By Olena Nizalova,University of Kent, Nataliia Shapoval, Kyiv School of Economics and VoxUkraine
In Ukraine too much emphasis and hope is put in hands of the doctors, who mostly deal with those who are already sick. However, the population health can be improved through policies in all areas which affect health and health behavior.
It may seem redundant and untimely to think about the Public Health System in a country at war. Yet, we would like to argue that the state of and the risks to population health in Ukraine, health consequences of the Russian invasion, and financial difficulties in curative health care provision make the thoughts about properly working Public Health system rather pertinent. We argue that current Health System in Ukraine is unable to deal with current catastrophic rates of mortality and upcoming spell of population health crisis. We do not pretend that we have the answer on how to set up efficient Public Health system in Ukraine – this answer would require significant research and policy development efforts before it can be presented to the people of Ukraine. However, we would like to set up the stage for the discussion of the urgency of the matter and highlight the need for such efforts.
According to CIA world factbook, Ukraine is ranked second worst in terms of death rate in 2014 and the war is far from the leading cause. Epidemiological and public health literature treats Ukraine as an exception with high prevalence of both infectious diseases and degenerative/man-made diseases with considerably low life expectancy at birth, while being a neighbor of European countries, which mostly moved into the fourth stage¹. Other countries in the post-socialist block over the course of transition managed to greatly improve population health setting on the path of convergence towards Western Europe. It has been shown in the literature that such health problems are more effectively dealt with via prevention, not treatment.
Our health behavior is formed under the influence of biological factors, traditions shared by the community we belong to, social and economic conditions, working conditions, etc. At higher levels, which we not always realize, our behavior will depend on ecology, built environment (like availability of sports infrastructure, parks, transport infrastructure), culture and religion, knowledge and information environment we live in, political and economic situation in the country, access and availability of high quality food, government policies, and functioning of the health care system.
However, in Ukraine too much emphasis and hope is put in hands of the doctors, who mostly deal with those already sick. Holistic approach can be reached if we follow a simple rule: population health can be improved through policies in all areas, which affect health and health behaviors (e.g. work safety, food safety regulation, physical education for children and young adults, education, smoking bans, ecological safety, taxation of unhealthy products, information campaigns promoting healthy lifestyles, and regulation of advertising industry with respect to unhealthy products).
The set of agents which affect health, and should be integrated in the country system under strategic leadership of the state is ample and covers²:
- ‘communities’, which include all the organizations and associations that make up civil society, including schools, law enforcement and so on;
- the health care delivery system;
- employers and business;
- the media;
- government and public health agencies.
What does a modern public health system look like?
Public health system is in fact more than prevention. It is concerned with population health both at the country and community level. Its activities change with the change in health problems people are facing, the technology and societal values. In past decades in developed countries the nature of public health systems has changed so dramatically that some authors started calling this change “Third Public Health Revolution” (Kickbusch & Payne, 2003; Scutchfield, 2004). Yet, any referral to public health in Ukraine inevitably boil down either to the notorious sanepidstations³, or to the promotion of healthy lifestyles, poorly implemented and not seriously taken by the people. Moreover, the latter function is thought to be of the second order in the times of war. So, before delving into the discussion of what is worth doing or forgetting about in the times of war, let me first describe the goals, approaches and actors of the modern Public Health system, and discuss whether these are applicable in Ukrainian setting.
The overall goal of the exemplary modern public health system is to increase healthy life years and reduce health inequalities across various population groups and regions while in the past the focus has been on the reduction of diseases and mortality. In our view, given the depth of population health crisis in Ukraine, we have to first focus on the reduction of disease and mortality with simultaneously paying attention to inequality in these outcomes, especially between rural and urban areas. Yet, keeping in mind the importance of movement towards the increase of healthy life years. Keeping this goal in mind, Public Health System has several purposes:
- Prevent epidemics and spread of disease
- Protect against environmental hazards
- Prevent injuries
- Promote and encourage healthy behaviors
- Respond to disasters and assist communities in recovery
- Assure the quality and accessibility of services
With respect to the approaches towards implementation of the Public Health measures,, “there was a shift from top-down, prescriptive measures to a participatory approach characterized by multi-component solutions addressing multiple causes of ill health at socio-economic, environmental, and individual level” . This is clearly a desirable change in Ukrainian context, as the top-down approach has failed in many dimensions of public life in the country, and this is a good time to change it. As it was already mentioned, the complexity of the problems with population health go beyond health sector.
Getting down to the earth, what are the functions which the Public System serves and whether we have any of them at the moment and which organizations perform them? Although the full answer to this question would require a serious research effort, we will try to provide observations from the existing thin literature and from personal experience living in the country and then open the floor to the discussion.
The following are ten essential Public Health Services:
- Monitor health status to identify and solve community health problems
Much of the statistics on the onset of the diseases and their prevalence is routinely collected by the hospitals and polyclinics, as each of them has a statistician which reports to the oblast Center for Medical Statistics. The latter aggregate the data to one figure and send this to the Ministry. Unfortunately, this does not allow proper surveillance of the population health problems at the community level. Example of the introduction of the mother and infant health monitoring system by the Mother and Infant Health Project (2006-2012) in Cherkassy oblast, although very successful, proved to be useless as no organization agreed to assume the responsibility for the system roll-over for the entire country after foreign funding stopped. Can anyone remember TV or radio shows speaking about evidence based findings on the causes of the population health decline, in spite of having a special Strategic Research Institute at the Ministry of Health? Yet, this is one of the services which is at the heart of Public Health System.
- Diagnose and investigate health problems and health hazards in the community
We do have the Ministry of Ecology and Natural Resources, which goal is to deal with ecological safety, environment protection, etc. However, we have not been able to locate activities of this Ministry in conjunction with the Ministry of Health, although the measure of the effectiveness of both would be an improved population health.
- Inform, educate, and empower people about health issues
This very important function in the face of low financing has always been highly underfunded. Rare programs which usually started with the help of international money, such as Mother and Infant Health Project, Healthy Baby, TB/HIV/AIDS in spite of showing steady progress, would be left out once the need for domestic funding would become inevitable.
- Mobilize community partnerships to identify and solve health problems
This function is entirely absent from the picture in Ukraine. However, the time now may be the best to mobilize community around local health problems.
- Develop policies and plans that support individual and community health efforts
This is the service at the national level which ensures continuing interaction with major stakeholders, patients’ groups, medical community and carers to put the existing policies and national plans in correspondence with community needs in terms of health care and healthy behaviors.
- Enforce laws and regulations that protect health and ensure safety
This may be a very difficult service, as the private interests of major economic players (e.g. tobacco and alcohol producers, chemical and metal corporations, mining companies, pharmaceuticals, etc.) are well represented in the political circles. Thus, development and enforcement of the regulations which would protect and improve population health at the cost of reducing profits of these companies, may be quite challenging, as the example of smoking ban legislation efforts show.
- Link people to needed personal health services and assure the provision of health care when otherwise unavailable
This is primarily done through community groups, local authorities, social assistance offices, and schools. But special training is needed for people who work in this agencies to identify the person in need and direct him/her to the appropriate health service.
- Assure a competent public and personal health care workforce
This is very important service, and is virtually non-existent in Ukraine. The only School of Public Health virtually turned into a school of health care management, leaving unsolved the matter of lack of public health workforce. In addition, the curricula of medical universities is still mainly focusing on the Soviet style sanepidemics, rather than modern approaches suitable to tackle today’s challenges.
- Evaluate effectiveness, accessibility, and quality of personal and population-based health services
This function is only possible if public health specialists are independent of the health services, yet having access to all the necessary statistics and support in access to such actors of the system as doctors, nurses, patients, to study what works and what does not work in the existing setup of the health care system.
- Research for new insights and innovative solutions to health problems
This service also does not exist at the moment, but is much needed in the future. It requires extensive collaboration of researchers from various disciplines and is best done if commissioned through research competitions across research institutes and universities.
The task is challenging, as the development of a modern Public Health System (PHS) literally means starting from ground zero. However there are steps that can be done immediately:
- Ensure that vaccination campaigns are de facto re-established
- Ensure uninterrupted functioning of the existing health programs on the occupied territories, such as TB and HIV/AIDS, possibly with advocating for continuing support from the existing donor organizations and attracting others.
- Support (don`t impede) big project aimed at research devoted to the development of the PHS
- Make small but tangible steps to tackle NCDs. (Examples may include wide information campaigns and screening projects on one of the major NCD risk factors, taxation of producers using trans fats, public campaigns in the regions aimed to reduce smoking and tobacco consumption, or other interventions to enhance health behaviors)
Professional experts are no longer the only relevant players in dealing with population health, but have been joined by a multidisciplinary group including institutional decision makers, professionals, civil society and the private sector.” Today, Ukraine is probably at its best time in this regard given the willingness of people to participate in changing society, and the formation of civic organizations which have improvement of population health as part of their agenda. There is also a considerable interest from the private sector. It is understandable that this sector is motivated by profit-making. However, if the incentives are designed properly and the process is controlled by civil society, surely better outcomes can be achieved.
¹ According to the theory of epidemiological transition, which “accounts for the extraordinary advances in health care made in industrialized countries since the 18th century”, developed by Abdel Omran in 1971, and augmented by Olshansky and Ault (1986), four stages of epidemiological transition are: 1) The Age of Pestilence and Famine; 2) The Age of Receding Pandemics; 3) The Age of Degenerative and Man-Made Diseases: Mortality continues to decline and eventually approaches stability at a relatively low level; 4) The “age of delayed degenerative diseases”. The fourth stage is characterized by rapid decline in mortality, which also becomes concentrated mostly at advanced ages (nearly the same pace for males and females) and age distribution is shifted progressively towards older age.
³ Sanitary-Epidemiological Stations (Sanepidstations/SES) are specialised institutions intended to guarantee safe sanitary conditions throughout the state territory. The network of SES should carry out organization of prevention and liquidation of infectious, parasitic and professional diseases. Sanepidstations were created in 1930es and existed only in USSR. SES still exist in Ukraine