The situation with health in Russia is still far from the ideal, but at least in the training in Public Health the situation starts slowly change. The more and more institutes, including both undergraduate and postgraduate start to look for improvment public health curriculum. Earlier this year during competition annunced by OSI (Soros foundation) for creation undergraduate public health curriculum two proposals has been judged to fulufill all requirements - one submitted by Assosication of the Schools of Public Health and the second, submitted by the several undergraduate training institutes of South Russia. Now both parties are in process in creating joint curriculum. Also widens geographic of institutes participating in Public Health training both in courses organized by members of Association of the Schools of Public Health and abroad. All this show renewed interest in new Public Health in Russia.
As a representation of this was decision of the Collegium of Ministery of Health which explicitely stated support from the side of Ministery to creation of the Schools of Public Health.
More and more regions in Russia and FSU countries express their interes in creating training in Public Health. Administration of the St.Petersburg School of Public Health has been approached with requests for help from the side of several Volga river regions, Kazachstan and Kyrgyzstan.
Moreover, the St.Petersburg School itself has gained recognition as one of the leading centers for training in Public Health in Russia, especially in fields of prevention and evidence-based medicine/health technology assessment. Only one fact could illustrate this: in the spring this year OSI has announced competition for creating evidence-based clinical recomendations. More than 50 proposals has been submitted, only 5 (out of maximal 10) got an approval of expert committee, of them 2 were submitted by MAPS groups (other winners included Russian Cochrane Collaboration and Moscow Medical Academy). Moreover, OSI has asked St.Petersburg School of Public Health to organize workshop on evidence-based medicine to inform more wide groups of specialists about this movement.
In general now Schools of Public Health start to play increasing role in Public Health training in Russia. And St.Petersburg School of Public Health occupies one of the leading roles among them.
Previously the School of Public Health in St.Petersburg has been mostly financed by foreign donors and Medical Academy for Postgraduate Studies. During previous 3 years of fnancing of the St.Petersburg School of Public Health (1999-2002) much has been accomplished:
School has been formed as independent entity, closely assocated with MAPS (year 2002)
Basic MPH-level curriculum has been created and tested on 11 courses and workshops (total training time more that 500 hours - legal lower limit for professional retraning in Russia)
School faculty underwent short-term training in PH in Sweden (8 persons) and Finland (5 persons), young faculty also has been traned in long-term courses (one- and two-year program) in Israel (3 persons) and USA (1 person)
School has became member (founding) of association of the Schools of Public Health in Russa
School is now part of the virtual Baltic Rim School of Public Health (formed from BRIMHealth project led by Nordic School of PH in Goteborg) offering an International MPH program for students from Russia, Lithuana, Latvia and Estonia
Scientific research under School umbrella has started, School is now being one of the leading places for training in EBM and HTA in Russia
In the years after 2004, School should continue to provide training in Public Health according to the Memorandum N 2 (School operation and curriculum). As was stated in this document, there are three major areas where School should specialize.
The analysis of the educational market led School administration to believe that the third track (health care management) could have widest market and is possible to generate much revenue. In the same time, it is area where most serious competition could be expected. The second track should also include training in basic epidemiology and biostatistics, and will include modules in pharmacoeconomics, which will overlap with track in Health care management.
To ensure sustainability, all three tracks should have appropriate MAPS Department to be responsible for the training. In present case it would be
Correspondingly, all three departments will have in their regular courses modules, which has been created in framework of the School curriculum and will coordinate training. Moreover, once or twice per year the School will conduct out-of-schedule courses (Summer and/or Winter Schools) which will be dedicated to the recent changes in corresponding field and new knowledge gained. Correspondingly, with one-per-year course each Department will be responcible for organization and conduction of one course in three years. In case of additional financing, there will be also on-demand seminars and workshops organized, with length from 3 to 5 days.
Full MPH curriculum at present will be offered to the MAPS postgraduate students whose work is related to Public Health and also all interested students. This curriculum will heavily rely of distance learning component and the task for year 2003-2004 will be to create several basic courses in this format (also as courses will be considered reading and comprehending basic textbook of epidemiology or biostatistics, which will have only exam as a Web-based distance learning component). Also it is necessary to train faculty to create such distance learning courses.
For a full MPH-like training student should take part in all three basic courses (prevention, HTA, Health Care Management) - totally 324 contact hours, take part in obligatory for postgraduate students at MAPS courses "Survey design" (36 hours) and "Design and analysis of biomedical studies - basics of clinical epidemiology" (144 hours) and take distance courses (workload at least 150 hours, two obligatory and at least two elective). This combined will give minimum 654 hourse of training. For completion of the training it will also be necessary to write Master Paper (either original investigation or systematic review) wich will demonstrate clear knowlege and appropirate application of Public Health methodology.
Obligatory distance learning courses to be prepared -
Also administration of the School could accredit other courses delivered at MAPS or elsewhere to credit to the full MPH program (i.e. instead of one of three Summer Schools or elective distance learning course).
So, for example, Prevention track with accent on STD prevention could look as follows:
| Course | Length | Type |
| Foundation of Public Health | 30 | Distance |
| Basic Epidemiology | 50 | Distance |
| Survey Design | 36 | Contact |
| Prevention and Health Promotion | 108 | Contact |
| Health Care Management | 108 | Contact |
| Design and analysis of biomedical studies | 144 | Contact |
| Dermatovenerology | 288 (144 count to MPH track) | Contact |
| Methods of barrier contraception in prevention of STD | 40 | Distance |
| Women's health | 50 | Distance |
| Total | 710 |
Also student will be expected to write Master Paper on questions of STD prevention and control, i.e. "Modelling of HIV spread among heterosexual population of Russian Federation"
In case of basic courses organized once per year, it will take at least three years for student to cover MPH program. Some special courses (like familistics) could be even more rare, which will take more time to completion course. If financing will permit, more courses will be organized with corresponding shortening of the training time
Correspondingly, after 2003 the School continue its operation in two modes:
The seamless operation of the School is dependent upon financing, so one of the important issue for the School beyond 2003 will be cost-conainment.
In previous years financing of the School has been made from the following sources: SEEC, STAKES, Baltic Sea TF on communicable dseases, OSI (Soros foundation), Russian federal government (through MAPS)
In the same time, financing situation is predicted to became more diffcult as foreign donors has announced plans to cut the support to projects due to end of project lifetime periods: SIDA has announced wish to pull out in 2004, OSI announced decision to cut all health care programs in 2004, as well as definitely stop financing of BRIMHealth, USAID has pulled out of majority of health care programs in the year 2000, whereas federal government, though supportive of creation of Schools of Public Health and interested in retraining "social hygene" specalists (Minstry of Health, meeting of the Rectors of the institute of postgraduate education, Penza, June 2002) is not ready to provide additional financial means to help operation of the newly founded schools.
In this case financal strategy for the School of Publc Health in St.Petersburg could have several variants (or combination of them):
1. Decrease in overhead costs by ceasing to provide students with free meals and lodging (main source of expendetures during previous schools)
2. Setting up individual fees for training
3. Providing training during regular courses at MAPS (which will effectively set up additional running cost to zero, but limit training availability)
4. Search for additional financing
5. Regionalization (providng training off main office, which will keep costs of lodging down)
6. Distance learning
Below pros and contras of all approaches analyzed in details.
At present almost all foreign sponsor's help was channeled for providing students of the School with free meals during the course and lodging for participants outside St.Petersburg. Even though lodging was provided at a reduced cost by MAPS, those overheads still consumed about 25 USD per participant residing outside St.Petersburg and 10 USD per participant from St.Petersburg. As a result for 10-day course with 60 participants F&L will be at least 11400 USD. It is important to note, that during regular courses at MAPS neither food nor lodging is provided for free, correspondingly refusal to cover those costs for participants will not be unusual. In the same time, necessity to pay for food and lodging will greatly reduce number of participants from outside of St.Petersburg, as in this case organization sending student for the traning will cover not only cost of workforce replacement and travel (as it was done before), but also feeding and lodging.
In the same time some steps in this direction could be done and will be done. First, decrease in training time is helping to get overhead costs down (for example, by converting 10-days course into 3-day seminar with increase in training time will deliver as much as 40% of the original material for the cost of 27% of original budget). The other means of keeping cost down is replacement of lunch with self-serving coffee-breaks. This attempt has been tested during SAS Workshop with satisfactory result costing only 1365 RUR (less than 50 euros) for 10 people. In the same time complete abolishing any kind of feeding during course will result in longer time for breaks (as people will go for better and cheaper feeding around).
At present only small portion of postgraduate training whatsever is paid for by student or employer. It is sometimes possible to attract top managers for paid training, providing it will be short, they will get necessary certificate (kind of demanded by Ministery of Health) and they will get only "famous" lecturers. As a main activity for the School such kind of training is not very suitable because
a) Program of certificate training is regulated by curriculum passed by Ministery of Health (curriculum on Social Hygene) which can be changed only on 25%
b) Majority of public health workforce will be unable to pay themselves and hardly they will be paid for by their employers
c) If curriculum will contain only this kind of workshops it will be very difficult to prepare new faculty, as they will limit possibiities for them to train their teaching skills.
In the same time it is quite possible to view those seminars as a kind of "cash cows" that are organized mainly to provide addtional means for other activities of the School
At present cheapest method of ensuring sustainability of the School work, but one which will lead to disappearance of the school as a separate entity. The additional running cost of seminars and wokshops after they have been included into MAPS training schedule is virtually zero. All courses that have been organized in 1999-2002 has underwent formal review at MAPS methodological council and now could be included in the regular training schedule. This has been done with course on EBM, course on prevention, and could be done with other courses.
There are several drawbacks in this approach
a) It is extremely inflexble - MAPS schedule is prepared at the beginning of calender year for the next calender year (so, end of the year courses are planned for almost two years before their start), being ncluded in the schedule they could not be cancelled or postponed or any other time changes could take place.
b) those courses are fixed to the department and all department workforce should partcipate in it - there is only small possibility for selection of teachers from other departments.
c) There is no mechanism of inviting guest speakers wthout additional financing
Correspondingly this approach should be viewed as a last resort to preserve already prepared courses.
This should be continued, at least for the School as an independent entity. Pecuilarity of the Russian Tax Law are such that being created, School should either spend some money on running cost (bank account, bookkeeper, etc.), or be closed. At present cost of running the school " bare boned " estimated to be 3600 USD. Moreover many types of activity, such as:
a) inviting foreign lecturers
b)subscription to foreign journals and purchasing of books
c) training aboroad
are unprobably to be covered by Ministery of Health. To further promote international cooperation it would be necessary to continue to search for additional grants, though it will be much more difficult. It is also possble to start searching for the Russian scientific grants (like RFFI) or promote joint cooperative work with other Universties and SPH aboroad.
Several foreign sources are also now under consideration, including Nordic Council of Ministers (projects for St.Peteburg Region), DIFID and USAID/IREX (though this donor will finance only projects with main activity in Volga region)
One approach that will be tested by St.Petersburg School of Public Health in 2003 is regionalization - conducting courses off St.Petersburg, in large cities of North-West region of Russia. In 2003 it is planned to conduct Summer School in Vyborg, also it is proposed to organize Workshops in Murmansk and Vologda. The regionalization of the School work is based on fact that MAPS has started creation of regional Departments (Pskov, Murmansk), and increased collaboration with regional Health committees.
Regionalization could work as cost-containment mechanism by decreasing travel cost for participants from this region, by willingness of regional health committees to cover lodging expences and sometimes even trainers costs.
Drawbacks are also clear - only students from this region could participate, employing lecturers from different departments is much more difficult (i.e. for Vyborg, lecturer will spend four hours traveling to and four hours from Vyborg, whereas during School in St.Petersburg he/she will spend only about one hour- one hour and a half one way). It would be also much more difficult to persuade, for example, lecturers from Moscow to go to Mrmansk than to St.Petersburg
In any case, the year 2003 will show strength and weaknesses of regionalization of the School activity.
One of the most promizing cost-containment mechanisms, as marginal cost of adding new students is very low. Moreover, once prepared, course administration is very cheap. During 2002 much effforts has been placed to development of Web-based module on distance learning. One such module has been created ("Methods of barrier contraception in prevention of STD") and soon will be tested on students (OSI grant, support from CDC, USA), another project is now starting ("Women's health", DIFID grant, support from Open University, UK).
There are still some drawbacks in distance learning courses:
a) Preparation cost is higher
b) In purely distance learning courses no official documents can be granted (fraud probability at exam is very high) - at present MAPS is working with Ministry of Health on creating system for recognizing distance learning credits
c) Many people in Russia are still unable to adequately use computers for distance learning (our estimation that among meddle-aged physicians only about 4% have aceess to the computer and knowlege enough for participating in DE
d) Distance learning courses are less attractible, especially for people outside St.Petersburg, as they are purely extra-work for them with no indirect benefits of visiting large city.
Still, distance learning is one of the attractive means of varying training inside different MPH tracks at the School
Taken together it is possible to say, that after cessation of SIDA/OSI funding School will be able to continue its operation by combining different approaches directed to cost-containment and fund-rising.
Takng into account forecasting of cessation of support of the School activity by major donors (SIDA and OSI) to ensure sustainability of the School work beyond 2003 it is necessary:
1) Start paid courses in Health Management for senior administrators to earn revenues for support of the school activity
2) Switch emphasis from face-to-face training to distance learning courses
3) Generate revenues from selling traning workbooks and training materials
3) Implement cost-containment mechanism consisting in limiting coverage of feeding and lodging for participants of the face-to-face courses
4) Introduce courses creating in the School to regular MAPS schedule
5) Regionalize School activity
6) Conduct training courses with other Schools on cost-sharing basis
7) continue to search for new financing resources including foreign donors and consultancy
To ensure sustainability and provide foundation for the School operation in the future next year (2003) it would be necessary to concentrate less on training and more on capacity-bulding. In terms of capacity-building during previous three years of School operation the curriculum has been created and tested on students, School is recognized by partners in Russia, faculty has been trained, new approaches to training has been tested. Now more attention should be paid to development materials for distance learning (books in Russian and Web-based materials), library to ensure supply of books for preparation of the new courses and research activity. Also courses on regional bases should be organized.