How to improve the health of the Polish population l ti Health 2020 – the European policy a e o framework Zsuzsanna Jakab WHO Regional Director for Europe 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 human, economic and social development • A major j economic i sector t in i it its own right i ht • Health as a human right and a matter of social justice 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 Why Health 2020? Significant improvements in health and well-being but … uneven and unequal Overall health improvement (5 years’ life expectancy gained) but with an important divide Source: WHO Health for All database, August 2010 CIS: Commonwealth of Independent States EU12: countries belonging to the European Union (EU) after f May M 2004 or 2007 EU15: countries belonging to the EU before Mayy 2004 Source: WHO European Health for All database Life expectancy trends in Poland and European regions Source: WHO European Health for All database Infant and maternal mortality in Poland and European regions Source: WHO European Health for All database Trends in premature mortality by broad group of causes in the European Region, 1980–2008 Standa ardized death rate, 0-64 pe er 100,000 140 120 100 80 60 40 Cause Heart disease Cancer Injuries and violence Infectious diseases Mental disorders 20 0 1980 1985 1990 1995 Year 2000 2005 Source: WHO European Health for All database Overall and premature mortality by groups of causes in Poland and European regions Source: WHO European Health for All database Heart disease and stroke mortality trends in Poland and European p regions g Source: WHO European Health for All database Mortality from lung cancer in Poland and European regions Source: WHO European Health for All database Smoking prevalence, cigarette costs and lung cancer trends in Poland and European p regions g Source: WHO European Health for All database Mortality from chronic liver disease and alcohol consumption in Poland and European regions Source: WHO European Health for All database Mortality from female cancers in Poland and European regions Source: WHO European Health for All database 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 women, with little decline over time (bronchial (bronchial, cervical) 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 H f health h lth density d it is i lower l th the than th European E average, as is health expenditure (although increasing over time). Increasing attention to inequity For richer, for poorer Growing inequality is one of the biggest social, economic and political challenges g of our time. But it is not inevitable … The Economist, special edition, 13 October 2012 Why Health 2020? Europe’s changing health landscape: new demands, challenges and opportunities 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. Noncommunicable diseases dominate the disease burden. People migrate within and between countries; ti cities iti grow bigger. Depression and heart disease are l di causes off leading healthy life-years lost. Infectious diseases, such as HIV and tuberculosis, remain a challenge to control. Antibiotic-resistant A tibi ti i t t organisms are emerging. Health systems face rising costs. Primary health care systems are weak and lack preventive services. Public health capacities are outdated. Why Health 2020? Economic opportunities and threats: the need to champion public health values and approaches The economic case for health promotion and disease prevention Cardiovascular diseases (CVD) €169 billion annually in the EU, health care accounting for 62% of costs Alcohol-related Al h l l t d harm €125 billion annually in the EU EU, equivalent to 1.3% of gross domestic product (GDP) Obesity-related illness (including diabetes and CVD) Over 1% GDP in the United States,, 1–3% of health expenditure in most countries Cancer 6.5% of all health care expenditure in Europe Road traffic injuries Up to 2% of GDP in middle- and highincome 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). 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* Unemployment • Strong correlation with increased alcohol poisoning, liver cirrhosis, ulcers, mental disorders** • Increase in suicide incidence***: Greece and Latvia 17%, Ireland 13% well • Active labour market policies and welltargeted social protection expenditure can eliminate most of these adverse effects**** 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. Health impact of social welfare spending and d GDP growth th Social S i l welfare spending GDP • Each additional US$ 100 per capita spending on social welfare (including health) is associated with 1.19% reduction in mortality. • Each additional US$ 100 per capita increase in GDP is associated with only 0.11% reduction in mortality mortality. Source: Stuckler D et al. BMJ 2010, 340:bmj.c3311. Health 2020 - reaching higher and broader • Going upstream to address root causes, such as social determinants • Investing in public health health, primary care care, health protection, health promotion and disease prevention • Making the case for whole-of-government and whole of society approaches whole-of-society • Offering a framework for integrated and coherent interventions Health 2020 strategic objectives Working to improve health for all and reducing the health divide Improving leadership, and participatory governance for health Health 2020: four common p policy yp priorities for health Investing in health through a lifecourse approach and empowering people Tackling Europe’s major health challenges of noncommunicable diseases and communicable diseases S Strengthening people-centred health systems and public health capacities and capacities, emergency preparedness, surveillance and response Creating resilient communities and supportive environments The Health 2020 development journey – two years’ years participatory process with countries and partners • Unprecedented evidence review • New evidence gathering • Solutions that work • Integrating and connecting • Stakeholder(peer)-reviewed Building g on public health history y • • • • • WHO Constitution Alma-Ata Declaration Health for All HEALTH21 Tallinn Charter Integrated policy frameworks can and have inspired health-generating actions ti on allll llevels. l New evidence informing g Health 2020 • Governance for health in the 21st century • S Supporting i H Health l h 2020 2020: governance ffor h health l h iin the h 21stt century • Promoting health, health preventing disease: the economic case • Intersectoral governance for health in all policies: structures actions and experiences structures, • Report on social determinants of health and the health divide in the WHO European p Region g • Review of the commitments of WHO European Member States and the WHO Regional Office for Europe between 1990 and 2010 The WHO European review of social determinants and the health divide: keyy findings g and recommendations to improve equity in health Policy goals • Improve overall health of the population • Accelerate rate of improvement for those with worst health P li approaches Policy h • 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 resilience, capabilities and strength of individuals and The review was carried out by a consortium of over 80 policy researchers and communities institutions across Europe, and chaired by Professor Sir Michael Marmot (2012) Assessment of health inequalities in Poland • Recommendations for strategy and policy formulation, monitoring and coordination • Recommendations R d ti ffor actions ti aiming i i tto iimprove the socioeconomic status of the population • Recommendations for targeted public health programmes Improving p gg governance for health Supporting whole-ofwhole of government and whole-ofsociety approaches Learning from a wealth of experience with work on intersectoral action and h lth iin allll policies health li i iin Europe and beyond Source: I Kickbusch (2011) 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) The Health 2020 framework: • is an adaptable and practical policy 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. Noncommunicable diseases action plan 2012–2016 Planning and oversight Health in all policies Healthy settings Secondary prevention Workplaces and schools Cardio-metabolic risk assessment and g management Active mobility Early detection of cancer Fiscal policies National plan Marketing Health information system with social determinants disaggregation Salt Trans-fat European Action Plan for Strengthening Public Health Services and Capacity 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) • P Prevention ti one off mostt cost-effective t ff ti approaches to improve health outcomes • Use of fiscal policy such as by raising taxes on tobacco and alcohol • Sin taxes have short-term benefits. Supporting Member States to navigate the crisis is central to our work (2). • Try to protect health budgets but 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 payments, which lead to impoverishment). • Thi Think k llong-term: t save in i good d ti times and d spend in bad times! Health expenditure trends in Poland and European regions, by type Total government expenditure as percentage of the gross domestic product Total health expenditure as percentage of the gross domestic product Year Year 50 8 40 6 30 4 20 2 10 0 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Public sector expenditure on health as percentage of total government expenditure 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Private households out-of-pocket payment on health as percent of private sector health expenditure Year Year 12 30 10 8 20 6 10 4 2 0 0 1995 Country EU 12 1996 1997 1998 1999 2000 European Region 2001 2002 Poland 2003 2004 2005 2006 2007 2008 2009 2010 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Source: WHO European Health for All database 2009 2010 Challenging the view of health as a cost to society: i t example l from f the th United U it d Ki Kingdom d The contribution of the health sector to the economy • • • • • Health and social care system in northwestern region g £8.2 billion ((10% of regional g 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 Source: The King’s Fund (2002) Health 2020 helps to rethink policies for health and approaches to stakeholder engagement engagement, such as fiscal policy to control harmful use of alcohol Mapping pp g allies and interests Ministry of Justice and police Alcohol-related harm €125 billion annually in the EU, equivalent to 1.3% of GDP Employers and development sectors Health Transport Local communities Health as a contributor to public policies European targets to increase participation of older people in the workforce Source: EUROSTAT Requires a healthy population and complementary policies among health, development and social sectors. Dear prime minister, minister, mayor or member of parliament: Good G d health h lth underpins d i social i l and d economic i d development l t and d strengthens t th policies li i across allll sectors. t 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. Y Your supportt for f Health H lth 2020 is i ttruly l essential. ti l THANK YOU!