In May, 2004, the border of the European Union (EU) will shift eastward such that the new frontier will be made up by Ukraine, Belarus, and a considerably longer Russian border. Here, we discuss three issues: first, the factors that have contributed to the growth of communicable disease in Russia, Ukraine, and Belarus; second, how public health systems have responded to these challenges; and third, the implications for the EU as a whole. Since the break-up of the Soviet Union, Russia, Ukraine, and Belarus have witnessed substantial political, social, and economic changes. These events have been reflected in changes in the epidemiology of communicable diseases, including tuberculosis and HIV (ie, HIV-1). Moreover, public health systems, rooted in Soviet traditions, are struggling to respond effectively to the challenges of resurgent infectious diseases, such as tuberculosis, and newly emergent challenges such as HIV. The changing patterns of communicable diseases east of the EU's new border has implications for how the EU aids the strengthening of public health systems east of the new frontier. Transborder spread of communicable diseases also challenges communicable disease control systems within the EU. Concerted action is needed by member states and the EU, building on models of cooperation between institutions that have been successful in areas beyond health, if public health systems are to meet the emerging challenges to communicable disease control.

Communicable Disease Control↗

PubMed2004

Mortality trends and setbacks: global convergence or divergence?

Health trends over much of the past century have been generally, and notably, positive throughout the world. In several regions, however, life expectancy has declined over the past 1-2 decades. This trend suggests that the expectation that emerged in the 1960s and 1970s of worldwide gains and convergence in population health status is not guaranteed by a general deterministic process. National populations can now be clearly grouped into those that have achieved rapid gains in life expectancy; those whose gains are slower or are perhaps plateauing; and those in which the trends have reversed. Over the past two centuries, outside times of war and famine, such reversals have been rare. Exploration of these varied population health trends elucidates better the close relation between population health and the processes of economic, social, and technological change. Such analysis has shown that the health status of human populations should be a guiding criterion in the debate on sustainable development.

Age Factors↗

PubMed2004

Ethics review in research: time has come for reassessment.

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Ethical Review↗

PubMed2004

Health expectancy in the Russian Federation: a new perspective on the health divide in Europe.

OBJECTIVES: To compare life expectancy and healthy life expectancy in the Russian Federation and in countries of Eastern and Western Europe. METHODS: WHO mortality data and data on self-reported health from the World Values Survey and the Russian Longitudinal Monitoring Survey were used to compare the above three regions. Life expectancy was calculated using Sullivan's method, with years of life lived divided into healthy and unhealthy. The gap in healthy life expectancy between the Russian Federation and Western Europe was examined by decomposing the difference by gender and age. FINDINGS: The probability of remaining alive and healthy declines faster in the Russian Federation than in Western Europe, with the gap between Eastern Europe and the Russian Federation widening at older ages. In the Russian Federation, this rapid decline is due mainly to the high probability of death or of poor health for men and women, respectively. CONCLUSIONS: There is a large toll of premature male mortality in the Russian Federation but there also appears to be a substantial burden of ill-health among women. As in other countries, the responses of men and women to adversity differ, leading to premature death in men but survival in a poor state of health in women. Epidemiological studies including objective measures of health would help policy-makers to estimate more precisely the scale and nature of this problem. Policy-makers must recognize that health expectancy in the Russian Federation is reduced in both men and women.

Europe↗

PubMed2004

Not everything that counts can be counted; not everything that can be counted counts.

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California↗

PubMed2004

Financing and planning of public and private not-for-profit hospitals in the European Union.

While much has been written about health care financing in Europe in recent years, discussion has almost entirely focused on revenue. In contrast, there has been remarkably little written on financing of capital investment in European health care systems. Yet major changes are underway in several countries, in particular involving new forms of public-private partnerships (PPP). At the same time, there is growing recognition of the way in which the inherited structure of the health care delivery system constrains the system's ability to adapt to changing circumstances. This paper reports the results of a survey undertaken among key informants in the member states of the European Union to begin to ascertain existing practices and future plans in relation to hospital planning and financing amongst public and private not-for-profit hospitals. The locus of hospital planning decisions reflect the constitutional framework of the country involved, and thus the emphasis on national or local plans. There has been an expansion of private sector involvement, with four basic models identified: private loans direct to the hospital; private loans to a regional health body; a PPP where the private sector's role is to build, design and operate the non-clinical functions of the hospital; and, finally, a PPP, where the private sector's involvement also includes management of the clinical functions of the hospital. It is too early to say whether these approaches will be more successful than the models they are replacing.

Capital Financing↗

PubMed2004

Avoidable mortality in Lithuania: 1991-199 compared with 1970-1990.

This paper assesses the changes in avoidable mortality in Lithuania in 1991-1999 compared with 1970-1990. Causes of death were disaggregated into causes most amenable to treatment and those amenable to prevention. Trends in age-standardised death rates were calculated. In 1970-1990, avoidable causes of death accounted for 26.3% of all deaths. By 1991-1999 this figure had decreased slightly to 24.6%. At the same time, age-standardised death rates from avoidable causes increased by 8%, from 118.1 per 100000 in 1970-1990 to 127.9 in 1991-1999. Avoidable mortality among men was considerably higher than for women in both periods. There was considerable fluctuation in both treatable and preventable mortality during the 1990s, reflecting diversity in trends in different causes of death. Increases occurred in death rates from tuberculosis, cervical cancer and liver cirrhosis and, immediately after independence, also in hypertensive and cerebrovascular diseases and, among men, lung cancer, followed by subsequent declines. Deaths from chronic rheumatic heart disease, asthma and other respiratory diseases, appendicitis, abdominal hernia, cholelithiasis and maternal mortality consistently declined. In conclusion, avoidable mortality declined as a proportion of total mortality in Lithuania during 1991-1999 compared with 1970-1990. This reflected the combined impact of an initial rise in death rates from treatable and, to a lesser extent, preventable causes, followed by subsequent declines. While this indicates some success in the development of medical care, it emphasises the need for more effective public health policies directed at the major determinants of health.

Adolescent↗

PubMed2004

Changing health inequalities in east and west Germany since unification.

The unification of Germany in 1990 brought about substantial social and economic changes in its eastern part, with new uncertainties and, despite increasing overall income, rising inequality. This paper explores the potential impact on health of these changes during the 1990s, looking specifically at income-related health inequalities in east and west Germany and its modulation by psychosocial factors. We used data from the German Socio-Economic Panel (GSOEP) for the years 1992 and 1997, including individuals aged 25+. We investigated changes in self-perceived health in the two parts of Germany and its socio-economic and psychosocial determinants. Analyses estimated odds ratios of less than good health using logistic regression. In 1992, 47% of east Germans rated their health worse than good compared with 54% in the west. By 1997, the east-west gap in self-rated health had disappeared, with the prevalence of poor health increasing to 56% in both parts. Income and education were important determinants of health in east and west, with, in the age-sex-adjusted model, those having available less than 60% of median equivalent income being at increased risk of poor health in 1992 (OR(east) 2.39, 1.45-3.94; OR(west) 2.04, 1.65-2.52). Addition of education reduced the strength of this relationship only slightly. In the west, income-related health inequalities widened between 1992 and 1997 yet the initially stronger gradient declined in the east, despite an overall increase in income inequality (OR(east) 1.63, 1.04-2.56; OR(west) 2.65, 2.19-3.21). The impact of education remained stable. Psychosocial variables were important determinants, mediating the effects of income, with leisure-cultural social involvement exerting the strongest effect in both east and west.The results show that, unlike in the west, the overall increase in income inequality in east Germany between 1992 and 1997 was not accompanied by a simultaneous increase in income-related health inequalities. This suggests that mechanisms involved in the association of socio-economic factors and health possibly behave differently in east and west.

Adult↗

PubMed2004

Reforming health care financing in Bulgaria: the population perspective.

Health financing reform in Bulgaria has been characterised by lack of political consensus on reform direction, economic shocks, and, since 1998, steps towards social insurance. As in other eastern European countries, the reform has been driven by an imperative to embrace new ideas modelled on systems elsewhere, but with little attention to whether these reflect popular values. This study explores underlying values, such as views on the role of the state and solidarity, attitudes to, and understanding of compulsory and voluntary insurance, and co-payments. The study identifies general principles (equity, transparency) considered important by the population and practical aspects of implementation of reform. Data were obtained from a representative survey (n=1547) and from 58 in-depth interviews and 6 focus groups with users and health professionals, conducted in 1997 before the actual reform of the health financing system in Bulgaria. A majority supports significant state involvement in health care financing, ranging from providing safety net for the poor, through co-subsidising or regulating the social insurance system, to providing state-financed universal free care (half of all respondents). Collectivist values in Bulgaria remain strong, with support for free access to services regardless of income, age, or health status and progressive funding. There is strong support (especially among the well off) for a social insurance system based on the principle of solidarity and accountability rather than the former tax-based model. The preferred health insurance fund was autonomous, state regulated, financing only health care, and offering optional membership. Voluntary insurance and, less so, co-payments were acceptable if limited to selected services and better off groups. In conclusion, a health financing system under public control that fits well with values and population preferences is likely to improve compliance and be more sustainable. Universal health insurance appears to attract most support, but a broader public debate involving less empowered people is needed to resolve misunderstandings and create realistic expectations.

Adult↗

PubMed2004

Physical inactivity in a country in transition: a population-based survey in Tirana City, Albania.

AIMS: This paper describes the work and leisure-time physical activity levels of adults living in Tirana City (Albania). METHODS: A cross-sectional survey was undertaken in Tirana City in mid-2001. It included 1120 adults aged 25 years and over (response rate=72.7%). RESULTS: Overall, 19.3% of male and 28.4% of female respondents reported a low level of physical activity at work. During leisure time, 49.5% of men and 57.6% of women (age-standardized prevalence [adjusted to the adult population of Tirana]: 43.4% and 51.9% for men and women respectively) said that they participated in only sedentary activities such as reading and watching television. The gender difference in the likelihood of low physical activity at work and during leisure time was significant even after adjusting for age (age adjusted odds ratios (OR)=1.86 99% confidence interval (CI) 1.12; 3.09 and OR=1.60 99% CI 1.17; 2.22 respectively). The likelihood of leisure-time sedentarity increased with age in both genders but it did not vary significantly with education level or income. Being sedentary during leisure time was also not significantly associated with other unhealthy lifestyle behaviours, including smoking, consumption of vegetables less than six days per week, and daily alcohol intake. CONCLUSIONS: In a country such as Albania that has undergone a rapid transition from a largely unmechanized society, characterized inevitably by high levels of exercise, the generalized high prevalence of low physical activity level during leisure time gives cause for concern regarding future health trends.

Adult↗

PubMed2004

Passing the baton.

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European Union↗