1. IMPACT OF THE HEALTH CARE REFORM ON THE PUBLIC HEALTH IN TRANSFORMATION PERIOD OF EASTERN EUROPEAN COUNTRIES. MORTALITY STUDY IN KRAKOW, POLAND Krystyna Szafraniec and Wieslaw Jedrychowski Chair of Epidemiology and Preventive Medicine, Jagiellonian University, Krakow, Poland

2. What do we know about human lifespan with regard to the length or shortness of life? The information to be had is small, observation careless and tradition based on fables. Francis Bacon, Historia Vitae et Mortis, 1645

3. Background The pattern of mortality by cause (but not the numbers) in Poland is quite similar to that in Western Europe: nearly two thirds of deaths were caused by the first three leading causes of death (circulatory diseases, cancer and injury). However, life expectancy, infant mortality rates and death rates fell behind most western countries. Krakow, the third large city in Poland was known for decades for its poor environmental conditions. Surprisingly, indices of residents’ health status are better than one may expected when compared to other Polish towns.

4. Improvements that have been made in 1975-1999:

5. 7580859095 1000 1100 1200 1300 1400 7580859095 660 710 760 810 Long-term trends in all causes mortality* in Krakow population Males Females SMR per 100 000 */ standardized to age

6. Long-term trends in cardiocirculatory mortality* in Krakow population Cardiovascular diseases Ischaemic heart diseases */ standardized to age

7. MalesFemales

8. Objective Describe health status of population, including prediction of trends with respect to implementation in 1999 health care reform and their impact on population health Describe health status of population, including prediction of trends with respect to implementation in 1999 health care reform and their impact on population health Assess the short-term health effects of functioning of the new system Assess the short-term health effects of functioning of the new system

9. Material Study place: Krakow, Poland 750 000 inhabitants Study place: Krakow, Poland 750 000 inhabitants Study period:1991-2000 Study period:1991-2000 Data:death certificates for Krakow residents Data:death certificates for Krakow residents

10. Methods Age-adjusted mortality rates (with the Krakow population in 1990 as a standard) were calculated Age-adjusted mortality rates (with the Krakow population in 1990 as a standard) were calculated linear regression was employed for assessing trends in mortality linear regression was employed for assessing trends in mortality the rates from 1991-1998 were used for calculating expected level of mortality in 1999 the rates from 1991-1998 were used for calculating expected level of mortality in 1999 excess mortality was defined as a ratio of observed vs. expected rates excess mortality was defined as a ratio of observed vs. expected rates

11. Description of mortality of Krakow inhabitants Total mortality: 6700 deaths per year 27% before 65 49% in men Cancer mortality: 27% of total deaths 36% before 65 52% in men Cardiovascular 49% of all deaths mortality 18% before 65 43% in men Ishaemic heart 13.5% of all deaths disease mortality: 22% before 65 55% in men Male/Female ratio

12. Selected indicators of mortality from leading causes of death among Krakow inhabitants in two year period before and after the health care reform were introduced

13. Excess in mortality* from all causes and cardiovascular diseases in males over the last 10 years Males */ standardized to age

14. Mortality* from all causes and cardiovascular diseases in females over the last 10 years Females */ standardized to age

15. Excess (?) in mortality* from cancer in males and females with respect to trends over the last 10 years */ standardized to age

16. Linear trend: y= -10.7x+173.7, p=0.000, R 2 =0.84 Excess in mortality* from heart attack in males and females with respect to trends over the last 10 years with respect to trends over the last 10 years 510 deaths more than expected Males Females */ standardized to age Linear trend: R 2 =0.30 Nonlinear (parabolic) trend: R 2 =0.82 282 deaths less than expected

17. Is there any change for the place to die?

18. Conclusions The results are more pronounced in men. Particularly, men in their early middle age have suffered from the effect of transition. In situation of acute social and economic changes they are more vulnerable than women. The results are more pronounced in men. Particularly, men in their early middle age have suffered from the effect of transition. In situation of acute social and economic changes they are more vulnerable than women. The excess in heart attacks indicates that emergency service may not work efficiently enough under the new circumstances. The excess in heart attacks indicates that emergency service may not work efficiently enough under the new circumstances.

19. Conclusions Although the data obtained for this study, regarding quality of recording and coding deaths, are in a good quality, the result must be treated with some caution because of short observation time. Although the data obtained for this study, regarding quality of recording and coding deaths, are in a good quality, the result must be treated with some caution because of short observation time. More analytical work, including broad social and environmental determinants of health, is needed to understand the present trends. More analytical work, including broad social and environmental determinants of health, is needed to understand the present trends.

20. Has health care improved for the average Pole today? - Definitely, yes. People are encouraged to think of their own health, take part in screening programs and ensure themselves to have the regular check-ups.

21. So, if health care reform is beneficial, what is behind the numbers? Things are likely to get worse before that get better. We have a hope this is the case here.