W ORL D H E A LT H O RG A N I Z AT IO N R EG I ON A L O F F I C E FO R EU R O P E UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Telephone: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eugovernance@who.int Web: http://www.euro.who.int/en/who-we-are/governance Regional Committee for Europe EUR/RC70/5 Rev.2 70th session Virtual session, 14−15 September 2020 13 September 2020 200691 Provisional agenda item 2(b) ORIGINAL: ENGLISH Report of the Regional Director The work of WHO/Europe in 2019–2020 The present report aims to capture the key activities of WHO/Europe in 2019–2020. WHO/Europe has focused substantially on supporting countries in dealing with the COVID-19 pandemic. At the same time, it has continued to work towards the targets set out in WHO’s Thirteenth General Programme of Work (GPW 13), while preparing to be fit for purpose for the country-focused vision of the proposed European Programme of Work, 2020–2025. EUR/RC70/5 Rev.2 page 2 Contents Foreword by the Regional Director ............................................................................................ 3 Introduction ................................................................................................................................ 4 The work of WHO/Europe ......................................................................................................... 5 Health emergencies ........................................................................................................... 6 Universal health coverage ............................................................................................... 11 Health and well-being ..................................................................................................... 15 Health security in a changing world: what have we learned from COVID-19? ...................... 20 Solidarity is the key to success ....................................................................................... 21 Stronger health systems for stronger health security ...................................................... 22 Health and the economy: two sides of the same coin ..................................................... 23 Transforming WHO/Europe to be fit for purpose .................................................................... 25 Supporting WHO’s transformation ................................................................................. 25 Restructuring WHO/Europe to deliver strategic priorities ............................................. 25 Establishing a new organizational culture through staff engagement ............................ 26 Ensuring accountability to Member States and external engagement ............................ 26 Mobilizing financial resources ........................................................................................ 27 Concluding remarks by the Regional Director ......................................................................... 28 EUR/RC70/5 Rev.2 page 3 Foreword by the Regional Director 1. The coronavirus disease (COVID-19) pandemic, with the tragic loss of too many lives and devastating effects on our societies, is confronting our vulnerabilities and challenging our health systems and way of life. It has brought sorrow and grief to many and uncertainty to the future of our younger generations. 2. At the same time, this unprecedented public health crisis reminds us of the importance and value of health. It also calls for solidarity and joint action and should strengthen us in our commitment and determination to achieve the health-related Sustainable Development Goals (SDGs) while leaving no one behind. More than ever, this is a time when health leadership is needed and policy-makers must deliver on the legitimate expectations of the citizens they serve. The crisis provides us with an opportunity to take the bold decisions required to lead us towards a true culture of health and an economy of well-being. 3. A year ago, I was still campaigning – travelling to Member States, listening to their needs and expectations, and sharing my vision of “united action for better health”, with two goals: “leaving no one behind” and “empowering health leadership”. Clearly, I could not have imagined being immediately confronted at the start of my tenure with the biggest public health crisis of our lifetime. But thinking about it now, the COVID-19 pandemic has bluntly revealed the structural problems we have been facing for a long time in the health sector: unity in health actions is rarely a reality, many vulnerable people are left behind, and health leaders are often struggling to assert their voices in the wider governmental and public arenas. The call I am making now as WHO Regional Director for Europe, along with my team, is to fight this pandemic in solidarity, for the equal well-being of all by demonstrating effective leadership. In line with this vision, the work of WHO/Europe1 throughout the pandemic has been guided by the recognition of two key facts. 4. First, mutual trust between Member States and WHO is fundamental, especially in times of crisis. This requires the maintenance of direct and close contact with countries in order to be able to tailor support that meets their specific needs. I have had the great privilege of speaking daily with health ministers, ministers of foreign affairs, prime ministers and presidents, and the people affected, among others, to understand what these needs are. These strong contacts have also allowed a continuous exchange of knowledge on every aspect of the pandemic as it has evolved. Through intensive day-to-day support from WHO country offices and more than 74 expert and high-level missions, we have worked closely with health authorities to transform global guidance into pragmatic solutions that address real country needs, taking into account the cultural and economic diversity of the Region. This dimension of trust should be an important element of the independent evaluation of the global response to the pandemic, leading to better definition of roles and responsibilities. It is also my conviction that any resulting reform should strengthen the role of WHO’s regional and country offices, not least in Europe, where opportunities for tailored support and knowledge sharing are abundant through targeted subregional health diplomacy. 1 WHO/Europe consists of the Regional Office in Copenhagen, Denmark; 32 country, field and liaison offices; three subregional WHO Health Emergencies Programme (WHE) hubs; five Geographically Dispersed Offices (GDOs); and one WHO-hosted Partnership. The WHO Barcelona Office for Health Systems Strengthening, Spain, does not have the same status as the GDOs, given the absence of an agreed legal framework for WHO’s presence in Spain. However, there is a renewed commitment by Spain and WHO to find a resolution to this longstanding issue and negotiations are in process with the involvement of the Director-General’s Office. EUR/RC70/5 Rev.2 page 4 5. Second, a crisis of this scope can only be addressed together. This battle against COVID-19 is not a sprint but a marathon, and united and strengthened regional and global partnerships are needed to overcome this situation. In our Region, close cooperation and coordination with the European Union (EU) is vital for acting in unity and synergizing activities. It is also crucial to extend partnerships to other parts of our Region and with other important subregional partners, such as the Cooperation Council of Turkic-Speaking States, the Council of Health Cooperation of the Commonwealth of Independent States, the Shanghai Cooperation Organization and the Central European Initiative, among others, in order to strengthen subregional cooperation and tailor support to Member States which have similar epidemiological and historical profiles. To honour my special commitment to the Member States in the eastern part of the Region, following my appointment I immediately travelled to central Asia and the western Balkans to initiate this newfound cooperation and partnership. 6. WHO/Europe’s presence at country level, and the phenomenal capacity housed therein, has positioned us well to respond to this pandemic. It has strengthened my conviction and resolve to scale up and strengthen support to countries through policy dialogue, technical assistance in strategic areas, as well as operational support through the country offices. The country offices represent a large part of our value, as they inform and support policy change by helping with the translation of evidence, and through their normative work in country-specific contexts. Ultimately, our country presence allows us to be closer to where leadership, coordination and assistance is required. 7. It is fitting that 2020 is the International Year of the Nurse and the Midwife. Through the strength, compassion and determination of all health and care workers, the scourge of COVID-19 is being contained, and many lives have already been saved. As this report describes the activities of WHO/Europe, please join me in applauding the bravery and commitment of the health workers who have been in the front line of fighting the pandemic, often with their own safety at stake. For this reason, I decided to extend the Year of the Nurse and the Midwife campaign into 2021 in the Region. 8. I will be dedicating myself over the next five years, together with the very committed staff of WHO/Europe across the Region, to building a healthier, safer and more prosperous European Region – one that builds back better and with more resilience. We are committed to serving the health and well-being of all people in the Region as best we can, leaving no one behind. Introduction 9. The present report aims to capture the key activities of WHO/Europe since the 69th session of the WHO Regional Committee for Europe (RC69) in September 2019; it should be read in conjunction with the verbal presentation of the Regional Director pertaining to this agenda item at the 70th session of the WHO Regional Committee for Europe (RC70). This report spans the terms of the former management and the current RD, who began his term on 1 February 2020. During this transition period, WHO/Europe has continued to work towards the targets set out in WHO’s Thirteenth General Programme of Work (GPW 13), while preparing to be fit for purpose for the country-focused vision of the proposed European Programme of Work, 2020–2025 (EPW), which was developed in consultation with all the Member States in the European Region, the Standing Committee of the Regional Committee EUR/RC70/5 Rev.2 page 5 (SCRC), the European Commission, United Nations agencies, non-State actors, WHO staff and the broader public. 10. This report does not intend to give a comprehensive account of WHO/Europe’s activities. More detailed information on programmatic activities can be found in accompanying Regional Committee documents, such as progress reports. Since the COVID-19 crisis has dominated WHO/Europe’s work in 2020, activities related to the crisis will be featured throughout this report. 11. The report presents highlights of some of the activities under each of the three pillars of the GPW 13 triple billion targets: health emergencies, universal health coverage (UHC), and health and well-being. Reflecting on the challenges and opportunities arising from the COVID-19 crisis, we draw three key lessons: the importance of solidarity; the need for health system preparedness; and the interdependence between health and the economy. This is followed by a description of WHO/Europe’s efforts to become more fit for purpose in line with the fourth, supporting pillar of GPW 13. The work of WHO/Europe 12. This section describes WHO/Europe’s programmatic work between RC69 (September 2019) and RC70 (September 2020), through the lens of the triple billion targets of protecting populations from health emergencies, increasing UHC, and improving health and well-being. 13. While important progress in health outcomes has been made over the last decade across the European Region, there is still a 10-year difference in total life expectancy and a 12.4-year difference in healthy life expectancy between countries. Within countries, clear gender gaps in both mortality and morbidity are combined with differences in educational and socioeconomic status. These health inequalities not only reflect differences in income and living standards, but also in exposure to risk factors and access to care. 14. The ferocity of the COVID-19 pandemic and its consequential socioeconomic impacts not only risk jeopardizing previous gains but may also lead to a further exacerbation of health inequalities. Therefore, a substantial focus of WHO/Europe’s activities has been on supporting countries in containing the pandemic, reducing stress on health systems, and preparing for a safe transition out of the acute crisis. At the same time, regular programmatic work has continued, but through a new lens of mitigating the detrimental effects of COVID-19. 15. The unprecedented public health challenge that the entire Region had been confronted with since the beginning of 2020 compelled WHO/Europe to rapidly repurpose itself for the COVID-19 response, mobilizing its whole staff – in the Regional Office, GDOs and country offices, hubs and field offices – in order to be able to tap into the expertise of all available personnel. Staff worked in agile teams across divisions to support Member States in their immediate response. While themselves under lockdown in Copenhagen and other duty stations, staff were repurposed (in the Regional Office and all country offices) and activities reoriented to support countries and the incident management support team (IMST) of the WHO Health Emergencies Programme (WHE). EUR/RC70/5 Rev.2 page 6 Health emergencies 16. With more than 3.5 million confirmed cases of infection and more than 215 000 confirmed deaths (as of 7 August 2020) in the Region as a result of the COVID-19 pandemic, prevention, detection and response to outbreaks has been the priority for WHO/Europe’s work. Excess mortality data are indicating an even higher toll and human impact: data from 23 European countries have shown a cumulated excess of 187 527 deaths (European Mortality Monitoring Project data as of 2 August 2020). 17. Clearly, the older populations of our Region have suffered the most during the pandemic. While 58% of infections have been reported in those of working age, 90.3% of excess mortality has occurred in people of 65 years and older, of whom half are aged 85 years and older. In addition to the tragic loss of lives, older persons have also been among those hit most by the restrictive measures of lockdown and isolation. As the Region with the highest old-age dependency ratio, our focus needs to be on better protecting older persons, including through investment in the prevention and management of underlying chronic conditions that increase the risk of complications from COVID-19. 18. Many countries in the Region are now experiencing a new surge in COVID-19 morbidity and mortality, indicating that the battle is not over. Continuous vigilance and country-specific strategies will have to be maintained and must take into account the additional burden on health systems posed by seasonal influenza during the winter months. The COVID-19 battle reminds us of the paramount importance of primary health care and the essential public health functions. Emergency preparedness 19. Prior to the COVID-19 outbreak, WHO/Europe delivered, through integrated packages at country level, and with the heads of country offices at the steering wheel, strategic guidance for developing, initiating, navigating and implementing comprehensive and impact-driven plans, with countries at the centre. Three hubs in the European Region support our country offices and provide inter-country support. 20. WHO/Europe has been working closely with Member States to assess and strengthen emergency prevention and preparedness capacity in line with the core capacities required under the International Health Regulations (IHR) (2005). This includes coordination and communication among relevant entities as well as training of personnel on how to plan, initiate and implement comprehensive and impact-driven emergency response plans. This work contributed to the agility, transparency, coordination and leadership shown by health authorities during the pandemic. Several examples of this preparedness work are presented below. • Following the multi-country measles outbreaks in 2018–2019 and their classification as a Grade 2 emergency, WHO/Europe supported many health authorities in the Region in: conducting strategic risk assessments; developing national emergency response plans; contingency planning for high-priority risks; carrying out assessments, planning and simulations in health facilities; developing operational readiness checklists; and documenting lessons learned through after action reviews. When the COVID-19 pandemic hit these countries, there were structures and systems in place to mount an immediate response, with an understanding of how to move from regular work to incident management mode in order to manage all elements of the response. EUR/RC70/5 Rev.2 page 7 • Towards the end of 2019, many aspects of the influenza-related infrastructure built after the H1N1 pandemic of 2009 were further strengthened and developed as part of implementation of the Pandemic Influenza Preparedness Framework. This meant that the infrastructure could be rapidly repurposed by combining the influenza preparedness network, the Better Labs for Better Health initiative, the Laboratory Task Force for High Threat Pathogens, the Regional Influenza network coordinated with European Centre for Disease Prevention and Control and national programmes for infection prevention and control, and others, as the main skeleton of a COVID-19 specific response platform. In particular, influenza surveillance and response systems have been repurposed for COVID-19. The annual Flu Awareness Campaign that boosts countries’ seasonal influenza vaccination programmes will be adapted in autumn 2020 to take into account the need for safe delivery of the vaccine to those at risk of complications due to both influenza and COVID-19. • The regular capacity building workshops for the European National IHR Focal Points (NFPs) continued in October 2019, followed by a Joint Assessment and Detection of Events simulation exercise for all 55 IHR NFPs in the Region. These activities turned out to be most timely, as prompt implementation of event management activities under the IHR (2005), including NFP coordination, information sharing, and communication, accelerated the reporting of COVID-19 cases, thereby potentially reducing the burden on societies. • In mid-December 2019, 20 countries participated in the second SocialNET training course that was provided and facilitated by experts from the United States Centers for Disease Control and Prevention, the European Centre for Disease Prevention and Control, the United Nations Children’s Fund, and the Red Cross. The chosen scenario for the week-long bootcamp, which bridged risk communication, community engagement and social sciences, was a pandemic, which a few weeks later became a reality. • Under the umbrella of the United Nations Issue-based Coalition on Health and Well-being, WHE established a coordinated platform of partners including WHO, United Nations agencies, the Red Cross and international nongovernmental organizations from across the Region. The platform enables discussions to be held on Strategic Preparedness and Response Plans (SPRPs), humanitarian response plans and country-specific challenges, and has facilitated a tightly coordinated and harmonized multisectoral response, which is not only saving lives but is also reaching beyond the health sector to support and inform Member States in shaping the wider COVID-19 response and building back better. 21. To strengthen WHO/Europe’s Region-wide support for emergency preparedness in countries, a financial agreement was signed on 8 July 2020 by the Regional Director and the Turkish Ministry of Health to establish a new WHO Centre of Excellence for Preparedness for Humanitarian and Health Emergencies in Istanbul. On this occasion, the Regional Director also visited the WHO field office and a primary health care centre with Syrian doctors and nurses trained and certified by Turkey in Gaziantep on the border between Turkey and the Syrian Arab Republic, which plays a key role in supporting humanitarian operations led by the United Nations in the north-west of the Syrian Arab Republic and WHO’s EU-funded Refugee Health Programme in Turkey. EUR/RC70/5 Rev.2 page 8 Emergency response 22. As soon as the first reports emerged on 31 December 2019, the WHE in the European Region established a team to monitor what was, at the time, a small cluster of atypical pneumonia cases. On 7 January 2020, when the novel strain of coronavirus was identified, the WHE further strengthened preparedness and readiness activities in the Region. On 23 January, in line with WHO’s risk assessment and emergency grading, the WHE formally activated the IMST to prepare for and respond to the growing threat posed by the virus. A day later, on 24 January 2020, the first cases of COVID-19 in the European Region were detected in France. The IMST accelerated its operations to support countries in rapidly detecting and reporting suspected cases and clusters. The WHO European Region public COVID-19 dashboard (in English and Russian) was established in February 2020, and to date has received more than 8 million unique visits. 23. Technical expertise and supplies were rapidly deployed across the Region, and in January staff were already being repurposed across WHO/Europe (country offices and the Regional Office) to assist with the pandemic response and support the IMST, with a clear country and operational focus. 24. With WHO/Europe’s support, based on the SPRP, Member States each undertook detailed analysis and developed a COVID‑19 Country Preparedness and Response Plan (CPRP) outlining the public health and essential health services needed to prepare for and respond to COVID-19. In some cases, national authorities have been able to implement the measures needed to prepare for and respond to COVID‑19 with minimal support from outside. In other cases, WHO/Europe and partners have intensively provided support and technical expertise, including procurement and distribution of personal protective equipment, tests, reagents and consumables; provision of technical support and guidance; development of standard operating procedures and capacity building; assistance with the implementation of control measures at the point of entry, case investigation and contact tracing. Repurposing the Venice Office A good example of repurposing in an emergency situation was when the WHO European Office for Investment in Health and Development in Venice, Italy, coordinated exchanges of clinical experience as knowledge on COVID-19 expanded. The Office organized more than 40 webinars with an average participation of 300 professionals from across the different regions of Italy and from other countries (including infectious disease specialists, intensive care unit staff and health facility managers) on various issues, such as therapeutic approaches, choice of drugs, facilitating communication with family members by patients in intensive care, and contact tracing. In addition, logistic support on the ground and technical advice (in areas such as laboratory work, epidemiology, and infection prevention and control) were provided through the extensive network of WHO experts. Through the Regions for Health Network and the Small Countries Initiative, these exchanges were further expanded internationally to include responders in numerous countries, reaching up to 1500 public health professionals in Europe and beyond. 25. Due to restricted opportunities to travel to countries, as well as lockdown measures, innovative approaches were applied to provide support to countries, such as virtual missions, webinars, and entering countries via cargo and other urgent flights. With the strong EUR/RC70/5 Rev.2 page 9 engagement and leadership of the WHO country offices, the three WHE regional hubs located in the Balkans, the southern Caucasus and central Asia allowed the provision of rapid assistance to countries in central Asia, eastern and south-eastern Europe. 26. The strong WHE network of operational teams allowed for the swift deployment of more than 20 standardized emergency medical teams and experts from more than 10 Global Outbreak Alert and Response Network partner institutions to countries in need. New standards for emergency medical teams and rapid response mobile laboratories were developed and have been helping to set and maintain standards for essential care services throughout the Region. 27. Alongside the significant and direct country support through in-person and virtual missions, WHO produced over 150 guidance documents and tools for nearly every aspect of the COVID-19 response required by countries on topics such as: infection prevention and control; clinical management; laboratory testing; maintaining essential health services; creating surge capacity; supplying essential medicines and health technologies; preventing and managing COVID-19 in long-term care services; risk communication and behavioural insight; and addressing the needs of at-risk groups and marginalized populations. 28. The ad hoc strategic advisory group on COVID-19 was established in March 2020 by the Regional Director with the aim of soliciting strategic feedback from experts across the European Region; the group provided valuable insights into WHO/Europe’s policy considerations for strengthening and adjusting public health measures during the COVID-19 transition phases (published in April 2020), and on strengthening COVID-19 preparedness and response for the autumn/winter season in 2020, when influenza and influenza-like illnesses will be at their peak. On 31 August 2020, the Italian Ministry of Health and WHO/Europe convened a regional high-level meeting on the safe reopening of schools to discuss concrete actions corresponding to the national and subnational context. Engagement with Member States, partners and the public 29. Open communication and exchange, as well as coordinated action, have proven to be key factors in the response to the pandemic. Despite travel restrictions, WHO/Europe – and the Regional Director in particular – devoted much effort to communicating with national policy-makers and international partners, as well as to proactively engaging with the European and global media in support of national health leadership transparency. 30. Frequent technical and strategic meetings were organized with Member States spanning the entire Region. By convening multilateral and subregional networks of Member States, WHO/Europe was able to facilitate the sharing of experiences and to promote an evidence- informed response. Regular ministerial briefings and subregional virtual meetings were held with the EU member countries, the Baltic States, the central Asian republics and the Russian Federation, the Nordic countries, members of the Small Countries Initiative, the Visegrad Four countries and the western Balkan countries. The Regional Director also engaged with the Central European Initiative, the Council of Health Cooperation of the Commonwealth of Independent States, the South-eastern Europe Health Network, the Cooperation Council of Turkic-Speaking States, and the Non-Aligned Movement, and took part in meetings of the Employment, Social Policy, Health and Consumer Affairs Council (EPSCO Council), the European Bank for Reconstruction and Development, and the European Parliament’s Committee on the Environment, Public Health and Food Safety. EUR/RC70/5 Rev.2 page 10 31. In addition, the Regional Director continuously engaged with the United Nations Resident Coordinator networks and the regional directors of other United Nations agencies in the Region to ensure coordinated multisectoral support to countries, in the context of the Issue-based Coalition on Health and Well-being (which is led by WHO/Europe). With the United Nations country teams, WHO/Europe also contributed to supporting Member States’ efforts to address the COVID-19 pandemic through other issue-based coalitions, including those on sustainable food systems, gender equality, social protection, and environment and climate change. Starting in mid-March, regular briefings were held for all diplomatic missions located in Copenhagen and Geneva, along with briefings for health ministers, director- generals and chief medical officers. The Regional Director was joined by Dr David Nabarro, the WHO Director-General’s Special Envoy on COVID-19 (who provides strategic advice and carries out high-level political advocacy throughout the world) in many of the technical, diplomatic, and strategic briefings. 32. In order to renew and strengthen the partnership with the European Commission, with a view to optimizing complementarities in relation to COVID-19 and coordinating support to EU Member States and other countries in the Region, the Regional Director maintained contact with the European Commissioners for Health and Food Safety and for European Neighbourhood and Enlargement Negotiations, as well as with other officials, such as the EU Special Representative for Central Asia, the Head of the EU Delegation to the United Nations in Geneva and the heads of EU delegations in countries. EU COVID-19 Solidarity Programme for the Eastern Partnership A good example of the agile teamwork within WHO/Europe on intensifying existing partnerships and forging new ones to provide immediate support to WHO Member States is the joint two-year €30.5 million project that was agreed upon in March 2020 with the European Commission’s Directorate-General for Neighbourhood and Enlargement Negotiations. The first component of this programme to support six countries in eastern Europe and the Caucasus aims to meet their short- and medium- term needs in the response to the COVID-19 pandemic as well as in the subsequent recovery and mitigation of further waves. More than 4.7 million items of personal protective equipment (PPE) procured by WHO/Europe have been delivered to the countries. The second component aims to strengthen health system and public health capacities in detecting and preventing potential public health emergencies in the future. The project’s funds are managed by the Regional Office and its country offices in close coordination with national authorities and international partners, including the concerned EU delegations and other partners in the United Nations system. This project is pioneering the model of agile transformation for WHO/Europe by tackling a complex issue through collaborative work, a constant Member State focus, and cutting time to delivery at the country level. 33. WHO/Europe intensified its media presence to strengthen national health leadership and to leave no one behind by informing the public about COVID-19, to counter the infodemic and to protect the integrity of the Organization. COVID-19 updates and evidence-based guidance were provided through weekly live-streamed press briefings that focused on topics of concern such as physical and mental health, older people, vaccinations, domestic violence, and population behavioural insights. For the first time, WHO/Europe also initiated live press briefings in Russian, with the Regional Director directly addressing the Russian-speaking EUR/RC70/5 Rev.2 page 11 community on the COVID-19 crisis. Each press briefing generated wide news coverage by the media in the Region and across the world. 34. In addition to these weekly live-streamed press briefings, the Regional Director also gave interviews to many leading international, regional and national media outlets, including Agence France Presse, Al Jazeera, Bloomberg, CNN, BBC, De Morgen, Euronews, Europe 1, The Guardian, Hürriyet, Khabar 24, La Republica, Russia One, RT, Sky News, The Telegraph and ZDF. Online press conferences held at the end of WHO missions to Belarus, Italy, North Macedonia, Tajikistan and Turkmenistan were covered by regional and international media. 35. WHO/Europe has also been involved in the implementation of the United Nations Children’s Fund COVID-19 Chatbot, a free platform that provides access to safe, fast and accurate COVID-19 information, with an added rumour-tracking function aimed at counteracting potentially harmful misinformation. Moreover, health advice has been disseminated across the Region through a collaboration with the Global Shapers Community, a group of youth influencers on social media. Universal health coverage 36. The United Nations Political Declaration on UHC of September 2019 issued a strong call for action to achieve target 3.8 of the Sustainable Development Goals and reaffirmed, following the Astana Declaration, the importance of primary health care (PHC) as the cornerstone of a sustainable health system. This has been a key focus of the support provided by WHO/Europe to countries to ensure that essential health services are available and affordable to all, irrespective of where people live, their gender or age, or their socioeconomic or health status. The WHO European Centre for Primary Health Care in Almaty, Kazakhstan, is at the forefront of efforts to support Member States in the Region in strengthening PHC in order to achieve UHC. 37. In this context and following the launch of a new phase of work in July 2019, the Region’s portfolio of work in relation to the WHO–European Commission Health System Strengthening for UHC Partnership Programme (the UHC Partnership) was further strengthened. Two countries joined the UHC Partnership, bringing the total number of countries engaged to seven, and international policy advisers were recruited and deployed to the countries involved. 38. COVID-19 particularly affects already vulnerable groups, including people with underlying chronic conditions and disabilities; people in need of long-term care services or those who are dependent on social services; refugees; migrant populations; homeless people; and people in prisons and other places of detention. As well as being at higher risk of morbidity and mortality related to COVID-19, the economic fall-out of the pandemic and the countermeasures taken in the health sector may have a further negative impact on their health and their access to health and social services, as was seen with the austerity measures taken in the aftermath of the 2008 financial crisis. Furthermore, the COVID-19 response exposed the shortcomings health systems still experience in providing holistic, multidisciplinary and integrated people-centred services and in maintaining essential health services during severe outbreaks. For all these reasons, UHC-related country support has never been so relevant. EUR/RC70/5 Rev.2 page 12 Access to quality health services enabled by a sustainable and competent workforce 39. Following up on the resolution adopted at RC69 on accelerating PHC strengthening, WHO/Europe has undertaken technical work and guidance to accelerate the positioning of PHC at the core of health systems and its integration with a range of secondary, tertiary and social services, including long-term care. In this context, assessments were conducted in several countries in order to design and pilot people-centred PHC service delivery models. 40. This work is also closely related to technical work on developing a competent, responsive and sustainable health workforce, which included the development by WHO of a national health workforce accounts resource pack to support national health workforce policy and planning. An expert meeting in December 2019 explored the challenges in developing sustainable health service delivery and a resilient health workforce in small countries. In relation to the Year of the Nurse and the Midwife, analytical work was conducted on strengthening the role of nurses, including on the key competencies for nurses working in PHC and country case studies (including success stories), as well as the publication of a midwifery assessment tool. WHO/Europe developed a competency framework for the public health workforce in cooperation with the Association of Schools of Public Health in the European Region. EUR/RC70/5 Rev.2 page 13 Supporting health systems to respond to COVID-19 To support health systems to respond effectively to the pandemic and to learn from the experiences of countries in the Region, WHO/Europe developed a wide range of technical guidance materials, policy recommendations, check lists, and planning and monitoring tools, including surge tools to support the planning of health system capacity and human resources during the peak of the outbreak. In early April 2020, the COVID-19 Health System Response Monitor, a web platform that maps and analyses responses to the pandemic across the Region (developed in collaboration with the European Observatory on Health Systems and Policies and the European Commission’s Directorate-General for Health and Food Safety), was launched. This was followed by the publication of key considerations for the gradual easing of the lockdown restrictions that had been introduced by many countries in response to COVID-19. A tool for establishing COVID-19 behavioural insights was also developed for rapid, flexible and cost-effective monitoring of public knowledge, risk perceptions, behaviours and trust, in order to enable countries to develop appropriate and practical responses to COVID-19, including safe and gradual easing of lockdown measures. Simultaneously, technical units have continued to develop guidance, training materials and other means of examining the impact of COVID-19 on specific groups and settings, including school children, people with disabilities, refugees and migrants, pregnant mothers and newborn children, elderly people and residents of long-term care facilities, people in prisons, and people with mental health problems, underlining the human rights dimension. A good example of this was the launch of a database to monitor COVID-19 outbreaks in prisons and the distribution of a checklist for Member States to self-assess their preparedness to prevent and control COVID-19 in prisons and other places of detention. WHO/Europe also issued interim guidance on the preparedness, prevention and control of COVID-19 in prisons and other places of detention, which has been translated into 11 different languages, and is being used by national and local authorities to guide response activities. 41. Accessible and high-quality PHC is a prerequisite for the early detection and treatment of noncommunicable diseases (NCDs); acknowledging this fact, WHO/Europe hosted a conference in February 2020 to launch regional guidance on screening of NCDs (with 45 Member States participating). At country level, increased effectiveness of screening programmes was pursued by advising against the use of certain non-evidence-based ones; by supporting countries to implement quality requirements in screening them; and by supporting the introduction of national cancer control plans that include adequate screening policies. At the same time, and in the context of COVID-19, tools were developed to help improve quality of care in NCD management, adapted to remote support where possible (for example, through standardized data collection for assessing essential cardiovascular disease interventions in resource-limited PHC settings, and a clinical audit tool for acute coronary syndrome and stroke). The technical support, operational guidance and training were organized in collaboration with professional associations and WHO collaborating centres. 42. Sexual and reproductive health (SRH) is a litmus test for progress towards UHC. High- quality SRH care services require a well-functioning health system, policy and legislative barriers to be overcome, and human rights and gender equality to be respected and promoted. EUR/RC70/5 Rev.2 page 14 A new tool was used to assess health systems barriers to UHC for SRH in eight countries. This sparked a policy dialogue with multiple country-level stakeholders on building and strengthening the evidence base for UHC and SRH. This dialogue is aimed at enabling a change in policies with regard to SRH that results in the development of related action plans and the reviewing of SRH interventions in health benefit packages. Reducing financial hardship caused by out-of-pocket payments 43. Analysis of coverage policy – the way in which health coverage is designed and implemented – is an essential component of monitoring national and regional progress towards UHC and can help to identify which groups of people are likely to be at high risk of experiencing unmet needs and financial hardship. Following the publication in 2019 of the Region’s first ever report on financial protection, Can people afford to pay for health care? New evidence on financial protection in Europe, the WHO Barcelona Office for Health Systems Strengthening, Spain, has continued to produce country reports on financial protection that generate evidence which can be used to support action on UHC through context-specific analysis. 44. This work will become even more important in the context of the pandemic and its devastating economic effects in the Region. To avoid a significant deterioration of financial protection, key health financing actions will need to be taken by Member States to reduce out- of-pocket payments for health and keep them at a low level by redesigning coverage policy and mobilizing additional public funds for health. Evidence from the analysis of financial protection in Europe supports our recommendation to keep out-of-pocket spending below 15% of total current spending on health as a benchmark for good financial protection through generic, non-targeted health spending policy. In contrast, most countries of the European Region still spend above this critical threshold which leads to financial hardship for many households and calls for additional, targeted policies such as exemptions from co-payments for vulnerable people and expenditure caps, especially on prescription medicines. 45. Experience from the financial and economic crisis over a decade ago suggests that the financial burden on households during and after an economic downturn increases unless counter-cyclical public funding arrangements are in place and special programmes for protecting the poor and most vulnerable populations are introduced. Prior to the current health and economic crisis, financial protection had already been worsening across the European Region, leading to impoverishing out-of-pocket payments for health affecting between 0.3% and 9% of the population in the 24 countries covered by the European report on financial protection. Catastrophic level of health spending affected between 1% and 17% of households. These numbers are likely to increase if countries fail to learn the lessons from the past. Our shared vision of a Europe free of impoverishing out-of-pocket payments for health is now supported by actionable evidence from detailed and context-specific country reports that are also used and referenced in publications by the European Commission, OECD and the World Bank. 46. While we had to postpone this year’s edition of the most popular WHO Barcelona course on health financing, the online version of the foundational basic course is now available in Russian as well. EUR/RC70/5 Rev.2 page 15 Access to medicines, vaccines and diagnostics 47. Ensuring access to safe, affordable and quality medicines and health products remains a major challenge for many Member States. Joint action and support are needed more now than ever as countries are increasingly faced with exorbitant price tags for new medicines on the market, and equitable access to affordable vaccines, diagnostics and therapeutics has become a crucial element in the fight against the COVID-19 pandemic. WHO/Europe has provided countries with technical guidance on the development, revision and implementation of comprehensive pharmaceutical sector policies, including on forecasting, procurement and health technology assessment. In the response to the pandemic, multi-country briefings with ministries of health, senior clinicians and experts were organized for 28 countries in the Region to help with the approval of the Solidarity Trial protocol. Another example is the creation of a help-desk function for COVID-19 related procurement to support WHO staff in country offices and GDOs in the Region to accelerate the implementation of SPRPs, leading to more timely and effective assistance to Member States. 48. With a view to implementing resolution WHA 72.8 on improving the transparency of markets for medicines, vaccines and other health products, the Belgian National Institute for Health and Disability Insurance hosted a technical meeting in February 2020 to prepare for a high-level meeting now scheduled for March 2021. This meeting, to be hosted by WHO/Europe, the Norwegian Ministry of Health and Care Services and the Norwegian Medicines Agency, will guide the development of a new vision for collaboration between the public and private sectors on improving access to effective high-cost innovative medicines. WHO/Europe and the aforementioned Norwegian partners will continue to raise awareness of this matter at the upcoming European Health Forum Gastein conference in September 2020. 49. In this context, the COVID-19 Vaccine Global Access Facility (COVAX), which aims to accelerate the development and manufacture, and ensure the equitable distribution of, safe and effective future COVID-19 vaccine(s), will provide an innovative mechanism for risk sharing to secure access to any such vaccine(s). Health and well-being 50. Helping countries to improve the health and well-being of their populations remains at the core of WHO/Europe’s efforts. This requires a life-course approach, addressing health determinants and risk factors upstream through a combination of individual services, population-based interventions and multisectoral action. 51. The risks and detrimental effects of both communicable and noncommunicable diseases have been prominent in the context of the COVID-19 pandemic. The pandemic has revealed the vulnerability of COVID-19 patients with underlying conditions, mostly stemming from NCDs. At the same time, many of the restrictive measures enacted to reduce the spread of infection, such as lockdowns, physical distancing and isolation, as well as the wider social and economic effects of the pandemic, have had negative impacts not only on NCD risk factors, such as alcohol and tobacco consumption, physical inactivity and unhealthy diets, but also on the continuity of NCD-related health services and prevention programmes. Several reports have also associated the pandemic with increases in mental health issues and domestic violence. EUR/RC70/5 Rev.2 page 16 52. WHO/Europe has continued to emphasize the importance of maintaining routine immunization services wherever feasible and safe, also using the current focus on COVID-19 to reinforce public health messages around the importance of immunization. Communicable diseases 53. During the COVID-19 pandemic, around 70% of countries in the European Region have maintained provision of immunization services as part of their essential health services. Technical assistance has been made available to Member States for resuming or catching up on vaccinations, where required, to ensure continued population protection from vaccine- preventable diseases. This is particularly vital given the recent surge in vaccine-preventable diseases in the Region, such as measles, which has revealed the presence of un- and under- vaccinated vulnerable population groups. The 2020 European Immunization Week was an important occasion for raising awareness of the importance of vaccines in preventing vaccine- preventable diseases. In a written statement, Her Royal Highness Crown Princess Mary of Denmark stressed the importance of vaccination as a vital step on the path to achieving health for all and as a crucial component of strong health care systems. She also praised the courage, commitment and resolve of the health workforce at a time of hardship and pain for so many across the Region. 54. As with vaccination, efforts to prevent COVID-19 from reversing hard-won gains have continued in the battle against antimicrobial resistance, including efforts to enhance stewardship and surveillance of antimicrobial resistance. As an example of using COVID-19 to reinforce a public health message, WHO/Europe has highlighted the risks of overprescribing antibiotics and self-medication in a COVID-19 context, while stressing the importance of good hygiene. 55. Again, within the framework of maintaining essential public health services, vital work related to communicable diseases continued during the past year in the Region, exemplified by the following: • Hepatitis: with submissions from 18 Member States, a compendium of 34 good practices in the health sector response to viral hepatitis was published in the lead up to World Hepatitis Day 2020, and technical support was provided to Member States to conduct serological surveys to evaluate the impact of hepatitis B vaccination and document the achievement of regional control targets. • HIV: tailored technical assistance was provided to countries to accelerate the uptake of WHO guidelines on HIV testing and treatment in the Region, with a record number of countries now implementing the recommendations. The Regional Director stressed the importance of maintaining HIV services at the virtual symposium on the impact of the COVID-19 pandemic and HIV on SDG target 3.32 jointly hosted by the Joint United Nations Programme on HIV/AIDS and the Russian Federation. • Tuberculosis (TB): under the slogan, “Rapid diagnostics. Shorter treatment. Time is running out fast for TB”, WHO/Europe has been highlighting the need to urgently accelerate the TB response in the Region in order to meet the 2030 eradication target, save lives and end suffering. The incidence of TB has now almost halved in the Region since 2010 to around 260 000 new patients per year, 2 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. EUR/RC70/5 Rev.2 page 17 and the recent introduction of more effective, patient-friendly treatment regimens, particularly for those suffering from multidrug-resistant TB, has already benefited 42 000 patients. • Measles and rubella: a strategic response plan for the measles emergency in the Region has been developed, which articulates the overall status of measles resurgence and the priority actions needed to ensure an effective response to interrupt transmission, save lives and reverse the upward regional trend in case numbers. Currently, 35 countries have been verified as having eliminated endemic transmission of measles, with this number rising to 39 in the case of rubella. • Human papillomavirus (HPV): WHO/Europe has supported four additional Member States to introduce HPV vaccines into their routine immunization programmes, bringing the total that do so to 38, in a further step towards the elimination of cervical cancer. • Malaria and polio: work has continued to maintain the Region’s malaria- and polio-free status. Member States have shown political commitment in this regard, with 41 of the 53 Member States in the Region submitting their annual polio reports in 2020 despite the pandemic. Ensuring country preparedness through simulation exercises, high-quality surveillance and containment of the poliovirus remains a major focus of WHO/Europe. 56. WHO collaborating centres have continued to provide valuable contributions to communicable disease control efforts, as highlighted in the coordination meeting of the existing and future centres working on TB, HIV, viral hepatitis and sexually transmitted infections held in November 2019, which addressed the challenges and gaps in the implementation of global and regional strategies and action plans. As a result of this meeting, a detailed plan of joint and collaborative activities for 2020–2022 was developed, and later reviewed based on the COVID-19 situation in March 2020. 57. The Regional Office has also set about strengthening its relationship and operational engagement with Gavi, the Vaccine Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria, through regular briefings. A new memorandum of understanding is set to be signed with the Global Fund in the coming months. NCDs and health determinants throughout the life course 58. Cardiovascular diseases, cancers, chronic respiratory diseases, diabetes and mental health disorders are among the main causes of death and disability in the Region. Even though a large proportion of this burden can be attributed to behavioural risk factors, including poor and unsafe diet, smoking, alcohol consumption and low rates of physical activity, many countries still invest relatively little in primary prevention and health promotion efforts. 59. Prior to the pandemic, WHO/Europe had been making progress in NCD surveillance (led by the WHO European Office for the Prevention and Control of Noncommunicable Diseases in Moscow, Russian Federation), with every Member State having completed and presented the results of the NCD country capacity survey and the new WHO STEPwise approach to surveillance (STEPS) risk factor survey. A meeting was held in Georgia in January 2020, with experts from nine countries who discussed how a gender analysis of NCD EUR/RC70/5 Rev.2 page 18 data collected through the STEPs country surveys can strengthen the evidence base for tackling NCD risk factors across the life course. 60. Activities aimed at tackling the major NCD risk factors of tobacco and alcohol included the organization of a technical meeting in October 2019 on novel tobacco products; the publication of a status report on alcohol consumption, harm and policy responses, and a report on content labelling and informed consumer decisions on alcoholic beverages; and the organization of a policy impact case study and workshop for delegates from 13 countries in eastern Europe and central Asia, both of which demonstrated how strengthened alcohol policies can be a game changer in reducing all-cause mortality and increasing life expectancy. Progress was made in the field of obesity, with now 37 countries in the Region having adopted a ban on trans fats, more than 80% of countries having completed the fifth round of the Childhood Obesity Surveillance Initiative, and eight countries using the WHO/Europe digital marketing of unhealthy products toolbox. 61. WHO/Europe also actively participated in the WHO global meeting on NCDs and mental health held at the end of 2019. The meeting drew attention to the need for accelerating the implementation of national responses to NCDs and mental health conditions in order to meet SDG target 3.43 and the triple billion targets, and ultimately reduce premature mortality. This is particularly relevant in the European Region, which ranks highest among the WHO regions in terms of NCD morbidity. 62. Since the outset of the COVID-19 outbreak, staff in WHO/Europe have been working tirelessly in many areas to limit the effect of setbacks to NCD work during the pandemic. There have been numerous communication initiatives aimed at the general public, in areas such as physical activity, healthy and safe diets, the well-being of children during lockdowns, and mental health. 63. Addressing the pandemic’s impact on mental health has been a priority in WHO/Europe, reflecting the vision of “no health without mental health”. Press briefings have provided information on the tools, techniques and interventions that can be used to address mental health issues in the context of COVID-19. WHO/Europe has also worked with partners to develop a new set of materials on mental health and psychosocial support in relation to COVID-19. A strong focus on mental health issues will be maintained in the context of the EPW and with the support of Her Majesty Queen Mathilde of the Belgians (one of 17 SDG Advocates appointed by the United Nations Secretary-General). 3 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. Domestic violence: addressing the unwanted impact of COVID-19 countermeasures With the recent regional report on violence and injuries revealing grim statistics on preventable deaths, the Region is already all too familiar with the scourge of interpersonal violence – and the pandemic has likely worsened this problem. Victims of intimate partner violence and family violence have found themselves confined with their abusers during lockdowns, with access to support services also disrupted. In a press briefing on 7 May 2020, the Regional Director summarized this violence as “preventable, not inevitable” and urged governments to keep health and social services running. WHO/Europe works hand in hand with partners under the regional United EUR/RC70/5 Rev.2 page 19 Health in All Policies and settings 64. Health literacy is a cross-cutting enabler for reducing the detrimental effects of both communicable diseases and NCDs. It is much more than being able to read pamphlets and make appointments; it supports the promotion of equity by improving people’s access to health information and their capacity to use it effectively. Incorporating the considerations and benefits of health literacy into all aspects of health and other public policies (Health in All Policies) will empower people to make informed and positive choices. WHO/Europe continues to promote and raise the level of health literacy across the Region. One example was in November 2019, when WHO/Europe trained participants from nine eastern European and central Asian countries on developing, implementing and evaluating national health literacy projects, with a focus on tackling NCDs. 65. Another major determinant of health is the environment. Environmental risk factors, such as climate change and air pollution, pose serious risks to people's health and well-being, and require coordinated multisectoral action. Estimates from 2018 show that 556 000 premature deaths in the Region were attributed to the joint effects of household and ambient air pollution. 66. To raise awareness and build capacity in Member States, and in order to encourage necessary multisectoral action, the Bonn School on Environment and Health (delivered in October 2019 by the WHO European Centre for Environment and Health (ECEH)) enabled participants from 33 Member States to learn about the relevant tools, guidance materials and resources, and to increase their expertise in assessment, prevention and management of environmental risk factors. On behalf of the RD, the ECEH also carried out secretariat functions for the fifth session of the Meeting of the Parties to the Protocol on Water and Health (Belgrade, Serbia, 19–21 November 2019), which was a high-level intergovernmental meeting on advancing the water, sanitation and health agenda in the Region. 67. The work of the ECEH has continued throughout the pandemic, with the development of technical guidance, advocacy initiatives and webinars to address various dimensions of environment and health in relation to COVID-19, including on reducing the risks of heat for vulnerable populations under lockdown conditions and on moving around in cities. The ECEH continued to work with the Healthy Cities Network, providing representatives of cities (by means of virtual platforms) with peer-learning and support, and technical guidance on how they could contribute to the COVID-19 response, with a particular focus on mental health, among other health conditions. Engagement was sought with several partner networks including the UNESCO Global Network of Learning Cities, the International Organization for Nations Issue-based Coalition on Gender Equality and joined the Coalition’s webinar in June on sharing lessons learned and challenges in addressing gender-based violence as part of country-level COVID-19 responses. The Regional Director highlighted the critical role of the health sector in preventing and responding to this human rights violation and public health problem. WHO/Europe is mapping the existing evidence on the impact of COVID-19 public health measures on violence against women and children. This evidence will serve to support the adaptation of global violence prevention frameworks, such as INSPIRE and RESPECT, and the vast body of guidelines and recommendations for the health sector, to local contexts and the unique circumstances of the COVID-19 response. EUR/RC70/5 Rev.2 page 20 Migration, the Mayors Migration Council, Eurocities, civil society platforms and health promotion networks such as the European Public Health Alliance and EuroHealthNet, to ensure a coordinated approach to local public health responses to COVID-19. 68. Further work in the Region has emphasized that health must not only be promoted across all policies but also in all settings. An example of this has been the WHO collaborative study on Health Behaviour in School-aged Children, which was undertaken in 45 Member States and published in May 2020, providing a basis for action in schools and beyond to improve children’s health and well-being. Another important aspect in this regard has been the informative snapshot of health in prison systems carried out across 39 countries in order to develop evidence-informed policies, as part of efforts to achieve UHC and reduce health inequalities. 69. As COVID-19 has shown us, health must be promoted in the sustainable development agenda. Accordingly, WHO/Europe provided collaborative policy briefs and factsheets on health in the Sustainable Development Goals, and a collaborative study was carried out with 29 countries to understand the level of integration of health into countries’ sustainable development practices. Health security in a changing world: what have we learned from COVID-19? 70. Many lessons have been learned in supporting countries in the European Region to respond to COVID-19, while taking into account the diversity of their needs and differences in the impact of the pandemic across the Region. These lessons have been supplemented by knowledge and practice garnered from other regions as well as from the global management of the pandemic. It is important to record and document these lessons in order to improve the ongoing response and to be better prepared to prevent or control any future public health crisis of this kind. It is also the best way to pay tribute to the many people who have tragically lost their lives, to their families, and to the health and care workers involved. 71. For these reasons, WHO/Europe started – even prior to the adoption of resolution WHA73.1 on the COVID-19 response by the World Health Assembly in May 2020 – to systematically document and track in real time all of its COVID-19-related preparedness and response activities, as one of the pillars of the WHO/Europe intra-action review toolbox. 72. The three fundamental lessons learned from the COVID-19 pandemic, discussed below, are intrinsically connected to the three core strategic areas of work described in the previous section: • the need for solidarity to succeed in health emergencies; • the need for stronger health systems for stronger health security; and • the need to acknowledge the interdependence between health and economic prosperity. EUR/RC70/5 Rev.2 page 21 Solidarity is the key to success 73. A global threat of virus transmission of the kind now being seen with COVID-19, and the challenges it creates at all levels of society, can only be met with solidarity of the same magnitude and scope. Where solidarity fails, the response fails. 74. The global interpersonal solidarity that we have witnessed from individuals and communities to help contain the virus, care for infected people, protect the vulnerable and support those who have been affected socially and economically, has been heartening and inspiring. People have demonstrated responsibility and determination in sacrificing their own freedom and following the restrictive measures of physical distancing. First and foremost, health professionals, caregivers and other frontline workers have set the example by saving lives, fighting the pandemic and keeping essential services running while risking their own health. This year in particular, the International Year of the Nurse and the Midwife, it is important to praise the admirable work and dedication of the health workforce, but also to call for the support and equipment needed to protect their physical and mental health. In the Member States that have reported COVID-19 data concerning the health care workforce, roughly one in four positive cases has been a health care worker, indicating that we may have failed to protect those who protect us. 75. As seen in previous public health crises, countries initially acted alone in the face of the outbreak. An example of this was the procurement of PPE on the global market and the issuing of export bans. But we have also seen great examples of solidarity between countries from across the Region: sharing supplies, hosting patients in hospitals, sending health professionals and providing logistic support. Standing united and acting in cooperation and coordination are the most sensible ways to avoid wasting time and resources. This global health crisis reminds us that we are as strong as our weakest link: the health security of one country depends on safety measures in place in other countries. No one is safe until everyone is safe. Even if solidarity does not come from the heart, it should come from the head. 76. As no country has been spared from this crisis, it is crucial for the principles of international cooperation, coordination and transparency to be followed, for experiences and clinical data to be widely shared, and for action to be taken on a “no regrets” basis. At the Seventy-third World Health Assembly, political leaders from across the world called for multilateral cooperation and solidarity, especially in searching for effective means to detect, treat and prevent COVID-19 as well as in securing equitable access to the required technologies. This call was responded to through the Access to COVID-19 Tools (ACT) Accelerator, a landmark initiative that WHO launched to facilitate collaboration across governments, scientific communities, industries and civil society, as well as philanthropic and international organizations, in order to speed up research, development, production, fair allocation and administration of diagnostics, therapeutics and vaccines on an unprecedented scale. Global leadership was demonstrated in this regard by the European Commission, which convened a major pledging event for the ACT Accelerator but also mobilized, together with EU Member States, a large amount of resources for the Coronavirus Global Response in support of neighbouring countries and other regions of the world. Contributions and pledges from the entire WHO European Region to the global COVID-19 SPRP appeal have amounted to a considerable 50%. It is to be hoped that all these lessons learned and sworn commitments will not be forgotten as soon as the first COVID-19 vaccines leave the production sites. EUR/RC70/5 Rev.2 page 22 77. In addition, the International Health Regulations (2005) are a key tool for international solidarity and mutual cooperation between Member States in the fight against the spread of the disease. Despite its strong operative mandate, which allowed WHO to act fast globally on the COVID-19 outbreak, the IHR (2005) functions remain largely dependent on the national core capacities to fulfill the obligations. It will be important to carefully analyse how this normative instrument and its implementation can be further improved so that the world is better prepared to prevent, detect and manage any future health emergencies. For the WHO European Region, the newly established WHO Centre of Excellence for Preparedness for Humanitarian and Health Emergencies in Turkey will also be an important new instrument to help strengthen Member States’ capacities and preparedness to better face future humanitarian and health crises. Stronger health systems for stronger health security 78. Even though Member States in the European Region mobilized unprecedented resources to respond to COVID-19 during the first half of 2020, and in many cases rapidly reconfigured their health systems to save lives, no single health system was sufficiently prepared to face an outbreak of this nature and size. Health systems, even the best ones, struggled with deficiencies in their responses, such as shortages of PPE to protect their health workers, lack of test kits, insufficient intensive care capacities, and missing infrastructure and strategies for tracking and tracing transmission. The pandemic has also created the perfect storm to enable substandard and falsified medicines and equipment to enter the supply chain. 79. While great efforts have been made to ensure the continued delivery of essential health services, as described above, disruptions have been increasingly documented in the Region, raising concerns about the pandemic’s impact on mortality not due to COVID-19. According to a recent WHO rapid assessment on the impact of the COVID-19 pandemic on the continuity of essential health services in the European Region, the five most significantly disrupted services were: rehabilitation services; dental services; NCD diagnosis and treatment; family planning and contraception; and outreach services for routine immunizations. With the interruption or slow-down of screening and disease-management programmes, we risk seeing a higher incidence of non-communicable diseases in the longer term, with more severe cases and complications affecting especially chronic patients. 80. Innovative and integrated models of health-care delivery, through a properly trained workforce with the right mix of skills, closely interlinked with social services, may provide a sustainable, dynamic and people-centred means of effectively addressing multi-morbidity in the post-COVID-19 era. A pandemic cannot be overcome in hospitals alone. PHC has a critical role to play in the early detection, isolation and referral of COVID-19 cases, and possibly also in the management of mild cases. At the same time, PHC facilities need to be enabled and optimized to ensure continuity of care and maintain essential health services when hospitals are at risk of being overburdened by the pandemic. 81. This public health crisis has also sparked the innovative use of existing and the development of new digital health solutions. These have been applied in diverse contexts, ranging from remote diagnosis, treatment and monitoring of suspected or confirmed COVID-19 cases, to entirely new approaches for contact tracing, disseminating health information to the public, or conducting accelerated testing and clinical trials. This increased demand extends to the use of digital technologies in supporting the continuity of essential EUR/RC70/5 Rev.2 page 23 health services, for example, through the use of telemedicine for the delivery of primary care, or electronic prescribing and dispensing of medicines. Perhaps one area where the current pandemic has exposed significant shortcomings is the access to accurate, real-time data for decision-making and guiding COVID-19 response actions. It has demonstrated the need for appropriate legislation and transparent mechanisms for governance and accountability to address the legitimate concerns and claims to guarantee human rights, respect of privacy, and equitable access for all. Democratic participation and health literacy are necessary aspects to ensuring the population’s acceptance and compliance to the measures and solutions introduced. To that effect, a better understanding of people’s behaviours and preferences will also help to build stronger health policies. 82. It is clear that health systems will have to continue operating in a challenging context over the medium term, with demand increasing for health services while resources are increasingly tightened. Countries will have to apply dual-track service delivery. On the one hand, they will need to contain the transmission and mitigate the impact of COVID-19 on health systems, through a combination of measures such as testing, contact tracing, self- isolation and mobilization of acute and intensive care service capacity dedicated to COVID-19 patients. On the other hand, health systems will experience a pent-up demand for essential health services for other health conditions, which will need to be met. Simultaneously, the emerging economic crisis is likely to increase mortality and morbidity and spur the use of health care services, particularly for chronic conditions and mental health problems, as has been documented during previous economic downturns. Evidence gathered over recent months shows that it is possible for countries to maintain routine health services while ramping up capacity to respond to the pandemic. Innovations such as testing facilities outside hospitals, mobile units that treat mild COVID-19 cases at home and the implementation of contact-tracing apps are encouraging examples of the resilience of our health systems. Health and the economy: two sides of the same coin 83. The COVID-19 pandemic is much more than a public health crisis. It has swiftly turned into a global economic crisis. Projections forecast an economic recession on a far bigger scale than the one experienced after the global financial crisis in 2008. The International Monetary Fund has estimated that for every month the pandemic continues, US$ 375 billion is lost from the global economy, leading to a nearly 5% reduction of gross domestic product globally in 2020. This will have serious effects for many years to come, including on the social and health status of populations. It is likely to compound inequalities and divisions that are weakening our societies and to hamper progress towards the achievement of the SDGs. This is also the reason why, within the United Nations multilateral response to the COVID-19 crisis, next to the health and humanitarian response, socioeconomic recovery is an important third pillar of support to countries. 84. Although the lockdowns, border closures and other restrictive measures that were imposed by governments to contain the outbreak and prevent health systems from collapsing have seriously affected economic activities and international trade, it must be stated clearly the choice between lives and livelihoods is a false one. Health is not opposed to the economy, and saving lives is not opposed to saving the economy. Any prioritization of the economy over health ultimately risks crippling the economic recovery. If virus transmission is not under control, re-opening businesses and trade will not be a sustainable solution. EUR/RC70/5 Rev.2 page 24 85. At the same time, the evidence of the past few months has shown that countries can indeed manage the containment of the pandemic while ensuring that the economy and educational system continue to run. In addition, we cannot ignore the negative effects and collateral damage that have been caused by the public health measures, even if they were necessary to flatten the curve. Many groups have been left behind in these difficult times, including children with special educational needs, victims of gender-based violence, elderly people isolated in their homes and chronically ill patients deprived of medical attention. Therefore, the transition to a so-called “new normal” will need to carefully strike a balance between public health principles and social and economic considerations. Economic recovery cannot be dissociated from the health response. 86. It will be equally important for health to be kept high on the political agenda once we move out of the acute phase of the crisis. Although we are already witnessing the temptation to go back to business as usual and focus all attention on restoring the economy, the overwhelming impact of the pandemic, together with the awareness that the next pandemic might be just around the corner, should be a sufficient reminder that we cannot afford to lose any time in strengthening our health systems and investing in their preparedness and resilience. Further investment in health will also be needed to address the longer-term health effects that this crisis will have caused, including with respect to NCDs. The experience of the financial crisis has taught us that cutting health expenditure and implementing austerity measures are not the best recipes for recovery and that countercyclical investment in health and social protection can provide a better and quicker way out of an economic crisis. It is encouraging to see that in the wake of the COVID-19 outbreak, many countries proactively took measures to support and protect the most vulnerable groups in their societies. 87. In this way, moving from response to recovery provides us with an opportunity to do things differently, to fundamentally reconsider our priorities and the way we will organize and shape our societies in the future. If economic development in the post-COVID-19 era is more closely linked with social progress and environmental sustainability, this could pave the way towards a true economy of well-being that leaves no one behind, puts people and their health at the centre of policy and sees public health as a driver of economic development, security and peace. 88. To prepare for this economy of well-being and culture of health, WHO/Europe on 26 August 2020 convened a Pan-European Commission on Health and Sustainable Development. This Commission is composed of former heads of states and governments, distinguished life scientists and economists, heads of health and social care institutions, and leaders of the business community and financial institutions. Under the Chairmanship of Professor Mario Monti, Former Prime Minister of Italy and EU Commissioner, the Commission will advise European leadership on key policy options to shape a future landscape where health and wellbeing are valued as the cornerstones of sustainable development, economic prosperity and growth. The Commission will play a significant role, alongside Member States, in taking the lessons learned from the COVID-19 response in Europe and proposing recommendations on future health system investments and reforms to improve the resilience of European health and social care systems. Its work will be supported by a Scientific Advisory Board to establish the evidence base and identify policy options and priorities. Ultimately, the Commission’s final report, with their key findings and recommendations, will be released in September 2021, when it will be presented at the 71st session of the WHO Regional Committee for Europe (RC71). EUR/RC70/5 Rev.2 page 25 Transforming WHO/Europe to be fit for purpose 89. The experiences and lessons learned over the last six months in responding to the COVID-19 pandemic are contributing to WHO/Europe’s efforts to transform itself into a more fit-for-purpose organization: one that is flexible and agile and that has the capacity to rapidly respond and adapt to the needs of Member States – ultimately delivering impact in countries – while keeping a steady focus on its corporate mission and strategic long-term priorities. Supporting WHO’s transformation 90. Over the previous year, WHO/Europe has been fully engaged with the WHO transformation process aimed at optimizing country impact across the three levels of the organization, which in addition to WHO headquarters and regional offices, includes the strengthening of country offices. WHO/Europe has taken transformation forward along the five workstreams of: strategy and leadership; processes and tools; operating model; external engagement and partnerships; and organizational culture and staff engagement. As part of the WHO transformation process, all WHO/Europe staff have been involved in a range of activities and consultations, which have drawn on the WHO Values Charter. 91. In October and December 2019, for example, two whole-of-office meetings were held to drive the corporate cultural change process. A General Service Staff Task Force was established to provide a constructive channel for identifying opportunities for improvement in working processes and environment, and recommending improvements in relation to, among other topics, WHO’s administrative processes, career paths, and ways of working among general service staff. Restructuring WHO/Europe to deliver strategic priorities 92. To match the response and actions of its Member States, WHO/Europe must effectively address the challenges and changing operating realities it encounters, in order to deliver enhanced country impact and continuously respond to the priority needs of the countries in the Region in line with the EPW. Structural alignment of its activities with the strategic priorities of the EPW and GPW 13 is currently under way, in close consultation with all staff and with the WHO/Europe Staff Association. 93. In February 2020, a new draft high-level organigram for the Regional Office that aligns the organizational structure with the core strategic priorities was presented and discussed at a townhall meeting. The new flat structure represents a reduction from five to three technical divisions, which better corresponds to the three pillars of GPW 13, has a leaner executive council, focuses on country support, fosters collaborative ways of working through agile and cross-divisional teams, and promotes innovation and efficiency at all levels of the Organization. 94. A virtual consultation on the draft high-level organigram was launched in May 2020, in which almost 300 staff members from the Regional Office, the GDOs and the country offices participated. In addition, a Management Project Plan Steering Committee and working groups were established to lead work in a number of key transformative areas: capturing innovative and agile ways of working, examining team-based structures; planning and implementing the EUR/RC70/5 Rev.2 page 26 new structure in the corporate programme management system; and simplifying an initial six business processes prioritized through a survey among all WHO/Europe personnel. In parallel, the digitalization of administrative processes and forms has been initiated to better support technical delivery at country level. 95. Through a transparent selection process, the new team of directors was appointed in May, making up the WHO/Europe Executive Council. An in-depth functional review process is under way with a view to finalizing the organizational restructuring in September 2020. A special adviser on transformation and organization development has also been appointed to enhance staff development and learning and to drive an internal communications strategy, in order to support organizational effectiveness and foster innovation. Establishing a new organizational culture through staff engagement 96. In February 2020, the newly appointed Regional Director organized two inaugural townhall meetings with all WHO/Europe staff during which he committed to and signed the WHO Values Charter, invited all staff to co-sign and presented his vision for the future and how to operationalize it. 97. Consultation and engagement with staff, as well as staff health and well-being, have been key concerns in the transition process, and these were further accentuated by the COVID-19 pandemic during which staff were repurposed and had to work remotely. Reflecting the commitment to ensuring a safe and respectful workplace, a zero-tolerance policy on workplace harassment has been followed through, a full-time ombudsperson has been recruited, and monthly meetings have been held with the WHO/Europe Staff Association to take staff interests and concerns into account. 98. Further frequent and interactive virtual townhall meetings with staff working across the Region (each with more than 600 unique views) have been held to keep staff updated on business continuity status, on the COVID-19 response as well as on the transition process. Other channels such as an “Ask Hans” mailbox, have been set up to ensure free and frank communication – ensuring confidentiality where necessary. 99. During the lockdown period, various support services were organized for staff members and their families to ensure their mental and physical well-being (for example, access to a staff physician, online mental health sessions, virtual fitness classes, WhatsApp peer groups, online guidance and tips) as well as to enable effective remote teleworking and virtual meetings. The Regional Director quickly initiated twice-weekly check-ins with WHO representatives and heads of country offices, country office staff and country mission teams, to keep abreast of country needs and encourage those working on the front line of the WHO emergency response in the Region. Ensuring accountability to Member States and external engagement 100. As a Member-State-driven organization, it is crucial that WHO/Europe maintains close contact with countries and frequently reports to and consults with them in order to build and maintain mutual trust. This has proven to be even more important during the COVID-19 pandemic, during which the frequency of meetings, briefings and exchanges with national political representatives and policy-makers was greatly stepped up. EUR/RC70/5 Rev.2 page 27 101. Strengthening corporate governance through close engagement with the Region’s governing bodies has also been a priority. In consultation with the Chairperson and Vice- Chairperson, the Regional Director convened two additional (virtual) ad hoc SCRC meetings. The first one, in April 2020, followed the formal statement on the COVID-19 pandemic that the SCRC adopted at its March meeting, expressing its support to WHO and calling for joint and coordinated action. At this ad hoc meeting, SCRC members were informed about and consulted on WHO/Europe’s COVID-19 response and the support it had been providing to countries. A second ad hoc meeting on 29 June assessed the options for holding RC70 in light of the latest developments in the pandemic and the inter-session decision taken by the Regional Committee to revise the arrangements for RC70. 102. Earlier, in November 2019, the SCRC members had also taken part in a brainstorming session on options for making Regional Committee sessions more responsive to the needs of ministers and how to better structure the programmes of those sessions. The SCRC was also systematically informed and consulted about the development of the EPW and provided comments on the various drafts. Through the subgroups on countries at the centre and governance, the SCRC is also providing guidance on new and innovative approaches to country-specific support and corporate governance, respectively. Linkage with the European members of the WHO Executive Board was also ensured to align discussions and actions at the global and regional levels. • The EPW has been shared with many other stakeholders and partners to obtain their input and feedback on the proposed priorities and how to implement them, as well as to prepare the ground for developing new partnerships and engagements. In June 2020, an online consultation process was launched, with the draft EPW posted online for public comment. A virtual briefing on the EPW with non-State actors was also held. Representatives of eight European nongovernmental organizations accredited to the Regional Committee shared their thoughts on the EPW and on how to collaborate to build safer and healthier societies in the Region, especially in the context of the COVID-19 pandemic. • At meetings organized by the Regional Coordination Mechanism for Europe and Central Asia and the Issue-based Coalition on Health and Well-being, the Regional Director consulted with the United Nations Resident Coordinators and his fellow United Nations regional directors in Europe and central Asia on joint COVID-19 action and on how the EPW can help to align efforts to achieve the SDGs and health-related targets in these regions. The EPW was also presented to the EU Commissioner and Director-General for Health and Food Safety to explore synergies with the draft EU4Health programme. In each country, the UN country teams discussed health and the EPW in the spirit of integration into the UN Sustainable development cooperation framework. Mobilizing financial resources 103. WHO’s ability to provide dedicated support to all Member States is dependent on adequate financing. WHO/Europe has experienced chronic funding gaps over the last three bienniums. In 2018–2019, WHO/Europe managed, through support from WHO headquarters and other sources, to cover US$ 6.4 million worth of unfunded expenditures against the base EUR/RC70/5 Rev.2 page 28 budget. Estimates for the current biennium are that WHO/Europe will end the biennium with an unfunded salary expenditure of US$ 10 million against the base budget (at the time of writing this report). As much of the funding to WHO/Europe consists of earmarked voluntary contributions, flexibility to move funds to underfunded segments of the programme is limited. It should also be noted that several critical programmes, such as those relating to immunization, TB and HIV/AIDS, as well as the emergencies pillar, are heavily reliant on funding by the United States. 104. Addressing the inherited financial deficit and ensuring future financial stability has been an important preoccupation of the new Regional Director since his nomination by RC69. In March 2020, he convened a meeting of resource partners to discuss how to ensure more predictable and sustainable funding for WHO/Europe, eliminate financial shortfalls within programmatic areas and make an investment case for the proposed EPW flagship initiatives. Further bilateral consultations have secured increased resources for support to countries in specific European subregions. Building on the GPW 13 investment case and the global WHO resource mobilization strategy, an EPW engagement strategy 2020–2025 is under development to promote coherent resource mobilization and results-driven partnerships and to ensure more strategic allocation of funding at country and regional levels. 105. The financial situation has already led to some immediate mitigation measures, including the vetting by the Regional Director (as nominee) of all human resources decisions following RC69 and, before his term began, ending the automatic replacement of vacant posts and rationalizing short-term and consultant contracts. It has also inspired the intention to develop a leaner but technically stronger organizational structure, with a reduction of director- level positions, and a gradual reduction of staff presence in the Regional Office in Copenhagen through mobility, while maintaining the commitment to strengthening the policy focus in Copenhagen as well as the country presence in priority countries in line with the draft EPW. WHO/Europe is also working closely with WHO headquarters and other regional offices to mitigate the added impact of the announcement by the United States Government concerning the country’s withdrawal from the Organization. Several short-term solutions are being identified while the full implications are analysed in consultation with the SCRC, the Staff Association and WHO headquarters. Concluding remarks by the Regional Director 106. As much as the past year has been unpredictable, it may be difficult to anticipate what the next twelve months will bring for WHO/Europe after the 70th session of the Regional Committee for Europe. While it is clear that the management of the global pandemic will continue to require our full attention and mobilize a lot of our resources, our strategic focus will be on best serving our 53 Member States and preparing for a better future and health for its citizens, drawing on the lessons learned as presented in this report and on the vision for WHO/Europe that is presented in the draft EPW, also guided by the future recommendations of the Independent Panel for Pandemic Preparedness and Response and the pan-European Commission on Health and Sustainable Development. 107. With the GPW 13, EPW, SDGs and Global Action Plan for Healthy Lives and Well- Being for All as our compass, our work will concentrate on how to implement them and achieve impact at the country level. This will require close cooperation and engagement with Member States. If there is one thing that I personally have become even more convinced of, it EUR/RC70/5 Rev.2 page 29 is the absolute importance of trust and interpersonal relations in effectively addressing a public health crisis of this nature. While the mandate of improving international public health stands with the WHO globally, the experience of the last few months has taught us that no single country or organization can face these global and regional public health challenges alone. For this reason, establishing and strengthening partnerships will be another key component of our work ahead. 108. WHO as an organization is naturally caught by this crisis and is subject to criticism and scrutiny. In my view, the best way for us to respond at a regional level is to demonstrate full transparency in our actions and to demonstrate our willingness to serve and to change for the greater sake of the general good, with a clear understanding of the role that has been mandated by the Member States and under the continued guidance of the WHO/Europe governing bodies board, the SCRC. = = =
World Health Organization (WHO) · Governing Bodies documents
Seventieth Regional Committee for Europe: virtual session, 14–15 September 2020: report of the Regional Director on the work of WHO in the European Region in 2019–2020
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