Sixty-ninth Regional Committee for Europe: Copenhagen, 16–19 September 2019: report of the Regional Director on the work of WHO in the European Region in 2018–2019

WORLD HEALTH OR GANIZA T I ON REGIO NAL OFF I CE FOR E UROPE UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Telephone: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eugovernance@who.int Web: http://www.euro.who.int/en/who-we-are/governance Regional Committee for Europe EUR/RC69/5 69th session + EUR/RC69/Conf.Doc./1 Copenhagen, Denmark, 16–19 September 2019 30 August 2019 190442 Provisional agenda item 2(a) ORIGINAL: ENGLISH Report of the Regional Director on the work of WHO in the European Region in 2018–2019 This report highlights some of the most important work of the WHO Regional Office for Europe in 2018–2019 for better health in the WHO European Region. In responding to the challenges facing the Region in 2018–2019, the Regional Office continued to organize its activities in line with the 2030 Agenda for Sustainable Development and the Health 2020 policy framework, while also taking into account the strategic priorities and shifts set out in the Thirteenth General Programme of Work, 2019–2023. EUR/RC69/5 page 2 Contents Abbreviations ............................................................................................................................. 4 1. Better health for Europe: more equitable and sustainable ...................................................... 6 Introduction ....................................................................................................................... 6 European health report 2018: the inequitable state of health in Europe ........................... 7 WHO European Health Equity Status Report Initiative ................................................... 8 Implementing the 2030 Agenda: health as a driver of development ................................ 8 Governance for health and well-being .............................................................................. 9 Partnerships for improved health and policy coherence ................................................. 11 Networks for groups of countries ................................................................................... 14 Regions for Health Network ........................................................................................... 17 Patron .............................................................................................................................. 18 Implementing the roadmap to implement the 2030 Agenda for Sustainable Development in European Member States ..................................................................... 18 2. Environment and health in Europe ....................................................................................... 21 European Environment and Health Task Force .............................................................. 22 The Transport, Health, and Environment Pan-European Programme ............................ 22 Cross-cutting issues in environment and health ............................................................. 22 3. Health emergencies, AMR and communicable diseases ...................................................... 28 WHO Health Emergencies Programme .......................................................................... 28 Managing infectious hazards .......................................................................................... 29 Country Health Emergency Preparedness and the IHR (2005) ...................................... 33 4. Applying the life-course approach and tackling NCDs: leaving no one behind .................. 39 Life-course approach: focusing on a healthy future ....................................................... 39 Stepping up leadership on gender-responsive health policy ........................................... 42 Bold action required for healthy ageing in the Region ................................................... 44 Promoting sexual and reproductive health and rights ..................................................... 45 Combating NCDs and their risk factors .......................................................................... 48 High-level conference on NCDs ..................................................................................... 48 Road safety ..................................................................................................................... 60 Disability and rehabilitation: addressing gaps to leave no one behind ........................... 61 Progress on implementation of the European Mental Health Action Plan 2013- 2020 ................................................................................................................................ 62 Cancer screening ............................................................................................................. 62 5. Strengthening people-centred health systems and public health capacity ........................... 63 Progress towards UHC .................................................................................................... 63 Health Systems for Prosperity and Solidarity: leaving no one behind ........................... 67 Global Conference on Primary Health Care ................................................................... 68 Health system governance: transforming health systems ............................................... 71 EUR/RC69/5 page 3 Innovations for better health outcomes ........................................................................... 73 6. Health information, evidence and research: the foundation for effective policy and action ........................................................................................................................................ 80 Action Plan to Strengthen the Use of Evidence, Information and Research for Policy-making in the WHO European Region ............................................................... 81 Enhancing access to, and dissemination of, health information ..................................... 82 The future of digital health systems ................................................................................ 83 Strengthening health information systems and country capacities for the development of evidence-informed policies ................................................................... 83 7. Advancing WHO reform and financial sustainability .......................................................... 84 WHO reform and the transformation agenda ................................................................. 84 Working with countries at the centre .............................................................................. 86 Financial situation ........................................................................................................... 87 Strategic communications ............................................................................................... 88 EUR/RC69/5 page 4 Abbreviations AMR antimicrobial resistance ASPHER Association of Schools of Public Health in the European Region DALYs disability-adjusted life years ECD early childhood development ECDC European Centre for Disease Prevention and Control ECEH WHO European Centre for Environment and Health EDC Endocrine disrupting chemical EHII European Health Information Initiative EHTF European Environment and Health Task Force EMT emergency medical team EU European Union EVAP European Vaccine Action Plan 2015–2020 EVIPNet Evidence-informed Policy Network FAO Food and Agriculture Organization of the United Nations FENSA Framework of Engagement with Non-State Actors GOARN Global Outbreak Alert and Response Network GDOs geographically dispersed offices GPW 13 Thirteenth General programme of Work, 2019–2023 HBSC HEN HESRi HIPP Health Behaviour in School-aged Children Health Evidence Network Health Equity Status Report Initiative Health in Prisons Programme HRH Human Resources for Health programme IARC IBC International Agency for Research on Cancer Issue-based Coalition IHR (2005) International Health Regulations (2005) IMCI strategy Integrated Management of Childhood Illness strategy IPC infection prevention and control JMF Joint Monitoring Framework MHM menstrual hygiene management NCDs noncommunicable diseases NGOs nongovernmental organizations NIS newly independent states of the former USSR EUR/RC69/5 page 5 OECD Organisation for Economic Co-Operation and Development PHC primary health care RHN Regions for Health Network SCRC Standing Committee of the Regional Committee for Europe SDGs Sustainable Development Goals SEEHN South-eastern Europe Health Network SHE Schools for Health in Europe Network SSA Social Services Agency TB tuberculosis TB-REP TB Regional EECA Project UHC universal health coverage UNFCCC United Nations Framework Convention on Climate Change UNICEF United Nations Children’s Fund VNR voluntary national review WHE WHO FCTC WHO Health Emergencies Programme WHO Framework Convention on Tobacco Control WSP water safety plans EUR/RC69/5 page 6 1. Better health for Europe: more equitable and sustainable Introduction 1. The celebration of the World Health Organization’s 70th anniversary, the 40th anniversary of the Alma-Ata Declaration, and 30 years of the WHO European Healthy Cities Network: certainly, 2018 offered ample occasion for looking back on the truly impressive progress in health that has been achieved in our lifetimes – from routine vaccination against childhood diseases to vastly improved maternal health, a focus on healthy environments and protection from health threats, and a strong legal framework to stop tobacco use, for example. 2. However, such occasions also offer an opportunity to reflect not just on the progress made, but also on the path ahead, prompting a recommitment to our most fundamental goal of “better health for Europe: more equitable and sustainable” – of better health for all, at all ages. 3. Europe has a strong history of recognizing the right to health for all and equality of access. These are guiding values for our health systems. Yet despite the impressive progress made in the WHO European Region, even the most advanced countries have not been able to protect everyone from financial hardship caused by out-of-pocket payments for health care, and the heaviest burden falls on poor and vulnerable people. 4. To support countries in making informed choices, the WHO Regional Office for Europe undertook a regional analysis of the strength of financial protection and of the health coverage policies that influence health system performance in 25 countries. Findings suggest that all countries can do more and better to move towards universal health coverage (UHC). Health is our most precious asset. It must not be a luxury enjoyed by the privileged few. 5. We all benefit socially, economically and environmentally from a world that seeks health for all. 6. We have the commitment, the knowledge and the opportunity to transform health. Recognizing the multidimensional and multisectoral nature of health and its determinants, we have transformed the way we work. We have built synergies across sectors, mobilized communities and individuals, and engaged civil society by building consensus around the targets. We have striven to make a reality of whole-of-government, whole-of-society and health-in-all-policies approaches. 7. These are exciting and challenging times. Yet in the current state of political flux, which has shaken some long-held common political and social assumptions and fostered a prevailing sense of uncertainty, it is all the more important for us to pursue our agreed values in our health investments: the right to health, universality, solidarity, equity and fairness. 8. To attain this, we need to achieve multisectoral policy responses, able to address all health determinants and health promotion through the life course. We have expanded and deepened our partnerships and our efforts at all levels of our work, as they are vital for effective implementation. Examples of our partnerships can be found interwoven through the pages of this report, just as the partnerships themselves are interwoven through our work. 9. We must rise to the challenge of ageing populations and the increased burden of noncommunicable diseases (NCDs). We must respond to the continuing threat from EUR/RC69/5 page 7 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. 10. We also have important new opportunities. We understand better the complexity of interactions between the human genome and the environment over the life course. We are 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. 11. 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 our commitment to ensuring our progress on the path to better health is less uneven and more equitable. European health report 2018: the inequitable state of health in Europe 12. The 2018 edition of the European health report analyses the key trends underlying the current state of health and well-being in Europe. The picture it paints reveals the inequitable state of health in Europe, pointing to the challenges still ahead for the Region in its progress towards reducing health inequities. 13. Although premature mortality from the four major NCDs, as well as all-cause (all ages) mortality, continues to decline, lifestyle-related indicators such as tobacco smoking rates, alcohol consumption levels and the high prevalence of overweight and obesity continue to present major challenges for a number of countries in the Region. 14. Average life expectancy in the European Region is increasing (life expectancy at birth increased to 77.9 years in 2015), and the gaps in life expectancy, both between countries and between the sexes, are narrowing. Yet the gap between the country with the highest life expectancy (83.1 years) and the country with the lowest (71.6 years) is still more than a decade. 15. The good news is that 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. However, there are still major inequities in health and well-being between and within European countries. For example, women in the bottom 20% income group of the population die between 2.3–7.4 years sooner than women in the top 20%. For men, the bottom 20% income group can expect to die between 3.4–15.5 years sooner than men in the top 20%. Where in a country you are born also affects your chance of thriving: for every 1000 babies born, up to four more babies will not survive their first year of life in the most deprived areas, compared with the two babies per 1000 born in the most advantaged areas. In almost two thirds of countries across the European Region, these gaps in infant mortality rates between the most disadvantaged and most advantaged subnational regions stayed the same or increased between 2005 and 2016. 16. For well-being and mental health in the European Region, the inequities are just as prevalent as the inequities in physical health. Within countries across the Region, men and EUR/RC69/5 page 8 women living on the lowest incomes are, on average, twice as likely to report poor mental health compared to those with the highest incomes. 17. The impact that wider government policies and decisions have on health is well known. Over the past 15 years, fiscal and growth policies have impacted negatively on key determinants of health, giving rise to growing income insecurity, housing deprivation, food insecurity and unsafe living and working conditions. As a result, progress towards reducing health gaps has been slower than expected and new groups have emerged, including the working poor, who have significantly higher risk of poor mental health, increased risk for cardiovascular disease and have higher rates of illnesses that limit their daily activities. 18. Yet efforts to reduce health inequities are core investments for achieving inclusive growth, and vice versa. Economic analysis by the WHO European Health Equity Status Report Initiative (HESRi) of middle- and high-income countries in the European Region shows that a 50% reduction in the gap in life expectancy between social groups would create an economic dividend for countries ranging from 0.3% and 4.3% of gross domestic product. WHO European Health Equity Status Report Initiative 19. HESRi is a suite of tools developed and launched by the Regional Office in 2018–2019 in order to promote and support policy action for health equity and well-being in the Region. HESRi has brought forward innovations in the analysis of the relationships between health status and the security and quality of five conditions, which are essential for every child or adult to be able to live a healthy life in Europe in the 21st century. Never before have we had such a clear picture of the factors that drive and compound health inequities in our societies, or about the incentives, policy options, and solutions that can deliver positive changes. 20. The HESRi suite of tools includes a Health Equity Policy Tool. This sets out 51 policies that are relevant to the European Region and have a positive effect in reducing inequities in health. Policy-makers are already starting to use the tool in priority-setting and resource allocation decisions to identify where they can have greatest impact for health equity through interventions in the health sector and with other sectors across government. 21. The suite of tools also includes 35 intervention approaches that are easily incorporated into the design and delivery of services and programmes. These are based on evidence of what works in practice and are already inspiring policy-makers and planners across the Region to scale up mainstream practices for better health equity outcomes. 22. The first WHO European Health Equity Status Report was launched in 2019. More information on HESRi is provided in Section 4. Implementing the 2030 Agenda: health as a driver of development 23. Health is an essential component and driver of the Sustainable Development Goals (SDGs), which reflect the complexity, as well as the multidimensional and multisectoral nature of health and its determinants. 24. In 2017 the WHO Regional Committee for Europe endorsed the roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy EUR/RC69/5 page 9 for health and well-being. Relevant to all countries in the Region, the SDGs placed health and well-being for all, at all ages, at the centre of development as determinants, enablers and outcomes. Better health is needed to achieve many of the targets in all 17 SDGs, although only SDG 3 focuses specifically on health. 25. In 2016–2017, the Regional Office changed its way of working to respond to current political and social challenges, while carrying out its activities within the new global framework of the United Nations 2030 Agenda for Sustainable Development. This required the Regional Office to continue and intensify the approach and strategic directions it had pursued since 2010, when the European Region adopted the WHO Regional Director for Europe’s new vision for health in response to changing circumstances and new challenges, and 2012, when it had adopted Health 2020 as the framework for action to pursue more equitable and sustainable health in the Region. 26. The particular changes included enhancing UHC, health determinants and healthy places as a strategic priority, together with health governance and health equity, and launching investment for health, partnerships, health literacy, innovation and research and monitoring as enablers for development. Previous reports on the Regional Office’s work have traced these processes. 27. In 2017 WHO took the SDGs as its starting point in drafting the Organization’s Thirteenth General Programme of Work, 2019–2023 (GPW 13). In 2017 the Regional Committee discussed the draft as a policy framework aligned with the SDGs, and the roadmap to implement the 2030 Agenda for Sustainable Development, focusing on health policies and health systems for the 21st century, within the context of UHC. Senior leaders from all levels of the Organization met at WHO headquarters in October–November 2017 to discuss the strategic directions and actions required to transform and strengthen WHO’s work at the country level, in order to deliver the GPW 13. These activities fed into the development process, which culminated in its approval by the Seventy-first World Health Assembly in May 2018. 28. The SDGs, Health 2020 and the GPW 13 are truly coherent and integrated. All three show clearly how health is positioned at the centre of development. 29. Since we began implementation of the SDGs and Health 2020 and adopted the roadmap to implement the 2030 Agenda for Sustainable Development, many countries have started developing national roadmaps and creating whole-of-government mechanisms at the highest level to drive the agenda forward. Governance for health and well-being 30. The Governance for Health Programme in the Division of Policy and Governance for Health and Well-being supported Member States in 2018–2019 in improving governance for health and well-being across the Region, as well as the ongoing implementation of Health 2020 and the 2030 Agenda. The goal of the Governance for Health Programme is to develop strategies, tools and capacities in relation to governance for health and well-being, provide technical assistance to Member States in developing and implementing mechanisms, processes and institutional arrangements supporting governance approaches for health and well-being, and coordinate the implementation of Regional priorities through Regional platforms such as the EUR/RC69/5 page 10 WHO European Healthy Cities Network. The programme also works to ensure coherence and coordination of the Regional Office’s work across divisions on governance. 31. Moving towards models of governance that are designed to deliver health, equity and well-being is an example of the transformative response called for by the 2030 Agenda. In order for us to achieve our global, regional and national goals and targets and effectively address today’s complex global challenges, it is necessary to manage, coordinate and develop accountability and coherence, and support the implementation of action between diverse actors across all levels of government and beyond. 32. The transformative approach to improved governance is facilitated through whole- systems approaches at each individual level/node within a system (whole-of government, whole-of-society, whole-of-city, whole-of-school) that engage all levels of governance within a system, from the supra- and international through to the national, regional and the local. The governance programme produced a factsheet on governing for health and well-being for the SDGs: Achieving the 2030 Agenda through strengthened governance for health and well-being, to support Member States in governance for health and well-being in the context of the SDGs. 33. Whole-of-society, whole-of-government and health-in-all-policies approaches require systematic multi- and intersectoral governance structures and processes that can facilitate and support the requisite policy action. These enable and support the policy cycle and include mechanisms for coherence and accountability, enabling regulatory and legal frameworks, instruments for financing and joint action, as well as improved capacity both within and beyond government actors. These have been supported consistently by the Governance for Health Programme throughout 2018–2019, including through the development of nine further briefs in the multi- and intersectoral sector briefs series, expected for publication in the second half of 2019. 34. A key milestone during the reporting period was the development of the Assessment tool for governance for health and well-being. The tool was developed to assess countries’ capacities to design, coordinate and implement different governance approaches for improved health and well-being, including whole-of-society, whole-of-government, across sectors (multisectoral and intersectoral) and within sectors (intrasectoral). It is being piloted in three Member States thus far, and piloting is continuing through thematic adaptation to particular public health priority areas and cross-cutting issues, as well as adaptation to regional and municipal levels of government. The tool is designed to support countries in: • developing national development strategies focused on health and well-being • developing national health policies, strategies and plans • strengthening health systems performance • strengthening public health services and functions • addressing social determinants of health and • tackling public health priorities and challenges. 35. The Assessment tool is supported through the Tool for mapping governance for health and well-being: the organigraph method, the first WHO tool of its kind allowing mapping of accountability and governance for health and well-being. EUR/RC69/5 page 11 36. Furthermore, a mapping exercise was undertaken and published in 2018 in the report Multisectoral and intersectoral action for improved health and well-being for all: mapping of the WHO European Region. Governance for a sustainable future: improving health and well- being for all (2018), which includes 36 case stories from across the European Region, and includes key findings and recommendations that contribute to the evidence base for multi- and intersectoral action and the implementation of the 2030 Agenda. 37. The Governance for Health Programme supported the Regional Office’s work on NCDs through the publication of the chapter “Governing for better noncommunicable disease outcomes” published in 2018 in the European Region’s publication Health systems respond to noncommunicable diseases: time for ambition, and the publication A multilevel governance approach to preventing and managing noncommunicable diseases: the role of cities and urban settings, produced for the April 2019 WHO European High-level Conference on Noncommunicable Diseases: Time to deliver – meeting NCD targets to achieve Sustainable Development Goals in Europe, held in Ashgabat, Turkmenistan. 38. A further chapter, “Adopting a systematic approach to understanding the relationship between health diplomacy, governance for health, and multi- and intersectoral action in the area of refugee and migrant health in the WHO European Region”, was produced for the forthcoming publication Health diplomacy: spotlight on refugees and migrants. 39. A meeting on governance for health is planned for the last quarter of 2019 in order to further develop the tools and the role of governance for health in achieving the objectives of the 2030 Agenda and the GPW 13. The Joint Monitoring Framework 40. The European Region has developed the Joint Monitoring Framework (JMF) to ease the burden on Member States of reporting under Health 2020, the 2030 Agenda for Sustainable Development and the Global Action Plan for the Prevention and Control of NCDs 2013–2020. The indicators were adopted by the 68th session of the Regional Committee for Europe (see document EUR/RC68/10 Rev.1), which agreed that the Regional Office should implement the proposed monitoring framework, by collecting, analysing and regularly publishing information on progress made on the common set of indicators in its regular publications. 41. In the next phase in the development of the JMF, the Regional Office will develop a reporting template to be used by Member States in its implementation. This will be followed by regular reporting by the Regional Office through the European Health Information Gateway and the development of a mechanism for forwarding JMF data to WHO headquarters for inclusion in the WHO Global Health Observatory, with subsequent submission to the United Nations for monitoring and reporting on SDG 3 progress. Partnerships for improved health and policy coherence 42. The Regional Office is committed to strengthening collaboration with important existing partners, including the United Nations family; the European Union; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Gavi, the Vaccine Alliance; and the Organisation for Economic Co-Operation and Development (OECD). EUR/RC69/5 page 12 Regional partnerships and networks 43. The interconnected nature of the SDGs means that working in partnership is key to achieving their implementation. Coordination and partnership among the agencies of the United Nations to improve health and well-being is therefore crucial to ensuring that the efforts of the United Nations are harmonized and streamlined across all entities involved. As is apparent throughout this report, working in partnership with others is a cornerstone of the Regional Office’s strategy in tackling all aspects of its work. 44. Partnership is also one of the priority areas of the Director-General’s transformation agenda. The Regional Office has actively participated in the United Nations development system reform and has prepared to implement it at regional and country level. Collaboration with agencies of the United Nations at the regional level has been exemplary in a broad range of areas, through the active collaboration of the Regional Director in the United Nations regional directors group and active participation in various issue-based coalitions that WHO is leading on the health-related SDGs. 45. WHO has worked extensively with the European Union (EU) institutions on health and health-related topics, including in the fields of humanitarian and development aid, research and development and the environment, and held successful meetings with senior EU officials in June 2018 and July 2019, involving headquarters and all regions, to discuss our future work and collaboration. There have been multiple visits by the Director-General and the Regional Director for Europe with the European Commission President and various Commissioners with the European Parliament, and the active involvement in the activities of the consecutive Presidencies of the Council of the EU and in multiple technical meetings demonstrates the strong collaboration and policy coherence towards health. 46. During a meeting on 15 January 2018, the Regional Office and the European Centre for Disease Prevention and Control (ECDC) strengthened their commitment to collaborating on infectious diseases and disease outbreaks by establishing operational guidelines on collaborative actions and endorsing a set of new General Principles of Collaboration. The document outlines the principles of existing and future collaboration between the Regional Office and the ECDC, with the purpose of providing operational guidelines for implementing joint and collaborative action in the areas defined in the bilateral Administrative Arrangement. 47. This collaboration focuses on communicable disease surveillance, prevention and control, risk assessment and communication, health emergencies and utilizing the International Health Regulations (IHR) (2005) to prevent and respond to health threats. 48. The renewed collaboration of the European Region and ECDC will improve support to European countries to reach the SDGs through addressing communicable diseases and antimicrobial resistance (AMR) and strengthening immunization. It will also contribute to ensuring that 1 billion people are better protected from health emergencies, as set out in WHO’s vision for 2019–2023. The Coalition of Partners 49. The Regional Office is leading the establishment of the Coalition of Partners for Strengthening Public Health Services in the European Region (‘The Coalition of Partners’). The Coalition of Partners was convened to develop the joint Agenda for Action, focusing on EUR/RC69/5 page 13 the four enablers of public health service delivery, and on strengthening national prevention, health promotion and health protection capacities. It provides a multi-stakeholder, systemic platform that is open to decision-makers and experts from national public health services, international organizations and academia; to date, an interactive group of 42 partners has been providing input. 50. The Coalition of Partners aims to catalyse action, foster learning and incubate new initiatives in public health services. More information is available further on in this report in the chapter on strengthening health systems and public health capacity. Issue-based coalitions 51. Issue-based coalitions (IBCs) are broad, multi-partner coalitions led by one or several agencies intended to facilitate improved cooperation between different agencies of the United Nations and their partners, help realize synergies among related areas of work of different entities of the United Nations, and serve as platforms to reach out to non-United Nations stakeholders. The work of the IBCs is guided by the regional United Nations system meetings, which decide on the establishment of new coalitions and review the work of existing coalitions. 52. The Regional United Nations System Meeting has set up six IBCs clustered around cross- cutting policy issues: on Health; Gender Equality; Youth and Adolescents; Social Protection; Large Movements of People, Displacement and Resilience; and SDG data and monitoring. 53. The IBC on health and well-being is led by the Regional Office and is focused on the achievement of SDG 3 – to ensure healthy lives and promote well-being for all at all ages – and of the health-related targets present in other SDGs. A coordination mechanism, it builds on other ongoing partnership initiatives, such as those on migration and health and on environment and health. Four work streams are being pursued: health over the life course, communicable diseases, UHC, and migration. 54. Activities for 2017–2019 aimed to: (a) strengthen the regional partnership and involvement of stakeholders at all levels of governance to support Member States in the implementation of the health and related targets of the SDGs; (b) map existing norms, policies and standards and identify priorities, opportunities and gaps in programming and in developing mechanisms in order to address them; (c) provide coherent and timely programming as well as policy and/or normative guidance and technical support on health- related issues at the regional and country levels; (d) increase the effective and efficient use of human and financial resources within and among United Nations agencies and partners on health-related initiatives and interventions, including regional joint resource mobilization efforts; and (e) improve coordination, communication and information sharing on key lessons and good practices on the basis of the focus to leave no one behind due to poor health. 55. Given that almost all of the other 16 SDGs are either directly related to health or will contribute to health indirectly, the Regional Office is also actively promoting health evidence and health perspectives through involvement in other IBCs, such as the Issue-based Coalition on Gender Equality, which aims to ensure a coordinated United Nations system approach to promoting gender equality and women’s empowerment in the Region. The membership of the Issue-based Coalition on Gender consists of 14 United Nations agencies of the United Nations and is co-chaired by UN Women and the United Nations Population Fund. EUR/RC69/5 page 14 Networks for groups of countries 56. The Regional Office is actively involved in supporting a number of networks that allow groups of countries within the Region to work together in various subregional collaborations. 57. For example, the Regional Office, working in collaboration with Riga Stradiņš University and the Nordic Council of Ministers, organized a 3-day workshop at the end of February 2019, with the aim of initiating dialogue with countries in the Baltic Sea region on the topic of sustainable diets. The participants of the workshop, which included a diverse group of stakeholders from the health and non-health sectors, jointly conducted a food systems mapping exercise to understand how ongoing activities aligned and could be brought together to strengthen the food policy response to health and environment challenges. The Visegrad Initiative for Health 58. In October 2018 and in February 2019 the Regional Office, together with the WHO Representatives for the Visegrad countries or V4 (the ‘4’ being Czechia, Hungary, Poland, and Slovakia) started to explore possible collaboration on technical issues relevant for all Visegrad countries. The following technical areas of collaboration such as digitalization of health care, vaccine procurement practices, strengthening IHR (2005) and cross-border collaboration were put forward as areas of joint interest. The plan is that the V4 group will continue with follow-up meetings under the Czech Presidency of the Visegrad Countries. WHO will provide support for the selected events of the Czech V4 presidency. Small Countries Initiative 59. The Small Countries Initiative was established in 2013 at an informal meeting in Turkey, during the 63rd session of the Regional Committee, with the aim of enabling countries in the European Region with a population of less than 1 million people to share their knowledge on implementing Health 2020. The eight founding members of the initiative are: Andorra, Cyprus, Iceland, Luxembourg, Malta, Monaco, Montenegro and San Marino. 60. The portfolio of the Small Countries Initiative is diversified and provides Member States with: support to align national policies with WHO strategies and plans; topic-specific technical assistance; opportunities for networking and bilateral/multilateral relations; and a forum for mutual learning and sharing innovative approaches. The Initiative’s mandate was realigned to provide technical support around the 2030 Agenda for Sustainable Development, in addition to Health 2020. At a subsequent meeting in Reykjavik, Iceland, in July 2018, countries in the network not only confirmed that the Initiative should continue, but also agreed to add to their network three more countries with populations just over 1 million: Estonia, Latvia and Slovenia. 61. This group of small countries has made a significant contribution to the region, by setting up the Small Countries’ Health Information Network, one of the first actions of which was to bring the moving average methodology to the mainstream and get this important methodology accepted across the region. In the six years since its inception, the Small Countries Initiative has developed a forum for mutual learning and the sharing of innovative approaches between countries. The Initiative has its own series of featured publications, mostly based on case studies from, and good practice existing in, the small countries in relation to the implementation of Health 2020 and the 2030 Agenda; examples of such good EUR/RC69/5 page 15 practice include taking intersectoral action for health, using the life-course approach, and strengthening resilience. 62. The Small Countries Initiative benefits countries by: sharing best practices around implementation of Health 2020 and 2030 Agenda; strengthening technical capacity in key areas of Health 2020 and 2030 implementation; documenting processes of adoption and outcomes of WHO strategies, polices and plans; receiving dedicated technical assistance; filling the gap in the European policy-making literature with regard to health policy development in the contexts of small countries. 63. WHO benefits from the Initiative too, by: getting strengthened commitment and better alignment of national strategies with Health 2020 and 2030 Agenda; acquiring knowledge on how WHO policies are operationalized (practical know-how); inspiring larger countries; and using the Initiative as cost-effective vehicle for providing assistance to countries. 64. In 2019 the Sixth high-level meeting of the Small Countries Initiative, held in San Marino under the theme “Equity and sustainable development – keeping people at the centre”, was opened by the WHO Director-General, who commended the European Region on leading such a forward-thinking initiative and called for a side meeting to the World Health Assembly to be held on regular basis for all global small countries. Healthy Cities 65. In February 2018 a gathering of 43 mayors and 85 high-level political representatives adopted the political vision for the network, the Copenhagen Consensus of Mayors: Healthier and happier cities for all (2018). It is fully aligned with the 2030 Agenda, and will provide the political direction for the network until 2030. In October 2018, at the International Healthy Cities Conference in Belfast, Northern Ireland, United Kingdom, the WHO European Healthy Cities Network officially adopted the Belfast Charter for Healthy Cities. In January 2019 the WHO European Healthy Cities Network entered Phase VII (2019–2024) of operation. This new phase focuses on the WHO European Healthy Cities Network acting as a partner and vehicle for implementation of global, regional, and national agendas at the local level, as well as building local level public health capacity within countries. 66. In the 30 years of the Healthy Cities Network, it has brought together over 100 designated cities and approximately 30 accredited national networks. Its success within the European Region has been noticed at a global level, and there is a call for the Network to share its knowledge, operations and learning with partners involved in healthy cities movements in other WHO regions. 67. Since the national networks that provide technical and strategic support to the efforts of their member cities are an essential pillar of the Healthy Cities movement in the European Region, the priority for the next phase of work is to strengthen and support national networks to take a leading role in developing and supporting the Healthy Cities movement across the Region and beyond. 68. In May 2019 the Annual Meeting of the WHO European National Healthy Cities Network in Lisbon, Portugal, explored ways to implement the plans and priorities for Phase VII, as outlined in the Belfast Charter for Healthy Cities and the WHO European Healthy Cities Network Implementation Framework for Phase VII, and discussed and EUR/RC69/5 page 16 strategized ways to share healthy cities approaches and learning gained from 30 years of the healthy cities movement. It brought together WHO national counterparts, national technical focal points, national network coordinators, as well as representatives from the WHO African Region, the Region of the Americas, and the European Region to discuss healthy cities from a global perspective. 69. The five key outcomes of the meeting were: situation analysis of the work of national networks in relation to the Phase VII implementation framework in the European Region, including strengths, gaps and opportunities; identification of case studies of good practice and of approaches to strengthening synergy and coherence between networks and national counterparts as part of implementation of Phase VII; identification of good practice in the scientific and technical support to be provided to national networks; a draft outline of a national network action plan and accountability and impact framework; identification of new tools for leadership training. 70. In October 2018, in Almaty, Kazakhstan, the WHO European Healthy Cities Network also held an historic event that brought together mayors and city political leaders from across the globe to discuss the role of cities in taking forward the legacy of the Declaration of Alma-Ata, including primary health care (PHC) and UHC. The Summit of Mayors was a pre- conference event of the Global Conference on Primary Health Care, and celebrated the 40th anniversary of the Declaration of Alma-Ata. The Declaration was central to the founding of, and is entrenched within, the WHO European Healthy Cities Network, most recently in the political vision for its next phase. Cities from across the globe committed to strengthen PHC to achieve UHC and the SDGs, through the adoption of the Almaty Acclamation of Mayors. 71. As part of support for the whole-of-society approach in the Region, as well as under the framework of the implementation of the roadmap to implement the 2030 Agenda for Sustainable Development, the first international conference on place and the Place Standard tool was held in June 2019 in Glasgow, United Kingdom, by NHS Health Scotland, the Scottish Government and Architecture and Design Scotland, in partnership with the WHO European Healthy Cities Network. 72. The WHO European Healthy Cities Network supports Member States in the implementation of the SDGs roadmap at the local level, through supporting the implementation of the “Place” theme of Phase VII (2019–2024) of the Network, as outlined in the political vision for the Network presented in the Copenhagen Consensus of Mayors: Healthier and happier cities for all. This meeting was followed by the WHO European Healthy Cities Network Flagship Training: The Place Standard Tool – a whole-of-society participatory governance tool for use at the local level. 73. In addition, a healthy city tool is under development together with the Regional Office’s Migration and Health Programme, to strengthen capacity to promote the health and well-being of refugees, asylum seekers and migrants, and the members of communities in urban settings. South-eastern Europe Health Ministerial Meeting on Immunization 74. On 20 February 2018 the South-eastern Europe Health Network (SEEHN) Ministerial Meeting on Immunization, held in Podgorica, Montenegro, endorsed a statement of intent to speed up progress towards the goals and strategic objectives of the European Vaccine Action Plan 2015–2020 (EVAP) and called on WHO to act swiftly in a few key areas, including: EUR/RC69/5 page 17 proposing options for joint procurement of vaccines; supporting capacity-building on resource mobilization for sustained financing of immunization programmes; establishing a subregional centre on vaccine demand; and strengthening the role and responsibilities of the National Immunization Technical Advisory Groups. They also approved the development of a roadmap to outline the activities and initiatives to be implemented in the subregion to meet specific strategic objectives. 75. In July 2018 ministers of health from the nine SEEHN Member States and the partner State of Slovenia gathered in Tel Aviv, Israel for a meeting focused on ensuring PHC for an ageing population. The meeting provided an opportunity for ministers to share good practices from their countries, especially in the area of healthy ageing. Israel in particular shared innovations in policies and technologies for their ageing population. 76. The meeting concluded with the signing of the first Subregional Cooperation Strategy of the Regional Office by the Regional Director, Dr Zsuzsanna Jakab, on behalf of the Regional Office and Dr Dasic on behalf of SEEHN. The Interparliamentary Assembly of the Commonwealth of Independent States 77. Collaboration between the European Region and the Interparliamentary Assembly of Member Nations of the Commonwealth of Independent States has strengthened in recent years, and in March 2018 a memorandum of understanding on broader cooperation was signed. This includes WHO providing technical assistance in preparing and localizing model laws relevant to health. Other mechanisms include information exchange on the Commonwealth of Independent States and international health, invitations to each other’s statutory and other meetings, cooperation through the Interparliamentary Assembly’s expert committee on health, and organizing joint events when necessary. 78. The Regional Director requested the Interparliamentary Assembly to consider its political advocacy in promoting ratifications of the Protocol to Eliminate Illicit Trade in Tobacco Products by the national Parliaments of the Member Nations of the Commonwealth of Independent States, and the Interparliamentary Assembly agreed at its 48th Plenary Session, to support this initiative. An agreement was also reached to work jointly to ensure that international agreements such as the WHO Framework Convention on Tobacco Control (WHO FCTC) and the IHR (2005) are transposed into national law. A request was also made for WHO’s assistance in developing a plan of model law-making related to health in the Commonwealth for Independent States for 2020–2024. Regions for Health Network 79. In addition to the various partnerships the Regional Office engages in at international and regional level, the WHO Regions for Health Network (RHN) is the only WHO network which specifically deals with the subnational level of governance. 80. This meso level of governance (regional/subnational), which sits between the national and the local level, is of paramount importance in the European Region because functions such as the design, management and evaluation of health systems (to name just one sector) are often devolved from the national level to the subnational level, yet must be in full agreement and full coherence with strategic directions provided by the central, federal level. EUR/RC69/5 page 18 81. The RHN has evolved over its 25-year history and now includes 41 regions from 28 countries. Its creation in 1992 was linked with three trends at the time: 1) the growing international importance of the health agenda from the Declaration of Alma-Ata, the health for all policy framework for the European Region, and the Ottawa Charter for Health Promotion; 2) the growth of WHO networks to support international collaboration; 3) the growing importance of regions within European countries and the development of institutional arrangements to support them. 82. The RHN has a strong self-governance mechanism, which is facilitated by the Regional Office for Investment for Health and Development, with coordination overseen by the RHN Steering Group and members, as a very strong and determinant asset of the Network itself. 83. Since its establishment, the RHN’s aim has been to exchange promising practices and know-how, and develop synergies to promote health and reduce inequities at the subnational (regional) level. The Göteborg Manifesto, formulated by the RHN in 2012, soon after the endorsement of Health 2020 by the 53 Member States of the European Region, presents the vision and mission of the RHN, calling for commitment at the subnational level around the core values, principles and approaches of Health 2020. In 2015 the Network re-oriented its mandate to fully align itself with the 2030 Agenda for Sustainable Development and was the first network to set up a meeting (in Kaunas, Lithuania) specifically targeting the cascade of implementation necessary for moving the 2030 Agenda forward. This required setting up discussions involving all levels: from global, to international, national, regional, municipal, and civil society levels. 84. The Göteborg Manifesto, Health 2020 and the 2030 Agenda for Sustainable Development (and now the GPW 13) mark a clear shift in the Network’s essence from a group of people looking to share experiences and best practices, to an alliance of regions that are striving to promote health and reduce health inequities, keeping Health 2020 and the SDGs as pivotal reference policies. 85. The 25th annual meeting of the WHO RHN took place in June 2019, hosted by the Meuse-Rhine Euroregion, in four different locations: Aachen, Germany; Maastricht, Netherlands; and Liège and Hasselt, Belgium. Patron 86. The Regional Office continued to receive invaluable support from its Patron, Her Royal Highness The Crown Princess of Denmark, including her video statements in support of European Immunization Week 2018 (Vaccination is our shared responsibility) and 2019 (We can all be vaccine heroes). Implementing the roadmap to implement the 2030 Agenda for Sustainable Development in European Member States 87. By July 2019, 43 European countries have presented their voluntary national reviews (VNRs) to the High-level Political Forum. The High-level Political Forum is also informed by reviews of the Economic and Social Council and other intergovernmental bodies and forums. EUR/RC69/5 page 19 88. The analysis of the VNRs highlights that, in all reporting countries, political oversight mechanisms have been established, implementation priorities discussed, and that there is engagement of parliaments and civil society. All countries address health and well-being to varying extents. Many of the national health policies, building on Health 2020, include some essential elements of the SDGs, though not all address the complexity of the SDGs and priority action areas for acceleration. As many of the national health policies will expire soon, efforts to harmonize national health strategies and plans with the 2030 Agenda and the SDGs are further required, including priorities, accelerators and accountability mechanisms. All Member States have clearly stated their commitment to leaving no one behind and broad health equity goals are expressed in the form of health access and coverage, reducing lifestyle gaps, reducing gaps in life expectancy and tackling the social gradient. Financing for Development is foremost generated through domestic resource mobilization. More actions need to be done to promote health throughout the life course when implementing action to achieve the health determining SDGs. Reports on SDG activities in the VNRs often had clear commitments on effective prevention programmes, and ensuring access to essential health services, though health financing needs to be further strengthened. The roadmap to implement the 2030 Agenda for Sustainable Development has placed the Region in an excellent position to implement the GPW 13 and to accelerate the SDG implementation. 89. The last three sessions of the Regional Committee had specific high-level sessions dedicated to the implementation of the SDGs, and all high-level European Region conferences addressed SDG implementation. All WHO country offices in the European Region along with the Regional Office have been directly supporting the implementation of the SDGs in Member States. The main support to countries was on UHC, building capacity to influence other sectors, implementing regulatory frameworks, advice on health-related targets, and producing an evidence-based SDG resource package for Member States. 90. Albania, Belarus, Georgia, Kyrgyzstan, Serbia, Turkmenistan, Ukraine, and Uzbekistan, were supported as part of the one United Nations approach implementation, reinforcing the need to address health and well-being. High-level policy dialogues were carried out with the President of Romania1 and within the Romanian EU presidency. Migration and health 91. Migration and displacement are social determinants of health affecting the health of refugees and migrants. The Regional Office’s work on migration and health, although important in itself, also provides an example of WHO’s multilevel efforts to respond to Member States’ requests for action, to seek to improve the health of vulnerable groups, to address health issues through intersectoral action and to ensure that all its technical work serves the larger goals of the unifying policy frameworks, Health 2020 and the 2030 Agenda. Almost one in 10 people in the European Region is currently an international migrant. 92. The Strategy and Action Plan for Refugee and Migrant Health in the European Region, which was developed by the Regional Office in response to increasing requests from Member States, was adopted by the Regional Committee in 2016. It was hailed as an illustration of how to transform a crisis into an opportunity to improve public health capacity in the Region. 1 Policy dialogue on implementing the 2030 Agenda held during the Regional Director’s visit to Romania. In: Countries: Romania [website]. Copenhagen: WHO Regional Office for Europe; 2018 (http://www.euro.who.int/en/countries/romania/news/news/2018/6/policy-dialogue-on-implementing-2030- agenda-held-during-regional-directors-visit-to-romania, accessed 13 May 2019). EUR/RC69/5 page 20 93. Drafted to take account of Health 2020 and the 2030 Agenda, the strategy and action plan strongly emphasizes the need for an approach based on human rights, driven by equity and sensitive to gender issues. It identifies nine strategic priority areas: • establishing a framework for collaborative action • advocating the right to health of refugees, asylum seekers and migrants • addressing the social determinants of health • achieving public health preparedness and ensuring an effective response • strengthening health systems and their resilience • preventing communicable diseases • preventing and reducing the risks posed by NCDs • ensuring ethical and effective health screening and assessment and • improving health information and communication. 94. In 2018 the 68th session of the Regional Committee considered a progress report on implementation of the Strategy and Action Plan (EUR/RC68/8(F)); a further progress report will be considered by the 70th session of the Regional Committee. The Regional Committee also discussed the development of a draft global action plan on the health of refugees and migrants (EUR/RC68/Inf.Doc./9), a process in which the European experience of finding the best humanitarian, legal and technical solutions, accumulating knowledge and achieving consensus and dialogue had made a valuable contribution. 95. On International Migrants Day on 18 December 2018, the Regional Director launched five technical guidance documents on migration and health, produced by the migration and health programme: • Health of older refugees and migrants (2018); • Health of refugee and migrant children (2018); • Health promotion for improved refugee and migrant health (2018); • Improving the health care of pregnant refugee and migrant women and newborn children (2018); • Mental health promotion and mental health care in refugees and migrants (2018). 96. The aim is to inform and provide technical guidance or advice to policy-makers and decision-makers on the different areas of migration and health. In addition to these five, the Migration and Health programme in the Regional Office launched the sixth technical guidance in this area in 2019, entitled “Prevention and control of noncommunicable diseases in refugees and migrants” (2019). 97. In January 2019, at the Palais des Nations in Geneva, the Regional Director launched the WHO Report on the health of refugees and migrants in the WHO European Region: no public health without refugee and migrant health (2018) – the first WHO report of its kind. The report has been further presented in Athens, Greece, Limerick, Ireland, Rome, Italy, Moscow, Russian Federation, and Ankara, Turkey, with high-level participation and hosted by the ministries of health and in the case of Limerick was hosted by the newly appointed Migration and Health Programme’s Collaborating Centre. EUR/RC69/5 page 21 98. Further publications included Spain: assessing health system capacity to manage sudden large influxes of migrants (2018) and What strategies to address communication barriers for refugees and migrants in health care settings have been implemented and evaluated across the WHO European Region? (2018). 99. The Second Summer School on Refugee and Migrant Health was held on 24–28 September 2018 in Palermo, Sicily, Italy under the Umbrella of the WHO European Knowledge Hub on Health and Migration. While this and the first Summer School took place in Italy, the Third Summer School was held on 15–19 July 2019 in Cesme, Turkey with the theme: From Emergency response to long-term inclusion policies. The school is the flagship activity of Knowledge Hub with the aim of building expertise and competency on the public health aspects of migration and making knowledge and information in this area widely available. The school involves expert speakers, nominees from Member States and participants from all over the world. 100. Four new webinars were added in 2018 to the webinar series launched the previous year with the aim of tackling alternative, emergent, and critical concepts surrounding health and migration through interactive information sharing. They were livestreamed, enabling a worldwide audience to interact and raise questions to panellists through an online tool. The webinars were recorded so they can be accessed on the Regional Office’s website by all who wish to expand their knowledge. 101. The Migration and Health Programme and the WHO European Office for the Prevention and Control of NCDs (Moscow) conducted the first Expert Group Meeting on NCDs in the Migrant Population in Russia and the Commonwealth of Independent States subregion on 19 March 2019. The aim of the expert group meeting was to discuss opportunities to strengthening the research agenda on NCDs in the eastern part of the European Region; stimulate cross-border and intercountry work on NCDs in the refugee and migrant population; share examples of good practice between countries to inform future plans in this area of work; and make proposals for programmatic and research priorities for the subregion. 102. In April 2019 the Migration and Health Programme, with the Bosnia and Herzegovina country office, conducted a joint assessment mission of the health authorities in Bosnia and Herzegovina to assess health systems capacity to manage large influxes of migrants; an assessment report is under development with the aim of publishing during 2019. 103. In addition, a healthy city tool is under development to strengthen capacity to promote the health and well-being of refugees, asylum seekers and migrants, and the members of communities in urban settings. 2. Environment and health in Europe 104. Risks related to environmental exposures continue to require attention, as preventing the 1.4 million deaths per year attributable to these risk factors offers a major opportunity to contribute to the goal in GPW 13 of 1 billion more people enjoying better health and well-being. 105. The Regional Office continues to address these challenges by working with Member States and partners through its European Centre on Environment and Health, generously EUR/RC69/5 page 22 hosted by Germany in Bonn, where all Regional Office activities on environment and health have been strategically consolidated, to provide enhanced support to Member States. European Environment and Health Task Force 106. As mandated by the Sixth Ministerial Conference on Environment and Health, hosted by Czechia in Ostrava in 2017, new institutional arrangements have been established for the European Environment and Health Process. These consist of a renewed European Environment and Health Task Force (EHTF), as the steering and supporting body for the implementation of the commitments taken through the Ostrava Declaration, and of an elected Bureau to support the EHTF chairperson and co-chairperson between meetings and steer the preparations for EHTF meetings. The renewed EHTF met in Bonn, Germany on 20–21 March 2018 for the eighth meeting of the EHTF, with the purpose of supporting Member States’ work in the development of national portfolios for action on environment and health addressing one or more of the seven priority areas of the Ostrava Declaration. Member States discussed tools and approaches for each of the priority areas; possible methods for assessment and monitoring of the Ostrava commitments; and the indicators and data already available, including those of the monitoring and evaluation framework set up for the SDGs. They elected a new Chair, co-Chairs and Bureau of the Task Force and approved the programme of work and budget for the European Health Process Secretariat for 2018–2019. 107. The Bureau of the EHTF met three times in 2019 to review progress across the Region in the implementation of the commitments taken in Ostrava, and to prepare the agenda for the ninth meeting of the EHTF. The Transport, Health, and Environment Pan-European Programme 108. The Regional Office has continued to serve the Transport, Health, and Environment Pan-European Programme, working in a joint secretariat with the United Nations Economic Commission for Europe to advance the preparations of the Fifth High-Level Meeting on Transport, Health and Environment, scheduled to be kindly hosted by Austria in October 2020. It is anticipated that Member States will adopt a Declaration endorsing, among other things, the first-ever Pan-European Master plan for Cycling Promotion. The Regional Office has also continued to provide technical support on integrating health considerations in transport policies, and in 2018 published Making THE (Transport, Health and Environment) Link. Cross-cutting issues in environment and health 109. The European Centre on Environment and Health in Bonn has addressed several cross- cutting, emerging issues in environment and health, given their established or potential importance for public health in the Region. These include: • Environment and health inequalities. A second assessment report on environment and health inequalities (updating and expanding on the first, completed in 2012) was launched in June 2019 on the occasion of a High-Level Conference on Health Inequalities, held in Ljubljana, Slovenia. The new report underlines that, despite the overall progress observed in many environmental determinants, marked inequalities exist not only between countries, but also, disturbingly, within countries. In some cases, these inequalities are even increasing. Given the EUR/RC69/5 page 23 frequent association with social disadvantage and the fact that inequalities are often preventable, the uneven picture of environment and health conditions constitutes an unacceptable form of environmental injustice. • Environment and health economics. The Bonn Office has also been engaged with developing evidence and resources for considering the economic dimension of environment and health, given its extremely influential role in decision-making. Recent work has focused on circular economy, a fast-growing concept of production and consumption, aiming at drastically diminishing the use of material resources and waste, replacing the prevailing “take-make-use-dispose” linear economy. Despite the high level of political interest and investment in the area, and its potentially far-reaching implications, the health sector has not been involved in this important debate. WHO has convened expert consultations and published a first review of the possible health benefits and risks of a transition towards circular economy in Circular Economy and Health: opportunities and risks (2018). A follow-up report, proposing specific approaches to addressing health in a circular economy, is in preparation. Air pollution 110. In 2019 the theme for World Environment Day on 5 June was “Beat air pollution”. Air pollution is the second leading cause of deaths from NCDs: in the European Region more than 550 000 deaths were attributable to the joint effects of household and ambient air pollution in 2016. Tackling air pollution is therefore a key factor in reducing premature mortality, and it is one of the priorities of the Ostrava Declaration on Environment and Health, which identifies a set of actions to address this major public health issue. 111. The Regional Office published Evolution of WHO air quality guidelines: past, present and future (2017), which summarizes key WHO publications in the field of air quality and health since the 1950s that led to the development of the series of WHO air quality guidelines. 112. In 2018 and again in 2019 representatives of Member States, experts and stakeholders came together for the annual meetings of the Joint Task Force on the Health Aspects of Air Pollution. The Task Force, established under the Convention on Long-range Transboundary Air Pollution, works to assess how long-range transboundary air pollution affects human health, helps to define priorities to guide monitoring and abatement strategies, and advises on monitoring and modelling activities to improve the quality of assessments. 113. In May 2018 the Regional Office launched a new version of AirQ+ (Version 1.2). This is a software tool developed by the Regional Office to perform calculations that allow quantification of the health effects of exposure to air pollution, including estimates of the reduction in life expectancy, and has been downloaded by thousands of users since it originally launched in 2016. For the first time, the new version presents an interface in Russian, making it now available on the website of the Regional Office in three languages (English, French and Russian). 114. Improvement of ambient and indoor air quality to protect health is one of the priorities of the Ostrava Declaration. With the aim of strengthening capacities of Member States in assessing the health impacts of air pollution and applying the AirQ+ software, the WHO European Centre for Environment and Health (ECEH) developed a training curriculum, and organized the first subregional Training Workshop on Air Quality and Health - Strengthening EUR/RC69/5 page 24 Capacities in Assessing Health Risks of Air Pollution in Sarajevo, Bosnia and Herzegovina, 12–16 November 2018. Noise guidelines are the most popular publication 115. In October 2018 the Regional Office launched the Environmental Noise Guidelines for the European Region, based on the growing understanding of the health impacts of exposure to environmental noise. Work on the guidelines was supported by Switzerland and Germany. 116. Targeted at decision-makers and technical experts, the guidelines provide recommendations for protecting human health from exposure to environmental noise from transportation (road traffic, railway and aircraft) noise, wind turbine noise and leisure noise. They provide robust public health advice underpinned by evidence, essential to drive policy action that will protect communities from the adverse effects of noise. 117. Compared to previous WHO guidelines on noise, this version contains five significant developments: 1) stronger evidence of the cardiovascular and metabolic effects of environmental noise; 2) inclusion of new noise sources, namely wind turbine noise and leisure noise, in addition to noise from transportation; 3) use of a standardized approach to assess the evidence; 4) a systematic review of evidence, defining the relationship between noise exposure and risk of adverse health outcomes; and 5) use of long-term average noise exposure indicators to better predict adverse health outcomes. 118. In terms of their health implications, the recommended exposure levels can be considered applicable in other regions and suitable for a global audience. 119. The Environmental Noise Guidelines were the most popular publication of the European Region from 2018, in spite of their launch in October that year, underscoring the interest and relevance of this normative product of the WHO. Water and sanitation 120. While some people in the European Region take clean drinking water for granted, many communities throughout the Region – and the world – still suffer from water-related issues. In 2019 World Water Day focused on “leaving no one behind”, providing equitable and safely managed water services for all, including remote rural communities. 121. The provision of safe drinking water is a challenge for small water suppliers across the European Region, which experience higher frequencies of waterborne disease outbreaks than larger water supply systems. WHO recommends water safety plans (WSPs) as the most effective approach to ensuring safe drinking water 122. In Tajikistan, more than 73% of the population lives in rural areas, with small systems being the main source of drinking water. As part of its biennial collaborative agreement with the Ministry of Health and Social Protection of Tajikistan, the Regional Office has supported the Tajik government in improving access to safely managed drinking water by jointly implementing the project “Small and safe: scaling up water safety planning and effective water quality monitoring in rural Tajikistan”. The project was coordinated by the ECEH and funded by the Ministry for Foreign Affairs of Finland under Finland's Water Sector Support to Kyrgyzstan and Tajikistan programme, and was completed in November 2018. EUR/RC69/5 page 25 123. The project accomplished several key achievements: WSPs were introduced in five districts across rural Tajikistan, improving the health and well-being of communities; a national team of WSP facilitators was established, who now advise water suppliers on water safety planning; a national WSP roadmap now defines key steps by various stakeholders in support of long-term sustainable uptake of WSPs in Tajikistan; the new drinking water and sanitation law incorporating the WSP approach was supported through an advisory process; the guidance for surveillance authorities was developed on effective risk-based approaches to drinking water quality monitoring; water quality monitoring equipment was upgraded in the laboratories of the partnering Sanitary Epidemiological Service office; awareness was increased in rural communities of the human right to water and the relationship between safe water, sanitation, hygiene behaviour and disease prevention. 124. Following the endorsement of the Iceland Statement “Ensuring safe and climate- resilient water and sanitation” at the Fifth high-level meeting of small countries in Reykjavik, Iceland in June 2018, Cyprus and Monaco, both members of the WHO Small Countries Initiative, are setting an example in taking urgent policy action to combat the effects of climate change on water and sanitation. 125. As small Mediterranean countries, Cyprus and Monaco are all too aware of the impact of climate change on water resources, as well as the health issues poor water sanitation can cause, such as waterborne diseases. Having developed multifaceted plans, they are now implementing intersectoral interventions to ensure the availability of sustainably managed water for their whole populations. These measures seek to increase the capacity of the countries for, and resilience in, improving response to climate-related emergencies, decreasing the burden of disease linked to environmental factors and ultimately protecting population health from the effects of climate change. 126. The current initiatives in Cyprus and Monaco serve as an inspiration to the other countries participating in the Small Countries Initiative – Andorra, Iceland, Luxemburg, Malta, Montenegro and San Marino – all of which have committed to enhancing intersectoral and multilateral cooperation and coordination and supporting each other in combating the effects of climate change. 127. The fifth session of the Meeting of the Parties to the Protocol on Water and Health, scheduled for November 2019, is being organized by the Government of Serbia, with support of the joint secretariat of the United Nations Economic Commission for Europe and the Regional Office. The meeting is expected to bring together representatives of over 40 countries to discuss how the Protocol can best support pan-European countries to improve access to safe water and sanitation and achieve the water and health-related SDGs. Menstrual hygiene: tackling the taboo 128. To help tackle the taboo and encourage more supportive environments for menstrual hygiene management (MHM), health and education sectors came together to discuss joint action at the third expert meeting on water, sanitation and hygiene in schools, held in Bonn, Germany, on 23–24 October 2018 under the framework of the Protocol on Water and Health. 129. Inequality in relation to MHM has many causes, such as lack of information about menstruation, unsatisfactory sanitation infrastructure and the fact that menstrual management supplies are often unavailable or unaffordable. A recent study on menstrual poverty in EUR/RC69/5 page 26 North Macedonia found that inadequate conditions for managing menstrual hygiene at school and the high price of products for MHM were cited as the most common reasons for the high percentages of female students missing school while on their period. 130. In Scotland, United Kingdom, an initiative by the Scottish Government to provide access to free menstrual products to students in schools, colleges and universities aims to ensure that lack of access to products does not impact on anyone’s ability to fully participate in education at all levels, while a digital platform gives young people all the information they need about periods and access to menstrual hygiene products. In Kyrgyzstan, the United Nations Children’s Fund (UNICEF) supported the Ministry of Education in developing educational materials on MHM which were distributed to all schools in the country, as well as MHM education materials in alternative (braille and audio) formats for children with visual and hearing disabilities to provide them access to critical information on girls’ hygiene, child rights and safety. Chemical safety 131. In the context of the Minamata Convention, standard operating procedures for the assessment of prenatal exposure to mercury were developed and made available on the Regional Office website. The work was performed in the framework of the project “Development of a Plan for Global Monitoring of Human Exposure and Environmental Concentrations of Mercury” funded by the Global Environment Facility. The module on human biomonitoring was coordinated by the Regional Office, in coordination with WHO headquarters. 132. Endocrine disrupting chemicals (EDCs) were the focus of a two-country (Belarus and Ukraine) capacity-building project funded by the Quick Start Programme of the Strategic Approach to International Chemicals Management. The project contributed to creation of a subregional network of institutions with expertise in hazardous chemicals and human health; development of a harmonized educational programme on EDCs for medical students and public health professionals; and an agreement on an instrument for the planning of epidemiological studies to assess selected health effects linked to exposure to EDCs. 133. Support was provided for capacity building in Member States on emerging policy issues and chemical risk assessment. In the framework of a project on establishing key elements of chemicals management system funded by the German Environment Agency (UBA), a training course was organized for representatives of five European Members States from eastern Europe, Caucasus and central Asia (29–31 October 2018, Minsk, Belarus). 134. In April 2019, training on chemicals management in Nur-Sultan, Kazakhstan, was organized by the Regional Office, in cooperation with WHO headquarters, the WHO Country Office in Kazakhstan, and the National Public Health Centre of the Ministry of Health of Kazakhstan, for the representatives of governments, including the health sector, and stakeholders from 11 countries in the European Region (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Tajikistan, Ukraine, and Uzbekistan), as well as Mongolia from WHO Western Pacific Region. EUR/RC69/5 page 27 Waste management and contaminated sites 135. The Bonn Office has made significant progress on this newly established European environment and health priority, which was included in the 2017 Ostrava Declaration for the first time in the series of Environment and Health Ministerial Conferences. The EU-funded European Cooperation in Science and Technology Action: Industrially Contaminated Sites and Health Network (ICSHNet), coordinated in close partnership with the WHO Collaborating Centre for Environmental Health in Contaminated Sites, is based at the Italian National Institute of Health. 136. Involving 33 Member States over four years, the ICSHNet European Cooperation in Science and Technology Action produced a wealth of resources, training, reports and assessments, including a statement on contaminated sites and health that was presented at the aforementioned Environment and Health Task Force meeting held in March 2018 in Bonn, Germany. The Action has also spawned national projects such as one in Serbia, Strengthening Serbian national capacities and intersectoral synergies for safe management of contaminated sites and related hazardous substances to prevent negative impact on human health and the environment, which resulted in the production of the national roadmap for dealing with industrially contaminated sites. Health effects of climate change 137. The Working Group on Health in Climate Change met on 12–13 June 2018 at the ECEH in Bonn, Germany. The ECEH supports Member States in assessing vulnerabilities to and impacts of climate change, enhancing disease surveillance for climate-sensitive vector- borne diseases, and improving preparedness planning and response to extreme events such as heat waves and flooding. The Working Group was established by the EHTF in 2012 to promote the protection of health from the adverse effects of climate change and has provided a regular platform to share the technical expertise that has been steadily building in the Region to protect populations from the health effects of climate change. 138. The meeting in Bonn was an opportunity to further support the work of Member States in the development of their national portfolios of action, to provide an update on policy developments, to facilitate the exchange of experience, and to identify priority themes and actions to advance implementation of the Ostrava commitments on climate change and health. The meeting also provided an opportunity to inform Member States of the outcomes of the joint WHO–European Commission project on addressing the impacts of climate change on health, to launch the joint WHO–United Nations Framework Convention on Climate Change (UNFCCC) initiative on developing climate and health country profiles, and to drive forward the ongoing update of WHO guidance on heat–health action planning. 139. At the 24th Conference of the Parties (COP24) to UNFCCC, WHO provided health- based arguments for action on climate change as well as tools to quantify the physical and economic benefits of improving air quality. 140. Three products launched at an event on 3–4 December 2018 in Katowice, Poland, will support Member States in developing policies to tackle climate change and its effect on health and well-being: Public health and climate change adaptation policies in the European Union, which analyses developments in health policies to address adaptation to climate change in European countries and presents a selection of good practice case studies; Achieving health EUR/RC69/5 page 28 benefits from carbon reductions: Manual for CaRBonH calculation tool, which allows for the quantification of the positive physical and economic consequences for health achieved through improvements in air quality from carbon reduction; and the COP24 Special report on health and climate change produced to support UNFCCC negotiation, which highlights why health considerations are critical to the advancement of climate action and outlines key recommendations for policy-makers to help countries avoid the worst health impacts of climate change. 3. Health emergencies, AMR and communicable diseases WHO Health Emergencies Programme 141. Disease outbreaks, natural and man-made disasters, chemical spills, radio-nuclear accidents and deliberate events – such humanitarian crises affect over 130 million people around the world today, with devastating effects on health, societies and economies. 142. Emergencies not only know no borders, they exhibit a strong domino effect on countries and regions, affecting even those not directly impacted. The Syrian crisis, for example, and the outbreaks of Ebola virus disease and Zika virus disease in other regions, all had repercussions in the European Region. In addition to these, the European Region has been affected by its ‘own’ emergencies, including outbreaks of measles and West Nile virus, infections from contaminated food and water, as well as floods and earthquakes, conflicts and terrorist attacks. 143. The WHO Health Emergencies Programme (WHE), established in 20162 across all levels of the Organization, provides the Organization’s response to ever more demanding crises. WHE is geared to better protect people from health emergencies by establishing people-centred health systems which can prevent, prepare for, detect, assess, communicate and respond to crises in a matter of hours. A five-year global strategic plan 2018–2023 has been endorsed by all countries to achieve that. 144. The WHE Programme in the European Region has tailored the global emergencies strategy into a European Action Plan. The Action Plan to Improve Public Health Preparedness and Response in the European Region was adopted through a resolution by the Regional Committee.3 The Action Plan bonds together countries with comparable levels of capacity and capability to avert or respond to emergencies. This requires cooperation across sectors and across borders. 145. The outcome summary of the ministerial consultation and high-level meeting held on 12–14 February 2019 in Istanbul, Turkey, gives the Regional Office a stronger mandate to coordinate action to accelerate countries’ political and financial commitment. More than 150 European ministers of health and high-level delegates gathered in Istanbul identified sustained investment, mutual learning and support, and regular monitoring of progress as critical to scale up health emergency preparedness and response in the European Region. 2 Decision WHA69(9) adopted by the Sixty-ninth World Health Assembly in 2016. 3 See EUR/RC68/14 and EUR/RC68/R7. EUR/RC69/5 page 29 146. The WHE country business model has been fully operational in the Region, with 33 staff based in 15 countries. Territories have been identified as priorities based on hazards mapping and vulnerabilities. Investments in emergency preparedness in these countries and territories can yield the greatest return on investment. The WHE support team is therefore placed in the countries, centred around three hubs located in Georgia, Kyrgyzstan and Serbia. Each hub is led by international WHO staff. These hubs play a central role in enhancing leadership and strengthening relations with countries and national health authorities. Their technical and advocacy role is crucial in promoting and strengthening public health preparedness and response and ensuring that evidence, technical guidance and WHO tools are available to support decision-making processes, planning, risk communication and capacity building towards measurable country impact. In 2019, the Regional Office supported the hubs by developing a tailored advocacy package to support the case for investment in emergency preparedness. 147. Hubs and countries are supported with technical expertise and surge capacity at the Regional Office level. Staff from the Regional Office has been deployed to respond to health emergencies in the WHO African Region, specifically those relating to Ebola in the Democratic Republic of Congo and cyclones in Mozambique. 148. The Regional Office expresses deep gratitude to the Governments of Australia, France, Germany, Italy, Japan, the Russian Federation, the United Kingdom of Great Britain and Northern Ireland and the United States of America for their generous financial support to activities implemented under the WHE. Managing infectious hazards Influenza 149. Ten years after the 2009 influenza pandemic, significant gaps remain in pandemic preparedness in the Region with fewer than one in three countries having revised their pandemic plans. The list of publicly available national pandemic plans prepared after the 2009 pandemic can be found on the website of the Regional Office. 150. During the same period, there has been a steady decline in uptake of seasonal influenza vaccine in a number of European countries and low access to vaccines in lower-resourced countries.4 This is a concern not only for ensuring the protection of vulnerable groups against seasonal influenza, but also because it affects the Region’s pandemic preparedness, since the production of pandemic vaccines is closely linked to seasonal vaccine use. 151. Given the scale of threat, and the fact that all countries are equally vulnerable, pandemic influenza preparedness should be a priority for all Member States. This is a major public health opportunity in the European Region. Countries can prepare by revising and updating their pandemic influenza preparedness plans in line with the latest WHO guidance by 2021, and by increasing uptake of seasonal influenza vaccine in persons most in need. 4 See How close are countries of the WHO European Region to achieving the goal of vaccinating 75% of key risk groups against influenza? Results from national surveys on seasonal influenza vaccination programmes, 2008/2009 to 2014/2015, in Vaccine Vol. 36, Issue 4, January 2018, pp 442–452. EUR/RC69/5 page 30 152. To support these efforts, the Regional Office conducted a wide range of activities including: • Joint influenza surveillance with ECDC during the 4th, 5th and 6th seasons of the Flu News Europe bulletin;5 • The 6th Joint Regional Office–ECDC Annual European Influenza Surveillance Meeting, held in June 2018, celebrating the achievements of the first decade of the Region’s influenza network and taking stock of the status of pandemic preparedness 100 years after the severe pandemic of 1918; • Developing new country profiles showing seasonal influenza vaccination policies and uptake on the European Health Information Gateway;6 • Risk assessment on a pandemic reassortant virus in the Netherlands and a swine reassortant virus in Switzerland. 153. At the country level, the following outcomes were recorded in 2018–2019: • The uptake of seasonal influenza vaccine more than doubled in 2018–2019 compared to 2015–2016 in four countries (Albania, Armenia, Kyrgyzstan and Republic of Moldova), which received donations through the Partnership for Influenza Vaccine Introduction in collaboration with WHO; • Under the auspices of the Global Action Plan for Influenza Vaccines, Serbia successfully developed production capacity for a seasonal inactivated trivalent influenza vaccine, gaining the opportunity to become a regional supply hub for both seasonal and pandemic influenza vaccines if sustained investment is secured; • Fourteen countries worked with the Regional Office to raise awareness of the importance of influenza vaccination during the October 2018 Flu Awareness Campaign; • All five recipient countries of Pandemic Influenza Preparedness (PIP) Partnership Contributions (Armenia, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan) increased their capacities to prevent and control influenza and developed guidelines and associated training for outbreak investigation. All except Uzbekistan expect to revise their pandemic plans by the end of 2019. The PIP Framework implementation in these countries is an example of how national commitment, sustained funding and a solid methodological approach can lead to enhanced pandemic preparedness; • National influenza centres in five countries (Armenia, Cyprus, Montenegro, North Macedonia and Turkmenistan) were formally recognized by WHO. This brought the number of countries in the Region that are members of the Global Influenza Surveillance and Response System and have a WHO-recognized national influenza centres to 47 out of 53; • Some countries recommended a switch from trivalent to quadrivalent vaccines to ensure broader protection, especially among older people. Due to the higher price of quadrivalent vaccines, for countries with limited resources this might result in 5 See the joint ECDC–Regional Office Flu News Europe bulletin (Flu News Europe), https://flunewseurope.org/. 6 See the European Health Information Gateway’s dataset on influenza on the Regional Office’s website, https://gateway.euro.who.int/en/datasets/influenza/. EUR/RC69/5 page 31 fewer available doses; however, quadrivalent vaccines can also prove cost- effective when the overall costs for the health care sector are considered. Middle East Respiratory Syndrome Coronavirus 154. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) continued to be of concern in the Region, with one of only three imported cases reported outside Saudi Arabia and neighbouring countries in 2018–2019 occurring in the United Kingdom. This is the fifth case of MERS-CoV diagnosed in the United Kingdom; seven other countries in the European Region have also reported cases since 2012. The Regional Office continues to support countries to develop preparedness plans for MERS-CoV and other emerging infections. In particular, 40 Syrian public health responders were trained on early detection and investigation of new influenza viruses in humans in support of the Early Warning Alert and Response Network (EWARN), a critical resource in the absence of routine surveillance during the ongoing conflict. Foodborne diseases 155. Foodborne diseases continue to pose a significant threat to health in the Region according to data from the newly launched report The burden of foodborne diseases in the WHO European Region. The report shows that 23 million people fall ill from unsafe food each year and 4700 of them die. These are the known cases, and it is assumed that this is just the tip of the iceberg. These findings were presented on the occasion of the first-ever World Food Safety Day on 7 June 2019, established by means of a resolution adopted at the United Nations General Assembly. To promote World Food Safety Day, WHO Regional Office for Europe worked alongside the United Nations Food and Agriculture Organization (FAO) and Codex Alimentarius. 156. Of the 53 WHO Member States in the European Region, 49 are now members of the International Food Safety Authorities Network, an increase of four compared to 2016. There were 45 food safety events involving produce from countries in the European Region in 2018, compared to 19 in 2017. This increase reflects the global dimension of trade and increased recognition of food safety events. 157. Throughout the reporting period, countries in the European Region (particularly Kyrgyzstan, North Macedonia and Republic of Moldova) received tailored technical support on foodborne outbreak management, One Health coordination and rapid risk assessments. Sixteen countries in the eastern part of the Region received training on collaboration with Codex Alimentarius secretariat and revision of standards. 158. A subregional meeting on AMR held in Almaty in October 2018, addressed AMR, surveillance and monitoring for humans, food producing animals and food, with a focus on improved collaboration. High threat pathogens: improving surveillance and laboratory detection 159. In order to enable the Regional Office to estimate the frequency and impact of outbreaks caused by high threat pathogens, it has updated its annual collection of data from European countries to include 27 diseases. The first annual report will be published by the end of 2019. EUR/RC69/5 page 32 160. Country support aimed at improving the quality of national surveillance systems and of public health laboratory capacities as part of the Better Labs for Better Health initiative in 13 countries (Armenia, Belarus, Kazakhstan, Kyrgyzstan, Lithuania, Malta, Montenegro, Republic of Moldova, Serbia, Tajikistan, Turkmenistan, Ukraine and Uzbekistan). 161. Through mentoring delivered through the Better Labs for Better Health initiative, the quality of laboratory services was improved by 30% in 15 laboratories in nine countries. In particular, Kyrgyzstan, Tajikistan, Turkmenistan, Ukraine and Uzbekistan benefited from this support. In 2019, Armenia, Belarus and Kazakhstan formally requested to participate in the Better Labs for Better Health initiative. The Third Partners’ Meeting, held in October 2018 in Almaty, Kazakhstan, recognized the results achieved under the Better Labs for Better Health initiative and endorsed the approach to sustainable laboratory system strengthening. 162. Countries were also recommended to increase their capacities for diagnosis of high threat pathogens. To serve this need, a new task force was launched in 2019 to strengthen diagnostic capacities for high threat pathogens (such as those causing influenza, Crimean- Congo haemorrhagic fever, West Nile fever, anthrax and brucellosis) in priority countries in eastern and south-eastern Europe and central Asia: the European Regional Laboratory Task Force for High Threat Pathogens, known as the Lab Task Force.7 Clinical management of infectious hazards 163. Defective infection prevention and control (IPC) practices during everyday health care delivery cause harm to hundreds of millions of patients worldwide every year. Health care- associated infections (HAI), including those resistant to antimicrobials, are among the most common complications of hospital stays and no country or health system, not even the most developed or sophisticated, can claim to be free of HAIs. On any given day, 98 000 patients in Europe have at least one HAI according to ECDC data. 164. In recent years, the spread of MERS-CoV and the Ebola virus disease outbreaks have revealed gaps in IPC measures. Furthermore, the IHR (2005) and the Global Action Plan on Antimicrobial Resistance call for Member States to strengthen hygiene and infection prevention and control. In 2016, WHO published new guidelines on the core components of IPC programmes and in 2017, released tools to implement the core components of IPC programmes. 165. Between 2018 and 2019, the Regional Office supported Albania, Armenia, Georgia, Kyrgyzstan, Montenegro, Republic of Moldova, Turkey, Turkmenistan and Ukraine to conduct self-assessments to identify gaps in their implementation of the core components of IPC programmes. Ensuring the sustainability of the programme with the adequate human and financial resources is a common challenge, among many others. Member States acknowledged that international technical support through partners such as WHO, ECDC, the European Society of Clinical Microbiology and Infectious Diseases, the Baltic Antibiotic Resistance collaborative Network and others is invaluable in building up national programmes. 166. In order to facilitate better integration of clinical management into epidemic/pandemic planning and response, the Regional Office is developing a series of simulation exercises which are expected to be rolled out to Member States in 2020. These exercises will serve as a tool for 7 See European Regional Laboratory Task Force for High Threat Pathogens. Term of reference (2019) http://www.euro.who.int/en/health-topics/Health-systems/laboratory-services/publications/european-regional- laboratory-task-force-for-high-threat-pathogens.-terms-of-reference-2019 EUR/RC69/5 page 33 improving IHR (2005) medical countermeasures capacities, and can also be used for training emergency medical teams prior to deployment on missions to support outbreak response. Country Health Emergency Preparedness and the IHR (2005) 167. In general, there is high IHR (2005) capacity in the European Region. The 2018 self- assessment from 53 of the 55 (95%) State Parties to the IHR (2005) in the Region records an average score of 3.7 (74%) across all 13 IHR (2005) technical areas: 3.0 (60%) in priority countries and 3.9 (78%) in other countries in the Region. 168. The two strongest technical areas overall in the Region are: laboratories (average score: 4 (80%)) and IHR Coordination and National IHR Focal Point Functions (4 (79%)). The five technical areas in the Region with the highest strengthening potential are: Points of entry (average score 2.9 (58%)), Risk Communication (3.4 (69%)), Chemical Events (3.4 (69%)), Human Resources (3.5 (71%)), and National Health Emergency Framework (3.6 (72%)). Zoom-in on specific monitoring and evaluation activities 169. Between January 2016 and June 2019, 16 countries in the European Region – including eight priority countries – requested WHO support and completed Joint External Evaluation (JEE).8 Four countries are currently in the pipeline for 2019.9 Analysis of the JEE results show that the technical areas with the highest potential for improvement are Biosafety and Biosecurity, AMR, Risk Communication and Points of Entry. 170. Finland, Latvia, and Switzerland have officially finalized their National Action Plans for Health Security after their JEEs; while Albania, Armenia, Kazakhstan, Kyrgyzstan, Lithuania, and Serbia are in the process of developing their plans and Georgia, Montenegro, North Macedonia, and Republic of Moldova are anticipated for 2019. 171. Since July 2017, five after-action reviews have been conducted with Regional Office support, including in Iceland (cholera) and the Netherlands (polio) in 2017; in Romania (measles and West Nile fever) in 2018; and Kyrgyzstan (measles) and in Serbia (West Nile fever) in 2019. After-action reviews of measles outbreaks in Azerbaijan and Georgia are in the pipeline for 2019. 172. More than 30 countries across the Region engaged in simulation exercises ranging from providing input to the European Aviation Crisis Coordination Cell’s crisis management exercise entitled ‘PANDEMIC19’ in the Netherlands, to tabletop exercises, to full scale field exercises. 173. The Joint Assessment and Detection of Events exercise, a functional simulation exercise, tested communication and coordination between IHR National Focal Points in 27 countries and the IHR duty officers at the Regional Office and thus contributed to preparedness at the regional level. 8 2016: Albania, Armenia, Kyrgyzstan, Turkmenistan. 2017: Belgium, Finland, Latvia, Liechtenstein, Slovenia, Switzerland. 2018: Lithuania, Republic of Moldova, Serbia. 2019: Georgia, Montenegro and North Macedonia. 9 Bosnia and Herzegovina, Germany, the Netherlands and Tajikistan. EUR/RC69/5 page 34 Capacity building projects and activities 174. Areas of focus for capacity building based on monitoring and evaluation results include the following: • Points of entry are at the front line of prevention, detection and response to public health events that may arise via international travel and transport. Points of entry has been shown to be one of the technical areas with the highest improvement potential for almost all countries in the Region. The Regional Office has been working to strengthen this capacity through simulation exercises in Turkmenistan (2016), Germany (2018), and the European Aviation Crisis Coordination Cell exercise on pandemics (2019); organization of a regional Point of Entry Assessment Tool training for priority countries (2019); and a close technical partnership with EU Healthy Gateways, and support to Member States to participate in the annual Collaborative Arrangement for the Prevention and Management of Public Health Events in Civil Aviation (CAPSCA) meetings. • Emergency risk communication (ERC) has the potential to be a life-saving part of any emergency situation and should be considered an important investment in health, safety and security. ERC is among the areas where the Regional Office scaled up the most its support to countries during 2017–2019. As of July 2019, 19 countries and territories (14 of the priority countries) are enrolled in the ERC five step capacity building package, first launched in 2018. The package – including tailored training, capacity mapping, plan writing, testing and adoption – was rolled out to the global organization in 2019 following its proven use as an effective tool for numerous countries in the European Region. • Assessment of risks, vulnerabilities and capacity is a starting point of the emergency preparedness cycle described in A Strategic Framework for Emergency Preparedness (World Health Organization, 2017). The Regional Office supported Armenia, Azerbaijan, Georgia, Kyrgyzstan, Republic of Moldova and Ukraine to conduct national strategic risk assessment using the WHO tool for strategic risk assessment (STAR). Kyrgyzstan conducted strategic risk assessments at subnational level and Republic of Moldova plans to do so in the coming months. The Regional Office offered a series of trainings on WHO methodology for conducting risk assessments, emergency planning, simulation exercises and after-action reviews to multisectoral participants from all priority countries to help them operationalize emergency preparedness at national level. • Hospital safety is critical to ensure hospital resilience during emergencies. The Hospital Safety Index helps identify measures to ensure the safety, security and functionality of health infrastructure at national and community levels. Overall, the Regional Office has supported the assessment of 358 hospitals in the Region through this tool, and Georgia and Kyrgyzstan have published their reports to share experiences. • Mass casualty incident management is critical to prepare health care workers to provide emergency services and public assistance during or immediately after a disaster to save lives. A training developed by the Regional Office was conducted in Kyrgyzstan. • Multisectoral approach to all-hazards, is needed to ensure effective prevention, mitigation, preparedness and response to all types of emergencies. To support EUR/RC69/5 page 35 Member States to develop and regularly update national all-hazard and hazard- specific emergency preparedness and response plans, the Regional Office developed ‘off the shelf’ packages for an Emergency Operations Plan and hazard- specific Contingency Plan tailored to the contexts and needs of the European Region. In 2019, the package was implemented in Armenia, Azerbaijan, Georgia and Republic of Moldova. Training on hazard-specific contingency planning and WHO methodology was undertaken in Serbia. The FAO-World Organisation for Animal Health-WHO (Tripartite) guidance document on taking a multisectoral, One Health approach was piloted in Georgia in July 2019 to develop Joint Risk Assessments. Activities in partnership 175. The WHE programme of the WHO Regional Office for Europe: • Actively supported the organization of the Seventh Meeting of CAPSCA which took place in Finland in April 2019. WHO guidelines for disinfection and disinsection were presented during the meeting. • Continued to collaborate and coordinate closely with the ECDC, including collaboration on Strengthened International HeAlth Regulations and Preparedness in the EU – Joint Action. • Sustained cooperation with SEEHN on health emergencies in the spirit of the Chisinau Pledge and the priority actions stipulated in the SEEHN Subregional Cooperation Strategy. Detection and response 176. Reaching the ambitious goal set out in GPW 13 of one billion more people better protected from health emergencies will require substantial investments in global public goods, including increased collection and analysis of epidemiological data and surveillance of infectious diseases. Early intelligence of public health events is critical for timely intervention and mitigation of consequences. 177. Every day, 365 days a year, WHE experts at global, regional and country level monitor for outbreaks, disasters and emergencies. In the European Region in 2019, WHE staff continued conducting robust event-based surveillance to provide Member States with invaluable information and understanding of all hazards and most appropriate interventions to address them. They reviewed more than 20 000 warnings of public health threats from different sources, conducted formal assessments of 2,000 of them and responded to about 50, or one every week. 178. WHE in the Regional Office also actively contributed to producing an important global public good for health, the Event Information Site (EIS) that provides detailed epidemiological descriptions, risk assessments, updates on all events, implemented measures and other relevant information for senior professionals and disease control specialists, decision-makers and other relevant authorities. This stream of work is summarized as follows: • number of events created in Event Management System = 40 • number of EIS postings created = 6 • number of EIS postings updated = 10 EUR/RC69/5 page 36 • number of EIS announcements = 2 • number of verification requests sent = 7 179. The effective use of IHR (2005) Annex 2 depends on each national authority and its IHR National Focal Points carrying out risk assessments of public health events occurring within their territories. In order to provide technical guidance and support to develop and strengthen capacities for rapid risk assessment, WHE organized capacity building events for its priority countries in the European Region. These events, along with workshops for IHR National Focal Points, were designed to strengthen and maintain IHR core capacities in the Region. 180. A new tool, “communities of practice” was launched on 13 June 2019 under the IHR National Focal Points Knowledge Network platform for all 55 IHR National Focal Points in the European Region in order to support peer to peer learning and accelerate sharing of best experiences. Emergency response 181. WHE experts in the regional and country offices work closely with health partners to preposition life-saving health interventions and essential health packages to be delivered during emergencies. They establish a network of skilled specialists in the Region (emergency medical teams (EMTs) and the Global Outbreak Alert and Response Network (GOARN)) that can be rapidly deployed to save lives. 182. This work, conducted jointly with health systems and public health experts, is linked to the country-specific capacities to implement the IHR (2005), the essential public health functions and any gaps in UHC. In this way, countries are guided to address critical shortcomings identified through IHR (2005) monitoring and evaluation activities, and to bridge life-saving operations to recovery and rehabilitation. This is a major opportunity for the “development, health and peace nexus”, aiming to “build back better” and by using “health as a bridge for peace”. 183. WHE uses WHO Emergency Response Framework (ERF) as an internal mechanism to grade emergencies. The humanitarian crises in Ukraine (grade 2) and in the Syrian Arab Republic (grade 3) with response in and from Turkey are the highest graded protracted emergencies that the Regional Office is responding to date. 184. Measles outbreaks in the European Region have led to over 100 000 cases in just a 14-month period from 1 January 2018. In May 2019, WHO decided to scale up its support and utilize emergency surge capacity to support the multi-country outbreak response and address the underlying immunization gaps that are fuelling these outbreaks. A grade 2 multi- country measles emergency was declared, and its response is led by the Regional Office jointly by Vaccine Preventable Infections and WHE programmes. This cross-cutting work ensures that the needed expertise is provided using ERF procedures. A forgotten – though continuing – humanitarian crisis in Ukraine 185. The conflict in eastern Ukraine is often referred as a “forgotten crisis”. However, it continues – with 1.6 million people displaced and with tens of thousands ceasefire violations recorded in 2018. EUR/RC69/5 page 37 186. The Ukrainian armed conflict enters its fifth year with 3.4 million people are affected in eastern Ukraine. Over 800 000 residents along the 457 kilometres ‘contact line’ are those most in need. Continued shelling, limited freedom of movement, shortage of medicines and medical supplies significantly affect their life and health. Due to an impaired access to health services people are exposed to increased health risks. 187. Since the beginning of the conflict, WHO has been working with health partners to ensure access to health services for affected populations. WHO prioritized health services for vaccine-preventable diseases, HIV and tuberculosis (TB), maternal health, NCDs and psychosocial support. WHO and partners also provided services and tools for prevention, preparedness and recovery. 188. In 2018 WHO continued to address the needs of people living in the conflict affected areas by procuring medicines, medical supplies and medical equipment for selected secondary and tertiary health care facilities; and training health care specialists to improve the quality of the health care services. WHE operates through its main office in Kyiv and four field offices in Donetsk, Kramatorsk, Luhansk and Severodonetsk. Two-faceted response: whole-of-Syria operations in and from Turkey 189. Several years into the conflict in the Syrian Arab Republic, millions of people still need humanitarian assistance. Not only has the Syrian humanitarian crisis tragically affected the Syrian Arab Republic and its people, it has also had an enormous ripple effect on neighbouring countries, such as Turkey. 190. The WHO Regional Office for Europe has been supporting the response to this emergency from and in Turkey. During 2018, WHO operations in Turkey comprised of a cross-border response from the field office in Gaziantep and a health response to refugees in Turkey, coordinated from the WHO Country Office in Ankara. The staff in WHO offices in Ankara and Gaziantep, Turkey, has the experience, skills and dedication needed to conduct operations, with the support of the WHO Regional Office for Europe. 191. In north-west Syria, WHO served over three million people by responding to urgent health needs and supporting health facilities in the delivery of health services in coordination with partners. This included interventions such as the delivery of vital medicines and medical supplies to 180 health facilities covering hundreds of thousands of people and support with operational costs of health facilities. Primary health care services were expanded to include NCDs. WHO and partners delivered vaccinations to hundreds of thousands children against polio and supported 86 fixed immunization centres providing on average 66 500 children every month with their routine vaccinations. They have trained 160 health workers to deal with mass trauma incidents and 11 doctors on chemical incident management. Mapping of mental health services in northern Syria was finalized highlighting severe shortage of services for 3 million people in need. As attacks on health care facilities impede the delivery of these health operations, WHO strongly condemns them as obstructing people’s right to access health and humanitarian support. 192. In Turkey, efforts were made to strengthen the national health system through integrating Syrian health care workers and translators, to build capacity for mental health care, to provide linguistically and culturally sensitive health services and to support home care for older and disabled refugees. The WHO Refugee Health Programme is a flagship role model of EUR/RC69/5 page 38 UHC. Syrian health care workers – trained and integrated in the Turkish health system – provide health services to their 3.6 million fellow citizens in an affordable and culturally sensitive way. About 600 000 consultations were provided in 2018. Some of these Syrian refugees were doctors, nurses and midwives in their homeland. They had the opportunity to start afresh in Turkey, helping their people while practicing their professions. Operational Partnerships in Emergencies 193. In the spirit of GPW 13 and on the basis of its Action Plan for the European Region, WHE has intensified its collaboration with partners, especially with GOARN, EMTs, Health Cluster Partners, Standby Partners, international nongovernmental organizations (NGOs) and WHO collaborating centres. GOARN 194. Since 2016, the European Region has been expanding the GOARN 2.0 regional footprint to build national preparedness capacities and deliver a more robust country and regional approach for outbreak response. Important progress has been made in the area of Public Health Rapid Response Capacities, and the European Mobile Labs initiative has been further enhanced to develop pre-qualified and multi-disciplinary experts’ teams and systems, providing laboratory services for all-hazards. 195. There are 103 GOARN partner institutions in the Region. Twenty were deployed during 2018–2019 to provide support to seven missions, through 81 deployments. Rospotrebnadzor, Russian Federation, was accepted as a new GOARN partner institution in 2018, and other institutions from non-English speaking countries are keen to join. Emergency Medical Teams 196. Currently there are 13 WHO classified EMTs in the European Region (5 – Type 1; 7 – Type 2; and 1 – Type 3). Following the first meeting of the EMT European Regional Group in April 2018, a regional work plan has been developed and agreed upon, including a set of standards and minimum packages of essential health services in emergencies for different levels of care. The EMT Blue Book presents the minimum standards for EMTs in sudden onset disasters, while the EMT Red Book is a guidance document for preparing for and responding to armed conflict and complex emergencies. 197. In 2019, four classified European EMTs were deployed to respond to Cyclone Idai in Mozambique: • Johanniter International; • Regione Piemonte (Italy); • Spanish Agency for International Development Cooperation; and • Instituto Nacional de Emergência Médica (Portugal). Health Clusters 198. Health Clusters continue activities in the two protracted emergencies in the Region: Grade 2 emergency in Ukraine (1.3 million people in need, 9.4% funded of the US$18.1 million EUR/RC69/5 page 39 requested) and Grade 3 emergency –whole-of-Syria/ Gaziantep/Turkey (13.2 million people in need, 0.7% funded of the US$449 million requested). Standby Partnerships 199. Standby Partners are organizations with strong networks of deployable technical professionals, selected on the basis of their proven capacity to source standby personnel with skills that match WHO and Health Cluster needs in emergency work; quickly deploy standby personnel to the field; provide standby personnel with appropriate financial compensation and insurance coverage; and work within the terms of WHO Standby Partnership Agreement. Standby Partners are a strong complement to other WHO surge mechanisms. 200. Standby Partnerships are managed by WHO headquarters. In the European Region, Standby Partners currently support Ukraine and the whole-of-Syria operations in Gaziantep, Turkey, through an information management function. WHO collaborating centres 201. A special assessment carried out by WHE in the European Region revealed that of the 276 collaborating centres, 103 are capable of supporting the implementation of the Action Plan to Improve Public Health Preparedness and Response. These collaborating centres cover specific hazards including biological, technological, societal, hydrometeorological and geological hazards. Work with these collaborating centres has intensified. Gavi, the Vaccine Alliance 202. The Regional Office for Europe and the WHO country offices support the coordination of activities by Gavi in countries in the European Region eligible for Gavi support. WHO offices assist country health authorities in drafting applications for Gavi support and drawing up a plan of action for introducing vaccines. In addition, the Regional Office provides technical support to implementing immunization programmes, including storage and logistics, as well as undertaking monitoring and evaluation measures. 4. Applying the life-course approach and tackling NCDs: leaving no one behind 203. The life-course approach recognizes that all stages of a person’s life are intricately intertwined with each other, with the lives of others born in the same period, and with the lives of past and future generations of their families. Aimed at increasing the effectiveness of interventions throughout a person’s life, it focuses on a healthy start to life and targets the needs of people at critical periods throughout their lifetime, aiming to address the causes, not the consequences, of ill-health. Life-course approach: focusing on a healthy future 204. As described in Section 1 above, HESRi is being developed as a tool to promote and support policy action and commitment for health equity and well-being in the European Region. Specifically, the initiative aims to shift political and policy focus from describing the problem, to capturing progress and enabling action to increase equity in health. One of the components of EUR/RC69/5 page 40 the HESRi – Life-Course Policy Options – offers policy briefs which include baskets of evidence-based policies shown to increase equity in health at four key stages in life: • early years, childhood and adolescence (0 to age 17); • young adults (age 18–25); • working years (age 26 to retirement); • later life (from retirement onwards). 205. The baskets are collections of recommended policies drawn from existing international and Member States’ commitments, action plans, and policy frameworks. A life-course approach has been selected because of the accumulation of multiple and interacting determinants of health across the life-course that worsen health equity, especially for those most left behind. 206. The baskets of policies will be presented as an online tool and resource for policy- makers to support actions for health equity. The approach is designed to reduce confusion among policy-makers and practitioners on “what to do”; provide a clear framework to guide multisectoral and interdisciplinary actions for health equity i.e. ‘who to work with’; and focus the attention of policy-makers on the need to use a combination of policies that will create conditions for all people to be able to live an equally healthy life and remove barriers which hold people back, i.e. “how to increase impact”. 207. A life-course approach to reduce inequities in health is important due to the way in which poor health accumulates throughout life but can be prevented or mitigated with the right mix of interventions and approaches. 208. The guidance is designed to reduce confusion among policy-makers and practitioners on what to do to reduce inequities at different stages across the life-course. The four guides provide a clear framework for assessing the risk of inequity at each stage in the life-course and the evidence and mix of policy options that are most effective in mitigating inequities. Indicators for monitoring progress to reduce inequities are provided, together with the key partners and sectors that can be engaged. Situation of child and adolescent health in Europe 209. A WHO progress report on the Situation of child and adolescent health in Europe was published in English and Russian and the collected data was made available on the European Health Information Gateway. The key findings of the report include: • Childhood obesity and the mental health of adolescents are key areas of concern in the Region. • Access to sexual and reproductive health services for adolescents is unequal across the Region. • Promotion of breastfeeding, regulation of marketing of food for infants and toddlers, and improvement of school nutrition is needed across the Region. • Most countries do not systematically collect key data on children and adolescents and therefore cannot address areas of concern for health. EUR/RC69/5 page 41 210. A summarizing article was published in the Lancet10 in November 2018. Individual feedback on the situation was provided to countries. Strategy development is being supported in Albania and Romania. From lip service to meaningful youth participation – beyond 2020 211. The European Child and Adolescent Health Strategy adopted by the Regional Committee at its 64th session expires in 2020. As a first step in the development of the new strategy, a meeting on youth participation was called to ensure that youths are engaged in the development of the new strategy from the outset. 212. In November 2018, a high-level international road safety conference was organized by the NGO YOURS – Youth for Road Safety, with support from the WHO Regional Office for Europe and the Government of Malta. The panel discussed meaningful youth engagement in designing a safe mobility system, from policy-making to implementation and evaluation. Improving the quality of care for children and adolescents at primary health and hospital level 213. A new report analysed the recent European review of the Integrated Management of Childhood Illness (IMCI) strategy and found that, where implemented adequately, IMCI strategy was perceived as having contributed to the reduction of mortality in children under five and improved quality of care for children. At the same time IMCI strategy was found not be fully adequate for the European Region and therefore never to have been fully implemented. 214. Member States and stakeholders requested the development of treatment guidelines for children and adolescents that meet the needs of the European Region. In response to these requests, a consultation was held, and an editorial group established. Contents were drafted which will provide health care standards for UHC and benefits packages for children and adolescents. Important new components are guidelines for monitoring developmental delays in early childhood development (ECD) and the integration of adolescent health guidelines. 215. The WHO Pocket book for hospital care for children has been adapted in several countries as a standard of care for hospitals and electronic app is being developed. ECD 216. A technical expert consultation was held in October 2018 to identify specific needs for ECD in the Region and adaptation of the Global Nurturing Care Framework for ECD. Improving CAH services integration and coverage within the context of UHC 217. The IMCI review also showed that health systems barriers to quality care for children and adolescents had not been taken into account and addressed sufficiently. A concept paper on strengthening reproductive, maternal, newborn, child and adolescent health services at the PHC level in the frame AlmaAta40 was developed for the Global Conference on Primary Health Care (40th Anniversary of Alma-Ata Declaration). To improve knowledge and understanding of CAH services provided within the context of UHC in countries of the 10 Child and adolescent health in Europe: monitoring implementation of policies and provision of services Lancet Child and Adolescent Health, 2018 Dec; 2(12): 891-904. doi: 10.1016/S2352-4642(18)30286-4. EUR/RC69/5 page 42 European Region to inform planning, review and remedial action for provision of universal entitlement to children and adolescents, case studies of country-level progress towards UHC and CAH-inclusive benefits packages and existing equity gaps were undertaken in Albania, Azerbaijan, Kazakhstan, Kyrgyzstan, Republic of Moldova, and Romania. The assessments represent a first step of targeted technical support to countries to inform policies for coverage design for UHC and ensuring health systems deliver for children and adolescents. Scaling up of adolescent-friendly health services 218. Based on standards for adolescent-friendly health services developed by the WHO collaborating centre for adolescent health in Lausanne, training material for teaching of adolescent health in medical and nursing schools (the EuTEACH collaboration) has been translated and adapted into Russian. In February 2019, a training course for master trainers from Commonwealth of Independent States countries was delivered in Russian in Armenia. Schools for health: teaching health literacy and healthy behaviours 219. The Schools for Health in Europe Network (SHE) is actively expanding, and orientation is being held on the approach in several countries of central and eastern Europe. A working group has been constituted to review the SHE materials. Core materials, such as the SHE manual and assessment tools and a guide on water, sanitation and hygiene in schools, were updated to support European countries in using the health promoting school approaches, which help children acquire health literacy, life skills and address risk taking behaviours, mental health and well-being. 220. A new WHO collaborating centre for global health and education, which is also a United Nations Educational, Scientific and Cultural Organization Chair in Global Health and Education, has been designated at the University of Clermont Auvergne in France. Health Behaviour in School-aged Children 221. The Health Behaviour in School-aged Children (HBSC) network is a WHO collaborative network of countries within the European Region, now active in 48 countries. It conducts surveys every four years. A survey was undertaken in 2017–18. The Regional Office provided support for Armenia, Georgia and Romania. Orientations were carried out for Bosnia and Herzegovina and for Montenegro, that are in a good condition to join the network. 222. Plans for papers have been developed and data analyses drawn up with the intention of publishing the results early in 2020. 223. A joint HBSC/SHE working group was established in order to link HBSC data on health behaviours in school children with the problems identified in the context of the SHE Network, which developed and piloted ways of using the data through school approaches with pupils, parents and teachers. This approach was tested in three countries: Croatia, North Macedonia and Scotland (United Kingdom). Stepping up leadership on gender-responsive health policy 224. GPW 13 requests WHO to step up leadership for gender equality and human rights. In 2016 and 2018 respectively, European Member States adopted two strategies developed by EUR/RC69/5 page 43 the Regional Office that make this commitment concrete and operational – the Strategy on Women’ Health and Well-being in the WHO European Region (2016) and the Strategy on the Health and Well-being of Men in the WHO European Region (2018). 225. Each strategy was supported by an evidence review, collected in a report, and substantial consultations with Member States, local government, experts and partners. A description of the process by which the Strategy on Women’s Health and Well-being in the WHO European Region was developed can be found in Leaving no one behind: report of the Regional Director on the work of WHO in the European Region in 2016–2017 (EUR/RC68/5 Rev.1, paras. 65–71). 226. Strategy on the Health and Well-being of Men in the WHO European Region, adopted in 2018 by the 68th session of the Regional Committee, was the first-ever WHO strategy on men’s health, and was described by delegates as ground-breaking. The Strategy contributes to the further development of a modern understanding of the impact of gender norms, roles and stereotypes on health, and the potential of gender-responsive health policy to overcome barriers and accelerate progress. 227. In the Regional Committee’s resolution on the Strategy on the Health and Well-being of Men in the WHO European Region (EUR/RC68/R4), the Regional Director was requested to undertake implementation, monitoring and progress reporting in combination with the Strategy on Women’ Health and Well-being, thereby linking the two strategies into a comprehensive framework for action on gender and health in the European Region. 228. Priority implementation areas include: making health systems gender-responsive and rights-based (focusing on PHC services, NCD prevention and control, violence against women, long-term care); strengthening gender-transformative health promotion (in particular addressing NCD risk factors and mental health), strengthening policies and practices that address the health impact of gender inequalities and discrimination (violence against women, human trafficking, sexual and reproductive health rights); supporting initiatives contributing to increased policy coherence between gender equality policy and health policy on national and subnational levels. Sharpening the focus on men’s health 229. The Regional Office’s report The health and well-being of men in the WHO European Region: better health through a gender approach (2018) provides background to the Strategy on the Health and Well-being of Men in the WHO European Region and was launched in September 2018 at the 68th session of the Regional Committee. 230. One of the triggers for the increasing attention paid to men’s health in the Region has been the high level of premature mortality among men, particularly in the eastern part of the Region. Although levels of premature mortality are slowly improving in all countries, variations remain high. The adverse mortality among working age men has a profound demographic, economic and political impact on the Region. 231. The evidence from the report shows that men’s health in the Region is largely affected by NCDs, injuries and mental problems. Men’s uptake of health services differs from women’s. Types of healthy behaviour favoured by men differ from those of women. EUR/RC69/5 page 44 232. The report has allowed the Region to sharpen its focus on the health and well-being of men, in offering not only more detailed information about the causes of premature mortality and ill-health for men, but also deeper understanding of how the gender dimension plays into patterns of health behaviour. 233. The Strategy seeks to improve the health and well-being of men through gender- sensitive approaches. Its objectives are to reduce premature mortality among men from NCDs and unintentional and intentional injuries; reduce inequalities in physical and mental health and well-being between men of all ages across the Region and within countries; and improve gender equality by engaging men in self-care, fatherhood, unpaid care, violence prevention, and sexual and reproductive health. Bold action required for healthy ageing in the Region 234. The population of the European Region is ageing rapidly: by 2050, 27% of the population of the Region is expected to be 65 years and older. The Region is therefore facing health issues commonly affecting older people such as multiple chronic conditions, mental and cognitive disorders, injuries and violence. In addition, ageist stereotypes are still widespread. To tackle these challenges, a vast majority of countries in the Region have been mainstreaming healthy ageing in their national policies and strategies. Moreover, during 2018–2019, ageing-related topics have continued to be mainstreamed in a broad range of programmes, strategies and action plans at the Regional Office. Examples are a report entitled “Health of older refugees and migrants” (2018), the Strategy on the Health and Well-being of Men in the WHO European Region, and integrated, person-centred health and long-term care for older people. 235. In December 2018, international experts, government officials, representatives of professional associations and observers from 27 countries came together in Almaty, Kazakhstan, for a three-day workshop on integrated delivery of health and social services for older people entitled “Leapfrogging the integration of long-term care for older people in the WHO European Region: getting it right, fast”. 236. The meeting was organized jointly by the WHO Centre for Primary Health Care, the programme for healthy aging, disability and long-term care and the programme for gender and health. It was the first of its kind, bringing together streams of work on health services delivery, healthy ageing and gender. The meeting reviewed trends in long-term care reforms in Europe, discussed preliminary results of country assessments and shared innovative country practices. 237. In February 2019, national policy experts on healthy ageing from more than 30 countries of the Region, at the meeting in Moscow, Russian Federation, called for bold action to promote healthy ageing and invest in a future where all older people have the freedom to live an active and healthy life that allows them to continue doing what they value. 238. Strengthening health systems by making them more person-centred and less fragmented is key to responding to the need of older people. Recognizing that healthy ageing cannot be achieved without the involvement of all sectors, especially health and welfare authorities working together to ensure that nobody is left behind, participants discussed an integrated care approach and agreed on priority action areas. EUR/RC69/5 page 45 239. The Russian Association of Healthy Cities, Districts and Villages, a member of the WHO European Healthy Cities Network, highlighted successful practices from Russian cities whose residents enjoy active ageing through lifelong learning, travel, volunteering, work opportunities, and physical activity. The movement of age-friendly cities and communities that the Regional Office supports continues to grow. Members of the Healthy Ageing Task Force of the European Healthy Cities Network met in May and October 2018. 240. Healthy ageing will be high on the global health agenda over the next 10 years, with plans to launch a Decade of Healthy Ageing from 2020 to 2030. The Regional Office continues to be involved in the developments of some of the global tools needed to support its implementation, such as on integrated long-term care systems and health workforce issues for ageing populations. A comprehensive report on progress with implementing the Strategy and action plan for healthy ageing in Europe, 2012–2020 is under preparation, and will be based on a policy survey of Member States that will be held in September 2019. Promoting sexual and reproductive health and rights 241. In 2016, the Regional Committee adopted the Action Plan for Sexual and Reproductive Health: towards achieving the 2030 Agenda for Sustainable Development in Europe – leaving no one behind (2016). 242. In August 2018, the Regional Office, in close collaboration with the Public Health Agency of Sweden and the United Nations Population Fund Eastern Europe and Central Asia Regional Office conducted a Regional meeting attended by 25 Member States on progress and challenges in implementation of the Action Plan, and its implications to achieving UHC were discussed with policy-makers and experts from Member States. Technical support needed from the Regional Office and partners were identified. 243. The regional meeting resulted in Member States’ expressions of interest in and requests for support in the evaluation of existing strategies and development of new ones, demonstrating Member States’ commitment to accelerating implementation of the Action Plan. France, Georgia and the Republic of Moldova developed and approved new strategies in 2017–2018. Azerbaijan, Kyrgyzstan, North Macedonia, Spain, Tajikistan, Turkmenistan, and a number of other countries are in the process of preparation of new sexual and reproductive health strategies and action plans. As a result, reviews of existing national sexual and reproductive health and public health policies and programmes to identify their linkages with global and regional strategies on sexual and reproductive health and rights were conducted in several countries. Strengthening integration of sexual and reproductive health and rights in UHC 244. Integrating sexual and reproductive health and rights into UHC is essential to fulfilling the goals of the 2030 Agenda. Achieving this requires both political commitment and well- defined and coherent policies. EUR/RC69/5 page 46 245. The Regional Office conducted country assessments of policies on sexual and reproductive health coverage within the context of UHC, health systems enablers, and barriers to the provision of services for women and adolescents in six eastern European and central Asian countries (Albania, Azerbaijan, Kazakhstan, Kyrgyzstan, Republic of Moldova, and Romania). The country case studies developed as a result of these assessments describe: • UHC policies and service packages on sexual and reproductive health; • how service provision can ensure access by adolescents and women to sexual and reproductive health services, including sensitive services such as safe abortion; • policies on comprehensive sexuality education; • financial protection of essential services for addressing the health of adolescents and women; and • how UHC policies pay attention to gender and sexual and reproductive health inequalities in terms of their design. 246. These country case studies will help Member States to strengthen their policies and health systems responses in order to achieve progressive realization of universal access to quality sexual and reproductive health and rights. The assessment tool and methodology can be used systematically in countries across the European Region to assess progressive realization of sexual and reproductive health rights in the context of UHC and health systems response to sexual and reproductive health needs for all. Promoting comprehensive sexuality education policies to improve enabling environments for sexual and reproductive health literacy 247. Comprehensive sexuality education supports children and young people in their sexual and general development. Implementation of comprehensive sexuality education policies is enhanced by strengthening capacities to deliver it. 248. In response to Member States’ requests for more guidance in this area, the Regional Office and the Federal Centre for Health Education (BZgA), Germany (a WHO Collaborating Centre for Sexual and Reproductive Health) developed Training matters: A framework for core competencies of sexuality educators (2017) and a training programme. A core group of sexuality educators from selected countries of eastern Europe and central Asia was responsible for designing policies and conducting training of sexuality educators. The training programme and framework for core competencies will enable countries to adapt the training programme to their national contexts. Helping countries to address stillbirths, maternal and newborn deaths 249. Although good progress has been made in improving maternal and child health in the Region, understanding the number and causes of stillbirths and neonatal deaths is key to finding ways of preventing future perinatal losses. 250. Perinatal death audit combined with remedial action at national and facility levels is a WHO methodology that has been shown to be an effective tool for identifying and addressing potentially modifiable factors that contribute to the death of a newborn baby or a stillbirth, improving professional practice and improving health outcomes. EUR/RC69/5 page 47 251. In December 2018, the Regional Office’s sexual and reproductive health programme invested in a 3-day workshop, titled Regional Expert Capacity Building for Implementation of Perinatal Death Reviews, which brought together 21 experts from Georgia, Italy, Kazakhstan, Latvia, North Macedonia, Republic of Moldova, Russian Federation, Ukraine and Uzbekistan and, along with representatives from WHO collaborating centres and UNICEF, in order to develop core capacity in the Region and drive implementation of this methodology in European countries. 252. Beyond the Number (BTN) methodology implementation to end preventable maternal deaths has been reviewed and plan of action for sustainability of the BTN has been developed in high burden maternal mortality countries in the Region. Addressing “epidemic” of unnecessary caesarean sections 253. The use of caesarean sections (C-sections) to deliver babies has increased dramatically over the past 20 years, reaching proportions that have been described as “epidemic”: at an international conference in December 2018, presentations from countries across the Region revealed C-section rates ranging from 7% to 51%. Although vital when complications occur during pregnancy and birth, once C-section rates are above 10-15% there is no evidence to suggest that the procedure helps reduce maternal and newborn mortality. Mothers were not always aware of the potential risks associated with C-sections for mothers and infants. 254. With a view to addressing this worrying trend, the Regional Office brought together representatives of Member States, policy-makers, health systems specialists, and maternal and perinatal health experts from 20 countries at an international conference in Tbilisi, Georgia, to agree on how unnecessary C-sections can be reduced in the Region. The recently launched WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections formed the basis for discussions. 255. The Regional Office provides context-specific support to countries to identify and analyse groups of women which contributed most and least to C-section rates, to compare practices and quality of care between facilities, address financial incentives and other health system factors, conduct implementation research to expand evidence for interventions, to help formulate an action plan and recommendations, and assess the effectiveness of interventions targeted at optimizing caesarean section rates. WHO Health in Prisons Programme – a setting for health promotion 256. It is estimated that six million people are incarcerated every year in the Region. Prison may provide an opportunity to deliver preventive interventions and treatments to people who previously have had limited or no access to health care and healthy living. However, the prevalence of diseases is much higher among prisoners than in the general population. 257. Incarceration represents a regrettable yet critical public health opportunity for improving access to health services for people with significant health needs, who may face substantial barriers to accessing health care in the community, and to identify and commence treatment for unmet health needs. Given the number of people who experience imprisonment each year globally, improving the health of people who experience incarceration is important to global health, to public health, and to reducing health inequalities. EUR/RC69/5 page 48 258. In 2018, the Regional Office’s Health in Prisons Programme (HIPP) launched publicly online the Health in Prisons European Database, which provides valuable, comparable data for policy-makers, practitioners and academics on the state of prison health in the European Region that can help Member States identify areas where preventive and treatment efforts are needed. The database was produced with financial assistance from the Ministry of Social Affairs and Health of Finland. 259. At the Sixth Prison Health Conference held in Helsinki, Finland, in March 2019, the Regional Office launched a report titled Health in prisons: fact sheets for 38 European countries, which summarizes select indicators corresponding to the eight domains of the Health in Prisons European Database to provide a snapshot of prison health systems and services across the Region. The data will provide a basis for the development of evidence- informed policies regarding prison health systems and services in Europe, including their relationship with broader policies relating to health inequalities and UHC. 260. HIPP has been a pioneer in generating evidence and experience for consideration of possible expansion beyond the European Region. In 2018, the HIPP was invited to represent WHO at the United Nations Office on Drugs and Crime’s 27th session of the Commission on Crime Prevention and Criminal Justice, presenting in two side meetings on issues related to prison health, and to collaborate in the United Nations Global Study on Children Deprived of Liberty, to be presented at the United Nations General Assembly in 2019, introducing health as a cross-cutting theme. Combating NCDs and their risk factors 261. Of the six WHO regions, the European Region is the most affected by NCDs, and their growth is startling. The impact of the major NCDs (diabetes, cardiovascular diseases, cancer, chronic respiratory diseases and mental disorders) is equally alarming: taken together, these five conditions account for an estimated 86% of the deaths and 77% of the disease burden in the Region. High-level conference on NCDs 262. The first European high-level conference on NCDs was held in Ashgabat, Turkmenistan, in December 2013. It led to the adoption of the Ashgabat Declaration on the Prevention and Control of Noncommunicable Diseases in the Context of Health 2020, later adopted by the Regional Committee at its 64th session. The Declaration was a landmark for the Region. 263. In April 2019, the 53 Member States of the European Region were invited again to Ashgabat, to the WHO European High-level Conference on Noncommunicable Diseases. Participants at the Conference walked the talk, engaging in two-minute active breaks during plenary sessions with simple aerobic stretching exercises led by a professional fitness trainer. Lunches and snacks included a wide variety of fresh, healthy options low in sugar, salt and fat. The approach contributed to energizing participants throughout the entire event. 264. The European Region has long been leading the fight against NCDs – and is currently on track to achieve SDG target 3.4: “By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being”. EUR/RC69/5 page 49 However, more progress is needed in areas such as tobacco use, harmful use of alcohol, obesity, unhealthy diets, physical inactivity, hypertension and diabetes – and new bold measures to bring the best buys to scale are necessary. 265. Although the European Region is a champion in addressing the NCD agenda globally, achieving the SDGs by 2030 remains a challenge. With only 11 years left to reach the SDGs, it is time to review progress made and decide on the next steps. To reach the target on NCDs (SDG 3.4) of reducing premature mortality by one third, countries need to scale up implementation of the best buys, capitalizing on and implementing the political commitments from the third United Nations High-level Meeting on NCDs. In April 2019, the WHO European High-level Conference on NCDs in Ashgabat discussed implementation of global and regional commitments at the country level, across sectors, with multiple stakeholders and in different settings. 266. The Region has been successful in sustaining a 1.5% annual reduction in premature mortality from cardiovascular diseases, cancer, diabetes and chronic respiratory diseases. However, although success rates in reducing the burden of NCDs in the Region have given rise to cautious optimism, progress is uneven both among and within countries and across risk groups. To achieve SDG 3.4, we must close the divide in NCD mortality and morbidity rates between eastern and western European countries. While high-income, western European countries are consistently reducing deaths, several countries of central and eastern Europe – though showing great improvement – are lagging at least 20 years behind. The key social and economic determinants of NCDs in these countries will require more specific assessment and intervention if the underlying causes are to be modified. Tobacco control: a powerful lever for improving public health 267. On 27 June 2018, the conditions were met for the entry into force of the first legally binding instrument adopted under the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products, paving the way to eliminate the illicit trade of tobacco products. 268. With ratification by the United Kingdom of Great Britain and Northern Ireland, the Protocol to Eliminate Illicit Trade in Tobacco Products (the Protocol) reached the number of Parties necessary for its entry into force. This is a milestone in the history of tobacco control, as the Protocol contains a full range of measures to combat the illicit trade in tobacco products, under three categories: preventing the illicit trade, promoting law enforcement and providing the legal basis for international cooperation. 269. As mentioned above, in November 2018, the Interparliamentary Assembly of Member Nations of the Commonwealth of Independent States agreed, at its 48th Plenary Session, to support the ratification of the WHO Protocol to Eliminate the Illicit Trade in Tobacco Products by national parliaments. 270. A number of individuals and organizations from the European Region were recognized in the World No Tobacco Day Awards, which focused in 2018 on tobacco and heart disease and in 2019 on tobacco and lung health. 271. In May 2018, new tobacco control legislation came into effect in Georgia. The new law is the result of several years of behind-the-scenes support from national and international EUR/RC69/5 page 50 partners, including WHO. WHO contributed to the adoption and implementation of the new law with some practical support such as: • technical assistance for development of sub-legislative normative acts regarding health warnings, standardized packaging, protection of state tobacco control policy from interference by the tobacco industry and others; • development of a consolidated state action plan; • development and realization of a communication campaign; • a study visit to Romania by Georgian enforcement agencies; • preparation of a guide for implementation of smoke-free regulations; • training of trainers of the Ministry of Internal Affairs and other stakeholders and enforcement agencies, and development of training modules for police officers; • coordination of multisectoral activities. 272. As part of the overall support, WHO in close collaboration with the WHO FCTC Secretariat and the United Nations Development Programme, completed an investment case for tobacco control in Georgia. This was the first such investment case to be conducted globally. The results of the analysis were handed over to the national authorities on 27 February 2017. 273. Efforts in the fight against tobacco in the Region were given a further boost in 2018 by Kyrgyzstan’s decision to declare the 3rd World Nomad Games, which it was hosting, a smoke-free event for the first time. WHO provided technical assistance and financial support for the smoke-free activities of the Games in accordance with the biennial collaborative agreement for 2018–2019 between the Ministry of Health of Kyrgyzstan and WHO. This included technical advice and assistance to the Ministry of Health on developing the smoke- free concept and an action plan, as well as the provision of training for Games secretariat staff, volunteers, medical workers and police officers on the smoking ban, the reasons behind it, and on informing participants and visitors about the ban. WHO also contributed through mass gathering simulation exercises and emergency preparedness drills, which helped the national authorities to strengthen health security and to increase national capacity in order to minimize health risks during the Games. 274. A court ruling in the Netherlands banned smoking areas in restaurants, bars and cafes, which had been allowed as an exception since 2008. The court ruled that this exception for smoking rooms is contrary to the WHO FCTC, which the Netherlands has ratified. Evidence is clear that smoke-free environments result in a healthier workforce and a healthier and wealthier clientele, both of which strengthen the future for the hospitality and catering industry. 275. A new tobacco control law was signed by the President of Tajikistan in January 2018. The new law applies to all tobacco products, including cigarettes and cigars as well as hookahs, smokeless cigarettes and electronic cigarettes. 276. Azerbaijan’s Parliament adopted a new tobacco control law that the President subsequently signed. This marks an important step forward in protecting the entire population – especially children and young people – from tobacco and tobacco-smoke exposure. EUR/RC69/5 page 51 277. Turkey took a major step in tobacco control by passing an amendment to adopt plain packaging for all tobacco products in December 2018. WHO provided technical assistance to the Health, Family, Labour and Social Affairs Commission of the Turkish Parliament and the Ministry of Health in drafting the amendment in line with guidelines under the WHO FCTC. 278. A series of natural experiment studies, conducted by the Regional Office and presented in a supplement of the European Journal of Public Health, are among the first to use new, more robust techniques to evaluate the impacts of national policy and public health interventions on the prevention and control of NCDs. The studies were developed with research teams nominated by ministries of health – using pragmatic approaches to natural experiment studies, they evaluated public health interventions to prevent chronic diseases. This exercise aims to help build capacity and culture for better and more influential public health evidence. 279. A new report from the WHO Regional Office for Europe, European tobacco use – trends report 2019, offers confirmation that tobacco use remains a public health issue of the utmost importance. This is particularly true in the European Region, which has the highest proportion of tobacco use in the world, with an estimated 209 million people (or 29%) smoking. The report emphasizes the need for Member States to intensify preventive action, from health interventions, to marketing, to fiscal policy and stronger regulation. Countries should consider embedding tobacco control in the sustainable development agenda and approaching it from a human rights perspective. This can help open doors to new partners and expand the tobacco control community beyond ministries of health and public health organizations. 280. Smokeless tobacco products are a complex and widespread challenge to public health but have so far received limited attention globally. In the European Region, two populations have a longstanding tradition of smokeless tobacco use – people in Scandinavian countries, particularly Sweden, where snus is traditionally consumed, and those in central Asian countries such as Kyrgyzstan and Uzbekistan, where nasvay is the most widely used form of smokeless tobacco. Thanks to funding from the Russian Federation and Turkmenistan, the Regional Office published a report on the consumption and approaches to the regulation of nasvay in the Commonwealth of Independent States (2018), which considers the latest smokeless tobacco prevalence data and details the available policy responses. Alcohol: reducing attributable mortality and promoting policy solutions 281. The European Region has the highest levels of alcohol consumption in the world, with 10.1% of all deaths and 10.8% of all disability-adjusted life years (DALYs) lost in the Region being attributable to alcohol consumption. However, the level of awareness of the links between alcohol consumption and particular diseases remains low, such as increased risk of cancer. WHO used the World Cancer Day in February 2018 to emphasize that alcohol is a Group 1 carcinogen and to highlight the positive linear relationship between alcohol intake and increased risk of cancer, calling for the implementation of effective measures to reduce the overall use of alcohol. 282. This initiative was followed by a training course focusing on the role of alcohol in NCDs and road traffic injuries, hosted in Moscow, on 12–15 March 2018. The 4-day course brought together 44 participants from Eurasian Economic Union countries and other newly independent states (NIS) and aimed to support Member States in improving national action EUR/RC69/5 page 52 and collaborative work to promote the co-benefits of legislative, enforcement and social marketing practices in the prevention of NCDs and drink driving. 283. In September 2018, the Regional Office launched a report on adolescent alcohol-related behaviours, looking at trends on alcohol consumption between 2002 and 2014. The report reveals that alcohol use has declined among adolescents in Europe. However, despite the reductions, levels of consumption remain dangerously high and this continues to be a major public health concern. Almost 30% of 15-year-olds still reported that they started consuming alcohol at age 13 years or younger. 284. At the end of 2018, under the MOPAC project (monitoring of national policies related to alcohol consumption and harm reduction), a successful WHO/EC initiative leading to comparable data and harmonized indicators regarding consumption, harm and policies, WHO held two important meetings with Member States and launched several publications. The first meeting, held in October 2018, aimed at supporting 11 Member States in their efforts to enhance alcohol surveillance and improve the national processes for estimating alcohol consumption and the burden of alcohol-attributable diseases. 285. The second meeting was held in Edinburgh, United Kingdom, on 19 November 2018, where WHO presented the findings from the project, which indicate that the harm caused by alcohol is still significant, and that reducing it will require increased efforts. 286. During the event, the Regional Office launched a fact sheet on alcohol-related mortality and policy responses in all EU Member States, Norway and Switzerland, and factsheets on alcohol consumption, harm and policy responses for 30 European countries. 287. The country fact sheets present data on consumption, harm and policy implementation for 2016 in each of the 30 countries, aiming to give guidance to national decision-makers for further priority-setting in the field of alcohol and public health. The fact sheets also present, for the first time, an individual overview of the composite indicator scores of the 10 areas of action to reduce the harmful use of alcohol. 288. In January 2019, the Regional Office convened a consultation process involving both Member States and civil society in order to revisit the implementation of the policy areas for action defined in the European Action Plan to Reduce the Harmful Use of Alcohol 2012–2020, discuss achievements as well as the obstacles and the way forward. Emphasis was put on the implementation of WHO’s “best buys”, where the data clearly shows room for improvement. Pricing policies were the worst performing policy area in terms of implementation. 289. During 2018, the Regional Office provided support to several Member States in strengthening their alcohol polices, being involved in several country-based publications such as an evidence brief for policy on alcohol for the Republic of Moldova, or the NCD case for investment publication for Uzbekistan. 290. Alcohol intake in the European Region is the highest in the world. In 2016, the Region had the highest proportion of all deaths (10.1% of all deaths) and DALYs (10.8% of all DALYs) caused by alcohol consumption. During a meeting in Moscow, Russian Federation, in October 2018, WHO presented instruments to support Member States in their efforts to enhance alcohol surveillance and improve the national processes for estimating alcohol consumption and the burden of alcohol-attributable disease. These instruments included a new EUR/RC69/5 page 53 fast-track process for annual monitoring of alcohol use in the Region and new software designed to make the estimates of alcohol-attributable mortality and morbidity more accurate. The software tool presented at the meeting, the International Model of Alcohol Harms and Policies, is an open-access tool designed to be used by international alcohol research teams for alcohol harm estimation and policy scenario modelling. 291. A new alcohol policy initiative, SAFER, presented during the meeting, focuses on the five key areas of the Global strategy to reduce the harmful use of alcohol: • restricting availability; • enhancing drink driving counter measures; • screening and brief interventions; • comprehensive marketing and advertising policies; • increasing prices on alcoholic beverages. 292. Examples of good practice in alcohol policy implementation include: work by Scotland (United Kingdom) in implementing minimum unit pricing, which came into force in May 2018 and won Scotland the newly established award for “outstanding contribution to reducing NCDs”; and Estonia, where new regulations regarding availability, price and marketing of alcohol (published in the September 2018 issue of Public Health Panorama) earned Estonia the “European Award for Reducing Alcohol Harm” during the 8th European Alcohol Policy Conference. Nutrition: progress and challenges 293. In 2018, a study by the Regional Office in collaboration with a team from the University of Leeds, United Kingdom, reviewed national dietary surveys from the 53 Member States of the Region and assessed nutrient intakes in children and adolescents against those recommended by WHO. The study revealed a lack of data for child and adolescent nutrient intake, with data reporting inconsistent and age groupings and the number and type of nutrients reported varying across countries; many countries did not report by sex in the youngest age groups. 294. The study identified that the majority of reporting gaps were in central and eastern European countries, and that there was significant under-reporting, meaning that nutrition- related issues could be underestimated across all countries. 295. Given the importance of easily accessed, robust data to tailoring policies to meet national needs and improve diets across the Region, national nutrition and health surveys remain the best source of information on dietary risk factors. In many cases, the Regional Office’s efforts to support countries in achieving the SDGs are constrained by a lack of data. WHO encouraged national dietary survey implementation to obtain relevant data to inform policies addressing all forms of malnutrition, which remained a pressing issue throughout the Region. 296. Better food and nutrition in Europe – Progress report (2018) presents selected epidemiological data on the nutritional status of populations throughout the Region and on implementation of policies recommended in regional and global frameworks to promote healthy nutrition and prevent obesity. Implementation of key policies has improved EUR/RC69/5 page 54 significantly in recent years, with substantial progress made in areas such as school food, food product reformulation, fiscal approaches and surveillance of childhood obesity. 297. Areas in which implementation is lagging and which therefore require more attention include front-of-package labelling and comprehensive marketing restrictions. Other areas in which work might be reinvigorated or extended include support for breastfeeding and good complementary feeding practices. The report identifies some differences among countries in the breadth and depth of policies. Reformulation is a good example: some countries have taken a minimal approach and others a more ambitious one. More ambitious approaches in food and nutrition policy might be required in the years to come if we are to achieve the SDGs and related targets, agreed upon by governments throughout the European Region. 298. Another project to assess the response of health care delivery systems in 19 countries in the Region to the childhood obesity epidemic collected primary data by administering a questionnaire to relevant stakeholders and experts through the WHO Childhood Obesity Surveillance Initiative network, which was complemented by a literature review and semi- structured interviews in selected countries. The project, published as Mapping the health system response to childhood obesity in the WHO European Region. An overview and country perspectives (2019), found that, overall, a health system response to childhood obesity was lacking. Nevertheless, several practices and examples were reported that may inspire other countries. 299. In order to assist countries in their efforts to reduce salt intake, the Regional Office published a policy brief entitled “Using dietary intake modelling to achieve population salt reduction – A guide to developing a country-specific salt reduction model” (2018), which provides guidance for countries on how to identify the specific sources of sodium in diets and how to calculate their relative contribution to overall sodium intake. Based on this, a theoretical “salt reduction model” can be developed in countries that can help determine the level of reduction needed in the sodium content of food product categories that are the main contributors to salt intake, including discretionary salt, in order to achieve a significant reduction in population salt intake. Breastfeeding: a window of opportunity for obesity prevention 300. A WHO study entitled “Association between characteristics at birth, breastfeeding and obesity, in 22 countries” (2019) found that despite the consistent flow of research evidence showing the health benefits from breastfeeding, along with numerous policy initiatives aimed at promoting optimal breastfeeding practices, adoption of exclusive breastfeeding in the European Region remains below the global recommended level. 301. The study showed that, in nearly all the countries examined, more than 77% of children were breastfed; but there were a few exceptions – in Ireland 46% of children were never breastfed, in France 38% and in Malta 35%. Only four out of 12 countries had a prevalence of exclusive breastfeeding (for six months or more) of 25% or higher: Tajikistan (73%), Turkmenistan (57%), Kazakhstan (51%) and Georgia (35%). 302. To turn this tide, the Regional Office hosted a conference in Moscow, Russian Federation, in November that brought together representatives of 18 countries from the Region. The conference presented a wide array of policy measures to support breastfeeding that can be tailored to the specific country or subregion’s needs, and recognized that although EUR/RC69/5 page 55 breastfeeding support starts with governments, ensuring growth in breastfeeding rates requires a multisectoral, whole-of-society approach to create supportive environments. This includes informing women of the health benefits of breastfeeding, providing them with advice and support at the initial stages, and making sure they can breastfeed at work – and everywhere else. Global comparative analysis suggests that larger percentages of women practise exclusive breastfeeding in countries where laws guarantee breastfeeding breaks at work. Additionally, WHO policy underscores the need to restrict the use and advertisement of infant formulas. Research shows that cutting down on marketing of formula contributes to more mothers choosing to breastfeed. 303. The promotion of breastfeeding presents a window of opportunity for obesity prevention, as the longer a child is breastfed, the greater their protection from obesity. The study “Prevalence of severe obesity among primary school children in 21 European countries” (2019) found that severe obesity affected almost 400 000 of the roughly 13.7 million children aged 6–9 years living in the 21 participating countries. Severe obesity in children is associated with immediate and long-term cardiovascular, metabolic and other negative health outcomes. Given its impact on education, health, social care and the economy, the new report emphasizes that obesity needs to be addressed via a range of approaches, from prevention to early diagnosis and treatment. Restricting digital marketing of unhealthy products to children 304. The WHO European Office for the Prevention and Control of Noncommunicable Diseases organized an expert meeting on monitoring of digital marketing of unhealthy products to children and adolescents in June 2018 and, based on that meeting, published a report, Monitoring and restricting digital marketing of unhealthy products to children and adolescents (2019). 305. While children’s time spent online, including on social media, has steadily grown, meaning that their exposure to digital marketing has also increased, and the advertising industry continues to target children and adolescents on social media and difficult-to-track mobile devices, data on the digital lives of children are scarce. 306. The report aimed to provide a tool to support Member States in monitoring digital marketing of unhealthy products to children, with the idea of establishing a panel-based methodology that can be implemented in a standard way across Member States to benchmark and highlight issues to regulators and policy-makers. The resulting tool – the so-called CLICK monitoring framework – is flexible and can be adapted to national context. 307. The CLICK tool would assess the extent of children’s exposure to digital marketing on a regular basis; findings from such a tool could help sensitize national governments to the harm of digital marketing of unhealthy foods and catalyse action to protect children not just from advertisements for unhealthy foods, but also from those for tobacco and alcohol. The tool focuses on the following five key components. • C – Comprehend the digital ecosystem: map the global, regional and national digital marketing ecosystem and children’s website and digital application usage, and supplement this with focus groups to gauge the thoughts, experiences and awareness of children (and parents/guardians) about marketing techniques and campaigns. EUR/RC69/5 page 56 • L – Landscape of campaigns: assess campaigns of leading national brands by collecting information from advertising agencies and by sampling whole-country social media for relevant content to ascertain what is viewed by different age groups. • I – Investigate exposure: map exposure to a selection of paid digital marketing among a panel of children in each age bracket using an installed smartphone application that (with consent) monitors and aggregates data on children’s interaction with advertisements in some websites and social media. • C – Capture on-screen: use real-time screen-capture software on a subgroup of devices to assess what a representative sample of children actually sees online on their devices to better understand wider marketing techniques, including user- generated content and product placement. • K – Knowledge sharing: create user-friendly materials from the research data and develop partnerships with young people, parents, policy-makers and members of civil society who together can advocate for change, raise awareness and influence policy. 308. The report also describes current digital marketing strategies, the challenges arising from current practices, and some policy options to tackle digital marketing to children and adolescents. Front-of-pack nutrition labelling: what works for consumers 309. Poor diet is the leading cause of mortality and morbidity across the European Region, including contributing to obesity, type 2 diabetes mellitus, cardiovascular disease and some types of cancer. Nutrition labelling – when it is readily noticeable, understandable and compelling – has the potential to stimulate consumers to make informed healthier food choices and to drive reformulation of products, as manufacturers seek to avoid disclosure of unfavourable nutrient content. 310. Nutrition labels that are presented on the front of food packages and that use interpretational aides, such as interpretative words, colours and symbols, are more likely to be used and understood by consumers. Consequently, the WHO European Food and Nutrition Action Plan 2015–2020 identifies the introduction of interpretative, consumer-friendly labelling on the front of packages as a priority policy issue. 311. Surveys undertaken by the Regional Office show that the majority of countries in the Region have some form of front-of-pack labelling, although fewer countries have interpretive systems which provide judgements about the relative healthfulness of foods. 312. A new Health Evidence Network (HEN) report, which summarizes information on the development and implementation of interpretive front-of-pack nutrition labelling policies across the Region, was commissioned and developed jointly by the Division of Noncommunicable Diseases and Promoting Health through the Life-course, including its geographically dispersed office (GDO) based in Moscow, Russian Federation, and the Division of Information, Evidence, Research and Innovation. 313. Fifteen countries in the Region were identified as having a government-endorsed policy on interpretive front-of-pack nutrition labelling; in 13 of these countries, endorsement logos EUR/RC69/5 page 57 had been adopted. These logos serve to signpost better-for-you choices, but provide no direct information to indicate if a product contains too much of a nutrient or ingredient that should be limited in the diet, for instance saturated fat, salt or free sugars. 314. Governments in France, Israel and the United Kingdom had endorsed front-of-pack nutrition labelling policies that provided directive information about high nutrient content (i.e. a negative evaluation relating to high fat, salt or sugar content). 315. The HEN report also identified common steps involved in policy development, including establishing front-of-pack labelling as an important nutrition policy pillar, engaging stakeholders and the public, and collecting formative evidence on which to base the labelling system. In all but one country, front-of-pack labelling policies have been implemented under voluntary arrangements, with variable penetration of the labels into the marketplace. 316. However, existing policies across the Region vary in the extent that they: • apply only to products that achieve a set standard/threshold or that apply across all products; • provide information on individual nutrients or summary information on products overall; • provide evaluative judgements about product healthfulness or information about relative or absolute unhealthfulness of products. 317. Based on the evidence synthesized in the report, a number of considerations were identified for the adoption or review of front-of-pack nutrition labelling policies at the national or regional levels, to ensure that policies achieve their aim. These included: • applying a single front-of-pack nutrition labelling system to aid consumer use and understanding of the label; • utilizing a system of interpretive front-of-pack nutrition labelling that allows for negative evaluative judgements about high nutritional content (i.e. an indicator of high fat, salt or sugar content); • opting for government-led policy development rather than a commercially based system, as consumers perceive the latter as less credible; • conducting stakeholder engagement and formative research to ensure that the right policy is chosen for the population; • exploring ways to overcome issues with implementation through guidance documents, public education and, possibly, mandatory implementation; • creating a formal and comprehensive policy monitoring and evaluation programme. Physical activity: progress stalling 318. Three years after European Member States committed to implementing the Physical Activity Strategy for the WHO European Region 2016–2025, a progress report submitted to the 68th session of the Regional Committee revealed that levels of physical activity are stagnant. EUR/RC69/5 page 58 319. One of the nine global targets outlined in the report is a 10% relative reduction in the prevalence of insufficient physical activity by 2025. However, the report describes a worrying reality in which levels of physical activity across the Region are stalling, particularly among children, adolescents and vulnerable populations. 320. Engaging in at least 150 minutes of moderate-intensity aerobic physical activity each week lowers the chances of developing NCDs such as cardiovascular diseases, cancers, diabetes and obesity, and decreases the risk of premature mortality. 321. If Member States are to meet the global target on physical inactivity and contribute to the achievement of other NCD-related targets by improving physical activity levels among the population, it will be important to address persistent inequalities and promote cross-sectoral work. 322. While some progress has been made, Member States can do more to aid individuals in achieving good health, regardless of sex, race or socioeconomic background. The five priority areas for improvement are: focusing on children and adolescents; promoting physical activity in the workplace and through the health care system; providing leadership and coordination for the promotion of physical activity; engaging the older population; and supporting action through surveillance, evaluation and research. 323. A how-to guide on planning healthy and sustainable meetings recommended offering participants appropriate opportunities to be physically active by incorporating physical activity in meeting agendas, organizing meetings that are in a moving format, and allowing enough time during lunch breaks for people to be physically active and refocus the mind. 324. In February 2019, a team from WHO joined local experts in North Macedonia on a fact- finding visit to assess current activities, barriers and opportunities related to the promotion of physical activity across the life course. There is widespread support for these efforts at the highest levels of government, including endorsement from the Prime Minister’s Special Adviser for Sport. 325. The team met with a range of government representatives and conducted school visits to witness demonstrations of physical education classes and inspect school recreational facilities to assess available infrastructure to support physical activity. The WHO team and local experts agreed that a lack of quality physical education, access to school recreational facilities and opportunities for extracurricular physical activities outside school hours are significant problems that need to be addressed urgently now that high-level political commitment has provided momentum. 326. The visit concluded with the country’s first multisectoral stakeholder meeting specifically addressing physical activity, which brought together representatives of the sport, education, health, university and labour sectors, as well as local municipalities. The event yielded consensus on the following lines of action: establishing a national coordinating mechanism; strengthening surveillance and monitoring; developing physical activity programmes to target all age groups and populations; and increasing opportunities for physical activity for schoolchildren. WHO will continue to support North Macedonia in its ongoing efforts to ensure that all members of the population can be active in their daily lives. EUR/RC69/5 page 59 Reducing violence and injuries: a safer and fairer Europe for all 327. To reduce the burden of violence and unintentional injury the Regional Office advocates the use of a public health approach. This requires evidence-based action and multisectoral cooperation. 328. Child maltreatment is a major public health problem, affecting at least 55 million children in the European Region. The impact of abuse and/or neglect in childhood is detrimental to physical, psychological and reproductive health throughout the life course, yet the high costs to society are avoidable. There are clear risk factors for maltreatment at the level of the individual, family, community and society. 329. The European status report on preventing child maltreatment (2018) documents the progress that has been made by Member States in implementing the European Child Maltreatment Prevention Action Plan 2015–2020 at its midpoint. The plan has a target of a 20% reduction in child maltreatment and homicides by 2020. Data were collected through a survey of government-appointed national data coordinators of 49 participating countries in the Region. Results show that good progress is being made overall towards achieving the objectives. 330. Development of national policy for the prevention of child maltreatment has increased across the Region, with three quarters of countries reporting an action plan, but these must be informed by robust national data. Surveillance of child maltreatment remains inadequate in many countries, with information systems in low- and middle-income countries most in need of strengthening. Legislation to prevent maltreatment is widespread, but better enforcement is warranted. The implementation of child maltreatment prevention programmes, including home-visiting, parenting education, school and hospital-based initiatives, has accelerated, but evaluation of impact is needed. Child maltreatment is a societal issue that crosses sectoral boundaries, meaning a sustained, systematic, multidisciplinary and evidence-informed approach to prevention must remain a priority for governments. Plan to stop violence against children in Ukraine 331. Ukraine is one of the countries in the European Region committed to the prevention of violence against children. A survey of adverse childhood experiences in Ukraine among a representative sample of the student population showed high prevalence of child maltreatment (emotional neglect was experienced by 28%, physical neglect by 25%, physical abuse by 12%, emotional abuse by 10% and sexual abuse by 5%), household dysfunctions, and peer and community violence. Adverse childhood experiences were associated with increased odds of health-risk behaviours, especially suicide attempt, early smoking initiation, alcohol abuse, drug use and risky sexual behaviour. 332. To support the country in the development of a national action plan to stop violence against children, WHO held a policy dialogue on 6–7 February 2019 in Kyiv, Ukraine; the policy dialogue brought together over 40 participants. 333. On reviewing the results of Ukraine’s national situation analysis on violence against children, participants held high-level discussions on the development of a national action plan based on the WHO technical package INSPIRE (seven strategies for ending violence against children), which is an evidence-based tool that supports countries in their efforts to prevent EUR/RC69/5 page 60 and address violence against children aged 0–17 years and identifies strategies that have shown success in reducing violence against children. 334. Following the policy dialogue, an expert working group was convened to further discuss the implementation of INSPIRE. The experts identified the following actions that can be implemented in the Ukrainian context: finalize the Ukraine National Situation Analysis to assess gaps and opportunities for the prevention of violence against children; develop a policy document to identify and map out programmes and resources needed to implement INSPIRE; and develop a national action plan to strengthen intersectoral actions in the prevention of violence against children. Road safety 335. Road safety is a priority in the 2030 Agenda for Sustainable Development. The progress we are able to make hinges on decision-makers’ political will to act: stronger leadership for road safety is needed to save lives. 336. The European Region marked the Fifth United Nations Global Road Safety Week on 6–12 May 2019 with a focus on leadership and the theme “speak up”. Road crashes are the leading killer of people aged 5–29 years and are responsible for over 84 000 deaths in the European Region every year. Thirty per cent of road crash deaths involve pedestrians and cyclists, who are among the most vulnerable road users. 337. In order to raise awareness about the preventable deaths each year on the Region’s roads, WHO country offices and NGOs across the Region organized events and engaged with high-level policy-makers, NGOs, police forces, churches, emergency services and civil society to commemorate the lives lost or irreversibly impacted by road trauma on World Day of Remembrance for Road Traffic Victims. 338. Throughout the Region, victims were remembered and honoured. In Slovenia, people at a candle-lit mass in Ljubljana Cathedral reflected on loss and grief. In Malta, citizens took part in a remembrance walk while carrying candles and images of loved ones lost to road tragedies. In Croatia, people lit candles by roads where crashes had happened and in windows across the country in memory of victims. In Turkey, a gallery exhibition with the pictures and names of victims highlighted their individuality. This visual story put faces to the numbers in order to convey the magnitude of road traffic injury, which is often difficult to conceptualize. 339. In events organized by NGOs, Varna Pot (Safe Road) in Slovenia pushed for Vision Zero – a road traffic safety project that aims to achieve a highway system with no fatalities or serious injuries – during an event at City Hall in Ljubljana. In Georgia, participants in vigils organized by the Georgian Alliance for Safe Roads held banners with messages such as “Roads have history”, “Remember me” and “Slow down” to engage the general public. 340. Awareness also spread beyond the grass roots level. In the Russian Federation, spokespeople shared information about deaths and injuries, notified people of prevention tactics, and made promises of change, on the streets as well as on the radio via the station “Komsomolskaya Pravda”. In Turkey, various national film, television and sports celebrities lent their star power to advocate for safety on national roads. In Kazakhstan, Kyrgyzstan and Malta, press conferences ensured that information about road safety and preventive measures EUR/RC69/5 page 61 were disseminated far and wide. These events were intended to prompt authorities across the Region to prioritize road safety in national agendas. 341. Many events placed a particular emphasis on engaging youth. In Malta, passionate youth advocates personally impacted by road trauma urged youth to step up and step forward for road safety. In the Republic of Moldova, schools, NGOs, the General Inspectorate of Police, the National Road Patrol Inspectorate and the Ministry of Health, Labour and Social Protection participated in a flash mob to stimulate interest and discussion about road safety. 342. Road crashes are not accidents, which are random, unpredictable and unpreventable events; they have risk factors, predictors and determinants such as speed, alcohol, and non-use of helmets, seatbelts and child restraints. Improvements in legislation, road infrastructure, vehicles and enforcement can reduce the amount of trauma experienced on our Region’s roads. Disability and rehabilitation: addressing gaps to leave no one behind 343. In the 21st century, the world faces a new challenge: rapid population ageing accompanied by a rise in chronic conditions and multimorbidities. People live longer and with disabling chronic conditions that impact their functioning and well-being. Rebuilding health systems is essential to create an effective workforce, accessible services, and sustainable means to provide ongoing rehabilitation. Rehabilitation has long been recognized as an integral part of UHC and a key strategy to achieve and maintain population health – along with prevention, promotion, treatment and palliative care. Rehabilitation is key to the achievement of all three of WHO's ambitious targets: one billion more people with UHC; one billion more people better protected from health emergencies; and one billion more lives made healthier. As such, the availability of accessible and affordable rehabilitation plays a fundamental role in achieving SDG 3 and many other SDGs with a view to leaving no one behind. 344. In 2018, to scale up access to rehabilitation services (including assistive products), the Regional Office has initiated a new programme to improve rehabilitation systems in Europe relevant to the whole population, across the lifespan and across the continuum of care in order to leave no one behind. The programme promotes rehabilitation standards within the Region, facilitates coordination and promote synergies across rehabilitation programmes in the Region and supports Member States to develop or strengthen policies, plans and country models related to rehabilitation. 345. In 2019, the programme initiated technical support in Georgia and Ukraine to improve the availability, accessibility, affordability and quality of rehabilitation services, needed to help people overcome difficulties in their everyday lives. The technical support included intensive country missions to meet with key stakeholders, identify existing gaps, and opportunities for coordinated action. 346. In addition, WHO continued to support Tajikistan with new approaches to rehabilitation and a reformed system for providing services and assistive devices established for patient groups such as those with injuries, impairments or disabilities due to NCDs. In addition, WHO provided technical support to Tajikistan in development of its first country priority assistive product list. The list includes 30 priority assistive products that are essential for the well-being of people with disabilities, older people and people with NCDs, among others. EUR/RC69/5 page 62 347. At regional level WHO has also reformed its webpage on disability and rehabilitation to ensure access for Member States to WHO resources on rehabilitation. Progress on implementation of the European Mental Health Action Plan 2013-2020 348. Political attention and commitment to mental health as a public health and development priority continue to rise, as demonstrated by the declaration arising from the third high-level meeting of the United Nations General Assembly in September 2018 on the prevention and control of NCDs, in which mental health conditions are formally recognized as the “fifth” NCD for prioritized action. Such recognition provides new opportunities for a more holistic, collaborative and person-centred approach to preventing and treating mental and physical health conditions, including co-morbidities. 349. In line with further declarations arising from the WHO conference on PHC held in Astana, Kazakhstan, and the first global ministerial mental health summit in London, United Kingdom, the Regional Office has been targeting its efforts on the integration of mental health into PHC as well as the promotion and protection of human rights for people affected by mental health conditions and psychosocial disabilities. For example, German BMG funds have enabled further implementation of the European Mental Health Action Plan 2013–2020 by building up new national capacity in Ukraine and all five central Asian countries in the identification and management of mental health conditions in non-specialized care settings using the mhGAP intervention guide. 350. Regarding mental health and human rights, advanced workshops have been held in response to requests by Czechia, Croatia, Latvia and Serbia for training of mental health care professionals working within long-term psychiatric institutions in strategies to improve quality and reduce seclusion and constraint, as part of the WHO QualityRights initiative to enhance care standards and human rights protection. 351. The Regional Office has supported the governments of Czechia, Malta, Montenegro and Ukraine in the development or revision of mental health, suicide and dementia policies, and is working with Belarus, the Russian Federation and other countries on scaled-up efforts to prevent self-harm and suicide, especially among younger people. Progress towards the implementation of the European Mental Health Action Plan 2013–2020 has been documented by the publication of a Region-specific mental health atlas report. 352. The High-level Conference on Noncommunicable Diseases held in Ashgabat, Turkmenistan, in April 2019 (see above), asked ‘What are the optimal strategies for mainstreaming mental health within the NCD agenda?’ A publication titled Time to Deliver: meeting NCD targets to achieve Sustainable Development Goals in Europe. Integrating The Prevention, Treatment And Care of Mental Health Conditions and Other Noncommunicable Diseases Within Health Systems presents some answers. Cancer screening 353. The Regional Office organized sessions on cardiovascular disease and cancer management at the WHO European High-level Conference on Noncommunicable Diseases (April 2019). EUR/RC69/5 page 63 354. In 2018–2019 important efforts were undertaken to rationalize and improve screening in Member States, notably in the NIS. The Regional Office: • assisted a WHO collaborating centre in shaping the agenda of an NIS scientific conference on cancer screening (Minsk, Belarus, May 2018); • organized, in collaboration with the International Agency for Research on Cancer (IARC), a large intercountry meeting on cancer screening (Lyon, France, January 2019) to raise awareness about harms of screening and the need for strong quality assurance; • organized a technical consultation on screening for NCDs through the life course (Copenhagen, Denmark, February 2019) to review screening practice in the European Region. 355. The Regional Office provided tailored support in the field of cancer control to more than 13 countries in 2018–2019 with a focus on early diagnosis and screening (Armenia, Bulgaria, Georgia, Kyrgyzstan, Malta, Montenegro, North Macedonia, Romania, Turkmenistan, Ukraine, Uzbekistan), palliative care (Armenia, North Macedonia, Russian Federation, Ukraine), cancer registration (Armenia, Kyrgyzstan, Malta, North Macedonia, Russian Federation, Tajikistan, Ukraine, Uzbekistan) and national cancer control planning (Armenia, Kyrgyzstan, North Macedonia, Ukraine). 356. Support was provided in close collaboration with WHO headquarters, IARC, the International Atomic Energy Agency and/or United Nations Population Fund as well as WHO collaborating centres according to country needs. Specific support has been provided to Uzbekistan as part of the United Nations Joint Global Programme on Cervical Cancer Prevention and Control. 357. An advanced intercountry course on cancer registration was held in January 2019 in the Republic of Moldova to help countries to better analyse cancer registry data. 5. Strengthening people-centred health systems and public health capacity 358. Helping countries in the Region to strengthen public health capacity and develop people-centred health systems that are universal, equitable and sustainable has been a cornerstone of the Regional Office’s work to achieve Health 2020 and the SDGs. This section outlines the work done by the Regional Office in 2018-2019 to ensure that the Region’s health systems are optimally designed to reduce health inequities and improve population health outcomes. Progress towards UHC Can people afford to pay for health care? 359. The Division for Health Systems and Public Health is responsible for implementing a work programme on moving towards UHC for a Europe free of impoverishing out-of-pocket payments – one of the two priorities for health systems strengthening for the European Region from 2015 to 2020. Monitoring financial protection in the European Region gained additional EUR/RC69/5 page 64 significance following the adoption of the SDGs in 2015, which included SDG target 3.8: achieve UHC. This flagship project aims to strengthen the evidence base on moving towards UHC at global, regional and country levels by assessing the impact of out-of-pocket payments for health on household living standards and poverty. 360. To ensure relevance to all Member States in the European Region, the Regional Office has developed a new method of measuring financial protection to complement global monitoring of SDG indicator 3.8.2, which concerns the proportion of a country’s population with large household expenditure on health as a share of household total consumption or income (catastrophic spending on heath). The new method is more suited to high- and middle- income countries and is better able than other methods to capture financial hardship among poor households, which in turn provides actionable evidence for more effective pro-poor policies. 361. In 2018, the Regional Office published 10 country reports on financial protection and presented a summary of the regional report at the 68th Session of the Regional Committee. Several country reports (Austria, Croatia, Estonia, Kyrgyzstan, Latvia and Lithuania) were launched at national conferences with high-level participation from government and other health system stakeholders. 362. In 2019, the regional report, Can people afford to pay for health care? New evidence on financial protection in Europe, was launched on World Health Day. The report covers 25 countries (Albania, Austria, Czechia, Croatia, Cyprus, Estonia, France, Georgia, Germany, Greece, Hungary, Ireland, Kyrgyzstan, Latvia, Lithuania, the Netherlands, Poland, Portugal, the Republic of Moldova, Slovakia, Slovenia, Sweden, Turkey, Ukraine and the United Kingdom) and finds that: • Out-of-pocket payments have the greatest impact on those least able to pay for health care: the poorest households, people with chronic illnesses and older people. • A significant share of households are impoverished after having to pay out of pocket, even in Europe’s richest countries; as a result, these households cannot afford to pay for basic needs – food, rent, utility bills. • The incidence of impoverishing or catastrophic health spending is heavily concentrated among poor households; across countries, it increases as the out-of- pocket share of total spending on health increases. • Medicines are a major source of financial hardship in many countries, especially among poorer households. 363. Many middle- and high-income countries in the European Region still rely heavily on people paying out of pocket for health care. In 2015, out-of-pocket payments accounted for 26% of total spending on health on average, with substantial variation (5–72%) across countries. WHO recommends that countries aim to keep out-of-pocket payments below 15% of total spending on health. 364. Investing in health systems is a prerequisite for reducing out-of-pocket payments, but improving coverage policy is equally important. Although the Region has a wealth of good practice, many countries can do more to reduce financial hardship and prevent people from having to choose between health care and other basic needs – for example, by carefully EUR/RC69/5 page 65 redesigning user charges to minimize co-payments (especially for medicines) and ensuring additional protection for poor people and regular users of health care. Health financing 365. The Regional Office has supported a large number of countries to design and implement comprehensive health financing policy for UHC including through the WHO Barcelona Office for Health Systems Strengthening, Spain. 366. Health financing technical assistance in these areas focused on a number of areas including: (1) supporting Member States to optimize the revenue mix for health care, allocate stable and sustainable levels of financing, and establish transparent and explicit priority-setting mechanisms balancing equity and efficiency considerations; (2) advising on the design of pooling of fund flows maximizing the potential for redistribution for equity purposes and for triggering efficiency gains; (3) strengthening national capacity for strategic purchasing to enable countries to make better use of limited resources and move towards UHC; (4) strengthening public finance management practices for efficient use of resources; and (5) advising on good governance structures and practices in health financing. Examples include: • In Azerbaijan, WHO has reviewed the proposed plans of the government to roll out mandatory health insurance, and is advising the MOH on how best align service delivery reforms for maximum impact with a focus on primary care and public health. • In Georgia, WHO has worked closely with the Ministry of Health and the purchasing agency to support the development of a national strategy for active purchasing; assess the purchasing agency’s organizational needs; and supporting it to transform the way in which hospitals are paid, which will enhance transparency, efficiency and quality of care. • In Kyrgyzstan, WHO has provided technical assistance to strengthening the governance of the purchasing agency and its operating practices such as planning, monitoring, and use of evidence in making purchasing decisions. • In Ukraine, WHO provided technical assistance to the establishment of the National Health Service of Ukraine – a national single purchaser agency funded from general tax revenues, to the development of the benefit package, and the introduction of new contractual mechanisms with providers. • In Uzbekistan, WHO supported the Ministry of Health to develop a health financing strategy for the introduction of mandatory health insurance and a feasibility study for its revenue mix. Currently, discussions are underway regarding the governance of the mandatory health insurance fund. Health Systems Respond to NCDs: celebrate, share, inspire 367. Strengthening health systems for more effective prevention, early detection and management of NCDs is central to the implementation of Health 2020, the European policy framework for health and well-being; it underpins the attainment of the United Nations SDGs; and is closely linked to moving towards UHC. 368. A high-level regional meeting, Health Systems Respond to NCDs: Experience in the European Region, hosted by the Regional Office on April 16–18, 2018 in Sitges, Spain, was EUR/RC69/5 page 66 attended by 250 participants representing 40 Member States, WHO headquarters and other WHO regional offices as well as partner organizations like the OECD and the World Bank. 369. The event celebrated progress on NCD outcomes and health systems strengthening in the European Region; provided a platform to share lessons learned on implementing a comprehensive health system response to NCDs, and inspired action across Member States for health systems strengthening and the scaling up of core NCD interventions and services by taking an in-depth look at good practice. The meeting was dynamic and participatory, with interactive plenary sessions, policy labs, walk-through poster sessions and opportunities for dialogue and engagement. 370. As health systems performance assessment varies across the Region, a HEN synthesis report titled Health system performance assessment in the WHO European Region: which domains and indicators have been used by Member States for its measurement? (2018) summarizes health system performance assessment domains and indicators used by Member States in their HSPA or health system-related reports. The number of indicators reported per Member State ranged from 9 to 146, with a mean of 50. Further refinement of frameworks, both in clarity of scope and function and in the conceptual robustness of domains, is warranted, and further standardization of generic sets of indicators should be sought. 371. The regional report Health systems respond to NCDs: Time for ambition presents an evidence-informed vision for a comprehensive and coherent health systems response to NCDs. The report summarizes the nine cornerstones of a strong health system response to NCDs. It is aimed at national and subnational policy-makers and implementers, including health ministries, public health departments/centres, health care purchasing agencies, regional and local community administrations, NGOs and academic institutions influencing policy. Accordingly, the report is policy and solution oriented. Each chapter highlights 4–5 key policy messages and ends with a summary table of potential policy responses. The report draws on: (i) country assessments; (ii) good practice briefs; (iii) published literature; and (iv) author experiences. Its messages were validated in two author meetings: one in Copenhagen, Denmark hosted by WHO and the second in Madrid, Spain, co-hosted by WHO and the Ministry of Health, Social Services and Equality of Spain. 372. A Compendium of 22 good practices from Europe accompanies the regional report. These good practice briefs highlight health system policies and practices that have overcome health system barriers to scale up core NCD interventions and services and contributed to improved outcomes. They typically reflect large-scale (national or regional) implementation of a policy instrument rather than isolated pilots or projects. Each brief provides evidence on the impact of the instrument and highlights lessons for countries planning to implement similar efforts. 373. Following the regional activities in 2019, the focus of the Regional Office has shifted to implementing these policy recommendations and good experiences at country level. Key lessons have been mainstreamed into the ongoing work of the Regional Office with Member States. Some examples include technical assistance to Member States on strengthening governance for intersectoral public health action, moving towards multi-profile PHC, better aligning incentives across levels of care, transforming health workforce generation and deployment, and stepping up digital solutions. EUR/RC69/5 page 67 Health Systems for Prosperity and Solidarity: leaving no one behind 374. The WHO European Ministerial Conference on Health Systems, Health Systems for Prosperity and Solidarity: Leaving No One Behind, held in Tallinn, Estonia, in June 2018, was a milestone in strengthening health systems in the Region. Ministers and senior representatives from all Member States came together with partners, members of civil society and experts to discuss the increasing evidence that investing in health systems contributes to improvements in population health, economic wealth and, in turn, societal well-being. The result of their deliberations was the Tallinn Charter: Health Systems for Health and Wealth. The Charter sets out seven commitments that continue to drive our efforts to strengthen health systems throughout the Region. In emphasizing the values of solidarity, equity and participation as the first commitment, the Charter reflected Member States’ joint pledge to a values-driven agenda for health systems. This commitment to act on shared values has been a consistent thread in the work of Member States and the Regional Office ever since. In 2015, in consultation with all Member States, the final report on the Tallinn Charter was published, documenting the myriad impacts and influences it has had, and continues to have, across the Region. 375. But in the 10 years since the Tallinn Charter was signed, the European environment is very different. The political sphere is increasingly polarized, the economic climate uncertain (including in relation to health and social budgets), NCDs are the leading cause of death, disease and disability in the Region, and there are massively changing demographic patterns around ageing and the movement of people. Health systems are at the forefront of responding to these challenges, which puts pressure on the values we espouse. It is against this backdrop that the high-level meeting Health Systems for Prosperity and Solidarity: leaving no one behind was convened on 13-14 June 2018, marking the 10-year anniversary of the Tallinn Charter. 376. The meeting had two purposes. First, it represented a celebration of the health systems strengthening achievements in the Region over the previous 10 years, reflecting the legacy of the Tallinn Charter. Second, it provided an occasion both to restate the arguments for stronger health systems for better health and wealth – in the light of further evidence – and to leverage and build on present opportunities that reflect the values and commitments that lie at the heart of the Charter, urging their protection in the future. In this regard, the meeting’s title was chosen to reflect a forward-looking view and was oriented around three key themes referred to as the ‘3 Is’. These are: • Include: improving coverage, access and financial protection for everyone; • Invest: making the case for investing in health systems; and • Innovate: harnessing innovations and systems to meet people’s needs. 377. The ‘3 Is’ are key to driving forward not just the Regional Office’s health systems strengthening work, but so too that of its Member States. And the commitment to work together in this direction was reflected in the outcome statement of the meeting, signed on behalf of all participants. 378. The meeting was attended by more than 240 participants from 41 countries in the Region including: ministers of health; senior policy-makers; health policy, system and change management experts; and many partners. It attracted widespread attention on social media, with over 1000 tweets and an audience of approximately 50 000 on the Regional Office’s Facebook EUR/RC69/5 page 68 page. Live web streaming related to the event also accumulated nearly 10 000 views across social media channels. Global Conference on Primary Health Care 379. Primary health care plays a vital role in bringing health services closer to people’s homes and communities, thereby improving access. In October 2018, 1200 delegates from more than 120 countries around the world gathered in Astana, Kazakhstan, for the Global Conference on Primary Health Care. Together they adopted the Declaration of Astana, vowing to strengthen their PHC systems as an essential step towards UHC. 380. PHC is a whole-of-society approach to health that aims to ensure the highest possible level of health and well-being and equitable distribution through action on three levels: meeting people’s health needs through comprehensive and integrated health services throughout the life course, prioritizing primary care and essential public health functions; systematically addressing the broader determinants of health through evidence-informed policies and actions across all sectors; and empowering individuals, families and communities to optimize their health as advocates for policies that promote and protect health and well- being, as co-developers of health and social services, and as self-carers and caregivers. 381. PHC increases efficiency by improving access to preventive and promotive services, early diagnosis and treatment and by ensuring people-centred care that focuses on the needs of the whole person and reduces avoidable hospital admissions and readmissions. PHC also indirectly achieves wider macroeconomic benefits through its capacity to improve population health in low- and middle-income countries as well as high-income countries. Health and well-being related SDG targets rely on the implementation of PHC through multisectoral policies and actions. 382. Currently, one of the major areas of focus of the global community is achieving UHC, and coverage with PHC is a necessary foundation of this effort. PHC plays a key role in reducing household expenditure on health by addressing the underlying determinants of health and by emphasizing population-level services that prevent illness and promote well-being. PHC is a cost-effective way of delivering services and the involvement of empowered people and communities as co-developers of services improves cultural sensitivity and increases patient satisfaction, and ultimately improves health outcomes. 383. In the coming years, WHO will support countries to implement the Declaration of Astana, which provides direction for the development of PHC as the basis of health care systems. This support will form part of WHO’s ongoing work to help countries move towards UHC, including efforts to better understand the causes of financial hardship and to make a strong case for investment in health systems. 384. The WHO European Centre for Primary Health Care in Almaty, Kazakhstan, supports Member States in reforming systems to deliver PHC. European Member States have made great progress in translating policies, plans and strategies in the European Region into action, beginning to pave the way for the development of comprehensive PHC towards achieving UHC. In 2018, the regional report, From Alma-Ata to Astana: Primary health care – reflecting on the past, transforming for the future, explored innovations across the health system in the Region. Country experiences are wide-reaching, and include innovations in organizational design and governance, devolved decision-making, enhancement of local EUR/RC69/5 page 69 accountability and management, and innovations in the financing of provider payment schemes, as well as improvements in performance and outcomes and reduction of inequalities in access. Good practices with regard to training and education, the roles and responsibilities of health workers and the use of technology, especially information solutions, are a testament to the strong evidence and knowledge that has accumulated in Europe. 385. In the Declaration of Astana,11 Member States called for a renewal of PHC, reaffirming their commitment to the fundamental right of every human being to the enjoyment of the highest attainable standard of health without distinction of any kind and to the values and principles of justice and solidarity, underlining the importance of health for peace, security and socioeconomic development. There is a recognition that elements of PHC need to be updated to respond adequately to ongoing and new health and health system challenges, as well as to take advantage of new resources and opportunities for success in the 21st century and to mobilize all stakeholders around national policies, strategies and plans across all sectors, and to take joint actions to build stronger and sustainable PHC towards achieving UHC. Renewing PHC is critical for three reasons: (a) the features of PHC allow the health system to adapt and respond to a complex and rapidly changing world; (b) with its emphasis on promotion and prevention, addressing determinants and a people-centred approach, PHC has proven to be a highly effective and efficient way to address the main causes of, and risk factors for, poor health, as well as for handling the emerging challenges that may threaten health in the future; and (c) universal health care and the health-related SDGs can only be sustainably achieved with a stronger emphasis on PHC. The global conference on PHC 386. WHO, UNICEF and the Government of Kazakhstan organized the Global Conference on PHC in Astana, October 2018 to reaffirm high-level commitment to the PHC approach in order to reach global targets for UHC and other health-related SDGs. 387. The sharing of best practices, discussions and the Declaration of Astana adopted by the Conference will all contribute to the debates at the high-level meeting of the General Assembly on UHC, due to be held in September 2019. It is expected that this Conference will generate the following outcomes: strengthened political commitment to PHC and UHC; appropriate financing and resource allocations to primary care and essential public health functions; appropriate health workforce development; increased investment in relevant research and health system innovation; increased appropriate use of technology; and improved assessment of progress on PHC as countries periodically review the implementation of the Declaration in cooperation with stakeholders. Transforming vision into action 388. The global commitment to PHC in the Declaration of Astana, when fully implemented, has the potential to bring about demonstrable change. The European Region is acting as the spearhead for the implementation by proposing a package of policy accelerators for countries to make a quantum leap towards implementation of the Declaration of Astana. These policy accelerators are based on evidence and lessons learned from those countries that are fully committed to PHC. 11 Declaration of Astana. Geneva: World Health Organization/United Nations Children’s Fund; 2018. EUR/RC69/5 page 70 Health services delivery programme (WHO European Centre for Primary Health Care, Almaty) 389. The Regional Office explored three avenues of integrated health services delivery: the integration of health and social sectors through country cases, the role of hospitals for person- and community-centred services in a global position paper, and the integration of public health services and primary care as a policy accelerator for UHC. 390. The Regional Office advanced measuring the performance of health services delivery with the development of the Primary Health Care Impact, Performance and Capacity Tool for monitoring in the Region, including modules on policy priorities like out-of-hours primary care. The Regional Office also reported on findings following a health services delivery data scan in the Region and developed platforms for storing and analysing data. 391. The Regional Office reviewed the governance of quality of care and quality of care mechanisms, cataloguing and mapping these in a framework from the perspective of health system stewards, supporting stewards to scan the use of mechanisms in their system, identify gaps and explore options for prioritizing action. 392. The Regional Office prioritized strengthening PHC by exploring UHC concepts from a services delivery perspective, reviewing and cataloguing PHC policy accelerators, developing a rapid assessment tool from a population health perspective, and unpacking the critical role of PHC in tackling AMR. 393. The Regional Office applied a health services delivery perspective to investigate the crossroads of services delivery and men’s health and well-being and NCDs, as well as the intersection of health services delivery and the health workforce – looking to the role of professional stakeholders in advancing team-based primary care. 394. The Regional Office conducted rapid PHC assessments to explore the feasibility of new PHC models in Albania and assess the current state of PHC in Kosovo,12 helping to inform priority-setting and policy development. 395. The Regional Office delivered quality of care technical assistance in a number of countries including Belarus, Kyrgyzstan, North Macedonia and Ukraine, where efforts centred on mapping the current quality of care and supporting priority-setting. In others, like Tajikistan, the Regional Office focused on supporting the rollout of quality improvement initiatives in primary care. 396. The Regional Office supported performance measurement in countries to identify opportunities to accelerate PHC strengthening, for example by conducting a comprehensive assessment of PHC in Albania and exploring the performance of PHC from the perspective of practitioners in Montenegro. 397. The Regional Office leveraged trainings and twinning for capacity building in Belarus to advance professional competencies in primary care to respond to NCDs; in Hungary to develop a pilot for the delivery of integrated, people-centred services for chronic obstructive pulmonary disease; and in Kazakhstan to support primary care nurses and doctors to explore and apply communication skills. 12 In accordance with United Nations Security Council Resolution 1244 (1999). EUR/RC69/5 page 71 398. The Regional Office supported integrated health services delivery policies and pilots in countries including Greece, Kazakhstan, Romania and Serbia, where efforts are underway to plan and implement pilot projects and demonstration sites, and in Poland and Uzbekistan where policy dialogues explored opportunities to invest in the primary care workforce and transform the model of care. 399. The Regional Office organized joint technical events in coordination with technical units of the Regional Office and a wide network of partners, bringing together country representatives, experts and civil society for consultations on topics including men’s health, AMR and integrated delivery of long-term care. 400. The Regional Office disseminated publications, newsletters and multimedia in English and Russian, including the release of full-length country reports, working documents, chapters and scientific articles; publication of a biannual newsletter; and the development of multimedia products such as informative videos on PHC and long-term care services as well as photo stories of services delivery in practice. 401. The Regional Office delivered training and capacity building through lectures, seminar schools, workshops and other courses. The Regional Office promoted more effective communication on PHC through media training of health professionals. The Regional Office also hosted students and sponsored Member States to attend trainings courses. Health system governance: transforming health systems 402. The Health Systems Governance programme has further developed the Health Systems Transformation Initiative, which looks into how Member States can implement large-scale health system transformation and what are the mechanisms to support the development of macro level reforms. 403. The Health Systems Transformation Initiative aims to: • identify lessons learned in the implementation of health system reforms at a macro level that could strengthen the existing evidence base; • provide insights from health system policy-makers on how to initiate reforms, accelerate/improve their implementation and overcome any barriers or inhibitors encountered. 404. A checklist for countries offering a structured approach to assess their readiness for change and implementation has been developed and it is currently being tested. A case study on Sweden, which is the first of a series looking at the key factors and drivers facilitating large-scale transformation in specific national contexts, is being finalized. 405. The Health Systems Governance programme also co-organized a joint WHO–OECD event on health systems transformation examining the role of digital health and technologies in strengthening national health systems and improving the delivery of high-quality health care. The event took place in June 2019 in Paris, France. EUR/RC69/5 page 72 Supporting efforts to build sustainable health workforces in the Region 406. Health workers play a critical role in health systems by ensuring sustainability, resilience and the delivery of high-quality services. An effective, well-motivated, appropriately skilled and well-managed health workforce sits at the very heart of service delivery. 407. During 2018–2019, the Human Resources for Health (HRH) programme at the Regional Office continued its work to support Member States in their efforts to move towards sustainable health workforces for people-centred health systems and improved health outcomes of populations. 408. In line with the Regional Framework for Action on sustainable health workforces, an emphasis was placed on topics such as health workforce planning, labour market analysis, HRH policies and their implementation, health workforce governance and HRH management. To support Member States across these areas, in 2018 HRH developed and published a toolkit for a sustainable health workforce in the Region. 409. In October 2018, the importance of data and information to support HRH policy-making was discussed with representatives of 16 Member States at a subregional meeting on HRH statistics held in Minsk, Belarus. Following this meeting, the HRH programme worked with the Health Workforce Department in Geneva, Switzerland, to finalize the Russian language translation of the National Health Workforce Accounts and related materials for publication. 410. In December 2018, using the domains of the Regional Framework for Action, HRH challenges for small countries were considered at an expert meeting of representatives of 12 Member States. The recognition that there was a need to assess in specific detail the HRH challenges and potential solutions that were relevant and applicable to small countries gave the impetus for the Regional Office, in collaboration with the WHO European Office for Investment for Health and Development, to organize the meeting. Following presentation of the meeting outcomes and further discussion of HRH challenges and solutions at the sixth High-Level Meeting of Small Countries in San Marino on 2 April 2019, an ad hoc expert working group is being established comprising expert representatives of Member States with population of less than 2 million and selected regions (subnational level) with characteristics similar to those of small countries. 411. Strengthening nursing and midwifery across the Region continues to be a priority for the Regional Office. In October 2018, the HRH programme organized the biannual meeting of government chief nursing officers, WHO collaborating centres on nursing and midwifery, and the European Forum of National Nursing and Midwifery Associations in Athens, Greece. The two-day meeting considered progress in implementation of the European Strategic Directions for Nursing and Midwifery Towards Health 2020 Goals as well as looking forward towards 2030 and the Agenda for Sustainable Development. 412. Nurses and midwives comprise a majority of health professionals in Europe and play a key role in the successful delivery of health and social care services. Throughout 2019, and as part of the joint 2019–2020 work plan, the Regional Office, in collaboration with the European Forum of National Nursing and Midwifery Associations, is showcasing the richness and diversity of nursing and midwifery leadership across the European Region on the Regional Office website and through social media. EUR/RC69/5 page 73 Innovations for better health outcomes Coalition of Partners for Strengthening Public Health Services in the European Region 413. Health 2020 draws attention to the need for improving leadership and participatory governance for health. The SDGs emphasize the importance of multi-stakeholder partnerships that mobilize and share knowledge, expertise, technology and financial resources, to support the achievement of the SDGs in all countries. 414. In this context, the Regional Office continued to invest in the establishment of the Coalition of Partners for Strengthening Public Health Services in the European Region. More than a coalition for action, the Coalition of Partners also strives to function as a whole-systems platform, a community of practice and an incubator for new initiatives. At its most recent meeting in Ljubljana, Slovenia, in November 2018, the Coalition of Partners brought together representatives of the multitude of different stakeholders and disciplines that constitute public health services, including colleagues serving in national and subnational public health services, policy-makers, as well as colleagues serving in a number of international organizations such as the World Federation of Public Health Associations, the European Public Health Association, the International Association of National Public Health Institutes, the Association of Schools of Public Health in the European Region (ASPHER), the European Public Health Alliance, EuroHealthNet, the Healthy Cities and RHNs, and others. 415. As with any coalition, an important goal is to provide a platform for these colleagues to plan joint actions, but it does not stop there. Recognizing that there are no easy answers, another important goal is to function as a community of practice, that is a group of colleagues who agree to convene periodically to learn from each other, explore ideas, and act as sounding boards for one another. The members of the Coalition of Partners collaborate to create shared tools, case studies and other resources. Beyond contributing to the work of the colleagues involved, the added value of the Coalition of Partners accrues in the personal satisfaction of knowing colleagues who understand each other’s perspectives, the sense of belonging to the European Coalition of Partners community and the personal relationships that are being developed within this community. 416. Two years into the process, substantial results are now emerging: • As a result of their involvement in the Coalition of Partners, colleagues in Kyrgyzstan have launched a participatory process to design a reform of their public health services, and mobilized a national coalition in support of the reform. Other countries such as Estonia, Hungary, Slovakia and Slovenia, are currently considering taking similar action. • Partners such as the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, the International Network of Health promoting Hospitals and the WHO Collaborating centre for Public Health Education and Training, convened with Member States to explore barriers to and enablers of the integration of primary care and public health services. • ASPHER and the WHO have led the development of a roadmap for professionalizing the public health workforce and the WHO/ASPHER Core Competencies for the Public Health Workforce in the European Region, which a EUR/RC69/5 page 74 number of countries have expressed an interest in working with at the country level. • The International Association of National Public Health Institutes and WHO have partnered to hold workshops on change management processes where Member States merge various institutions to form comprehensive national public health institutes to drive public health action. • Colleagues at the University of Neuchatel worked with colleagues in Georgia, Kyrgyzstan, Serbia and Switzerland to map the implementation of the IHR (2005) in legislation in these countries. • EuroHealthNet is leading the development of a compendium of case studies illustrating novel approaches to financing health promoting services. 417. The capacity for activating generative social fields among complex and often conflicting multi-stakeholder groups is at the core of all advanced leadership work today, and the Regional Office is proud to embark on this journey together with the other members of the Coalition of Partners. Broad range of courses on health systems 418. The WHO Barcelona Office, Spain, organizes annual training courses for policy- makers, government officials, health professionals in managerial positions and other stakeholders who influence policies and the performance of health systems in the European Region. The two editions of the WHO Barcelona course on health financing for UHC continued to attract up to three times more applications than there were places available. In 2019, the course was offered with Russian interpretation to facilitate access for participants from Russian-speaking countries of the European Region. The course is a great opportunity for health policy-makers in Europe to improve their knowledge on UHC, share experience and learn from good as well as less successful practices in countries. 419. The WHO Barcelona course on health systems strengthening for improved TB prevention and care was held in 2018 in collaboration with the Division of Communicable Diseases, Health Security and Environment. This training programme aims to support transformation of financing and delivery of TB services in the European Region. This was the third edition of the course supporting the implementation of the Tuberculosis Regional Eastern European and Central Asian Project (TB-REP), financed by the Global Fund. The digitalization of health systems 420. The inaugural WHO symposium on the future of digital health systems in the European Region, held in Copenhagen in February 2019, brought together more than 350 stakeholders working in digital health, health systems and public health communities. The event represented the second major deliverable of the Regional Office’s Digitalization of Health Systems initiative which was launched in June of 2018 at a meeting in Budapest, Hungary, made possible by support from the Hungarian Ministry of Human Capacities, Semmelweis University and the European Health Management Association. 421. During the symposium, Member States highlighted their activities through demonstrations, lessons learned, and insights gathered along their journeys in the digitalization of their health systems. Technical sessions included real world examples of EUR/RC69/5 page 75 strategies, systems, services, portals, tools and approaches, as well as the key “back end” elements that enable digital health–governance, roadmaps, policy, workforce training and retention and more. 422. The symposium provided an ideal forum for tough and honest discussions about the challenges Member States face in digital health, their approaches in addressing them, and their vision for the future of health systems in the European Region. 423. Technical sessions of the symposium were centred on the thematic areas of: • governance and leadership for the future of digital health • national success in digital health • working together to create health services of the future • next generation digital health systems. 424. Presenters repeatedly underscored the profound impact of digital health on revolutionizing national health systems operation and health service delivery. The extent and pace of the change being driven by this digitalization (taken to include, inter alia, digital health information and services, genomics, artificial intelligence and robotics) is challenging our understanding of how and where care can be delivered and is driving a transition to predictive and preventive models of health care. 425. Digitalization of health systems is not simply “continuing what we’re doing now, faster and more efficiently”, but is a comprehensive transformation that is: completely redefining our understanding of how health services can and should be delivered; addressing how the rights and consent of the individual can be respected and acted upon; and harnessing the value of data for health. 426. Digital health is centrally important to achieving UHC with more efficient and effective modes of providing quality and equitable access to health for all without the risk of financial ruin or impoverishment. However, innovating towards a future enabled by digital health requires concretely linking investments for digital health to the achievement of public health objectives. Without such an approach, Member States risk their investments in digital health driving an increase in inequity, creating divides where resources are not aligned to the greatest burden of disease, and where the most vulnerable do not benefit. Next steps 427. There was a clear call to the Regional Office to continue and enhance its leadership role in digital health. Member States strongly expressed their approval that a health systems approach was the most relevant and effective means of doing so. The need for public health thinking and practical guidance in digital health implementation was again reiterated. 428. There is an urgency and impetus to move forward and the Regional Office, together with its partners, was encouraged to lead through the development of the proposed European roadmap for accelerating the digitalization of health systems. This will guide Member States in developing and integrating solid and coherent digital health foundations and preparing for the adoption of emerging technologies in health. EUR/RC69/5 page 76 429. The immediate focus of future efforts under the Regional Office digitalization of health systems initiative will be to increase country support and presence in accelerating the safe adoption of digital health by Member States. By also engaging a strong network of digital health partners, the aim is to facilitate the transition by Member States to a future of health systems in the region where: • innovation creates a culture of health where everyone has the opportunity to make choices leading to a healthy lifestyle – contributing to the paradigm shift from reactive care to disease prevention guided by public health; • services are meaningfully integrated, affordable and universally accessible to the entire population – and individuals are empowered and informed to prevent avoidable causes of ill-health; and • investments in digital health are aligned to the achievement of key public health objectives. Examples of work with countries: Georgia and Uzbekistan 430. In addition to its work with groups of countries, the Regional Office also provided tailored assistance to individual countries, such as Georgia and Uzbekistan, on all the topics discussed above. Georgia 431. Behind the scenes support from WHO contributed to the entry into force, on 1 May 2018, of new tobacco control legislation in Georgia that requires enclosed public and workplaces to be smoke-free, and prohibits advertisement, promotion and sponsorship of tobacco products. The new legislation is considered one of the strongest tobacco control laws in the European Region. 432. This next generation tobacco control law includes implementation of the following key provisions in 2018, as well as entry into force of further provisions of the law which will gradually follow over the coming few years: • prohibition on smoking (including e-cigarettes and hookah) in all enclosed public places, enclosed workplaces and public vehicles; • ban on advertisement, sponsorship and promotion of tobacco products; • ban on tobacco point-of-sale and retail displays; • enforcement of health warnings covering 65% of smoking tobacco packaging and inclusion of an information leaflet with e-cigarettes; • protection of state tobacco control policy from interference by the tobacco industry and regulation of relations between the state and the industry; • classification of e-cigarettes with nicotine as a tobacco product; • ban on retail sales of tobacco products via the Internet, post and drive-in tobacco points. 433. The new law is the result of work over several years by national and international partners, including the Regional Office and the Secretariat of the WHO FCTC. An investment case for tobacco control in Georgia was the first such investment case to be conducted EUR/RC69/5 page 77 globally. In 2017, Georgia was selected for the WHO FCTC 2030 project, which aims to support Parties to the WHO FCTC that are eligible to receive official development assistance to achieve the SDGs by advancing implementation of the WHO FCTC. Georgia is the only Party from the European Region to have been selected. 434. As part of its biennial collaborative agreements with Georgia, the Regional Office has also contributed to implementation of the new law with practical support such as: • technical assistance for development of sublegislative normative acts regarding health warnings, standardized packaging, protection of state tobacco control policy from interference by the tobacco industry and others; • development of a consolidated state action plan; • development and realization of a communication campaign; • a study visit to Romania by Georgian enforcement agencies; • preparation of guide for implementation of smoke-free regulations; • training of trainers of the Ministry of Internal Affairs and other stakeholders and enforcement agencies, and development of training modules for policemen; • coordination of multisectoral activities. 435. On UHC, Georgia has been working since 2013 to improve health financing policy by extending population entitlement to publicly financed health care and gradually increasing public funding of the health system. The Social Services Agency (SSA) acts as a single purchasing agency for the health sector, an approach in line with European and global best practices. Evidence shows that these reforms have led to progress in meeting the goal of UHC in Georgia: they have increased access to health services and improved financial protection in areas targeted for expanded coverage. 436. The Regional Office has scaled up its support to Georgia and through the UHC Partnership, supported by the EU, the Grand Duchy of Luxembourg and WHO, is providing technical assistance to strengthen capacity for strategic purchasing. 437. Technical assistance provided in in 2018 aimed to further develop the capacity of the SSA, focusing on three key areas: preparing a strategy for strategic purchasing and providing support to strengthen the SSA’s capacity to implement it; supporting the implementation of diagnosis-related groups to enhance transparency in provider payment and supporting strategic purchasing; and designing best practice patient pathways for selected priority clinical areas and developing tools to support their implementation. 438. Increasing access to rehabilitation services and assistive devices is another area of work in which Georgia has received WHO technical support. Assistive devices, such as wheelchairs, hearing aids and glasses, are designed to assist people in carrying out day-to-day activities, while rehabilitation services are critical for improving the well-being of people with injuries, NCDs and disabilities, as well as the ageing population. 439. For Georgia as for other countries in the Region, strengthening rehabilitation within health systems is essential in light of the rapid population ageing it is facing. The Regional Office has initiated a four-year programme (2018–2022) to strengthen rehabilitation in the EUR/RC69/5 page 78 Region, and Georgia is one of the priority countries. The programme is supported by the United States Agency for International Development. 440. The Regional Office is assessing the current disability, rehabilitation and assistive technology landscape in Georgia to define how to best support the country in strengthening rehabilitation policy, systems and services as part of UHC. During a visit on 15 to 19 April 2019, Regional Office staff met with staff of ministries, United Nations agencies, development partners and with user groups to assess the current situation and define the scope of engagement. This will support Georgia in developing an overall policy framework on rehabilitation, and strengthening both rehabilitation services and access to assistive products through the country’s flagship programme on UHC. 441. In May 2019, as the first step in a series of activities aiming at strengthening PHC in rural areas, a joint visit was conducted to the Kartli region, which included visits to PHC services in three villages, including reviews of the premises and available equipment, interviews with health workers, managers and beneficiaries of health services on different aspects of PHC provision in rural areas. The visits concluded with a consultation with PHC professionals at Gori State Teaching University. 442. In February 2019, Georgia hosted the First Regional Consultation on Viral Hepatitis in the European Region in Tbilisi, which gathered 120 participants from 45 of the Region’s Member States and a wide range of stakeholders – partners, technical experts, civil society organizations and patient’s associations – to discuss all aspects of the response to viral hepatitis and exchange tools and experiences to address common challenges. 443. With support from the Regional Office and partners, Georgia has pioneered the response to hepatitis C and has become an example for other countries: in only a few years, its national hepatitis C elimination programme has managed to successfully treat more than one third of those living with hepatitis C by implementing large-scale testing – including for groups at risk – and providing universal access to treatment. 444. The consultation provided an opportunity for exchanging good practices in reducing the costs of medicines to treat hepatitis and in ensuring people-centred service delivery models, including for the most vulnerable. The Regional Office plans to release a compendium of good practices in order to make them widely available across the Region. Uzbekistan 445. With support from the WHO Country Office, the Ministry of Health of Uzbekistan organized an interagency round-table discussion dedicated to tobacco and heart disease, held on the eve of World No Tobacco Day. Participants engaged in political debates on issues related to the WHO FCTC and anti-tobacco policy enforcement in Uzbekistan, while the WHO Country Office presented international experience and effective tobacco control measures – known as MPOWER measures – implemented in other countries. 446. In line with the roadmap of actions to strengthen implementation of the WHO FCTC in the European Region 2015–2025, the Ministry of Health and the WHO Country Office presented a structure for a national roadmap for tobacco prevention and control in 2018–2019. The event resulted in the establishment of a multisectoral working group to move forward EUR/RC69/5 page 79 WHO FCTC implementation in Uzbekistan and work towards attaining national tobacco- related goals. Wide media coverage attracted interest and support from the population. 447. WHO is also providing technical assistance to support Uzbekistan in the development of a comprehensive health financing reform on which the country has embarked to ensure equal access to health care, financial protection and equitable distribution of resources. 448. During an official visit to Uzbekistan by the Regional Director on 18–21 November 2018, at a national high-level intersectoral conference, the country launched an ambitious long-term strategic plan seeking to advance comprehensive national health reforms and meet the health- related SDGs by 2030. Implementation of the reform was mapped out, focusing on PHC development, health financing, and strengthening governance for health and well-being at the intersectoral level. 449. In April 2019, a policy dialogue held in Tashkent and co-hosted by WHO brought together over 100 participants including high-level decision-makers from the Government, and representatives of NGOs and international partners. This provided a unique opportunity to ensure that Uzbekistan makes evidence-informed choices by learning from international experiences. International experts shared good practices on health financing reform and effective policy instruments to inspire action and help Uzbekistan overcome its current challenges in health financing, such as high out-of-pocket payments, access barriers, and quality and efficiency problems. 450. Two regions of Uzbekistan – Kashkadarya and Ferghana – have implemented an innovative package of interventions to prevent and control NCDs, with particular benefits for men at risk of cardiovascular disease, high blood pressure and type 2 diabetes, as men tend to seek health care less frequently than women. 451. In attempting to make the change from treating disease to preventing it, a key issue has been the insufficient identification and management of high-risk patients. Part of the solution to this problem was in place already: Uzbekistan’s nurses. 452. Using a systematic approach that included changes to the regulatory framework, the pilot regions were able to expand the independent role of nurses, leading to better task-sharing between doctors and nurses, reducing the burden on general practitioners. 453. In local communities, teams of doctors and nurses now use patient registers to identify target groups and invite them for a cardiovascular risk assessment. When patients arrive, nurses ask them about risk factors and measure height, weight and blood pressure before they see the general practitioner. Nurses also visit patients at home and use questionnaires to detect risk factors. When people fail to attend their assessments, health care workers conduct follow- ups. 454. The regions have also transformed clinics, making available cholesterol and other blood tests with rapidly accessible results. Specially designed software that makes it easier to track high-risk patients and evaluate results is being integrated into the information system for outpatient care services. Coordination teams visit the health clinics regularly to provide supportive supervision based on evaluations from both staff and patients. EUR/RC69/5 page 80 455. These changes in public health care were supported by a community health promotion project called Healthy Life. Led by local government, this project draws support from a wide variety of stakeholders, from youth leaders to government agencies, religious representatives to women’s committees. 456. After one year, the eight pilot facilities saw a nearly 80% uptake of cardiometabolic risk screening in people over 40 years of age. Levels of participation among men are high – up to 86%, which is nearly the same as the rate among women – and the data show an increase of approximately 50% in newly detected cases of arterial hypertension and type 2 diabetes. 457. Other results from the pilot project have included: • improved quality and effectiveness of patient counselling on NCD risk factors and healthy lifestyle; • increased completeness of clinical examinations by doctors; • increased use of public health care services by the male population for cardiovascular risk assessment; • higher patient satisfaction attributed to the feeling that clinicians are showing more interest in patient health; • increased task-sharing between doctors and nurses and promotion of team decision-making; and • increased confidence and empowerment among nurses regarding their expanded role. 458. It is hoped that the lessons learned in Uzbekistan from implementing this cocktail of measures in a coordinated way can inspire other countries. 6. Health information, evidence and research: the foundation for effective policy and action 459. The overarching framework for the work on health information, evidence, and research in the Regional Office is provided by the European Health Information Initiative (EHII), a network committed to improving the health of the people of the European Region by enhancing the information and evidence that underpin policy-making. 460. EHII Members include Member States, WHO collaborating centres, health information networks and associations such as the European Public Health Association, and charitable foundations such as the Wellcome Trust. The European Commission and the OECD are also active participants. The EHII has met 13 times, with the latest meeting taking place in Copenhagen, Denmark, in March 2019. One priority area of work for the EHII is the comparison and mapping of existing and emerging indicator frameworks for health reporting and enhancing access to and dissemination of health information. EUR/RC69/5 page 81 Action Plan to Strengthen the Use of Evidence, Information and Research for Policy-making in the WHO European Region 461. The Action Plan developed by the Regional Office is the only WHO action plan on this topic globally. Its long-term vision is to contribute to reducing health inequalities and improve the health status and well-being of individuals and populations within the Region. 462. Good progress has been achieved across all four action areas. • Strengthening national health information systems, harmonizing health indicators and establishing an integrated health information system for the European Region (Action Area 1). The JMF was adopted at RC68 as a means of reducing the burden of reporting on Member States through identifying a common set of available indicators across: Health 2020, the SDGs and the Global Action Plan for the Prevention and Control of NCDs 2013–2020. The EHII is now supporting the implementation of the JMF, the first round of data collection having taken place in 2019. Furthermore, the Regional Office has provided advice and assistance to Member States in establishing governance mechanisms for health information systems and e-health, and in developing, assessing and evaluating strategies and policies to support these. A total of 10 assessments have been conducted so far, applying the support tool to assess health information systems and develop and strengthen health information strategies. This support tool is currently being revised on the basis of advice from a subgroup of the EHII Steering Group, as well as the experience gained from national pilots and the joint health information system and e-health assessments. • Establishing and promoting national health research institutes and systems to support the setting of public health priorities (Action Area 2). During 2018–2019, the Regional Office has produced nine peer-reviewed HEN reports in collaboration with all divisions of the Regional Office. These reports provide detailed analyses and policy considerations for policy-makers on key public health issues, in the areas of migration and health, cultural contexts of health, vaccination, TB, social determinants of health, and evidence-informed policy- making. HEN synthesis reports are in general developed and published in English and Russian, increasing accessibility to multilingual technical and scientific evidence. • In response to the Action Plan’s call to advance health research systems in the Region, the European Health Research Network was fully established in 2018, with the aim of providing strategic direction and leadership in health research systems strengthening and coordinating a platform for communication, exchange and advocacy in the European Region (Action Area 2). • The European Advisory Committee on Health Research is the Region’s highest- level consultative body. It advises the Regional Director through its recommendations and provides ad hoc operational and technical expertise to all technical divisions at the Regional Office on topics of relevance to the Regional Committee and the Region, including big data, childhood obesity, immunization, implementation research and mental health. In 2018, the European Advisory Committee on Health Research created an important new task force to foster the EUR/RC69/5 page 82 generation and use of implementation research throughout the Region (Action Area 2). Enhancing access to, and dissemination of, health information 463. The European Health Information Gateway is the Regional Office’s standard portal for making available relevant health information and data. It focuses on high usability and the use of visualizations to support users in easily accessing and understanding public health information. The functionality is steadily growing and includes country profiles and a broad range of thematic areas, like disease prevention and environmental health. 464. The cultural contexts of health and well-being project at the Regional Office project seeks to enhance public health policy-making through a more nuanced understanding of how cultural factors affect perceptions of health and delivery of health care. As part of this project, WHO released two major publications in 2019. 465. The first is a policy brief that explores the centrality of culture to the challenge of AMR. The policy brief examines how the prescription and use of antibacterial medicines, the transmission of resistance, and the regulation and funding of research are influenced by cultural, social and commercial, as well as biological and technological factors. The second is a HEN synthesis report which examines the evidence base for the role that the arts can play in improving health and well-being. 466. The Regional Office published the 2018 edition of its flagship publication, the European health report. The report was produced in two forms – a full report and highlights. It was launched just before the 68th session of the Regional Committee and became one of the most popular Regional Office publication of the year. The report is published every three years and provides a vital snapshot of health in the Region and progress towards health and well-being for all. It also shows trends in and progress towards the goals of Health 2020, and reveals some gaps in progress, inequalities and areas of concern and uncertainty, where action must be taken. 467. The 2018 edition brings the story up to date, describing how Member States, actively supported by a range of initiatives from the Regional Office, have begun to expand the evidence base beyond numbers and statistics, taking in data from the medical humanities and social sciences and capturing real-life narratives and subjective experiences. In so doing, it has brought various core values that lie at the heart of Health 2020, such as community resilience, community empowerment and a life-course approach, to the forefront of the new research agenda. It is clear, however, that the focus on new research methodology is not sufficient in itself to realize the ambition outlined in Health 2020 of establishing equitable, sustainable and universal health care systems that are people-centred and give individuals control over the decisions that most affect their lives. Robust health information must be turned into robust policy action. To this end, the 2018 report places a new emphasis on the use of data, in which effective knowledge translation bridges the research–policy gap and is the catalyst for evidence-informed policy-making. 468. The Regional Office publishes Public Health Panorama – a quarterly journal that is bilingual (English and Russian), peer-reviewed, open access, and with no fee for authors. Public Health Panorama is the youngest of WHO’s journals, but has quickly become a respected publication with high-quality content supported by high-quality translations and EUR/RC69/5 page 83 publishing practices. The topics of 2018 issues of the journal were country work, health emergencies, NCDs and PHC. The 2019 issues have been dedicated to health information, healthy cities and health literacy. The topic of the last issue of 2019 will be TB. The future of digital health systems 469. In February 2019 the Regional Office, together with the Norwegian Centre for e-Health Research, hosted a landmark WHO symposium on the future of digital health systems in the European Region. 470. The aim of the symposium was to engage Member States, partners and key thought leaders in a dialogue to shape the priorities for public health action to accelerate digital health in the European Region and gather further input towards the development of a European vision and roadmap for the digitalization of national health systems. Strengthening health information systems and country capacities for the development of evidence-informed policies WHO Evidence-informed Policy Network 471. The WHO Evidence-Informed Policy Network (EVIPNet) – a key implementation pillar of the evidence-informed policy action plan (Action Area 3) – provides and facilitates technical assistance to increase Member States’ capacity in evidence-informed policy-making, including through the development and provision of tools and guidelines.13 472. The network (currently comprising 21 Member States) aims to create and institutionalize innovative, multisectoral and multidisciplinary partnerships and teams at the country level, which initiate and implement national research-to-policy processes, such as developing evidence briefs for policy and holding policy dialogues. 473. Innovative approaches are currently being tested to accelerate the production of evidence briefs for policy-making and further strengthen links between EVIPNet Europe members. This includes the creation of two cohorts of 10 Member States that are simultaneously developing or finalizing national evidence briefs for policy on AMR, which is an increasingly serious threat to global public health requiring action across society and all government sectors. 474. In 2018–2019, three EVIPNet Europe evidence briefs were developed and published by EVIPNet Europe member countries. Evidence briefs for policies synthesize the best available global and local research evidence to answer a high-priority policy problem in a concise way, written in non-expert language to guide policy development. • Republic of Moldova – Evidence brief for policy: Informing amendments to the alcohol control legislation directed at reducing harmful use of alcohol in the Republic of Moldova (2019). 13 The Facilitator’s guide: using research in the EVIPNet framework, was published in 2018; a new manual to develop evidence briefs for policies has just been finalized. EUR/RC69/5 page 84 • Hungary – Promoting the appropriate use of antibiotics to contain antibiotic resistance in human medicine in Hungary (2018). • Slovenia – Antibiotic prescribing in long-term care facilities for the elderly (2018). Networks for groups of countries 475. There are now eight health information networks under the EHII umbrella. A large proportion of EHII activity is undertaken by these networks. 476. The Small Countries Health Information Network has held five meetings to date and has been chaired by Iceland since July 2018. It has carried out important political work, delivering joint statements on behalf of all eight Member States at the 68th session of the Regional Committee in support of health information. 477. The European Burden of Disease Network currently includes 14 Member States. Three meetings have been held in London, United Kingdom, Oslo, Norway, and Berlin, Germany, hosted jointly with the Institute for Health Metrics & Evaluation. The Network has recently published an editorial in the European Journal of Public Health, and is currently finalizing the national burden of disease manual, which will be useful for countries reporting on GPW 13. Building capacity 478. The Autumn School on Health Information and Evidence for Policy-making is one of the main capacity building events under the EHII umbrella, which focuses on equipping participants with practical knowledge and skills. The sixth Autumn School was held in The Hague, the Netherlands in early 2019. Twenty participants from nine countries worked on the interface of data analysis, data visualization, research/knowledge integration and policy, and were able to obtain practical insights and solutions for improving national health information systems. 7. Advancing WHO reform and financial sustainability 479. To continue increasing the effectiveness with which it carries out its commitments, the Regional Office continues to contribute to WHO reform processes, to seek sustainable funding and strengthened governance in the European Region, and to expand the number, depth and types of its partnerships, its technical capacity and its communications and its publishing work. WHO reform and the transformation agenda 480. As in previous years, the Regional Committee in 2018 discussed the impact of WHO reform processes on the work of the Region. The goal of the transformation agenda, as stated by the Director-General, was to make WHO a modern organization fit for purpose in the 21st century that works seamlessly across programmes, major offices, and its three levels, to make measurable improvements to people’s health at country level. GPW 13, and in particular its triple billion targets, provide a clear purpose for the transformation and articulate what the Organization is, what it will do, and how it will do it. EUR/RC69/5 page 85 481. Although the current transformation exercise is broader and more comprehensive than past reforms, key lessons learned from WHO’s previous experience in implementing reforms and change have informed WHO’s transformation agenda. The process of transformation has involved listening to Member States, staff and partners, and carrying out detailed process mapping and benchmarking with the support of global experts. The focus of attention is to shift from outputs to results and impact. WHO headquarters will concentrate on its normative role, while the capacity of regional and country offices will be strengthened in order to allow them to translate that normative work into country-level impact. 482. In the European Region, the transformation built on “Better health for Europe”, the programmatic manifesto of the then newly appointed Regional Director, which had been adopted by the Regional Committee in 2010 (resolution EUR/RC60/R2). Given its close compatibility with the global WHO transformation, “Better health for Europe” has been the Regional Office’s springboard to the transformation agenda. 483. The regional transformation team was integrated into the global team, and senior staff, including WHO country representatives, were engaged in all work streams. Key regional developments have included the establishment of a regional coordination team and the appointment of senior technical officers and WHO representatives to all the workstreams of the transformation. 484. The Regional Office actively engaged with all Member States in the first planning exercise for the implementation of GPW 13. The results of the global survey on organizational culture carried out in October 2017 were being followed up on. Through the Standing Committee of the Regional Committee for Europe (SCRC) and its working groups, the Region had been proactive in governance reform, focusing on: nomination procedures for membership of the Executive Board and SCRC; the procedure for nomination of the Regional Director; strengthened governance oversight by Member States; management of the agendas of sessions of the Region’s governing bodies; management of resolutions and amendments; alignment of global and regional governance; and management of regional conferences. 485. In the ensuing discussion, participants in the Regional Committee welcomed the steps already taken to transform WHO following the adoption of GPW 13 and to ensure that it was a modern organization able to play a pivotal role in meeting future health challenges. 486. The Regional Director provided strong input to the Global Policy Group. Moves to develop action plans and working groups at the three levels of the Organization were welcomed. It was agreed that Member States must be consulted on and involved in major decisions concerning the transformation plan, and notably in the further development of the programme budget for 2020–2021. The Organization’s programme budgets should be based on realistic evaluation of Member States’ resource mobilization capacities. 487. Placing countries at the centre of WHO’s work while sustaining its normative function continued to be a major challenge. WHO’s country presence should be strengthened through closer cooperation between WHO representatives and United Nations resident coordinators and better alignment with United Nations budget centres. The repercussions on WHO of reform of the United Nations system needed to be further discussed. WHO’s central resource was its staff; employment practices should be in line with best practice (gender parity, teleworking, flexible working hours, etc.). EUR/RC69/5 page 86 488. Member States emphasized the Executive Board’s responsibility to carry forward governance reform, reducing the agendas of sessions of the Organization’s governing bodies, adopting a more disciplined approach to resolutions, and ensuring alignment with United Nations reform initiatives. 489. With regard to management tools, WHO mapped existing processes and benchmarked with successful organizations, to match best performances. Various consulting companies had been brought in, and support had been secured from experts within and outside the Organization. Further consultations would be held with Member States to ensure their ownership of the transformation. 490. On partnerships, WHO would move from a stance of risk aversion to risk management. The transformation of the Organization should bring deep changes to WHO’s culture and mind set. The aim was to create an agile and modern organization that was fit for purpose. As the normative functions of the Organization only made sense when carried out at country level, WHO’s country offices would be strengthened. Engagement with Non-State Actors 491. Following the adoption of the Framework of Engagement with Non-State Actors (FENSA) by the World Health Assembly in 2016 (World Health Assembly resolution 69.10), the Regional Committee endorsed, at its 67th session in 2017, a new procedure for accrediting European non-State actors (NSAs) not in official relations with WHO to enable them to participate as observers, without the right to vote, in future Regional Committee sessions and to submit written and oral statements. 492. FENSA was intended to help manage conflicts of interest. In 2018, in a procedure that is fully in line with FENSA, the Regional Office took a step forward in its collaboration with non-State actors when it officially accredited 19 NSAs to the Regional Committee for the first time, on the basis of reviews and recommendations by the SCRC. 493. The Regional Office will also continue its strong collaboration with NSAs at regional and country level. Working with countries at the centre 494. GPW 13 puts countries at the centre and shifts WHO’s efforts closer to the country level, recognizing that working on the ground is by far the best way to support national health authorities in their efforts to achieve equitable and affordable health for all. This is aligned with the WHO priority objective of ensuring UHC, with countries at the centre. 495. In June 2018, a new WHO country office was opened in Athens, Greece – the 30th in the Region. The new country office will provide assistance to Greece and also support multicountry cooperation programmes such as migration and health, vector-borne diseases and zoonoses among others, as agreed between WHO and the Greek government. EUR/RC69/5 page 87 Country Visits 496. The Regional Director visited six countries in 2018–2019 (Bulgaria, Greece, Israel, Italy, Kazakhstan and Uzbekistan) and there were three visits to the Regional Office by ministers and delegations from countries (North Macedonia, Norway and Portugal). SCRC visit to Kyrgyzstan 497. As part of efforts to further strengthen the governing bodies’ understanding of the Regional Office’s work in countries with various contexts and in complex partnership environments, the Regional Office continued the series of visits by SCRC and European Executive Board members to WHO country offices in the Region with a visit to Kyrgyzstan in June 2019. These visits provided an opportunity to see how WHO has managed to influence the strategic developments of countries, through all its offices, including the country offices and their sub offices, the Regional Office, and the centres of excellence – the GDOs backstopped by WHO headquarters and WHO collaborating centres. Parliamentary network 498. Over the years, the Regional Office has been progressively engaging either on a bilateral basis or on a subregional basis with parliamentarians from the European Region. This engagement aims at supporting, on request, national parliaments in their discussions on public health issues. 499. Considering the need expressed for more support on public health issues coming from a significant number of national parliaments, the Regional Office is now looking at setting up a framework for collaboration on the regional/European level with European parliamentarians. 500. A first consultative meeting, which brought together a small number of parliamentarians from the European Region took place in July 2019 in Copenhagen, Denmark. Participants in this meeting discussed with the Secretariat the various issues pertaining to the setting up of a European network of parliamentarians. The recommendations and conclusions of this consultative meeting formed the basis of the technical briefing for parliamentarians that is planned to take place during the 69th session of the Regional Committee. Financial situation 501. The approved programme budget for 2018–2019 for the European Region is US$ 261.9 million of which US$ 256.4 million is the base programme. Overall, the approved base programme budget was well financed in the Region at the end of June 2019 (89% funds available, as opposed to 83% at the same point in the last biennium). Including the projected voluntary contributions, base programme funding is expected to increase to 96% by the end of the biennium. 502. Flexible funds are continuously used in a strategic manner to bridge the gaps and maintain all areas, particularly underfunded programme areas, at operational levels. However, the relatively small share of allocations from flexible corporate resources places limitations on the extent to which gaps can be bridged. The Regional Office continues to raise most voluntary contributions locally; a larger share of allocation from global voluntary contributions should be further explored. EUR/RC69/5 page 88 503. Executive management, WHO representatives and the heads of WHO country offices, as well as programme managers, continue to closely monitor and track implementation for approved plans and allocation shares from the approved programme budget through monthly reports and dashboards. A monitoring report of implementation of the programme budget for 2018–2019 will be presented to the 69th session of the Regional Committee. 504. During the 2018 session of the Regional Committee in Rome, a draft Proposed high- level programme budget 2020–2021 was presented to the Regional Committee for consultation. The document presented an overview of the process for preparing the programme budget for 2020–2021, including a summary analysis of the preliminary prioritization results for GPW 13 and an overall budget indication by major office and split by country and regional levels. In the subsequent discussions, participants expressed concern regarding the ambitious increase in the budget, and the proposed United Nations reform levy. Given the proposed new operating model under the transformation agenda, a major shift of resources to countries was foreseen, a shift that Member States said should be discussed thoroughly before being implemented. Member States had enquired how country work would be increased in the many EU countries that did not have WHO country offices. 505. The high-level format constituted a departure from the usual presentation of a proposed programme budget. Most of the comments received were incorporated into the revised version that was presented to the 144th session of the Executive Board in January 2019. In May 2019, the Seventy-second World Health Assembly adopted the programme budget for 2020–2021, the first programme budget within GPW 13. The regional plan for implementing the programme budget for 2020–2021 will be submitted to the Regional Committee at its 69th session. Strategic communications 506. Communications strategy has emphasized the Regional Office’s unique contribution to public health in the Region and beyond, through credible, reliable, understandable, relevant, timely and easily accessible information and messaging, shared with target audiences through the most appropriate platforms, including the Regional Office’s website, social media channels and media outreach. The website serves over 2 million users annually, and 240 000 people now subscribe to the Regional Office’s corporate social media channels. 507. Since early 2018, anticipating the adoption of GPW 13, the communications team has made consistent efforts to illustrate WHO’s impact at country level to key audiences, placing emphasis on sharing evidence-based findings and compelling human stories. Communicating the fundamental importance of achieving UHC and health equity has been a recurring theme across communications activities and campaigns. The strategic priorities, goals and impact of Health 2020 and the 2030 Sustainable Development Agenda are fully integrated into communications strategies and products. 508. Several innovations – such as Facebook Live events, high-production value videos and microvideos – have been introduced to enhance engagement with audiences. Telling people’s health stories using video has offered nuanced, accessible insights into the health concerns and challenges facing people across the Region. These videos have showcased a community volunteer in rural Kyrgyzstan, a German mother concerned about measles, home care addressing mental health issues in Belgium, the work of a dementia care nurse in Denmark, and EUR/RC69/5 page 89 the Prime Minister of Iceland explaining intersectoral aspects of the SDGs and health, among others. The continued development and use of meeting apps has ensured that information, collaboration and participation at WHO events is optimized for participants. Similarly, internal communications have also created more and varied content, such as regular podcasts. 509. Despite budget and human resource limitations, country office capacity in communications has been strengthened through several strategic developments. This has been achieved through a survey mapping of country office communications needs in January 2018, the establishment and regular contact with a country office communications group with a focal point from each country office; and the development of templates for communications strategies, action plans, campaigns and brochures. Much of this work in 2018 was possible thanks to a junior professional officer position sponsored by Finland. 510. A key success has been the five missions to date in 2019 by communications staff and staff of the Strategic Relations with Countries team to Azerbaijan, Estonia, Romania, the Russian Federation and Turkey. These missions have not only strengthened communications capacity at country level for country office staff, but also built direct relations and identified opportunities for collaboration with ministries, boards of health and others, highlighted initiatives to promote, and led to the development of strategies, brochures and web surveys. Most recently, a mentoring initiative has been initiated to ensure sustainable capacity building and skills exchange for WHO communications staff across the Region. 511. Communications staff also accompanied governing body members on country office visits, recording their findings on WHO work at country level and disseminating the final video at the 68th session of the Regional Committee in 2018. Regular contact has been maintained with the national technical focal points for communication, ensuring communications exchange with all Member States in the European Region, enhanced through outreach on specific campaigns and activities to national partners. 512. Further opportunities for outreach have been taken through participation in United Nations communications networks and participation by communications staff in WHO network events, including workshops and plenary sessions of the Small Countries Initiative meetings and at Healthy Cities events, as well as strategic support to SEEHN network meetings. Sharing information about WHO’s invaluable collaboration with NSAs, including donors, has also been a priority. 513. The Regional Office has participated actively in global discussions and developments relating to the Organization’s transformation, thus strengthening the Regional Office’s position as an innovative leader in communications across WHO. Digital and social media communication 514. The Regional Office’s social media channels have seen impressive growth over the past years, and they now reach a combined audience of nearly 245 000 – resulting in thousands of daily impressions of the content shared via Facebook, Instagram, Twitter and YouTube. 515. This growth is linked to taking a more strategic approach to social media – one that prioritizes developing engaging content focused more on WHO’s key messages, rather than specific activities (e.g. meetings, workshops) that generally have limited relevance to a broader audience. Efforts to elevate the quality of social media content, placing a particular EUR/RC69/5 page 90 emphasis on clear, compelling messages and engaging visuals, has resulted in increasingly strong social media performance. At the same time, social media remains a vital and important channel for sharing news and information about the Regional Office’s contributions to improved health and well-being in the Region and its collaboration with Member States, particularly at the country level, as well as the outcomes of major high-level events. 516. In the past 18 months, The Regional Office’s social media audiences have grown consistently and sometimes exponentially. Well-established accounts, such as the @WHO_Europe Twitter account (opened in 2010), have continued with steady audience growth, seeing a 30% increase in followers since January 2018. As priority and extra resources have been given to bolstering the Russian Twitter account, @WHO_Europe_RU, the number of followers has increased by 92%. At the same time, growth on the @whoeurope Instagram account has been most impressive, showing a 783% increase over the past 18 months. 517. The YouTube channel of the Regional Office has been gaining popularity over the years. Nearly 200 videos were produced and published in 2018, including videos for internal and special events. They were watched 116 000 times. The number of subscribers to our YouTube channel increased by 35% over 2017. 518. Social media performance has been consistently strong for campaigns related to major health and awareness-raising days, such as World No Tobacco Day, World AIDS Day, World Health Day and others. At the same time, the creation of pre-packaged, curated content for major conferences and meetings, such as the Tallinn Conference in June 2018, the 68th Regional Committee for Europe and the recent High-level Conference on Health Equity in Slovenia, have helped to bolster the social media performance for the Regional Office’s major events. 519. Other notable successes include tweets and posts related to measles cases in the European Region (a single tweet in August 2018 had nearly 140 000 impressions, while a Facebook post had a reach of more than 200 000), UHC/health for all (a single tweet on UHC Day in December 2018 earned nearly 100 000 impressions), and a series of social media tiles on stigma and discrimination for World AIDS Day (the top performing tile had more than 700 likes on Instagram, a record for the @whoeurope account). A number of Regional Office videos have also been high-performers on social media, such as a lab workers appreciation video (more than 120 000 views and 3 000 shares on Facebook), the story of HPV vaccine advocate Laura Brennan (nearly 25 000 views on Facebook), and a set of 3 NCD-related videos for the FIFA World Cup (15 000+ views across Twitter and Facebook). 520. The communications team works to continuously update its social media tactics to stay in line with the latest social media trends, including using new features (e.g. Twitter threads and Instagram stories) and carefully tracking analytics in order to gain insight into which types of content yield the best performance. The team collaborates with country offices, GDOs and technical programmes throughout the Regional Office to develop a wide variety of content covering all areas of the Regional Office’s work. 521. The Regional Office events app was used for communication and engagement with participants of all major meetings in 2018, including the Regional Committee session in Rome, Italy, the global conference on PHC in Astana, Kazakhstan, and the health systems conference in Tallinn, Estonia. The app’s adoption rate went up to 83% last year, which is EUR/RC69/5 page 91 much higher than the non-profit sector average of 48.5%. Participants’ engagement (all in-app actions) in one event reached a high of 52 300. 522. A report such as this can provide only a snapshot of the Regional Office’s most important activities; the pages of its website reflect more fully the breadth and depth of its work. In 2018, the Regional Office website continued to attract more traffic and give greater visibility to WHO’s work, with 2.2 million users – an increase of 21% compared to 2017. The greatest success on the website was the launch of the Environmental Noise Guidelines for the European Region, generating the highest number of page views for the entire year on its launch date, 8 October. Areas that increased significantly in popularity were the topical sub- sites for AMR, influenza and public health services, and specific content that attracted users included The European Health Report, measles outbreaks and an interactive quiz on alcohol consumption. 523. The website was also essential for the sharing of data and evidence through the European Health Information Gateway, which now encompasses the HFA database, which continues to be the Regional Office’s most popular database. The Gateway’s popularity has increased dramatically with a 138% increase in users compared to 2017. Pages containing data related to NCD topics continue to be some of the most viewed pages on the site. Publishing and multilingualism 524. Publishing continues to be the primary means by which the Regional Office spreads its technical and policy messages to and beyond the European Region, primarily through its website. More than 10 times as many readers access the most popular publications online as obtain printed copies; in 2018 the number of total downloads of Regional Office publications exceeded 403 000. For example, the Environmental Noise Guidelines for the European Region, the most successful Regional Office publication in 2018, was downloaded over 8300 times, and the Noise sub-site received 36 200 visits, a 75% increase compared to 2017. 525. The number and range of publications produced by the Regional Office is testimony to its significant role in producing and disseminating health information in the Region. New publications in 2018–2019 span the full breadth of the Regional Office’s work. 526. Although budgetary limitations mean that some publications are not available in all languages, the Regional Office continues to actively support the WHO policy on multilingualism by publishing all working documents for meetings of European governing bodies, major publications and content in many areas of the website in all four official languages (English, French, German and Russian), and holding workshops and technical meetings in two or more languages. 527. The Regional Office paid special attention to providing content in English and Russian in Public Health Panorama and the European Health Information Gateway, and worked to align English and Russian terminology in the field of public health and to increase the amount of information available in both languages. = = =