Report on the work of the WHO Regional Office for Europe
Zsuzsanna Jakab
WHO Regional Director for Europe
Mr President, Mr Executive President, dear Director-General, dear friends, ladies and gentlemen,
I warmly welcome you to this session of the WHO Regional Committee for Europe and would like to express our determination to continue our work for better health and well-being and a fairer distribution of health in the WHO European Region that we jointly decided at last year’s session in Moscow, Russian Federation. Although life expectancy in our Region has continuously improved over the last 20 years, we have to continue this trend and reduce inequalities. With the present level of knowledge and evidence, we can do more and we can achieve better results.
Now let me briefly describe our collective achievements and plans, as well as some of the most pressing challenges and the opportunities we have for overcoming them. I will spend less time on achievements and successes, which are described in detail in my report, and would like to concentrate more on the remaining challenges.
Before doing so, however, let me express our deep condolences to Norway for the tragic events during the summer and for the loss of innocent lives. Our hearts go out to those who lost their lives and to their families. In WHO, we have lost three dear colleagues in a cowardly attack on the United Nations office in Abuja, Nigeria. Our sympathy also goes to those who lost their lives or were injured in other emergencies in the Region.
First I would like to focus on the health threats in our Region that we have successfully tackled since the Regional Committee last year, beginning with emergencies, public health crises and major communicable diseases.
Everyone in this room knows that, when an emergency strikes, citizens demand the most rapid and effective response possible from their health authorities. In events like this, countries can always count on support from WHO.
As proven during the North Africa crisis, the issue of migration and health is an evolving priority. Italy therefore organized a ministerial meeting in Rome in April, to coordinate efforts for refugees from North Africa. The draft action plan I presented during that meeting was finalized immediately afterwards; implementation began right away, and will continue, hopefully leading to a long-term programme on migration and health in the Regional Office.
Emergencies do not happen only in Member States. During the past year, the Regional Office experienced emergencies on its premises. Since the flood right before the 2010 Regional Committee, we have experienced two more floods in July and August this year. It was a difficult summer for us.
The Emergency Steering Committee, chaired by me, took immediate measures to ensure the safety of staff, the continuity of the work, cleaning of the premises and reopening of the Office as soon as possible. At the same time, we interacted with the Danish Government to seek short-, medium- and long-term solutions.
I would like to thank the Regional Office’s staff for their dedicated work in difficult times, and the Danish authorities for taking immediate short-term action and making long-term plans with us to avert floods in the future. We are looking forward to the full implementation of this plan by 1 October this year.
The Regional Office does all its emergency-related work within the framework of the International Health Regulations (IHR). We continuously monitor potential events of public health concern in the Region. During 2010–2011, we followed up with Member States 3–4 events every week, which shows that Europe needs to continue to be vigilant and emphasizes the importance and urgency of the full implementation of IHR in our Region. One of our continued priorities is to support Member States in developing and strengthening their IHR core capacities by the deadline of June 2012, in partnership with the European Union (EU) and other institutions and agencies.
Last year I stood before you and reported on the unfortunate outbreak of wild poliovirus in Tajikistan, which affected three other countries – Kazakhstan, the Russian Federation and Turkmenistan – causing paralysis in 475 people and 30 deaths. Since then, countries have done great work, supported by us and other partners. The last reported case was at the end of September 2010, and 45 million doses of oral polio vaccine were administered through very successful synchronized campaigns in the affected countries and their neighbours. Under the leadership of WHO, strongly supported by the United Nations Children’s Fund (UNICEF) and other global partners, we were able to mobilize more than US$ 9 million for this effort.
In addition, I am delighted to inform you that the European Regional Certification Commission for Poliomyelitis Eradication confirmed the polio-free status of our Region, but cautioned that the risk of transmission if wild poliovirus is introduced remains high in nine Member States. I hope you will look at the map in the lobby to see the status of your countries, as we have to be vigilant and sustain our efforts until global polio eradication is achieved. Thanks to the ministers in affected and neighbouring countries for their fantastic leadership and great collaboration!
Similarly, all your commitment and leadership are needed to address the large measles outbreaks in the Region, and we need to scale up efforts to reach the targets for measles and rubella elimination set by the Regional Committee last year. The highly successful European Immunization Week, in which 52 Member States took part this year, is an instrument in these efforts. Azerbaijan has made great achievements in this regard.
I now turn to three additional alarming problems and one success story in our Region. Our Region has historically been in the forefront of tuberculosis prevention and control, but now faces an alarming problem: multidrug- and extensively drug-resistant tuberculosis (M/XDR-TB). In response, I established a special project to prevent and combat M/XDR-TB in the Region, which also pays special attention to the previously neglected childhood TB. To scale up activities and ensure a comprehensive response to prevent and control M/XDR-TB, a Consolidated Action Plan for 2011–2015 is being submitted for endorsement by the Regional Committee.
Europe is the first WHO region to establish a Green Light Committee at the regional level (on 1 July and it is operational) to oversee the efforts and assist Member States in developing and implementing national plans to address MDR-TB. The Regional Office works closely with all partners, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Stop TB Partnership and EU institutions. As the Consolidated Action Plan was developed with our partners and Member States, we will implement it jointly, working hand in hand with Member States.
Another alarming phenomenon is that the number of people living with HIV has tripled in eastern European and central Asian countries since 2000. HIV affects most seriously the populations that are socially marginalized and whose behaviour is socially stigmatized or illegal. Those key populations face structural barriers in access to HIV services and evidence-based strategies are not fully implemented in all Member States. As a result, although antiretroviral therapy (ART) has proved to be important in preventing HIV transmission, access to ART in eastern Europe and central Asia is unfortunately among the lowest globally. According to recent research, ART is 96% effective in reducing heterosexual transmission in couples where one partner has HIV. This further demonstrates the need to scale up access to ART and increase early HIV diagnosis and treatment.
To address this situation, on Thursday the Regional Committee will be presented with the European Action Plan for HIV/AIDS 2012–2015; its aims for the Region are to halt and reverse the spread of HIV, and achieve universal access to HIV prevention, diagnosis, treatment and care by 2015.
Another growing health threat – antimicrobial resistance – was the focus of World Health Day 2011. On this occasion, we supported a number of key activities across the European Region, such as the main launch event in Moscow, and other launch events in Copenhagen, Strasbourg, Rome, Kyiv and London. We also published a book on antibiotic resistance from a food safety perspective.
The problem is huge and driven by complex factors, including misuse of antibiotics (not only in humans but also in the agriculture sector), weak regulations and lack of awareness in many countries. Unfortunately there are no new drugs in the pipeline, and we do not want to lose our powerful weapon to against infectious diseases.
The Regional Office therefore developed a European strategic action plan on antibiotic resistance, which will be presented to you on Thursday. This builds on WHO’s work for and before World Health Day 2011, and the excellent work done by the EU.
And here is the success story. Extraordinary progress towards malaria elimination has been made across the WHO European Region, and now we are on course to meet the goal of the Tashkent Declaration: eliminating malaria by 2015. In 2010, only 5 countries in the Region reported only 176 locally acquired cases of malaria. WHO certified Turkmenistan as malaria free last year; we hope Armenia will be certified by the end of 2011, and experts are optimistic that malaria transmission was interrupted in Georgia in 2010. I would like to acknowledge the achievements of our host country, Azerbaijan, in working towards the elimination of malaria.
Let me now turn to the major burden of disease in the Region, “the silent killers” spreading via the evolution of culture and environments and policies that facilitate unhealthy behaviour.
As you know, the burden of noncommunicable diseases (NCDs) is the predominant public health challenge in each of your countries. Among the six WHO regions, Europe and the Americas share the dubious honour of having the highest proportion of deaths from NCDs and injuries. Further, Europe is leading in nearly all risk factors.
Nevertheless, Europe has also been a leader in prevention and health promotion, and we have experience that suggests that we can achieve measurable improvements in the period covered by the action plan for implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012–2016, which will be submitted to you at this Regional Committee session. The action plan builds on evidence accumulating across the world that the burden of NCDs is not a chronic burden at population level, and many countries and trials have shown quick results, including the rapid fall in deaths from ischaemic heart diseases in many European countries in the last two decades.
The year since the 2010 session of the Regional Committee has been an extraordinary year of immense progress against NCDs, globally and in Europe. The regional consultation in Oslo, Norway brought forth vigorous debate but also a deep consensus on the global priority to be accorded to NCDs; this constitutes the Region’s input into the United Nations high-level meeting on NCDs to be held next week. European leadership was also strongly apparent in the formulation of the Moscow Declaration at the First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, which contains a commitment to action that is very much the foundation of our European action plan.
A concrete action plan is being proposed to implement the European Strategy for the Prevention and Control of Noncommunicable Diseases, which was approved unanimously in 2006. Its aim is to make a measurable impact on the epidemic and its determinants in our Region. This will be discussed on Wednesday. The action plan will be fully coherent with the outcome statement of the United Nations meeting, with one difference: target setting has been dropped and we will drop it, too.
I believe we could build on the proud traditions and experiences of our Region and – with the recent endorsement of the Moscow Declaration by the World Health Assembly, the launch of the Global status report on noncommunicable diseases 2010 in April and the United Nations high-level meeting – the stage is set for a strong implementation of the European action plan, which I hope the Regional Committee will adopt.
In addition, mental health is high on our list of priorities and next year we will bring this topic to the Regional Committee’s attention. The Regional Office’s Athens centre on NCDs, which is hosted by the Greek Government and will be launched this month, will provide additional capacity to this important area of work. I thank the Greek Government for its commitment and support.
I will now highlight the exposure to health determinants that lead to the appearance or prevention of disease. The burden of NCDs arises from a complex but well-understood sequence of causation with multiple points of intervention. The four diseases and their biological risk factors on which we focus arise from a modifiable set of behaviours that are socially determined and, within larger globalized trends, increased urbanization and the ageing of the population.
Our solutions, both regional and national, cannot therefore focus on only one point of entry to this network of causes. We need to alleviate the consequences of the four diseases, especially among disadvantaged groups. We must influence behaviour and risk factors, and we must act on the social and environmental determinants of NCDs, as with our work on the new European health policy. The WHO Regional Office for Europe has always been strong on addressing these determinants, playing a leading role in Europe through its offices in Venice, Rome, Bonn and now Athens.
Our overall goal must be to create an intersectoral policy environment in which the healthy choice is the easy choice, as said in the Ottawa Charter for Health Promotion, and in line with the health-in-all-policies approach promoted so robustly under the Finnish Presidency of the EU, to which we are fully committed.
Good progress in tobacco control was made in our Region in 2010–2011, with many countries acceding to the WHO Framework Convention on Tobacco Control (FCTC) and making strong smoke-free policies. It is an honour for our Region that the WHO Director-General gave her special recognition award to the Prime Minister of Greece for his leadership in tobacco control through a whole-of-government approach very strongly supported by the Minister of Health and Social Solidarity, Mr Loverdos.
And there is one determinant for which now is the time to make much more progress, and this is alcohol. We need a renewed commitment to address the harmful use of alcohol, which is the second most important risk factor for deaths and disability in our Region, just after tobacco use. The Regional Office’s European status report on alcohol and health 2010 (published in January 2011) gives clear evidence for this. This is why the European action plan to reduce the harmful use of alcohol 2012–2020, which is fully compatible with the global strategy and the World Health Assembly resolution, has been put forward. The action plan proposes many evidence-based options for action as a menu for you to choose from. The main areas for policy interventions in both the alcohol and NCD action plans are intersectoral in nature and include some regulatory issues.
The Fifth Ministerial Conference on Environment and Health, held in Parma, Italy, gave new impetus to the Regional Office’s activities in this important area and strengthened the governance of the European environment and health process, building on the excellent long-standing collaboration between the two sectors. This led to the establishment of the European Environment and Health Ministerial Board, which met for the first time in Paris, France in May 2011, and agreed on how to monitor progress in achieving the commitments and targets endorsed by the Parma Declaration. This will be followed by the meeting of the European Environment and Health Task Force – bringing together national counterparts, stakeholders and partners, who are steering implementation of the Parma commitments at the national level – which will be hosted by Slovenia in October.
With other United Nations agencies, the Regional Office is participating in the development of the European regional report on sustainable development for the United Nations Conference on Sustainable Development, to be held in Rio de Janeiro, Brazil in 2012; our Office is leading, in cooperation with partners, the joint writing of a chapter on the social and health dimensions.
A major review of the Regional Office’s work on environment and health took place, prompted by the necessity to close the Rome Office by the end of 2011, owing to a change in priorities of the Italian Government. I would like to take this opportunity to emphasize the important role Rome Office played and its contribution to 20 years of the environment and health process, and to thank the Italian Government for its generous support to the centre over the past two decades.
An agreement with the German Government will enable the expansion of the Bonn Office, consolidating the environment and health programmes in Bonn by January 2012, supported by a small core presence in Copenhagen. I thank the German Government for its support.
Significant progress is being made towards achieving the health-related Millennium Development Goals (MDGs) in certain areas. As progress in the European Region varies significantly, however, I have made them a cross-Office priority and appointed a special representative for them.
WHO is the leading agency in the United Nations interagency working group on tackling inequities in progress towards the health-related MDGs, to agree on a coherent and coordinated approach by the United Nations system. A first draft of the group’s report is available as an information document for your comments at this Regional Committee session. In addition, we have been privileged to work with the First Lady of Georgia, Ms Sandra Roelofs, after her appointment as WHO Goodwill Ambassador in the European Region for the health-related MDGs.
Now I would like to concentrate on health systems – including the public health dimension, which has been revitalized in our work.
The full implementation of the Tallinn Charter: Health Systems for Health and Wealth is a priority and will go hand in hand with the new European health policy, Health 2020. The two reinforce each other: under the influence of Health 2020, work to strengthen health systems has focused more on health outcomes, and Health 2020 will take a great step further, rejuvenating public health and governance.
An interim report on the Charter’s implementation is on the agenda of the Regional Committee for Tuesday. Exchanges with Member States have confirmed that the Tallinn Charter had led to a more vigorous policy dialogue on preserving, reforming and investing in health systems and that countries were putting its values and policy objectives into practice.
As mentioned, we are in developing a new approach that focuses on health systems for health outcomes by, for example, applying the health systems approach, or systems thinking, to diseases and conditions such as NCDs, M/XDR-TB, etc. This fresh health systems and public health approach comes from 15 years of generic work to strengthen health systems, putting the building blocks in place to ensure health systems’ strategic orientation towards health outcomes. This approach requires putting service delivery in the centre, on three pillars:
1. starting with expected health outcomes and priorities;
2. then focusing on optimal service delivery strategies, in which the content comes from technical areas; and
3. identifying barriers that prevent health systems from providing effective services, which can be grouped under the headings of service delivery, governance, financing and resources.
We are also developing a consolidated package of strategies and services in health system strengthening, which includes the tools and instruments to assist Member States now and in the future; this is available to the Regional Committee as an information document.
The European and global health contexts have changed. The financial crisis calls on us all to scrutinize health expenditures, and the rise in NCDs, coupled with other challenges, highlights once again the need for comprehensive system responses. Against this background, national health policy frameworks with system-wide analysis become more important then ever. This is a project led by the Global Policy Group, and is a priority.
For the most efficient use of scarce resources, it is vital that preventive measures take a more prominent role, public health functions be strengthened and the health-in-all-policies approach promoted and advanced. These are also core elements of our new European health policy, Health 2020. As you will have seen, there is evidence that prevention can bring more immediate returns than previously thought. I have commissioned a study on the economics of prevention by the Observatory, supported by the Regional Office’s Chief Scientist.
Public health services are a priority for us because they are essential in protecting and promoting health and preventing disease, and perhaps the most efficient and economic way to improve the health of the whole population. I therefore decided to reposition public health services as an essential component of the health systems approach, and a framework for action complementary to Health 2020 will be presented to you on Tuesday for a first discussion. We plan to present the final result to the Regional Committee next year.
I invite countries in our Region to join in assessing their essential public health operations, functions and capacities, using the tool developed for this purpose. This is needed to provide evidence that will form the basis of the action plan to strengthen public health capacities and services in Europe, which will be presented to you at the 2012 session of the Regional Committee in Malta, hand in hand with the final version of Health 2020.
As another step towards strengthening public health, I am very pleased to inform you that the Kazakhstan School of Public Health has fulfilled its pledge to the Regional Committee in 2010 and has set up an annual scholarship in public health. I am also pleased to report that Jo Eirik Asvall’s memorial guide has truly been a best seller.
I consider the assessment of health systems’ performance an increasingly used and critical tool for health governance in the 21st century, and we call on all Member States to do their own performance assessment to ensure a country-owned and participatory process. This is because such assessments underlie and support national strategies, and improved health outcomes and equity are mainstreamed in the assessment process and the report.
Supporting Member States to move towards universal coverage and sustain it in the face of fiscal pressures has been at the heart of the Regional Office’s work on health financing; landmark publications brought this topic into the limelight in 2010–2011, such as Implementing health financing reform: lessons from countries in transition and the report on sustaining equity, solidarity and health gain in the context of the financial crisis. In addition, the WHO Regional Office for Europe contributed to the development of the World health report 2010 – Health systems financing: the path to universal coverage. Our efforts in 2011 continued with preparation of an action plan to follow the 2010 world health report, which will guide our work on health financing in the next biennium.
The renewed emphasis on universal coverage helped countries focus on minimizing the adverse effects of fiscal austerity measures on health and health systems. For example, the Regional Office has worked closely with Estonia, Ireland and Latvia. In this regard, I am proud to mention that the first WHO Barcelona course on health financing was held in 2011, with universal coverage as a special theme. In addition, the Regional Office continued courses for the Baltic countries and Poland, central Asia, the Caucasus and the Republic of Moldova. All these courses had extensive participation by policy-makers from across the Region, who expressed a high level of satisfaction and appreciation of the strong links to country work.
The penultimate strategic direction covered in my report deals with health information and communication. The Regional Office has made much progress in health information in 2010–2011; this is crucial as it provides the underlying evidence for our work in all areas. I invite you to the daily demonstrations taking place in the foyer during the breaks.
We are working with all our partners, including the EU, to develop a common health information system and a health information strategy for Europe will be on the Regional Committee agenda in 2012. Similarly, we have also worked on communication, using many new tools such as social media, which leads to more effective communication.
In this final part of my address to you, I would like to first emphasize the overarching priority, Health 2020. Then I will briefly mention our new organizational structure and strategic partnerships, and finally touch upon governance and financing, which are aligned with the WHO reform process.
We have done substantial work on the overarching European health policy initiative, Health 2020, which we will discuss later today and tomorrow. As many of you remember, Europe has had a European health policy since 1982, when the Regional Committee approved the Health for All strategy. Then 38 targets were adopted in 1984.
Following two updates in 1991 and 1998, the 2005 Regional Committee, in resolution EUR/RC55/R4, approved a further update and requested a report on the Health for All policy framework in 2008. In addition, you requested me last year to make a report by 2012, and do this work through a truly participatory two-year process. That is what we have been doing.
I am very pleased to report to you that your request and decision have struck a chord across Europe. I believe we have started a movement that will take us not only to 2012 but also far beyond. This feeling comes from the feedback that has been personally communicated to me at many countries’ conferences: that such a policy is very timely, long overdue, just what people are looking for and what is needed to help them in what they do. It is this feedback that perhaps should be the most gratifying to the Regional Committee, as it shows that what you decided in last year is indeed both useful and historic.
In 2010–2011, the Regional Office worked to strengthen itself by concentrating core policy, strategic and technical functions in the office in Copenhagen, fully streamlining and integrating the geographically dispersed offices (GDOs) and integrating the work of country offices. To support decision-making about the better integration of the GDOs and country offices in the Regional Office, I set up two groups of external experts to conduct independent reviews of each. Both reported their findings in November 2010. Intensive collaboration with all countries continued, and remains an outstanding priority.
The Regional Office conducted an in-depth analysis of its core functions and completed its reorganization, aligning its structures and human resources with its new priorities. Staff were recruited (or seconded) to fill mission-critical senior technical positions. Financial uncertainties have not helped (as I am sure you have also found), and I am grateful to all Member States that have supported us despite their own difficulties. In addition, we established an internal committee to foster an enabling working environment; it made recommendations that were approved and are now being followed.
Networks – of, for example, WHO collaborating centres and national institutes and schools pf public health– are excellent vehicles for public health, and are being renewed and revitalized. This is work for the upcoming months.
The WHO Director-General, Dr Chan, asked me take on a global function on relations with the EU and to chair the WHO steering committee on this topic. As in 2010, the Regional Office continues to establish and strengthen close collaboration with countries holding the EU presidency, both before and during their terms, for coherence and synergy; we worked with Spain and Belgium in 2010, Hungary and Poland in 2011 and have begun work with Denmark and Cyprus for 2012.
The ninth meeting of senior officials of WHO and the European Commission took place in March 2011, with the Director-General and three regional directors attending. After a very productive discussion, full agreement was reached on six roadmaps for the strategic priorities for collaboration. In addition, the Regional Office has renewed the memorandum of understanding with the European Centre for Disease Prevention and Control (ECDC). We also took action for enhanced collaboration with the World Bank, the Global Fund and the Organisation for Economic Co-operation and Development (OECD), and joined the United Nations regional development team.
There have been great improvements in relations with other United Nations agencies, ensuring coherence and coordination. Within WHO, the Regional Office hosted the meeting of regional directors’ teams in Copenhagen in March 2011. We have also improved our collaboration with associations and forums.
We are now developing a strategy on partnerships to be submitted to the Regional Committee in 2012, in line with WHO reform. Also in line with WHO reform, we have focused on improving governance functions within WHO. This included strengthening the Region’s governing bodies: referring European policies, strategies and action plans for decision to the WHO Regional Committee for Europe, making the programme more participatory for representatives and adding such events as ministerial days.
To improve oversight and transparency, membership of the Standing Committee of the Regional Committee (SCRC) was increased from 9 to 12 countries in 2010. All Member States were invited to attend the fourth session of the SCRC. A meeting of European delegations preceded the Sixty-fourth World Health Assembly in May 2011, and daily coordination meetings are held with European Member States during the Health Assembly and meetings of the Executive Board, to strengthen the links between the global and regional governing mechanisms. It is quite important that all the 53 Member States attend these, as was discussed with health ministers during the pre-meeting for this session of the Regional Committee.
Finally, a few words about financing: based on our current income of US$ 228 million, as of August 2011, it is expected that, by the end of the 2010–2011 biennium, our income will be comparable to that in previous biennia. As to income/expenditure per strategic objective for 2010–2011, the Regional Office has a solid macro financial situation for all strategic objectives except 12 and 13. During the biennium, however, we faced critical financial gaps for nearly all strategic objectives. This was due to the high level of earmarking, which continues to be an issue both globally and in the European Region. We have overcome this problem through regular progress reports, scrutiny of awards and follow-up by executive management. Nevertheless, the high level of earmarking – often without proper provision for paying salaries and enabling the managerial and administrative support needed for technical work and country offices – will cause numerous challenges in the next biennium.
As shown by the distribution of funds mobilized by WHO headquarters among the regions, the WHO Regional Office for Europe receives the lowest amount of corporate resources in WHO, so its self-reliance is highest. This issue needs further discussion, for which the reform process offers a good opportunity; Member States say that they do not want to pay WHO twice – and they are right.
To support our efforts to mobilize the resources required to support our Member States, the Regional Office developed advocacy papers for each of WHO’s strategic objectives. These papers specify the actions we will take if we receive the necessary funds, and I call for your continued support, including from new donor countries.
Your continuous support for our work is much appreciated and welcomed, and I look forward to excellent discussions during this Regional Committee session. Thank you.
