ReviewQuo vadis SANEPID? A cross-country analysis of public health reforms in 10 post-Soviet states
Introduction
Following the dissolution of the Soviet Union in 1991, it became evident that the public health services of the newly independent states were severely underfunded and unresponsive to the populations’ needs. Since then, these states have had to reconcile the Soviet sanitary-epidemiological (san-epid) system with new and more complex public health challenges.
This article will look at overall trends in public health reforms in 10 post-Soviet states: Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Ukraine and Uzbekistan. In response to a lack of comparative studies in the region, this article aims to provide a cross-country comparison of reforms based on a two-fold approach: (i) processes and (ii) contents of reforms. The section on reform processes will summarize the main characteristics of organizational reforms in the countries, whereas the second section will outline specific programme contents, including developments in health protection, disease prevention, health promotion and intersectoral collaboration.
Section snippets
Methods
The article is based on a review from two different types of sources: (i) a literature search of major health databases2; and (ii) the sections on public health in the Health Systems in Transition (HiT) series published by the European Observatory on Health Systems and Policies. Search terms used included terms on public health, the san-epid services and organizational reforms in one or several post-Soviet states.3
Historical background of the former Soviet san-epid system
Public health reforms in the post-Soviet states, as well as their patterns, strengths and weaknesses can best be understood by examining historical developments. Spearheaded under Soviet rule, public health systems in the region are rooted in the san-epid services which existed throughout the former Soviet Union [2], [3], [4]. The mission implied by the name was initially shaped, as was the Semashko system itself, by the German hygienists of the 19th century and by the context of ongoing
Public health reform processes in the post-Soviet states—from slight re-structuring to rigorous reforms
The first reforms of the san-epid systems in the early 1990s logically had to do with reviewing existing levels of authority, governance and responsibilities. Reform attempts at local governance and decentralization in many newly minted republics were largely unsuccessful in the first years after independence, with unclear competencies for local, regional and national bodies [16].
Since then, the post-Soviet states have been carrying out diverse reforms in public health. There is ongoing debate
Discussion
Although the post-Soviet states commenced reforms from a similar starting point in terms of san-epid structure, reforms since the mid-1990s evolved into different directions and at a variety of depths. The three broad reform directions identified in our study show that Azerbaijan, Belarus, the Russian Federation and Ukraine largely concentrated reform efforts on the traditional san-epid functions, whereas Armenia and Georgia, on the other end of the spectrum, implemented rigorous organizational
Conclusions
In this descriptive, exploratory study of public health reforms in ten post-Soviet states, we examined public health activity from two angles: organisational and contents-related reforms. In analysis of the former aspect, we identified three broad reform strands that were taken: modernizing the san-epid system, building upon it or replacing it with a new system. With regard to reform contents in the four core functions of public health, the literature available showed that public health
Conflicts of interest
None declared.
Acknowledgements
The authors are grateful to Josep Figueras, Matthias Wismar and Willy Palm (European Observatory on Health Systems and Policies), as well as Maria Haralanova (WHO Regional Office for Europe) for their comments on earlier versions of this article. The valuable editing and research assistance of Meggan Harris throughout the drafting process is also acknowledged.
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