BMJ  2005;331 (23 July), doi:10.1136/bmj.331.7510.0-g

Editor's choice

Untangling a skein of wool

Democracy is good for health—studies have shown this. But the transition from totalitarianism to democracy has taken its toll on the health of people in the former Soviet bloc. In almost all countries in the region, life expectancy has fallen in the past 10-15 years, as health systems struggled to cope with the loss of centralised bureaucracies and the rise of market forces. This theme issue is a snapshot of countries in transition, presenting honest appraisals of their shared problems and diverse attempts at solving them.

The challenges facing these countries are enormous. Economic collapse after transition has fuelled epidemics of HIV (p 216) and tuberculosis. Tobacco consumption is the single biggest cause of preventable death (pp 198, 191). Corruption is still endemic and healthcare infrastructure, especially in primary care, is lacking (pp 201, 204).

Many people thought that transition would allow them to keep the good things about the communist system—universal access to free health care—and lose the bad—lack of drugs, out of date training, failing technology, authoritarianism, and low wages. They have been disappointed. As Peter Toon says (p 243), "changing a health service is like untangling a skein of wool: pulling at one point creates a knot somewhere else. Health care cannot be reformed piecemeal." Reforms in Croatia have saved costs and increased efficiency but have created inequities and left Croatians feeling betrayed (pp 223, 226).

Miklós Szócska and colleagues describe the "perverted policy cycle" in Hungary (p 231). Managers in the newly emerging democracy were inexperienced. Health ministers changed constantly, each bringing a new set of ideas to meet the heightened expectations born of the latest political crisis. Reforms were introduced rapidly using law and regulation rather than training and communication, creating a damaging gap in perception: senior policy makers now believe that changes were effective, while managers feel they were frequent but superficial.

Amidst the challenges, Poland represents an important success story. Here coronary heart disease has fallen by over a third in the past 15 years, largely because of changes to the nation's diet (p 187). As Karen Lock and Martin McKee explain (p 188), these dietary changes have little to do with health promotion and almost all to do with economic reforms.

The clear message that emerges is one that all countries would do well to hear: improvements in health cannot be expected from health reform or promotion alone. Indeed, the real improvements in health have come from political and economic reform: in Poland (p 187), Croatia (p 208), Estonia (p 210), and the Slovak Republic (p 213). Meanwhile, intensive health promotion campaigns have failed to dent the growth in consumption of tobacco and alcohol, which still enjoy liberal tax status.

We can tell people what the healthy choices are, but unless we make it easy for them to make those choices, through sensible political and economic reform, we may cause only greater inequity.

Fiona Godlee, editor

(fgodlee{at}bmj.com)


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Relevant Articles

Changes in dietary fat and declining coronary heart disease in Poland: population based study
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Rapid Responses:

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How widely can these principles be applied?
Angshu Bhowmik
bmj.com, 24 Jul 2005 [Full text]
Re: How widely can these principles be applied?
Charles A Akle
bmj.com, 29 Jul 2005 [Full text]
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