HEALTH AND DEMOGRAPHY Local Multi Sectoral Collaboration: Preventing premature mortality among the working-age population of Ukraine “The voice of one man is the voice of no one.” – a Ukrainian proverb Human Development Sector Unit Europe and Central Asia Region Table of Contents Executive Summary ..........................................................................................................................i Introduction ...................................................................................................................................... 1 Key Findings .................................................................................................................................... 1 Toward effective multisectoral collaboration at the local level........................................................ 9 A. Fostering local input in planning and developing integrated programs and strategies ....... 10 B. Improving collaboration in program implementation ........................................................ 10 Reference ........................................................................................................................................ 11 Annex 1: Research Methodology ................................................................................................. 12 List of Boxes, Tables and Figures Box 1. Key population statistics......................................................................................................................... 1 Box 2: Case Study: Delivering emergency care to traffic accident victims ....................................... 5 Table 1. Examples of existing programs as cited by respondents ....................................................... 2 Table 2. Challenges to program development and implementation as perceived by respondents....................................................................................................................................................... 4 Table 3. Methods of collaboration cited by respondents ........................................................................ 7 Table 4. Challenges to collaboration as cited by respondents .............................................................. 8 Figure 1. Intersectoral and inter-sphere collaboration…………..……………...…………………..............6 This report is the third study in the Ukraine Health and Demography series. The task was led by Rekha Menon and this report is an abridged version of a technical report “Use of collaboration to increase the effectiveness and efficiency of public programs to reduce premature mortality among working age population in Ukraine” prepared by Anjali Dotson, Natalia Zaytseva-Chipak and Joel Gittlesohn. The report was produced under the guidance of Abdo Yazbeck, HNP Sector Manager, Human Development Unit, Europe and Central Asia Region and Martin Raiser. Country Director, Ukraine. The team thanks all the respondents who contributed to the preparation of the study in the six study oblasts. Beth Goodrich provided editorial support. -2- Executive Summary 1. Ukraine faces a health crisis and demographic decline of tragic proportions, especially among the working-age population. The cause is largely unhealthy lifestyles, but the failure of mortality reduction programs is also part of the problem. Recognizing this, the World Bank is preparing a series of reports under its “Health and Demography” program the objective of which is to understand: “How government and key stakeholders, at the national and regional level, can be more effective in improving adult health outcomes thus slowing down the decline in population in Ukraine in the medium and long term?” 2. The first report in this series “An Avoidable Tragedy: Combating Ukraine’s Health Crisis – Lessons from Europe” showed that premature mortality among working age males is caused in part by modifiable behavioral risk-factors such as alcohol abuse and smoking that are avoidable and for which cost-effective targeted interventions exist. However Ukraine’s health system designed for acute care episodic disease management is not equipped to deal with this and needs comprehensive reform. Recognizing the key role of lifestyle factors in pre-mature mortality, a second report “Prevalence and Determinants of Alcohol, Tobacco and Illicit Drug Use in Ukraine” used data from the Demographic Health Survey 2007 to identify the levels of substance use, the population subgroups at high risk, and the social context for substance use. The report identified key interventions that could result in quick wins and key target groups at whom policies and interventions need to be targeted to achieve impact. 3. In this third report in the series, the focus is on key stakeholders at the regional level and the level of collaboration between these stakeholders in the design and implementation of chronic disease prevention and management programs. Qualitative research methods are used to: (i) validate findings from the quantitative work conducted at the national level under the first study, and (ii) identify local inputs to solutions for reducing working–age mortality in Ukraine. 4. Through interviews and focus group discussions, sixty respondents representing the public and private sectors, the city and oblast levels of government and four selected spheres: medical, labor, education/environment and traffic/police, discussed existing programs and modes of inter-sectoral collaboration, listed causes of programmatic failures and offered local solutions. 5. Local stakeholders appear to be fully aware of the direct and indirect causes of working-age mortality – high, untreated blood pressure; smoking; poor food choices; traffic and workplace accidents, etc. They are also familiar with existing programs and interventions to reduce mortality among the working age population. They however note that several programmatic failures, listed below, have led to inefficient and ineffective collaboration across the various sectors, levels of government and spheres. First, programs are implemented in a piece meal manner and not within a comprehensive strategic framework, resulting in programming gaps that causes programs to fail and end with the high mortality rates seen today. Second, state-level procedures for developing and implementing programs are weak. Lack of local input in policy making, inadequate funding, compliance failures, systemic failures and corruption, contribute to program failures and high mortality rates. Third, where laws and regulations exist, there are often not enforced or complied with. for example lack of enforcement to occupational safety standards leave workers exposed to workplace hazards, 6. The stakeholders offered various solutions to program design and effectiveness which could be grouped into two categories. The first addresses improving program design by incorporating local input in such design. The second offers solutions to improving local level collaboration in program implementation. 7. As to the first, stakeholders noted that programs should be designed with consideration of the sectors, government levels, spheres and community that could contribute to such design, thus ensuring i that programs are appropriate in the local context. Also, goals, budgets and time frames should be realistic. Lastly, bridges in the local government structure should be fostered to support collaboration with respect to ideas, programs, people and money: all four of these elements must be in place for successful programming, and bringing them all together requires many participants and stakeholders, all of them willing to collaborate to contribute to program success. 8. This last point leads to the importance of collaboration, which can help bring together needed ideas, programs, people and money. Collaboration would allow for the unobstructed flow of information, thus improving the efficiency of state-designed programs. Networks and bridges for cooperation and communication can include informal forums for information sharing, the compiling and sharing of information so that people and stakeholders will be aware of the appropriate use of government services, and the sharing of best practice examples. Collaboration would also enable the development of local solutions to ensure compliance with measures and, where necessary, the enforcement of sanctions. 9. Essential to collaboration, however, is eliminating funding constraints, contradictory and/or confusing legislation, and corruption. These forces diminish the effectiveness of mortality reduction programs and policies and reduce the ability of state and local officials and the private sector to productively collaborate, which, in turn, further diminishes the effectiveness of programs. 10. Most importantly, public and private sector respondents alike believe that reducing working-age mortality in Ukraine is possible, despite numerous obstacles, with available strategies, including widespread collaboration. The importance of collaboration going forward is reflected in a concluding warning from one study respondent who cited a local proverb, “T he voice of one man is the voice of no one.” ii Introduction 1. Rich in natural resources, Ukraine is losing the Box 1. Key population statistics working-age people who make its resources valuable (Box 1). Declining fertility rates and increasing emigration and  Ukraine’s population fell between 1991 and 2007 from 52 million to 46.2 million; at this mortality rates have converged in “an unprecedented rate, its 2050 population will be 36.2 million. demographic decline compounded by a health crisis,”  A third of Ukrainians die before age 65. according to the World Bank’s 2009 report, “An  Four-fifths die prematurely of Avoidable Tragedy: Combating Ukraine’s Health Crisis.” noncommunicable diseases, many preventable. However, much of the disease burden is amenable, and  A third have high blood pressure. with proper intervention and a well-functioning  Almost two-thirds over age 15 smoke. preventative and curative health system, the crisis could be averted (World Bank, 2009, page 57).  Primary care could have averted 80% of premature male and 30% of premature female 2. This report presents the results of research that deaths. had two objectives:  Traffic and work-related accidents are common and often fatal.  To reveal oblast- and city-level understanding Source: World Bank (2009). among certain stakeholders of the causes of working-age mortality and strategies to address it and  To determine the extent to which collaboration is practiced at these levels, what methods of collaboration are used and what challenges prevent collaboration from being effective. 3. Six oblasts were identified for the study, assuring diversity in several respects: Ivan-Frankivsk and Ternopil oblasts in western Ukraine; Mykolaiv Oblast in the southeast; and Dnipropetrovsk, Cherkassy and Poltava in the east. Known stakeholders in each oblast were interviewed between December 2008 and May 2009 to glean not only their comments but also their contacts in each oblast who might participate in focus group discussions. These two data collection methods garnered the opinions of nearly 60 representatives of the public and private sectors, oblast and city government levels, and the medical, labor, education/environment, and traffic/police “spheres.” (For clarity, these four sectors are referred to here as spheres to distinguish this category from that of the public and private sectors.) After these discussions, the grounded theory approach was used to analyze comments and develop themes. The methodology is more fully described in the annex. Key Findings 4. Unhealthy lifestyles were cited as the leading cause of premature mortality among the working- age population, followed by occupational and environmental factors. Lifestyle decisions and lack of financial protection were known by stakeholders to be the causes of working-age mortality. Commonly cited as detrimental choices were smoking, alcohol, drugs, physical inactivity, poor diet, delay in care seeking and infrequent general medical examinations. Also discussed, were the common failure of factory and labor workers, to comply with requirements to use personal protective equipment. A “culture” of poor health was identified as the overarching cause of working -age deaths, with the government seen as doing too little to promote a healthy lifestyle. A sedentary lifestyle defines much of today’s population: according to an oblast-level health center director: Our nutrition is not rational. We overeat. When we go home, the first thing we do is eat and make ourselves comfortable in front of the TV, instead of taking the kids for a walk or somewhere that would enrich their intellectual potential. It is all about building a culture of health. 5. Environmental factors were also seen as important causes of working-age mortality. With some of the largest deposits of natural resources in the region, Ukraine’s misuse of its resources has generated -1- significant, health-threatening environmental destruction and pollution. The Chernobyl accident was just one of many examples cited. 6. Organizational factors such as low-quality health services and lack of enforcement of occupational safety standards further exacerbate the situation. Economic and organizational factors were cited as associated with mortality among workers. Low wages and expensive medical care were commonly cited economic factors, while lack of law enforcement, poor training of health care professionals, and inadequate and poor-quality medical and industrial equipment topped the organizational reasons for high pre-mature mortality. 7. Several programs exist, but there is no comprehensive strategy at the local level to reduce premature mortality among the working-age population. Programs to prevent working-age mortality exist in the stakeholders’ majority view but seem not to be sufficiently comprehensive. The current programs, policies and regulations to prevent working-age mortality most often mentioned by respondents are listed in Table 1. Some, such as programs for cancer prevention and traffic safety, focus on prevention. Others – such as the national Methadone Replacement Therapy Program and Cherkassy’s mobile outpatient unit – focus on treatment and harm reduction. Still others, such as the Presidential Decree for Improving Social Dialog, foster communication and multisectoral collaboration. Most programs were state funded; collaboration occurred in some. Table 1. Examples of existing programs as cited by respondents Program or informal Funding source Objective(s) identification State Local Education/ environment Pure Water Program Improve the quality of the water supply in Cherkassy Oblast, for X-Chr example, through adoption of automated purifying systems Development of Soccer Increase soccer uptake by building fields and stadiums to encourage X in Ukraine soccer playing by youth Traffic/ police Hero/ Rescuer Encourage training in first-aid and good Samaritan practices by X recognizing citizens who save a life Automobile Inspection X Improve traffic safety through regular vehicle inspections Child Injury Prevention Prevent injuries from traffic-related accidents among children, for X X Program* example, through educational campaigns in schools Program for Traffic Improve road conditions through design and repair, rail lines, X X Safety railings for walkways, etc. Labor Hygiene and Production Monitor and improve workplace hygiene X-Chr Environment* Rehabilitation Program Improve the health and standard of living of persons with disabilities X-Chr and accident victims, for example, through the purchase of resort vouchers for those with the greatest disability Improving Safety of Work with managers of local firms to improve employee working X-Myk Working Conditions conditions Social Program for Improve worker health conditions through organizational reform of Improving Workplace X industrial safety: workplace fire inspections, technical inspections, Hygiene* accident investigations and accident prevention Interaction of Services Collaborate with other departments to improve working conditions for Lowering Industrial X-Myk by monitoring firms and enforcing agreements when violations have Injury* occurred and an agreement reached -2- Program or informal Funding source Objective(s) identification State Local Medical Health of the Nation Comprehensively address both prevention/ treatment of disease and X health impediments Methadone Replacement Reduce crime, overdoses, and HIV by providing methadone to drug X Therapy addicts Professional Medical Provide all citizens’ medical records to all medical professionals to X- Chr Examination aid in consultations and treatment Rat Eradication Program Decrease incidence of rodent-related diseases through systematic rat X-Ter eradication Occupational Disease Investigate workplace cancers, improve unsafe conditions and X Prevention Program* prevent future cases Cancer Prevention Prevent cancer by testing foods and soils for radio-nuclides and by X X Program providing preventative medical exams to educate people Mobile Outpatient Provide medical services to rural populations Chr Unit** Public Smoking Ban Reduce smoking prevalence and smoking-caused diseases by X banning smoking in public (discos, theaters, bus stops, etc.) Social Development Ensure comfortable, safe housing, improve environment, provide X-Chr Program* medical services, and provide equipment to medical facilities Comprehensive (all Address issues of socioeconomic protection of the population, spheres): Presidential establishment of oblast and district-level agreements, etc. X decree to improve social dialog* Notes: Chr = Cherkassy Oblast; Myk = Mykolaiv Oblast; Ter = Ternopil Oblast; Collab = Interdepartmental collaboration; * Collaboration cited. ** Funded by an international NGO. 8. Prevention was seen as the appropriate policy response to reducing premature death among the working-age population. The need to change social norms to make health “fashionable” was particularly clear among government officials. That healthy lifestyles were rare, especially in rural areas was the common view. An oblast-level physician from a rural area reported having aroused bemusement among nurses by jogging in the streets, where others publicly guzzled, conforming to the norm. Programs to prevent working-age mortality, respondents urged, should include:  Occupational safety, including promoting the use of safety equipment;  Enforcement of alcohol and tobacco laws;  Consumer information on food labels;  Sanctions to prevent unhealthy decisions and stronger enforcement; and  A health system that is responsive to chronic diseases and provides universal financial protection. 9. Where programs exist, weaknesses in state-level procedures led to programmatic failures. Several reasons were given for programmatic failures (Table 2) – these are described below. Lack of local input in policy making. Most programs originate at the state level, respondents reported, for local implementation. Modification occasionally occurs based on locally drafted proposals, but local officials have little influence on the state-level program development processes. Programs should be developed locally, almost all respondents urged, to leverage the in-depth knowledge of local issues. One respondent described a presidential decree requiring hockey programs in all oblasts: in the respondent’s oblast, hockey was much less popular than other sports: a -3- locally tailored program would have been more effective. Where opportunities have arisen to develop new programs and ideas and submit them to the state, these stakeholders noted, state officials only “entertain” these local proposals. State officials “are obliged to stick to procedure [i.e., review local recommendations], but then everything goes into the trash, and they pass whatever they want,” one noted. Table 2. Challenges to program development and implementation as perceived by respondents Number citing Challenge Description challenge Lack of funding for programs and salaries; lack of resources Financial 56 (human and material); and inefficient allocation of funds Resource Unqualified professionals and inadequate equipment/ facilities 24 Compliance/ Non-compliance by the general public and businesses of laws and 20 corruption regulations and corruption among officials and employers Legislative loopholes and inconsistencies leading to confusion, Legislative 18 non-compliance and lack of enforcement State dominance in the decision-making and program development Local influence 15 processes, resulting in weak local influence Poor planning of program content and lack of efficiency in Organizational 9 implementation Inadequate funding. The state’s inadequate replenishing of funds to local budgets was a common complaint. It leaves local officials in a position of having to decide what they can afford to implement. A Department of Labor Hygiene manager said: The [programs] that don’t require large expenditures are executed. The ones that need funds are not. All [programs] are declarative: not supported by money. When we receive a program from above, we discuss it and take from it what we can realistically execute, really need, and can back up with money. That is, we try to adapt it to the local level so that it will be realistic. Where new programs are state mandated for local implementation, the requisite funds are not provided, forcing local administrations to “resort to deception” when submitting reports on programs never fully implemented due to underfinancing. A city civil defense committee member said, “Programs from above are no more than ideas. They are beautifully described, but there’s no funding. . . . It exists only on paper.” Compliance failures. Non-compliance with laws and regulations by both the general public (i.e., failure to abide non-smoking messages) and private businesses was seen as a challenge to program and policy implementation. For instance, a regulation may be passed stipulating standards of safety and cleanliness to which an industry manager must adhere, but fines are not sufficiently severe to ensure compliance. Moreover, monitoring and enforcement efforts are often lacking. Laws tend to be enforced only after a failure to enforce them brings tragedy to the personal realm of a high-ranking official or person of other notoriety. Systemic failures. Systemic failures also deter program implementation: understaffing of health facilities, inadequate training of medical professionals and insufficient resources for health care. A specialist in anti-epidemic protection at the oblast level reported that several years earlier, all clinics and hospitals received funding to screen patients with a cough for TB. If positive, patients had to remain at the facility during treatment to reduce transmission risk. However, limited resources meant -4- that many TB patients received out-patient treatment, traveling home for meals the health system couldn’t afford and thereby reintroducing the transmission risks. Corruption. State-level government corruption – especially in alcohol and tobacco dealings – was also cited as undermining program implementation. Some respondents, mainly from oblast and city medical agencies, criticized state officials for their failure to pass legislation banning these products or increasing taxes on them. Expressing his sense of powerlessness, a physician from a city health facility said: Apart from awareness campaigns, we have nothing [to deter alcohol consumption]. What we do have are advertisements for alcohol, everywhere. The government is thus building its revenues, and that’s why it’s advantageous to sell alcohol. [Government officials] say not to drink but keep the price of alcoholic beverages low: they are sold at every step around the clock. . . . There are no [alcoholism programs], because directors of breweries and distilleries are in parliament. 10. Box 2 presents a case study showing ways the above-noted challenges interconnect and exacerbate each other. Pulled from different experiences familiar to respondents, it describes several challenges in the context of a program to reduce traffic deaths. 11. 2: Case Study: Delivering emergency care to traffic accident victims Box A leading cause of death among Ukraine’s working -age population, road traffic accidents also result in injury so severe that the speed of the ambulance and quality of care by the response team are a matter of life or death. Recalling an horrific bus accident, a senior official at the Ternopil Ministry for Emergency Situations noted the critical importance of the quality of care victims receive at the accident site and the sources of system failures: The victim’s life depends on the qualification of those administering first aid. Failures, first and foremost, lie in the training system both at the Ministry of Internal Affairs and in the state traffic inspector’s ofice. Now about ambulances: It was sheer luck that the accident occurred near Ternopil. Otherwise, I don’t know what the consequences would have been. In addition to responder qualifications and the distance between the accident site and ambulance location, factors such as road conditions, the emergency vehicle’s condition, and having functional and appropriate equipment are also critical. As the Ternopil official noted, medical facility staff have some control over care quality, it’s different on the road: Even lacking money for treatment, when a person has a serious health problem, he finds the money. . . . When he is in an accident, care arrives by an out-dated ambulance and the road to the accident is identically in very bad shape. Yet another challenge to providing quality care to traffic accident victims is poorly drafted legislation. In response to the misuse of flashing vehicle lights and sirens by people affiliated with the mafia, parliament passed a law making it illegal for any non-law enforcement vehicle to use flashing lights or sirens but failed to make exception for ambulances. Now, ambulance drivers must apply for permission to use their lights and siren when responding to an accident; the application process is expensive and time-consuming. Even with such permission, ambulances may be unable to respond to accidents: Lack of funding means little money for gasoline; so many drivers first ask victims if they will pay for gas for the ambulance. Only after funding is secured can they respond. Similarly, severely inadequate ambulance first aid kits result in poor care at the scene. Some drivers require victims to pay for bandages and medications so they can replenish stocks for the next call. -5- 12. Collaboration occurs between the public and private sectors, among various government agencies (or spheres), and between administrative levels. Figure 1 illustrates respondents’ reports of the frequency of intersectoral and inter-sphere collaboration. It was most common in the public sector, with respondents citing 71 examples of collaboration between two or more government agencies in different spheres and 44 examples of intersectoral collaboration. In public-private partnerships, matching public-private spheres collaborated more that different ones, and the private sector labor Figure 1: Intersectoral and inter-sphere collaboration: the heaviness sphere (trade unions) was reported of the lines connecting spheres indicates the relative frequency with as cooperating most frequently with which respondents referred to collaboration between two spheres. public sector spheres. Collaboration between oblast and city officials was mentioned only 18 times. 13. The levels of collaboration, however, vary by oblast. Ivano-Frankivsk respondents painted the bleakest picture, saying that they often collaborate through meetings, etc., but no desirable outcome usually results. On the other hand, they did note the ease of communication in their small region and that forging personal contacts was a crucial first step to effective collaboration. 14. Examples of efficient collaboration were cited both between government agencies and spheres and across public and private sectors. Efficiency was reported by Cherkassy respondents who also voiced the need for closer cooperation between local bodies and the state. Some questioned the effectiveness of some methods of collaboration, such as meetings, round tables and lectures. More and longer lasting results derived from workshops, commissions and conferences, they said. Dnipropetrovsk respondents were quite positive, citing an example of a favorable outcome from their experience where, after as an explosion in a residential neighborhood, social workers and psychologists worked together to address emotional trauma, and a mobile team formed to work with affected children. Mykolaiv respondents indicated their collaboration was effective and efficient despite legislative and funding challenges. Both intersectoral and inter-sphere collaborative efforts were underway there. Poltava respondents reported excellent collaboration within spheres and between sectors and local government levels. They cited a special epidemic emergency commission, with members from several spheres, that addressed noncompliance with regulations over dairy and meat sales. These oblast officials also recognized the importance of NGOs in filling service gaps and finding solutions to problems. One called for creative initiatives, saying that understanding the different perspectives of the various groups was beneficial. 15. Methods of collaboration range from cooperation and communication to joint financing or implementation of activities. Almost all respondents reported having collaborated using at least one method from Table 3. Although several claimed that their cooperation and communication with other sectors, levels of administration and spheres could be more efficient and frequent, most said that the current efforts were productive. Some, however, noted ineffective methods. Citing no method as the most efficient, many pointed out the strengths and disadvantages of each. 16. Information exchange, a common form of collaboration, between or among spheres and levels was seen as valuable, but formalities hinder efficiency. A mandate requiring formal requests from a government department for information from another department was said to slow the process of information exchange and discourage such requests. Nevertheless, respondents agreed that sharing -6- experiences and information with specialists in different fields was bound to produce positive effects. For instance, respondents discussed a number of programs that address worker safety and hygiene, encompassing not only labor protection, but also medicine and sanitation, so several spheres must be involved. The head of a city occupational hygiene office emphasized the importance of working with those who have a deeper or different understanding of an issue. She cited as an example that being a physician, she has a particular knowledge that someone from the labor sphere may not. Conversely, she appreciated the expertise of engineers who could supplement her knowledge with information to help establish safer working conditions. Table 3. Methods of collaboration cited by respondents Timeframe: Times Method Structure Type of work Participant(s) cited Formal and tending to be exclusive; led by Decision- Commissions, councils, Short or long a single group/ member; state recommends making and/ or 43 committees, boards term: State their use but no legal stipulation standard-setting Decision- Short-term, Meetings, conferences, making and/or Informal; no clear leader repeated events: 40 round tables information Private and state exchange Workshops, seminars, Short- and long- Educational, Informal; usually a clear leader or initiating personnel training term events: Information 22 body publications Private and state exchange Joint inspections, Formal; inspection team members are Short-term, monitoring and appointed legislatively, state financed and repeated events: Regulatory 19 evaluation legally required State Public events, aware- Short-term: Practical, ness campaigns, Informal; open to everyone 18 Private and state educational seminars Informal; open to everyone, state Long-term, on- Reports, letters, emails, departments are legally bound to reply Information going event: 15 consultations interdepartmentally within a month of exchange Private and state receipt of request Formal; require that members sign on, since they are legislatively approved; established by government departments with potential Long-term, single Normative documents for private sector input, these documents event: Private and Regulatory 8 may be drafted by joint commissions and state are approved by local councils and then the state parliament Formal; stipulating joint actions, standards Long-term, single or protocols; enforced by the same Agreements event: Private and Regulatory 7 departments that are involved in their state drafting and signing Short- or long- Joint financing of Formal, according to the needs of a given Financial, term: Private and 2 programs program practical state 17. Normative documents, which are equal in force to temporary legislation, were a commonly mentioned, formal method of collaboration among government agencies and departments. Often drafted by joint commissions, they typically incorporate the views of several different public players. A physician at a city epidemiology and sanitation station discussed the benefit of accountability associated with these documents: “When they exist, no one can ignore them. Everyone reads them and knows his -7- responsibility. There will then be less resistance between professionals: They must be fulfilled.” Another physician disagreed, saying that normative documents are not always completely fulfilled, due largely to underfinancing, resulting in incomplete program implementation. This physician emphasized the need for parallel financial investment in regional and national program implementation. Another respondent claimed that normative documents take too long to develop, propose, approve and implement. 18. Although some respondents seemed to prefer the more formal methods of collaboration, a few shared experiences where informal, unstructured communication generated a positive outcome. A manager of a city-level directorate for youth and sports cited a collaborative experience with the city education directorate to make a school gym available to a group of elderly people seeking a place to play basketball. Knowing of a school gym that was unused afternoons and evenings, the respondent asked authorities for permission for the group. Access was easily granted for all regional school gyms with the agreement that users would pay for the extra electricity. This example illustrates the potential for informal cooperation to improve the conditions and healthy lifestyle of local residents. 19. Yet another method of collaboration is the joint inspection team. Some claimed these are productive, but others found fault. The new Law on Regulation of Entrepreneurial Activity requires that an inspection team inform a firm 10 days in advance of an inspection. It was felt that this could undermine the team’s efforts to identify risks and unsafe working conditions: managers would simply impose mandatory vacations on the day of the inspection or close problematic production units so that the inspection team could not see the problems. Others cited cases where an inspection service was abused for political purposes. 20. There was a common view however that effective collaboration was often deterred by underfinancing, lack of accountability and too much formality, especially in the public sector, thus hindering innovation. There was not a large discrepancy between the experiences of private and public sector officials in collaborative efforts, nor did any government sphere have more negative experiences than any other. However, respondents identified several challenges to collaboration, as listed in Table 4 and described below. Table 4. Challenges to collaboration as cited by respondents Number of Challenge Description respondents Issues regarding funding of programs, joint financing, and low wages for Financial 24 public officials Attitude/ Negative attitude toward collaboration, lack of compliance with agreements reached during collaboration and lack of accountability and personal/ 16 compliance departmental responsibility Difference of opinion and perspective of individuals or working bodies and/or Perspective 5 unwillingness to compromise Lack of information needed to recognize potential collaborations or inability to Informational 4 maintain information exchange during collaborative effort Underfinancing. Collaboration faces numerous obstacles, respondents said, especially due to underfinancing, which they saw as the main impediment to achieving long-lasting collaboration among government departments and agencies. Poor attitude. Poor attitudes within the collaborative process results from low government salaries: personnel would simply not commit to additional “non-mandatory” actions. A common feeling among those interviewed was the difficulty in holding themselves and other departments accountable -8- for their actions and responsible for their duties and promises. Officials shy away from difficult tasks: a physician with the Ministry of Emergency Situations said: This problem concerns low cooperation of all services. When we assemble to solve some problem, everybody begins to disassociate himself. The ambulance service says the Ministry for Emergency Situations arrived late, the Ministry for Emergency Situation affirms that they were the first to arrive, the ambulance hadn’t arrived yet. We do this from A to Z. Corruption. Respondents often singled out state-level officials for their complacency and corruption. An official from a district epidemiology and sanitation station in an eastern oblast cited empty pre- election promises to exemplify the disregard with which state-level officials approach the issue of mortality among the working-age population. Different working styles. Achieving efficient and effective collaboration is also restricted by the different perspectives and/or working styles between two departments or, more often, between the private and public sector. Unwillingness to compromise was a concern, while some respondents from the public sector felt that NGOs often develop initiatives and new ideas that are not easily compatible with the “old structures” still in place in the government, possibly referring to the formality with which government structures function. Formality. Indeed, this formality was noted by many respondents representing government agencies and departments as a challenge to both program implementation and collaboration. When asked if they collaborate, most respondents reported that they do cooperate with multiple departments, in large part due to the fact that they are legislatively bound to do so (e.g., in the case of joint inspection teams and coordinating councils/ commissions). Many of these more formal methods of collaboration followed somewhat strict protocols on who could participate and how the sessions would proceed. Many felt that the increased time required to write and process inquiries as well as other tasks involved in various protocols hampered their ability to address issues efficiently. The department head from an oblast epidemiology and sanitation station said, “We hold so many meetings that there is no time left to combat ailments.” Lack of clear responsibilities. Ternopil representatives differed in their perceptions of the efficiency and effectiveness of their collaboration. Some stated that they themselves collaborated with other spheres but a clear responsibility structure was necessary to coordinate all these efforts. Others were less enthusiastic about the oblast’s cooperation, criticizing bureaucratic information inquiries for taking too long and colleagues for lacking a sense of mutual responsibility in collective efforts. A senior traffic inspection official, however, told of a traffic accident where 16 organizations and investigative teams responded, resulting in reporting discrepancies and little cooperation at the scene. Toward effective multisectoral collaboration at the local level 21. The World Bank’s 2009 “Avoidable Tragedy” report, states that almost half of all dea ths among Ukrainians under the age of seventy five years could be averted with proper prevention and treatment (World Bank, 2009). All respondents participating in this study agreed that collaboration has the potential to revitalize fatigued health promotion, protection and care systems; they also cited several instances of collaboration. A weak health system, lack of funding for programming, and poorly drafted and enforced legislation are just a few of the challenges facing those seeking to curb demographic and health declines. Insufficient and poor collaboration among Ukraine’s medical, labor, education/ environment and traffic/ police spheres, at all levels of government and in the private sector are hindering effective policy implementation. Several challenges to effective collaboration, identified here, could contribute to the design of improvements in how programs should be implemented. While many of the challenges cited in this study involve lack of state funding, simply increasing investment in the health system will not likely be effective in reducing the country’s working -age mortality rate. Respondents agreed that local input in the planning and design of programs and strategies and improved collaboration in implementation of programs at all levels and between spheres were essential to programs’ success. -9- The following ways were proposed to achieve both local input in program/ strategy design and improved collaboration during implementation: A. Fostering local input in planning and developing integrated programs and strategies (i) First, program design needs to integrated, not just within medical services but between sectors, government levels, spheres and the community. When programs are designed, consideration should be given to the sectors, government levels, spheres and community that could contribute to program efficiency and effectiveness; these participants’ roles should be included in programs’ designs (with their input starting during the development phase). Soliciting the opinions of local stakeholders in the state process of program development could help ensure that programs are appropriate in the local context. (ii) Second, programs must have realistic goals. Consideration should be given to the feasibility of planned programs. Built-in mechanisms to monitor and evaluate program implementation would signal program failures and the need for correction. Also, a collaborative attitude on the part of state-level officials would reduce distorted reporting from the local level and foster collaboration between the local and state levels to resolve rather than hide problems. (iii) Third, programs should be based on realistic budgets and time frames. Inadequate local budgets undermine the effectiveness of many programs. Both state and local funds should be invested in programs to ensure buy-in at both levels. Monitoring and evaluating program implementation would either ensure that the time and money suffice or signal that more time and/or money is needed. (iv) Finally, bridges should be fostered in the local government structure to support collaboration with respect to ideas, programs, people and money. Although cooperation does exist at the local level, interdependency is not sufficiently deep rooted to produce fruitful and lasting results. More organizational connections should be developed between departments, protocols should exist for their coordination, and funding systems should be modified to facilitate collaboration. B. Improving collaboration in program implementation (i) An unobstructed flow of information would ultimately improve the efficiency of state-designed programs. Networks and bridges for cooperation and communication should be embedded within the system to facilitate collaboration. These can take various forms: a. Informal forums for information sharing can increase transparency and communication within government agencies. As recommended by respondents, such forum would be an informal but still structured form of information exchange to enable government agencies and departments to report to each other and share experiences and information without the time-consuming formality of reports, letters, emails, and consultations. b. Compiling information on resources and services and sharing it with the public and among spheres, sectors and levels of government would help raise awareness and encourage appropriate use of services. A well-informed public is critical to reducing working-age mortality. The state government should communicate with the public both directly and through the sectors, government levels and spheres. Communications should in particular focus on personal health habits, including careful driving and occupational and environmental safety. It is necessary to recognize that no one always adheres to behavior change messages but that everyone can improve. To protect the working-age population, messages should be targeted to that group but also to younger groups so that they will develop habits of self-protection early -10- c. Sharing best practice examples as they occur can foster wider collaboration. Sharing information and experience among specialists at workshops and seminars, opportunities for informal collaborative efforts, and the like will foster wider collaboration. (ii) Finding local solutions to ensure compliance with measures and where necessary enforce sanctions can yield results. The public’s and businesses’ failure to comply with regulations negatively affects the success of programs at the local level. In particular, from the perspective of working-age mortality, traffic, workplace safety and environmental protection laws and regulations should be enforced and carry sanctions sufficiently punitive to ensure compliance. Enabling the participation of local level officials will help reduce poor attitudes toward collaboration and communication. (iii) Eliminating funding constraints, contradictory and/or confusing legislation, and corruption. These forces diminish the effectiveness of mortality reduction programs and policies and reduce the ability of state and local officials and the private sector to productively collaborate, which, in turn, further diminishes the effectiveness of programs. The frequency with which local stakeholders pointed to corruption as a challenge to effective programming recommends a coordinated effort addressing the problem. A first step is building transparency into decision- making processes and funding flows. The engagement of civil society in programs, where practical, can also prevent corruption and mismanagement. Corruption, however is only part of the problem: poorly drafted legislation and regulations were cited several times by respondents, with three examples given here: ambulance drivers were prohibited from using flashing lights and sirens, a sport unpopular in an oblast was mandated for implementation there, and inspection teams were required to provide warnings of their planned visits. 22. Public and private sector respondents alike indicated that change is possible. While acknowledging the numerous obstacles their country will need to overcome, respondents recognized the availability of and advocated for strategies to reduce working-age mortality in Ukraine. These strategies involve the efficient use of extant collaborative methods or the development of new ones to bridge the gaps between sectors, administrative levels, and spheres. Working together with a single purpose is critical: As a local proverb warns, “The voice of one man is the voice of no one.” Reference World Bank, 2009. “An Unavoidable Tragedy: Combating Ukraine’s Health Crisis: Lessons f rom Europe.” Human Development Sector Unit (Health and Demography), Europe and Central Asia Region, World Bank, Washington, DC. -11- Annex 1: Research Methodology 1. The study team defined collaboration as “the use of processes, events or materials that facili tate communication between groups existing in different social sectors [“spheres”], levels of government administration, and/or government departments in order to reach some collective objective of benefit to society.” They then conducted in-depth interviews and focus group discussions with key stakeholders in the public and private sectors who were working at the oblast or city level to address issues related to working-age mortality. The team collected stakeholders’ comments on the development and implementation of mortality reduction programs as well as professional collaboration. 2. The interviews and focus group sessions were held in six of Ukraine’s 24 oblasts from December 2008 to May 2009. World Bank staff selected the oblasts based on diversity in a number of indicators, including geography. 3. The research team asked all departments (in the selected oblasts) that address health and mortality among the working-age population to identify a representative to participate in the study. In-depth interviews were conducted with the identified representatives to solicit the names and contact information of potential focus group discussants. Some interviewees were invited back for a focus group discussion. The main criterion for selection was a willingness to participate productively. While only heads of regional government departments and directors of non-profit organizations were invited, many of them cited time restraints and sent members of their staffs. Each focus group had 8 to 13 participants, each of whom was paid 100 UAH (~US $13) upon completion of the discussion. 4. The team conducted 27 interviews lasting 15–60 minutes and 6 focus group discussions lasting 90–120 minutes. Team members who facilitated these sessions used a semi-structured interview form that had been pilot tested in Ternopil Oblast. All interviews and discussions were audio-recorded, transcribed and translated into English for analysis. Comments from 58 respondents were analyzed. 5. Analysis approach: grounded theory. Grounded theory is an inductive method for conducting interviews, collecting data, coding the data, and developing theories and models (Creswell, 2007). This approach enables the development of a theory grounded in the data that describes a system or process (in this case, intersectoral collaboration) based on experiences and perspectives of several respondents (Starks and Brown, 2007). The research team chose this approach so they could develop theories and frameworks that would describe the use of collaboration in the development and implementation of mortality reduction programs. 6. Respondents. Twenty-six interviews were analyzed, garnering robust input from all four spheres at the oblast level. At the city level the medical sphere had only four respondents and the traffic/ police sphere only two. Also, among non-profits, only medical and labor organizations were interviewed. All spheres at both levels were represented in the focus group sessions, except no private sector traffic-related organization participated. 7. The most represented groups were medical and labor-related public sector spheres at the oblast level, as well as private sector labor groups, mostly trade unions. The least represented groups were the labor and traffic/ police in the public sector spheres at the city level and private educational or environmental organizations. These representational imbalances may have skewed the intensity of collaboration that Figure 1 attempts to portray. References Creswell John W. 2007. Qualitative Inquiry & Research Design: Choosing Among Five Approaches, 2nd ed. Thousand Oaks, CA: Sage Publications. Starks H and Brown Trinidad S. 2007. Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research, 17: 1372–80. -12-