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Programma di Sostegno alla Cooperazione Regionale

. Welfare and health cooperation in the Balkans. Workpackage 2: Epidemiologic analysis and healthcare planning Giovanni de Gaetano Francesco Gianfagna Campobasso, 4-5 Nov 2010. Programma di Sostegno alla Cooperazione Regionale. Demography. Shkoder 120.000 (est. ‘09).

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Programma di Sostegno alla Cooperazione Regionale

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  1. . Welfare and healthcooperation in the Balkans Workpackage 2: Epidemiologic analysis and healthcare planning Giovanni de Gaetano Francesco Gianfagna Campobasso, 4-5 Nov 2010 Programma di Sostegno alla Cooperazione Regionale

  2. Demography • Shkoder 120.000 (est. ‘09) • 55% rural areas - recent urbanization • Over65 ys will double in next 20 ys Albania 3.650.000 (est. ‘09)

  3. Epidemiological change Population Pyramid 1989 Male Female 85+ 7656 3661 80 - 84 6131 10513 75 - 79 12841 19052 70 - 74 19080 23094 65 - 69 31415 35538 60 - 64 38492 41593 55 - 59 53100 49420 50 - 54 66387 58044 45 - 49 76559 70285 40 - 44 76328 68729 35 - 39 99116 71452 30 - 34 130079 122053 25 - 29 153496 144149 20 - 24 156070 146149 15 - 19 167368 153639 10 - 14 169888 157069 5 - 9 179737 164736 0 - 4 197986 181172 0

  4. Epidemiological change Population pyramid 2001 Male Female 85+ 4592 10104 9623 80 - 84 14575 75 - 79 16701 22421 70 - 74 30802 33606 65 - 69 45183 42363 60 - 64 57825 55382 55 - 59 61732 58356 50 - 54 73840 69707 45 - 49 87736 83307 40 - 44 108671 106385 35 - 39 108476 110670 30 - 34 104517 111658 25 - 29 101909 111003 20 - 24 111107 120906 15 - 19 144829 150322 10 - 14 165782 159288 5 - 9 155602 147941 0 - 4 139755 130054 0

  5. Epidemiological change Life expectancy at birth, years 70-74

  6. Health Service change • Healthcare provider network out of line with the health needs • Mainly small hospitals Low health services effectiveness • Lower perceived quality care (low socio-economic groups) • By-pass of primary care, low health services utilization Inequalities in access to health services • Inform. System – IPH • Hospitals – HealthInsuranceInstitute (HII) • Primary Care – Directorates • – Rural health centers • – Management of HC provisionbyGPs • Improving HS utilizationthrough HC qualityimprovement

  7. Physician per 100,000 Albania 110 (HFA 2007)

  8. Aims • Shkodra Intervention support in • Health information system management • Education and training of healthcare workers • Health promotion in the population • Clinical activity • Albania, focusing on Shkodra Epidemiologic analysis for healthcare planning • Assessment of population health needs • Analysis of socio-health care system

  9. Methods • Analysis on availablenational data • administrative data from MOH, INSTAT and IPH • international databases HFA, World Bank • published surveys • Survey in ShkodraRegion • toverifynationalresults • toidentifycriticisms in Primary Care Service • toplaninterventions • questionnaires based on national results • perceptions of 30 HCWs (16 GPs, 7 pediatricians, 2 obstetric-gynecologists, 3 midwives, 2 nurses) Limit: lackofstandardized data

  10. Difference between WHO estimates and reported infant mortality

  11. 1. Population health status

  12. Risk factors - National data • Smoke (daily 40% of adults - M 60%, F 20%; children 16%) • Soft or hard illicit drugs (4% of youths from main cities) • Changes in diet habits and physical activity(malnutrition in 50% of children 1-5 yrs) • 40% of sexually active (transiting) migrants had sex with a sex worker abroad, 80% did not always use a condom • Sewage water contamination • Piped water and toilet in house • Daily interruptions of electricity

  13. Risk factors - Regional data

  14. Albania 2000 Bosnia and Herzegovina 2002 Greece 2000 Andorra 2002 Russian Federation 2004 Germany 2003 Bulgaria 2001 Latvia 2006 Hungary 2003 CIS 2005 Netherlands 2007 Poland 2006 Slovakia 2004 Georgia 2001 European Region 2006 Belarus 2008 Croatia 2003 Turkey 2008 Republic of Moldova 2006 Ireland 2008 Armenia 2008 EU members since 2004 or 2007 2006 EU 2006 Lithuania 2006 Spain 2006 Serbia 2006 Estonia 2008 EU members before May 2004 2007 Eur-A 2007 France 2003 Luxembourg 2008 Israel 2007 Denmark 2007 Cyprus 2003 Austria 2006 Kazakhstan 2004 Italy Ukraine 2008 Italy 2008 Belgium 2007 Czech Republic 2008 Norway 2008 United Kingdom 2007 Portugal 2006 Finland 2008 Malta 2008 Romania 2008 Switzerland 2007 Kyrgyzstan 2005 Slovenia 2007 Iceland 2008 Azerbaijan 2008 Sweden 2007 Uzbekistan 2002 0 10 20 30 40 Regular daily smokers in >15yrs, %

  15. SDR, smoking related causes per 100000 Albania 2000 Kyrgyzstan 2006 Bosnia and Herzegovina 2002 Kazakhstan 2003 Greece 2000 Ukraine 2004 Andorra 2002 Republic of Moldova 2008 Russian Federation 2004 Belarus 2001 Germany 2003 CIS 2004 Bulgaria 2001 Armenia 2003 Latvia 2006 CARK 2005 Hungary 2003 Azerbaijan 2000 CIS 2005 Uzbekistan 2005 Netherlands 2007 Eur-B+C 2006 Poland 2006 Georgia 2001 Slovakia 2004 Latvia 2007 Georgia 2001 Lithuania 2008 European Region 2006 Romania 2008 Belarus 2008 Hungary 2008 Croatia 2003 Slovakia 2005 Turkey Bulgaria 2006 2008 TFYR Macedonia Republic of Moldova 2003 2006 Ireland 2008 Tajikistan 2005 Armenia Estonia 2008 2008 EU members since 2004 or 2007 EU members since 2004 or 2007 2006 2008 Croatia 2008 EU 2006 Serbia 2008 Lithuania 2006 Albania 2004 Spain 2006 Serbia 2006 Czech Republic 2008 European Region 2008 Estonia 2008 Poland 2007 EU members before May 2004 2007 Denmark 2006 Eur-A 2007 United Kingdom 2007 France 2003 Malta 2008 Luxembourg 2008 Finland 2008 Israel 2007 EU 2008 Denmark 2007 Ireland 2008 Cyprus 2003 Portugal 2004 Austria 2006 Germany 2006 Kazakhstan 2004 Greece 2008 Ukraine 2008 Belgium 2004 Italy 2008 Iceland 2008 Belgium 2007 Luxembourg 2006 Czech Republic 2008 Austria 2008 Norway 2008 Slovenia 2007 United Kingdom 2007 Eur-A 2008 Portugal 2006 EU members before May 2004 2007 Finland 2008 Sweden 2007 Malta 2008 Norway 2007 Romania 2008 Spain 2005 Switzerland 2007 Italy 2007 Kyrgyzstan 2005 Cyprus 2007 Slovenia 2007 Netherlands 2008 Iceland 2008 Israel 2007 Azerbaijan 2008 Switzerland 2007 Sweden 2007 San Marino 2005 Uzbekistan 2002 France 2007 0 10 20 30 40 0 100 200 300 400 500 600 700 800 900 Regular daily smokers in >15yrs, % Expected to increase in the next years

  16. Morbidity - National data The health care system is ill prepared to face the increasing incidence of non-communicable diseases Decrease in infectious diseases, increase in chronic diseases • Prevalence of CVD and cancer have risen markedly over the past decade • Prevalence of Type II diabetes rapid increase in the last years (0.1% in 2008) • Incidence 6.3%, double the figures for Western countries • expected to double again in the next 20 years

  17. Morbidity – GP regional data Underdiagnosis? Increasing incidence, low service utilization

  18. Mortality • 7% 50 external causes • 5-10 violence • 10 road accidents, high with respect to traffic 4% 35 infant mortality 15-25 per 1000 live births <1% 5 infectious diseases <5yrs, resp. and diarrhea <1% 1 maternal mortality50 per 100,000 live birth 420 abortions ……...…230 per 1000 live births Death per 100,000 inhabitants per year - SDR, total 810 50% 420 CVD 15% 115 cancers - 25% lung cancer

  19. Births in • 84% maternity hospital (13% cesarean) • 8% other health center • 8% home births, more likely: • rural areas • the least educated • older women • no prenatal c. • Postpartum visit • 20% yes • 80% no rural areas, the least educated Maternal mortality & HS utilization – National data • Prenatal care • 10% adequate • 70 % inadequate (the highest in ECA) • 20% no care • 77% 1(or>)US,but low technical capacity

  20. Infant mortality & HS utilization – National data • Women registering their newborns: 20 % of them during the first week 72 % after the first week 8 % NO (25% of deaths just occurred) • Important predictor of infant mortality: • poor sanitary conditions in hospitals: • gloves and antibiotics not widely available • delivery practices substandard, drugs used inappropriately • midwives did not have the required skills and were infrequently supervised • the parent’s educationand mountainous region (5%, 1.3%Tir) • the number of prenatal visits and cesarean sections

  21. Maternal and infant mortality & HS utilization – Regional data Pregnants without gynecologist examination Urban area: 0% Rural area: 9.0% • All births in hospital, with neonatological examination • …however 2% of births in other hospitals, no gynecologists?

  22. 2. HCWs criticisms

  23. Criticisms – GPs • 44 GPs, mean experience of 10 years • About 3000 patients (comprising 600 children in rural areas) • 50% at least 1 visit per year • Requests: • ECG, Echo, Otoscope • Laboratory tests • Consummables (gloves…)

  24. Criticisms – ObsGyn • 2 gynecologists (mean exp: 30 years) and 12 midwives • Instrumentneeds: • Echo, computers, gynecologicbed • Labtests (pregnancy detection, urine albumine, microbiol.) • Perceived training needs: • Echographutilization • sex-transmitteddiseases

  25. Criticisms – PEDs • 10 pediatricians (mean exp: 25 yrs) in city, child 0-14 yrs • Instrument needs: • Computers and connections (100%), echo, otoscope • Drugs for urgent interventions • Lab tests • Car for transports • Perceived training needs: • Autism management (80% pediatricians) • Nutrition in child (nurses)

  26. 3. Interventions

  27. Interventions – Information System • Strengthen health information system to allow for informed policy decisions and monitoring of performance • Instruments and training for data management • No informatic archives in Primary care (paper records including name-surname-ID, profession, diagnosis and treatment) • Informatic skills: 7% high, 86% medium, 7% low

  28. Interventions – web based courses and consulting • Afford chronic disease increase by • preventive care (screening, build up the capacity of providers to adequately manage the conditions) • health promotion (mainly tobacco consumption)

  29. Interventions - Health education

  30. Conclusions • Intervention on Health Informative system according to IPH standards • HCWs training (regarding lifestyles, diabetes and echography during pregnancy) combining all the HCWs and hospital HCWs • health education in population (lifestyles) focusing on low income groups and rural areas …thankyou

  31. Malta 2008 Albania 2008 Ireland 2007 Latvia 2008 Russian Federation 2006 Sweden 2007 TFYR Macedonia 2006 Poland 2007 Israel 2008 Armenia 2008 Eur-B+C 2006 CIS 2008 Finland 2008 Norway 2003 EU members since 2004 or 2007 2008 European Region 2003 Czech Republic 2008 EU 2003 Lithuania 2008 Switzerland 2007 Ukraine 2008 United Kingdom 2007 Azerbaijan 2008 Republic of Moldova 2008 Slovakia 2008 Tajikistan 2006 Denmark 2008 Slovenia 2008 Uzbekistan 2008 Germany 2007 Kazakhstan 2008 Hungary 2003 0 50 100 150 N of mental patients in hospitals 365 days per 100,000

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