Current and former directors of the Polish National Institute of Public Health – National Institute of Hygiene talk about the past and future of the institute. Collaboration and standardisation emerge as key themes – for both Poland and the rest of Europe.
The Situation in Poland
The National Institute of Public Health – National Institute of Hygiene was founded one hundred years ago in 1918, when Poland gained independence. Dr Grzegorz Juszczyk, the current director, and former director Professor Mirosław J. Wysocki explain how the institute works and the state of health in Poland
Dr Juszczyk describes the three main aims of the institute:
- Monitoring health status, risks (epidemiological and risks, including unhealthy behaviour), and collecting statistics on unhealthy behaviours. Every two years the institute publishes a report on the state of health in Poland, and on the determinants of this status.
- Making recommendations concerning communicable and non-communicable diseases based on evidence, to support all organisations responsible for delivering public health interventions
- Evaluate processes in health care and public health system to implement and perhaps change strategies locally and nationally.
These are spread across three areas of activity:
- Epidemiological surveys and prevention and control of communicable diseases
- Environmental threats – issues such as air pollution and water quality.
- Non-communicable diseases (NCDs), health promotion, prevention, communication, and education.
Professor Wysocki explains NCDs are the main killers in Poland: cardiovascular diseases are responsible for 45% of deaths and cancer 25%. Accidents account for 6-7%. Some of the main contributors to disability are also NCDs. Mental ill-health, particularly depression and dependencies, is a major problem along with COPD, chronic non-specific respiratory diseases, and degenerative muscular-skeletal diseases. From a population of 38 million, approximately 3 million people suffer from some form of diabetes of which the most prevalent is type two. He stresses that disease prevention and health promotion are, therefore, an important part of their work.
Government spending on health is low at c.4.8% of GDP, which is once of the lowest in the EU. Professor Wysocki explains that an additional 1.2% comes out of people’s pockets. He adds that this will soon change and by 2023 the government’s contributuon rate will increase to 6%. However only 2-3% of the budget goes to public health.
Health inequalities in Poland
To explain health inequalities in Poland, Professor Wysocki describes the situation in Warsaw. The difference in life expectancy for both men and women living in the south of the city compared to the north is about 12-13 years. He attributes this to social determinants. The levels of smoking, alcohol misuse, and homelessness are much higher in the ‘North Praga’ neighbourhood than in the south of the city which also has higher levels of education.
When asked how the institute can respond to such stark inequalities in a population of around three million, collaboration is the answer. “We cannot run interventions alone as an institute, but we can publish data, collaborate with ministries, and inform local authorities to explain the problem and what can be done. Good cooperation with traditional and social media is also very important. We can motivate local and government authorities to develop interventions, and inform people living in these neighbourhoods about the causes of their poor health” explains Wysocki
“At the moment, an individuals’ access to public health initiatives depends on where they live.” acknowledges Dr Juszczyk. He explains that “There is a need for a system which gives every citizen access to certain activities, either in education, in the primary care setting, or through all local governments.” The PROFI BASE project (ongoing, ending in 2021) aims to support this idea. It is analysing the many different initiatives currently on offer from the diverse organisations working on public health, shaping them, and trying to make them available to all. By the end of the project, Citizens, local government sanitary inspections, and primary care professionals will be able check online what kind of activities are available in their neighbourhood. It is funded by the European Commission and the Ministry of Health.
Professor Wysocki also describes a relatively new government initiative which may impact health inequalities called ‘500 plus’. Mothers with more than one child gets 500 PLN (c. €120) per month per additional child until that child reaches 18. The scheme has been in place for nearly two years so the long term results cannot yet be established, but in the first year the number of live births increased by about 20,000 and the poverty rates have lowered.
Dr Juszczyk explains that two groups have been identified as being at risk of health inequalities in particular. The first is men in towns with less than 5,000 people – there is a need to understand their personal motivations to convince them to think about their health, seek information, and understand the information provided. The second group is elderly people who have a clear need for information, but a different capacity to learn.
30 years of changes
The health of the population has changed quite radically in the 29 years since the end of communism in Poland. Life expectancy has increased by eight years. Around 8 million Poles have stopped smoking. Infant mortality –a measure of living standards, health, wellbeing, and wealth – has also gone from 16 per 1,000 live births to below 4 per 1,000 today. Professor Wysocki explains that although the institute could not carry out its own large interventions by collaborating with various ministries and the media, they have been able to make a difference. “By monitoring health status, promoting healthy lifestyles, improving the environments, monitoring and promoting vaccinations, the institute contributed to these improvements.” During Wysocki’s tenure as director, the institute began to work more on the epidemiology of non-communicable diseases such as cardiovascular diseases, malignant neoplasms and diabetes.
Integration and Collaboration Between Institutes
Dr Juszczyk explains that in Poland, there are several different institutes working on different aspects of public health and all with a shared goal – a long term, stable increase in the health status of our population. Initiatives currently are scattered, and there is no shared long-term strategy. He strongly believes that collaboration is the key to unlocking potential and improving efficiency; it would allow organisations to cooperate rather than compete for funds
“The idea is to integrate many institutes under one umbrella and ensure all are ‘speaking the same language’. Initiatives can be integrated developed into a long-term, multi-faceted, diverse approach. We know that we have many different initiatives, and now we would like to pull them all together under our monitoring, recommending, and evaluating umbrella. This would help us to spend funding on public health initiatives in a more efficient way.”
He explains that the vaccination programme (explained below) is a good example of such a long term, collaborative initiative which addresses health inequalities but “We don’t have such an approach that would reduce health inequalities in other areas, for example in access to evidence based initiatives for smoking cessation, reducing alcohol consumption, and supporting physical activities.”
Some collaborating work is already underway. “When we had a project that aimed to educate young people about UV protection, instead of thinking about how to reach the young people directly, we went to the sanitary inspection which already has access to every young person in school.”
Dr Juszczyk envisages the institute taking a connecting role – bridging and linking all other organisations.
Professionalisation of the public health workforce
For Dr Juszczyk the professionalisaton of the public health workforce is a key issue, for Poland and for Europe. “There needs to be a clear definition of public health professionals, and their role in the health care system needs to be clarified” he explains.
His aim is to create standardisation and a clear career path for graduates in the public and private sector. The institute is currently working with other similar bodies, ASPHER, and the WHO to make this happen
The first step is to collaborate with large employers and schools to establish competencies and skills needed. This, he explains, is key “we are currently analysing needs in order to develop a short term skills development programme that would enable the public health professionals to really fit into the needs of the employers.”
This analysis will form a framework agreed with ASPHER and WHO, and then a voluntary registration scheme will be opened. Finally, certification will be introduced using a common exam. This will ensure that all graduates are capable of delivering the activities required by the health care sector. Continuing professional development opportunities will be introduced by universities and the institute.
The primary target for this professionalisation scheme is students graduating from public health courses, but the hope is that eventually the scheme will expand to related professionals where the value of collaboration is clear. This includes nutritionists and social workers.
Communication – Making health information accessible to all.
Currently multiple institutes provide information on different aspects of health, but an initiative to create a centralised reference website, similar to the well-established NHS choices site, is now underway. It will provide evidence based materials for all – appropriate for different levels of literacy – on all major communicable and non-communicable diseases, as well as information about how to navigate oneself in the health care system.
This is, again, thanks to a collaborative effort. Whilst the institute can’t be responsible for national strategy or mass communication campaigns, it can help provide evidence. It is therefore collaborating the national chamber of physicians, the patients ombudsman, the sanitary inspectorate, and others to create, develop and promote the tool.
High Vaccination Rate at Risk
The vaccination rates in Poland are high. Some 93% of children are vaccinated on schedule explains Professor Wysocki, but over the last 10 years the number of parents not vaccinating their children has increased from 3,000 to 30,000 “You explain what a vaccine is, how it’s done, how much good they do, how many diseases disappeared and how, if you don’t vaccinate, some diseases like measles return, but very often those anti-vaccination movements are convincing and it’s hard to communicate. This is a very special and difficult issue. This is a big issue for the ministry of education, the ministry of health, and our institute.”
Dr Juszczyk agrees the clear need to address vaccine hesitance, and on the importance of persisting with clear communication. The institute will continue monitoring the situation, and a plan is in place to produce more information for the public which is tailored for different levels of education. To that end, a website addressing these issues has been created.
Hepatitis C: Clear progress made
Hepatitis C is the main infectious disease in Poland explains Professor Wysocki. There are an estimated 180,000 cases in the country – although only 15,000-20,000 infected people know they have the disease. Despite the high numbers, progress is being made. Effective treatments are being delivered and 7-8,000 patients are now being treated annually. Over the last four years, the institute has been contributing to an important, multi-faceted intervention based on a Swiss-Polish project. Training was one key element of this: around 1,000 medical staff were trained, including those working in places such as medical intervention sites dental surgeries where infection can still occur. A further 5,000 non-medical staff such as tattooists and barbers were also trained. In addition, a media campaign providing information about the diseased was launched in traditional and social media.
In recent years the institute has begun to collaborate with a number of other organisations on to study the prevalence of mental ill-health in the population. In order to better understand the level of ill-health and its determinants, a first study has been conducted using a survey addressing different aspects of mental health. The findings were surprising to some extent explains Professor Wysocki. For example, the level of depression was estimated to be well below 10% of the population. The results of a similar study run by the institute of Psychiatry and Neurology will now be consulted.
A personal mission
Talking of his personal motivations, Dr Juszczyk hopes that by the time he retires public health will be understood in the same way as primary care, with public health professionals fully embedded in the health care sector. The development of a model to provide information about health risks and opportunities to improve health to the population in a systematic way is also a goal
Professor Wysocki recently stood down as director but retains his positions as the head of the institute’s Department of Health Promotion and Prevention of Chronic Diseases, and National Consultant in the area of Public Health. Looking back at a rich and diverse career, he notes the institute’s work on hepatitis C as one of many achievements. After retiring, he plans to continue lecturing and looks forward to having more time to write. He is about to finalise a book on his 12 years of WHO work in South-East Asia (1988-2000)
About the directors
Dr Grzegorz Juszczyk is the director-general of the National Institute of Public Health in Poland since October 2017. He is a public health specialist who has worked as a researcher at the Department of Public Health at the Medical University of Warsaw in Poland. He received his Master of Public degree in Poland (Jagiellonian University in Kracow) and in the Netherlands (Maastricht University). He has also graduated from the one-year preMBA managerial training.
Dr Juszczyk earned his doctorate degree in public health from Medical University of Warsaw in 2008. His main research interest concerns health of working population and interventions that may increase healthy life years. Since 2003 he has worked as a consultant and had the opportunity to plan, implement and evaluate health promotion activities for employees and their families in more than 200 public and private companies in Poland. He has also supervised the processes of health needs assessment for employees and teams implementing preventive and educational activities for more than 1,200,000 people. In 2013-2016 on behalf of Polish employers he had been a member of the Advisory Committee on safety and health at work (ACSH) by the European Commission.
Professor of medicine, Dr. Mirosław Wysocki graduated with a degree in medicine from Warsaw Medical University. In 1971–72, he was WHO Senior Research Fellow in the Department of Epidemiology and Social Medicine of St. Thomas’s Hospital Medical School, London, UK. From 2007, Prof. Wysocki was Acting Director and between 2010 and February 2015, Director of the National Institute of Public Health – NIH, Warsaw. In October 2015 he was again nominated by the Minister of Health for the post of Director of NIPH – NIH. He held this post until September 2017. He continues he work as a National Consultant int the area of Public Health.
He has specialisation degrees in epidemiology, internal medicine and public health. Regional Advisor (P5), Health Situation & Trend Assessment, WHO/SEARO and WHO/HQ Geneva, 1988-2000. In 2006 he took part in WHO 2 months “Tsunami Mission” in the countries of South-East Asia. He is the coordinator of international epidemiological studies of NCDs (COPDs, diabetes, rheumatic diseases) and author and co-author of some 180 publications and chapters on epidemiology of NCDs and public health. He chaired the Senior Level Public Health Group of EC during Polish EU Presidency in 2011.
Prof. Wysocki represented Poland at many WHO WHAs, EBs and Regional Committees. Member of WHO/EURO Standing Committee 2010-2013. National Public Health Consultant in 2010-2011 and at present since October 2014. Member of Independent Expert Group of DG Research and Innovations of EC (2012-2013) on the priority public health research in HORIZON 2020.