III. NATIONAL HEALTH PROGRAMME OBJECTIVES AND TARGETS

STRATEGIC TARGET

Improving the health status of the population and enhancing the related quality of life through:

1. Creating conditions and developing personal motivation, knowledge and skills to choose healthy lifestyle and undertaking actions for improving own health and that of the others.

2. Creating environments supportive to health, work and education.

3. Reducing inequalities in health and access to health services.

OPERATIONAL TARGETS

1. Promoting physical activity among the general population.
2. Promoting healthy diet and improving food quality.
3. Reducing tobacco smoking.
4. Reducing alcohol consumption, changing alcohol consumption patterns, and reducing alcohol abuse-related health damage.
5. Reducing abuse of other psychoactive substances and drug abuse-related health damage.
6. Improving efficiency of health education and health promotion programmes.
7. Promoting mental health and preventing mental disorders.
8. Reducing exposure to harmful factors in the living, working and educational environment and mitigating their health effects.
9. Improving sanitation throughout the country.
10. Reducing the incidence of accidents, and traffic accidents in particular.
11. Improving efficiency and effectiveness of emergency services in life threatening conditions.
12. Improving access to and efficiency of primary health care.
13. Preventing premature births, low birth weight and reducing related health effects.
14. Improving early diagnosis and active care of persons at risk of ischaemic heart disease.
15. Improving early diagnosis and treatment of breast and cervical cancers.
16. Providing better opportunities for people with disabilities and developing their capacities to lead active lives.
17. Improving prevention of communicable diseases.
18. Improving prevention of dental caries and periodontal disease in children, adolescents and pregnant women.

TARGET 1

Promoting physical activity among the general population

• About 50% of children and adolescents, and 30% of adults will practice at leisure time various forms of physical activity.
• About 80% of communities will provide conditions for regular physical activity in different groups of the population at the place of habitation.

Rationale of the target

The contribution of physical fitness and appropriate physical activity to physical, mental and social health and wellbeing of people in all age groups has become widely acknowledged. Physical activity:

• counterbalances mental work load, excessive stresses or monotonous physical strains,
• prevents disorders and diseases of the muskuloskeletal system and obesity,
• reduces the risk of arteriosclerotic vascular disease and related conditions,
• plays a vital role in preventing social pathologies, especially among young people,
• becomes an important therapeutic tool in various diseases and helps people with disabilities in
• returning to normal life,
• may become a source of success and joy.

Expected health gain

• Increased physical efficiency and capacity, and enhanced mental condition of the population.
• Reduced psychosomatic disorders, obesity, diseases of the musculoskeletal and circulatory systems and social pathologies among young people.

To achieve this target it is required:

1. to ensure weekly 5 hrs of physical exercises in all types of primary and secondary schools;
2. to organise gym halls in, at least, 75% of schools;
3. to introduce new, more attractive programmes of physical exercises, creating opportunities for individual initiatives, helping to acquire the habit of practicing physical activities throughout the adulthood, promoting not only sport but also ideas of health and culture and to train teachers how to implement those programmes;
4. to modify physical education curricula in order to equip teachers with necessary skills to perfom new roles effectively and to act as animators of lifestyles conducive to health;
5. to encourage local self-governments, nongovernmental organizations and different institutions to create opportunities to promote physical activity in different social groups;
6. to introduce attractive forms of motivating people to eisure physical activities.

Indicators:

• The number of schools with 5 hrs of physical exercises per week, the number of schools with gym halls and which implemented modified physical education programme.
• The number of communities providing conditions for regular physical activity of residents.
• The number of children, young people and adults practicing at leisure time various forms of physical activity.
• Indicators of physical fitness of children and adolescents.

TARGET 2

Promoting healthy diet and improving food quality

• An increase of at least 30% in breast feeding of newborns up to 6 months of age.
• Consumption of any meal at school by, at least, 50% of students.
• A reduction to 30% in the share of the total dietary energy from fat, especially animal fat containing cholesterol, in daily diet.
• The consumption of meat and meat products will be maintained at the level of 1995, however, more lean meat, poultry and fish shall be consumed.
• The increase in the consumption of low fat milk and dairy products, jogurt and cheese as well as cereals, potatoes, beans and other leguminous plants, vegetables and fruits.
• A reduction in the consumption of salt.
• Full satisfaction of the demand for food of good quality meeting the requirements of healthy diets.

There is strong interrelationship between healthy diets and food quality and the normal physical and mental development, nourishment, health, wellbeing and life span.
Overnutrition, undernutrition and unbalanced nutrition as well as food of bad quality in terms of healthy standard value can all lead to health problems such as ischaemic heart disease, arterial hypertension, atherosclerosis, certain neoplasms, diabetes type II, osteoporosis, endemic goitre, obesity, certain diseases of the alimentary tract, iron deficiency anaemia etc. These diseases are responsible for lowered biological, economic and intelectual potential of the population. Methods for improving human health which involve proper nutrition and better food quality are well known and their efficiency has been already evidenced in many countries.

Expected health gain

• Better psychophysical condition of the population: increased learning capability of children and working capability of adults.
• Reduced incidence of allergic and communicable diseases in infants and children induced by formula feeding of newborns.
• Reduced risk of diseases and disorders generated by inappropriate unbalanced nutrition.

To achieve this target it is required:

1. to promote education of people in the area of healthy diet, especially at schools under the comprehensive national health education programme;
2. to supply the national market with good food of standard nutritive value;
3. to verify or establish new legislation, harmonised with requirements of the European Union, that will provide for the promotion of healthy eating patterns and the development of healthy food production, processing and marketing;
4. to promote and encourage further breast feeding of newborns;
5. to implement, in cooperation with local self-governments and parents, the system of providing meals at schools;
6. to impose the treatment of table salt with iodine, promote its proper distribution and encourage people to use only iodized salt;
7. to organise the dietetary counselling for healthy and sick persons under the public health care system;
8. to promote administration of folic acid to women at reproductive age in order to prevent congenital defect of neural tube in newborns;
9. to reorganise the system of food and nutrition safety control putting special emphasis on better coordination;
10. to provide food and nutrition support for social groups with the lowest income and particularly difficult living conditions;
11. to promote the production of certified food from ecological farms and develop education in ecological issues addressed to decision-makers, producers and consumers.

Indicators:

• The percentage of breast fed newborns under six months of age.
• The percentage of students having meals at schools.
• The results of studies carried out in the area of eating patterns and nourishme of selected groups of the population as well as the results of food quality monitoring and control.

TARGET 3

Reducing tobacco smoking

• A reduction of 25% (compared to 1995) in tobacco smoking.
• An increase of 60% in the proportion of never smoking males and of 80% in the proportion of never smoking females in the total population.
• A reduction of at least 50% in smoking among pregnant women in comparison to the early nineties.

In better off countries tobacco smoke is a major environmental pollutant affecting the health of active and passive smokers. The adverse health effect of smoking in terms of both physical and mental condition has been already well documented. The nicotine-related smoking addiction can be reduced by developing and implementing well designed preventive programmes addressed mainly to children and young people in order to prevent their first contact with smoking.

Expected health gain

• A decrease of 10% (compared to 1995) in mortality from malignant neoplasms, especially those related to smoking.
• A 15% decrease (compared to 1995) in mortality from diseases of the circulatory system.
• A considerably decreased incidence of nonspecific pulmonary diseases, their circulatory complications and other smoking-related diseases.

To achieve this target it is required:

1. to enforce the provisions of the Health Care Law, especially those included in the section on the effects of tobacco smoking;
2. to reduce smoking among teachers and health service workers and to promote nonsmokers among candidates for employment in schools and health facilities;
3. to strengthen anti-smoking campaigns among students of all types of schools;
4. to make provisions for smoke-free institutions and public places;
5. to impose strong controls on cigarette advertising;
6. to maintain relatively high prices of tobacco products;
7. to reduce systematically the content of harmful substances in tobacco and smoke of cigarettes available on the Polish market;
8. to encourage the authorities, local self-governments and nongovernmental organizations to participate in anti-smoking campaigns;
9. to establish networks of antinicotine counselling services to help existing smokers to stop smoking and to encourage them to overcome their addiction to tobacco. They should operate, at least, in bigger cities, especially in those where medical schools are located.

Indicators:

• The percentage of smokers, ex-smokers and nonsmokers and those who have never smoked in random samples of the population.
• The percentage of smokers, ex-smokers and nonsmokers in random samples of the educational and health service personnel.
• The results of controls carried out in order to find out whether anti-smoking regulations are observed in public places.
• Evaluation of the exent of smoking problem in schools of different types.
• Evaluation of the access to and efficiency of antismoking counselling services.

TARGET 4

Reducing alcohol consumption, changing alcohol consumption patterns, and reducing alcohol abuse-related health damage

Expected outcome by 2005

• A reduction of 10% (compared to 1994/95) in the average alcohol intake per capita.
• A reduction of 20% (compared to 1994/95) in the proportion of spirits in the alcohol consumption patterns.
• A reduction in alcohol-induced health damage.
• A reduction in mortality and health impairments among alcohol addicts.
• A reduction of 20% (compared to 1994/95) in alcohol intake among young people.

It is estimated that in 1995 the substantial, mean, annual alcohol intake accounted for 7-9 litres of pure alcohol per capita. A rapid increase in alcohol consumption observed during the years 1989- 92 has been recently supressed. Nevertheless, the problems like heavier drinking among young people and women, the prevalence of spirits in the alcohol consumption pattern (spirits - 57%; wine - 15%; beer - 28%), alcohol intoxication among drivers, alcohol consumption by patients under treatment and during recovery, and violence in alcoholic families still exist.
The estimated number of alcohol addicts reaches 800-900 thousand persons, including 139 thousand of those registered in alcohol treatment out- and in-patient facilities. The efficiency of withdrawal therapy among these patients is still low and the majority of them continue to drink.
The extent of alcohol-related health damage could be reduced even with the same level of global alcohol intake in Poland by improving the axcess to out- and in-patient treatment among alcohol abusers and strengthening its efficiency as well as by promoting modern diagnostic methods in primary health care centres and in other health facilities and by immediate intervention in the case of alcohol abusing patients.

Expected health gain and social improvements

A reduction in alcohol-related health damage and the extent of social problems, including:

• alcohol-related mortality and disability resulting from traffic and other accidents, suicides, homicides, alcohol intoxication, cirrhosis, certain malignant neoplasms, arterial hypertension etc.,
• family pathologies (violence, negligence of children, poverty), conflicts with law and behavioural disorders induced by alcohol abuse,
• health impairments in members of alcohol families (psychosomatic disorders induced by pathological stresses, lack of responsibility for own health etc.).

The priorities and relevant tasks are identified in the National Programme for Alcohol Prevention and Solving Alcohol Problems adopted by the Council of Ministers on 13 August 1996. The national strategy aimes at:

1. limiting access to alcohol and controlling the alcohol market;
2. promoting administrative, fiscal and educational mechanisms in order to change the alcohol consumption pattern;
3. imposing efficient mechanisms of legal and social control of alcohol-related pathologies;
4. promoting educational programmes addressed to young people and risk groups;
5. improving the efficacy of and access to therapeutical programmes for alcohol abusers and their families.
6. training of different professional groups in the area of alcohol problems;
7. supporting and promoting activities of self-help groups and sobriety associations.

Monitoring and evaluation of outcomes

Indicators:

• The average alcohol consumption per capita in the selected populations, patterns of alcohol consumption in different age groups.
• The incidence of alcohol psychoses, cirrhosis and injuries in intoxicated persons.
• The number of alcohol-related road accidents.
• The number of cases of alcohol-related violence in the family.
• The statistics on alcohol drinking children and young people made during the last month preceding the data collection.
• The frequency and number of persons treated in out- and in-patient clinics, and those admitted to sobriety stations.

TARGET 5

Reducing abuse of other psychoactive substances and drug abuse-related health damage

Expected outcome by 2005

• Drug demand reduction.
• Limited access to psychoactive substances.
• Implementation of generally accessible treatment and rehabilitation programmes for persons experimenting with drugs and drug addicts.

In Poland it is difficult to estimate a real number of drug addicts. At present, the number of only opiate addicts is accounted for 25-30 throusand of persons. Recently, the amount of illicit psychoactive substances such as amphetamine, cocaine, hallucinogens, cannabis-type drugs has rapidly increased on the Polish market. The same applies to opiate, volatile solvents and multiple drugs. The increase in consumption of illicit drugs has been observed especially among younger people who are not as yet addicted but are exposed to risk of intravenous use of drugs.
Since the efficacy of drug addict treatment is rather limited throughout the world, and the risk of acute health damage (mental disorders) is growing profoundly, treatment and rehabilation programmes are supported and promoted.

Expected health gain

A reduction in drug-related health damage, including lower incidence of:

• mental disorders (withdrawal symptom, psychoses, depression with attempted suicides),
• somatic diseases (AIDS, viral hepatitis B, opportunistic infections with tubercle bacillus, cachexy etc).

Tasks designed to achieve the target

To achieve this target is it required:

1. to establish drug policy aimed at managing psychoactive substances and harmonising legislation with current and changing needs;
2. to promote reliable information on psychoactive substances in all types of schools within the general health education programmes, and develop social and personal skills to protect young people against temptation to reach for drugs;
3. to encourage preventive programmes in mass media and other special programmes designed for high risk groups, and to train personnel how to implement these programmes;
4. to reduce supply of psychoactive substances through legislative mechanisms, and greater involvement of the police and customs personnel;
5. to train health service workers, teachers, policemen and penitentiary personnel etc. in early identification of drug-related problems, and to develop skills essential in working with persons experiencing such problems and providing addicts with comprehensive, professional assistance;
6. to train primary health care medical personnel in the safe application of psychoactive drugs which may induce addiction;
7. to implement programmes of effective detoxication, treatment and rehabilitation of drug abusers and addicts, as well as programmes reducing health damage such as metadon programmes, needle and syringe exchange programme, and promote sexual education (use of condoms).

Indicators:

• The percentage of addicts (data on persons who benefit from services of health facilities, screening in representative groups of the population).
• The police, court and customs records on the production, illicit traffic and distribution of psychoactive substances and drug-related crimes.
• Monitoring and evaluation of preventive programmes.
• Evaluation of treatment and rehabilitation programmes.

TARGET 6

Improving efficiency of health education and health promotion programmes

Expected outcome by 2005

• Incorporation of health education in curricula of all types of schools.
• Promotion of health education of society in the mass media and improvement of its quality and efficacy.
• Development of the infrastructure for health promotion at the regional and local levels.
• An increase in the number of well trained persons able to develop and implement health education programmes in all sectors of public life.
• Health promotion and health education will be encouraged at the community level: healthy cities, health-promoting communities, schools, workplaces and hospitals (about three thousand schools will join the National Network of Health-Promoting Schools).

Raising health awarness and health competence both in professional groups and in the whole society is now crucial to shaping and promoting healthy lifestyle. This can be achieved mainly by developing more effective health education in society, especially among children and young people. Despite the fact that health promotion is recognised as good investment, in Poland there has not as yet been developed a comprehensive health education programme compulsory at schools. There is also an urgent need for health education programmes focusing on the elimination of risk factors responsible for chronic diseases and promoting lifestyles conducive to health addressed to the whole population.
In order to stimulate initiatives and effective actions for health promotion it is necessary:

• to support training in this area of different professional groups (thus far training was addressed mostly to health service workers, whereas intersectoral action is needed to ensure access to the prerequisites for health and to protect from risks and hazards occurring in the physical, economic and social environment),
• to establish the infrastructure for supporting health education programmes and activities as well as for coordinating allocation of funds (Poland is lacking such an infrastructure, therefore the use of already trained personnel is limited).

• Expected health gain will cover majority of health aspects, and it will be particularly visible in lifestyle-related areas.

To achieve this target it is required:

1. to establish and implement a comprehensive health education programme at primary and secondary schools (the program should tackle such issues as drug addiction prevention, HIV/AIDS and sexual education) and develop mechanisms supporting its implementation (system of under- and postgraduate education of teachers, methodology counselling, production of teaching and audio-visual materials for students and teachers;
2. to intesify promotion of healthy lifestyles in mass media, stressing the need for developing people's skills and highlighting their options so that they can exercise more control over their health and cope with major health hazards;
3. strengthen the infrastructure for health promotion and improve the system of allocation of funds needed for implementation of health education programmes and projects at the local, regional and national levels;
4. to implement the system of under- and postgraduate education for health services workers and other professional groups in the field of health promotion (journalists, self-government workers, teachers, politicians, members of non-governmental organizations);
5. to stimulate and support health promotion projects and activities based on the settings approach (healthy cities, healthy communities, healthy homes, health-promoting schools and workplaces);
6. to develop healthy lifestyle counselling focusing on family problems, psychological aspects, healthy diet, smoking cessation and reducing alcohol abuse;
7. to support local self-governments and nongovernmental organizations in their activities for health education and health promotion.

Indicators:

• The percentage of schools implementing health education programmes and the number of trained teachers.
• Evaluation of the quality and efficacy of health education in the mass media.
• Evaluation of the infrastructure for health promotion at the central and regional levels.
• The number of persons involved in health promotion in different sectors and the evaluation of their knowledge and competence.
• The number of cities, communities, schools, workplaces, hospitals implementing health promotion projects based on the settings approach.
• The number of facilities involved in healthy lifestyle counselling.
• The number of nongovernmental organizations involved in health education and health promotion.

TARGET 7

Promoting mental health and preventing mental disorders

Expected outcome by 2005

• The establishment of legislative, administrative and economic mechanisms for developing the infrastructure and local initiatives supporting families at crisis.
• Broad and easy access to education in the area of mental health protection and promotion among different groups of the population, particulaly among parents, teachers and managers.
• An increase in the number of institutions involved in rendering preventive services, counselling and professional assistance to persons facing difficult situations and suffering from mental disorders.

In Poland 15-25% of persons suffer from mental disorders and 10-20% of children and adolescents at the school age need mental health and psychological care: psychogenic disorders or conditions in which psychogenic factors play important role are most frequent. During the recent years a systematic increase in the number of persons seeking help of psychiatrists and psychologists or general practitioners because of neurotic disorders has been observed. The incidence of depressions and psychosomatic disorders, and the number of problems related to abuse of alcohol or other psychoactive substances are also growing. This increase can be attributed mostly to present conditions of life, and especially to rapid political, economic and social changes that increase people's vulnerability to mental distress.
Mental health promotion encompasses primarely:

• development of conditions which are supportive to harmonious mental development of children and which allow to meet psychic needs of adults, - development of educational programmes to strengthen people's skills to satisfy their needs and aspirations and to lead creative life and to cope with difficult situations as wel as to establish good interpersonal relations within own community,
• ensuring professional and social support to persons and families facing difficult situations.

• Improved mental health condition of the population, better interpersonal relations, stronger motivation for cooperation between individuals, groups and local communities.
• A reduction in the incidence of mental disorders: emotional, neurotic and psychosomatic, and problems related to abuse of alcohol and other psychoactive substances.

To achieve this target it is required:

1. to impose effective legal and economic measures, and ensure the provision of comprehensive support and assistance in the family crisis in order to restore its normal functioning;
2. to foster local initiatives in organising leisure time activities for the community groups as an alternative to their paticipation in activities of different subcultures;
3. to provide training in mental health protection and promotion for people involved in bringing up, care, education, social reintegration and treatment of children and young people, as well as in management and organisation of work and recreation;
4. to assist parents in acquiring knowledge of the mental development and relevant needs of the child, and in developing their skills to stimulate and support this development, to acquint children with the role of the family and principles of its functioning, to shape creative personalities and healthy life styles;
5. to develop, within school comprehensive health education programme, personal and social skills (responsibility for own health, communication with other people, solving own problems and conflicts, coping with stress and outside pressure etc.), create conditions and atmosphere supportive to mental health and foster school movements promoting mental health;
6. to provide community- and institutionally-based support to families in difficult financial and emotional situation;
7. to ensure access to counselling and professional assistance for:
   • parents with children under 6 years of age (psychological counselling, including detection of mental development disorders),
   • young people during their adolescent crises and diffulties,
   • parents in cases of conflicts and family dysfunctions,
   • adults who wish to advance their knowledge and skills to satisfy own psychic needs and cope with different problems,
   • unemployed persons and persons with disabilities (employment counselling, professional reorientation);
8. to support the development of self-help groups and nongovernmental organizations in their activities for mental health promotion.

Indicators:

• The number of persons treated in hospitals and mental health out-patient centres.
• The evaluation of the standard of and access to family counselling and other forms of counselling in selected regions of the country.
• The evaluation of training of selected professional groups in mental health issues.

TARGET 8

Reducing exposure to harmful factors in the living, working and educational environment and mitigating their health effects

• Annual emission of sulphur dioxide into the air will be maintained below 2 million tones.
• Emission of nitrogen oxide will be maintained at the level of 1995.
• A reduction of 15% (compared to 1995) in the number of untreated communal and industrial seweges.
• A reduction of 25% (compared to 1995) in exposure to noise.

Although the state of the environment has been gradually improved in Poland, the situation is still far from being satisfactory and actions aimed at further improvement should be intensified.
Indoor air pollution (at workplaces, homes), outdoor air pollution, pollution of drinking water and surface waters, soil and food are responsible for many health problems like reproduction disorders, neurological, immunological, renal and behavioural disorders. They also increase the risk of chronic diseases, diseases of the respiratory and digestive systems, neoplasms and also congenital malformations.
Over the last 25 years the incidence of occupational diseases has shown a growing tendency. The following seven categories of diseases contribute most to this increase: hearing impairment, chronic disease of the voice organ, infectious and invasive diseases, pneumoconioses, skin diseases, vibration syndrome, poisoning. These diseases make about 85% of the total incidence of occupational diseases.

Expected halth gain

In relation to 1995:

• a reduction of 5-10% in the incidence of acute and chronic respiratory diseases,
• a reduction of 50% in the incidence of increased blood lead level in children living in big cities,
• a reduction of 20-30% in the incidence of pneumoconiosis,
• a reduction of 50% in the incidence of occupational hearing impairments,
• a reduction in the incidence of chronic occupational poisoning.

To achieve this target it is required:

1. to develop the governmental strategy "Environment and Health" based on the guidelines laid down by the WHO Regional Office for Europe and incorporated in the Helsinki Declaration, signed by Poland in 1994;
2. to continue the implementation of the strategic governmental programme "Safety and Human Health Protection in the Working Environment";
3. to elaborate and implement programmes of preventing health effects of exposure to the environmental harmful factors;
4. to develop new and improve the existing information systems for monitoring the environmental health hazards and their effects;
5. to eliminate or update technologies contributing to the pollution of working and communal environment;
6. to introduce ecological heating systems in urban areas with levels of sulphur dioxide and suspended dust exceeding MAC values;
7. to impose effective measures to eliminate lead containing petrol from the market and to reduce the number of old cars without catalysts; to promote ecological fuels and rail transport;
8. to improve legislative mechanisms in the building industry towards the reduction of health hazards related to technologies used, and the promotion of ecological building materials;
9. to restructure the agricultural production in areas with soils overpolluted by toxic substances;
10. to accelerate the construction of water supply and purification systems and sewages in rural areas;
11. to impose effective technologies of water treatment in the systems supplied from surface water reservoirs in order to prevent the process of secondary water micropollution;
12. to mitigate the effects of wrong localisation of various objects by constructing acoustic screens and applying other protective measures;
13. to develop and implement integrated programmes of ecological and health education addressed to decision-makers, self-governments, producers and consumers;
14. to improve the systems of early detection of health and environmental hazards induced by ionizing and nonionizing radiation;
15. to elaborate and introduce local programmes aimed at reducing the volume of wastes and promoting their utilization, and to introduce central programmes of ecologically safe treatment of toxic wastes; to put special emphasis on dangerous wastes, including biologically contaminated wastes from health service facilities, wastes left after actions taken to mitigate outcomes of chemical accidents; to limit combustion of wastes and apply it only if it proves to be the most safe for the human health and the environment way of the waste neutralization;
16. to establish the efficient system for control of activities undertaken by individual institutions to protect human health against adverse effects of physical, chemical, biological and social environment.

Environmental factors:

Emission and concentration of basic pollutants related to combustion of mineral fuels (dust, SO2. NO2, CO, AHs, Pb) and other hazardous substances emitted as a direct result of technological process (Cd, CS2) or resulting from atmospheric reactions (O3, SO4); carcinogenic AHs and trihalometanes and nitrates in drinking water; selected heavy metals and AHs in soil and food; selected chlororganic compounds in food and biological material; products of biological corrosion and substances most frequently emitted from building and furniture materials (fungi and mould spores, formaldehyde, selected aromatic hydrocarbons); blood and urine concentrations of selected heavy metals.

The incidence of occupational neoplasms, bronchial asthma, respiratory disorders in children, congenial malformations, low birth weight, infant mortality from selected causes.

TARGET 9

Improving sanitation throughout the country

• Systematic reduction in the number of facilities which do not satisfy sanitation requirements.

Sanitation throughout the country, and especially of public services (schools, offices, health service facilities, catering facilities, railway stations etc.) departs considerably from the standard recommended by the European Community. However, certain improvements have been made recently. This situation contributes among others to the incidence of food poisoning and viral hepatitis A. In addition, it limits the efficacy of health education.
The sanitation can be improved if the access to means and instruments for maintaining hygiene, removal of wastes etc. becomes easier and is associated with advancements in health education.This should involve concerted actions of all sectors.

Expected health gain

• A reduction of 40% in the incidence of food poisoning.
• A reduction of 50% in the incidence of diarrhoea in children under two years of age.
• A reduction in the incidence of viral hepatitis A.

To achieve this target it is required:

1. to provide conditions and support further development of the market with cleansers, detergents and articles of personal hygiene at prices acceptable for mass buyers;
2. to introduce legal and technological norms of the removal, storage and utilization of wastes, harmonised with the norms of the European Union;
3. to provide sufficient number of public lavatories in urban areas and to control their technical and sanitary condition;
4. to improve the system of waste neutralisation;
5. to improve sanitation at health service and educational facilities so that they could serve as examples to be followed by other public services;
6. to tighten the sanitation criteria for public services and to increase sanctions towards persons responsible for sanitation at the all country levels who fail to perform their duties.

Indicators:

• The precentage of public facilities of different categories which do not satisfy sanitation requirements.

TARGET 10

Reducing the incidence of accidents, and traffic accidents in particular

• A gradual reduction in the number of accidents, especially road accidents, and in the number of casualties.
• A reduction of 20% (compared to 1995) in the overall scale of mortality from accidents;
• A reduction of 50% (compared to 1995) in the number of occupational accidents.

In Poland traffic accidents are one of major causes of death in the category of injury and poisoning, and the major cause of death among young people. The year 1995 brought about 6.900 deaths and 70.226 injuried in traffic accidents. In Poland traffic accidents are characterised by profoundly high mortality: 12 deaths per 100 traffic accidents, whereas in the European Community member States this rate accounts for 3.5. In high industrialised countries much success has been achieved in combating road accidents due to effective implementation of preventive programmes and well developed systems providing first aid for those injuried in traffic accidents.
Despite recent improvement, the scale of occupational accidents is still very large. The annual number of persons involved is higher than 100 thousand, including 600 deaths.

Tasks designed to achieve the target

To achieve this target it is required:

1. to reduce the number of causalties of road accidents caused by excessive speed, mainly through:
   • reaching the social consent for imposing speed limits,
   • increasing awarness among drivers that speed has to be adjusted to road conditions,
   • retraining of drivers who break speed limit regulations,
   • increasing the police control over speed limits,
   • establishing zones of limited speed in urban areas;
2. to reduce the number of causalties of road accidents caused by unexperienced drivers, mainly through:
   • stimulating social disapproval of risky behaviours,
   • introducing driving licences of two kinds "tentative" and "with an accompanying person" before granting permanent driving licence,
   • introducing more careful psychological tests when granting driving licence,
   • increasing liability insurance fees for newly licenced drivers,
   • lowering insurance fees for "safe" drivers (a 10, 15 and 20-year driving without accident);
3. to reduce the number of causalties of traffic accidents caused by drunk road users, mainly through:
   • stimulating social disapproval of drunk road users,
   • increasing the frequency of random controls of drivers' sobriety,
   • severe punishment or imposed retraining of drivers who drink and drive,
   • differentiated liability insurance indemnities depending on the drivers' sobriety;
4. to reduce the number of causalties of traffic accidents involving unprotected road users, mainly through:
   • modifying the training rules for persons driving one-track vehicles,
   • promoting reflective elements placed on the cloth of pedestrians and bicycle drivers,
   • tightening technical norms of one-track vehicles: traffic segregation (shoulders, paths, railings) and division of roads in zones,
   • improving and protecting pedestrian cross-walks (warning signs, light signals);
5. to reduce adverse effects of accidents, mainly through:
   • promoting first aid,
   • committing drivers to possess certificates confirming their capability of providing traffic accident causalties with first aid before doctor's arrival,
   • imposing proper equipment of vehicles (safety belts, baby safe, safety and protective helmets),
   • introducing more severe supervision over technical overhauls of vehicles,
   • promoting safe road environment (railings and other protective measures),
   • establishing the effective first aid system;
6. to reduce the number of causalties at cross-walks in small towns, mainly through:
   • creating favourable social atmosphere for soothing road traffic tension,
   • modifying pedestrian cross-walks across arterial roads,
   • introducing solutions soothing road traffic (road narrowings, round-abouts),
   • constructing roads and ring roads allowing to omit compact settlements;
7. to reduce the number of causalties at places of high risk of accidents, mainly through:
   • disseminating information about such places,
   • idenitifying areas where repairs and other preventive measures are needed,
   • modifying dangerous road-crossings;
8. to update teaching methods in the area of labour safety and hygiene, and information about occupational hazards;
9. to impose on employers safe and hygienic conditions at workplaces;
10. to promote legislative and information mechanisms contributing to the reduction of accident risks;
11. to establish a national agency for accident prevention.

Indicators:

Evaluation of the scale of human and material losses and the incidence of traffic and occupational accidents with particular emphasis put on:

• the incidence of traffic and occupational accidents analysed by causes,
• mortality resulting from accidents,
• the incidence of injuries resulting from registered accidents (in relation to the number of the population and the number of vehicles,
• involvement of pedestrians and other non-protected road users in causalties,
• the number and frequency of accidents and the number of persons injured due to alcohol abuse.

TARGET 11

Improving efficiency and effectiveness of emergency service in life threatening conditions

• Easier access to emergency medical care, providing a reduction in the number of unjustified calls.
• A reduction in the waiting time for emergency services.
• The extension of emergency facilities.

The number of accidents involving casualties, including deaths at the place of accident continues to increase; still high numbers of deaths occurring shortly after the onset of acute episodes of cardiovascular diseases and an increasing number of sudden deaths from unknown causes before arrival of the first aid are registered.

Expected health gain

• A reduction (compared to 1995) in mortality from diseases of the circulatory system.
• A reduction (compared to 1995) in mortality from injury and poisoning.
• A stronger sense of security among people at risk of disease and life threatening circumstances.
• Equity in access to medical care in emergency regardless of social status or place of residence.

To achieve this target it is required:

1. to reduce waiting time for emergency service in life threatening conditions to 15 min;
2. to reduce the number of deaths during the first hour after an accident;
3. to reduce time elapse between an acute episode and rendering of medical aid in the case of diseases of the circulatory system;
4. to draft the law on life-saving procedures;
5. to implement a uniform programme of first aid education at primary schools;
6. to incorporate medical first aid into responsibilities of fire brigades, the police and ship salvaging units;
7. to update the regulations and equipment of sanitary aviation;
8. to unify the organisation, equipment, training and regulations of public emergency services throught the country;
9. to establish and implement regulations of the functioning of public health care facilities and state administration bodies in cases of calamities and accidents;
10. to establish the telematic system of cardiological supervision.

Indicators:

• The number and frequency of road accidents, including deaths at the place of accident.
• The number and frequency of successful life-saving attempts outside hospital.
• The number, distribution and equipment of emergency stations.

TARGET 12

Improving acess to and efficiency of primary health care

• A reduction in differences in health status and equity in access to health services.
• Stronger feeling of security among persons seeking medical care.
• Equity in access to preventive services.
• Promotion of care of patients at risk of chronic diseases.

High standard and easy access to primary health care services are prerequisites for reducing social and regional inequalities in the medical care. Well organised primary care ensures prevention, and facilitates treatment of diseases in their earlier, frequently reversible stage. This is the field of practice where the patient usually makes his first contact with the physician and where health supportive attitudes can be promoted.

Expected health gain

• A reduction in the risk of chronic diseases, especially those of the circulatory and musculoskeletal systems.

To achieve this target it is required:

1. to promote the concept of family health physicians;
2. to expand the network of well equipped primary health care centres;
3. to shift the responsibility for primary health care management to local self-governments;
4. to promote contracting of health services;
5. to educate about 2.500 physicians in the field of family medicine within the resident system and about 1.200 physicians with longer experience at short-term intensive courses;
6. to advance qualifications of nurses and midwives employed in primary health care;
7. to alter the system of primary health care financing and to replace the service provision-based system by insurance system.

Indicators:

• The number of primary health care centres and their distribution.
• Employment rates.
• Services rendered.

TARGET 13

Preventing premature births, low birth weight and reducing related health effects

• A reduction of 5% in the incidence of prematurity and low birth weight (below 2.500 g).
• A reduction in perinatal mortality rate to 11 per 1.000 births.

Despite significant decreasing tendency observed in Poland, infant mortality rates are still twice as high as in Western Europe. Prematurity and low birth weight are major contributors to high infant mortality. In 1995 infant mortality rate accounted for 13.6 per 1.000 live births, and the percentage of newborns with low birth weight (below 2.500 g) reached the value of 6.7% (in Western Europe it ranges between 4 and 6%). In Poland death risk in newborns with low birth weight is twofold when compared to developed European countries.

Expected health gain

• A reduction in infant mortality rate to 8 per 1.000 live births (average rate in Europe).
• A reduction in the incidence of chronic diseases and disabilities resulting from prematurity and low birth weight.

To achieve this target it is required:

1. to improve diagnostic measures and treatment of infections of the genitourinary system in pregnant women;
2. to reduce smoking among pregnant women to the level below 10%;
3. to improve nourishment among pregnant women living in poverty;
4. to reduce by 20%, in relation to 1995, the number of pregnancies among women aged under 18 and above 35 years;
5. to promote pre-pregnancy care of women and improve diagnostics and active care of pregnant women at risk of premature delivery;
6. to promote the reference system in regard to premature delivery (transport of the mother) and improve the quality of care of premature infants.

Indicators:

• Infant mortality.
• Perinatal mortality.
• The incidence of prematurity and low birth weight.
• Age of delivering women, sequence of pregnancies, time relapse between pregnancies.
• Frequency of smoking among pregnant women.

TARGET 14

Improving early diagnosis and active care of persons at risk of ischaemic heart disease

• Significant improvement in the detection of arterial hypertension together with increased rate of patients under successful treatment and prevention of cerebral stroke.
• Promotion of screening for ischaemic heart disease risk factors in the population of Poland and implementation of preventive methods.

Poland belongs to only a few European countries where "epidemic" of ischaemic heart disease - the most life threatening disease of the circulatory system - has not as yet been effectively controlled. Persons under 65 years of age are at greatest risk. In most countries this disease is still a major cause of death.

Expected health gain

• A reduction of 15% (compared to 1995) in mortality from diseases of the circulatory system.

To achieve this task it is required:

1. to improve detection of arterial hypertension already at the stage of primary health care. The frequency of newly detected cases of hypertension should increase with the pace of at least 2% per year;
2. to promote nonpharmacological treatment and early therapy of hypertension in out-patient facilities;
3. to promote broader evaluation of blood fat level and in the case of its increase undertake appropriate dietetic and pharmacological therapy;
4. to expand the scope of basic analytical methods in district laboratories in order to include the analysis of fat levels.

Indicators:

• The number of screening tests for arterial hypertension and hypotensive therapy undertaken.
• The number of screening tests for hypercholesterolaemia and dietetic and pharmacological therapy undertaken.

TARGET 15

Improving early diagnosis and treatment of breast and cervical cancers

• Broadly accepted and easily accessible system of early detection and treatment of malignant neoplasms occurring most frequently in women.
• A reduction of 10% (compared to 1995) in mortality from malignant neoplasms in the whole population under 65 years of age.

Breast cancer is the most dangerous neoplasm which still spreads among women in Poland. The incidence of malignant neoplasm of cervix uteri is lower than that of breast. The effective treatment of both cancers depends, to the great extent, on their early detection.

Tasks designed to achieve the target

To achieve this target it is required:

1. to increase women's awarness concerning the need for regular tests and to develop their skills to perform them in order to facilitate early detection of breast cancer and diseases leading to its occurrence;
2. to increase the frequency of detection of preinvasive breast cancer by 2% annually;
3. to increase the frequency of cytological tests of cervical smears among women under 60 years of age. The annual increase should account for at least 2%;
4. to establish units for performing screening tests for breast cancer at branches of the National Institute of Oncology and in most other microregions and to provide them with necessary diagnostic equipment;
5. to promote cytological tests among women aged 18-60.

Indicators:

• The frequency of breast tests and collection of cervical smears based on interviews held with representative sample of women.
• The frequency of detection of noninvasive cancer of breast and cervix uteri based on the national register and local registers of malignant neoplasms.
• The evaluation of the progress made in investments and purchase of equipment needed for mass regular performance of screening tests.

TARGET 16

Providing better opportunities for people with disabilities and developing their capacities to lead active lives

• An increased number of workplaces of sheltered employment and workposts for people with disabilities in regular workplaces.
• More students with disabilities integrated into groups of healthy youth.
• Much better adjustment of the living environment to the needs of people with disabilities.
• Better access to rehabilitation services.

According to estimated figures there are about 4.8 million people with disabilities, including about 300 thousand children and adolescents. Diseases of the circulatory system, nontraumatic diseases of the musculoskeletal system (including osteoporosis), consequences of injury and poisoning, chronic respiratory diseases, impairments and dysfunctions of locomotor system, and mental disorders in children and adolescents are major causes of disability.
Living conditions of people with disabilities are difficult and the quality of their lives is far from satisfactory. They are denied the opportunities of complete successful treatment and rehabilitation, and they suffer restricted educational opportunities. The supply of orthopaedic equipment and technical aids is not sufficient. Because of limited mobility the disabled encounter a great number of barriers in transport, public services and buildings. All these contribute to the fact that in Poland, in comparison to other countries, less people with disabilities, especially young people, are able to participate in productive life, and very often they do not return to normal life, suffering psychic and social discomfort. Such a sitituation increases an economic burden for the whole society.

Expected health gain

• A reduction in the number of persons with high degree of locomotor disability.
• An increase of at least 20% in the number of disabled persons integrated into occupational and social environment.

To achieve this target it is required:

1. to remove urbanistic, architectural and transport barriers in places of habitation and work, in public services and means of public transportation in order to improve mobility of people with disabilities;
2. to facilitate and encourage the production of orthopaedic equipment and other technical aids to provide the disabled with the opporunities for normal functioning; to change the rules of setting limits of funds for purchasing orthopaedic equipment and technical aids by providing for in the Budget Law (in the state budget and that allocated to regional governors) a certain quota of financial means to be used for this purpose;
3. to improve and advance education of people with disabilities, including:
   • better opportunities for children and adolescents to attend integrated classes in state schools,
   • better opportunities for the disabled adults to qualify for another job and to acquire a new profession,
   • better opportunities for persons with disabilities to complete secondary and university education and not restrict them only to vocational schools;
4. to assist the disabled in getting employment by establishing workplaces with sheltered employment and adjusting to their needs workposts in regular workplaces;
5. to develop positive social policy supportive to families taking care of their disabled members in order to alleviate their burdens (especially in the case of severe disability) and to provide the disabled with the opportunity for staying with the family instead of living in a welfare home;
6. to promote positive attitudes in society towards people with disabilities (understanding problems of the disabled, tolerance, creation and promotion of different forms of integration);
7. to encourage social movements and support local self-governments and nongovernmental organisations in their activities for better quality of life enjoyed by people with disabilities, their greater activity in the working environment and social integration;
8. to reform the system of disability certification, putting more emphasis on social, economic and occupationl situation of the disabled and their rehabilitation before granting them a disability pension;
9. to improve the rehabilitation system for the disabled, including:
   • the advancement of the existing system by introducing into practice the following principle:rehabilitation must be comprehensive, continuous, broadly accessible and applied as early as possible,
   • bringing rehabilitation services closer to the patient's place of habitation through establishing small, local units and developing different forms of community rehabilitation,
   • the establishment of comprehensive rehabilitation centres at regional levels,
   • the integration of services rendered by personnel involved in rehabilitation and social workers in order to ensure the continuation of social rehabilitation in the place of residence after returning from the rehabilitation centre;
10. to modify the system of education designed for the rehabilitation personnel towards a comprehensive model (medical, psychological, occupational and social rehabilitation).

Indicators:

• The number of persons living on a disability pension.
• The number of workplaces of sheltered employment and workposts adjusted for the disabled in regular workplaces.
• The number of disabled students in integration classes.
• The evaluation of the progress in adjusting living environment to needs of persons with disabilities.
• The number of rehabilitation centres and their distribution throughout the country.
• The evaluation of supply of orthopaedic equipment and technical aids for people with disabilities.

TARGET 17

Improving prevention of communicable diseases

• Introduction of new compulsory vaccinations and improved quality of vaccines and vaccinations.
• Reduced transmission of certain infections.

Mortality from and morbidity of communicable diseases decreased considerable after the war, nevertheles, the rates are still higher in Poland than in more developed countries. Tuberculosis still remains a major cause of deaths caused by communicable diseases. Diseases transmitted by the skin damage create a severe problem. Among them viral hepatitis B takes the first place. Infant communicable diseases controlled by vaccinations have not as yet been eradicated.

Expected health gain

• A reduction of 15% (compared to 1995) in TB incidence.
• A reduction in the annual incidence of viral hepatitis B to 2.500 cases.
• A reduction in the percentage of HIV carriers in the population of drug addicts.
• A reduction in the incidence of mumps.
• Prevention of imported cases of communicable diseases which do not occur in Poland.

To achieve this target it is required:

1. to introduce combined vaccine for measles, mumps and rubella;
2. to cover all risk groups with vaccanation for viral hepatitis B;
3. to increase the efficacy of detection and treatment of tuberculosis to the level of 90% through close cooperation with primary health care in the area of disease detection and treatment (training of family physicians and pediatricians); to improve the efficacy of TB vaccinations through:
   • proper training of nurses who are involved in the immunization programmes and better supervision over the performance of tuberculinic tests,
   • ensuring good quality of immunization equipment;
4. to prevent blood transmitted infections through expanding the national information system of blood services in order to facilitate, among others, the identification and registration of persons whose blood should not be collected for therapeutical purpose; to implement the existing "Programme of AIDS Prevention and Control" which encompasses education of the whole population and risk groups and identification of infection sources;
5. to prevent the spread of food infection and poisoning through:
   • improvement of sanitation in the whole country, especially in animal breeding, the food and fodder industries,
   • health education of food producers, people involved in food storage and distribution, and consumers;
6. to promote ecological technologies of sterilisation of medical instruments and food conservation, including techniques which involve ionizing radiation;
7. to increase awarness of possible import of communicable diseases, that do not occur in Poland, among people who travel abroad, employing health education programmes;
8. to make vaccination for diphteria compulsory among the adult population, especially among risk groups living close to endemic areas.

Indicators:

• The incidence of selected communicable diseases.
• The proportion of vaccinated persons in the population.

TARGET 18

Improving prevention of dental caries and periodontal disease

• Establishment health education and counselling units dealing with prevention of oral cavity in children and pregnant women in at least 50% of primary health care centres.
• An increase of 25% (compared to 1994) in the number of school children covered with fluoride preventive programmes.
• Preventive sealing of oclusal surfaces of first molars or varnish application on smooth surfaces in 60% of children aged 6-8 years.

In Poland dental caries, very frequent in the whole population, is considered as a social problem closely related to healthy-damaging behaviours. During the years 1987-95 no decreasing tedency in the incidence of dental caries could be observed (only a 0.1 reduction was noted in children aged 12, whereas during 1970-87 it was equal to almost 2). The worsening condition of parodontium is also found in children aged 12 and young people aged 18. These negative changes result from the fact that the planned dental care of children and young people had to be terminated because of financial constrains and other difficulties.
Dental caries and periodontal disease can be prevented. In many countries due to consistent policy the frequency and severity of these two dental problems have fallen dramatically, and certain groups of children are free from dental caries, and part of adults above 30 years of age have no decayed, missing or filled teeth and have own detintition to the end of their days. Pregnant women, children aged 1 - 7 and young people belong to most vulnerable groups and must be covered by an intensive preventive programmes.

Expected health gain

• A reduction of 10% (compared to 1995) in the incidence of dental caries in children aged 7 and 12 years; the rate of advanced caries in children aged 12 will not exceed the value of 3.0.
• Over 70% of children aged 7 and 30% of children aged 12 with healthy parodontium;
• A reduction of 10% (compared to 1995) in the incidence of gingivitis

In order to achieve this it is required:

1. to promote more effective health education in the area of oral cavity health addressed especially to:
   • pregnant women within the prenatal care, in delivery schools and in obstetric wards,
   • parents of children under 7 in paediatric out-patient clinics, nurseries and kindergardens,
   • youth at schools;
2. to introduce teeth brushing after each meal in the daily programme of activities in nurseries, kindergardens, health resorts, children's homes, recreation centres for children, and during summer or winter holiday camps;
3. to promote topical fluorid application in children of all types of schools, if there are no local contraindications in the place of residence;
4. to promote administration of fluoride tabletes in children between the age of 6 months and 10 years in areas with trace amounts of fluor in drinking water if there are no contraindications;
5. to continue, in children aged 6-8 with high risk of early development of dental caries, preventive sealing of oclusal surfaces of first molars and varnish application on smooth surfaces;
6. to use locally antibacterial and anticaries effect of chlorhexidine in the form of gel or teeth laquer in pregnant women and children with high risk of dental caries.

Indicators:

• The percentage of children with healthy dentition and healthy parodontium.
• The mean value of DMFT indicator in children aged 7 and 12 years children.
• The number of children aged 6-8 years covered by varnish application preventive programme.
• The frequency of teeth brushing in young people aged 11, 13 and 15 (studies of healthy behaviours).