Application for SMDP Applied Management Learning Project Award 2006

Submitted by Davorin Gajnik

The Zagrebacka County – Healthy County

Our experience with “Health – Plan for it” Project

MIPH Alumni Sponsoring the Submission Dr. Selma Sogoric, MD, MPH, Ph.D. (MIPH 2001) Andrija Stampar School of Public Health Department of the Social Medicine and Organization of Health Care Services Medical School, University of Zagreb Rockefellerova 4 10 000 Zagreb, Croatia tel: 385 1 45 66 996 fax: 385 1 45 90 275 e-mail: ssogoric@snz.hr Dr. Ognjen Brborovic, MD (MIPH 2003) Andrija Stampar School of Public Health Department of the Social Medicine and Organization of Health Care Services Medical School, University of Zagreb Rockefellerova 4 10 000 Zagreb, Croatia tel: 385 1 45 66 996 fax: 385 1 45 90 275 e-mail: obrborov@snz.hr Project leader

Davorin Gajnik County of Zagreb Administrative department of health and social welfare Ulica grada Vukovara 72/V, ZAGREB Tel: 385 1 6009 430, Fax: 385 1 6009 432 e-mail: d.gajnik@zagrebacka-zupanija.hr

1

Project team members: Mirjana Matausic-Pisl, Deputy County Governor, Zagrebacka County Davorin Gajnik, Head of Administrative department for health and social Welfare of Zagrebacka County Tihana Zemljak, Adviser for social welfare, Administrative department for health and social welfare of Zagrebacka County Zvjezdana Fabijan, Epidemiologist, Institute of Public Health, City of Zagreb Slavko Lovasic, MD, Manager, Medical Center Samobor Paula Radisic-Huzjan, Manager, Medical Center Zapresic Katarina Gerbl, Managing director, The County Center for Drug Addiction Prevention, Zagrebacka County Damir Burcar, Member of County Council Josip Blazak, Member of County Council Jasna Lesicki, Head, Center for rehabilitation “Stancic” Marija Belaic, Director, Center of social welfare Dugo Selo Andrija-Miso Damic, Epidemiologist, Institute of Public Health, City of Zagreb

I. PROJECT BACKGROUND Zagrebacka County encompasses the area around the Croatian metropolis Zagreb. It defines Zagreb’s western, southern and eastern boundaries with its irregular hors-shoe shape. Naturally, Zagrebacka County is historically and economically related to the City of Zagreb, the capital of the Republic of Croatia, situated on the banks of the river Sava and on the slopes of Medvednica at an altitude of 120 m. Zagrebacka County has a population of about 310.000 in 8 cities and 26 districts. It is situated in the central part of northwestern Croatia on an area covering 3.067,50 square kilometers. At the end of 2001, the Ministry of Health, Ministry of Labor and Social Welfare, County Governors, National Institute of Public Health and Andrija Stampar School of Public Health, officials agreed to begin with a ''learning-by-doing'' training program for public health capacity building at the county level. A four-module format spread over a four-month period was selected to minimize participants’ time away from their jobs in any one month and to allow them time to assimilate the material and complete assignments between sessions. Each County team in training was expected to plan and conduct assessments, and elaborate a County Health Profile and a County Health Plan. Ministries offered to support the direct costs of training (training packet development, teaching and staff expenses) and the counties have to covered trainees' lodging and travel expenses. In the mid 2002 the “Health – Plan for it” training program was present to the Zagrebacka County during the Motovun Summer School. Later on in November 2002, during the meeting with super-sponsors held in Krapinske Toplice, program was officially presented to County politicians. Team members from first pilot cohort of Counties (Istarska, Varazdinska, and Dubrovacko-neretvanska) were good program promoters and advocates, so their Counties progress reports convinced us to join the

2

program. The end of 2002 accepted Zagrebacka County accepted for training within third cohort of Counties, together with Primorsko-goranska and Osjecko-baranjska County. Members of the County training teams were selected from County Council, Administrative Department for Health and Social Welfare, Institute of Public Health, Health Centers, Center for Social Welfare and Institution for youth with special needs.

II. ZAGREBACKA - HEALTHY COUNTY PROJECT DEVELOPMENT

From January to May 2003 Zagrebacka County training team passed through the following process: Module 1 – Assessment functions (Osijek, 29 January – 1 February) During the first module, county team reviewed the core public health functions and practices and get familiar with the participatory needs assessment approach, methods and tools. Team developed a framework for county health needs assessment and decided on methods to involve citizens. Between modules the team has carried out the questionnaire survey inquiring about health and health condition of the County’s residents. Data collected through the questionnaire, together with health statistic data, were used to determine County priorities. Module 2 – Healthy Plan-it™ (Jastrebarsko, 26 February -1 March) At the beginning of the second module county team presented the results of the health needs assessment exercise. Although still in draft form, Zagrebacka County Health Profile reflected community health concerns and served as a basis for selecting priorities. Through application of ''Healthy plan-it™”, an educational program developed by the CDC's Sustainable Management Development Program, out team was guided through a health planning process. First we were introduced to techniques for selecting priorities among community health needs, then to problem-solving and decision-making techniques. Our team selected following six county health priority areas:

- high mortality and case fatality from cardiovascular diseases - pollinosis caused by pollen of ambrosia - high breast cancer mortality - early drinking, i.e. alcohol consumption in young generation - bones breakages caused by osteoporosis - care for elderly and disabled people

The team learned how to identify and analyze problems, find the root causes of problems, and trace the possibilities for solving problem inside complex, multi-organizational systems. On 12 April 2003 consensus conference was held with more than 100 participants. The priorities were confirmed and actions, to address them, proposed. Module 4 – Assurance function (Topusko, 7 – 10 May) At the beginning of the fourth module our county team presented the draft versions of our County Health Plan, including priorities and intended activities. Change was a key word during this module. Skills developed in this module include planning change, building institutional capacity for change and conflict recognition and resolution. Presentations given by representatives of the Ministry of Health,

3

Ministry of Labor and Social Welfare and by the leader of the health care system reform project helped us to view our county project from a larger, national perspective, anticipate changes and foresee potential obstacles. After training we completed the County health Profile and Plan and present them first to the County Council, and then to County Assembly. The County Health Profile and Plan were accepted by the Zagrebacka County Assembly and became the binding (bylaw) document by the end of 2003. The Zagrebacka County successfully completed its modular education with an oral exam, presenting the County Health Profile and Plan to the members of public health academia, in Topusko, in January 2004. In mid 2003, after our cohort completed modular training, we joined (with our troika) the second stage of the program. During 2003, 2004 and 2005 we gathered regularly with other troikas to report on progress and get additional training (Mljet - October 2003, Samobor - March 2004, Uvala Scott – May 2004, Motovun – July 2004, Split – October 2004, Terme Tuhelj – February 2005, Vinkovci – April 2005, Motovun – July 2005, Labin – November 2005). PROBLEM STATEMENT Before entering into the “Health – Plan for it” training program Zagrebacka County did not have experience in assessing public health needs in a participatory manner, in planning for health or assuring provision of the type and quality of services tailored to local health needs. Existing public health programs were either that of the national interest (like prevention of cardiovascular diseases, smoking or drug misuse) or those carried out by few cities and districts that had, from time to time, some interest in health promotion issues. County did not have Health Profile or Plan to systematically address unhealthy behaviors or diseases in its population.

III. TOOLS USED a) Needs assessment - QUALITATIVE AND QUANTITATIVE DATA COLLECTION AND ANALISIS For example, mortality data were gained from Institute of Public Health:

Nm. Diseases % 1. Cardiovascular diseases 52,14 2. Malignant diseases 25,89 3. Injuries, intoxication, other consequences

of outer causes 5,21

4. Digestion system problems 4,67 5. Respiratory system problems 4,25 6. Infective and parasite diseases 1,50 7. Nutrition problems and diseases 1,32 8. Mental and behavior disorders 1,23 9. Other abnormalities 1,08 10. Urinary system and genital diseases 1,02

4

MORTALITY AND MORBIDTY IN THE ZAGREB COUNTY IN THE YEAR OF 2001. The team members conducted questionnaire survey inquiring about health and health condition of the County’s residents, with the following groups:

- population aging from 25 -70 198 examinees - students aging from 16 -17 113 examinees - political officials 22 examinees - people over 60 years of age which are consumers of any form of social welfare

60 examinees b) Consensus building – selection of priorities - CONSENSUS CONFERENCE Consensus conference was held on 12 April 2003. More than 100 people have participated in it:

- Members of County training team - Representatives of non-governmental organizations - Experts from various medical fields - Heads of County Hospitals and Health Centers - Red Cross Organizations representatives - Members of County Council - Members of County Assembly - Head of The Center for Rehabilitation “Stancic”

c) Legislative institutionalization of change through County Assembly Zagrebacka County project team and County Administrative department of health and social welfare presented County Health Profile and Plan to their County Assembly, which accept them as the strategic documents. This act made them a regulation by which Zagrebacka County will address chosen public health priorities in promoting health and preventing diseases of its population. We would like to represent the Conclusion that has been voted.

CONCLUSION about acceptance of report considering condition and organization of health service in The Zagrebacka County, acceptance of report about The County

Health Profile and Plan, and determining priorities for health promotion and prevention for The Zagreb County population

I.

The report about condition and organization of health service in The Zagrebacka County has been accepted.

II.

The report, the County health profile has been accepted.

III.

5

The priorities in health promotion and prevention for the Zagrebacka County population go as fallow:

- to decrease high mortality and case fatality from cardiovascular diseases - to decrease pollinosis caused by pollen of ambrosia - to increase level of care for elderly and disabled people - to decrease alcohol consummation in youngsters - to decrease high rate of breast cancer mortality - to decrease bones breakages caused by osteoporosis.

IV.

This Conclusion is valid from the day it was voted.

The Zagrebacka County budget will support determined priorities.

Before project PROJECT- PROGRAM 2004. g. 2005. g. prevention - decreasing high mortality and case fatality from cardiovascular diseases

50.000,00 50.000,00 --

- decreasing pollinosis caused by pollen of 100.000,00 100.000,00 20.000,00

- decreasing mortality of breast cancer 350.000,00 400.000,00 50.000,00- increasing level of care for elderly and disabled people

50.000,00 50.000,00

- decreasing alcohol consummation in youngsters

50.000,00 50.000,00 -

- decreasing bones breakages caused by osteoporosis

- 50.000,00 -

ALLTOGETHER 600.000,00 700.000,00 70.000,00

ambrosia

(The amounts are in Croatian kunas – 1 kuna is 6 $)

Zagrebacka County has also invested considerable amount of money in acquisition of equipment that was needed for activities. Since non-governmental organizations are included in this project, too Zagrebacka County has also financially supported their activities in connection to County Health Plan implementation.

Ambrosia 150.000,00 kn Breast Cancer 100.000,00 kn Older people 300.000,00 kn Drug related associations 250.000,00 kn ALLTOGETHER 800.000,00 kn

6

IV. HEALTH PROBLEM ANALYSIS

For every given priority the determinants were analyzed, factors that would help us to solve each problem specified, and course of intervention determined. We will give an example PRIORITY – elderly care

7

V. INTERVENTION DECISION MATRIX

8

VI. HOW THE WORK PLANS WORKED For every priority an action plan was made. Being limited with space we have enclosed THE ACTION PLAN FOR AMBROSIA EXTERMINATION IN THE ZAGREB COUNTY IN 2005. 1. DECRAESEMENT OF POLLINOSIS CAUSED BY POLLEN OF AMBROSIA It is considered that every seventh resident of The Zagrebacka County has allergy problems considering ambrosia. Having that in mind, the questionnaire has been carried out and involved 301 examinees. The results have shown us that the number of residents allergic to ambrosia was even higher than we could ever imagine. As well as educative measures, a lot of concrete measures were taken in order to exterminate ambrosia. By helping them financially we involved “green” organizations and other individuals that wanted to be a part of this action. The course of action that was taken included:

- making, printing and distributing fliers involving various scout organizations, green organizations and others

- better maintenance of the environment by city services - making The action plan for ambrosia extermination.

THE ACTION PLAN FOR AMBROSIA EXTERMINATION IN THE ZAGREB COUNTY IN 2005.

Nb. What? Who? Time frame 1. - preparing the budget and ensuring the

funds needed for plan execution - Administrative dep. for health and social welfare

- October, 2004.

2. - making an analyses of what was accomplished regarding ambrosia extermination

- Administrative dep. for health and social welfare and Institute for Public health

- October, November, 2004.

3. - making an analyses of pollen monitoring during 2004.

- Administrative dep. for health and social care and Institute for Public health

- February, 2005.

4. - redefining methods and executors of particular actions regarding ambrosia extermination

- Administrative dep. for health and social welfare, and other factors

- March-April 2005.

5. - distribution of funds between organizations that participate in ambrosia extermination

- Administrative dep. for health and social welfare, Zagrebacka County Council

- April, 2005.

6. - giving each executor their assignment - - May, 2005. 7.

a) school in nature, education, chemical and physical extermination of ambrosia

- schools, physician, doctors, counseling services, city services

- May, June

9

b) flier printing Administrative dep. for health and social welfare

- June

c) flier distribution Administrative dep. for health and social welfare

- June, August

d) public campaign - TV, radio - June, August 8.

- ambrosia extermination, mowing, picking

- volunteers, green organizations, people who own a property where ambrosia grows, city services

- July, November

- pollen monitoring, especially ambrosia

- Institute of Public Health

- constantly 9.

- bio prognosis - Institute of Public Health

- constantly

10. -control of actions taken, reporting areas where ambrosia grows

-Citizens, City service officials

- July, November

a) giving orders regarding obligatory ambrosia extermination

- City service officials

- July, November

b) areas covered with ambrosia - City services - July, November

11.

c) giving orders to exterminate ambrosia, and those who do not do that will be fined

-City service

12.

- evaluation

-Administrative dep. of health and social welfare, Institute of Public Health

- October, November

13. - preparing the budget for 2006. and ensuring funds for carrying out The action plan

- Administrative dep. for health and social welfare

- October, 2005.

2. PREVENTION OF CARDIVASCULAR DISEASES Along with constant care and medical treatment of persons that have symptoms or disorders regarding cardiovascular system, we are performing activities on population level where a danger of cardiovascular diseases has not been determined. In short, it considers the part of population that is proven to bee healthy. In the 2004 more than 2000 persons were included in screening program, and more that 1000 persons were immediately sent to a doctor. In the 2005, through the screening program, 495 persons were find with high blood pressure, 310 persons with high blood sugar and 163 persons with high cholesterol. Who ever had any of the mentioned symptoms was sent immediately to their physician to do a complete check up. 3. PREVENTION OF OSTEOPOROSIS Since we purchase a vehicle that contains a densitometry we are able to provide more complex health protection. It also saves time, because of its mobility, so one does not have to go to the hospital to do the check up, but we provide this particular check up

10

in the city or the district where people live. From September to December 2005, 1485 women were check but the results are still unknown. 4. PREVETION OF DRUG ADDICTION The Center for drug addiction prevention, non-governmental organizations and several counselors work on drug misuse prevention in Zagrebacka County area. In addition to that, in February, 2005 “The Program of prevention of drug addiction in primary school”, has been introduced. The program is applied in 23 primary schools (to seventh grade students), and done by experts that were educated for that purpose only. It involves 1750 pupils. The program has been widely accepted and offered to the other Counties for use. 5. DEACREASEMENT OF BREAST CANCER MORTALITY With our “extended troika” we participate at the meeting held in Mljet in October 2003, devoted to “Evidence based public health programs of early detection and breast cancer treatment”. Based on knowledge and guidelines presented on that occasion our County developed a set of interventions, addressing breast cancer early detection, that rest on our local organizational and human resources. Being aware of this problem, we have organized a mammography, so that women can have, free of charge, this particular check up. As we also have, on our dispose, a mobile mammography we are able to go from town to town, and from district to district and provide this service to who ever needs it. In 2004, 2450 women were checked. In 2005 2708 women were checked. Results were:1848 were healthy, 1869 had benign changes, 1276 had undefined changes, 67 had possibility of malignant changes and 17 had malignant changes (operational required). Altogether, County invested 1.950.000,00 KN and managed to save 17 lives – PRICELESS. 6. INCREASED CARE FOR OLDER PEOPLE Zagrebacka County has over 40.000 old people, and by all means it could be called “The Old County”. The state government, cities and districts have the authority over many of the measures and activities considering care for old and disabled people. To improve that care County invest every year cca. 40.000.000,00 KN, and it do not consider. So, Zagrebacka County joined the project “Creating Preconditions (Human and Organizational Infrastructure) for Elderly Care Services Improvement in Six Croatian Regions”. On the grounds of the recognized elderly people needs this project will bring, through improved coordination and collaboration between the subjects at the county level, better provision of existing and introduction of new forms of services for elderly. As a part of this project a guide for elderly will be produced. That will be a handbook with all the necessary information regarding health care, home care, pension rights, social care, and will also give advice on how the elderly person can exercise its legal rights. County is, as well, co financing the Red Cross organization public kitchens whose volunteers are delivering meals to poor older people, unable to come or prepare food by themselves.

11

12

VIII. FUTURE PLANS AND BUDGET In 2006 Zagrebacka County will proceed with realization of the action plan, which is based on determined priorities considering health promotion and protection. Founds ensured in budget for 2006 are:

PROJECT- PROGRAM 2006 g. Decreasing high mortality and case fatality from cardiovascular diseases

100.000,00

decreasing pollinosis caused by pollen of ambrosia

250.000,00

decreasing breast cancer mortality 350.000,00 increasing level of care for old and disable persons

100.000,00

decreasing alcohol consummation in youngsters

150.000,00

decreasing bones breakages caused by osteoporosis

100.000,00

ALLTOGETHER 1.050.000,00 Besides mentioned, County will also financially support non-government organizations that participate (organize and conduct) health promotion and protection activities determined by the County Health Plan. IX. CONCLUSION Zagrebacka County is very eager to participate in the evaluation workshop, to be held in February 2006, to gain feedback from academic community on what was the impact of this project on the county macro and micro environment and project users. To conclude, through the “Health – Plan for it” education Zagrebacka County team have learned how to recognize the health needs of our citizens, how to determine public health priorities and how to organize (and finance) health promotion and protection programs that will ensure better health of all its residents. Physicians, social workers, political officials and employees of Administrative department for health and social welfare that participated in this project, together with hundreds of others who participate in research and consensus conference, had developed the first County Health Plan. This Plan is based on the population health needs, on selected (by consensus) health priorities, on County financial abilities and human recourses, on County’s cities and districts resources, on existing County institutions (health centers and centers of social welfare), as well as on various voluntary groups and organizations. Today, County Health Plan is seen as the basic document that will guide all health promotion and protection activities targeting our County population.