A health movement starting in small countries

On 2–3 July 2015 in Soldeu, Andorra, the second high-level meeting of the small countries initiative took place. During the event, Andorra, Cyprus, Iceland, Luxembourg, Malta, Monaco, Montenegro and San Marino met to share their experience concerning national health plans and their alignment with Health 2020. "The health and welfare of people is one of the pillars of a welfare state," said Antoni Marti Petit, Prime Minister of Andorra.

The main point is that small countries provide many examples of intersectoral action for health, which leads to opportunities for small countries to agree on shared development goals. Small countries are agile and have an acute understanding of the dynamics of globalization. "Countries with small populations have a social and cultural cohesion that makes it easier to design and test innovative policies that can be adapted by larger and more complex countries," said the WHO Regional Director for Europe, Zsuzsanna Jakab, in her keynote speech.

Good practices to fight social inequ(al)ities

Key questions discussed at this meeting were about health and social inequalities.

  • What inequalities affect each country? 
  • What similar problems, if any, do small countries face? 
  • How does the example of good practice from one country help another improve its policies?

All members agreed that the health sector requires support, cooperation, integration and coordination with other sectors. Many mechanisms for intersectoral collaboration were discussed, including improving the efficiency of resources. Examples were given of early treatment of obesity as crucial to improve health status.

For instance in Andorra, intersectoral involvement means that education is a driver for change in many areas including health. Moreover, Andorra elaborated a plan over the course of a year in which a pilot project will soon be launched to combat diabetes and other chronic diseases. "Primary care could be improved, and also communication and governance for health. We need to move towards a more comprehensive system taking into account that primary care is the entry point into the system," said Rosa Ferrer Obiols, Minister of Health, Social Affairs and Employment of Andorra.

"In Luxembourg, we have a yearly national health conference, which allows for exchange with other sectors," added Robert Goerens, Chief Physician, Luxembourg.

In San Marino, intersectorality has been translated into better waste management and sustainable agriculture. "We implement rigorous controls of food through food change," explained Francesco Mussoni, Minister of Health and Social Security, Social Affairs, Family and Economic Planning of San Marino. He added, "We obtained a 20% reduction in hospital waste, and recently we identified an area for treatment of organic waste. It needs large investments as per equipment and training, but this is an issue of environmental sustainability; so the active involvement of public through awareness campaigns is crucial. Also, we need to make people feel part of this process. We are working towards an environmentally friendly community."

"In Montenegro, over the past few years, we had experience with preventing child maltreatment. For us it is not only a public health problem but also one to do with education, employment and income," said Jasna Sekulic, Adviser, Ministry of Health of Montenegro.

In Monaco, health and social ministries came together to find a solution to a need identified in the care of disabled children. "We have a new programme set up by the Ministry of Health and Social Affairs, a programme for children with mental and physical disabilities to attend school with other children. We supported them with special education workers and monitored all their medical aspects. It took us only 6 months to develop the initiative," said Isabelle Rosabrunetto, Director General, Ministry of Foreign Affairs and Cooperation.

How the economic crisis and migration affect small countries

Small countries also felt the impact of the economic crisis, which created social and health inequalities. Eyglo Hardardottir, Minister of Social Affairs and Housing of Iceland said, "We experienced a crash in the financial sector in 2008, when 90% of banks and 60% of companies went bankrupt. Even when we go through huge difficulties, there are opportunities to grab to make society better. Now we have the same level of equity as in 2012; people's salaries were low, but now they have started to go up."

Iceland also shared its experience with domestic violence. "Rather than police taking victims of violence to health care services, we relied on social services and involved the social sector in all parts of Iceland," added Eyglo Hardardottir.

However, the financial crisis is not the only issue that worries Europe and small countries alike: migration is at the core of the debate on social inequalities too. Cyprus and Malta shared their interesting experience in fighting health inequalities in the context of migration. "The economic crisis should not be seen as a challenge but as an opportunity instead to work on health inequalities. And we need to focus on health determinants. We must also try to take into account the most socially disadvantaged and marginalized groups," said Olga Kalakouta, Chief Medical Officer, Ministry of Health, Cyprus.

Malta faces problems with, for example, a low vaccination level among migrant children and cultural realities like female genital mutilation. "Social workers, police and many others need to be aware of this," explained Chris Fearne, Parliamentary Secretary for Health. He added, "The mental health of migrants is also a big issue since the country is culturally different to them. Gender is also important, since many women have antenatal mental stress that has affected the future health of their children."

Finally, the ministers discussed the importance of creating supportive environments and resilient communities in small countries.

Social participation is fundamental

To make all these goals effective, all countries underlined the importance of social participation, and some expressed interest in understanding how collaboration with partners took place and how consultation processes were organized.

However, social participation means people participation and, above all, mass media awareness on the importance of health inequalities. "Adequate access to public health information includes communication so that people can participate in decisions that affect their environment and their health," said Ina Parvanova, Regional Communications Adviser at WHO/Europe.

Hence, a workshop for communication professionals was organized to provide journalists of small countries with advice on how to cover social determinants of health related news and features.

No improvement without data

Another fundamental feature of health care systems is data collection on, for example, mortality, life expectancy and diseases. All small countries seem to experience the same problems with data collection: irrelevance of yearly data, considerable cross-border issues affecting data and human resource constraints.

A good practice comes from San Marino, which adopted in 2014 a new information system where all figures are merged into one electronic health record. In general, most delegates underlined the advantages of data from small countries, and the value of the initiative as interesting laboratory.

However, to reach this goal it is important to identify common challenges and opportunities that could make the platform improve and flourish.

The life-course approach and the Andorra Statement: towards Monaco 2016

During the closing of the meeting, Member States talked about the importance of focusing on health promotion and disease prevention throughout the life course – a priority area of Health 2020.

The meeting ended with the adoption of the Andorra Statement, which reconfirms the values stated in the San Marino Manifesto (2014) and reiterates the pledge of the 8 small countries to implement the Health 2020 framework, and its principles and approaches in their national policies, strategies and plans.

The third high-level meeting of the WHO small countries initiative will take place in Monaco in 2016.