Włodzimierz Cezary Włodarczyk

In the process of searching for nearly half a century of new possibly effective forms of satisfying the health needs of societies, which have been undertaken with limited success in all countries of the world, an exceptional position should be attributed to the experience in the Netherlands. There are many reasons: not only the success of the changes carried out, not only the concept of a guaranteed health benefits basket confirmed by practice, not only the rarely used mechanism of competition between payers, but above all the consistency in the long-term preparation of a comprehensive change in the health system. At the same time, the constant dialogue with the society was not neglected, which allowed it to treat the introduced changes as its own.

The article presents the thesis that there is information available in the public sphere on the basis of which the situation in the Polish health system can be diagnosed. Such a diagnosis would make it possible to identify the problems experienced by patients as ailments and other problems which may lead to missing the chance of positive impact on the health condition. Since the study is focused on and confined to the diagnosis of problems, especially those perceived by patients as limiting, and leaves their explanation to be considered further, the range of sources is necessarily restricted. The following sources are indicated: WHO reports, European Health Consumer Index reports, Centre for Public Opinion Research (Pol. CBOS) reports, National Health Fund (Pol. NFZ) annual reports, WHC BAROMETER results and OECD documents. On this basis, it can be argued that a serious problem for the system is the multi-cause perception of the patients’ failure to meet their health needs, long waiting times for specialist consultation, diagnostic tests and hospitalisations, shortage of time and attention devoted to patients, issues of equal treatment of patients and – oftentimes – dissatisfaction with the functioning of the system. After formulating the outline of the diagnosis presented in this text, considerations were made aimed at explaining the revealed problems. 

According to the WHO definition Health Impact Assessment (HIA) refers to “procedures, methods and tools by which a policy, programme  or project may be judged as to its potential effects on the health of the population and the distribution of those effects within the population”. HIA has emerged from weather forecasts and is founding much  broader use. It helps to identify the factors, which have a potential impact on health. HIA may be relevant for all sectors to determine the effects, also unintentional, of their policies and actions on health and it has the potential to bring greater transparency to the decision-making process. Usually, it is very important to be able to foresee future health related effects, also by clarifying the nature of trade-offs in policy. Comparing and judging wanted and unwanted results is essential to choose a possibly best alternative and avoid harm.
In European Union where modern tools to rationalize decision making process are broadly accepted HIA has been welcomed, at least in declarations. Although some approaches to assess actions targeted at environment have been formalized and are binding, but others, including HIA, still depend on good will of partners involved. Both member countries and institutions are a bit reserved to use HIA. Insufficient popularity of HIA may result from scarce educational opportunities but also from deficit in well grounded scientific evidence.

Population ageing has been affecting all countries across the European Union (EU). To address the challenges resulting from this process, a healthy ageing strategy has been proposed. Healthy ageing aims at keeping older people in good health and independent as long as possible, and thus, improves their wellbeing. The aim of this paper is to present the EU healthy ageing policy, based on a review of EU documents related to this concept. A method of narrative literature review using a snowball approach has been applied.

The results of the review show that healthy ageing is a broad concept which covers various issues, such as promoting health enhancing behaviour, disease prevention, changing the social perception of older people and providing conditions for the independent living of older people. Healthy ageing has often been dominated by active ageing strategies which are focused on increasing older people’s labour market participation and social involvement. The EU actions in the area of healthy ageing include: increasing awareness and encouraging relevant stakeholders to undertake actions to address the needs of older people (e.g. the 2012 European Year for Active Ageing and Solidarity between Generations), providing funds (e.g. Health Programmes) and providing platforms for cooperation and exchange of good practices (e.g. the European Innovation Partnership on Active and Healthy Ageing). 

Public health has always sought to use scientific findings in health-enhancing activities. At the end of the twentieth century, a program to use scientifically validated evidence in public health – evidence based public health (EBPH) – was formulated. Rigorous application of evidence was supposed to guarantee effective and efficient interventions. When the global threats of Covid 19 pandemic appeared, it seemed to be a great opportunity for EBPH to reaffirm its value. Societies, as well as governments, could have hoped that scientifically equipped public health would be able to cope well with the threat. However, reality has brought disappointment. It turned out that public health does not have enough confirmed evidence to support policymakers. In many situations, both politicians and medical doctors had to make quick and inevitably intuitive decisions, without documented evidence. The pandemic has forced the need to search for evidence more quickly, but it has raised the question of whether the procedure for validating evidence must be as rigorous as it had been recommended in the past. Under pressure emerging needs, a number of evidence-based recommendations have been prepared and offered to decisionmakers to be used.

This paper concerns the events that occurred in the span of thirty years – from the 1986 Ottawa Charter for Health Promotion to the 2016 Vienna Declaration supporting it. The purpose, however, is not to discuss the substance of these events, but what should be defined as their context, in particular the political one. The text is divided into two parts relating to both of the documents mentioned, where the content of the message about health promotion formulated at that time is presented, together with the context in which it was created and received, and – briefly – its consequences. With reference to the context of the Vienna document, the issue of post-truth era will be discussed in more detail. The analyses devoted to the two parts will include addressing two problems that affect the issues under consideration: the concept of Health in All Policies and the issue of the susceptibility of various social classes to the arguments presented in health promotion programmes.

The concept of „Health in All Policies” (HiAP) was presented for the first time, under this name, in 2006 in a book devoted to the issue. Even if traditionally it relied on ideas of “intersectoral cooperation” or “healthy public policy” which had been disseminated and popularized by World Health Organization it was unquestionable contribution by experts and politicians from  Finland to make it theoretically relevant and politically attractive. The initiators enriched the concept itself and furnished  sufficient amount of energy to acquire partisans in many countries and international institutions.

The concept is founded on models accepting many determinants of health and their dynamic nature. Many factors impact health status, it changes over time and they evolve as well. Even when external factors are not taken into account individual’s health goes forward, or rather backward.  A great majority of all these factors lie outside control of medicine, medical sciences and ministries of health.  The multi causational models of health determinants help to identify these areas of human activities – undertaken also in a form of many public policies – where processes affecting health may appear.  Very often the authors of a public policy remains unaware that his/her initiative can influence health and sometimes the results are deplorable.  The decision makers can avoid taking improper decisions provided they have sufficient consciousness and access to necessary information. It is also workable of in a government a special job is set up to warn in advance that a project or programme under consideration may cause health consequences. It is very practical to use procedures and tools offered by Health Impact Assessment (HIA) approach but it is essential to guarantee all indispensable political acceptance and support to make the process appropriately    efficient.

Set of procedures referred to as Health Technology Assessment (HTA) becomes more and more popular among health policy makers in many. There are two factors contributing to this process. Firstly, it is universal access to health services and their guaranteed financing from public  esources.
Secondly, a pressure exerted by manufacturers of pharmaceuticals and medical equipment who looks for profit. The choice which is to be made by decision makers is difficult. If new technologies are implemented too late – there are losses in health and a dissatisfaction of citizens is growing. If they are implemented to hastily, without necessary tests, there are losses in health again and public payer has to pay – and waste – a lot of money. HTA opens a way to make more rational decisions.

In European Union democratic values have been approved unquestionably. They may be derived from many sources like from its own, dignified tradition linking back to Declaration of the Rights of Man and of the Citizen of 1789 or United Nations documents. In the Lisbon Treaty on functioning of European Union there are words about the space of freedom, safety and justice, equality between men and women, and equality of chances. UE has obliged itself fighting against all forms of inequalities and discrimination. As one of authors said: equality, cohesion and social justice this is the material of which Europe is constructed. They are not only the object of declarations and recommendations, but active implementation attentively watched by the whole world.
In this paper I deal with two aspects of the workings undertaken within the UE which are aimed at reduction of health inequalities. First refers to actions resulting from common initiatives, therefore activities belonging to responsibility shared by EU and member countries. In second part questions raised from initiatives promoted by countries holding presidency are analysed. Rather frequently these countries made a very essential influence on the way of perception and solving the problems of health inequalities.

Occurrence of the COVID-19 Pandemic was totally unexpected, and governments of all countries were surprised. Pandemics always raises the feel­ing of fear and health policy is interested in such phenomena. In this specific case it was fully justified as COVID-19 was new and unknown. Every­where the populations found themselves in psychological position presented years ago by Ulrich Beck in book Risk Society. Influencing and shaping society’s emotions – both feelings of safety and feelings of fear had a fundamental importance for social behaviour.

In time when first information about COVID-19 came from China and Poland was still free from any infection, the government’s representatives tried to play down the seriousness of the virus and equated the COVID-19 to a seasonal flu. At that time, it could have been justified as an attempt to avoid panic. But with the first episodes of infections the tone of messages essentially changed, and the virus was presented as a lethal danger. Such a con­text was applied as a direct rationalization of general lockdown and a broad catalogue of restrictions in social contacts.

However, when The Presidential Election was approaching (with the act of balloting demanding presence of people in a polling station), the content of messages presented to the public changed again. In the new version the virus itself was shown as rather innocent and the pandemic was contained and under control. In this way all voters, including elderly people, were encouraged to take part in the election.

If lessons are to be drawn from the past, we might conclude that in time of a pandemic, the instrumental management of social emotions and feel­ings is not always the best way of communicating with the general public.

Health policy as a process and as activities in the sphere of public responsibility may cause different evaluation problems but at the same time the proper and reliable assessment should be understood as the essential interest of the engaged stakeholders: government at different levels, payers, providers and patients as well. The paper concerns the problem of difficulties influencing the research focused on the health policy description aiming at the indication of the most important factors, effects, possible development dimensions that may significantly change the health system. The methodology in this case is also a complicated issue: quite often based on the instruments typical for social disciplines but not completely applicable for the presented subject. The paper describes the new innovative and universal tool for the purpose of the analysis aiming at reliable and comparable health policy assessment, it presents the stages and objectives of such evaluation and the perspectives of the HPA matrix development both for research and for didactic purposes.

Public health community worldwide encouraged by successes of former campaigns have always accepted vaccination as the most effective way to handle infectious diseases pandemics. Even before the outburst of SARS-CoV-2 pandemic in many countries mandatory vaccination against many diseases, especially child related had been implemented. From among 193 countries under study in as many as 105 (54%) such obligation existed and in 62 of them (59%) at least one form of punishment or harm for those opposing was involved. Following this sort of available solutions and facing COVID-19 pandemic disaster the authors on behalf of the Public Health Committee of the Polish Academy of Science recommend to the government implementation od mandatory vaccination against COVID-19 for all workers in sectors of health care, education and welfare.

When pandemics Covid 19 hit Poland, the people’s readiness to observe the recommended rules of rational healthy behaviour was partially hampered by the lasting activities of anti-vaccination circles which were appearing at grass root level and among parliamentary politicians. These activities were supported by a component the medical persons who provided an impression of professional authority. This situation to the growing scepticism in the face of rational sanitary recommendations, the fact what was revealed the social attitudes investigations. Decision-makers’ negligence who implemented many inappropriate legislative measures also contributed to the disappointing effects. Sometimes the authorities tried to withdraw partly from this mistake - obligatory masks wearing is an example - but such facts did not strengthen people’s willingness to follow recommendations. The authorities abandoned its concern of employees and clients health and refused to equip the management with the rights to check up their vaccination status. Following the same line the Government confirmed the Universities could not verify the students’ vaccination status or implement any restrictions for unvaccinated. The rectors trying to undertake any measures were criticised.

It is justified to assert that decision-makers’ mistakes contributed at least partially to smaller efficiency anti-pandemic interventions, than this was potentially possible.