Investing in healthier cities: multistakeholder action to prevent noncommunicable diseases

Health in All Policies Eurohealth — Vol.23 | No.3 | 2017 9 INVESTING IN HEALTHIER CITIES – MULTISTAKEHOLDER ACTION TO PREVENT NONCOMMUNICABLE DISEASES By: Téa Collins, Bente Mikkelsen, Oddvar Kaarboe, Siegfried Walch and Oleg Chestnov Summary: Noncommunicable diseases (NCDs) are the leading cause of death worldwide. To address NCDs, policy coherence between health and other sectors, as well as the implementation of health in all policies through the whole-of-government and whole-of-society approaches are paramount. Healthy Cities is a platform to promote multi-sectoral work on NCDs through building sustainable partnerships between public and private sectors to act collectively and overcome the global NCD challenge. Healthy Cities could be used as a novel tool to implement the 2030 Agenda for Sustainable Development and make linkages among NCDs, universal health coverage and resilient and sustainable cities, and promote partnerships for action on NCDs. Keywords: Noncommunicable Diseases, Health Promotion, Disease Prevention, Healthy Cities, Universal Health Coverage Téa Collins is Adviser, Global Coordination Mechanism on NCDs, World Health Organization (WHO), Geneva, Switzerland; Bente Mikkelsen is Head of the Secretariat, Global Coordination Mechanism on NCDs, WHO, Geneva, Switzerland; Oddvar Kaarboe is Professor of health economics, Department of health management and economics, University of Oslo, Norway; Siegfried Walch is Professor of social and health management, Management Center Innsbruck, Austria; Oleg Chestnov is Assistant Director- General, NCDs and Mental Health, WHO, Geneva, Switzerland. Email: collinst@who.int Introduction Noncommunicable diseases (NCDs) – mainly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – are the leading causes of death worldwide. The World Health Organization (WHO) estimates that in 2015, 15 million people between the ages of 30 and 69 died from NCDs. Over 80% of these premature deaths were due to these four major groups of NCDs. 1 The impact of NCDs is alarming in the European Region. Taken together, the four NCDs, along with mental disorders, account for an estimated 86% of deaths and 77% of the disease burden in the Region. 2 They represent a challenge not only from the health perspective but also from the perspective of economic development, due to unnecessary labour productivity losses. A consensus is growing that to address NCDs, policy coherence between health and the sectors impacting health, as well as the implementation of health in all policies through the whole-of-government and whole-of-society approaches, will be paramount. The need for a multistakeholder and multisectoral approach to counter NCDs was clearly articulated in the political declaration and the outcome > #EHFG2017 Workshop 1: Invest in healthier cities: “insuring” prevention Health in All Policies Eurohealth — Vol.23 | No.3 | 2017 10 document of the two United Nations High-level Meetings on NCDs, first in September 2011, and then during the second follow-up meeting in July 2014. In addition, the new agenda for sustainable development – Transforming Our World: the 2030 Agenda for Sustainable Development – recognised NCDs as an important part of the agenda and included a target of a one-third reduction of premature mortality from NCDs by 2030. 3 ‘‘ building sustainable partnerships between public and private sectors However, the translation of the high-level political commitments into country-level action has proved to be difficult. Some have argued that the “neglect of NCDs is a political, not a technical failure, since cost- effective interventions are available.” 4 In many languages, policy and politics are the same word. Therefore health in all policies can be interpreted as health in all politics as well. Politicians’ involvement is critical to ensure that health is visible in other sectors. The politics of NCDs can best be addressed through strong local government leadership and collaboration between health and social services, business, industry, transport, education, insurance, education, economic and environment sectors. 5 Local government should be empowered to improve citizens’ health and well-being, prevent disease and promote health, and support health literacy for building resilient communities. Health promotion and disease prevention should be considered a shared societal value and a political goal for all. This requires intersectoral cooperation, which is particularly relevant at the local level, where global policies are adapted to local needs and priorities. Many social determinants of health can be effectively tackled at either the local government or local community levels. However, implementation challenges remain and are often due to poor governance for health and financial constraints. We suggest Healthy Cities as a platform to promote multi-sectoral work on NCDs through building sustainable partnerships between public and private sectors to act collectively and overcome the global NCD challenge. The concept of healthy cities is nothing new. WHO has been promoting the healthy cities concept for decades, recognising health as a core city value and acknowledging the role of every stakeholder to fulfil their responsibility for creating healthy environments. 5 However, what we believe is novel is using the platform as a tool to implement the 2030 Agenda and making linkages with NCDs (SDG 3.4), universal health coverage (UHC) (SDG 3.8) and resilient and sustainable cities (SDG 11), and to promote partnerships (Goal 17) for action on NCDs. In practice, this means bringing together city governments and the insurance industry along with other actors in joint efforts for shared governance for health to overcome the NCD challenge. With a growing interest in private insurance as countries around the globe strive to achieve UHC, public-private partnerships with insurance companies may be a win-win solution. According to WHO, 39 countries have private health insurance (PHI) exceeding 5% of total health expenditure. The dependence on PHI varies from region to region and country to country depending on the variation in income level and institutional development. However, even in countries where health care systems are primarily publicly funded, PHI provides important supplementary coverage. For example, in France over 85% of the population buys supplementary private insurance policies, while in the Netherlands this number is over 90%. Australia and Ireland are known for encouraging private insurance to complement public financing. From the public sector, local governments are best placed to provide leadership for health. City mayors are well positioned to integrate public health into local governance and build solid inter- sectoral alliances for sustainable urban development. On the other hand, the insurance industry, which increasingly favours healthy consumers to avoid the proliferation of health care costs due to chronic illness and overuse of medical technologies, has an inherent interest to work with city governments to build healthier communities. As a result, new kinds of insurance models are emerging based on a health rather than a sickness paradigm. 6 Urbanisation and health Since 2008, a majority of the world’s population lives in cities. Between 2000 and 2014, one billion people were added to urban areas globally. 7 Rapid urbanisation is expected to continue, and by 2050, two in three people will be living in cities. This is not surprising given the major transition that is taking place from an agrarian to an industrialised, service-oriented economy, with cities playing a central role in ensuring major economic, political and cultural opportunities. It is estimated that 600 cities are providing over 60% of global economic output. 8 In addition to economic progress, urbanisation has a strong health dimension. Evidence shows that there is an “urban advantage” with respect to better availability and accessibility to health care services when compared to rural areas, due to better health system infrastructure and high concentration of human resources in cities. On the other hand, urban lifestyles tend to create an environment conducive to unhealthy behaviours, such as a lack of physical activity, diets rich in processed fast food lacking essential nutrients and high in fats and sugar, as well as use of tobacco and alcohol abuse. Cities can also concentrate urban poverty and ill health and exacerbate inequalities in health outcomes due to inequities in access to health resources, and contribute to the rise of NCDs. According to WHO, urbanisation is one of the key challenges of public health in the 21st century. 9 Involving cities in discussions on UHC The emerging importance of NCDs increases the imperative for health promotion and disease prevention. Health in All Policies Eurohealth — Vol.23 | No.3 | 2017 11 Preventing diseases rather than caring for the sick can have a huge impact on population health, yet it is often overlooked in UHC efforts. Although prevention is justifiable economically, as well as from the health and human rights perspective, it is common for health care systems in general and health insurance plans in particular (e.g. social insurance in Europe, as well as private insurance companies) to focus on curative care without sufficient attention to health promotion and disease prevention. Rapid urbanisation, demographic changes (such as ageing populations and migration), and epidemiological transition with a growing burden of NCDs, are posing multiple challenges to city mayors and municipal authorities in their efforts to ensure the health of their citizens in the context of competing priorities and fiscal constraints. 10 ‘‘ potential to make lasting and positive changesAs national governments move forward to achieving UHC and/or expanding benefits packages, cities should be part of the dialogue on a wide range of policies related to health and social services, as well as the determinants of NCDs. Traditionally, health promotion activities have focused on immunisation, family planning, breastfeeding, water and sanitation and preventing violence. However, a contemporary agenda for health promotion needs to address the NCD risk factors, such as tobacco, alcohol, over-nutrition, physical activity, substance abuse and injuries. 11 The commercialisation of health promotion Some argue that 21st century health promotion is increasingly being privatised, with the private sector embarking on a “wellness revolution” with the explosion of media that focus on health and wellness in electronic and print outlets, the Internet and TV programming, and the growing wellness market with dietary supplements and functional foods that help manage specific diseases (such as diabetes). The commercialisation of health promotion calls for a shift from a traditional approach to regulate industries producing unhealthy products (such as tobacco or highly processed food) to educating communities to increase their health literacy and take charge of their lives. On the bright side, the interest of the private sector in health and wellness offers opportunities for partnerships to increase the attractiveness of health promotion messages and encourage healthy competition for positive lifestyles. 12 Companies have already started using technologies to drive behavioural change. For example, SidekickHealth, a company developed by researchers from Harvard University and the Massachusetts Institute of Technology (MIT), provides an interactive eHealth platform to help employers and health care providers deliver programmes that promote health and tackle chronic diseases. The company uses smartphone technology with a data-driven approach to engage people to adopt healthier behaviours by increasing their motivation to get better results and improve their health. 13 Digital Inclusion Technology-driven smart cities are most successful when their focus is on people and when they actively engage citizens in creating, using and monitoring the smart devices designed for them, as well as improving their living environments and quality of life. Digital inclusion is becoming central to ensuring no one is left behind by providing e-training to older and technologically challenged people, Box 1: Mayors’ ten priority Healthy City Action Areas As mayors we commit to ten Healthy Cities action areas which we will integrate fully into our implementation of the 2030 sustainable development agenda. We will: 1. Work to deliver the basic needs of all our residents (education, housing, employment and security), as well as work towards building more equitable and sustainable social security systems; 2. Take measures to eliminate air, water and soil pollution in our cities, and tackle climate change at the local level by making our industries and cities green and ensure clean energy and air; 3. Invest in our children, prioritise early child development and ensure that city policies and programs in health, education and social services leave no child behind; 4. Make our environment safe for women and girls, especially protecting them from harassment and gender-based violence; 5. Improve the health and quality of life of the urban poor, slum and informal settlement dwellers, and migrants and refugees – and ensure their access to affordable housing and health care; 6. Address multiple forms of discrimination, against people living with disabilities or with HIV AIDS, older people, and others; 7. Make our cities safe from infectious disease through ensuring immunization, clean water, sanitation, waste management and vector control; 8. Design our cities to promote sustainable urban mobility, walking and physical activity through attractive and green neighbourhoods, active transport infrastructure, strong road safety laws, and accessible play and leisure facilities; 9. Implement sustainable and safe food policies that increase access to affordable healthy food and safe water, reduce sugar and salt intake, and reduce the harmful use of alcohol including through regulation, pricing, education and taxation; 10. Make our environments smoke free, legislating to make indoor public places and public transport smoke free, and banning all forms of tobacco advertising, promotion and sponsorship in our cities. Source: 14 Health in All Policies Eurohealth — Vol.23 | No.3 | 2017 12 and helping them lead productive lives, re-entering the workforce in new, less demanding ways and further contributing to the economy. 14 Conclusions Health is a cornerstone of sustainable development and therefore including health in all policies is important for coherent public policies with a major developmental impact. NCDs are responsible for premature death and lower quality of life for millions of people. Partnerships between public and private sectors led by local governments have the greatest potential to making lasting and positive change. Of the many actors at all levels of government, city mayors and local government leaders are uniquely positioned to contribute in a major way to making cities healthier and reducing NCDs via action on the risk factors and the social and economic determinants of health. Mayors and local leaders also play a defining role in delivering on the 2030 Agenda. They have the political responsibility to ensure that health becomes an important value in cities’ vision for future development and draws together all relevant sectors for action on population health. The evidence to date is encouraging: many city governments now have the power and support to work across sectors, departments, independent agencies and community groups to develop partnerships with a common purpose to promote health and prevent disease. There is evidence that most Nordic countries, notably Finland, have transferred the main responsibility for health promotion to the municipal level. Similarly, public health in England, which was the responsibility of the National Health Service since 1974, was transferred back to local government. 5 More recently, 100 mayors from around the world came together on 21 November 2016 in Shanghai, China at the 9th Global Conference on Health Promotion, and committed to making bold political choices for health and implementing healthy cities programmes of action (see Box 1). The time is ripe for cities to make the political, economic, moral and ethical arguments for action for collaboration across sectors and to ensure the health of their citizens. References 1 Preparation for the third High-level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases, to be held in 2018. Report by the Director-General, World Health Organization, 2017. Available at: http://www.euro. who.int/__data/assets/pdf_file/0010/340786/ A70_27-en-cover.pdf 2 Noncommunicable diseases web page, 2017. Copenhagen: WHO Regional Office for Europe. Available at: http://www.euro.who.int/en/health- topics/noncommunicable-diseases 3 United Nations General Assembly RES/70/1. Transforming our World: the 2030 Agenda for Sustainable Development, 2015. 4 Geneau R, Stuckler D, Stachenko S, et al. Raising the priority of preventing chronic diseases: a political process. The Lancet 2010;376:1689 – 98. 5 Tsouros A. City Leadership for Health and Well-being: Back to the Future. Journal of Urban health: Bulletin of the New York Academy of Medicine 2013;90(1). 6 Sekhri N, Savedoff W. Private Health Insurance: Implications for Developing Countries. Discussion Paper. Geneva: World Health Organization, 2004. 7 World urbanization prospects, the 2014 revision. New York: United Nations, Department of Economic and Social Affairs, Population Division, 2014. 8 McKinsey Global Institute. Urban world: mapping the economic power of cities. McKinsey and Company, 2011. Portugal: health system review By: J Simões, GF Augusto, I Fronteira & C Hernández-Quevedo Copenhagen: World Health Organization 2017 (on behalf of the European Observatory on Health Systems and Policies) Number of pages: 184; ISSN: 1817-6127 Freely available to download at: http://www.euro.who. int/__data/assets/pdf_file/0007/337471/HiT-Portugal.pdf?ua=1 While overall health indicators for Portugal have notably improved in recent years, they still hide significant health inequalities, which are mostly related to health determinants, such as child poverty, mental health and quality of life. Even though the Portuguese National Health Service (NHS) is universal, comprehensive and almost free at point of delivery, there are also inequities in access to health care, mostly related to geography, income and health literacy. The so-called health subsystems, the special health insurance schemes for particular professions or companies that exist next to the NHS, as well as private voluntary health insurance, provide easier access for certain groups. Since the financial crisis, health sector reforms in Portugal have been Portugal Health system re view Vol. 19 No. 2 2017 Health Systems in T ransition Jorge de Almeida Simões Gonçalo Figueire do Augusto Inês Fronteira Cristina Hernánd ez-Quevedo guided by the Memorandum of Understanding that was signed between the Portuguese Government and three international institutions (the European Commission, the European Central Bank and the International Monetary Fund) in exchange for a €78 billion loan. Measures were implemented to contain costs, improve efficiency and increase regulation. Nonetheless, financial sustainability of the Portuguese health system remains a challenge. Due to cuts in public workers’ salaries the increasing migration of health care workers risks negatively affecting the quality and accessibility of care. While several reforms are aimed at improving coordinated care and developing the use of Health Technology Assessment, there is still scope for increasing efficiency in the health system. Health in All Policies Eurohealth — Vol.23 | No.3 | 2017 13 9 The world health report. Primary health care (now more than ever). Geneva: World Health Organization, 2008. 10 Ross A. Universal Health Coverage: How can cities play a leading role? Kobe, Japan: WHO Centre for Health Development, 2014. 11 Coe G, Beyer J. The imperative for health promotion in universal health coverage. Global Health: Science and Practice 2014;2:1. 12 Kickbusch I, Payne L. Twenty-first century health promotion: the public health revolution meets the wellness revolution. Health Promotion International 2003;18(4):275 – 8. 13 SidekickHealth: Improve your health the fun way web site. Available at: https://www.sidekickhealth. com/ 14 Boulos M, Tsouros A, Holopainen A. Social, innovative and smart cities are happy and resilient: insights from the WHO EURO 2014 International Healthy Cities Conference. International Journal of Health Geographics 2015;14:3. 15 Shanghai Consensus on Healthy Cities. Healthy Cities Mayors Forum. 9th Global Conference on Health Promotion. Available at: http://iogt.org/ wp-content/uploads/2016/12/9gchp-mayors- consensus-healthy-cities.pdf INCLUSIVE WORK- PLACES TO AVOID SOCIAL EXCLUSION By: Katalin Sas and Timothy Tregenza Summary: Employment is key for social inclusion as well as being an important determinant of health. To improve health, occupational safety and health cannot operate in isolation from public health and other policy areas. Creating inclusive workplaces and reducing health inequalities requires policy initiatives that bring together different actors and stakeholders. Keywords: Employment, Workplaces, Social Inclusion, Social Rights, Inclusive Labour Markets Katalin Sas is Project Manager and Timothy Tregenza is Network Manager, European Agency for Safety and Health at Work (EU OSHA), Bilbao, Spain. Email: sas@osha.europa.eu Employment is key for social inclusion The European Union (EU) has long been combating social exclusion and sees work as playing a key role in this. Active inclusion strategies look to get as many people as possible into the labour market and keeping them healthy and safe while they are in work. The European Commission’s Communication on the European Pillar of Social Rights 1 moves forward efforts at building a fairer Europe and strengthening its social dimension. It reaffirms existing rights in the EU and in the international legal acquis while complementing them to take account of new realities and seeking to make them more visible and explicit for citizens and for actors at all levels. The Pillar sets out the main principles and rights to promote the social dimension in Europe, including among others, equal opportunities, access to the labour market and secure employment, and a healthy, safe and well-adapted working environment. Employment is key for social inclusion as well as being an important determinant of health. Having a job or an occupation not only means income and financial security, it is also an important determinant of self-esteem. It provides a link between the individual and society and enables people to contribute to society and, ideally, to achieve personal fulfilment. Long-term unemployment presents a risk for social exclusion and the loss of a job or the threat of losing a job is detrimental to health. 2 3 In the context of an ageing workforce, keeping people in employment and increasing employment rates is essential for ensuring the sustainability of Europe’s social model, welfare systems, public finances, and economic growth. Yet too many workers leave the labour market permanently because of health problems or disability, and too few people with reduced work capability manage to remain in employment. Do working conditions affect health? While recognising the importance of employment for social inclusion and > #EHFG2017 Workshop 8: Social inclusion, work and health