Public Institution Nicolae Testemit anu State University of Medicine and [601562]

Ministry of Health of the Republic of Moldova
Public Institution “Nicolae Testemit anu” State University of Medicine and
Pharmacy of the Republic of Moldova
FACULTY OF MEDICINE N2
Department of Hygiene
DIPLOMA THESIS
Student: [anonimizat], group 1640
Scientific advisor: Cebanu Serghei,
PhD, associate professor
Chisinau, 2015COMPARATIV EVALUATION OF HEALTH PROMOTION
SYSTEM IN THE REPUBLIC OF MOLDOVA AND ISRAEL

2CONTENT
Introduction………………………………………………………………………..…3
Chapter 1
HEALTH PROMOTION AND HEALTH EDUCATION – THE MAIN
CHARACTERISTICS AND ACTUALITY…………………………………………5
1.1. Principles of health promotion…………………………………………………..5
1.2. Health promotion partnerships in Israel: motives, enhancing and inhibiting
factors, and modes of structure………………………………………………………10
1.3. Methods of promoting health…………………………………………………..17
Chapter 2
MATERIAL AND METHODS………………………………………………………28
Chapter 3
HEALTH STATUS OF THE POPULATION AND HEALTH PROMOTION
ACTIVITIES IN ISRAEL……………………………………………………………29
3.1 Characterisation of health infrastructure in Israel……………………………….29
3.2 Health outcoms in Israel…………………………………………………………31
3.3 The Healthy Israel 2020 initiative…………………………………….…………38
3.4 Health Promotion in Israel……………………………………………………….46
Chapter 4
HEALTH STATUS OF THE POPULATION AND HEALTH PROMOTION
ACTIVITIES IN THE REPUBLIC OF MOLDOVA……………………………….50
Conclusions………………………………………………………………………….63
Recommendations……………………………………………………………………64
References…………………………………………………………………….……..65

3INTRODUCTION
Health promotion is the process of enabling people to increase control over their
health and its determinants and thereby improve it. It is important element of public
health and addresses both communicable and NCDs. Health promotion includes a
range of activities such as the promotion of changes in lifestyle, practices and
environmental conditions to facilitate the development of a “culture of health” among
individuals and the community; educational and social communication activities
aimed at promoting healthy conditions, lifestyles, behaviour and environments;
reorientation of health services to develop care models that encourage health
promotion; intersectoral partnerships for more effective health promotion activities; ●
assessment of the impact of public policies on health; isk communication (Marks,
Hunter & Alderslade, 2011).
The World Health Organization defines health promotion as the “process of enabling
people to increase control over, and to improve, their health. It moves beyond a focus
on individual behavior towards a wide range of social and environmental
interventions” [WHO, 2010: http://www.who.int/topics/health_promotion/en/]. A
focus on group or population interventions distinguishes health promotion programs
from medical or clinical health services, which typically focus on one patient’s health
status and health behaviors. Health promotion programs can range from education
programs, preventive screening events, health support groups, community organizing
and advocacy work, in addition to many other activities.
There is growing emphasis in Israel on the cultural appropriateness of health
promotion programs as a way to facilitate health-enhancing behavioral change. The
literature indicates that culturally-appropriate programs take into account, among
other things, language differences, knowledge, values, customs, health beliefs,
religion and religiosity, family roles, the relative emphases on the collective versus
the individual, lifestyles (e.g., eating patterns and hospitality), self-efficacy and the
sense of trust in the health system.

4A significant number of large-scale health promotion programs are implemented in
Israel. Some target the general population while others target specific sub-
populations. Cultural adaptation of these programs is especially important for the
Arab population, which constitutes 20% of Israel's population. This minority group
has both unique needs and unique social, ethnic, and cultural characteristics.
The study goals were to develop criteria for assessing the cultural appropriateness of
health promotion programs for the Arab population, to assess the cultural
appropriateness of health promotion programs and to identify ways to enhance it.
Research purpose
Evaluation of health promotion systems in the Republic of Moldova and Israel and
development of the recommendation for improving population health in both
countries.
Research objectives
Analysis of bibliographical sources concerning development of health
promotion and health education principles and theories;
Evaluation of health status of the population and health promotion activities in
Israel;
Evaluation of health status of the population and health promotion activities in
the Republic of Moldova;
Development of the recommendation for improving population health in both
countries.

5Chapter 1
HEALTH PROMOTION AND HEALTH EDUCATION – THE MAIN
CHARACTERISTICS AND ACTUALITY
1.1. Principles of health promotion
Empowerment – a way of working to enable people to gain greater control over
decisions and actions affecting their health.
Participative – where people take an active part in decision making.
Holistic – taking account of the separate influences on health and the interaction of
these dimensions.
Equitable – ensuring fairness of outcomes for service users.
Intersectoral – working in partnership with other relevant agencies/organisations.
Sustainable – ensuring that the outcomes of health promotion activities are
sustainable in the long term.
Multi Strategy – working on a number of strategy areas such as programmes, policy.
The World Health Organisation took a leading role in action for health promotion in
the 1980's with, the Ottawa Charter been published in 1986. It suggested that health
promotion happens at five key levels.
1.Developing Personal Skills
2.Creating Supportive Environments
3.Strengthening Community Action
4.Developing Public Policy
5.Re- orienting the Health Services.
Developing Personal Skills
Youth organisations, through the broad range of programmes and activites delivered
to young people, including health education and health information, positivelly
influence the development of personal skills, for example self esteem, self efficacy,
communication, negotation, life skills and motivation. The development of these
skills has a positive impact on health.
Creating Supportive Environments

6Through creating safe and secure physical and social environments, youth
organisations provide young people and staff with opportunities to discuss and
explore health issues and practice health-enhancing behaviours, thus supporting
health education and 'making the healthier choice the easier choice'; for example
providing healthy food options in the tuck shop; providing healthy snacks for after
schools clubs; providing a smoke free environment, implementing an anti-bullying
policy, providing an adolescent friendly health service.
Strengthen Community Action
Through developing partnerships and alliances with other organisations and sectors in
the community, youth organisations can build capacity and positively influence
health within the wider community, which in turn, can continue to support the health
of their target groups who live in the community, for example delivering parent
programmes, working in partnership with healthy towns initatives.
Delivering Health Public Policy
Through the development of health-related policy internally, youth organisations
demonstrate evidence-based practice indicating the importance of having policy in
place to support practice, for example sexual health policy; substance use policy.
Additionally, youth organisations have a key role to play in raising awareness and
advocating for public policy development and change in order to support their health-
related work and the health of their target groups, for example national alcohol
policy.
Reorient the Health Services
Advocating for the development and provision of health services that can respond to
the health needs of young people is a key role of youth organisations, for example
youth organisations have a role in creating awareness and advocating for the
provision of an adolescent friendly health service for young people.
The eight principles of practice are essential to any effective health promotion
intervention. They are drawn from a number of national and state policies, directions,

7strategic plans, and from consultation with DHHS staff. Applying them to our health
practice helps the effectiveness of health interventions.
The principles have their foundation in the World Health Organisation Declaration of
Alma Ata (WHO 1978), the Ottawa Charter for Health Promotion (WHO 1986), the
Jakarta Declaration on Leading Health Promotion into the 21st Century(WHO 1996),
and the Bangkok Charter for Health Promotion in a Globalised World. (WHO
1997b).
PHMC Research and Evaluation staff interviewed key experts in the field of
Health Promotion and Nutrition Education from the Health Promotion Council of
Southeastern Pennsylvania, an affiliate organization of PHMC [ Since 1981, HPC has
worked in the area of chronic disease education, prevention, and management, with
programs serving vulnerable populations in the Philadelphia area (www.hpcpa.org].
These experts provided valuable insight into best practices of health promotion
programs, as well as special considerations for congregations with an interest in
providing health promotion or nutrition programs.
Key Characteristics
Leadership: A successful health promotion program must have committed
leadership and sound organizational structure. This is especially important in a faith-
based setting, where health and wellness is not always part of the congregation’s
mission. Since some faithbased organizations concentrate solely on spiritual issues

8and not physical/material issues, to have a successful health program, one respondent
noted that congregation leaders must “intentionally include health as part of the
organization’s mission”. If faith leaders show their commitment to addressing health
and wellness issues, the congregation will follow suit and support the programs. Staff
interviewed for the project noted that they believed the only reason why some health
programs existed was because faith leaders encouraged their members to volunteer or
become involved with the program in some capacity.
Staffing: Trained staff are critical to health and nutrition education programs.
Staff do not need to have degrees in health education or nutrition, but they should
receive training from an agency about the specific health behaviors that the program
is promoting. For nutrition educators in particular, one expert said that it is most
important that staff be able to cook, since cooking demonstrations are an important
element of nutrition programs.
Volunteers: Many health promotion programs are staffed by volunteers, so it is
very
important to have a volunteer coordinator position to manage their work. The
coordinator can be a volunteer or a paid position, but someone needs to manage all
the different tasks and shifts for volunteers. Without a coordinator, volunteers may
feel isolated or overlooked without concrete things to do.
For faith-based organizations that are interested in having a health promotion
program, members of the congregation who work in the health field often volunteer
their time and skills. Drawing upon resources from within the congregation builds
more congregational support for the program. However, the program must consider
whether or not services can be sustained on volunteer time. If the program is an
annual health fair, then volunteers would be suitable. If the health program is a
weekly exercise and cooking group, they need to evaluate volunteers’ willingness to
commit to a prolonged timeline.
Program content: Health promotion and nutrition activities should be hands-on
and

9practical. Healthy cooking demonstrations and free samples of food engage
participants and allow them to experience firsthand how they might be able to
incorporate new foods into their diet.
Space: A health program must have enough space to comfortably carry out its
activities, whether they are focused on cooking demonstrations, food distribution,
exercise classes, or health screenings. Certain programs that involve food or food
preparation require external certification for sanitation reasons.
Accessibility: HPC staff mentioned the importance of bringing services to the
community, instead of having the community come to the program. Recruiting people
to go to a health promotion event is difficult, so to ensure participation, the services
should be delivered at a site where people already congregate, such as faith-based
organizations. Health and nutrition programs can also work with food pantry and
emergency food programs to deliver nutrition education when people pick up their
food packages. Healthy recipe cards and information about how to cook the food in
the package are ways to ensure that participants receive some helpful advice about
the products they receive.
Partnerships: Since the main mission of congregations is not to deliver health
promotion services for their members, partnerships with health agencies are
important for health programs success. Local hospitals usually have community
outreach departments that are able to work at health fairs, deliver preventive
screenings, and provide health education sessions. Students working towards a health
degree may also be available to work at events that faith-based organizations conduct.
In addition to partnering with health agencies, congregation-based programs
should collaborate with other local community groups to ensure that the services they
provide do not overlap. If many services are already provided in the community, a
congregation may want to consider fulfilling a different need. Being aware of all the
community resources also enables the faith organization to refer congregation
members to other groups that can provide help. Partnering is an efficient way for
faith-based groups to help their community without needing to invest too many of

10their own resources into developing their own programs and managing staff and
volunteers.
Community relationships: Successful community-based health programs establish
solid relationships with the community where it is located. Programs should assess
community needs and deliver targeted services to meet those needs. When a program
is new, marketing the program to the community is critical to establishing the
program as a viable resource in the community.
Faith-based organizations that have successful community health programs
extend their reach beyond the congregation and make the programs open to all
members of the community. Having a neutral secular name instead of a religiously
themed name is important so that all people feel welcome to attend. If a program has
a religious name, community members are more likely to assume that the program is
only for people who belong to that faith. Houses of worship should not proselytize to
program participants or require them to attend services as part of program
membership.
1.2. Health promotion partnerships in Israel: motives, enhancing and inhibiting
factors, and modes of structure
Multisectoral cooperation is an important strategy in working for health
promotion. Fifty-two health professionals completed a questionnaire measuring
factors motivating, enhancing and inhibiting partnerships. The respondents also
reported the type or structure of the partnerships. The results indicated that
partnerships were formed primarily in order to promote the project; however,
previous positive experience with partnerships was also very important as a
motivating force for joining partnerships. The three most important facilitating
factors were related to project management: effective leadership, aims of the project,
and sharing a vision and goals. The two most frequent items mentioned as very
important barriers to partnerships were related to dysfunction of the steering
committee. Two types or structures of partnerships were identified. The first was

11fragmental, where partnerships existed only at specific stages of the project; most
respondents reported working within this structure. The second type was continuous,
where partnerships existed through all the project’s stages. Using multiple regression
analysis we found that health staff (mainly nurses) worked more frequently in
fragmental partnership structures than did health promotion and welfare workers. In
addition, the more experienced the respondents, the less they worked in fragmental
partnership structures. These results highlight the importance of acquiring skills for
working in partnerships and indicate a need for guidelines to be agreed by the
partners at the beginning of the working process.
The need for new strategies to promote health arose due to the realization that
health was influenced by a combination of social, political, environmental and
medical factors. The health care system has only a small role in enhancing health in
the community and cannot be expected to cope with all the factors causing ill health.
One of the strategies suggested by the World Health Organization (WHO) was to use
multisectoral cooperation [ WHO, 1985 ]. This strategy has been developed around the
world during the last 20 years. Many terms are used to describe ‘working together’
[Naidoo and Wills, 2000 ]. Some of these terms, such as collaboration and
cooperation, refer to the process of working together, whereas others, such as
partnerships, coalitions and alliances, pertain more to the organizational structure or
unit that enables the process of collaboration. For example, Gray defined
collaboration as a process through which parties who see different aspects of a
problem can explore constructively their differences and search for solutions that go
beyond their own limited vision of what is possible [ Gray, 1989 ]. In contrast, words
such as ‘partnership’, ‘networks’, ‘coalition’ and ‘alliance’ are sometimes used
interchangeably to pertain more to the structures or organizational units that enable
individuals and organizations to combine their human and material resources so that
they can accomplish the objectives they are unable to bring about alone. For example,
Gillies defined health promotion partnerships as ‘a voluntary agreement between two
or more partners to work cooperatively towards a set of shared health outcomes’

12[Gillies, 1998 ), p. 101]. These organizational units can function on a local level, a
national level, or both. In the present study, we will use the term ‘partnership’ to
describe the structure that permits ‘working together’.
Creating a partnership and making it work is a time- and resource-consuming
challenge. The assumption is that outcomes achieved by collaboration will be greater
than those achieved by each organization working alone, so the effect of partnerships
will be synergistic. However, research in this area is sparse [ Gillies, 1998 ;Lasker et
al., 2001 ].
Some research has examined variables enhancing and inhibiting partnerships. Naidoo
and Wills suggested that a common task, selection of members for specific expertise,
knowledge of one’s role, support while performing the task, and other characteristics
are important for successful partnerships [ Naidoo and Wills, 2000 ]. Other facilitators
of these partnerships may be continuity of participation, a funded coordinator,
participants of appropriate seniority, skilled chairing, and a supportive organizational
culture [ Green, 2000 ].
Not all partnerships have been successful. Barriers to successful partnerships
are numerous, including such variables as competing professional rationales and
interpersonal relations [ Beattie, 1994 ]. Other barriers are organizational uncertainty,
limited resources and rapid turnover of participants [ Green, 2000 ]. General skills for
working together are needed, and their absence may obstruct partnerships. They
include communication skills, participation at meetings, managing time, and knowing
how to work in a team [ Naidoo and Wills, 2000 ]. A review of the above-mentioned
facilitators and inhibitors of partnerships revealed that most research focused on the
project level and primarily emphasized factors of project management (e.g. common
task, selecting the appropriate team), while neglecting other factors associated with
the organization in which the participant works and interpersonal relationships
between the participants. Factors such as the policy and goals of the home
organization as well as personal acquaintances and aims should also be considered.

13Most of the research on partnerships has typically examined their development, and
explored specific barriers and facilitators for partnerships, assuming that continuous
partnership is the preferred mode of working [ Butterfoss et al. , 1998 ;Kegler et al. ,
1998a ;Kegler et al. , 1998b ;Armbruster et al. , 1999 ;Green, 2000 ]. However,
continuous partnership may not be the only way to form successful partnerships
among organizations, communities and individuals. For example, Ancona and
Caldwell argued that partnership success depended partially on the need to create
more fluid and changing team boundaries [ Ancona and Caldwell, 1998 ]. These
authors held that partnerships could be structured along four dimensions: high or low
use of experts; full or part cycle membership; full- or part-time assignment to the
team; and the extent to which there is a mix of core and peripheral membership
[Ancona and Caldwell, 1998 ]. Variance along these dimensions shifts the
permeability and breadth of the team boundary on a range from ‘no partnerships’ to
‘full partnerships’, where the partnership forms a new organizational unit, with the
collaborating organizations in the background.
Health promotion projects frequently share a common life cycle with identified stages
such as needs assessment, and planning, implementing and evaluating the project
[Naidoo and Wills, 2000 ]. Hence, partnerships might vary in the stages they perform
collaboratively as compared with stages that are performed by only some of the
partners. These modes of structures are working patterns that are suitable for the
individual partners and their needs, as well as the project’s need to relate successfully
to the external environment [Ancona and Caldwell, 1996]. For example, certain
partnerships only work on developing mutual strategies and others may only deal
with the actual operation of the project. Different demographic factors, and type of
profession or experience with partnerships, might be related to the form of structuring
due to the partner’s background and needs. Health promotion professionals coming
from different professions such as health and social work may adopt different
approaches to health promotion. A medical approach or a social change approach

14may be adopted depending on the personal approaches of the participants [ Naidoo
and Wills, 2000 ].
Furthermore, the type of project can also affect the working patterns partners
choose to employ. In general, project type can be: (i) disease- or behaviour-oriented,
such as preventing heart diseases or smoking cessation, which are both subject-
related; (ii) setting oriented, such as the ‘health city’ collaborations or a partnership
for health promotion in school; or (iii) age oriented, such as old age and adolescence.
In this survey, we asked what were the motives and factors enhancing partnerships,
alongside barriers to partnerships, as perceived by the health promotion professional.
We also asked what types of modes of partnership structure prevail in the Israeli
health promotion arena and what personal aspects (occupation and experience), as
well as type of project (health behaviour-oriented as compared with age- or class-
oriented), contribute to their existence. The understanding of the different types of
structure should promote research into characterizing the best-suited structure to the
type of project, the participating organization and the personal aspects of the team.
An understanding of these factors may facilitate interventions to enhance working in
partnerships and to increase their effectiveness.
The study had three major components:
The development of criteria of cultural appropriateness;
An extensive mapping of existing health promotion programs and the extent of
their implementation in the Arab population; and
An in-depth analysis of leading, culturally-appropriate organizations and
programs.
Projects were examined in five areas: smoking, home accidents, physical activity,
nutrition and diabetes control.
The study examined the extent of cultural competence at two levels: the program
and the organization. The report indicates that while most health promotion programs
in Israel do target also the Arab population, there is substantial variation in their
cultural competence. At the organizational level, though almost all the organizations

15are aware of the importance of cultural appropriateness, there is a great deal of
variation in the extent of infrastructure they have created to promote it.
This is the first systematic study of the cultural responsiveness of an Israeli
human-service system to the Arab population in Israel. As such, it can serve as a
model for similar studies in additional areas of healthcare as well as in other fields
such as education and social services.
This study was supported by Michael and Andrea Dubroff of Massachusetts,
USA, the Israel National Institute for Health Policy, and an anonymous foundation.
Health promotion in Sri Lanka has been very successful during recent decades
as shown by the health indicators. Despite the numerous successes over the years, the
integrity of the health system has been subjected to many challenges. Sri Lanka is
already facing emerging challenges due to demographic, epidemiological,
technological and socio-economic transitions. The disease burden has started to shift
rapidly towards lifestyle and environmental related non-communicable diseases .
These are chronic and high cost and will cause more and perhaps unaffordable burden
to the country’s health care expenditure, under the free of charge health services
policy. The previous success of health development increased the life expectancy of
Sri Lankan people to 72 for male and 76 for women but the estimated “healthy life
expectancy” at birth of all Sri Lanka population is only 61.6
Health is affected by biological, psychological, chemical, physical, social,
cultural and economic factors in people’s normal living environments and lifestyles.
With the current rapid changing demographic, social and economic context and the
epidemiological pattern of diseases, the previous health promotion interventions
which found to be effective in the past may not be effective enough now and the
future to address all the important determinants that affect health. Promoting people’s
health must be the joint responsibility of all the social actors. These challenges
require significant changes in the national health system toward new effective health
promotion which has been accepted worldwide as the most cost effective measure to

16reduce the disease burden of the people and the burden of the nation on the increasing
cost for treatment of diseases.
The development of this National Health Promotion Policy is based on: (a) the
evidences from Sri Lanka health promotion situation analysis, (b) the international
accepted concept, the WHO guiding principle for health promotion and the World
Health Assembly resolutions and WHO South East Asia Regional Committee
Resolution, and (c) the State Policy and Strategy for Health and the Health Master
Plan 2007–2016.
The key strategies for health promotion are: advocacy and mediate between
different interests in society for the pursuit of health; empower and enable individual
and communities to take control over their own health and all determinants of health;
improve the health promotion management, health promotion interventions,
programs, plans and implementation; and partnership, networking, alliance building
and integration of health promotion activities across sectors.
In Sri Lanka, other non health government sectors and NGOs are currently active
implementing their community development projects with the community
empowerment concept that resemble the healthy setting approach for health
promotion. These projects are the high potential entry points and good opportunity
for the formal commencement of the new effective setting approach health promotion
and the holistic life course health promotion. It is also an opportunity for partnerships
and alliance building for concerted action to promote health of the nation. This policy
is formulated to promote health and well-being of the people by enabling all people
to be responsible for their own health and address the broad determinants of health
through the concerted actions of health and all other sectors to make Sri Lanka a
Health Promoting Nation where all the citizens actively participate in health
promotion activities continuously for a healthy life expectancy.
The policy objectives are as follow :
1. To strengthen leaderships for health promotion at all levels and all
sectors through advocacy.

172. To mobilize the society and create nationwide health promotion actions.
3. To develop and implement effective comprehensive holistic and
multisectoral approach health promotion interventions.
4. To establish an effective system and mechanism for health promotion
management and coordination at all levels.
5. To build capacity for health promotion at all levels and across sectors.
6. To improve financing and resources allocation and utilization for health
promotion.
7. To establish an evidence-base for health promotion effectiveness.
Various strategies have been developed for the attainment of each objective focus
on the multi-sectoral comprehensive approach and participation of all
stakeholders and the people themselves. This National Health Promotion Policy
will be monitored and evaluated at all levels. Participatory monitoring and
evaluation will be encouraged at implementation level.The National Health
Promotion Consortium and the National Health Council will be responsible for
the regular monitoring and evaluation of the implementation of this National
Health Promotion Policy. Implementation of this policy will also be monitored
regularly as part of the overall process of monitoring the activities of the
Government and Ministries and covering various sectors and levels of
government.
1.3. Methods of promoting Health
Health promotion in a school setting could be defined as any activity
undertaken to improve and/orprotect the health of all school users. * It is a broader
concept than health education and it includesprovision and activities relating to:
healthy school policies, the school’s physical and social environment,the
curriculum, community links and health services.
World-wide, education and health are inextricably linked. In simplest terms:
healthy young people are more likely to learn more effectively;

18health promotion can assist schools to meet their targets in educational
attainment and meet their social aims; young people that attend school have a
better chance of good health;
young people who feel good about their school and who are connected to
significant adults are les likely to undertake high risk behaviours and are likely to
have better learning outcomes;
schools are also worksites for the staff and are settings that can practice and
model effective worksite health promotion for the benefit of all staff and ultimately
the students.
In many countries of the world, government health ministries and education
ministries work separately with different goals. However, the evidence is growing
from across the world that health and education are inextricably linked to each
other and to other issues, including poverty and income level. This is evident in the
importance the United Nations Millennium Development Goals attach to education
and health in setting out their development targets. It is now clear that education
has the power to improve not only economic prosperity in a country, but that it has
a major effect on health outcomes. This is particularly true of girls in developing
countries, where improved education leads to smaller, healthier families and lower
infant mortality rates. It has been known for over 100 years that providing healthy
food and social support at school is one method of improving attendance and
enabling young people from disadvantaged backgrounds to benefit from the
education provided. Healthy young people who attend school tend to learn better
and good education leads to healthier people. Sometimes the difference between
cause and effect may not be clear. Moreover, there may be intermediate factors or
more complex routes, such as good education leading to better economic
development, which may result in people having more control over their lives and
thus experiencing better health. We do not totally understand all of the complex
ways health and education interact, but we certainly know enough about promoting
health in young people to improve their educational outcomes and lives in general.

19We make the case that not only does the provision of good education improve
health outcomes, but also that there is research evidence demonstrating that
actively promoting health in schools can improve both educational and health
outcomes for young people. In fact, there is evidence that health promotion in
schools can support and give added value to schools as they strive to meet a whole
host of social aims through their curricula and a whole-school approach.
WHO's Global School Health Initiative, launched in 1995, seeks to mobilise
and strengthen health promotion and education activities at the local, national,
regional and global levels. The Initiative is designed to improve the health of
students, school personnel, families and other members of the community through
schools.
The goal of WHO's Global School Health Initiative is to increase the number of
schools that can truly be called "Health-Promoting Schools". Although definitions
will vary, depending on need and circumstance, a Health-Promoting School can be
characterised as a school constantly strengthening its capacity as a healthy setting for
living, learning and working.
The general direction of WHO's Global School Health Initiative is guided by
the Ottawa Charter for Health Promotion (1986); the;Jakarta Declaration of the
Fourth International Conference on Health Promotion(1997); and the WHO's Expert
Committee Recommendation on Comprehensive School Health Education and
Promotion (1995).
Our strategies
Research to improve school health programmes: Evaluation research and expert
opinion is analyzed and consolidated to describe the nature and effectiveness of
school health programmes.
Building capacity to advocate for improved school health programmes: technical
documents are generated that consolidate research and expert opinion about the
nature, scope and effectiveness of school health programmes.Each advocacy
document makes a strong case for addressing an important health problem, identifies

20components of a comprehensive school health programme, and provides guidance in
integrating the issue into the components.
Strengthening national capacities: collaboration between health and education
agencies is fostered and countries are helped to develop strategies and programmes to
improve health through schools. Pilot projects implemented by the GSHI and partners
include Helminth Interventions with China in 1996, HIV/STI Prevention in China in
1997, and Health-Promoting Schools/Health Insurance in Vietnam in 1998.
Creating networks and alliances for the development of health-promoting
schools: regional Networks for the development of Health-Promoting Schools have
been initiated in Europe, Western Pacific and Latin America. A global alliance has
been formed to enable teachers' representative organizations, worlwide, to improve
health through schools. The alliance includes Education International, Centers for
Disease Control and Prevention, Education Development Center, UNESCO,
UNAIDS and NGTZ. WHO's Global School Health Initiative invites all
governmental and nongovernmental organisations, development banks, organisations
of the United Nations system, interregional bodies, bilateral agencies, the labour
movement and co-operatives, as well as the private sector to help all schools to
become Health-Promoting Schools.
It is important to acknowledge that the concept of health promotion is familiar
to many working in the health sector. It is also important to acknowledge that many
in the education sector have a broad concept of the term curriculum, and would
describe several or all of the above six components as being part of the extended or
whole curriculum of the school. Therefore, many in the education sector do not make
this distinction between health education and health promotion in the same way as in
the health sector. This is not necessarily a problem, but requires mutual
understanding and respect for each others’ conceptual frameworks and associated
language when working in partnership. Both the education and health sectors have a
common goal to provide opportunities for students to be more empowered about
health and related issues as they go through school. This need for partnerships and a

21collaborative approach involving the education and health sectors in school health
promotion is universal, and there are indications that it is now being addressed in
many parts of the world. This is exemplified in “Case Studies in Global School
Health Promotion” in which a wide range of quality cas studies from Africa, the
Americas, Europe, the Eastern Mediterranean, Asia and the Western Pacific are
explored. It provides many examples of good planning, implementation and
collaborative approaches to promoting health in schools.
Health promotion is any event, process or activity which facilitates the protection or
improvement of the health status of individuals, groups, communities or populations.
Its objective is to prolong life and to improve quality of life, that is to prevent or
reduce the effects of impaired physical and/or mental health on those individuals who
are directly (e.g. patients) or indirectly (e.g. carers) affected. Health promotion
includes both environmental and behavioural interventions. Environmental
interventions target the built environment (e.g. fencing around dangerous sites) and
involve legislation to safeguard the natural environment (e.g. maximum water
pollution targets) as well as the production of goods (e.g. the ban on certain beef
products). Behavioural interventions are primarily concerned with the consequences
of individuals' actions. Behavioural interventions include raising awareness and
knowledge about health hazards, teaching technical (e.g. how to floss one's teeth;
how to use a condom) and social skills (e.g. how to say no to drugs; how to negotiate
condom use), as well as cognitive behavioural techniques (e.g. how to practise
progressive muscle relaxation; how to re-focus one's thoughts). All of these measures
require the active co-operation of those who benefit from them and the use of
persuasive and effective communication.
Health Promotion Theories
Just as there are many definitions regarding health promotion, there are different
theories and models that are used to explain health promotion and incorporate it into
practice. Many of the theories involving health promotion target health behavior of
the individual. This section will discuss the common health behavior theories

22identified within the nursing textbooks reviewed. These theories include: Health
Belief Model: Transtheoretical Stage of Change Model: Social Cognitive Theory:
Theory of Reasoned Action: Theory of Planned Behavior: and Health Promotion
Model. Theories that focus on factors from within an individual are intrapersonal
theories (Cottrell, Girvan, & McKenzie, 2002). These theories focus on an
individual’s cognitive ability, attitudes, beliefs, past experiences, skills and
motivation. The intrapersonal theories examined are the Health Belief Model,
Transtheoretical Model, and Theory of Planned Behavior (Glantz & Rimer, 2002).
The Health Belief Model (HBM) is a valueexpectancy theory (Hochbaum, 1958).
This type of theory states that individuals must have a desire to avoid an illness
(value) and believe that participating in a certain behavior will prevent the illness
from happening (expectancy). This theory relies on the concepts of perceived
susceptibility, perceived severity, perceived benefits, perceived barriers, cues to
action and self-efficacy. Perceived susceptibility pertains to an individual’s belief
regarding the chance of contracting a medical disease or illness. The construct of
perceived severity relates to an individual’s feelings of the seriousness of contracting
the disease or illness, medically and socially. Perceived benefits relates to an
individual’s belief about how effective the plan is at reducing the disease threat. The
concept of perceived benefits also considers non health-related benefits, such as
financial 24 concerns and pleasing family members. In addition to perceived benefits
are perceived barriers. Perceived barriers can include cost, pain, danger of the
treatment, and time constraints. The construct, cues to action, involves triggers that
motivate the individual to take action. An intrapersonal theory also takes into
consideration a person’s characteristics, experiences, and perception of the
environment (Cottrell, Girvan, & McKenzie, 2002). An example of an intrapersonal
theory is The Social Cognitive Theory. Albert Bandura developed the Social
Cognitive Theory in the 1950s. It describes learning as the constant reciprocal
interaction of environmental events, personal factors, and behavior (Bandura, 1986).
Human activity has four special characteristics that allow an individual to symbolize

23one’s own experiences, learn from others, regulate one’s own actions, and reflect on
the situation (Hubley & Copeman, 2008). The Social Cognitive Theory uses
constructs of symbolizing capability, forethought capability, vicarious capability,
selfregulatory capability, self-regulatory, and self- efficacy to describe the learning
process (Bandura, 1986; Cottrell, Girvan, & McKenzie, 2002). Symbolizing
capability describes the process and transformation of an experience into internal
model, which will serve as a guide for future action. It is the symbol that gives
meaning to the experience. This symbolization allows individuals to cognitively solve
a problem prior to actually performing the action. Symbolization also allows for
communication to occur among individuals (Bandura, 1986). Forethought capability
explains the notion that individuals do not merely react to the environment, but
instead use past experiences to perform a behavior that is purposeful and thoughtful
(Bandura, 1986). It is forethought that motivates individuals into 25 performing
actions to achieve goals. Vicarious capability is a major concept included in The
Social Learning Theory. It explains that individuals do not learn by trial and error,
but instead learn through watching others. This observational learning allows the
individual to watch a role model perform the behavior and witness the consequences
of it. This modeling of the behavior is an essential aspect of learning, especially if a
behavior is a combination of unique elements. Modeling also speeds up the
acquisition of the new behavior by an individual (Bandura, 1986). The self-regulatory
concept explains that individuals do not perform a specific behavior to please others,
but instead that most behaviors are regulated by internal mechanisms of control.
Individuals monitor their own behavior through the use of internal standards and self-
evaluation (Bandura, 1986). Self-reflective capability is the ability for individuals to
reflect on not only the behavior, but also their own thought process. This allows
individuals to gain understanding of their actions and their thoughts (Bandura, 1986).
Self-efficacy is the judgment of one’s ability to carry out a task. Bandura believes
that self-efficacy is the most important predictor of behavior change because it gives
value to a given task (Glantz & Rimer, 2002). The more confidence an individual has

24in performing a behavior, the greater the effort to try the behavior (Pender,
Murdaugh, & Parsons, 2006, Glantz & Rimer, 2002). The last behavior theory to be
discussed is Nola Pender’s Health Promotion Model (Pender, Murdaugh, & Parsons,
2006). The Health Promotion Model is an approachoriented model. It does not
depend on fear or threat to motivate an individual to perform 26 a behavior. The
Health Promotion Model uses constructs from expectancy-values theories and Social
Cognitive Theory in addition to a holistic nursing perspective to explain the
multidimensional nature of an individual interacting with his interpersonal and
physical environments. Biological, psychological, sociocultural, and prior experience
make up the individual characteristic and experiences that affect subsequent actions.
Behavior-specific cognitions and affect are the major motivators for behavior. These
include perceived benefits of the action, perceived barriers, and perceived
selfefficacy activity-related affect. The activity-related affect construct is used to
identify the subjective feelings the individual has before, during, and after an activity.
The feelings experienced throughout the activity affect the probability of the
individual performing the activity again. The Health Promotion Model also
recognizes that interpersonal influences affect an individual’s behavior. Interpersonal
influences, which include expectations of significant others, the social support
received, and observational learning, come from family, peers, and health care
providers (Pender, Murdaugh, & Parsons, 2006). The Transtheoretical Model is a
model developed based on a comparative analysis of psychotherapy and behavioral
change theories (Prochaska & Velicer 1997). The Transtheoretical Model has the
construct of the stages of change which represent the thought process individuals
must go through in order for change to occur. The stages of change include
precontemplation, contemplation, preparation, action and maintenance. During the
precontemplation stage, the individual is unaware of a problem and has no intention
of making a change within the next six months. The individual moves into the
contemplation stage when he/she becomes aware of the problem and intend to take
action within the next six months. The preparation stage occurs when an individual

25makes some 27 behavioral steps towards a change within the next thirty days. The
action stage is when the individual has made the behavioral change and continued it
for less than six months. The final stage, maintenance, is when the behavior change
persists for longer than six months. The Theory of Reasoned Action considers the
individual and the influences of those around him/her (Fishbein & Azjen, 1975). This
theory takes into consideration the person’s own beliefs about the consequences of
their action along with their belief about how others within the same social network
would approve, or disapprove, of the action. The Theory of Reasoned Action was
developed to understand the relationship between attitudes and behavior. To allow for
consideration of factors outside of an individual’s control, The Theory of Planned
Behavior was added to the Theory of Reasoned Action. Control is determined by
control beliefs and perceived power (Fishbein & Azjen, 1975). Ecological Models of
Health Behaviors are models that relate to health promotion that were missing from
the nursing textbooks reviewed. Ecological approaches are highly relevant when
attempting to improve the health of many (Fischer, 2008). The most common
diseases affecting Americans are directly related to lifestyle behaviors, so these are
important models that must be considered. Ecological approaches identify that health
behaviors are influenced and affected by multiple factors such as intrapersonal,
sociocultural, policy, and physical environment factors. The ecological approach
recognizes that in order to promote health, multilevel intervention must be
implemented. This multilevel implementation needs to include various disciplines
and public sectors (Glanz, Rimer & Lewis 2002). The ability to address needs from a
broad approach, like the ecological approach, 28 rather than the individual level, has
the potential to be more effective since nurses care for many people who have similar
health promotion needs. Nurses hold professional positions in hospitals,
communities, and political organizations, and currently have the means to promote
health from an Ecological Model. Nurses have the ability to be members of
professional organizations that lobby for health care laws, funding, and standards that
recognize the importance of the environment on the health of individuals, groups, and

26communities. It is necessary for nurses to recognize their ability to influence health
from an approach that is much broader than just the individual. Nursing and Health
Promotion Research Studies Clark and Maben (1998) conducted a qualitative study to
identify the understanding of health promotion and health education by student nurses
in England, as well as their understanding of their role as health promoters. The
results indicated that the students’ focus shifted from illness to health, but they
remained confused about the terms health education and health promotion. These
students’ viewpoints were found to be reflective of the views and knowledge of their
teachers. Piper (2008) conducted a qualitative research study that focused on the
definition and meaning of health education and health promotion within the United
Kingdom. The United Kingdom’s Hospital-based nurses had a formal understanding
of health education which was specific to the needs of the clients and behavior
changes clients needed to make in relation to their disease or health. These nurses had
less of an understanding when it came to health promotion. They believed health
promotion involved mass media campaigns for general health advice, but did not
include a socio-political component. Piper concluded that nurses who participated in
the study did not have an understanding 29 of health promotion. Other researchers,
Liimatainen, Poskiparta, Sjögren, Kettunen & Karhila’s (2001), found that student
nurses in the United Kingdom understood the concepts of health promotion and
health education, but were unable to apply the ideas in complex situations, such as
hospital wards. Irvine (2005) and Clark and Maben’s (1998) findings also indicated
the inability of nurses in the United Kingdome to transfer theory into practice. A
study conducted by Irvine (2005) on district nurses found that nurses have an
individualist ideology practice that focuses on disease and individual behavior
changes, but not the socio-political health promotion role. Clark and Maben’s (1998)
findings indicated that student nurses, diplomats and nursing educators were unclear
about the meanings of health education and health promotion. The study recognized
that the inability of students to understand these terms was directly related to the
limited knowledge and understanding of their nurse educators. Other studies designed

27to look at nursing in regards to health promotion revealed similar findings to those
conducted in the United Kingdom (Whitehead, Wang, Wang, Zhang, Sun & Xie,
2007; McBride & Moorwood, 1994; Whitehead, 2008; Irvine, 2005; Davis, 1995;
McBride, 1994). A study conducted in England found hospital-based nurses who
worked with a health promotion facilitator had an increased understanding of health
promotion and reported more health promoting activities as compared to nurses
working on a ward that did not have a health promotion facilitator (McBride &
Moorwood, 1994). Whitehead (2008) conducted an international Delphi study to
define health education and health promotion. A purposive sample of 62 international
nurses, who were 30 considered to be experts in health promotion and health
education, were selected for the study. The study hypothesized that the nursing
profession had been unable to incorporate health promotion into theory, practice, or
policy because of the inability to agree on what constitutes health promotion
activities. The findings of the study indicated that experts were in agreement in
regards to the definition of health promotion and health education, but total
agreement was elusive in regards to policy, practice, and theory. This study was the
first time a group of nurses agreed on definitions for health promotion and health
education.

28Chapter II
MATERIALS AND METHODS
To carry out the work were used statistical data from the National Bureau of
Statistics from the Republic of Moldova and Central Bureau of Statistics from Israel.
Reviews of official health statistics were made in order to analyse the progress
of the health sector reforms in Republic of Moldova and Israel.
When collecting this statistical information, two principles were followed:
– The information should be reliable and easily accessible, with no special studies
needed for data collection.
– The indicators should be comprehensive enough to describe the progress of the
reforms from the quality point of view – the level of population health and the
accessibility of the health services.
To describe the level of population health the following indicators were
selected: life expectancy (males and females), infant mortality, mortality rates
(cardiovascular diseases, cancer, accidents), incidence of tuberculosis per 100,000
inhabitants, incidence of HIV infections per 100,000 inhabitants.
The prevalence of the following individual risk factors among the population
was considered as well: dietary habits (use of vegetable oil or animal fat for cooking,
use of fresh vegetables), proportion of smokers and consumers of strong alcohol.

29Chapter III
HEALTH STATUS OF THE POPULATION AND HEALTH PROMOTION
ACTIVITIES IN ISRAEL
3.1. Characterisation of Health Infrastructure in Israel
The modern State of Israel was founded in 1948 within the general area of the ancient
biblical Land of Israel in the Middle East on the eastern shore of the Mediterranean
Sea. It is a relatively small county, measuring only 470 kilometers (290 miles) from
north to south and 135 kilometers (85 miles) at its widest point.
Since achieving nationhood, Israel experienced massive immigration from the Jewish
Diaspora in other Middle-Eastern countries, post Holocaust Europe, and to some
degree from the Americas, South Africa, and Australia. During the period from 1980-
2005 there was a large influx of immigrants from two very different areas and
cultures: nearly one million from the former Soviet Union, and roughly 80,000 from
Ethiopia.
This massive immigration, coupled with a high (3.0) average fertility rate for a
developed country, have led to a near ten-fold increase in the population, growing
from roughly 800,000 in 1948 to over eight million inhabitants in 2013.
Approximately 75 percent of the population is Jewish and 25 percent is of Arab or
other ethnicity. The Jewish population is multi- ethnic, with 27 percent born outside
of Israel. The Arab/non-Jewish population is primarily Moslem (82.5%), with small
Christian (9.5%), and Druze (8%) minorities.
Beginning in 1911, health care began to be provided by Sick Funds created by local
labor unions. The Sick Funds were funded through membership fees. In 1973, a law
was passed requiring employers to contribute as well. The 1995 National Insurance
Law led to provision of government-financed universal health insurance for all Israeli
citizens. The four health funds currently in operation are funded by the government
on a per capita basis from payroll and general tax revenues. The employer health tax
was cancelled in 1997. The National Insurance Institute, the organization responsible
for social security in Israel, tranfers funding to the health funds through a capitation

30scheme that incorporates the number of insurees in each fund, their age, and other
factors. These health funds competitively serve the citizenry, with the largest, Clalit,
insuring roughly 50 percent of the population, the next largest fund, Maccabi, serving
about 25 percent, and the other two (Meuhedet and Leumit) splitting the rest of the
population between them. Close to half of the hospitals are owned and operated by
the government, about a third by Clalit, and the rest are operated by a mix of for
profit and not-for-profit organizations.
Health promotion and preventive care is delivered in a variety of ways: well-baby
clinics (“Tipot_Halav” or Drop of Milk stations, first established in 1922) are
operated by both the government (national or municipal) and by the Clalit health
fund. They provide health counseling, vaccines, child development services, and
preventive examinations for pregnant women, infants, and children. District health
offices are responsible for public health services such as infectious disease control,
food hygiene, and traveler’s health.
Clinical therapeutic care and preventive medicine for the population is provided by a
county-wide network of primary care physicians and nurses employed in community
clinics by the four health funds. District health promoters provide support for a
variety of health promotion initiatives along with local authorities and/or non-Ministry
of H ealth
National
Insurance Institute
Sick
Funds
Sick
Funds Public
Health
Mental HealthMental
Hospitals
Clinics MDs HospitalsAmbulator y
careIsraeli
Health System
Tipot H alav

31governmental organizations. Ambulatory patient data systems are world class, with
full electronic medical file coverage for primary and specialist care. Israel’s Quality
Indicators in Community Healthcare program, along with health fund-based quality
initiatives, have led to impressive gains in screening test coverage of the population
over the past decade, e.g., fecal occult blood to detect colorectal cancer. Health
promotion and preventive medical guidelines have been published by the Israeli
Preventive Services Task Force since 1996 and have been updated on a regular basis
since then, with the latest edition issued in early 2013.
New health technologies are reviewed annually by a multi-specialty “Health-Basket
Committee” to advance public funding for new technologies, medications, and
vaccines. A combination of evidence-based, ethical, and cost considerations are
weighted to decide how best to spend the approximately US $100 million dollar
annual budget. Recent preventive additions to the basket have included tobacco
cessation medication and group counseling, as well as the human papilloma virus
vaccine. Vaccine coverage and inclusiveness in Israel is on par with most western
countries with respect to pediatric vaccines. Influenza vaccines have recently been
distributed free of charge by the various health funds. The herpes zoster vaccine for
older adults still awaits public funding.
3.2 Health outcomes in Israel

32Israeli citizens enjoy a long life expectancy. In 2011, life expectancy at birth was 81.8
years, nearly two years higher than the OECD average of 80.1 years. Israeli men, in
particular, enjoy one of the highest life expectancies in the world. Infant mortality
was 3.5/1000, below the OECD average of 4.1/1000.10 A multi-year trend of life
expectancy compared to European Region World Health Organization country
groupings appears in Figure 2.
Leadingcausesof deathinIsrael
(%of totaldeathsfromallcauses,2009)
606570758085
1970 1980 1990 2000 2010 2020France
Israel
Russian Federation
United Kingdom
EU members since 2004 or 2007Life expectancy at birth, in years

33Based on a report from 2009, Israel ranked seventh and fifteenth (out of 34 OECD
countries) in male and female coronary artery disease mortality, respectively. Israel’s
preeminence is even more apparent with respect to stroke mortality: Israeli men have
the lowest, and women the second lowest rate in the OECD.
These achievements in cardiovascular health may be traced to “upstream” preventive
interventions, especially hypertension and hyper- lipidemia detection and control. For
example, over 90 percent of those aged 55-74 measuring LDL cholesterol in the
previous year had normal values ( ≤ 160 mg/dl). Gradual annual improvement in
adherence has been evident. Proactive hypertension and diabetes management is
given high priority in primary care.0100200300400
1970 1980 1990 2000 2010 2020Israel
Republic of M oldova
Romania
Russian Federation
United KingdomSDR, cerebrovascular
diseases, all ages per 100000

34Despite these achievements on a national level, more work is needed to narrow gaps
between disadvantaged groups in the population. Diabetes is a good example:
prevalence is almost double in the Arab population relative to the Jewish population.
There are also areas such as the incidence of cancer, for which the Arab population
has traditionally experienced lower rates than the Jewish population. This gap,
though, is shrinking in size, due to improved cancer screening and increased early
detection in the Arab population, as well as the impact of unhealthful lifestyle
behavior changes.0100200300400500600
1970 1980 1990 2000 2010 2020Israel
Republic of M oldova
Romania
Russian Federation
United KingdomSDR, ischaemic heart disease,
all ages per 100000

Lifestyle behaviors present a mixed picture. Smoking prevalence has decreased in
recent years and is below the
populations is still quite high (e.g
of Israelis a re either overweight or obese.
Arab population. Only 32 percent of adults age 21 and above are as phy
as recommended. Twenty percent sleep less than six hours nightly and 18 percent feel
very sleepy during the day. Almost a quarter
and nine percent fre quently feel depressed.
The transport accident mortality rate declined from 12/100,000 to 5/100,000 from
1995 to 2010, and at 5.9 percent in 2011 was well below the OECD av
percent. While improved post
rates, it may also be explained by a reduction in the number of serious and fatal
accidents.
Lifestyle behaviors present a mixed picture. Smoking prevalence has decreased in
and is below the OECD average of 22.3 percent. Yet prevalence in some
populations is still quite high (e.g ., 43.8% of Arab males smoke).
re either overweight or obese. This is slightly (53%) higher among the
Arab population. Only 32 percent of adults age 21 and above are as phy
Twenty percent sleep less than six hours nightly and 18 percent feel
very sleepy during the day. Almost a quarter of the population is frequently stressed,
quently feel depressed.
The transport accident mortality rate declined from 12/100,000 to 5/100,000 from
1995 to 2010, and at 5.9 percent in 2011 was well below the OECD av
While improved post -crash care is partly responsible for these improved
rates, it may also be explained by a reduction in the number of serious and fatal
Lifestyle behaviors present a mixed picture. Smoking prevalence has decreased in
Yet prevalence in some
., 43.8% of Arab males smoke). Forty -nine percent
This is slightly (53%) higher among the
Arab population. Only 32 percent of adults age 21 and above are as phy sically active
Twenty percent sleep less than six hours nightly and 18 percent feel
of the population is frequently stressed,
The transport accident mortality rate declined from 12/100,000 to 5/100,000 from
1995 to 2010, and at 5.9 percent in 2011 was well below the OECD av erage of 7.6
crash care is partly responsible for these improved
rates, it may also be explained by a reduction in the number of serious and fatal

36Administration and adherence to certain preventive interventions is impressive: in
2011, vaccination rates of children ranged from 93 percent (Hib3) to 99 percent
(HepB). On the other hand, among those 65 and above, only 57 percent received the
annual vaccination against influenza. Only partial success has been achieved in
improving adherence to cancer screening: in 2010, 68 percent of eligible women were
screened for breast cancer with mammography. Colon cancer screening was even less
wide- spread: only 47 percent of those eligible were screened. That said, a consistent
improvement in coverage rates over time is evident.051015202530
1970 1980 1990 2000 2010 2020France
Israel
Russian Federation
United Kingdom
EU members since 2004 or 2007SDR, motor vehicle traffic
accidents, all ages per 100000

37These data highlight various challenges facing the health system, but also
demonstrate advances that have been made over recent years. But back in 2005, when
senior leaders in the Ministry of Health (MOH) surveyed the preventive health 1020304050
1970 1980 1990 2000 2010 2020France
Israel
RussianFederation
UnitedKingdom
EUmemberssince2004or2007SDR, malignant neoplasm female
breast, all ages per 100000
1234567891011
1970 1980 1990 2000 2010 2020France
Israel
Russian Federation
United Kingdom
EU members since 2004 or 2007SDR, cancer of the cervix, all ages, per 100000

38landscape, the picture was not as encouraging as it is today. It was then that a
decision was made to embark on a visionary initiative to be fully implemented 15
years in the future. The stage was set for the introduction of the Healthy Israel 2020
Initiative.
3.3 The Healthy Israel 2020 initiative
The Healthy Israel 2020 (HI2020) initiative was conceived with a goal of creating a
preventive blueprint to improve the quality of life, increase overall longevity, and
maximize health equity among Israelis. This built upon an existing ethos of health
promotion and prevention manifest in well-developed local programs such as Israel’s
well-baby clinics and community-oriented primary care system. On the other hand,
the focus and funding streams of the health system revolved around treatment rather
than prevention, as evident from the fact that Israel spent only 0.6 percent of its total
health expenditure on prevention and public health services in 2005.
The concept of a prevention-oriented health-targeting initiative had already been
established internationally. Utilizing the core concept of management by objective,
the United States Healthy People initiative began defining health objectives with
accompanying targets to reach over a decade, back in 1979.24 The WHO employed
this methodology in its Health for All program, originally launched in 1979 as the
Global Strategy for health for all in the year 2000 by the World Health Assembly.
This document invited Member States to act individually in formulating national
strategies and collectively in formulating regional and global strategies. Israel
followed this model and drafted health objectives in 1989, but these were not
formally implemented or funded by the MOH. Consequently, they were only realized
if they happened to coincide with preexisting organizational goals and objectives.
In contrast with its predecessor health targeting initiatives, HI2020 did not only
formulate objectives and measurable targets: the scientific literature was carefully
reviewed in order to formulate recommendations to be made based on proven
strategies and evidence-based interventions to employ to meet the targets. Other
criteria considered when deciding upon recommendations were their feasibility (in

39terms of political will, funding availability, and manageability) and public support.
Where baseline data did not exist or there were insufficient data regarding the
existence of interventions or their suitability to Israel, developmental data objectives
and interventional objectives were set, respectively.
Thus in 2005, the Associate Director General of the Ministry of Health (Boaz Lev), a
strong proponent of healthful lifestyle behaviors, led the decision to create the
HI2020 initiative as a means of generating a preventive blueprint for Israel. Two
professional staff members were hired to move the initiative forward: a national
coordinator trained in epidemiology and biostatistics, and the lead author (Elliot
Rosenberg), a specialist in general preventive medicine, to serve as scientific
consultant to the initiative. A scientific committee, chaired by the Associate Director
General of the Ministry of Health, was established. In addition to the aforementioned
staff members, this committee included a senior MOH staff member with a health
economic background as well as a seasoned staff member with experience in health
promotion and legislation. A steering committee composed of leaders in the health
field from both government and nongovernmental organizations was formed oversee
the entire process.
To implement the initiative, 20 committees were initially formed. The focus areas
selected generally paralleled those of an existing similar initiative (US Healthy
People 2010), with local adjustments.
Committee composition was determined by the initiative’s scientific committee. Each
committee was led by either a health professional in a senior leadership position in
the MOH or by a leading subject matter expert in each respective area. Committee
members were selected from a variety of sources: government ministries, health
funds, academic centers, and non- governmental organizations. Subcommittees were
created within committees as mandated by the scope and variety of the subject
matter. For example, the health behaviors committee initially included six separate
subcommittees to cover the topics of tobacco control, obesity control, nutrition,
physical activity, sleep/alertness, and ultraviolet exposure/melanoma prevention. An

40international board of consultants from a variety of countries was recruited to assist
each committee. All told, over 300 committee members and roughly 50 consultants
were recruited.
Each committee/subcommittee received guidelines specifying the desired structure of
the reports. These included the following: epidemiology/ disease burden, financial
burden, objectives and target values (international and Israeli), recommended
interventions, and references. Objectives were separately crafted by age, gender, and,
where the data indicated the existence of a substantive gap between groups (e.g., BMI
or physical activity level), by ethnic group (Jews and Arabs). Target values for the
year 2020 were set in accordance with the baseline data and by assuming reasonable
intervention- driven improvements over time. Several methods were used: achieving
a better outcome than the leading subgroup for which data existed (“better than the
best”), improving by a fixed percentage (e.g., 10%), or continuing existing trends into
the future. Finally, committees were charged with creating viable implementation
plans for their recommendations: to prioritize the interventions on the basis of their
scientific validity, their ability to reduce
* Over the 2007-2010 period personnel changes occurred in the management of the
initiative and in the scientific committee: Elliot Rosenberg replaced the national
coordinator of the initiative, a preventive medicine specialist (Tunie Dweck), took
over as scientific consultant/ intervention specialist, and Itamar Grotto (a public
health physician) and Tuvia Horev (a dentist with health economic training) joined
the scientific committee, the latter replacing the original health economist who left
the MOH.
CURRENT AND FUTURE CHALLENGES
HI2020 has established itself as a key feature in the Israeli health landscape, bringing
health promotion and disease prevention into sharper focus than ever before. This has
been achieved through its publications, internet site offerings, conferences, and
incorporation into the curriculum of university health promotion degree courses and
medical residency syllabi. Its science- based, cutting edge content has been

41recognized by a series of international bodies: the alcohol control report was
presented to the French National Academy of Medicine and was received “with
honor.” In November 2011, the First WHO European Conference on the New
European Policy for Health- Health 2020 was held in Jerusalem, in part, to recognize
Israel’s leadership in the area of health targeting for 2020. Needless to say, the
initiative has broad cachet among health professionals and decision-makers in Israel.
Obesity and chronic disease in Israel
Fifteen percent of Israel’s adult population is obese; roughly one out of two is
overweight. More than one out of five children aged 12-18 are overweight or obese.
Overweight/obesity levels have increased steadily over the last four decades [24],
more drastically among individuals of lower socio-economic status.
Obesity and overweight account for approximately 3,105 deaths per year, 7.7% of all
yearly deaths [26]. The rate of mortality due to diabetes in Israel is twice as high as
the average in Western countries [23], with the Arab population suffering in
particular [27]. In 2007, for example, mortality attributed to diabetes was
approximately 61% for Arab men and 27% for Jewish men [27].
Since 1994, hypertension levels have increased by more than 250%. Diabetes levels
have doubled since the 1950s and are expected to double-triple again in the next 20
years, barring a radical change in nutrition and exercise patterns [23]. Treatment of
morbidity due to obesity and overweight in Israel costs an estimated 1.92 billion
shekels, with an additional 1.89 billion shekels in productivity losses and 1.95 billion
in other indirect costs [26].
Only 32% of Israelis ages 21 and over engage in the recommended amount of
physical activity (34.6% among Jews/21.6% among Arabs, 36.3% among men/28.8%
among women). Individuals with greater income and higher education are more
physically active than those of lower socio-economic status [28]. In the Arab sector,
only 14.7% of adolescents exercise regularly [29]. According to the most recent
“Health Behaviors in School-Aged Children (HBSC)” cross-national survey, Israel

42has the second highest rate of children ages 11, 13, and 15 who had not engaged in
physical activity during the previous 7 days (12.3%). The same study revealed that
Israel has the highest rates of children ages 11, 13, and 15 who play computer games
for more than 4 hours per day (28.5%) [30].
All segments of the population consume substantial amounts of sweetened drinks
every day, especially Arab men (65.1%) and Arab women (42.6%), according to one
sample [31]. Caloric intake in Israel has increased consistently since the 1970s, and in
2007, surpassed the European average [29]. According to one sample, whole grain
products are consumed in just half of the homes in Israel [32]. Israelis’ average salt
intake is more than double the recommended level [29]. While Israelis, in the past,
have consumed adequate amounts of fruits and vegetables, recent evidence from the
Ministry of Agriculture suggests a decrease, especially among low income groups
[33].
The national program to promote active, healthy lifestyle
In December, 2011, the Social and Economic Affairs Cabinet accepted a resolution
outlining a National Program to Promote Active, Healthy Lifestyle, aimed at curbing
obesity and the rise in chronic disease. Initiated by the Health Ministry, it is a
government-wide effort, led by the Ministries of Health, Education, and Culture and
Sport. The Ministries of Finance, Agriculture, Industry, Trade and Labor,
Transportation, Communications, Environmental Protection, as well as local
governments, the private sector, NGOs and civil society have signed on, as well.
Remaining steps toward health in all policies
The majority of the National Program’s content is initiated, paid for and implemented
by the Ministry of Health. This may be inevitable; it is, after all, a health promotion
program. But as discussed above, HiAP entails addressing determinants of health. By
leveraging additional ministries’ budgets and policy spheres and intensifying the use
of the governance mechanisms described in the WHO framework, the National
Program may increase its impact on determinants of obesity and chronic disease
outside of its traditional boundaries. While aspects of the National Program resonate

43with Health in All Policies, the following additional steps could strengthen the health
sector’s intersectoral potential and increase the likelihood of fulfilling HiAP’s
promise.
A first step: strengthening the intersectoral steering committee. The committee was
designed to guide planning and implementation – to lead the National Program. In
practice, it became a forum for status updates between members of the Ministry of
Health. The mostly low-level representatives from other ministries played a passive
role, contributing only when the discussion turned to their specific area of expertise.
This must change if the Ministry of Health expects to affect change on a systematic
level and catalyze large-scale action on the part of the other ministries involved.
One potential objective is policy coherence, to strive toward a cross-governmental
agenda that is conducive, or at the very least, not counterproductive to citizens living
an active, healthy lifestyle. The Ministry of Health sits on national and local
committees on subjects like food imports, agriculture, meal-services in schools and
homes for the aged, urban planning and workplace safety. For example, ministry
representatives ensure that hygienic and environmental health standards are
considered in urban planning and land development. These memberships can be
leveraged in order to coordinate policies which protect and promote healthy lifestyle.
More broadly, ministry members can utilize their presence in such forums to defend
values which promote population-wide health, like equity, access to services,
community, environmental justice, employment and fair housing.
There is, of course, a counterpoint: health professionals already fulfill critical roles in
society. Whether out of a sense of pragmatism or professional modesty, it may be
best for them to stick to what they know. But more than a decade of research on
social determinants of health reveals the extent to which social factors impact health,
and gives the health sector a unique perspective on the importance of equitable
distribution of resources and protection of rights. This perspective can complement
the perspectives of others defending similar values. It may be critical, though, to train
members of the health sector to work effectively with professionals from other

44sectors, in order to provide them with the practical tools to fulfill HiAP.
Knowledge translation is an additional direction. In order to further mobilize other
sectors, health expertise can be accessible to and disseminated toward non-health
sectors, as well as synthesized and framed according to their language, policymaking
contexts and needs [13]. Several countries have implemented Health Impact
Assessment (HIA) and Health Equity Impact Assessment (HIEA) toward this end [9].
These tools allow other sectors to understand how their actions affect or will affect
health. Israel has not yet adopted assessment tools in policy areas which influence
lifestyle. Negev et al [35] present HIA as a platform for facilitating collaboration
between the health and environmental sectors in Israel, a vital example worth
studying, and perhaps, implementing in other sectors, as well. An additional, related
direction could include adding academic representatives from outside of health to the
evaluation committee, in order to ensure that data and conclusions are geared toward
the sectors upon which the National Program is leaning. Finally, the Health Ministry
releases an annual “Minister’s Report” on the state of smoking. It may be beneficial
to release a yearly report on the state of nutrition and physical activity, as well.
Ginsberg and Rosenberg’s [26] cost-benefit analysis of several of the National
Program’s components is valuable in Israel and abroad. Follow-up study could
include breaking down the data according to the sectors whose budgets will be most
directly impacted by the National Programs’ components. In addition, policy
proposals may be more acceptable at high policymaking levels if issues are expressed
as systematic or market failures like externalities, monopolies and information
asymmetries, all of which have societal consequences beyond health.
Ollila [13] cites the need to anticipate policy needs and political realities in other
sectors, and to be ready when windows of opportunity open. This demands that health
professionals step out of the “health box” and become acquainted with other
policymaking environments. Doing so would make it more likely to identify
additional “win-win” situations between sectors, and strengthen the networks
Kickbusch [3] describes as fundamental to HiAP.

45Ollila [13] articulates the importance of the health sector delving into developing
policies in order to identify areas where adverse – or beneficial – health effects are
prevalent. Potential overlapping of interests exist, for example, with the Ministry of
Agriculture, which represents growers of fruits and vegetables, the Ministry of
Environmental Protection, whose broad vision for sustainability shares much in
common with public health and the Ministry of Welfare, which is responsible for
food security among Israel’s needy.
HiAP literature discusses the need to strengthen collaboration between government
and civil society. While the Health Ministry supports several NGO pro- grams, there
is not yet a clearly defined and efficiently applied mechanism for galvanizing
grassroots health promotion initiatives. In addition, the social protests of summer
2011 revealed that the general public is concerned about social injustice. The depth of
research on the social determinants of health, as well as Israel’s health sector’s
experience in providing across-the-population access to care, position public health as
a potential leader for other sectors amidst public demands for equality and social
justice.
While several specific programs feature shared budgets with other sectors, the
majority of the National Program’s budget comes from and is managed by the Health
Ministry. There is no integrated “National Program Budget,” owned by several
sectors. As such, the Health Ministry bears much of the burden of decision-making,
management and implementation, which lightens commitments from other sectors.
While the National Program is officially a program of three ministries, in practice, it
is owned mostly by the Health Ministry. Some in the ministry may see this as an
advantage. But if genuine commitment from non-health sectors is a goal, then, over-
reliance on the Health Ministry could be a disadvantage.
As mentioned earlier, HiAP sets sights on supra- governmental policy issues like
power distribution, poverty and social equity [7]. While the National Program cannot
be expected to eliminate poverty, there may be upstream directions to pursue. One
example: The value a nation places on health is, in part, a function of the value it

46places on social welfare. As such, the health sector can play a central role in
advancing measurements beyond Global National Product (GNP) to assess national
success. Baum and Laris [4] suggest the Happy Planet Index (HPI), which expresses
life satisfaction, life expectancy and ecological footprint. The Ministries of Finance
and Environmental Protection are currently exploring models like HPI to accom-
pany economic indexes. Promoting such indicators could increase the value the
government places on health, and as such, would be worthy pursuits for the National
Program.
3.4 Health Promotion in Israel
Ministry of Health
Health promoter in each regional/district office
Training in health promotion
Participatory programs
National council for health promotion
Laws / regulations (smoking)
Primary care service include Health education & promotion departments; Provide
health education to patients ; Participate in health promotion activities in the
community.
Education sistem
Health promotion department in the Ministry of Education – regional referentsMinistry
of Health
Hospitals
Primary
care
Education
systemLocal
authoritiesUniversitiesNGO’s

47Health promotion programs in kindergartens and schools
Health promoting schools
“The year for the promotion of healthy & active living”
Health promotion hospitals
The health promoting hospitals (HPH) project and network facilitates change to
promote total quality management of the hospital. It produces evidence to help
hospitals achieve their health mission and to support cooperation and exchanges of
experience between participating hospitals.
Objectives:
1. To change the culture of hospital care towards interdisciplinary working,
transparent decision-making and with active involvement of patients and
partners.
2. To evaluate health promotion activities in the health care setting and build an
evidence-base in this area.
3. To incorporate standards and indicators for health promotion in existing quality
management systems at hospital and at national levels.
Health promotion hospitals promote human dignity, equity and solidarity, and
professional ethics, acknowledging differences in the needs, values and cultures of
different population groups; be oriented towards quality improvement, the well-being
of patients, relatives and staff, protection of the environment and realization of the
potential to become learning organizations;

48Standards of a health promotion hospitals
1. A hospital has a written policy for health promotion. This policy must be
implemented as part of the overall organization quality system and is aiming to
improve health outcomes. It is stated that the policy is aimed at patients, relatives
and staff.
2. Describes the organizations' obligation to ensure the assessment of the patients'
needs for health promotion, disease prevention and rehabilitation.
3. The organization must provide the patient with information on significant factors
concerning their disease or health condition and health promotion interventions
should be established in all patients' pathways.
4. Gives the management the responsibility to establish conditions for the
development of the hospital as a healthy workplace.
5. Deals with continuity and cooperation, demanding a planned approach to
collaboration with other health service sectors and institutions.

49Health promotion universities
Teaching health promotion in all schools of public health
Health promotion university

Chapter 4
HEALTH STATUS OF THE POPULATION AND HEALTH PROMOTION
ACTIVITIES IN THE REPUBLIC OF MOLDOVA
Demografic situation s:
Each fourth person is aged over 60
The Moldovan population’s average life expectancy at birth in 2011 was of
71.1 years (67.3 years
According to the UN forecast calculations, the Moldovan population aged
and over will represent 23.2 per cent in 2025
Economically active population
Fertility rate -1,3 children
The level of coverage of the population with mandatory medical insurance is of
80 per cent
Fig . Life expectancy at birth in the Republic of Moldova.6868
64 647172
6970
67 67
6264666870727476
2000 2005
ambele sexe
HEALTH STATUS OF THE POPULATION AND HEALTH PROMOTION
ACTIVITIES IN THE REPUBLIC OF MOLDOVA
Each fourth person is aged over 60
The Moldovan population’s average life expectancy at birth in 2011 was of
71.1 years (67.3 years –for men and 75.0 years for women)
According to the UN forecast calculations, the Moldovan population aged
and over will represent 23.2 per cent in 2025
Economically active population -41 %
children
The level of coverage of the population with mandatory medical insurance is of
Fig . Life expectancy at birth in the Republic of Moldova.6969 69 6971
6566 6565677373 73 7375
7071 727273
6868 686769
2005 2007 2008 2009 2010 2011
ambele sexe bărbați femei urban
HEALTH STATUS OF THE POPULATION AND HEALTH PROMOTION
The Moldovan population’s average life expectancy at birth in 2011 was of –
According to the UN forecast calculations, the Moldovan population aged 60
The level of coverage of the population with mandatory medical insurance is of
71
6775
74
70
2012
rural

51As a country in transition, Moldova has the double epidemiological burden of
communicable and noncommunicable diseases (NCDs). Since becoming an
independent country, a constant decrease in the incidence of communicable diseases
has been noted due to the implementation of disease control and health promotion
measures. An exception to this trend is the case of tuberculosis (TB) and HIV/AIDS,
for which incidence rates remain high. Incidence rates for NCDs have remained
consistently high since the early 2000s.
NCDs are estimated to have accounted for 87% of all deaths in 2011. The main
causes of death are cardiovascular diseases (CVD) (57%), cancer (15%), chronic
gastrointestinal diseases (9%), chronic respiratory diseases (5%), injuries and
poisoning (8%), diabetes (1%) and others (5%). A specific feature of the mortality
structure of the Moldovan population is extremely high mortality from cirrhosis (8%
out of the 9% of chronic gastrointestinal diseases), without difference by sex. Low
incomes, alcohol and tobacco are the key health determinants in this regard, and
mortality and morbidity from these factors account for a sizeable burden on society.
The principal health concerns include low life expectancy, along with diseases
associated with ageing and with demographic trends in the population. Future
changes in the structure of the population will lead to an increase in the elderly
populations requiring health and social care. It is also expected that there will be an
additional need for health services responding to cardiovascular, chronic
gastrointestinal diseases and cancer diagnosis and treatment. A large preventive
potential for cardiovascular and respiratory diseases – as well as accidents – is also
foreseen.
The disability-adjusted life years (DALy) index measured by WHO in 2002 presents
the 10 top risk factors that contribute to disease burden (WHO, 2006). For men the
three main risk factors that account more than half of the total DALys (53.4%) are:
alcohol consumption, tobacco use and arterial hypertension. For women, the top three
risk factors are arterial hypertension, high cholesterol and alcohol consumption,
accounting for 41% of the total DALys.

The infant mortality rate rose in the early 19
births in 1992 to 22.9 per 1000 in 1994. The trend has since been reversed, and in
2011 it reached 11.0 per 1000 live births. Since 2010, the infant mortality rate has
shown a tendency towards reduction and during the p
compared to that of CIS countries, but higher compared to the 27 EU countries.
The maternal mortality rate fell from 52.9 deaths per 100 000 live births in 1993 to
15.8 per 100 000 in 2007; however, two peaks in growth rates wer
2008 and 2010 . In 2010 maternal mortality as an indirect obstetrical risk was
identified in a half of the deaths, while five of them were reported as a consequence
of pandemic influenza. The difference between maternal mortality rates in ur
rural areas is almost 2 -fold; it can be explained partially by the provision (and
quality) of essential services and the unequal distribution of resources.
Fig00. Infant mortality rate in RM.
Along with NCDs, incidence rates for communicable
HIV/AIDS are quite high compared with EU countries. Since the mid
incidence rate has dropped, but the Republic of Moldova still has one of the highest
incidence rates in Europe
countries globally for in terms of multidrug
18.3
16.314.714.423.320.3
18.217.8
0510152025
The infant mortality rate rose in the early 19 90s from a low of 18.3 per 1000 live
births in 1992 to 22.9 per 1000 in 1994. The trend has since been reversed, and in
2011 it reached 11.0 per 1000 live births. Since 2010, the infant mortality rate has
shown a tendency towards reduction and during the p eriod 2011
compared to that of CIS countries, but higher compared to the 27 EU countries.
The maternal mortality rate fell from 52.9 deaths per 100 000 live births in 1993 to
15.8 per 100 000 in 2007; however, two peaks in growth rates wer
. In 2010 maternal mortality as an indirect obstetrical risk was
identified in a half of the deaths, while five of them were reported as a consequence
of pandemic influenza. The difference between maternal mortality rates in ur
fold; it can be explained partially by the provision (and
quality) of essential services and the unequal distribution of resources.
00. Infant mortality rate in RM.
Along with NCDs, incidence rates for communicable diseases, such as TB and
HIV/AIDS are quite high compared with EU countries. Since the mid
incidence rate has dropped, but the Republic of Moldova still has one of the highest
incidence rates in Europe .The Republic of Moldova is among 18 “hi
countries globally for in terms of multidrug -resistant TB (MDR -TB) incidence; it was
4
12.212.4
11.811.312.212.111.710.99.898
15.315.714 14 14.514.313.613.412.111
0-1 ani
<5 ani
90s from a low of 18.3 per 1000 live
births in 1992 to 22.9 per 1000 in 1994. The trend has since been reversed, and in
2011 it reached 11.0 per 1000 live births. Since 2010, the infant mortality rate has
eriod 2011 –2012 it is lower
compared to that of CIS countries, but higher compared to the 27 EU countries.
The maternal mortality rate fell from 52.9 deaths per 100 000 live births in 1993 to
15.8 per 100 000 in 2007; however, two peaks in growth rates wer e registered in
. In 2010 maternal mortality as an indirect obstetrical risk was
identified in a half of the deaths, while five of them were reported as a consequence
of pandemic influenza. The difference between maternal mortality rates in ur ban and
fold; it can be explained partially by the provision (and
quality) of essential services and the unequal distribution of resources.
diseases, such as TB and
HIV/AIDS are quite high compared with EU countries. Since the mid -2000s, the TB
incidence rate has dropped, but the Republic of Moldova still has one of the highest
The Republic of Moldova is among 18 “hi gh-burden”
TB) incidence; it was
9.511.9

estimated that in the year 2010, 44% of TB patients are infected with MDR
(WHO Regional Office for Europe, 2012). TB treatment in the Republic of Moldova
shows a negative trend, whereby only half of patients complete their treatment.
Fig 00. The incidence of tuberculosis in RM.
There has been a steady increase in the number of newly reported HIV cases since the
mid-2000s and a slight decrease in 2009
are sexually transmitted, and women account for the majority of these.
According to national data, the rate of hospital infections is very low. Of the overall
number of nosocomial infections, 51.2% are recorded in mater
44.6% in hospitals with a surgical profile and 4.2% in those with therapeutic profiles.
CVDs are the leading cause of death in the Republic of Moldova, comprising around
57% of total mortality. Among the countries of the WHO European Regi
Republic of Moldova takes second place after Ukraine for having the highest
standardized death rate (SDR) from diseases of the circulatory system (WHO
Regional Office for Europe, 2012). People of working age (18
26% of deaths related to circulatory system diseases. The most frequent cause of
13%19%62% 62%
19 19
0%10%20%30%40%50%60%70%
2005 2006
MDR, caz nou, %estimated that in the year 2010, 44% of TB patients are infected with MDR
(WHO Regional Office for Europe, 2012). TB treatment in the Republic of Moldova
ws a negative trend, whereby only half of patients complete their treatment.
Fig 00. The incidence of tuberculosis in RM.
There has been a steady increase in the number of newly reported HIV cases since the
decrease in 2009 . More t han half of the newly reported cases
are sexually transmitted, and women account for the majority of these.
According to national data, the rate of hospital infections is very low. Of the overall
number of nosocomial infections, 51.2% are recorded in mater
44.6% in hospitals with a surgical profile and 4.2% in those with therapeutic profiles.
CVDs are the leading cause of death in the Republic of Moldova, comprising around
57% of total mortality. Among the countries of the WHO European Regi
Republic of Moldova takes second place after Ukraine for having the highest
standardized death rate (SDR) from diseases of the circulatory system (WHO
Regional Office for Europe, 2012). People of working age (18 –62 years) account for
related to circulatory system diseases. The most frequent cause of
% 18%24%22%25% 26%24% 62%
58% 57%
52%62% 62
1920
1718
1816
14
2006 2007 2008 2009 2010 2011 2012
MDR, caz nou, % Rata de succes TB clasic, % Mortalitatea, estimated that in the year 2010, 44% of TB patients are infected with MDR -TB
(WHO Regional Office for Europe, 2012). TB treatment in the Republic of Moldova
ws a negative trend, whereby only half of patients complete their treatment.
There has been a steady increase in the number of newly reported HIV cases since the
han half of the newly reported cases
are sexually transmitted, and women account for the majority of these.
According to national data, the rate of hospital infections is very low. Of the overall
number of nosocomial infections, 51.2% are recorded in mater nity departments,
44.6% in hospitals with a surgical profile and 4.2% in those with therapeutic profiles.
CVDs are the leading cause of death in the Republic of Moldova, comprising around
57% of total mortality. Among the countries of the WHO European Regi on, the
Republic of Moldova takes second place after Ukraine for having the highest
standardized death rate (SDR) from diseases of the circulatory system (WHO
62 years) account for
related to circulatory system diseases. The most frequent cause of
24% 23%62%
14
11
0510152025
2012 2013
Mortalitatea, 100 mii

death resulting from CVD is myocardial infarction (heart attack), which constitutes
6.3% of the total number of deaths caused by CVD across all age groups, and 20%
among the population aged
Since the mid -2000s a small decrease in the deaths from CVDs
can be partly explained by active intervention in hypertension control, such as
implementing screening measures, and the NHIC’s coverage of a proportion of
cost of hypertension treatment medications.
Cancer is the second leading cause of death after CVDs, accounting for 15% of
overall mortality in the Republic of Moldova. The SDR from malignant neoplasms in
2010 (165.34 per 100 000 population) was in the
the WHO European Region; it was almost equal to those from group Eur
per 100 000). Nevertheless, the general trend t
from malignant neoplasms in Eur
Moldova it is increasing.
According to the data from the National Institute of Oncology the most frequently
diagnosed types of cancer in females are breast cancer (22.1%), followed by
631 617 654126 130135103 10911093 9810169 65108 83
02004006008001,0001,200
2000 2001 2002
bolile circulatoriideath resulting from CVD is myocardial infarction (heart attack), which constitutes
6.3% of the total number of deaths caused by CVD across all age groups, and 20%
among the population aged 18–62 years.
2000s a small decrease in the deaths from CVDs has been recorded
can be partly explained by active intervention in hypertension control, such as
implementing screening measures, and the NHIC’s coverage of a proportion of
cost of hypertension treatment medications.
Cancer is the second leading cause of death after CVDs, accounting for 15% of
overall mortality in the Republic of Moldova. The SDR from malignant neoplasms in
2010 (165.34 per 100 000 population) was in the mid-range among the countries of
the WHO European Region; it was almost equal to those from group Eur
per 100 000). Nevertheless, the general trend t ells a different story
from malignant neoplasms in Eur -A countries is decreasing , in the Republic of
According to the data from the National Institute of Oncology the most frequently
diagnosed types of cancer in females are breast cancer (22.1%), followed by
654 678 653699 670 675 657 663 688135138141146153 152 157 160160110114 116128122 119 112 115122101103 101108105 102 99 97104 7479697973 7269 6568 81787478 8180 8183
2002 2003 2004 2005 2006 2007 2008 2009 2010
bolile circulatorii tumori bolile digestivedeath resulting from CVD is myocardial infarction (heart attack), which constitutes
6.3% of the total number of deaths caused by CVD across all age groups, and 20%
has been recorded . It
can be partly explained by active intervention in hypertension control, such as
implementing screening measures, and the NHIC’s coverage of a proportion of the
Cancer is the second leading cause of death after CVDs, accounting for 15% of
overall mortality in the Republic of Moldova. The SDR from malignant neoplasms in
range among the countries of
the WHO European Region; it was almost equal to those from group Eur -A (164.02
ells a different story . Whereas the SDR
, in the Republic of
According to the data from the National Institute of Oncology the most frequently
diagnosed types of cancer in females are breast cancer (22.1%), followed by
633 642 622160 163 165100 1039586 878053 494869 6860
2011 2012 2013
bolile digestive

55colorectal cancer (11.1%); in men these are respectively lung (17.7%) and colorectal
cancer (14.2%).
Traditionally, smoking has not been widespread in the Republic of Moldova.
However, probably because of fashion, relatively low prices of cigarettes and
aggressive marketing by tobacco companies, access to tobacco products and their
consumption have increased. The results of the Moldova Demographic and Health
Survey 2005 show that there is a significant difference in smoking prevalence among
men and women: 51% of men and 7% of women stated that they smoke. Smoking is
more common among men in rural areas (53%) than in urban areas (49%) (NCPM
Moldova & ORC Macro, 2006). In the case of women, however, the situation is
reversed: 2% smoke in rural areas and 14% in urban areas. In 2010, there was a
decline in tobacco consumption among adults: male consumption decreased from
51% to 34% and female from 7% to 2% (NBS, 2011a).
The share of smokers correlates with socioeconomic status, but the influencing
factors differ for men and women. A higher prevalence of smoking is recorded
among men from poor households (60%) and those with a lower level of education
(54.1%), while in the case of women, the situation is reversed: smoking prevalence is
higher among women from wealthier households and those with a higher level of
education. In terms of the number of cigarettes smoked per day, 85% of men and
40% of women smoke 10 or more cigarettes per day (NCPM Moldova & ORC
Macro, 2006). The results of the Moldova Demographic and Health Survey 2005
show that there are significant differences in the inequality index with regard to
smoking, assessed by level of education and economic welfare.
Hazardous alcohol use is one of the most important social and health concerns at
national level. A fairly large proportion of the adult population of the Republic of
Moldova consumes alcohol. According to data recently published by WHO, the adult
population (aged over 15 years) of the Republic of Moldova consumes the highest
quantity of pure alcohol per capita globally (WHO, 2011), amounting to 18.22 litres
per capita.

56Within the period 2000–2008, alcohol use in the Republic of Moldova remained at a
high level in comparison with countries from the EU, registering a decrease during
the period 2003–2004 and an increase in alcohol use since 2004.
The results of the Moldova Demographic and Health Survey carried out in 2005
(NCPH Moldova & ORC Macro, 2006) revealed that 59% of women and 81% of
men had consumed at least one alcoholic drink 5 during the month preceding the
study. Of the 81% of men who reported consuming at least one alcoholic drink during
the month preceding the survey, only 7% of men consumed alcohol once a month and
none did it less frequently than once a month. In total, 17% of men reported daily or
almost daily consumption of alcohol and 41% consumed alcohol at least once a week.
The Republic of Moldova has the highest rate of deaths from chronic liver diseases
and cirrhosis in Europe. Chronic hepatitis and cirrhosis caused 3533 deaths, or 99.2
deaths per 100 000 population in 2010, constituting almost 10% of total deaths.
27
The National Health Policy for 2007–2021 and the Health System Development
Strategy for 2008–2017 have served as the main guiding documents for subsequent
reform initiatives in the Moldovan health system – even though there have been three
changes of government since that time. This stability has allowed policy-makers to
build on the successes of previous reforms while tackling outstanding issues, albeit
against a background of severe financial constraints. The overall aims of these
documents have been to reduce health inequalities for all social groups as well as to
consolidate improvements of the health system and intersectoral working to
strengthen population health.
The full potential of intersectoral working has not yet been realized, but the national
programmes on tobacco and alcohol control introduced in 2012 are strong evidence
that such intersectorality is a genuine new feature of health policy development.
To improve equity in the system, amendments to the Law on Mandatory Health
Insurance in 2009 and 2010 sought to expand access to services by making access to
primary care universal and to increase the financial protection of vulnerable

57households by extending automatic MHI cover to families registered as living below
the poverty line even if they are formally “self-employed”.
Major changes to pharmaceutical pricing and procurement policies have sought to
improve access to pharmaceuticals by introducing reference pricing to ensure
pharmaceuticals are not more expensive in the Republic of Moldova than in
neighbouring countries and by centralizing procurement of essential medicines for
public health facilities. The latter is important not only to optimize purchasing power
but also to ensure that the supply of medicines is sufficient; otherwise inpatients
would have to pay out of pocket to obtain drugs that should be covered under MHI.
System and adapt it to the new conditions and the new social, economic and health
demands it faces. The key task has been to improve the efficiency of facilities and the
way they are financed. However, changing the mentality of those working in the
system as well as service users (who are often resistant to change) is a much greater
task. This has an impact on developing new regulatory mechanisms as the Soviet way
of working with regulation does not fit with the current socioeconomic reality, and
many of the regulations still in use pre-date independence. New levers are needed as
well as new skills in negotiating the market and ways of working with commercial
interests. Different reform initiatives have faced varying levels of political support or
resistance – particularly with optimization of the health system as
this involves rationalization of the hospital network, which is politically very
challenging irrespective of the party in power.
Since 2005, greater attention has been paid to health promotion activities and some
progress has been made in recent years. To promote healthier lifestyles, the Ministry
of Health developed the National Programme for the years 2007-2015 and
collaborates with the following entities.
75● Ministry of Education, on the promotion of healthy nutrition, physical activity
and health education in schools. Some aspects of health promotion are included in the
school “Civic Education curricula”; however, the problems addressed are too general.

58For the schoolchildren aged 12–14 years a facultative “Health Education hour” is
envisaged, but the necessary information-based support (guides, manuals, and so on)
is not available.
● Ministry of Agriculture and Food Industry, on food safety and healthy diet, mainly
to increase production of fruit and vegetable and ensure their availability on the
market.
● Labour Inspectorate, on prevention of occupational diseases and accide nts and to
ensure healthy workplaces.
Activities related to healthy diet, physical activity, and obesity prevention and control
An important element of health promotion is to ensure healthy nutrition in schools.
According to national legislation, it is forbidden to commercialize food products with
high energy density in schools (including preschools). However, there are fewer
choices for children to consume fruit and vegetables in educational institutions
(preschools, schools and other education institutions) and there is an inadequate level
of healthy food promotion.
In collaboration with various NgOs, recommendations on healthy nutrition and
healthy behaviour have been developed (manual and exercise book for teachers and
students, respectively, from professional colleges), which are to be approved by the
Ministry of Education as part of the training curricula in the country’s vocational
education institutions.
A handful of projects implemented at community level address some strategies for
promoting healthy nutrition and prevention of NCDs, but these are not implemented
regularly and are not national in scope.
Physical education is part of the school curricula in the Republic of Moldova. For two
hours per week, children engage in different physical exercise activities at school and
the majority of schools have equipped sports halls. Physical activities have begun to
be promoted by family doctors – not only to patients but also in the framework of
communication, information and educational activities that are carried out
periodically.

5976
Health promotion activities on tobacco and alcohol
Tobacco smoking and hazardous alcohol use are the most important social and health
concerns at national level. A fairly large proportion of the adult population of the
Republic of Moldova consumes alcohol. Prevalence of smoking in the country is also
high among the adult male population, at 51.1%. Due to a lack of resources, activities
at national level for health education and health promotion directed towards reducing
tobacco and alcohol consumption are limited only to seminars, speeches, lectures,
and information materials within the framework of the WHO World No Tobacco Day
(31 May) and the World No Alcohol Day (2 October).
With WHO and EU support, the Communication Strategy for a National Anti-
tobacco Campaign was recently developed and approved by the Ministry of Health. A
National Communication Strategy for Alcohol Control is also being developed.
Before lunching campaigns, the national baseline knowledge, attitudes and practices
(KAP) surveys were carried out. During 2012 and 2013 a number of communication
and health promotion activities are to be developed and implemented. Evaluation of
the communication campaigns will be carried out at the end of 2013.
Activities directed to drug abuse prevention and control
National actions to prevent and tackle drug consumption and illicit trafficking are
provided in government Decision No. 314 of 17 March 2007 on the approval of
measures to combat drug addiction and drug-business, and in the National Anti-drug
Strategy.
The national standards on reducing risks associated with injecting drug use and the
national standard on providing psychosocial assistance to drug users were approved
by Order of the Minister of Health No. 551 of 30 June 2011.
In the Republic of Moldova, various NgOs implement measures to reintegrate and re-
socialize drug addicts in residential settings. There are 19 mutual aid groups offering
psychosocial support to drug addicts in outpatient conditions. Existing programmes
do not provide any measurable objectives and performance indicators that would

60allow evaluation of their envisaged activities and impact. In addition, a lack of
adequate financial coverage for such activities has a negative influence on their
implementation. 77
At all levels, there is a lack of educational and information programmes for young
people to familiarize them with the consequences of consuming psychotropic
substances, as well as to motivate them to adopt a healthy lifestyle.
Activities related to prevention of infectious diseases (HIV/AIDS, TB)
The Republic of Moldova has a legal framework on the prevention of HIV/AIDS and
TB, incorporating various laws,8 the National TB Prevention and Control
Programme for 2011– 2015, and communication strategies for the prevention of
HIV/AIDS and TB.
The health and education sectors, NgOs, and other public order services are involved
in prevention activities. Educational/information materials are developed at national
level within different projects, taking into account high-risk groups, age and
language(s) spoken. It is worth mentioning that the majority of prevention activities
are funded by donors.
Communities (including young people, NgOs, local public authorities, families,
schools) are actively involved in implementing activities to prevent HIV/AIDS and
TB. Communication, information and education activities are based, to a great extent,
not only on accumulation of knowledge but also on communication for behaviour
change.
Complex annual and multiannual plans are in place in the field of HIV/AIDS and TB
prevention and control. Surveillance and control services for HIV/AIDS and TB are
focused on high-risk population groups.
Activities related to prevention and control of occupational and work-related
health hazards, including workplace health promotion
Public health specialists from the regional Centres of Public Health and the NCPH
are involved in promoting the need for healthy working conditions. groups of workers
from different fields are trained on specific public health issues. Workplace risk

61analysis and risk assessment in big companies is conducted systematically; however,
in small and medium-sized companies, it is only performed occasionally. Incidence
of injuries, accidents at the workplace and occupational diseases are also monitored.
8 Law No. 23-XVI on prevention of HIV/AIDS (10 February 2007) and Law No.
76 to amend and supple- ment Law No. 23-XVI (12 April 2012). 78
Activities undertaken in this area are intersectoral in nature; mutual collaboration
takes place between the work protection departments of the enterprises involved, and
the Ministry of Labour, Social Protection and Family.
No surveys are conducted on the KAP of the target groups of the population, which
means that activity planning is not survey based. No health education materials are
currently being developed.
Services for the prevention and control of occupational health hazards and workplace
dangers are not aimed at the entire population, and aspects such as poverty, ethnicity,
sex and other socioeconomic factors are not taken into consideration.
The issue of injuries and trauma (drafting of legislation, information campaigns,
prevention activities, workshops, training) is tackled at intersectoral level, involving
the Ministry of Health, the Ministry of Labour, Social Protection and Family, the
police, and so on. Educational/information materials on preventing trauma, accidents
and violence are financially and technically supported by various donors within the
framework of the specific projects. Due to a lack of continuous financial and
technical support, these activities were only implemented for a short period of time.
The Public Health Services make efforts to involve the community, family and school
in activities related to prevention of trauma and violence through education and
communication, “round table” meetings, and various group activities (competitions,
exhibitions, and so on).
Activities related to dental hygiene education and oral health
Dental hygiene and oral health in the Republic of Moldova are addressed less
systematically, at the level of educational institution, within one-off activities
(lessons, contests, themed events, and so on) or within certain projects implemented

62at community level. At the national level this issue is not properly addressed
(programmes, action plans, awareness campaigns, and so on).
The legal framework for health promotion in the Republic of Moldova is only partly
developed and consists of a national programme on health promotion and specific 79
activities within various health programmes and action plans. Information materials
on health education are developed sporadically, to an insufficient extent, by
organizations implementing individual national or regional projects. These materials
address only few public health problems (TB, HIV/AIDS, and reproductive health,
for example). At national level, health promotion activities are organized by health
education specialists from regional (rayon and municipal) Centres of Public Health
on World Prevention Days/Weeks/ Months, with activities focusing on prevention
lectures, individual talks, themed evenings, training sessions, and so on.
Strengths
●Political commitment to health promotion and disease prevention activities,
reflected in various policy documents.
● Methodological and financial support provided by international organizations in
health promotion and disease prevention activities.
Weaknesses
● Insufficient funding of national and local health promotion interventions/activities.
● Insufficient involvement of local public authorities in the development and support
of local-level activities.
● Insufficient motivation of health workers
● Lack of surveys on NCD risk factors.
● Insufficient capacities and resources for developing and printing health promotion
materials on priority public health issues for different target groups.
● Insufficient administrative capacity in health promotion (structures, trained staff,
local trainers, hobby clubs).

63CONCLUSIONS
1.The Healthy Israel 2020 (HI2020) initiative was conceived with a goal of
creating a preventive blueprint to improve the quality of life, increase overall
longevity, and maximize health equity among Israelis.
2.Fifteen percent of Israel’s adult population is obese; roughly one out of two is
overweight. More than one out of five children aged 12-18 is overweight or
obese.
3.The legal framework for health promotion in the Republic of Moldova is only
partly developed and consists of a national programme on health promotion
and specific 79activities within various health programmes and action plans.
4.At national level, health promotion activities are organized by health education
specialists from regional (rayon and municipal) Centres of Public Health with
activities focusing on prevention lectures, individual talks, themed evenings,
training sessions, and so on.

64RECOMMENDATIONS
●Develop a strategy and an action plan for health promotion and health
communication.
● Optimize the financing of national prevention and health promotion programmes.
● Train and motivate health promoti on specialists at central and local levels to
develop and carry out health promotion activities.
● Optimize activities to promote physical activity, healthy nutrition, oral health,
prevention of accident and injury, and to reduce tobacco, alcohol and drug use, and so
on.

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67Declaration
I hereby declare that the diploma thesis entitled " Comparative evaluation of health
promotion system in the Republic of Moldova and Israel " is written by me and
has not been presented before at another college or institution of higher education in
the country or abroad. Also, I declare that all sources used, including the Internet
sources, are indicated in the paper, considering the rules for avoiding plagiarism: – all
text fragments are reproduced exactly, even the proper translations from other
languages are written in quotes and have detailed reference source; – paraphrasing in
own words of text written by other authors has detailed reference; – summary of the
ideas of other authors has a detailed reference to the original text.
Date
Name and surname of student Hujeirat Ahmad

_______ _____
(Original signature)