EPHA/ASPHER public health event in Debrecen, Hungary

The event took place on 18 and 19 May 2010 at the Faculty of Public Health of the University of Debrecen, an active ASPHER member organisation who also provided first rate logistical support and arranged the local speakers. Hungary represents one of EPHA’s three target countries for ongoing capacity building activities (alongside Poland and Russia) and this event represented a first step to gauge the level of interest and identify those public health issues most in need of attention at European level.

The conference - attended primarily by staff and students from the University of Debrecen and other Hungarian research institutes - was spread over two half days, each split into two sessions of approximately 2 hours. The conference language was English and a number of international students were present, notably a group from Nigeria who were also the conference Rapporteurs.

The first day focused on identifying the many different yet overlapping health challenges faced in Hungary today, as well as on structural and economic issues that have an impact not only on health, but also on civil engagement and social cohesion. EPHA demonstrated the role Europe can play in bringing about a mentality change in favour of more active stakeholder communication and networking. Day two focused on the public health education system in Hungary and the value of introducing a European competencies system as proposed by ASPHER.

Following a brief opening speech by Conference Chair Professor Roza Adany, Dean of the Faculty of Public Health, EPHA’s Governance and Membership Coordinator Sascha Marschang welcomed the audience and explained that this was the first in a series of capacity building events EPHA was planning for Hungary. Hungary is one of the few Eastern European countries where EPHA currently has no member organisations and although many NGOs existed in the country, their voices remained weak, especially at EU level. This event was an opportunity to identify and discuss the major health challenges and needs in a country where - as EPHA had repeatedly heard from its Hungarian contacts - economic and political factors had hampered the progress of public health and the leverage of NGOs. EPHA, ASPHER and the Faculty of Public Health at the University of Debrecen all shared a commitment to stakeholder dialogue and intersectoral communication.

Public health advocacy in Europe

The first session was facilitated by Sascha Marschang.

EPHA’s European Policy Manager Anne Hoel provided the first presentation by explaining the structure and working methods of the European Institutions, as well as their activities and competencies in the field of public health. She highlighted that transparency was important to all EU actors and that the openings for CSOs and ordinary citizens were more numerous and less complicated than many believed. Participation in consultations, lobbying national MEPs or regional representatives, and writing letters to the relevant authorities (e.g., to the European Commission to influence various policy documents or to the European Ombudsman in cases of maladministration) were some of the avenues available to influence EU politics. Individuals could make a difference and given Hungary’s upcoming EU Presidency in 2011, this was a good time to become active.

Anne also disentangled the Brussels ’’lobbyist jungle’’ that EPHA was a part of and that many non-EU actors found difficult to grasp. As an NGO umbrella platform and "network of networks", EPHA was active on all layers affecting individual health and given its broad mission, it could intervene both at high level meetings in Brussels and stimulate dialogue at national and regional levels. By engaging EU actors in advocacy campaigns the profile of an issue could be raised significantly.

Peter Makara, Associate Professor at the University of Debrecen, Secretary of the NGO Hungarian Association of Public Health Training and Research Centres, and also a former civil servant, contributed his experience in different sectors. His presentation focusing on the status quo of public health civil society and advocacy in Hungary. He started off by highlighting the specific historical reasons (e.g., existence of centralised, top-down political and economic structures, rapid move from socialism to capitalism, etc.) as to why local and civil engagement were still nascent in the country.

He then underlined the benefits and risks of civil society-government interaction, e.g. governments could gain support in promoting national and EU values as well as fresh policy perspectives and expertise, while CSOs might gain legitimacy and social capital through access to training, etc. One risk for CSOs was that oftentimes, a few select organisations were taken to be a unified movement - yet there were many different types of NGOs and other organisations active in Hungary, addressing a whole array of issues ranging from the individual to the social. Dependence on public funding could also distort their voices.

Rounding off the first session, EPHA’s Policy Officer for Global Health Threats Dorota Sienkiewicz gave an overview of the main mental health challenges experienced in Hungary and the role that Europe could play in mitigating these. She emphasised again the importance of advocacy: Europe was not just about programmes and funding. An article on her presentation can be found here.

The subsequent discussion focused on the value of having reliable data on mental health, e.g. in the Eurostat database. Therefore it was hard to draw reliable comparisons. The role of impact assessments and gender mainstreaming in achieving ’’Health in all Policies’’ was also addressed. With regards to impact assessments, participants deplored the lack of a homogenous methodology. Dr. Makara pointed out that the Hungarian government instigated a national budgetary fund that the 2,000 NGOs working on health-related issues could draw from.

Hungarian public health challenges: "Waiting for Godot?"

This session was facilitated by Peter Makara who explained there was a window of opportunity to influence politics following the Hungarian elections the previous week. Political change was welcome but a lack of resources often impeded the successful implementation of health policies. He singled out smoking, alcohol and cardiovascular disease-related problems as some of the main health problems in Hungary, particularly affecting the poor and also women. Cancer was the most common cause of death amongst the poor.

Professor Janos Sandor, University of Debrecen, delivered the first presentation showing statistical evidence related to trends in the major health problems and social determinants of health in Hungary. The country experienced particular problems with regards to e.g. life expectancy at birth and mortality rates due to cervical cancer, alcohol- and smoking-related health problems. Referring to the WHO Commission call for ’’closing the health gap in a generation’’, he stressed the relationship between wealth and health and also underlined the social determinants of health and health inequalities. Sadly, mortality at the end of the 20th century was still almost as high as it had been at the beginning, which proved that the material base (in terms of equipment and technology) was not enough to explain the current complex situation.

He then showed how EU health action - whether translated into policies, strategies, programmes or research - can have a positive impact on health inequalities, health care access, disease prevention and health promotion.

Professor Adany then identified the major challenges and opportunities that existed in the Hungarian public health landscape. Her comparative data showed that Hungary now featured almost at the bottom of the table for life expectancy at birth amongst CEE countries. There were very high rates of non-communicable disease morbidity and mortality (e.g. due to malignant neoplasms, chronic liver disease, diabetes, unknown causes, etc.) - also owing to the absence of adequate screening and monitoring programmes - and individual health behaviours were unfavourable, e.g. low rates of physical activity and bad nutrition.

Other issues highlighed were high suicide rates, health outcome discrepancies between rural areas and county capitals, and the devastating impact of home-made spirits containing toxic ingredients of unknown and illegal origin. Moreover, the evidence showed the correlation between Roma communities and high mortality rates.

Perhaps even more telling was the low level of communication between policy makers and health professionals. Regarding the financing of the health system, one major problem flagged was that GPs are financed on a capitation system which means that performance - and health prevention - are not really that important. That said, the Hungarian health system had seen important reforms over the last decade; however, the public health community was still waiting to see tangible results.

To finish off the day, Professor Karolina Kosa, also of the University of Debrecen, illustrated a concrete example of applied public health research related to Roma health. She reminded the audience that it was difficult to collect reliable data on Roma populations and that often there were no clear linear relationships between factors influencing health. The University of Debrecen has been working with local Roma communities for years and one particular example of a Roma community was given where research and impact assessments undertaken contributed to an integrated project that addressed, and ultimately improved, the specific health needs related to housing, education, substance abuse, employment, and intra-group relations. This was also part of an advocacy strategy including lobbying (creation of a public-private consortium including representatives from the university, local government, social services, the Church, employers, etc.) and, following this step, the creation of an NGO (Opre Roma).

The NGO in particular contributed to giving the project an institutional identity (e.g., the simple act of having it registered on university premises conveyed trustworthiness, which helped Roma representatives to be seen as equal partners). However, subsequent attempts to receive local government funding for a self-managed, sustainable housing complex project failed, which demonstrated the limits of NGO-government partnerships in Hungary.

The ensuing discusssion established that overall, the national government’s Roma strategy was a pitfall not in terms of financing, but for lack of proper coordination.

The final two sessions were moderated by Sascha Marschang who stated that the previous day had contributed common ground for common thinking. From EPHA’s perspective this was particularly important for an audience composed of public health students who would become the next generation of researchers, administrators and practitioners in the sector. He provided some background information on the EPHA-ASPHER collaboration and explained that stakeholder involvement was a priority for both parties. The ASPHER presentations were part of phase 3 of a strategic planning initiative that also included the development of a European system of competencies to support public health education and practice.

Session 1: Public health education in Europe and Hungary

Professor Adany addressed the audience again and gave the necessary background information on the public health education system in Hungary, with a particular emphasis on the courses offered by her faculty and the European Bologna process to facilitate a border-free higher education area (with shared learning priorities and quality expectations) that would facilitate mobility through the recognised compatibility of qualifications.

Her overview was followed by Anders Foldspang, Co-Chair of the ASPHER competencies program and the new Dean and Director of the Nordic School of Public Health based in Gothenburg, Sweden. After recounting the main public health challenges in Europe, he talked about the many complex difficulties that public health students and professionals had to tackle: one one hand, existing and new population health challenges needed to be met, on the other hand new methods for disease prevention and health promotion had to be continually developed, and that in a cost-effective way. Public health professionals must work to make these interact. This was particularly hard to achive in Europe, where no comprehensive public health systems existed at national levels and different and/or fragmented models were in place in different countries. Therefore, an awareness of the essential public health functions, including research, and the demonstrated competence in a number of key professional skills was becoming more and more urgent.

Finally, Dr. Christopher Birt, a Board member of both ASPHER and EPHA, Chair of the Competencies Program and also employed by the University of Liverpool and Sefton Primary Care, addressed the audience and presented ASPHER’s initiative to develop a set of European public health competencies that would at the same time have general applicability, i.e. they could be applied and recognised in all EU countries thus facilitating mobility and common standards of training, while also leaving room for national and regional differences (e.g., specific health challenges faced in a country). The ASPHER initiative was educationally based to provide a service to public health schools, however competencies would only be useful if they were applicable in a ’’real life’’ context. He thus asked the audience about their thoughts about European core competencies, in particular whether they were relevant to (and could be tested on) the public health workforce, whether they supported professional development, and whether practitioners could be engaged in such discussions.

The post-presentation discussion addressed overlaps between the efforts made by ASPHER and the American Public Health Association, with Dr. Birt stressing that the heterogenity of the EU did not really allow for an easy comparison with the US. However, certain core elements could be identified and/or developed which could then be ’’translated’’ into unique health systems in the EU.

A student asked whether there had been any regional efforts to create generalised situational competencies, referring to minorities groups such as Muslims in France, or Roma in Hungary. Dr. Birt stated that the ability to identify the basic needs of a given community was a key skill, and that the ability to put health into the hands of a community could also empower minorities. Knowledge and skills competencies were thus closely interlinked.

The Nigerian group of students affirmed that many of the competencies they had acquired in Hungary would also have direct applicability in Nigeria, however this would not change structural or societal problems.

Session 2: Using Europe to lever better Hungarian health

This final session was cut short as a result of the discussions surrounding the usefulness and applicability of the ASPHER competencies programme and the need to finish on time due to other scheduled events at the university.

The Rapporteurs of the different sessions, a group of Debrecen-based Nigerian public health students who had also actively engaged in the formal and informal discussions on both days, summarised the main points contained in the different presentations of the three previous sessions. Finally, Roza Adany thanked the audience and said it was important to continue the work started here and remain optimistic.

Prior to the Debrecen conference, EPHA’s Dorota Sienkiewicz and Sascha Marschang attended a number of stakeholder meetings in Budapest to learn more about health inequalities and gaps in Hungary. The message they took with them was that, following increased activity surrounding EU accession in 2004 and high expectations connected to this momentous event, there appears to be a certain sense of disempowerment which is connected to economic and political problems. While there is currently a "window of opportunity’’ to address the most pressing public health challenges and lobby a newly elected government, the communication between different sectors (government, NGOs, academia, industry) remains poor. The country also lacks an effective public health umbrella network that can address multiple challenges, unite NGOs working on different health issues, and that could also become an effective player at European level.

EPHA will therefore create a capacity building task force that will continue its work with ASPHER to highlight advocacy and communication (as core competencies in Europe), but that will also seek to engage local NGOs and other Hungarian organisations to participate in future events to obtain a broader view of how the various health threats and priorities identified at this conference can best be approached.

For Futher Information

 Association of Schools of Public Health Education in the European Region, Working Group on Public Health Core Competencies
 University of Debrecen Faculty of Public Health

Related EPHA Articles

 Mental health in Hungary - what role for Europe?
 EPHA Briefing Paper and Policy Recommendations on Roma Health
 Training seminar on alcohol related harm and primary care, 4-5 May 2007, Budapest, Hungary
 Mapping of NGOs in the new Member States, 2006