- Email: [email protected]
Towards a new health policy in Hungary
183
Health Policy, 8 (1987) 183-192 Elsevier HPE 00168
Towards
a new health policy
in Hungary
Ivan Forg6cs’ and Michael Kokeny’ ‘Institute Hungary
of Social Medicine, Postgraduate Medical School, Budapest, and 20ffice of the Government of the Hungarian Parliament;
Budapest, Accepted
Hungary
27 June
1987
Summary The health situation of the Hungarian population in the postwar period with respect to the socio-economic changes has been evaluated and as a consequence a new health policy programme is outlined. It has been established that between 1945 and 1965 the development of the socio-economic and the public health situation, due to the introduction of a national health insurance system, the decreasing trends of the infectious diseases and malnutrition, and the raising of the cultural standards of the people has resulted in a rapid improvement of the health status at population level. Between 1965 and 1985 the rapid changes of the economic situation were followed by deep intra- and intergeneration family pattern behavioral and life-style changes. As a consequence of these a significant increase in the alcohol, tobacco and fat consumption, and the mortality rate of the 35-59-year-old male population was observed. The introduction of a national health promotion programme is necessary with a special emphasis on the healthy life-style at individual and at multisectoral level as well. The structure and function of the health service has to be changed according to the programme. The health promotion programme is based on a nationwide consensus. Health status and socio-economic tion programme
changes; National
HFA stragety;
Health promo-
1. Introduction Following an extremely rapid and demonstrable development in the health status of the population between 1945 and 1956 a gradual deterioration of the morbidity and mortality patterns of the adults (mainly men) was seen in Hungary between 1966 and 1986. The first period (1945-1965) is characterized by the sharp
Address for correspondence: Professor Dr. Ivan Forgks. Director. Institute of Social Medicine, graduate Medical School, Budapest XIII., Szabolcs u. 35, H-1389-Pf. 112, Hungary.
Post-
184
decrease of the infectious diseases and the improvement of the basic public health and social circumstances. In the second period (1966-1986) a marked increase of the non-infectious diseases was observed with an especially high mortality rate in the 40-69-old-male population, as is seen in Table 1 [l]. Paradoxically enough the most dynamic development in the health service system happened during this second period. Some quantitative parameters of these changes are seen in Table 2. It also necessary to mention that a new economic mechanism was introduced in 1968 accompanied by an increase in living standard and a change in life-style. The economy changed again in the late seventies and as a consequence the living standard stopped rising and incomes polarized. A great deal of the working population was faced with the choice of taking on extra jobs in order to maintain their standard of living but sacrificing their leisure time, and so living a more stressful life. As a consequence the alcohol and tobacco consumption increased further.
2. The need of a new health policy The impact of the rapid and profound economic and social changes in the last 20-25 years on the health status of the Hungarian population has not yet been Table 1 Age specific mortality
rate for men and women
in 1959-1960 and in 1965 (for 1000 inhabitants)
Age group
Men
(years)
1959-1960
1985
1959-1960
1985
:4 5-9 10-14 15-19 20-24 25-29 3&34 35-39 40-44 45-49 5c-54 55-59 6C-64 65-69 7c-74 15-79 8G84 85-x
55.13 4.13 1.59 0.83 0.58 0.62 1.20 1.60 1.62 1.99 2.54 3.48 5.50 9.14 16.08 25.30 40.02 63.35 101.79 162.29 271.33
22.34 0.92 0.63 0.47 0.30 0.30 0.97 1.50 1.97 2.84 4.38 6.95 10.89 15.56 23.11 33.35 43.90 70.42 105.83 161.24 259.85
44.65 3.69 1.45 0.69 0.40 0.33 0.59 0.79 0.99 1.28 1.84 2.72 3.85 5.93 9.41 15.82 28.07 48.98 86.92 145.96 239.91
18.27 0.68 0.47 0.39 0.23 0.19 0.40 0.49 0.70 1.20 1.86 2.87 4.41 6.64 9.93 14.79 23.36 40.70 70.20 120.09 214.02
10.93
15.17
9.73
12.64
ir
Women
185
evaluated enough. Some consequences of the economic-social changes on the health status of the population can be semiquantitatively deduced from statistical data, some of which are still hypothetical. The social risk factors
The geographical intracountry migration was very high during the last 25 years. The population of the Capital (Budapest) increased by 12% between 1960 and 1970, and by a further 3% between 1970 and 1984, respectively, to reach 25%. The population of the Capital consists of one-fifth of the entire Hungarian population. The inhabitants of the other cities increased by 40%, while the number of village dwellers decreased by 13% between 1960 and 1984. It is well known that life in overcrowded cities may cause conflict situations especially among the adult and elderly new-comers. The metropolitan area of Budapest is serious burden for health care and other services. Around 75% of the active population of this area is working or studying in the Capital. The proportion of commuters is more than 20% of the working population. The life-style is profoundly influenced by intra-generation changes of schooling and working activity. The number of employees practically did not change between 1960 and 1984. On the other hand, drastic changes took place within the occupational structure (Table 3). It seems almost obvious that the enhanced deTable 2 Some health care parameters
expressed
GP’s offices Pediatric offices (only in towns) Physicians in industries Outpatient specialists care consulting No. of dispensaries tuberculosis venereal cancer nervous and mental Inpatient care No. hospital beds No. neurology and psychiatry No. of ambulance cars Blood transfusion stations quantity of donated blood Health manpower physicians pharmacists nurses others Budgetary expenditures on health national income
hours
in percentual
changes between
1960 and 1985 +33% +434% +135% +48%
-12% +2% +95% +192%
beds
+40% +95% +246% + 100% +236% +109% +28% +150% +185% +468% +316%
186 Table 3 Social mobility The distribution
Working class Not agrarian Agrarian Together
of active earners
1910
1920
1930
1941
1949
1960
1970
1978
27 29 56
32 24 56
26 27 53
31 20 51
32 22 54
29 9 38
42 7 49
53 2 55
55 2 57
_
_
0
12
17
13
Agrarian in cooperatives manual workers White
collared,
intellectuals
Small-scale producer capitalist Not agrarian Agrarian Together
in %
1900
4
5
6
7
7
9
18
25
21
9 31 40
10 29 39
10 31 41
10 32 42
9 30 39
9 44 53
2 19 21
1 2 3
2 1 3
and
mand for the industrial manpower was supplied from the agricultural pool, while new-comers in the trade and service industries were coming from the agricultural and industrial field as well. The employment of women in the age group 20-55 years became almost complete. With the increase in living standard, industrialization and urbanization, the family model changed significantly. The number of marriages decreased by 17%, while the number of divorces increased by 77% between 1960 and 1985. The yearly incidence of the widows and widowers increased by 50% during this period. It may be also interesting to note that despite the decreasing number of marriages about 30% of them consisted of second marriages. While in 1960 55% of the divorced couples had children, this proportion in 1985 was 67%. In 1985 52% of the women over 60 years were widows as a consequence of the increased mortality rate of middle-aged men. The changing family pattern is also characterized by the one-child model families. A negative demographic trend developed in the last years. The intergeneration mobility - another life-style influencing factor - is seen by the fact that in 1981 52.4% of leading managers and university-graduated professionals orginated from worker or peasant families. Among skilled workers 27.3% came from peasant families. Schooling and education. Education including the higher and university cation is free of charge in Hungary. Among the 18-22-year-old population in 4.1% in 1985 and 9.9% were enrolled in higher education. This is still rather among the industrialized countries. About 18.2% of the age group 20-44 years some kind of on-the-job training in 1985. The educational level increased quickly between 1960 and 1985, but a rather
edu1960 low had high
187
proportion involved on-the-job training which caused changes in life-style and stress situations. For example, in 1984 26.4% were trained at a secondary level and 35.3% at a university level following this form of training [2]. The leisure-time decreased generally as was mentioned earlier. Leisure-time differs amont the different social groups but in all social groups women have less leisure time than men. The morbidity among the different social groups differs strongly. According to a recent survey - made by the Central Statistical Office - there is a lo-year difference in the morbidity pattern between the highest qualified and lowest qualified social groups, e.g. the same morbidity pattern is seen in the 30-39-year-age group of unskilled workers as in the 40-49-year-old managers. Eating, drinking
and smoking
habits
Eating habits. The energy content of the average daily food intake increased by 20% between 1950 and 1985. The average energy intake in 1985 was 13,578 KJ/day/person (in the Western European countries the range is 12000-14000). The fat consumption increased from 21 to 32 kg/person/year from 1960 to 1985. The meat consumption increased from 50 to 75 kg/person/year, while the consumption of sugar rose from 25 to 35 kg/person/year during this period. The later seems to be confirmed by a caries survey; only one-fifth of the children older than 7 years have caries-free teeth). The potato consumption decreased from 100 to 65 kg/person/year. The food consumption between 1938 and 1985 and the composition of fat consumption during this period are shown in Figs. 1 and 2. In the 40-59year-old population more than 40% of the men and almost 50% of the women are
-._._
kg _
,50_
Meat Mi,k
and fish
kg
--. Fats ..“‘. Flour and rice ----Sugar ‘.-” Potatoes _..*
,.... ‘..
_.:
/
_. .’
...’ ‘_. ._.....‘......_ . . ...........,
/ /’ /’
./
./’ -150
. ... ... ...... ., .i *-+ ‘:N..... . ..._ ‘._.,yc.. \ ../.:<-Jr::‘:,._ ” ‘.. ./..,,,/’ P-.*.-.x’.’ ,oo_+-• ._. .._.. N. ‘.\ !(” ./ .’ “.‘_‘l ‘\.’ 50-
,oo
-50 *-.. _*-*
II IIIJIIIIIIIIIIII 1934-36 1950 1955 Average
Fig. 1 Food
consumption
consumption
------~\__s_.~, __.__.__.--._-.--.-..
__-----
___---/;.=..__.__.--.--’ _-_.&. __c -..
1960 m 1934-1936
,,,,,,,,,,,,,,,, 1965 1970 years
(pro year/head)
1934-1982.
_
1975
1980
188
-
28
----.-. ““... --.
Fat from milk Butter Fat of swine and poultry Vegetable oil and butter All fats
-32 _ /./‘_ .-e
.__._d.
/C’ -28
,../ ,-.’
1934-35 Average
19501955 consumption
Fig. 2 Fat consumption
1965 1960 in 1934-1938 years
1970
1975
1980
(pro year/head) 1934-1982.
above the ideal body weight by more than 1635% Index [3].
or more, based on the Broca
Drinking habits. Alcohol consumption increased from 6.1 to 11.6 litres/ person/year (in absolute alcohol) between 1960 and 1985. Beer consumption rose 2.4 times, the consumption of brandies 3.3 times during the same period while there was a slight decrease in the consumption of wine. The consumption between 1938 and 1985 of different kinds of alcoholic beverages is shown on Fig. 3. The death rate caused by liver cirrhosis was 89/100000 in 1960, and 43.1/100000 in 1985. Between 1980 and 1985 this death rate increased by 55.6%. habits. There was an increase in the tobacco consumption during the last 25 years (see Fig. 3). It is estimated that 50% of the males and 19% of the females older than 15 years are smokers. According to a recent survey among the lO-14-year-old children 22% are casual smokers. Cigarette consumption in 1970 was 22449 million and 23224 million in 1985. It is impossible to estimate the number of passive smokers [4]. Smoking
Violent
death
The death rate caused by traffic accidents was 21.11100000 by non-traffic accidents 56.0/100000 and the rate of fatal suicides was 44.4/100000 in 1985.
189 -Coffee -----Tobacco .._.. -Wine
.-.-. go-
_-.__
BO-
Beer Spirits with 50 consumption (100% olcohollc
per cent alcoholic of alcohol COntent)
. All
/’ _
40-
-.-._.’
-40 .0..-..-..
...‘._.._..H’
.._
._,
-60
._.-.
._.-.-. .._
t
_.._,.
‘.N.._“_
-
.. -
..
\.‘*_20
-.-
J
c2
-60
,.F.-.-‘H’.(’ .’
60-
2.
content
,,..,. .,.. . . .. . . . _ ll-
:’ .’
: ..‘.....,.. 9-
:. ..-
7-
. . . ...’ .
5-
3,_
1934-36 Average
. .. . . . . .
,A . . .. . _-.
___ ___
0
- y__..
‘Z
r”
-9
i’ .’
c C”.,/
I
.J
-7 -5
. .
__-
19501955
-1 1960
consumption
Fig. 3 Consumption
I’*..C
1’-\,I
,. . .
. .. .
_-. ..___
....
/’ ,‘.y
-11 -
1965 !n 1934
of alcohol,
-1936
coffee
1970
1975
1960
years
and tobacco
(pro year/head)
1934-1982.
In Hungary where the health status of the adult, mainly male, population worsened, a negative correlation with the development of the health service has been observed and the reason may be found among the human ecological factors. In the last 40 years the country has undergone the most profound economical and social changes of its entire history. From a humanitarian point of view, most of these changes were beneficial, but the changes carried their own risk.
3. lntersectorial
action for health
The increasing trend of the mortability and morbidity rate in the adult male population due to the non-communicable diseases as well as the adopted targets of the European Health-for-All Strategy stimulated the Hungarian government to launch an overall nationwide health promotion project with intersectoral cooperation [5]. The first draft of the project was discussed by several ministries and state offices as well as by social associations and communities before it was discussed by the Cabinet. A relatively small committee of experts was established under the chairmanship of the Deputy Prime Minister to work out the detailed action programme proposal of the national health promotion programme with intersectoral cooperation based on community involvement and individual responsibility as well. The draft was discussed by an international group of specialists involved in health promotion programmes. The basic principle of the programme is the following: among a given range individuals, communities and society have the possibility to diminish or ban the
190
harmful risk-factors from the life-style, or at least to promote a life-style which can diminish the multiplication of the risk-factors. Thus the national health promotion programme has to be based on a health-promoting life-style. Adherence to such a life-style by the individuals largely depends on economic and social circumstances as well as on the individuals’ determination. The main objective of the programme is to motivate for changes in life-style, for this would enable more people to be able to maintain their health for a long time and to avert the risk of cardiovascular diseases, tumors and other serious illnesses. By increasing the number of and possibilities for screening, by propaganda for health reaching larger masses and by more efficient cures, it could be attained that every individual should increase by at least 10% his years free of disease. The healthier generation of young grown-ups who bear greater responsibility will have a positive effect on the life chances of the generations to come. In a 15-20 years perspective the following are to the achieved. (1) In infant mortality rates and in mortality due to the major chronic non-communicable diseases the considerable differences that exist within the country between regions and counties could be reduced below 10%. In order to create equity, health campaigns or programmes based on local circumstances could be elabora ed in the counties, towns and municipalities, first of all in the most badly affecte ones. (2) By i ncreasing prenatal care, preparing for planned motherhood and by decreasing the number of premature births by about 30% infant mortality rate can be decreased considerably, from the present 20 per 1000 to at least 15 per 1000 live births. (3) To influence mortality due to cardiovascular diseases the deteriorating trend should be stopped within the next 7-8 years, whereas mortality of those aged less than 65 years should be decreased by at least 10% in the perspective of 15-20 years, by means of propre life-style changes and improvements in health care delivery. In this respect it is of primary importance to prevent complications of hypertensive disease, especially the cerebrovascular and coronary complications. (4) In the population aged under 65 years, mortality due to cancer should be decreased by at least 10% mainly by preventing lung cancer through controlling smoking and by prevention and early diagnosis of cervical cancer through expanded screening. (5) The increasing trend of fatal accidents could be stopped and decreased by about 10%. Factors required to achieve this include improving traffic, conduct, strengthening road traffic safety, improving working conditions, strengthening work discipline, disseminating technological knowledge as well as safe housing design and improved home safety. The presence and strengthening of social networks and social sup ort can be helpful in putting a stop to the high suicide rate. To reali e these targets the health service has as tasks: “, - primary health care services (GP’s services, pediatrician’s services, industrial health services) should be better prepared to carry out responsibilities relating to systematical and conscious health promotion and disease prevention; their interests to engage in these activities should be encouraged;
191
- outpatient-clinics should become more open towards public and community selfhelp initiatives, should increase their services towards healthy population groups who are not yet ill but at risk of illness (e.g. smoking cessation programs, Weight Watchers’ clubs, etc.), thus strengthening the social integration of their activities; - in order to enhance mental wellbeing the organizational system of mental hygiene and forms of support networks provided for families should be enlarged; - coordinated measures should be instituted to gradually extend population screening; - health actions should be launched which already in the relatively short run are capable of promoting the achievement of targets set in the national programme (e.g. preparing the layman to perform resuscitation, introduce a unified system for follow-up care of persons with hypertension); - the efficiency of rehabilitation should be increased in cooperation with social insurance agencies; - health care providers at all levels of the health care system should have an active part in advocating healthy life-style through legislative support; - the organization and functional structure of health education should be adapted to the requirements of the national programme; and - research, international scientific and professional links which promote programme implementation should be enhanced. The main multisectoral activities are the following: The ministries and national agencies concerned, the executive councils of the metropolitan and county councils, in collaboration with social organizations, should prepare medium-term programmes of work comprising their responsibilities in the field of enhancing healthy life-styles and controlling environmental hazards by synthetizing their previous concepts and operative resolutions. The programme of work should cover primarily the following areas: - production, marketing, and advertising required for healthy nutrition; - improving goods, possibilities and other conditions for leisure-time physical activities; - possibilities of action against harmful habits, abuses and addiction; - expanding conditions for the protection of health during work and for preventing occupational diseases (technological development, individual protective devices, etc.); - exploring and controlling the unfavourable effects of natural and man-made environments, protecting water, air and soil from pollution, disposition of hazardous wastes and rendering them harmless; and - preventing road traffic and home accidents more efficiently. It is necessary that social and mass organizations as well as health insurance companies elaborate similar programmes.
192
References 1 Statistical Yearbook 1985, Ministry of Health, Budapest, 1986. 2 Statistical Yearbook 1985, Central Statistical Office, Budapest, 1986. 3 Some parameters of the health status of the population relating to some life-style parameters, tral Statistical Office, Budapest, 1986. 4 For&s, I., Egeszstgtigy (Health System) Kossuth Publ., Budapest, 1985, pp. 1-114. S KiikCny, M. et al., Health Promotion 1 (1986) 85.
Cen-
Health Policy, 8 (1987) 183-192 Elsevier HPE 00168
Towards
a new health policy
in Hungary
Ivan Forg6cs’ and Michael Kokeny’ ‘Institute Hungary
of Social Medicine, Postgraduate Medical School, Budapest, and 20ffice of the Government of the Hungarian Parliament;
Budapest, Accepted
Hungary
27 June
1987
Summary The health situation of the Hungarian population in the postwar period with respect to the socio-economic changes has been evaluated and as a consequence a new health policy programme is outlined. It has been established that between 1945 and 1965 the development of the socio-economic and the public health situation, due to the introduction of a national health insurance system, the decreasing trends of the infectious diseases and malnutrition, and the raising of the cultural standards of the people has resulted in a rapid improvement of the health status at population level. Between 1965 and 1985 the rapid changes of the economic situation were followed by deep intra- and intergeneration family pattern behavioral and life-style changes. As a consequence of these a significant increase in the alcohol, tobacco and fat consumption, and the mortality rate of the 35-59-year-old male population was observed. The introduction of a national health promotion programme is necessary with a special emphasis on the healthy life-style at individual and at multisectoral level as well. The structure and function of the health service has to be changed according to the programme. The health promotion programme is based on a nationwide consensus. Health status and socio-economic tion programme
changes; National
HFA stragety;
Health promo-
1. Introduction Following an extremely rapid and demonstrable development in the health status of the population between 1945 and 1956 a gradual deterioration of the morbidity and mortality patterns of the adults (mainly men) was seen in Hungary between 1966 and 1986. The first period (1945-1965) is characterized by the sharp
Address for correspondence: Professor Dr. Ivan Forgks. Director. Institute of Social Medicine, graduate Medical School, Budapest XIII., Szabolcs u. 35, H-1389-Pf. 112, Hungary.
Post-
184
decrease of the infectious diseases and the improvement of the basic public health and social circumstances. In the second period (1966-1986) a marked increase of the non-infectious diseases was observed with an especially high mortality rate in the 40-69-old-male population, as is seen in Table 1 [l]. Paradoxically enough the most dynamic development in the health service system happened during this second period. Some quantitative parameters of these changes are seen in Table 2. It also necessary to mention that a new economic mechanism was introduced in 1968 accompanied by an increase in living standard and a change in life-style. The economy changed again in the late seventies and as a consequence the living standard stopped rising and incomes polarized. A great deal of the working population was faced with the choice of taking on extra jobs in order to maintain their standard of living but sacrificing their leisure time, and so living a more stressful life. As a consequence the alcohol and tobacco consumption increased further.
2. The need of a new health policy The impact of the rapid and profound economic and social changes in the last 20-25 years on the health status of the Hungarian population has not yet been Table 1 Age specific mortality
rate for men and women
in 1959-1960 and in 1965 (for 1000 inhabitants)
Age group
Men
(years)
1959-1960
1985
1959-1960
1985
:4 5-9 10-14 15-19 20-24 25-29 3&34 35-39 40-44 45-49 5c-54 55-59 6C-64 65-69 7c-74 15-79 8G84 85-x
55.13 4.13 1.59 0.83 0.58 0.62 1.20 1.60 1.62 1.99 2.54 3.48 5.50 9.14 16.08 25.30 40.02 63.35 101.79 162.29 271.33
22.34 0.92 0.63 0.47 0.30 0.30 0.97 1.50 1.97 2.84 4.38 6.95 10.89 15.56 23.11 33.35 43.90 70.42 105.83 161.24 259.85
44.65 3.69 1.45 0.69 0.40 0.33 0.59 0.79 0.99 1.28 1.84 2.72 3.85 5.93 9.41 15.82 28.07 48.98 86.92 145.96 239.91
18.27 0.68 0.47 0.39 0.23 0.19 0.40 0.49 0.70 1.20 1.86 2.87 4.41 6.64 9.93 14.79 23.36 40.70 70.20 120.09 214.02
10.93
15.17
9.73
12.64
ir
Women
185
evaluated enough. Some consequences of the economic-social changes on the health status of the population can be semiquantitatively deduced from statistical data, some of which are still hypothetical. The social risk factors
The geographical intracountry migration was very high during the last 25 years. The population of the Capital (Budapest) increased by 12% between 1960 and 1970, and by a further 3% between 1970 and 1984, respectively, to reach 25%. The population of the Capital consists of one-fifth of the entire Hungarian population. The inhabitants of the other cities increased by 40%, while the number of village dwellers decreased by 13% between 1960 and 1984. It is well known that life in overcrowded cities may cause conflict situations especially among the adult and elderly new-comers. The metropolitan area of Budapest is serious burden for health care and other services. Around 75% of the active population of this area is working or studying in the Capital. The proportion of commuters is more than 20% of the working population. The life-style is profoundly influenced by intra-generation changes of schooling and working activity. The number of employees practically did not change between 1960 and 1984. On the other hand, drastic changes took place within the occupational structure (Table 3). It seems almost obvious that the enhanced deTable 2 Some health care parameters
expressed
GP’s offices Pediatric offices (only in towns) Physicians in industries Outpatient specialists care consulting No. of dispensaries tuberculosis venereal cancer nervous and mental Inpatient care No. hospital beds No. neurology and psychiatry No. of ambulance cars Blood transfusion stations quantity of donated blood Health manpower physicians pharmacists nurses others Budgetary expenditures on health national income
hours
in percentual
changes between
1960 and 1985 +33% +434% +135% +48%
-12% +2% +95% +192%
beds
+40% +95% +246% + 100% +236% +109% +28% +150% +185% +468% +316%
186 Table 3 Social mobility The distribution
Working class Not agrarian Agrarian Together
of active earners
1910
1920
1930
1941
1949
1960
1970
1978
27 29 56
32 24 56
26 27 53
31 20 51
32 22 54
29 9 38
42 7 49
53 2 55
55 2 57
_
_
0
12
17
13
Agrarian in cooperatives manual workers White
collared,
intellectuals
Small-scale producer capitalist Not agrarian Agrarian Together
in %
1900
4
5
6
7
7
9
18
25
21
9 31 40
10 29 39
10 31 41
10 32 42
9 30 39
9 44 53
2 19 21
1 2 3
2 1 3
and
mand for the industrial manpower was supplied from the agricultural pool, while new-comers in the trade and service industries were coming from the agricultural and industrial field as well. The employment of women in the age group 20-55 years became almost complete. With the increase in living standard, industrialization and urbanization, the family model changed significantly. The number of marriages decreased by 17%, while the number of divorces increased by 77% between 1960 and 1985. The yearly incidence of the widows and widowers increased by 50% during this period. It may be also interesting to note that despite the decreasing number of marriages about 30% of them consisted of second marriages. While in 1960 55% of the divorced couples had children, this proportion in 1985 was 67%. In 1985 52% of the women over 60 years were widows as a consequence of the increased mortality rate of middle-aged men. The changing family pattern is also characterized by the one-child model families. A negative demographic trend developed in the last years. The intergeneration mobility - another life-style influencing factor - is seen by the fact that in 1981 52.4% of leading managers and university-graduated professionals orginated from worker or peasant families. Among skilled workers 27.3% came from peasant families. Schooling and education. Education including the higher and university cation is free of charge in Hungary. Among the 18-22-year-old population in 4.1% in 1985 and 9.9% were enrolled in higher education. This is still rather among the industrialized countries. About 18.2% of the age group 20-44 years some kind of on-the-job training in 1985. The educational level increased quickly between 1960 and 1985, but a rather
edu1960 low had high
187
proportion involved on-the-job training which caused changes in life-style and stress situations. For example, in 1984 26.4% were trained at a secondary level and 35.3% at a university level following this form of training [2]. The leisure-time decreased generally as was mentioned earlier. Leisure-time differs amont the different social groups but in all social groups women have less leisure time than men. The morbidity among the different social groups differs strongly. According to a recent survey - made by the Central Statistical Office - there is a lo-year difference in the morbidity pattern between the highest qualified and lowest qualified social groups, e.g. the same morbidity pattern is seen in the 30-39-year-age group of unskilled workers as in the 40-49-year-old managers. Eating, drinking
and smoking
habits
Eating habits. The energy content of the average daily food intake increased by 20% between 1950 and 1985. The average energy intake in 1985 was 13,578 KJ/day/person (in the Western European countries the range is 12000-14000). The fat consumption increased from 21 to 32 kg/person/year from 1960 to 1985. The meat consumption increased from 50 to 75 kg/person/year, while the consumption of sugar rose from 25 to 35 kg/person/year during this period. The later seems to be confirmed by a caries survey; only one-fifth of the children older than 7 years have caries-free teeth). The potato consumption decreased from 100 to 65 kg/person/year. The food consumption between 1938 and 1985 and the composition of fat consumption during this period are shown in Figs. 1 and 2. In the 40-59year-old population more than 40% of the men and almost 50% of the women are
-._._
kg _
,50_
Meat Mi,k
and fish
kg
--. Fats ..“‘. Flour and rice ----Sugar ‘.-” Potatoes _..*
,.... ‘..
_.:
/
_. .’
...’ ‘_. ._.....‘......_ . . ...........,
/ /’ /’
./
./’ -150
. ... ... ...... ., .i *-+ ‘:N..... . ..._ ‘._.,yc.. \ ../.:<-Jr::‘:,._ ” ‘.. ./..,,,/’ P-.*.-.x’.’ ,oo_+-• ._. .._.. N. ‘.\ !(” ./ .’ “.‘_‘l ‘\.’ 50-
,oo
-50 *-.. _*-*
II IIIJIIIIIIIIIIII 1934-36 1950 1955 Average
Fig. 1 Food
consumption
consumption
------~\__s_.~, __.__.__.--._-.--.-..
__-----
___---/;.=..__.__.--.--’ _-_.&. __c -..
1960 m 1934-1936
,,,,,,,,,,,,,,,, 1965 1970 years
(pro year/head)
1934-1982.
_
1975
1980
188
-
28
----.-. ““... --.
Fat from milk Butter Fat of swine and poultry Vegetable oil and butter All fats
-32 _ /./‘_ .-e
.__._d.
/C’ -28
,../ ,-.’
1934-35 Average
19501955 consumption
Fig. 2 Fat consumption
1965 1960 in 1934-1938 years
1970
1975
1980
(pro year/head) 1934-1982.
above the ideal body weight by more than 1635% Index [3].
or more, based on the Broca
Drinking habits. Alcohol consumption increased from 6.1 to 11.6 litres/ person/year (in absolute alcohol) between 1960 and 1985. Beer consumption rose 2.4 times, the consumption of brandies 3.3 times during the same period while there was a slight decrease in the consumption of wine. The consumption between 1938 and 1985 of different kinds of alcoholic beverages is shown on Fig. 3. The death rate caused by liver cirrhosis was 89/100000 in 1960, and 43.1/100000 in 1985. Between 1980 and 1985 this death rate increased by 55.6%. habits. There was an increase in the tobacco consumption during the last 25 years (see Fig. 3). It is estimated that 50% of the males and 19% of the females older than 15 years are smokers. According to a recent survey among the lO-14-year-old children 22% are casual smokers. Cigarette consumption in 1970 was 22449 million and 23224 million in 1985. It is impossible to estimate the number of passive smokers [4]. Smoking
Violent
death
The death rate caused by traffic accidents was 21.11100000 by non-traffic accidents 56.0/100000 and the rate of fatal suicides was 44.4/100000 in 1985.
189 -Coffee -----Tobacco .._.. -Wine
.-.-. go-
_-.__
BO-
Beer Spirits with 50 consumption (100% olcohollc
per cent alcoholic of alcohol COntent)
. All
/’ _
40-
-.-._.’
-40 .0..-..-..
...‘._.._..H’
.._
._,
-60
._.-.
._.-.-. .._
t
_.._,.
‘.N.._“_
-
.. -
..
\.‘*_20
-.-
J
c2
-60
,.F.-.-‘H’.(’ .’
60-
2.
content
,,..,. .,.. . . .. . . . _ ll-
:’ .’
: ..‘.....,.. 9-
:. ..-
7-
. . . ...’ .
5-
3,_
1934-36 Average
. .. . . . . .
,A . . .. . _-.
___ ___
0
- y__..
‘Z
r”
-9
i’ .’
c C”.,/
I
.J
-7 -5
. .
__-
19501955
-1 1960
consumption
Fig. 3 Consumption
I’*..C
1’-\,I
,. . .
. .. .
_-. ..___
....
/’ ,‘.y
-11 -
1965 !n 1934
of alcohol,
-1936
coffee
1970
1975
1960
years
and tobacco
(pro year/head)
1934-1982.
In Hungary where the health status of the adult, mainly male, population worsened, a negative correlation with the development of the health service has been observed and the reason may be found among the human ecological factors. In the last 40 years the country has undergone the most profound economical and social changes of its entire history. From a humanitarian point of view, most of these changes were beneficial, but the changes carried their own risk.
3. lntersectorial
action for health
The increasing trend of the mortability and morbidity rate in the adult male population due to the non-communicable diseases as well as the adopted targets of the European Health-for-All Strategy stimulated the Hungarian government to launch an overall nationwide health promotion project with intersectoral cooperation [5]. The first draft of the project was discussed by several ministries and state offices as well as by social associations and communities before it was discussed by the Cabinet. A relatively small committee of experts was established under the chairmanship of the Deputy Prime Minister to work out the detailed action programme proposal of the national health promotion programme with intersectoral cooperation based on community involvement and individual responsibility as well. The draft was discussed by an international group of specialists involved in health promotion programmes. The basic principle of the programme is the following: among a given range individuals, communities and society have the possibility to diminish or ban the
190
harmful risk-factors from the life-style, or at least to promote a life-style which can diminish the multiplication of the risk-factors. Thus the national health promotion programme has to be based on a health-promoting life-style. Adherence to such a life-style by the individuals largely depends on economic and social circumstances as well as on the individuals’ determination. The main objective of the programme is to motivate for changes in life-style, for this would enable more people to be able to maintain their health for a long time and to avert the risk of cardiovascular diseases, tumors and other serious illnesses. By increasing the number of and possibilities for screening, by propaganda for health reaching larger masses and by more efficient cures, it could be attained that every individual should increase by at least 10% his years free of disease. The healthier generation of young grown-ups who bear greater responsibility will have a positive effect on the life chances of the generations to come. In a 15-20 years perspective the following are to the achieved. (1) In infant mortality rates and in mortality due to the major chronic non-communicable diseases the considerable differences that exist within the country between regions and counties could be reduced below 10%. In order to create equity, health campaigns or programmes based on local circumstances could be elabora ed in the counties, towns and municipalities, first of all in the most badly affecte ones. (2) By i ncreasing prenatal care, preparing for planned motherhood and by decreasing the number of premature births by about 30% infant mortality rate can be decreased considerably, from the present 20 per 1000 to at least 15 per 1000 live births. (3) To influence mortality due to cardiovascular diseases the deteriorating trend should be stopped within the next 7-8 years, whereas mortality of those aged less than 65 years should be decreased by at least 10% in the perspective of 15-20 years, by means of propre life-style changes and improvements in health care delivery. In this respect it is of primary importance to prevent complications of hypertensive disease, especially the cerebrovascular and coronary complications. (4) In the population aged under 65 years, mortality due to cancer should be decreased by at least 10% mainly by preventing lung cancer through controlling smoking and by prevention and early diagnosis of cervical cancer through expanded screening. (5) The increasing trend of fatal accidents could be stopped and decreased by about 10%. Factors required to achieve this include improving traffic, conduct, strengthening road traffic safety, improving working conditions, strengthening work discipline, disseminating technological knowledge as well as safe housing design and improved home safety. The presence and strengthening of social networks and social sup ort can be helpful in putting a stop to the high suicide rate. To reali e these targets the health service has as tasks: “, - primary health care services (GP’s services, pediatrician’s services, industrial health services) should be better prepared to carry out responsibilities relating to systematical and conscious health promotion and disease prevention; their interests to engage in these activities should be encouraged;
191
- outpatient-clinics should become more open towards public and community selfhelp initiatives, should increase their services towards healthy population groups who are not yet ill but at risk of illness (e.g. smoking cessation programs, Weight Watchers’ clubs, etc.), thus strengthening the social integration of their activities; - in order to enhance mental wellbeing the organizational system of mental hygiene and forms of support networks provided for families should be enlarged; - coordinated measures should be instituted to gradually extend population screening; - health actions should be launched which already in the relatively short run are capable of promoting the achievement of targets set in the national programme (e.g. preparing the layman to perform resuscitation, introduce a unified system for follow-up care of persons with hypertension); - the efficiency of rehabilitation should be increased in cooperation with social insurance agencies; - health care providers at all levels of the health care system should have an active part in advocating healthy life-style through legislative support; - the organization and functional structure of health education should be adapted to the requirements of the national programme; and - research, international scientific and professional links which promote programme implementation should be enhanced. The main multisectoral activities are the following: The ministries and national agencies concerned, the executive councils of the metropolitan and county councils, in collaboration with social organizations, should prepare medium-term programmes of work comprising their responsibilities in the field of enhancing healthy life-styles and controlling environmental hazards by synthetizing their previous concepts and operative resolutions. The programme of work should cover primarily the following areas: - production, marketing, and advertising required for healthy nutrition; - improving goods, possibilities and other conditions for leisure-time physical activities; - possibilities of action against harmful habits, abuses and addiction; - expanding conditions for the protection of health during work and for preventing occupational diseases (technological development, individual protective devices, etc.); - exploring and controlling the unfavourable effects of natural and man-made environments, protecting water, air and soil from pollution, disposition of hazardous wastes and rendering them harmless; and - preventing road traffic and home accidents more efficiently. It is necessary that social and mass organizations as well as health insurance companies elaborate similar programmes.
192
References 1 Statistical Yearbook 1985, Ministry of Health, Budapest, 1986. 2 Statistical Yearbook 1985, Central Statistical Office, Budapest, 1986. 3 Some parameters of the health status of the population relating to some life-style parameters, tral Statistical Office, Budapest, 1986. 4 For&s, I., Egeszstgtigy (Health System) Kossuth Publ., Budapest, 1985, pp. 1-114. S KiikCny, M. et al., Health Promotion 1 (1986) 85.
Cen-