Estonian Human Development Report

Figure 2.6.1. Overview of the components of the
health system
Personal services
Non-personal services
Public sector activities
Other factors
I
N
V
O
L
V
E
M
E
N
T
Health
Source: World Health Organization. Health systems performance
assessment: debates, methods and empricism. Geneva, 2003
health-related services. Hospital care in the case of a serious
illness is the most easily understandable type of service,
although the category also includes initial medical
attention from a family physician as well as vaccination,
cancer screening, and syringe exchange services.
Non-personal health care services include, for example,
the provision of clean drinking water and all possible
sanitary hygiene, as well as information campaigns and
other methods of motivating beneficial health behaviour.
A significant part of the public sector activities aimed
at influencing health are actually related to the coordination
of policies in different fields and the consideration of
their impact on health. Economic and social conditions
related to people’s living and working environment affect
their health, as does the limitation of behaviour that damages
people’s own health as well as that of others close to
them, or the facilitation of activities beneficial to people’s
health. For example, limiting smoking has had a considerable
effect on the decrease in cardiovascular diseases and
lung cancer. Sales and advertising limitations have also
affected alcohol consumption, especially among children
and youth.
Thus, in addition to the coordination of the actual
provision of services, the role of the health system is also
important in inspiring all other sectors to act as beneficially
as possible to public health in their policy fields.
According to the WHO Tallinn Charter, general responsibility
for the joint effect of various policies on health lies
with the agency accountable for health in the public sector.
The role of health services
in health development
The roles of the provision of medical services and the population’s
health behaviour in the development of public
health are often contrasted. According to the modern
approach, both play equally significant and complementary
roles in improving the population’s quality of life. The
Tallinn Charter confirms that the ministers of health and
finance in the European region believe in the capacity of
strong health systems to save lives (Tallinn Charter, June
25–27, 2008).
The most complete recent approach to measuring the
effect of health systems on the population’s health stems
from the concept of “avoidable mortality” (Nolte & McKee
2004). This is a further development on the method created
by Rutstein et al. in the 1970s for measuring the quality
of health care services. According to the method, the
researchers select a list of diseases which are very unlikely
to end in death if there is an effectively functioning health
system in place (conventionally, premature mortality is
seen as death before the age of 75). It is not expected that
all deaths occurring as a result of the chosen diseases be
avoided, but the provision of a successful health service is
presumed to drastically decrease mortality rates related to
those illnesses. Thus, taking into account the interrelation
between illness and causes of death, the general effect of
health services on public health is more likely to be underthan
overrated.
The causes of death selected first are ones that are preventable
through medical care as well as secondary prevention
and medical treatment (i.e. “mortality avoidable
through treatment”), for example cervical cancer, hypertension,
appendicitis, etc. In the case of the second diagnosis
group, the avoidance of mortality is successful not
primarily due to immediate medical help, but rather
through inter-sector intervention of outside medical
care (i.e. “mortality avoidable through prevention”). For
example, this can be observed in the case of lung cancer
(avoidable through intervention that decreases smoking)
and liver cirrhosis (avoidable through intervention that
decreases the misuse of alcohol) (Nolte & McKee 2004).
Mortality related to ischemic heart disease – one of the
most frequent causes of death in developed countries – is
treated separately, since prevention and treatment play an
equal role in its avoidance (ibid).
According to a study based on this method, about
20% of men’s mortality and 30% of women’s mortality
(i.e. of total deaths in the population during a certain
time) would have been avoidable in Estonia as recently as
during the turn of the century through better organization
and provision of medical and public health services.
These percentages showed no significant decrease during
the entire last decade of the 20th century (see Figure
2.6.2.).
A comparison conducted by the same research team on
the changes that occurred in EU member states during the
1990s shows that compared to the old EU member states,
Central and Eastern European countries had higher mortality
rates across all types of mortality by the beginning
of the 21 st century. Comparing the changes during the last
decade of the 20th century, we notice that advancement
has been slowest in the Baltic countries (including Estonia)
and that the mortality rate even increased during the
period with regard to illnesses not directly related to the
health system.
What could be the stake of public services in increasing
people’s quality of life through improving and developing
their health? Table 2.6.1. presents a comparison
of the distribution of total health expenses calculated
according to the OECD method by service type in
2000 and 2006. In keeping with the health service concept
described above, this includes the majority of pub-
| 44