5. Provision of services
he public system has a large network of providers throughout the country. This network operates alongside that of the private sector, which offers primarily ambulatory care and to some extent hospital care, although data and documentation regarding the private sector is sparse. The link between secondary care and the social care system is informal, the latter of which is mostly the responsibility of the Ministry of Labour and Social Security.
The fragmentation of the health system, with little continuity of care and poor communication between doctors and other health care providers within and between the private and public sectors, is a major weakness that leads to inefficiencies in both sectors, duplication of services and underutilization in the private sector. Within the public sector there are problems related to organization and coverage since there is no referral system. There are also difficulties accessing some services due to long waiting times. Access for specific groups, such as immigrants, is problematic while there is limited coverage in dental care (since orthodontics and fixed prosthetics are not provided by the public sector), long-term care, rehabilitation care and palliative care, the last two of which are mostly provided by NGOs and the charitable sector. Additionally, there is an issue of affordability, especially for the above-mentioned services, since patients in many cases bear the cost of care. The affordability issue is evident not only from several Eurobarometer surveys but also by high private expenditure as a percentage of total health expenditure.
5.1 Public health
The importance of public health and specifically prevention and health promotion has long been recognized by the Ministry of Health as a cost-effective way to improve population health. The Department of Medical and Public Health Services within the Ministry of Health is responsible for organizing and delivering a wide spectrum of preventive and health promotion activities, including:
- epidemiological monitoring
- control of sexually transmitted diseases
- services for expectant parents, pregnant women and children
- school health services
- immunization services
- control of environmental and communicable diseases
- occupational health
- health education and promotion.
To accomplish these objectives various programmes have been implemented by the medical and public health services, the health visitors and the mother and child health centres in cooperation with local authorities, voluntary and non-profit organizations, as well as other ministries such as Agriculture, Natural Resources and Environment, Labour and Social Insurance, and Education and Culture.
Public health services are mainly delivered by health professionals in public health centres and hospitals. The public health services in close cooperation with the State General Laboratory monitor and control food and water safety. Furthermore the State General Laboratory monitors and controls pharmaceuticals and illegal drugs, cosmetics, children’s toys and other industrial supplies, and environmental pollutants. To a lesser degree, public health is delivered by the private sector, local authorities, non-profit organizations and other ministries.
5.1.1 Immunization services
The Ministry of Health specifies the child immunization policy in line with WHO guidelines. Immunizations in the public sector are provided free of charge and performed by health visitors under the guidance of doctors/paediatricians and in the private sector by paediatricians. The Ministry of Health estimates that 58% of immunizations are performed by paediatricians in the private sector. The immunization coverage for DTP (diphtheria, tetanus, pertussis), OPV/IPV (oral polio/inactivated polio) and HBV (hepatitis B) vaccines is almost 100%, leading to the eradication of neonatal tetanus, diphtheria and poliomyelitis. The coverage for MMR (measles, mumps, rubella) is 87% and therefore cases of measles and rubella appear very rarely. Data from a survey on immunization coverage among children aged 17– 24 months are presented in Table5.1.
5.1.2 Food safety and water sanitation
The Public Health Services department of the Ministry of Health is charged with implementation of the community and national (harmonized) legislation for foodstuffs and drinking water. In cooperation with the other departments of the Ministry of Health, the Public Health Services of the municipalities along with the Ministry of Agriculture, Natural Resources and Environment (Veterinary Services and Department of Agriculture) have developed a uniform and integrated policy for food safety in Cyprus. Ninety-four Health Officers/Inspectors spread all over Cyprus are responsible for taking samples of foodstuffs from food businesses, restaurants, hotels etc., and of drinking water in order to ensure food safety and water sanitation. In 2010 they undertook 15 348 official control inspections collecting 3279 samples of foodstuffs and 6981 samples of drinking water that were sent to the General Laboratory for further examination (Ministry of Health, 2012c). If samples do not meet the relevant legislation, the Public Health Services department takes the necessary corrective and enforcement measures. In addition to food safety and drinking water quality control, Health Officers/Inspectors are also responsible for guaranteeing the water used in public swimming pools and beaches, campaigns against rats, mosquitos and other pests, as well as the audit and control of smoking products and implementation of smoking related legislation.
The Food Safety Board is responsible for proposing food safety policies, defining priorities and coordinating activities between the above-mentioned institutions. All competent authorities are represented on the board, which is chaired by the Permanent Secretary of the Ministry of Health.
5.1.3 School health services
The Department of Medical and Public Health Services in the Ministry of Health is also responsible for collaborating with health visitors and the Ministry of Education and Culture for the planning and provision of preventive services in schools. Paediatricians, general practitioners and health visitors play a role in delivering school health services. The main school health activities include medical and dental examinations, screening tests for vision, hearing, scoliometresis, provision of vaccinations and prevention and control of epidemics. Emphasis is given to maintaining and promoting a healthy school environment. There are activities to promote student physical and psychosocial health, some of which target domestic abuse, drug addiction and school bullying. This is carried out in cooperation with other services such as psychiatric and social services and the Ministry of Education and Culture.
5.1.4 Services for expectant parents, pregnant women and children
Health promotion for infants, children and pregnant women is also the responsibility of the Department of Medical and Public Health Services. Health visitors in collaboration with other professionals carry out health education programmes in addition to specialized services such as screening tests, assessment of children’s growth, and counselling and support to parents.
5.1.5 Control of sexually transmitted diseases
Another responsibility of the Department of Medical and Public Health Services is the control of sexually transmitted diseases, with special emphasis on HIV/AIDS. Cyprus has a low prevalence of HIV/AIDS, with an estimated prevalence rate of 0.1%. According to data from the Ministry of Health, 681 people have been infected between 1986 and 2010 – 410 Cyprus residents and 271 non-residents; in 2010 there were 41 new cases. Prevention of the sexual transmission of the virus is one of the main objectives of the National AIDS Programme through intersectoral collaboration and introduction of relevant educational programmes to high-risk groups. Patient treatment, clinical care and antiretroviral drug therapy, counselling, diagnosis and follow-up tests are provided free of charge. Additionally, there are programmes for psychological and financial support as well as programmes to combat prejudice and stigma.
5.1.6 Surveillance and control of infectious diseases
Since 2004 a special unit has been established under the Department of Medical and Public Health Services that is responsible for surveillance of all infectious and communicable diseases, early detection and control of epidemics, and the monitoring and evaluation of control programmes. This surveillance system has five components:
- the obligatory reporting system of communicable disease incidence to WHO
- the voluntary reporting system of infectious diseases for which diagnosis is via laboratory tests
- the reporting system of diseases and syndromes for which diagnosis is only clinical
- the reporting system of sexually transmitted diseases
- the reporting system for foodborne infectious diseases.
5.1.7 Health Monitoring Unit
The Health Monitoring Unit in the Ministry of Health is relatively new, and is mainly responsible for setting up mechanisms for the collection, analysis and dissemination of data related to currents trends and determinants of population health. Indicators cover causes of death, cancer incidence, perinatal statistics, injury data and diabetes. The Health Monitoring Unit is also responsible for clinical coding in public hospitals, necessary for the introduction of a remuneration system based on diagnosis-related groups (DRGs).
5.1.8 Other activities related to public health
Other public health programmes include the national screening programmes for the early detection of breast cancer for women aged 50 – 69,5 the screening programme for detection of chromosomal abnormalities in pregnant women, the national thalassaemia screening programme, the monitoring and surveillance programme for pandemic influenza (H1N1), the nutrition programme in elementary schools, participation in the European network of health-promoting schools, research for the assessment of the oral health status of children 7 – 12 years old and studies conducted for particular issues and problems of occupational and environmental health. Smoking indoors in public places is also prohibited in Cyprus.
5.1.9 Intersectoral activities in the field of public health
As mentioned (see section 2.6), apart from the Ministry of Health, other ministries (e.g. Labour and Social Insurance, Agriculture, Natural Resources and Environment, Education and Culture, Commerce, Industry and Tourism, Interior) and agencies independently or in collaboration with the Ministry of Health and/or other public organizations or NGOs (e.g. consumer associations, police, fire service) plan and implement public health programmes for food safety, school health services, lifestyle and health education, environmental policies and road safety. For example, the Department of Labour Inspection within the Ministry of Labour and Social Insurance is responsible for occupational health and safety, air quality and air emissions; all relevant information, programmes and other measures are presented each year in an annual report (Ministry of Labour and Social Insurance, 2011). There are several examples of intersectoral cooperation in the planning and implementation of programmes for the prevention of family violence and child abuse, childhood obesity, illegal drug use and sexually transmitted diseases, as well as programmes geared towards food safety and promoting healthy diets.
5.1.10 Accessibility, adequacy and quality
Although there are little data available, public health services appear to be accessible and of high quality. This conclusion is based on data that indirectly can be connected to particular components of public health services. Such data include the high (nearly 100%) immunization coverage for basic vaccines, the low prevalence of HIV/AIDS, the effectiveness of the thalassaemia programme that has nearly eliminated new thalassaemia cases, the low values for fundamental health indicators such as infant and neonatal mortality, and the generally good level of health. Prevention programmes targeting childhood obesity, smoking, healthy diet and driving practices have not so far demonstrated positive results.