The development of a health care model, which will provide highly efficient health care with minimal cost, is an important issue for both political leaders and medical specialists in most world countries. Several aspects can be considered. The fast development of medical technologies has lead to an increase in health care expenditure. In turn, the high cost of individual procedures decreases availability of health care resources for the general population. Typically, in most countries the aging population increases pressure on health care resources. Importantly, an increase in expenditure on in-patient treatment does not result in a dramatic improvement in the nation's health. Reform of health care system is characteristic of many Western countries. The main areas for health system development have been changes in health administration, development of health technology assessment (HTA) approach, evidence-based medicine, analysis of epidemiological data for improved planning and decision-making as well as highlighting preventive measures and healthy life style information.
Russian health care, a legacy of the Soviet system, has both positive and negative aspects. The main drawback of the system was the high cost of maintenance due to the declared availability and free-of-charge for all. The present changes in economical situation both within the country and on the international markets means that conserving the present system is impossible. There is currently budget deficit, aging equipment and an impossibility of renewing the technical base. This, in turn, influences the health situation in the country. The reform of health care has become an imperative for the all levels of health care administrators, but in doing this it is necessary to take into account our own experiences, the results of scientific investigations and the Western experience. Previous reforms of the health care structure, adoption of population wide preventive programs and health technology assessment programs have shown that it is possible to increase quality of health care with concomitant stabilization of health care costs. These lessons from United Kingdom, Finland and Sweden are to be built upon.
The health care administration of the North-West Region of Russia, principally the heads of the Health Care Committees of St.Petersburg and Leningrad oblast propose to develop a strategy for education within the field of Public Health. Interest in this project is led by the Medical Academy for Postgraduate Studies (MAPS), which is occupies a leading position in the medical postgraduate education in North-West Russia. St.Petersburg has traditionally maintained a close relationship to her Nordic neighbors and collaboration with the Eastern Europe Committee of Sweden and Ministry of Social Affairs of Finland have been asked to participate in the project. The Ministry of Health of Russia also supports the project.
Fig.1 Meeting on the development of School of Public Health at the Eastern Europe Committee in Stockholm (participants l.t.r. Prof. V.Filatov, MAPS; Prof. O.Kuznetsova, MAPS; Dr. G.Wennstrom, EEC; Dr. C.Ortendahl, EEC; Dr. E.Mikhaeli, EEC)
The aim of the discussion was to organize the School of Public Health in St. Petersburg.
While medical competence are often high within the Russian Health Care system, knowledge that supports the development of the system is less prominent. An important consequence is that although Russia invests substantial economic and staff resources (in relation to its economic development), the health care outcomes are less impressive.
The academic (education and research) elements of Public Health Medicine are present in Russia, but in a fragmented form and not in the structure of a School of Public Health. The general concepts of public health research also differ in parts from those current in other advanced countries.
A School would need to combine the fragments into a more comprehensive knowledge base required for developing and managing a complex health system. With ambitious goals and high quality, motivated staff, it would soon form the natural base for investigations and consultation in Health Service Development. It would also rapidly emerge as the Russian point of contact for international Schools and organizations working in the field.
Areas of work include both advanced education & training and research & development (R/D). Resources will be required for training, for research and for development - with a general consultancy profile. That would suggest, mixed forms of financial support with the general base found from the Ministry of Health and from the Ministry of Education or similar federal or state institutions. For further sources application of teaching charges for specific training programs paid by users (individually or by their employer) could be levied. Additionally, co-operation with state/oblast, municipalities and internal/external donors could bring further income to the School for specific projects.
It is likely that the activities of the school will be concentrated in the North Western Region of Russia, but there is no need for a fixed attachment area. The school needs to build gradually and MAPS is the natural starting point.
MAPS, the oldest medical postgraduate Institution, was founded in 1885. Today MAPS includes 80 departments in 7 colleges. Every year 30 000 physicians attend short-term courses ranging from one to five month. More that 800 physicians are taught on a long-term basis (one to three years), of whom approximately 200 are postgraduate fellows. MAPS trains physicians for the whole of Russia, but most come from the North-West Region of Russia.
Fig.2 MAPS filial 1, place where School of Public Health will have its office and information center
Apart from teaching, all faculty members are obliged to participate in the research work. MAPS is now one of the leading scientific centers in St. Petersburg and the whole of Russia.
MAPS has several Departments that could be viewed as a crucial part of the School of Public Health. These include departments of Foreign Languages; Medical Informatics; Health Care Management and Economics; Occupation Medicine and others. The limitation of these departments is that they are responsible for the education of specialists in narrow fields. For the School of Public Health it will be necessary to combine the best teachers from different departments under a common curriculum. As the first step in this direction, the MAPS administration has organized a special Division that will combine several departments, the medical library and other informatics based units (computing center, bibliographical unit, etc.).
Fig.3 Internal yard of the MAPS filial N 1.
The School would strongly benefit from a clear organizational identity within MAPS from the start. Once the organization is fully developed it would become independent, but would benefit from a close relationship to MAPS.
To serve the interest of Russian citizens, health professionals, as well as the systems top decision-makers, a School of Public Health will need to direct its activities along the following lines:
The School will need to be based on a sound knowledge of the health status of the
Russian population and would therefore need to strengthen data on:
· the state of health in the population
· the use of health care resources (including quality and outcome data)
· the health care costs
Data is also needed to identify groups with health care needs that are inadequately met. This department of epidemiology needs to have resources to address technical / statistical questions such as standardization of data. Furthermore it needs to have sufficient resources for the efficient dissemination of epidemiological data.
From the training perspective, the priority should be a general understanding of epidemiology and the use of epidemiological data for medical sociology, for performance analysis and to form and test hypothesis about disease causation.
From the research and development perspective, the priority should initially be the development of new and the restructuring of old databases. In addition there must be improved access to data for local and regional health authorities, health care organizations, news media and research. A second area of research and development could be further medico-social analysis of the health situation in NW Russia. Projects run in co-operation with foreign partners may play an important role in the development of databases and the use of new dissemination methods.
B. Clinical management and financial health economy
From the training point perspective the emphasis should be on equipping health providers
· staff structuring and training
· organizational development
· economic incentives structure
· accounting (money, operations and human resources)
· values and ethics in health care
· leadership issues
From the research and development perspective the priorities include the publication of Russian textbooks in the field, research on leadership issues, staffing and economic incentives. Another important research issue is the ethics of prioritization and rationing of health care resources.
C. Health Systems Development
This area of competence will particularly address the needs of health administrators in hospitals, in health committees, insurance companies and health ministries. Training needs to particularly address the following issues:
· Health legislation
· Health finance
· Health system performance analysis
· Health organization
· Health system integration (working on the finks between the
health system and other systems such as social services). The R/D field contains numerous areas that also may influence finance for the School from official organizations in the health field and from foreign partners.
D. Health Promotion
This area of competence will particularly address the training needs of organizations, municipalities, companies and health professionals. Issues of particular importance are:
· intervention techniques
· health promotion organization
· primary and secondary prevention
· evaluation of health promotion interventions.
This part of the School also needs to work actively in the R/D field on individual projects in particuarly important areas such as:
· alcohol and narcotics
· physical activity
E. Health Technology and Procedures Assessment
This part of the School should work predominantly with professions, groups and with health administrators that are affected by the introduction and withdrawal of medical technologies and procedures.
Training needs may focus on the use of HTA in clinical work and in the creation of disease management plans.
Much of the work in relation to HTA will be of a developmental character. Particular areas of interest are: -assessment of group administration
· international co-operation (i.e. Cochrane and HTA groups in
· local dissemination teams working as outreach services of MAPS
· a central dissemination group
· evidence-based medicine
This direction of work will be one of the most important from the very beginning of the School work. It will form the basis for R/D work, and will influence the practice of medicine in clinical settings.
F. Health Informatics
Health informatics as a separate department in a School of Public Health may lend the St Petersburg School of Public Health a particular profile.
The target group of the School should be professionals and health administrators, lines of work in training could be the following
· general knowledge of working in PC and Workstation environment,
· Information search in medical databases
· Working on the internet
· Development of home pages
· IT strategy work
Much work needs to be done as research and developmental work. This is a very complicated procedure, since standards need to reach a high level of acceptance among future users and software developers to achieve a break through. Possible important area of developmental work can be
· Standardization in health informatics (communication, identification and interface)
· Standards for computerized patient records
· Telemedicine technology standardization
· Knowledge base use in medicine
· Computer support to medical training
· Data security and identity confirmation technologies for the use of computerized patient records.
The School will seek its market all over North-West Russia and will therefor need special methodology to be able to reach out to its trainees.
It is suggested that the School should build its training programs with a strong share of computer supported training in a well built computer network. Trainees would thereby not have to travel but for brief but intensive periods of lectures and seminars in St.Petersburg.
The School may also benefits its trainees by forming an understanding; whereby a masters degree from the School also would be supported by further continuos training for the masters in a well co-ordinated systems of post-graduate computer assisted seminars. An interactive home page may serve to achieve a continuous dialogue between the School and its pupils.
Before putting a large-scale distance learning projects it is necessary to organize and conduct the studies assessing the effectiveness of the distance learning approach and best ways to utilize computers in distributed education.
Exams need to have a Strong position in the Health care system and the School will need to seek ways to underline the particular quality to pupils that have passed the School. Participation in international accreditation arrangements may well serve this purpose, as will co-operation with foreign partners in Schools of Public Health.
Two Master degrees with different orientations would be offered as study options. One focusing on clinical management and one on Health Systems Development.
Since research is an important part of the School's profile, it is important that a Doctoral degree program be developed.
A cadre of staff needs to be developed after secondment of the initial group from other departments.
A system of fellowships in Finland and Sweden will have the explicit intention of training young staff. Other donors will be approached as partners for the further expansion of the fellowship program.
The first experience in teaching in the framework of the School of Public Health was the organization of a summer school in June 1999. This School taught 52 health care administrators from North-West Russia and the MAPS faculty. They were given lectures and participated in discussions on health care system development, management in health care and the usage of research data in health planning. The teaching was judged to be successful by the participants, most of whom wanted to participate in the next summer school. An examination showed the academic success of the teaching organization
Fig. 4. Meeting between SEEC President, Dr. C.Oertendahl and Vice-Director of Health Programs of Open Society Institute (Soros foundation) Mrs. N.Vasiljeva
The successful organization of the School of Public Health will require the resolution of several problems:
· Preparation of faculty and staff on topics not fully developed in Russia. This problem is being resolved in collaboration with Swedish and Finish colleagues.
Fig. 5 Meeting between representatives of Tampere School of Public Health (Finland), Finnish Ministery of Health and Social Affairs and MAPS.
· Access to informational resources. To fulfill the goals of the School it will be necessary to have rapid access to good informational resources (including full-text databases).
· Incomplete information network for education. This work on distance education is being constructed.
· Insufficient teaching materials and books for use in the School. This will need to be written and problems of shortage of printing materials will need to be resolved.
Basic economical support for the School of Public Health will be secured from the organizers. MAPS will provide the facilities for its operation, as well as will pay salary for Russian faculty and support staff. Also MAPS will cover all indirect costs connected with the School operation. As MAPS is federally-financed organization it is possibly to say, that bulk sum of the financing for the School of Public Health, at least in the first years of its operation, will come from Russian government. In the same time it will take time to achieve a secure financial basis for the School. In the first years all potential sources need to be sought out in search of financial solutions. Business donors should not be avoided but ethical principles of not including donors from companies working with hazardous products observed.
If donors want to support individual projects a mechanism for including general support to the School, (for example an overhead levy on salary costs).
The support could be roughly classified into two broad categories: long-term and short-term funding. Short-term funding could be a one-time fellowships, financing of short-term research projects or conferences, equipping the lecture halls (with indicating of which donation was that), etc.
In order for the School to be successful, much is dependent on proper evaluation and follow-up of teaching. From the very beginning the structure of the School allows the selection of the best available teachers. The absence of the fixed staff allows to select teachers according to the most important topics and not vice verse. Correspondingly it would be necessary to create system for the evaluation of the teaching results, the work is now undertaken by the Department of Teaching skills of MAPS. The major points in assessing the teaching quality will be
- Knowledge assessment
- Written essay exam
- MCQ knowledge assessment
- Peer review
- Students satisfaction
- Rating scales
- Course completion
- Return for training
- Training transfer
- intention to transfer
- transfer initiation
- Higher levels of transfer (partial transfer and transfer maintenance) could be assessed only at later stages of School activity but instruments for its measurement and possibilities should be explored from very beginning
Research work at the school will be assessed by the amount and quality of publications (amount of publications in peer-reviewed journals with high citation rate divided by total number of publications) and by combination of internal and external quality audit.