Articles/1998/6
RHP&EO is the electronic journal of the International Union for Health Promotion and Education

Public health in Latvia with particular reference to health promotion

Report of a team from the World Health Organization Regional Office for Europe

(this report is an abstract of a much longer written report that includes 2 tables and 4 annexes)

Public Health in Latvia with Particular Reference to Health Promotion. Internet Journal of Health Promotion, 1998. URL: ijhp-articles/1998/6/index.htm.

1. INTRODUCTION

1.1 Background and Terms of Reference

Public health and health promotion are currently in a positive phase of development in Latvia, but face a number of problems, upon which the State Minister of Health, Dr Vi:ktors Jaksons, invited expert technical advice from the European Regional Office of the World Health Organization (WHO/EURO).

A WHO/EURO team visited Latvia from 31 May to 5 June 1998, under the leadership of the Regional Adviser for Health Promotion and Investment for Health, Dr Erio Ziglio, and comprising two other members, both with substantial prior experience in Latvia. The full team membership is set out in Annex A.

The Terms of Reference of the team were:

To review the health promotion function in Latvia, giving particular attention to:

the measurement and interpretation of health determinants which are especially amenable to health promotion

policy-making for health promotion; and

the infrastructure, organization and funding of health promotion practice within the overall public health system.

To make recommendations for achievable improvements.

To take fully into account the proposed health promotion component of the World Bank health sector loan to Latvia.

1.2 Working method

The team:

considered the documents which are listed in Annex B;
discussed the issues with senior people from the Latvian health sector and other sectors, as set out in the programme of work which forms part of Annex A;
analyzed the information it had collected and formulated preliminary conclusions and recommendations;
discussed its analysis and preliminary conclusions and recommendations with a small 'sounding board' (listed in the programme of work);
prepared a draft report for discussion with Dr Jaksons and subsequent finalization.

1.3 Acknowledgements

The WHO team gratefully acknowledges the great cooperation and assistance it received from many people in undertaking this work.

Without the initiative of Dr Jaksons the work would not have happened at all. Moreover, WHO is especially grateful that he gave his time so generously to the work of the team, enabling its understanding to be broadened by his experience and learning.

To all the other people who were prepared to break away from demanding responsibilities to give their time and the benefits of their knowledge and experience to the work of the team, WHO offers its thanks. Without their input the work could not have been undertaken at all, and the quality of their documents, knowledge, ideas and reflections contributed inestimably to the analysis, conclusions and recommendations made by the team. Inevitably, in an exercise conducted with so many busy people in a very limited time, the pace of work did not allow everybody to make their full contribution. WHO apologises for this and accepts full responsibility for any omissions or contentious emphases that may have resulted. Every attempt has been made to keep these to a minimum, so that this report will be a useful and practical document, and so that in due course the Latvian authorities may wish to follow up some of its proposals for further advice and assistance from WHO.

Finally, WHO wishes to offer its thanks to two groups of people who ensured the smooth operation of the work of the team. The staff of the Public Health Department of the Ministry of Welfare warmly welcomed and accommodated the team in well serviced accommodation throughout its work. The commitment, organizational skills and selflessness of the staff of the WHO Latvian liaison office opened many doors to the team and ensured the optimum use of the limited time available. These contributions enabled optimal professional use to be made of limited time in a welcoming, tolerant and supportive fashion. They are deeply appreciated.

2. REVIEW OF THE HEALTH PROMOTION FUNCTION

2.1 Overall review of the health promotion function

2.1.1 The people of Latvia are emerging from a difficult period of transition, during which old social and economic norms disappeared almost overnight. They are being steadily replaced by many new constructs, above all the re-introduction of democratic accountability, the development of the practices and institutions of civil society, and the evolution of openness and transparency in public administration. The dislocations resulting from the transition continue to have a profound impact, not least on the health of the people; this is only now recovering to and beyond pre-1991 levels. Until recently, organized efforts to promote better health have played a small part in Latvian society. Now, as social recovery and economic development have become more established, recognition of the potential contribution of public health and health promotion has grown in parallel. This has resulted in some important initiatives, and the emergence of considerable talent, but is beset by three major difficulties:

First, policy-making for public health and health promotion is not systematically established, and lacks vital skills and input, for example in population health survey techniques and the interpretation and presentation of findings. There is also a lack of clarity about existing agreed policies, leading to a fragile situation for the acceptability and implementation of policy decisions. Policy issues are further considered in section 2.3.

Second, there is fragmentation of effort, with weak management and accountability structures, much episodic activity and some important initiatives, but an overall lack of coherence and co-ordination. This issue is raised at many points in this report and is dealt with in detail in section 2.4.

Third, there appears to be a widespread misunderstanding, with some notable individual and organizational exceptions, of the concept and principles of modern health promotion and their implications for the organization and conduct of practice in policy and programme terms.

2.1.2 The most common conceptual misunderstanding equates health promotion merely with the provision of a limited part of the health promotion agenda - namely, with individual or population-level health education or, even more narrowly, with health information. This misunderstanding appears to be part of the basis for a further widespread view, that primary health care, and in particular family doctors, should carry most of the responsibility for 'health promotion', and be rewarded accordingly. Such views could lead to expectations which could not be fulfilled, and to poor returns from scarce investment resources. This is explained further below, and in sub-section 2.1.3.

Without a well planned, appropriately resourced and competently implemented health promotion strategy, European countries will experience difficulties in achieving lasting improvement in the health of the population. Furthermore, they are likely to encounter problems in sustaining economic development and regeneration. This issue - of enabling all citizens to achieve the highest possible levels of health and well-being - is of particular relevance to countries of the size and population of Latvia. As a point of reference, Appendix C provides a selection of terms and definitions from the WHO Health Promotion Glossary, 1997.

The key elements of modern health promotion are:

analysis of policies in all sectors of society for their impact on the health of the population, and the development and implementation of a range of many different policies, in many spheres of life, which are designed to improve the health of the population;

action at all levels and in many different spheres of society, to identify existing 'social capital' - in public, private and voluntary organisations and groups, and in informal networks - which are already contributing to the health and well-being of the population, and

the design and implementation of measures to enhance this capacity so as to enable individuals and communities to increase control over the determinants of their health and thereby improve it;

These challenging tasks require a range of skills, from people with many different backgrounds and occupations. The core functions of effective health promotion are based on the skills of:

advocacy to different agencies at different levels of society, of the foundations of public health and of the policies and practices required to improve it;

enablement of people and organizations to bring about positive change; and

mediation among different, and often conflicting interests, in the common interest of better health.

Health promotion thus actively engages many sectors of society, stretching well beyond health care services to all the areas which impact on health, or which may create opportunities for health promotion. Therefore, there is scope at all levels of government - nationally and locally -to identify priority areas for investment for health. There are many opportunities in different sectors. Action can be taken by social organizations such as schools, workplaces and voluntary agencies, and by individuals. The greatest impact is achieved by the synergy of carefully planning, co-ordinating and implementing policy development, legislation, and appropriate, effective actions in different organizations in different sectors and at different levels. From its vantage point, WHO/EURO is well placed and always willing to offer countries advice and assistance, based on learning from the widespread variety of experience across Europe.

Later in this report, recommendation 3.1.1 is intended to help to develop a better understanding of the health promotion concept and principles. Recommendations in sections 3.3 and 3.4 propose steps towards the further operationalisation in Latvia of this concept and principles.

2.1.3 Turning now to the role which it appears that primary health care, and in particular the family doctors, may in future be asked to play in promoting better health in Latvia.

First, there is absolutely no doubt of the importance of high quality primary health care. It is vital in many important respects, for example:

simply through its existence as a key element of a social security system, it provides assurance and thus contributes to underlying wellbeing and hence to health;

through its ability to advise and enable individuals and families to have greater self confidence in health and medical matters and become more competent in their own and their family's self-care;

as the key point of self-referral, providing primary clinical services, and acting as an effective and efficient gatekeeper to the rest of medical care services;

as the best-placed provider of a small number of very important specific preventive procedures, which are the clinical component of public health programmes organised and managed at population level, such as immunisation and vaccination, and cervical screening; and

as the provider of a number of other interventions in health promotion and disease prevention for individuals at increased risk; these include both clinical and non-clinical measures and are axiomatic to ethical modern primary care practice:

e.g. smoking and alcohol advice and counselling;

e.g. nutrition advice and counselling;

e.g. physical activity advice;

e.g. blood pressure measurement and, where necessary, control;

For these to be effectively introduced and sustained in primary health care, requires thoughtful consideration and planning by the primary health care team of how they are going to reach and engage the relevant members of the population they serve, most of whom are 'well' and ordinarily make only rare contact with primary health care; this in turn requires the learning of appropriate skills, and needs backing up by proper performance management; the proposed Cardiovascular Health Programme offers the opportunity to undertake and evaluate such planning, management and practice.

Likewise, the Cardiovascular Health Programme offers the chance to develop and test in the field situation in Latvia the potential roles of the primary health care team in population-based health promotion and disease prevention.

It was already clear from sub-section 2.1.2, and is confirmed by the foregoing that, while primary health care has an important contribution to make to health promotion and disease prevention, it is simply not positioned to carry the main weight of health promotion. International experience confirms these conclusions. They are especially important in Latvia, where primary health care is embarking on a fundamental transformation and does not need the additional burden of unachievable expectations. Recommendation 3.1.1 is framed accordingly.

Recommendations are provided in sub-section 3.1.3 concerning the Cardiovascular Health Programme.

2.2 Measurement and interpretation of health determinants which are especially amenable to health promotion

2.2.1 Fundamental to the public health function has always been the systematic collection, collation, analysis, interpretation and presentation of information about the health of the population, and about the effectiveness of the measures being taken to improve it, thus contributing centrally to the effective performance of many public health tasks, from policymaking, through strategic planning to outbreak control.

The rise of the epidemics of non-communicable diseases, and the application of the concept and principles of health promotion to combating them, has placed new demands on the scope and capacities of the information functions. These range, for example, from the need for regular monitoring and reporting of behavioural and other risk factors in populations, through assessment of social capital, to information from social, industrial, agricultural, retail and other sectors which is essential to the tasks of policy impact assessment and to the formulation of policies to improve health.

2.2.2 There seems little doubt that high quality public health information systems are being established in Latvia, and that these are resulting in a valuable flow of information, which is increasingly accessible to potential users. Among the impressive published outputs are an attractive annual public health report on Latvia, a regular epidemiological bulletin from the Environmental Health Service, and joint comparative publications with the other two Baltic States. However, current arrangements appear to fall far short of meeting Latvia's needs, for the following reasons:

there is no overall coordinating institute with the key roles (under clear policy direction) of drawing up and managing a coordinated programme of routine information collection for public health, including:

supervising methodological practice;

commissioning data from many different sources;

complete data collection, professional collation, analysis and interpretation, and the publication and dissemination of necessary reports, have not yet been developed in some of the most important areas of public health information practice These include important aspects of epidemiology, health economics and population questionnaire and examination survey design;

too many episodic surveys take place without reference to their place in the overall public health system, often without best use being made of their findings, and usually without arrangements for the necessary follow-up of changes and trends; this is a waste of scarce resources, even when funding is externally gifted, as it does not contribute to planned capacity building;

dedicated finances are apparently inadequate to ensure essential basic tasks.

2.2.3 Recommendations to address these issues are provided in section 3.2

2.3 Policy-making for health promotion

2.3.1 Within the overall public health function, sound policy-making is fundamental to the formulation of robust strategies and effective practices in health promotion. There appears to be a significant deficit in establishing systematic health promotion policy-making in Latvia. There is also a lack of clarity about existing, agreed policies. This all leads to a fragile situation for the acceptability and implementation of policy decisions.

Responsibility at national level is vested in the Public Health Department of the Ministry of Welfare. It appears to be facing the following constraints on performing its tasks effectively:

public health and health promotion policy-making does not seem to have achieved sufficiently high political priority, such that all existing Government policies are clearly recognised and acted upon by all those affected by them.

there seem to be some deficits of accountability and transparency, and the formulation of specific criteria and guidance documentation is often very imprecise;

resources for policy-making are extremely limited, and the process suffers, for example, by comparison with the EU legislative and regulatory harmonization process undertaken by the Public Health Department;

although Parliament considers forthcoming annual budget proposals in Committee, the transparency of the decision process is widely questioned.

2.3.2 As a result:

the cycle of policy-making - of problem identification, policy analysis, policy formulation, decision-making, implementation, evaluation and review - including all necessary public, professional and political consultation at each appropriate stage, appears weak in comparison with advanced European societies;

there is evident policy fragmentation, and the constant risk of being driven by crises and external agendas.

Since social and economic development require the concept, principles and strategies of health promotion to be at the heart of government business, these issues are of serious concern. This is particularly the case in the light of Latvia's needs in the EU accession process, where a great many items for negotiation are directly linked to public health. Addressing these issues would hasten actual realisation of the social and economic benefits which could be derived from Latvia's existing commitment to health promotion, contained in policy documents from the highest level.

Recommendations are provided in section 3.3 which address two needs, namely:

very urgent short term needs, in view of the World Bank health sector loan negotiations starting to enter their final phase (recommendation 3.3.1);

the longer-term need for sustainable capacity-building for public health and health promotion policy-making (recommendation 3.3.2)

2.4 The infrastructure, organization and funding of health promotion practice within the overall public health system

2.4.1 This review has already suggested that a number of deficits in infrastructure and organization are critically inhibiting the further development of public health and health promotion in Latvia. This section considers these, together with the other generally recognised infrastructure and organization needs of health promotion, including the question of funding.

Table I provides a checklist of all these basic functions and agencies needed for effective health promotion; the apparent situation in Latvia is compared with the checklist. Further consideration is provided in subsection 2.4.2.

2.4.2 Further consideration of functions follows.

Key function 1

This was considered in detail in section 2.2.

Key function 2

Starting with the existing Annual Public Health Report, Parliamentary debate and well prepared media coverage could provide a focus for increased interest in public health and lead to an increase in both its status and understanding. This in turn could stimulate increased accountability for health by Parliament and the Government, helping to create forward movement on some of the more difficult infrastructure, organization and funding issues.

Key function 3

Analysis of the way inter-ministerial committees work elsewhere in Europe, and their achievements and problems, suggests the following critical success factors:

a small highly professional secretariat is essential, to prepare the issues for the committee's consideration and ensure that decisions are followed up and acted upon;

using such a committee for routine business rapidly downgrades the seniority of attendance;

likewise, it is important to avoid any tendency to use the committee only to react to issues;

the committee needs to deal with matters which regularly lead to follow up discussions at Parliamentary and Government level;

the committee's very senior membership and organizational position can enhance the status and understanding of public health; it should be a major contributor to the debates on the Annual Public Health Report.

Key function 4

The Parliamentary committee also needs professional and technical assistance if it is to play a

constructive part.

Key function 5

Appropriate points in the policy cycle, such as the publication of the Annual Public Health

Report, provide the most constructive basis for wider social engagement in improving public health.

Key function 6

Recent innovations - the National Centre for Environmental Health and the Health Promotion Centre - appear to be making impressive progress in public health and health promotion, despite serious resource limitations. The resource problem is particularly severe for the Health Promotion Centre. This has led the Health Promotion Centre to accept funds from commercial interests, and to appear to endorse specific products, for example manufactured foods. This runs the risk of breaching the centre's code of practice and undermining the credibility of health promotion. Activities are often fragmented and isolated from those of other agencies, but work is about to begin on an overall strategy for public health, on the initiative of the head of the Public Health Department of the Ministry of Welfare. This is a priority for formulating appropriate implementation arrangements and clarifying all the key agency responsibilities at both national and local level.

Nevertheless, the need to get on with the development of health promotion at local level in Latvia appears to present a serious problem. The concept and principles of modern health promotion, and the conditions needed for its effective functioning, point strongly towards a base in democratically controlled institutions at local level, and thus away from the hierarchically organized regional environmental health centres. However, there are apparently wide differences in the ability of individual municipalities to cope with such responsibilities at present.

Key function 7

In April 1998, the WHO/EURO working group on health promotion evaluation issued a short set of recommendations to policymakers. They include recommendations that adequate resources need to be devoted to the evaluation of health promotion, and that multiple methods are needed to evaluate health promotion. It is worth introducing this set of recommendations into World Bank loan and other technical assistance negotiations.

Key function 8

Getting human resource planning right can make an impact quickly in a country of Latvia' s size.

International technical assistance, perhaps through the World Bank loan, could be useful.

Key function 9

Linked to human resource planning, this again could make good use of the World Bank loan. At this stage in Latvias health promotion development careful attention needs to be given to the choice of learning, trying to avoid long absences of critical people, but creating opportunities for people who work with each other across organizational boundaries to learn together away from their regular workplaces.

Key function 10

Providing secure long-term funding for health promotion seems to have been an important issue in Latvia for some time, judging by the innovatory ideas which have been adopted as policy, some of them legislatively. The problems of turning 'commitment' into action are unlikely to be resolved, unless the following issues in particular are squarely addressed:

the ability to obtain adequate funds without causing dislocations in other services;

the strategy and criteria against which expenditure decisions would be made;

the capacity of the health promotion infrastructure to utilise funds effectively;

openness, transparency, effectiveness and fairness in the allocation of funds;

performance management, monitoring and evaluation.

Recommendations about infrastructure, organization and funding are set out in section 3.4.

Key function 11

Like the individual components of which they are composed, systems need active management.

This enables them to cope with the ever evolving demands placed upon them, the ever changing

external environment in which they operate, and their internal tensions.

3 RECOMMENDATIONS

3.1 The health promotion function

3.1.1 Primary health care is not in a position to act as the principal focus for health promotion.

3.1.2 The need to develop an understanding of the health promotion concept and principles among key decision makers could be met through a course which WHO/EURO has developed for very senior public officials, tailored to their country's needs. Drawn from different sectors, about 50 top civil servants, opinion leaders and politicians have been inducted into how health promotion can be instrumental in the overall social and economic development of the country. The outcome is a shared understanding, the reduction of bureaucratic and professional boundaries, and increased skills and commitment. It has been used in Poland, Italy and (on behalf of the Pan-American Health Organisation) by Brazil.

3.1.3 Developing the role of the primary health care team is a centrally important feature of the Cardiovascular Health Programme. The programme provides the opportunity for developing local learning as a basis for subsequent countrywide implementation. For it to succeed, the following criteria need to be met before implementation in Kuldiga:

the experimental design needs to take into account and properly evaluate operational transferability;

per capita expenditure at local level should be in keeping with resources available elsewhere in Latvia.

3.2 Health determinants

The public health function is in urgent need of a greatly enhanced information service able to act as described in subsection 2.2.2. The Medical Statistics Bureau would appear to be a good starting point for a Public Health Information Institute to fulfill this need. It would have to develop a number of new functions to meet modern requirements. Its early development would not however be best served by adding yet further responsibilities at its onset. The functional scope and the performance of the institute to date ought to be fully reviewed after three years, with the full participation of the institute itself.

Development of the new functions would be enhanced by well chosen international partnerships, for which the World Bank loan might be considered a logical source of funding. Such partnerships, to improve local capacity to measure and interpret health determinants, are already well established in Latvja, through programmes such as the Health Behaviour of School Children survey and the Food and Nutrition Survey, both linked to WHO/EURO. These activities need to be further supported and sustained in the years to come.

Appropriate channels for discussion and interpretation of the policy implications of research findings would also need to be designed and implemented.

3.3 Policy making

3.3.1 Urgent high level decisions appear to be needed about the status of a number of policy documents, so that Latvia's position on several important issues in the forthcoming World Bank negotiations can be confirmed and clear.

3.3.2 As soon as possible, the Public Health Department will need to develop sustainable policy-making capacity, so as to fulfill its responsibilities to lead the development and implementation of a modern public health and health promotion agenda. Funding the necessary technical assistance and staff development should be considered by the World Bank, given the critical role to be played by the Department in initiating and sustaining modern public health practice.

3.4 Infrastructure, organization and funding

The recommendations in this section have two main intentions, namely:

to replace episodic practices, incompleteness and fragmentation in public health, with particular reference to health promotion, by a coherent, comprehensive and coordinated system, under the provisions of the proposed new public health law;

to improve the quality of health promotion practice within the new system.

Sub-sections 3.4.1 3.4.11 are recommendations relating to the key functions set out in Table 1 and sub-section 2.4.2, and are numbered correspondingly.

3.4.1 For a public health information institute to be able to fulfill its key roles in the coordinated public health system, at least six conditions would need to be met, namely:

the institute would need clear and achievable Terms of Reference;

its programme of work would need to be drawn up under clear policy direction, with the input of good professional advice;

the institute would need to be subject to strong performance management;

there would need to be significant development in skills;

its suppliers would also need to develop their skills to meet the new demands;

adequate funding would be needed.

Governance of such an institute might be best achieved by a combination of three main measures, namely:

the director should be accountable for the performance of the work of the institute to the Head of the Public Health Department of the Ministry of Welfare (PHD/MoW) or her nominated deputy;

the director should be advised on professional and management issues by a small advisory board with appropriate qualifications, appointed by the Head of the PHD/MoW;

the director should be a member of a Public Health Co-ordination Board (PHCB), which should be established to assist the management of the public health service as a whole.

Under the present division of responsibilities, the Deputy State Secretary of the Health Department would appoint and chair such a Board, and would be accountable to the Minister of Health for its performance. Its membership would need to include the Head of the PHD/MoW and her deputy/deputies, together with the directors of the dependent institutes of the PHD/MoW. It would have to include senior representatives of other very important public health functions and interests, such as local government and academia. For its effective functioning, as a core group of senior people who need to work together in a trusting relationship, it should not be further enlarged. A task which required additional skills could be performed by a small task-limited working group, established for that specific purpose and dissolved at its completion.

The principal function of the PHCB would be to co-ordinate strategy in the field of public health. It would thus play the central role in filling the present strategic hiatus, ending fragmentation, and identifying solutions to problems such as gaps in provision and boundary disputes over responsibilities. Its Terms of Reference should be kept simple, short and transparent, and the temptation to add further tasks and responsibilities should be resisted during its establishment and first period of activity. This should last two years and lead to a thorough review of achievements, undertaken interactively with the assistance of appropriately skilled and experienced outside consultants.

The management innovations recommended here would have the additional benefit of releasing sufficient of the day to day tasks of the Minister of Health to enable him to give greater attention to overall policy, strategic direction, and the really serious issues which could not be resolved at a lower level. As the Deputy State Secretary is also Project Manager of the proposed World Bank-funded Project, it would also place the public health function in an appropriately close and constructive organizational relationship with that Project.

3.4.2 Members of the PHCB should provide assistance from their departments and institutes to the Deputy State Secretary and the director of the public health information institute for the preparation of the Annual Public Health Report. This should have four main aims - to provide more data, more analysis and more interpretation, and lead to a set of recommendations for action by different social agencies and members of the public. Bilateral or World Bank-loan funded technical assistance with the 1999 and 2000 reports could significantly accelerate and improve this process.

3.4.3 In keeping with the analysis in subsection 2.4.2, it is recommended:

that a widely representative, high level, inter-ministerial committee for public health is established under the provisions of the proposed new public health law;

that the principal responsibility of the committee is to draw up a multi-sectoral investment for health strategy for Latvia, and monitor its implementation;

that, in addition, the committee deals only with matters which regularly lead to follow up discussions at Parliamentary and Government level;

that provision is made in the new public health law for the appointment of a small highly professional secretariat to prepare the issues for the committee's consideration and to ensure that decisions are followed up and acted upon.

3.4.4 An enhanced role for the Parliamentary Social and Labour Affairs Committee is likely to evolve in response to other developments in public health in Latvia, for example:

consultation about the work of the inter-ministerial committee;

the increased legislative, fiscal and regulatory activity which will be required to support modern public health.

As its role evolves, the committee is likely to need the support of a small technical secretariat.

3.4.5 The Public Health Co-ordination Board should be asked to advise and help to plan measures designed to achieve wide social legitimation and constructive support for health promotion. Bilateral or other technical assistance would be of assistance, including the advice of WHO/EURO. A priority should be the formulation of a good communications strategy, which:

utilises many different communications channels in a well planned annual programme;

sticks to a small number of issues, whose importance is clear, and which would evidently benefit from wide input and engagement, such as consultation on a draft national strategy for health promotion, or on the Annual Public Health Report

It would therefore benefit the PHCB if its membership included a strategic communications manager who was accountable to the Deputy Secretary for formulating the communications strategy and its implementation. Ideally, the person would be a member of the MoW public relations team.

3.4.6 Since the principal function of the PHCB would be to co-ordinate strategy in the field of public health, its work in relation to an overall strategy for health promotion would be critical, in particular for formulating appropriate implementation arrangements and clarifying all the key agency responsibilities at both national and local level. Tough decisions are needed to these sort out.

It is strongly recommended that responsibilities under the new public health law are allocated on the basis of careful functional analyses, taking health promotion principles carefully into account. It is essential that the law contains a description of the fundamental role of local government in the arrangements, and of the responsibilities of the national centres to help to develop locally-based skills and support local work. Carefully selected technical assistance could be of help.

3.4.7 The development of multi-disciplinary research capacity is covered by recommendation 3.4.1.

3.4.8 Assessment of professional staff needs - assessing establishment needs and planning deployment, plus basic and post-graduate education and training, and continuing professional development, would be an important early task of the PHCB. It is recommended that it sets up a task force to undertake this work and make recommendations. A member of the PHCB should chair the task force.

3.4.9 It would appear logical to ask the task force described at 3.4.8 to examine in addition the range of education and training facilities for basic, postgraduate and continuing professional education and training, and to make recommendations.

3.4.10 It is strongly recommended that reliable funding for health promotion is provided as a matter of priority. There is no need - indeed it would be infeasible, and probably inappropriate, to try to provide at once all of the funding promised by legislation and government decisions. There needs to be an incremental annual build up, perhaps starling with 0.1% of the State Compulsory Health Insurance Fund in 1999, plus other funds. This percentage should be increased yearly to reach 1% of the State Compulsory Health Insurance Fund, as decided in the Strategy for Health Care Development in Latvia, 1996. Additional methods of funding could also be considered and these are summarized in Appendix D.

In order to achieve even a comparatively modest start, the issues set out in subsection 2.4.2 need to be addressed by the PHCB, as another of its early priorities. This would probably be best undertaken by a short term working group, including outside members, for example from the State Compulsory Health Insurance Fund and the Ministry of Finance. Its task would be to propose solutions to the problem of providing robust funding, addressing:

sources of funding;

the ability to obtain adequate funds without causing dislocations in other services;

the strategy and criteria against which expenditure decisions would be made;

the capacity of the health promotion infrastructure to utilise funds effectively;

openness, transparency, effectiveness and fairness in the allocation of funds;

performance management, monitoring and evaluation.

Appendix D - the main text of WHO/EURO's publication on resourcing health promotion -evaluates the pros and cons of many different practical approaches. WHO would be willing to offer further advice, drawing on the wide experience of other countries in Europe and further afield. Specific technical assistance, perhaps under the World Bank health sector loan, to help to establish robust funding for health promotion, would be helpful.

3.4.11 The co-ordination of organization and management development would fall within the remit of the PHCB. Technical assistance would be essential to help the Board to delineate the scope of this task, and to help to develop the capacity to undertake it as an inherent part of management throughout the public health function. The scope and duration of such assistance would point to a long term donor or the World Bank health sector loan as a possible source of funding.

4 IMPLEMENTION OF RECOMMENDIONS

4.1 Overview

The terms of reference for this work (section 1.1) and the briefings and interviews which informed the overall review of the health promotion function (section 2.1) drew attention to three major difficulties in fulfilling the health promotion function in Latvia: fragmentation, lack of policy-making capacity and conceptual misunderstandings. The recommendations are essentially a set of proposals for addressing these difficulties. Their implementation would clearly depend on many factors, especially their acceptability to the Minister of Health, their compatability with other plans for developments in public health, their priority in competition for limited resources, of management time as well as funds, and the availability of professional and managerial skills to supervise implementation.

If the proposals are accepted, it will therefore be important to schedule their implementation carefully, making best use of local management resources and taking greatest advantage of technical co-operation, assistance and funding. Sections 4.2 and 4.3 deal with each of these issues in turn.

4.2 Implementation scheduling

Without being in a position to take into account the many factors listed in section 4.1, and many other variables, not all of which are currently known (for example, the final shape of World Bank-funded project), sophisticated scheduling is not possible, even if it were desirable. Therefore a possible schedule is proposed as if all other factors were equal, but taking into account constraints known to the WHO team. Additional information, the passage of time, and the process of implementation itself, would all affect the timing and contents of the process. All other things being equal, the Team would propose a schedule along the lines set out in Table 2.

4.3 Technical co-operation, assistance and funding

The rapid growth in ability and confidence in modern public health in Latvia should be a cause of pride and hope by the people and government of Latvia. However, a demanding agenda lies ahead, and this will more than ever require skilled and courageous leadership and full inclusivity in meeting the challenge. All those who have appropriate skills, experience and willingness to contribute need to be included in the tasks to be done.

It will also need well-designed foreign technical and professional expertise, and the very carefully tailored exposure of Latvians in key professional and managerial positions to learning from other countries' experiences, both in Latvia and abroad. This can be achieved through well organized partnership, taking the form of bilateral or multilateral cooperation (e.g. the recently endorsed Special Memorandum of Agreement between Latvia and the United Kingdom through the Health Education Authority for England and WHO/EURO).

In Latvia's tightly managed financial situation, much of what needs to be done to bring public health, and in particular health promotion, rapidly up to modern standards will require outside funding. It is of great importance to the social and economic development of Latvia to develop modern public health infrastructures, and sustainable capacity, for policy-making and practice. Therefore, it is highly desirable, and strongly recommended, that future assistance, including a significant part of the World Bank loan, is applied to these purposes.

The WHO Regional Office for Europe has been honoured by the Minister's invitation to provide advice, and is always ready to be of future service when required.

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