How to improve the health of the Polish population. Health 2020 – the European policy framework
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Zsuzsanna Jakab, WHO Regional Director for Europe, 3 June 2013, Warsaw, Poland
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How to improve the health of the Polish population. Health 2020 – the European policy framework
- 1. How to improve the health of the Polish population Health 2020 – the European policy framework Zsuzsanna Jakab WHO Regional Director for Europe
- 2. Health – a precious global good • Higher on the political and social agenda of countries and internationally • An important global economic and security issue • A major investment sector for human, economic and social development • A major economic sector in its own right • Health as a human right and a matter of social justice
- 3. Health 2020 was adopted by the WHO Regional Committee in September 2012 Health 2020 aim: to significantly improve health and well-being of populations, to reduce health inequities and to ensure sustainable people-centred health systems
- 4. Why Health 2020? Significant improvements in health and well-being but … uneven and unequal
- 5. Source: WHO Health for All database, August 2010 Overall health improvement (5 years’ life expectancy gained) but with an important divide CIS: Commonwealth of Independent States EU12: countries belonging to the European Union (EU) after May 2004 or 2007 EU15: countries belonging to the EU before May 2004 Source: WHO European Health for All database
- 6. Life expectancy trends in Poland and European regions Source: WHO European Health for All database
- 7. Infant and maternal mortality in Poland and European regions Source: WHO European Health for All database
- 8. Year Standardizeddeathrate,0-64per100,000 0 20 40 60 80 100 120 140 1980 1985 1990 1995 2000 2005 Cause Heart disease Cancer Injuries and violence Infectious diseases Mental disorders Source: WHO European Health for All database Trends in premature mortality by broad group of causes in the European Region, 1980–2008
- 9. Overall and premature mortality by groups of causes in Poland and European regions Source: WHO European Health for All database
- 10. Heart disease and stroke mortality trends in Poland and European regions Source: WHO European Health for All database
- 11. Mortality from lung cancer in Poland and European regions Source: WHO European Health for All database
- 12. Smoking prevalence, cigarette costs and lung cancer trends in Poland and European regions Source: WHO European Health for All database
- 13. Mortality from chronic liver disease and alcohol consumption in Poland and European regions Source: WHO European Health for All database
- 14. Mortality from female cancers in Poland and European regions Source: WHO European Health for All database
- 15. In summary… • Life expectancy has risen steadily in Poland, in line with the European average, to a large extent as a reflection of the declines in infant and maternal mortality. • The principal causes of death are the “classics”, noncommunicable diseases such as cardiovascular diseases, cancers and injuries. • In contrast to the European average for premature deaths, cancers predominate over cardiovascular diseases (which have declined), especially in women, with little decline over time (bronchial, cervical). • Chronic liver disease has increased slowly over time, accompanied by increases in the consumption of alcohol. • Mortality from suicides has increased in men, accompanied by a rise in unemployment rates. • Human resources for health density is lower than the European average, as is health expenditure (although increasing over time).
- 16. Increasing attention to inequity For richer, for poorer Growing inequality is one of the biggest social, economic and political challenges of our time. But it is not inevitable … The Economist, special edition, 13 October 2012
- 17. Why Health 2020? Europe’s changing health landscape: new demands, challenges and opportunities
- 18. European Region landscape • We are dealing with complexity and uncertainty • Health challenges are multifaceted and require active involvement of all levels of government (international, national, and local) People live longer and have fewer children. People migrate within and between countries; cities grow bigger. Health systems face rising costs. Primary health care systems are weak and lack preventive services. Public health capacities are outdated. Infectious diseases, such as HIV and tuberculosis, remain a challenge to control. Antibiotic-resistant organisms are emerging. Noncommunicable diseases dominate the disease burden. Depression and heart disease are leading causes of healthy life-years lost.
- 19. Why Health 2020? Economic opportunities and threats: the need to champion public health values and approaches
- 20. The economic case for health promotion and disease prevention Cardiovascular diseases (CVD) Alcohol-related harm Cancer Road traffic injuries Obesity-related illness (including diabetes and CVD) €169 billion annually in the EU, health care accounting for 62% of costs €125 billion annually in the EU, equivalent to 1.3% of gross domestic product (GDP) Over 1% GDP in the United States, 1–3% of health expenditure in most countries 6.5% of all health care expenditure in Europe Up to 2% of GDP in middle- and high- income countries Sources: Leal (European Heart Journal, 2006); DG Sanco (2006); Stark (The European Journal of Hospital Pharmacy: Science and Practice, 2006); Sassi (Organisation for Economic Co-operation and Development, 2010).
- 21. Austerity adds layer of complexity: lessons learned from past and present crises • Associated with a doubling of the risk of illness and 60% less likelihood of recovery from disease* • Strong correlation with increased alcohol poisoning, liver cirrhosis, ulcers, mental disorders** • Increase in suicide incidence***: Greece and Latvia 17%, Ireland 13% • Active labour market policies and well- targeted social protection expenditure can eliminate most of these adverse effects**** Unemployment Sources: * Kaplan G (2012). Social Science & Medicine, 74:643–646. ** Suhrcke M, Stuckler D (2012). Social Science & Medicine, 74:647–653. *** Stuckler D et al. (2011). The Lancet, 378:124–125. **** Stuckler D et al. (2009). The Lancet, 374:315–323.
- 22. Health impact of social welfare spending and GDP growth • Each additional US$ 100 per capita spending on social welfare (including health) is associated with 1.19% reduction in mortality. Social welfare spending • Each additional US$ 100 per capita increase in GDP is associated with only 0.11% reduction in mortality. GDP Source: Stuckler D et al. BMJ 2010, 340:bmj.c3311.
- 23. Health 2020 - reaching higher and broader • Going upstream to address root causes, such as social determinants • Investing in public health, primary care, health protection, health promotion and disease prevention • Making the case for whole-of-government and whole-of-society approaches • Offering a framework for integrated and coherent interventions
- 24. Working to improve health for all and reducing the health divide Improving leadership, and participatory governance for health Investing in health through a life- course approach and empowering people Tackling Europe’s major health challenges of noncommunicable diseases and communicable diseases Strengthening people-centred health systems and public health capacities, and emergency preparedness, surveillance and response Creating resilient communities and supportive environments Health 2020: four common policy priorities for health Health 2020 strategic objectives
- 25. The Health 2020 development journey – two years’ participatory process with countries and partners • Unprecedented evidence review • New evidence gathering • Solutions that work • Integrating and connecting • Stakeholder(peer)-reviewed
- 26. Building on public health history • WHO Constitution • Alma-Ata Declaration • Health for All • HEALTH21 • Tallinn Charter Integrated policy frameworks can and have inspired health-generating actions on all levels.
- 27. New evidence informing Health 2020 • Governance for health in the 21st century • Supporting Health 2020: governance for health in the 21st century • 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 health divide in the WHO European Region • Review of the commitments of WHO European Member States and the WHO Regional Office for Europe between 1990 and 2010
- 28. The WHO European review of social determinants and the health divide: key findings and recommendations to improve equity in health Policy goals • Improve overall health of the population • Accelerate rate of improvement for those with worst health Policy 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 and communities The review was carried out by a consortium of over 80 policy researchers and institutions across Europe, and chaired by Professor Sir Michael Marmot (2012)
- 29. Assessment of health inequalities in Poland • Recommendations for strategy and policy formulation, monitoring and coordination • Recommendations for actions aiming to improve the socioeconomic status of the population • Recommendations for targeted public health programmes
- 30. Improving governance for health Source: I Kickbusch (2011) Supporting whole-of- government and whole-of- society approaches Learning from a wealth of experience with work on intersectoral action and health in all policies in Europe and beyond Two governance for health studies led by Professor Ilona Kickbusch (2011, 2012) Inter-sectoral governance for health in all policies, by Professor David McQueen et al. (2012)
- 31. The Health 2020 framework: • recognizes that countries engage from a different starting point and have different contexts and capacities; • recognizes that every country is unique and that countries will pursue common goals through different pathways and use different entry points and approaches but be united in purpose. • is an adaptable and practical policy framework;
- 32. Noncommunicable diseases action plan 2012–2016 Planning and oversight National plan Health information system with social determinants disaggregation Health in all policies Fiscal policies Marketing Salt Trans-fat Healthy settings Workplaces and schools Active mobility Secondary prevention Cardio-metabolic risk assessment and management Early detection of cancer
- 33. European Action Plan for Strengthening Public Health Services and Capacity
- 34. Supporting Member States to navigate the crisis is central to our work • Strong economic case for health promotion and disease prevention, as economic cost of noncommunicable diseases extremely high (only 3% investment) • Prevention one of most cost-effective approaches to improve health outcomes • Use of fiscal policy such as by raising taxes on tobacco and alcohol • Sin taxes have short-term benefits.
- 35. Supporting Member States to navigate the crisis is central to our work (2). • Try to protect health budgets but, if cuts have to be made, avoid across-the-board budget cuts and target public expenditures more tightly on poor and vulnerable (avoiding or reducing out-of-pocket payments, which lead to impoverishment). • Think long-term: save in good times and spend in bad times!
- 36. Health expenditure trends in Poland and European regions, by type Source: WHO European Health for All database
- 37. Challenging the view of health as a cost to society: example from the United Kingdom • Health and social care system in north- western region £8.2 billion (10% of regional total GDP of £88 billion): 60% on staff, with £2 billion on goods and services • 340 000 people employed directly (12% of regional employment) • 0.5% of regional businesses primarily in the health sector: 780 businesses • 50% of health sector firms have turnovers of £100 000–499 000 • Capital spending on programmes for 5 years is £4.5 billion The contribution of the health sector to the economy Source: The King’s Fund (2002)
- 38. Health 2020 helps to rethink policies for health and approaches to stakeholder engagement, such as fiscal policy to control harmful use of alcohol Alcohol-related harm €125 billion annually in the EU, equivalent to 1.3% of GDP Mapping allies and interests Ministry of Justice and police Employers and development sectors Health Transport Local communities
- 39. Requires a healthy population and complementary policies among health, development and social sectors. Health as a contributor to public policies European targets to increase participation of older people in the workforce Source: EUROSTAT
- 40. 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 potentially risks undermining the positive progress that has been made. Nevertheless, it also presents an important opportunity 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 health and well-being can make a tremendous difference for the people of your country, state, region or city and for the European Region as a whole. Your support for Health 2020 is truly essential.
- 41. THANK YOU!
Notas do Editor
- Good health benefits all sectors and the whole of society, making it a valuable resource. Good health is essential for economic and social development and a vital concern to the lives of every single person.What makes societies prosper and flourish also makes people healthy – policies that recognise this have more impact: access to education, decent work, housing and income all support health. Health contributes to increased productivity, a more efficient workforce, healthier ageing, and less expenditure on sickness and social benefits and fewer lost tax revenues. The health sector is also one of the largest economic sectors in every medium and high incomes country. It is a major employer, important landowner, builder and consumer. It is also a major driver of research and innovation, and a significant sector for international trade.Health is also a matter of human rights and social justice. In many countries in the European Region, improving the health of the population and the system in place to achieve this is seen as a value by itself. There is a broad agreement that health policies, programmes and practices can have a direct bearing on the enjoyment of human rights, while a lack of respect for human rights can have serious health consequences. Protecting human rights is recognized as key to protecting public health.
- For these reasons, health ministers and senior officials from the 53 countries in the WHO European Region gathered in Malta in September 2012 to adopt an ambitious long-term European policy for health and well-being, Health 2020.The Health 2020 policy is an innovative roadmap, which sets out our new vision and forms the basis of the strategic health priorities for our Region in the years ahead. It provides a unique Region-wide platform for sharing expertise and experience, so that, at a time of economic downturn, we leverage our individual strengths and multiply our health gains.The aim of the new European health policy is to turn the tide by addressing key factors in a more integrated and coherent way, including tackling the NCD epidemic, universal access to health care of appropriate quality and the root causes of ill health, the social determinants.
- Health 2020 is a response to the significant challenges to health and wellbeing across the European Region. Across the WHO European Region as a whole, health has greatly improved in recent decades – but not everywhere and for everyone equally; this is unacceptable. Many groups and areas have been left behind and in many cases as economies falter, health inequalities are growing within and between countries.
- This is graph presenting some of today’s health challenges across the European Region. Looking at life expectancy shows clearly the health divide between countries which is growing in Europe. Paradoxically In the 1970s the situation was far better from an equity perspective. Our present knowledge of the social determinants means that we must look across the whole of society and the whole of government for responses, linking health to wider issues and not just focusing on health services. For example Health 2020 considers educational performance, employment and working conditions, social protection and poverty reduction. And it adopts approaches that address community resilience, social inclusion, cohesion and assets for health and wellbeing.
- Life expectancy has risen steadily in Poland, in line with the European average; this is to a large extent a reflection of the declines in infant and maternal mortality; and cardiovascular diseases.
- In Poland, the principal causes of death are the ‘classics’, non-communicable diseases: Cardio-vascular diseases, cancers and injuries; In contrast to the European average in premature deaths, cancers dominate over cardio-vascular diseases (which have declined), especially in women with little decline over time (bronchial, cervical);Chronicliverdisease has increasedslowlyover time; thisisaccompaniedbyincreases in theconsumption of pure alcohol;Mortalityfromsuicides has increasedin men; thisisaccompaniedby a rise in unemploymentrates;
- The economic crisis in Europe has led to an increased focus on inequalities in Europe.Explanations for how health inequities arise and persist over time are not only shaped by scientific evidence and models but by political ideology and the interests of different stakeholders with access to decision making arenas. A further influence on explaining inequities comes from a more practical perspective linked to what is deemed possible to change. In some countries whilst there is acknowledgement of many factors and their interactions in producing equity/inequity decisions are sometimes made on the basis of what is possible to achieve. This is more evident in countries where there is high level of silo working ie where instruments for cross sectoral working are limited and/or where sector specific performance is valued above that of delivering shared results. Acting on a range of determinants concurrently stretching health systems, behaviour, material conditions and structural factors in the distribution of power and resources in society is not an easy task. National and European reviews suggest that investment in each of these domains will have different “payback” times – with improvements in early detection and treatment of existing undiagnosed illness in primary care showing the fastest results in improving health outcomes and reducing health inequities. However, without interventions addressing the wider social determinants (and their lifestyle/behavioural consequences) there will be diminishing returns on such investment, as the factors causing the need for intervention (demand) continues to rise (or is sustained) unchecked.
- Europeischanging – and with this new demands, challenges and opportunitiesarise.
- We must keep an eye on the long term health system challenges, and this is what Health 2020 aims to address. The challenges result from demographic changes, with falling fertility and ageing populations; they result from the political, social and economic currents of globalization; from powerful new technologies that are changing health and health care; as well as from the demands and expectations of citizens for information and closer involvement in decisions about their health and the services they access.Yet they are also many positive trends. We know much more about the range of determinants of disease, particularly the social determinants, and we have more evidence based information about what works and what does not. Also the technologies available to us have greatly improved, with the promise of much more to come.
- Countries in the WHO European Region differ greatly in the extent to which their public finances have been affected by the financial crisis, with countries to the west particularly badly hit. But across the Region we see lower economic growth, higher unemployment and as a result, downward pressure on public finance. These economic constraints notably affect and challenge health systems. However, whilst exacerbated by present economic difficulties these challenges were already present and have been for some while.
- This slide presents some examples of the present economic burden from chronic diseases.In many countries, the health share of government budgets is significant, and health care costs have grown faster than national income. Nevertheless, data in many countries show a lack of correlation between expenditure and health outcome. Many systems fail to contain costs, while financial pressures on health and welfare systems make it ever harder to get the balance right for health. But real health benefits can be attained at an affordable cost and within resource constraints if effective strategies are adopted. A growing body of evidence on the economics of disease prevention shows how health costs can be contained, but only if they also address inequalities across the social gradient and support the most vulnerable people. At present, governments spend only a small fraction of health budgets on disease prevention – some 3% in the OECD countries – and do not systematically address inequalities. In many countries, budgets and policies in sectors other than health currently lack either a health or equity focus.
- We have considerable evidence from previous crises on the relationship between unemployment, social welfare and health. Here we see affects on risks of illness from alcohol poisoning, liver cirrhosis, ulcer and mental disorders, with reduced likelihood of recovery. In addition we are already seeing increases in suicide rates in several countries in relationship to this economic crisis, including in Greece, Latvia and Ireland. We have also learnt that the adverse health effects can be countered by effective polices, including active labour market policies and well targeted social protection.
- Here we see the significantly greater effect of social welfare spending on mortality compared with the effect of GDP increase, there is a 1.19% decrease in mortality for every $100 / per person specifically invested on health and social carewhilst a general increase in GDP of $100 per person reduces mortality by only 0.11%The reverse effect applies to cuts: each 100USD cut in social welfare spending is associated with 1.19% increase in mortality.
- It was clear to me that in response to these challenges and opportunities we needed collectively a coherence in our policies and programs for improvement in health and wellbeing. This is this coherence that Health 2020 provides. It encourages a broad re-think of current mechanisms, processes, relationships and institutional arrangements across all sectors and society as a whole. Health 2020 is about: - Going upstream to address root causes e,g. social determinants - Invest into public health, primary care, health protection, health promotion and disease prevention - Making the case for whole-of-government and whole-of-society approaches - Offering a framework for integrated and coherent interventions
- The goal of Health 2020 is:“To improve health and well-being of populations, to reduce health inequities and to ensure sustainable people-centred health systems with further strengthened public health capacities”. The The two main strategic objectives are: Working to improve health for all and reducing the health divideImproving leadership, and participatorygovernanceforhealthThe four policy prority areas for health are:- Investing in health through a life-course approachTackling Europe’s major health challenges of noncommunicable and communicable disease Strengthening people-centres health systems and public health capacities, emergency preparedness and responseCreating resilient communities and supporting enviromentsCrucially Health 2020 is built on values: Health as a fundamental human rightSolidarity, fairness and sustainability
- Developing the Health 2020 policy was a very inclusive and participatory process.
- The Health 2020 policy builds on the public health history build up in Europe through the years and its lessons learned.
- Throughout the Health 2020 development process, the growing body of evidence and learning concerning the improvement of the health and wellbeing of individuals’ and communities was considered and critically reviewed in relation to the current and emerging drivers of health in Europe. In addition a number of studies concerning areas where further in-depth investigation would be crucial for the Health 2020 policy framework were either directly commissioned or adopted.
- We know that health inequities remain substantial across the WHO European Region and are worsening in many instances. These inequities are substantially socially determined and are unnecessary and unjust, arising from differences in life circumstances and inequities in opportunities to lead a full and meaningful life. Such inequities, and their social and economic costs, directly challenge solidarity and social cohesion. Responding requires broadly rethinking current mechanisms, processes, relationships and institutional arrangements across all sectors and society as a whole. National and local health policy-makers often lack the authority and instruments to lead a coherent, integrated approach to these key challenges, and current structures and processes are not adequate in this new environment and need revisiting.To address these issues, I commissioned the European review of social determinants of health and the health divide, led by Michael Marmot. This research shows that effective interventions require a policy environment that overcomes sectoral boundaries and enables integrated programmes. For example, evidence clearly indicates that integrated approaches to child well-being and early childhood development produce better and fairer outcomes in both health and education. Urban development that considers the determinants of health is crucial, and mayors and local authorities play an ever more important role in promoting health and well-being. Participation, accountability and sustainable funding mechanisms reinforce the effects of such local programmes.
- Tackling inequities in health is a public health challenge gaining increasing prominence in Poland, as elsewhere. Effective policy responses are complex and demand the development of intersectoral, long-range strategies informed by evidence, along with whole-of-society approaches and strong international cooperation.Through extensive WHO Europe and MoH Poland collaboration, a first assessment of social determinants of health and health inequalities in Poland was published in 2012. This study presents a first comprehensive summary of the current knowledge on the scale of health inequalities in Poland, the measurement methods used to assess them, and the risk of health inequalities in different age groups, populations and regions. The numerical data are supplemented by numerous accounts of preventive initiatives aimed at tackling health inequalities.It ends with a set of recommendations on strategy and policy formulation, monitoring and coordination, on actions to improve the socioeconomic status of the population, and on public health interventions. This study is an important step in realizing the health potential of the Polish population and in contributing to a more fair and sustainable society, thereby reflecting the key values and goals of the new European policy for health, Health 2020.
- Health 2020 is an adaptable and practical policy framework. It provides a unique platform for joint learning and sharing of expertise and experience between countries.Health 2020 recognises the diversity of countries across the European Region and that every country is unique.In taking Health 2020 forward, countries will not only face different contexts and starting-points but will also need to have the capacity to adapt to both anticipated and unanticipated conditions under which policies must be implemented.Member States will choose different approaches and align their actions and choices on their particular political, social, epidemiological and economic realities, their capacity for developing and implementing policy, and their respective histories and cultures. Member States are encouraged to analyse and critically appraise where they stand in relation to the Health 2020 policy framework and whether their policy instruments, legislative, organizational, human resource and fiscal situations and measures support or impede the implementation of Health 2020. Health 2020 sets out the present, emerging and future issues that need to be addressed, but it also highlights the fact that policy-makers are challenged to accommodate unforeseen issues as well as changes in context that will have an impact on policy goals. Continuous analysis and policy adjustments will be necessary, as will the readiness to terminate policies that are no longer relevant or effective.
- Examples of key Health 2020 action plans – the NCD action plan.With attention to noncommunicable diseases reaching unprecedented levels worldwide, this action plan was adopted in September 2011. It identifies priority action areas and interventions for countries to focus on over the next five years (2012–2016). Health 2020 supports intensifying efforts to implement global and regional mandates in relation to noncommunicable diseases.
- Examples of key Health 2020 action plans – The European Action Plan for Strengthening Public Health Capacities.The strengthening of public health is a vital component of Health 2020, as well as pillar for its implementation. Strengthened public health is vital if we are to tackle the complex and inter-linked public health challenges of the 21st centuryAccordingly the Regional Committee also adopted an Action Plan to Strengthen Public Health, centred around 10 so-called Essential Public Health Operations. I was delighted to be able to launch this Action Plan at the annual conference of the European Public Health Associations, again in Malta, on the 9th of November 2012.
- Health 2020 supports countries in achieving high-quality care and improved health outcomes requires health systems that are financially viable, fit for purpose, people-centred and evidence-informed.
- Health 2020 further reconfirms the commitment of WHO and its Member States to ensure universal coverage, including access to high-quality and affordable care and medicines.
- In 2009, Poland spent 7.4% of its gross domestic product (GDP) on health. Around 70% of health expenditure came from public sources and over 83.5%of this expenditure can be attributed to the (near) universal health insurance. The relatively high share of private expenditure is mostly represented by out-of-pocket (OOP) payments, mainly in the form of co-payments and informal payments. Given that Poland has modest financial, human and material health care resources at its disposal and achieves satisfactory outcomes, the overall financial efficiency of the health system is not bad. As in most other EU and OECD countries, the Polish system is able to provide a comprehensive set of health services for the population at a relatively low total expenditure. Limited financing seems to be the biggest barrier in achieving accessible and good quality of health care services and in improving patient satisfactionwith the system.