Dear Reader…Welcome back after the summer holidays! This autumn brings important

changes in the NDPHS Secretariat. The Secretariat’s Director Mr Marek Maciejowski is leaving the post after 11 years in service. In his farewell article he shares his ob-servations about those past years and reflects on the Partnership’s future. In this issue you can also read about the seminar on cross-border health data transfer in the Baltic Sea Region organised during the 8th Annual Forum of the EU Strategy for the Baltic Sea Region. In addition, you will find an invitation to the training on project development and implementation, to be co-organized by the NDPHS Secretariat in November 2017. Finally, you will find several articles on prison health that is the thematic focus of this issue. While this very specific part of the health-care system run by the state has witnessed many positive developments during past years, it still faces challenges that our societies need to address and resolve as part of our bid for a better healthcare for all of us. Enjoy reading!

NDPHS Secretariat

It is time for me to bid farewell and at the same time ex-press my thanks to all of you – those who I had a privilege to work with, and those readers whom I have never met with but who, in one way or another, contributed to the many success-es of the NDPHS, including those of the NDPHS Secretariat.

More than 11 years have past since I have joined the Part-nership as head of the NDPHS Secretariat, and almost 18 years from the moment when I had joined my previous organisa-tion, i.e. the Baltic 21 Secretariat (in the meantime integrated into the Council of the Baltic Sea States Secretariat and more recently renamed to Baltic 2030). Working with our region’s national governments, the European Commission, an array of intergovernmental or-ganisations and a large variety of other stake-holders engaged in the international coopera-tion has been both an honour and a great ex-perience for me. I was also lucky to meet and interact with many in-teresting people who made their mark on our uniquely diverse and dynamic region.

Looking back at my time with the NDPHS,

it gives me great satisfaction to see how much this organi-sation has grown during those past years. Together, we de-signed and took a wide array of concrete and pragmatic ac-tivities which included, but were not limited to, policy shaping and advocacy (the latter also outside the public health sector), monitoring of regional trends, expertise exchange, dialogue with and support to various stakeholders, project develop-ment and implementation, and last but not least information gathering, production and dissemination. One of our achieve-ments that I am especially fond of is having public health prominently anchored in the EU Strategy for the Baltic Sea Region (none of the other three EU macro-regional strategies

cover health so explic-itly and comprehen-sively) and successfully coordinating the Poli-cy Area “Health” within the EUSBSR.

The many achieve-ments, which our Part-nership contributed to the cooperation on public health and so-cial well-being in our region and beyond it, could not have been possible without hard work and commit-ment of those from

A partnership committed to achieving tangible results

e-Newsletter Issue 1/2017

N o r t h e r n D i m e n s i o n P a r t n e r s h i p i n P u b l i c H e a l t h a n d S o c i a l W e l l - b e i n g

Northern DimensionPartnership in Public Health

and Social Well-being

Farewell words from the outgoing NDPHS Secretariat Director

ContentsFarewell words from the outgoing NDPHS Secretariat Director 1Cross-border data transfer of eHealth 2 data in the BSRCall for Applications: “Capacity building for EUSBSR stakeholders” 3Interview with Lars Møller, WHO Health in Prison Project Manager 3Using periods in state detention centres to improve health status. Reasons for intensification of measures 4Treatment of addicted prisoners in Latvia – a new resocialization method 5Hepatitis C in Prison Health – a Swedish Perspective 5Conditions of incarcerated mothers and their children need to be improved in Russia 6

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A common eHealth strategy for the Baltic Sea Region (BSR) member states is significant since the BSR holds a high poten-tial to become a role model for the rest of Europe in eHealth and electronic health data transfer. The differences between the member states in the behaviour towards eHealth and cross-border data exchange and a lack of legal clarity lead to barriers for electronic data flow.

The challenges of eHealth in the Baltic Sea Region via cross-border exchange of electronic health data could create value for the BSR by opening new possibilities for patients, health-care service providers, businesses, governments and the wider public through research and development. The connected aspects were discussed during a seminar “Cross-border data transfer of eHealth data in the BSR” which was organised by the lead partner Life Science Nord Management GmbH of the Interreg flagship project Baltic Fracture Competence Centre (BFCC) on 14 June 2017 in Berlin, Germany, as part of the 8th Strategy Forum of the EU Strategy for the Baltic Sea Region.

Invited speakers talked about the importance of open data and that “the more data we have, the more innovation we’ll get” (Joakim Wernberg, Lund University, Sweden). Marek Maciejowski (NDPHS Secretariat) spoke about the Policy Area “Health” and how it helps to raise strategic issues to policy level. Wolfgang Hoffman (Institute for Community Medicine, University Medicine Greifswald, Germany) introduced the project BFCC, explained how it is facing the challenge of EU data protection conformance and that the transnational frac-ture registry BFCC contributes to the digitalisation agenda for the BSR. Finally, Gudrun Mernitz (BioCon Valley GmbH, Greif-swald, Germany) talked about the risk of Antimicrobial Re-

sistance (AMR) and how cross-border Electronic Surveillance could contribute to prevent the spread of AMR.

The seminar was moderated by Prof. Dr. Roland Trill of the Flensburg University of Applied Sciences, Germany, who started the following panel discussion with the question “What is the problem with data sharing across borders from your perspective?”

The panellists, consisting of Wolfgang Hoffman, Piret Hirv (Advisor for E-services and Innovation, Ministry of Social Af-fairs, Republic of Estonia), Jaanus Pikani (Chairman of Scanbalt fmba, Tartu Biotechnology Park, Estonia), Thomas Karopka (BioCon Valley GmbH, Greifswald, Germany) and Lars Lind-sköld (eHealth Unit, Department of Region Health, Region Västra Götaland, Sweden) discussed issues regarding stand-ardisation and strict safety regulations. Furthermore, data alone is not enough - it needs to be transformed into informa-tion! There was a common sense that patients currently are not involved enough in the process of data sharing. The front runner role of Estonia regarding data sharing was highlighted and the big potential for businesses in the field of data shar-ing. A strong business model for handling eHealth data is still lacking and needs to be developed. It has been pointed out that the point of view should be switched from “patients” to “citizens” as not only ill people provide eHealth data.

An EU-wide solution (a common EU regulation) has been considered as not realistic in the near future. The BSR as a frontrunner in the area of eHealth can yield as a test-bed for

cross-border data sharing and push the topic on EU-level. A strategy is needed to overcome the lack of visibility and also legal clarity in this context. The Estonian EU presidency will push the politician level with the Estonian eHealth declara-tion which will be published in October 2017.

For further information see the webpage of the EUSBSR: https://www.balticsea-region-strategy.eu/ and for informa-tion regarding the BFCC project: http://bfcc-project.eu/.

Anna Eckers

Project Manager BFCC

Life Science Nord Management GmbH

Cross-border data transfer of eHealth data in the BSR

both within and beyond the NDPHS. I want to thank them all for their efforts and determination in pursuing regional goals and objectives, and wish them all the best in further advancing the regional cooperation in public health and so-cial well-being.

My special thanks go to my present and past staff. It is also their hard work that has made our modest in size, but high on achievements, office so successful and visible on the regional cooperation map. As I am just about to hand over the NDPHS Secretariat’s helm to my successor, Ms. Ülla-Karin Nurm of Es-

tonia who will become the NDPHS Secretariat’s Director as of September 1st, I want to wish her and the current staff best success in future work.

Finally, I wish to express my very best wishes to all of the Readers. I hope that my path will cross again at least with some of you someday.

Marek Maciejowski

Director of the NDPHS Secretariat

1 Farewell words from the outgoing NDPHS Secretariat Director

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The NDPHS Secretariat as the Coordinator of the Policy Area “Health” within the EU Strategy for the Baltic Sea Region (EUS-BSR), along with coordinators of the EUSBSR Horizontal Action “Capacity”, invites regional stakeholders to apply for training on project design, development and implementation. The training will be organized on 8-9 November 2017 in Riga, Latvia.

The training aims at stakeholders active in the Policy Area “Health” and will be held over two days. During the first day (ran by coordinators of the Horizontal Action “Capacity”), the focus will be on the EUSBSR in general, and the Policy Area “Health” in particular. On the second day, the NDPHS Secre-tariat will hold training on project development and imple-mentation for stakeholders active in the Policy Area “Health”. Its focus will be on proper planning of project elements by employing various project management tools.

During the training participants will have a possibility to split into separate teams to discuss the concrete ideas and ac-tions as well as to exercise tools introduced during the training.

The training will be held as part of a project “Support to coordination and implementation of activities within the EUSBSR Policy Area “Health” currently being implemented by

the NDPHS Secretariat thanks to a grant provided by the Euro-pean Union through its Interreg BSR Programme 2014-2020.

The call for applications is open until 20 September 2017.

For more information about the training:

http://www.ndphs.org/?mtgs,capacity_building_for_eusbsr_stakeholders

Online application form is available at:

https://goo.gl/forms/xtS276MxDIZG6GEY2

Project concept template is available at:

http://www.ndphs.org/?download,10511,Training__Project_concept_template.docx

NDPHS Secretariat

At the end of his professional career as WHO Programme Manager for Alcohol & Illicit Drugs and Prison Health, the NDPHS Expert Group on Prison Health had the privilege to interview Dr. Lars Møller.

Lars, how many meetings con-cerning prison health have you had during your time at the post?

LM: The WHO programme on prison health started in 1995 and since then we have managed to organize one yearly meeting with our Member States on different topics related to health in prisons. I took over the task in 2002 and my first meeting was in Edinburgh, October 2002, and since then we

have organized yearly Member States’ meetings. In 2006, we also established a Steering Group for prison and health where we or-ganize one yearly meeting with different experts representing national or international organizations as well as a number of important NGOs in the field of prison health. Furthermore, we link to a number of other UN organizations like UNODC, UNOPS and UNAIDS.

What are the most important challenges in prison health in the WHO Europe region or more specifically in the NDPHS area?

LM: I think the challenges in the prison setting related to health are very similar – and there are three big problems in all countries. These are drug use disorders, mental health disorder and then communicable diseases where HIV, hepatitis C and B and tuberculosis are difficult to manage. Many countries deal with problems related to overcrowding, limited resources, and a huge staff turnover. The exclusion of prison health care from the civilian system is also a huge challenge and very often there are

very limited resources to deal with prison health. Which are the most important actions needed to be taken in the

field of prison health?LM: For WHO side we have been focused to get the Ministry

of Health involved in prison health and ensure that prison health has a similar standard as the health care service in the society. Therefore, we have been promoting that prison health should be under the responsibility of the Ministry of Health. We would then expect that guidelines, treatment systems and good monitor-ing would be the same inside and outside prisons. Furthermore, follow-up on incarceration and on release would be easy to han-dle. This is happening in Europe but still only a limited number of countries have made the transition. Some of these are Norway, France, UK, Finland and Italy.

What do you expect as a result from the WHO Prison health questionnaire?

LM: It is our hope that a prison database will allow us to com-pare Member States on a number of indicators related to prison health. This can then be used to point out problems and solu-tions for improving the system in different countries. The data-base will be followed by good examples from Member States on prison health. We know from other programmes in WHO that it is very difficult to assist in health care unless we have good data. This will also allow us over time to monitor progress in the health indicators.

Do you think elimination of Hepatitis C viruses can be achieved in prison within the next few years?

LM: We know that good and early treatment for both hepa-titis C and HIV will reduce the risk of spreading the disease but there is a huge challenge to introduce treatment to all infected due to high costs and also due to the fact that many prisoners serve shorter sentence. Many Member States in our region will not be able to cover the costs to this treatment at the moment.

Interview with Lars Møller, WHO Health in Prison Project Manager

Call for Applications: “Capacity building for EUSBSR stakeholders”

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Deprivation of liberty by state (e.g. prison, detention awaiting trial, compulsory placement in psychiatric clinics) generally occurs against the will of the person concerned. Those who are detained in this way usually suffer from complex problems includ-ing a high level of need for medical care. Infectious diseases, drug con-sumption and psychiatric disorders are known to occur frequently. It is less well known that there are major

shortcomings in the areas of dental health and health education including dietary behaviour and the resultant increase in biologi-cal ageing in the sense of premature ageing.

If human rights are to be taken fully into account, the funda-mental principle is that people deprived of liberty by the state should receive health care that is equivalent to that provided to the general population. Framework conditions now need to be created for this, which will allow this defined objective to be reached. This has also been recognised by the group of the NDPHS member states, who reactivated the Prison Health Expert Group in 2015. Firstly, the problems of access to medical care aris-ing because of the deprivation of liberty must be made good. No difference may be allowed to result from the fact that the doors first need to be opened before someone can access a doctor. It must also be possible to make an appointment as confidentially as it would be outside prison. There is no need for those who are in charge of the keys to find out information, such as diagnoses or therapies, which would normally be classed as confidential. In-stead, efforts should be made to provide medical care that is both independent of the institution and professionally independent. The provision of health care should be supervised from outside the detention system.

The precondition for the equivalence of health care is an ap-propriate provision of resources. This concerns both the quality of care and, especially here, the qualification of the specialist staff, and also access to external specialists. In material terms, it can be assumed that, in comparison with the general population, higher expenditure per inmate per year will be necessary. This is essen-tially due, on the one hand, to the fact that that prison inmates suffer in far higher numbers from many illnesses than the “average population” and, on the other hand, to the complexity of the ac-cessibility situation. If the number of infectious diseases is higher, the medication costs are likely to increase. In addition, it has been found that periods spent in state detection have, in themselves, a negative effect on health. It is important to take action to counter this. Psychological disorders in particular often deteriorate in situ-ations where liberty is restricted.

The influence of the framework conditions for appropriate health care should not be underestimated.

Expenditure on health care rises in proportion to the number of people housed;

Only a person who has received appropriate health care is in a position to take part properly in resocialisation measures;

Appropriate treatment of infec-tious diseases makes sense economically and prevents new infections both inside and outside/after prison;

Treatment of psychological disorders including addictions re-duces the risk of further criminal activity;

Continuous health care can reduce care shortcomings and avoid duplication of measures.

Against the background of these problems, standards for medical care have been agreed at international level. The fol-lowing are just a few: (i) UN Nelson Mandela Rules, (ii) WHO HIPP Standards, (iii) CPT Standards, (iv) European Prison Principles, (v)WHO Istanbul Protocol.

For those responsible for state detention systems, these standards thus form the basis for clear guidelines for the design of human prison systems. These should be taken into account both in the preparation of national rules and in the establishment and monitoring of the system. Compliance with these guidelines can-not be achieved at zero cost, nor should it be the place for logical cost avoidance strategies. The NDPHS Prison Health Expert Group supports the participating states in achieving these objectives.

Basically, the people who have been deprived of liberty come from society and will return to it once the relevant measure has ended. They could be your neighbour tomorrow. Alongside the humanitarian, ethical aspects, this should also be the factor driv-ing effective health care attitudes.

Marc Lehmann

Medical Advisor Prison Health,

MoJs States Berlin and Western Pomerania, Germany

Chair of the NDPHS Expert Group on Prison Health

Jana Feldmane

Ministry of Justice, Latvia

Vice Chair of the NDPHS Expert Group on Prison Health

Using periods in state detention centres to improve health status. Reasons for intensification of measures.

What could be the next steps toward smoke free prisons in the area?LM: I think all juvenile prisons immediately could be smoke

free and other prisons could be smoke free in a stepwise ap-proach. We have countries where the prison system is smoke free and it seems to work well. I have visited prisons in Sri Lanka and there were almost no problems with that policy.

Is there any other important message you would like to send to our readers?

LM: Prisoners are a hard to reach group of people outside

prisons and we should try to use the time in prisons to educate, to treat medical conditions and to give prisoners knowledge on healthy behaviour so they on release have a better chance of get-ting accepted in the society and to remain outside prisons.

We would like to thank you for all your intense work in the field of health, for the interview today and we wish you all the best for the future.

NDPHS Expert Group on Prison Health

3 Interview with Lars Møller, WHO Health in Prison Project Manager

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In October 2016, a newly built Center for Addicted Prison-ers was opened in Olaine prison. This centre can accommo-date up to 200 prisoners with alcohol or drug addiction prob-lems. Prisoners are accommodated in double cells. The centre is located inside Olaine prison, due to the fact that the Prison Hospital is located in this prison as well. This allows providing necessary health care to addicted prisoners.

In the centre two resocialisation programs are provided for adult prisoners for a period of up to 12 months. The pro-grams aim to reduce addiction; these are not medical treat-ment programs. Prisoners can apply for a voluntary transfer to the centre at any stage of their sentence. The prisoner is scrupulously evaluated before the decision on his transfer to the centre is taken.

Most daily activities in the centre are performed with pris-oners together with special contact staff. This is not a tradi-tional practice in the Latvian prison system. The specialized staff of the centre is trained in a new manner compared to general prison staff. Through these programmes, new ap-proaches, possibilities and ways of treatments of addictions are introduced to the Latvian prison system.

Both programs are designed to reduce addiction of adult prisoners. One of the programs is based on a Norwegian ex-perience with the treatment of addiction in Oslo prison, the other one is based on experiences made in the Polish prison system. The programs are based on the assumption that the

specific treatment of prisoners with addiction gives more op-portunities for the prisoners to begin life without crimes and helps to achieve better results in following resocialization re-sults during the sentence. This will also help reduce the level of repeated crimes in society in general and have a positive economic impact, if treated persons do not return into the prison system. Building of the new centre, programs address-ing addicted prisoners and staff training was introduced with the financial support of Norwegian financial mechanism.

Kristine Kipena

Head of Sentence Execution Policy Unit

Sectoral policy department

Ministry of Justice, Latvia

Sweden has a prison population of about 4,000 inmates. From self reports from the inmates we know that at least 70% have substance use disorders (SUD) and 50% use il-legal drugs. Among those using ille-gal drugs 60-70% have injected the drugs at least once. The proportion of persons who inject drugs (PWID) is quite high in prison settings. All persons taken to a remand prison

are offered testing for HIV and hepatitis and due to those tests we estimate that one third of the inmates are carrying hepatitis C virus.

New more effective and less harmful pharmaceuticals for treatment of hepatitis C are available now. When WHO has a goal that hepatitis C should be eliminated by 2030, the Swedish Prison service has been an interesting arena for reaching and treating PWIDs carrying hepatitis C. The following projects have started or are to start in the different regions of the prison service.

In cooperation with the Regional unit for communicable disease control in the two most northern counties, the Swedish Prison service in the Region “North” has started a project where physicians and nurses from the Unit for communicable disease control visit different prisons and measure the degree of liver cir-rhosis with fibroscan. Fibroscan or elastography, is a non-invasive method to measure the stiffness or fibrosis of the liver. According to the Swedish national guidelines for treating hepatitis C only

patients with liver cirrhosis in degree 2 or higher could be pre-scribed medication for hepatitis C. The physicians who are spe-cialists in infectious diseases also educate the inmates and the prison staff about hepatitis C, the treatment and the side effects of the treatment. These educations are very appreciated.

In the Region “Stockholm” it is the Karolinska Institute which initiates treatment and investigations for hepatitis, and the spe-cial profile on that project is that the fibroscan investigation is performed by nurses from the clinic of infectious diseases at the prison but the visits to specialists in infectious diseases are made through a video link.

In the Region “South” the nurses working inside the prisons are to be educated in the fibroscanning methods to be able to make the investigations themselves before referring to special-ists. Then the specialists have to take care of only those patients who fulfill the criteria for receiving a treatment.

Of course, the outcome of treatment, reinfection and the pos-itive advantages of the treatment setting should be measured, but we also plan to follow relapse rate in crime 2 and 5 years after prison release. We think that if the Prison service and the gen-eral health society communicate to the inmates that their health is important, this could be a possibility to get themselves more prone to receiving tools and taking care for their own health.

Lars Håkan NilssonSenior Medical Advisor

Swedish Prison and Probation service

Treatment of addicted prisoners in Latvia – a new resocialization method

Hepatitis C in Prison Health – a Swedish perspective

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Conditions of incarcerated mothers and their children need to be improved in RussiaNowadays Russia

holds a second place in the world regarding the number of female prisoners. 700 chil-dren, who were born to female prisoners, live in 13 orphanages that are part of the prison settlements for women. Since 2005, the number of pregnant women in the Russian peniten-tiary system has been growing from year to year. The Federal Penitentiary Service is entrusted with the function of the main-tenance, upbringing and medical care of young children who live with mothers in a penitentiary.

The medical and social support for maternity and childhood in the penal system is aimed at improving the standards of liv-ing of pregnant or lactating women and their children in pris-ons. However, current conditions of their life are characterized by a set of penitentiary factors such as penitentiary stress, social deprivation, exacerbation of existing and acquisition of new diseases, changes in spatial and temporal parameters of vital activity. All of these factors affect the quality of prisoners’ life.

Therefore, an important goal is to reform the medical ex-amination system for children and their mothers in prisons in order to disclose and prevent the diseases, especially the so-cially significant ones.

One of the priorities is to develop the professional engage-ment and interaction between the medical service of the pe-nal system and municipal and state healthcare facilities. Also the involvement of social workers and teachers for children and their mothers is needed in the penitentiary system.

As it is known, con-victed women are of-ten representatives of the marginal strata of the society (drug ad-dicted, homeless peo-ple, alcohol addicted, etc.). They need not only treatment and prevention, but also a commitment to a healthy lifestyle. It is necessary to create the most favourable conditions for the co-habitation of convict-ed mothers and their children.

Currently, in Russia the system of the pro-

viding medical and social assistance to prisoner mothers and their children is being developed in the penitentiary system. It is planned that this system will be put in place throughout Russia. To date, there have been made suggestions in chang-ing the legislation regulating the life of women and children towards humanization of detention conditions.

DM Prof. Sergey Ponomarev

Chief of the branch of

National Research Institute of the Penal System

Russian Federation

DM Prof. Yulia Mikhailova

Coordinator of collaboration between

Russian Federation and NDPHS,

Chair of the NDPHS Expert Group on Primary Health Care

NDPHS Secretariat

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E-mail: secretariat@ndphs.org

Website: www.ndphs.org

Visiting addres:

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The NDPHS e-Newsletter is published by the Northern Dimension Partnership in Public Health and Social Well- being (NDPHS) Secretariat in Stockholm, Sweden.

It is published bi-annually and is available in electronic format through direct mailing to subscribers, and on the NDPHS website, where you can also subscribe to it (www.ndphs.org).

The newsletter may be freely reproduced and reprinted, provided that the source is cited.

While the contributions received for this issue are highly appreciated, it should be noted that the views and opin- ions expressed by the contributors do not necessarily reflect those of the publisher.

We plan to publish the next issue in late 2017.

Contributions are encouraged and welcome. If you are interested, please contact us at the NDPHS Secretariat.