Health 2020: A New European Policy Framework for Health and Well-Being
Health 2020:a new European policy framework forhealth and well-beingZsuzsanna JakabWHO Regional Director for Europe20 June 2013, Yerevan Armenia
Why Health 2020?Significant improvements in healthand well-being but … uneven andunequalEurope’s changing healthlandscape: new demands,challenges and opportunitiesEconomic opportunities andthreats: the need to championpublic health values andapproaches
Health – a precious global good• Higher on the political and social agenda ofcountries and internationally• Important global economic and securityissue• Major investment sector forhuman, economic and social development• Major economic sector in its own right• A human right and matter of social justice
What is Health 2020?Health 2020 is a value-basedaction-oriented policyframework, adaptable todifferent realities in the countriesof the WHO European Region.Health 2020 is addressed toministries of health but also aimsto engage ministers and policy-makers across government andstakeholders throughout societywho can contribute to health andwell-being.
Health 2020 documentsThe longer Health 2020policy framework andstrategy document providesthe contextual analysis andthe main strategies andinterventions that work; anddescribes necessarycapacities to implement theHealth 2020 policy.The short Health 2020 policyframework contains the keyevidence, arguments andareas for policy action toaddress the public healthchallenges and opportunitiesfor promoting health andwell-being in theEuropean Region today.(www.euro.who.int/health2020)
WHO Regional Committee for Europeadopted Health 2020 in September 2012Aim – To significantly improve health and well-being of populations, toreduce health inequities and to ensure sustainable people-centredhealth systems.
Building on public health history• WHO Constitution• Declaration of Alma-Ata• Health for All• HEALTH21• Tallinn CharterIntegrated policy frameworkscan and have inspired health-generatingactions on all levels.
Overall health improvement (+ 5 years life expectancy)but with an important divide in the RegionCIS: Commonwealthof Independent StatesEU12: countriesbelonging to theEuropean Union (EU)after May 2004EU15: countriesbelonging to the EUbefore May 2004Source: EuropeanHealth for Alldatabase.Copenhagen, WHORegional Office forEurope, 2010.
Life expectancy at birth in the European Region,last reported data, 2006–2010Source: European Health for All database. Copenhagen, WHO Regional Officefor Europe, 2010.
Total DALYs lost per 100 population in countries inthe European Region, 2004Source: adapted fromGlobal burden ofdisease:2004 update. Geneva,World HealthOrganization, 2004.
Tuberculosis incidence per 100 000, 1970–present0102030405060701980 1990 2000 2010 2020ArmeniaEUTuberculosis incidence per 100000
HIV incidence per 100 000, 1970–present012345671980 1990 2000 2010 2020ArmeniaEUHIV incidence per 100000
Infants vaccinated against diphtheria (%),1970–present607080901001980 1990 2000 2010 2020ArmeniaEU% of infants vaccinated against diphtheria
Increasing attention to inequityFor richer, for poorerGrowing inequality is one of thebiggest social, economic andpolitical challenges of our time. Butit is not inevitable …– The Economist, special edition, 13 October 2012(http://www.economist.com/node/21564414)
Changing health landscape• The global health architecture has become more extensive butvery complex• Globally and regionally health has improved, yet deep inequitiesremain• Health challenges are multifaceted and require active involvementof all levels of government (international, national, and local)People live longerand have fewerchildren.People migratewithin and betweencountries; citiesgrow bigger.Health systemsface rising costs.Primary health caresystems are weakand lack preventiveservices.Public healthcapacities areoutdated.Infectious diseases,such as HIV andTB remain achallenge tocontrol.Antibiotic-resistantorganisms areemerging.Noncommunicablediseases (NCDs)dominate thedisease burden.Depression andheart disease areleading causes ofhealthy life-yearslost.
Trends in premature mortality by broad group of causes inthe European Region, 1980–2008YearStandardizeddeathrate,0-64per100,0000204060801001201401980 1985 1990 1995 2000 2005CauseHeart diseaseCancerInjuries and violenceInfectious diseasesMental disordersSource:EuropeanHealth for Alldatabase.Copenhagen,WHO RegionalOffice forEurope, 2010.
1. surveillance and assessment of thepopulation’s health andwell-being;2. identification of health problems andhealth hazards in the community;3. health protection services(environment, occupation, foodsafety);4. preparedness for and planning ofpublic health emergencies;5. disease prevention;6. health promotion;7. assurance of a competent publichealth and personal health careworkforce;8. governance, financing and evaluationof quality and effectiveness of publichealth services;9. communication for public health; and10.health-related research.10 essential publichealth operations(EPHOs):
Working to improve healthfor all and reducingthe health divideImproving leadership, andparticipatory governancefor healthInvesting in health through alife-course approach andempowering peopleTackling Europe’s majorhealth challenges: NCDsand communicable diseasesStrengthening people-centred health systems,public health capacities andemergencypreparedness, surveillanceand responseCreating resilientcommunities and supportiveenvironmentsHealth 2020: four common policy priorities for healthHealth 2020: strategic objectives
New evidence informing Health 2020• Governance for health in the 21st century• Supporting Health 2020: governance for health in the 21stcentury• Promoting health, preventing disease: the economic case• Intersectoral governance for health in all policies:structures, actions and experiences• Report on social determinants of health and the healthdivide in the WHO European Region• Review of the commitments of WHO European MemberStates and the WHO Regional Office for Europe between1990 and 2010
WHO European review of social determinants and thehealth divide:* key findings and recommendations toimprove equity in healthPolicy goals• Improve overall health of the population• Accelerate rate of improvement for those with worsthealthPolicy approaches• Take a life-course approach to health equity.• Address the intergenerational processes that sustain inequities• Address the structural and mediating factors of exclusion• Build the resilience, capabilities and strength of individuals andcommunities* The study was carried out by a consortium of over 80 policy researchers andinstitutions across Europe (2012), and led by Sir Michael Marmot.
GDP per capita in countries in the European RegionSource: European Health for All database.Copenhagen, WHO Regional Office for Europe, 2010.GDP: gross domestic product.
Chief Medical Officer’s MeetingCopenhagen 12-13 April 2012Improving governance for healthSupporting whole-of-government and whole-of-society approachesLearning from a wealth ofexperience withintersectoral action andhealth-in-all-policies (HiAP)work in Europe and beyondTwo studies on governance for health led by Professor Ilona Kickbusch(2011, 2012)Intersectoral governance for HiAP, by Professor David McQueen et al.
Health 2020 framework• that countries engage from a different startingpoint and have different contexts and capacities; and• that every country is unique and they will pursue commongoals through different pathways and use different entrypoints and approaches but be united in purpose.An adaptable and practical policy framework that recognizes:
Health 2020 – reaching higher and broader• Going upstream to address root causes such associal determinants• Invest in public health, primary care, healthprotection and promotion, and disease prevention• Making the case for whole-of-government andwhole-of-society approaches• Offering a framework for integrated and coherentinterventions
Economic case for health promotion anddisease preventionCardiovasculardiseases (CVD)Alcohol-relatedharmCancerRoad-trafficinjuriesObesity-relatedillness (includingdiabetes and CVD)€169 billion annually in the EU, healthcare accounting for 62% of costs€125 billion annually in the EU, equivalentto 1.3% of gross domestic product (GDP)Over 1% GDP in the United States, 1–3%of health expenditure in most countries6.5% of all health care expenditure inEuropeUp to 2% of GDP in middle- and high-income countriesSources: data from Leal et al. (Eur Heart J, 2006, 27(13):1610–1619 (http://www.herc.ox.ac.uk/pubs/bibliography/Leal2006)),Alcohol-related harm in Europe – Key data (Brussels, European Commission Directorate-General for Health and Consumer Protection, 2006(http://ec.europa.eu/health/archive/ph_determinants/life_style/alcohol/documents/alcohol_factsheet_en.pdf)),Sassi (Obesity and the economics of prevention – Fit not fat. Paris, Organisation for Economic Co-operation and Development, 2010) and Stark (EJHPPractice, 2006, 12(2):53–56 (http://www.google.co.uk/url?q=http://www.eahp.eu/content/download/25013/162991/file/SpecialReport53-56.pdfandsa=Uandei=BNI4T-K7JoKL0QGXs6HFAgandved=0CBwQFjAFandusg=AFQjCNHS922oF8d0RLN5C14ddpMVeRn8BA).
Using fiscal policy to improve health outcomesTobaccoA 10% price increase intaxes could result in up to1.8 million fewer prematuredeaths at a cost of betweenUS$ 3 and US$ 78 perDALY in eastern Europeanand central Asian countriesAlcoholIn England, benefits closeto €600 million in reducedhealth and welfare costsand reduced labor andproductivity losses, at animplementation cost of lessthan €0.10 per capitaSource: McDaid D, Sassi F, Merkur S, eds. The economic case for publichealth action. Maidenhead, Open University Press (in press).
Health impact of social welfare spendingand GDP growth• Each additional US$ 100 percapita spent on social welfare(including health) is associatedwith a 1.19% reduction in mortalitySocialwelfarespending• Each additional US$ 100 percapita increase in GDP isassociated with only 0.11%reduction in mortalityGDPSource: Stuckler D et al. Budgetcrises, health, and social welfare programmes.BMJ, 2010(http://www.bmj.com/content/340/bmj.c3311).
Total health expenditure as share of GDP(%), 1970–20103456789101995 2000 2005 2010 2015ArmeniaEUTotal health expenditure as % of grossdomestic product (GDP), WHO estimates
Out-of-pocket expenditure as a proportion of total healthexpenditure in the European Region, 2009Source: European Health for All database.Copenhagen, WHO Regional Office for Europe, 2010.
Universal health coverageEnsure that people have equal access to quality health servicesand financial protection:• coverage with health services (prevention, promotion,treatment and rehabilitation);• coverage with financial risk protection.Potential indicators, focusing on coverage and protection:1. increased coverage of essential services: build on the presentMillennium Development Goals plus NCDs and preventive services;2. increased equity and financial protection: reduced gap betweenthe first and fifth quintiles, reduced levels of out-of-pocketexpenditure, etc.; and3. strengthening health systems: indicators onworkforce, management and leadership capacity, informationsystems, governance, infrastructure and quality.
Preserving health in times of austerity• The effects of the crisis vary greatly across countries.• Across the Region we see lower growth and higher unemployment.• The crisis exacerbated health-system challenges that already existed.• It is important to avoid across-the-board budget cuts.• Target expenditure by focusing on supply side efficiency gains, e.g.:– the wiser use of technologies and medicines– rationalizing service delivery structures.• Think long-term and implement counter-cyclical spending (save ingood times to spend in bad times).
Additional layer of complexity from austerity:lessons learned from past and present crises• Associated with a doubling of the risk ofillness and 60% less likelihood of recoveryfrom disease*• Strong correlation with increased alcoholpoisoning, liver cirrhosis, ulcers, mentaldisorders**• Increase of suicide incidence: 17% inGreece and Latvia, 13% in Ireland***• Active labour market policies and well-targeted social protection expenditure caneliminate most of these adverse effects****UnemploymentSources: * Kaplan, G. (2012). Social Science and Medicine, 74: 643–64Sources: *Kaplan, G. (2012). Social Science and Medicine, 74: 643–646.** Suhrcke M, Stuckler D (2012). Social Science and Medicine, 74:647–653.*** Stuckler D. et al. (2011). Lancet, 378:124–125.**** Stuckler D. et al. (2009) . Lancet, 374:315–323.
Challenging the view of health as a cost to society:example from the United Kingdom• Health and social care system in north-west region £8.2 billion (10% ofregional total GDP: £88 billion): 60%on staff with £2 billion on goods andservices• 340 000 people employed directly(12% of regional employment)• 0.5% of regional businesses primarilyin the health sector :780 businesses• 50% of health sector firms haveturnovers of £100 000–499 000• Capital spending programmes for 5years is £4.5 billionHealth sector’s contribution to the economySource: Claiming the health dividend. London, The King’sFund, 2002(http://www.kingsfund.org.uk/publications/claiming-health-dividend).
NCD action plan 2012–2016Planning andoversightNational planHealthinformationsystem withsocialdeterminantsdisaggregationHiAPFiscal policiesMarketingSaltTrans fatsHealthysettingsWorkplaces andschoolsActive mobilitySecondarypreventionCardio-metabolicrisk assessmentandmanagementEarly detectionof cancer
Health 2020: rethinking policies for healthand approaches to stakeholder engagementAlcohol-related harmSource: McDaid D, Sassi F, Merkur S, eds. The economic case for public healthaction. Maidenhead, Open University Press (in press).€125 billion annually inthe EU, equivalent to1.3% of GDPMapping allies and interestsMinistry of justice, policeEmployers and development sectorsHealthTransportLocal communitiesExample: fiscal policyto control harmful useof alcohol
Health 2020 lays the foundation for ahealthier European Region“So many factors affect health, and health has an impact on so many areas of our livesthat progress on public health can only come from whole-of-society and whole-of-government efforts.That is why there is a role for everyone to play in implementing Health 2020, from primeministers, to civil society, to citizens.”– Zsuzsanna Jakab, WHO Regional Director for Europe
Dear prime minister, minister, mayor or member of parliament:Good health underpins social and economic development and strengthens policies across all sectors.However, the economic and fiscal crisis facing many countries presents serious challenges and potentiallyrisks undermining the positive progress that has been made. Nevertheless, it also presents an importantopportunity to refocus and renew our efforts to improve the health of all people.All sectors and levels of government and society contribute to health creation. Your leadership for healthand well-being can make a tremendous difference for the people of your country, state, region or cityand for European Region as a whole.Your support for Health 2020 is truly essential.