Bosnia and Hercegovina

Public Health Reform II

PUBLIC HEALTH REFORM II

IPA — 2011/S 57-091678

Project Executive Summary

1Contents

1SUMMARY......

2INTRODUCTION......

2.1Terms of Reference and Consortium......

2.2Activities Planned for Inception Phase......

3MISSIONS AND PREPARATORY ACTIVITIES......

3.1Preparatory activities......

3.2Missions and Meetings......

4KEY ISSUES......

4.1Component 1 EWS......

4.2Component 2 IHR......

4.3Component 3 NHA......

5FINAL PROJECT MODEL......

5.1Project Purpose and Expected Results......

5.2Project Implementation......

5.3Human Resources......

6REFERENCES......

1

IPA — 2011/S 57-091678

Public Health Reform II

2SUMMARY

The European Union has launched a new project to strengthen public services aimed at controlling public health threats in BiH. The project, which began in December 2011 and will end in December 2013, will support health care reforms in BiH through harmonization of relevant public health legislation with the EU directives and regulations in order to enhance evidence based planning of public health strategies. Activities planned under this project are organized into the following components: (a) institutional and capacity building of public health systems in BiH in order to increase its readiness to response on public health threats (pandemic, bio terrorism, natural disasters etc.); (b) enhancement and improvement of assessment of global health of BIH population and system of reporting on communicable diseases; and (c) improvement of national financial reporting system of the National Health Account.

This project will continue the efforts of the previous EU project “Strengthening the PHIs in BiH” and will link with other on-going health care reform projects and complementary activities of other international organizations. The Public Health Reform II – Bosnia and Herzegovina is an important project that recognizes the need to provide better protection against communicable diseases through an effective monitoring and evaluation system, to use the information for action. The project will benefit from the interaction with WHO and the EU ECDC providing a good example of international co-operation in the field on Early Warning Systems and International Health Regulations. The improved use of data related to the National Health Accounts will provide the basis for sustainable health sector strategies within the context of Health Sector Reforms.

The project will analyze gaps in the health information system to implement an effective plan to strengthen the use of information envisaged under the three components. This will allow to fully exploit data which are presently under-utilized and to set up a health intelligence system, which is the pre-requisite to implement cost-effective strategies to control the spread of public health threats. This is particularly important not only for the population of BiH but also for international public health, which is the main focus of the International Health Regulations.

The financial support is being granted under the EU revised instrument for Pre-Accession Assistance (IPA). As stated in the IPA, “The objectives of the revised assistance are to better translate political priorities into key actions, focusing on specific policy areas. The needs of the beneficiaries will be more closely addressed and the administrative burden reduced. The assistance will be more coherent, more effective and will help leverage more investments. Through IPA, the EU will continue to assist the enlargement countries in implementing the comprehensive reforms needed for future membership”.

The Economic Project and Policy Consulting GmbH (CEEN) and its consortium partners Diadikasia Business Consultants S.A. will manage the project. They will support the BiH Health authorities through Dr. Martin Rusnak, Senior Public Health Specialist and team leader, Dr.Venanzio Vella, Senior Epidemiologist and Mr. Stephen Batts, Senior Health Financing Expert.

The main outcome of the project will be a more effective use of information to control public health threats, reducing the burden of communicable diseases. The approach will not only secure good quality reporting but will prepare decision makers on various levels of public health in BiH to use data in their daily routine and thus to prioritize, monitor and evaluate public health activities. This project has all the potentials to set the ball rolling towards the strategic goals as described in European Public Health Strategy for the years to come.

3INTRODUCTION

The project was devised as the continuation of previous Public Health Reform I. While it has concentrated on issues related to Public Health services and noncommunicable diseases current project Public Health Reform II concentrates predominantly on communicable diseases and financing of PH services.

3.1Terms of Reference and Consortium

The project Public Health Reform II is based on finances provided from the EU through the Instrument for Pre-Accession Assistance (IPA) financing structures and registered under 2011/S 57-091678. The project started on 1 December 2011 and will last until December 2013.

The project aims to contribute to the accession of BiH to the European Union. In particular, the project aims to assist BiH in implementing EU-directives and recommendations in the field of public health and the use of statistical tools for managerial purposes.

The purpose of the project is to support health care reform in BiH through harmonization of relevant public health legislation with the EU directives and regulations in order to enhance evidence based planning of health care system.

The following project results are anticipated:

Institutional and capacity building of public health systems in BiH in order to increase its readiness to respond to public health threats (pandemic, bio terrorism, natural disasters etc.)
Enhancement and improvement of assessment of global health of BIH population and system of reporting on communicable diseases
Improvement of national financial reporting system NHA.

According to the Terms of Reference, the primary beneficiary of the project is the Ministry of Civil Affairs of BiH, Sector for Health. Other beneficiaries and main project partners are the Federal Ministry of Health, the Ministry of Health and Social Welfare of RS, and the Department for Health in Brcko District, the Entity PHIs, Public Health Department in Brcko District and statistical agencies. Final beneficiaries of this project will be medical workers in health institutions and citizens of BiH.

A consortium consisting of CEEN Economic Project & Policy GmbH (CEEN) from Austriatogether with Diadikasia Consultanting Services S.A from Greece is providing consultancy services. PROGRESS IN THE INCEPTION PHASE

Inception Phase was based on activities of the key experts. Dr. Rusnak, the Team Leader and Dr. Vella, the Key Expert 2 initiated the phase by visiting most of the relevant institutions in Sarajevo. Dr. Rusnak visited Banja Luka towards the end of the Year 2011 as well as Brcko in the first week of 2012. Dr. Rusnak visited most of the institutions relevant to the Component 2 during January 2012. Mr. Batts, Key Expert 3 spent his 4 weeks in the country familiarizing with the situation in the National Health Account collection, usage and reporting. The KAG meeting was called, too. In total more then 30 meetings and visits were made which gave the experts enough materials for assessment and for preparing the report.

3.2Activities Planned for Inception Phase

Activities within the Inception Phase attempted to allow the implementation team finding facts, which would be incorporated into the final project model. It also facilitated the awareness about the projects goals, objectives and methods. The team was introduced to a majority of stakeholders. Discussions revealed many gaps and points of interest to focus on. The Work Groups were defined and ToRs were formulated. Repeated discussions with the beneficiary (MoCA) helped to find answers to many questions of uncertainty related to individual components, procedures, formats, visibility, etc.. Given the weather conditions in February some of the activities and visits were especially demanding on team members. The Kick-off meeting prepared for 10th of February had to be postponed because of snow calamity.

Activities inception phase related to Component 1

Institutional and capacity building of public health systems in BiH in order to increase its readiness to respond to public health threats

The situational analysis regarding current practices in use to respond to public health threats and status of implementation of WHO recommendations was carried out in form of face to face interviews with epidemiologists in different Public Health Institutions in all entities, as well as in relevant Ministries of Health.

Two meetings were carried to establish working cooperation with the country WHO office in BiH in order to implement complementary activities regarding early warning system and IHR implementation. Documents from projects supported by the Office were collected and studied. Many of them were found to be useful for further work for the Project. Drs. Vella and Rusnak took part at the polio meeting organized by the WHO European Regional Office for countries of former Yugoslavia.

Two WGs were established for component 1. Because of specificity of the tasks and people involved, it was decided to have one WG for EWS and EUROHIS, as these two activities are similar in terms of contents and have a separate WG for the data processing and maintenance. IHR will be tackled by members of the WG3 and NHA by the WG4 members.

Training needs assessment was done using face-to-face interviews and focus group discussion, which helped to document significant variations in the capacity of staff across institutions.

Activities inception phase related to Component 2

Capacity enhancement to assess global health in BIH population and in reporting communicable diseases and other public health threats of international concern.

Links and cooperation were established with principal stakeholders during the visits. Gaps were identified and major differences among professionals were observed. The WGs were established and ToRs designed. Substantial need for trainings in the area of public health was observed, too.

Activities inception phase related to Component 3

The consultant Mr. Batts spent his time primarily collecting information on the NHA. He met principal stakeholders and the Working party[P1]. He formulated the next steps of Component 3 on the basis of the information collected and on the latest international guidelines on NHA .. The training of the main stakeholders is crucial for the sustainability of the NHA reporting.

4MISSIONS AND PREPARATORY ACTIVITIES

4.1Preparatory activities

The project was initiated on the 5th December, 2011 at a meeting with Dr. Jadranka Mihić, responsible Program Manager at the Delegation of the European Union to BiH.(see minutes attached).

The project`s office was established, connected to Internet and equipped in Sarajevo as well as in Banja Luka. Requests for meeting were distributed to potential stakeholders. The draft report from the previous project (Public Health I) was studied and the suggestions and identified gaps were included into this report. Lists of queries to be addressed during initial meetings were discussed within the team, formulated and used during meetings.

4.2Missions and Meetings

Meetings were paid to institutions that were suggested by the beneficiary. The selection was partially based on results from[P2] the previous project PHI, representativeness (institutions from all entities, large and small ones, good and bad performance). The meetings were requested and organized according to a uniform structure, in terms of the aims, fact-findings, collection of contacts, specification of future activities and preparation of future networking[P3].

Delegation of the European Union to BiH and EU Special Representative
Federal Ministry of Health
Federal Ministry of Health
WHO Office for BiH
Federal Public Health Institute
Ministry of Civil Affairs BiH
Federal Public Health Institute
Public Health Institute, Canton Sarajevo
Chamber of Physicians in Canton of Sarajevo
Institut za zaštitu zdravlja Republike Srpske
Department of health and other services, District of Brćko
Public Health Institute for Sarajevo Canton
University of Sarajevo
Ministry of Civil Affairs
Public Health Institute of SBK/SBŽ, Travnik
Public Health Institute, Livno
Zavod za Javno Zdravstvo, Mostar
Web Portal, Sarajevo
Dr. Rusmir Mesihović, minister
Health Insurance, Republic of Srpska
Public Health Institute for Republika Srpska
Ministry of Health, Republika Srpska
Dr. Ranko Škrbić, Ministerof Health and Social Welfare, Republika Srpska
Agency for Statistics, Brcko District
Brcko Health Insurance Agency
NHA Working Party
Cantonal Public Health Institute of Zenica
Public Health Institute of Tuzla Canton, Tuzla
Dom Zdravlja, Canton Sarajevo
Visit to major NHA players in Banja Luka

Table 1 List of institutions visited by the team members

5KEY ISSUES

There are issues, which are common for all three components. The easiest way to define them is to admit, that there is substantial knowledge in most central institutions, while outstanding issues were identified at the periphery.

Among those issues, which are crucial for all three components, the lack of communication among stakeholders is noticeable. Despite all technical means, which are now available, the communication is limited and many problems are being sent upward in the hierarchy instead of taking decisions and responsibilities on the spot[P4]. This complicates many routine activities, which require too much time and efforts just to overcome these hurdles. [P5]As it was observed in the case of collection of notifiable diseases data or fulfilling the requirement of IHR, communication between professions within health sector as well as on intersectoral levels is limited or frequently non-existent.[P6]

Another issue is the lack of analytical skills for decision-making purposes. In general the feeling of majority of people interviewed was to undervalue the need for data. [P7]Decision makers on any position rarely use analysis of situation probably being aware of low quality of available information. [P8]Thus skills in analyzing and interpreting collected information are rather limited, as well as technical resources are lacking as well. Financial constraints do not allow purchasing good quality software to support analytical activities. [P9]All institutions visited produce reports with many times fancy charts and graphics, but critical deep insight on the result was not observed. Frequent answer on a purpose of the report was either that the institution above requires it or the requirement came from an international body.[P10]

The Inception Phase brought those observations and thus allowed to focus activities on most of them by proposing courses, trainings, and workshops on the issues mentioned, provide introduction to managerial techniques, to amend or add to existing legislation, ect. The project Key Experts recognize that the core of the activity should be on hands on exercises through out the country and facilitating intrasectoral as well intersectoral cooperation.[P11]

5.1Component 1 EWS

Full title for the Component 1: Institutional and capacity building of public health systems in BiH in order to increase its readiness to respond to public health threats

Abbreviated to: EWS

This section is divided into following subcomponents: EWS.1.1. Quality of notifiable diseases recording; EWS.1.2. Web portal; EWS.1.3. Data Analysis; EWS.1.4. Decision and Policy Making; as well as EWS.1.5. Evaluation and Dissemination

EWS.1.1. Quality of notifiable diseases recording

5.1.1.1First step

The WG1Epidemiology and EUHIS will plan the validation on the quality of reporting by going through a methodological exercise to become aware of the anatomy of the system they are going to evaluate. This exercise will be a brainstorming session on how the reporting system is supposed to work so that they can assess the present status v.s. the blueprint. This preliminary exercise will include the discussion on the list of reportable diseases and the case definition, which are used across entities.

The list of notifiable diseases according to laws[1][2]will be the starting point for a common list of diseases to be monitored by the EWS. The next step will be to assess each disease according to a set of priority criteria which could include: high mortality, high morbidity, high case fatality rate, elimination or eradication, communicable disease control feasibility, cost involved, epidemic potential, existing control programmes and global targets. Outcome will be an agreement on a final list of communicable diseases which could be adopted in the whole of BiH and which will be standardized in case definition.

5.1.1.2Second Step

Once the above-mentioned list of notifiable disease is finalized, the evaluation methodology will assess the capacity of the surveillance system to report them. The methodology will have to include the following areas:

Case definition used by the physicians to classify cases according to clinical and diagnostic criteria for individual cases;
Routine vs immediate reporting. The WG1Epidemiology and EUHIS will plan how to evaluate the criteria used at the periphery of the health system to decide when a case should be reported immediately to the upper level, why, how and to whom;
Data recording and data flow. The WG1 will have to devise a method to summarize how the weekly recording is carried out in terms of how each sampled physician aggregate the data from a well defined source such as a patient register; Case confirmation. This area of evaluation will cover the issue of the laboratory confirmation, as well as hospital records and reports from health insurance and how this is used in reporting;
Analysis and interpretation. This will cover the areas related to the interpretation of records by physicians at various levels to identify trends and geographic clusters. This will be based on the presence of graphs and tables to describe time, person and place for reported diseases and conditions, the identification of unusual trends or patterns exceeding defined threshold values and public health actions taken as a result of the analysis;
Outbreak investigation. The evaluation will have to gather information on the latest outbreak investigations which were carried out by the IPHs, including case finding, case management, contact tracing, procedures for investigating source of infection, collection and transport of specimens, confirmatory testing, interpretation of laboratory results, infection control measures adopted such as immunization activities, vector and other environmental control, community information and education, alerting nearby areas and districts and impact derived from the outbreak control.

5.1.1.3Methodology

The above mentioned discussions in the WG will pave the way to the methodology of the evaluation study on completeness, timeliness and accuracy of reporting by GPs, hospitals and labs. The scope will be to have a snapshot view of the recording system in a few sampling units taken from a roster of GPs, hospitals and Laboratories. The sample size and the sampling strategy will be according to the budget available and will not be based on any specific hypothesis to be tested.