Statement by Zsuzsanna Jakab, World Health Organization Regional Director for Europe, at the EU Open Health Forum, Brussels, 29-30 June 2010

Zsuzsanna JakabHealth in All Policies from the international perspective

Zsuzsanna Jakab, World Health Organization Regional Director for Europe, joined the EU Health Commissioner John Dalli for the opening of the two-day conference, which gathered more than 350 participants, representing a broad range of health stakeholders from all across Europe. Here is an overview of the key points she made.

[blockquote]{EU Open Health Forum
Together for Health – A Strategy for the EU 2020

29-30 June 2010, Brussels}[/blockquote] 

The World Health Organization (WHO) fully supports the call for action presented at the Forum and commends the Forum members for the powerful statements in it. WHO will continue to work with all stakeholders presented, in the spirit of the EU Health Strategy Together for Health, to help ensure that the economic recovery is full and inclusive. At times of economic crises it is even more important to take short-term decisions with a long-term perspective in mind: investment in public health, prevention and health promotion should continue.

A “Health in all Policies” (HiAPs) approach is crucial for the health of European citizens. In the course of the years, WHO/Europe has gathered abundant and convincing evidence for that.

Life expectancy at birth in EU countries has improved since 1980, all across the EU. However, there are still substantial differences between the countries members of EU after 2004 (EU-12) as compared to the pre-2004 EU members (EU-15). Trends in life expectancy also show large differences between men and women in all countries.

WHO/Europe calls for a joint effort to address the pandemics of non-communicable diseases in Europe. Mortality from chronic non-communicable diseases represents almost 80% of all causes of death in the EU.

– Cardiovascular diseases are priority for action in the EU-12, as the rates there are increasing. Since the 1980s, dramatic decreases, have been observed since the 1980s for cardiovascular diseases (for instance, in ischaemic heart disease), in particular for men. These changes have been attributed to a combination of factors, including disease prevention, improved care and health promotion activities. Overall, the mid-90s trend of rising ischaemic heart diseases has been reversed, but the EU-12 rates for men are still very high and remain unchanged for the last 10 years. The gap within the EU continues to increase.

– Addressing the disease burden from cancers is equally important for the EU-15, where little change has been achieved, and in the EU-12, where cancers are on the rise. Mortality from cancer has increased in some cases. This is especially true for lung cancer among women in Nordic countries (and for the EU-15 on average). Lung cancer has now in fact become one of the predominant causes of death from cancer. Since the main risk factor for lung cancer is tobacco smoking, this finding suggests that public health policies need to continue and we should step up efforts to reduce smoking. Huge disparities in cancer rates still exist between the EU-15 and the EU-12.

Of course, communicable diseases cannot be neglected as they are on the increase in many countries of EU, particularly regarding tuberculosis and HIV. We need to remain cautious in Europe, although our main attention should be on non-communicable diseases.

Measuring the health status of European and doing this well is a key priority for WHO/Europe. We therefore draw continuously the attention of stakeholders to the fact that health is more than mortality. We use the disability-adjusted life years indicator (DALYs), which tries to encapsulate both mortality and disability. Distributed into three groups: communicable diseases and maternal and child health, non-communicable and injuries and other external causes, DALYs provide a possibility to address health challenges by risk factors and across income groups.  

Risk factors are usually grouped in several categories: childhood and maternal under-nutrition,  other nutrition-related risk factors, use of addictive substances (tobacco, alcohol and drugs), sexual and reproductive health and environmental risks (such as water and sanitation, urban outdoor air pollution, indoor air pollution, lead exposure, global climate change etc). Prevention and health promotion and strong health systems, including public health systems,are needed to eliminate these risk factors. Many risks lie outside the health sector and therefore the HiAPs approach is a must. Evidence shows that action on just seven risk factors would reduce nearly 60% of DALYs in the wider Europe and 45% in high income European countries

Stronger evidence is needed in areas where we still have gaps. One such domain are the social determinants of health. Acting on them enables all sectors of society to address the root causes that affect health. We already know a lot. WHO uses an important measure of burden of disease in the population – amenable mortality (i.e. death that is premature and essentially avoidable by different known public health and medical care interventions). It is important to act on it, because it helps identify health inequalities and is considered an indicator of the performance of the health system. Some socioeconomic factors, such as for instance disposable income, are thought to influence the occurrence of avoidable mortality – the lower the disposable income, the higher the mortality level.

If, however, we are to convince our colleagues responsible for policies in other sectors (especially related to the social determinants for health, social equity and equity in health), then we have to improve further the evidence base. WHO/Europe is therefore starting a new European study on social determinants of health. It is a continuation of the work of the WHO global commission on social determinants of health, but will address specific European problems.

The worrying trends outlined above only emphasise why during a time of crisis investment in health, in public health and in prevention should not be stopped. In a period of severe and continuous crises, governments usually have to cut the budget. WHO/Europe calls the attention of policy makers to the need that these cuts not be short-sighted and short-term; rather, they should be done in a long-term perspective. This means continued investing in health, health prevention and promotion. Failure to do so will bring the opposite of what we all want to achieve – continued health improvement for all population groups in Europe. I agree with the EU Health Commissioner on this subject, and also on the need to act together. This will therefore be a topic at the next WHO Regional Committee for Europe, where WHO/Europe will discuss with the health ministers how long term investment in health should be taken into account in order to avoid negative impact of short term decisions.

As many causes of ill health lie beyond the health sector, likewise most of the solutions need also other sectors’ involvement. The Health in All Policies (HiAP) approach should continue, its evidence-base further explored together with practical tools for its implementation. WHO/Europe has numerous examples for strategies to deal with key health concerns, where real intersection of policies is indispensible and we need various sectors in order to be successful. Health in All Policies is no longer a slogan. WHO/Europe offers good practical examples that the HiAP approach works. The more the “territory” of health expands to involve non-health sectors, the more we can improve the health of Europeans.

Some key features of HiAP approach are:

Acoordinated (joined-up) approach to government policies where health and health equity are considered core values in government vision and strategies

HiAP applies to the international as well as to all levels of government in countries: most successful!

Health most often is not an (explicit) value or goal in most of other sectors policies and therefore aiming for common, consistent (health enhancing) goals is essential

HiAP is increasingly becoming an imperative  in the light of our accumulating knowledge on the determinants of health (and the root causes of ill-health) and a number of pressing global challenges: climate change, economic crisis, ageing of population, urbanization, chronic diseases, growing inequalities, migration trends

Government mechanism

The Adelaide policy statement on HiAP offers a good example for joint governmental action:

Economy and Employment

Economic resilience and growth is stimulated by a healthy population. Healthier people can increase their household savings, are more productive at work, can adapt more easily to work changes, and can remain working for longer. Work and stable employment opportunities improve health for all people across different social groups.

Education and early life

Poor health of children or family members impedes educational attainment, reducing educational potential and abilities to solve life challenges and pursue opportunities in life. Educational attainment for both women and men directly contributes to better health and the ability to participate fully in a productive society, and creates engaged citizens

Housing and community services

Housing design and infrastructure planning that take into account of health and well-being and involve the community can improve social cohesion. Well-designed, accessible housing and adequate community services address some of the most fundamental determinants of health for disadvantaged individuals and communities

WHO/Europe has looked into various sectors and has increasingly learned to demonstrate how health can make a difference in their sectoral policy-making. Transport is one such example. The external costs of are estimated at about 8% of GDP in the EU. Health effects represent the largest element of these external costs. Savings from improved health could be re-invested in health prevention and other societal priorities. Yes, in order to successfully do that, we from the health community must help each sector achieving its own goals.

We must be realistic about this, because policy integration is easier said than done. When you want to move, you often discover conflicts in responsibilities and leadership and lack of governance mechanisms to integrate. Most positive experiences are developed either locally (e.g. responsibility for cycling/walking and urban planning is facilitated by easier contacts between involved parties) or on specific policy aspects.

The most frequent types of collaboration (based on 48 case studies from 11 countries), are domains such as engineering/infrastructure and publicity; behaviour change campaigns, publicity and awareness-raising campaigns, financial incentives, policies and surveys. In such complex matters, it is imperative that health is able to make the case for the health impacts of investments decision, e.g. develop tools that help policy makers in transport and urban planners to include health in their economic analysis.

Significant WHO leadership can be shown in the field of Environment and Health.

A lot has been done, in four strands:

– Policy processes (e.g. the European Environment and health policy platform, the cornerstone of WHO work in environment and health, which is a unique policy platform for Ministries of Environment, Ministries of Health and stakeholders);

– Protection of health through legally binding multilateral environmental agreements;

– WHO’s normative work, which is the evidence-based cornerstone for EU environmental (and national) legislation on key environmental aspects; and

– WHO advocacy work (the World Health Day in 2008, on climate change and health, was a prominent example of corporate advocacy for health in climate change policies).

The EU institutions were part of this WHO work and process, we were doing it hand in hand together with our EC partners. At the last WHO European Ministerial Conference on Environment and Health in Parma, few months ago, we brought together all stakeholders, and were happy to welcome the EU Health Commissioner, who signed a supplementary statement to the Parma Declaration, as a recognition of this joint EC-WHO/Europe commitment.

If we are to be serious about ensuring health equity, we should do it from the start: the conclusions of the global WHO Commission on Social Determinants of Health clearly show that if you want to make investment in health, the best investment is in early child development:

Ensure policy coherence for early child development

Give every child best start in life

Increase the proportion of overall expenditure allocated to early years

Quality early child development programmes and services for children, mothers and other care givers regardless of ability to pay

Provide quality education that pays attention to children’s physical, social/emotional and language/cognitive development, starting in pre-primary school

Identifying and addressing barriers to children enrolling and staying in school

Reduce social gradient in life skills and qualifications

Invest in health literacy and increase access to and use of quality lifelong opportunities across the social gradient

Lifelong learning is important for providing the skills and qualifications for employment and progression in work:impacts health behaviours and outcomes

In short, Health in All Policies is an absolute must. I am happy to be here with you and agree how WHO/Europe can work together with you all in the years to come. We see as essential and need to enhance to enhance the cross-sectoral collaboration, building on the good work already done; to involve sectors, partners, stakeholders – civil society and citizens in an active and meaningful manner and to facilitate the exchange of knowledge and best practices.

The way forward lies in incorporating the good progress already achieved in health outcomes over the last 30 years, in the EU. The evidence base of most interventions is also available, although some additional work is on-going, in some areas. Especially in view of the social determinants of health as a major contributor for health, we see a need for action in the EU but also in the EU neighbouring and accession countries. This work must continue, even – perhaps especially – during the times of crisis, when cuts should be made with a long-term perspective in mind. To provide the evidence for that, a European Study on Social Determinants is under way. As most of the solutions are outside the health sector, the HiAP approach should continue, both its evidence-base further explored as well as practical tools for its implementation.

In this context, I intend to renew the European Health Policy with full participation of all stakeholders, including you all in what we hope to be a challenging and fruitful exercise all across the WHO European Region. A future European Health Policy will provide the framework and basis for further action, with additional sectors to be involved and a systematic cross-sectoral analysis and collaboration envisaged. With an additional focus on education and early childhood development and invest, we shall work extremely closely with the Commissioner, I hope, keeping this close to our hearts. This is impossible without the support of you all. Thank you for your commitment and strong voice, that enable us collectively to bring health improvement in Europe.


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