Address by Dr Zsuzsanna Jakab, WHO Regional Director for Europe at the 68th session of the WHO Regional Committee for Europe

17 September 2018, Rome, Italy

Your Royal Highness the Crown Princess of Denmark, Director-General of WHO, Dr Tedros, Honourable Ministers and delegates and dear guests...

I warmly welcome you to this 68th session of the WHO Regional Committee for Europe.

These are exciting and challenging times. We have the commitment, the knowledge and the opportunity to transform health and achieve our goal of “better health for Europe; equitable and sustainable”.

So far, with our implementation of the Sustainable Development Goals and Health 2020, we have achieved a lot. The SDGs, Health 2020 and the 13th General Programme of Work are truly coherent and integrated.

All three show clearly how health is positioned at the centre of development. This is our crucial message.

Health investment is the smartest investment – it pays off.

Yet the environment has changed, and there is a state of political flux in which some long held common political and social assumptions have been shaken, and there are profound security anxieties and a prevailing sense of uncertainty.

In this situation, more than ever, we must pursue our agreed values in health investments: the right to health, universality, solidarity, equity and fairness.

We need to achieve multisectoral policy responses, able to address all health determinants and health promotion through the life-course.

We must rise to the challenge of ageing populations and the increased burden of noncommunicable disease.

We must respond to the continuing threat from communicable diseases and health emergencies; the exponential explosion of health technologies; and increasing public expectations.

We must face ever-present financial pressures including constant cost pressures for the efficient use of resources, yet also achieve UHC and good financial protection.

We also have important new opportunities. We must continue to be innovative and think differently, considering new scientific knowledge.

We understand better the complexity of interactions between the human genome and the environment over the life course.

We are well aware that these interactions are shaped by policies, opportunities and social norms created by society, like political, environmental and cultural contexts, that we can influence.

There are huge opportunities arising from the use of digital technology and other innovations that help reduce inequities in access.

We know that mobilizing communities and increasing health literacy will lead to making the right choices.

Working together, in stronger partnerships and with multi-stakeholder engagement, will pay off.

And progress will depend upon securing the highest level of political commitment and increased resources for health as a smart investment.  
Health is a political choice, and it is the one we urge you all to make.

Progress in achieving the SDGs and Health 2020

After adoption of the SDG roadmap last year, many countries started developing national roadmaps and creating whole-of-government mechanisms at the highest level to drive the agenda forward.

So far, 35 European Member States have reported on SDG implementation at the High-level Political Forum. You will hear more about this tomorrow.

Also, a majority of countries now have a national health policy with defined targets and indicators aligned with Health 2020.

These are real achievements, presented now in our ground-breaking publication, The European health report 2018.

The report also explains the alignment of indicators in a proposed “Joint Monitoring Framework” for the SDGs, Health 2020 and the Global Action Plan for the Prevention and Control of NCDs, as well as with GPW 13.

The report presents exciting new work on the use of qualitative evidence, bringing to life Health 2020 concepts such as well-being, community empowerment and resilience, and the whole-of-society approach.

Now three snap-shots demonstrating the progress on health and well-being against these targets:

• Life expectancy at birth increased to 77.9 years in 2015.
• The maternal mortality rate decreased to 11 deaths per 100 000 live births in 2015.
• We are on track to achieve the Health 2020 target to reduce premature mortality from cardiovascular diseases, cancer, diabetes and chronic respiratory diseases by 1.5% annually.

Yet, ladies and gentlemen, there are still major inequities in health and well-being between and within countries.

The difference between the countries with the highest and lowest life expectancy at birth is still more than 10 years.

Despite the progress, tobacco use in the Region is not decreasing fast enough. We are still the Region with the highest alcohol consumption.

Overweight and obesity are on upward trends which give cause for serious concerns.

While by the end of 2017, 43 countries had eliminated or interrupted endemic measles transmission, persistent immunity gaps have resulted in a large number of outbreaks.

We are absolutely not on track to meet our HIV targets and co-infections are increasing.

Working in transformative ways

Making progress towards better health challenges us to work in transformative ways.

We have to ensure policy coherence across different sectors at all levels, using inclusive and transparent governance mechanisms.

National health and development policies are the principal mechanism here, and I urge Member States to review their existing policies against the SDG roadmap and the monitoring framework.

To help Member States, we have developed a range of SDG instruments and tools, including national health policy reviews.

Networks are a key platform for implementation

Our broad coalition of partnerships, networks and platforms plays a vital and excellent role in implementation.

Here, I will mention some, although there are many others:

• the small countries initiative, with excellent recent meetings we had in Malta and Iceland;
• the WHO European Healthy Cities Network, with a very successful Summit of Mayors in Copenhagen;
• and the South-eastern Europe Health Network, with very productive meetings this year in Montenegro and Israel.

We look forward to another Healthy Cities meeting in Almaty in October and the 30th anniversary of Healthy Cities later this year in Belfast.

The determinants of health

The social determinants of health

A majority of countries in the Region now have a policy or strategy to address the social determinants and health inequities, thanks to the European Region leading this work globally.

However, there are still significant income inequalities across the Region with humanitarian, health and economic implications, which need collaborative responses across sectors.

The Region has seen a considerable reduction in infant mortality; however, the variation between countries remains high. While the proportion of children not enrolled in primary school is falling, a large variation between countries is reported.

A similar picture emerges for unemployment rates, which ranged from 0.5% to 26% in 2015.

Later this year we will publish a health equity status report, providing transformative thinking with new evidence and policy directions to help reduce these gaps.

I thank the Government of Italy and the Veneto Region for their continuing support to our Office for Investment for Health and Development in Venice.

The behavioural determinants of health

Ladies and gentlemen, let me now turn to behavioural determinants.

Tobacco

There are many success stories in tobacco control; for example, eight European Member States now have plain packaging legislation for tobacco products and several are moving towards becoming “tobacco-free”, with a smoking prevalence of 5% or less. Yet, tobacco use in the Region is not reducing fast enough to meet the global targets. Tobacco products are still far too affordable in many countries.

The Protocol to Eliminate Illicit Trade in Tobacco Products will enter into force on 25 September and the first Meeting of Parties will take place in October. Entry into force is a major milestone and I call upon all Member States to ratify the Protocol in order not to lose momentum.

The war against tobacco has not ended – we need to step up the work against this most deadly risk factor.

Alcohol

Recent evidence confirms that, compared to 2010, alcohol consumption has decreased in the Region, and so have overall levels of alcohol-related mortality and morbidity.

Despite these achievements, the European Region still has the highest adult alcohol consumption of all WHO regions. Pricing policies and restrictions on availability and marketing continue to represent a highly cost-effective intervention for alcohol prevention and control.

In 2017 we developed various tools to assist Member States to assess the adoption of the recommended policy standards, and we are committed to the implementation of solutions.

Nutrition and physical activity

The tripling of obesity prevalence in many countries compared to the 1980s and a major increase in overweight among children and adolescents are threatening the gains we are making in premature mortality in the Region.

We continued to support the WHO European Childhood Obesity Surveillance Initiative and launched a new Health Evidence Network Synthesis Report, which creates momentum to act.

On physical activity, collaboration between WHO, Member States and the European Commission to promote health-enhancing physical activity throughout the Region led to several innovative projects.

All these behavioural determinants are closely linked to the social and environmental determinants, and therefore efforts should be made to align them in a coherent national policy framework for intersectoral action.

Environmental determinants

Despite improvements, environmental risks still cause one fifth of the burden of disease in the European Region.

Following the Ostrava Ministerial Declaration last year, many Member States developed national portfolios for action on environment and health.

The Environment and Health Task Force, with its new chairs and governance mechanism, plays a key role in the implementation of the Ostrava commitments across the Region.

Looking to the future, we are working with Member States on the development of a new global strategy on environment and health, which will be presented to the WHA next year.

I wish again to express my gratitude to the Government of Germany for their continuing generous support to the work of the WHO European Centre for Environment and Health in Bonn. The Bonn Centre is making important contributions to the global normative work, while leading the Ostrava Declaration implementation.

Cultural determinants

This year, The European health report captures the full range of health concerns, including the cultural context.

This gives us a much richer understanding of the context to inform policy development and implementation, moving beyond quantitative to more qualitative information, and engaging local communities.

Commercial determinants

I now turn to the commercial determinants of health. It is clear that today’s rise in noncommunicable diseases reflects a system which prioritizes economic and financial growth and advantage over better health.

We need to address and prevent conflicts of interest, particularly those involving commercial interests.

While we have no common interest with, for example, the tobacco and alcohol industries, I believe that we should do our best to convince the food and soft drinks industries to follow WHO standards and norms.

While working with the private sector, appropriate governance mechanisms need to be enforced that affirm the primacy of public over private interests, which are within the principles of FENSA.

Advancing public health for sustainable development

Facing today’s health challenges and dealing with all determinants require a strong and transformed public health for the 21st century.
This is a public good, and a shared social and political responsibility, not only of health, but of all sectors.

It is also an indicator of success for the government as a whole and is an investment in the economic development of countries.

This is where strong and high-level political commitment and leadership are required, which are not present in every country.

Public health across the Region needs to be strengthened with good legislation, governance, institutional structures and a competent workforce.

I am personally committed to strengthening public health further in the Region. I therefore commissioned a broad consultation process, engaging external experts, and we will be presenting our vision for advancing public health on Wednesday.

Migration and health

The review of implementation of the European strategy for refugee and migrant health indicates that there has been notable progress, which forms the core of the forthcoming European migrant health report.

Now we are contributing to the establishment of a global action plan on the health of refugees and migrants for consideration by the WHA in 2019.

We have also contributed to ensuring that health is a key component of the United Nations Global Compact for Safe, Orderly and Regular Migration and the Global Compact on Refugees.

I offer my thanks to the Government of Italy and the Regional Health Council of Sicily for their support to the second Summer School on Refugee and Migrant Health that will take place in Sicily this month.

Noncommunicable diseases

I turn now to noncommunicable diseases, where Europe can present a major success story in the reduction of premature mortality from NCDs, since we see a fast decline everywhere in the Region and among both sexes.

With this rate of decline, we estimate that achievement of target 3.4 of the SDGs will take place earlier than 2030.

As the Regional Director, I was proud to present these results at the WHO Global Conference on NCDs in Montevideo last year, when we also launched our report, “Monitoring NCD commitments in Europe”.

This report demonstrated that cost-effective NCD interventions are not implemented in many Member States.

We cannot just sit back and enjoy our successes; we need to accelerate our interventions. We know what to do! But we are not doing enough!
Otherwise it will take two decades for countries with higher mortality to catch up with those with lower mortality.

There are equality gaps due to different socioeconomic means, environmental exposures, and access to social policies and benefits.

There are also pockets of avoidable high mortality among men under 70 years – with significant social and economic implications.

We must accelerate improvements in NCD outcomes by strengthening the equity orientation of health system policies – to leave no one behind and to break the harmful cycles of health inequalities.

We were all inspired by the successful and comprehensive health system transformation efforts in Europe to respond to NCDs that were shared at the high-level meeting in Sitges in April this year.

There, we agreed on the required building blocks and actions to be taken, as well as on the need for leapfrogging.
We know that we must strengthen health systems to achieve better NCD outcomes.

There is a need for ambitious transformation in how we deliver public health, primary care and specialist services, with a sharpened focus on outcomes, coordination, continuity and comprehensiveness.

I believe this to be a groundbreaking initiative from the WHO European Region in connection with the third UN high-level meeting on NCDs in New York next week.

I hope that your countries will be represented at the highest level at this historic event.

All these will be discussed tomorrow, and on Wednesday we will launch our new report, Health systems respond to NCDs, which describes efforts to act in unison with all countries to beat NCDs.

On Wednesday we will also discuss the Strategy on health and well-being on men that contributes to this effort through a gender approach.
I express my deepest gratitude to the Russian Federation for their generous support to the Office for the Prevention and Control of NCDs in Moscow.

Health systems

Ladies and gentlemen, strong health systems are a prerequisite for advancing universal health coverage and achieving sustainable development.

Many high-level events this year underlined the importance of strong, people-centred and agile health systems.

We celebrated the 10th anniversary of the Tallinn Charter – thanks to Estonia for hosting this high-level meeting in Tallinn in June.  
At the meeting, we reaffirmed our commitments towards solidarity, equity and participation. We agreed that strong health systems have to be inclusive, leaving no one behind, and that no one should become poor as a result of ill-health.

We also considered how health system innovations can be harnessed to better meet people’s needs.

Our health systems should not be passive in the face of changing economic, political, social and health challenges, but instead be able to prepare for and adapt to the future.

Financial protection

In Tallinn, we presented the results of a regional study on financial protection, producing up-to-date estimates of the incidence of impoverishing levels of out-of-pocket payments. We use a new approach suited to high- and middle-income countries in this study and also present actionable policy recommendations which are being implemented in several countries. While some Member States are progressing well, we still have a long way to go to achieve that no-one becomes poor as a result of ill health.

Among the 25 countries in the regional study, the share of households impoverished or further impoverished due to out-of-pocket payments ranges between 0.3% and 9%.

The study suggests that it is possible to avoid poverty due to ill health through a combination of reducing out-of-pocket expenditure to 15% of the total spending on health and strengthening pro-poor coverage policies.

We also engaged in dialogue between health and fiscal decision-makers to make the case for public investment in health systems, and public health in particular. We will be discussing all these tomorrow.

Primary health care development

Another important meeting this year will be held in Astana in October on the occasion of the 40th anniversary of the Alma-Ata conference on primary health care.

I request your governments to participate at the highest level possible.

The meeting will commemorate the 1978 Alma-Ata Declaration, plan for the forthcoming Global Conference on Primary Health Care, and aim to renew the political commitment to developing people-centred PHC.

It will also provide the foundation for the United Nations high-level meeting on UHC to be held in New York next year.

In this context, I am pleased to announce the launch of the WHO Task Force on the Economics of Primary Health Care, which met for the first time two weeks ago, generously hosted by the Danish Health Authority.

I thank the Government of Kazakhstan for their support to the WHO European Centre for Primary Health Care in Almaty.

Courses on HS strengthening

We continued the series of courses on strengthening health systems for improved TB prevention and care, and included representatives from health and finance ministries, and national health insurance funds.

The annual WHO Barcelona course on health financing for universal health coverage will be delivered in October. I offer my thanks to the Government of Spain and the Regional Government of Catalonia for their continued support to the WHO Barcelona Office for Health Systems Strengthening.

We also continued the Summer School on Pharmaceutical Pricing and Reimbursement Policies together with the Collaborating Centre in the Austrian Public Health Institute.

Access to medicines

Access to affordable, effective, quality medicines is another major component of UHC and is of great concern in many Member States.
Improving access requires multidimensional interventions, with comprehensive national policies, together with supportive legal and regulatory frameworks and efficient supply chains.

It is encouraging to see several cross-border country collaboration projects seeking better negotiating powers and alignment of prices and costs.

As global external financial instruments are not available any more to most countries in the Region, efficient transitioning to domestic financing and supply management is crucial. We will support national planning for this transition.

Enhanced availability and dissemination of health information

The analysis and dissemination of health information has become ever more sophisticated. This is evident in many of our initiatives, like the European Health Information Gateway, the peer-reviewed journal Public Health Panorama and our Health Evidence Network reports.

In our two annual flagship courses, including the Autumn School on Health Information for Policy, we continue to build capacity in countries to collect, assess and use evidence for policy. We are now establishing a new curriculum for the second phase of the Autumn School and its Advanced Course.

Health research and knowledge translation

The Evidence-Informed Policy Network, which is now active in 21 countries, is helping to strengthen country capacity to develop health policies through evidence for policy briefs and policy dialogues in countries.

This year, we launched the European Health Research Network in Bulgaria to support the development of health research systems in countries.
The European Advisory Committee on Health Research continued its crucial role in the formulation of policies for the development of health research.

This year the EACHR recommended that WHO establish a European high-level task force for big data and develop a strategy, which we are now pursuing.

All these activities are coordinated and guided by the European Health Information Initiative, which now has 39 members, from countries as well as international partners such as the EC and the OECD. Under this initiative, we now have eight health information networks, which form the basis for evidence and information for health policy.

Communicable disease prevention and control

Ladies and gentlemen, I turn now to communicable diseases.

The Region has kept its malaria- and polio-free status

The good news is that we have been able to keep our malaria- and polio-free status and we plan to certify malaria elimination this year.

Building upon the Ashgabat commitments, malaria interventions like surveillance, vector control, and intersectoral and cross-border collaboration, contribute to the prevention and control of other vector-borne diseases, which are worryingly on the increase in the Region.
We will be discussing this on Thursday.

Measles and rubella elimination

Progress regarding measles and rubella elimination is mixed. In spite of success in interrupting endemic measles or rubella transmission in 43 Member States, large measles outbreaks, especially in western European countries, with deaths and complications, are unacceptable in the presence of effective and affordable vaccines. We are working closely with the affected countries, and many have taken steps to strengthen immunization, including through legislative frameworks, to contain outbreaks.

Immunization and VPDs

We have to place the highest political commitment on immunization in order to achieve the goals established in the European Vaccine Action Plan and avoid disease outbreaks. The midterm report provides valuable findings on ensuring equitable access to affordable and effective vaccines. We will discuss this in detail tomorrow.

I urge all Member States to extend the benefits of vaccination equitably across the life course to all individuals in the Region. Let me acknowledge the commitment of south-eastern European ministers to accelerating actions towards immunization in Montenegro this year.

Our Patron, HRH the Crown Princess of Denmark, as in previous years, was with us on the occasion of European Immunization Week and we are grateful for her continuous support.

Tuberculosis

We have good news regarding tuberculosis control. We are the Region with the fastest decline in TB incidence and we also observe a significant decline in mortality. Thanks to your efforts and in collaboration with partners, MDR-TB case detection has more than doubled and treatment success has slowly but steadily continued improving.

These achievements were made possible through strengthening the health system response with implementation of people-centred models of care. Despite the progress, the Region still has the highest rate of MDR-TB in the world, with one out of five people with MDR-TB living in our Region. There is an increase in HIV coinfection, to 12%, and every eighth TB patient is now co-infected with HIV.

Now is the time to accelerate our efforts. Based on the ministerial meeting in Moscow last year, the UN high-level meeting on TB in New York next week will be a unique opportunity to renew our commitments to Ending TB by 2030.

HIV

Regarding HIV, the challenges are substantial, and one fifth of all people living with HIV in the Region still do not know their status.
In 2017, 82% of all new HIV infections were from eastern Europe and central Asia, where only one third of people living with HIV were receiving antiretroviral therapy.

The highest political commitment and bolder actions are required for HIV prevention and care, particularly among the key populations. At a policy dialogue in July this year in Amsterdam, we agreed with the ministers of health of eastern Europe and central Asia that the time to accelerate our efforts is now and that we cannot afford to do “business as usual”. We have to scale up implementation of evidence-based interventions and take urgent collective actions to curb the HIV epidemic.

We are working towards a road map with country-specific action in all affected countries.  I would like to thank the Government of the Netherlands and UNAIDS for co-hosting that important meeting, back to back with the 22nd Global AIDS Conference.

Viral hepatitis

Another challenge is viral hepatitis, which leads to at least 60% of liver cancers and which requires accelerated actions and commitment. We will continue to support you in strengthening surveillance and laboratory capacities and updating treatment guidelines, thereby ensuring that everyone living with viral hepatitis has access to safe, affordable and effective prevention, care and treatment services.

Antimicrobial resistance

The global effort to address antimicrobial resistance continues with unwavering determination, and Europe continues to lead the way. I am pleased that 34 countries in our Region have developed multisectoral national action plans and we are supporting the remaining countries to finalize theirs, as well as with implementation.

As the picture of antimicrobial consumption and the resistance patterns of our Region becomes more complete through the work of our dedicated surveillance networks, we will focus on policy interventions that reduce overuse of antimicrobials, as well as on infection prevention and control, especially in health care settings. Here again, I would like to acknowledge the valuable support provided by HRH the Crown Princess of Denmark in raising awareness of AMR whenever possible.

Health emergencies, preparedness, surveillance and response

Ladies and gentlemen, preparedness and response to health emergencies continue to be a priority, with a major focus on detecting early warning signals and helping countries get prepared.

Taking a step forward, the draft regional action plan to improve public health preparedness focuses on the interdependence of health emergency preparedness, health systems strengthening and the essential public health functions, towards universal health coverage. We will discuss this on Wednesday.

In health emergency response operations, let me commend Turkey for providing universal access to culturally sensitive, people-centred, quality health services for the 3.5 million Syrian refugees in Turkey. Training of the Syrian health workforce and engaging them within the Turkish health system is an example of social inclusion and adaptation, which at the same time provides universal health services to all refugees by their fellow health personnel. This flagship model will be presented on Wednesday.

Working for and with countries

Working for and with countries is at the core of WHO’s mandate and it has been my highest priority since I became the Regional Director. We have been delighted to welcome ministers and high-level officials from many countries to the Regional Office.

Within WHO reform, the focus has been on strengthening WHO leadership at the country level. We have been empowering country staff and upgrading them to become international WHO representatives. We have continued to strengthen our country offices and have recently opened a new WHO office in Greece. This aims to better support countries to achieve the highest possible impact in their health-related policies and actions.

Thanks also for warmly receiving me during my visits to many countries across the Region. I am extremely grateful for the many high-level discussions on health with presidents, prime ministers, ministers and high-level national officials.

I am pleased that the visits of Standing Committee members to countries was the opportunity to demonstrate WHO’s work at country level.
You will hear more about this later this week.

Partnerships for improved health and policy coherence

Partnership is one of the priority areas of the Director-General’s transformation agenda. I have been personally committed to strengthening partnerships over the last eight years across the Region, which culminated in a partnership strategy last year.

Collaboration with UN agencies at the regional level in a broad range of areas has been exemplary, as was the case with the UN issue-based coalition on the health-related SDGs that WHO is leading. I want to thank Cihan Sultanoglu, the Chair of the regional UNDG team, who is leaving this position, for her outstanding leadership during the past six years. I have been requested to act as interim UNSDG Chair in Europe and central Asia until the new appointment is made, which I accepted as a great honour. This function will give us further insights into UN reform and it will help WHO to position itself in its implementation, while keeping our normative work intact.  

We have been actively preparing for the UN reform process throughout the three levels of the Organization and we will also be aligned with its implementation.

WHO has worked extensively with the European Union on health, including in the fields of humanitarian and development aid. We held a successful meeting of Senior Officials of the EU and WHO, involving HQ and all regions, to discuss our future work, including work in research and development and on the environment. We have collaborated strongly with current and past EU presidencies in taking forward many high-priority health topics.

The last example I would like to share with you is our collaboration with non-State actors. The agenda item on Thursday will be a major milestone, when we will be officially accrediting 19 NSAs for the first time, on the basis of reviews and recommendations by the SCRC. This procedure is fully in line with FENSA.

WHO leadership in implementation of the 13th General Programme of Work 2019-2023

Director-General, we are working together to make WHO fit to implement GPW 13 and enhance its impact in countries to deliver the “triple billion” goal. Under your leadership, and that of the Global Policy Group, we see important efforts across the three levels of WHO to define and align our common values, culture and operating models and processes.

Here in the Regional Office we are ready, committed and well equipped to respond to this challenge. We are implementing the comprehensive transformation process, building upon our “Better health for Europe” initiative of 2010, which addresses the same strategic dimensions of WHO reform.

Our Regional Office business model enables us to be highly efficient and effective within a relatively small budget envelope, providing a broad range of support to Member States, from policy and strategic advice to technical assistance.

I am pleased that the effectiveness of the Regional Office’s risk management and internal control processes were successfully validated by recent internal audits. This makes us proud and at the same time more committed to sustaining and enhancing accountability and transparency in delivering results.

I would like to thank my team in all offices across the Region, for their hard work, dedication and commitment in delivering high quality results in a most efficient and effective manner.

Conclusions and vision

Ladies and gentlemen, we should be proud of the tremendous results we have collectively achieved.

Yet, to make more progress and close the gaps we need a stronger political commitment to health and well-being as an integral component of sustainable development. This commitment needs strong actions by all relevant sectors and stakeholders. It should impact parliamentary decision-making and build policy coherence across different sectors at all levels.

WHO is committed to taking the lead and engaging with governments and with all partners to ensure that health is placed firmly on political agendas.

WHO is committed to streamlining the way we do business, to work efficiently for the highest impact.

The SDGs, Health 2020, and our renewed public health vision lead the way, and GPW 13 gives us the means and tools to succeed.

We share a vision: to build a world where everyone realizes their right to a healthy and prosperous life. To reach this vision, all of us – politicians, decision-makers, professionals and people in all walks of life – need to pledge their commitment.

I ask you for that commitment!