention), the regional budget (all programs), local budget (tuberculosis, HIV prevention, diabetes), Mandatory Health Insurance (MHI) Fund (Prevention of arteriosclerosis and hypertension, Safe Motherhood, Effective and Safe ray diagnostics). In addition, nearly all programs have external funding, mostly sponsoring and commercial activities. It is difficult to define the size of this funding, as this source is officially mentioned only in the Prevention of arteriosclerosis and hypertension program, and the professional are reluctant to provide information.
It is unclear whether the external funding is used for the strategies prioritized in the programs or for some other prevention and treatment activities. For instance, the head of the diabetes program said that the decision on where to allocate the external funding is made by him, and does not depend on the program. It is mainly spent on diagnostics and treatment of children. The attitude of the professionals towards the priority of the strategies proposed in the programs should be further clarified. As the external funding may vary considerably, it is not mentioned formally in the programs. This may lead to the fact that resources are spent on the activities that do not necessarily meet the objectives determined in the programs and disperse the resources available. The innovation proposed in the program on prevention of arteriosclerosis and hypertension, that external funding should be included as one of the official sources of financing and the amount of its should be assessed, is seen as positive for the future.
Data on funding from the federal budget and MHI Fund are available only on some programs. For instance, vaccination program was funded from the federal budget in 1998, in full, diabetes- in part ( no precise data). Safe Motherhood program was funded from MHI Fund, in half.
4. Program evaluation
At present, there is no data on the evaluation of effectiveness of any of the program strategies. Specialists in the area, often chief specialists of the region/city, usually develop the programs. It is important to find out to which extent national and international data on the evidence of a particular intervention are taken into account. Because no special study to evaluate the effectiveness of programs has been planned within the framework of this analysis, the assessment will be primarily based on the statistical data. However, it will be difficult, as most of the strategies are oriented on treatment. To evaluate the impact of the interventions on mortality will also be difficult, because, as the head of the diabetes program said, the cause of death is often misdiagnosed.
5. Conclusions
The preliminary analysis of the programs allows to make the following conclusions:
1. The cost of the programs adopted by the Vologda Duma exceeds the real financial capacities of the region. The programs should be reconsidered and restricted, either the number of programs or the number of proposed strategies.
2. Each program contains too many activities within different areas. Each program should imply a single well determined intervention where the effect can be measured and which can be realistically financed.
3. The activities within the programs include both prevention and treatment. Scarce funds force a choice between interventions. This is usually done by a particular specialist based on his/her personal views or experiences, but not the evidence from research or international practice. The analysis shows that most of the activities include treatment. Therefore these target programs can not be referred to as prevention programs. Treatment activities can be priorities, but only if they were prioritized based on the economic evaluation compared to preventive interventions.
4. The choice of priorities between the programs and on the interventions within a program can be correct only of the total costs and costs per a program effect were compared.
5. Many activities within the programs, such as purchasing equipment are very expensive. It can hardly be efficient given the financial constraints and excessive human resources within the current Russian health care system. The equipment will also require further spending on maintenance. It is worth of making an evaluation of effectiveness of the use of the equipment in those facilities where it was supplied between 1996 and 1998 and calculate the cost per a unit of effect if there is any.
Prepared by Elena V. Tkatchenko, MPH, DLSHTM
29.04.1999.
ANNEX 7.1.12.
Program “ Work place health promotion and disease prevention among municipal employees in the city of Electrostal” ( final version)
Definition of the Project “ Workplace Health Promotion Program, Electrostal”
|Wider Objective |To develop federal and regional ( oblast and municipal) health policies and action programmes focusing on health promotion and disease prevention in order to reduce the main health problems. |
| |(Inception report, p. 10) |
|Purpose of the |To set up a workplace health promotion demonstration program in Electrostal. |
|Project |to plan, |
| |to implement and |
| |to evaluate |
| |Target population: specific groups of employees of the municipality of Electrostal: |
| |teachers, |
| |health care workers and |
| |administration employees |
| |2. To provide models of good practice of WHP from European countries |
| | |Objectivlye measurable indicators |Source of evidence |
|Specific |To organise a study tour where up to date methods of WHP can be seen |One study tour until the end of the project |final project report |
|Objectives |To organise seminars with foreign experts on up to date WHP methodology | | |
| | |2 seminars until the end of the project | |
| |The designing of the program will take into account needs of the target population |In each target group 2 priority topics of the needs survey of March 99 should be treated by |final project report |
| |assessed by survey in November 98 and March 99 |the interventions of the demonstration program | |
| |The program should be selfsustainable without the assistance of Tacis after August |At the end of the project the Center of Medical Prevention has trained and continuously |final project report |
| |2000. |employed staff of at least 3 persons, with a stable locality and a yearly budget for further | |
| |The Center of Medical Prevention will be developed as a co-ordinating and providing |interventions | |
| |institution for the WHP interventions. It should be able to carry out further |At the end of the project guidelines based on the experiences of the demonstration program | |
| |interventions based on the experiences of the demonstration programme after August |exist for: | |
| |2000. |risk factor measurement and counselling |guidelines |
| |The activities of the demonstration program should be suited for more widespread use|nutrition | |
| |in other workplaces in the future. |physical activities | |
| | |non-specific stress management | |
| | |specific stress management |final project report |
| | |There should be realistic (defined intervention, human and other resources defined) activities | |
| | |planned for the pilot groups for autumn 2000. | |
| |The WHP program will have two components: |In the end of the project period one or more interventions are running in the workplaces of the|participation records |
| |The first component is directed towards the prevention of Non-Communicable-Diseases |target groups, | |
| |and the lowering of the corresponding riskfactors: |where in total one third of the employees participate voluntarily, |comparison entrance / |
| |Risk factor measurement and counselling |that: |final participant |
| |Increasing physical activity |increase knowledge (participants know basic facts about risk factors), |questionnaire |
| |Healthy nutrition |change behaviour (practice at least monthly a healthy behaviour) or | |
| | |lower risk factors for NCD (change of cardiovascular fitness indicator +10%, lower weight - | |
| | |10%) | |
| |The second will address factors related to work that influence health negatively: |to have in the end of the project period one or more interventions running in the workplaces of|participation records |
| |stress management, non-specific |the target groups |comparison |
| |stress management specific by problem focused group work |where in total one third of the employees participate voluntarily, |entrance/final |
| | |that reduce strain factors in the workplace (average improvement by one category on a 5 |particip. quest. |
| | |category scale) | |
| |The target groups chosen out of the target population are: | | |
| |The teachers of School 7, | | |
| |Physicans and Nurses of Childrens Policlinic No 1, | | |
| |Physicans and Nurses of Adult Policlinic No 2, | | |
| |Physicans and Nurses of the rehabilitation department | | |
| |The employees of the central administration building | | |
|Activities |To establish a functioning project management structure: steering committee | | |
| |To do surveys on needs | | |
| |To design policies to influence nutrition, physical activity, stress, to measure | | |
| |risk factors and to counsel on them. | | |
| |To implement them | | |
| |To evaluate them | | |
| |To design an information policy for the target groups | | |
| |To build up the Center of Medical prevention with rooms, continuous staff and | | |
| |necessary equipment | | |
| |To train the staff of the CMP | | |
|Resources |City of Electrostal.....in the pilot cities of ..and Electrostal, the authorities | | |
| |have.... fully committed themselves to the implementation of demonstration | | |
| |activities (Annex 7.26 of inception report) | | |
| |Tacis: | | |
| |Expert advice | | |
| |Study tours | | |
| |Training courses for providing staff with respect to the need of the program | | |
| |Equipment for the CMP as already ordered | | |
| |Leaflets on health topics, | | |
| |Newsletter for employees | | |
| |Health education materials | | |
SWOT- Analysis of the WHP program
Strength
1. Commitment of top level of authorities towards the Workplace Health Promotion Program
2. In general a positive attitude towards Health Promotion exists in Electrostal since the CINDI program
3. From the CINID program some trained staff, skills still exist.
4. The motivation of participants seems to be high
Weaknesses
5. Time of the Tacis project is restricted. Final results are expected until summer 2000
6. The financial resources of Electrostal are restricted.
7. Until present (May 99) a structured strategy or project plan has not been developed.
Opportunities
8. If steering committee works effectively, it can have great impact on the results of the project
9. If Center of Medical Prevention is developed during the project, it can play a beneficial role for Health Promotion and Prevention in future
Threads
10. The planned program does not stimulate a sufficient number of people to participate.
11. Momentum can’t be maintained. Target groups loose interest.
Organisational structure for ” Workplace Health Promotion Program Electrostal”
Role of Steering Committee:
To develop together with Tacis experts an overall plan for the WHP program until August 2000 including activities, milestones and dates, resources
To develop together with Tacis experts policies on the components of the program
To decide over the plan and policies to be implemented.
To hand over certain organisational issues to the working groups in the target institutions
To control the execution of the plan
To report on ongoing developments and activities to P. Aarva, E.G. Hagenmeyer and T.V. Kamardina
One member of the steering committee, it’s head, should be responsible for the program as a project leader (See note)
Role of working groups in the target institution
To assist with development of policies and the implementation of interventions in the institution
To represent the interests and ideas of employees to the co-ordinator from the target institution
To take over the provision of certain activities like the facilitation of group work and the guidance of physical activities
Role of Tacis
Provision of experts, following the total project process:
E.G.Hagenmeyer and T.V. Kamardina:
To follow and support the total WHP program with advice from beginning until it’s end in August 2000
To assist in the development of the overall plan and the policies including evaluation procedures.
Provision of other resources
Experts on specific topics
Study tours to visit models of good practice
Training of providing staff of the WHP program related to the realisation of the program
Equipment for the CMP as already ordered
Leaflets on health topics, e.g. leaflets on smoking, alcohol, overweight, stress, physical activity
Production of newsletter for employees
Health education materials
Reporting
Monthly reporting from the steering committee to P. Aarva, E.G. Hagenmeyer and T.V. Kamardina on all ongoing processes concerning the WHP program in Electrostal
Regular reporting from the steering committee to the deputy mayor for social questions V.I. Ljushin
Regular reporting of E.G. Hagenmeyer and T.V. Kamardina about their activities to P. Aarva
Note:
In my opinion a person from Electrostal should take the responsibility of a project leader for the plan the steering committee has agreed upon. I propose Ms Pestun as the head of the steering committee.
Overall Planning for total lifetime of
„Workplace Health Promotion Program Electrostal“
until August 2000
First planning period until end of December 99
Start with Health Days in autumn 99 (September?)
Before that inform target groups about results of survey, Health Days and other planned activities
After Health Days start regular activities related to the priority topics (healthy nutrition, physical activity, stress). Preferably start with one for which the prerequisites already to a large extent exist. My opinion is, that there should be at least two topics covered. One of the might be physical activity. These activities should continue until end of December.
In December there should take place an evaluation of the project. The results should be used when developing plans and activities for the year 2000. The developing process should already start earlier, e.g.when the activities mentioned above have started.
Balint demonstration and the study tour to Britain and Germany should have taken place until the end of the year.
Until the end of the year a concept how to tackle group work for stress should exist.
Second planning period until the end of August 2000
In the second planning period the regular activities from the first period should continue.
In addition to that the left over topics from the 4 priorities should be tackled. One of them should include group work on stress.
Another risk factor assessment as follow up might take place during this second period
A final evaluation should take place in June 2000.
Resource requirements
Rough estimates, to be accomplished:
Human resources
A number of 4 permanent employed staff ( 1 psychologist, 1 physical activity trainer and 2 feldshers)
Additional temporary staff from the target institutions, mainly physical activity teachers. With regard to their working time it would be the best if activities could take place during working hours.
Skill requirements
Skills for risk factor measurement and the development of the health passport should already exist.
For counselling guidelines on different risk factors have to be developed.
For healthy nutrition the resource use is still undeterminded. It depends mainly whether one in addition to counselling wants to provide healthy meals in canteens.
For non-specific stress coping methods the skills should already exist. Similar activities have been provided at the EZTM plant.
For problem focused group work facilitators have to be trained. With regard to that a study tour to German institutions providing and using Health Circles is planned. Contact has been made with organisers of Balint group work. The purpose is to demonstrate the approach and if possible to train facilitators.
Materials
Material for blood sample analysing for risk factor measurement
Print materials: Health passports
Leaflets on health topics
Newsletter for target groups
Other resources
A rebuilt Center of Medical Prevention as a base for the work of the staff who provides the activities.
Detailed planning for the first period until the end of December 1999 ” Wprkplace Health Promotion Program Electrostal”
The program is divided into different components for each of which a policy is developed. One has to take care of date-dependencies. Therefore a system of milestones is helpful as outlined at the end of the document.
Policies on different components of the WHP program
Subgroups from the steering committee develop policies with the assistance of Tacis experts. The following systematic with the „W“ questions is meant as a guide for the development. The details added by E.G. Hagenmeyer are proposals.
Risk factor assessment:
Why?
Which factors?
How to measure?
How to document?
Passport has to be designed and printed.
How to implement?
Within a Health Day
How many participants do we expect?
How to evaluate procedure, success?
Human resources? Is training of providers needed?
Materials?
Health passport
I recommend to include into the passport already space for the documentation of follow ups.
I recommend a double documentation anonymously with a number code for follow up. This data can be used for a longitudinal analysis of the development of the risk factors by the Center of Medical Prevention.
The health passport gives the opportunity to document the participation of the owner at different program activities by stamps. One might chose a winner of the WHP program according to the number of stamps he collected.
Stress management
Why?
Which procedure?
I recommend as a methodology for non-specific stress management the methodology of muscular relaxation.
For specific, problem focused stress management I recommend Balint group work and/or the Health Circle methodology. Demonstrations and training for these methods are planned to be provided by Tacis within the project.
How to implement (group sessions?)
How to inform employees about the activity to stimulate participation?
How many participants do we expect?
How to evaluate procedure, success (stress level at the beginning, and follow up? Participation, application of the method)
Human resources. Is training of providers needed?
Materials?
Financial resources?
Physical activities
Why?
Which procedures?
How to implement (Health Day? Groups?).
How to inform employees about the activity? How to stimulate participation?
How many participants do we expect?
How to evaluate procedure, success?
Human resources. Is training of providers needed?
Materials?
Financial resources?
Healthy nutrition
Why?
Which topics, activities?
How to implement?
How to inform employees about the activity to stimulate participation?
How many participants do we expect?
How to evaluate procedure, success?
Human resources. Is training of providers needed?
Materials?
Financial resources?
Health days
Why?
The Health days are a starting activity, they should create publicity.
The Health Days should be used to create interest for following activities e.g. on nutrition, on physical activities, on stress management
They should also serve as opportunity to create a data base on monitoring risk factor levels.
One might create an incentive system with stamps for a final healthy life style winner
Therefore the passport should be very carefully designed to include all options: documentation of risk factors, follow-up, coding for follow-up, documentation of participation at workplace health promotion activities.......
Which topics, activities?,
Hand out print materials from Tacis
Physical activities: short (10 min?) sequence of easy to do exercises
How to implement?
How to inform employees about the activity to stimulate participation?
Target groups should be informed about the health days not to long before that (2 weeks?)
Mass media should be invited
How many participants do we expect?
How to evaluate procedure, success?
Human resources. Is training of providers needed?
Materials?
54. Scales, leaflets
Financial resources?
Information policy
Why?
Whom do we want to inform?
How?
What message?
When?
Milestones:
Dates have to be set as soon as possible for the following activities. This list is not complete!!!
Staff has to be sent to cardiovascular fitness test training before summer holidays.
Passport has to be ready designed to go to printing
Newsletter has to be ready designed to go to printing
Dates for Health days have to be set for autumn (September)
Handing out date for newsletter and article in the newspaper
Start of physical activities groups in the institutions
ANNEX 7.2.
NETWORK AND TRAINING.
ANNEX 7.2.1.
Materials of the 4th ToT Seminar, March, 1999.
The Annex was prepared in Russian and is presented in the Russian version of the Report.
ANNEX 7.2.2.
Proposal on the introduction of Public health Schools in the Russian Federation.
Moscow, 3 March 1999
To: Mr. N.Volodin, MoH, Deputy Head of the Department of the Research and Educational Institutions Under the Ministry of Health
From: Board of the Faculty of the Health Care Management, Sechenov Medical Academy
Proposals Prepared by the Participants of the Round Table on the Curricula Development for the Medical Educational Institutions (Moscow, 19 February 1999).
Dear Mr. N.Volodin,
Within the Tacis Preventive Health Project and according to the initiative of the Board of the Faculty of the Health Care Management, Sechenov Medical Academy, the Round Table called as “Curricula Development Focused on Health Promotion and Disease Prevention” took place in Moscow on 19 February 1999 (the program is attached).
The following presentations were delivered:
• Prof. O. Heinonen, University of Helsinki, Training in Health Promotion and Disease Prevention – Why, How and What?;
• Prof. Yu. Lisitsyn, Russian National Medical University, Integration of a Such Subject as Sanology into the Curricula of the Russian Medical Educational Institutions;
• Prof. I. Denisov, Sechenov Medical Academy, Curricula Updating for the Post-Graduate Training of the Health Professionals;
• Prof. L. Syrtsova, Sechenov Medical Academy, Role of the Health Care Management Faculties and Public Health Schools in the Training in Health Promotion and Disease Prevention in Russia.
Within the frameworks of the Round Table the issue of curricula development
focused on health promotion and disease prevention has been discussed with a respect to:
1) undergraduate training (for medical students of the faculties of clinical studies, pediatrics, medical prevention);
2) postgraduate training (for GPs, medical doctors specialized in the social hygiene and health care management).
Among the participants of the Round Table there were 29 lecturers from the
various medical educational institutions of the city of Moscow, the Tacis Project Manager and experts, media representatives.
In the presentations and in the course of the followed discussion an idea has been expressed on the necessity of curricula development focused on health promotion and disease prevention both at the undergraduate and postgraduate levels. It has been also said that it is necessary to take into practice the new institutional forms such as public health schools. As for the specialization in public health, this is to be included into the list of specializations available for health professionals in Russia.
The participants of the Round Table came up with the following proposals:
1) To convene the Board of the Ministry of Health in order to discuss the issue “Preventive Health Care in the Russian Federation: Current State and Prospects (policy, legislation, networks and training, financing, cost-effectiveness)”;
2) To send a request to the Ministry of Health on the establishment of the working groups including the representatives of the relevant kafedras (departments) of the Sechenov Medical Academy, Russian National Medical University, Ural Medical Academy for the Post-Graduate Training (Chelyabinsk), Chelyabinsk Medical Academy, National Medical Academy for the Post-Graduate Training and also the key experts of the National Center for Preventive Medicine for the development of new curricula in such medical specializations as social hygiene and health care management, therapy, family medicine, valeology (teaching about the healthy life-styles), cardiology, etc.;
3) To send a request to the Ministry of Health on the establishment of the ToT Center for the training in HP & DP under the Faculty of Health Care Management, Sechenov Medical Academy. The Center’s activities will be running within the overall framework of the program of the teaching level upgrading for the lecturers teaching on social hygiene and health care management;
4) To train the above-mentioned lecturers in the recent developments in the HP & DP field within the framework of the continuously running series of the training seminars supervised by the heads of kafedras of social hygiene and of the health care management (Faculty of Health Care Management, Sechenov Medical Academy);
5) To advise the Board of the Faculty of Health Care Management, Sechenov Medical Academy to arrange the series of the training seminars in HP & DP at the both undergraduate and postgraduate levels with regard to the needs identified by the Chelyabinsk Medical Academy and Ural Medical Academy for the Post-Graduate Training;
6) To send a request to the Ministry of Health on the establishment of the working group for the development of the integrated inter-disciplinary curriculum for the continuous training of the medical students and public health experts in HP & DP;
7) To ask the Ministry of Health to consider an issue of the establishment of such an institution as a school of public health in Russia with a regard to the experience in this field which is available in the Sechenov Medical Academy, Chelyabinsk Medical Academy and Ural Medical Academy for the Post-Graduate Training;
8) To encourage the kafedras of social medicine, health economics & health care management, epidemiology, therapy, occupational health, cardiology, valeology, human ecology within the medical schools, the relevant research institutes and units, the editorial boards of the relevant professional journals to join an intersectoral cooperation by means of taking of an active part in the open discussion on the issue of establishment of schools of public health in Russia and of curricula development focused on HP & DP;
9) To ask the Ministry of Health to address the municipal authorities of the city of Moscow with a proposal to arrange a joint Board of the municipal health care department and municipal education department in order to discuss the issue of training in HP & DP.
Dean of the Faculty of the Health Care Management, Prof. V. Kucherenko
Sechenov Medical Academy
Deputy Dean, the Tacis expert Prof. L. Syrtsova
ANNEX 7.2.3.
Materials of the Round Table on Sexually- Transmitted Diseases, March 1999.
Round Table “Role of NGOs in the STD prevention”.
Date: 4 March 1999.
Place: National Center for Preventive Medicine, the Tacis office.
Hosts: The Tacis Russia Preventive Health Care Project, the Training Center.
Participants:
- Prof. V.V.Sudakov (Chairman), Vice-Rector of the Vologda University, Chairman of the Vologda Regional Peace Foundation;
- Dr. G.B.Tkachenko, the Tacis Russian Vice-Director;
- Dr. A.M.Kalinina (Co-Chairperson), National Center for Preventive Medicine;
- Dr. V.V.Stan, National Center for Preventive Medicine;
- Dr. G.T.Kholmogorova, National Center for Preventive Medicine;
- Prof. L.E.Syrtsova (Co-Chairperson), Sechenov Medical Academy;
- Mr. R.A.Kasimov, The Tacis Vologda Coordinator;
- Mrs. T.N.Melnikova, Chief Medical Officer, the Vologda Municipal Center for the Control Over AIDS and Other Communicable Diseases;
- Mrs.M.M.Olenina, the Vologda Regional VD Dispensary.
Representatives of the Non-Governmental Organizations (Moscow and Vologda):
- Mrs. E.N.Bazhenova, Medicine Sans Frontiers;
- Mrs. A.G.Grigorieva, Medicine Sans Frontiers;
- Mrs. E.Kushmanaeva, Hera (Information Center);
- Mrs. N.Surkova, Hera (Information Center);
- Mrs. M.A.Kuzmina, Imena (Foundation);
- Mrs. O.Subbota, Imena (Foundation);
- Mr. A.Chikin, Podval (Theatre);
- Mr. A.Galiev, Podval (Theatre);
- Mr. A.Yu.Ziminov, priest, the Russian Orthodox Church;
- Mr. M.R.Nashkoev, AIDS-Info (Center);
- Mr. Starovskii, the Youth Volunteer Organization (Vologda).
Resolution.
1. All the participants of the round table agreed on the landmark character of this event. For the first time, the representatives of various governmental and non-governmental organizations gathered to discuss the issues of the population health status, community participation in the preventive activities with a special emphasis on the STD prevention. The spread of the STD is a burning problem, both health and social, for the younger generation. The participants of the round table believe that the problem could be tackled by the set of preventive measures. The latter, in the ultimate run, might evolve into the state policy. The state policy would presume the activities at the federal level, activities at the level of regions and enterprises, and, what is the most important, activities at the household and individual level.
2. The participants appreciated the fact that the NGOs dealing with the STD risk groups are relying on the modern well-tested techniques of social marketing, able to make a situation analysis with regard to the circumstances, needs and intentions to receive a certain health information.
3. According to results of the surveys done by the NGOs among the most risk groups, the level of their knowledge on the STD is insufficient for taking of the proper measures aimed at the prevention of the latters.
4. The experience in the school-based activities done a number of the NGOs can be not only approved but recommended for dissemination. As for the sexual education materials for children and adolescents, they are to be designed very carefully. The materials are to be informative. At the same time, they should not cause too much agitation concerning sexual matters.
5. It is necessary to study the experience of the VD research institute in terms of the involvement of the risk group members (prostitutes) in the STD prevention and in terms of the development of the health education materials.
6. It is necessary to take into account the results of the survey done in the schools. The survey meant to clarify the attitude of the pupils towards such subjects as “safety basics” and “valeology” (teaching on the healthy life-styles). The survey results showed that the interest to the subjects is quite high. At the same time, many of the high school pupils mentioned that they would like to see more professional competence in the lecturing. They expressed their wish to see health professionals delivering an information when a talk concerns health matters. As to the lecturers on the health subjects, the pupils pay more respect to health professionals. As the second best, those might be the teachers of biology.
7. Some NGOs need a support on the part of the Russian authorities. Thus, for example, Medicine Sans Frontiers put forward an initiative to arrange a health care outpost for the homeless of Moscow. Yet, despite the repeated claims there was no reply on the part of the Moscow municipal authorities. It would be worthwhile to resume this talk, to discuss the justifications and to submit a request again having already a back-up from the influential public institutions.
8. All the participants of the round table stressed that among the reasons for the wide spread of STD there are not only social and economic plagues, but a decline in moral standars as well. Here, the role of culture is undeniable. To this respect, an initiative of the Podval Theatre could be praised. Their performances are, no doubt, worth of high expert esteem. If necessary, they could be video-recorded for the further dissemination. This would be an alternative to the display of sex, violence and deviant behavior what, unfortunately, dominates the TV screen nowadays.
9. The participants of the round table expressed their wish to enlarge the spectrum of publications on the subject. This concerns not only professional journals, but mass-media as well.
10. All the participants supported an idea to proceed with the meetings like this. The other forms of cooperation were also mentioned. It has been decided to arrange an exhibition accompanied by the contest for the best health education material, organize a press-conference and set-up a library. It has been also decided to organize a festival with a demonstration of health education materials, theatrical performances, TV spots, etc. This may serve healthy life-styles advocacy and search for the new and relevant forms of the STD prevention with the NGOs’ involvement.
11. The participants of the round table expressed their concern over the authorities’ inaction in terms of prostitution and advertisements of commercial sex in the mass-media.
12. The participants urged a necessity of the journalists’ involvement in case of the next meetings. This is to be done not only to highlight the events, but also to develop a joint policy and prepare further steps in health protection and disease prevention.
13. It has been mentioned that the current event passed successfully. Most of the participants said that it was beyond their expectations. Everybody concluded that an arrangement of the next meeting is necessary. NGOs are still in rudimentary state in Russia. Rather fragments are available than the system. At the same time, people share the same views, what is the most important. As the Russian citizens, we can move forward. Meetings like this are in the interests of the whole society. The Moscow Tacis office has been asked to take a lead in the arrangement of the next meeting.
Prepared by Dr. A.M.Kalinina, 05.03.1999.
Translated by Dr. A.Verizhnikov, 06.04.1999
ANNEX 7.2.4.
Draft articles on training on HP & DP.
This Annex was prepared in Russian and is presented in the Russian version of the Report.
ANNEX 7.3.
MONITORING AND INFORMATION.
ANNEX 7.3.1.
Progrom and materials of the Training course on survey methodology.
19.5.1999/IV
APPLICATION OF SURVEY METHODOLOGY AND STATISTICS IN MONITORING OF HEALTH ISSUES AMONG POPULATION:
An intensive post-graduate course for administrators
Objectives: To teach participants how to use survey methodology in collecting
information and monitoring of population’s lifestyles, health and
use of health services
Participants: Federal, regional and local administrative authorities on selective basis
Teaching methods: Interval teaching with highly participatory approach using
actual survey data from the Vologda Population Health Survey
Instructors: Theory of monitoring and data collection
Professor Tamara Maximova, Shemasko Research Institute
Mail surveys, interviews and applied statistics
Professor Ilkka Vohlonen, Tacis Russia Preventive Health Care t
Use of computers, software and information processing
Computer specialists
Teaching institute: The Shemasko Research Institute
Time and Place: The course takes place once a month for two day sessions from
February to May in the Shemasko Research Institute and
includes homework in-between sessions
Learning time: In class-room 50 hrs and assumed homework 25 hrs
I. Interval
1. BASICS OF PROBABILITY
- Theory of relativity
- Normal distribution
- Characteristics of distribution
2. BASIC RATES AND INDICATORS
Expected and unexpected rates
Frequency
- Consistency
- Causal interdependence
- Chi-square assumption
3. CALCULATION OF STATISTICAL INDICATORS
- Average
- Standard deviation
- Coefficient of variation
- Slope
- Regression
- Prevalence
- Incidence
- Attack rate
- Gamma coefficient
- Kappa coefficient
4. STANDARDIZATION AND ADJUSTMENT OF DATA
- Regression with assumption of causality
- Direct with specific rates and common population
- Indirect with common rates and specific populations
II. Interval
5. USE OF REFERENCE VALUES AND STANDARDS
Sample characteristics and base population
Height
Weight
- Body-Mass-Index (weight/ height in square meters)
6. CHOOSING COMPUTER PROGRAMS
Fit software with hardware
- For survey analyses old software is often enough
- Software from 1970’s is sufficient
- If you have hardware get old software
- Do not trust only a computer specialist but rather ask your collegue
7. SOFTWARE CHOICES
SPSS
SAS
- BMDP
- EXCELL
- Problems often occur with the English language
- If you purchase a software, buy a dictionary program at the same time
- There are more statistical software choices than choices of statistics that
- you will know how to apply or need
8. PRACTICAL EXERCISES AND DESIGNS
Designs
Cross-sectional
Forward & Backward
T1= 0/1 T2= 0/1
T1+T2 = 00 10 10 11
The 80/20 rule
With individual follow-up design (T1+T2) the sample size is reduced considerably
III. Interval
9. STATISTICAL PERFORMANCES
- - +
- A B
+ C D
always refer to the observed and the expected values in A,B,C, and D classifications
10. SAMPLING TECHNIQUES
- Frequency = assumed DELTA
- Alfa/Beta values
- Consistency
11. STUDY AND SAMPLE DESIGNS
- Backward
- Cross-sectional
- Forward
12. SAMPLE SIZE
- Cross-sectional
- Cohort
- Hawthorn effects
- Start small
IV. Interval
13. SOURCES FOR SAMPLES
- Official registers
- Consumers
- Never rely on people who consume
14. REPRESENTATIVE SAMPLING
- Usually 2.5 – 3.5 % enough for administrative purposes
- Cost down
- Quality up
- Speed up
15. HOMEWORK
- Observation methods
- Data collection
- Planning of analysis
- Performing of statistical analysis
16. INTERPRETATION
- Statistical analysis
- Interpretation of statistics
- Writing of conclusions
ADDITIONAL MATERIALS
- students undergo a final written (prof. Vohlonen) and oral (prof. Maximova) examination
- passed students will receive a Russian and international certificate
- students with certificate will be equipped with the Vologda survey data, the SPSS program, and availability of computer capacity
ANNEXES
- the Vologda survey questionnaire
- the SPSS file description of the Vologda survey data
- examples of the students´ analyses of the Vologda survey in the end of the course
ANNEX 7.3.2.
Materials of the meetings of the monitoring group, April- May 1999
The Tacis Russia Preventive Health Care Project
Mr. Alexander N. Kolba, MoH.
On Establishment of the Public System of Monitoring Over the Health Status of the Russian Population.
For the first time, the issue of an establishment of the system of monitoring over the health status of the Russian population has been raised at the level of public authorities in 1993. According to the Presidential Decree No. 468 (issued 23.04.1993) “On Urgent Measures to Protect Health of the Russian Population”, the Ministry of Health, Russian Academy of Medical Sciences, Committee for Public Sanitary and Epidemiological Surveillance were authorized to develop and put into the practice the system of monitoring over the health status of the Russian Federation (Point 4 of the Decree).
According to the initiative of the Ministry of Health and Committee for Information Supply, there has been established the Inter-Ministerial Coordination Council. Besides these two, the Council included the following structures:
- Russian Academy of Sciences;
- Russian Academy of Medical Sciences;
- International Academy of Computerization and Information Supply;
- Russian Academy of Natural Sciences;
- Ministry for Emergency;
- Ministry of Communications;
- Ministry of Labor;
- Ministry of Nationalities;
- Ministry of Social Protection;
- Ministry of Education;
- Committee for Public Sanitary and Epidemiological Surveillance;
- Committee for Meteorology;
- Inter-Regional Association (NGO) “Computer Technologies in Medicine”.
Additionally, there has been established the Intersectoral Workgroup for the
development of the Concept for Monitoring of the Health Status of the Russian Population. The Concept has been agreed upon by the Inter-Ministerial Coordination Council plus 22 ministries and agencies. In 1996 it has been approved by the Ministry of Health and Committee for Information Supply.
The Concept serves as a basic document while designing the public system of monitoring. It includes the whole set of underlying principles, objectives and tasks for all those elements of an infrastructure for health information supply that are based on the advanced computer technologies.
The major purpose of the project is to establish the state-run inter-ministerial hierarchical system for gathering, processing and storage of health information. The system is to be based on the modern computer technologies. It is expected to follow the situation in the field of public health in dynamics and help in the decision-making in health matters.
The major objectives for the public system of monitoring over the health status of the Russian population are the following:
❑ To study the trends in the population health status and factors that influence the latter;
❑ To identify the priorities in a provision of the sanitary and epidemiological well-being of population; problems of medical and social character in the field of health protection;
❑ To identify those population groups that require the special care (medical and social) with respect to their health status;
❑ To develop the federal and regional programs aimed at the improvement of the population health status;
❑ To provide the information supply in the development of legislative proposals by the health care authorities, sanitary and epidemiological services, social protection bodies and environmental control agencies;
❑ To forecast and make justifications for the resource allocation in the field of health protection.
Currently, the study of the population health status is based on:
❑ Official statistics of the Ministry of Health, State Committee for Statistics, Ministry of Labor and other public authorities;
❑ Results of the health surveys done in some regions;
❑ Research activities aimed to identify health determinants;
❑ Epidemiological data on non-communicable diseases;
❑ Norms prescribing the ways of gathering, processing and storage of information and stating the rules of an access to information.
In many regions of the Russian Federation there are introduced the systems of
monitoring over the current level of communicable diseases. In the recent years such publications became available as:
- Official Report “On Health Status of the Russian Population”;
- Periodical “Health of the Russian Population and Activities of the Health Care Institutions”;
- Periodical “Mortality in the Russian Federation”.
Thus, in Russia a certain potential is available to serve as a foundation for the
building of the system of monitoring over the population health status and of the system of socio-hygienic monitoring.
According to the MoH’s Decree No. 158 “On the Program for Computerization and Development of Information Systems Within the Health Care Sector in Russia for the Years of 1996-1998” (issued on 23.04.1996), MEDSOCECONOMINFORM, the research & development center, has been identified as a key institution in the process of development of the public system of monitoring over the health status of the Russian population.
The Terms of Reference and some software were prepared.
More than that, according to the Governmental Decree No. 414 “On the Federal Goal-Oriented Program for the Cleaner Environment of the Volga-river Basin” (issued 26.04.1998), monitoring of the population health status has been identified as a sub-program within the larger program. MEDSOCECONOMINFORM is involved here as well.
Unfortunately, the lack of money specially allocated for the use of the program for the building of the public intersectoral system of monitoring of the population health status impedes its implementation.
Still, with a financial support of the Ministry of Health, something has been done within the “Program for Computerization and Development of Information Systems Within the Health Care Sector in Russia for the Years of 1996-1998”. As the elements of monitoring there are introduced the following registers:
- Register of Diabetic Patients (Diabetes Research Insititute);
- Register of TB patients (TB Research Institute Under the Sechenov Medical Academy);
- Register of Cancer Patients (Cancer Research Institute named after Gertzen);
- Federal Genetic Register (Moscow Research Institute of Pediatrics and Pediatric Surgery);
- Register of the Disabled Children (Moscow Research Institute of Pediatrics and Pediatric Surgery);
- Register of Psychiatric Patients (National Center for Psychiatry named after Serbskii);
- Register of Patients With Osteo-Muscular Problems (National Research Institute of Traumatology and Orthopedics named after Vreden);
- Register of Dental Patients (National Research Institute of Dentistry);
- Register of Drug-Addicts and Alcoholics (Information Processing Center Under the Ministry of Health of the Republic of Udmurtia).
In December 1999 it is expected to see what are the outcomes of the “Program for
Computerization and Development of Information Systems Within the Health Care Sector in Russia for the Years of 1996-1998”. With a regard to these outcomes the further steps in the development of the public system of monitoring over the health status of the Russian population are to be planned.
Translated by Dr. Aleksei Verizhnikov, 27.04.1999.
|[pic] |The Tacis Russia Preventive Health Care Project |
Mr. Kolba, MoH, Deputy Head of the Department of Health Information.
10.01.1999.
Review of the Paper Produced by Dr. Fokko de Vries.
The given paper consists of the introduction, five chapters and two annexes. The paper is produced within the Component 3 “Monitoring and Information Systems” of the Tacis Preventive Health Care Project.
Despite the usefulness of this study and its relevance to the purposes of the Project, it is necessary to mention a number of the inaccuracies and lack of the complete understanding of the nuances of the Russian health care system on the part of the author.
In the Introduction there is a statement about the overstaffing of the Russian health care system. At the same time, no figures have been provided to confirm this statement and to compare the Russian and international practices (standards) to this respect. The author’s claim concerning the necessity of a shift from the health care system mainly focused on curative services to the health care system mainly focused on health promotion and disease prevention can also be considered as improper. In fact, both curative and preventive health care is available in Russia. What is really needed is an adequate allocation of the existing resources for the sake of health promotion and diseases prevention. In the former USSR the experience of the total prophylactic examinations, large-scale preventive activities and screenings was available. Still, the received data on a true morbidity had shown then an inadequacy of the financing with respect to the existing needs in the provision of the health care services.
The third paragraph of the Introduction causes a feeling of perplexity. There an attempt is made to identify the Vologda health information system with the Vologda health care system as such, although these two are not identical things.
In the Chapter 1 “Methodology” the usage of a semi-structured questionnaire has been mentioned. It is not perfectly clear, what does it mean “semi-structured questionnaire”? The sample of a questionnaire is not attached. So, it is unclear what kind of questions made the content of the questionnaire. The clear description of the techniques of analysis of the survey results is also lacking.
In the Chapter 2 the abundant numerical characteristics of the health care institutions (size of networks, numerical strength of the personnel, number of beds) are provided. It is unclear, what are they provided for? For example, it is unclear how these numbers are related to the amount of the provided health care services and to their adequacy with a respect to the existing needs of population. The relevance of these numbers to the health information system is unclear as well, although the analysis of the latter is major purpose within the given component of the project. The numbers as such without a proper analysis are of no help. Besides, they could be easily taken from the reporting forms.
The author’s unawareness in terms of the existing ways of health information reporting is visible. As for the analysis of the ways of reporting of health information, it would be worthwhile to show what kinds of forms are actually used for the reporting by the health care institutions and how far these forms are in common with those officially approved by the Ministry of Health and by the Goscomstat (the State Committee for Statistics). Thus, for example, while analysing the information flows in the municipal hospital No. 1, the author has not specified the No. of the reporting form which is daily filled in the hospital’s departments. The most probably, it was the form No. 7. The latter had been mixed up with the monthly reporting form No. 16. It would be more reasonable for the author to list the forms which are actually used and changes in them, if any, than to quote an incomplete content of a certain form taken out of context of this reporting document.
Dr. Fokko de Vries has not specified the types of software used for health information processing. The issue, how well the health care institutions are equipped with the computers to deal with the medical statistics, has not been highlighted as well. The author has not mentioned, if any requests on the part of the heads of health care institutions are available, which concern the lack of certain data necessary for the reporting.
Such issues as the proper codes for diagnoses according to the form No. 066 (discharges from hospitals), proper codes for the causes of death in the death certificates according to the ICD, ability of the health professionals to apply the ICD-10 are not studied. According to the experts from the Semashko research institute, the proportion of mistakes in the codes for the causes of death is 50-70 % in average.
As for the vaccination, it would be more reasonable not to dwell on the vaccination cases as such, but rather to highlight the reporting of the occurred vaccination cases by the health care institutions and by the public sanitary and epidemiological services (gossanepid). Here, the issue of reporting of the same information might be revealed and, the ways how to avoid it, be shown.
The notions of screening and of an annual reporting of the results of mandatory prophylactic examinations for the certain occupational groups are mixed up.
In the de Vries’s paper it is not mentioned at all, what are the chief medical officer capacities to analyse the information monthly supplied to the insurance companies and, then, to the regional fund for the mandatory health insurance.
It is not clear from de Vries’s report, what kind of data are confidential and how this confidentiality is secured. Probably, these data are processed by the computer networks. Yet, in the report there is no word on it. In case of the computer processing, it would be better to talk not on the anonymity of information, but rather on its impersonal character. The very nature of the health information reported by public authorities is impersonal.
In the given paper it would be nice to have a confirmation of the fact of overlapping of data on STD, TB, cancers, mental diseases reported by the various specialised health care institutions, out-patient and in-patient clinics with the help of particular reporting forms. It would be also nice, if the ways how to avoid this overlapping are shown.
The similar comments are valid for the rest of health care institutions. Let us take an example of the municipal out-patient clinic No.3. The description of the computer processing of health information is lacking. It is not clear what kind of the out-patient slips belonging to the 025-u series is used in the information processing. It is unclear as well, whether the same slip is used for both health information services and health insurance.
The author’s statement that the software programs might be responsible for the wrong inputs in terms of the sex/age divisions and the list of the ten most common diseases is unclear. Most probably, he meant not the major deficiency of the software programs in general, but rather an inadequate quality of the particular software program used in the out-patient clinic No. 3. There is available a number of the software programs certified by the Russian Ministry of Health. Those are running quite smoothly.
The role of the chief medical officer of out-patient clinic in terms of the reporting is interpreted in the wrong way. In fact, his duty is not to prepare a monthly report, but to exercise a control over its adequate compiling.
It is never mentioned, what kind of problems related to the functioning of information systems should be negotiated during the monthly regular meetings of the representatives of the health care departments and public sanitary and epidemiological services.
As for interpretation of the activities of bureau for medical statistics under the regional health department, it would be advisable to provide the list of the statistical forms processed by the bureau. In fact, Dr. de Vries mentioned only 7 positions (number of patients, age, sex, code according to the ICD-9, number of the provided counsels, type of treatment, number of the referrals) according to which the health information is processed by the bureau. Those seven positions are just a tiny part of the bulk of information processed by the bureau. It is not clear from the author’s paper, in which statistical reporting forms the sex/age divisions are available. The thing is that, in the basic reporting forms such as “Report on the Number of Cases of Diseases Registered Among the Patients Provided by the Given Health Care Institution”(Form No. 12) and “Report on the Activities of the In-Patient Clinic”(Form No. 14) there are no sex/age divisions. The issue of the necessity to introduce the sex/age divisions into the reporting forms have been repeatedly raised by the Russian experts in the field of health care management. Probably, the problem has been somehow solved in Vologda oblast. It would be interesting to know in more details, what were the solutions, if any. It would be also interesting to know in what forms (booklets, analytical reports, requests, etc., including the number of pages) the calculated indexes are presented and what are deadlines for their deliveries.
There are no comments on the issue how the “Data on the Activities of the Health Care Institution Functioning Within the System of Mandatory Health Insurance”(Form No. 52) are processed. The thing is that, the Form No. 52 contains information on the financing of these institutions. Yet, the author claims that the bureau for medical statistics is not dealing with the financial data.
As for the mortality data, they are a component part of the larger demographic data presented by the Goscomstat. So, it is wrong to divide them into various categories. It is not excluded, that in the annual report the Goscomstat may provide the data similar to those provided by the Gossanepid. Still, in the author’s paper it is not clarified, how far the data on communicable diseases provided by the both institutions are comparable.
Dr. Fokko de Vries has not considered the issue of technical characteristics of the software in use.
As for the activities of the Vologda regional branch of the Goscomstat, the problems related to the codes according to the ICD-10 have not been identified. The author has not considered the issues related to the data on the birth rates.
As for the activities of the Vologda regional branch of the Gossanepid,
Dr. Fokko de Vries has not provided the detailed information on the kind of data, indicators and reporting forms that are submitted to the regional health authorities and gossanepid services.
The software used for the processing of data on communicable diseases has not been described.
As for the activities of the Vologda municipal branch of the Gossanepid, the same comments would be appropriate as for the above-mentioned regional branch.
As for the Fund for the Mandatory Health Insurance, the author made a mistake when he said that the latter is financed through the federal budget. He never mentioned whether the regional norms for health insurance approved by the Governor are in an accord with those ones recommended by the federal government.
As for the activities of the municipal health care department, it would be advisable to identify what are the positions and forms according to which the municipal health care institutions report monthly to the municipal health care department.
As for the activities of the regional health care department, its key role in the development of regional health information system is never mentioned. Its major tasks with the regard to the further development of health information system are not listed. Similarly, there is lacking an analysis of the legal aspects of an interaction of the regional health care department with the other agencies and structures in the field of health protection. The prospects for the development of the shared data-bases available for the various agencies are not outlined. The same concerns the prospects for the putting into practice of the single regional software program for the processing of health information that would be compatible with the software developed at the federal level. The author did not dwell upon the prospects for the ordered flows of health information at the regional level with an access to the ordered information flows at the federal and international(WHO-countries) levels.
In the Chapter 3 one can find a good discourse on the situation in Vologda oblast in terms of the data quality, their availability and sufficiency, in terms of the feedback, software and hardware, data confidentiality, health promotion activities, health information system and training.
Still, the conclusion that the true mortality picture has to serve as a corner-stone for any health information system is not well grounded. According to the “Concept for the Development of the State-Based Monitoring of the Health Status of the Russian Population” approved by the Ministry of Health, the following activities are considered as the priorities:
- study of the population health status (including the causes of its deterioration such as the risk factors, demographic trends, etc.);
- development of recommendations for the health authorities in terms of the rational allocation of resources for the sake of health promotion, improvement of the quality of curative and preventive services.
It would be worthwhile for the author to mention a switch to the ICD-10 in Russia starting from 1 January 1999.
It would be good, if the author paid a special attention to the problem how to avoid a situation when the same health information is reported by the health care departments, regional gossanepid and regional fund for the mandatory health insurance. It would be also good to pay an attention to the issue of an interaction of all the structures dealing with the health protection, in first run, with respect to the legal aspects of an interaction and the single standards for the health information reporting.
One can disagree with the author’s opinion that the importance of the up-to-date software and computer high-tech is exaggerated. It is evident that an incomplete, unreliable and out-of-date information supply is among the primary reasons for the bad management. In the Russian Federation the certified software programs are available which are suitable for the computer networks of the health care institutions. They allow to process and analyse health information for its further submission to the management bodies (See the special literature on the subject that is available in Russia).
As for the confidentiality of the health information, the procedures should meet the requirements set by the Federal Law “On Information, Information Systems and Information Confidentiality”.
Dr. Fokko de Vries paid too small attention to the issue of training. Sending of the several persons to a short training session will not solve the problem of the establishment and proper functioning of the health information system.
In the Chapter 4 one can find a short list of proposals that could be enlarged during the implementation phase of the project. As for the third point in the list, the implementation of the given proposal is hardly feasible, since the health administrators will not deal personally with an identification of the minimum set of indicators. These sets may vary from region to region. More than that, the set can make a health information system too rigid and unable to keep up with the events. In fact, the comprehensive computer-based HP & DP monitoring is required. The latter would allow to identify the sets of the least suitable indicators with regards to any reporting periods and any regions.
As for the Chapter 5, it is difficult to read it, if the CINDI Protocol is not attached. Without having a look to the Protocol, no comments to the Chapter 5 are possible.
It may be concluded that, as whole, the report produced by Dr. Fokko de Vries is a paper of a certain value. In case the comments are answered and the Chapter 4 is properly changed, this report might be further used for the Tacis activities.
Translated by Dr. Aleksei Verizhnikov, 04.03.1999.
Mr.V.Samoshkin, Mrs.N.Lide, MoH.
03.02.1998.
Proposals.
1) According to the Decree No.9 “On Medical and Environmental Monitoring in the Regions With the Polluted Environment” issued by the Inter-Ministerial Committee Under the Security Council of the Russian Federation on 24.12.97, the Ministry of Health has been identified as a supervising authority in the study of the environmental risk factors. Lack of coordination in the activities of the various ministries and agencies possessing data on environmental health prevents an establishment of the efficient system for an ecological security and health protection of the Russian population.
In order to implement the above-mentioned Decree and to create the inter-
ministerial data-base on environmental health, it is necessary to establish the inter-ministerial working group.
The group will face the following tasks:
• To prepare the proposals concerning the dissemination of experience of a number of regions (Leningrad oblast, Sverdlovsk oblast, Perm oblast, Vologda oblast) in terms of the inter-ministerial and inter-departmental cooperation in an exchange of information on the population health status and the state of environment;
• To prepare the package of documents authorizing an every relevant agency and structure to take part in the establishment of the system of medical and environmental monitoring;
• To prepare the package of documents that would reflect a particular contribution of an every agency involved in a creation of the commonly available data-base on risk factors (natural, anthropogenic, social ones);
• To prepare the package of documents that would prescribe the ways and orders of an information exchange among the institutions exercising monitoring over the state of environment and over the population health status;
• To involve the representatives of the Ministry of Health, State Committee for the Environment, State Committee for Meteorology, Ministry of Emergencies (floods, earthquakes, etc.) into the inter-ministerial working group.
2) To establish the working group for a development of the Concept of Information Supply for the Use of Public Sanitary and Epidemiological Service. The representatives of the Ministry of Health and of the regional centers for sanitary and epidemiological surveillance are to be included into the working group.
Translated by Dr. A.Verizhnikov, 19.03.1999.
Prof. E.Skvortsova, MEDSOCECONOMINFORM.
The Underlying Principles of Monitoring of the Unhealthy Habits Among the Russian Adolescents.
Since the 1980s the WHO calls on the member-countries to arrange monitoring at the national level to deal with the issue of smoking, alcohol abuse and drug-addiction (See the WHO’s reports).
As for the situation in Russia, before recently the major part in the information gathering on the consumption of psychoactive substances (alcohol, drugs, tobacco) belonged to the Centers (Dispensaries) for Prevention and Treatment of Alcoholism and Drug-Addiction. In terms of monitoring of unhealthy habits of the Russian adolescents the information gathered within these Centers was far from being complete. The main principle of information gathering used to be a registration of the cases of the voluntary/forced coming to the Centers. This could not allow to judge about a possible size of the risk group, not to say, about the prevalence of unhealthy habits among the Russian youngsters.
So, the official data on the registered cases of alcoholism and drug-addiction, alongside with data on the results of prophylactic examinations can not serve as a reliable basis for the establishment of a system of monitoring for the consumption of psychoactive substances among the younger generation. They are insufficient for both situation analysis and development of a proper preventive program.
The situation is even worse when talking about the prevalence of smoking among the Russian children and adolescents. The Goscomstat (State Committee for Statistics) possesses only an information on the amount of the produced and sold tobacco-stuff. On the basis of this information it makes possible to calculate an index of the tobacco consumption per capita. As for the smoking prevalence, only the fragmented information is available which is received on the basis of a few studies done according to the random sampling method. This information is not enough to produce a larger picture on the situation with smoking in Russia as a whole, not to say, to trace the current trends in prevalence of smoking among the younger generation.
The Selection of Indicators That Are to Be Monitored.
As a major indicator to be monitored one could offer a proportion of consumers of the psychoactive substances (drugs, alcohol, tobacco) out of an every hundred of adolescents of the respective age and sex. As for the definition of “consumer”, by the “consumer” one implies a person who drinks, dopes or smokes with a certain regularity up to the moment when the survey is conducted. The “regularity” may vary from a daily consumption to a consumption once per year.
Within the monitoring of the adolescents’ unhealthy habits, as a tool of the information gathering, an anonymously filled questionnaire could be used. This is not only reasonable, but simply necessary. The use of such a questionnaire would allow to identify all the stages of getting addicted to drugs, alcohol, tobacco among the adolescents, including the initial or “try’ stage. These data are very important for the timely prevention of addiction among the adolescents. To be an “adolescent” in Russia officially means to belong to the 14-18 age group.
According to Russian experts’ estimates, the representative sample should consist of, at least, 1367-1439 adolescents. With regard to the fact, that 2-3 per cent of all the questionnaires are normally filled in the wrong way or left blank, the optimal sample size would be of 1400-1500 adolescents.
So, in order to get a knowledge on the prevalence of smoking, alcoholism and drug-addiction among the adolescents of a certain neighborhood, municipality or region, it would be sufficient to survey a sample consisting of 1400-1500 adolescents belonging to the 15-17 age group. While making a proper sample, it is necessary to take into an account that city neighborhoods or rural districts may vary in terms of socio-economic development or ethnic composition. The latter can influence in direct or indirect way the degree of addiction among children and adolescents.
In the process of sampling an equal representation of an every neighborhood, municipality or region is to be secured. This can be done by means of a random sampling of the schools (technical schools) belonging to an every neighborhood, municipality or region. The lesser is the size of population of a neighborhood, municipality or region under research, the lesser will be the error in the sample’s representativeness, and vice versa.
Monitoring Data-Base.
Making of data-base is unalienable part of an every sort of monitoring. Nowadays, this job is hardly imaginable without the use of modern computer technologies. MEDSOCECONOMINFORM can offer its own software program called as “Risk Factors”. The latter allows to create, store and process data-bases. The software program is well-tested. One of the merits of the given software program is that it is never getting obsolete. It allows to store and process any sort of primary information without an upgrading of the software (a general number of the questions in the processed questionnaire should not exceed 100, and a general number of options of answers to an any question should not exceed 15). The software allows to create both primary data-base (data-base on the interviewed individuals) and secondary data-base (data-base on a neighborhood, municipality, region).
The Activities of the Center for Monitoring of Unhealthy Habits Among Children and Adolescents.
In September 1997 the Center for Monitoring of Unhealthy Habits Among Children and Adolescents has been established under the MEDSOCECONOMINFORM. The Center serves for the epidemiological surveillance over the prevalence of smoking, drug-addiction and alcoholism among children and adolescents and for the elaboration of a set of the proper preventive measures.
The main activities of the Center are the following:
• Development of the techniques for data gathering and processing, making of the data-bases on prevalence of smoking, alcoholism and drug-addiction among the children and adolescents of the Russian Federation;
• Systematization and analysis of the above-mentioned data coming from the regions of the Russian Federation; analysis of the social and psychological factors contributing to an addiction to the psychoactive substances among the Russian adolescents;
• Making of an analytical report describing the situation in Russia in general and containing recommendations for the particular regions. The report is submitted to the Department of Public Sanitary and Epidemiological Surveillance, Ministry of Health;
• Consulting and training in the techniques of monitoring of unhealthy habits for the representatives of the regions of the Russian Federation.
With a regard to the difficulties emerging in the process of territorial spread of
the system of monitoring for the unhealthy habits of children and adolescents, the Russian Ministry of Health considers as reasonable to introduce this system first in the pilot regions of the Tacis Preventive Health Care Project. Those are the Vologda oblast, municipality of Electrostal, Chelyabinsk oblast and Orenburg oblast. The issue has been preliminarily discussed with Dr. Galina Tkachenko, the Tacis Russian Vice-Director, and with Mr. Peter Anderson, the WHO representative. The latters approved an idea in general.
Following the idea, in October 1998 the people from the Center for Monitoring of Unhealthy Habits Among Children and Adolescents trained the representative of the Vologda Center for Medical Prevention in use of the “Risk Factors” software. The software package was granted for the further usage in Vologda oblast.
Translated by Dr. A.Verizhnikov, 17.03.1999.
The issue, what pieces of this text are to be translated into English, has been agreed upon with Dr. G. Tkachenko on 17.03.1999. The pencil’s marks in the Russian original are hers.
ANNEX 7.3.3.
Monitoring on the level of the Primary Care in Holland.
|[pic] |The Tacis Russia Preventive Health Care Project |
| |Petroverigskyi pereulok 10, Moscow 101953, The Russian Federation |
THE HEALTH INFORMATION SYSTEM
ON THE LEVEL OF PRIMARY CARE
IN HOLLAND
F. de Vries MD MA
Reactions:
fdevries@worldonline.nl
This paper provides an overview of the collection of epidemiological data on the level of Primary Care in Holland.
It has the following components:
1) Basic characteristics of Primary Care in Holland
2) Collection of morbidity data
3) Collection of mortality data
4) Collection of data on infectious diseases
5) Other sources of data in Primary Care
6) Routinely monitoring the population
7) Ad-hoc surveys
8) Comparison with the Russian Federation
1) Basic characteristics of Primary Care in Holland
Holland has a population size of 15.5 million inhabitants (1996) and is one of the most densely populated countries in the world (450 persons/km2, compared to 9 persons/km2 in the Russian Federation).
The country spends about 10% of its gross national product (GNP) on health care. Access to health care is almost universal. Only 1% has no health insurance for religious reasons, or these people are illegal immigrants.
70% of the population has a compulsory health insurance (“sickness fund”). This is financed through the collection of a certain percentage of the salary, equally paid by employer and employee. The ideology of this compulsory health insurance is based on solidarity: wealthier persons pay a higher contribution than poor persons do and pensioners and unemployed people pay the lowest contribution. The coverage is the same for every body. Nobody can be refused by this compulsory health insurance.
People that earn more than about 30.000 $ per year (about 30% of the population) have no right for this compulsory insurance and they chose a voluntary (private) health insurance of which there is –due to competition- a large choice.
The higher the premium, the more extensive is the coverage. For a dentist and physiotherapist additional money has to be paid. Healthy and young persons pay less than persons with a significant health risk do.
Patients pay doctors and hospitals directly for their services. The Government determines the tariffs. Patients are reimbursed afterwards by their health insurance.
Holland has a strong system of Primary Health Care, provided by about 7000 Family Doctors. Family Medicine is considered a medical specialty and involves three years of post-graduate training. Each Family Doctor is in charge of about 2500 persons, usually living in his neighborhood. This number of patients –that has reduced significantly over the last decade- is based on several considerations. A higher number would lead to a too high caseload. A lower number would introduce the risk of not seeing certain pathology frequently enough to get acquainted with it.
Family Doctors are gatewatchers: only they can refer patients to a hospital. No one is allowed to go to a hospital directly, only in the case of an emergency. Family Doctor practices are private enterprises. There is however a strong state influence: municipal authorities decide the number of practices and the government decides the tariffs.
For patients with a compulsory health insurance a Family Doctor is paid by capitation: he receives a fixed amount of money per patient, regardless of the number of consultations and home visits. Private patients however are charged per consultation and home visit.
Family Doctors work community based and have a strong knowledge about the patient’s background, his family and the living conditions. Most of their activities are related to primary and secondary prevention. The Family Practice ideology is to keep patients out of the hospital, and to discriminate between serious and not-serious disorders.
For diagnosis and treatment, Family Doctors make use of protocols that are developed for the most common disorders in Primary Care. These protocols are not compulsory, but they have a solid scientific basis and are based on the principles of “evidence based medicine”.
2) Collection of morbidity data
Most of the Family Doctors do not collect and report data on morbidity factors. The only obligation they have is to report monthly on certain infectious diseases and to report causes of death. About 5% of the doctors routinely collect morbidity data as a part of the Continuous Morbidity Registration that is organized by NIVEL or participate in registration systems that are organized by the University of Amsterdam (“Transition Project”), Nijmegen and Maastricht.
For a clear understanding of the concept of monitoring on the Primary Level, the difference between a medical record and data-collection as part of a monitoring system has to be clearly understood.
Family Doctors keep a medical record for every patient. This medical record is for his own professional use. It contains basic data on the patient, like name, address, age, sex, composition of the family, profession, type of health insurance, and the past medical history: previous family doctor, main diseases, allergies, previous operations, medication etc. The Family Doctor enters his own diagnosis and therapy on the record. The medical record contains copies of the letters that Family Doctors sent to Medical Specialists in the hospitals (secondary level) when they refer a patient. It also contains the letters from the Medical Specialist to the Family Doctor in which he reports the diagnosis and the therapy that was offered to the patient. Finally, the medical record contains results from laboratory investigations, X-rays etc. When the patient changes his Family Doctor, the medical record is presented to his successor.
So in a nutshell, the medical record contains:
1. patient characteristics
(name, age, sex, family composition, type of insurance, profession, allergies, past medical history etc)
2. present (problem)diagnosis and therapy
3. letters of referral to medical specialists on Secondary Level
4. letters from medical specialists to the Family Doctor
5. results from investigations: laboratory, ECG, X-rays etc.
The information on the medical record is confidential. Only the Family Doctor and his patient have access to it. The format of the medical record is not standardized. Some doctors still use pencil and paper (“green card”). A large number of them use the so-called “SOEP” classification. “SOEP” stands for: Subjective, Objective, Evaluation and Plan. This classification scheme is used for clarifying diagnostic and therapeutic procedures. Most of the doctors use a Personal Computer and one of the many types of software that are available for medical record keeping.
The advantages of a computerized system are obvious: the information is much clearer (doctor’s handwritings are notoriously bad), prescriptions can be directly printed, the PC gives directly on-line information on adverse reactions and dangerous drug interactions etc.
The PC can also warn you that a certain female patient of fertile age has not been screened for cervix cancer. Moreover, it allows the stratification of data: for instance it is possible to ask the computer to give the names of all pregnant women, or of all patients over 65 years of age. Or to give the names of all patients that use a certain anti-hypertensive drug.
This stratification is useful in the process of “case-finding”, a practice much used for primary and secondary prevention. Case-finding is the principle that a Family Doctor
tries to detect riskfactors among riskgroups, regardless of the reason of the visit to the doctor. If an elderly persons visits a Family Doctor for a cough, or a skin disease, his cholesterol, weight and blood pressure are be measured in order to discover hidden morbidity. The riskgroups that are eligible for case-finding are easily identified in a computerized system of medical record keeping.
A medical record can be as limited or as extensive as the Family Doctor thinks it needs to be in order to provide adequate health care, although the Dutch Family Doctor’s Association provides some recommendations.
The medical record always remains with the Family Doctor. It is not used and not fit for investigating the health status of the population at large. With respect to the collection of morbidity data, Holland has gained extensive experience with the so-called sentinel site monitoring. In order to investigate the health status of the population, it is not necessary to register all doctor-patients interactions. That would be too expensive, too time-consuming and has no real added value. It is enough to collect data in certain sentinel-sites only, as long as certain criteria are met. The number of sentinel-sites has to be large enough and the demographic properties of the sample should not differ significantly from the population at large.
The most extensive system of the collection of data in Family Medicine is designed by NIVEL. The methodology –as described in their 1992 annual report and which is in principle still the same- is discussed here.
Data are collected in 161 sentinel sites (each of them a Family Medicine practice). They form 2.5% of all Family Medicine practices, involving 335.000 patients. The sentinel site were randomly chosen according to three criteria:
1. region
2. distance from a hospital
3. degree of urbanization
Data are collected in four registration periods, each of three months (spring, summer, autumn and winter).
There are several classification systems in medicine, like the International Classification of Diseases (most recent version ICD-10), the E-list of the British Royal College of General Practitioners, the International Classification of Health Problems in Primary Care (ICCHPPC) and the Reason for Encounter Classification (RFEC).
The nature of medical problems presented on the Primary Level is much different from the nature of medical problems presented in hospitals. A Family Doctor is practicing more problem-oriented. His patients present complaints rather than discrete diseases. The ICD is strongly clinically oriented and contains almost exclusively diagnoses. Most of the Family Doctors work with a “problem definition”. That implies a preliminary working hypothesis about what might be the underlying medical problem. He will be rarely capable of making a definite (ICD) diagnosis during the first encounter. Moreover, he often comes across diseases that are still at their pre-clinical stage. And finally, the Family Doctor has far less diagnostic facilities, like laboratory and X-rays, than his colleagues in the hospital have.
A good example is pneumonia. Most of the cases of pneumonia in Holland are diagnosed and treated by a Family Doctor. Patients are not admitted to a hospital but treated at home. They receive a broad-spectrum antibiotic that kills most of the common microorganisms. In treatment, the Family Doctors have a pragmatic approach. He is not interested in the exact cause of the pneumonia. He does not order bacteriograms or a bacterial culture. Thus he will not be able to provide a complete ICD code. At the same time, this is not relevant because the main objective is to cure the patient. Unnecessary diagnostic procedures and hospital admission were avoided, leading to a significant saving of money. In this pragmatic approach, success or failure of the therapy confirms the diagnosis.
NIVEL has chosen the International Classification of Primary Care (ICPC) for the Continuous Morbidity Registration in the Family Doctor Practices, which is more useful for the classification of medical problems that are presented to Family Doctors.
The ICPC classification is simple, straightforward and allows international comparison. Most of the European countries are now familiar with ICPC.
An ICPC code consists of one letter followed by two figures.
Each of the 17 letters refers to a certain localization:
A. General and unspecified
Blood
D. Digestive
F. Eye
H. Ear
K. Circulatory
L. Musculoskeletal
N. Neurological
P. Psychological
Respiratory
Skin
Endocrine/metabolic/nutritional
Urology
W. Pregnancy/family planning
X. Female genital system
Y. Male genital system
Z. Social problems
The figures (01-99) refer to the following components:
Code
29. symptoms/complaints
49. diagnostic/preventive services
59. medication/treatment/therapeutic services
61. results
62 administrative services
69. referrals and other reasons for encounter
99. diagnosis/diseases
Some examples are:
A60: iron deficiency anemia
B67: referral to secondary level
D36: examination of faeces
D89: hernia inguinalis
F71: allergic conjunctivitis
H01: earache
P06: sleeping disturbances
S50: prescription
U71: cystitis
Z12: marital problems
More specific information can be found on the diskette that was made available to the members of the TACIS working group on Health Information System, Monitoring and Evaluation.
The ICPC code is registered per episode of three months. That means that during this period due to the development of the complaints/disease or the diagnostic process the final code will be defined during this episode. The goal of the episode-oriented registration is to give a more accurate picture of the incidence and the prevalence than would be possible on the basis of individual encounters. During an episode, a certain medical problem usually crystallizes into a clearer medical diagnosis.
By coding first consult or repeat consult, a difference can be made between incidence and prevalence. More specifically, the following indicators are used:
Cumulative incidence: the number of new cases of disease that occur in the course of three months, divided by the number of persons present in the population at the beginning of the period of time.
Period-prevalence rate: the number of existing cases of disease in three months divided by the average population. The period prevalence is built up from the prevalence at a given point in time, plus the number of new cases and relapses during three months.
The incidence has been determined by counting those episodes in which the Family Doctor indicated in the first encounter of the episode in question that a first encounter
for the problem in question or an encounter in connection with a relapse for the problem was involved. The prevalence has been determined by counting the total number of episodes in which identical episodes were also counted once only per patient. Conversion of the numbers into figures on an annual basis is possible by multiplying the incidence by a factor of four, by which a cumulative incidence per year is obtained. In the case of an acute disorder with a high incidence and a high prevalence, the prevalence per 3 months has to be multiplied by four to obtain the prevalence per year. As regards to a chronic disorder with a low incidence and a high prevalence, the prevalence per 3 months is equal to the prevalence per year.
For stratification purposes, the following variables are registered per patient:
1. sex
2. age: 0-4
5-14
15-24
25-44
45-64
65-74
> 75
3. marital status: child
single
married
divorced
widowed
4. level of education: age < 18 years
no/primary education
secondary education
higher professional/university
unknown
5. form of insurance: public
private
no insurance
unknown
6. country of birth: Holland
Turkey/Morocco
other Western
other non-Western
unknown
7. occupational status/class: headwork: high + medium
headwork: low
self-employed + farmers
manual work: high + medium
manual work: low
non-classifiable
other: age < 16 years
child/student
national service
housewife/husband
unemployed
recipient of disablement benefit
early retirement/pension
not working/no reason
other unknown
In the calculation of the rate, the total population is considered as the population denominator. First it is calculated to what extent the sample population is different from the population at large, with respect to be above mentioned seven variables. If the differences are significant, statistical weighting is used to correct these differences.
In every health system has the problem of the so-called hidden morbidity.
There are different stages that can be discriminated between the beginning of a medical complaint/disease and its disappearance:
1) The patient experiences a health problem
2) The patient feels the need to do something about the problem
3) The patient consults a doctor
4) The doctor makes a (preliminary) diagnosis
5) The doctor starts a therapy
6) The health problem disappears
The patient visits the health facility at the third stage. Only at this level the complaints and diseases are registered. To what extent does this system provide real information about the morbidity of the total population and what are real health needs? For several medical complaints, patients do not visit a doctor. There is also the phenomenon of self-medication or alternative treatment. All these things are not routinely registered. It is difficult to assess the quality and quantity of this practice. This is the so-called the “iceberg phenomenon”: the presented morbidity is often only the top of the real morbidity. There are however some characteristics of the health care system in Holland that probably significantly reduces this phenomenon: Almost all inhabitants have both a health insurance and an own Family Doctor. The pre-conditions for a good accessibility of health care are present. Moreover, more and more types of treatment that were previously considered “alternative”, are now practiced by Family Doctors, like homeopathy, which is covered by most of the health insurance companies. That means that the morbidity of people that previously sought treatment outside the official health sector, now comes within the range of the monitoring system, and therefore visible.
Data are collected, processed and analyzed. Descriptive epidemiology gives us information about the distribution of diseases in the population. The Continuous Morbidity Registration is a useful tool for analytical epidemiology. The collected data can be analyzed in depth by using certain stratification criteria. Cross-tables can be produced that present relations between individual patient characteristics (sex/age/education/profession/ health insurance/etc) and ICPC code. For instance:
1. What is the top-10 of chronic diseases?
2. How often do patients over 65 years of age consult a Family Doctor?
3. Who are the patients that suffer from asthma?
4. What is the relation between medical and social problems, as presented
to Family Doctors?
5. Is there an increase in cases of hyperventilation syndrome over the last 10 years?
6. Are persons with a higher education healthier?
7. Are there less infectious diseases in rural areas?
8. Is there a difference in morbidity between people with public or private health
insurance?
9. Do people who are born in Morocco have more eye diseases?
10. Which types of diseases are most often referred to hospitals?
11. How many women of fertile age use oral anticonceptives?
12. Is there a seasonal fluctuation in the presentation of headaches?
13. Are married people more depressive?
In principal there is no limit to what one can analyze. The answers to these questions are relevant for Health Policy makers. They must understand the main health problems in order to prioritize and to allocate resources (staff/knowledge/finance) based on health needs. The system also makes it possible to evaluate the effects and quality of medical care over time.
3) Collection of mortality data
Mortality statistics are relevant for the evaluation of the health status of the population and are an essential tool in the planning and resource allocation within a health policy. The calculation of life expectancy at birth can predict the number of elderly people, but also, together with morbidity statistics, their health needs and medical consumption. At this moment, life expectancy at birth for men in Holland is 74 years and for women 80 years.
Indicators, like neonatal death rates of infant mortality rates, are often used as indicators to evaluate the quality of health services. They also allow international comparison.
The calculation of case-fatality rates can be used for the evaluation of different therapies and types of prevention. One can for example assess if the yearly immunization of people over 65 years of age against influenza really leads to a significant reduction.
The collection of mortality statistics and the establishment of the cause of death are not such simple procedures as they may seem. Especially among elderly people, death is determined by a combination of factors rather than one causal determinant. In Holland, 75% of the death cases happen among persons over 70 years of age. Imagine a patient with chronic heartfailure, who also suffers from insulin dependent diabetes, emphysema of the lungs and ischaemia of the heart muscle. Even if the person dies of natural causes, it is virtually impossible to establish one single cause of death. It is therefore essential that there exist clear uniform guidelines for registration and reporting.
Causes of death are established by the doctor in charge. If a patient dies in a hospital, the specialist who was treating him determines the cause of death. If a patient dies at home (the majority of cases), the cause of death is determined by the Family Doctor. The causes are registered on a standard formula, that is sent to the “Central Bureau for Statistics (Centraal Bureau voor de Statistiek) This bureau is in charge of recoding the causes of death into ICD-10 classifications.
The standard formula, called declaration of death, contains two parts. The doctor uses part A to declare “that the patient died of a natural cause”. Only this part contains the name of the patient. Part B is used to register the cause of death. This part B does not contain –for reasons of privacy- the name of the patient, but some parameters like age and sex.
Part B contains the following questions:
1A
What was the direct cause of death?
1B/1C
What were the underlying diseases that lead to 1A?
2
What were circumstantial medical factors that have no causal relation with 1A?
A final question refers to the time between the onset of the disease and the moment of dying.
An example of possible answers can be:
1A: pulmonary emboli
B: hospital operation
C: appendicitis
2 : epilepsy
1A: liver failure
B: liver metastases
C: carcinoma of the stomach
2 : hypertension
The answer to question 1C is usually considered the main cause of death.
Most of the “declarations of death” are filled in by the Family Doctor. He usually knows the patient and his medical situation for many years. In cases of doubt about a natural cause of death, or suicide or an accident, the municipal chief doctor fills in the declaration.
In Holland there are some specific problems with the underreporting of non-natural causes of death. Family Doctors in Holland practice euthanasia. That means that in the case of unbearable suffering and in the absence of any perspective of recovery, Family Doctors give a fatal dose of morphine to patients at home. (so-called active euthanasia). Hospital doctors usually refrain from feeding and rehydrating the patient (passive euthanasia). The conditions for euthanasia are strict: a doctor needs permission from the patient (if feasible) or relatives and has to consult a colleague.
There is still no clear legal base for this practice. It is against the law, but it does not lead to prosecution. In practice the Family Doctors report “natural death” when they practice euthanasia, and this leads to the underreporting of non-natural deaths.
4) Collection of data on infectious diseases
All Family Doctors are obliged to report every month to the Ministry of Health on certain infectious diseases. There are three categories.
Diseases in Category A have to be reported immediately to the mayor of the city, even if there is only a suspicion. The name of the patient has to be given. These are diseases with an immediate Public Health threat, like typhoid, pest and rabies.
For diseases in Category B, the Doctor has to take immediate sanitary measures. The mayor has to be warned and the name of the patient given only after the disease is confirmed. Examples of Category B diseases are: cholera, hepatitis A and B, whooping cough and tuberculosis.
Category C refers to diseases that have to be reported monthly and anonymously. This includes the Sexually Transmitted Diseases.
An essential characteristic of this notification system is the so-called zero reporting. Even if a Family Doctor has not seen any case, he is still obliged to report that he has seen “zero” cases. This procedure is useful in avoiding underreporting.
Infectious diseases in Category A and B are usually beyond the competence of a Family Doctor. Concerning Sexually Transmitted Diseases, most of the larger cities have a policlinic where patients can be screened and treated anonymously and without payment. This is a good alternative for patients who do not want their Family Doctor to know about their disease.
5) Other sources of data in Primary Care
a) Youth health
All children 0-19 year are regularly seen by health services for immunization, screening, health education activities and life style monitoring. These activities are actively offered. For a description of the principles of monitoring and data-collection I refer to the TACIS paper, called: “Youth health care and lifestyle monitoring in Holland”.
b) Midwives
Most of the antenatal services are provided by midwives. They have an independent professional status after four years of medical training. In 1995 a total number of 190.500 babies was born in Holland. Midwives are supervising the deliveries and doctors are not involved, unless a certain type of pathology is present. Although the number is decreasing, 33% off all children are born at home, which is still the highest percentage of home deliveries in Europe. In about 10% of all the deliveries, women are hospitalized for a Caesarian section.
After each delivery, the midwife (or gynecologist) fills in a standard reporting form that is centrally processed. It is called: “Countrywide Obstetrical Registration” (Landelijke Verloskunde Registratie). The data are processed anonymously and contain information about the mother, the pregnancy, the delivery, the post-partum period and the newborn. After processing and analyzing, much relevant data are available on issues like hepatitis B seroprevalence, maternal riskfactors like smoking, the percentage of forceps deliveries, the average birth weight of children etc.
c) Ambulant psychiatry
Every region between 150.000 and 300.000 inhabitants has a center for ambulant psychiatry, called RIAGG (“Regional Institute for Ambulant Mental Health Care”). They treat patients with (minor) psychiatric disorders and addictions. Although most of the patients are referred by a Family Doctor, it is possible to present oneself there without referral. In this respect, it can be considered a Primary Care facility. The diagnosis is made by using DSM-IV. (Diagnostic and Statistic Manual of Mental Disorders). This international classification system is a multi dimensional classification system that takes five axes into consideration, like psychosocial traumas, organic disorders and the level of social functioning.
6) Routinely monitoring the population
An important source of information is the annual health survey, organized by the Central Bureau for Statistics (CBS). Every year, 10.000 persons, randomly chosen, are interviewed by using a standard questionnaire. The strength of this survey is that it actively approaches respondents, thus providing invaluable information about the hidden morbidity and the health status of the population. Data are collected about age, sex, type of insurance, level of education etc. The questions relate to objective and subjective components. Attention is also paid to the way health problems are perceived and experienced, and to so-called healthseeking behavior.
There are more specific questions related to 25 subjective health problems (like headache, stress) and 24 chronic diseases (hypertension, epilepsy). Other questions relate to the (dis)abilities of the respondent: questions related to daily activities
(climbing stairs, undressing etc.) and body functions (vision, hearing, walking etc.).
Questions are taken from internationally used questionnaires, like the ADL-list (Activities of Daily Life) and the International Classification of Impairments, Disabilities and Handicaps (ICICDH).
The annual character allows comparison over time. Apart from standard questions, there are specific question added every year.
7) Ad-hoc surveys
Beside the routine collection of data, a lot of surveys are organized by the following institutions:
A) Universities
There are eight medical faculties in Holland. There are numerous research projects in the field of medicine, which have both scientific and practical implications.
The faculties of sociology, psychology and health sciences also organize regularly ad-hoc surveys.
B) State Institutions
They are mostly Municipal Health Services that monitor health problems and life-styles within a community.
C) Private Institutions
These are research institutes that have the status of a not-for-profit foundation. Their ideology is to serve the public interest. The foundations are partly financed by the state (per project), through sponsoring or through fund-raising by approaching the public for financial contributions.
Some of the institutions are:
TNO-Prevention and Health
NIGZ-Netherlands Institute for Health Promotion and Disease Prevention
NISSO-Netherlands Institute for Social Sexual Research
The Heart Foundation
The surveys are focussed on the identification of both riskgroups and riskfactors. This allows the targeting of prevention activities. It is useless to focus prevention programs on people that do not need it, or that are already too ill.
The methodology that is used is usually a questionnaire, combined with indirect sources of information.
The life-styles that are monitored per survey relate mostly to issues like: dietary habits, alcohol and tobacco consumption, substance abuse, physical activities, leisure time, sports, absenteeism from school, sexual behavior, personal hygiene, psycho-social well-being, etc.
The targetpopulation can be teenagers, elderly people, ethnic minorities, diabetes patients, refugees, etc.
The results of surveys are published in books and scientific magazines. Some of the information is available through Internet. Newspapers and popular magazines usually present simplified versions results, in order to inform the public at large. Radio and television are also involved in the dissemination of results.
The following websites on Internet provide information in English about surveys and publications.
Central Bureau for Statistics (CBS):
WWW.CBS.NL
Netherlands Institute for Health Promotion and Disease Prevention (NIGZ):
WWW.NIGZ.NL
Netherlands Institute for Primary Health Care (NIVEL):
WWW.NIVEL.NL
Netherlands Institute for Social Sexual Research (NISSO):
WWW.NISSO.NL
Carenet Holland:
H.NL
Aids Foundation (Aidsfonds):
WWW.AIDSFONDS.NL
Netherlands Institute for Care and Well-being (NIZW):
WWW.NIZW.NL
8) Comparison with the Russian Federation
When comparing the Dutch system with the Russian system, the following differences are significant.
a. total surveillance
Russia is practicing total surveillance. Every patient-physician contact is registered and reported to the statistical department of the health facility. They report it to higher levels (municipal/oblast/federal). In Holland, only about 5% of all Family Doctors are -as a sentinel site- involved in the registration of a wide range of parameters. The only exception is that all Family Doctors have to report monthly on certain (rare) infectious diseases.
b. problem and episode oriented
In Primary Care, patients often present medical complaints and problems, rather than a clearly defined disease that fits in a diagnostic category. Moreover, the presented problem develops over time into a more concrete diagnosis. A lot of the problems presented in Primary Care are so-called “self-limiting diseases”. It is therefore that Holland has introduced the International Classification of Primary Care (ICPC) with is much more orientated on the registration of problems and “reasons for encounter” (RfE). The registration is also per episode, as described elsewhere. This increases the validity and reliability. In Russia, the ICD-10 is used, of which the use on the level of Primary Care is too clinical and too sophisticated. It also does not describe the medical problem as perceived by the patient himself. And it is virtually impossible to reach a final diagnosis during the first encounter.
c. record keeping
Every Family Doctor in Holland uses a medical record that is exclusively used by him. It is as simple or extensive as the Family Doctor considers necessary for practicing good medicine. Some Family Doctors use pencil and paper, others use sophisticated software. This medical record is confidential, and only accessible to the Family Doctor and the patient himself. This medical record is not used for registration purposes at a central level.
d. communication with secondary care
Dutch Family Doctors have to write clear letters when they refer a patient to Secondary Care. In this letter they describe the past medical history, previous treatment, symptomatology etc. Especially they describe the results of investigations that were recently done, like X-rays, ECG, blood and urine examinations. This prevents duplication of investigations and is cost saving, reducing the workload of hospital services and protection the patient against unnecessary procedures. It seems that there is in Russia, although exact figures can not be provided, a wide spread practice of duplication.
Medical Specialists working in Secondary Care are obliged to send extensive discharge letters to the Family Doctor. It describes diagnosis and treatment, but moreover gives advises to the Family Doctor to enable him to take over, especially in the case of chronic diseases, the treatment from the Medical Specialist.
This is not only more pleasant for the patient, who prefers to go to his Family Doctor in the neighborhood instead of going to a hospital far away, but is also cost saving.
It has again to be stressed that Family Doctors are paid by capitation (in case of a public health insurance, 70% of the population), regardless of the number of consultations and home visits.
e. motivation
The Family Doctors that participate in the Continuous Morbidity Registration are doing this on a voluntary basis. They participate because they want to participate and believe in its relevance. In Russia, doctors are obliged to register. There is no data available on how time consuming this is, but it may well be at the expense of time the doctor would like to spend on other issues, like the reading of professional magazines. The obligation to register may well have an effect on the validity of the registration.
e. feedback about own performances
Most of the Family Doctors have a subscription on weekly medical magazines, like “Medical Contact” and “Dutch Magazine for Health”. There is also a monthly magazine called “Family Practice and Science”. Each of these magazines provides regular epidemiological data on Primary Care. NIVEL and the Transition Project (University of Amsterdam) have their own regular publications. This allows each Family Doctor to compare his experience with that of his colleagues. In this way a Family Doctor becomes aware of his own practice and its peculiarities. Recently a CD-ROM was published, which allows a Family Doctor to compare the morbidity patterns and demographic properties of his patients with the standard population.
f. hidden morbidity
With the exception of the health surveys, data are collected at the moment that a patient visits a Family Doctor. The presented morbidity is the top of the iceberg, and little is known about the morbidity at population level. Moreover, the morbidity presented to the secondary level is highly selective.
Given the continuity in the relation of a patient with his Family Doctor and the absence of financial constraints, the accessibility of health care in Holland is assumed to be good.
Concerning Russia, little is known about the real morbidity and health status at population level. There are large geographical distances in the country, Family Doctors have a low status and there exists a strong tradition of self-medication and alternative treatment. A wide range of drugs can be freely bought in pharmacies, in Moscow even in Metro stations. In Holland, these drugs can only be obtained with a prescription from the Family Doctors, thus including a registration moment. All these factors together lead to a situation that the presented morbidity is significantly different from the real morbidity at population level.
Several post-communism countries have introduced privatization in the health sector, with dramatic results. It leads often to a significant under-utilization of health services. If patients have no money to go to a doctor, and data are only collected in the health facility, then the presented morbidity will differ significantly from the real morbidity. Although officially denied in Russia, there is an increase in the practice of out-of-pocket payment and there are more and more private doctors. With the increasing poverty of the population, patients will delay or even cancel their visits to doctors. In this way, their morbidity remains unregistered.
ANNEX 7.3.4.
Youth Health Care and life- style monitoring in Holland.
|[pic] |The Tacis Russia Preventive Health Care Project |
| |Petroverigskyi pereulok 10, Moscow 101953, The Russian Federation |
YOUTH HEALTH CARE
AND
LIFESTYLE MONITORING
IN HOLLAND
Fokko de Vries MD MA
March 1999
reactions: fdevries@worldonline.nl
This paper presents an overview of the organization of health care for children in Holland, and the way lifestyles are monitored.
The paper has the following components:
I) The organization of youth health care in Holland
II) Some basic health indicators of children
III) The methodology of the routine collection of data on life styles of children
IV) Some data on the lifestyles of children
V) The rationale for monitoring: some examples of the relation between data and
preventive interventions
VI) Ad-hoc surveys
I) The organization of youth health care in Holland
Holland has a population size of 15.5 million inhabitants (1996) and is one of the most densely populated countries in the world (450 persons/km2, compared to 9 persons/km2 in the Russian Federation). 0-19 years old compose 22% of the population.
Holland spends about 10% of its gross national product (GNP) on health care.
Access to health care is almost universal. 99% of the population has a health insurance, which covers most of the medical interventions. 1% has no health insurance, either for religious reasons or because these people are living in Holland as illegal immigrants.
Holland has a strong system of Primary Health Care, provided by about 7000 General Practitioners (“family doctors”). Each of them provides preventive and curative care to about 2600 persons, who are usually living in the neighborhood. GP’s (providing primary care) are gate watchers: only they are allowed to refer patients to specialists working in hospitals (providing secondary care). A patient can not visit a hospital directly, except in the case of an emergency. GP’s are estimated to treat 80% of the presented morbidity.
Concerning health care for children, one has to clearly discriminate between pediatricians and “youth doctors”. Pediatricians are medical specialists working in hospitals. Their principal task is curative care. They can only be visited after referral by a GP. Youth Doctors are specialized in preventive and Public Health activities. Their services are actively offered to all children from 0-19 years old. For the age group 0-4 years, these services are offered through so-called “Consultation Bureaus” (Mother and Child Health Care). For the age group 5-19 years, these services are offered through primary and secondary schools (School Health Care). Services involve both primary and secondary prevention.
Children 0-4 years:
The following monitoring, screening and preventive activities are offered to them:
After the delivery, the mother receives home maternity care by a maternity nurse during eight days. This maternity nurse is not only involved in cooking and cleaning, but moreover has an import role to play in giving practical advises to the mother in the field of feeding and child care. After these eight days, mothers are invited at regular intervals to the Consultation Bureaus where their children are seen till the age of five years.
At birth mothers receive advice about:
- breastfeeding
- the risk of the Sudden Infant Death Syndrome (“cot death”)
- the risks of passive smoking for the baby
The baby is screened for:
- congenital hipdysplasia
- non descended testes
- Phenylketonuria (bloodtest)
- Congenital hypothyroidism (bloodtest)
Supplementary feeding is advised:
- Vitamin K (against bleeding disorders, given at birth)
- Vitamin D (against rickets)
- Fluor (against caries)
Vaccination against:
- Diphtheria
- Bordetella Pertussis (whooping cough)
- Poliomyelitis
- Tetanus
- Morbilli
- Parotis epidemica (mumps)
- Rubella
- Heamophilus Influenzae type B (type of meningitis)
Sensory-motoric development:
- Testing of eyes (vision/strabismus/amblyopia)
- Testing of hearing (at 9 months: Ewing test)
- Van Wiechen test (at regular intervals)
Antropometric parameters:
- Weight and height (at regular intervals)
Participation is on a voluntary basis for a small participation fee. The attendancy rate is more than 90%. Immunization coverage is closely monitored. Parents that do not bring their children for vaccination receive written invitations to remind them. Coverage rates are above 90%. The vaccination scheme is different from other European countries. BCG is not given because of the low prevalence of tuberculosis and the fact that it makes the Mantoux/PPD test false positive and therefore less useful for screening. The polio vaccine is given intra-muscular instead of orally. Hepatitis B vaccine is only given if the mother is proven to be HbsAG positive (0.5 % of all mothers).
The Van Wiechen test is a standard protocol that evaluates the psycho-motoric development of the child. It registers milestones in development and compares this with a standard reference population. For instance, it registers when the child is capable of lifting his head, taking objects in his hand, or saying “mama” for the first time.
The antropometric parameters are filled in on a growth-monitoring chart. If compares weight for height with a standard reference population, providing a percentile score. It is easy to detect if a child is starting to fall behind.
All results are registered in one medical record that is presented –at the age of 5 years- to a Youth Doctor.
Children 5-19 years:
At the age of five, school education becomes compulsory. At the age of twelve, they go to a secondary school that they attend for a length of time between four and six years. After the age of sixteen it is compulsory for them to attend school for at least two days a week. At the end of the school year in which the adolescent has his seventeenth birthday, school is no longer compulsory.
All children have three individual examinations by a Youth Doctor at separate intervals. The children are tested for hearing, vision and receive a general physical examination.
Through a group approach in the classroom, children receive education on the risks of smoking, drinking alcohol and unsafe sex. Another approach is to focus on risk-groups, since preventive interventions for these children have a higher a priori change of resulting in improvements.
Children that have somatic problems are referred to their GP. Youth Doctors are not involved in the individual treatment of patients.
II) Some basic health indicators of children
A total number of 190.500 babies were born in 1995. The life expectancy for this cohort is 74.2 years for boys and 80.2 years for girls. There is a significant presence of non-Dutch persons living in Holland: 17% of the population is born abroad or has at least one foreign-born parent. These children are mostly from Suriname (a former colony) or from Morocco and Turkey (guest workers and their relatives).
In 1995 around 33% of all children were born at home. Although this number is gradually decreasing, it is still the highest percentage of home deliveries in Europe. The ideology of obstetrics in Holland is that the birth of a child is considered a normal physiological process, a natural process that should occur spontaneously, without anesthesia and with a minimum of operative interventions. There is an increase of hospital deliveries, but this happens under the supervision of a trained midwife and not a doctor. Usually the mother leaves the hospital the same or the next day. Holland has a low maternal and neonatal mortality rate. Moreover, the system is well appreciated by mothers, a factor that is highly relevant. There is usually a strong personal relationship with the midwife who is also responsible for the pre-natal controls. Again it has to be stressed that, unlike the situation in other countries, doctors are usually not involved in deliveries. Hospitalization for a Caesarian section occurs in about 10% of the deliveries. About 2% of all newborn are admitted to a neonatal intensive care unit.
In 1975, 45% of all mothers practiced breastfeeding. In 1991 this figure was 60%. It is still the lowest of all European Countries. Women with a higher level of education as well as Turkish women are more likely to breastfeed.
Perinatal mortality rate is 6 per 1000 life births (1994) and Infant Mortality Rate is 8 per 1000 life births.
Causes of death by age and sex per 100.000 in 1995 for boys:
AGE
0 1-4 5-9 10-14 15-19
1. other diseases 409.0 16.8 6.1 5.9 15.7
2. congenital anomalies 195.7 6.7 2.1 2.2 2.8
3. respiratory diseases 8.2 1.0 0.8 0.2 1.5
4. neoplasma 6.1 2.7 5.7 4.1 5.1
5. accidents (incl. suicide) 6.2 7.1 3.2 6.7 27.5
6. drowning 2.1 3.7 1.4 0.4 0.8
TOTAL: 625.3 38.0 19.3 19.5 53.4
Causes of death by age and sex per 100.000 in 1995 for girls:
AGE
0 1-4 5-9 10-14 15-19
1. other diseases 274.3 11.4 5.3 7.1 7.3
2. congenital anomalies 174.3 4.9 1.3 1.1 2.0
3. respiratory diseases 5.4 1.8 0.2 0.9 1.1
4. neoplasma 5.4 5.7 3.0 2.9 4.7
5. accidents (incl. suicide) 4.3 3.1 1.3 4.8 8.6
6. drowning 0.0 1.3 0.0 0.0 0.0
EUROCAT (European Registration Of Congenital Anomalies) registers congenital anomalies in European countries. There are 28 categories, of which the most prevalent ones are: (per 10.000 live births)
Neural Tube defect: 8.0
Heart disease: 59.1
Cleft palate: 6.0
Down’s syndrome: 9.9
To prevent neural tube defects, mothers are advised to take folic acid tablets from four weeks before conception (if feasible) till two months after conception.
All mothers over 35 years are screened through amniocentesis (chromosome analysis) to reduce the incidence of Down’s syndrome (trisomy 21). This screening is on voluntary basis and may lead to an induced abortion.
antropometric parameters
Dutch children are the tallest in the world. The median height of 20-year-old girls was 1.70 meters and of 20-year-old boys was 1.83 meters (1994). Every decade these figures increase with 1-2 cm. The mean age of menarche in Dutch girls was 13.3 years. Dutch children are on average 4 cm larger than children of Moroccan or Turkish background are.
10% of the children aged 4-15 have a Quetelet index above the 97th percentile, thus having overweight. Further stratification shows that this percentage is 19% among Moroccan girls.
asthma
Twenty percent of children aged 4-17 has a physical handicap. Of these, 90 % have pulmonary problems. The number of children with asthma has increased. At the age of 4-6 years, 11% of children suffer from asthma.
diabetes mellitus
One out of 1000 children suffers from Insulin Dependent Diabetes Mellitus (IDDM, type-I). This incidence is increasing. Between 1988 and 1994 the incidence in girls ages 0-4 years has doubled. Since the genetic profile of the population is hardly changing, this dramatic increase can only be attributed environmental factors.
hearing
One out of 1000 children suffers has a congenital hearing loss. In 1965 the mean age of discovery was six years. This is late for introducing sign language and avoiding cognitive impairment. Due to the introduction of more modern screening methods, the mean age of the discovery of congenital hearing is now at 1,5 years. Most of the initially discovered hearing losses are temporary and attributed to otitis media effusa (“glue ear”).
mental health
In 1993, 21% of 13-18 year-olds had psychiatric problems, mostly related to domestic and school situations. For assessing the seriousness of it, the Child Behavior Check List (CBCL), the Youth Self Report Form and the Teacher’s Report Form were used. These tests have diagnostic categories that correspond with the international Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). Girls more often suffer from phobic complaints, whereas boys suffer more often from manic episodes, behavioral problems, attention deficit disorders (ATT) and tic disorders.
III) The methodology of the routine collection of data on the lifestyles of children
In 1991 the so-called Child Health Monitoring System (CHMS) was developed in order to understand the health status of young people. This is an ongoing system whereby one third of all municipal and regional Public Health Services are functioning as sentinel sites. In total they assess every year 7.000 children in the age 0-4 years and 5.000 school children (5-17 years). The organization “TNO Prevention and Health” is responsible for the data collection and analysis, which financial support by the Ministry of Health.
The data are collected through questionnaires and physical examination. Every year the same standard questions are included, in order to allow comparison over time (longitudinal). Moreover, extra questions are included, related to specific topics of interest that vary over with time.
As an example, the results from the monitoring in 1992/1993 are given relating to children 5-17 years old. About 5.000 schoolchildren were approached through 18 randomly chosen Municipal Public Health departments. In total there were 2,3 million children 5-17 years old in the population.
The standard questions relate to:
1. Mean and variation of length, weight, weight for height en Quetelet-index.
2. Absenteeism from school due to illnesses
3. Percentage of children suffering from diabetes mellitus
4. Percentage of children taking medication
The specific questions relate to:
1. Which food was consumed the day before the survey?
2. Which food do children avoid, and for what reason?
3. What percentage of children is deliberately trying to lose weight?
4. What is the prevalence of pediculosis?
The questionnaire was first pre-tested on a sample of schoolchildren not involved in the final survey. The answers were coded and entered on a floppy by using Oracle database software on a PC with a 386 processor. All floppies were sent to central level where the data were analyzed by using Statistical Packages for the Social Sciences (SPSS). All illogical answers were left out. It was first assessed in howfar the sample was representative for the population at large. The Chi-square test was used to test for significance. A multivariate analysis was used in order to detect correlation between the following analysis factors:
1. sex
2. age
3. level of education
4. size of the city of residence
5. ethnicity (Dutch, Moroccan, Turkish etc)
6. educational level of parents
All children that participated were guaranteed anonymous processing of the data, thus increasing the validity and reliability on more delicate questions.
The results are published annually in yearbooks, called “the monitoring of the youth health status”. The books provide the results, general conclusions and recommendations for interventions.
IV) Some data on the lifestyles of children
The results of the CHMS are mentioned, as well as some results from other surveys on lifestyles of children.
dietary habits
Almost all children have a daily intake of milkproducts (96%) and grainproducts (98%). Other percentages are: potatoes (72%), vegetables (79%), meat (87%) and fruit (86%). Sweets were consumed by 92%. Only 6% consumed fish the day before the CHMS survey in 1993.
Non-Dutch children consume significantly less milk and milk products than Dutch children and children from families with a low Socio-Economic Status (SES) consume significantly less fruit and vegetables than children from families with a higher SES.
5% of all boys and 13% of all girls in the age group 12-16 years deliberately tried to lose weight in 1994. They often did not take breakfast. In general there is an increase in eating disorders (bulimia and anorexia nervosa) among schoolchildren. This is often related with a distorted body image and an obsessive relation with food. Only 20% of the girls that tried to lose weight, suffered indeed from overweight.
personal hygiene
11% of all the schoolchildren in 1994 suffered from pediculosis capitis (head lice) during any period of that year (cumulative incidence). This percentage seems rather high but is related to the whole year. The prevalence of pediculosis during the survey itself was 1.5 %. Head lice are more often present with girls than with boys and the highest incidence is amongst children aged 4-9 years in autumn.
absenteeism from school and the use of medication
25% of all school children were at least one week absent from school in 1994 due to a temporary disease. The highest absenteeism was found in children aged 4-6 years.
18% of all school children used prescribed medication (excluding vitamins) during the month before the survey.
living conditions
In 1992, 13% of 0-19 year-olds lived in single-parent families. Most single-parent families consist of divorced women and their children. Most children live in a single-family house with a garden. More than 75% of the children have their own bedroom, not sharing it with a brother or sister.
dental hygiene
In 1994, 77 % of the 0-14 year olds visited a dentist annually. During the seventies the prevalence of caries in children aged 6 and 12 years was almost 100%. In 1993 this percentage has decreased to 40% in 12-years old, presumably due to the introduction of fluoride.
freetime
Sport and watching television are very popular among children under the age of 15 years. For instance in 1993, 56% of boys (aged 10-14) and 37% of girls (aged 10-14) spent more than 8 hours per week on sporting. Of children 10-12 years old, 22% watches more than 2 hours television per day. For children over 12 years, this percentage is 33%.
tobacco consumption
In 1995 a sample of adolescents was asked if they had smoked in the 4 weeks prior to the survey. The results were the following:
10-12 years old: 4 %
13-14 years old: 24 %
15-19 years old: 46 %
Boys smoke more than girls. Smoking increase with age, both in terms of the percentage of adolescents and the number of cigarettes per day.
alcohol consumption
Regular alcohol drinking is defined as drinking beer, wine or other alcoholic drinks at intervals between daily and once a week. In 1995, 47 % of boys aged 11-19 and 36% of girls aged 11-19 reported to fit in this category
drug consumption
In 1995, 17% of adolescents aged 11-18 used marihuana at least once, and 9% repeatedly. 2% had experience with XTC.
teenage sexuality
In 1995, 40% of the 16-17 year-olds and 50% of the 18 year-olds had experience with sexual intercourse. Of the girls aged 16-19, 44% used oral anticonceptives in 1995 compared to 27% in 1985.
Concerning risky behavior, 70 % used a condom during the first sexual intercourse. 37% used oral anticonceptives (with or without condom) and 15% took no preventive measures. With increasing age, condom use diminishes in favor of oral anti-conception, thereby raising the risk of Sexually Transmitted Diseases (STDs). Prevention campaigns advise the use of the “pill” for contraception and condoms for the prevention of STDs.
Adolescents aged 19 or less are responsible for 8,5% of all cases of STD in Holland.
In 1995 there were 9 cases of syphilis and 71 cases of gonorrhea among 15-19 years old. Among 20-24 years old, these numbers were 32 and 281 respectively.
Teenage pregnancies are rare in Holland. In 1994, 1.6% of all births in Holland occurred in mothers under 20 years of age (compared to 12.9% in the USA).
The abortion rate is also very low. In 1992, 4.2 girls per 1000 in the age group 15-19
had an abortion. The overall abortion rate (women 15-44 years) is 6 per 1000. This is the lowest rate in the world. Moreover, about 40% of all abortions are performed on immigrant women. For instance, rates are 4 times higher for Moroccan women living in Holland.
V) The rationale for monitoring: some examples of the relation between data and
preventive interventions
Without data, health policy makers are blind. A monitoring system provides data that –after analyzing and interpreting them- makes it possible to develop and evaluate a health policy. A monitoring system is essential in order to detect major health problems; health needs, to be able to prioritize, to allocate resources and to assess the impact of an intervention. In healthcare for children, most of the interventions are related to prevention activities. This will be illustrated by some examples.
In 1986 it was discovered that there was a strong relation between the Sudden Infant Death Syndrome (“Cot Death”) and babies sleeping on their abdomen. From then on preventive health care workers advised that babies should sleep on their side or take a supine sleeping position. This national campaign has resulted in a drop in SIDS from 190 babies in 1986 to 50 in 1995. Without the proper monitoring of mortality statistics, such a relation could never be detected. The remaining cases of SIDS are possibly associated with passive smoking.
Holland has a lot of lakes, pounds and rivers. It is therefore essential for children to learn swimming as soon as possible. Most parents send their children to swimming lessons, where they receive a diploma afterwards. Moreover, there are swimming lessons in all primary school. Regrettably about 20 children in the age 0-19 drown every year. Further stratification of the data showed that most of these children are of non-Dutch origin. For religious reasons (they are Moslems), they do not participate in the swimming lessons in primary schools. With dramatic results. Prevention activities are therefore focussed on making their non-Dutch parents aware of the need of swimming lessons for their children.
Despite the high immunization coverage against whooping cough (bordetella pertussis), the monitoring system discovered an increase in the incidence of whooping cough. As a first step the quality of the cold chain and the vaccine were checked, which turned out to be good. There is a hypothese that the problem was related with late seroconversion. It was therefore decided to advance the first immunization against whooping cough with one month (from three to two months). The monitoring system will follow up if indeed this will lead to a significant decrease in whooping cough.
In 1975 the use of a helmet while driving a moped became obligatory. From that year onwards there was a significant reduction in adolescent mortality rates in the age group 16-19. This convinced the parliament that this type of legal interventions has an impact on the prevention of traumatology.
During the seventies, the prevalence of caries among the youth was almost 100%, despite the high attendancy rate of visits to dentist. The introduction of fluoride in almost all toothpaste plus the introduction of fluoride tablets from birth have significantly reduced the incidence of caries.
VI) Ad-hoc surveys
Beside the system of routine datacollection on about certain parameters, a lot of ad-hoc surveys are held every year. These surveys are organized by:
A) Universities
Surveys are usually organized as a part of a research project of scientists in one of the departments of sociology, child-psychology, pedagogy or paediatrics.
B) State Institutions
These are mostly Municipal Health Services, involved in the earlier described prevention, screening and monitoring activities.
C) Private Institutions
There are several private institutions that have the status of a not-for-profit foundation. Their ideology is to serve the public interest. They are mostly financed through the state or a municipality per separate project. Another source of financing is through sponsoring.
Most of the surveys are not only conducted out of scientific interest, but also because of the practical implications of the results. The main objective is to identify riskgroups and riskfactors, in order to be able to target prevention activities exactly on these groups and factors. The surveys focus around lifestyles (like dietary habits, sport, sexuality, social activities, substance abuse, leisure time etc) and on certain categories (like school drop-outs, children of asylum seekers, ethnic minorities etc.).
The results of the surveys are published in books and scientific magazines. Most of the information is also available through Internet. This allows feedback to all professionals that are working with adolescents. Newspapers and weekly magazines publish often a more popular version of the results, in order to inform the public at large. Television and radio are involved in disseminating information.
When it comes to practical implementation of a prevention program, there is a strong involvement of the Municipal Health Services and schools. More outreaching activities (eg. addressing the target population personally and directly) are organized by street corner workers and other community based professionals.
ANNEX 7.3.5.
Health system in Finland and the role of data registers and health surveys.
|[pic] |The Tacis Russia Preventive Health Care Project |
| |Petroverigskyi pereulok 10, Moscow 101953, The Russian Federation |
THE HEALTH SYSTEM IN FINLAND
AND THE IMPORTANT ROLE OF
DATA REGISTERS AND HEALTH SURVEYS
Fokko de Vries MD MA
May 1999
This paper presents an overview of the health system in Finland and the important role of data registers and health surveys.
The following components are described:
1) The Health System in Finland
2) National Health Survey
3) Morbidity data
4) Mortality data
5) Data on infectious diseases
6) Data on life styles
7) Data about other components
8) Conclusions and relevance for the Russian Federation
9) Websites for further referral
1) The Health System in Finland
Finland has one Ministry of Social Affairs and Health, unlike the situation in most other European countries where there is a separate ministry for Social Affairs and one separate Ministry of Health. Finland has a strong system of social security and makes a strong commitment between socio-economic well-being and health. It is also expressed by the fact that social welfare statistics and health statistics are often registered and published together.
In some way it is a reflection of the old WHO definition that: "health is more than the mere absence of disease; it is also a state of general well being etc." Social security provides the most vulnerable with financial means. Theoretically this also prevents starvation and unacceptable hygiene conditions, thus having an impact on health. 95.000 persons are working in the Social Welfare sector, compared to 111.000 persons in the Health Care sector. The expenditure on social protection in 1996 was 32.3 % (!) of the Gross Domestic Product, compared to 7.8 % on health care.
The total expenditure on health care in 1996 was about $ 8.4 billion, spend on:
In-patient care: 39.5 %
Out-patient care: 35.3 %
Pharmaceuticals: 14.5 %
Other: 10.7 %
In terms of its institutional structure, financing and goals, the Finnish health care system resembles those of the other Nordic countries and Great Britain in that it covers the whole population. Services are mainly produced by the public sector and financed through general taxation.
health reform
An important reform in the health care system took place in 1993 as part of the state subsidy system reform. An essential element of the reform was the revision of the grounds for determining state subsidies to municipalities (local government). Under the old system, state subsidies were earmarked and related to real costs. Hospitals were paid directly by the state. In the reformed system, municipalities receive non-earmarked lump-sum grants. The lump sum can be used for education, social services and health care.
The community is free to use the money as it wishes. The size of this lump sum is calculated prospectively, based on six criteria: size, density and age structure of the population, morbidity, area and the financial status of the municipality. The aim of the reform was to reduce central government control and to increase local freedom in the provision of services. The reform did not affect the municipalities' liabilities to provide health and social services, but it allowed them to undertake a more active role as purchasers.
So the financial power of the central national authorities has diminished and government control has been cut to a minimum. The decision making power of the 453 municipalities has increased and they are responsible for providing health care for their residents. They either produce the services themselves or buy them from other producers.
primary health care
Primary health care services are organised in the municipal health centres. These health centres provide a full range of primary care services, staffed with physicians, nurses, dentists, physiotherapists and social workers. A special feature of the Finnish system is the availability of primary care beds to nurses and general practitioners in health centres.
The concept of primary health care in Finland comprises the integration of preventive health care and hospital care services at the health centre, constituting a graduated system with specialised hospital care. Preventive services include maternal and child health, school health, physiotherapy, laboratory tests and X-ray facilities.
In addition to the network of health centres, employers are obliged to organise curative and preventive occupational services for employees and their family members. These can be arranged on their premises (large companies have their own health centres), in a health care centre owned by several employers, or in the municipal health centre. Since January 1995 there has been no charge for occupational health care, which is the main source of curative services for the working population.
general practitioners
GP's have an important role since they are involved in all the services rendered by the centres, including preventive, curative and emergency care, X-rays, diagnostics, forensic medicine and care of the chronically ill. The health centres account for 75% of the contacts in primary care.
As for the patient registration system, significant changes were introduced. Historically there was no personal registration system and GPs were collectively responsible for the population in the catchment area of their health centre.
Recent reforms have aimed at developing a personal doctor system, with each GP now responsible for providing primary medical services to a certain population in order to improve continuity of care and increase patient satisfaction. GP's working in the health centres are paid by a combination of basic salary, capitation fee (based on the size of the list and the case mix), fees for services provided and a 5% local allowance (1994).
nurses
The number of nurses per 1000 population is well above average, consistent with the greater emphasis put on nursing. The ratio of nurses to physicians is the highest in the European Union. In primary health care they are individually based, family-based or community-based. They traditionally make home visits, and home care is particularly well developed for elderly people and children. Under the small area resident approach, nurses now have a defined catchment population, which it is again believed will increase continuity of care and patient satisfaction.
With the shortening of hospital stays and the more home-oriented approach to care of the elderly, the role and functions of primary health care nurses have been widened beyond the traditional home visits and maternal and child health care.
Psychiatric primary nursing care emphasises co-operation between different parties through networking. Psychiatric care is also organised according to the small area resident approach.
pharmacies
Medicines can only be sold with the permission of the National Agency of Medicines. The retail prices of medicines are regulated, and the national health insurance subsidises or reimburses the cost of medicines prescribed by physicians. Pharmacies are privately owned but their number and location are centrally regulated.
dental care
Primary dental care is organised within the framework of the municipal health care centre and is free up to the age of 19 years. Dentists in private practices provide most adult dental treatment. People aged 19-38 years must pay 40% of the cost of normal dental treatment but only 25% of the cost of preventive measures. Patients born in 1956 or later are not reimbursed.
hospital care
Access to hospital services depends on referral by a GP, who is working as a gate keeper for secondary care, except in emergencies. For impatient medical treatment the country has been subdivided into 21 hospital regions, run by intercommunal associations. More specialised care is provided in five university hospitals. As stated earlier, there are also beds in the municipal health centres.
user fees
Patient have to pay user fees in hospitals and day care units. There are maximum fees defined and also the maximum number of bed days that can be charged.
private sector
In 1990, about 6% of all health care provided by communities, was provided by the private sector. Private physicians provide 20% of outpatient GP services and private dentists provide most of the adult dental care. However only 7% of all doctors work exclusively in private practice, so the overwhelming majority works in both types of health facilities. Only 5% of hospital beds are in private institutions. Private health insurance’s are relatively unimportant and account for only 2% of health care financing. (data from 1994)
In 1997 there were about 5000 consultations per 1000 inhabitants in a national health care centre compared to 639 per 1000 inhabitants in a private health care centre.
financing
The National Health Insurance (NHI) Scheme covers virtually all persons from Finland. The administration is organised by the government. It is funded by premiums from employers and employees. The NHI covers the following benefits: sickness allowances, parenthood allowances, special care allowances, occupational and student health services, rehabilitation services and certain medical expenses.
As a basic rule, the NHI covers a certain share of costs in excess of a fixed sum (minimum per purchase or so-called basic tariff).
Much use is made of the fact that every person has his own Personal Identification Number (PIN), that facilitates the linking of databases.
The National Health Insurance also reimburses the use of certain private health services and prescription medicines.
In order to fulfil their responsibilities as providers the smallest municipalities often co-operate to create a large enough catchment population to allow them to provide services they could never provide by themselves (like CT-scans). 195 out of the total 453 municipalities have even less than 4000 inhabitants. The health services are financed by municipal taxes, state subsidies and user charges. The public health centres, which anyone can contact, provide primary health care for ambulatory medical services.
data
In this new situation of decentralisation the local authorities need information in order to make rational decisions and for this reason a statistical tool was created, called SOTKA. This tool has about 3000 raw indicators and 200 ready-made indicators on every Finnish municipality. The SOTKA statistics collects data not only on health services, costs and use of services, but also on economy, population, families and housing services.
The organisations that provide data to SOTKA are:
-STAKES
-Statistics Finland
-The association of Finnish Local Authorities
-The Social Insurance Institution
-The National Public Health Institute
STAKES is the National Research and Development Centre for Welfare and Health. It is an independent, non-political institution, financed by the Ministry of Social Affairs and Health. It is a public professional centre and its customers are public and private decision-makers. STAKES has three highly integrated tasks: research, development and an information bank on social welfare and health statistics.
STAKES is not an administrative organisation. It has no control or supervisory roles. It is not an authoritative body that prescribes authoritarian norms and rules as was previously the case. STAKES provides information that helps local authorities at municipality level in the process of decision making. The data are used to facilitate this process.
A unique aspect is that the municipalities can compare their individual performance with other municipalities. This allows for "benchmarking" and "peer review". Benchmarking is the process of comparing own performances with the best municipalities. Peer review means comparing with identical and equal municipalities.
The high level of decentralisation and the freedom of municipalities to allocate financial resources may well lead to differences in performances.
The fact that data are collected at municipality level makes it possible to discover significant differences between municipalities with respect to certain input and output indicators.
STAKES has several research and development units, which collect and analyse data on the population, on issues of cost-efficiency and on input vs. output indicators. This includes indicators related to health promotion and disease prevention.
A key player in the field of health promotion is the Finnish Centre for Health Promotion collaborates with more than 100 member organisations. There is a large diversity among them and the strong NGO involvement is characteristic for the civil society that Finland is. Some examples of member organisations are: allergy and asthma federation, the central organisation for traffic safety in Finland, the Federation of Finnish midwives, the Finnish Association for Swimming Instruction and Life Saving, the Finnish lesbian and gay organisation, Women together against drugs, etc.
2) National Health Survey
Finland has a long-standing experience in the monitoring of a wide range of parameters within a representative sample of the population. Surveys were held already in 1964, 1968, 1976 and 1987. The last "Finnish Health Care Survey" was held in 1995/1996 and jointly organised by KELA and STAKES. KELA is an acronym for the Social Insurance Institute. This joint co-operation stresses again the fact that in Finland social welfare and health services are so much interrelated.
The Finnish Health Care Surveys are of great importance. They can be used in the development of health policies. Baseline data are regularly available. The results show the major health needs and priorities. The surveys can also be used to monitor the impact of previous interventions. In this way it can be evaluated if objectives were achieved or to monitor the impact of interventions like privatisation or socio-economical developments. Most of the chosen indicators are according to WHO standards and allow international comparison.
The Finnish Health Care Survey of 1995/1996 will be discussed more in detail, both with regards to methodology and results.
The survey was designed as a cross-sectional study. In principle the same design was used over the years in order to allow comparison. In the case that changes in the design were introduced, it was first assessed if these changes were so significant that they would no longer allow comparison over time, or need some sort of statistical weighing.
The following can serve as an example: the interviews for the surveys in 1964, 1968, 1976 and 1987 were carried out by public health nurses and health care professionals, using the traditional paper and pencil questionnaire method. In 1995/1996 the interviews were carried out by professional interviewers from Statistics Finland, using a computer-assisted data collection method.
A comparative study showed that both the differences in interviewers and data recording methodology had no significant impact on the final result. It has to be stressed that it is very relevant to assess the influence of interviewers and methodology bias before one is allowed to compare over time.
The target population was about 5.000.000 inhabitants, living in households. About 63.000 persons, permanently residing in institutions, were excluded. The final target sample consisted of 6000 households, identified through the population register and by using cluster sampling.
The overall response rate was over 85% (5171) households, with a total of 21.973 respondents. The defaulters, the dropouts that not participated, did not different significantly from the participants when considering the stratification criteria.
In order to increase validity, the interviews were held face-to-face and in order to reduce the costs, all household members were interviewed. Data on children 0-14 years of age were given by an adult, usually the mother. In a minority of cases, respondents were interviewed by phone.
A standard questionnaire was used and data were collected by a Computer Assisted Personal Interview technique (CAPI).
The questionnaire existed in an electronic version and the data were immediately entered in a portable computer. Since there is no separate data recording, this was time saving and thus cost reducing.
The following subjects were investigated through the Finnish Health Care Survey questionnaire.
a) demographic parameters and living conditions:
-family size
-employment status
b) health status:
-chronic morbidity
-asthma
-blood pressure
-mental disorders
-dental status
-days of restricted activity
-functional capacity
c) utilisation of medical services:
-inpatient care
-services of doctors:
1) visits due to illness
2) health examinations
-dental care services
-other outpatient services
-assistance from other people/ use of social service
-private insurance and use of private doctor
d) use of medicines:
-use of prescriptive medicines
-self-medication
-use of herbal medicines
e) health-related life-styles:
-tobacco consumption
-alcohol consumption
-physical activities
-overweight
f) medical expenses per household:
As defined as the household's total expenditure on medical care after all reimbursements from sickness insurance, insurance companies and subsidies from relief funds are deducted.
Some examples of questions are:
Question A3
Were the family's sickness expenses this year so great that you had to cover them:
A) by spending less on other regular items?: yes/no
B) with savings?: yes/no
C) by borrowing?: yes/no
D) with assistance from relatives or friends?: yes/no
E) with municipal support?: yes/no
Question B28A
Does the child wear glasses or contact lenses?: yes/no
Question C1K15
On account of your bad or deteriorating state of health have you ever had to:
A) change the contents of your present work?: yes/no
B) change working place?: yes/no
C) change your profession?: yes/no
Question C3K1
On account of your own illness how many times during this year have you seen a doctor:
A) at a health centre? - times
B) at an out patient department? - times
C) at an occupational health clinic? - times
D) in a private practice? - times
E) at your home? - times
F) somewhere else? - times
Question C6K10
In the last few years, have you for health reasons:
A) gone out on a diet?: yes/no
B) taken more physical exercise?: yes/no
C) cut down the salt in your diet?: yes/no
D) cut down the fat in your diet?: yes/no
E) cut down alcohol drinking?: yes/no
F) cut down coffee drinking?: yes/no
G) cut down the use of sugar?: yes/no
The subjective, self-perception of one's own health was assessed by using the 15D questionnaire. This relates to the health-related quality of life (HRQOL). A person describes his own physical, mental and social well-being on a five-point scale. The combination of the individual scores with the life expectancy from statistics enables the calculation of the expected number of quality-adjusted life years (QUALY's).
Some examples from questions from the 15D questionnaire are:
question 6: eating
1. I am able to eat normally, i.e. with no help from others.
2. I am able to eat by myself with minor difficulty (e.g. slowly, clumsily, shakily, or with special appliances).
3. I need some help from another person in eating.
4. I am unable to eat by myself at all, so I must be fed by another person.
5. I am unable to eat at all, so I am fed either by tube or intravenously.
question 12: depression
1. I do not feel at all sad, melancholic or depressed.
2. I feel slightly sad, melancholic or depressed.
3. I feel moderately sad, melancholic or depressed.
4. I feel very sad, melancholic or depressed.
5. I feel extremely sad, melancholic or depressed.
After the collection of the data, stratification was made into regions, sex, age-group and income-group. (five groups ranking from 20% poorest to 20% richest in terms of household equivalent gross income, in such a way that each quintile contains an equal number; OECD norms were used in calculating the contribution of adults and children in the household)
The statistical analysis was performed by using SUDAAN software.
Results were presented in the form of histograms and tables, showing differences between years, regions, sex, age, income groups etc. Whenever relevant, calculations were made in order to detect statistical significance at several levels (p ................
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