Address by Dr Zsuzsanna Jakab, WHO Regional Director for Europe at the 69th session of the WHO Regional Committee for Europe

16 September 2019, Copenhagen, Denmark

Welcome and introduction

Your Royal Highness The Crown Princess of Denmark, Director-General of WHO, Dr Tedros, Minister of Health of Denmark, President of the Regional Committee, Honourable Ministers and delegates, and dear guests.

I warmly welcome you to this 69th session of the WHO Regional Committee for Europe.

This is my last Regional Committee as Regional Director. It is not the end of my work with WHO, as Dr Tedros you honoured me by offering the opportunity to work in Geneva as Deputy Director-General, which I accepted with great honour. Yet I speak to you today as Regional Director, for the last time.

Usually in these speeches I review the work and progress of the WHO European Region over the previous 12 months. I shall do less of that today, and instead focus more on the 10 years since I took office in 2010.

What we have done, what we have achieved, and what remains to be done will be the subjects of my speech today, very much in line with what Dr Tedros has already said.

New thinking about health

Ten years ago, when I took over as Regional Director, I knew I wanted to achieve better and more equitable health and well-being for all the people of the Region, through strong collaboration with Member States and by engaging all stakeholders.

Previously health was seen too often as a matter for health systems alone. Health was even seen by some as a matter of hospital care alone.

I wanted to change that narrow perception.

More and more evidence had accumulated that health is powerfully influenced by the circumstances of life, what we now call the multiple determinants and contexts of health – political, social, environmental, commercial and cultural – as well as, of course, by health systems.

Also, a global narrative for health and well-being has emerged. Health has come increasingly to be seen as a global public good, as a human right, as a matter of social justice, and as an absolutely necessary element of development.

In addition, health is no longer seen as an expensive item of consumption; it is now accepted as an investment in development and as a necessary political choice.

As part of this wider perspective, health is also considered to be a vital issue for other sectors such as the economy, trade and security; and indeed, as a major economic sector in its own right.

I think we can be proud that over the last 10 years we in the European Region were among the first to take forward these values and perspectives, and to give these substance in terms of policies and strategies.

With Health 2020 – the European policy for health and well-being – we anticipated and reflected this narrative, now commonplace within the United Nations 2030 Agenda for Sustainable Development, the Sustainable Development Goals (SDGs) and WHO’s own Thirteenth General Programme of Work (GPW 13).

Today it is wonderful, after 10 years, to be able to report that Health 2020 made a major contribution to and had a major impact on health cross the Region as a whole, with the highest life expectancy now at 83.1 years.

We have also seen real progress with Health 2020, in terms of both policy development and implementation.

By 2016, 93% of countries indicated that they had a coherent, value-driven, and evidence-informed national health policy aligned with Health 2020, 35% more than in 2010; 86% of countries reported having implementation plans.

Ninety-eight per cent of countries reported having a policy or strategy to reduce health inequities, an increase of 10% since 2010. Eighty-eight per cent reported that they had defined targets or indicators for Health 2020, an increase of 15% since 2010.

Policy dialogues in Member States helped to shape these developments!

Today the narrative is moving forward again. Here Director-General, yours has been a key voice. Your “triple billion” targets within the GPW 13 inspire us all!

Being a lead for two out of the three triple billion targets, I feel a huge responsibility to achieve these results, and I am fully committed to doing so.

This assignment seems a natural extension of all the work we have been doing over these years.

My original vision: better health for Europe

Ten years ago, how did we arrive at Health 2020?

We looked at the many contemporary health and non-health system challenges, summarized here on the screen.

We wanted to deliver universal health coverage, putting emphasis on achieving people-centred, integrated and coordinated care at all levels.
We wanted a strong public health component, prioritizing health promotion and disease prevention.

We needed to take a multideterminant approach to these complex challenges with multiple, non-linear and interrelated causal factors.

We knew that this would require collaborative, coherent, whole-of society and whole-of-government approaches and the application of health in all policies.

Clearly, also, achievement would require strong leadership and clear goals.

Accordingly, I set out my vision with seven strategic priorities, shown here. These have guided all we have done over the last 10 years.
How were these seven action priorities addressed?

To achieve these priorities, as I have indicated, our main response was Health 2020 – the European policy for health and well-being – which was developed through a broad consultative process.

At the same time, in 2010, we also started working on the European Action Plan for Strengthening Public Health Capacities and Services. Both were adopted by you in 2012.

I was determined that both would be informed by our new knowledge about the full range of determinants of health, and by new thinking about advancing public health in the 21st century.

We developed tools and resources, adaptable to different countries and contexts, that would support the implementation of Health 2020 related health policies, including the Health 2020 implementation package.

Since then we have developed a range of other technical strategies and action plans which were all aligned with Health 2020.

We have also “seized the moment”. A good example here is our work on the health aspects of migration, where we took quick and courageous action when needed to support Member States.

The evidence and knowledge base for implementation of Health 2020

I was also determined that all our work must be based on science, evidence, data and monitoring.

Accordingly, I commissioned new work on the social determinants and the health divide in the European Region, and governance studies to help us understand better and advocate for and implement the vision of Health 2020.

I also commissioned economic studies to help policy-makers, health professionals and advocates better understand and promote the economic case for investing in health.

I reactivated the Regional Office’s European Advisory Committee on Health Research in order to promote and strengthen the use of research and evidence for public health decision-making and to inform policies for the development of health research in the Region.

Better health for Europe: our progress towards Health 2020

How have we done against our expectations of better health for Europe?

As well as the improvement in life expectancy, there have been significant improvements in other health indicators, shown here on this slide. Both maternal and infant mortality have fallen, alongside deaths from injuries, and there have been major achievements in relation to noncommunicable diseases and successes in the control of communicable diseases.

For noncommunicable diseases there are three important global targets for reductions in premature mortality, and the European Region is likely to be the only WHO region in which these targets will be met, or even exceeded.

Yet this positive picture remains scarred by persistent inequities in health and well-being within and between countries across the Region. For example, the lowest life expectancy in the Region is 70 years, well below the highest of 83.1 years.

When we look at overall age-standardized premature mortality from four main noncommunicable diseases, there is a similar regional variation in rates among people aged 30 to 70 years.

In relation to the social determinants of health, there are also some important gains to report.

The European health report 2018 shows that primary school enrolment numbers for the Region are moving in the right direction.

But again, the variation between countries is large, with 0.1% of children not enrolled at one extreme and 10.1% at the other.

Likewise, unemployment has fallen slightly from 8.9% in 2010 to 8.7% in 2015 in the Region as a whole.

Yet, again, there are large and persistent variations between countries, ranging from a minimum of 0.5% to a maximum of 26.1% in 2015.

In response, most Member States have explicitly included equity, social determinants, gender and human rights values and approaches in the design of national and local health policies.

Equity remains our biggest challenge, despite progress in setting broad health equity goals for access and coverage, reducing gaps in life expectancy and lifestyle risk factors, and tackling the social gradient.

I am particularly proud of the European Health Equity Status Report Initiative that we launched in 2018 to support countries, partners and WHO to strengthen the equity lens in all health policies and services.

We also followed up this Initiative with a recent successful meeting in 2019 on practical actions to improve health equity, which was held in Ljubljana. The first-ever WHO European Health Equity Status Report was launched on 10 September.

We showed that a number of multisectoral policies are important, including in the following areas: income and social protection;  employment and working conditions; good-quality early child-development programmes; whole-school approaches that prioritize emotional well-being as well as equitable educational attainment; minimum income, especially for families to achieve food security; housing interventions to reduce crowding and improve conditions; environment and green spaces; providing equitable access to water and sanitation facilities; and active travel. ¬

We also reemphasized the importance of human rights promotion and protection, including gender equality and minority rights in relation to social status, ethnicity, disability, sexual orientation and gender identity.

Please allow me to mention a few further highlights concerning the implementation of Health 2020.

We have made much progress on political, administrative, professional and technical leadership and governance, all of which are so crucial to promoting health and well-being.

To enhance staff capacities in these areas, we worked with the Graduate Institute of Geneva in conducting training in global health and health diplomacy.

There is so much to say about the technical work in the four action areas of Health 2020.

In previous years I have given a full overview in my speeches to the Regional Committee of the preceding year’s activities. This year I am going to select only a few landmarks from the last 10 years from each of these four areas. I will miss much out, and I apologize for this. However, a full review is available from other sources.

Public health

I placed special emphasis on advancing public health in the Region.

I presented a new vision for public health in the 21st century, which you considered and adopted last year.

We have aimed for improved recognition of the importance of public health, with the necessary institutional and workforce development as the cornerstone of work towards universal health coverage.

The Regional Office has now started to build a powerful collaboration, establishing a Coalition of Partners to strengthen enablers of public health in a more coordinated, systematic and proactive way.

The life-course approach

To further develop the life-course approach, an innovative, major international conference in Minsk was held to consider the life-course approach in the context of Health 2020.

This resulted in the Minsk Declaration, which set out strategies for countries to improve health and well-being, highlighting the importance of life-course transitions, including those from early childhood to adolescence, adulthood and old age, and changes in employment status.

The Declaration summarized actions to consider and commitments agreed to at the Conference, which reflected the objectives and priority action areas of Health 2020.

Intersectoral action for health

Another innovative conference was held in Paris in 2016 on promoting intersectoral and interagency action for health and well-being in the WHO European Region.

The conference culminated in the adoption of the Paris Declaration – “Partnerships for the health and well-being of our young and future generations” – as well as a proposal for the establishment of an ad hoc regional platform for working together for better health and well-being for all.

Member States committed to working together across sectors to increase understanding and build stronger policy synergies to benefit health and improve health equity.

One direct success of the platform was the establishment of a partnership between WHO and UNESCO to establish both a WHO Collaborating Centre for Research in Education and Health and the UNESCO Chair in Global Health and Education.

A further successful outcome has been the commitment of all 1400 WHO Healthy Cities in the European Region to ensuring that every school within their city is a WHO health promoting school.

NCDs and risk factors

Turning to the Region’s major disease burden, we are on track to meet the Health 2020 target of reducing overall premature mortality from the four major noncommunicable diseases by 1.5% annually until 2020.

Other good news is that reducing the burden from noncommunicable diseases is now a global priority, with a series of high-level meetings taking place at the United Nations in New York and commitments being made.

Here Health 2020 was anticipatory, emphasizing an approach that integrates risk factors, noncommunicable disease case management and responsive health systems.

This is another example of where the work of the Region has had global impact.

Yet not all is good news and challenges remain. Regrettably, as the Director-General said, tobacco use and alcohol consumption in the Region are declining too slowly, and the prevalence of overweight and obesity is rising rapidly. Unfortunately, the targets in those areas are unlikely to be achieved and making further progress is a top priority for the Region in the years ahead.

Communicable diseases

We have made major progress in the control of communicable diseases by addressing barriers related to health systems and focusing on high-risk populations and vulnerable groups.

A real success was that in 2015 we became the first Region to report zero indigenous malaria.

Maintaining zero cases in the European Region will require sustained political commitment, resources and constant vigilance, as indicated in the Ashgabat Statement.

We have done well with tuberculosis: from 2013 to 2017 we observed the fastest decline in TB among all WHO regions, with new cases decreasing from 36 to 30 new cases per 100 000 people. TB detection rates increased, and there has been progress in successful treatment outcomes, with a decline of  4.1 to 2.6 deaths per 100 000 people.

The Region was also the location for the first WHO Global Ministerial Conference on Ending TB, which took place in Moscow in 2017.

This culminated in the Moscow Declaration, providing input to the United Nations High-level Meeting on Ending TB in 2018, and committing to multisectoral action for universal access to care and prevention, increased and sustainable financing, research and innovation, and mechanisms to track progress.

The Region has made progress in increasing the number of people receiving treatment for HIV/AIDS and eliminating mother-to-child transmission.

Yet, the increasing HIV incidence is a major concern and one fifth of all people living with HIV in our Region still do not know their HIV status.
In July 2018, I invited the ministers of health of eastern European and central Asian countries to a policy dialogue in Amsterdam, where we agreed on ways to scale up and sustain evidence-informed interventions to end the AIDS epidemic by 2030. Good progress has been made to implement the jointly agreed roadmap.

Another priority has been antimicrobial resistance (AMR). When I took office in 2010, I made AMR a priority in the Region; the regional action plan adopted in 2011 was the first of its kind, and contributed to AMR becoming a global priority, with the global AMR action plan endorsed by the World Health Assembly in 2015.

I must, however, mention vaccination. Overall, we have seen a spectacular reduction in the incidence of measles and rubella and the polio-free status of the Region has been maintained.

Yet, since the beginning of 2017 a serious outbreak of measles has affected the Region, with an increasing number of countries affected.
Here I urge the vital importance of political commitment, of public awareness of the problem and its devastating consequences, and of developing more effective policy responses to vaccine hesitancy.

I warmly thank our Patron, Her Royal Highness The Crown Princess of Denmark, for her support in regard to vaccines and the contribution they make to our health and well-being.

Health systems

I turn now to the strengthening of people-centred health systems and public health capacity. Here we have focused on the implementation of a new European Framework for Action on Integrated Health Services Delivery.

Every five years we have revisited and celebrated the Alma-Ata Declaration on Primary Health Care in our Region to keep primary health care at the centre of our agenda.

That vision was renewed with the Astana Declaration at a global meeting in Astana, Kazakhstan, in October 2018 to mark the 40th anniversary of the Alma-Ata Declaration.

We celebrated the 10th anniversary of the Tallinn Charter, and held a high-level meeting again in Tallinn in June 2018 to review progress towards our goal of integrated and people-centred services available to all. Thanks go to Marc Danzon for the first Tallinn meeting.

Yet another ground-breaking meeting was the high-level regional meeting, Health Systems Respond to NCDs: Experience in the European Region, held in Sitges, Spain, in 2018, which provided policy-makers with a platform to share country experiences of strengthening health systems for better NCD outcomes.

The meeting addressed the role of health systems in enabling people to manage their own health conditions, taking action to reduce NCDs, and increasing the role of health professionals in NCD detection and management – all issues that were addressed in the conference outcome statement.

Now our attention focuses more than ever on implementing universal health coverage.

The Tallinn Charter indicated that “today it is unacceptable that people become poor as a result of ill-health”.

Our Director-General added the crucial point about access to health services, saying: “no one should get sick and die just because they are poor, or because they cannot access the health services they need”.

Linked to these ideas was an important meeting held in Oslo in 2013 to review the impact of the economic crisis on health and health systems across the Region.

The conference discussed the various policy responses, shared lessons learned and agreed on ways in which countries can better prepare for the future.

Since then we have stepped up our efforts to generate evidence to support universal health coverage, initiating a new programme of work to monitor coverage, access and financial protection across the Region, including the impact of impoverishing out-of-pocket payments.

Our team at the Barcelona office continues to support work on universal health coverage and financial protection, including reviews of out-of-pocket payments, and flagship courses on health financing and health systems strengthening in support of NCD management.

A last health systems point is one where I have a particular interest. I firmly believe, as the Director-General does, that digitalizing health systems is a key component in achieving universal health coverage.

We held an important symposium on the future of digital health systems in the European Region, in Copenhagen in February 2019.

This meeting helped us understand that new standards and regulatory approaches are needed to ensure security and transparency, and to ensure that digital health services are safe and accessible to all and that wrongful uses of technology are prevented.

Emergencies and preparedness

Health security is an important dimension of universal health coverage. As the Director-General has said: “Universal health coverage and health security are two sides of the same coin”.

Preparedness for all-hazard health emergencies and implementation of the International Health Regulations is a major element of public health capacity that I have prioritized.

In addition, the Regional Office has put into practice the assessment of national core capacities using voluntary tools, namely simulation exercises, after-action reviews and external evaluations.

We have been working in response to two major protracted emergencies in the Region, and the Regional Office continues to lead and coordinate the work together with partners and through our field offices in Turkey and Ukraine.

Environment

I would like to turn now to creating resilient communities and supportive environments.

Resilient communities respond proactively to new or adverse situations; prepare for economic, social and environmental change; and deal more competently with crisis and hardship.

The wider environment is also a major determinant of health, estimated to account for almost 20% of all deaths in the Region.

We need broad, primary prevention public health approaches, and intersectoral policy-making, to tackle poor air quality, poor water and sanitation, chemicals in the environment, housing conditions, occupational exposures and now crucially the impact of climate-related emergencies.

A unique intersectoral policy platform bringing together relevant sectors and partners to shape policies and actions on environment and health is the series of ministerial conferences of the European Environment and Health Process.

Thanks to Czechia for hosting the sixth Ministerial Conference, in Ostrava, in 2017.

The Ostrava Declaration showed European leaders’ commitment to taking action on environment and health in order to achieve the SDGs.
It also supported the goals of Health 2020, focusing on the creation of supportive environments and resilient communities.

Working with Member States

I realized that to really make Health 2020 work for the whole Region, a key priority had to be earning the trust of our Member States, by improving the relevance of the work of the Regional Office, promoting engagement and confidence, and improving governance.

One way to help achieve this was to strengthen governance and thus the decision-making and oversight role of the Regional Committee and the Standing Committee of the Regional Committee.

We also provided policy and technical support to Member States, taking account of their contexts and challenges, listening, engaging and responding to their needs effectively and efficiently.

Our aim was to find ways to support Member States in developing their capacity to respond to challenges, with the necessary skills, knowledge, partnerships, networks and relationships.

We developed our collaborative agreements with countries and strengthened the capacity of our country offices and geographically dispersed offices (GDOs) and other outpost offices.

We have always made a big effort to “be there” for countries when and where they needed us; for example, for critical parliamentary health debates and other urgent national health developments and reforms, and for policy dialogues.

Developing the Regional Office as a vehicle for 21st century public health action

So far, ladies and gentlemen, I have looked outside to the health impact of the work of the Regional Office. Within the Office how did we achieve our goals and outcomes?

When I started as the Regional Director, a main priority was to see the Regional Office become the “go-to” centre for excellence in public health in Europe.

We also aimed to be an initiator, tester, facilitator and driver of global health approaches.

We worked to make the concept of governance for health mainstream, aiming to deliver models of governance that are designed to enhance health, equity and well-being.

Here a key milestone was the development of the Assessment Tool for Governance for Health and Well-being.

We strengthened technical skills in areas where countries had expressed a need, such as health financing and financial protection, anticipating health needs, migration and health, and men’s health, to name just a few.

We strengthened our country offices with internationally appointed WHO representatives working collaboratively within United Nations country teams, in line with United Nations development reform.

We worked to create strong, enabling support functions and sustainable financing, and hence created a more sustainable path for the Regional Office.

We have worked hard on fundraising to enhance support for our technical programmes.

We have also worked to enhance partnerships and networks, and sustain existing and create new GDOs in Moscow and Almaty.

We are grateful to Member States which generously offered to host GDOs. They have been instrumental in ensuring that sufficient and sustained technical capacity has been available for priority areas of our work.

Building strategic partnerships and networks

I believe strongly in collaborative work with partners, as well as networks of like-minded Member States. We simply cannot deliver Health 2020 on our own.

I was determined therefore to broaden and deepen our engagement with partners, moving beyond competition to establish coherent policies, joint ownership and responsibility, and agreed mechanisms to monitor progress.

Reaching out through information and communication

Today communicating our vision, goals and policies is more vital than ever to help increase understanding and commitment, and to help promote health literacy.

This means giving everyone in the Region and beyond access to understandable and useful health information.

We have worked hard to amplify and broaden the reach of the Regional Office through enhanced web and social media feeds.

The social media app I hope you are all using at this Regional Committee is one example of this sort of innovation.
Investing in people

Making progress on all of these ideas has depended on the work of our dedicated, motivated, competent and hard-working staff.

I encouraged their active participation and involvement in developing and implementing Health 2020 and created an empowering environment for effective implementation.

I have prioritized the recruitment and retention of a motivated, gender- and geographically-balanced workforce who can lead the Organization into the future.

I wanted improved training opportunities to be provided, and was particularly keen to strengthen our intern programme.

I initiated improved internal management and financial procedures and accountabilities.

Health research and knowledge translation

Evidence has always been at the core of our work during the past 10 years.

I have emphasized that Health 2020 was built on the best available evidence – evidence which is accessible, understandable, useful and recognized as robust.

An important innovation has been the Health Evidence Network synthesis report series, which continues to turn published evidence into policy options.

One recent example was a very useful series on migration and health, published in 2018.

Another innovation has been the Evidence-Informed Policy Network, launched in the Regional Office in October 2012 as part of a global WHO initiative to assist with evidence transfer and translation.

The future

Ladies and gentlemen, Health 2020 will soon reach the end of its time, yet its approaches anticipated and supported newer innovations such as the SDGs, GPW 13, and the WHO transformation.

We now have all the policy and strategic documents and tools aligned to make real progress.

Health is a political choice

As we have emphasized throughout my time as Regional Director, ultimately health is a political choice and to achieve the equitable improvement in health that we all seek we need a high level of political commitment.

It is for this reason that I so wholeheartedly welcome the approach of our Director General to reach out to the policy- and decision-makers at the highest levels in Member States to ensure their support and leadership. This is the key to success.

Advancing health requires multisectoral actions

Health is complex, and improving health is a complex and non-linear process. The need for scientific evidence and analysis must be set against social and political contexts of growing complexity, unpredictability and ambiguity.

We must deal with multiple determinants through multi-level political and structural mechanisms, as well as behavioural interventions.
Here we need new organizational and institutional mechanisms to develop, implement and fund the required multisectoral actions.

More resources in health as investments for the future

All available evidence suggests that investments in health provide high returns in terms of sustainable development.

The evidence strongly suggests that many health interventions are highly cost-effective in their own right and can save downstream costs.
We must convey these messages to the highest levels of politics, policy and finance.

Universal health coverage

It is great news that in New York next week a high-level meeting on universal health coverage will be held at the United Nations General Assembly.

This meeting – Universal Health Coverage: Moving Together to Build a Healthier World – will bring together heads of state, political and health leaders, policy-makers, and universal health coverage champions to advocate for health for all. This will give a further boost to equitable health improvement, which is our aim.

We also need to focus on health promotion and prevention with visionary, new and more effective public health institutions and capacities.

Health systems

Our health systems must be open to innovation in order to create new and more integrated, high-quality and people-centred solutions for the benefit of public health. These must be organized according to best principles.

We must make the most of the opportunities offered by new technologies, including preventive and predictive approaches, and the epidemiological and patient management opportunities offered by digitalization, big data and artificial intelligence.

What about WHO?

I strongly believe that in the face of all these challenges we need a strong, efficient, relevant and responsive WHO, as a centre of global health excellence, with high-calibre and empowered staff.

This is the goal of our WHO transformation, and I think it will succeed as a result of our collective efforts.

Conclusion

Ladies and gentlemen,

Let me end on a more personal and passionate note.

Our health has improved, yet not enough by far. I strongly believe that we have the knowledge, the policies and the means to do better, in absolute terms and also in terms of reducing the health inequities which scar our societies.

We need to continue to promote and invest in health as a critical factor for the overall development of our societies.

I am confident that you will find the political will to make health a major political objective and a marker of political success.

A final comment.

Each generation of WHO staff works to preserve and advance the Organization’s values, approaches and impact, and then deliver these into the hands of their successors to be further developed.

When our turn came in 2010, Health 2020 became the platform for our contribution.

I really believe that that the voice and work of existing and future public health leaders in all 53 countries in our European Region have been greatly strengthened by our collaborative work and collective experience over these last 10 years.

I think that across the European Region we have, together, made a significant contribution to championing public health and delivering health for all, as well as positioning health on political agendas both regionally and globally. I would like to thank you for all your work and efforts!
It has been a great privilege to serve as your Regional Director. I now start the process of handing this mandate over to the next Regional Director and his or her extended staff.

I am sure that my successor will continue the task and I wish him or her every success in this work.

Thank you very much for your attention.