WHO in Europe: meeting the challenges

The Regional Office for Europe of the World Health Organiza- tion welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, WHO Regional Office for Europe, Scherfigsvej 8, DK -2100 Copenhagen 0, Denmark, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 1995 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this publication are those that obtained at the time the original language edition of the book was prepared. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Report compiled and edited by Mary Stewart Burgher with the assistance of Pamela M. Charlton Design and graphics: Sven Lund Layout: Wendy Enersen Printed in Denmark by Rapo Contents Foreword Health in Europe Fighting disease in the NIS Humanitarian action Information for environmental health Integrated action on environment and health Learning material for nurses Health care reform in Kyrgyzstan Reducing drug use Health promoting schools Profiles of women's health Promoting women's and children's health Nutrition training in the CCEE and NIS Telematics: early warning of disease Pharmacists helping smokers quit Quality of care development Policies for health for all Conclusion 2 3 4 5 6 7 8 9 10 11 12 13 14 14 15 16 17 WHO Library Cataloguing in Publication Data WHO in Europe: meeting the challenges (WHO regional publications. European Series ; No.57) 1.Regional health planning 2.Health for all 3.World Health Organization 4.Europe (.Series ISBN 92 890 1321 2 (Classification NLM: WA 541) ISSN 0378 -2255 INFORMATION ABOUT THE REGIONAL OFFICE The World Health Organization (WHO) is a specialized agency of the United Nations. Founded in 1948, it is the directing and coordinating authority on international health work. It has its headquarters in Geneva, Switzerland, and six regional offices: Regional Office for Europe (EURO), Copenhagen, Denmark Regional Office for the Americas /Pan American Health Organization (AMRO /PAHO), Washington, DC, USA Regional Office for the Eastern Mediterranean (EMRO), Alexandria, Egypt Regional Office for South -East Asia (SEARO), New Delhi, India Regional Office for the Western Pacific (WPRO), Manila, Philippines Regional Office for Africa (AFRO), Brazzaville, Congo Each regional office has its own programme, geared to the health problems of the countries it serves. The WHO Regional Office for Europe has a permanent staff of some 240 people, and a similar number of short -term staff, from about 40 nations. In addition, over 1000 experts work in the Region every year, along with collaborating centres and research institutes in many countries. Over 30% of Regional Office staff work in the field. The regular annual budget is about US $25 million. Funds donated by other sources, including the United Nations and individual governments, have grown to about US $30 million per year. The European Region embraces some 850 million people living in an area that stretches from Greenland in the north- west and the Mediterranean in the south to the Pacific coast of the Russian Federation in the east. The European programme of WHO concentrates on both the emerging democracies of the central and eastern part of the Region and the problems of industrial and post -industrial societies. Since 1990, the number of Member States has risen from about 30 to 50. The Regional Office is governed by a Regional Committee comprising representatives of every Member State; a Standing Committee from this body advises the WHO Regional Director for Europe. Through the Regional Committee, which meets once each year, the Member States collectively formulate regional policies, recommend technical activities and approve the programme and budget. The Regional Office in its turn provides Member States with technical and advisory services, directly or through networks of experts and other partners. As of June 1995, the Member States of the European Region are as follows: Albania France Luxembourg Spain Armenia Georgia Malta Sweden Austria Germany Monaco Switzerland Azerbaijan Greece Netherlands Tajikistan Belarus Hungary Norway The Former Yugoslav Belgium Iceland Poland Republic of Macedonia Bosnia and Herzegovina Ireland Portugal Turkey Bulgaria Israel Republic of Moldova Turkmenistan Croatia Italy Romania Ukraine Czech Republic Kazakhstan Russian Federation United Kingdom Denmark Kyrgyzstan San Marino Uzbekistan Estonia Latvia Slovakia Yugoslavia Finland Lithuania Slovenia WHO Regional Office for Europe, Scherfigsvej 8, DK -2100 Copenhagen 0, Denmark Tel: (+ 45) 39 17 17 17 Fax: (+ 45) 39 17 18 18 Telex: 15348 and 12000 who dk Teletex: 118785 Electronic mail: BITNET:WHOEURO @VM.UNI -C.DK TARGETS FOR HEALTH FOR ALL The work of the Regional Office is based on the regional policy for health for all, which includes 38 targets. They fall into five groups: targets for better health, lifestyles conducive to health, healthy environments, appropriate health care services and the support needed to attain them. These targets were adopted in 1984 and revised in 1991, retaining their essential framework with some changes of emphasis. Four targets now deal with specific population groups to emphasize positive health. The targets on health services now focus more clearly on specific health care settings (such as primary health care, hospitals and long -term care). The targets on the quality of care and appropriate health technology have been merged to allow the inclusion of a new target on health and ethics, a growing concern all over the Region. 1. Equity in health 20. Water quality 2. Health and quality of life 21. Air quality 3. Better opportunities for people with disabilities 22. Food quality and safety 4. Reducing chronic disease 23. Waste management and soil pollution 5. Reducing communicable disease 24. Human ecology and settlements 6. Healthy aging 25. Health of people at work 7. Health of children and young people 26. Health service policy 8. Health of women 27. Health service resources and management 9. Reducing cardiovascular disease 28. Primary health care 10. Controlling cancer 29. Hospital care 11. Accidents 30. Community services to meet special needs 12. Reducing mental disorders and suicide 31. Quality of care and appropriate technology 13. Healthy public policy 32. Health research and development 14. Settings for health promotion 33. Health for all policy development 15. Health competence 34. Managing health for all development 16. Healthy living 35. Health information support 17. Tobacco, alcohol and psychoactive drugs 36. Developing human resources for health 18. Policy on environment and health 37. Partners for health 19. Environmental health management 38. Health and ethics ORGANIZATION The Regional Office has four technical departments. Three mirror the main groups of targets and work for better health, healthy environments and appropriate care. The fourth ties together the threads of the various technical programmes into country projects, with particular emphasis on the countries of central and eastern Europe (CCEE) and the newly independent states (NIS) of the former USSR. A fifth department provides the Office with support services such as budget and finance, personnel and administration, as well as documentation and informatics. Executive Management gives overall guidance to the work of the Regional Office. Executive Management Disease Prevention Environment Health Policy Country Administration and and and Health and Lifestyles Health Health Care Development Finance Foreword A wave of change has broken over the European Region of the World Health Organization (WHO), transforming the social, political and economic land- scape. The most important feature of this landscape for health is the deep and widening gap between the eastern and western halves of the Region. Neverthe- less, WHO's recent work shows that the Regional policy for health for all, with its 38 targets, offers the best way to meet the health challenges of both the old Europe and the new. The policy's enduring value lies in its compre- hensive approach to health, its firm fundamental principles, and the flexibility of their application. This means that the WHO Regional Office for Europe pursues a wide variety of goals in all areas relevant to health - including lifestyles, the environment and health services - with any combination of methods and partners that suits the circumstances. The princi- ples of health for all harmonize these efforts, while the policy itself unites them. Principles in action The health for all policy and its seven principles guide all the activities described in this report. The 1994 European Health Policy Conference reaffirmed the value of this approach and urged that health for all form the foundation of country policies and greater international cooperation on health. Equity in health is the first principle in every sense. this goal has led the Regional Office to address the most serious health problems and the most vulnerable groups and countries. In particular, work with the countries of central and east- ern Europe and the newly independent states of the former USSR, to narrow the health divide, comprises two thirds of the activities of the Regional Office. This work, which constitutes the EUROHEALTH pro- gramme, underpins every article in this report, most notably those on responses to the resurgence of com- municable disease and humanitarian assistance to war -torn countries. Closely allied to equity is the second principle, ethics. This is the basis of WHO's work to improve the quality of health services. The next two principles of health for all empha- size primary health care and health promotion and disease prevention. Work here ranges from reducing substance use and promoting health in schools to improving maternal and infant health and promoting family planning in the central Asian republics. The last, closely linked principles form a theme that runs throughout this report: participation in decision -making by everyone concerned, and inter - sectoral and international cooperation. Health for all expresses WHO's recognition that health is every- body's business and that cooperation maximizes the effectiveness of all the partners in the task. In this area, WHO makes special efforts to build the capacities of different groups of professionals, including nutritionists, school staff and environmen- tal health managers. It has formed powerful alliances within the health sector, as well: with doctors for quality assurance, with nurses for educational development, with pharmacists for health pro- motion, and with health authorities and health adminis- trators for health care reform. Such alliances help to ensure the sustainability of WHO pro- grammes. The Regional Office con- stantly widens its network of international partners, which already includes WHO head- quarters and other regional offices, sister United Nations agencies, the European Union, governments and their agencies, and hundreds of nongovern- mental organizations. WHO brings its partners invaluable information, expertise and tech- nical advice on public health. WHO has turned partnership from a goal to a reality, resting on a solid and growing foundation of success- ful shared work. In the European health policy, the WHO Regional Office for Europe offers its many partners the best way to ensure the efficient and effective use of re- sources for health gain. The policy will continue to guide European countries forward to health for all. J.E. Asvall WHO Regional Director for Europe One of many WHO information products The health divide: life expectancy at birth The health divide: deaths from cancer in people under 65 Health in Europe IN EÛÂÔPE Implementing the WHO health policy for Europe in- cludes regular monitoring to measure countries' progress towards the goal of health for all. The WHO Regional Office for Europe recently published a sum- mary of the main results of the latest round of monitoring. This was an important part of WHO's work as a centre for information on public health. Health in Europe highlights the most important health problems in the WHO European Region, and describes country policies to tackle these problems and to achieve the 38 targets for health for all. Thus, the book indicates the areas for most effective re- sponse by countries and the Regional Office. Toll of change on health Everyone knows that the Region - particularly the countries of central and eastern Europe (CCEE) and the newly independent states (NIS) of the former USSR - is undergoing profound, some- times violent, political, social and economic change. Health in Europe points out the effects of economic problems, social unrest, migration and war on health. It shows the most important trend: growing inequities in health. For example, all citi- zens do not share in the improving health found in the western half of the Region. The clearest sign of inequity, and thus the clearest call for action, is CCEE European Union r' NIS Nordic countries 79 the gap in health between east and west. Measured in life expectancy, this gap is 6 years wide, and growing. The causes? The most important are deaths from cardiovascular diseases, injury and poisoning, cancer and respiratory diseases, as well as infectious and parasitic diseases in babies. Lifestyle plays an important role in all of these. But communicable diseases show a worrying resurgence (see p. 3), and poor living conditions threaten the health of vul- nerable groups such as the elderly, women and children (see pp. 11 and 12), the poor, members of minority groups, migrants and refugees. Better dis- ease prevention and healthier lifestyles and environments could reduce much of this burden of illness and death. A tool for these times These problems demand an integrated, innovative response from the countries of the Region. They call for effective solutions that use resources efficiently and promise better health for everyone. More than ever, the WHO policy for health for all is the tool for these times. It offers: the goal of equity in health; a stress on disease prevention and health promo- tion, in addition to appropriate treatment; a comprehensive approach to the determinants of health: lifestyles and the environment, as well as health services. As the wave of change broke upon the Region at the start of the 1990s, the Regional Office shifted its focus to the countries in greatest need. Through the EUROHEALTH programme, it now directs two thirds of its resources to the CCEE and NIS. This includes special efforts to help countries where war worsens already difficult conditions (see p. 4). As spelled out in Health in Europe, current con- ditions in the Region offer immense opportunities to make a difference. Seizing them is the main challenge for the Regional Office in its cooperation with the countries of the Region. CCEE European Union ® NIS Nordic countries 115 °110 ô105 0100O ô 95 90 85 ô 80 75 N V' (D N O N C (D N O N N- N. CO CO CO CO CO O) D)a) D) O) a) D) O) O) CO D) Q) Q) D) Fighting disease in the NIS Some communicable diseases have returned from the brink of elimination to threaten health in the Region. Particularly in the NIS, diphtheria epidemics continue and poliomyelitis is a growing menace. Thus, action against these diseases has regained priority in WHO. Recognizing that no single agency or donor can deal with the problems, the Regional Office helps to co- ordinate donor assistance to maximize effectiveness. Goal: vaccine independence Immunization is one of the best ways to control some communicable diseases. But political and economic changes in the NIS led to gaps in immunization cov- erage, and badly damaged former systems of vaccine supply and distribution. This forced most of the NIS to depend on donations. As part of the new Inter- agency Immunization Coordinating Committee (IICC), WHO is working towards vaccine independ- ence in the NIS. Established by the Kyoto Declaration in 1994, IICC comprises governments (of Canada, Denmark, France, Germany, Japan, Norway, Turkey and the USA), the European Union (EU), the International Federation of Red Cross and Red Crescent Societies (IFRC), the United Nations Children's Fund (UNICEF) and WHO. Its short-term aims are to strengthen coun- tries' immunization programmes and to take immediate action against current and potential out- breaks of disease. The next goal is vaccine self -sufficiency: to enable each of the NIS to acquire and control the quality of supplies that meet its needs. As secretariat to IICC, WHO's task is to supply donors with information on countries' needs and to track donors' assistance to avoid duplication and gaps. WHO has worked out with UNICEF a system to estimate needs, and is working on a system to track donors' pledges. The Regional Office secures the views of the NIS from the WHO European Informa- tion Service on Medical Supplies (ISMS). Through ISMS, the NIS voice their needs. ISMS issues quarterly reports to over 100 donors within and beyond IICC. The reports list countries' stocks of and needs for vaccines (against tuberculosis, diph- theria, pertussis, tetanus, measles and poliomyelitis), some 120 life- saving drugs and essential medical equipment. Donors have warmly welcomed the ISMS reports. Fighting disease WHO is acting to control diphtheria and poliomyeli- tis. Working closely with UNICEF and IICC members, the Regional Office has contributed guidelines on diphtheria diagnosis and case management. It has also helped the NIS to work out action plans to control the epidemics, and to mobilize donor support. For poliomyelitis, WHO launched an interregional project of mass immunization. The project team in- cludes WHO, UNICEF, IFRC, Rotary International, the Centers for Disease Control and Prevention and the United States Agency for International Devel- opment.The WHO Regional Offices for Europe and the Eastern Mediterranean coordinate the project, which covers 18 countries where poliomyelitis is en- demic. Through Operation MECACAR (Mediterranean, Caucasian and central Asian republics), 63 million children under 5 will be immunized in 2 rounds of national immunization days each year for 3 years. Operation MECACAR started on 7 April 1995, World Health Day, and will contribute substantially to the WHO goal of eradicating poliomyelitis by the year 2000. Launching Operation MECACAR, World Health Day 1995 Russian Federation Ukraine In Other NIS 50 40 30 o co O) Co N CO C' CO Co CO O) O) O) O) O)O) O) O) O) O) O) O) O) Incidence of diphtheria in the NIS wi on Pi E Humanitarian action ÉE C7 ¢ A young refugee in Croatia WHO plays a crucial role in organizing help for refugees Delivering the goods: WHO driver loads medicines Answering calls to action For the first time since WHO's founding, war has returned to the Region, affecting nine of the CCEE and NIS since 1990. The Regional Office makes spe- cial efforts to ease this terrible extra burden on health. The first and biggest example is its programme of humanitarian assistance to the countries of the former Yugoslavia. A recent external evaluation of this pro- gramme gave a ringing endorsement of WHO's role and work. Is it worth while? To help the former Yugoslavia, the Regional Office not only launched its biggest project ever, in difficult and dangerous conditions, but also added active in- tervention to its familiar role of adviser and coordinator. The vicious, messy conflict has caused millions of people to flee their homes, killed and wounded hundreds of thousands, and crippled health and environmental protection services. The Office of the United Nations High Commis- sioner for Refugees heads a joint programme of assistance that includes UNICEF and WHO. Since July 1992, WHO has coordinated health -related activities in the programme. This means assessing needs and ensuring that they are met, while avoiding duplica- tion of effort and filling gaps. It requires strong links with all the key partners: United Nations organiza- tions, other intergovernmental organizations, government ministries and agencies, over 180 non- governmental organizations, and local health authorities. To do its job, WHO has 85 staff in 7 lo- cations, and has received support totalling US $60 million in cash and in kind. In June 1994, WHO asked three international experts in public health and disaster management to make their own judgement. "Well worth repeating" The evaluation confirmed WHO's mandate for hu- manitarian assistance and stressed the respect won from WHO's partners and the good coordination in the field. They gave special praise to WHO's work in assessing public health needs. WHO partners "are turning to WHO for authoritative advice on all health matters" and "stressed WHO's unique contributions in setting standards, issuing guidelines and provid- ing specific expertise ". WHO staff "deserve the highest praise for their efforts ". "Local officials stressed the wide range of WHO contributions to epidemic preparedness and control." The 20 kits that WHO designed for special diagnos- tic and treatment needs "stood out for their standardized quality ". The evaluators also noted "un- deniable achievements" in physical and mental rehabilitation. They pointed out that WHO was already looking "beyond relief to development ", and had a "pre- eminent role as a technical adviser" in health care reform and reconstruction. WHO seminars, dis- cussions and literature on reform won "nearly universal praise ". Their final conclusion was: This programme has been highly successful in spite of its shortcomings. Even if none of the observed shortcomings were corrected before the next call for humanitarian action, this programme is still well worth repeating. Next steps The Regional Office has already applied the lessons of the evaluation to the next phase of its humanitar- ian work. New management and administrative structures are in place, and work for further improve- ment continues. In the former Yugoslavia, WHO is planning to meet needs for reconstruction. It contin- ues its work for peace through health: chairing the Health Committee of the Interim Coordinating Body in Sarajevo and promoting cooperation between the six medical associations of the region. In answering this and other calls for humanitar- ian action, the Regional Office seeks to be, in the words of its Regional Director: an organization with a real conscience for those most in need, sound technical competence to ad- vise on the best strategies available and an ability to create opportunities where they may seem hard to find. Information for environmental health Policy -makers need sound information to transform public concern about the environment into action. WHO has gathered such information in ground- breaking studies at the regional and country levels, and policy- makers have used it to make action plans. These are the first steps towards securing sustainable development and environments that protect health. Concern for Europe's Tomorrow In 1991, the new WHO European Centre on Environ- ment and Health (ECEH), working in Copenhagen, Bilthoven, Nancy and Rome, launched the project Concern for Europe's Tomorrow. It was the first and most comprehensive survey of the environment and its effects on health in the European Region. Its method was environmental epidemiology: showing where and in what environmental conditions deaths and cases of disease occurred. This permitted asso- ciations with factors in the environment, and thus indicated priorities for action. The report Concern for Europe's Tomorrow made recommendations on seven issues: gaps in informa- tion, contaminated water and food, accidents (on the road, at work and at home), air pollution, road traffic (as a cause of accidents and pollution), problems with housing and urban development, and issues that cross national boundaries. The report gave important input to the Second European Conference on Environment and Health, held in Helsinki in June 1994. WHO or- the Conference with the Commission of the European Communities (CEC). The participants at the Helsinki Conference in- cluded health and environment ministers from 47 countries of the Region, and representatives of 2 offices and 4 specialized agencies of the United Nations, and 4 intergovernmental and 13 non- governmental organizations. They all endorsed the WHO Environment and Health Action Plan for Eu- rope, and set up the European Environment and Health Committee to carry it out. The Action Plan called for countries to make their own plans, and six took the lead: Bulgaria, Hungary, Italy, Latvia, the United Kingdom and Uzbekistan. In addition, the Nancy Division of ECEH has developed many projects for the reconstruction of environmental pro- tection services in Bosnia and Herzegovina, for which it is seeking donor support. Environment and health in Italy Events in Italy have mirrored those in the Region. As one of the pilot countries, Italy is providing a proto- type of investigation and responsive policy- making. The Rome Division of ECEH used the methods of the Region -wide project to track deaths from over 30 causes at the municipality level. Like the regional report, Environment and health in Italy describes both health and risk factors in lifestyles and economic activities, and people's exposure to a range of envi- ronmental hazards. Its special feature is a discussion of areas of high environmental risk. High -risk areas, identified by the government, comprise about 6% of Italy's area but have 20% of the population. Most of the small areas suffer from a single, well known source of pollution, usually an industrial plant. The large areas, including Naples and most of Lombardy, have complex problems of envi- ronmental degradation. The report has sparked action. The Rome Divi- sion of ECEH will do further studies to confirm the associations found, while naming priority issues for the government to address in its national action plan. This points the way for the other pilot countries and the Region as a whole. Road traffic: accidents and pollution threaten health Concern for Europe's Tomorrow. Summary from 1994; the full report was published in 1995 High -risk areas in Italy Participants in NIPEH training activities Integrated action on environment and health The CCEE and NIS have inherited a sorry legacy of environmental degradation, inadequate systems to measure problems and their effects on health, and lit- tle money for clean -up or prevention. Nevertheless, protecting the environment and health requires inte- grated action. The WHO national integrated programmes on environment and health (NLPEHS) help six CCEE to build the systems and skills to tackle their own priorities. Building capacity for environmental health management Making the CCEE habitable and healthy means deal- ing with factors in the environment that can damage health: air and water polluted by mining and other industries, water polluted by farming practices, and contaminated food and drink. In many "hot spots ", widespread pollution from many sources seems to affect the whole population. Because the CCEE needed similar kinds of tech- nical assistance, the Bilthoven (Netherlands) Division of the WHO ECEH devised NIPEHS as a framework for activities. With country health and environment authorities, the Bilthoven Division has worked out NIPEHS for Bulgaria, the Czech Republic, Hungary, Poland, Romania and Slovakia. The aim is to upgrade and link the work of health and environment authori- ties and institutes. This will enable them to supply sound information to decision -makers for effective environmental health management. Training environmental physicians in Poland The Nii>i:iis work for and through partnership. In addition to the health and environment institutes in the participating countries, the Bilthoven Division works with governments (particularly those of the Netherlands and Switzerland) and their bilateral aid agencies, donor agencies (such as the United Nations Environment Programme, the World Bank and the PHARE programme of the EU) and environmental health institutes (such as the Karolinska Institute in Sweden, the London School of Hygiene and Tropi- cal Medicine and the Dutch National Institute of Public Health and Environmental Protection - RIVM). The Netherlands provided about US $700 000 to each NIPEH. The countries proved their commitment by matching these funds in cash or in kind. Activities past and future The NIPEHS concentrate on supplying tangible prod- ucts in three interrelated areas. First, they improve the understanding of the effects of pollution on health by linking environmental factors with chronic dis- eases in an area or region. The Bilthoven Division worked out a standardized protocol and has guided 12 studies of hot spots in the 6 countries, using cleaner areas for comparison. Second, the programmes strengthen local capac- ity in environmental health management. This includes supplying laboratory and other equipment, but focuses on training. The Bilthoven Division and its partners have conducted 23 courses for over 400 people on environmental epidemiology, quality assurance in environmental health monitoring, good laboratory practice, good agricultural practice, the use of geographical information systems, and mod- ern methods in toxicology. Third, the NIPEHS help to establish databases in which to collect, organize and analyse data from en- vironmental health monitoring. The programmes supply the hardware and software for a health and environment geographical information system; four regional and two national systems have been set up. Regular evaluations have praised the success of the first phase (1992- 1994). The participating coun- tries particularly value the chance to set their own priorities and to bring their health and environment systems into partnership, and the flexibility shown by the Bilthoven Division and other partners in implementing the programmes. The next phase is building on this success. This means developing NIPEHS for some NIS, strengthen- ing the best elements of existing programmes, and promoting networking among the participating coun- tries. A special success from the first phase, the scheme to train environmental physicians, is expected to be extended from Poland to Romania. Living links between the environment and health systems, such physicians will inform the public and advise the gov- ernment about environmental threats to health. Learning material for nurses Nursing development requires education at all lev- els - formal and informal, basic and continuing. The acute shortage of educational material is a major ob- stacle, particularly in the CCEE and NIS. In the long term, countries will produce their own materials. But they need help to develop this expertise, and they ur- gently need materials to use now. The WHO LEMON (LEarning Material On Nursing) Project helps to meet both these needs. The LEMON Project will provide a package of up- to -date educational materials, in each country's official language, to all nurses, midwives and feldshers in the CCEE and NIS: a target readership of over 2 million health workers. Answering twin needs Nurses in the CCEE and NIS want to provide the best possible care, but they have few educational re- sources. A nurse caring for an elderly person with multiple health problems, for example, can rely only on tradition and her instincts, and hope for the best. These nurses lack textbooks, professional journals and guidelines. Existing materials tend to be scarce, outdated or unavailable in local languages, and they usually fail to address current needs. Further, nurses do not find it easy to decide what materials they need. With the best intentions, foreign donors give them large numbers of western books and journals, but these are often inappropriate.LEMON helps nurses in the CCEE and NIS take the lead in choosing the best materials for their needs and cir- cumstances. Building materials and skills The LEMON project features strong interaction be- tween the Regional Office, an international advisory group of nursing experts, and LEMON groups in the 16 actively participating countries. In the first phase of the project, the advisory and country groups chose the subjects and materials for the package from the literature. Now that the English- language package is complete, phase two will begin. The country groups will translate the package into their languages, adapt it as necessary and test it. Phase three will begin about a year later. The country groups will supply the tested package to as many nurses, midwives and feldshers as possible, using local printers and publishers. This work is building capacity for the future, since nurses in the country groups run the project themselves. WHO acts as a supporter and coordina- tor, rather than a director. Further, the network of participating nurses and the project infrastructure in countries provide an excellent base for future activities. Growing from the seeds LEMON is a huge project in constant need of funds and skills. WHO launched the project in 1993. The first phase was financed mainly through donations from the Department of Health in the United Kingdom, and support for the second phase comes mainly from the Department of Health in Ireland. The country groups and WHO raise money for the project through the LEMONAID appeal. The great enthusiasm that greeted the project shows the urgency and clarity of the need for the pack- age. It has inspired partners in the CCEE and NIS, and supporters in other countries, including govern- ment agencies, nursing associations, educational institutes and individual nurses. WHO is confident that the seeds of LEMON are already bearing fruit. Adapting the material: writing a chapter in Slovenia The LEMON package Cards sold in the LEMONAID appeal Health care reform in Kyrgyzstan Training session for the Manas national team Manas and CARNET documents Independence left Kyrgyzstan, like other NIS, with a health care system battered by waves of change, including economic and social problems and wors- ening health. While many organizations helped with isolated problems in the health sector, WHO has helped Kyrgyzstan to develop and coordinate a pro- gramme for the comprehensive reform of its health care system. A hero's task The Kyrgyz health care system is rich in hospital beds, doctors and nurses. But staff are unevenly dis- tributed and badly paid, hospitals and equipment are old and in poor repair, and Kyrgyzstan depends on donor assistance for drugs and medical equipment. Although willing to reform the health system, the Ministry of Health has had to focus on keeping ser- vices running from day to day. External aid offers only temporary relief. Creat- ing and running a sustainable, equitable and effective health care system require careful consideration of a country's resources and priorities and realistic assess- ment of the options for action. In 1994, the Regional Office and the Ministry of Health worked out a frame- work for the reorganization of health services from 1995 to 2005. As this was a hero's task, the partners named the initiative after a Kyrgyz national hero born in 995: the Manas health care reform programme. Manas: work for reform In 1994/1995, the Manas programme had two ob- jectives: to help the Kyrgyz authorities to design a master plan for health care reform, and to enable them to carry it out by strengthening their management capacity. Three groups of partners cooperated on these tasks: a national team, including a coordinator in the Ministry of Health and 46 health officials from the central and regional levels; an international team, comprising the United Nations Development Programme (UNDP), the World Bank, WHO, the Danish International Development Agency, the Overseas Development Administration of the United Kingdom, the Swiss Federal Office of Public Health, the Turkish Inter- national Cooperation Agency and the United States Agency for International Development; and a WHO secretariat (two staff in the Regional Office and a technical adviser in Bishkek). The partners developed the master plan for reform in three stages. First, they analysed current conditions in all relevant areas: the needs of the population; the policies, financing, organization and management of the health sector; the providers, physical infrastruc- ture and delivery of health services; the health information system; and scientific support and research. Then they used the analysis to develop four policy options: preservation of the existing system, optimization of the system, contracting for health services and laissez-faire development. At a confer- ence in February 1995, the partners and Kyrgyz government officials, including the President and Prime Minister, discussed the pros and cons of each option, favouring a combination of the second and third. After the government made its final choice in April, the partners prepared a detailed plan, with strat- egies for the short, medium and long terms, for presentation to the Ministry of Health in September 1995. While working on the master plan, the inter- national team also worked to strengthen management capacity. It gave the national team technical know- ledge on health policy- making, and instruction in project management, English and computer skills. WHO's special role in Manas included providing technical knowledge, advising on policy and assist- ing in coordination. As the programme was also the framework for coordinating all assistance to health sector reform in Kyrgyzstan, WHO had not only to prevent duplication of effort but also to ensure that contributions complemented both Manas and one another. Finally, WHO enabled Kyrgyzstan to exchange information and experience with neighbouring coun- tries. Through the central Asian republics' network (CARNET) on health care financing and management, Kyrgyzstan not only receives support but provides a model in Manas. Turkmenistan has asked WHO to help in designing a similar programme. Reducing drug use Drugs cause terrible harm to users and society. Many national and international organizations are trying to reduce drug use in the European Region. WHO's approach is founded on the principles of health for all, stressing intersectoral cooperation on both pre- vention and control. The Regional Office both preaches and practises action to reduce the use of psychoactive substances: not only drugs but also al- cohol and tobacco. The problem Drug use and responses to it vary between the two halves of the Region, the CCEE and NIS, and commu- nities in a country. Throughout the Region, drug use bears hardest on the disadvantaged groups in society. In western countries, the problem is serious and well established. About 5 -10% of the population was estimated to use illegal drugs in the 1980s. "Designer drugs ", such as MDMA ( "Ecstasy ") are increasingly popular. Attacks on the supply of drugs by the crimi- nal justice system have not solved the problem. Many countries have thus combined such work with activi- ties to reduce demand, carried out by the health and welfare system. They have well established systems for treatment and rehabilitation, through specialized services and primary health care. Intersectoral action on a combined approach, long advocated by WHO, is becoming a reality. Further, countries cooperate through programmes of the EU and the United Nations. Drug use is not yet as serious a problem in the eastern countries, but is rapidly growing in many CCEE and some NIS. Drug injection is gaining popu- larity. The CCEE have infrastructures to deal with drug trafficking. The NIS do not, and opiate and marijuana production are big business in the central Asian republics. HIV transmission through drug injection adds urgency to the problem in the Region. Injecting drug users make up an ever larger fraction of HIV cases: over 40% in 1994. WHO advocates harm reduction programmes, including needle and syringe exchanges and drug substitution. The CCEE and NIS lack such programmes, but have a strong political commitment to prevention. A combined approach WHO promotes intersectoral action to reduce demand, as well as supply, and a combined approach to drugs, alcohol and tobacco as the most effective responses. Demand reduction should address all psychoactive substances. The same factors encour- age the use of drugs, alcohol and tobacco, particularly by young people: peer pressure, lack of self- esteem and the desire to belong. Demand reduction pro- grammes can give people the skills to cope with all three. The Regional Office has assessed substance use in many CCEE and NIS. This is part of WHO coop- eration with the United Nations International Drug Control Programme, which also includes training health and welfare workers to provide drug treatment 100 Other III Heterosexual contact l Injecting drug use Homosexual /bisexual contact (male) 1 Total number of annual new cases 25 000 20 000 15 000 2 U 10 000 5 000 0 services. WHO has a special programme to promote action to reduce demand in the CCEE and NIS. WHO's work with the EU includes serving on the management board of its European Monitoring Cen- tre for Drugs and Drug Abuse. WHO and the Council of Europe (CE) exchange information on drug use in the countries of the Region. Further, WHO advises countries on policy issues, such as reducing the risk of HIV infection, and main- tains a research network. The Regional Office recently issued a review of AIDS among drug users, and has now prepared a summary on substance use through- out the Region. The summary describes the extent of and trends in the problem, the associated harm, and the policies and responses in countries. It should pro- mote cooperation against this scourge to public health. Distribution of AIDS cases in adults and adolescents in the European Region, by mode of transmission, according to the year of diagnosis and adjusted for reporting delays, 1981 -1993 Opiate production: big business in the central Asian republics Health promoting schools Keeping in touch: newsletters from the European and country networks Because schools try to give students the knowledge and skills that will enable them to become independ- ent and responsible adults, they are an ideal setting for health promotion. With CEC and CE, the Regional Office has built a European Network of Health Pro- moting Schools. This project empowers everyone in the school community - staff, students and parents - to gain a deeper understanding of their health and to choose and carry out action to improve it. Cooperation and diversity Beginning as a pilot project in 1991/1992 in four of the CCEE, the Network now includes over 400 schools, with 300 000 students, in 27 countries. A further 1600 schools are linked to the Network through national or regional arrangements. And 10 more countries are expected to join in 1995. The reasons for this success? With partnership as both method and goal, the Network provides a flexible framework in which schools can determine their own needs and work to meet them in their own ways. To join the Network, countries commit themselves to cooperation between their education and health authorities and to promoting health in schools by making them into safe and health- enhancing social and physical environments. Participating schools commit themselves to this concept, and to devising and carrying out projects. Success stories Activities in the Network are as varied as the schools. All grow from the enthusiasm and commitment of staff, students and, often, parents. Many not only bring immediate benefits but enable the school community to acquire new knowledge and skills. The following are only the first success stories reported to the Network. Some activities focus on the school environment. Students in a Croatian school repaired walls dam- aged by bullets. In Slovenia, a project team cleaned up the school toilets, placed benches and rubbish bins in the playground and helped to plan healthier meals, while introducing exercise breaks in class. Other projects focus on relations and democracy in the school community, and address lifestyle issues. The project team in a Bulgarian school started a dia- logue between staff and students, a parents' committee and discussions of health. A Polish school surveyed students' feelings about their teachers and helped the teachers update their methods. In an Irish school, the canteen staff developed healthier menus while the prefects were trained as peer leaders. The parents of students in a Belgian school supplied food from and discussions of a different culture on every day of Multicultural Week. Students at a Danish school wrote and performed a play on drug and alcohol use. Those at a Swedish school studied resuscitation techniques and took part in an antismoking project with the parents' association. Several schools made policies that limited or banned smoking by students and staff; parents also took part in the process. Finally, some projects feature international coop- eration. Schools in the Czech Republic and Denmark worked together to conduct experiments on the local environment. Making the community their classroom, groups of students examined an issue and used their results to make recommendations to the local gov- ernment. This provided eye- opening lessons for the students, teachers and community. Commitment to the future The Regional Office, CEC and CE support the Net- work, through which schools share information, training, experience and examples of good practice. They also support a technical secretariat in the Re- gional Office. It gives day -to -day support to national coordinators in the countries, raises money for the Network and provides technical guidance through advice and documents, research, and training manu- als and workshops. The secretariat also maintains a special focus on the CCEE and NIS, where decen- tralization and health promotion were new ideas. The Network has brought these countries essential funds and expertise, and helped to strengthen their infra- structures and capacities for health promotion. The Region's children are its future. All children must have the chance to realize their potential to be healthy, educated adults. The European Network of Health Promoting Schools is dedicated to reaching this goal. Members of the Network Albania, Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Ger- many, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom Profiles of women's health 82 80 t- 78 76 ô- 74 J 72,--00 rn ci CO rn CO CO rn v CO rn LC)00 rn European Region European Union CCEE ® MS rn n CO rn 0 rn Women's health counts WHO stated its commitment to improving the health of women in target 8 of the European policy for health for all. It acted on this commitment by launching the Investing in Women's Health Initiative in 1993. Pro- files of women's health throughout the Region are both the first fruits of the Initiative and a catalyst for action within and beyond Europe. The Initiative has three parts: producing profiles of women's health in the Region; making a comparative analysis of the profiles that identifies the critical issues in women's health; and starting a European Women's Health Forum to develop an agenda for action in the Region. WHO launched the Initiative by encouraging the first -ever profiles of the health of women in every country of the Region. Because health is an integral part of life, this meant moving beyond the traditional focus on reproductive health to embrace other is- sues. It meant describing not only health status and services but also the influences of daily life and the environment, and women's position in society. Starting in the CCEE and NIS Women in eastern countries can expect to live 5 -10 years less than those in western countries, and they have up to 10 times the western rates of mater- nal death. This led the Regional Office and its partners (the World Bank and the governments of Austria, Finland, the Netherlands, Norway and Sweden) east- wards for the first country profiles. Eleven of the CCEE and NIS, and one city, agreed to take part. Health ministries chose coordinators for each country. The Regional Office developed guide- lines and a questionnaire, and the coordinators and their teams used them to assess women's current sta- tus in health, society and the economy. The resulting profiles pictured the day -to -day realities of women's lives. In 1994, the Regional Office made a comparative analysis of the profiles and, with the World Bank and the Austrian and Norwegian governments as co- sponsors, organized a Conference called "Women's 120 ô 110 g. 100 â 90_-aO 80 0 70 60 ° 50 40 0 30 r cu co v N-00 Oo CO CO CO CO CO rn rn rn rn rn rn rn European Region European Union CCEE NIS CO rn o CO CO rn rn rn rn rn rn Health Counts ". There the coordinators described the priorities revealed by the profiles, and used the analy- sis to design strategies for improvement. The participants summarized these in the Vienna State- ment on Investing in Women's Health in the Countries of Central and Eastern Europe. The Statement forms the basis for an approach to women's health that builds on the WHO commitment to equity, human rights and primary health care. Expanding the Initiative After the Conference, WHO published the compara- tive analysis on the CCEE and NIS, with the Vienna Statement. It also asked the other countries to name focal points for a similar report on the whole Region. With the support of the focal points and its partners, the Regional Office completed a new series of pro- files early in 1995. They identify several critical issues: reproductive health, particularly the prevention of maternal death and promotion of family planning; occupational health, including threats to health in the workplace and those related to unemployment; the environment; and the health of women who are elderly, migrants or members of a minority group, and thus at special risk. The Regional Office sent the profiles to the WHO Global Commission on Women's Health and the United Nations Fourth World Conference on Women, held in Beijing in September 1995. In addition, WHO and the United Nations Population Fund (UNFPA) issued a document to inform donors about priorities in reproductive health and activities already under way. The members of the expanded European Wom- en's Health Forum met for the first time in May 1995. They work together for better health for women, ad- vise the Regional Office on strategies, and urge their governments to give the issue a higher spot on the political agenda. Through the Investing in Women's Health Initiative, WHO and its partners are working to ensure the full participation of women in health for all. Female life expectancy at birth: east -west gap Deaths from cardiovascular diseases in females under 65: east -west gap PK LP Promoting women's and children's health Tajik girls: every girl presents a new chance to invest in the health of women and the next generation 60 50 t 40 -'- 300 20 10 ® Highest in the central Asian republics CI Target level a.. ® Lowest in the Region Infant mortality in the European Region 90 80 PPPr 70 t60'> 50 g 40 ° 30 `,11 20N fl 10 ° 0 Highest in the central Asian republics Target level Lowest in the Region Maternal mortality in the European Region Rates of death for pregnant women and mothers, and of babies under 1 year, highlight the width of the health divide in the European Region (see p. 2). Maternal and infant deaths are highest in the central Asian republics. Various international organizations and the countries themselves have assessed the prob- lem and worked to tackle it. WHO helped crystallize this process by bringing the organizations and coun- tries together to create and launch an integrated approach. A looming crisis In December 1994 WHO, with the International Planned Parenthood Federation, held an international meeting to strengthen maternal and child health and family planning in the central Asian republics (Kyrgyzstan, Tajikistan, Turkmenistan and Uz- bekistan) and in Azerbaijan and Kazakhstan. Some 28 obstetricians and paediatricians from the 6 coun- tries, and representatives of UNDP, UNFPA and UNICEF outlined their approach and a project to put it into action. The country representatives began by describing the situation. The rates of death for infants are 28 -54 per 1000 live births and the maternal deaths number 35 -83 per 100 000 live births. This forms a grim con- trast with the levels called for by regional targets 7 and 8 and the even lower rates already achieved in some western countries of the Region. The main causes of maternal death are haem- orrhage, toxaemia of pregnancy, infection and complications of abortion (which is the main means of family planning). The main causes of death in in- fants are premature birth, low birth weight, acute respiratory infections and diarrhoeal diseases. In a few countries, war is a further threat. The countries recognized that expensive high tech- nology is not the first priority. They need to change some basic practices (to leave babies with their mothers, to stop swaddling and to encourage breast - feeding) and thus the knowledge and skills of service providers. Families, policy- makers and the public must change, too. Vaccination, safe drinking -water and simple means to prevent and treat diarrhoeal diseases are important concerns. Outside the health sector, nutrition and hous- ing must be improved. The countries also need preventive services for young people that fo- cus on nurturing girls, and increasing people's knowledge of human sexuality and their in- formed choice of modern family planning methods. These are the best ways to promote the health of women and children. The Regional Office agreed to help the countries develop a joint, integrated, five -year project based on the principles of the regional policy for health for all, to tackle the loom- ing crisis. An innovative, integrated project According to WHO's proposal, the countries and their international partners will carry out the CARAK (central Asian republics, Azerbaijan and Kazakhstan) project from 1995 to 2000. The project will promote maternal and child health and family planning through a package of innovative, integrated, appropriate services delivered at the district level by providers with up -to -date training. WHO, UNFPA and the government of Uzbekistan have already pledged funds to the project. Additional partners would be welcome. The project will start in the hospitals, health cen- tres and feldsher /midwifery stations of 12 districts (with a total population of 360 000) in the 6 coun- tries. It will be sustainable because it is based on the countries' thinking and will build their capacities. It will be replicable because activities will be monitored and evaluated and the countries' information systems will be improved. The CARAK project will have seven products: 1. revised legislation, policies, procedures and guide- lines to ensure safe, efficient and effective services; 2. a network of service providers and consumers in the pilot districts who will share information and experience; 3. health personnel with up -to -date skills in mater- nal and child health and family planning; 4. new training packages and programmes; 5. a comprehensive information system on health and services; 6. educational messages delivered to the public through the mass media; and 7. additions to the curricula of schools and univer- sities on child development, reproductive health, pregnancy and childbirth, and family health. Nutrition training in the (:SEE and NIS The legacy of the past in the CCEE and NIS includes a lack of information on diet and nutrition. A few studies were made, but their results were rarely pub- lished. Struggling with worsening living conditions, governments urgently need to know their people's nutritional status and needs, so that they can make sound policies on food, agriculture and health. WHO is carrying out a project in the CCEE and NIS that creates much- needed expertise in public health nutrition while helping to supply this scarce infor- mation. Rapid nutrition assessment The project comprises a series of studies on the nu- tritional status of two of the most vulnerable groups in the eastern half of the European Region: women and children. It began with a study involving the Regional Of- fice and staff from three nutrition institutes in the NIS. The participants monitored 10 -year -olds at four sites (Almaty, Kazakhstan; Kiev, Ukraine; and two sites in Moscow, the Russian Federation) in April of 1992, 1993 and 1994. The results refuted the widespread fear of starvation in these areas. The city populations were resilient enough to protect their children, whose growth and diet did not deviate from global standards. The success of the study led the Netherlands Min- istry of Welfare, Health and Consumer Affairs to supply further resources for the project on rapid nu- trition assessment. The project continues to pursue the twin goals of securing information and supplying essential training in nutrition. A series of three over- lapping studies began in 1994 and will continue through 1996. All have the same structure and the same focus - maternal nutrition - but involve differ- ent groups of countries: Kazakhstan, the Russian Federation, Tajikistan, Turkmenistan and Uzbekistan in 1994/1995; Armenia, Belarus, Bulgaria, Georgia, Karal- kalpakstan (Uzbekistan) and Ukraine in 1995; and Albania, the Czech Republic, Estonia, Latvia, Lithuania, Romania, Slovakia and Slovenia in 1995/1996. Content and methods Each group follows the same five -step programme, which takes less than a year to complete: 1. WHO conducts a workshop for participating nu- tritionists on methods of assessing diet, and related topics such as nutrition policy, weighing and meas- uring people, and food composition; 2. facilitators help the participants to complete a common protocol for the multicentre study; 3. teams of participants apply what they have learned by assessing women's nutrition in their countries, using software supplied by WHO; 4. the teams meet the facilitators again to present their data and choose a final form for its presen- tation, with the facilitators commenting on their work and suggesting improvements; and 5. the teams finalize their results. Owing to reports of widespread anaemia, the teams also test haemoglobin levels, using equipment paid for by LISP, an Italian nongovernmental organiza- tion. The lecturers at the workshops are renowned experts from WHO collaborating centres in Europe and the USA. They donate their time and often pay their own expenses. Having completed their study, the partici- pants report their results to their governments, and in national and international journals. Results The most immediate result is the increase in expertise and the rapid growth of a network of nutritionists in the CCEE and NIS. The project participants are the nucleus of the network. The project links country teams and participating institutes in the exchange of ideas and information. For example, some people in the participating countries ascribe falling rates of breastfeeding to poor nutri- tion and anaemia in mothers. The project is not yet complete, but its early results challenge this belief. Once trained, many participants serve as facil- itators in the next project study. In addition, network members supply local expertise to other studies of nutrition and related topics, conducted by a wide va- riety of international and bilateral organizations. The WHO project on rapid nutrition assessment gives nu- tritionists in the CCEE and NIS the skills to work more effectively to improve the health of their people. A nutrition workshop: learning how to use new software 1992 Almaty Kiev Moscow -1 Moscow -2 Results from the first study: average intake of fresh fruit by 10- year -olds Informing health authorities through telematics The WHO guide and the Danish manual for pharmacists Telematics: early warning of disease As a centre for public health information, WHO has promoted computer links, the newest and fastest way to collect and supply information. The ENS CARE Telematics project of the EU helped national health administrations improve their decision -making by using computers to supply up -to- the -minute infor- mation. WHO conceived and coordinated the project, which involved 24 partners in different countries. The project embodied a unique partnership between the Regional Office and the EU, which could extend its benefits throughout the European Region. Early warning systems One of the project's four parts focused on early warn- ing systems, including systems to alert countries to communicable disease emergencies. The network for Legionnaires' disease, for in- stance, included 23 reference centres in 21 European countries. Using software developed by the Communi- cable Disease Surveillance Centre (CDSC) of the Public Health Laboratory Service in the United Kingdom, the centres reported new cases to CDSC, which identified the source of a cluster of cases and alerted the health ministry of the country concerned. Since mid -1993, CDSC has identified 13 such clusters. A similar system was started for salmonellosis. The early warning system for Legion- naires' disease has proved its value and provided a model for the surveillance of other communicable diseases. Pharmacists helping smokers quit Pharmacists throughout the European Region are working together to help their clients quit smoking. European pharmacists want to expand their role in health, adding counselling on lifestyle to their traditional work of dispensing safe and effective medicines. With a pharmacy on every high street, pharmacists are ide- ally placed to advise on health in the course of their daily work. In pursuing this goal, pharmacists have an exciting opportunity to help achieve health for all. WHO and national pharmaceutical associations in 30 coun- tries throughout the Region have therefore joined forces to form the EuroPharm Forum. The Danish model In spring 1992, the Regional Office and the Danish Pharmaceutical Association tested pharmacists' po- tential to help their clients quit smoking in an eight -week pilot project. After training in group dy- namics and tobacco use, 20 community pharmacists ran smoking cessation courses, combining nicotine replacement therapy with support groups. The project was a brilliant success. At the end of the course, 60% of the participants had stopped smok- ing, and 30% were still nonsmokers a year later. Pharmacists and the public demanded more courses. Today, 25% of Danish pharmacies offer them. The European project The EuroPharm Forum has pledged to promote simi- lar action by its all member associations. For their use, WHO and the Forum described the principles and methods of the Danish project in International guide: pharmacies and smoking cessation. The Forum has also created a task force to carry out a smoking cessation project. The task force prepared a document for adoption by the Forum at its fourth annual meeting in June 1995. It tells pharmacists how to intervene at three stages of the smoking process, describes activities in various countries, and will be presented to ministries of health as a policy document. The task force will also advise pharmacists on how to persuade their col- leagues to become involved in smoking cessation. Most importantly, the task force has planned an international course for autumn 1995, to train train- ers in each of the Forum's member countries. Participants must commit themselves to carrying out one of the models outlined in the task force docu- ment on their return home. The EuroPharm Forum will do all it can to ensure that pharmacists take effective action in smoking ces- sation. The task force's work will go a long way to help achieve this aim. Quality of care development Patients and the public are increasingly aware of the issue of the quality of health services. Politicians and health care authorities require both the documenta- tion of quality and its continuous development. The interests of the community require the attainment of the highest quality possible within the existing frame- work of the health services. The WHO concept and programmes for continuous quality of care develop- ment help all parties involved work together to improve the outcome of care. Concept and process Research and monitoring have so far focused mainly on the process of health care, not its results for health. The WHO concept of continuous quality of care de- velopment examines the outcomes of care. To improve the quality of care, health profession- als must accept responsibility for the task. In 1993, the European Forum of National Medical Associa- tions, in collaboration with WHO, made a recommendation that emphasizes doctors' primary re- sponsibility for ensuring the quality of medical care. This was a major breakthrough, and WHO encourages other health care professionals, such as nurses and physiotherapists, to reach a similar consensus. With professionals' commitment secured, the next step is developing indicators to measure the quality of outcome. The Regional Office has been instrumen- tal in achieving Region -wide consensus on clinical outcome indicators for the management of perinatal care, depression, oral health, upper respiratory tract infection, diabetes and hospital infections. Indicators are being developed for stroke, hypertension and myocardial infarction. Here WHO works closely with ministers of health, research institutions, donors, in- dustry and patients' associations, as well as medical associations. WHO cooperated with the CEC to develop out- come -based quality indicators on oral health and perinatal care. For the latter, a set of 21 suggested indicators was tested on 3 million births in 30 coun- tries in 1992/1993. This led to the selection of a final list of 17 indicators in 1994. These are now ready for use in countries. After consensus on indicators follows the crea- tion of both local and Region -wide information systems. Databases allow anonymous comparisons of performance, which enable care providers both to evaluate their own work and to learn about the best current practices. Data collection can lead to the con- struction of a curve showing the variations in performance among health care providers at a cer- tain time: an original outcome curve. Then, the providers with the best outcomes identify themselves. After external verification of the data from these best performers, they share their experience with all the participating health care providers, who use the information to improve their performance. Repeat- ing the process can gradually move the performance of the whole group towards excellent quality. Improving the quality of health care improves the outcomes for patients. WHO promotes the development and acceptance of outcome indicators in more and more areas of care, and the establishment and expansion of databases for anonymous compari- son of performance. This maximizes the contribution of quality of care development to health for all. Health workers' commitment to the task is essential The process: continuously improving the performance of all health workers s â E Original outcome curve Later outcome curve Best Best outcomes outcomes t . -s Excellent quality Policies for health for all The Copenhagen Declaration Some of the many national and regional policies based on health for all Target 33 of the European health policy calls on countries to make and carry out policies in line with the principles of health for all. WHO gives priority to helping countries, regions and communities to make such policies, which har- monize and unify the disparate activities of the various sectors and groups working to improve health. With the collaboration of the CEC and CE, the Regional Office re- cently held a conference on health policy that pointed the way ahead. The conference and the demand for health for all policies at all levels in countries affirm the continuing value of these policies as the best tool for building better health for all Europeans. Enduring value of health for all In December 1994, the European Health Policy Conference: Oppor- tunities for the Future brought together 300 participants, repre- senting 45 of the 50 countries of the European Region. The partici- pants examined current trends in and future challenges to health, and policy responses at all levels. Having broken new ground by introducing par- liamentarians as participants, the Conference continued its pioneering by expanding the opportu- nities for international cooperation on health. With six intergovernmental organizations sharing a plat- form for the first time, the discussion clearly revealed the countries' demand for closer cooperation and the keen desire of WHO, CE, CEC, the International Labour Organisation, the Organisation for Economic Public Health Status and Forecasts Co- operation and Development and UNICEF to respond. The Conference showed that, despite enormous changes in the European Region and health policy issues, the health for all approach remains the best way to ensure the effective and efficient use of re- sources for health gain. The participants strongly endorsed this approach in the Copenhagen Declaration. The Declaration calls on all countries to carry out policies based on the principles of health for all; poli- cies in the CCEE and NIS should guide international investors and donors offering assistance. The health for all approach should underpin closer and more ef- fective cooperation by all partners in an international alliance for health gain. The WHO Regional Com- mittee for Europe - the Region's "health parliament" - will consider a resolution welcoming the Declaration in 1995. Support to policy -making The Conference added impetus to WHO's continu- ing support to countries in policy- making. The enduring value of the health for all approach lies in its flexible application of firm principles. Policy- makers use common ingredients - such as equity, wide participation in decision -making and a focus on health gain, as well as health care - but combine them in different recipes to suit their needs and circumstances. While most western countries are already imple- menting health for all policies, many CCEE and NIS are just taking up the task. WHO is working with Albania, Armenia, Bulgaria, Croatia, Estonia, Hun- gary, Latvia, Lithuania and Kyrgyzstan, and is discussing such cooperation with Poland, the Rus- sian Federation, Ukraine and Uzbekistan. The demand is so great that some have called for the establish- ment of a WHO centre for policy analysis and training. In Latvia, the Ministry of Health asked the Re- gional Office to help prepare a national policy based on health for all early in 1994. The plan was to write a draft, consult a broad range of authorities, sectors and interest groups, and submit the final result to Parliament for adoption. By early 1995, the discus- sions had resulted in a draft document now being updated. Better living - better Latvia describes a de- tailed strategy for health and social care development with a target date of 2010. It spells out goals, targets and objectives for four themes, and action in six direc- tions to achieve them. Through such work, WHO helps policy- makers in countries not only to build capacity for the future but also to seize the present opportunity of moving towards health for all. Conclusion Health in Europe presents a sobering picture in the mid - 1990s. Improvements in health continue in the western half of the European Region, but wor- rying inequities are growing, threatening the inner cities, the elderly, the poor, minority groups and migrants. The health divide between east and west remains the largest inequity. Most of the CCEE and NIS suffer continuing economic de- cline, and public services - including those for health -are reeling from dramatic cuts in funding and the other effects of instability. These have severely reduced the ability of health service systems to provide es- sential care for the population. Vaccination programmes, basic environmental health services and even food supply systems have broken down or been dis- located. Worst of all, armed conflict has continued or spread. The consequences for health are disastrous. They include a resurgence of infectious dis- eases, such as diphtheria. In some areas, the decline in the quality of life and health ser- vices has led to rises in maternal and infant death. And unhealthy lifestyles and deficient preventive services contribute heavily to the deaths from cardiovascular diseases, external causes and cancer that account for most of the east -west health divide. With limited staff and financial resources, the WHO Regional Office for Europe has developed new tactics to face the new situation. This has meant focusing primarily on the countries in greatest need, while retaining many Region -wide activities for health. WHO has built on its strengths: the health for all policy, clear leadership in health policy development, the scientific ability to devise new approaches and methods that countries can use to convert policies into practical programmes, and well established networks for action at the local level. These strengths have given the Regional Office the chance to mobilize large -scale advice and support for the CCEE and NIS, which have demanded help from WHO in almost every area of health develop- ment. The Regional Office has maximized its contribution by cooperating with all the other partners working for health. This means more than harness- ing its special strengths to those of other United Nations organizations, the European Union and the Council of Europe, and many government and nongovernmental organiza- tions. It means developing a new ability to act as a catalyst, pointing the way to the most effective action. The European policy for health for all has gained influ- ence throughout the Region. Thus, a new model for public health action has emerged. Central governments, regions and cities are integrating a broader philosophy into their policies, and emphasizing dis- ease prevention, health promotion and primary health care. The policy and targets for health for all should now influ- ence public health more than ever before. The European Region today has gained breath -taking momentum for change. The opportunities to make a differ- ence are immense. In its cooperation with its partners and the countries of the Region, the WHO Regional Office for Europe offers its impressive ability to create ideas, to build strong new alli- ances and to act as a catalyst in stimulating new action to secure health for all Europeans. World Health Organization Regional Office for Europe Copenhagen WHO Regional Publications European Series No. 57 ISBN 92 890 1321 2 Sw.f r. 12.-

The Regional Office for Europe of the World Health Organiza- tion welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, WHO Regional Office for Europe, Scherfigsvej 8, DK -2100 Copenhagen 0, Denmark, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 1995 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this publication are those that obtained at the time the original language edition of the book was prepared. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Report compiled and edited by Mary Stewart Burgher with the assistance of Pamela M. Charlton Design and graphics: Sven Lund Layout: Wendy Enersen Printed in Denmark by Rapo Contents Foreword Health in Europe Fighting disease in the NIS Humanitarian action Information for environmental health Integrated action on environment and health Learning material for nurses Health care reform in Kyrgyzstan Reducing drug use Health promoting schools Profiles of women's health Promoting women's and children's health Nutrition training in the CCEE and NIS Telematics: early warning of disease Pharmacists helping smokers quit Quality of care development Policies for health for all Conclusion 2 3 4 5 6 7 8 9 10 11 12 13 14 14 15 16 17 WHO Library Cataloguing in Publication Data WHO in Europe: meeting the challenges (WHO regional publications. European Series ; No.57) 1.Regional health planning 2.Health for all 3.World Health Organization 4.Europe (.Series ISBN 92 890 1321 2 (Classification NLM: WA 541) ISSN 0378 -2255 INFORMATION ABOUT THE REGIONAL OFFICE The World Health Organization (WHO) is a specialized agency of the United Nations. Founded in 1948, it is the directing and coordinating authority on international health work. It has its headquarters in Geneva, Switzerland, and six regional offices: Regional Office for Europe (EURO), Copenhagen, Denmark Regional Office for the Americas /Pan American Health Organization (AMRO /PAHO), Washington, DC, USA Regional Office for the Eastern Mediterranean (EMRO), Alexandria, Egypt Regional Office for South -East Asia (SEARO), New Delhi, India Regional Office for the Western Pacific (WPRO), Manila, Philippines Regional Office for Africa (AFRO), Brazzaville, Congo Each regional office has its own programme, geared to the health problems of the countries it serves. The WHO Regional Office for Europe has a permanent staff of some 240 people, and a similar number of short -term staff, from about 40 nations. In addition, over 1000 experts work in the Region every year, along with collaborating centres and research institutes in many countries. Over 30% of Regional Office staff work in the field. The regular annual budget is about US $25 million. Funds donated by other sources, including the United Nations and individual governments, have grown to about US $30 million per year. The European Region embraces some 850 million people living in an area that stretches from Greenland in the north- west and the Mediterranean in the south to the Pacific coast of the Russian Federation in the east. The European programme of WHO concentrates on both the emerging democracies of the central and eastern part of the Region and the problems of industrial and post -industrial societies. Since 1990, the number of Member States has risen from about 30 to 50. The Regional Office is governed by a Regional Committee comprising representatives of every Member State; a Standing Committee from this body advises the WHO Regional Director for Europe. Through the Regional Committee, which meets once each year, the Member States collectively formulate regional policies, recommend technical activities and approve the programme and budget. The Regional Office in its turn provides Member States with technical and advisory services, directly or through networks of experts and other partners. As of June 1995, the Member States of the European Region are as follows: Albania France Luxembourg Spain Armenia Georgia Malta Sweden Austria Germany Monaco Switzerland Azerbaijan Greece Netherlands Tajikistan Belarus Hungary Norway The Former Yugoslav Belgium Iceland Poland Republic of Macedonia Bosnia and Herzegovina Ireland Portugal Turkey Bulgaria Israel Republic of Moldova Turkmenistan Croatia Italy Romania Ukraine Czech Republic Kazakhstan Russian Federation United Kingdom Denmark Kyrgyzstan San Marino Uzbekistan Estonia Latvia Slovakia Yugoslavia Finland Lithuania Slovenia WHO Regional Office for Europe, Scherfigsvej 8, DK -2100 Copenhagen 0, Denmark Tel: (+ 45) 39 17 17 17 Fax: (+ 45) 39 17 18 18 Telex: 15348 and 12000 who dk Teletex: 118785 Electronic mail: BITNET:WHOEURO @VM.UNI -C.DK TARGETS FOR HEALTH FOR ALL The work of the Regional Office is based on the regional policy for health for all, which includes 38 targets. They fall into five groups: targets for better health, lifestyles conducive to health, healthy environments, appropriate health care services and the support needed to attain them. These targets were adopted in 1984 and revised in 1991, retaining their essential framework with some changes of emphasis. Four targets now deal with specific population groups to emphasize positive health. The targets on health services now focus more clearly on specific health care settings (such as primary health care, hospitals and long -term care). The targets on the quality of care and appropriate health technology have been merged to allow the inclusion of a new target on health and ethics, a growing concern all over the Region. 1. Equity in health 20. Water quality 2. Health and quality of life 21. Air quality 3. Better opportunities for people with disabilities 22. Food quality and safety 4. Reducing chronic disease 23. Waste management and soil pollution 5. Reducing communicable disease 24. Human ecology and settlements 6. Healthy aging 25. Health of people at work 7. Health of children and young people 26. Health service policy 8. Health of women 27. Health service resources and management 9. Reducing cardiovascular disease 28. Primary health care 10. Controlling cancer 29. Hospital care 11. Accidents 30. Community services to meet special needs 12. Reducing mental disorders and suicide 31. Quality of care and appropriate technology 13. Healthy public policy 32. Health research and development 14. Settings for health promotion 33. Health for all policy development 15. Health competence 34. Managing health for all development 16. Healthy living 35. Health information support 17. Tobacco, alcohol and psychoactive drugs 36. Developing human resources for health 18. Policy on environment and health 37. Partners for health 19. Environmental health management 38. Health and ethics ORGANIZATION The Regional Office has four technical departments. Three mirror the main groups of targets and work for better health, healthy environments and appropriate care. The fourth ties together the threads of the various technical programmes into country projects, with particular emphasis on the countries of central and eastern Europe (CCEE) and the newly independent states (NIS) of the former USSR. A fifth department provides the Office with support services such as budget and finance, personnel and administration, as well as documentation and informatics. Executive Management gives overall guidance to the work of the Regional Office. Executive Management Disease Prevention Environment Health Policy Country Administration and and and Health and Lifestyles Health Health Care Development Finance Foreword A wave of change has broken over the European Region of the World Health Organization (WHO), transforming the social, political and economic land- scape. The most important feature of this landscape for health is the deep and widening gap between the eastern and western halves of the Region. Neverthe- less, WHO's recent work shows that the Regional policy for health for all, with its 38 targets, offers the best way to meet the health challenges of both the old Europe and the new. The policy's enduring value lies in its compre- hensive approach to health, its firm fundamental principles, and the flexibility of their application. This means that the WHO Regional Office for Europe pursues a wide variety of goals in all areas relevant to health - including lifestyles, the environment and health services - with any combination of methods and partners that suits the circumstances. The princi- ples of health for all harmonize these efforts, while the policy itself unites them. Principles in action The health for all policy and its seven principles guide all the activities described in this report. The 1994 European Health Policy Conference reaffirmed the value of this approach and urged that health for all form the foundation of country policies and greater international cooperation on health. Equity in health is the first principle in every sense. this goal has led the Regional Office to address the most serious health problems and the most vulnerable groups and countries. In particular, work with the countries of central and east- ern Europe and the newly independent states of the former USSR, to narrow the health divide, comprises two thirds of the activities of the Regional Office. This work, which constitutes the EUROHEALTH pro- gramme, underpins every article in this report, most notably those on responses to the resurgence of com- municable disease and humanitarian assistance to war -torn countries. Closely allied to equity is the second principle, ethics. This is the basis of WHO's work to improve the quality of health services. The next two principles of health for all empha- size primary health care and health promotion and disease prevention. Work here ranges from reducing substance use and promoting health in schools to improving maternal and infant health and promoting family planning in the central Asian republics. The last, closely linked principles form a theme that runs throughout this report: participation in decision -making by everyone concerned, and inter - sectoral and international cooperation. Health for all expresses WHO's recognition that health is every- body's business and that cooperation maximizes the effectiveness of all the partners in the task. In this area, WHO makes special efforts to build the capacities of different groups of professionals, including nutritionists, school staff and environmen- tal health managers. It has formed powerful alliances within the health sector, as well: with doctors for quality assurance, with nurses for educational development, with pharmacists for health pro- motion, and with health authorities and health adminis- trators for health care reform. Such alliances help to ensure the sustainability of WHO pro- grammes. The Regional Office con- stantly widens its network of international partners, which already includes WHO head- quarters and other regional offices, sister United Nations agencies, the European Union, governments and their agencies, and hundreds of nongovern- mental organizations. WHO brings its partners invaluable information, expertise and tech- nical advice on public health. WHO has turned partnership from a goal to a reality, resting on a solid and growing foundation of success- ful shared work. In the European health policy, the WHO Regional Office for Europe offers its many partners the best way to ensure the efficient and effective use of re- sources for health gain. The policy will continue to guide European countries forward to health for all. J.E. Asvall WHO Regional Director for Europe One of many WHO information products The health divide: life expectancy at birth The health divide: deaths from cancer in people under 65 Health in Europe IN EÛÂÔPE Implementing the WHO health policy for Europe in- cludes regular monitoring to measure countries' progress towards the goal of health for all. The WHO Regional Office for Europe recently published a sum- mary of the main results of the latest round of monitoring. This was an important part of WHO's work as a centre for information on public health. Health in Europe highlights the most important health problems in the WHO European Region, and describes country policies to tackle these problems and to achieve the 38 targets for health for all. Thus, the book indicates the areas for most effective re- sponse by countries and the Regional Office. Toll of change on health Everyone knows that the Region - particularly the countries of central and eastern Europe (CCEE) and the newly independent states (NIS) of the former USSR - is undergoing profound, some- times violent, political, social and economic change. Health in Europe points out the effects of economic problems, social unrest, migration and war on health. It shows the most important trend: growing inequities in health. For example, all citi- zens do not share in the improving health found in the western half of the Region. The clearest sign of inequity, and thus the clearest call for action, is CCEE European Union r' NIS Nordic countries 79 the gap in health between east and west. Measured in life expectancy, this gap is 6 years wide, and growing. The causes? The most important are deaths from cardiovascular diseases, injury and poisoning, cancer and respiratory diseases, as well as infectious and parasitic diseases in babies. Lifestyle plays an important role in all of these. But communicable diseases show a worrying resurgence (see p. 3), and poor living conditions threaten the health of vul- nerable groups such as the elderly, women and children (see pp. 11 and 12), the poor, members of minority groups, migrants and refugees. Better dis- ease prevention and healthier lifestyles and environments could reduce much of this burden of illness and death. A tool for these times These problems demand an integrated, innovative response from the countries of the Region. They call for effective solutions that use resources efficiently and promise better health for everyone. More than ever, the WHO policy for health for all is the tool for these times. It offers: the goal of equity in health; a stress on disease prevention and health promo- tion, in addition to appropriate treatment; a comprehensive approach to the determinants of health: lifestyles and the environment, as well as health services. As the wave of change broke upon the Region at the start of the 1990s, the Regional Office shifted its focus to the countries in greatest need. Through the EUROHEALTH programme, it now directs two thirds of its resources to the CCEE and NIS. This includes special efforts to help countries where war worsens already difficult conditions (see p. 4). As spelled out in Health in Europe, current con- ditions in the Region offer immense opportunities to make a difference. Seizing them is the main challenge for the Regional Office in its cooperation with the countries of the Region. CCEE European Union ® NIS Nordic countries 115 °110 ô105 0100O ô 95 90 85 ô 80 75 N V' (D N O N C (D N O N N- N. CO CO CO CO CO O) D)a) D) O) a) D) O) O) CO D) Q) Q) D) Fighting disease in the NIS Some communicable diseases have returned from the brink of elimination to threaten health in the Region. Particularly in the NIS, diphtheria epidemics continue and poliomyelitis is a growing menace. Thus, action against these diseases has regained priority in WHO. Recognizing that no single agency or donor can deal with the problems, the Regional Office helps to co- ordinate donor assistance to maximize effectiveness. Goal: vaccine independence Immunization is one of the best ways to control some communicable diseases. But political and economic changes in the NIS led to gaps in immunization cov- erage, and badly damaged former systems of vaccine supply and distribution. This forced most of the NIS to depend on donations. As part of the new Inter- agency Immunization Coordinating Committee (IICC), WHO is working towards vaccine independ- ence in the NIS. Established by the Kyoto Declaration in 1994, IICC comprises governments (of Canada, Denmark, France, Germany, Japan, Norway, Turkey and the USA), the European Union (EU), the International Federation of Red Cross and Red Crescent Societies (IFRC), the United Nations Children's Fund (UNICEF) and WHO. Its short-term aims are to strengthen coun- tries' immunization programmes and to take immediate action against current and potential out- breaks of disease. The next goal is vaccine self -sufficiency: to enable each of the NIS to acquire and control the quality of supplies that meet its needs. As secretariat to IICC, WHO's task is to supply donors with information on countries' needs and to track donors' assistance to avoid duplication and gaps. WHO has worked out with UNICEF a system to estimate needs, and is working on a system to track donors' pledges. The Regional Office secures the views of the NIS from the WHO European Informa- tion Service on Medical Supplies (ISMS). Through ISMS, the NIS voice their needs. ISMS issues quarterly reports to over 100 donors within and beyond IICC. The reports list countries' stocks of and needs for vaccines (against tuberculosis, diph- theria, pertussis, tetanus, measles and poliomyelitis), some 120 life- saving drugs and essential medical equipment. Donors have warmly welcomed the ISMS reports. Fighting disease WHO is acting to control diphtheria and poliomyeli- tis. Working closely with UNICEF and IICC members, the Regional Office has contributed guidelines on diphtheria diagnosis and case management. It has also helped the NIS to work out action plans to control the epidemics, and to mobilize donor support. For poliomyelitis, WHO launched an interregional project of mass immunization. The project team in- cludes WHO, UNICEF, IFRC, Rotary International, the Centers for Disease Control and Prevention and the United States Agency for International Devel- opment.The WHO Regional Offices for Europe and the Eastern Mediterranean coordinate the project, which covers 18 countries where poliomyelitis is en- demic. Through Operation MECACAR (Mediterranean, Caucasian and central Asian republics), 63 million children under 5 will be immunized in 2 rounds of national immunization days each year for 3 years. Operation MECACAR started on 7 April 1995, World Health Day, and will contribute substantially to the WHO goal of eradicating poliomyelitis by the year 2000. Launching Operation MECACAR, World Health Day 1995 Russian Federation Ukraine In Other NIS 50 40 30 o co O) Co N CO C' CO Co CO O) O) O) O) O)O) O) O) O) O) O) O) O) Incidence of diphtheria in the NIS wi on Pi E Humanitarian action ÉE C7 ¢ A young refugee in Croatia WHO plays a crucial role in organizing help for refugees Delivering the goods: WHO driver loads medicines Answering calls to action For the first time since WHO's founding, war has returned to the Region, affecting nine of the CCEE and NIS since 1990. The Regional Office makes spe- cial efforts to ease this terrible extra burden on health. The first and biggest example is its programme of humanitarian assistance to the countries of the former Yugoslavia. A recent external evaluation of this pro- gramme gave a ringing endorsement of WHO's role and work. Is it worth while? To help the former Yugoslavia, the Regional Office not only launched its biggest project ever, in difficult and dangerous conditions, but also added active in- tervention to its familiar role of adviser and coordinator. The vicious, messy conflict has caused millions of people to flee their homes, killed and wounded hundreds of thousands, and crippled health and environmental protection services. The Office of the United Nations High Commis- sioner for Refugees heads a joint programme of assistance that includes UNICEF and WHO. Since July 1992, WHO has coordinated health -related activities in the programme. This means assessing needs and ensuring that they are met, while avoiding duplica- tion of effort and filling gaps. It requires strong links with all the key partners: United Nations organiza- tions, other intergovernmental organizations, government ministries and agencies, over 180 non- governmental organizations, and local health authorities. To do its job, WHO has 85 staff in 7 lo- cations, and has received support totalling US $60 million in cash and in kind. In June 1994, WHO asked three international experts in public health and disaster management to make their own judgement. "Well worth repeating" The evaluation confirmed WHO's mandate for hu- manitarian assistance and stressed the respect won from WHO's partners and the good coordination in the field. They gave special praise to WHO's work in assessing public health needs. WHO partners "are turning to WHO for authoritative advice on all health matters" and "stressed WHO's unique contributions in setting standards, issuing guidelines and provid- ing specific expertise ". WHO staff "deserve the highest praise for their efforts ". "Local officials stressed the wide range of WHO contributions to epidemic preparedness and control." The 20 kits that WHO designed for special diagnos- tic and treatment needs "stood out for their standardized quality ". The evaluators also noted "un- deniable achievements" in physical and mental rehabilitation. They pointed out that WHO was already looking "beyond relief to development ", and had a "pre- eminent role as a technical adviser" in health care reform and reconstruction. WHO seminars, dis- cussions and literature on reform won "nearly universal praise ". Their final conclusion was: This programme has been highly successful in spite of its shortcomings. Even if none of the observed shortcomings were corrected before the next call for humanitarian action, this programme is still well worth repeating. Next steps The Regional Office has already applied the lessons of the evaluation to the next phase of its humanitar- ian work. New management and administrative structures are in place, and work for further improve- ment continues. In the former Yugoslavia, WHO is planning to meet needs for reconstruction. It contin- ues its work for peace through health: chairing the Health Committee of the Interim Coordinating Body in Sarajevo and promoting cooperation between the six medical associations of the region. In answering this and other calls for humanitar- ian action, the Regional Office seeks to be, in the words of its Regional Director: an organization with a real conscience for those most in need, sound technical competence to ad- vise on the best strategies available and an ability to create opportunities where they may seem hard to find. Information for environmental health Policy -makers need sound information to transform public concern about the environment into action. WHO has gathered such information in ground- breaking studies at the regional and country levels, and policy- makers have used it to make action plans. These are the first steps towards securing sustainable development and environments that protect health. Concern for Europe's Tomorrow In 1991, the new WHO European Centre on Environ- ment and Health (ECEH), working in Copenhagen, Bilthoven, Nancy and Rome, launched the project Concern for Europe's Tomorrow. It was the first and most comprehensive survey of the environment and its effects on health in the European Region. Its method was environmental epidemiology: showing where and in what environmental conditions deaths and cases of disease occurred. This permitted asso- ciations with factors in the environment, and thus indicated priorities for action. The report Concern for Europe's Tomorrow made recommendations on seven issues: gaps in informa- tion, contaminated water and food, accidents (on the road, at work and at home), air pollution, road traffic (as a cause of accidents and pollution), problems with housing and urban development, and issues that cross national boundaries. The report gave important input to the Second European Conference on Environment and Health, held in Helsinki in June 1994. WHO or- the Conference with the Commission of the European Communities (CEC). The participants at the Helsinki Conference in- cluded health and environment ministers from 47 countries of the Region, and representatives of 2 offices and 4 specialized agencies of the United Nations, and 4 intergovernmental and 13 non- governmental organizations. They all endorsed the WHO Environment and Health Action Plan for Eu- rope, and set up the European Environment and Health Committee to carry it out. The Action Plan called for countries to make their own plans, and six took the lead: Bulgaria, Hungary, Italy, Latvia, the United Kingdom and Uzbekistan. In addition, the Nancy Division of ECEH has developed many projects for the reconstruction of environmental pro- tection services in Bosnia and Herzegovina, for which it is seeking donor support. Environment and health in Italy Events in Italy have mirrored those in the Region. As one of the pilot countries, Italy is providing a proto- type of investigation and responsive policy- making. The Rome Division of ECEH used the methods of the Region -wide project to track deaths from over 30 causes at the municipality level. Like the regional report, Environment and health in Italy describes both health and risk factors in lifestyles and economic activities, and people's exposure to a range of envi- ronmental hazards. Its special feature is a discussion of areas of high environmental risk. High -risk areas, identified by the government, comprise about 6% of Italy's area but have 20% of the population. Most of the small areas suffer from a single, well known source of pollution, usually an industrial plant. The large areas, including Naples and most of Lombardy, have complex problems of envi- ronmental degradation. The report has sparked action. The Rome Divi- sion of ECEH will do further studies to confirm the associations found, while naming priority issues for the government to address in its national action plan. This points the way for the other pilot countries and the Region as a whole. Road traffic: accidents and pollution threaten health Concern for Europe's Tomorrow. Summary from 1994; the full report was published in 1995 High -risk areas in Italy Participants in NIPEH training activities Integrated action on environment and health The CCEE and NIS have inherited a sorry legacy of environmental degradation, inadequate systems to measure problems and their effects on health, and lit- tle money for clean -up or prevention. Nevertheless, protecting the environment and health requires inte- grated action. The WHO national integrated programmes on environment and health (NLPEHS) help six CCEE to build the systems and skills to tackle their own priorities. Building capacity for environmental health management Making the CCEE habitable and healthy means deal- ing with factors in the environment that can damage health: air and water polluted by mining and other industries, water polluted by farming practices, and contaminated food and drink. In many "hot spots ", widespread pollution from many sources seems to affect the whole population. Because the CCEE needed similar kinds of tech- nical assistance, the Bilthoven (Netherlands) Division of the WHO ECEH devised NIPEHS as a framework for activities. With country health and environment authorities, the Bilthoven Division has worked out NIPEHS for Bulgaria, the Czech Republic, Hungary, Poland, Romania and Slovakia. The aim is to upgrade and link the work of health and environment authori- ties and institutes. This will enable them to supply sound information to decision -makers for effective environmental health management. Training environmental physicians in Poland The Nii>i:iis work for and through partnership. In addition to the health and environment institutes in the participating countries, the Bilthoven Division works with governments (particularly those of the Netherlands and Switzerland) and their bilateral aid agencies, donor agencies (such as the United Nations Environment Programme, the World Bank and the PHARE programme of the EU) and environmental health institutes (such as the Karolinska Institute in Sweden, the London School of Hygiene and Tropi- cal Medicine and the Dutch National Institute of Public Health and Environmental Protection - RIVM). The Netherlands provided about US $700 000 to each NIPEH. The countries proved their commitment by matching these funds in cash or in kind. Activities past and future The NIPEHS concentrate on supplying tangible prod- ucts in three interrelated areas. First, they improve the understanding of the effects of pollution on health by linking environmental factors with chronic dis- eases in an area or region. The Bilthoven Division worked out a standardized protocol and has guided 12 studies of hot spots in the 6 countries, using cleaner areas for comparison. Second, the programmes strengthen local capac- ity in environmental health management. This includes supplying laboratory and other equipment, but focuses on training. The Bilthoven Division and its partners have conducted 23 courses for over 400 people on environmental epidemiology, quality assurance in environmental health monitoring, good laboratory practice, good agricultural practice, the use of geographical information systems, and mod- ern methods in toxicology. Third, the NIPEHS help to establish databases in which to collect, organize and analyse data from en- vironmental health monitoring. The programmes supply the hardware and software for a health and environment geographical information system; four regional and two national systems have been set up. Regular evaluations have praised the success of the first phase (1992- 1994). The participating coun- tries particularly value the chance to set their own priorities and to bring their health and environment systems into partnership, and the flexibility shown by the Bilthoven Division and other partners in implementing the programmes. The next phase is building on this success. This means developing NIPEHS for some NIS, strengthen- ing the best elements of existing programmes, and promoting networking among the participating coun- tries. A special success from the first phase, the scheme to train environmental physicians, is expected to be extended from Poland to Romania. Living links between the environment and health systems, such physicians will inform the public and advise the gov- ernment about environmental threats to health. Learning material for nurses Nursing development requires education at all lev- els - formal and informal, basic and continuing. The acute shortage of educational material is a major ob- stacle, particularly in the CCEE and NIS. In the long term, countries will produce their own materials. But they need help to develop this expertise, and they ur- gently need materials to use now. The WHO LEMON (LEarning Material On Nursing) Project helps to meet both these needs. The LEMON Project will provide a package of up- to -date educational materials, in each country's official language, to all nurses, midwives and feldshers in the CCEE and NIS: a target readership of over 2 million health workers. Answering twin needs Nurses in the CCEE and NIS want to provide the best possible care, but they have few educational re- sources. A nurse caring for an elderly person with multiple health problems, for example, can rely only on tradition and her instincts, and hope for the best. These nurses lack textbooks, professional journals and guidelines. Existing materials tend to be scarce, outdated or unavailable in local languages, and they usually fail to address current needs. Further, nurses do not find it easy to decide what materials they need. With the best intentions, foreign donors give them large numbers of western books and journals, but these are often inappropriate.LEMON helps nurses in the CCEE and NIS take the lead in choosing the best materials for their needs and cir- cumstances. Building materials and skills The LEMON project features strong interaction be- tween the Regional Office, an international advisory group of nursing experts, and LEMON groups in the 16 actively participating countries. In the first phase of the project, the advisory and country groups chose the subjects and materials for the package from the literature. Now that the English- language package is complete, phase two will begin. The country groups will translate the package into their languages, adapt it as necessary and test it. Phase three will begin about a year later. The country groups will supply the tested package to as many nurses, midwives and feldshers as possible, using local printers and publishers. This work is building capacity for the future, since nurses in the country groups run the project themselves. WHO acts as a supporter and coordina- tor, rather than a director. Further, the network of participating nurses and the project infrastructure in countries provide an excellent base for future activities. Growing from the seeds LEMON is a huge project in constant need of funds and skills. WHO launched the project in 1993. The first phase was financed mainly through donations from the Department of Health in the United Kingdom, and support for the second phase comes mainly from the Department of Health in Ireland. The country groups and WHO raise money for the project through the LEMONAID appeal. The great enthusiasm that greeted the project shows the urgency and clarity of the need for the pack- age. It has inspired partners in the CCEE and NIS, and supporters in other countries, including govern- ment agencies, nursing associations, educational institutes and individual nurses. WHO is confident that the seeds of LEMON are already bearing fruit. Adapting the material: writing a chapter in Slovenia The LEMON package Cards sold in the LEMONAID appeal Health care reform in Kyrgyzstan Training session for the Manas national team Manas and CARNET documents Independence left Kyrgyzstan, like other NIS, with a health care system battered by waves of change, including economic and social problems and wors- ening health. While many organizations helped with isolated problems in the health sector, WHO has helped Kyrgyzstan to develop and coordinate a pro- gramme for the comprehensive reform of its health care system. A hero's task The Kyrgyz health care system is rich in hospital beds, doctors and nurses. But staff are unevenly dis- tributed and badly paid, hospitals and equipment are old and in poor repair, and Kyrgyzstan depends on donor assistance for drugs and medical equipment. Although willing to reform the health system, the Ministry of Health has had to focus on keeping ser- vices running from day to day. External aid offers only temporary relief. Creat- ing and running a sustainable, equitable and effective health care system require careful consideration of a country's resources and priorities and realistic assess- ment of the options for action. In 1994, the Regional Office and the Ministry of Health worked out a frame- work for the reorganization of health services from 1995 to 2005. As this was a hero's task, the partners named the initiative after a Kyrgyz national hero born in 995: the Manas health care reform programme. Manas: work for reform In 1994/1995, the Manas programme had two ob- jectives: to help the Kyrgyz authorities to design a master plan for health care reform, and to enable them to carry it out by strengthening their management capacity. Three groups of partners cooperated on these tasks: a national team, including a coordinator in the Ministry of Health and 46 health officials from the central and regional levels; an international team, comprising the United Nations Development Programme (UNDP), the World Bank, WHO, the Danish International Development Agency, the Overseas Development Administration of the United Kingdom, the Swiss Federal Office of Public Health, the Turkish Inter- national Cooperation Agency and the United States Agency for International Development; and a WHO secretariat (two staff in the Regional Office and a technical adviser in Bishkek). The partners developed the master plan for reform in three stages. First, they analysed current conditions in all relevant areas: the needs of the population; the policies, financing, organization and management of the health sector; the providers, physical infrastruc- ture and delivery of health services; the health information system; and scientific support and research. Then they used the analysis to develop four policy options: preservation of the existing system, optimization of the system, contracting for health services and laissez-faire development. At a confer- ence in February 1995, the partners and Kyrgyz government officials, including the President and Prime Minister, discussed the pros and cons of each option, favouring a combination of the second and third. After the government made its final choice in April, the partners prepared a detailed plan, with strat- egies for the short, medium and long terms, for presentation to the Ministry of Health in September 1995. While working on the master plan, the inter- national team also worked to strengthen management capacity. It gave the national team technical know- ledge on health policy- making, and instruction in project management, English and computer skills. WHO's special role in Manas included providing technical knowledge, advising on policy and assist- ing in coordination. As the programme was also the framework for coordinating all assistance to health sector reform in Kyrgyzstan, WHO had not only to prevent duplication of effort but also to ensure that contributions complemented both Manas and one another. Finally, WHO enabled Kyrgyzstan to exchange information and experience with neighbouring coun- tries. Through the central Asian republics' network (CARNET) on health care financing and management, Kyrgyzstan not only receives support but provides a model in Manas. Turkmenistan has asked WHO to help in designing a similar programme. Reducing drug use Drugs cause terrible harm to users and society. Many national and international organizations are trying to reduce drug use in the European Region. WHO's approach is founded on the principles of health for all, stressing intersectoral cooperation on both pre- vention and control. The Regional Office both preaches and practises action to reduce the use of psychoactive substances: not only drugs but also al- cohol and tobacco. The problem Drug use and responses to it vary between the two halves of the Region, the CCEE and NIS, and commu- nities in a country. Throughout the Region, drug use bears hardest on the disadvantaged groups in society. In western countries, the problem is serious and well established. About 5 -10% of the population was estimated to use illegal drugs in the 1980s. "Designer drugs ", such as MDMA ( "Ecstasy ") are increasingly popular. Attacks on the supply of drugs by the crimi- nal justice system have not solved the problem. Many countries have thus combined such work with activi- ties to reduce demand, carried out by the health and welfare system. They have well established systems for treatment and rehabilitation, through specialized services and primary health care. Intersectoral action on a combined approach, long advocated by WHO, is becoming a reality. Further, countries cooperate through programmes of the EU and the United Nations. Drug use is not yet as serious a problem in the eastern countries, but is rapidly growing in many CCEE and some NIS. Drug injection is gaining popu- larity. The CCEE have infrastructures to deal with drug trafficking. The NIS do not, and opiate and marijuana production are big business in the central Asian republics. HIV transmission through drug injection adds urgency to the problem in the Region. Injecting drug users make up an ever larger fraction of HIV cases: over 40% in 1994. WHO advocates harm reduction programmes, including needle and syringe exchanges and drug substitution. The CCEE and NIS lack such programmes, but have a strong political commitment to prevention. A combined approach WHO promotes intersectoral action to reduce demand, as well as supply, and a combined approach to drugs, alcohol and tobacco as the most effective responses. Demand reduction should address all psychoactive substances. The same factors encour- age the use of drugs, alcohol and tobacco, particularly by young people: peer pressure, lack of self- esteem and the desire to belong. Demand reduction pro- grammes can give people the skills to cope with all three. The Regional Office has assessed substance use in many CCEE and NIS. This is part of WHO coop- eration with the United Nations International Drug Control Programme, which also includes training health and welfare workers to provide drug treatment 100 Other III Heterosexual contact l Injecting drug use Homosexual /bisexual contact (male) 1 Total number of annual new cases 25 000 20 000 15 000 2 U 10 000 5 000 0 services. WHO has a special programme to promote action to reduce demand in the CCEE and NIS. WHO's work with the EU includes serving on the management board of its European Monitoring Cen- tre for Drugs and Drug Abuse. WHO and the Council of Europe (CE) exchange information on drug use in the countries of the Region. Further, WHO advises countries on policy issues, such as reducing the risk of HIV infection, and main- tains a research network. The Regional Office recently issued a review of AIDS among drug users, and has now prepared a summary on substance use through- out the Region. The summary describes the extent of and trends in the problem, the associated harm, and the policies and responses in countries. It should pro- mote cooperation against this scourge to public health. Distribution of AIDS cases in adults and adolescents in the European Region, by mode of transmission, according to the year of diagnosis and adjusted for reporting delays, 1981 -1993 Opiate production: big business in the central Asian republics Health promoting schools Keeping in touch: newsletters from the European and country networks Because schools try to give students the knowledge and skills that will enable them to become independ- ent and responsible adults, they are an ideal setting for health promotion. With CEC and CE, the Regional Office has built a European Network of Health Pro- moting Schools. This project empowers everyone in the school community - staff, students and parents - to gain a deeper understanding of their health and to choose and carry out action to improve it. Cooperation and diversity Beginning as a pilot project in 1991/1992 in four of the CCEE, the Network now includes over 400 schools, with 300 000 students, in 27 countries. A further 1600 schools are linked to the Network through national or regional arrangements. And 10 more countries are expected to join in 1995. The reasons for this success? With partnership as both method and goal, the Network provides a flexible framework in which schools can determine their own needs and work to meet them in their own ways. To join the Network, countries commit themselves to cooperation between their education and health authorities and to promoting health in schools by making them into safe and health- enhancing social and physical environments. Participating schools commit themselves to this concept, and to devising and carrying out projects. Success stories Activities in the Network are as varied as the schools. All grow from the enthusiasm and commitment of staff, students and, often, parents. Many not only bring immediate benefits but enable the school community to acquire new knowledge and skills. The following are only the first success stories reported to the Network. Some activities focus on the school environment. Students in a Croatian school repaired walls dam- aged by bullets. In Slovenia, a project team cleaned up the school toilets, placed benches and rubbish bins in the playground and helped to plan healthier meals, while introducing exercise breaks in class. Other projects focus on relations and democracy in the school community, and address lifestyle issues. The project team in a Bulgarian school started a dia- logue between staff and students, a parents' committee and discussions of health. A Polish school surveyed students' feelings about their teachers and helped the teachers update their methods. In an Irish school, the canteen staff developed healthier menus while the prefects were trained as peer leaders. The parents of students in a Belgian school supplied food from and discussions of a different culture on every day of Multicultural Week. Students at a Danish school wrote and performed a play on drug and alcohol use. Those at a Swedish school studied resuscitation techniques and took part in an antismoking project with the parents' association. Several schools made policies that limited or banned smoking by students and staff; parents also took part in the process. Finally, some projects feature international coop- eration. Schools in the Czech Republic and Denmark worked together to conduct experiments on the local environment. Making the community their classroom, groups of students examined an issue and used their results to make recommendations to the local gov- ernment. This provided eye- opening lessons for the students, teachers and community. Commitment to the future The Regional Office, CEC and CE support the Net- work, through which schools share information, training, experience and examples of good practice. They also support a technical secretariat in the Re- gional Office. It gives day -to -day support to national coordinators in the countries, raises money for the Network and provides technical guidance through advice and documents, research, and training manu- als and workshops. The secretariat also maintains a special focus on the CCEE and NIS, where decen- tralization and health promotion were new ideas. The Network has brought these countries essential funds and expertise, and helped to strengthen their infra- structures and capacities for health promotion. The Region's children are its future. All children must have the chance to realize their potential to be healthy, educated adults. The European Network of Health Promoting Schools is dedicated to reaching this goal. Members of the Network Albania, Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Ger- many, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom Profiles of women's health 82 80 t- 78 76 ô- 74 J 72,--00 rn ci CO rn CO CO rn v CO rn LC)00 rn European Region European Union CCEE ® MS rn n CO rn 0 rn Women's health counts WHO stated its commitment to improving the health of women in target 8 of the European policy for health for all. It acted on this commitment by launching the Investing in Women's Health Initiative in 1993. Pro- files of women's health throughout the Region are both the first fruits of the Initiative and a catalyst for action within and beyond Europe. The Initiative has three parts: producing profiles of women's health in the Region; making a comparative analysis of the profiles that identifies the critical issues in women's health; and starting a European Women's Health Forum to develop an agenda for action in the Region. WHO launched the Initiative by encouraging the first -ever profiles of the health of women in every country of the Region. Because health is an integral part of life, this meant moving beyond the traditional focus on reproductive health to embrace other is- sues. It meant describing not only health status and services but also the influences of daily life and the environment, and women's position in society. Starting in the CCEE and NIS Women in eastern countries can expect to live 5 -10 years less than those in western countries, and they have up to 10 times the western rates of mater- nal death. This led the Regional Office and its partners (the World Bank and the governments of Austria, Finland, the Netherlands, Norway and Sweden) east- wards for the first country profiles. Eleven of the CCEE and NIS, and one city, agreed to take part. Health ministries chose coordinators for each country. The Regional Office developed guide- lines and a questionnaire, and the coordinators and their teams used them to assess women's current sta- tus in health, society and the economy. The resulting profiles pictured the day -to -day realities of women's lives. In 1994, the Regional Office made a comparative analysis of the profiles and, with the World Bank and the Austrian and Norwegian governments as co- sponsors, organized a Conference called "Women's 120 ô 110 g. 100 â 90_-aO 80 0 70 60 ° 50 40 0 30 r cu co v N-00 Oo CO CO CO CO CO rn rn rn rn rn rn rn European Region European Union CCEE NIS CO rn o CO CO rn rn rn rn rn rn Health Counts ". There the coordinators described the priorities revealed by the profiles, and used the analy- sis to design strategies for improvement. The participants summarized these in the Vienna State- ment on Investing in Women's Health in the Countries of Central and Eastern Europe. The Statement forms the basis for an approach to women's health that builds on the WHO commitment to equity, human rights and primary health care. Expanding the Initiative After the Conference, WHO published the compara- tive analysis on the CCEE and NIS, with the Vienna Statement. It also asked the other countries to name focal points for a similar report on the whole Region. With the support of the focal points and its partners, the Regional Office completed a new series of pro- files early in 1995. They identify several critical issues: reproductive health, particularly the prevention of maternal death and promotion of family planning; occupational health, including threats to health in the workplace and those related to unemployment; the environment; and the health of women who are elderly, migrants or members of a minority group, and thus at special risk. The Regional Office sent the profiles to the WHO Global Commission on Women's Health and the United Nations Fourth World Conference on Women, held in Beijing in September 1995. In addition, WHO and the United Nations Population Fund (UNFPA) issued a document to inform donors about priorities in reproductive health and activities already under way. The members of the expanded European Wom- en's Health Forum met for the first time in May 1995. They work together for better health for women, ad- vise the Regional Office on strategies, and urge their governments to give the issue a higher spot on the political agenda. Through the Investing in Women's Health Initiative, WHO and its partners are working to ensure the full participation of women in health for all. Female life expectancy at birth: east -west gap Deaths from cardiovascular diseases in females under 65: east -west gap PK LP Promoting women's and children's health Tajik girls: every girl presents a new chance to invest in the health of women and the next generation 60 50 t 40 -'- 300 20 10 ® Highest in the central Asian republics CI Target level a.. ® Lowest in the Region Infant mortality in the European Region 90 80 PPPr 70 t60'> 50 g 40 ° 30 `,11 20N fl 10 ° 0 Highest in the central Asian republics Target level Lowest in the Region Maternal mortality in the European Region Rates of death for pregnant women and mothers, and of babies under 1 year, highlight the width of the health divide in the European Region (see p. 2). Maternal and infant deaths are highest in the central Asian republics. Various international organizations and the countries themselves have assessed the prob- lem and worked to tackle it. WHO helped crystallize this process by bringing the organizations and coun- tries together to create and launch an integrated approach. A looming crisis In December 1994 WHO, with the International Planned Parenthood Federation, held an international meeting to strengthen maternal and child health and family planning in the central Asian republics (Kyrgyzstan, Tajikistan, Turkmenistan and Uz- bekistan) and in Azerbaijan and Kazakhstan. Some 28 obstetricians and paediatricians from the 6 coun- tries, and representatives of UNDP, UNFPA and UNICEF outlined their approach and a project to put it into action. The country representatives began by describing the situation. The rates of death for infants are 28 -54 per 1000 live births and the maternal deaths number 35 -83 per 100 000 live births. This forms a grim con- trast with the levels called for by regional targets 7 and 8 and the even lower rates already achieved in some western countries of the Region. The main causes of maternal death are haem- orrhage, toxaemia of pregnancy, infection and complications of abortion (which is the main means of family planning). The main causes of death in in- fants are premature birth, low birth weight, acute respiratory infections and diarrhoeal diseases. In a few countries, war is a further threat. The countries recognized that expensive high tech- nology is not the first priority. They need to change some basic practices (to leave babies with their mothers, to stop swaddling and to encourage breast - feeding) and thus the knowledge and skills of service providers. Families, policy- makers and the public must change, too. Vaccination, safe drinking -water and simple means to prevent and treat diarrhoeal diseases are important concerns. Outside the health sector, nutrition and hous- ing must be improved. The countries also need preventive services for young people that fo- cus on nurturing girls, and increasing people's knowledge of human sexuality and their in- formed choice of modern family planning methods. These are the best ways to promote the health of women and children. The Regional Office agreed to help the countries develop a joint, integrated, five -year project based on the principles of the regional policy for health for all, to tackle the loom- ing crisis. An innovative, integrated project According to WHO's proposal, the countries and their international partners will carry out the CARAK (central Asian republics, Azerbaijan and Kazakhstan) project from 1995 to 2000. The project will promote maternal and child health and family planning through a package of innovative, integrated, appropriate services delivered at the district level by providers with up -to -date training. WHO, UNFPA and the government of Uzbekistan have already pledged funds to the project. Additional partners would be welcome. The project will start in the hospitals, health cen- tres and feldsher /midwifery stations of 12 districts (with a total population of 360 000) in the 6 coun- tries. It will be sustainable because it is based on the countries' thinking and will build their capacities. It will be replicable because activities will be monitored and evaluated and the countries' information systems will be improved. The CARAK project will have seven products: 1. revised legislation, policies, procedures and guide- lines to ensure safe, efficient and effective services; 2. a network of service providers and consumers in the pilot districts who will share information and experience; 3. health personnel with up -to -date skills in mater- nal and child health and family planning; 4. new training packages and programmes; 5. a comprehensive information system on health and services; 6. educational messages delivered to the public through the mass media; and 7. additions to the curricula of schools and univer- sities on child development, reproductive health, pregnancy and childbirth, and family health. Nutrition training in the (:SEE and NIS The legacy of the past in the CCEE and NIS includes a lack of information on diet and nutrition. A few studies were made, but their results were rarely pub- lished. Struggling with worsening living conditions, governments urgently need to know their people's nutritional status and needs, so that they can make sound policies on food, agriculture and health. WHO is carrying out a project in the CCEE and NIS that creates much- needed expertise in public health nutrition while helping to supply this scarce infor- mation. Rapid nutrition assessment The project comprises a series of studies on the nu- tritional status of two of the most vulnerable groups in the eastern half of the European Region: women and children. It began with a study involving the Regional Of- fice and staff from three nutrition institutes in the NIS. The participants monitored 10 -year -olds at four sites (Almaty, Kazakhstan; Kiev, Ukraine; and two sites in Moscow, the Russian Federation) in April of 1992, 1993 and 1994. The results refuted the widespread fear of starvation in these areas. The city populations were resilient enough to protect their children, whose growth and diet did not deviate from global standards. The success of the study led the Netherlands Min- istry of Welfare, Health and Consumer Affairs to supply further resources for the project on rapid nu- trition assessment. The project continues to pursue the twin goals of securing information and supplying essential training in nutrition. A series of three over- lapping studies began in 1994 and will continue through 1996. All have the same structure and the same focus - maternal nutrition - but involve differ- ent groups of countries: Kazakhstan, the Russian Federation, Tajikistan, Turkmenistan and Uzbekistan in 1994/1995; Armenia, Belarus, Bulgaria, Georgia, Karal- kalpakstan (Uzbekistan) and Ukraine in 1995; and Albania, the Czech Republic, Estonia, Latvia, Lithuania, Romania, Slovakia and Slovenia in 1995/1996. Content and methods Each group follows the same five -step programme, which takes less than a year to complete: 1. WHO conducts a workshop for participating nu- tritionists on methods of assessing diet, and related topics such as nutrition policy, weighing and meas- uring people, and food composition; 2. facilitators help the participants to complete a common protocol for the multicentre study; 3. teams of participants apply what they have learned by assessing women's nutrition in their countries, using software supplied by WHO; 4. the teams meet the facilitators again to present their data and choose a final form for its presen- tation, with the facilitators commenting on their work and suggesting improvements; and 5. the teams finalize their results. Owing to reports of widespread anaemia, the teams also test haemoglobin levels, using equipment paid for by LISP, an Italian nongovernmental organiza- tion. The lecturers at the workshops are renowned experts from WHO collaborating centres in Europe and the USA. They donate their time and often pay their own expenses. Having completed their study, the partici- pants report their results to their governments, and in national and international journals. Results The most immediate result is the increase in expertise and the rapid growth of a network of nutritionists in the CCEE and NIS. The project participants are the nucleus of the network. The project links country teams and participating institutes in the exchange of ideas and information. For example, some people in the participating countries ascribe falling rates of breastfeeding to poor nutri- tion and anaemia in mothers. The project is not yet complete, but its early results challenge this belief. Once trained, many participants serve as facil- itators in the next project study. In addition, network members supply local expertise to other studies of nutrition and related topics, conducted by a wide va- riety of international and bilateral organizations. The WHO project on rapid nutrition assessment gives nu- tritionists in the CCEE and NIS the skills to work more effectively to improve the health of their people. A nutrition workshop: learning how to use new software 1992 Almaty Kiev Moscow -1 Moscow -2 Results from the first study: average intake of fresh fruit by 10- year -olds Informing health authorities through telematics The WHO guide and the Danish manual for pharmacists Telematics: early warning of disease As a centre for public health information, WHO has promoted computer links, the newest and fastest way to collect and supply information. The ENS CARE Telematics project of the EU helped national health administrations improve their decision -making by using computers to supply up -to- the -minute infor- mation. WHO conceived and coordinated the project, which involved 24 partners in different countries. The project embodied a unique partnership between the Regional Office and the EU, which could extend its benefits throughout the European Region. Early warning systems One of the project's four parts focused on early warn- ing systems, including systems to alert countries to communicable disease emergencies. The network for Legionnaires' disease, for in- stance, included 23 reference centres in 21 European countries. Using software developed by the Communi- cable Disease Surveillance Centre (CDSC) of the Public Health Laboratory Service in the United Kingdom, the centres reported new cases to CDSC, which identified the source of a cluster of cases and alerted the health ministry of the country concerned. Since mid -1993, CDSC has identified 13 such clusters. A similar system was started for salmonellosis. The early warning system for Legion- naires' disease has proved its value and provided a model for the surveillance of other communicable diseases. Pharmacists helping smokers quit Pharmacists throughout the European Region are working together to help their clients quit smoking. European pharmacists want to expand their role in health, adding counselling on lifestyle to their traditional work of dispensing safe and effective medicines. With a pharmacy on every high street, pharmacists are ide- ally placed to advise on health in the course of their daily work. In pursuing this goal, pharmacists have an exciting opportunity to help achieve health for all. WHO and national pharmaceutical associations in 30 coun- tries throughout the Region have therefore joined forces to form the EuroPharm Forum. The Danish model In spring 1992, the Regional Office and the Danish Pharmaceutical Association tested pharmacists' po- tential to help their clients quit smoking in an eight -week pilot project. After training in group dy- namics and tobacco use, 20 community pharmacists ran smoking cessation courses, combining nicotine replacement therapy with support groups. The project was a brilliant success. At the end of the course, 60% of the participants had stopped smok- ing, and 30% were still nonsmokers a year later. Pharmacists and the public demanded more courses. Today, 25% of Danish pharmacies offer them. The European project The EuroPharm Forum has pledged to promote simi- lar action by its all member associations. For their use, WHO and the Forum described the principles and methods of the Danish project in International guide: pharmacies and smoking cessation. The Forum has also created a task force to carry out a smoking cessation project. The task force prepared a document for adoption by the Forum at its fourth annual meeting in June 1995. It tells pharmacists how to intervene at three stages of the smoking process, describes activities in various countries, and will be presented to ministries of health as a policy document. The task force will also advise pharmacists on how to persuade their col- leagues to become involved in smoking cessation. Most importantly, the task force has planned an international course for autumn 1995, to train train- ers in each of the Forum's member countries. Participants must commit themselves to carrying out one of the models outlined in the task force docu- ment on their return home. The EuroPharm Forum will do all it can to ensure that pharmacists take effective action in smoking ces- sation. The task force's work will go a long way to help achieve this aim. Quality of care development Patients and the public are increasingly aware of the issue of the quality of health services. Politicians and health care authorities require both the documenta- tion of quality and its continuous development. The interests of the community require the attainment of the highest quality possible within the existing frame- work of the health services. The WHO concept and programmes for continuous quality of care develop- ment help all parties involved work together to improve the outcome of care. Concept and process Research and monitoring have so far focused mainly on the process of health care, not its results for health. The WHO concept of continuous quality of care de- velopment examines the outcomes of care. To improve the quality of care, health profession- als must accept responsibility for the task. In 1993, the European Forum of National Medical Associa- tions, in collaboration with WHO, made a recommendation that emphasizes doctors' primary re- sponsibility for ensuring the quality of medical care. This was a major breakthrough, and WHO encourages other health care professionals, such as nurses and physiotherapists, to reach a similar consensus. With professionals' commitment secured, the next step is developing indicators to measure the quality of outcome. The Regional Office has been instrumen- tal in achieving Region -wide consensus on clinical outcome indicators for the management of perinatal care, depression, oral health, upper respiratory tract infection, diabetes and hospital infections. Indicators are being developed for stroke, hypertension and myocardial infarction. Here WHO works closely with ministers of health, research institutions, donors, in- dustry and patients' associations, as well as medical associations. WHO cooperated with the CEC to develop out- come -based quality indicators on oral health and perinatal care. For the latter, a set of 21 suggested indicators was tested on 3 million births in 30 coun- tries in 1992/1993. This led to the selection of a final list of 17 indicators in 1994. These are now ready for use in countries. After consensus on indicators follows the crea- tion of both local and Region -wide information systems. Databases allow anonymous comparisons of performance, which enable care providers both to evaluate their own work and to learn about the best current practices. Data collection can lead to the con- struction of a curve showing the variations in performance among health care providers at a cer- tain time: an original outcome curve. Then, the providers with the best outcomes identify themselves. After external verification of the data from these best performers, they share their experience with all the participating health care providers, who use the information to improve their performance. Repeat- ing the process can gradually move the performance of the whole group towards excellent quality. Improving the quality of health care improves the outcomes for patients. WHO promotes the development and acceptance of outcome indicators in more and more areas of care, and the establishment and expansion of databases for anonymous compari- son of performance. This maximizes the contribution of quality of care development to health for all. Health workers' commitment to the task is essential The process: continuously improving the performance of all health workers s â E Original outcome curve Later outcome curve Best Best outcomes outcomes t . -s Excellent quality Policies for health for all The Copenhagen Declaration Some of the many national and regional policies based on health for all Target 33 of the European health policy calls on countries to make and carry out policies in line with the principles of health for all. WHO gives priority to helping countries, regions and communities to make such policies, which har- monize and unify the disparate activities of the various sectors and groups working to improve health. With the collaboration of the CEC and CE, the Regional Office re- cently held a conference on health policy that pointed the way ahead. The conference and the demand for health for all policies at all levels in countries affirm the continuing value of these policies as the best tool for building better health for all Europeans. Enduring value of health for all In December 1994, the European Health Policy Conference: Oppor- tunities for the Future brought together 300 participants, repre- senting 45 of the 50 countries of the European Region. The partici- pants examined current trends in and future challenges to health, and policy responses at all levels. Having broken new ground by introducing par- liamentarians as participants, the Conference continued its pioneering by expanding the opportu- nities for international cooperation on health. With six intergovernmental organizations sharing a plat- form for the first time, the discussion clearly revealed the countries' demand for closer cooperation and the keen desire of WHO, CE, CEC, the International Labour Organisation, the Organisation for Economic Public Health Status and Forecasts Co- operation and Development and UNICEF to respond. The Conference showed that, despite enormous changes in the European Region and health policy issues, the health for all approach remains the best way to ensure the effective and efficient use of re- sources for health gain. The participants strongly endorsed this approach in the Copenhagen Declaration. The Declaration calls on all countries to carry out policies based on the principles of health for all; poli- cies in the CCEE and NIS should guide international investors and donors offering assistance. The health for all approach should underpin closer and more ef- fective cooperation by all partners in an international alliance for health gain. The WHO Regional Com- mittee for Europe - the Region's "health parliament" - will consider a resolution welcoming the Declaration in 1995. Support to policy -making The Conference added impetus to WHO's continu- ing support to countries in policy- making. The enduring value of the health for all approach lies in its flexible application of firm principles. Policy- makers use common ingredients - such as equity, wide participation in decision -making and a focus on health gain, as well as health care - but combine them in different recipes to suit their needs and circumstances. While most western countries are already imple- menting health for all policies, many CCEE and NIS are just taking up the task. WHO is working with Albania, Armenia, Bulgaria, Croatia, Estonia, Hun- gary, Latvia, Lithuania and Kyrgyzstan, and is discussing such cooperation with Poland, the Rus- sian Federation, Ukraine and Uzbekistan. The demand is so great that some have called for the establish- ment of a WHO centre for policy analysis and training. In Latvia, the Ministry of Health asked the Re- gional Office to help prepare a national policy based on health for all early in 1994. The plan was to write a draft, consult a broad range of authorities, sectors and interest groups, and submit the final result to Parliament for adoption. By early 1995, the discus- sions had resulted in a draft document now being updated. Better living - better Latvia describes a de- tailed strategy for health and social care development with a target date of 2010. It spells out goals, targets and objectives for four themes, and action in six direc- tions to achieve them. Through such work, WHO helps policy- makers in countries not only to build capacity for the future but also to seize the present opportunity of moving towards health for all. Conclusion Health in Europe presents a sobering picture in the mid - 1990s. Improvements in health continue in the western half of the European Region, but wor- rying inequities are growing, threatening the inner cities, the elderly, the poor, minority groups and migrants. The health divide between east and west remains the largest inequity. Most of the CCEE and NIS suffer continuing economic de- cline, and public services - including those for health -are reeling from dramatic cuts in funding and the other effects of instability. These have severely reduced the ability of health service systems to provide es- sential care for the population. Vaccination programmes, basic environmental health services and even food supply systems have broken down or been dis- located. Worst of all, armed conflict has continued or spread. The consequences for health are disastrous. They include a resurgence of infectious dis- eases, such as diphtheria. In some areas, the decline in the quality of life and health ser- vices has led to rises in maternal and infant death. And unhealthy lifestyles and deficient preventive services contribute heavily to the deaths from cardiovascular diseases, external causes and cancer that account for most of the east -west health divide. With limited staff and financial resources, the WHO Regional Office for Europe has developed new tactics to face the new situation. This has meant focusing primarily on the countries in greatest need, while retaining many Region -wide activities for health. WHO has built on its strengths: the health for all policy, clear leadership in health policy development, the scientific ability to devise new approaches and methods that countries can use to convert policies into practical programmes, and well established networks for action at the local level. These strengths have given the Regional Office the chance to mobilize large -scale advice and support for the CCEE and NIS, which have demanded help from WHO in almost every area of health develop- ment. The Regional Office has maximized its contribution by cooperating with all the other partners working for health. This means more than harness- ing its special strengths to those of other United Nations organizations, the European Union and the Council of Europe, and many government and nongovernmental organiza- tions. It means developing a new ability to act as a catalyst, pointing the way to the most effective action. The European policy for health for all has gained influ- ence throughout the Region. Thus, a new model for public health action has emerged. Central governments, regions and cities are integrating a broader philosophy into their policies, and emphasizing dis- ease prevention, health promotion and primary health care. The policy and targets for health for all should now influ- ence public health more than ever before. The European Region today has gained breath -taking momentum for change. The opportunities to make a differ- ence are immense. In its cooperation with its partners and the countries of the Region, the WHO Regional Office for Europe offers its impressive ability to create ideas, to build strong new alli- ances and to act as a catalyst in stimulating new action to secure health for all Europeans. World Health Organization Regional Office for Europe Copenhagen WHO Regional Publications European Series No. 57 ISBN 92 890 1321 2 Sw.f r. 12.-

The Regional Office for Europe of the World Health Organiza- tion welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, WHO Regional Office for Europe, Scherfigsvej 8, DK -2100 Copenhagen 0, Denmark, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 1995 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this publication are those that obtained at the time the original language edition of the book was prepared. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Report compiled and edited by Mary Stewart Burgher with the assistance of Pamela M. Charlton Design and graphics: Sven Lund Layout: Wendy Enersen Printed in Denmark by Rapo Contents Foreword Health in Europe Fighting disease in the NIS Humanitarian action Information for environmental health Integrated action on environment and health Learning material for nurses Health care reform in Kyrgyzstan Reducing drug use Health promoting schools Profiles of women's health Promoting women's and children's health Nutrition training in the CCEE and NIS Telematics: early warning of disease Pharmacists helping smokers quit Quality of care development Policies for health for all Conclusion 2 3 4 5 6 7 8 9 10 11 12 13 14 14 15 16 17 WHO Library Cataloguing in Publication Data WHO in Europe: meeting the challenges (WHO regional publications. European Series ; No.57) 1.Regional health planning 2.Health for all 3.World Health Organization 4.Europe (.Series ISBN 92 890 1321 2 (Classification NLM: WA 541) ISSN 0378 -2255 CORRIGENDA copyright page, WHO Library Cataloguing in Publication Data: correct ISBN is 92 890 1321 4 back cover, line 6: correct ISBN is 92 890 1321 4 INFORMATION ABOUT THE REGIONAL OFFICE The World Health Organization (WHO) is a specialized agency of the United Nations. Founded in 1948, it is the directing and coordinating authority on international health work. It has its headquarters in Geneva, Switzerland, and six regional offices: Regional Office for Europe (EURO), Copenhagen, Denmark Regional Office for the Americas /Pan American Health Organization (AMRO /PAHO), Washington, DC, USA Regional Office for the Eastern Mediterranean (EMRO), Alexandria, Egypt Regional Office for South -East Asia (SEARO), New Delhi, India Regional Office for the Western Pacific (WPRO), Manila, Philippines Regional Office for Africa (AFRO), Brazzaville, Congo Each regional office has its own programme, geared to the health problems of the countries it serves. The WHO Regional Office for Europe has a permanent staff of some 240 people, and a similar number of short -term staff, from about 40 nations. In addition, over 1000 experts work in the Region every year, along with collaborating centres and research institutes in many countries. Over 30% of Regional Office staff work in the field. The regular annual budget is about US $25 million. Funds donated by other sources, including the United Nations and individual governments, have grown to about US $30 million per year. The European Region embraces some 850 million people living in an area that stretches from Greenland in the north- west and the Mediterranean in the south to the Pacific coast of the Russian Federation in the east. The European programme of WHO concentrates on both the emerging democracies of the central and eastern part of the Region and the problems of industrial and post -industrial societies. Since 1990, the number of Member States has risen from about 30 to 50. The Regional Office is governed by a Regional Committee comprising representatives of every Member State; a Standing Committee from this body advises the WHO Regional Director for Europe. Through the Regional Committee, which meets once each year, the Member States collectively formulate regional policies, recommend technical activities and approve the programme and budget. The Regional Office in its turn provides Member States with technical and advisory services, directly or through networks of experts and other partners. As of June 1995, the Member States of the European Region are as follows: Albania France Luxembourg Spain Armenia Georgia Malta Sweden Austria Germany Monaco Switzerland Azerbaijan Greece Netherlands Tajikistan Belarus Hungary Norway The Former Yugoslav Belgium Iceland Poland Republic of Macedonia Bosnia and Herzegovina Ireland Portugal Turkey Bulgaria Israel Republic of Moldova Turkmenistan Croatia Italy Romania Ukraine Czech Republic Kazakhstan Russian Federation United Kingdom Denmark Kyrgyzstan San Marino Uzbekistan Estonia Latvia Slovakia Yugoslavia Finland Lithuania Slovenia WHO Regional Office for Europe, Scherfigsvej 8, DK -2100 Copenhagen 0, Denmark Tel: (+ 45) 39 17 17 17 Fax: (+ 45) 39 17 18 18 Telex: 15348 and 12000 who dk Teletex: 118785 Electronic mail: BITNET:WHOEURO @VM.UNI -C.DK TARGETS FOR HEALTH FOR ALL The work of the Regional Office is based on the regional policy for health for all, which includes 38 targets. They fall into five groups: targets for better health, lifestyles conducive to health, healthy environments, appropriate health care services and the support needed to attain them. These targets were adopted in 1984 and revised in 1991, retaining their essential framework with some changes of emphasis. Four targets now deal with specific population groups to emphasize positive health. The targets on health services now focus more clearly on specific health care settings (such as primary health care, hospitals and long -term care). The targets on the quality of care and appropriate health technology have been merged to allow the inclusion of a new target on health and ethics, a growing concern all over the Region. 1. Equity in health 20. Water quality 2. Health and quality of life 21. Air quality 3. Better opportunities for people with disabilities 22. Food quality and safety 4. Reducing chronic disease 23. Waste management and soil pollution 5. Reducing communicable disease 24. Human ecology and settlements 6. Healthy aging 25. Health of people at work 7. Health of children and young people 26. Health service policy 8. Health of women 27. Health service resources and management 9. Reducing cardiovascular disease 28. Primary health care 10. Controlling cancer 29. Hospital care 11. Accidents 30. Community services to meet special needs 12. Reducing mental disorders and suicide 31. Quality of care and appropriate technology 13. Healthy public policy 32. Health research and development 14. Settings for health promotion 33. Health for all policy development 15. Health competence 34. Managing health for all development 16. Healthy living 35. Health information support 17. Tobacco, alcohol and psychoactive drugs 36. Developing human resources for health 18. Policy on environment and health 37. Partners for health 19. Environmental health management 38. Health and ethics ORGANIZATION The Regional Office has four technical departments. Three mirror the main groups of targets and work for better health, healthy environments and appropriate care. The fourth ties together the threads of the various technical programmes into country projects, with particular emphasis on the countries of central and eastern Europe (CCEE) and the newly independent states (NIS) of the former USSR. A fifth department provides the Office with support services such as budget and finance, personnel and administration, as well as documentation and informatics. Executive Management gives overall guidance to the work of the Regional Office. Executive Management Disease Prevention Environment Health Policy Country Administration and and and Health and Lifestyles Health Health Care Development Finance Foreword A wave of change has broken over the European Region of the World Health Organization (WHO), transforming the social, political and economic land- scape. The most important feature of this landscape for health is the deep and widening gap between the eastern and western halves of the Region. Neverthe- less, WHO's recent work shows that the Regional policy for health for all, with its 38 targets, offers the best way to meet the health challenges of both the old Europe and the new. The policy's enduring value lies in its compre- hensive approach to health, its firm fundamental principles, and the flexibility of their application. This means that the WHO Regional Office for Europe pursues a wide variety of goals in all areas relevant to health - including lifestyles, the environment and health services - with any combination of methods and partners that suits the circumstances. The princi- ples of health for all harmonize these efforts, while the policy itself unites them. Principles in action The health for all policy and its seven principles guide all the activities described in this report. The 1994 European Health Policy Conference reaffirmed the value of this approach and urged that health for all form the foundation of country policies and greater international cooperation on health. Equity in health is the first principle in every sense. this goal has led the Regional Office to address the most serious health problems and the most vulnerable groups and countries. In particular, work with the countries of central and east- ern Europe and the newly independent states of the former USSR, to narrow the health divide, comprises two thirds of the activities of the Regional Office. This work, which constitutes the EUROHEALTH pro- gramme, underpins every article in this report, most notably those on responses to the resurgence of com- municable disease and humanitarian assistance to war -torn countries. Closely allied to equity is the second principle, ethics. This is the basis of WHO's work to improve the quality of health services. The next two principles of health for all empha- size primary health care and health promotion and disease prevention. Work here ranges from reducing substance use and promoting health in schools to improving maternal and infant health and promoting family planning in the central Asian republics. The last, closely linked principles form a theme that runs throughout this report: participation in decision -making by everyone concerned, and inter - sectoral and international cooperation. Health for all expresses WHO's recognition that health is every- body's business and that cooperation maximizes the effectiveness of all the partners in the task. In this area, WHO makes special efforts to build the capacities of different groups of professionals, including nutritionists, school staff and environmen- tal health managers. It has formed powerful alliances within the health sector, as well: with doctors for quality assurance, with nurses for educational development, with pharmacists for health pro- motion, and with health authorities and health adminis- trators for health care reform. Such alliances help to ensure the sustainability of WHO pro- grammes. The Regional Office con- stantly widens its network of international partners, which already includes WHO head- quarters and other regional offices, sister United Nations agencies, the European Union, governments and their agencies, and hundreds of nongovern- mental organizations. WHO brings its partners invaluable information, expertise and tech- nical advice on public health. WHO has turned partnership from a goal to a reality, resting on a solid and growing foundation of success- ful shared work. In the European health policy, the WHO Regional Office for Europe offers its many partners the best way to ensure the efficient and effective use of re- sources for health gain. The policy will continue to guide European countries forward to health for all. J.E. Asvall WHO Regional Director for Europe One of many WHO information products The health divide: life expectancy at birth The health divide: deaths from cancer in people under 65 Health in Europe IN EÛÂÔPE Implementing the WHO health policy for Europe in- cludes regular monitoring to measure countries' progress towards the goal of health for all. The WHO Regional Office for Europe recently published a sum- mary of the main results of the latest round of monitoring. This was an important part of WHO's work as a centre for information on public health. Health in Europe highlights the most important health problems in the WHO European Region, and describes country policies to tackle these problems and to achieve the 38 targets for health for all. Thus, the book indicates the areas for most effective re- sponse by countries and the Regional Office. Toll of change on health Everyone knows that the Region - particularly the countries of central and eastern Europe (CCEE) and the newly independent states (NIS) of the former USSR - is undergoing profound, some- times violent, political, social and economic change. Health in Europe points out the effects of economic problems, social unrest, migration and war on health. It shows the most important trend: growing inequities in health. For example, all citi- zens do not share in the improving health found in the western half of the Region. The clearest sign of inequity, and thus the clearest call for action, is CCEE European Union r' NIS Nordic countries 79 the gap in health between east and west. Measured in life expectancy, this gap is 6 years wide, and growing. The causes? The most important are deaths from cardiovascular diseases, injury and poisoning, cancer and respiratory diseases, as well as infectious and parasitic diseases in babies. Lifestyle plays an important role in all of these. But communicable diseases show a worrying resurgence (see p. 3), and poor living conditions threaten the health of vul- nerable groups such as the elderly, women and children (see pp. 11 and 12), the poor, members of minority groups, migrants and refugees. Better dis- ease prevention and healthier lifestyles and environments could reduce much of this burden of illness and death. A tool for these times These problems demand an integrated, innovative response from the countries of the Region. They call for effective solutions that use resources efficiently and promise better health for everyone. More than ever, the WHO policy for health for all is the tool for these times. It offers: the goal of equity in health; a stress on disease prevention and health promo- tion, in addition to appropriate treatment; a comprehensive approach to the determinants of health: lifestyles and the environment, as well as health services. As the wave of change broke upon the Region at the start of the 1990s, the Regional Office shifted its focus to the countries in greatest need. Through the EUROHEALTH programme, it now directs two thirds of its resources to the CCEE and NIS. This includes special efforts to help countries where war worsens already difficult conditions (see p. 4). As spelled out in Health in Europe, current con- ditions in the Region offer immense opportunities to make a difference. Seizing them is the main challenge for the Regional Office in its cooperation with the countries of the Region. CCEE European Union ® NIS Nordic countries 115 °110 ô105 0100O ô 95 90 85 ô 80 75 N V' (D N O N C (D N O N N- N. CO CO CO CO CO O) D)a) D) O) a) D) O) O) CO D) Q) Q) D) Fighting disease in the NIS Some communicable diseases have returned from the brink of elimination to threaten health in the Region. Particularly in the NIS, diphtheria epidemics continue and poliomyelitis is a growing menace. Thus, action against these diseases has regained priority in WHO. Recognizing that no single agency or donor can deal with the problems, the Regional Office helps to co- ordinate donor assistance to maximize effectiveness. Goal: vaccine independence Immunization is one of the best ways to control some communicable diseases. But political and economic changes in the NIS led to gaps in immunization cov- erage, and badly damaged former systems of vaccine supply and distribution. This forced most of the NIS to depend on donations. As part of the new Inter- agency Immunization Coordinating Committee (IICC), WHO is working towards vaccine independ- ence in the NIS. Established by the Kyoto Declaration in 1994, IICC comprises governments (of Canada, Denmark, France, Germany, Japan, Norway, Turkey and the USA), the European Union (EU), the International Federation of Red Cross and Red Crescent Societies (IFRC), the United Nations Children's Fund (UNICEF) and WHO. Its short-term aims are to strengthen coun- tries' immunization programmes and to take immediate action against current and potential out- breaks of disease. The next goal is vaccine self -sufficiency: to enable each of the NIS to acquire and control the quality of supplies that meet its needs. As secretariat to IICC, WHO's task is to supply donors with information on countries' needs and to track donors' assistance to avoid duplication and gaps. WHO has worked out with UNICEF a system to estimate needs, and is working on a system to track donors' pledges. The Regional Office secures the views of the NIS from the WHO European Informa- tion Service on Medical Supplies (ISMS). Through ISMS, the NIS voice their needs. ISMS issues quarterly reports to over 100 donors within and beyond IICC. The reports list countries' stocks of and needs for vaccines (against tuberculosis, diph- theria, pertussis, tetanus, measles and poliomyelitis), some 120 life- saving drugs and essential medical equipment. Donors have warmly welcomed the ISMS reports. Fighting disease WHO is acting to control diphtheria and poliomyeli- tis. Working closely with UNICEF and IICC members, the Regional Office has contributed guidelines on diphtheria diagnosis and case management. It has also helped the NIS to work out action plans to control the epidemics, and to mobilize donor support. For poliomyelitis, WHO launched an interregional project of mass immunization. The project team in- cludes WHO, UNICEF, IFRC, Rotary International, the Centers for Disease Control and Prevention and the United States Agency for International Devel- opment.The WHO Regional Offices for Europe and the Eastern Mediterranean coordinate the project, which covers 18 countries where poliomyelitis is en- demic. Through Operation MECACAR (Mediterranean, Caucasian and central Asian republics), 63 million children under 5 will be immunized in 2 rounds of national immunization days each year for 3 years. Operation MECACAR started on 7 April 1995, World Health Day, and will contribute substantially to the WHO goal of eradicating poliomyelitis by the year 2000. Launching Operation MECACAR, World Health Day 1995 Russian Federation Ukraine In Other NIS 50 40 30 o co O) Co N CO C' CO Co CO O) O) O) O) O)O) O) O) O) O) O) O) O) Incidence of diphtheria in the NIS wi on Pi E Humanitarian action ÉE C7 ¢ A young refugee in Croatia WHO plays a crucial role in organizing help for refugees Delivering the goods: WHO driver loads medicines Answering calls to action For the first time since WHO's founding, war has returned to the Region, affecting nine of the CCEE and NIS since 1990. The Regional Office makes spe- cial efforts to ease this terrible extra burden on health. The first and biggest example is its programme of humanitarian assistance to the countries of the former Yugoslavia. A recent external evaluation of this pro- gramme gave a ringing endorsement of WHO's role and work. Is it worth while? To help the former Yugoslavia, the Regional Office not only launched its biggest project ever, in difficult and dangerous conditions, but also added active in- tervention to its familiar role of adviser and coordinator. The vicious, messy conflict has caused millions of people to flee their homes, killed and wounded hundreds of thousands, and crippled health and environmental protection services. The Office of the United Nations High Commis- sioner for Refugees heads a joint programme of assistance that includes UNICEF and WHO. Since July 1992, WHO has coordinated health -related activities in the programme. This means assessing needs and ensuring that they are met, while avoiding duplica- tion of effort and filling gaps. It requires strong links with all the key partners: United Nations organiza- tions, other intergovernmental organizations, government ministries and agencies, over 180 non- governmental organizations, and local health authorities. To do its job, WHO has 85 staff in 7 lo- cations, and has received support totalling US $60 million in cash and in kind. In June 1994, WHO asked three international experts in public health and disaster management to make their own judgement. "Well worth repeating" The evaluation confirmed WHO's mandate for hu- manitarian assistance and stressed the respect won from WHO's partners and the good coordination in the field. They gave special praise to WHO's work in assessing public health needs. WHO partners "are turning to WHO for authoritative advice on all health matters" and "stressed WHO's unique contributions in setting standards, issuing guidelines and provid- ing specific expertise ". WHO staff "deserve the highest praise for their efforts ". "Local officials stressed the wide range of WHO contributions to epidemic preparedness and control." The 20 kits that WHO designed for special diagnos- tic and treatment needs "stood out for their standardized quality ". The evaluators also noted "un- deniable achievements" in physical and mental rehabilitation. They pointed out that WHO was already looking "beyond relief to development ", and had a "pre- eminent role as a technical adviser" in health care reform and reconstruction. WHO seminars, dis- cussions and literature on reform won "nearly universal praise ". Their final conclusion was: This programme has been highly successful in spite of its shortcomings. Even if none of the observed shortcomings were corrected before the next call for humanitarian action, this programme is still well worth repeating. Next steps The Regional Office has already applied the lessons of the evaluation to the next phase of its humanitar- ian work. New management and administrative structures are in place, and work for further improve- ment continues. In the former Yugoslavia, WHO is planning to meet needs for reconstruction. It contin- ues its work for peace through health: chairing the Health Committee of the Interim Coordinating Body in Sarajevo and promoting cooperation between the six medical associations of the region. In answering this and other calls for humanitar- ian action, the Regional Office seeks to be, in the words of its Regional Director: an organization with a real conscience for those most in need, sound technical competence to ad- vise on the best strategies available and an ability to create opportunities where they may seem hard to find. Information for environmental health Policy -makers need sound information to transform public concern about the environment into action. WHO has gathered such information in ground- breaking studies at the regional and country levels, and policy- makers have used it to make action plans. These are the first steps towards securing sustainable development and environments that protect health. Concern for Europe's Tomorrow In 1991, the new WHO European Centre on Environ- ment and Health (ECEH), working in Copenhagen, Bilthoven, Nancy and Rome, launched the project Concern for Europe's Tomorrow. It was the first and most comprehensive survey of the environment and its effects on health in the European Region. Its method was environmental epidemiology: showing where and in what environmental conditions deaths and cases of disease occurred. This permitted asso- ciations with factors in the environment, and thus indicated priorities for action. The report Concern for Europe's Tomorrow made recommendations on seven issues: gaps in informa- tion, contaminated water and food, accidents (on the road, at work and at home), air pollution, road traffic (as a cause of accidents and pollution), problems with housing and urban development, and issues that cross national boundaries. The report gave important input to the Second European Conference on Environment and Health, held in Helsinki in June 1994. WHO or- the Conference with the Commission of the European Communities (CEC). The participants at the Helsinki Conference in- cluded health and environment ministers from 47 countries of the Region, and representatives of 2 offices and 4 specialized agencies of the United Nations, and 4 intergovernmental and 13 non- governmental organizations. They all endorsed the WHO Environment and Health Action Plan for Eu- rope, and set up the European Environment and Health Committee to carry it out. The Action Plan called for countries to make their own plans, and six took the lead: Bulgaria, Hungary, Italy, Latvia, the United Kingdom and Uzbekistan. In addition, the Nancy Division of ECEH has developed many projects for the reconstruction of environmental pro- tection services in Bosnia and Herzegovina, for which it is seeking donor support. Environment and health in Italy Events in Italy have mirrored those in the Region. As one of the pilot countries, Italy is providing a proto- type of investigation and responsive policy- making. The Rome Division of ECEH used the methods of the Region -wide project to track deaths from over 30 causes at the municipality level. Like the regional report, Environment and health in Italy describes both health and risk factors in lifestyles and economic activities, and people's exposure to a range of envi- ronmental hazards. Its special feature is a discussion of areas of high environmental risk. High -risk areas, identified by the government, comprise about 6% of Italy's area but have 20% of the population. Most of the small areas suffer from a single, well known source of pollution, usually an industrial plant. The large areas, including Naples and most of Lombardy, have complex problems of envi- ronmental degradation. The report has sparked action. The Rome Divi- sion of ECEH will do further studies to confirm the associations found, while naming priority issues for the government to address in its national action plan. This points the way for the other pilot countries and the Region as a whole. Road traffic: accidents and pollution threaten health Concern for Europe's Tomorrow. Summary from 1994; the full report was published in 1995 High -risk areas in Italy Participants in NIPEH training activities Integrated action on environment and health The CCEE and NIS have inherited a sorry legacy of environmental degradation, inadequate systems to measure problems and their effects on health, and lit- tle money for clean -up or prevention. Nevertheless, protecting the environment and health requires inte- grated action. The WHO national integrated programmes on environment and health (NLPEHS) help six CCEE to build the systems and skills to tackle their own priorities. Building capacity for environmental health management Making the CCEE habitable and healthy means deal- ing with factors in the environment that can damage health: air and water polluted by mining and other industries, water polluted by farming practices, and contaminated food and drink. In many "hot spots ", widespread pollution from many sources seems to affect the whole population. Because the CCEE needed similar kinds of tech- nical assistance, the Bilthoven (Netherlands) Division of the WHO ECEH devised NIPEHS as a framework for activities. With country health and environment authorities, the Bilthoven Division has worked out NIPEHS for Bulgaria, the Czech Republic, Hungary, Poland, Romania and Slovakia. The aim is to upgrade and link the work of health and environment authori- ties and institutes. This will enable them to supply sound information to decision -makers for effective environmental health management. Training environmental physicians in Poland The Nii>i:iis work for and through partnership. In addition to the health and environment institutes in the participating countries, the Bilthoven Division works with governments (particularly those of the Netherlands and Switzerland) and their bilateral aid agencies, donor agencies (such as the United Nations Environment Programme, the World Bank and the PHARE programme of the EU) and environmental health institutes (such as the Karolinska Institute in Sweden, the London School of Hygiene and Tropi- cal Medicine and the Dutch National Institute of Public Health and Environmental Protection - RIVM). The Netherlands provided about US $700 000 to each NIPEH. The countries proved their commitment by matching these funds in cash or in kind. Activities past and future The NIPEHS concentrate on supplying tangible prod- ucts in three interrelated areas. First, they improve the understanding of the effects of pollution on health by linking environmental factors with chronic dis- eases in an area or region. The Bilthoven Division worked out a standardized protocol and has guided 12 studies of hot spots in the 6 countries, using cleaner areas for comparison. Second, the programmes strengthen local capac- ity in environmental health management. This includes supplying laboratory and other equipment, but focuses on training. The Bilthoven Division and its partners have conducted 23 courses for over 400 people on environmental epidemiology, quality assurance in environmental health monitoring, good laboratory practice, good agricultural practice, the use of geographical information systems, and mod- ern methods in toxicology. Third, the NIPEHS help to establish databases in which to collect, organize and analyse data from en- vironmental health monitoring. The programmes supply the hardware and software for a health and environment geographical information system; four regional and two national systems have been set up. Regular evaluations have praised the success of the first phase (1992- 1994). The participating coun- tries particularly value the chance to set their own priorities and to bring their health and environment systems into partnership, and the flexibility shown by the Bilthoven Division and other partners in implementing the programmes. The next phase is building on this success. This means developing NIPEHS for some NIS, strengthen- ing the best elements of existing programmes, and promoting networking among the participating coun- tries. A special success from the first phase, the scheme to train environmental physicians, is expected to be extended from Poland to Romania. Living links between the environment and health systems, such physicians will inform the public and advise the gov- ernment about environmental threats to health. Learning material for nurses Nursing development requires education at all lev- els - formal and informal, basic and continuing. The acute shortage of educational material is a major ob- stacle, particularly in the CCEE and NIS. In the long term, countries will produce their own materials. But they need help to develop this expertise, and they ur- gently need materials to use now. The WHO LEMON (LEarning Material On Nursing) Project helps to meet both these needs. The LEMON Project will provide a package of up- to -date educational materials, in each country's official language, to all nurses, midwives and feldshers in the CCEE and NIS: a target readership of over 2 million health workers. Answering twin needs Nurses in the CCEE and NIS want to provide the best possible care, but they have few educational re- sources. A nurse caring for an elderly person with multiple health problems, for example, can rely only on tradition and her instincts, and hope for the best. These nurses lack textbooks, professional journals and guidelines. Existing materials tend to be scarce, outdated or unavailable in local languages, and they usually fail to address current needs. Further, nurses do not find it easy to decide what materials they need. With the best intentions, foreign donors give them large numbers of western books and journals, but these are often inappropriate.LEMON helps nurses in the CCEE and NIS take the lead in choosing the best materials for their needs and cir- cumstances. Building materials and skills The LEMON project features strong interaction be- tween the Regional Office, an international advisory group of nursing experts, and LEMON groups in the 16 actively participating countries. In the first phase of the project, the advisory and country groups chose the subjects and materials for the package from the literature. Now that the English- language package is complete, phase two will begin. The country groups will translate the package into their languages, adapt it as necessary and test it. Phase three will begin about a year later. The country groups will supply the tested package to as many nurses, midwives and feldshers as possible, using local printers and publishers. This work is building capacity for the future, since nurses in the country groups run the project themselves. WHO acts as a supporter and coordina- tor, rather than a director. Further, the network of participating nurses and the project infrastructure in countries provide an excellent base for future activities. Growing from the seeds LEMON is a huge project in constant need of funds and skills. WHO launched the project in 1993. The first phase was financed mainly through donations from the Department of Health in the United Kingdom, and support for the second phase comes mainly from the Department of Health in Ireland. The country groups and WHO raise money for the project through the LEMONAID appeal. The great enthusiasm that greeted the project shows the urgency and clarity of the need for the pack- age. It has inspired partners in the CCEE and NIS, and supporters in other countries, including govern- ment agencies, nursing associations, educational institutes and individual nurses. WHO is confident that the seeds of LEMON are already bearing fruit. Adapting the material: writing a chapter in Slovenia The LEMON package Cards sold in the LEMONAID appeal Health care reform in Kyrgyzstan Training session for the Manas national team Manas and CARNET documents Independence left Kyrgyzstan, like other NIS, with a health care system battered by waves of change, including economic and social problems and wors- ening health. While many organizations helped with isolated problems in the health sector, WHO has helped Kyrgyzstan to develop and coordinate a pro- gramme for the comprehensive reform of its health care system. A hero's task The Kyrgyz health care system is rich in hospital beds, doctors and nurses. But staff are unevenly dis- tributed and badly paid, hospitals and equipment are old and in poor repair, and Kyrgyzstan depends on donor assistance for drugs and medical equipment. Although willing to reform the health system, the Ministry of Health has had to focus on keeping ser- vices running from day to day. External aid offers only temporary relief. Creat- ing and running a sustainable, equitable and effective health care system require careful consideration of a country's resources and priorities and realistic assess- ment of the options for action. In 1994, the Regional Office and the Ministry of Health worked out a frame- work for the reorganization of health services from 1995 to 2005. As this was a hero's task, the partners named the initiative after a Kyrgyz national hero born in 995: the Manas health care reform programme. Manas: work for reform In 1994/1995, the Manas programme had two ob- jectives: to help the Kyrgyz authorities to design a master plan for health care reform, and to enable them to carry it out by strengthening their management capacity. Three groups of partners cooperated on these tasks: a national team, including a coordinator in the Ministry of Health and 46 health officials from the central and regional levels; an international team, comprising the United Nations Development Programme (UNDP), the World Bank, WHO, the Danish International Development Agency, the Overseas Development Administration of the United Kingdom, the Swiss Federal Office of Public Health, the Turkish Inter- national Cooperation Agency and the United States Agency for International Development; and a WHO secretariat (two staff in the Regional Office and a technical adviser in Bishkek). The partners developed the master plan for reform in three stages. First, they analysed current conditions in all relevant areas: the needs of the population; the policies, financing, organization and management of the health sector; the providers, physical infrastruc- ture and delivery of health services; the health information system; and scientific support and research. Then they used the analysis to develop four policy options: preservation of the existing system, optimization of the system, contracting for health services and laissez-faire development. At a confer- ence in February 1995, the partners and Kyrgyz government officials, including the President and Prime Minister, discussed the pros and cons of each option, favouring a combination of the second and third. After the government made its final choice in April, the partners prepared a detailed plan, with strat- egies for the short, medium and long terms, for presentation to the Ministry of Health in September 1995. While working on the master plan, the inter- national team also worked to strengthen management capacity. It gave the national team technical know- ledge on health policy- making, and instruction in project management, English and computer skills. WHO's special role in Manas included providing technical knowledge, advising on policy and assist- ing in coordination. As the programme was also the framework for coordinating all assistance to health sector reform in Kyrgyzstan, WHO had not only to prevent duplication of effort but also to ensure that contributions complemented both Manas and one another. Finally, WHO enabled Kyrgyzstan to exchange information and experience with neighbouring coun- tries. Through the central Asian republics' network (CARNET) on health care financing and management, Kyrgyzstan not only receives support but provides a model in Manas. Turkmenistan has asked WHO to help in designing a similar programme. Reducing drug use Drugs cause terrible harm to users and society. Many national and international organizations are trying to reduce drug use in the European Region. WHO's approach is founded on the principles of health for all, stressing intersectoral cooperation on both pre- vention and control. The Regional Office both preaches and practises action to reduce the use of psychoactive substances: not only drugs but also al- cohol and tobacco. The problem Drug use and responses to it vary between the two halves of the Region, the CCEE and NIS, and commu- nities in a country. Throughout the Region, drug use bears hardest on the disadvantaged groups in society. In western countries, the problem is serious and well established. About 5 -10% of the population was estimated to use illegal drugs in the 1980s. "Designer drugs ", such as MDMA ( "Ecstasy ") are increasingly popular. Attacks on the supply of drugs by the crimi- nal justice system have not solved the problem. Many countries have thus combined such work with activi- ties to reduce demand, carried out by the health and welfare system. They have well established systems for treatment and rehabilitation, through specialized services and primary health care. Intersectoral action on a combined approach, long advocated by WHO, is becoming a reality. Further, countries cooperate through programmes of the EU and the United Nations. Drug use is not yet as serious a problem in the eastern countries, but is rapidly growing in many CCEE and some NIS. Drug injection is gaining popu- larity. The CCEE have infrastructures to deal with drug trafficking. The NIS do not, and opiate and marijuana production are big business in the central Asian republics. HIV transmission through drug injection adds urgency to the problem in the Region. Injecting drug users make up an ever larger fraction of HIV cases: over 40% in 1994. WHO advocates harm reduction programmes, including needle and syringe exchanges and drug substitution. The CCEE and NIS lack such programmes, but have a strong political commitment to prevention. A combined approach WHO promotes intersectoral action to reduce demand, as well as supply, and a combined approach to drugs, alcohol and tobacco as the most effective responses. Demand reduction should address all psychoactive substances. The same factors encour- age the use of drugs, alcohol and tobacco, particularly by young people: peer pressure, lack of self- esteem and the desire to belong. Demand reduction pro- grammes can give people the skills to cope with all three. The Regional Office has assessed substance use in many CCEE and NIS. This is part of WHO coop- eration with the United Nations International Drug Control Programme, which also includes training health and welfare workers to provide drug treatment 100 Other III Heterosexual contact l Injecting drug use Homosexual /bisexual contact (male) 1 Total number of annual new cases 25 000 20 000 15 000 2 U 10 000 5 000 0 services. WHO has a special programme to promote action to reduce demand in the CCEE and NIS. WHO's work with the EU includes serving on the management board of its European Monitoring Cen- tre for Drugs and Drug Abuse. WHO and the Council of Europe (CE) exchange information on drug use in the countries of the Region. Further, WHO advises countries on policy issues, such as reducing the risk of HIV infection, and main- tains a research network. The Regional Office recently issued a review of AIDS among drug users, and has now prepared a summary on substance use through- out the Region. The summary describes the extent of and trends in the problem, the associated harm, and the policies and responses in countries. It should pro- mote cooperation against this scourge to public health. Distribution of AIDS cases in adults and adolescents in the European Region, by mode of transmission, according to the year of diagnosis and adjusted for reporting delays, 1981 -1993 Opiate production: big business in the central Asian republics Health promoting schools Keeping in touch: newsletters from the European and country networks Because schools try to give students the knowledge and skills that will enable them to become independ- ent and responsible adults, they are an ideal setting for health promotion. With CEC and CE, the Regional Office has built a European Network of Health Pro- moting Schools. This project empowers everyone in the school community - staff, students and parents - to gain a deeper understanding of their health and to choose and carry out action to improve it. Cooperation and diversity Beginning as a pilot project in 1991/1992 in four of the CCEE, the Network now includes over 400 schools, with 300 000 students, in 27 countries. A further 1600 schools are linked to the Network through national or regional arrangements. And 10 more countries are expected to join in 1995. The reasons for this success? With partnership as both method and goal, the Network provides a flexible framework in which schools can determine their own needs and work to meet them in their own ways. To join the Network, countries commit themselves to cooperation between their education and health authorities and to promoting health in schools by making them into safe and health- enhancing social and physical environments. Participating schools commit themselves to this concept, and to devising and carrying out projects. Success stories Activities in the Network are as varied as the schools. All grow from the enthusiasm and commitment of staff, students and, often, parents. Many not only bring immediate benefits but enable the school community to acquire new knowledge and skills. The following are only the first success stories reported to the Network. Some activities focus on the school environment. Students in a Croatian school repaired walls dam- aged by bullets. In Slovenia, a project team cleaned up the school toilets, placed benches and rubbish bins in the playground and helped to plan healthier meals, while introducing exercise breaks in class. Other projects focus on relations and democracy in the school community, and address lifestyle issues. The project team in a Bulgarian school started a dia- logue between staff and students, a parents' committee and discussions of health. A Polish school surveyed students' feelings about their teachers and helped the teachers update their methods. In an Irish school, the canteen staff developed healthier menus while the prefects were trained as peer leaders. The parents of students in a Belgian school supplied food from and discussions of a different culture on every day of Multicultural Week. Students at a Danish school wrote and performed a play on drug and alcohol use. Those at a Swedish school studied resuscitation techniques and took part in an antismoking project with the parents' association. Several schools made policies that limited or banned smoking by students and staff; parents also took part in the process. Finally, some projects feature international coop- eration. Schools in the Czech Republic and Denmark worked together to conduct experiments on the local environment. Making the community their classroom, groups of students examined an issue and used their results to make recommendations to the local gov- ernment. This provided eye- opening lessons for the students, teachers and community. Commitment to the future The Regional Office, CEC and CE support the Net- work, through which schools share information, training, experience and examples of good practice. They also support a technical secretariat in the Re- gional Office. It gives day -to -day support to national coordinators in the countries, raises money for the Network and provides technical guidance through advice and documents, research, and training manu- als and workshops. The secretariat also maintains a special focus on the CCEE and NIS, where decen- tralization and health promotion were new ideas. The Network has brought these countries essential funds and expertise, and helped to strengthen their infra- structures and capacities for health promotion. The Region's children are its future. All children must have the chance to realize their potential to be healthy, educated adults. The European Network of Health Promoting Schools is dedicated to reaching this goal. Members of the Network Albania, Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Ger- many, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom Profiles of women's health 82 80 t- 78 76 ô- 74 J 72,--00 rn ci CO rn CO CO rn v CO rn LC)00 rn European Region European Union CCEE ® MS rn n CO rn 0 rn Women's health counts WHO stated its commitment to improving the health of women in target 8 of the European policy for health for all. It acted on this commitment by launching the Investing in Women's Health Initiative in 1993. Pro- files of women's health throughout the Region are both the first fruits of the Initiative and a catalyst for action within and beyond Europe. The Initiative has three parts: producing profiles of women's health in the Region; making a comparative analysis of the profiles that identifies the critical issues in women's health; and starting a European Women's Health Forum to develop an agenda for action in the Region. WHO launched the Initiative by encouraging the first -ever profiles of the health of women in every country of the Region. Because health is an integral part of life, this meant moving beyond the traditional focus on reproductive health to embrace other is- sues. It meant describing not only health status and services but also the influences of daily life and the environment, and women's position in society. Starting in the CCEE and NIS Women in eastern countries can expect to live 5 -10 years less than those in western countries, and they have up to 10 times the western rates of mater- nal death. This led the Regional Office and its partners (the World Bank and the governments of Austria, Finland, the Netherlands, Norway and Sweden) east- wards for the first country profiles. Eleven of the CCEE and NIS, and one city, agreed to take part. Health ministries chose coordinators for each country. The Regional Office developed guide- lines and a questionnaire, and the coordinators and their teams used them to assess women's current sta- tus in health, society and the economy. The resulting profiles pictured the day -to -day realities of women's lives. In 1994, the Regional Office made a comparative analysis of the profiles and, with the World Bank and the Austrian and Norwegian governments as co- sponsors, organized a Conference called "Women's 120 ô 110 g. 100 â 90_-aO 80 0 70 60 ° 50 40 0 30 r cu co v N-00 Oo CO CO CO CO CO rn rn rn rn rn rn rn European Region European Union CCEE NIS CO rn o CO CO rn rn rn rn rn rn Health Counts ". There the coordinators described the priorities revealed by the profiles, and used the analy- sis to design strategies for improvement. The participants summarized these in the Vienna State- ment on Investing in Women's Health in the Countries of Central and Eastern Europe. The Statement forms the basis for an approach to women's health that builds on the WHO commitment to equity, human rights and primary health care. Expanding the Initiative After the Conference, WHO published the compara- tive analysis on the CCEE and NIS, with the Vienna Statement. It also asked the other countries to name focal points for a similar report on the whole Region. With the support of the focal points and its partners, the Regional Office completed a new series of pro- files early in 1995. They identify several critical issues: reproductive health, particularly the prevention of maternal death and promotion of family planning; occupational health, including threats to health in the workplace and those related to unemployment; the environment; and the health of women who are elderly, migrants or members of a minority group, and thus at special risk. The Regional Office sent the profiles to the WHO Global Commission on Women's Health and the United Nations Fourth World Conference on Women, held in Beijing in September 1995. In addition, WHO and the United Nations Population Fund (UNFPA) issued a document to inform donors about priorities in reproductive health and activities already under way. The members of the expanded European Wom- en's Health Forum met for the first time in May 1995. They work together for better health for women, ad- vise the Regional Office on strategies, and urge their governments to give the issue a higher spot on the political agenda. Through the Investing in Women's Health Initiative, WHO and its partners are working to ensure the full participation of women in health for all. Female life expectancy at birth: east -west gap Deaths from cardiovascular diseases in females under 65: east -west gap PK LP Promoting women's and children's health Tajik girls: every girl presents a new chance to invest in the health of women and the next generation 60 50 t 40 -'- 300 20 10 ® Highest in the central Asian republics CI Target level a.. ® Lowest in the Region Infant mortality in the European Region 90 80 PPPr 70 t60'> 50 g 40 ° 30 `,11 20N fl 10 ° 0 Highest in the central Asian republics Target level Lowest in the Region Maternal mortality in the European Region Rates of death for pregnant women and mothers, and of babies under 1 year, highlight the width of the health divide in the European Region (see p. 2). Maternal and infant deaths are highest in the central Asian republics. Various international organizations and the countries themselves have assessed the prob- lem and worked to tackle it. WHO helped crystallize this process by bringing the organizations and coun- tries together to create and launch an integrated approach. A looming crisis In December 1994 WHO, with the International Planned Parenthood Federation, held an international meeting to strengthen maternal and child health and family planning in the central Asian republics (Kyrgyzstan, Tajikistan, Turkmenistan and Uz- bekistan) and in Azerbaijan and Kazakhstan. Some 28 obstetricians and paediatricians from the 6 coun- tries, and representatives of UNDP, UNFPA and UNICEF outlined their approach and a project to put it into action. The country representatives began by describing the situation. The rates of death for infants are 28 -54 per 1000 live births and the maternal deaths number 35 -83 per 100 000 live births. This forms a grim con- trast with the levels called for by regional targets 7 and 8 and the even lower rates already achieved in some western countries of the Region. The main causes of maternal death are haem- orrhage, toxaemia of pregnancy, infection and complications of abortion (which is the main means of family planning). The main causes of death in in- fants are premature birth, low birth weight, acute respiratory infections and diarrhoeal diseases. In a few countries, war is a further threat. The countries recognized that expensive high tech- nology is not the first priority. They need to change some basic practices (to leave babies with their mothers, to stop swaddling and to encourage breast - feeding) and thus the knowledge and skills of service providers. Families, policy- makers and the public must change, too. Vaccination, safe drinking -water and simple means to prevent and treat diarrhoeal diseases are important concerns. Outside the health sector, nutrition and hous- ing must be improved. The countries also need preventive services for young people that fo- cus on nurturing girls, and increasing people's knowledge of human sexuality and their in- formed choice of modern family planning methods. These are the best ways to promote the health of women and children. The Regional Office agreed to help the countries develop a joint, integrated, five -year project based on the principles of the regional policy for health for all, to tackle the loom- ing crisis. An innovative, integrated project According to WHO's proposal, the countries and their international partners will carry out the CARAK (central Asian republics, Azerbaijan and Kazakhstan) project from 1995 to 2000. The project will promote maternal and child health and family planning through a package of innovative, integrated, appropriate services delivered at the district level by providers with up -to -date training. WHO, UNFPA and the government of Uzbekistan have already pledged funds to the project. Additional partners would be welcome. The project will start in the hospitals, health cen- tres and feldsher /midwifery stations of 12 districts (with a total population of 360 000) in the 6 coun- tries. It will be sustainable because it is based on the countries' thinking and will build their capacities. It will be replicable because activities will be monitored and evaluated and the countries' information systems will be improved. The CARAK project will have seven products: 1. revised legislation, policies, procedures and guide- lines to ensure safe, efficient and effective services; 2. a network of service providers and consumers in the pilot districts who will share information and experience; 3. health personnel with up -to -date skills in mater- nal and child health and family planning; 4. new training packages and programmes; 5. a comprehensive information system on health and services; 6. educational messages delivered to the public through the mass media; and 7. additions to the curricula of schools and univer- sities on child development, reproductive health, pregnancy and childbirth, and family health. Nutrition training in the (:SEE and NIS The legacy of the past in the CCEE and NIS includes a lack of information on diet and nutrition. A few studies were made, but their results were rarely pub- lished. Struggling with worsening living conditions, governments urgently need to know their people's nutritional status and needs, so that they can make sound policies on food, agriculture and health. WHO is carrying out a project in the CCEE and NIS that creates much- needed expertise in public health nutrition while helping to supply this scarce infor- mation. Rapid nutrition assessment The project comprises a series of studies on the nu- tritional status of two of the most vulnerable groups in the eastern half of the European Region: women and children. It began with a study involving the Regional Of- fice and staff from three nutrition institutes in the NIS. The participants monitored 10 -year -olds at four sites (Almaty, Kazakhstan; Kiev, Ukraine; and two sites in Moscow, the Russian Federation) in April of 1992, 1993 and 1994. The results refuted the widespread fear of starvation in these areas. The city populations were resilient enough to protect their children, whose growth and diet did not deviate from global standards. The success of the study led the Netherlands Min- istry of Welfare, Health and Consumer Affairs to supply further resources for the project on rapid nu- trition assessment. The project continues to pursue the twin goals of securing information and supplying essential training in nutrition. A series of three over- lapping studies began in 1994 and will continue through 1996. All have the same structure and the same focus - maternal nutrition - but involve differ- ent groups of countries: Kazakhstan, the Russian Federation, Tajikistan, Turkmenistan and Uzbekistan in 1994/1995; Armenia, Belarus, Bulgaria, Georgia, Karal- kalpakstan (Uzbekistan) and Ukraine in 1995; and Albania, the Czech Republic, Estonia, Latvia, Lithuania, Romania, Slovakia and Slovenia in 1995/1996. Content and methods Each group follows the same five -step programme, which takes less than a year to complete: 1. WHO conducts a workshop for participating nu- tritionists on methods of assessing diet, and related topics such as nutrition policy, weighing and meas- uring people, and food composition; 2. facilitators help the participants to complete a common protocol for the multicentre study; 3. teams of participants apply what they have learned by assessing women's nutrition in their countries, using software supplied by WHO; 4. the teams meet the facilitators again to present their data and choose a final form for its presen- tation, with the facilitators commenting on their work and suggesting improvements; and 5. the teams finalize their results. Owing to reports of widespread anaemia, the teams also test haemoglobin levels, using equipment paid for by LISP, an Italian nongovernmental organiza- tion. The lecturers at the workshops are renowned experts from WHO collaborating centres in Europe and the USA. They donate their time and often pay their own expenses. Having completed their study, the partici- pants report their results to their governments, and in national and international journals. Results The most immediate result is the increase in expertise and the rapid growth of a network of nutritionists in the CCEE and NIS. The project participants are the nucleus of the network. The project links country teams and participating institutes in the exchange of ideas and information. For example, some people in the participating countries ascribe falling rates of breastfeeding to poor nutri- tion and anaemia in mothers. The project is not yet complete, but its early results challenge this belief. Once trained, many participants serve as facil- itators in the next project study. In addition, network members supply local expertise to other studies of nutrition and related topics, conducted by a wide va- riety of international and bilateral organizations. The WHO project on rapid nutrition assessment gives nu- tritionists in the CCEE and NIS the skills to work more effectively to improve the health of their people. A nutrition workshop: learning how to use new software 1992 Almaty Kiev Moscow -1 Moscow -2 Results from the first study: average intake of fresh fruit by 10- year -olds Informing health authorities through telematics The WHO guide and the Danish manual for pharmacists Telematics: early warning of disease As a centre for public health information, WHO has promoted computer links, the newest and fastest way to collect and supply information. The ENS CARE Telematics project of the EU helped national health administrations improve their decision -making by using computers to supply up -to- the -minute infor- mation. WHO conceived and coordinated the project, which involved 24 partners in different countries. The project embodied a unique partnership between the Regional Office and the EU, which could extend its benefits throughout the European Region. Early warning systems One of the project's four parts focused on early warn- ing systems, including systems to alert countries to communicable disease emergencies. The network for Legionnaires' disease, for in- stance, included 23 reference centres in 21 European countries. Using software developed by the Communi- cable Disease Surveillance Centre (CDSC) of the Public Health Laboratory Service in the United Kingdom, the centres reported new cases to CDSC, which identified the source of a cluster of cases and alerted the health ministry of the country concerned. Since mid -1993, CDSC has identified 13 such clusters. A similar system was started for salmonellosis. The early warning system for Legion- naires' disease has proved its value and provided a model for the surveillance of other communicable diseases. Pharmacists helping smokers quit Pharmacists throughout the European Region are working together to help their clients quit smoking. European pharmacists want to expand their role in health, adding counselling on lifestyle to their traditional work of dispensing safe and effective medicines. With a pharmacy on every high street, pharmacists are ide- ally placed to advise on health in the course of their daily work. In pursuing this goal, pharmacists have an exciting opportunity to help achieve health for all. WHO and national pharmaceutical associations in 30 coun- tries throughout the Region have therefore joined forces to form the EuroPharm Forum. The Danish model In spring 1992, the Regional Office and the Danish Pharmaceutical Association tested pharmacists' po- tential to help their clients quit smoking in an eight -week pilot project. After training in group dy- namics and tobacco use, 20 community pharmacists ran smoking cessation courses, combining nicotine replacement therapy with support groups. The project was a brilliant success. At the end of the course, 60% of the participants had stopped smok- ing, and 30% were still nonsmokers a year later. Pharmacists and the public demanded more courses. Today, 25% of Danish pharmacies offer them. The European project The EuroPharm Forum has pledged to promote simi- lar action by its all member associations. For their use, WHO and the Forum described the principles and methods of the Danish project in International guide: pharmacies and smoking cessation. The Forum has also created a task force to carry out a smoking cessation project. The task force prepared a document for adoption by the Forum at its fourth annual meeting in June 1995. It tells pharmacists how to intervene at three stages of the smoking process, describes activities in various countries, and will be presented to ministries of health as a policy document. The task force will also advise pharmacists on how to persuade their col- leagues to become involved in smoking cessation. Most importantly, the task force has planned an international course for autumn 1995, to train train- ers in each of the Forum's member countries. Participants must commit themselves to carrying out one of the models outlined in the task force docu- ment on their return home. The EuroPharm Forum will do all it can to ensure that pharmacists take effective action in smoking ces- sation. The task force's work will go a long way to help achieve this aim. Quality of care development Patients and the public are increasingly aware of the issue of the quality of health services. Politicians and health care authorities require both the documenta- tion of quality and its continuous development. The interests of the community require the attainment of the highest quality possible within the existing frame- work of the health services. The WHO concept and programmes for continuous quality of care develop- ment help all parties involved work together to improve the outcome of care. Concept and process Research and monitoring have so far focused mainly on the process of health care, not its results for health. The WHO concept of continuous quality of care de- velopment examines the outcomes of care. To improve the quality of care, health profession- als must accept responsibility for the task. In 1993, the European Forum of National Medical Associa- tions, in collaboration with WHO, made a recommendation that emphasizes doctors' primary re- sponsibility for ensuring the quality of medical care. This was a major breakthrough, and WHO encourages other health care professionals, such as nurses and physiotherapists, to reach a similar consensus. With professionals' commitment secured, the next step is developing indicators to measure the quality of outcome. The Regional Office has been instrumen- tal in achieving Region -wide consensus on clinical outcome indicators for the management of perinatal care, depression, oral health, upper respiratory tract infection, diabetes and hospital infections. Indicators are being developed for stroke, hypertension and myocardial infarction. Here WHO works closely with ministers of health, research institutions, donors, in- dustry and patients' associations, as well as medical associations. WHO cooperated with the CEC to develop out- come -based quality indicators on oral health and perinatal care. For the latter, a set of 21 suggested indicators was tested on 3 million births in 30 coun- tries in 1992/1993. This led to the selection of a final list of 17 indicators in 1994. These are now ready for use in countries. After consensus on indicators follows the crea- tion of both local and Region -wide information systems. Databases allow anonymous comparisons of performance, which enable care providers both to evaluate their own work and to learn about the best current practices. Data collection can lead to the con- struction of a curve showing the variations in performance among health care providers at a cer- tain time: an original outcome curve. Then, the providers with the best outcomes identify themselves. After external verification of the data from these best performers, they share their experience with all the participating health care providers, who use the information to improve their performance. Repeat- ing the process can gradually move the performance of the whole group towards excellent quality. Improving the quality of health care improves the outcomes for patients. WHO promotes the development and acceptance of outcome indicators in more and more areas of care, and the establishment and expansion of databases for anonymous compari- son of performance. This maximizes the contribution of quality of care development to health for all. Health workers' commitment to the task is essential The process: continuously improving the performance of all health workers s â E Original outcome curve Later outcome curve Best Best outcomes outcomes t . -s Excellent quality Policies for health for all The Copenhagen Declaration Some of the many national and regional policies based on health for all Target 33 of the European health policy calls on countries to make and carry out policies in line with the principles of health for all. WHO gives priority to helping countries, regions and communities to make such policies, which har- monize and unify the disparate activities of the various sectors and groups working to improve health. With the collaboration of the CEC and CE, the Regional Office re- cently held a conference on health policy that pointed the way ahead. The conference and the demand for health for all policies at all levels in countries affirm the continuing value of these policies as the best tool for building better health for all Europeans. Enduring value of health for all In December 1994, the European Health Policy Conference: Oppor- tunities for the Future brought together 300 participants, repre- senting 45 of the 50 countries of the European Region. The partici- pants examined current trends in and future challenges to health, and policy responses at all levels. Having broken new ground by introducing par- liamentarians as participants, the Conference continued its pioneering by expanding the opportu- nities for international cooperation on health. With six intergovernmental organizations sharing a plat- form for the first time, the discussion clearly revealed the countries' demand for closer cooperation and the keen desire of WHO, CE, CEC, the International Labour Organisation, the Organisation for Economic Public Health Status and Forecasts Co- operation and Development and UNICEF to respond. The Conference showed that, despite enormous changes in the European Region and health policy issues, the health for all approach remains the best way to ensure the effective and efficient use of re- sources for health gain. The participants strongly endorsed this approach in the Copenhagen Declaration. The Declaration calls on all countries to carry out policies based on the principles of health for all; poli- cies in the CCEE and NIS should guide international investors and donors offering assistance. The health for all approach should underpin closer and more ef- fective cooperation by all partners in an international alliance for health gain. The WHO Regional Com- mittee for Europe - the Region's "health parliament" - will consider a resolution welcoming the Declaration in 1995. Support to policy -making The Conference added impetus to WHO's continu- ing support to countries in policy- making. The enduring value of the health for all approach lies in its flexible application of firm principles. Policy- makers use common ingredients - such as equity, wide participation in decision -making and a focus on health gain, as well as health care - but combine them in different recipes to suit their needs and circumstances. While most western countries are already imple- menting health for all policies, many CCEE and NIS are just taking up the task. WHO is working with Albania, Armenia, Bulgaria, Croatia, Estonia, Hun- gary, Latvia, Lithuania and Kyrgyzstan, and is discussing such cooperation with Poland, the Rus- sian Federation, Ukraine and Uzbekistan. The demand is so great that some have called for the establish- ment of a WHO centre for policy analysis and training. In Latvia, the Ministry of Health asked the Re- gional Office to help prepare a national policy based on health for all early in 1994. The plan was to write a draft, consult a broad range of authorities, sectors and interest groups, and submit the final result to Parliament for adoption. By early 1995, the discus- sions had resulted in a draft document now being updated. Better living - better Latvia describes a de- tailed strategy for health and social care development with a target date of 2010. It spells out goals, targets and objectives for four themes, and action in six direc- tions to achieve them. Through such work, WHO helps policy- makers in countries not only to build capacity for the future but also to seize the present opportunity of moving towards health for all. Conclusion Health in Europe presents a sobering picture in the mid - 1990s. Improvements in health continue in the western half of the European Region, but wor- rying inequities are growing, threatening the inner cities, the elderly, the poor, minority groups and migrants. The health divide between east and west remains the largest inequity. Most of the CCEE and NIS suffer continuing economic de- cline, and public services - including those for health -are reeling from dramatic cuts in funding and the other effects of instability. These have severely reduced the ability of health service systems to provide es- sential care for the population. Vaccination programmes, basic environmental health services and even food supply systems have broken down or been dis- located. Worst of all, armed conflict has continued or spread. The consequences for health are disastrous. They include a resurgence of infectious dis- eases, such as diphtheria. In some areas, the decline in the quality of life and health ser- vices has led to rises in maternal and infant death. And unhealthy lifestyles and deficient preventive services contribute heavily to the deaths from cardiovascular diseases, external causes and cancer that account for most of the east -west health divide. With limited staff and financial resources, the WHO Regional Office for Europe has developed new tactics to face the new situation. This has meant focusing primarily on the countries in greatest need, while retaining many Region -wide activities for health. WHO has built on its strengths: the health for all policy, clear leadership in health policy development, the scientific ability to devise new approaches and methods that countries can use to convert policies into practical programmes, and well established networks for action at the local level. These strengths have given the Regional Office the chance to mobilize large -scale advice and support for the CCEE and NIS, which have demanded help from WHO in almost every area of health develop- ment. The Regional Office has maximized its contribution by cooperating with all the other partners working for health. This means more than harness- ing its special strengths to those of other United Nations organizations, the European Union and the Council of Europe, and many government and nongovernmental organiza- tions. It means developing a new ability to act as a catalyst, pointing the way to the most effective action. The European policy for health for all has gained influ- ence throughout the Region. Thus, a new model for public health action has emerged. Central governments, regions and cities are integrating a broader philosophy into their policies, and emphasizing dis- ease prevention, health promotion and primary health care. The policy and targets for health for all should now influ- ence public health more than ever before. The European Region today has gained breath -taking momentum for change. The opportunities to make a differ- ence are immense. In its cooperation with its partners and the countries of the Region, the WHO Regional Office for Europe offers its impressive ability to create ideas, to build strong new alli- ances and to act as a catalyst in stimulating new action to secure health for all Europeans. World Health Organization Regional Office for Europe Copenhagen WHO Regional Publications European Series No. 57 ISBN 92 890 1321 2 Sw.f r. 12.-