Transition and public health in the Slovak republicBMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7510.213 (Published 21 July 2005) Cite this as: BMJ 2005;331:213
- Gabriel Gulis, associate professor ()1,
- Jarmila Korcova, deputy head2,
- Peter Letanovsky, research assistant3,
- Daniela Marcinkova, research and teaching assistant2
- 1 Unit of Health Promotion Research, Institute of Public Health, University of Southern Denmark, Niels Bohrsvej 9-10, 6700 Esbjerg, Denmark
- 2 Department of Hygiene and Epidemiology, Faculty of Health Care and Social Work, Trnava University, Trnava, Slovak Republic
- 3 Ministry of Health, Bratislava, Slovak Republic
- Correspondence to: G Gulis
Like other Central and Eastern European countries, the Slovak Republic is in transition from a directive, centralised, political system to a democratic, market economy based system. However, since the break-up of the former Czechoslovakia on 1 January 1993, the republic is also undergoing transition from the federal system of policy making and leadership to an independent sovereign state (infrastructural transition). The development of a fully independent health sector within the Slovak Republic has posed serious challenges for public health policy makers and practitioners. We describe the main steps and changes during transition and discuss the achievements and tasks ahead.
In 1994, an update of the act for the protection of human health restructured the public health system. Responsibility was delegated to the Ministry of Health, the main hygienist of the Slovak Republic, and regional hygienists. The National Office of Public Health currently has 36 regional offices. A new public health act is being prepared, which focuses more on health determinants, health promotion, and assessment of effect. It is expected to be passed this year.
Three major policy documents also passed through government and parliament during 1990-2004: the national health promotion programme in 1991, the state health policy in 2000, and the national environmental health action plan in 2001. The state health policy introduced the World Health Organization's Health for All policy into the country, and the environmental health action plan introduced major ideas to solve environmental health problems. All three documents share one common problem: no clear responsibilities or funding schemes have been developed to implement them.
Education and research
Before transition, most public health professionals were educated at the medical hygienic faculty of Charles University in Prague. Postgraduate schools in Prague and Bratislava offered different specialisations, including general and community health, occupational health, health of children and young people, food safety and nutrition, epidemiology of infectious diseases, social medicine, and health management. The main change in education began in 1993, with the opening of the public health programme at the faculty of health care and social work at the university in Trnava. Courses in public health have since opened at the Comenius University Medical School and Slovak Medical University in Bratislava.
Public health training is slowly approaching international standards. Summer schools (at the London School of Hygiene and Tropical Medicine, WHO, the University of Iowa, and others) and foreign fellowships have contributed greatly to the growth of a new generation of public health workers.
Research is an important part of public health, and is closely allied to education and practice. Major research institutes such as the Health Education Institute, the Nutrition Research Institute, and the National Health Promotion Centre were dissolved because of economic constraints at the end of the 1990s. Nevertheless, Slovak public health researchers are increasingly participating on international projects within US supported research schemes, the framework programmes of the European Union, and the recent European public health strategy. Another positive development is the establishment of the National Agency for Science and Research, which operates under internationally recognised rules for research funding. The agency has obtained increasing funding for national research in the past few years, rising from nothing in 2001 to 1.3m koruny (£2.3m, €3.5m, $4.2m) in 2003.1
Health status of population
WHO's health for all database2 provides information on the health status of the Slovak Republic population, and also allows comparison with the Czech Republic, the historically closest partner. The table shows selected health status and health determinants.
Life expectancy increased less in the Slovak Republic than the Czech Republic during 1993-2002. The percentage of men who smoke regularly is higher in the Slovak Republic, and it has done less well than the Czech Republic on most of the health determinants listed in the table.
One of the explanations for slower progress may be the double transition. Most of the administrative institutions had to be established before they could take control of development. The best example for this is public health research funding, where the research funding agency had to be set up before funding could be generated. Another explanation is the size of transition. The unemployment data show that the Slovak Republic was hit harder by economic transition than the Czech Republic. The almost doubled incidence of salmonellosis in the Slovak Republic between 1993 and 2002 (although still lower than in the Czech Republic) reflects the damage done to agriculture by transition. The rise in salmonellosis incidence also raises questions about the effectiveness of the surveillance system and its ability to prevent disease. Pure reporting, as ensured by current legislation, is not enough.
Attitudes and beliefs
The transition from authoritative to democratic government increases the involvement of the public in decision making, both in general and also regarding public health. How do people assess their health? What do they think is crucial information for planning public health services? Three large surveys have been conducted in the Slovak Republic. The international health and behaviour survey is a questionnaire survey of health related behaviour, risk awareness, and associated attitudes that was carried out with university students worldwide.3 The former Institute of Health Education in collaboration with the Institutes of Hygiene and Epidemiology surveyed the general public's health attitudes, beliefs, and self assessed health in 1992, 1995 and 1998.4 The third survey was conducted as a pilot within WHO's European health interview study. Data from all these surveys show no significant differences between Slovak respondents and participants from other countries.5
Recently, a survey was conducted among key policy makers to assess their knowledge and awareness of major national and international health policy documents and the issue of health inequalities. The national response rate was only 1.7%, and the best regional response only 17%, suggesting low awareness about responsibilities regarding public health (D Marcinkova, G Gulis, 25th Association of Schools of Public Health in European Region annual conference, Caltanissetta, Sicily, September 2004). Among those who responded to the questionnaire, 43% had knowledge of national health policy documents and 18% had knowledge of international documents. Only 40% of decision makers thought that their decisions influenced health, and just 10% thought that they influenced health inequalities.
These data show that public health is still largely considered solely as a part of health care and therefore the responsibility of the ministry of health. Awareness of the wider influences on public health needs to be increased and truly intersectoral work introduced.
A long path
Transition is clearly a long path, which in fact may never end. It affects health by influencing all the major determinants, as shown by Dalghren in 1995 in his famous conceptual model of determinants of health as concentric circles.6 The main determinants of health in the Slovak Republic are the same as those in other countries. Key factors enabling and obstructing advances in public health include overall macroeconomic and social conditions, general attitudes to public health, lack of multisectoral collaboration, and better consideration of policy options.7 International organisations have helped greatly with development of training, and the country now needs to make more efficient use of international help with legislation and shaping the attitudes of key decision makers.
The health of Slovak citizens is slowly improving since transition
Training of public health professionals is increasing and improving in quality
Progress has been slowed by the need to set up new institutions as part of a second transition to a sovereign state
Lack of awareness and interest in public health issues among policy makers outside health needs remedying
We thank Robin Ungar, Center of International Rural and Environmental Health of the University of Iowa, for help and valuable comments during preparation of this article.
Contributors GG designed the paper, wrote the health status part of the paper and edited other parts of it. JK wrote the education part of the paper. The legislation part of the paper is by PL. DM wrote the attitudes and beliefs part of the paper. GG is the guarantor.
Competing interests None declared.