Final Report

Evaluation of
Swedish and Finnish economic support to
St. Petersburg School of Public Health

     Prepared by Finn Kamper-Jørgensen April 2003

 

Executive summary

The Swedish and Finnish financers i.e. SEEC and STAKES have asked for a one-man external evaluation of the economic support to the project: St. Petersburg School of Public Health. A conceptual model for the evaluation has been developed together with criteria of project success.

The long-term objective of the project is to establish a school of Public Health in St. Petersburg with training and research of an international standard. In the short run activities must however have a more modest public health profile and shall also support ongoing reforming and restructuring of the health delivery system. A “tree of objectives” has been set up.

The Swedish and Finnish support to the project is economic and advisory of nature.

The project began in 1999 with teaching activities at MAPS and has expanded gradually since then. MAPS is a postgraduate medical institution annually in contact with 25.000 doctor. MAPS has established a College of Public Health chaired by a dean. Contributions to teaching and research come from a widespread number of departments in MAPS. The School concept is a network in MAPS - not a unified organisational concept.

In early 2003 a full Master of Public Health programme has been developed and field testet, most teachers now come from Russia and a number of teachers now have a PhD. A model for IT distance learning has been developed, the first research programs have been started and a build up of infrastructure like library, teaching materials etc. is continuing.

An evaluative status related to the “objective tree” is presented followed by a SWOT analysis

A major conclusion from the evaluator is that the project so far has been a success creating much value for the invested money.

It is also concluded that the project has not yet reached a degree of stability allowing for a stop of external support. In Russia a Master of Public Health degree is still not accepted and Schools of Public Health in principle do not exist. Therefore no direct financial support from Federal authorities exist. It seems possible that things change the coming years.

The recommendation to SEEC and STAKES reads:

 

1. Introduction and background

SEEC (The East Europe Committee of the Swedish Health Care Community) and STAKES (The National Research and Development Centre for Welfare and Health in Finland) have for a number of years economically and otherwise supported the development in St. Petersburg, Russia, of a School of Public Health (SPH) related to MAPS (The Medical Academy of Postgraduate Studies).

With a background in a serious deterioration of health in Russia following the system break down and change in early 1990’ies it was realised that a change in health policy had to take place.

Back in 1995 the early contacts between SEEC and St. Petersburg and the Russian North West Region took place. During 1996 – 1997 this contact was further developed and the idea of a SPH in St. Petersburg was launched and further elaborated.

A direct initiative to establish a SPH in St. Petersburg was taken by the Leningrad Oblast Health Committee and St. Petersburg City Health Committee in 1998. MAPS and SEEC further developed the idea and also later the Finnish Ministry of Social Affairs and Health joined the group of interested parties.

In a background document to the evaluator it is stated: From Finnish side the year 2003 and from the Swedish side the year 2004 will surely be the last years for the ongoing project. An evaluation of the project in the beginning of 2003 would therefore be helpful for making a new future plan for the school, for its further development and for its financing from domestic and international sources.

In the contract between the financers and the evaluator it is further stated: The overall purpose of the evaluation is to find out if the SweFi (Swedish and Finnish) support has created value for the invested money.

The evaluation was started primo 2003 and ended with a report to SweFi supporters May 2003.

2. Purpose and methodology of evaluation

The overall purpose of the evaluation is to find out if the SweFi support has created value for the invested money. But – as already stated above – an evaluation would also be helpful for the further development of St. Petersburg SPH.

Based on these considerations the evaluator proposed and had acceptance for a future-oriented evaluation approach to the SPH project based on the so-called SWOT concept combined with the well-known evaluation model of structure, programme, process and outcome.

SWOT means S=Strengths, W=Weaknesses, O=Opportunities, T=Threats. The S and W characterises the actual situation at the institution while O and T deals with future developments of the surrounding world.

In Annex 1 a conceptual model for the evaluation of SweFi economic support is presented. Further a list giving overview of criteria of success is presented. The main categories of criteria of success are: Overall criteria like value for money – structural criteria like the existence of a SPH, a budget and a staff – programme criteria like existence of a programme for Master of Public Health – process criteria like volume of education and volume of research – outcome criteria like change of professional skills, increased public awareness of health issues, published research.

The approach has been used in a systematic attempt to elucidate the induced effects of an investment in an already existing organisation.

In the contract between the financers and the evaluator it is explicitly stated, that the evaluation is not

·
  
A thorough evaluation of MAPS or SPH since the SweFi contribution is not universal but incremental
·
  
An evaluation according to the heavy ASHER-ideas of evaluation of a School of Public Health  as expressed in “Quality Improvement and Accreditation of training programmes in Public Health” (July 2001)

·
  
An evaluation of how SPH-education contributes to changes of Russian health policy – except for impressionist ideas of possible contributions to internal and external health policy debates and changes.

The sources of information to supply data into the described model have been obtained through a number of different sources, among these:

The evaluator has performed some testing of reliability and of validity in relation to the various sources of information fx formulation of objectives as expressed in several documents. Some variation was found. This is taken up later in the report. Also reporting on courses and programme developments towards a Masters degree have been mutually checked against each other.

The evaluator has also tried to get an impression of resource-utilization and accounting in St. Petersburg SPH. The Russian tax-police is fairly strict in their controller function. Therefore it is fair to state that money has been spent according to budgets and intentions.

In general the evaluator feels that sufficient critical information has been obtained in order to fulfil the intention of the designed evaluation – and thereby respond to the evaluative need of SEEC and STAKES.

3. The project: St. Petersburg School of Public Health

3.1 Health in the 1990’ies in Russia

Russia is facing serious health problems. Life expectance to-day in the Russian Federation is among the lowest in Europe. The development has shown a characteristic pattern: A rise in 1985-86 as a result of the anti-alcohol policy, a return to the previous level in 1992, a sharp fall in 1992-1994 related to the disintegration of the Soviet Union and an increase since 1995. Main causes of death are diseases of the circulatory system, accidents and intoxications, cancer, respiratory diseases and infectious diseases. Mortality is very high among middle aged men. In some regions a very high infant mortality rate is seen.

Tuberculosis has increased since 1990, syphilis is spreading since 1994 like an epidemic and HIV infection is a rising problem among young people with drug abuse. Respiratory diseases, cardiovascular diseases, accidents and intoxications, diseases of the digestive system and infectious diseases are dominating the morbidity pattern. Prevalence of chronic diseases have increased. Large groups of children suffer from diseases.

Inequality in health is large and seems to increase.

From a public health perspective such disease and mortality pattern is seen in a society of transition building up a new system based on different economic thinking and different values. The living conditions have periodically deteriorated, creating much poverty, street children, increased outcasting from working life and society. Further the environmental conditions and working conditions in Russia represent problems. The health behaviour of Russian citizens is very problematic with excessive drinking among many people, with a high prevalence of smoking and bad food habits.

Based on epidemiological knowledge the link between life style and living conditions and the actual health, morbidity and mortality pattern seems very logic.

The current health situation represents an enormous challenge to society, to public health, to health care.

3.2 Transition in health care and public health in Russia

During the 90’ies industrial output and gross national product have declined dramatically exerting enormous pressure on health budget. From 1996 the industrial recession was halted.

Under such circumstances the 90’ies represent attempts to change incentives and health care system. Ideas of changing the very specialized and bed-intensive health care system towards a system focussing much more on ambulatory services, on primary health care, including family medicine and orienting it much more towards health promotion and disease prevention was launched and is now influencing policy. Also health insurance reforms have taken place. Rebuilding a system requires a long-term strategy and incentives and mechanisms able to change the system. Among these factors are economic mechanisms, efficiency in management, changed attitude and practice among health professionals.

3.3 The need for a new public health concept and for training and re-training of Medical personnel and administrators and leaders

The content of education for health professionals did not match the challenges described above in 3.1 and 3.2. Therefore it was natural to develop a strategy for postgraduate training towards the new orientation of health care and towards the changed health situation. From this perspective the idea of developing a long term strategy of education in public health was developed from the middle of 90’ies.

3.4 St. Petersburg School of Public Health - Project objectives

The objective of the project is phrased slightly different in different documents

In the contract with the evaluator one reads:

The long-term objective of the project is to establish a School of Public Health with training and research of an international accepted standard. In a short run the activities must however have a more modest public health profile and shall also support the ongoing reforming and restructering of the health delivery systems

In other documents - for example Stakes preliminary project plan for 2003 - one reads:

The overall objective of this project is improved capacity of health care professionals to develop public health. ….The purpose of the project is defined as “functioning Public Health School within MAPS responding to the development needs at international standards and with resources for sustainable functions in the future” ..Long term objective is that the SPH will be an independent, fully integrated and respected member of the academic community

According to this tree the hierarchy of objectives begin with improved public health – continue through improved capacity of health care professionals to develop public health – and ends with functioning SPH within MAPS

The project components in the objective tree are:

The intention of the project is to serve the North West Region of Russia which has a population of about 22 million inhabitants

3.5 Organisation

The project is organised inside MAPS (Medical Academy of Postgraduate studies) and supplemented with a registered non-profit organisation called School of Public Health.

Laws in Russia require doctors to get postgraduate education every five years. For this purpose MAPS has been developed into a huge postgraduate study organisation. It was founded in 1885 and has a long tradition. It has the same status as a University.

Every Russian region has a postgraduate training institute, a total of 7. MAPS have about 1/3 of all postgraduate doctor training in Russia, about 25.000 doctors per year.

Training at MAPS in general comprise

To-day MAPS includes about 80 departments reflecting the very specialised parts of health care – and 6 colleges – one of these is College of Public Health. The dean is Sviatoslav Plavinski..

The rector of the academy is a very powerful person. Usually the so-called Scientific Council of the Academy – comprising among others the deans of colleges – discuss important issues of MAPS before rector decides on the issues.

In 2002 MAPS had a total budget of about 8 million US $. The internal budget of the College of Public Health was about 200.000 US $ (tuition fee money exclusive of federal salary, renovation, running costs etc).

MAPS in general is financed by the Ministry of Health of Russia. Such finances are based on recognised courses by the ministry. The recognised course of social hygiene and management – in 2000 renamed public health – receives support – but most other parts of the planned courses to enter a master of public health are not recognised courses because there exists no degree of public health in Russia yet. MAPS also get tuition fees paid by health authorities or hospitals for certain student courses. Property and buildings belong to Committee of Federal Property but is given to rector to lease. If MAPS earns money it goes to MAPS. Finally MAPS receives support from funds like STAKES and SEEC.

MAPS to-day is one of the leading scientific centres of St. Petersburg and of Russia. Apart from teaching faculty members conduct research.

Late 2001 under the name of “St. Petersburg School of Public Health” an independent non-profit organization was created. The project money from Sweden and Finland are placed in this organisation. It functions as an economic transfer and accounting organisation – and should not be mixed up with the concept of a real SPH.

The SPH concept at MAPS operates in a very complex way. There is no clear cut structure where one can identify an institute or department of public health containing the usual sub disciplines like epidemiology, health care management, sociology, environmental health, health promotion and prevention etc. Quite many of the 80 departments of MAPS deliver contributions to a public health curriculum. Across this departmental organisation exists the College of Public Health with a dean –S. Plavinski. He is at the same time head of a department of teaching skills. Other departments contributing to public health have different heads of department.

The College of Public Health is responsible for organising components to enter the planned master of public health (MPH) and for the overall further development of public health initiatives at MAPS.

The project - which has the character of counselling and of incremental economic support to a development towards a SPH - has a management structure with an advisory committee and a project management team The advisory committee includes representatives from MAPS, SEEC, STAKES, Norway and has a broad agenda, - planning, advising, follow up etc.

The project management team consist of the project manager and dean S. Plavinsky, Project-coordinator, vice rector Olga Kuznesova and foreign and local experts. This team is responsible for the daily running of the project and for reporting on progress, activities, financing ets.

In Sweden and Finland the project is supported and reviewed by various teams.

3.6 Overview of economic support to project

The financing of the overall project is based on financing from a number of sources

It has been very difficult for the evaluator from the Swedish and Finnish plans, reports and Russian material to find out the exact size of financial support to the project. The evaluator’s best guess is presented in the table

Financial data deleted...

... Categories of supported activities include research projects, participation in international congresses, computers and equipment, translation, communication items.

The Swedish financial reports exclude Swedish staff and administrative costs. It only deals with money used for Russian related activities directly. A heavy part of the support goes to training. Feeding students costs a lot. Support to library, translation and to the Health Technology Assessment Laboratory also weighs in the budget.

Apparently Swedish stipends to be used in Sweden by Russians do not appear in financial breakdowns.

It seems as if a shift over time in financial structure can be traced – indicating increased support today for other items than training - for example translation, library etc.

3.7 Developing programmes and activities towards a school-concept

It seems reasonable to describe the development in different phases

·
  
Phase 1: Planning 1998 – 1999
·
  
Phase 2: Experimental development of PH training concept and programme and field testing. Primary steps towards SPH. 1999 – 2003.
·
  
Phase 3: Implementation of a MPH programme and further developments towards a SPH, 2003-2005?
·
  
Phase 4: Sustainable full scale SPH with international standards 2005? –

The very first ideas and discussions began in the mid af 90’ies with a background in the health situation and the need for reforming the health care system. Supportive training was considered instrumental for such processes of change. Initiatives came partly from varies interested parties in Russia, partly from Sweden. A contact was taken to the other Nordic Countries and to the School of Public Health in Gothenburg. Planning began in 1998 and in 1999 the first course was organised, taking the form of a summer school: Modern principles of management in health care

During phase 2 various components from the earlier described tree of objectives has been developed and tested.

Most important has been item 1: A generally accepted PH training concept and item 2: Substance contents identified, analysed and improved. A modern concept of PH has been adopted, organisational structures supporting the development of a PH curriculum have been created at MAPS – although not taking the form of a department or institute of public health within MAPS. Detailed plans for a curriculum leading to a masters degree of PH has been developed and tested at least once for each component of the entire programme.

The curriculum – compared to usual western PH programmes - has a different structure. It consists of three tracks:

These tracks are supplemented with special courses and regular MAPS courses

Altogether the curriculum consists of the following subjects/disciplines: General and special epidemiology, statistical analysis, prevention & health promotion, medical psychology and sociology, prevention of sexually transmitted diseases, HTA & EB, effectiveness in health care, medical ecology and occupational health, general questions of health care management, other questions of public health.

According to current rules, MAPS issues a diploma of professional training when passing 506 hours of postgraduate training. The latest plan for a master (application for grant 2003) indicate a total time schedule of 710 hours.

As part of developing teaching methods the first IT distance learning programme has been developed. It deals with sexually transmitted diseases.

Many more courses are planned for IT distance learning.

Training of faculty is another important part of phase 2.

8 persons have been trained in Sweden, 5 in Finland, 3 persons have been in MPH training in Israel and one in USA

Some research projects have been started. A larger project in Krasnogvardejskij on cardiovascular diseases, stroke and cancer has been started and e few young scientists have received support for research projects.

St. Petersburg SPH has developed a special expertise in HTA and EBM. A HTA laboratory has been created in 2000 and the school has a leading role in Russia in this field. The school delivers teaching to other parts of Russia.

A functioning information system involves the development of a library, access to computers and development of a home page on internet. Such developments have gradually taken place

International relationships have gradually been developed. MAPS take part in the development of Baltic International School of Public Health, which issues an MPH degree according to the ASPHER standards. MAPS hold responsibility for a 2-week course in health care management. Also faculty participation in international meetings and congresses has expanded.

Taking stock phase 2 has been an experimental phase emphasising the teaching obligations but also beginning to develop research.

Phase 3 implying implementation of training as a running operation and multifocal steps towards a SPH seem to indicate a new era.

A huge amount of details of the developments are found in the following documents etc

3.8 Status early 2003

A short, overall status early 2003 related to the objective tree reads as follows:

4. Observations and reflections by evaluator

This chapter is based on applying the evaluation model presented in annex 1 to the case. The model illustrates the possible impact from the SweFi intervention and economic support on structure, programme, process and outcome. In the annex criteria of success are also presented. In this chapter the evaluator comments on the criteria of success.

4.1 Overall criteria of success

Three criteria are listed

SweFi contribution to “functioning Public Health School within MAPS, responding to the development needs at international standards and with resources for sustainable functions in the future” This criterion is not fully met. A functional concept of a school has been established within MAPS. This school concept in principle is a response to the needs for changing conceptual thinking and health policy in order to improve the health situation within an acceptable budget for a more efficient health care system.

The school curriculum is moving towards international standards of a SPH but has not yet reached it.

The school has not yet moved into a phase of sustainability in the future. There are too many unstable factors in the present organisation and situation.

From a structural perspective MAPS as a postgraduate educational institution is extremely important because is has a long and perceptive approach to postgraduate medical education and is a well recognised institution in the health care system

The evaluator is left with some ambiguity having read the Swedish and Finnish documents from the very beginning of the project. The evaluator is under the impression that on the Swedish side a slight change in motivation has taken place. It seems from the documents that the Swedish starting point is a strong wish to support change of health policy. From this perspective public health training is instrumental to policy change – and the end goal need not be a SPH established with international standards if the training is sufficient supportive to policy change. From such a perspective the present development fulfils criteria of success. The SweFi project can be closed.

However if the end goal is to establish a stable and separate school with international standards many more steps are needed. Documents from both Finland and Sweden support this interpretation of the current attitude to the project.

That the objectives set up by the specific SweFi project and economic support is met i.e. improved capacity of health care professionals to develop public health

This criterion is fully met. Capacity has increased enormously.

Value for money from the SweFi support

The evaluator concludes that the SweFi support so far has contributed to a highly successful development. Great value for money has been achieved. The speed of development is high and both productivity and efficiency for the invested money seem to be high. The internal dynamics of the project is high based on much enthusiasm.

The evaluator feels that this case can be used in Finland and Sweden as an example of how successful modest investments can be.

This is a short-term reflection – and it must be seen from the perspective of a SWOT analysis presented in chapter 5.

4.2 Structural issues

Seven criteria are listed

The existence of SPH within MAPS

MAPS have decided to establish a MPH like programme, a College of PH with a dean and a separate economic transfer and accounting mechanism called St. Petersburg School of Public Health. This organisational form could be called a network for PH inside and outside MAPS, a potential infrastructure for a school but it is not a structured SPH concept.

During an interview with the rector of MAPS the evaluator asked him: Are you willing to change the organisation of MAPS into a real SPH? The answer was yes – and he has the necessary power to do so – provided that there is sufficient demand for public health in the health care sector.

MAPS hold a very pragmatic approach to public health. They recognise the importance of the professional skills to be obtained through such training but they also face the following realities in Russia: 1. There is no recognised MPH education and degree, 2. The concept of SPH does not exist in Russia, 3. The Federal Ministry of Health bases the financing of MAP activities on courses recognised.

On such conditions pushing for the establishment of a SPH as a separate structure is not wise. The establishment of a Russian Public Health Association, the “existence” of a total of four schools in Russia, and some apparent morally supportive signals from the Ministry of Health point in the direction of a recognition of Public Health soon from a formal point of view. The evaluator believes that a joint diplomatic approach towards the Russian Ministry of Health could enhance development.

Further the evaluator has experienced a very positive attitude towards public health issues and public health training from the interview with the leadership of the Health Committee of St. Petersburg.

The existence of a mission statement

Such an explicit statement has not been found in any document.

The existence of a budget for SPH activities

The MAPS parts of the budget consist of at least three parts. Salaries to teachers, support to students, running costs. There is no separate salary budget for a SPH. This is due to the structure. The teachers are based in their departments and paid through such department. The departments reflect the specialised health care structure. The financing is based upon recognised courses. The College of PH basically is a network structure rooted in departments. MAPS has guaranteed a minimum sum for running costs to the project.

The SweFi support so far has had a substantial size of total budget to SPH activities.

The existence of leadership and management structure

The project has a very positive and dynamic leadership with vice rector Olga Kuznetsova and dean S. Plavinsky on the project management team.

A network organisation based on many separate departments having activities within PH and being coordinated by a small College of PH, directed by a dean, is a rather problematic management structure unless the heads of departments have sympathy for the PHS idea etc. and are willing to contribute constructively. Conflicts between specialised departments basically geared towards narrower specialties and the leadership of PH college are foreseeable.

Dynamic synergy from a department with relevant PH disciplines is missing – and the possibility for a dynamic leadership to develop along the same conceptual and practical lines is very weak. MAPS might as a first organisational step create moderate fusions of some of the most appropriate departments.

The existence of a permanent or ad hoc staff for the functioning of SPH

Ad hoc staffs exists based on teachers from the various departments.

In the very beginning many foreign teachers gave courses. This is now reduced and most teachers come from Russia. More and more PhD trained Russian teachers appear in the courses. Since no long-term security for a SPH exists a natural consequence is a short-term staff commitment and a rather unstable staff situation. But the situation gradually seems to improve.

As to HTA and EBM the staff is recognised as national specialists.

The existence of facilities for teaching and research - for example rooms for teaching and for staff, computers, library

Teaching facilities exist – based on Russian norms. Apartments for ad hoc teachers travelling to the school exist. A basic set of computers exist but not for class teaching. Library is about to be build up. The internet home page is well developed.

Basic support to further develop these facilities is needed.

The existence of a structured training, teaching and research programme (see below)

As to teaching and training it exists – there is no structured research programme

Altogether the present structure is to be considered an interim structure on its way to a structured SPH concept. There are good reasons to believe that a general political acceptance in Russia of PH and SPH and MPH as part of the health care sector may lead to a better structure of the SPH work at MAPS.

In the St. Petersburg University sector the evaluator talked with the initiator of a new MPH programme to be established at St. Petersburg State University. The MPH is planned to be part of the usual educational structure at university – bachelor 3 years, master 2 years. A 2-year masters programme is foreseen. The curriculum has 4 blocks: Core courses for MPH training, additional specialisation requirements, scientific research work, master thesis and certification. Specialisations offered are epidemiology, biostatistics, sociology, psychology, administration in public health, environmental health. In other words a rather classical MPH curriculum. Yale University, USA is supporting the development.

Universities in Russia apparently have no postgraduate educational programmes.

The evaluator has had a long discussion with the University dean and with S. Plavinsky on the significance of establishing a second MPH in St. Petersburg. From a long-term perspective the evaluator believes that good candidates with other background than medical can be produced from this University MPH education.

It is not known if the University sector is able to construct a monopolised MPH education through decisions in the Federal Ministry of Education - thereby hindering the health care sector and postgraduate institutions like MAPS to create a MPH degree.

However within the time horizon of the SweFi project support the University initiative is of no interest and represents no competition to the MAPS MPH initiative.

4.3 Programme issues

Three items are listed.

A structured programme – based on courses, modules, lectures leading to acknowledged certification of skills obtained and with varying degree of professionalisation

A structured programme has been available on the internet homepage and has been studied extensively by the evaluator. A revised structured programme for a MPH totalling 710 hours etc. is presented in the latest application for SEEC grants.

A structured programme – still developing – thus exists. It seems clear that a full MPH programme now has been created. However more selective skills in public health can be obtained by selectively taking relevant courses.

As indicated earlier MAPS issues a diploma of professional training when passing 506 hours of postgraduate training. The evaluator assumes that MAPS from a pragmatic point of view has chosen a level of MPH education which actually fulfils the diploma criterion of MAPS, exceeds it somehow, but is lower than the full ASPHER accreditation criteria.

In Europe education now operates with so-called ETCS points – this also holds for certified MPH education. ETCS points have not been worked out for the current programme. However internal weights of various components of MPH education exist.

A future exercise should be to look at the current plans for MPH education based on ETCS scoring. This gives a better idea of the international level of education.

Courses, modules and lectures relevant for public health education and training

This criterion is fully met.

The evaluator has studied curriculum and to a certain extent detailed contents of courses. Contents evaluated by reading key words of courses hold a standard according to usual MPH education. The evaluator wants to underline that the curriculum from many perspectives contains up-to-date theory and empirical knowledge. It seems to have been very important to have inputs in health promotion from Finland, health economics and HTA from Sweden and also EMB from abroad. Russian teacher can take over. In some established MPHs in Europe these items are not up to date.

The evaluator holds the view that St. Petersburg historically has been the open window towards Europe – and that modern trends in public health thinking and teaching coming from Europe now also enters the St. Petersburg SPH. This trend should be reinforced in the future development. The evaluator finds that Sweden has a strong tradition in HTA and that it should be considered to create a mini SBU (HTA organisation) by combining SEEC and SBU efforts. Locating such an organization to a postgraduate medical organisation like MAPS – and transferring the knowledge to the MAPS courses - could be an extremely important contribution to policy change in the North West Region of Russia.

From a change perspective in health policy the evaluator knows that the development of a good health information system is important. Population based data on health, health behaviour, living conditions and use of the health care system are important. Registers on contacts and performance on various parts of the health care system also. Information systems on economy and of staff also are important. Also clinical quality databases support change and development. All this is poorly developed in Russia. The reform process needs good information tools.

The evaluator proposes the development of a new shorter course on Health Information Systems – starting with a workshop, later developing into a separate module. To-day fragments of such knowledge is found in the epidemiology course and in the management course.

The Scandinavian countries have much experience in this field and should professionally and economically support the described development.

The skills of students in English and in biostatistics seem to be poor. This is blocking for international participation, for reading research journal and for the conduct of quantitative research.

A research programme

Staff is scarce – therefore also research. Epidemiological thinking seems to dominate the few research projects. In a situation where great reforms in health care take place the evaluator had expected health services research projects.

Basically the evaluator finds no structured research programme. It is still a new fairly individual based activity.

When asking for research publications the evaluator got nothing during his visits to St. Petersburg. Later the evaluator learned that it is difficult to judge if research should be included under the heading of MAPS ordinary activities or School of Public Health. It is part of the obligations of being faculty member that research is produced. In annex 3 some references to research publication are presented.

MAPS should put a list of public health research on their Internet home page and ask for the development of a structured public health research programme, relevant for the health situation and for the reform of health care.

Altogether moving towards a full scale SPH requires both an education programme and a research programme

4.4 Process considerations

Items below have been presented.

A pattern of relevant courses and lectures

Already discussed

Research activities

Some research projects are ongoing and seem to follow usual progress of research projects

International participation

Faculty - and especially PhD trained staff – take part in many international meetings and congresses. It is important that staff has taken teaching responsibility at the Baltic International School of public Health.

Public health debate – health policy debate

Some student told the evaluator that they take part in the public health debate in mass media and elsewhere contributing with public health views and contributions to change of health policy. Some students are active in policy and strongly support the development of family medicine and increased health promotion and prevention.

Quantity of teaching activities – at location, at distance, - number of students and number of certified students

There has been a gradual increase over time in amount of teaching at location. The scheme – taken from the activity report of 2002 - illustrates the type of training offered and the quantity of students and number of hours. 243 students have been trained and a total of 603 hours of teaching has taken place.

Comparative time series have not been presented to the evaluator. Therefore exact productivity cannot be calculated

A model course of IT based distance learning has been developed on sexually transmitted disease. Since the North West Region covers a huge area it is cost-effective to develop much more distance learning material. However initially it is costly to develop teaching material and the staff must be trained for such pedagogic challenge.

If the future decentralisation strategy of SPH is going to be successful intensive development of such courses are necessary. External funds should contribute to this development.

The scheme illustrates a problem. A core subject in PH is epidemiology. A course of epidemiology was not offered in 2002. When teaching capacity does not allow for such course it will take very long time for the students to get a full MPH.

4.5 Outcome

Items below have been presented

Improved public health skills, attitude and behaviour of professionals having been students at SPH Professional position after SPH training Health policy debate based on ideas of organising health services and de facto changes Increased public awareness of public health issues based on contributions from SPH training

It is only possible for the evaluator to get an impressionistic view of these outcome parameters. A formal survey of students having been on SPH on these parameters does not exist and it was outside the scope of this evaluation to conduct such one.

The formal interviews with students and informal talks gave a positive picture of training contributing to new skills and to reflections on attitude and behaviour of personnel activities.

A few examples were presented to the evaluator of promotion of professional position following PH training. There are no formal requirements for MPH in the Russian health care system. Some courses seem to qualify for at better position for example in administrative work and in leadership and in some jobs in the health care institutions. In general it seems that there is very little formal demand for public health skills because the career structure emphasises other skills. Restructuring health care in Russia may change this picture.

One student – also an active politician – could tell stories of the importance of having public health skills as a background for reforming health services.

It would be useful for the SPH to conduct a survey among past students on the outcome parameters presented here. It would give a good feed back to teaching.

Altogether the evaluator received positive indications on these outcome parameters – but it was very impressionistic.

5. Overall SWOT analysis

The idea of a SWOT analysis is to present S=Strengths, W=Weaknesses, O=Opportunities and T=Threats in a short, compressed and schematic way in order to have a good starting point for future developments. Opportunities and threats typically relate to how one expects the external conditions to develop.

Below the SWOT analysis is presented in a scheme without comments.

 

Strengths Weaknesses

Overall

  • A project gradually developing - through improved capacity of health care professionals to develop public health - towards the ultimate objective: Sustainable establishment of a St. Petersburg School of Public Health according to international standards – servicing the North West Region of Russia
  • The project so far is a success creating high value for Swedish and Finnish project money
  • Much enthusiasm within and around the project
Overall
  • Initial project development began 1999. Project is not stable in 2003

 

 

 

 

Structure

  • Firmly rooted in MAPS. MAPS is a strong postgraduate medical institution with a contact to about 25.000 doctors a year and with a big budget
  • Formal acceptance from MAPS of establishing a functional school of Public health with a master programme – within the existing departmental structure – coordinated by a College of Public Health, headed by a dean
  • Enthusiastic and competent leadership of coordinating body: College of PH
  • Network organisation of PH with a potential to develop into an institute or into a larger department of PH at MAPS
  • Acceptable basic teaching facilities of a Russian standard

Structure

  • No formal MPH degree in Russia
  • No formal acceptance of Schools of Public Health in Russia
  • Only financial recognition from Federal authorities of few elements in the planned MPH curriculum
  • Too many independent departments dealing with public health issues without sufficient coordination – and rooted in traditional specialist structure of Russian health care
  • Non-existence of the traditional common organisation of public health disciplines

 

 

 

Programme

  • Fully developed MPH programme exists –components field tested at least once
  • International concept of PH implemented and usual themes and disciplines included in programme
  • HTA, EBM and modern health promotion thinking included in programme
  • PhD trained Russian teachers still more common
  • Some research projects started

Programme

  • Level of programme in accordance with MAPS postgraduate norms but below international ASPHER norms
  • Teaching capacity does not allow for an annual possibility to take all types of courses – thereby prolonging a total MPH programme much
  • Still foreign teachers needed for certain courses
  • No structured research programme. No visible health services research looking at health reforms in St. Petersburg

Process and outcome

  • High productivity in teaching
  • International participation increasing
  • Impressionistic evidence that PH training influences personal skills, attitude and behaviour - gives contributions to public and political debate and increases public awareness of public health issues

Process and outcome

  • no studies of outcome parameters of past students (like skills, attitude and behaviour – career promotion – influence on public debate – change of health policy)

 

 


 

Opportunities Threats

Overall

  • Changed attitude in Russia: PH is needed and is useful
  • Continued MAPS support to project
  • Continued external professional and economic support to project
  • A continued and revised strategy

Overall

  • Internal and external enthusiasm missing
  • A lot of formal public hindrances imposed on project

 

 

Structure and programme

  • Formal public recognition at the Federal level of MPH degree and of SPH
  • Financial acceptance at the Federal level of public health training in SPH
  • Re-organisation of MAPS as to Public Health creating a common structure for the departments working with PH issues
  • Increased research funds for public health research
  • Increased cooperation between SPH and local health authorities on developing PH
  • Increased experience with all programme components
  • IT distance learning programmes further developed

Structure and programme

  • No formal recognition at the Federal level of MPH degree and of SPH
  • University monopoly of MPH degree at the graduate level
  • Economic recession in Russia cutting educational funds
  • Dean of College of PH leaves MAPS
  • Negative salary incentives for qualified staff
  • No moral or economic willingness to increase programme level to international ASPHER standard
  • Relevant teaching material missing

 

 

Process and outcome

  • Increased public demand for PH skills and debates
  • Need for PH research in the political reform process
  • Formal recognition of PH skills for careers and promotion in the health care system

Process and outcome

  • Reduced productivity following reduced enthusiasm of project development
  • Too difficult to do research – therefore lack of research

 

6. Recommendation to SEEC and STAKES

A major conclusion from the evaluator is, that the project so far has been a success creating much value for the invested money. It is a success story to tell in political debates in Sweden and Finland when support to Russia and Baltic Countries is discussed. An enthusiastic and visible development has taken place for a limited sum of money.

In this chapter the evaluator presents numbered recommendation in order to help the SweFi project financers to say yes or no to a proposal.

1. Revise overall strategy of project

Strategy revision has already been approached. To ensure sustainability beyond 2003 it is necessary

The evaluator fully supports this revised strategy – an adds a number of proposals below.

As discussed elsewhere in this report different ultimate objectives call for different strategies. The evaluator assumes that the ultimate objective is to establish a SPH in St. Petersburg working from international standards of SPH.

If however the ultimate objective is change of health policy and the establishment of increased public health training capacity and training is seen as instrumental to policy change - not an ultimate objective – then the objective has already been met.

2. The SweFi economic support should continue 2-3 years to ensure sustainability

The development towards a St. Petersburg SPH within MAPS and the devlopment of programme elements leading to MPH degree has passed a kick-off phase but is still unstable and in a phase where sustainability is endangered.

The changed structure of future support should underline an increase in support to translation, distance learning courses, library etc and a decrease to students feeding, accommodation and travel - a trend already seen in 2003 applications.

3. Be pragmatic when considering present structure of SPH at MAPS

An optimal structure for a SPH is a unified organisation under dynamic leadership. Departments in such a structure represent all the disciplines of PH and relvant PH themes.

To-day MAPS hold a very pragmatic position as to restructuring the public health field in MAPS. If Federal recognition of a MPH degree and of SPH takes place then financing follows for education. If not - important finances are lost through restructuring.

The evaluator recommends a “soft approach” to a discussion of at least some fusions between the most PH relevant departments.

4. Approach the Ministry of Health of Russia for clarification

It is recommended the SweFi financers – if required through diplomatic channels - to approach the Russian Ministry of Health in order to get a clearer picture of

5. Develop a mini SBU at MAPS also including evidence based medicine (EBM)

A good start of a stronger development has already been made with the establishment of a laboratory of HTA. MAPS today has a recognised leading position in this field in Russia. MAPS being a postgraduate medical institution annually meeting 25.000 doctors is an ideal place for incorporating EBM and HTA results in the training The present HTA laboratory is too week for a strong development. Therefore it is recommended particularly the Swedish financers to develop a SEEC-SBU strategy to expand the HTA activities.

6. Ask for the development of a course in Health Information Systems

Good health informations systems are important instrument for policy change and development. The current Russian health information systems have very little value in a reform process. The Scandinavian countries have much experience in building health information system and should help developing such course.

7. Create St. Petersburg Public Health Prize and finance it next 5 years

The purpose of such a prize is to create public awareness of public health issues, to acknowledge important public health initiatives and to support further development of PH.

The prize is given to a person or a project leader, - to a department in the health care system or in the public health sector – or to an organisation inside or outside the public system in North West Region of Russia.

A prize committee for example could include rector of MAPS, chairman of health committee St. Petersburg, another leader from public Health in the North West Region and the SweFi financers. It is suggested that the next 5 years prize is donated in 2004 as a lumpsum.

8. Develop better link between SPH and relevant parts of practical life in the health care sector

The link between school and administrations like St. Petersburg Health Committee seems week. The same holds as to parts of clinical or preventive life in the sector.

Shared positions are a well-known tool for better links. It is recommended to use this tool more.

9. Develop a structured PH research programme at MAPS

The PH research to day appears very week. On the Internet home page MAPS/School could create a catalogue of PH projects from MAPS and use this as a basis for creating a structured research program useful for tackling the current health situation and health care reform process.

 

Annex 1

A conceptual model for the evaluation of SweFi economic support to the School of Public Health in St. Petersburg

Criteria of succes

(See also figure )

Overall

Structure

Programme

Process

Outcome

 

Annex 2

Sources of information for the evaluation

Visit and discussions with SEEC & STAKES

STAKES: annual project plan, reports on activities

SEEC: ÖEK Årsredovisninger, Anslagsframställen, historical material

Applications from St. Petersburg SPH to financers

Internet – St. Petersburg School of Public Health – homepage: Annual activity reports, about curriculum, teaching materiale etc

Scientific literature on Health in Russia and change of health policy in Russia ASPHER guidelines and publications Evaluators personal European network

Personal interviews:

MAPS: Rector, vice rector, dean of Public Health, various academic staff, Students St. Petersburg Health Committee: Vice chairman Soros Foundation, Russia: Coordinator St. Petersburg State University: Dean of Faculty on biology and soil sciences

 

Annex 3

Some research publications

1.
  
Plavinski S.L. Mathematical modelling of the STI spread. Importance for public health. Russian Family Physician.- 2002.-N. 1.- P 16-22 (in Russian)
2.
  
Plavinskii S.L., Plavinskaya S.I. Increased level of lipid peroxidation products as a risk factor of death in a prospective study.//Human Physiology .- 2002.- N 1.- p. 102-105
3.
  
Goody S., Swanson E., Bossen A., Frolova E., Kuznetsova O., Plavinski S. Russian citizens' trusted sources of health promotion information.//Int. J. Global Health.- 2001.- v.1.- N 1.-p.35-49
4.
  
Plavinski S.L. The Role of HIV infection in the Russian Federation. The role of sexually transmitted diseases (STDs). In: Being Positive. Perspectives on HIV/AIDS in the EU's Northern Dimension and Finland's Neighbouring Areas./ ed by Aaltonen U., Arsalo U., Sinkkonen.- STAKES, 2002.- p. 121-128
5.
  
Plavinski S.L., Merkusheva E.V. The level of blood cholesterol in the population of St.Petersburg. Is there any need for concern? In: Lipoproteinmetabolismus und aterosklerosepravention. Hrsg. von V.Richter, W.Reuter, F.Rassoul, J Thiery - 2002, Verlag Wissenschaftlische Scripten, Zwickau.- S. 365-370

Soon appearing in BMJ: Mortality increase in Russia in the 90th. Were all social strata hit equally? Data from prospective cohort study (Plavinski)


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