1 Introduction

For centuries the free contacts of people from Northern Finland, Norway, Sweden and Northwest Russia have contributed to dynamic relations in a region characterised by hard climatic conditions. For a long period in this century co-operation and contacts were scarce while military preparedness was high.

Today people from the Barents Euro-Arctic Region again travel and trade freely and come together across the borders. Co-operation at national, regional and local levels takes place in nearly all sectors from energy production to cultural activities. We welcome this co-operation which is essential for the stability, progress and prosperity of all Europe.

There are, however, huge challenges connected with the difficult transition from planned to market economy in parts of the Barents Euro-Arctic Region. Among the countries within the northern region, disparities in social welfare are vast. Social differences between countries and within countries are a serious threat to the stability of the whole region. One of the major threats is to be found in the health sector.

Among the most noticeable challenges could be mentioned:

• A decreasing longevity, particularly noticeable among the males and the indigenous population (Sami, Nenets, Veps and Karelian) due to i.a. alcoholism and high rates of suicide.

• A considerable rise of infectious diseases like tuberculosis, diphtheria and syphilis. The figures for tuberculosis are particularly worrying, as there is a high prevalence of the multi-drug resistant type. There has been a sharp increase in sexually transmitted diseases and this opens discouraging perspectives for the transmission of HIV.

• Special challenges in the area of reproductive health, with high and increasing rates of abortion.

• Problems in the area of child and baby health care, including insufficient childhood vaccination and insufficient support for breastfeeding

• Worrying trends in lifestyle related health problems, including smoking, alcoholism and nutrition related diseases.

Another concern is the possible effects on health of environment contamination.

Health problems in the region are closely connected with social inequality. Limited resources for health care adds to the severity of the situation. Primary health care services are weak.

In a more open Europe, infectious diseases know no borders and threaten the public health situation of the whole continent. There is among all concerned countries a strong need to exchange experience and expertise in order to strengthen prevention and improve disease control.

2 Present international co-operation in the Barents Euro-Arctic region.

Projects of some magnitude .

1. Co-operation on a WHO-level

Activities have been mainly on the Arkhangelsk oblast in co-operation with the Medical University and local health authorities.

The programme on Quality of Care and Technologies has been running "The Archangel Project" since 1995 on the implementation of the St. Vincent Diabetes Programme (a regional model) which has facilitated improving the quality of diabetes care and reducing the cost and complications of treatment.

The EURO programme for Nutrition Policy, Infant Feeding and Food Security has been organising regular international summer schools in Arkhangelsk for a number of years. There have also been some contacts through other EURO programmes in the areas of health care reform, maternal and child health, and pharmaceuticals.

In Murmansk and Arkhangelsk, following several generous contributions from the Barents Initiative, many training sessions have been carried out in maternity hospitals and now one of the Murmansk maternity hospitals has achieved the recognition of being the second hospital in Russia to be awarded the status of Baby-Friendly Hospital by WHO and UNICEF.

2. Co-operation in a EU-setting

The European Union has started in the Barents area a TACIS project "Support to the implementation of Social and Health Care Reforms in the Republic of Karelia". The project has a Duration of 24 months (1997-1999) and a budget volume of 2,6 million ECU. The focus of the project is to support the authorities in the following priority areas:

• Development of primary health care;
• Development of the reforms to social security;
• Strengthening human resources through training, and providing advice to social and health professionals and civil servants within the administration;
• Development of the managerial and planning capacity of health and social services;
• Co-ordination of various international health and social projects to improve their overall effectiveness.

Three other TACIS projects in Russia will develop activities that may be relevant for the North of Russia:

• "Preventive Health Care Systems" with a duration of 36 months (1997-2000) and a budget volume of 4 million ECU. The activities of the project are concentrated on epidemiological issues in selected regions.

• "Support to Public Health Care Management" with a duration of 30 months (to be contracted in 1998) and a budget volume of 3 million ECU. The main components are: Strategies for the implementation of health sector management and funding reform; Institution building; Education and training (including demonstration projects in pilot regions).

• "Support of Health Care Financing" with a duration of 24 months (tendering procedure started in 1998, hence not to end before 2000) and a budget volume of 2,5 million ECU. The objective is to develop a system of financing, accounting and audit mechanisms which will allow an efficient monitoring of the real costs of health care services, in particular in the regions, and will contribute to the preparation of policy decisions.

3. Co-operation between Russia and the Nordic countries

The project "Infectious disease control in the Barents and Baltic Sea regions" aims to strengthen infectious disease control in the areas adjacent to the Nordic countries through increased collaboration and exchange of knowledge and expertise in infectious disease epidemiology and control. The project is funded by the Nordic Council of Ministers.

4. Co-operation between Russia and Norway

Infectious diseases

• In collaboration with the authorities in Arkhangelsk, the Norwegian Heart and Lung Association has started a tuberculosis project based on the guidelines of the International Union Against Tuberculosis and Lung Diseases (IUATLD) and WHO.

• The University and the Regional Hospital of Tromsø have several co-operation projects within infectious disease control together with colleagues from Northwest Russia, both bilaterally between experts at universities and between hospital personnel.

• The Russian Red Cross and the Norwegian Red Cross co-operate in order to re-establish medical preparedness in the hospitals of Murmansk to prevent outbreaks of infectious diseases like dysentery.

Mother and baby care

Projects to support breastfeeding and to improve the conditions in the birth clinics in accordance with the Baby Friendly Hospital Initiative. Strengthening competence on nutrition of women and children is also part of the aim of the projects.

Indigenous people

Regional and national institutions co-operate on projects, which are directed towards improving the social services, health care and living conditions of the indigenous population in the Barents Euro-Arctic Region, based on information from a recent report on health conditions of the indigenous population in Lovozero.

Competence building

There are a number of projects, in which hospitals and institutions in the Russian and Norwegian part of the Barents Euro-Arctic Region co-operate on the exchange of information and knowledge within fields like cardiology, baby care, reproductive health and general nursing.

In February 1998 the health administrations in the Murmansk Region and the Finmark County entered a collaboration protocol for 1998-1999 which includes bilateral acute medical assistance in the border areas, dental health projects in Apatity, Lovozero and Murmansk, public health measures for the indigenous population at the Kola peninsula, measures for maintaining and improving the health status for women and children and prophylactic measures in order to reduce infectious diseases. Dental projects and continuation of conferences on ultrasound and new medical techniques have priority.

Telemedicine

There is a rather large-scale project on the establishment of a network for exchange of data on patients with heart diseases between nine different hospitals in Norway and Russia. This project will include the Sami settlements of Karasjok in Norway and Lovozero in Russia. There is also a well established co-operation between the Tromsø hospital and the hospitals in Arkhangelsk on telemedicine. The EU Intereg.

Programme supports the co-operation financially.

Bilateral Agreement on Co-operation between Russia and Norway

From 1994 the Russian and Norwegian Ministries responsible for health have an agreement on co-operation in the field of medicine and public health. A co-operation programme is now under preparation, covering the following areas:

• Organisation of medical aid;
• Environmental and health questions;
• Health in emergency situations;
• Mother and child health;
• Medicines and medical equipment;
• Infectious diseases (the programme will include an annex on infectious disease control co-operation).

The co-operation aims at exchange of experience and knowledge and increased direct co-operation at national, regional and local level .

5. Co-operation between Russia and Sweden

There is a wide range of Swedish financed projects going on in the Barents region. Many of the projects are financed by the Swedish international development co-operation agency Sida, but most of the regional authorities, county councils and county administrations, have financed projects of their own as well.

A main actor, apart from the regional authorities, is the East Europe Committee of the Swedish Health Care Community (Hälso- och sjukvårdens Östeuropakommité, ÖEK).

ÖEK organised with Sida and the County Council of Västerbotten in April 1988 a conference at Umeå in northern Sweden on the co-operation between Swedish and Nordic organisations which support health and social activities in the Russian Barents region. The aim of the conference was to discuss how to adapt activities to the reforms going on in Russia through better co-ordination and exchange of information. It appeared that there is a strong need for better exchange of information and experience between the involved Russian and foreign authorities and organisations. As a consequence, a thorough overview of all projects in the region is being worked out.

Within the Swedish priority areas the following projects could be mentioned:

Maternal and child care

• There is an exchange of experiences between family physicians and primary health care nurses in the regions of Arkhangelsk and Västerbotten.

• The co-operation with Apatity on the Kola Peninsula includes training of the staff for homes for children, and support to childcare.

Infectious diseases

• There are plans for giving young Russian physicians courses in epidemiology in Sweden.

• Information on sexually transmitted diseases is given to Russians and Swedes with a high-risk behaviour.

Psychiatric care

• There is an on-going exchange of researchers and competence between the psychiatric clinics of Arkhangelsk and Umeå.

• Another project between Arkhangelsk and Gällivare is especially directed towards psychiatric care of children and youth.

Care of people with disabilities

It includes in particular support to mentally disabled in Apatity.

Dental care

• A dental clinic will be established in co-operation with the Health ministry of the Karelian Republic.

• There is also a project for improvement of dental care among the children and youth in Kandalaksa on the Kola Peninsula.

In addition there are several projects aiming at alcohol and drug prevention, care of the elderly, abortion prevention and information on contraceptives and sexuality, competence building within primary health care physicians, nurses and social workers, telemedicine and supply of medical equipment.

f)Co-operation between Russia and Finland

Prevention of tuberculosis

The project on prevention of tuberculosis and intensification of its treatment in the Murmansk region 1997-2001 is run by the Finnish Lung Health Association. The purpose of the project is to stop the increase of tuberculosis and the disability and mortality caused by it and to obtain a reduction. The goal of the project is to serve as a model in developing outpatient services and in particular in the treatment of tuberculosis in the region.

Support to the social and health care reforms in the Republic of Karelia

Hedec, the International Development Collaboration Centre at Stakes (National Research and Development Centre for Welfare and Health) has since 1997 carried out an EU/TACIS project that aims at fundamental changes in social protection and health care services in Karelia. The project assists the local authorities in defining the priorities and policies and also in reforming and restructuring the institution.

Hedec is also carrying out a bilateral project in Karelia since 1995, supporting the reform in the field of health care and social welfare. The main areas of this project are the development of mother and child health care service and the development of services for the handicapped.

Occupational safety and health

Co-operation in occupational safety and health issues is carried out by the Finnish Institute of Occupational Health and its Oulu Regional Institute. The co-operation with institution in the Murmansk Region includes research projects, a model workplace project, development of a contact network and publishing the Barents Newsletter on Occupational Health and Safety.

Prevention of alcohol and drug abuse

A collaboration between Finnish authorities and organisations in the field of substance abuse in Murmansk, Karelia and St. Petersburg area has started. Several joint seminars have already been organised. The plan for the future co-operation includes e.g. development of methods of treatment, preventive programmes and statistical data collection.

Rehabilitation of severely disabled children

This project is carried out by the Kolpene Service Centre in Rovaniemi. The goal of the project is to develop multisectoral rehabilitation of severely disabled children. The project is also developing a rehabilitation centre, a multi-function centre and social workshops for the disabled.

EU-Interreg Projects

Finnish organisations are implementing following projects with the support of the EU-Interreg Programme:

- Project of the Kainuu Hospital District in Segeza 1994-2004. The main fields of the project are: development of mother and child health care, prevention of cardiovascular diseases and development of the welfare for the disabled.

- Project of the National Public Health Institute in Karelia 1998-2001. The aim of the project is to develop prevention of chronic diseases through prevention programmes and collecting information on health behaviour, risk factors and mortality. The main forms of co-operation are training of personnel and joint research projects.

Co-operation of institutions and organisations

Provincial boards, municipalities, different institutions and organisations in the field of health care and social welfare carry out co-operation projects by exchanging information, specialists and delegations, and organising joint seminars and training courses.

3 A health programme for the period 1999-2002

a) Areas and Aims

The communiqué of the 5th Barents Euro-Arctic Council in Luleå 19-20 January 1998 stated "Taking into consideration the health situation in Northwest Russia several national Governments as well the Regional Council have decided to give priority to health issues. Special attention should be paid to joint actions that will lead to rapid improvements in the health situation".

In accordance with the communiqué it is proposed to launch a major health programme for the period 1999-2002. The aim would be to support projects contributing to both short-term and long-term improvements in some main fields of great common interest and which would benefit from the Barents Euro-Arctic co-operation:

1. Combating new and re-emerging infectious diseases,

2. Supporting reproductive health care and child health care

3. Counteracting life style related health problems

4. Improving services for indigenous people

5. Quality improvement of medical services

Within all prioritised areas, special attention should be given to projects focusing on children .

The health programme must support existing and future bilateral and multilateral health projects under the umbrella of the Barents Euro-Arctic Council.

The general basis for the co-operation would be:

• Broad and regular exchange of information of activities in the concerned areas of the Barents Euro-Arctic Region in order to facilitate the identification of possible overlapping projects and of areas insufficiently covered. Better information should also stimulate dialogue and co-operation between the different bilateral and multilateral actors.

• Competence building through extensive mutual exchange of information, specialists and delegations, participation of experts in seminars, congresses and scientific conferences organised in the respective countries.

• Co-operation between international, national, regional and local authorities for the planning and implementing of joint projects.

• Support the work of non-governmental organisations which, with flexibility and rapidity, can reach significant parts of the population through their health and social projects.

Especially for infectious disease control:

• Regular meetings with the infectious disease control authorities of the relevant countries and with the participation of the relevant regions.

• Regular exchange of updated statistics concerning cases of infectious disease in the relevant countries, both nationally and at regional level.

• Development of alert systems for infectious diseases.

Especially for the field of reproductive health care, child health care and lifestyle related health problems:

• Strengthen primary health care as a basis for services that reach out to the local community.

• Health promotion directed towards target groups.

• Support prevention of unwanted pregnancies and sexually transmitted diseases.

• Support the children vaccination programmes against infectious diseases like tuberculosis, poliomyelitis, diphtheria, pertussis/whooping cough, measles and tetanus.

• Support care and habilitation of mentally retarded and disabled children.

• Increase the knowledge and support prevention of premature death, e.g accidents, suicide.

Especially for indigenous people:

• Increase the knowledge and the understanding of the specific health problems among the indigenous people in the region.

• Strengthen primary health services that address this group's special needs.

• Encourage health projects that involve the indigenous people themselves in improving their health situation.

Especially for quality improvement of medical services, by means of evidence based practice:

• Health systems development with focus on primary health care and by means of training personnel, improving financing and management, and quality assurance.

• More collaboration between the health institutions in the region.

• Develop further the co-operation in the field of telemedicine.

b) Administration

The Barents Health Programme does not create new multilateral structures. The Programme will be based on bilateral projects and projects carried out by international organisations. The projects must, however, fall within the programme's five main areas. The co-ordination of the different projects will be secured through exchange of information and adaptation in order to avoid overlapping in some areas and insufficient action in other areas.

The following set-up for exchange of information is foreseen:

• The Barents Secretariat in Kirkenes, which has developed the Barents Information Service, co-ordinates all information concerning health projects within the Barents Health

Programme 1The Barents Secretariat has developed the Barents Information Service, a data-based structure, connected to the Internet (http://www.barents.no) since October 1998. It gives a full overview in English and Norwegian of on-going and finalised bilateral Russian-Norwegian projects in the Barents region. Information on bilateral Russian-Finnish and Russian-Swedish projects will soon be available. .

• A reference group - with one representative from each republic, oblast, okrug or county of the Barents Regional Council, one representative from the indigenous people and one representative from each participating country or international organisation - meets once a year (or more if necessary) to discuss the activities of the Programme. The reference group reports to the governments of participating countries and international organisations.

Major issues on the implementation of the programme would be discussed at the meetings of the Committee of Senior Officials of the Barents Euro-Arctic Council.

c)Financing

The gravity of the health and social problems in the region advocates measures on a large scale under the umbrella of the Barents Euro-Arctic Council. For the implementing of such major initiatives, the support from member countries of the Council and from international organisations is needed.

WHO underlines its commitment to make available to the Barents Health Initiative, following consultation with the Russian authorities, part of its Medium Term Plan allocation for the Russian Federation for the years 2000 and 2001.

The Nordic Council of Ministers is in 1999 spending an estimated 2 mill. Danish kroner for projects in the Barents area covering fields such as infectious diseases, health statistics and living conditions for children and youth. The Nordic Council of Ministers plans to continue its activity in this field during the next few years.

Subject to Parliamentary approval, the Norwegian Government intends to grant an annual contribution of NOK 10- 15 millions to the health programme during the period 1999-2002.

Sweden will make a substantial increase in the financial support (possibly 5 million SEK yearly) for health related projects in the Barents region in accordance with the above mentioned guiding principles.

The Finnish Government is allocating yearly approximately 3-4 million FIM to the co-operation projects in the field of health care, social welfare and labour protection in North-West Russia.