Prevention of Chronic Non-Communicable Diseases in Russia: Analytical Review of General Institutional Issues

Objective: The purpose of this research is to assess regulatory, organizational and methodological documents, as well as Russian and international recommendations, to use infromation from them to identify and systematize problems in prevention of chronic non-communicable diseases, and tooffer solutions. Materials and Methods: Analysis encompasees the key Federal Laws of the Russian Federation; orders, records, and reports provided by various ministries and departments of the Russian Federation,as well as by the leading research institutes; guides, manuals, and federal recommendations; the latest Russian and foreign guidelines and recommendations on prevention of chronic non-communicable diseases. Results and Discussion: Analysis was faced with a number of problems:poor correlation between changes in regulatory documents governing the prevention of chronic non-communicable diseases; incomplete allowance for international experience and guidelines on prevention of chronic non-communicable diseases, incomplete epidemiological data; poor coordination and uneven assignment of responsibilities in structures involved in prevention; shift in emphasis from population-oriented prevention and high-risk groups towards secondary prevention; below-satisfactory efficiency of tuberculosis screening in clinical examination. Conclusions: Their resolutionmay significantly increase the effectiveness of measures intendedfor prevention of chronic non-communicable diseases and their risk factors from occurence in Russia.


Introduction
Chronic non-communicable diseases (NCDs) accaunt for about 75% of death cases among adultsinRussia, causing demographic losses and GDPlosses, down 3% annually 1 .This defined the priority of Russin demographic policy until 2025 -socially significant reduction of CNCD and their risk factors (RF), as well as motivation of population to a healthy lifestyle (HLS) 2 . Public health policies in most countries are driven by outbreaks of non-communicable diseases (NCDs), which become the leading cause of death and disability. Accorying to experience of countries where death rates from these diseases dispay a steady decline,institutional preventive measures are effective when it comes to control over NCDs if introduced on an interdepartmental basis.Such measures imply not only improving of the health care system, but also improving of a responsible attitude to health among the population, as well as providing of conditions for a healthy lifestyle. This tentacles almost all spheres of society (governmental, political, public, cultural, religious, and business spheres). In Russia, prevention of NCDs has been priority in the field of public health since 1993, but the first WHO Global Ministerial Conference held in Moscow on April 2011 with the participation of more than 800 delegates from 164 member countrieswas a crucial event that strengthened state and public efforts in this direction. At this conference, problems of a healthy lifestyle and control over NCDs were not only essential -the emphasis was placed on a sector wide approach to solving them. Emphasized was the significance of making preventive services a must routineto take in the health care system, especially in primary health care (PHC), thereby creating a unified preventive platform 3 . The greatest boost to NCD prevention improvement was given in primary health care ofthe Russian Federation in 2013,when a new methodological and organizational basis was introduced to general screening practice for adults. Massscreeningexamination of adult population was chosen as a measure that could accelerate the decline in death rates, which is still insufficient. Medical screening examination refers to highrisk strategic measures intended for reduction of premature mortality. This strategy centers around identification of individuals that are at increased risk of NCD development. In Russian-language literature, general medical examination is the term to describe a preventive strategy that implies checkups and statistical analysis, while abroad, this term isscreening. According to the UK National Screening Committee, screening is a systematic application of a testor inquiry, to identify individual sat sufficient risk of a specific disorder to warrant further investigation or direct preventive action, amongst persons who have not sought medical attention on account of symptoms of that disorder. The world accumulated great experience in conducting mass surveys, namely in screening. In most national programs of Europe (Lithuania, Belgium, Denmark, the United Kingdom, Ireland, Spain, Italy, the Netherlands, Finland, France, Sweden, Hungary, Latvia, Slovakia, Estonia, etc.), NCD risk identification is currently focused on those risk factors affecting NCD emergence and development that arise from lifestyle and behavioral habits (tobacco smoking, low physical activity, unbalanced nutrition, excessive alcohol consumption, etc.). In Russia, medical screening examination has a long history. Preventive framework of national health care was established from the moment of system creation. Prevention is the path we take, screening is a method for solving preventive problems (from speeches of N.A.Semashko, the first the first Soviet People's Commissar of Public Health). Although public health protection priorities were different those days, preventive focus of health care was clear. The first detailed and most complete national program of medical examination was adopted in 1986 However, its implementation was accompanied with organizational difficulties, which were not taken into account at development stageas they should be, as well as with a number of methodological drawbacks associated with the content of a survey program, and with evaluation criteria. This is why in 1986, medical screening examinationwas a costly and organizationally complex practice that proved to be performance-inhibitive to polyclinics, and not effective enough as well. As a result, doctors and the population have formed a rather formal likely negative attitude towards its implementation that has been standying there for many years. On a regular basis, medical screening examination was re-implied in 2006. This time practice was guided by the principle of occupational preventive medical check-up. This event was much smaller with an annual involvement of about 2.5 to 4 million people of working age (about 75 million working citizens in total). Still, this organizational model of medical examination hadmethodological and organizational shorcomings of its own. Medical screening examination was organizedby specialization, which in practice broke the continuity between doctors conducting these medical and primary care physicians, general practitioners or family physicians. The consequence here was a disturbance of additional examination process conductedfor clarification, and of necessary medical interventions, including preventive ones. Active implementation and updating of medical examinations and screeningwere catalized by the Federal Law No. 323-FZ on Basics of Health Protection of the Citizens in the Russian Federation, dated 21.11.2011. Guided by its implementation plan, the Ministry of Health adopted the Procedure of Health Examination of Certain Population Groups on December 3, 2012 (hereinafter referred to as the Screening Procedure) 4 ,which was developed with regard to peculiarities of populationhealth care organization in Russia, previous experience in medical examinations, and international experience in population screening. The Procedure for Preventive Health Examination was adoptedin parallel with the Screening Procedure 5 . Preventive medical examination, considered as a shorter version of screening, serves as a substitute tool in years when a citizen is not subject to screening examination. Besides those two procedures, a regular check-ups procedure was adoptedon December 21, 2012, No. 1344n 4 , which defines the process of controlling NCDs and other chronic diseases after detection. Even though a range of strategic measures was undertaken, this analysis shows that the existing concept of prevention of chronic NCDsinvolves poorly developed mechanisms of solving that problem.At this point, regulatory documents should be revised forconfirmity with one another and with Russian and international clinical guidelines. The untimely emergence of organizational and methodological support become an obstacle to a unified coordination of preventive measures in practice. So far, their effectivenessis reduced. The purpose of this research is to assess regulatory, organizational and methodological documents, as well as Russian and international recommendations, to use infromation from them to identify and systematize problems in prevention of chronic noncommunicable diseases, and to offer solutions.

Material and methods
In modern Russia, pressing nature of chronic NCD issues together with public concern triggered the adoption of the Order of the Non-Communicable Disease Prevention and Healthy Lifestyle Promotion in Medical Organizations was adopted to coordinate preventive activities for chronic NCD. However, it failed to create a system with delimitation of authority and withrelations between different prevention directions 20 . General institutional problems that may affect the effectiveness of chronic NCD prevention programs are shown in Figure 1.
Below are details on every single problem from Figure 1, evidence on problem relevance, negative consequences, and solutions.

Case 1.
Under the Order of the Ministry of Health of the Russian Federation No. 869n of 26.10.2017, some phase I tests were excluded from NCD screening, namely complete blood count, biochemical blood test,common urine test, ultrasound examination of abdominal and small pelvis,ultrasound examination of abdominal aorta. New added was a definition of prostate-specific antigen (PSA) in blood (for men aged 45 and 51). Consulting service was distinguished as short-term and individual prophylactic consulting. Phase II screening process was shortened by the exclusion of esophagogastroduodenoscopy, sigmoidoscopy, lipid, and glycated hemoglobin tests. Statistical reporting forms, approved by the Order of the Ministry of Health No. 87non March 6, 2015, did not change so far. Tests that remained were tests for malignant diseases and suspected esophageal diseases, stomach diseases,pancreatic diseases,uterine diseases,ovarian diseases,kidney diseases (except those oftherenalpelvis),blood diseases, diseases of blood-forming organs, and certain disorders involving the immune mechanism.
No changes were made to сonsulting 16,19 . Population-oriented screening examination is an expensive service, so the reason for conductiong such must be good from clinical and economic points of view. The most recognised approach to selecting examination methods is the European approach, known as the evidence-based medicine approach, and the USPSTF recommendations.
The first implies the definition of how intervention should be performed and to what extent, while the secondcenters aroundrisk-benefit ratio. In Russia, incomplete allowance for international experience resulted in high screening costs that have been so for five years. Despite a significant number of interventions taken off the list in 2018, some items thereare still to question 1,16 .

Case 2
Health centers were created to promote healthy lifestyle among citizens of the Russian Federation, and to reduce alcohol and tobacco consumption. From this goal, objectives arosewith the following majors: shaping of a responsible attitude to health, identifying and eliminating of NCD risk facotrs, and chronic NCD prevention. Units similar to thesewere created in other countries to prevent chronic NCDs from development on a national level. These units operated effectivelly due to minimal costs of risk factor assessment and eliminationprocesses oriented on the population. This effectiveness was evidenced froma decline in chronic NCD incidence/mortality rates. In health centers, about 90% of time goes for determining functional changes, but their effect on chronic NCD incidence/mortality rates was not proven. Therefore, one can witness a featherbedding practice: equipment standards encompass hardware and software packages for psycho-physiological and somatic health screening, for assessingfunctional and adaptive reserves of the human body. Their use takes too much time, as well as the use ofcomputerized heart disease screeningsystems, angiological screening systems, bio-impedancemetry systems; pulse oximetry systems; exhaled carbon monoxide analyzer kits; spirometers; blood and urine test kitsused to detect cotinine and other markers (narcotic drugs); dental hygienist and optometrist equipment, which are also in equipment standards. Even spirometry is not recommended for asymptomatic citizens as a screening method 14 For prevention and early detection of cancer, women 18 years and older, as well as men 30 years and older,suppose to make a visit to the exam room every 2 and 3 years, respectively. Thus, a person canapply to medical organization for NCD prevention 7-9 times in three years (2-3 times a year), but some examination methods will be used on him/her more than one time 1,5,7,16,20 .

Case 2
Organizing screening and complete medical examinations is one of the main functions that preventive care facilities have 20 . However, according to the Order No. 869n of 8/16/2017, head physician is the only person responsible for their overall organization, responsibilitiesof medical personnel were not specifed. This document does not secure the coordination of biological samplying, laboratory and instrumental surveys, and consultations of screening specialists to anybody either. In countries that stuck to three strategies of chronic NCD prevention, NCD mortality rate dropped by more that 50%. Population-oriented strategy suggests an impact on 100% of the population. With 10% of money allocated for mortality reduction spent on chronic NCD prevention, NCD mortality will reduce by 25%. Screening/preventive health examinations provide an opportunity to attract health group I people that are at high risk of NCD development. Initially, these individuals were deprived of individual and/ or group in-depth preventive consulting, which may act not only as an information-providing tool, but also as a motivator to change behavior and live a healthy life while the NCD risk is still low. 3 According to the Orders No. 1006n (03. 12.2012) and No. 36an (03.02.2015), health group II citizensat high NCD risk and at very high risk of absolute total cardiovascular disease developmenthave the oppotyunity to get individual and/or group screening consulting.The Order of the Ministry of Health No. 869n of 26.10.2017 obligated refferal of these categories of people, as well as patients with obesity, total cholesterol of ≥8 mmol/L, and smokers that takeover 20 cigarettes per day, to individual preventive consulting in preventive care facilities. This approach is ineffective because patients that do not have any symptoms have poor adherence to further therapy and preventive interventions, so the follow-upis minimal 16,23,24 . Since screening/ preventive health examinations are part of a high-risk strategy, health group II people are the target group. Proportion of the population at high NCD risk above 20%, and the contribution to mortality reduction via rational chronic NCD prevention is also estimated as 20% 1 .

Case 2
Individual and/or group preventive consulting is provided for IIIa and IIIb health groups by Order of the Ministry of Health No. 869n of October 26, 2017 No. 869n, but it has to do nothing with screening, since elimination of risk factors in this case requires additional examination and depends on the nosologicalformand stage of disease, its severity. Accordying to Russian classification: Group I citizens are citizens with no evidence of chronic NCDs (pathological conditions), which are the main cause of disability and premature mortality, and with no NCD risk factors, or these risk factors may be present at low/moderate total CVD risk and that do not require regular follow-up for other diseases (conditions). This category of citizens go through brief preventive consulting, and visit primary care physicians, medical doctors, or assistants, in preventicce care offices and/ or health centers for managing risk factors. Group II citizens are citizens with no evidence of chronic NCDs (pathological conditions), which are the main cause of disability and premature mortality, but do have NCD risk factors and high, or very high, risk of developing CVD. Thus, they need to be checkupped on a regular basis. This category of citizens have their risk factors corrected in preventicce care offices and/or health centers. If necessary, medicine is indicated for this purpose. Group III citizens are citizens that have diseases requiring rugular check- Carrying out of lung X-ray screening to detect chronic NCD is a not justified practice, as it has been proven that population-orientedstrategy of screening is not effective in detecting tuberculosis 5,16,25  .

Case 2
A number of essential risk factors for oncological diseases are not considered, but they, as well as other common risk factors for CVD, make a significant contribution to morbidity and mortality. These factors are communicablediseases, ultraviolet radiation, ionizing radiation, reproductive and hormonal factors, environmental pollution, and occupational exposure 17 .

Case 3
The algorithm for detecting diabetes does not involve the FINDRISKscale, which allows assessing the risk of diabetes development and reducing the extent of clarification examination 26  2. Apply universal screening with different methods of automatic ranking, for example, by month of birth: 18 years,1-4 months; 19 years, 5-8 months; 20 years, 9-12 months. etc.

Conclusion
Even though Russian Federation put a lot of effort in population health improvement within the past year, some general problems remain. Once they are solved, measures aimed at the prevention of chronic NCDs and elimination of associated risk factors can be significantly improved in terms of effectiveness. Despite a range of strategic measures undertaken, this research shows that the existing concept of chronic NCD prevention does not involve complete mechanisms for solving given problem. This nessecitated the revision of regulatory documents for confirmity with one another and with Russian and international clinical guidelines. The untimely emergence of organizational and methodological support become an obstacle to a unified coordination of preventive measures in practice. So far, thier effectiveness was reduced. Nevertheless, objective organizational difficulties and subjective factors,generated by inadequate fulfillment of requirements imposed by regulatory documents, as well as new screening procedure implementation experience of the first years, did not hinder the government from doing a significant job. New screening procedure implementation experience put on display that methodological and organizational problemsshould be solved in order to improve the quality of screening and to achieve real outcomes. Screening quality is not the only case; solutions together with an effectiveregular checkups organization will allow bring a real preventive component to the practice of providing medical services. This is the only practice that will reduce the number of exacerbation-related visits.

Conflict of interests
The authors declare no conflict of interests.