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KAUNAS UNIVERSITY OF MEDICINE FACULTY OF PUBLIC HEALTH DEPARTMENT OF PREVENTIVE MEDICINE

KAUNAS UNIVERSITY OF MEDICINE FACULTY OF PUBLIC HEALTH DEPARTMENT OF PREVENTIVE MEDICINE. “HEALTH POLICY DEVELOPMENT IN LITHUANIA”. PROF. Vilius GRABAUSKAS. BISPH TRAINING COURSE PUBLIC HEALTH SCIENCE. LEARNING OBJECTIVES. TO PRESENT PRINCIPLES OF HEALTH POLICY

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KAUNAS UNIVERSITY OF MEDICINE FACULTY OF PUBLIC HEALTH DEPARTMENT OF PREVENTIVE MEDICINE

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  1. KAUNAS UNIVERSITY OF MEDICINE FACULTY OF PUBLIC HEALTH DEPARTMENT OF PREVENTIVE MEDICINE “HEALTH POLICY DEVELOPMENT IN LITHUANIA” PROF. Vilius GRABAUSKAS BISPH TRAINING COURSE PUBLIC HEALTH SCIENCE

  2. LEARNING OBJECTIVES • TO PRESENT PRINCIPLES OF HEALTH POLICY FORMULATION IN LITHUANIA • TO PRESENT VALUE SYSTEM AND SCIENTIFIC BACKING-UP OF HEALTH POLICY FORMULATION IN LITHUANIA • TO PRESENT PROCESS OF HEALTH POLICY DEVELOPMENT INCLUDING SOME MONITORING AND EVALUATION ELEMENTS Vilius GRABAUSKAS

  3. POLICY AND POLITICS • ETHIMOLOGICALLY “POLITICS” COMES FROM OLD GREEK AND LATIN LANGUAGES GREEK “POLIS” CITY – STATE) BY EVOLUTION DEVELOPED INTO LATIN “POLITIA” (STATE) • IN ENGLISH THIS TERMINOLOGY DEVELOPED INTO “POLITY” WHICH MEANT STATE AND “POLICY” WHICH MEANT DOMINATION OF ADMINISTRATIVE POWER IN PUBLIC AFFAIRS • THIS IS WHY TODAY IN THE SCIENTIFIC DISCUSSION “POLITICS” IS USUALLY ASSIGNED TO POLITICAL SCIENCE, WHILE “POLICY” – ADMINISTRATIVE AND MANAGERIAL ISSUES Vilius GRABAUSKAS

  4. LITHUANIAN DEFINITIONS OF HEALTH POLICY • POLICY- COORDINATED AND AGREED PLAN OF ACTION • HEALTHPOLICY - COORDINATED AND AGREED ACTION PLAN AIMED AT IMPLEMENTATION OF HEALTH PROMOTION, DISEASE PREVENTION, CARE AND REHABILITATION IN A BALANCED WAY • PUBLIC HEALTH POLICY - COORDINATED AND AGREED ACTION PLAN AMONG ALL SECTORS OF SOCIETY AIMED AT IMPLEMENTATION OF HEALTH PROMOTIVE AND DISEASE PREVENTIVE ACTIVITIES IN THE ENTIRE SOCIETY Vilius GRABAUSKAS

  5. DEFINITION OF HEALTH “HEALTH IS COMPLETE PHYSICAL, MENTAL AND SOCIAL WELL BEING, NOT JUST MERELY THE ABSENSE OF DISEASE OR IMPAIRMENT” WHO CONSTITUTION, 1948 m. GENEVA Vilius GRABAUSKAS

  6. FACTORS INFLUENCING HEALTH General socioeconomic and environmental conditions Age, sex and hereditary factors Vilius GRABAUSKAS

  7. FACTORS INFLUENCING HEALTH GENETICS (20%) ENVIRONMENT (20%) LIFESTYLES (50%) MEDICAL CARE (10%) Vilius GRABAUSKAS

  8. RISK FACTORS RESPONSIBLE FOR PREMATURE DEATHS IN THE WORLD CAUSED BY DISEASES AND INJURIES WORLD STATISTICS. 1990 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Vilius GRABAUSKAS

  9. PROPORTION OF DEATHS CAUSED BY TOBACCO, ALCOHOL AND TRANSPORT INJURIES IN LITHUANIAN POPULATION AGED 15-64 60 50 40 SMOKING 30 TRANSPORT INJURIES 20 ALCOHOL 10 0 90 91 92 93 94 95 96 97 Vilius GRABAUSKAS

  10. TRADITIONAL UNDERSTANDING OF ILL HEALTH BIOMEDICAL MODEL OF DISEASE CONTROL PRINCIPAL ORIENTATION  DISEASE OUTCOMES: • SYMPTOMS • DIAGNOSIS • TREATMENT • REHABILITATION PASSIVE HEALTH CARE STRATEGY Vilius GRABAUSKAS

  11. MODERN UNDERSTANDING OF ILL HEALTH BIOSOCIAL MODEL OF DISEASE CONTROL PRINCIPAL ORIENTATION CAUSES OF DISEASES: • SOCIAL STRUCTURES • LIFE STYLES • ENVIRONMENT • HEALTH CARE ACTIVE HEALTH CARE STRATEGY Vilius GRABAUSKAS

  12. NECESSITY OF SCIENTIFIC BACKING-UP FOR HEALTH POLICY FORMULATION PREVENTION IF EFFECTIVE IS ALWAYS BETTER THAN DISEASE TREATMENT • SCIENTIC EVIDENCE FOR DISEASE CAUSATION - LIFE STYLES • POLITICAL, ECONOMIC AND SOCIAL ENVIROMENT • PHYSICAL ENVIRONMENT • HEALTH SYSTEM CAPACITY TO DEAL WITH CAUSES • EARLY DIAGNOSIS • EFFECTIVE TREATMENT AND REHABILITATION • ACCESSIBLE MEDICAL CARE • SUFFICIENT RESOURCES • HUMAN • FINANCES • EFECTIVE MANAGEMENT Vilius GRABAUSKAS

  13. HEALTH INFORMATION SYSTEM MAJOR TASK: NEED FOR INFORMATION THAT HELPS EFFECTIVE FUNCTIONING OF HEALTH (NOT JUST CARE!) SYSTEM THROUGH PROPER PLANNING, IMPLEMENTATION, MANAGEMENT, MONITORING AND EVALUATION MAJOR COMPONENTS: • BROAD INDICATORS DESCRIBING ECONOMIC-DEMOGRAPHIC SITUATION • TRADITIONAL ILL-HEALTH DESCRIBING INDICATORS • HEALTH RESOURCE DESCRIBING INDICATORS • HEALTH RESOURCE FUNCTIONING INDICATORS • HEALTH RISK DESCRIBING INDICATORS • INTERSECTORAL COLLABORATION FOR HEALTH INDICATORS Vilius GRABAUSKAS

  14. WHO PRINCIPLES FOR HEALTH POLICY DEVELOPMENT • PREREQUISITS FOR HEALTH • POLITICAL • SOCIAL • ECONOMIC • ORGANIZATIONAL • PROMOTION OF HEALTHY LIFE STYLES • PROTECTION OF HEALTHY ENVIRONMENT • APPROPRIATE HEALTH CARE • HEALTH SYSTEM INFRASTUCTURE SUPPORT • TRAINING OF HEALTH PERSONEL • HEALTH INFORMATION SYSTEM AND MONITORING • RESEARCH AND DEVELOPMENT Vilius GRABAUSKAS

  15. LITHUANIAN HEALTH POLICY: KEY PRINCIPLES • SCIENCE BASED • EQUITY FOCUSSED • PUBLIC HEALTH ORIENTATION - HEALTH PROMOTION - DISEASE PREVENTION } PRIORITY • HEALTH CARE IN BALANCE - PRIMARY - SECONDARY - TERTIARY } REFORM • COMMUNITY PARTICIPATION • INTERSECTORAL ACTION • ACCOUTABILITY • RESEARCH Vilius GRABAUSKAS

  16. PROCESS OF HEALTH POLICY DEVELOPMENT IN LITHUANIA • SITUATION ANALYSIS • DEMOGRAPHIC PROCESSES • MORBIDITY • MORTALITY • DISABILITY • RESOURCES • DETERMINANTS • TREND ANALYSIS • PRIORITY SETTING • TARGET SETTING • RESOURCE ALLOCATION • INTERSECTORIALITY/PARTNERSHIP • MONITORING AND EVALUATION Vilius GRABAUSKAS

  17. FROM EPIDEMIOLOGY TO PUBLIC HEALTH (CONTRIBUTION OF RESEARCH) - 1 • 1970 -1980 –EPIDEMIOLOGY & PREVENTION: KRIS, (WHO/HQ),AMI COMMUNITY REGISTERS (WHO/EURO), MRFICT, JUVENILE HYPERTENSION,PRECURSORS OF ATHEROSCLEROSIS IN CHILDREN, BIOLOGICAL MARKERS OF ATHEROSCLEROSIS, ETC. COLABORATION WITH WORLD HEALTH ORGANIZATION Vilius GRABAUSKAS

  18. FROM EPIDEMIOLOGY TO PUBLIC HEALTH (CONTRIBUTION OF RESEARCH) - 2 • 1980 -1990 – INTEGRATED APROACHES IN NCD PREVENTION AND HEALTH PROMOTION: CINDI (WHO/EURO), INTERHEALTH (WHO/HQ) COLABORATION WITH WORLD HEALTH ORGANIZATION Vilius GRABAUSKAS

  19. FROM EPIDEMIOLOGY TO PUBLIC HEALTH (CONTRIBUTION OF RESEARCH) - 3 • 1990 -1994 – HEALTH PROMOTION IN ACTION AND NATIONAL HEALTHPOLICY FORMULATION: NATIONAL CONCEPT OF HEALTH (1991), HEALTHY CITIES, HP SCHOOLS, HP KINDERGARDENS, HP HOSPITALS, HP UNIVERSITIES NATIONAL NETWORKS; EURO REGIONS FOR HEALTH NETWORK COLABORATION WITH WORLD HEALTH ORGANIZATION Vilius GRABAUSKAS

  20. FROM EPIDEMIOLOGY TO PUBLIC HEALTH (CONTRIBUTION OF RESEARCH) - 4 • 1994 -2000 – RESEARCH AND TRAINING IN PH, NATIONAL HEALTHPOLICY IMPLEMENTATION: BRIMHEALTH 1992, OPENING OF PH FACULTY AT KMU (1994); NATIONAL HEALTH PROGRAMME (1998); PRESIDENCY OF NATIONAL BOARD OF HEALTH (1998 – 2000), ASPHER MEMBERSHIP (2001) COLABORATION WITH WORLD HEALTH ORGANIZATION Vilius GRABAUSKAS

  21. ADOPTING MEDICAL EDUCATION TO THE PRIORITIES OF HEALTH REFORM IN LITHUANIA • NEW NATIONAL CONCEPT OF HEALTH MORE HEALTH FOR LITHUANIAN PEOPLE THROUGH HEALTHIER ENVIRONMENT AND LIFE STYLES THUS LEADING TO HEALTH PROMOTION AND DISEASE PREVENTION PRIORITY TO PRIMARY HEALTH CARE WITHIN HEALTH CARE SYSTEM BALANCE BETWEEN PRIMARY, SECONDARY AND TERTIARY CARE • NEW SPECIALTIES WITHIN HEALTH PROFESSION • GENERAL PRACTICE/FAMILY MEDICINE • NURSING • SOCIAL WORK • PUBLIC HEALTH • ADMINISTRATION / MANAGEMENT • OTHER • REDUCING NARROW SPECIALIZATION Vilius GRABAUSKAS

  22. MAJOR STEPS INHEALTH POLICYDEVELOPMENT IN LITHUANIA MAY, 1989 REESTABLISHMENT OF LITHUANIAN MEDICAL ASSOCIATION OCTOBER, 1991 APPROVAL OF NEW NATIONAL CONCEPT OF HEALTH BY THE PARLIAMENT MARCH, 1993 FIRST NATIONAL HEALTH POLICY CONFERENCE DECEMBER, 1993 ESTABLISHMENT OF HEALTH REFORM MANAGEMENT BUREAU JUNE, 1994ADOPTION OF HEALTH SYSTEM LAW NOVEMBER, 1995 PARLIAMENTARY DISCUSSION ON HEALTH SYSTEM REFORM Vilius GRABAUSKAS

  23. LINKAGES: LITHUANIAN HEALTH INFORMATION SYSTEM LITHUANIAN HEALTH INFORMATION CENTRE (UNDER MINISTRY OF HEALTH) AS EXECUTING AGENCY STRUCTURE OF INFORMATION ANALYSED AND PUBLISHED ON ANNUAL BASIS • DEMOGRAPHIC SITUATION • MORBIDITY • LIFE STYLES • HEALTH CARE FACILITIES • HEALTH CARE SYSTEM PERFOMANCE • HEALTH CARE FINANCING • ENVIRONMENTAL HEALTH RESEARCH INSTITUTIONS WHO/HFA DATA BASE NATIONAL DEPARTMENT OF STATISTICS Vilius GRABAUSKAS

  24. LIFE EXPECTANCY AT BIRTH TRENDS IN BALTIC, NORDIC AND EU COUNTRIES 78 76 74 72 70 68 66 64 1970 1975 1980 1985 1990 1995 2000 Estonia Lithuania Nordic average EU average Latvia Vilius GRABAUSKAS

  25. 80 75 70 65 60 55 LIFE EXPECTANCY TRENDS IN LITHUANIAN URBAN AND RURAL POPULATION Urban Females Rural Males Urban Rural 1970 1980 1975 1985 1990 1997 Vilius GRABAUSKAS

  26. RATIO OF PROBABILITY OF DEATH OF URBAN AND RURAL LITHUANIAN MALES IN 1970 AND 1996 (URBAN MALE MORTALITY EQUALS 1) Ratio 2,5 2 1,5 1 0,5 0 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ Age 1970 1997 Vilius GRABAUSKAS

  27. FEMALE - MALE DIFFERENCE OF LIFE EXPECTANCY IN BALTIC, NORDIC AND EU COUNTRIES 14 13 12 11 10 9 8 7 6 5 1970 1975 1980 1985 1990 1995 2000 Estonia Lithuania Nordic average EU average Latvia Vilius GRABAUSKAS

  28. INFANT MORTALITY IN BALTIC, EU AND CEE COUNTRIES Deaths per 1000 live births 26 EU 24 CEEC 22 20 Latvia 18 Estonia 16 Lithuania 14 12 10 8 6 4 80 82 84 86 88 90 92 94 96 98 Years Vilius GRABAUSKAS

  29. STRUCTURE OF CAUSE-SPECIFIC MORTALITYOF LITHUANIAN POPULATION, 2002 55.0 % Cardiovascular diseases 18.0 % Cancers External causes ( injuries, poisoning, suicides) 13.0 % 4.0 % Respiratory diseases 3.0 % Digestive system diseases Infectious and parasitic diseases (tuberculosis=78%) 1.2 % 5.8 % Other Total: 100.0 % Vilius GRABAUSKAS

  30. MORTALITY TRENDS OF CIRCULATORY SYSTEM DISEASES IN BALTIC, NORDIC AND EU POPULATIONS, AGED 0 - 64 300 250 200 150 100 50 1970 1975 1980 1985 1990 1995 2000 Lithuania Estonia Nordic average EU average Latvia Vilius GRABAUSKAS

  31. MORTALITY TRENDS OF CEREBROVASCULAR DISEASES IN BALTIC, NORDIC AND EU POPULATIONS, AGED 0 - 64 70 60 50 40 30 20 10 0 1970 1975 1980 1985 1990 1995 2000 Nordic average Estonia Lithuania Latvia EU average Vilius GRABAUSKAS

  32. CANCER MORTALITY TRENDS IN BALTIC, NORDIC AND EU POPULATIONS AGED 0 - 64 100 000 130 120 110 100 90 80 70 1970 1975 1980 1985 1990 1995 2000 Estonia Lithuania Nordic average EU average Latvia Vilius GRABAUSKAS

  33. EXTERNAL CAUSE MORTALITY TRENDS IN BALTIC, NORDIC AND EU POPULATIONS AGED 0 - 64 100 000 250 200 150 100 50 0 1970 1975 1980 1985 1990 1995 2000 Estonia Lithuania Nordic average EU average Latvia

  34. PREVALENCE OF SOME RISK FACTORS FOR MAJOR NONCOMMUNICABLE DISEASES IN ADULT LITHUANIAN POPULATION AGED 25-64 • HYPERTENSION • HYPERCHOLESTEROLEMIA • OVERWEIGHT • SMOKING • LACK OF PHYSICAL ACTIVITY • PROPORTION OF ENERGY FROM FATS • RISK SCORE: AT LEAST ONE RISK FACTOR PRESENT IN 90 % OF POPULATION • PUBLIC HEALTH STRATEGY IS REALISTIC SOLUTION Vilius GRABAUSKAS

  35. EXPERIENCE OF DEVELOPED COUNTRIES WHO CONCLUSION: IT IS NOT THE RICHEST SOCIETIES THAT ENJOY HIGHEST LEVEL OF HEALTH BUT THOSE WHERE IS LOWEST DIFFERENCE BETWEEN RICH AND POOR Health Promotion and Investment

  36. Individuali rizika Vilius GRABAUSKAS

  37. FOOD SELECTION CRITERIA IN LITHUANIAN POPULATION (BALTIC NUTRITIONAL SURVEY) 80 66,8 70 60 50 40 30 20 16,1 8,3 6,4 10 2,4 0 Prevention Special diet Price Taste Food preference Vilius GRABAUSKAS

  38. FOOD SELECTION CRITERIA IN LITHUANIAN POPULATION BY FAMILY INCOME (BALTIC NUTRITIONAL SURVEY) 77 Prevention 80 Price 69 Taste Food preference 60 45 40 30 15 14 20 11 8 8 8 8 7 0 LOW INCOME 1TERTILE MEDIUM INCOME 2 TERTILE HIHG INCOME 3 TERTILE Vilius GRABAUSKAS

  39. COMPARISON OF MORTALITY OF POPULATION WITHUNIVERSITY AND PRIMARY OR LOWER EDUCATION BY AGE (MORTALITY OF THE GROUP WITH UNIVERSITY EDUCATION=1) Ratio 13 12 11 10 9 8 7 6 5 4 3 2 1 0 25 30 35 40 45 50 55 60 65 70+ Age, years Men Women Vilius GRABAUSKAS

  40. PROPORTION (%) OF DAILY SMOKERS, BY EDUCATIONAL LEVEL % 68.0* 70 60 48.5** 50 36.7 40 30 17.4* 20 10.8 9.1 10 0 Incomplete secondary Secondary University Men Women Vilius GRABAUSKAS

  41. PROPORTION (%) OF DAILY SMOKERS, BY FAMILY INCOME % Vilius GRABAUSKAS

  42. * p<0.001 LOW BIRTH WEIGHT (>2500 G.) PROPORTIONS BY EDUCATIONAL LEVEL OF MOTHERS Primary Secondary University • Pradinis • vidurinis • aukštasis % Vilius GRABAUSKAS

  43. RELATIVE RISK OF UNMARIED LITHUANIAN POPULATION BY AGE AS COMPARIED TO MARIED (MARIED= 1) Males Females AGE V. GRABAUSKAS

  44. * p<0.001 LOW BIRTH WEIGHT (>2500 G.) PROPORTIONS BY MARITAL STATUS OF MOTHERS % Vilius GRABAUSKAS

  45. TOTAL MORTALITY LEVEL (PER 100 000 OF POPULATION) IN ADMINISTRATIVE AREAS OF LITHUANIA IN QUINTILES (1996 YEAR DATA) Vilius GRABAUSKAS

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