Address to the Meeting of Chief Medical Officers of the European Union
16 November 2010, Liège, Belgium
Ladies and gentlemen,
It is a very great pleasure to be speaking to you today at this meeting of the Chief Medical Officers of the European Union (EU). I took up my position as WHO Regional Director for Europe in February, and have given the greatest priority to extending our strategic partnership with the EU.
The EU is a major global and regional actor with competencies in many fields. The EU is also the world’s largest provider of development assistance and humanitarian aid. In all of these spheres it is a natural partner for the United Nations.
The EU also has an increasing role in health matters and, most importantly for our partnership, the EU and WHO share the same geographic constituency, the same values for health: human rights, universality, equity and solidarity. These are also the values captured in the Lisbon Treaty and the European Social Charter. These same values have underpinned the policies of WHO since it was founded and through the years of its Health for All policies, HEALTH21 and the Tallinn Charter. These mutual values and strong commitment to multilateralism make the EU and WHO natural allies.
The EU reflects the aspirations of 27 Member States, plus those in the European Economic Area and the European Free Trade Association. The WHO European Region comprises 53 Member States, and must be relevant to and serve all of these, so, as I have mentioned, there is great coterminosity between the two organizations and both have presence in the same countries. There is a history here: I think of the work we did during the time of my predecessors in the pre-accession and accession processes in the countries of eastern and south-eastern Europe. For some countries that work continues.
In parenthesis, globally there is also much interplay between the work of the EU and WHO. Our six regions and 193 Member States reflect the huge diversity in economic and health development in the world, which includes the economic rise of Brazil, the Russian Federation, India and China and newly important regional groupings in Asia and the Americas. To give just one example of where these interests come together, there is progress towards the Millennium Development Goals, about which I shall say a little more later.
It is for all these reasons of shared interest that I have placed the very highest priority on extending and developing WHO’s work with the EU for health. We each have our own constitutions and accountabilities, yet we can do so much more for health across Europe if we work together. I am delighted that already we have, with the European Commission, developed a shared vision for joint health action that Commissioner Dalli and I symbolically exchanged at the recent Regional Committee meeting in Moscow, Russian Federation.
This shared vision has six specific flagship initiatives:
- one health security system to protect Europe;
- one health information system to inform Europe;
- sharing and exploiting good practice and innovations ;
- exchanging information and advocating policies to tackle health inequalities, also for future generations;
- informing and facilitating efforts to invest in health to mitigate effects of economic crisis; and
- strengthening in-country cooperation through joint advocacy, information exchange and health assessments.
The WHO Regional Committee for Europe was presented with the overall health situation in Europe during its sixtieth session in Moscow and commented extensively on the need to tackle the main health priorities, especially noncommunicable diseases (NCDs). Here I will only briefly review the situation with selected examples. In the handouts prepared for you, there is a more extensive compilation of selected slides on the health situation and priorities in the EU.
In Europe as a whole, the overall health has improved as shown by the continuing improvement in life expectancy (the “Eur-A” blue line comprises the majority of EU countries), yet the gap between countries remains unacceptably wide.
Also, we all know that health-related inequalities persist between and within countries, stratifying populations according to ethnicity, gender, socioeconomic status, educational status and geographical area. I will choose just one statistic here to further illustrate this phenomenon: in 2007 the infant mortality rate in the poorest countries of the European Region was 25 times that in the richest.
The overall burden of disease shows that today NCDs, particularly cardiovascular disease and cancer, are the leading cause of mortality and morbidity in the European Region, with mental disorders also a main contributor.
As I mentioned earlier, the Regional Committee emphasized that NCDs are a serious threat to health and socioeconomic development. For many of our citizens these diseases create a poverty trap, causing catastrophic health expenditures and poverty. This epidemic of NCDs threatens to overwhelm health systems in some countries. Yet although these are sombre facts, investments in prevention and mental health remain low, accounting for just 1–5.9% of overall European health expenditure, well below the average for Organisation for Economic Co-operation and Development (OECD) countries.
For the main NCD components of the disease burden, we increasingly have proven capacities to intervene across the spectrum of health promotion, disease prevention, therapy and rehabilitation. Promoting healthier lifestyles is of pre-eminent importance, including the fields of smoking, alcohol, physical activity and substance abuse. We have seen success in tackling smoking prevalence, yet there are increasing signs of the resurgence of the tobacco industry (e.g. easing of advertisement rules). Just one statistic to show that we must not let our guard down is the female lung cancer mortality in the EU.
With alcohol, we are at same stage as we were with the tobacco industry in the 1960s and 1970s, and an effective package of public health interventions that addresses all of these risk factors must be developed to reduce the NCD burden and the subsequent costs for health systems. Accordingly, the Regional Committee strongly supported my view that a European integrated action plan on NCDs is required urgently. I intend to take this plan back to the Regional Committee in 2011.
There is also significant evidence showing how investments and decisions made outside the health sector influence (directly and indirectly) health outcomes for NCDs at the population and individual levels. For example, urban planning, agricultural policies, income level and market regulation have all been shown to influence diet, lifestyles and the related levels of obesity in society. As such, reducing the avoidable burden of NCDs requires joint planning and action across sectors, to ensure solutions are effective and sustainable.
There is also increasing evidence to show how well-planned and implemented behaviour-change programmes that address social and economic factors, in addition to individual knowledge and skills, have greater sustained impact on health decisions. This is particularly so in relation to high risk and vulnerable groups. Therefore, promoting health and influencing behaviour requires coordinated actions across several sectors, specifically to create and sustain the conditions that support healthier choices: a theme I shall come to later.
Yet also, in spite of this predominance of the NCD burden, emerging and re-emerging communicable diseases (CDs) remain a priority area of concern in many countries in the Region, including not only HIV/AIDS and tuberculosis (TB), including multidrug-resistant and extensively drug-resistant TB, but also alarming outbreaks of potential global significance, such as pandemic (H1N1) 2009 influenza. This year has seen the re-emergence of poliomyelitis (polio) in Tajikistan, which threatens the Region’s polio-free status, which it has held since 2002. The growth of antimicrobial resistance and hospital-acquired infections is also of great concern, and the latter is increasingly also a public concern (as you all know from media attention in your countries).
Also within the EU we must not let our guard down against CDs because the mortality from this cause is starting to rise in the 15 countries that belonged to the EU before May 2004 (EU15) and is now higher there than in the 12 countries that have joined the EU since then (EU12).
These changes are so pronounced within the European Region that they must be key drivers of public health policy. There is an influx of migrants, as well as the international migration of health professionals leading to shortages of health professionals.
This current epidemiological position in the Region is set against many changes in the determinants of and circumstances that affect health. Along with the longstanding demographic shift (including decreased fertility rates) and a rise in the old age dependency ratio there are more recent changes associated with globalization.
Indeed, one of the powerful drivers of the inevitability of working for health in a strategic partnership with the EU is the new interrelationship between health and foreign policy: to counter or harness, as the case maybe, the health effects of the globalized world of economy and trade, both legal and otherwise; the health affects of migration and trafficking; and the workings of intellectual property.
These are all examples of the new interrelationship between health and the changed nature of its determinants. We know a lot more now about the spectrum of these various determinants of health, and increasingly we understand how we may intervene. Our understanding of the technologies of health promotion, disease prevention, therapy and rehabilitation has increased dramatically. And we are at the dawn of new technologies, particularly those of medical genetics, with its capacity to revolutionize our ability to intervene.
Then, on the part of our populations, there are new and increased expectations. There is a growing sense of health as a human right, and an expectation that what can be available should be available. People are much more literate and demanding about health and health care services, and expectant about what can and should be provided. They are much more literate about health issues and the possibilities of intervention.
Lastly, as context, there is the growing realization that health is a vital component of human development, and that an investment in health can make a vital contribution to economic and social improvement. This is a transformation of the view of some decades ago, when health care was seen as an expensive item of consumption, and this change of view has revolutionized our thinking about the mechanisms of health improvement.
This global and regional context provides a compelling need to think again about European health policy and the capacities and strengths of European public health. When I took office as Regional Director, I was determined to do this and I made a number of proposals recently to the Regional Committee to achieve these new policy goals. I am delighted to say that the Regional Committee offered very strong support.
Most importantly, there will be a new European health policy, Health 2020, which will build upon what has gone before in the WHO European Region: Health for All, HEALTH21 and the Tallinn Charter. This new policy will embrace the entire spectrum of social and economic, environmental, and health-care-system determinants. It will be set in the context of what we know now, but will be sufficiently flexible to embrace new knowledge in the future. I want this policy to “catch fire” as a broad participatory movement for improvement across the whole of Europe. It must be rooted in the needs and experiences of our Member States.
We will develop the policy through a participatory and innovative consultative process and engage with decision-makers, health professionals and civil society across Europe, as a collaborative initiative between WHO, Member States and their health-related institutions and diverse stakeholders, whose actions directly and indirectly influence the realization of national and European health potential for 2020 and beyond. The WHO Regional Office for Europe will seek collaboration from scientific partners and relevant professional groups, civil society and policy communities. Diverse stakeholders – scientific experts, policy makers, professional and other networks, nongovernmental organizations (NGOs) and development institutions from across sectors and covering European, national, regional and local levels of administration – are being engaged in order to strengthen existing evidence, know-how and support for action to achieve better health for Europe.
This process is required for:
- strengthening public health infrastructure, capacity and functions;
- reinforcing linkages between all components of health systems, most notably between public health and primary care, and expanding them to all government policies; and
- scaling up actions on social determinants of health and the reduction of health inequities through both public health programmes and broader government policies.
Another core component will be our developing understanding of the interrelationship between health and health care services and our commitment to the Tallinn Charter and its follow-up, especially strengthening the public health component.
The Regional Committee supported my view that this whole approach of Health 2020 to comprehensive health improvement and optimal health system performance must be firmly focused around a renewed commitment to a strong public health infrastructure. Public health systems, capacities and competencies need strengthening across the whole of the European Region. We need to strengthen public health systems, functions, infrastructures and capacities, but also increase the capacities and performance of health systems, giving increased focus to primary prevention and health promotion.
As my definition of public health, I very much favour that of Sir Donald Acheson, a distinguished former Chief Medical Officer from the United Kingdom, who was also a member of the WHO Executive Board.
Sir Donald famously wrote that: “Public health is the science and art of preventing disease, prolonging life and promoting health through organized efforts of society.”
This definition has since achieved global recognition. It has sometimes been modified a little, but its essence remains. Public health then is both a science and an art, and it is also an organized societal responsibility. It is always a combination of knowledge and action. Public health is a practical business, based on knowledge but also on organization and activity. It is, put very simply, a function and responsibility of the whole society. Governments of course have a primary role here, reflecting their responsibilities to fulfil the rights of their citizens to health improvement and health services.
To reflect this responsibility, government must ensure certain essential core public health functions are carried out in whatever organizational form they have locally determined. These functions must be effective. These have been well described, for example, by the Pan American Health Organization as part of its Public Health in the Americas initiative. The functions are a vital component of the wider health system within society, giving expression to health across the whole political and administrative spectrum of policy-making.
Strong public health is vital if we are to promote strategic thinking about health, particularly about the control of noncommunicable and other high-burden diseases. We are too often hampered by the lack of developed and effective public health infrastructure, poor public health services, and the lack of capacity in countries to implement public health programmes.
Unfortunately, today in many countries the public health role and infrastructures have become institutionally weak; therefore, as part of the new European health policy, we shall be working extensively to improve the strategy for public health development, and public health functions and capacity, in Europe, with a strong emphasis on prevention.
To be a public health leader is very challenging. Public health practitioners must initiate and inform a health policy debate at the political, professional and public levels, taking a “horizontal” view of the needs for health improvement across society as a whole. They must create innovative networks for action among many different actors, be catalysts for change, and develop and support the systematic use of tools and instruments that will move from goals to action and on the scale necessary to deliver sustainable results. Yet also they must be an integral part of the management and development of current and future health systems. These are demanding expectations.
Please allow me to discuss some of the elements of Health 2020 in a little more detail.
I want to speak particularly about socioeconomic determinants. The circumstances of people’s lives have a most powerful effect on their health and longevity, and these differences in these socioeconomic circumstances explain much of the differences in health experience. Within countries we also see great variations in income and the command of resources. It is here that much of the health variations have their origins.
Accordingly, across the European Region there are persistent differences in opportunities to be healthy and risks of illness and premature death between social groups living in the same country. This is true for higher-, middle- and lower-income countries alike. Even between countries with similar development conditions, political history and culture, significant and avoidable differences in health are observed.
The 2008 report of the WHO Commission on Social Determinants of Health, which was led by Professor Sir Michael Marmot, signalled the ethical imperative of acting on inequalities and set out the evidence showing how the opportunity to be healthy and the risk of poor health and premature morbidity and mortality follow a pattern by number of years in education, job type and security, housing and living conditions, level and security of income, degree of social capital, community cohesion and access to affordable and appropriate health services. Many of these factors are also priorities for other sectors, for civil society and governments overall, and there is strong evidence that these inequities are amenable to intervention. However, they require solutions that are aligned with an intersectoral approach.
For these reasons I have launched an independent review of social determinants of health and the health divide in Europe. This review will be chaired by Professor Sir Michael Marmot and bring together a consortium of scientists, academics, policy-makers and representatives of the public health community, drawn from across the whole WHO European Region, to set out the policy relevant evidence, options and domains for systematic action and key tools to strengthen:
- monitoring and analysis of health equity;
- public health programmes;
- intersectoral action; and
- the broader governance of the social determinants of health and reduction of health inequities within and between countries.
An interim report on the nature and magnitude of the current European health divide was presented to and discussed by the Regional Committee in September 2010 and the review will also underpin the values, goals and objectives of Health 2020.
This collaborative work between all of the countries in the Region is one of the success stories of the last years, and we recently saw a very successful Fifth Ministerial Conference on Environment and Health held in Parma, Italy in March 2010. The environmental determinants of health are ever changing and, alongside old concerns (around water, air, noise, and the various contaminants), we must embrace new environmental factors. For example the effects of climate change (including rising temperatures, sea levels and frequency of natural disasters and extreme weather conditions) are also becoming increasingly evident.
The evidence base
Across all of this work we need to improve the evidence base, and I am delighted to announce that I have recently appointed a Chief Scientist in the WHO Regional Office for Europe to systematically improve our evidence-based thinking.
The example of heart disease shows graphically why governance is a challenge, as we empower ministries of health to lead on a horizontal, cross-cutting, whole-of-government policy.
Strengthening the governance and leadership roles of health ministries must be a major focus of our activities, and we need to develop new tools for national health policy work to ensure that public health perspectives and goals are accepted across government: for example, through horizontal policy boards, a coherent and integrated regulatory framework, embedded performance assessment systems, communication and collaborative mechanisms that work across and within government at all levels, and initiatives to promote accountability and citizen involvement. Lastly, two tools, health impact assessment and intersectoral targets, have a real potential to strengthen policy-making across all sectors.
As I have indicated, just as it has been in the past, public health today is about a combination of knowledge and action. Knowledge on the socioeconomic determinants of health, for example, is vital and scientifically derived. Action, however, is ultimately socially and politically determined. The one needs the other.
Considering socioeconomic determinants, it is clear that these are amenable to change but affected by policy decisions in a wide range of sectors. Health ministries may not readily be able to change or even address many of the determinants of health because they lie “outside” its political mandate and beyond the boundaries of the health system.
This is where health in all policies (HiAP) has a key role with its emphasis on intersectoral governance. How can the health system work proactively with other sectors to identify the impact of their policies on health determinants and health status, and search for practical policy options that both maximize the positive health impacts of other policies and minimize any unintended negative impacts? The overall goal is to improve determinants and health by implementing intersectoral action and promoting policy coherence. In many cases, HiAP also produces dividends for other sectors.
HiAP builds on a long tradition going back to the Declaration of Alma-Ata on primary health care in 1978. It develops the thinking underpinning the WHO Health for All policy, introduced in Europe in 1980 and renewed and updated several time since. It incorporates the Health for All experience, along with the 1986 Ottawa Charter’s “healthy public policies” action dimension, and emphasizes the central role of governance. It promotes a suite of intersectoral approaches with a view to enabling a dialogue on health-related aspects of all policies, and creating an entry point for work across government to change the determinants of health.
HiAP has itself developed significantly in scope and influence since its introduction through the Finnish EU Council Presidency in 2006. Subsequent developments have seen the inclusion of HiAP in the EU health strategy, “Together for Health: a Strategic Approach for the EU 2008–2013”. Indeed collaboration with the EU must and will be a core component of the development of the new European health policy.
To be successful, we will need strong political leadership, evidence that demonstrates the impact of the approach across government, and innovative forms of intersectoral governance structures at cabinet level and between ministries to enable constant dialogue and action: for example, horizontal public health committees, intersectoral programmes and public health reporting, combined with formal consultation with other sectors.
Public health instruments
We also need to focus our modern knowledge of the burden and lifestyle factors associated with noncommunicable disease with effective action, and be innovative in terms of approaches and instruments. We have seen real progress in the development and acceptance of effective control measures in the field of tobacco consumption, for example internationally with the WHO Framework Convention on Tobacco Control, and nationally in many countries with a variety of measure on price, advertising, and use of tobacco products at work, in bars and restaurants, and in public places. Here also the Global Strategy on the Harmful Use of Alcohol is very relevant to the European Region.
The evidence is clearly that where good science, a clear ethical imperative, and strong political support come together real progress can be made, with general public support. After tobacco now we need to see the same combination of fundamental contributory factors working in other lifestyle areas such as alcohol, diet and exercise, and indeed more widely in an integrated group of public health interventions to address the totality of risk, for example as demonstrated in WHO’s action plan for 2008–2013 on the Global Strategy for the Prevention and Control of Noncommunicable Diseases.
There are a number of other international public health instruments in place: for example, in the CD field the new International Health Regulations, and in the environmental field the WHO Protocol on Water and Health. We need to evaluate their effectiveness, with a focus on the long-term commitments needed to tackle the difficult and protracted public health challenges faced by the European Region. What are the relative advantages of the different types of public health instruments? How can their impact be improved? How can gaps be addressed, and evaluation and monitoring of these instruments be made more effective? I intend to hold a policy dialogue on these issues.
Ladies and gentlemen, I have reviewed the background of shared common interests that underpin the necessity and opportunity of a shared strategic partnership for health between the EU and the WHO Regional Office for Europe. The EU global health strategy explicitly recognizes the importance of a stronger leadership role for WHO in its normative and guidance functions to improve global health, and I and my colleagues are committed to this objective.
One way forward supported by the Regional Committee would be to establish a high-level forum of government officials to ensure full engagement in the development of all these policies and strategies, including Health 2020, the European study on health determinants and the health divide, a renewed commitment to action on NCDs, public health and primary health care development, and disease prevention. There will shortly be a discussion on all these issues at a forthcoming meeting of the Standing Committee of the Regional Committee, and, subject to that discussion, I intend subsequently to write to all health ministers to propose the establishment of this high-level forum.
In summary, our pre-eminent commitments are:
- to develop a coherent European health policy (Health 2020);
- to promote a renewed political commitment to the development of comprehensive national health policies, strategies and plans;
- to maintain our commitment to strengthen health systems; and
- to renew our focus and rejuvenate our commitment to public health capacity, functions and services.
In all of this we must ensure a real commitment and investment in disease prevention and health promotion.
To tackle all these challenges we need the strongest support from our Member States and other partners. We need a broad collaborative movement for health, and I am committed to achieving this objective. I would welcome discussion, within this meeting of vitally important focal points for public health in Europe, about we might work together to achieve these objectives.