South Eastern European Journal of Public Health

228

Authors: Ulrich Laaser

A regionalized even fragmented world – as it was – is converging rapidly in our days at the beginning of the 21st century. Countries embark increasingly on global arrangements (like the World Trade Organisation) and a globalizing civil society – supported by mobile technologies - connects across borders. At the same time unprecedented waves of migration diversify the Northern societies and deplete the qualified workforce in the South. Social disruption, military conflict, and climate change create increasingly a 90/10 situation where 90% of the global disease burden affects the South but only 10% of the world‟s resources are available there. To really change this state of affairs we have to think new and to try new avenues.

5

Authors: Bernard Merkel

A few months ago, the South Eastern European Journal of Public Health (SEEJPH) published a lengthy article by Hans Stein on the importance of the Maastricht Treaty of 1992 and how the European Union (EU) health policy has developed since then. Undoubtedly, Dr. Stein made a major contribution to this story himself and in his paper he sets out his own viewpoint on key events and trends, offering us a wealth of historical detail and many real insights. But, like all good commentators who try to condense and make sense of a tortuous and convoluted sequence of events spanning more than two decades and involving very many players, he inevitably omits parts of the story, and his interpretations can sometimes give rise to more questions than answers.

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Authors: Craig Meisner, Dragan Gjorgjev, Fimka Tozija

Aim: This paper assesses the magnitude of health impacts and economic costs of fine particulate matter (PM) air pollution in the Republic of Macedonia. Methods: Ambient PM10 and PM2.5 monitoring data were combined with population characteristics and exposure-response functions to calculate the incidence of several health end-points known to be highly influenced by air pollution. Health impacts were converted to Disability-Adjusted Life Years (DALYs) and then translated into economic terms using three valuation approaches to form lower and higher bounds: the (adjusted) Human Capital Approach (HCA), Value of a Statistical Life (VSL) and the COI (cost of illness). Results: Fine particulate matter frequently exceeds daily and annual limit values and influences a person‟s day-to-day health and their ability to work. Converting lost years of life and disabilities into DALYs - these health effects represent an annual economic cost of approximately €253 million or 3.2% of GDP (midpoint estimate). Premature death accounts for over 90% of the total health burden since this represents a loss of total life-long income. A reduction of even 1μg/m3 in ambient PM10 or PM2.5 would imply 195 fewer deaths and represent an economic savings of €34 million per year in reduced health costs. Conclusion: Interventions that reduce ambient PM10 or PM2.5 have significant economic savings in both the short and long run. Currently, these benefits (costs) are „hidden‟ due to the lack of information linking air quality and health outcomes and translating this into economic terms. Policymakers seeking ways to improve the public‟s health and lessen the burden on the health system could focus on a narrow set of air pollution sources to achieve these goals.

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Authors: Aleksandra Jovic-Vranes, Vesna Bjegovic-Mikanovic

Aim: Children represent the future, and ensuring their healthy growth and development should be a prime concern of all societies. Better health for all children is one of the leading objectives of the National Plan of Action for Children and a key element of the tailored Millennium Development Goals for Serbia. Methods: Our analysis was based on relevant literature and available information from the primary and secondary sources and databases. We analyzed health status of children that can be illustrated by indicators of child and infant mortality, morbidity, and nutritional status. Results: There has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five years of age. However, the current mortality rate of Roma children is still three times as high as the Millennium Goal set at the national level for Serbia. Most deaths of children under the age of five are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia and sepsis. The rate of malnourished children among the poor and in Roma settlements is twice as high as in the general population of Serbian children. A growing number of obese children was also noted in the Roma population. Conclusion: Political awareness, commitment and leadership are required to ensure that child health receives receive the attention and the resources needed to accelerate the progress of Serbia.

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Authors: Mariela Stefanova Kamburova, Petkana Angelova Hristova, Stela Ludmilova Georgieva, Azhar Khan

Aim: This paper aims to study the relationship between mothers’ age, body mass index (BMI), gestational weight gain (GWG) and smoking and the risk for premature birth in Pleven, Bulgaria. Methods: A case-control study was conducted in Pleven in 2007. The study was comprehensive for all premature children (N=58) and representative for full-term infants (N=192, or 10.4% of all of the 1827 full-term children) born in 2007 at the University Hospital of Pleven and resident in the city of Pleven. Retrospective data on determinants under study were collected from all the mothers included in this study (N=250). Results: Mothers of premature children were more likely to be above 35 years old (27.6%), with a BMI ≥25 kg/m² (23.1%), GWG below the recommended value (38.5%) and to smoke during pregnancy (37.9%). The odds of being a smoker during pregnancy were five times higher among mothers with low birth weight (LBW) newborns compared with their counterparts with normal birth weight newborns (OR=5.1, 95%CI=2.4-10.6). There was a positive association between BMI and LBW in infants whose mothers were overweight (OR=2.1, 95%CI=1.0-4.0). The risk of LBW increased when GWG was less than recommended (OR=1.8, 95%CI=1.0-3.1). Conclusion: Our results indicate that pre-pregnancy BMI ≥25 kg/m², less than recommended GWG and smoking during pregnancy are risk factors for premature birth in Pleven region. Findings from this study suggest the need for active health and educational actions by health professionals in order to avoid premature births in Bulgaria.

14

Authors: Helmut Wenzel, Vesna Bjegovic-Mikanovic, Ulrich Laaser

Aim: Political decisions usually emerge from the competing interests of politicians, voters, and special interest groups. We investigated the applicability of an advanced methodological concept to determine whether certain institutional positions in a cooperating network have influence on the decision-making procedures. To that end, we made use of the institutional network of relevant health care and health governance institutions, concentrated in Belgrade, Serbia. Methods: We used a Principal Component Analysis (PCA) based on a combination of meas-ures for centrality in order to evaluate the positions of 25 players in Belgrade‟s institutional network. Their directed links were determined by a simulated position approach employing the authors‟ long-term involvement. Software packages used consisted of Visone 2.9, UCINET 6, and KeyPlayer 1.44. Results: In our analysis, the network density score in Belgrade was 71%. The PCA revealed two dimensions: control and attractiveness. The Ministry of Health exerted the highest level of control but displayed a low attractiveness in terms of receiving links from important play-ers. The National Health Insurance Fund had less control capacity but a high attractiveness. The National Institute of Public Health‟s position was characterized by a low control capacity and high attractiveness, whereas the National Drug Agency, the National Health Council, and Non-Governmental Organisations were no prominent players. Conclusions: The advanced methodologies used here to analyse the health care policy net-work in Belgrade provided consistent results indicating that the intended decentralization of the health care network in Belgrade may be incomplete, still with low participation of civil society representatives. With the present study we set the stage for a broad-range survey-based data collection applying the methodology piloted in Belgrade.

5

Authors: Genc Burazeri, Peter Achterberg

The former communist countries of South Eastern Europe (SEE) have been undergoing a rapid process of transformation from state-enforced rigid economies to market-oriented societies in the past 25 years. However, these fast changes have unevenly affected various countries and different segments of the populations within each country.

8

Authors: Edlira Harizi (Shemsi), Arben Rroji, Elton Cekaj, Sazan Gabrani

Aim: The purpose of this study was twofold: i) in a case-control design, to determine the relationship between anatomical variations of the circle of Willis and cerebrovascular accidents; ii) to assess the association between anatomical variations of the circle of Willis and aneurisms among patients with subarachnoid hemorrhage. Methods: A case-control study was conducted in Albania in 2013-2014, including 100 patients with subarachnoid hemorrhage and 100 controls (individuals without cerebrovascular accidents). Patients with subarachnoid hemorrhage underwent a CT angiography procedure, whereas individuals in the control group underwent a magnetic resonance angiography procedure. Binary logistic regression was used to assess the association between cerebrovascular accidents and the anatomical variations of the circle of Willis. Conversely, Fisher’s exact test was used to compare the prevalence of aneurisms between subarachnoid hemorrhage patients with and without anatomical variations of the circle of Willis. Results: Among patients, there were 22 (22%) cases with anatomical variations of the circle of Willis compared with 10 (10%) individuals in the control group (P=0.033). There was no evidence of a statistically significant difference in the types of the anatomical variations of the circle of Willis between patients and controls (P=0.402). In age- and-sex adjusted logistic regression models, there was evidence of a significant positive association between cerebrovascular accidents and the anatomical variations of the circle of Willis (OR=1.87, 95%CI=1.03-4.68, P=0.048). Within the patients’ group, of the 52 cases with aneurisms, there were 22 (42.3%) individuals with anatomical variations of the circle of Willis compared with no individuals with anatomical variations among the 48 patients without aneurisms (P<0.001). Conclusion: This study provides useful evidence on the association between anatomical variations of the circle of Willis and cerebrovascular accidents in transitional Albania. Furthermore, findings from this study confirm the role of the anatomical variations of the circle of Willis in the occurrence of cerebral aneurisms.

10

Authors: Adesuwa Q. Aigbokhaode, Essy C. Isah, Alphonsus R. Isara

Aim: Timely and appropriate healthcare seeking behaviours if practiced by caregivers of under-five children can have a significant impact on child survival. This study assessed the knowledge of, and general health seeking practices among mothers of under-five children in Nigeria. Methods: This descriptive cross-sectional study was carried out among caregivers of under-five children in Edo State, Nigeria, in 2013. A multi-staged sampling technique was used to recruit respondents. Data collection was done by means of a structured interviewer-administered questionnaire adapted from UNICEF/IMCI household baseline survey questionnaire. Results: A total of 370 caregivers (mean age: 31.1±5.9 years) participated in the study. Almost all of them were females 368 (99.5%), 234 (63.2%) had secondary education and 283 (76.5%) were in the unskilled social class. Over 70%, 76%, 72%, 76% and 82% of participants did not know that being unable to eat/drink, fast breathing, blood in stool and convulsion, respectively, were symptoms of a child not feeling well. The place of primary care of children by caregivers was at home 142 (38.4%), chemist shop 91 (24.6%) and health facility 80 (21.6%). Cost and long waiting time were major reasons for not seeking care in health facilities. Conclusion: This study showed poor health seeking practices among caregivers of under-five children in Edo State, Nigeria. There should be continuous education of caregivers on recognition of danger signs in children and the need to seek appropriate medical care in health facilities.

12

Authors: Mihajlo Jakovljevic, Ulrich Laaser

Aim: Population aging has profoundly reshaped demographic landscapes in all South Eastern European (SEE) countries. The aim of this study was to provide a thorough comparative inter-country assessment on the speed of population aging in the entire SEE region for the period 1950-2010. Methods: Descriptive observational analysis of long-term trends on core primary and composite indicators of population aging across seventeen countries of the wider SEE region, with panel data sets at a national level. Results: During the past six decades, the entire SEE region has experienced a rapid increase in the median age (from 25.2 years in 1950 to 37.9 years in 2010), with a simultaneous fall of fertility rates for two children per woman (from 3.55 children per each childbearing woman in 1950 to 1.49 in 2010), coupled with significant rise in the population of elderly citizens. The speed of population aging has vastly accelerated (with a 2.5 fold increase) over the past three decades. The percentage of individuals over 65 years has doubled from 7% in 1950 to 14% in 2010. Conclusion: Complex national strategies are needed to cope with the shrinking labour force coupled with the growing proportion of the older population. With all likelihood, population aging will further accelerate in the near future. This profound long-term demographic transition will threaten financial sustainability of current health systems in all SEE countries.

13

Authors: Maria Ruseva, Snezhana Chichevalieva, Meggan Harris, Neda Milevska Kostova, Elke Jakubowski, Hans Kluge, Jose M. Martin-Moreno

Inter-country alliances, articulated through regional approaches, have increasingly been used to drive economic development and social progress in the past several decades. The South Eastern Europe Health Network (SEEHN) stands out among these types of initiatives for the tangible improvements it has achieved in regional governance for health, with several important lessons for public health leaders worldwide. This review paper, written by several key participants in SEEHN operation, follows the main milestones in network development, including its foundation under the Stability Pact’s Initiative for Social Cohesion and the three ministerial forums that have shaped its evolution, in order to show how it can constitute a model for regional collaboration in public health. Herewith we summarise the main accomplishments of the network and highlight the keys to its success, drawing lessons that both international bodies and other regions may use in their own design of collaborative initiatives in health and in other areas of public policy. Keywords: collaborative networks, health systems, public health, regional cooperation, South Eastern Europe.

21

Authors: Hans Stein

Aim: The article contains a personal view of the history as well as the future of the European Union‟s (EU) health policy. Describing and evaluating the developments on the road from the Treaty of Maastricht to a new Europe it asks and tries to answer the question if we – especially the EU Member States – really know where we want to go to and how to get there. Method: Based on personal experiences, countless EU documents, as well as scientific publications the paper shows the impact EU Health policy has had in the Member States in the past. Historical development: Considering that the legal basis for health has been and remains to be very weak limiting EU action to support, coordinate, and supplement actions of Member States – which, as a rule, still consider health to be first and foremost a national responsibility and therefore do not want interference from international institutions – the amount and content of EU health activities in the past years has been quite remarkable. Health policy may not be an EU priority and as a crosscutting policy sector it is dominated by many other EU policies. However, especially the “hard law” regulations and directives of the Internal Market give EU the power and competence to achieve health objectives. The size of this growing influence is shown by direct interventions, made possible by the legal acts to improve economic policy coordination. Health and health care in this context are considered as a key policy area for economic growth and EU macroeconomic policy. On the other hand, there is a risk that such regulations affecting health policy and population health may be dominated too much by economic institutions and their interests, whereas health authorities play only a minor role to date. Conclusion: For the future of EU health policy it is essential that its position is considerably strengthened, in order to assure that health interests of the EU population are sufficiently safeguarded.