Working together for better health outcomes in Europe: strategic health system priorities and areas for collaboration: partners meeting: Brussels, Belgium, 30 April 2015

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan : WORKING TOGETHER FOR BETTER HEALTH OUTCOMES IN EUROPE: STRATEGIC HEALTH SYSTEM STRENGTHENING PRIORITIES AND AREAS FOR COLLABORATION Division of Health Systems and Public Health Working together for better health outcomes in Europe: strategic health system priorities and areas for collaboration Partners meeting Brussels, Belgium, 30 April 2015 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int Working together for better health outcomes in Europe: strategic health system strengthening priorities and areas for collaboration Partners meeting Brussels, Belgium, 30 April 2015 Photo: WHO, 2015 ABSTRACT On April 30 2015, the Division of Health Systems and Public Health of the WHO Regional Office for Europe hosted a meeting of partners who have worked closely with WHO Europe on health systems strengthening in the European Region. The meeting was an opportunity to gather input for, and endorsement of, the draft strategic document as called for by WHO’s European Member States; to better understand the work that each organization is undertaking to support Member States; and to identify common priorities and potential areas of collaboration to best support member states. Keywords DELIVERY OF HEALTH CARE HEALTHCARE SYSTEMS MEETING REPORTS PUBLIC HEALTH UNIVERSAL COVERAGE Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2015 All rights reserved. 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Document number: WHO/EURO:2015-6158-45923-66180 CONTENTS Page Background ....................................................................................................................... 1 Setting the scene for Europe: Priorities of Member States and the WHO Regional Office in health systems strengthening .............................................................................................. 2 WHO Regional Office priorities for health systems strengthening in the European Region 2015– 2020……….. ....................................................................................................................... 6 Areas for collaboration in strengthening health systems in the European Region ...................... 8 Mechanisms for collaboration in health systems strengthening in the European Region .......... 10 Conclusions ..................................................................................................................... 12 References. ..................................................................................................................... 13 Annex 1. Strategic Document .................................................................................... 15 Annex 2. Provisional Programme ............................................................................... 31 Annex 3. List of participants ...................................................................................... 32

Working together for better health outcomes in Europe Page 1 Background Strengthening people-centered health systems is one of the four priority areas of WHO Europe’s Health 2020 policy framework and strategy for the 21st century (3). It is built on the strong track record of the Regional Office in providing guidance and technical assistance to its Members States on improving the performance of their health systems. In addition to direct country support, WHO Europe’s commitment to health system strengthening is reflected in key documents such as the 1996 Ljubljana Charter on Reforming Health Care (2) and the 2008 Tallinn Charter on Health Systems, Health and Wealth (2). To mark five years since the signing of the Tallinn Charter and to examine both the progress made and the potential way forward, a high-level meeting was held in Tallinn in October 2013(1). Meeting participants proposed that a draft resolution accompanied by a strategic document setting out priorities for health systems strengthening for the next five years be submitted to the 65th sitting of the Regional Committee of the WHO Regional Office for Europe. To meet this request, the Division of Health Systems and Public Health (DSP) prepared a draft strategic document, Priorities for health systems strengthening in the European Region 2015–2020: walking the talk on people centredness. In pursuing its health systems strengthening (HSS) agenda (2), WHO Europe works with a range of international partners. This includes expert representation from across the Region, non- governmental bodies, civil society and professional groups but also, crucially, strategic partnerships and collaboration with other international bodies engaged in health system strengthening activities as well. These include the European Commission (EC), the European Observatory on health systems and policies, European Patients’ Forum (EPF), the Global Fund, the Organisation for Economic Cooperation and Development (OECD), the Secretariat to the Social Protection Committee and the World Bank. To consult with some of these key partners, DSP convened a meeting entitled‘Working together for better health outcomes in Europe: strategic health system strengthening priorities and areas for collaboration’ on April 30 2015 in Brussels, Belgium. The aim of the meeting was threefold: first,to gather input for, and endorsement of, the draft strategic document as called for by WHO’s European Member States; second, to better understand the work that each organization is undertaking to support countries in Europe; and third, to identify common priority areas in health systems strengthening for all partners, in order to explore avenues for collaboration. The meeting was attended by senior DSP staff and representatives of the above-mentioned organizations, leading to a number of key points of agreement and potential areas for future collaboration. Working together for better health outcomes in Europe Page 2 Setting the scene for Europe: Priorities of Member States and the WHO Regional Office in health systems strengthening The European Region is clearly facing the challenge of increasing burden of disease and an ageing population. This burden of disease amounts up to the equivalent of 1 - 6% of GDP, with cardiovascular disease representing 7 - 15% of health care costs and diabetes representing 2.5 - 15% of health care costs(4). There are several important opportunities to consider as we work towards compressing morbidity. They include structural delivery reform strategies, innovation and technologies, engaging people more in their planning and implementation of their health systems and responding to the lessons learned from the financial crisis. These were explored briefly by the European Patients’ Forum (EPF) and the European Observatory on health systems and policy. Structural delivery reform A series of structural delivery reform strategies have been shown to be effective on the whole in moving towards people-centredness and increasing the efficiency of health services, most notably in the reorientation to primary care and public health. It is clear that we need to look at decreasing the burden of diseases not just with treatments but also by addressing risk factors. It has been shown that risk factors contribute to 50 % of reduction even there where systems are primarily focused on treatments (5). It has been shown that tackling smoking, excessive consumption of alcohol and obesity have an impact on GDP equal to that of tackling violence, war, and terrorism (6). Despite these known knowns, Member States can still do more in implementing these structural delivery reform strategies. The financial crisis: exposing success factors for increasing resilience of health systems The financial crisis has tested health systems and exposed challenges and Member States’ ability to cope with a significant external shock (7). The tree in figure 1 depicts the reform behavior and the response of many countries in the European Region to the financial crisis. Many Member States have focused on the activities among the low-lying fruit and as a result we now have plenty of evidence on how to increase efficiency, effectiveness and coverage in these areas. Member states and partners however, have been less able on focusing on the high lying fruit. As a result there is less evidence in these areas and poor understanding of the governance required of these activities. Moreover, reaching only for the low-hanging fruit (ie. budget cuts and staff lay-offs) has made some of the high-lying fruit more difficult to reach and more difficult to implement. There is therefore a ceiling for implementing some of these low-lying fruit. Furthermore implementing low lying fruit activities do not actually bring about savings immediately (ie. closing hospitals is expensive) as perhaps finance ministers perceive when requesting that ministries of health implement these activities. The average European Union (EU) country that experienced the financial crisis experienced little growth in their economies since implementing these low-hanging reforms and in the majority of cases, increasing efficiencies does not bring about any savings. Investments therefore are necessary before savings can be made. This has been made clear from the Austrian example where primary care reform is being successfully implemented without any cuts to salaries. If we are to make health systems more people-centred and more resilient in adapting and responding to future internal and external shocks it will be important for partners to support Member States with structural reform implementation that address the high lying fruit and the low lying fruit simultaneously. Also important will be engaging patients and populations on helping define benefits, helping identify priorities and becoming involved in the management of their own care. There is thus still an untapped potential in including people in the Working together for better health outcomes in Europe Page 3 implementation of each of the activities depicted in figure 1 that may contribute to both increased cost-effectiveness, efficiency and coverage. The challenge will be to do this while also sustaining public funding / universal access, securing effective health care coverage (ie.not a question of rationing but rather selecting services that are actually effective); and improving performance and efficiency of health systems. In this context, managing change and innovation to meet emerging demands and resolve growing health system constraints will become increasingly important. Partners therefore agreed that they are best place to support Member States in pursuing these activities through: 1) technical & political capacity to implement, 2) increasing transparency, 3) knowledge brokering, 4) participation mechanisms, 5) maintaining focus on equity and particularly, 6) strengthening good governance. Fig.1: Response to the financial crisis Source: Based on Bengoa and Repullo, 2013 Innovation and new technologies Clearly the introduction of innovations and new technologies will push costs up but there are however clear benefits. New innovations can serve as important business and growth opportunities for the trade sector. They can help drive and improve productivity as services are reorganized and can substitute old treatments with novel ones, thereby increasing productivity gains and improved health outcomes. Ultimately these new innovations can help expand access to treatments and services. It is already clear however, that the adoption of these technologies and innovation requires careful calculation. This calculation involves not only balancing costs with improved outcomes but also aligning these new innovations with incentives, skill mix, local and professional culture, and organization of health services and patient needs. Involving patients with priority setting means better alignment of innovation with patients’ needs and Integrated Care Skill Mix Public Health Hospital Rationalization Clinical Guidelines Payment for Performance Innovation ICT E Health HTA Benefit Packages User Charges Staff Cuts Salary Reductions Population Exclusions Delayed Investments Rationing Benefits Training & Research Cuts Price Controls Working together for better health outcomes in Europe Page 4 preferences. Patients may focus on issues that researchers, companies or regulators may not identify as important. Advances in medicine are also only possible with the voluntary participation of patients and thus patients have a moral right to be involved in how research is developed, managed and evaluated. Thus, involving patients in the entire innovation chain can lead to better quality research results, strengthening the trust and acceptance of research results, but also crucially increasing the trust and acceptance of the policy implications of that research and how that research and innovation gets translated into practice. Countries’ ability to harness the benefits of innovation will therefore depend on a range of factors beyond just paying the bill. European Patient Forum and understanding patient centredness There are many ways of putting people at the centre of systems but relatively little evidence to show which of these strategies will lead to better outcomes and be cost effective. Most systems now have legislations that define patient rights, but there exists little clarity on which strategies help increase patient participation in health systems decision making, or help patients navigate the health system and contribute to more involvement in clinical decision making. The EPF has been instrumental in helping clarify patient-centredness. The forum’s constituency includes patients who are already diagnosed with a chronic disease or serious long term condition. The forum has recently expanded its focus to not only ensuring equitable access to high quality, patient-centred health care but also to patient-centred social care. Patient organizations are natural partners. Partnership is a key modality in the forum’s work and thus the opportunity to meet with other partners in health systems strengthening was very welcomed by the forum. EPF’s work has involved engaging with members at national levels and capacity building through their capacity building programme to ensure robust, effective, patient leadership to feed into the European debate and collaborate in a national context. The programme to date has supported efforts by members is discussing cross border healthcare, initiating regional advocacy projects, and developing strategic plans to action that build the credibility and confidence necessary for patient associations to participate in national healthcare debates. The EPF has also expanded its work to partner with healthcare professionals, healthcare industries, public health experts, health researchers and key decision makers through its multi- stakeholder Patient Access Partnership. This has built on the momentum that stemmed from the Vilnius declaration during the Lithuanian presidency which focused on sustainable health systems and has continued building momentum during the Latvian presidency to the EU which has focused on universal coverage. The partnership aims to join forces to explore solutions to overcome inequities, based on individual and collective expertise, put the issue of access higher on EU political agenda and also to map more thoroughly and measure access in new and innovative ways that is fit for purpose. In the EU policy context, patient-centredness has been recognized as a key dimension of quality and the EPF has been included on the expert panel on EU’s future quality of care agenda. There are also pockets of empowerment in existing EU regulations and soft laws including several laws onsafety and quality of medicines and medical devices and the cross-border healthcare directive. The EMPATHiEproject (8) has recommended that a strategy is still needed to develop a systematic structured approach towards patient empowerment at the EU level. Such a strategy would help address the lack of understanding and consensus around patient empowerment. The EPF is therefore launching a patient empowerment campaign to help clarify what is meant by patient empowerment, how to measure it, and how to document patient empowerment and its impact in a more robust and systematic manner. The campaign will build on three pillars of Working together for better health outcomes in Europe Page 5 patient empowerment: health literacy, relationships between patients and providers and patient self-management. The ability to better understand what is meant by people-centred health systems and how to achieve this offers important gains for health systems. Engaging health professionals One of the bottlenecks in increasing patient empowerment is getting health professionals to adopt more patient-centred practices at the bedside and their interactions with patients. To date mechanisms to incentivize clinicians and support clinicians are not very clear. Through its multi- stakeholder Access Partnership, the EPF has been working closely with the European professional associations to create a roadmap for how professional associations and patient associations can work together to increase patient empowerment. In addition to this however, it is important to consider training of health professionals but also what happens when health professionals leave their training to work in the service setting. Typically health professionals leave their training settings with high aspirations. Upon entering the vocational setting these aspiring health professionals are faced with a lot of changes in their first year including dealing with systems, professional obligations and hierarchies. The reality is that their initial aspirations are moved down the chain of priorities and take the back seat. It is therefore critical to engage with health professionals in their vocational settings. Indeed, in some European countries patient associations are linking up with health professionals in these vocational settings to exchange and support professional practice. Regulation and incentives can help but are not enough in changing the culture of health professionals. Working together for better health outcomes in Europe Page 6 WHO Regional Office priorities for health systems strengthening in the European Region 2015–2020 The operational approach of the DSP is set out in the document Towards people-centred health systems: An innovative approach for better health outcomes (2). This approach represents a paradigm shift towards focusing health systems strengthening on desired health outcomes and strengthening systems accordingly. This approach considers health systems from the perspective of the patients and populations. The visualization of the real-life experience of a patient from the UK with advanced Alzheimer’s disease (Malcolm) and his principle care giver and spouse (Barbara) – see box 1- shows the range of clinical and non-clinical services required to support their needs. It conveys health systems as a highly diverse but largely unconnected web of health providers, technologies, and services. The visualization exposes the potential incongruence between a system and the patient when it does not consider the needs of patients in practice. People-centred health systems apply a design principle that is critical to achieving the goals of Health 2020 and recalls the Alma Ata primary health care approach posited by the WHO more than three decades ago and appeals to the principles of comprehensiveness, equity, respect, ethics, sustainability, coordination, continuity, holistic services, preventive services, people empowerment, collaboration, governing through shared accountability, using evidence to inform policies and whole-systems thinking. Such an outcome-focused approach has been put into practice for a number of tracer diseases including the control and prevention of non-communicable diseases (9) and for multi-drug resistant tuberculosis (MDR TB) and anti-microbial resistance (AMR). This has been an effective way of promoting inter-divisional work within the Regional Office, and is one that has been very well received by Member States, who commented on the benefits of such collaboration at the recent Regional Committee (RC) 64. Box 1: Strengthening people-centred health systems: an individual’s perspective The Regional Office has prepared a draft strategic document to be presented at the RC65 Priorities for health systems strengthening in the European Region 2015–2020: walking the talk on people centredness as a follow up to the Tallinn Charter, that is also in line with the DSP Source: Adapted from National Voices (2013) Coordinated Endowed with rights and ibiliti Continuous Shared Ethi Alzheimer’s social outreach worker Dementia advisory nurse Continence adviser Consultant Out-of-hours doctors Dietician Community dentist Physiotherapist Speech & language adviser District nurses Occupational therapist Equipment service Wheelchair service Social worker GP Live-in c r rs Oxygen service People-centred h lth t Malcolm & Barbara Working together for better health outcomes in Europe Page 7 operational approach, the new European health policy Health 2020 and in response to the challenge that the example of Malcolm and Barbara convey. The strategic priorities set out in the document have been informed by a number of processes. First, the Division of Health Systems and Public Health has worked with many countries on health systems strengthening, providing an overview of trends and directions in the Region. Secondly, the WHO Regional Office engages with many Member States on discussions of priorities of collaboration, including for health systems strengthening, on the basis of the biennial collaborative agreements. Thirdly, to mark the five-year anniversary of the adoption of The Tallinn Charter: Health Systems for Health and Wealth,(10)the WHO Regional Office for Europe, in collaboration with the Government of Estonia, is leading an assessment to follow up on the successes and challenges in health systems strengthening under the banner of the Tallinn Charter. This has included a ministerial meeting hosted by the Government of Estonia (1), a questionnaire about future health systems strengthening priorities for Member States, and a forthcoming final report on the implementation of the Tallinn Charter, to be submitted to the 65th session of the Regional Committee for Europe in 2015. The strategic document was developed to ensure that activities over the next five years accurately position and signal high-leverage entry points and are based on the current context and understanding of future health system challenges. The preparation of this document was overseen by a core group of Member States including Belgium, Estonia, France, Germany, Kazakhstan, Norway, Slovenia and the United Kingdom. The strategic document proposes two key strategic directions (transforming health services to meet the challenges of the 21st century; and moving towards universal health coverage for a Europe free of impoverishing out-of-pocket health expenditures) and three enabling factors for both Member States and the Secretariat (enabling a competent health workforce; innovating medicines and technology; boosting health information). Managing change and innovation is a key component for governing these strategic directions. The strategic document to be presented at the RC65 can be found in annex 1. Working together for better health outcomes in Europe Page 8 Areas for collaboration in strengthening health systems in the European Region Participants expressed support for the WHO Regional Office for Europe’s strategic document for 2015-2020 but also discussed several important areas that could contribute to realizing the priorities outlined in the strategic document. These are primarily in the areas of understanding unmet needs, cooperation around health systems performance assessments (HSPA), scaling up and implementing research, strengthening patient-centredness and developing a stronger evidence base for policies. Understanding unmet needs Participants agreed that the figures for out-of-pocket payments are indeed significant. Additionally important is highlighting the need to have more information on people who are not able to afford treatment at all and are therefore not receiving treatment at all. At the country level we have programs working with marginalized groups (migrants, disease specific programs) but would be important to also capture unmet needs among these and other populations. The World Bank has a health utilization survey which can help identify distribution across a number of countries but this is not standardized in a way that every country is collecting this data. There exist several issues around surveys - how they are administered, how frequently and where that impose limitations on our ability to compare define unmet needs but even for out-of-pocket payments and catastrophic payments. Thus the agenda of data collection remains an extremely important agenda item for all partners. Cooperation around health systems performance assessments (HSPA) The European Commission has been working on a joint assessment framework that has engaged many partners (World Bank, WHO, OECD) to guide the development of indicators to compare countries at a high level and identify their main strengths and weaknesses. The HSPA work that DG Sanco is developing serves as an in depth complement to this joint assessment framework work. To do this DG Sanco has set up an HSPA expert group to develop one HSPA format with one voice. The HSPA expert group includes an internal expert group that represents the various bodies in the European Commission and an external group of experts from partner organizations including the WHO Regional Office for Europe, OECD and the World Bank. The goal of the expert is to provide a space for EU Member States, organizations and different European Commission bodies to share their experiences with HSPA. The second goal is to identify a methodology and tools to support national policy makers to implement HSPA. Here the comparative advantages of different organizations is of great importance and experience thus far has been very positive demonstrating how much faster these sorts of initiatives can be done when all partners are involved. It will be important to continue this collaboration and maintain a focus on helping countries on the national level to draw conclusions from the data, use this data as the basis for developing strategies, implement these strategies, and improve the mobilization of resources to implement these strategies. Scaling up and implementing research At least three important research priorities were mentioned by partners. First, more involvement of the end-user in the design of research is needed and is an obvious means by which to ensure better scale up and implementation of research. This is central to designing people-centred health systems. Cost effectiveness, cost benefit and comparative effectiveness research continues to be Working together for better health outcomes in Europe Page 9 important but increasingly research is needed to help understand how systems can change and transform to support the development of resilient health systems. Any platform that can allow for implementation and scaling up of research would be important for partners to support. Strengthening patient-centredness Work will require more attention on how this work engages patients and populations. Important to this will be the existence of patient associations. This was emphasized by EPF and is an area where it can help not only to create patient associations but ensure that the associations and governments have the tools to conduct meaningful dialog with each other. The Global Fund has been particularly successful with its HIV and TB programs. Interestingly, some of the most innovation in engaging patients has also occurred there were the need is most urgent in the emerging economies rather than in more established and seemingly more developed and more mature health systems. Focusing on waste and inefficiency Hesitation towards reform continues to be observed among policy makers. This hesitation seems to be exacerbated by 1) lack of clarity on implementation models, especially in the fine details and minute logistics in such areas as e-health and health services delivery and 2) there is still little evidence for the impact of health sector on economic growth. There is a real need for cost benefit analyses that explore the long term impact, the outcomes, of reforms and an evidence base for health system reforms to help policy makers understand what they can expect from health policies. Giving the fear of inefficiencies and potentially costly reforms for governments involving the high hanging fruit, partners agreed that “waste” is an important entry point by which to discuss reform with ministries of health and of finance. Working together for better health outcomes in Europe Page 10 Mechanisms for collaboration in health systems strengthening in the European Region Partners identified several important mechanisms by which they could work more closely together: harmonizing data collection, coordinating analysis and recommendations, clarifying processes and implementation strategies, speaking a common language, capitalizing on differing mandates and country specific work. Harmonizing data collection On the data front OECD, Eurostat and the WHO Regional Office have worked closely to establish joint data collection. This process has been on going for 10 years now and continues to evolve not only in collecting data on health expenditure but also data on health utilization, the health workforce and recently on migration of health professionals. This collaboration has been very strong and serves to reinforce data collection and ensure that countries and partners are working with the same data. Coordinating analysis& recommendations All partners are interested in similar issues around access, quality and efficiency. Here coordination in analysis on public health, health care delivery and health system strengthening could be a valuable area for more cooperation, especially if jointly we can do better than working alone. Similarly, where programs and projects overlap it would be important to be aware of each other’s recommendations and join forces. For example the OECD is currently working on some recommendations for several of its Member States on the management, measurement and governance of health care quality systems. Should another organization work on this it would be productive and helpful to countries to coordinate recommendations but also to help policy makers in countries know what the different organizations offer. Clarifying processes & implementation strategies A lot of the work partners are pursuing is to guide countries on what to do. Issues emerge where and when organizations differ in how to do things, what priorities to pursue. It would therefore be useful to work together on strategies and priorities. Furthermore, there is also a lot of fragmentation because other actors and donors are working vertically and not at the health systems level. This impacts the processes pursued by organizations to get there and while what they are working on is clear, the processes by which they are getting there is not always clear. Speaking a common language It was agreed that most of the documents partners are producing are saying the same thing but all are using different language to say the same thing. This was noted in a study looking at the way different organizations were discussing governance of health systems. Using different language is detrimental for Member States and coordination across partners. If terminology could be unified that would be a significant advancement especially given that the last 20 years have seen more synergy in what we are pursuing: access, quality and efficiency while maintaining universal health coverage and working intersectorally. Capitalizing on eachother’s mandates While some activities can be done together, not all can be. Partners for example have different mandates with different comparative advantages. Here perhaps exploiting each other’s comparative advantage could be increased. For example the World Bank has started working Working together for better health outcomes in Europe Page 11 more on implementation and could exploit perhaps WHO’s advantage and experience in implementation. Country specific work There has already been some very successful collaboration around country specific work. For example the collaboration between the WHO and the EU in Cyprus around implementation of UHC or the collaboration between the EU and the World Bank in Ukraine and Romania on health financing and change in health services delivery. On the country level partners are clearly pairing up on a case by case basis and no national mechanisms exist for collaboration as they do for cross country international work. In the EU mechanisms are perhaps a bit more established given the mandate of the EU and the agreements that Member States agree upon with entering the EU but outside of the EU national mechanisms for collaboration between partners is less established and could potentially be an area of development. On the other hand work such as the Global Fund, which has focused on non-EU countries and disease-specific countries has really tried to focus on country ownership and fit its activities into national priorities. Working together for better health outcomes in Europe Page 12 Conclusions The meeting was an important step in strengthening collaboration among WHO Europe’s partners for health systems strengthening, with a view to better aligning priorities for health systems strengthening from 2015 to 2020, and to explore possible collaboration in this important area. Key summary points include: 1) Partners endorsed the WHO’s document Priorities for health systems strengthening in the European Region 2015–2020: walking the talk on people centredness agreeing it is both relevant and important for health systems strengthening. 2) The meeting underscored the importance of making health systems people-centred and finding new ways of engaging civil society. 3) The meeting was an important opportunity to connect with the EPF, a key stakeholder in building people-centred health systems. EPF emphasized the need for a value based approach, that is: “doing what is right, not just always doing things in the right way”. This supports our approach at DSP where we promote value-based health systems to improve health outcomes. 4) The meeting clarified how much is being done by all partners and confirmed that while partners have come a long way in improving collaboration, clearly collaboration is still required on multiple fronts. It is however necessary to recognize the different organization mandates and that these differing mandates offer opportunities for exploiting each other’s comparative advantage. 5) There are at least five joint action areas (understanding unmet needs, cooperation around health systems performance assessments (HSPA), scaling up and implementing research, strengthening patient-centredness and developing a stronger evidence base for policies) and six modalities by which partners can increase cooperation (harmonizing data collection, coordinating analysis and recommendations, clarifying processes and implementation strategies, speaking a common language, capitalizing on differing mandates and country specific work). 6) The next steps should be to identify some key issues around which to meet. Meetings, it was proposed, could be chaired on a rotational basis and organized around the themes identified in the WHO strategic document. An important focus for these meetings should be on how partners can make information more available and easy to use by policy makers. Working together for better health outcomes in Europe Page 13 References 1. Health systems for health and wealth in the context of Health 2020: follow-up meeting on the 2008 Tallinn Charter.Tallinn, Estonia, 17–18 October 2013. Copenhagen: World Health Organization Regional Office for Europe; 2014(http://www.euro.who.int/en/media- centre/events/events/2013/10/health-systems-for-health-and-wealth-in-the-context-of-health- 2020/documentation/health-systems-for-health-and-wealth-in-the-context-of-health- 2020follow-up-meeting-on-the-2008-tallinn-charteraccessed 16 July 2015). 2. Towards people-centred health systems: An innovative approach for better health outcomes. 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(http://www.euro.who.int/en/about- us/partners/observatory/publications/policy-briefs-and-summaries/economic-crisis,-health- systems-and-health-in-europe-impact-and-implications-for-policy , accessed 16 July 2015). 8. EMPATHiE: empowering patients in the management of chronic diseases – final summary report. Brussels: European Commission; 2014 (http://ec.europa.eu/health/patient_safety/key_documents/index_en.htm, accessed 16 July 2015). Working together for better health outcomes in Europe Page 14 9. Health system challenges and opportunities for better NCD outcomes. Copenhagen: World Health Organization Regional Office for Europe; 2013 (http://www.ndphs.org///documents/3965/NCD_8-9- 5__HSS%20NCD%20Country%20Assessment%20Guide_v7.pdf , accessed 16 July 2015) 10. The Tallinn Charter: Health Systems for Health and Wealth. Copenhagen: World Health Organization Regional Office for Europe; 2008 (http://www.euro.who.int/document/e91438.pdfaccessed 16 July 2015). Working together for better health outcomes in Europe Page 15 ANNEX 1.STRATEGIC DOCUMENT Twenty-second Standing Committee of the Regional Committee for Europe EUR/SC22(4)/10 150317 Fourth session 21 April 2015 Geneva, Switzerland, 16–17May2015 ORIGINAL: ENGLISH Priorities for health systems strengthening in the European Region 2015–2020: walking the talk on people centredness This document captures the strategic priorities of the WHO Regional Office for Europe in the area of health systems strengthening for 2015–2020, taking its vision from the European health policy frameworkHealth 2020. It complements the document “Towards people-centred health systems: an innovative approach for better health outcomes” and aligns with the WHO global strategy on people-centred and integrated health services, which is currently under consultation together with the second global strategy on workforce education.Both of those documents are to be submitted to the World Health Assembly for approval in May 2016. The WHO Regional Office for Europe supports Member States in strengthening health systems to become more people-centred in order to accelerate health gain, reduce health inequalities, guarantee financial protection and ensure an efficient use of societal resources. To strengthen value-driven health systems, the Regional Office will work intensively with Member States over the 2015–2020 period in two priority areas: (1) transforming health services to meet the health challenges of the 21st century; (2) moving towards universal health coverage for a Europe free of impoverishing out-of-pocket payments. To make progress in these areas requires whole-of-society and whole-of- government efforts to embrace intersectoral actions, while designing effective and evidence-informed policies on service delivery and health financing. In addition, high-quality health-system inputs enable transforming health services and moving towards universal health coverage, including in the areas of the health workforce, medicines and other health technologies and health information. The document sets out some of the challenges Member States face in the two priority areas and highlights ways in which the WHO Regional Office can provide support. Working together for better health outcomes in Europe Page 16 Contents page “My ideal health system”: a people-centred perspective from Portugal ................................. 17 Background ..................................................................................................................... 18 Values-driven health systems strengthening ....................................................................... 19 Strategic priorities in health systems strengthening 2015–2020 ............................................ 20 Strategic priority 1: transforming health services to meet the health challenges of the 21st century................................................................................................... 21 Strategic priority 2: moving towards universal health coverage and a Europe freeof impoverishing out-of-pocket payments ............................................................. 23 Essential health system foundations: the health workforce, medicines and other technologies and health information................................................................................... 26 Foundation 1: enhancing the health workforce ........................................................... 26 Foundation 2: ensuring equitable access to cost-effective medicines and technology ..... 27 Foundation 3: improving health information and health information systems ................. 27 Health systems governance: managing change and innovation in health systems .................. 28 Key partners and support to Member States ....................................................................... 29 Working together for better health outcomes in Europe Page 17 My ideal health system: a people-centred perspective from Portugal1 “In my ideal health system, I am healthy from my safe and peaceful birth to my dignified death, late in life, surrounded by my family.” “Safety is a priority at my school and general legal requirements help keep me safe and healthy – such as fences around pools, mandatory child car seats, helmets for sports and no smoking in public places. When I go to school, the lunchroom serves healthy meals and junk food is not a part of my life.” “I have had all the vaccines currently available. My parents get texts reminding them when to take me in.” “When I have a specific question about my health, I text the cell phone of my health manager (or send an email in case of something needing a longer explanation) and they get back to me that day. They might ask me to send more diagnostic information from my cell phone. Then they either give me an answer that solves my problem or they schedule an appointment with them or the person best able to resolve my issue within the next week.” “In the case of an appointment, I arrive on time at the government funded ... Wellness Centre, which has parking, public transport access and is wheelchair accessible. This facility, which is in my community, resolves all my ambulatory issues: vaccines, screening procedures, prenatal care and diagnostic exams, including imaging exams.” “In the case of an emergency, ... the hospital has access to my health records and my health manager. ... If my problem can be resolved at that time (stitches, cast), I’ll expect to be discharged that day and to have a follow-up care appointment already booked with my health manager back at my Wellness Centre. If I need emergency surgery, I would expect to be admitted.” “If I do [get a chronic illness], I would like to be an active partner in my care and to do as much as possible on an outpatient basis and to perform the bulk of my care via self-management. My health manager would need to be an expert in my condition and so, though I would remain connected to my primary Wellness Centre, most of my interaction would be with and via my new chronic/serious disease coordinator.” 1“Me and my ideal health system” [Appendix 2]. In: The future for health: everyone has a role to play. Lisbon: Calouste Gulbenkian Foundation; 2014: 203–205 (http://www.gulbenkian.pt/mediaRep/gulbenkian/files/institucional/FTP_files/pdfs/FuturodaSaude2014/ReportFutur eforHealth_FCG2014/files/assets/basic-html/page203.html, accessed 16 February 2015). Working together for better health outcomes in Europe Page 18 Background This document captures the strategic priorities of the WHO Regional Office for Europe for strengthening health systems through a people-centred perspective. This document follows the directions of the European health policy framework – Health 20202– which, along with developing priorities and actions for health improvements more widely, sets out a comprehensive vision of the Regional Office to improve health and reduce health inequalities. It is also in close alignment with the document “Towards people-centred health systems: an innovative approach for better health outcomes”,3 which sets out the vision, mission, operational approach and products and services offered to Member States by the Regional Office. In line with the comprehensive approaches outlined in these two umbrella documents, this paper highlights the strategic priorities of the WHO Regional Office for Europe for 2015–2020. The strategic priorities set out here have been informed by a number of processes. First, the Division of Health Systems and Public Health has worked with many countries on health systems strengthening, providing an overview of trends and directions in the Region. Secondly, the WHO Regional Office engages with many Member States on discussions of priorities of collaboration, including for health systems strengthening, on the basis of the biennial collaborative agreements. Thirdly, to mark the five-year anniversary of the adoption of The Tallinn Charter: Health Systems for Health and Wealth,4 the WHO Regional Office for Europe, in collaboration with the Government of Estonia, is leading an assessment to follow up on the successes and challenges in health systems strengthening under the banner of the Tallinn Charter. This has included a ministerial meeting hosted by the Government of Estonia,5 a questionnaire about future health systems strengthening priorities for Member States, and a forthcoming final report on the implementation of the Tallinn Charter, to be submitted to the 65th session of the Regional Committee for Europe in 2015. Additional crucial inputs have been the results of an expert meeting on health systems priorities, hosted by the Division of Health Systems and Public Health in Barcelona, Spain, on 3–4 November 2014, and the on going feedback from the core group of Member States6that have helped guide the final report on the Tallinn Charter. Finally, this document aligns with the WHO global strategy on people-centred and integrated health services and the second global strategy on workforce education, which are currently under development for approval by the World Health Assembly in May 2016. 2 Health 2020: a European policy framework and strategy for the 21st century. Copenhagen; WHO Regional Office for Europe.2012 (http://www.euro.who.int/__data/assets/pdf_file/0011/199532/Health2020-Long.pdf?ua=1, accessed 16 February 2015). 3 Towards people-centred health systems: an innovative approach for betterhealth outcomes. Copenhagen; WHO Regional Office for Europe; 2013(http://www.euro.who.int/__data/assets/pdf_file/0006/186756/Towards-people- centred-health-systems-an-innovative-approach-for-better-health-outcomes.pdf?ua=1, accessed 16 February 2015). 4 The Tallinn Charter: health systems for health and wealth. Copenhagen: WHO Regional Office for Europe; 2008 (http://www.euro.who.int/__data/assets/pdf_file/0008/88613/E91438.pdf, accessed 16 February 2015). 5Health systems for health and wealth in the context of Health 2020: follow-up meeting on the 2008 Tallinn Charter.Tallinn, Estonia, 17–18 October 2013. Copenhagen: WHO Regional Office for Europe; 2014 (http://www.euro.who.int/__data/assets/pdf_file/0008/249731/HEALTH-SYSTEMS-FOR-HEALTH-AND- WEALTH-IN-THE-CONTEXT-OF-HEALTH-2020-FOLLOW-UP-MEETING-ON-THE-2008-TALLINN- CHARTER,-Tallinn,-Estonia,-1718-October-2013-Eng.pdf?ua=1, accessed 16 February 2015). 6Belgium, Estonia, France, Germany,Kazakhstan, Norway, Slovenia and the United Kingdom. Working together for better health outcomes in Europe Page 19 Values-driven health systems strengthening A vision for people-centred health systems underlies the objectives and interventions set out in Health 2020 and is the driving force behind the strategic priorities articulated here. The subtitle of this document – walking the talk on people centredness – reflects the importance that the Regional Office attaches to ensuring that health systems in the European Region meet people’s needs and live up to their expectations. In a people-centred health system, the design of core system functions prioritizes the preferences and needs of individuals, their families and communities, both as participants and beneficiaries. Designing and orienting health systems in this way includes partnering with patients to understand but also define the quality of health systems. It means involving people in their own care and management, and developing the evidence base to inform people centred health systems. It is organized around the health needs and expectations of people throughout the life- course rather than around episodic diseases. It not only ensures that the voice of the majority is heard but also takes into account the voice of the vulnerable. People-centred health systems provide high-quality comprehensive and coordinated services in an equitable manner and involve people as partners in decision-making. This requires investments in health literacy and empowerment so that people have the necessary education and support to make decisions and to participate in their own care. It requires that people, including the poor and the vulnerable, do not face barriers or financial hardship in accessing the services that they need.7People-centred health systems are flexible and respond rapidly, for example, to emergencies or pandemics and the implementation of the International Health Regulations (IHR). The shift towards people-centred health systems requires a cultural readjustment, as well as technical solutions. The mission of the WHO Regional Office for Europe is to support Member States in strengthening health systems that put people at the centre in order to accelerate health gain, reduce health inequalities, guarantee financial protection and ensure an efficient use of societal resources, including through intersectoral actions consistent with whole-of-society and whole-of- government approaches. This involves responding to the diverse needs of all people, paying particular attention to the values of solidarity and equity. It means that people should not face financial hardship when accessing needed health services. It requires a focus on efficiency so that valuable resources are not wasted. It also requires greater transparency and a renewed commitment to performance assessment for accountability. Greater health gain and smaller health inequalities are high on the agenda of all Member States in the European Region. However, technocratic and provider-led solutions are not always optimal in improving health outcomes.8 For example, adherence to screening programmes, tuberculosis treatment or medication for hypertension is low in many countries despite solid evidence of effectiveness.9 Configuring health services to meet diverse needs in a more flexible manner can help to change health behaviour, enhance early detection of illness and increase adherence to treatment. 7 Transforming health services delivery towards people-centred health systems. Copenhagen: WHO Regional Office for Europe; 2014(http://www.euro.who.int/__data/assets/pdf_file/0016/260710/Transforming-health-services- delivery-towards-people-centred-health-systems.pdf?ua=1, accessed 15 April 2015). 8The world health report 2008: primary health care, now more than ever. Geneva: World Health Organization; 2008 (http://www.who.int/whr/2008/whr08_en.pdf, accessed 16 February 2015). 9Van den Boogaard J, Boeree MJ, Kibiki GS, Aarnoutse RE. The complexity of the adherence-response relationship in tuberculosis treatment: why are we still in the dark and how can we get out? Trop Med Int Health. 2011;16(6):693–698. doi:10.1111/j.1365-3156.2011.02755.x. Working together for better health outcomes in Europe Page 20 People-centred health systems reflect the values of solidarity and equity. They do not leave anyone behind; they minimize social exclusion and promote financial protection.10 The socioeconomic realities in the European Region are sobering, especially in the wake of the financial and economic crisis. Millions of people experience financial hardship when accessing the health services that they need. Some are impoverished or pushed further into poverty by having to pay out-of-pocket for health care. Others face catastrophic levels of out-of-pocket payments.11 A commitment to health gain and lower inequalities in health requires moving towards universal health coverage. Targeted approaches may be necessary to reach the most vulnerable groups of people. Economic hardship, ineffective social policies, a lack of transparency and weak accountability can limit people’s willingness to sustain the redistributive pact underpinning European social systems. Resources are stretched and may remain so for some time. One way of addressing this situation is to use available resources more efficiently. Inefficiencies waste valuable resources that could be used to enhance coverage, transform health service delivery and reduce inequalities. They limit a country’s health potential, are likely to affect the poor more than other people and undermine willingness to invest in health systems. Because of this, tackling inefficiency should be a priority for everyone. Strengthening health systems that put people at the centre involves trade-offs, especially at times of economic hardship. There are no ready-made solutions to balancing social goals and prioritizing limited resources. The WHO Regional Office provides tailored support to Member States, helping them to address problems and assess policy options through context-specific analytical work that draws on international experience, policy dialogue, knowledge brokering and direct technical assistance. Strategic priorities in health systems strengthening 2015–2020 To strengthen health systems towards a people-centred focus in line with the values outlined above, the Regional Office will work intensively with Member States over the 2015–2020 period in two priority areas: • strategic priority 1: transforming health services to meet the health challenges of the 21st century; • strategic priority 2: moving towards universal health coverage for a Europe free of impoverishing out-of-pocket payments. To make progress in these areas requires carefully designed policies on service delivery and health financing. It also requires a special focus on the health workforce, medicines and other technologies and health information. These are the essential foundations of health systems, which need to be aligned with the strategic priorities. In addition, strengthening health systems is 10 Strengthening people-centred health services delivery in the WHO European Region: concept note. Copenhagen: WHO Regional Office for Europe; 2014(http://www.euro.who.int/__data/assets/pdf_file/0005/258224/Strengthening-people-centred-health-services- delivery-in-the-WHO-European-Region-concept-note.pdf?ua=1, accessed 15 April 2015). 11Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A et al.Economic crisis, health systems and health in Europe: impact and implications for policy. European Observatory on Health Systems and Health Policies: policy summary 12. Copenhagen: WHO Regional Office for Europe; 2014 (http://www.euro.who.int/__data/assets/pdf_file/0008/257579/12-Summary-Economic-crisis,-health-systems-and- health-in-Europe.pdf?ua=1, accessed 16 February 2015). Working together for better health outcomes in Europe Page 21 an effort that is sensitive to factors outside the health system, such as the social determinants of health and the policies of non-health sectors. The following sections set out some of the challenges that Member States face in the two priority areas and highlight ways in which the Regional Office can provide support. The focus in this document is primarily on those policies that lie within direct control of the health system, while factors outside the health system are acknowledged throughout. Fig. 1. From values to action: strategic priorities of the WHO Regional Office for Europe in people-centred health systems strengthening 2015–2020 Strategic priority 1: transforming health services to meet the health challenges of the 21st century Health services need to adapt to meet new needs. In the 21st century, this means putting non communicable diseases, chronic conditions, multi morbidity and multidrug- and extensively drug-resistant tuberculosis and a number of other health threats, such as HIV and antimicrobial resistance, at the top of the health policy agenda. Population-based interventions and individual services are equally important; for example, some of the observed decline in mortality due to coronary heart disease is the direct result of tackling risk factors, such as high blood pressure, tobacco use, high cholesterol and salt intake, through a mix of population-based and individual services. Progress in people-centred health gain can come from moving away from reactive, disease- based, episodic service delivery towards a proactive approach involving better coordination of health promotion, disease prevention and condition management throughout the life-course. As the burden of chronic illness increases, more prevention and care take place in different settings, including the home. This demands stronger public health systems, primary and community care, Working together for better health outcomes in Europe Page 22 the development of specialist networks, and integrated models of care for disease prevention and health promotion. It also demands greater unity between public health and individual services; for example by integrating essential public health operations into primary health care and hospitals. Importantly, greater health literacy and people more engaged in health protection, disease prevention and the self-management of disease add value to system changes and improve outcomes. Strategic purchasing contributes to the people-centred transformation of health services by linking provider payment to performance. This can encourage the formation of interdisciplinary provider teams that better coordinate patient care, share health information and other technologies, and ensure, monitor and assess quality. The WHO Regional Office for Europe supports Members States in: • empowering people through enhanced health literacy and engaging patients in clinical decision-making, self-management, care planning, provider choice, within reasonable limits, self-monitoring and self-treatment. Particular attention to empowering and engaging vulnerable and marginalized populations can help to address inequalities in access to care and care outcomes; • building capacity to restructure public health services so that they can respond effectively to public health emergencies and deliver better occupational and environmental health, and safe and healthy food and nutrition; • ensuring a comprehensive continuum of services with strengthened primary health care as the provider hub and first contact point for people, coordinating services from health promotion, health protection, disease prevention, diagnosis, treatment and long-term rehabilitation to palliative care; • moving away from traditional modalities of service delivery, for example by empowering people to self-manage their chronic conditions, modernizing evidence-based guidelines and standards, developing care pathways flexible enough to meet individual needs, promoting the appropriate use of medicines and other technologies, and redesigning the role of hospitals; • breaking down boundaries across care levels and settings to promote coordination among a wide spectrum of professionals and services, including pharmacists, social and long-term care and informal carers, to ensure continuity of care and to remove barriers to access to needed care; and • managing processes for quality and better outcomes through effective intersectoral action and regular monitoring of performance, including systematic feedback to providers. Transforming service delivery in this manner requires an understanding of the social determinants of health and care-seeking behaviour and implies working with community outreach and social care in a harmonious manner. For example, community organizations can reach and mobilize people who traditionally do not seek health services and are invisible to health-care providers and encourage them to attend screening activities. From a health systems perspective, identifying clever organizational and financial arrangements that enable this joint work at the level of primary health-care centres and population outreach programmes is a new frontier. People-centred, more integrated services require new ways of training, deploying and managing the health workforce, better management and appropriate use of medicines, and stronger health information. Working together for better health outcomes in Europe Page 23 To build the right competencies for integrated service delivery and people-centred care, the pre- service and in-service training of health professionals should be planned and implemented based on the expected future needs of patients and societies. Training curricula based on competencies may be more responsive to changing needs. Optimizing the skill mix by organizing health workers in multidisciplinary teams, with a greater emphasis on team work and non-physician clinicians, not least nurses and midwives, can lead to greater efficiency and more responsive health services. Interdisciplinary education may help to break down professional silos and enhance collaboration in teams. The improved management and more appropriate use of medicines are essential to the successful transformation of health services. It is estimated that 30–50% of medicines are not taken as intended,12 affecting health outcomes and wasting resources. Innovative interventions need to look beyond the clinic and support both clinicians and patients to get the most from medicines and prescription-related consultations. Pharmacists can make a significant contribution, for example by enhancing patient motivation between consultations. Other innovative and effective strategies to improve the use of medicines include therapeutic committees, electronic formularies and clinical guidelines, feedback on medicine use, medicine information policies and the evaluation of health outcomes. Improving and making better use of health information is critical to transforming health services and to making them more people-centred. Health information systems are often not as effective as they could be because they are disjointed across levels of care, providers or type of ownership; they often serve higher-level monitoring needs instead of facilitating clinical and managerial decision-making; and they rarely serve the needs and interests of people. There are an increasing number of good practices to address these concerns. These include integrated systems, following the principle of moving data, not patients, and creating a publicly accessible information technology interface to facilitate self-management by patients. Improved collection, monitoring and reporting of key health data allows for informed decision-making, thereby better targeting interventions that maximize the health impact. Strategic priority 2: moving towards universal health coverage and a Europe free of impoverishing out-of-pocket payments Moving towards universal health coverage is a cornerstone of health and social policy of the Member States in the European Region and a key mechanism for delivering the commitments of the Tallinn Charter. In promoting universal health coverage, Member States aim to narrow the gap between health needs and utilization, improve the quality of care, ensure financial protection and enhance equity by identifying and protecting vulnerable and marginalized groups. To achieve this with limited resources, Member States need to build resilience to economic cycles and develop incentives for efficient behaviour among a wide range of health systems actors. Health financing policy plays a critical role in moving towards universal health coverage. The WHO Regional Office for Europe supports Members States in the following areas. • Promoting policies to reduce out-of-pocket payments, especially among poorer people and other vulnerable groups. There are no quick fixes for reducing out-of-pocket payments. Instead, what is needed is a comprehensive approach that assembles and aligns all dimensions of health financing for greater efficiency and equity, including in the areas of revenue collection, pooling, purchasing,benefit design and coverage decisions. 12Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003 (http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf?ua=1, accessed 16 February 2015). Working together for better health outcomes in Europe Page 24 • Ensuring adequate public financing for health systems. The boundaries between general tax funded and social insurance systems are becoming increasingly blurred. Many countries that have traditionally relied on payroll taxes now realize that a mixed public revenue base is more conducive to achieving high levels of coverage and reducing out-of- pocket payments without unduly burdening the labour market. • Reducing fragmentation in health system funding channels (pooling) to achieve a more efficient and equitable allocation of resources and more rational service delivery. Multiple funding channels often lead to duplication in the service delivery infrastructure, creating inefficiencies, coordination problems and inequalities in access to and the use of health services. • Adopting strategic purchasing mechanisms. Strategic purchasing is an important policy instrument that allows Member States to prioritize cost-effective medicines, technologies and services (including health promotion and prevention services, such as vaccination and screening), promote evidence-based clinical practice, reduce inappropriate utilization and minimize health-care errors. In contrast, passive purchasing agencies using out dated provider payment mechanisms will encourage inertia and inefficiencies. • Ensuring effective and equitable coverage decisions based on systematic, evidence- based and transparent processes. Ambiguity over rights and entitlements shifts coverage decisions to providers, which often exacerbates inequalities in access to care. Systematic and transparent coverage decisions involve balancing resource constraints with cost– effectiveness, equity criteria and public preferences. Identifying and protecting vulnerable and marginalized groups is a core challenge for progress towards universal health coverage. The definition of vulnerable and marginalized is context dependent and the Regional Office supports Member States to approach this challenge in an evidence-informed manner. Depending on the context, vulnerable and marginalized groups may include the poor, the disabled, the chronically ill, the elderly, Roma and documented and undocumented migrants. In making the right definition, it is critical for health systems to work closely with other sectors in order to obtain a comprehensive picture of social vulnerability and to provide comprehensive social protection and a range of services. For example, pensioners in countries with relatively low retirement pensions are much more susceptible to the price of medicines and are more vulnerable to a catastrophic level of expenditure than those in countries with higher retirement pensions. Accelerating progress towards universal health coverage cannot be achieved without an adequate, skilled and motivated health workforce, timely and equitable access to medicines and other technologies, and careful, context-specific monitoring and analysis. Tackling inefficiencies is also vital to securing political and public support for universal health coverage. Equitable access to quality health services relies on the availability, accessibility, acceptability and quality of the health workforce. Policy challenges in the European Region include a lack of sufficient public funding for health systems, low salaries, inadequate living and working conditions for staff, particularly in rural areas, and a punitive and demotivating supervisory culture. These factors fuel health workforce migration throughout the Region, leading to access problems in countries that lose staff. Medicines are the main driver of out-of-pocket payments and a key source of catastrophic and impoverishing health expenditures. Weak pharmaceutical policies and the inappropriate use of medicines are leading sources of inefficiency in many health systems. To safeguard timely and equitable access to medicines, while promoting a more efficient use of resources, Member States Working together for better health outcomes in Europe Page 25 can focus on the following policies: careful management of the entry of medicines; pricing new medicines and other technologies on the basis of their added therapeutic value, using systematic criteria and transparent processes, such as health technology assessment; rewarding genuine clinical innovation; and assessing the budgetary impact of adopting new technologies. Monitoring progress towards universal health coverage can generate important health evidence which, in turn, can be used to inspire and drive further reforms. Few countries have established systematic mechanisms for monitoring universal health coverage, but the financial and economic crisis has provided added impetus to do so. Monitoring changes in population entitlements, in the range of publicly financed benefits and in the extent of out-of-pocket payments, enables countries to develop better targeted policies that are more likely to protect poorer people and other vulnerable groups. The WHO Regional Office is working with several Member States to facilitate institutionalized universal health coverage monitoring. Addressing inefficiency in health systems is vital to securing popular and political support for moving towards and maintaining universal health coverage, especially during economic downturns. It is difficult to advocate for more public spending on health when the system displays inefficiency and waste. However, improving efficiency is not the same as reducing spending and does not always result in savings; in practice, it often requires added investment.13 Short-term quick fixes – such as delaying investment in health-care facilities – can help to keep the system running during a crisis but are unlikely to be sustainable in the longer term. The transition to a more efficient system needs to be carefully managed and appropriately resourced to avoid undermining service quality, exacerbating financial hardship or creating new barriers to access. 13Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A et al.Economic crisis, health systems and health in Europe: impact and implications for policy.Copenhagen: WHO Regional Office for Europe; 2014 (http://www.euro.who.int/__data/assets/pdf_file/0008/257579/12-Summary-Economic-crisis,-health-systems-and- health-in-Europe.pdf?ua=1, accessed 16 February 2015). Working together for better health outcomes in Europe Page 26 Fig. 2.Distinguishing between savings and efficiency gains Essential health systems foundations: the health workforce, medicines and other technologies and health information High-quality health systems inputs enable transforming health services and moving towards universal health coverage, including in the areas of the health workforce, medicines and other health technologies, and health information. The WHO Regional Office for Europe supports Member States in each of these areas in a number of ways. Foundation 1: enhancing the health workforce The health workforce is an essential input in health systems and improving health outcomes is dependent on their availability, accessibility, acceptability and quality. The health workforceis central to the transformation of service delivery to meet 21st century needs and to translating the vision of universal health coverage into improved health services on the ground. The WHO Regional Office for Europe supports Member States in a number of ways. • Rethinking the roles of health workers and optimizing the skill mix in the context of demographic trends, technological advancements, patterns of diseases and changing population health needs. This is accompanied by a progressive shift in the demand for patient-centred health services and personalized care. Changing roles and shifting tasks can lead to better use of the available health workforce, especially nurses and midwives, and to more efficient and responsive health services, including an improved capacity for working with other sectors. • Investing in and transforming health workforce education and training for the development of a fit-for-purpose body of health professionals, whose education and training should be planned and implemented in line with the expected future needs of patients and societies. The adoption of competency-based curricula, the promotion of interdisciplinary education and life-long learning should be embraced. Working together for better health outcomes in Europe Page 27 • Improving the performance of health workers and promoting innovative cost-effective practices require designing more effective management and reward systems, thereby developing an attractive working environment. • Establishing policies to ensure a sufficient and sustainable health workforce. Effective retention strategies are needed to deploy and to keep health workers where they can best make a positive difference in population health. • Ensuring the ability of the health workforce to quickly respond, In line with the IHR, to changing events that may constitute emergencies or pandemics. Foundation 2: ensuring equitable access to cost-effective medicines and technology Ensuring the availability of and equitable access to cost-effective medicines and technology is an important input into health systems, in particular for transforming health services and moving towards universal health coverage. The WHO Regional Office for Europe supports Member States in a number of ways. • Improving access to essential medicines and medical devices, establishing and using transparent systems and processes for (i) selection of medical products to be authorized for use in Member States, (ii) pricing and coverage of medical products using public funds, and (iii) direct procurement of medical products by public or quasi-public agencies. These transparent systems and processes should be based on health technology assessments, models for the rational use of medicines and careful review with due regard for public health relevance and evidence on efficacy, safety, comparative effectiveness, cost– effectiveness and equity. • Defining the vision and directions of pharmaceutical policy in Member States based on international evidence and contextualized situation diagnosis through a participatory process in consultation with stakeholders. • Supporting the appropriate use of medical products and developing pharmaceutical services as an integral part of primary health care. Foundation 3: improving health information and health information systems Health information and research are the foundations for strengthening health systems and health policy, and health information systems are an integral part of health systems (World Health Assembly resolution WHA60.27). This includes strengthening not only the information content but also the information systems themselves, including health information platforms and infrastructure, as well as eHealth. Strengthening health information systems is therefore a key prerequisite for the implementation of Health 2020. The WHO Regional Office supports Member States in a number of ways: • improving data and information collection, analysis, reporting and dissemination mechanisms to continuously monitor and assess the health status of the population and the performance of health systems, paying particular attention to monitoring inequalities and moving towards universal health coverage; • carrying out in-depth analytical work to provide evidence for policy-makers, including through the Health Evidence Network and other mechanisms; • harmonizing and standardizing health information, improving the quality of data and reporting through the WHO European Health Information Initiative; and Working together for better health outcomes in Europe Page 28 • translating evidence into sound policies and practices, such as through the Evidence- informed Policy Network (EVIPNet), which requires up-to-date and user-friendly information systems at all levels of the health system. These should not only transfer data but also assist in effective decision-making most appropriate to the situation and setting. At the policy level, mechanisms to evaluate the effectiveness of implemented policies can be established to ensure continuous learning and progress. Health systems governance: managing change and innovation in health systems Smart health systems governance creates mechanisms to manage change and innovations in health systems. Health systems must adapt and be responsive to changing environments, new priorities and innovations. Technology is dramatically changing the way in which pain is treated, health is restored and life is extended. The rapidly evolving field of science has resulted in pharmaceuticals that are more focused, affordable and effective, with cutting-edge research committed to the discovery, development and adoption of value-added medicines. The information revolution and its potential successes have unquestionably been absorbed by the health systems of today. In European Union countries, for example, a survey of general practitioner offices in 2013 found that the majority of medical practices had a functioning information technology infrastructure, with around 80% able to store patient data electronically; nearly all (97%) reported using a computer during consultation with a patient.14The innovative use of technology for communicating health messages, such as mobile telephones with text messaging, is increasingly common. Health systems must continuously adapt to such progress. In order to keep pace with and respond to those challenges, complex transformational changes in health systems require a long-term horizon and proactive management. The complexity of health systems changes does not lend itself to business redesign processes. Change management strategies therefore need to recognize contextual factors in national and local specificities. Technical components of change need to be embedded in a positive culture of improvement which can be supported by many strategies: for example, through building social opportunities for team-building; harnessing local opinion leaders; clinical and managerial leadership; effective stakeholder management; partnership working; and building the knowledge, skills and attitudes of people to support the proposed changes. Aligned with this vision, health systems require leaders and managers who are comfortable managing change and innovation, empowered by both technical competence and communication skills. Engaged leaders and managers can make a major contribution to achieving better health outcomes and overall performance. People-centred health systems require shared leadership both within and across organizations, involving providers, people and managers, all with differentiated roles but working collaboratively across organizational and professional boundaries in a framed vision and strategy. Active managers who interact between people, health staff and organizations to ensure positive health outcomes and overall performance are equally key. 14Codagnone, C, Lupiañez-Villanueva F. Benchmarking deployment of eHealth among general practitioners (2013).Brussels: European Union; 2013 (http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&ved=0CCgQFjAB&url=http%3 A%2F%2Fec.europa.eu%2Finformation_society%2Fnewsroom%2Fcf%2Fdae%2Fdocument.cfm%3Fdoc_id%3D4 897&ei=SAreVPWnNMrYau6CguAI&usg=AFQjCNH_qTDHVSrLfVULGLO0rRnIazko6A, accessed 16 February 2015). Working together for better health outcomes in Europe Page 29 For transformational changes to be sustainable, solutions must be contextualized and linked to broader development and social policies with the participation of a wide range of stakeholders and partners. This includes the education, employment and transport sectors, among others. Moreover, sustainable and resilient health systems are likely to be those that also take environmental considerations into account and that work closely with the environment sector. A tailored approach to policy work should be combined with global and regional guidance, standards and evidence. Generic tools and instruments are of help, but it is necessary to seek country solutions through multidisciplinary team-based problem solving on the basis of a balanced mix of top-down and bottom-up approaches. Step-by-step hands-on learning through institutional capacity-building leads to more sustainable solutions than quick fixes and externally imposed recommendations. Institutional capacity-building therefore needs to be incorporated in approaches to people-centred health systems strengthening. The experiences, collegiality and growth in networking that can happen during the process of change have the power to act as a major cohesive force for the future when the process is led and managed successfully. This building of collective values, distributed leadership and commitment to change can leave an enduring legacy. Indeed, reforms happen more effectively where there is a history of good working relations. While achieving transformational change requires managing change and innovations, ensuring accountability for performance is also a key governance challenge. Accountability goes hand in hand with people-centredness; it is at the heart of policy discussions in Europe and is enshrined in the Tallinn Charter. Evaluating various facets of the performance of health systems is a key aspect of accountability. Performance assessments can be comprehensive or focused on selective outcomes. For example, the WHO Regional Office for Europe has been working with Member States to assess their health systems response to non-communicable diseases – a specific type of performance assessment. Key partners and support to Member States The WHO Regional Office for Europe seeks to provide support to Member States in these areas in a competent, effective, integrated and evidence-informed manner, working closely with key partners. To make the most of limited resources, the Regional Office engages in areas where experts thatcan provide a comparative advantage and add value. As a result, the Regional Office aims to strike a balance between in-depth country-level work and multi-country comparative analysis and capacity-building. Core areas of the Regional Office’s work include: • systematizing evidence for knowledge translation using a common health systems framework, such as WHO’s work on the impact of the crisis on health and health systems performance; • creating platforms to facilitate learning through the unique ability of the Organization to bring together Member States and leading academic experts, as well as special-interest groups, including patient and provider associations, international organizations and global think-tanks, such as the WHO European advisory group on the European action plan for strengthening public health capacities and services; • providing technical assistance and advisory services at the country level through state-of- the-art analytical work, support to policy development, including regulatory reviews and dialogue, translating findings into practical know-how and identifying priority lists of actions, policy options and mechanisms for system leaders, such as WHO’s assistance to system reforms in the wake of the financial crisis in Cyprus and Greece, and support for scaling up the health systems response to non-communicable diseases in Belarus, Bosnia Working together for better health outcomes in Europe Page 30 and Herzegovina, Croatia, Estonia, Hungary, Kyrgyzstan, the Republic of Moldova, Tajikistan and Turkey; • organizing policy dialogues with broad stakeholder participation, including policy seminars and expert workshops, such as the senior policy seminars on primary health care and universal health coverage; • providing targeted capacity-building opportunities through national, regional and multicountry courses, such as the Flagship Course on Health Systems Strengthening, the Barcelona Course on Health Financing with the theme of universal health coverage, and EVIPNet, among others. In all these areas, the Regional Office works closely with partners, such as patient organizations, the European Commission, the European Observatory on Health Systems and Policies, the GAVI Alliance. the Organisation for Economic Co-operation and Development, The Global Fund, the World Bank and WHO collaborating centres, in addition to bilateral cooperation agencies. Working in partnerships enables the Regional Office to deliver in areas whereithas a comparative advantage and expertise. The Regional Office participates in and contributes to the functioning of many important networks in Europe. These include but are not limited to the Association of Schools of Public Health in the European Region, the Eurasian National Health Accounts network, the EuroHealthNet, the European Network of Health Promoting Schools, the European Public Health Association, the Healthy Cities Network, the International Network of Health Promoting Hospitals and Health Services, the Pharmaceutical Pricing and Reimbursement Information network and the South-eastern European Health Network. = = = Working together for better health outcomes in Europe Page 31 ANNEX 2. PROVISIONAL PROGRAMME Thursday, 30April 2015 09:00-09:15 Welcome and introduction Objective: To introduce the meeting rationale and meeting participants. • Dr. Hans Kluge, Director of Division on Health Systems and Public Health WHO Regional Office for Europe 09:15-10:00 Setting the scene for Europe. Objective: To outline the main health challenges for Europe. • Main health challenges Dr.JosepFigueras, Director of the European Observatory on Health Systems and Policies • Patient perspective Ms Nicola Bedlington, Secretary General of the European Patients’ Forum 10:00-11:00 1. Transforming health services to meet the health challenges of the 21st century; 2. Moving Towards Universal Health Coverage (UHC) and a Europe free of impoverishing out-of-pocket payments. Objective: For participants to share their health system strengthening activities and workplans – planned and current – in support of countries in the Region. As a starting point, the WHO Regional Office for Europe will outline the strategic directions of its HSS work over the next five years, as based on the mandate issued by its 53 Member States, in order to explore with partners where potential synergies, joint projects and areas for collaboration can be developed. • European Commission – Director-General for Economic and Financial Affairs • European Commission - Directorate-General for Employment, Social Affairs and Inclusion • European Commission - Directorate-General for Health and Food Safety • European Commission – Director-General for International Cooperation and Development • European Commission - Directorate-General for Research and Innovation • European Observatory on health systems and policies • Global Fund • Organisation for Economic Cooperation and Development • Secretariat to the Social Protection Committee, European Commission • World Bank. 11:00-11:20 Health break. 11:20-12:20 Strategic health system strengthening priorities in Europe 2015-2020 (cont’d). 12:20-13:20 Discussion. Objective: To learn from successful collaborativeworkamonginternational organizations and to identifypotentialareas of futurecollaboration. Working together for better health outcomes in Europe Page 32 ANNEX 3. LIST OF PARTICIPANTS Ms Nicola Bedlington Secretary General European Patients' Forum 31 Rue du Commerce B- 1000 Brussels Belgium Mr Paolo Carlo Belli Program Leader World Bank Ukraine, Belarus, and Moldova Country Unit World Bank 1, DniprovskiyUzviz, 2nd Floor 01010 - Kyiv Ukraine Mr Nicolas Cantau Regional Manager The Global Fund to Fight AIDS, Tuberculosis and Malaria Chemin de Blandonnet 8 1214 - Vernier, Geneva Switzerland Mr Sylvain Giraud Head of Unit European Commission Directorate-General for Health and Food Safety Brussels Ms BorianaGoranova European Commission DG Employment, Social Affairs and Inclusion Directorate D - Europe 2020: Social Policies J-27 01/233 B-1049 Brussels Belgium Working together for better health outcomes in Europe Page 33 Mr BartoszHackbart Policy Officer European Commission Directorate-General for Health and Food Safety 4 Rue Breydel 1040 Brussels Belgium Mr Ralf Jacob Head of Unit European Commission DG Employment, Social Affairs and Inclusion Directorate D - Europe 2020: Social Policies J-27 01/233 B-1049 Brussels Belgium Dr Barbara Kerstiens Head of Sector European Commission Directorate-General for Research and Innovation Rue du Champs de Mars, 21 B-1049 Brussels Belgium KorneliaKozovska Secretary of the Social Protection Committee European Commission DG Employment, Social Affairs & Inclusion Unit 01: Coordination and Planning, Inter- Institutional Relations B-1049 Brussels Belgium Mr GaetanLafortune Senior Economist Organisation for Economic Co-operation and Development Health Division 75775 Paris Cedex 16 France Working together for better health outcomes in Europe Page 34 Mr Jean-Baptiste Lebras Policy Officer European Commission Directorate-General for Health and Food Safety Rue du Champs de Mars, 21 B-1049 Brussels Belgium Ms KatjaNeubauer Deputy Head of Unit European Commission Directorate-General for Health and Food Safety Rue du Champs de Mars, 21 B-1049 Brussels Belgium Mr Federico Paoli Policy Officer European Commission Directorate-General for Health and Food Safety Rue du Champs de Mars, 21 B-1049 Brussels Belgium Dr Matthias Reinicke European Commission International Cooperation and Development Unit B4 Education, Health, Research, Culture J59 03/84 B-1049 Brussels Belgium DrChristophSchwierz Policy Analyst European Commission DG ECFIN Rue de la Loi 170/Wetstraat 170 1049 Brussels Belgium DrMasoud Dara Senior Advisor The World Health Organization Office to the European Union UN House, 14 Rue de Montoyer B-1000 Brussels Belgium Working together for better health outcomes in Europe Page 35 DrJosepFigueras Head WHO European Centre for Health Policy Victor Horta 40/10 B-1060 - Brussels Belgium Dr Hans Kluge Director, Division of Health Systems and Public Health WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Denmark Ms Margrieta Langins Consultant, Health Services Delivery Division of Health Systems and Public Health WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Denmark Dr Juan Tello Programme Manager, Health Services Delivery Division of Health Systems and Public Health WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Denmark Dr Stephane Vandam Public Health Officer The World Health Organization Office to the European Union UN House, 14 Rue de Montoyer B-1000 Brussels Belgium The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan : WORKING TOGETHER FOR BETTER HEALTH OUTCOMES IN EUROPE: STRATEGIC HEALTH SYSTEM STRENGTHENING PRIORITIES AND AREAS FOR COLLABORATION Division of Health Systems and Public Health Working together for better health outcomes in Europe: strategic health system priorities and areas for collaboration Partners meeting Brussels, Belgium, 30 April 2015 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int WHO/EURO:2015-6158-45923-66180