Public health is back on European countries’ agenda

The second day of the European Health Policy Forum in Andorra focused on health systems and public health. Countries described the progress they had made with health reforms, sometimes in difficult economic circumstances, since adopting the Tallinn Charter: “Health Systems for Health and Wealth” in 2008.

Ms Zsuzsanna Jakab, WHO Regional Director for Europe, reminded the participants of Gandhi’s words: “It is health that is real wealth and not pieces of gold and silver.” WHO is promoting a whole-of-government approach, and promoting health in all sectors. The command-and-control operating mode was being replaced by more participatory ways. There was renewed emphasis on public health. WHO was mapping the progress made since the Tallinn Charter and would evaluate it for the WHO Regional Committee for Europe.

Dr Hans Kluge, Director, Division of Health Systems and Public Health at WHO/Europe, described some of the actions taken that were consistent with the Charter’s principles of equity, solidarity, better targeted public resources and revised service delivery for hard-to-reach populations. A number of countries – including Belgium, Bulgaria, the Czech Republic, Georgia, Kyrgyzstan, the Republic of Moldova, Serbia and other countries in south-eastern Europe – had achieved concrete results in areas such as increased health coverage, revised services for specific communities such as the Roma, health performance assessment, patients’ rights and web-based hotlines, and reduced out-of-pocket payments. Countries such as Estonia, Latvia and Armenia had used economic crisis as an opportunity to gather evidence, and set up a priority-setting process to protect the most important areas and direct their resources more effectively.

Public health challenges in Europe

Dr José Martin-Moreno discussed the public health challenges in Europe, starting with the increasing prevalence of noncommunicable diseases, which now constitute more than 85% of the disease burden in the WHO European Region. Tackling this and the associated lifestyle risk factors will involve engaging citizens directly; people have a right to health, and it is important to ensure that health systems and public health are sustained. Yet health care services are only a part of this. Public health services in many countries are inadequate, presenting major challenges to health and equity.

Defining public health has proved elusive. It is a science and an art, preventing disease, prolonging life and promoting health. Although an evidence base is essential, action has to be taken even in the context of uncertainty. Ministers of health are responsible not only for health care, but for public health and for considerations about the quality of life. Dr Martin-Moreno listed 10 essential public health operations, and raised the need to update modes of communication to reflect the current opportunities. Public health and primary care professionals work closely together, and health systems can renew their work on public health.

Finally, he outlined the role of WHO as it supports Member States in their strategic developments to improve health outcomes, reminding participants: “We are at the service of citizens, both the healthy and the ill, all of them potential patients and all individuals with faces and hearts, dignity and feelings. They are at the core of our mission.”

Need for measurable indicators and standardized information

Country representatives reported their experience with looking at a systematic approach to public health operations and services, noting the importance of having measurable indicators so that information could be used to persuade other sectors. Standardized information enabled comparisons with other countries, which made an impact on decision-makers. The new WHO/Europe Division of Information, Evidence, Research and Innovation was working with the European Union and the Organisation for Economic Co-operation and Development (OECD), seeking to develop an integrated health information system for the European Region. WHO/Europe maintained its Health for All database and had published an atlas on social inequalities.

Performance assessment for greater accountability

Professor Peter Smith, of the Business School and Centre for Health Policy, Imperial College London, United Kingdom, described the use of performance assessment as a tool for greater accountability. Performance assessment shows the health system’s outputs and is the key to its smooth functioning and development. His research had showed that only 10% of the variation in health outcomes was due directly to medical care; 40% was due to behaviour and 15% to social circumstances. To improve health, countries should address the determinants where they can be changed. He highlighted six areas: population health and health services’ performance, responsiveness, financial protection, equity and productivity (efficiency).

Given the various tools and evidence, what steps could countries take in practical terms? Were countries using health system performance assessment productively? Representatives from a range of countries responded with differing experiences, mostly positive. Nevertheless, an assessment by external experts such as WHO could have more effect than one by the professionals already in situ, even if the burden of advice was the same.

Many countries faced fast-changing political or economic situations. One was moving away from sophisticated, centralized performance management and a target culture (“sometimes hitting the target but missing the point”) to a focus on health outcomes and incentives. Working across sectors remained a challenge, and caring for and maintaining the health of old people was a pressing need.

The last session focused on WHO/Europe’s work to develop a European action plan on noncommunicable diseases. Dr Gauden Galea, Director, Division of Noncommunicable Diseases and Health Promotion at WHO/Europe, identified nine possible areas for inclusion, where concrete action would make a difference, such as: salt reduction, trans fat elimination, secondary cardio-metabolic risk assessment and screening for cancer, particularly colorectal, cervical and breast cancer. WHO/Europe would also develop an action plan on alcohol. Important meetings on noncommunicable diseases in 2011 would include the global event in Moscow, Russian Federation, followed by the United Nations high-level consultation in New York, United States of America. There was still much to debate; communication and information strategies were vital, and young people were particularly important, as people developed their habits and could be easily manipulated in adolescence. Participants welcomed the development of the action plan on noncommunicable diseases, which they felt was much needed.