WHO in a new Europe

WHO INA NEW EUROPE ... . ,s69 / V0* 114 Qi/v7z0 EUROPE The Regional Office for Europe of the World Health Organization welcomes requests for permis- sion to reproduce or translate it . publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, WHO Regional Office for Europe, Scherfigs- vej 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 1993 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 prefer- ence 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 Pamela M. Charlton with the assistance of Mary Stewart Burgher Design and graphics: Sven Lund Layout: Wendy Enersen and Marcelle Ledoseray Photography: Knud Thoby Printed in Finland by West Point Printers, Rauma Contents Foreword Health in Europe Strategy for the CCEE Humanitarian aid programme in the former Yugoslavia Women's and children's health Preventing noncommunicable disease Developing quality of care Tobacco and alcohol Threat of AIDS to CCEE Healthy Cities European Centre for Environment and Health European Charter on Environment and Health The aftermath of Chernobyl Health care reform Health information Family health Conclusion: how healthy could Europe be? 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 WHO Library Cataloguing in Publication Data WHO in a new Europe (WHO regional publications. European Series ; No.50) I.Regional health planning 2.Health for all 3.World Health Organization 4.Europe I.Series ISBN 92 890 1314 I (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 230 people from about 40 nations. In addition, over 1000 experts work with the Office every year, along with collaborating centres and research institutes across the Region. Its regular annual budget is about US $23 million. Funds donated by other sources, including the United Nations and individual governments, have grown in recent years to about US $10 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 therefore concentrates both on the problems of industrial and post -industrial societies and on those faced by the emerging democracies of the central and eastern part of the Region. Since 1990, the number of Member States has increased from about 30 to 50. The Regional Office is governed by a Regional Committee comprising representatives of every Member State. Through the Regional Committee, which meets once a year, all the Member States collectively formulate regional policies, supervise the activities of the Office, recommend technical activities and approve the budget. The Regional Office in its turn advises and guides the Member States in their technical activities and promotes the development of networks of experts and other partners. As of June 1993, the Member States of the European Region are as follows:a Albania France Luxembourg Spain Armenia Georgia Malta Sweden Austria Germany Moldova Switzerland Azerbaijan Greece Monaco Tajikistan Belarus Hungary Netherlands The Former Yugoslav Belgium Iceland Norway Republic of Macedonia Bosnia and Herzegovina Ireland Poland Turkey Bulgaria Israel Portugal 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 who dk Teletex: 118785 Electronic mail: BITNET:WHOEURO @VM.UNI -C.DK a For the latest list, please contact the Regional Office. 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 thealth, 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 five technical departments. Four mirror the main groups of targets and work for better health, healthy lifestyles, healthy environments and appropriate care. The fifth ties together the threads of the various technical programmes into country projects, with particular emphasis on the countries of central and eastern Europe (CCEE). The Disease Prevention and Quality of Care Department helps Member States prevent communicable and noncommunicable diseases and accidents, promote immunization and family planning programmes, and improve the quality of health care and technology, including pharmaceuticals. It deals directly with specific population groups such as women, children, the disabled and the elderly. The Lifestyles and Health Department helps Member States promote health by advocating healthy living (through programmes in nutrition, mental health and sexual health), action against harmful substances (such as alcohol, tobacco and psychoactive drugs), settings that are conducive to healthy living (healthy cities, schools, hospitals and workplaces), and better care for lifestyle -related conditions such as AIDS, mental disorders and addictions. The Environment and Health Department helps Member States tackle the long -term prevention of environmental health hazards, including the pollution of air, water and soil, as well as environmental emergencies and accidents. It promotes food safety, occupational health and healthy housing. It has a network of staff and offices in Athens, Bilthoven, Nancy and Rome, as well as Copenhagen. The Health Services Department helps Member States, particularly the CCEE, reform their health care systems. It focuses on three closely related areas: services (in primary health care, hospitals and long -term care), the people who deliver them (nurses, doctors and other health professionals), and the information needed to improve them (including training, research and statistics). The Country Health Development Department manages Regional Office activities in countries, particularly in the CCEE. A sixth department provides the Office with support services such as budget and finance, personnel and administration, as well as documentation and informatics. Foreword Great changes have swept the European Region of the World Health Organization (WHO) in the last two years, resulting in an astounding 50% increase in the number of its Member States. Coinciding as these unprecedented events do with a period of world recession, how is WHO meeting the needs of the countries of central and eastern Europe (CCEE), including the newly independent states (NIS) of the former USSR, as well as the other Member States of the Region? Thé latest WHO evaluation in the Region has revealed that unemployment, recession and pov- erty are on the increase. Inequities in health within and between countries are growing. In particular, the health divide between the CCEE and the rest of the Region is large and widening. The Regional Office has met change with change, developing a whole new approach to bring assistance to the CCEE. Maintaining immunization levels and a steady supply of vaccines is one of the Regional Office's most pressing tasks. Unfortunately, civil unrest and even war have followed the birth of some countries. In response, the Regional Office set up a large -scale programme of assistance to these war -torn countries in July 1992, an impor- tant part of the joint United Nations appeals and the consolidated interagency programme that fol- lowed. This difficult period puts the solidarity of the countries of the Region to the test. In 1991, they created the EUROHEALTH programme to refocus much of the work of the Office towards the needs of the CCEE. At the Regional Committee for Europe in 1992, they reaffirmed their commit- ment to achieving greater equity in health among peoples and countries in the Region. What is more, many western countries have not only given up to this programme all or part of the regular WHO budget allocated to them, but also made voluntary donations to various specific projects. Their support to much of the urgent work in the Region can be seen throughout this report. The recognition that change in one part of the Region must affect the other parts has resulted in greater rapprochement among intergovernmental organizations.;. WHO is developing closer rela- tions with the Council of Europe and the European Community, not only at the technical but also at the political level. It has also joined forces with other members of the United Nations family in health assessment missions to the NIS. The European policy for health for all requires all sectors to consider the effects of their policy on health. The sectors of health, fmance and environ- ment are beginning to do this. At a meeting on AIDS, ministers of health and of finance launched a joint initiative to help prevent AIDS from taking hold in the CCEE. Collaboration between the health and the environment sectors was crystallized in the creation of the WHO European Centre for Environment and Health in 1990; both sectors are working to produce a plan of action for the CCEE, in preparation for the Second European Confer- ence on Environment and Health to be held in 1994. While the Regional Office adjusts to meet the needs of the new Europe and extends its cooper- ation with other agencies, it continues to sharpen and further develop its most successful tools. The European policy for health for all is ideally suited to the needs of the future, and its 38 tar- gets have been updated to reflect con- ditions towards the end of the century. A new Regions for Health Network now helps subnational structures across Europe to exchange experience in the development of health for all policy. The tried and tested vehicles convey- ing the health for all message are show- ing their soundness. The Healthy Cities project is entering its second phase, and the countrywide integrated noncom - municable disease intervention ( Cuvai) programme can usefully be applied to other problems and is spreading through- out the Region. Despite their differences, the coun- tries of the Region are taking joint ac- tion on their shared problems, using WHO as their tool. They are working together to follow up the effects of the Chernobyl accident. They are strengthening the role of such primary health care workers as general practitioners and nurses in work for family health. They have adopted WHO's Regionwide action plans on tobacco, alcohol and diabetes. Dissatisfied with their health care sys- tems, they have founded a forum to discuss the issues of reform. Lack of resources need not be a bar to improving the quality of services. Indica- tors are being developed to monitor and improve the quality of care in the fields of diabetes, oral health, surgery and stroke in the elderly. Informa- tion is the key to all this work. Countries are striving to understand their problems and search- ing for international examples to learn from. In this task, they are turning to the Regional Office as a European health information centre. The demands of the new Europe are many and various. But if we all work together, we can grasp this unique opportunity to pursue our fundamental aspirations of greater equity in health. 1 Jo E. Asvall WHO Regional Director for Europe 2Rate per 100 000 population 600 500 400 300 200 O C)c00)N u')a0 On) O) On) ON. ) CI, OCO ) OCO ) Q ) NIS CCEE European Region European Community Nordic countries The health divide: difference in mortality between east and west among people under 65. The sudden drop in NIS figures between 1984 and 1986 is largely due to the campaign against alcohol. This report summarizes the most recent evaluation of health in the Region (above). A series of documents review the issues of equity in health (right). Health in Europe The most recent picture of health in the European Region shows encouraging progress towards health for all. But this hides wide differences both within and between countries, most notably between east and west. How do we know this? Because the Region as a whole has a common policy for health for all, 38 targets to aim for, and health for all indicators used by every country to measure progress in periodic monitoring and evaluation exercises. Development of policy Since the Member States adopted a common European policy for health for all in 1984, many have drawn up a national policy for health for all based on the regional model. England, France and Turkey have produced the most recent examples. Comprehensive policies to improve health have also been developed at other administrative levels in countries, such as cities, cantons, Länder or communities, and other subnational structures, such as local health auth- orities. Reacting to these developments, WHO and 11 regions created a Regions for Health Net- work in 1992 to help regions share their experi- ences in the development of health policies based on the principles of health for all. When the Member States adopted the targets nearly ten years ago, they also agreed both to monitor their progress towards them and to share the results with one another in regular evaluations. Since then, the monitoring and evaluation have taught us many lessons about the implementation of the health for all strategy. For example, they supplied the information that enabled the Regional Committee for Europe to update the targets in 1991. Further, they put the Office in a unique pos- ition to draw a detailed picture of health through- out the Region. The Regional Office coordinated the most recent evaluation in 1991, using the statistical data supplied by countries. This mech- anism of collecting, consolidating and disseminat- ing health information gave both quantitative esti- mates and qualitative insights into health status and likely future trends. Progress and problems On balance, health in the Region has improved. Countries have increased life expectancy towards the target of 75 years, and advanced towards the elimination of some infec- tious diseases that immunization can prevent. They d strategics p,,l(l,lll lilt ltl:nlnl 1N)noeonhn have reduced deaths from two of the leading causes of death - cardiovascular diseases and accidents - and reduced infant and maternal mortality. A closer inspection of the health picture, however, reveals that, for example, mortality from cancer - another leading cause of death in the Region - is still rising. The worst problem, however, is inequity in health. Despite some gains in northern and west- ern countries, inequities are increasing. Inequali- ties in health persist in every country in the Re- gion, and vulnerable groups include the old, the young, migrants and the unemployed. Current economic conditions are increasing the health prob- lems that result from social deprivation. Never- theless, the greatest inequalities are those between countries. A health divide has opened in the Re- gion, and is growing wider. The countries of central and eastern Europe (CCEE), including the newly independent states (NIS) of the former USSR, have about half of the Region's population and significantly worse health than their fellow Member States. A few facts underline the disparities between "the two Europes ": life expectancy is on average 6.4 years lower than in Nordic and European Community coun- tries; infant mortality is double that of the rest of Europe, and rates in some of the easternmost countries are ten times higher than the best in the Region; the incidence of diseases preventable by im- munization is high; greater consumption of alcohol and tobacco and poor nutrition and living conditions have led to a high incidence of chronic disease; health care systems are poor in organization, financing, equipment and supplies, and moti- vated staff. Some of these countries are worse off than others, and poor health is just one of the problems that the CCEE and the NIS face in trying to transform every sector of their societies. War or civil unrest in some countries aggravates the situation. Acute shortages of vaccines, essential drugs and finan- cial resources are further damaging health, at least in some vulnerable groups and particularly in some of the NIS. New role for the Regional Office The new con- ditions in and the unprecedented problems of these countries call for new responses from the Re- gional Office. With a staff of under 250 and a regular annual budget of US $23 million, its strength is in its extensive relationships with peo- ple and organizations in the health field. It has therefore developed new tools and working rela- tionships, with both new and familiar partners, to help channel funds into health work and narrow the health divide. Strategy for the CCEE The importance of equity and the need to reduce the health divide between eastern and western Europe have led the Regional Office to give first priority to improving health in the CCEE through the EUROHEALTH programme. The governments of these countries risk losing sight of health in trying to meet a host of crying needs. International agen- cies may forget that health is vital to development. The Regional Office's aim is to be the advocate for health. Change in the Region has begotten change in the Regional Office. It is establishing links with new countries and coping with fundamental and rapidly changing needs in others. To tackle these tasks, the Regional Office has adapted its methods and created new structures, most notably a Coun- try Health Development Department to manage, coordinate and evaluate its activities in countries, helped by a new network of liaison offices in the CCEE. Principles The Regional Office bases its assist- ance on solid information. This means not only collecting and disseminating data, but a great em- phasis on analysis and evaluation. Assistance must be based on a knowledge of conditions in the area concerned, the groups and organizations involved, and the action already taken. This indicates the action most likely to be effective in the circum- stances. Such knowledge is offered to users within and outside the Regional Office. International aid to the CCEE must be well coordinated to make the best use of the resources available. The Regional Office has a unique pos- ition in the Region: political neutrality, long- standing links with and knowledge of these countries, and considerable experience with health activities and the building of consensus. Its aim is to become the preferential health agency in the international com- munity. This means pursuing closer cooperation with funding institutions, nongovernmental and intergovernmental organizations, other United Nations agencies and WHO headquarters. Assistance from the Regional Office aims to reinforce countries' capacities, and thus reduce their need for international aid. In other words, its activities will lead to institution building and to sustainable social and economic development in the CCEE. Developing human resources is essen- tial to this process. WHO can help through its networks of experts, collaborating centres and fellowships programme. The Regional Office works with countries on their immediate health problems, while supporting them in the longer process of developing policies and programmes for health, using the framework of the regional policy for health for all. An important way to do this is to help their officials and experts to take part in international networks and activities. This permits a two -way exchange, in which people from the CCEE both learn from and teach their counterparts in other countries. Tools Both familiar and new tools are used: not only the Health for All Database, other Regional Office databases, and networks of collaborating centres and national counterparts, but also liaison offices, country missions and the MS clearing- house. The Regional Office negotiates two -year col- laborative agreements with each of the countries in the CCEE. Since the NIS are new countries and the situation is pressing, missions have been organized to the NIS: to negotiate an agreement; to begin to influence the country's health strat- egy; to identify technical counterparts and liaison officers; and to promote contact with other key people, in- stitutions and organizations in the country. At the behest of the international community, the Office has set up a clearing -house to collect and disseminate information on health assistance to the NIS. Its main task is to record donor activity in the area and ensure timely and coordinated help where most needed. Initially, it is concentrating on supplies of vaccines, pharmaceuticals and small medical supplies. By mid -1993, the Regional Office had liaison offices in Albania, Bosnia and Herzegovina, Bul- garia, Croatia, the Czech Republic, Georgia, Hun- gary, Kazakhstan, Latvia, Poland, Romania, the Russian Federation, Slovakia and Slovenia; more are being established. They allow permanent con- tact and information exchange between the Re- gional Office and countries, and better coordi- nation with the other organizations présent in the countries. The main tasks of locally recruited liaison officers are to collect information on health status and needs, and help the country to make the best use of Regional Office resources. 3 WHO reports on its missions to the NIS Some young boys in Kyrgyzstan, a new Member State in WHO's European Region Refugees wait anxiously for evacuation A UN convoy brings food and medical supplies to besieged Bosnians Humanitarian aid programme in the former Yugoslavia Nowhere is a new response from the Regional Office more needed than in the new independent republics that have emerged from the former Yu- goslavia. In these countries, hundreds of thou- sands have been killed, wounded or disabled and millions have fled their homes. Hospitals are tar- gets for artillery, food and water supplies are used as a weapon, humanitarian aid workers are at- tacked, women are raped and children are tar- geted victims. Such conditions have elicited an unprecedented response from the entire United Nations family. Public health adviser The Regional Office's role in Bosnia and Herzegovina is to act as the public health adviser to the United Nations, and to work in partnership with many other agencies to meet the health needs of over 4 million people. This means on -the -spot assessment of medical and nu- tritional needs, and carrying out public health measures in the field. The food and medical sup- plies in the white UN lorries that have reached the besieged areas of Bosnia and Herzegovina are selected on the basis of WHO advice, as were the supplies dropped by helicopter over eastern Bosnia and Herzegovina in March. Since aid workers risk their lives to ensure delivery, supplies must be strictly related to need. Therefore, WHO experts carry out health and nutritional surveys in the field throughout Bosnia and Herzegovina in very dangerous situations. WHO has also secured donations of large amounts of medical supplies, in the form of standard kits (such as for anaesthetics, special hygiene kits, basic medical kits, kits for chronic diseases and mental health kits) and arranged for their delivery. A small number of experienced and resource- ful WHO field staff has spearheaded this wide range of humanitarian operations. But success is largely attributable to the will of the population, which has enabled them to withstand winter cold, famine and war injuries. The health sector has continued to function despite being under fire and without medical supplies, while families without enough food for themselves have opened their doors to refugees. The average weight loss in adults over the winter has been 12 kg, women losing most since they have been giving their food to their children. The spring and summer bring worsening con- ditions. Water supplies become contaminated through cracked pipes and diseases spread through a population weakened by poor hygiene, malnu- trition, and stress. Perhaps, the women suffer the most as they undergo the stress of not knowing the fate of their fathers, husbands and sons, and many have been subjected to rape and violence. Joint appeal Needs must continue to be met. The United Nations humanitarian aid programme is funded from voluntary donations. The first joint appeal was launched in September 1992 to raise US $250 million. Of the US $40 million compo- nent intended specifically for WHO, just over US $15 million was actually raised and has been spent in the period up to the end of March 1993. Major contributors were the European Commu- nity, Canada, Denmark, Germany, the Nether- lands, Sweden, the United Kingdom and the United States. A second appeal for US $42 million was made to cover operations until the end of 1993. It had been hoped that this work would have been moving on to reconstruction. But as long as the conflict drags on, only humanitarian assistance can be provided. To run its humanitarian assistance programme, WHO now has some 50 people in the field. The hub is the area office in Zagreb, Croatia, with field offices in Belgrade (in Serbia), Split (in Croatia), Sarajevo, Tusla and Zenica (in Bosnia and Herzegovina) and Skopje (in The Former Yugo- slav Republic of Macedonia). Like all the United Nations personnel involved in The programme, they have displayed more than professional ex- pertise. They show political sensitivity, initiative and great personal courage. New trouble spots The future looks bleak as other trouble spots rumble. Social, economic and politi- cal changes, often exacerbated by internal con- flicts, are weakening the fabric of many of the NIS. Under the United Nations humanitarian aid programme, interagency teams have completed missions to assess needs in Armenia, Azerbaijan, Georgia, Tajikistan and Uzbekistan. In mid -1993, a WHO staff member was coordinating health assist- ance in Tajikistan, but appeals have been launched to meet the needs of the other countries, too. Women's and children's health Childhood is a most vulnerable period of life and birth can be the most dangerous episode of all. But immunization against the major childhood dis- eases and improvements in birth practices greatly increase the chances for the survival of babies and children and their mothers. Immunization and vaccines Immunization is one of the most cost -effective weapons in public health. The WHO Expanded Programme on Immuniz- ation (EPI) uses it to eliminate the main childhood diseases - polio, diphtheria, neonatal tetanus, measles, mumps and congenital rubella. The Eu- ropean Advisory Group, set up to guide the imple- mentation of the EPI in the Region, has drawn up operational targets for the 1990s. They cover: immunization coverage, surveillance of target dis- eases, and outbreak investigation and response. Immunization coverage is generally high and stable in the Region and diseases are on the decline. Coverage is now reported from the dis- trict level and upwards in most countries, how- ever, revealing that districts often fall below the target level of 90 %. The level of immunization coverage as a national average must be a mini- mum of 95% to ensure good protection in a country. As to levels of illness, measles has de- clined by a dramatic 75% since the introduction of the umbrella vaccination against measles, mumps and rubella. Polio continues to decline steadily and neonatal tetanus is very low, though persistent in 3 -4 countries. Nevertheless, pockets of non -immunization in the Region can lead to dangerous outbreaks of disease. The polio outbreak in the Netherlands in 1992 cost millions of dollars to contain. Outbreaks also result from declines in the overall rates of immunization coverage in some CCEE. Diphthe- ria has reappeared. By 1992, nearly 6000 cases had occurred in the Russian Federation and Ukraine, a level not seen in the Region for 20 years. Vaccines are now in short supply, par- ticularly in some parts of the NIS, and infant and child mortality are rising. Two things are urgently needed: a guaranteed supply of vaccines in the short term, and improve- ments in the quality of locally produced vaccines in the long term. The Regional Office has launched a programme to address both these needs. Both donations and expert advice are being provided, much of it through this programme. As to vaccine supply, UNICEF, Canada, Japan, USAID and the European Community Humani- tarian Office are planning ways to meet the needs of the NIS for the next few years. Denmark, Finland, Iceland, Norway and Sweden have committed funds for adequate supplies for 1993 to Estonia, Latvia and Lithuania. The Regional Office is assisting work to im- prove vaccine production in the CCEE. The Netherlands may support its project in Albania. Experts recruited by the Regional Office (from Canada, Denmark, Germany and the Netherlands) are advising on modernizing production in Roma- nia. The other partners in this work are the Institut Pasteur (Paris), the World Bank and the European Community PHARE project. Similar advice is planned for other CCEE, including the Russian Federation and Ukraine. The Regional Office is seeking further re- sources so that it can organize regional training programmes for vaccine production scientists and those responsible for vaccine registration and qual- ity control. Women and children Maternal mortality need not be high in any country of the Region. In most, it is well below the target level of 15 per 100 000 live births. In some CCEE, however, it is not only higher but rising. The Russian Federation is a case in point. St Petersburg, for example, has a maternal mortality rate of 60 per 100 000, some 10 times higher than rates in the west. Twice as many newborn babies have low birth weight as in western countries, and intrauterine and neonatal infections are rising. St Petersburg St Petersburg has reviewed its health needs as part of WHO's Healthy Cities project. One priority is better health services to improve the health of its women and children. The Regional Office has worked with the people of the city in drawing up recommendations on the devel- opment of their maternal, neonatal (including breastfeeding) and family planning services. An action plan based on these recommendations was launched in early 1993, with indicators of out- come and level of services to monitor its progress. The review was supported by a donation from Sweden, matched three times over by contribu- tions from other members of the Healthy Cities project (Hamburg, Milan, Rotterdam, Stockholm, Turku) and Indianapolis. The work in St Petersburg will make an equally valuable contribution to the exchange of experiences with other cities in the Healthy Cities project. Cases 1 000 000 800 000 600 000 400 000 200 000 NM I 111111 11111111 1111111 g F., A g 5 The outbreak of diphtheria in the Russian Federation and Ukraine Vaccine supplies must be safeguarded if immunization cam- paigns such as this one in Kyrgyzstan are to succeed The dramatic fall in measles in the Region This report outlines the policy framework for CINDI countries to use in the prevention of noncommunicable disease Preventing noncommunicable disease Noncommunicable diseases - cardiovascular disease, cancer, respiratory diseases and cirrho- sis - cause three quarters of all deaths in the Re- gion. They have certain risk factors in common, such as smoking, poor nutrition, alcohol abuse, physical inactivity and psychosocial stress. Clearly these risk factors are rooted both in individual lifestyles and in environmental and social condi- tions. An integrated approach appears to be the most efficient way of tackling them all. The countrywide integrated noncommunicable disease interven- tion (CINDI) programme was launched just over 10 years ago to link partners from both the health and non -health sectors, action both within and between sectors, and work to prevent disease and to promote health. A wide range of European countries" partici- pate in the CINDI programme (and several others are joining). This entails setting up both demon- stration programmes and national activities. The demonstration programmes are vital. They are small enough, for instance, to show how people in a community have understood and reacted to in- formation they have been given, how their behav- iour has changed and why. They show decision - and policy -makers how prevention is possible. Such projects may involve a community (such as in Lithuania, where five small rural areas are involved), a region (such as Setubal in Portugal or Chelyabinsk in Russia) or an entire country (such as Malta). The CINDI programme has been adopted equally enthusiastically in both the east and the west of the Region. The upheavals in the CCEE have recently revealed a lack of consensus about what precisely should be done to prevent noncommunicable dis- eases. What issues should be addressed and what strategies should be used to deal with them? A recent review of the CINDI programme has answered some of these questions. Seven of the CINDI countries looked at the progress they have made in the last 10 years. They identified the key programme issues that face the CINDI member countries in the next five years and the collabor- ative strategies to address these issues. They also set out a clear -cut policy framework. The countries participating in the CINDI pro- gramme have been so enthusiastic that the Re- gional Office has only had to provide seed money. a Austria, Bulgaria, Canada, the Czech Republic, Fin- land, Germany, Hungary, Israel, Lithuania, Malta, Poland, Portugal, the Russian Federation and the United Kingdom (Northern Ireland). It is very much their programme, and they have given both money and time to make it succeed. Collaborating centres in Heidelberg and Moscow have also supported the programme with special- ist help. CINDI recently received an additional boost from substantial donations from Canada and Austria. Canada will support the CINDI programmes in the Czech Republic, Hungary, Lithuania, Po- land, the Russian Federation and Slovakia, while Austria will concentrate on a project in the Rus- sian Federation. Canada is the only country out- side the Region involved in the programme, but one of its most active proponents. The Canadian Heart Health Initiative is the result of extensive cross -pollination of ideas between Canada and the Regional Office about the concept and application of health promotion and disease prevention. The CINDI programme is one of the cogs in the partner- ship model that the Initiative has developed. The Canadian cooRDINAnNGHeart Health Initiative- coMMrn ES A Partnership Model °ONWMUNITIES HEART & STROKE FOUNDATIONSPRIVATE SECTOR COPI PROVINCIAL HEART HEALTH PROGRAMS PROVINCIAL .) HEALTHIIW CANADIAN HEART HEALTH NEIIVORKINfERNAT1oNAL CINDI SCIENTIFIC COMMUNITY HEART HEALTH INTERNATIONAL CONFERENCE NETWORKS PROFESSIONAL ASSOCIATIONS GOVERNMENT DEPARTMENTS CANCER FOUNDATIONS CINDI as a tool The CINDI approach to tackling the risk factors for noncommunicable diseases has resulted in its becoming a tool that could well be applied to different but analogous situations. For instance, Croatia recently asked the Regional Office to assess whether the method can be ap- plied to the health and social problems facing displaced persons, of which Croatia has some half million at present. The Russian Federation and Belarus are considering using the method to deal with the problems of radiation resulting from the accident at Chernobyl, as well as a nuclear acci- dent over 30 years ago in the Urals. CINDI is an excellent vehicle for delivering the health for all message in both the European Re- gion and Canada. It has sensitized health pro- fessionals to the principles of health for all and mobilized them to participate in debates and in networking. It has also shown the feasibility of building and maintaining an evaluation system as an intrinsic part of the programme. As more coun- tries express an interest in joining the programme, the time has probably come to turn CINDI into a European coordinated policy, geared to diminish- ing the burden of noncommunicable disease in every country in the Region. Developing quality of care People are taking greater responsibility for their health, so they expect to have greater choice in health care. They want more say in choosing their options for treatment. They demand more accountability from the health professionals who treat them. And this sharpens everyone's focus on the outcomes of treat- ment and the most appropriate use of resources. Pilot studies have shown that the differences in outcomes cannot be blamed on lack of resources, poor professional skill or low professional ethics. The cause is a lack of awareness that these differ- ences are occurring. Health professionals are not motivated to evaluate their work or improve it. They need mechanisms to help them monitor the services they provide and to ensure their quality. The Regional Office has been developing out- come indicators to measure the quality of care. In the past, most quality assurance activities defined and introduced standards to control the way care was given. But WHO' s new indicators measure the outcome of the care, rather than the process. They are yardsticks against which professionals and institutions can continuously measure their performance. In this way, centres of excellence can easily be identified and their experience quickly disseminated to teach others. This becomes a dy- namic process that continuously strives to identify the best solutions and make the most constructive use of them. Dramatic improvements WHO has used this proc- ess in several areas such as the management of diabetes, the prevention of surgical wound infec- tions and oral health care to reduce caries. The results of these demonstration projects have been very promising. For example, the number of sick days and stays in hospital for diabetic patients in Moscow fell by 80% after they had taken part in a pro- gramme developed by a WHO collaborating cen- tre in Düsseldorf. It mainly taught them to monitor their blood glucose levels regularly to improve their metabolic control. A DiabCare centre set up in Munich will eventually monitor the quality of diabetic care across Europe and help diabetes centres compare their performances. Infections from surgical wounds have been cut by 25 - 50% in some hospitals in Denmark and Italy, saving bed days and enormous costs. Five years ago, only a few surgical departments in Den- mark performed this kind of self -evaluation and comparison of results. Surgeons resisted such ac- tivities. Over the last few years, however, their view and understanding of the importance of evalu- ation has changed. Today, nearly 80% of all surgi- cal departments in Denmark actively monitor the quality of their care. A similar movement has begun in Belgium and the Netherlands. In oral health, the number of decayed, miss- ing and filled teeth (DMFT) has been used as an outcome indicator, to measure the results of d 7- Number ô of DMFT ô o ä Outcome curve 1987 ® Outcome curve 1991 d g m < n v é n preventive oral health care services, especially in children. This field has had a long- standing tradition of reporting and comparing results be- tween different intervention programmes. Over the last ten years, this has resulted in quite dra- matic changes for the better. The idea of measuring the quality of care with outcome indicators is being explored in various new areas such as mental illness, acute respiratory diseases, maternal and child care, cardiovascular disease including stroke, and the whole area of the care of the elderly. For instance, stroke is a major health problem in the Region, mostly affecting people over the age of 60. Though rates of stroke are dropping in some areas, the number of elderly people is grow- ing so fast that the numbers of stroke victims are actually increasing. In the CCEE, rates of stroke are 2.5 times higher than in the west, while tradi- tions of care and rehabilitation vary throughout the Region. This area would therefore benefit from the development of better quality in care. In practice, setting up a quality of care process has several phases. First, the outcome indicators for stroke are chosen, on the basis of a consensus on which indicators are relevant, valid and obtain- able as measurements of good practice in stroke care. Then, health professionals can collect and analyse their own data consistently, with a spe- cially developed, user -friendly information sys- tem. In this way, they can begin to evaluate their own performances in comparison with their peers and improve the quality of the care they give. Finally, international comparative databases can be set up that highlight the best performing cen- tres. Information about the practices that are shown to be the most successful can be widely dissemi- nated and their application promoted. Through this process of learning by feedback, health pro- fessionals can take more responsibility for the quality of care. Everyone has the right to the best obtainable level of health. This means not only reducing inequities but also continuously improving the quality of care. By enabling health professionals systematically to monitor the quality of care they deliver and by making assessment a permanent part of their activities, shortcomings can be iden- tified, good practices rewarded and quality of care improved. 7 How better care improved the dental health of Danish children between 1987 and 1991 Improving outcome of patient care 6110 1 Success and problem identification Quality assessment Action for improvement A World No- Tobacco Day poster in Kaunas, Lithuania, offering the choice between tobacco or health The emblem of the newly launched European alcohol action plan Tobacco and alcohol The health hazards of using tobacco are indisput- able, and public opinion is turning against its production and use. In 1987, WHO launched a Region -wide action plan to promote these changes throughout society. The first action plan for a tobacco -free Europe ran to 1991. The second will run until 1996. Tobacco -free Europe The first action plan showed that comprehensive policies implemented through multisectoral action will prevent tobacco use and reduce disease and death. But the target of 80% of the population being nonsmokers will not be achieved without stronger Region -wide action. The new action plan has three aims - to help smokers quit, to prevent young people from taking up the habit, and to protect people from involuntary exposure to tobacco smoke. In essence, measures to combat the use of tobacco are of three types: those that make money (taxation), those that cost money (health edu- cation) and those that are free (advertising bans and laws for smoke -free public and work places). The new plan advocates all three, and recom- mends that tobacco taxation be used to finance the most expensive form of dissuasion: health edu- cation. This has been successful in the Australian State of Victoria, in California and in Finland. It will be increasingly attractive as health care bud- gets shrink. It also makes sense. Action on to- bacco works better if a combination of measures is used synergistically. The first action plan showed the need for wide social and political support to achieve a tobacco - free Europe. This requires both stronger commit- ment and greater capacity, secured through alli- ances among all possible partners and more staff and funds. The new action plan will involve na- tional policy -makers in the field of tobacco or health, and programme implementers and people outside government. The WHO projects for healthy cities, healthy workplaces, health promoting schools and health promoting hospitals also work for a tobacco -free society. With the European Community as a key actor and ally in the first action plan, the Regional Office is building a strong alliance with the World Bank, UNICEF, the United Nations Development Programme, the Council of Europe, the Nordic Council and others. Already some international agencies and national governments have decided to stop giving development aid and subsidies that encourage tobacco growing, production and trade. The sporting community and the media are also vital allies. The Olympics in Barcelona and Albertville were smoke -free, conveying a posi- tive message to the audience. While smoking rates in western countries have peaked, they are still high (in men) and rising (in women) in the CCEE and in southern countries. The international tobacco industry is taking ad- vantage of the vulnerability of the CCEE to put pressure on their governments to allow the indus- try to expand. To help them resist these aggressive promotional and economic pressures, the Regional Office has set up a special task force of experts from various European countries and organiz- ations. They are conducting country missions and organizing consensus conferences, to assist these countries to develop a strategy for tobacco -free societies. European alcohol action plan Learning from the tobacco action plan, the Regional Office launched the European alcohol action plan in 1992. Of course, people regard alcohol and tobacco very differently. While tobacco is dangerous at any level of consumption, some say that alcohol is mildly beneficial in low doses. Yet this distinction must not hide the very real harm that alcohol consumption causes. The European Region has the world's highest level of production of and trade in alcohol. In the CCEE, alcohol consump- tion and its ill effects have risen sharply. Like the tobacco industry, the alcohol industry has aggres- sively moved into these new markets. The action plan has two aims: an overall re- duction of 25% in alcohol consumption and a specific reduction in harmful alcohol use. The first aim is based on the general agreement that the higher the consumption level in a population, the higher the number of problems caused. There is less agreement about the level below which no harm is done. Cultural attitudes towards alcohol differ widely, so the action plan recognizes the need for diverse approaches. Nevertheless, price and tax increases, and controls on availability and advertising, are universally effective. The second aim is more widely accepted across the Region: the reduction of alcohol consumption in specific groups (such as young people) and situations (such as driving). Consumption by young people can lead them to have accidents, commit crimes, have unsafe sex and miss out on edu- cation. Car accidents are closely associated with excessive drinking. The first phase of the action plan will run until 1995, concentrating on developing the support necessary to implement it. Threat of AIDS to CCEE While the AIDS epidemic continues in the Region (reaching over 90 000 cases by mid - 1993), the number of new cases no longer doubles annually in the west. In the CCEE, on the other hand, it is comparatively rare, and could still be kept that way. Yet barriers are falling across the Region, and the CCEE are beginning a process of rapid social change. People's growing mobility and other factors linked to change increase the potential for a rapid growth in HIV transmission. This remark- able opportunity for prevention must not be lost. The painful lessons of other countries teach that safer sex must be promoted to help reduce high -risk behaviour, and harm- reduction strategies must be introduced among people who inject drugs. Health workers must have adequate equipment and training to avoid transmitting HIV infection. The Riga Initiative The Riga Initiative calls for comprehensive AIDS programmes to prevent HIV and AIDS in the CCEE. The Initiative was launched at a meeting held in Riga, Latvia, in early 1993. It assesses the action needed to prevent HIV infec- tion, reduce its personal and social impact, and mobilize and unify national and international ef- forts against HIV /AIDS. It also estimates the funds needed for the first three years, until sustainable programmes have been established. These funds will launch well targeted and timely action and develop technical cooperation and institution build- ing in countries. They will increase coordination between countries and international donor agen- cies. The participants agreed: "We need to act now on the lessons learned worldwide, before the epidemic becomes established." Reform in the CCEE demands a truly multisectoral approach. The Riga meeting, aptly entitled "Investment in health ", was an important landmark not just for AIDS but for health policy development in general. It was attended by minis- ters of health and of finance from all over the Region, and was organized with the World Bank. The central theme of AIDS in the CCEE was the entry point to examine the range of policy chal- lenges facing these countries as they remodel their health and social systems. Concrete examples were given of how various policies and programmes could work. Finally, the participants' Riga Statement set out the principles of action for working together to meet the challenge of HIV and AIDS in the CCEE: Coordination of investment in health Social and political commitment Health promotion Respect for human dignity Safe health care settings Monitoring the epidemic Health promotion Much recent WHO work in the CCEE has concentrated on preventing HIV and AIDS in vulnerable groups (such as women, men who have sex with men, people who inject drugs, sex workers and their clients, and migrants) as well as young people, prisoners, tourists, busi- ness travellers, seafarers, people with sexually transmitted diseases or living with HIV, and the general public. This means almost everyone, but the approach required for each target group dif- fers with their risk of infection and their attitudes towards that risk. Nongovernmental organizations Self -help organ- izations - of people living with HIV or at particu- lar risk of HIV infection - have burgeoned all over the Region, vigorously meeting the challenge of AIDS. The active involvement of such community and nongovernmental organizations is the key to success in prevention, care and the advocacy of human rights. The Regional Office works closely with these organizations, promoting their full par- ticipation at all levels in national AIDS programmes and actively supporting their pan- European net- working activities. Some of these networks con- centrate on specific problems, such as access to treatment and trials, home care, information and resource mobilization. Others represent and ad- dress the needs of vulnerable groups and commu- nities, as reflected in the theme of World AIDS Day 1992, "AIDS - a community commitment ". Obviously, nongovernmental organizations, particularly those representing stigmatized and marginalized communities, are new to the CCEE. The Regional Office has successfully supported the creation and mobilization of organizations active against AIDS. This support includes promot- ing twinning programmes to forge links with west- ern organizations, arranging training workshops, mobilizing resources, and advocating human rights and legal emancipation. A dangerous and widespread belief is the idea that violation of the human rights of the few can save the many. While many countries, particu- larly in the CCEE, initially introduced coercive measures such as mass screening, obligatory test- ing and contact tracing, quarantine and travel restrictions, significant progress has been made in overturning them. 9 The Riga Initiative: a call for action to prevent HIV and AIDS in the CCEE Number of new cases of AIDS each year <1985 1985 1986 1987 1988 1989 1990 1991 1992 Cases I AIIIIIIMINI CCEE 5 000 10 000 0 Western Europe 15 000 20 000 Estimated 10 An elderly participant at the Copenhagen Healthy Cities Sympo- sium dons a Healthy Cities T -shirt to exercise her way to health Healthy Cities The Healthy Cities project is proving to be one of the most effective vehicles for conveying the mes- sage of health for all. By reaching into the settings where people live and work, it aims to help people take action to improve the physical, mental and social environments that affect their health. The first phase The project has just completed its first five -year phase. It has grown to include a WHO network of 35 European cities and 19 na- tional networks (incorporating some 500 cities and towns). They are committed to building sup- port for a new kind of public health, based on the willingness of all sectors to adopt policies that promote health. This means creating and promot- ing safer and more supportive environments and services in the community, with an explicit empha- sis on promoting wellbeing. To this end, the WHO network of cities has helped decision -makers, pro- fessionals and communities agree on how to apply the principles of health for all through health promotion strategies. The project's main achievement has been to create the organizational structures that will per- mit change. These include task forces and con- sultative bodies that enable different parts of the public sector to collaborate on healthy public policy. As a result, the health departments of about half the cities have drawn up city health plans jointly with some or all of the other public sector departments, for example, on environmen- tal issues, health promotion or HIV /AIDs preven- tion. These are the first steps towards comprehen- sive city health plans that involve all sectors. As the cities' mayors said at the close of the annual Healthy Cities Symposium in Copenhagen in 1992: The WHO project has widened our understanding of health and its determinants at the local level ... Our involvement ... has high- lighted the need to overcome sectoral separation in order to respond to new health challenges. In particular, the project has confirmed to us the need to involve partners throughout the city in health, above all the citizens themselves. Action centred on people is particularly impor- tant. This may involve, for example, children and old people in decision -making on health or taking comprehensive action in a deprived area. Demon- strating the immediate action that people can take to solve seemingly intractable problems catches the imagination both of policy- makers and of the public. For example, membership of the WHO net- work has enabled St Petersburg to tackle the health of women and infants. WHO mobilized the tech- nical support and other project cities gave practi- cal assistance. Groups of cities have developed multicity ac- tion plans on common problems, such as tobacco (coordinated by Belfast), the Baltic region (Turku), city health indicators (Nancy), and AIDS (Liver- pool). The city of Pécs, Hungary has started major environmental initiatives on water, sanitation and waste disposal, partly in collaboration with Horsens, Denmark. The WHO network has given many kinds of support to cities in special need. For instance, Horsens, Sandnes, Mechelen, Eindhoven and other cities gave assistance and support worth over US $9 million in response to an appeal from the Regional Office to support Zagreb, Croatia. The Horsens contribution alone was worth US $7 mil- lion. The Healthy Cities project approach is in- valuable not just to help cities carry out their health care reforms, but also to mobilize commu- nity participation. The second phase The next five -year phase of the Healthy Cities project will consolidate and extend the progress made. The WHO network will promote action on healthy public policies based on the health for all strategy, the creation of city health plans, and the introduction of mechanisms to ensure accountability for health. It will also promote action on such pressing issues as in- equity, social disadvantage, health -damaging behaviour and how to create sustainable economic structures. The aim will be to create a vision of a healthier city and to mobilize public support to realize this vision. The new phase begins with a review of the membership of the WHO network. Some 80% of the existing cities will become part of a new network. It will also take in new members, mostly from the CCEE. National networks will be strengthened and extended to countries where none yet exist, and a new Region -wide organization will link them together. European Centre for Environment and Health The WHO European Centre for Environment and Health was established in 1990, as an immediate follow -up to the 1989 European Conference on Environment and Health in Frankfurt. Its job is to strengthen collaboration on the health aspects of environmental protection and to improve under- standing of the relationships between environ- mental conditions and human health and well- being. One of its most pressing tasks is to gather data on the nature and extent of environmental health problems throughout the European Region, to be published as a report entitled Concern for Eu- rope's tomorrow. By drawing conclusions about the quality and availability of data and identifying priorities for future action, this report will form the basis of an action plan to be presented at the Second European Conference on Environment and Health, in Helsinki in June 1994. The project has entailed close collaboration with both coun- tries and intergovernmental organizations such as the European Community and the Economic Com- mission for Europe. Over 30 countries have al- ready established national focal points for infor- mation on environmental health. Concern for Eu- rope's tomorrow is the beginning of a long -term project to strengthen the environment and health database in the Region. In addition, the Centre is involved in a wide spectrum of technical cooperation activities, for both the Region as a whole and in individual CCEE. The Centre is coordinated from the Regional Office in Copenhagen, which also deals with over- all policy, strategies and planning. There are oper- ating divisions in Rome and in Bilthoven, and a project office in Nancy. The governments of Italy, the Netherlands and France have provided basic funding. The Centre already employs 38 staff, and experts are recruited for particular tasks. Bilthoven division The Bilthoven division has programmes on descriptive epidemiology, toxi- cology and the health impact of air pollution. A priority is the updating of the air quality guide- lines for Europe, which are widely used by gov- ernmental and other bodies as a basis for assess- ment and control. The European Community is also using them in developing its framework di- rective, which will provide the monitoring criteria for mandatory national surveys of pollution levels and for the setting of objectives for air quality. Work is also proceeding to develop guidance for the protection of people's health in both smog episodes and chemical accidents. The Bilthoven division has started a series of projects, funded by the Netherlands Government, in the Czech Republic, Hungary, Poland and Slovakia. They work to strengthen institutions, develop human resources, assess health hazards and control specific hazards. Projects are also being developed in Bulgaria and Romania. Rome division The Rome division has units re- sponsible for radiation protection, food safety, water, analytical epidemiology and data science. The radiation unit is developing follow -up studies of the health consequences of the Chernobyl nu- clear accident. It is also planning a project in the area affected by nuclear testing in Kazakhstan. The food safety unit is collaborating on the European Community ENs /CARE project, part of an ambitious plan to revolutionize the use of tele- communications in the Community. The ENs /CARE project is intended to improve the efficiency and effectiveness of national public health adminis- trations by the use of telecommunications systems and technology. Drawing on its wide network of WHO collaborating centres and other expert part- ners, the Rome division is leading the food safety part of the project. Four databases are being de- veloped: on foodborne infections, dietary expo- sure to potentially hazardous substances, food safety services and legal limits in food legislation. Three are based on existing Regional Office net- works. The water unit is advising Latvia on water supply and quality control issues, and developing guidelines for the use of recreational waters throughout the Region. In addition, it will embark on a rolling revision of the drinking -water guide- lines, using the most recent available scientific information, and will be involved in applying the existing WHO guidelines in the CCEE. Nancy project office The Nancy project office, which began operations in the second half of 1992, specializes in the public health engineering aspects of water supply and sanitation, waste man- agement and urban development. It will concen- trate almost exclusively on country projects in the CCEE. Its first project is to advise the city of Moscow on the restructuring of its water quality control operations. 11 The Nancy project office, the most recent addition to the European Centre for Environment and Health 12 Environmental degradation is a serious threat to people's health in the CCEE European Charter on Environment and Health The most significant result of the European Con- ference held in 1989 was the adoption of the European Charter on Environment and Health. It is now available in 18 languages and has been widely adopted as a basis for action by central, provincial and local governments and non- governmental organizations. It continues to influ- ence decision -makers throughout the Region. Gov- ernments have referred to it when drawing up national plans on the environment and health. It has also sparked lively debate among European parliamentarians at a Council of Europe confer- ence in Vienna in 1990, at a 1991 meeting of the International Union of Local Authorities in Oslo, and at the International Congress on Environmen- tal Health in Brighton in 1991. The implementation of the Charter by organ- izations and population groups was reviewed at a workshop organized by the Regional Office in Düsseldorf in August 1990. Since then, two subregional meetings have shown how the Char- ter can be applied in particular geographical areas. Baltic Sea countries The first of these was a workshop for countries surrounding the Baltic Sea, held in Stockholm in November 1991. These countries have many common features and close cultural and historical links. Those that, until re- cently, had centralized socialist economies are suffering from severe environmental degradation, which has harmed people's health. Natural re- sources had been seriously misused and little at- tempt had been made to alleviate industrial pollu- tion and decay. Inevitably, the impact of some of the resulting problems has spread beyond national frontiers. For example, heavy metals and toxic organic materials have contaminated the Baltic Sea. The workshop brought together representatives from Denmark, Estonia, Finland, Germany, Latvia, Lithuania, Norway, Poland, the Russian Feder- ation and Sweden. They reviewed the problems they face and decided how to tackle them to- gether, in the spirit of the Charter. They also gave clear descriptions of the environmental conditions in each country and their effect on people's health. The depressing stories of the eastern Baltic coun- tries spell out a clear need for urgent action. The burning of low- quality fossil fuels for heating and energy production pollutes the air, while untreated municipal and industrial wastewaters pollute both surface and groundwaters. Large areas of land are so contaminated with deposited wastes that they are a public health hazard. The western Baltic countries were willing to help resolve these problems, by using their own long experience in dealing with similar issues. They agreed to make special efforts to provide technical and financial support to improve the monitoring of environmental conditions and the evaluation of their effects on health, particularly among vulnerable groups such as workers, preg- nant women and children. CCEE The second workshop was organized in collaboration with the World Bank, the United Nations Environment Programme and the Gov- ernment of Switzerland, as part of the preparations for an intergovernmental conference to be held in Lucerne. The theme of this workshop, held in Copenhagen in early 1993, was the importance that should be given to environmental protection in the CCEE because of its effect on health. Clearly, these countries have much in com- mon, with conditions resulting from a long period of neglect and abuse of natural resources. A major difficulty now is the absence of adequate data on which to base rational decisions. An environmen- tal action programme for these countries is being developed for the Lucerne conference, and the workshop put the health considerations of such a programme in a proper perspective. Represen- tatives from ministries both of the environment and of health in eight of the CCEE took part in the workshop, demonstrating the growing cooperation between the two sectors in the spirit of the Euro- pean Charter. The participants described the extent of the dangerous environmental degradation in their countries and they agreed on mechanisms to ad- dress both national and international issues. In accordance with the European Charter, they rec- ognized the need to give high priority to the inter- action of environment, health and economics when addressing the problems of the CCEE. This issue is receiving particular attention in the preparations for the Second European Conference on Health and the Environment, to be held in 1994. The aftermath of Chernobyl The accident to reactor No. 4 at the Chernobyl nuclear power plant in Ukraine in 1986 produced a radioactive plume that trailed across Europe. Up to half the 10 million inhabitants of neighbouring Belarus may have been exposed to the plume and many still live in areas contaminated by fallout. They are now beginning to witness one of the first late effects of this exposure: an increase in thyroid cancer in children. Thyroid cancer in children Although increases were expected, the early appearance of relatively large numbers took a sceptical scientific commu- nity by surprise. Thyroid cancer is very rare in young children, so, however few the cases, they are much more numerous than would be expected naturally. This may indicate a much larger prob- lem to come. Though some experts still disagree about the cause, WHO has taken up the challenge of relieving the suffering and learning from the situation. The Regional Office sponsored a mission to Minsk, Belarus in June 1992, to investigate local physicians' claims of sharp increases, particularly in the Gomel region closest to Chernobyl. The mission confirmed the claims and the Regional Office launched a project to help Belarus improve the diagnosis, treatment and monitoring of the disease, and determine the origin, nature and likely extent of the outbreak. The project will be run from the Rome division of the WHO European Centre for Environment and Health. A WHO collaborating centre in Minsk is planned, to conduct research and training and coordinate all the activities in Belarus. An inter- national network of WHO collaborating centres will be set up in centres of excellence in the relevant disciplines. Belarus physicians will col- laborate in research with these centres, and re- ceive technical assistance and training from them through exchange visits. The project has received donations from the Government of Switzerland and may be implemented as part of the Inter- national Programme on Health Effects of the Chernobyl Accident coordinated by WHO. Fur- ther funds are needed. Childhood thyroid cancer need not be fatal but the prognosis depends on diagnosis and treatment. The aggressive nature of the disease means that early diagnosis is essential, yet screening the en- tire population is out of the question. The project must identify the people most at risk, to make screening more effective. Thyroid cancer is so rare that experience in treating it is scarce. The project will draw on worldwide experience to define the best treatment regime and help make it available in Belarus. In addition to thyroid cancer, the Regional Office is concerned about possible breast cancer in young women and the effects of the hot par- ticles that fell on southern Belarus. Reliable epi- demiological surveys of the populations are ur- gently needed. Clean -up workers The population around Chernobyl is not the only one at risk. Many of the 400 000 people brought in to clean up the accident site were exposed to high levels of radiation and may also be suffering the effects. Many were army conscripts, now dispersed to their homes throughout the former republics of the USSR. At the urging of the Baltic states, the slow process of tracing and studying the clean -up work- ers has begun. The Rome division held a meeting in May 1992, with the support of the Government of Switzerland; it revealed that studies of clean-up workers and sometimes their offspring have be- gun in Estonia, Latvia, Lithuania, Belarus, the Russian Federation and Ukraine. The International Agency for Research on Cancer is planning a feasibility study on the most affected countries (Belarus, the Russian Federation and Ukraine) but still lacks funds. Accurate and reliable dose estimates may be impossible to obtain but the consequences of the Chernobyl accident demand study. Only coordi- nated studies, however, using compatible proto- cols will produce comparable results and provide the public with the information that it needs and will believe. A committee of Baltic country rep- resentatives has been created to carry out this work. Meanwhile the time bomb continues to tick. The remains of reactor No.4 at Chernobyl present a serious hazard of further contamination. The existing containment could collapse, injecting sev- eral tons of radioactive dust into the atmosphere. Many Soviet -designed reactors are still in use throughout the CCEE. As the Chernobyl accident has shown, radiation respects no boundaries. We are all at risk. 13 Belarus Gomel Region O Estimated The sharp rise in childhood thyroid cancer in Belarus Clean -up workers brought in to Chernobyl were exposed to high levels of radiation 14 Health care reform Europe is changing rapidly. What was thought to be stable and predictable until a few years ago is now insecure and in constant turmoil. The health sectors in rigid, centrally planned economies have had to get used to raging market forces and gallop- ing inflation. In pluralistic societies, hospitals have suddenly been awakened from their Sleeping Beauty dreams to deal with contracting and com- petition for scarce funds. Even in affluent so- cieties, citizens have been horrified to learn that the heavy taxes they pay do not automatically give them access to every scientifically possible form of technical care, because funds are lacking. Medi- cal personnel are graduating with high qualifi- cations only to hear that society does not need their expertise or that they have studied the wrong subjects. What went wrong, during the last dec- ade, despite all the good intentions and the poli- cies for health for all? EUROCARE project Nothing has gone wrong. The world is just changing, as it always does, and we Discussion of the pertinent issues by the First Working Party on Health Care Reforms in Europe, Madrid, 1992 To have a common goal and to work towards it in a coordinated way - that's what reform is about must change with it as fast as we can. WHO's response has been to go into the reform process by launching the EUROCARE project. It has provided a forum for top -level decision -makers (ministers of health, first secretaries and directors -general) and their advisers from both east and west to discuss how to handle the process of change. In 1992, the WHO working party on health care reforms held its first meeting in Madrid, where members ex- changed their experiences and evaluated the vari- ous options open to them. But theory and words are no longer enough in a Europe where health conditions are in many ways beginning to resemble those in the third world. Through its EUROCARE project, WHO can play a significant role in helping its Member States halt this decline. Since the meeting in Madrid, WHO has been drawing on the project's networks in the fields of financing, management, hospitals and training, and setting up think tanks of key players to debate the issues in depth. WHO soon realized that, despite the vast amount of information available, no one knew enough about the actual health care reforms tak- ing place in the Region. Now the EUROCARE project is building up a monitoring system to track them. It aims to keep all parties informed of these events, and their outcomes, in a pragmatic way. The re- sulting health in transition (or HIT) profiles will be available on Belarus, Hungary, Kazakhstan, Latvia, Poland and Uzbekistan by the end of 1993. They will be supplemented by some 15 reform overviews (or Rovers). Experience counts In the present climate of de- centralization and decreasing ministerial control, the EUROCARE project cannot reach its goals sim- ply by working through top -level decision -makers and by imposing legislative measures. A powerful tool is to influence the reform process through local projects on health care development. For example, in Austria, several experiments have helped to improve the collaboration between health professionals and social workers for the benefit of their clients. In the Czech Republic, a town of 100 000 people has introduced a new information system to tailor the health services more closely to the needs of the population. In Finland, the system of having a personal physician has been introduced and the physicians' salary system changed accordingly. In a district of Mos- cow, the health services aimed to improve their efficiency and quality by identifying external funds and putting more emphasis in the budget system on results. In the United Kingdom, a workshop brought together 40 health care providers, pur- chasers and consumers to simulate a model for a better local health care system. Through these local examples, brought together by the EUROCARE project, innovations in the prac- tical implementation of health care reforms can be shared with the whole population of the Region. Health information Countries need to share information about health and related issues. Learning both from their own experience and from that of other countries will help them update their health policies and track their progress towards health for all. The Regional Office acts as a catalyst, a facilitator and a clear- ing- house: a European health information centre. The Office takes two approaches to this role. First, it collects, maintains, interprets and dissemi- nates information about people's health through- out the Region. Its main tool is the triennial Regionwide monitoring and evaluation of progress towards health for all. The feedback from such international comparisons enhances countries' own efforts on issues ranging from health policy to service delivery. It also highlights some of the dramatic differences between countries and groups of countries. The Regional Office's second ap- proach is to help countries strengthen their own information systems. This has the additional ben- efit of improving their contribution at the inter- national level. International exchange For the past seven years, the Office has developed and maintained the Health for All Database. It contains readily accessible and coordinated comparative information about health, gleaned from the Member States of the Region. A user -friendly PC version of the data- base is in great demand and a new Windows version was developed in 1992. The Office also regularly meets requests for information on vari- ous other topics (including nutrition, quality as- surance systems and health documentation). This wealth of information is updated periodically, en- abling the Office to measure and analyse the health situation in the Region. The reform of health care in the CCEE re- quires detailed knowledge of the existing systems and health in these countries. In March 1992, the Regional Office extended its database to include data on the NIS. Many donors and other agencies are commit- ted to assisting reform in the CCEE. Their de- mands for information are growing rapidly. To meet this demand, the Regional Office started to produce highlights on health for these countries. The highlights are an extract and analysis of the most important information held by the Office. The Regional Office also produces more detailed profiles for these countries in specific areas such as nursing and health care reform. Better country information The Regional Office helps countries strengthen their health information systems, which improves the quality and compar- ability of the health data they collect. For exam- ple, guidelines have been drawn up on conducting health interview surveys that will comparably measure health for all indicators. This will help harmonize health monitoring in the Region. Simi- larly, guidelines on producing public health re- ports are intended to improve international stand- ards of health reporting. Another aim is to help countries make better use of health data in planning and management. A major project has begun to help the CCEE develop a system of health service indicators, similar to the one used in the United Kingdom. So far, Bulgaria, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania and Slovakia have joined the project. To help the CCEE make better use of available mortality data, an atlas of avoidable mortality is being prepared in collaboration with the Hungar- ian Central Statistical Office. The atlas will help health administrators in planning and in assessing health care quality. Finally, the Regional Office coordinates a longi- tudinal study on risk factors in children, ac- cumulating valuable epidemiological data. In the United Kingdom, for instance, these data have been used to monitor the results of a campaign to prevent cot deaths. Though a slow process, it is vital to study today's children in order to help tomorrow's. Documentation Units throughout the Regional Office collect, analyse and disseminate information in many forms. Much of it appears in publications and documents, which are distributed through net- works, sold in bookshops, displayed in libraries, and widely translated into the many languages of the Region. Details of this documentation are available on the Regional Office bibliographic database, EuaoDOC, which will soon become pub- licly accessible. Over 20 libraries and health documentation centres in 20 countries have been officially ap- pointed as Regional Office documentation cen- tres. They ensure that documents and publications of the Regional Office are prominently displayed and easily available. Liaison offices in the CCEE have been given ready -to -use WHO reference libraries. These will soon be available to the MS. Comparative health information at inter- national, national and subnational levels is essen- tial in the drive to improve health. The objective of the Regional Office as a European health infor- mation centre is to help countries to share and learn from each other's experience. 11111111 IIiIIIIII I! ._ '1:114111.10111111401.1 15 As a European health information centre, the Regional Office disseminates vital information on health, through such reports as these The Health of Europe offers a wider public access to Region -wide information collected by experts 16 Family health The policy of health for all rests on primary health care: essential care that is available to everyone and easily accessible from homes and workplaces. It gives people the information they need to lead healthier lives. It treats common diseases before they get worse. It gives individuals and families control over their lives and their health. Every country in the Region adopted this ideal over 15 years ago. Putting it into practice has been less easy. The need to reform health care systems throughout the Region and particularly in the CCEE, however, makes it all the more urgent and relevant today. Basing a health care system on pri- mary health care requires health pro- fessionals (nurses, midwives, general practitioners and others) to work to- gether as a team in the community. Countries therefore allocated budgets to fund teams and set up local health care centres where they could work. But somehow, the awaited transfor- mation did not happen. The Regional Office therefore re- assessed the assumption that setting up the right organization will ensure that the right jobs are done in the best poss- ible way. The aim now is to identify the key functions whose performance is critical to a good health care system. By focusing on the function instead of the performer, one can separate the two. What matters is what is done well, not who does it. The function may be carried out effectively by differ- ent people or services in different settings, such as schools, workplaces or homes. A good health care system defines its effec- tiveness by the outcome of patients' contact with it. The more their health improves, the better the system. To change the way they work, health profes- sionals must first know more about their current practices. With the support of WHO, general practitioners and nurses have begun to describe what they do and to try new approaches that might work better. They are identifying models of good practice: those that lead to a measurable improvement in health outcome. This approach has a number of benefits, chief among them flexibility. Countries may choose the models that suit them best. These models can answer questions, such as what makes an interdisciplinary team function well and what are the roles of different health care providers. They can show how different sectors of the health system can cooperate best. Finally, they contribute to the general review of health care systems, by showing the effects of different health Primary health care workers hold the key to family health This report will help nurses create a new role as autonomous, skilled professionals care policies (including financing systems) on health and the health care system. General practitioners To help general prac- titioners break out of their traditional mould, WHO is promoting the development of a Charter of General Practice. It will not only define what general practitioners already do well, but also indicate what more they could do, particularly in prevention. WHO has also become a partner in a new project, the Integrated System Architecture for Advanced Primary Care (Isaac), launched by the European Community in 1992. The project investigates the information needs that general practitioners share with other health professionals in the primary health care field. Both the Charter and Isaac will lead to new definitions of general practice and show its place within primary health care. The CCEE are also learning about the role of general practice from the experiences of southern Europe. Since 1986, WHO has held regular meet- ings on the development of primary health care in southern European countries. The 1993 forum reviewed the relevance of these discussions to the CCEE. This tied in with various WHO reviews of the development of primary health care in indi- vidual CCEE. Nurses Nurses and midwives also need to work in new ways. As the largest occupational group working in the health services, they are a major force in the development of primary health care. The entire nursing infrastructure needs to be im- proved, particularly in the CCEE. Apart from drawing up models of good practice to learn from, their priorities are to reform basic nursing edu- cation, and develop management and leadership. The changes that result will enable nurses to take up their role as partners in the primary health care team. WHO has launched the learning materials on nursing (LEMON) project to supply nurses and mid- wives with the modern, high -quality educational materials they urgently need. The WHO Nursing in Action project brings together the nurse leaders of the Region to discuss national action plans for nursing and how to link them to national health policies. Clinical nurse leaders have been trained . in project management. Projects that improve the outcome for patients are being studied to identify models of good practice. Family health Nurses and general practitioners are the two main agents of primary health care. By addressing the family and taking their work to people's homes, they may learn to share their functions more efficiently and ultimately bring better health to everyone in the community. Conclusion How healthy could Europe be? In general, the Region has moved towards better health. Healthy lifestyles and environ- mental issues are gaining ground. Reforms in health services are begin- ning. Countries, regions, provinces, cities and even neighbourhoods are adopting health for all as a policy basis. But this overall progress hides a widening gap in health status between the northern and western and the central and eastern parts of the Region. The changing political map of Europe, increasing migration, slow economic develop- ment, high unemploy- ment and the aging of the population are formidable challenges for the European Region and the Regional Office. Yet progress can continue, and the health divide can be narrowed, if we are prepared to learn from experience. Advances in health are slow and require sustained and cumulative effort. But health development on the basis of the principles of health for all is the most economical way of maintaining and promoting health. Health and welfare, after all, are resources, not just areas of expenditure. Policy -makers at national, regional and local levels must accept their social responsibility by being aware that every decision they make may affect people's health. Health is not the sole concern of governments and health professionals: it depends on the creativity, resources and commitment of a wide range of other people and social groups, including those in business and industry, the law, education and the media. Putting these lessons into practice is our task for the coming decades. 17 World Health Organization Regional Office for Europe Copenhagen WHO Regional Publications European Series No. 50 ISBN 92 890 1314 1 Sw.fr. 12.-

WHO INA NEW EUROPE ... . ,s69 / V0* 114 Qi/v7z0 EUROPE The Regional Office for Europe of the World Health Organization welcomes requests for permis- sion to reproduce or translate it . publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, WHO Regional Office for Europe, Scherfigs- vej 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 1993 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 prefer- ence 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 Pamela M. Charlton with the assistance of Mary Stewart Burgher Design and graphics: Sven Lund Layout: Wendy Enersen and Marcelle Ledoseray Photography: Knud Thoby Printed in Finland by West Point Printers, Rauma Contents Foreword Health in Europe Strategy for the CCEE Humanitarian aid programme in the former Yugoslavia Women's and children's health Preventing noncommunicable disease Developing quality of care Tobacco and alcohol Threat of AIDS to CCEE Healthy Cities European Centre for Environment and Health European Charter on Environment and Health The aftermath of Chernobyl Health care reform Health information Family health Conclusion: how healthy could Europe be? 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 WHO Library Cataloguing in Publication Data WHO in a new Europe (WHO regional publications. European Series ; No.50) I.Regional health planning 2.Health for all 3.World Health Organization 4.Europe I.Series ISBN 92 890 1314 I (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 230 people from about 40 nations. In addition, over 1000 experts work with the Office every year, along with collaborating centres and research institutes across the Region. Its regular annual budget is about US $23 million. Funds donated by other sources, including the United Nations and individual governments, have grown in recent years to about US $10 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 therefore concentrates both on the problems of industrial and post -industrial societies and on those faced by the emerging democracies of the central and eastern part of the Region. Since 1990, the number of Member States has increased from about 30 to 50. The Regional Office is governed by a Regional Committee comprising representatives of every Member State. Through the Regional Committee, which meets once a year, all the Member States collectively formulate regional policies, supervise the activities of the Office, recommend technical activities and approve the budget. The Regional Office in its turn advises and guides the Member States in their technical activities and promotes the development of networks of experts and other partners. As of June 1993, the Member States of the European Region are as follows:a Albania France Luxembourg Spain Armenia Georgia Malta Sweden Austria Germany Moldova Switzerland Azerbaijan Greece Monaco Tajikistan Belarus Hungary Netherlands The Former Yugoslav Belgium Iceland Norway Republic of Macedonia Bosnia and Herzegovina Ireland Poland Turkey Bulgaria Israel Portugal 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 who dk Teletex: 118785 Electronic mail: BITNET:WHOEURO @VM.UNI -C.DK a For the latest list, please contact the Regional Office. 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 thealth, 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 five technical departments. Four mirror the main groups of targets and work for better health, healthy lifestyles, healthy environments and appropriate care. The fifth ties together the threads of the various technical programmes into country projects, with particular emphasis on the countries of central and eastern Europe (CCEE). The Disease Prevention and Quality of Care Department helps Member States prevent communicable and noncommunicable diseases and accidents, promote immunization and family planning programmes, and improve the quality of health care and technology, including pharmaceuticals. It deals directly with specific population groups such as women, children, the disabled and the elderly. The Lifestyles and Health Department helps Member States promote health by advocating healthy living (through programmes in nutrition, mental health and sexual health), action against harmful substances (such as alcohol, tobacco and psychoactive drugs), settings that are conducive to healthy living (healthy cities, schools, hospitals and workplaces), and better care for lifestyle -related conditions such as AIDS, mental disorders and addictions. The Environment and Health Department helps Member States tackle the long -term prevention of environmental health hazards, including the pollution of air, water and soil, as well as environmental emergencies and accidents. It promotes food safety, occupational health and healthy housing. It has a network of staff and offices in Athens, Bilthoven, Nancy and Rome, as well as Copenhagen. The Health Services Department helps Member States, particularly the CCEE, reform their health care systems. It focuses on three closely related areas: services (in primary health care, hospitals and long -term care), the people who deliver them (nurses, doctors and other health professionals), and the information needed to improve them (including training, research and statistics). The Country Health Development Department manages Regional Office activities in countries, particularly in the CCEE. A sixth department provides the Office with support services such as budget and finance, personnel and administration, as well as documentation and informatics. Foreword Great changes have swept the European Region of the World Health Organization (WHO) in the last two years, resulting in an astounding 50% increase in the number of its Member States. Coinciding as these unprecedented events do with a period of world recession, how is WHO meeting the needs of the countries of central and eastern Europe (CCEE), including the newly independent states (NIS) of the former USSR, as well as the other Member States of the Region? Thé latest WHO evaluation in the Region has revealed that unemployment, recession and pov- erty are on the increase. Inequities in health within and between countries are growing. In particular, the health divide between the CCEE and the rest of the Region is large and widening. The Regional Office has met change with change, developing a whole new approach to bring assistance to the CCEE. Maintaining immunization levels and a steady supply of vaccines is one of the Regional Office's most pressing tasks. Unfortunately, civil unrest and even war have followed the birth of some countries. In response, the Regional Office set up a large -scale programme of assistance to these war -torn countries in July 1992, an impor- tant part of the joint United Nations appeals and the consolidated interagency programme that fol- lowed. This difficult period puts the solidarity of the countries of the Region to the test. In 1991, they created the EUROHEALTH programme to refocus much of the work of the Office towards the needs of the CCEE. At the Regional Committee for Europe in 1992, they reaffirmed their commit- ment to achieving greater equity in health among peoples and countries in the Region. What is more, many western countries have not only given up to this programme all or part of the regular WHO budget allocated to them, but also made voluntary donations to various specific projects. Their support to much of the urgent work in the Region can be seen throughout this report. The recognition that change in one part of the Region must affect the other parts has resulted in greater rapprochement among intergovernmental organizations.;. WHO is developing closer rela- tions with the Council of Europe and the European Community, not only at the technical but also at the political level. It has also joined forces with other members of the United Nations family in health assessment missions to the NIS. The European policy for health for all requires all sectors to consider the effects of their policy on health. The sectors of health, fmance and environ- ment are beginning to do this. At a meeting on AIDS, ministers of health and of finance launched a joint initiative to help prevent AIDS from taking hold in the CCEE. Collaboration between the health and the environment sectors was crystallized in the creation of the WHO European Centre for Environment and Health in 1990; both sectors are working to produce a plan of action for the CCEE, in preparation for the Second European Confer- ence on Environment and Health to be held in 1994. While the Regional Office adjusts to meet the needs of the new Europe and extends its cooper- ation with other agencies, it continues to sharpen and further develop its most successful tools. The European policy for health for all is ideally suited to the needs of the future, and its 38 tar- gets have been updated to reflect con- ditions towards the end of the century. A new Regions for Health Network now helps subnational structures across Europe to exchange experience in the development of health for all policy. The tried and tested vehicles convey- ing the health for all message are show- ing their soundness. The Healthy Cities project is entering its second phase, and the countrywide integrated noncom - municable disease intervention ( Cuvai) programme can usefully be applied to other problems and is spreading through- out the Region. Despite their differences, the coun- tries of the Region are taking joint ac- tion on their shared problems, using WHO as their tool. They are working together to follow up the effects of the Chernobyl accident. They are strengthening the role of such primary health care workers as general practitioners and nurses in work for family health. They have adopted WHO's Regionwide action plans on tobacco, alcohol and diabetes. Dissatisfied with their health care sys- tems, they have founded a forum to discuss the issues of reform. Lack of resources need not be a bar to improving the quality of services. Indica- tors are being developed to monitor and improve the quality of care in the fields of diabetes, oral health, surgery and stroke in the elderly. Informa- tion is the key to all this work. Countries are striving to understand their problems and search- ing for international examples to learn from. In this task, they are turning to the Regional Office as a European health information centre. The demands of the new Europe are many and various. But if we all work together, we can grasp this unique opportunity to pursue our fundamental aspirations of greater equity in health. 1 Jo E. Asvall WHO Regional Director for Europe 2Rate per 100 000 population 600 500 400 300 200 O C)c00)N u')a0 On) O) On) ON. ) CI, OCO ) OCO ) Q ) NIS CCEE European Region European Community Nordic countries The health divide: difference in mortality between east and west among people under 65. The sudden drop in NIS figures between 1984 and 1986 is largely due to the campaign against alcohol. This report summarizes the most recent evaluation of health in the Region (above). A series of documents review the issues of equity in health (right). Health in Europe The most recent picture of health in the European Region shows encouraging progress towards health for all. But this hides wide differences both within and between countries, most notably between east and west. How do we know this? Because the Region as a whole has a common policy for health for all, 38 targets to aim for, and health for all indicators used by every country to measure progress in periodic monitoring and evaluation exercises. Development of policy Since the Member States adopted a common European policy for health for all in 1984, many have drawn up a national policy for health for all based on the regional model. England, France and Turkey have produced the most recent examples. Comprehensive policies to improve health have also been developed at other administrative levels in countries, such as cities, cantons, Länder or communities, and other subnational structures, such as local health auth- orities. Reacting to these developments, WHO and 11 regions created a Regions for Health Net- work in 1992 to help regions share their experi- ences in the development of health policies based on the principles of health for all. When the Member States adopted the targets nearly ten years ago, they also agreed both to monitor their progress towards them and to share the results with one another in regular evaluations. Since then, the monitoring and evaluation have taught us many lessons about the implementation of the health for all strategy. For example, they supplied the information that enabled the Regional Committee for Europe to update the targets in 1991. Further, they put the Office in a unique pos- ition to draw a detailed picture of health through- out the Region. The Regional Office coordinated the most recent evaluation in 1991, using the statistical data supplied by countries. This mech- anism of collecting, consolidating and disseminat- ing health information gave both quantitative esti- mates and qualitative insights into health status and likely future trends. Progress and problems On balance, health in the Region has improved. Countries have increased life expectancy towards the target of 75 years, and advanced towards the elimination of some infec- tious diseases that immunization can prevent. They d strategics p,,l(l,lll lilt ltl:nlnl 1N)noeonhn have reduced deaths from two of the leading causes of death - cardiovascular diseases and accidents - and reduced infant and maternal mortality. A closer inspection of the health picture, however, reveals that, for example, mortality from cancer - another leading cause of death in the Region - is still rising. The worst problem, however, is inequity in health. Despite some gains in northern and west- ern countries, inequities are increasing. Inequali- ties in health persist in every country in the Re- gion, and vulnerable groups include the old, the young, migrants and the unemployed. Current economic conditions are increasing the health prob- lems that result from social deprivation. Never- theless, the greatest inequalities are those between countries. A health divide has opened in the Re- gion, and is growing wider. The countries of central and eastern Europe (CCEE), including the newly independent states (NIS) of the former USSR, have about half of the Region's population and significantly worse health than their fellow Member States. A few facts underline the disparities between "the two Europes ": life expectancy is on average 6.4 years lower than in Nordic and European Community coun- tries; infant mortality is double that of the rest of Europe, and rates in some of the easternmost countries are ten times higher than the best in the Region; the incidence of diseases preventable by im- munization is high; greater consumption of alcohol and tobacco and poor nutrition and living conditions have led to a high incidence of chronic disease; health care systems are poor in organization, financing, equipment and supplies, and moti- vated staff. Some of these countries are worse off than others, and poor health is just one of the problems that the CCEE and the NIS face in trying to transform every sector of their societies. War or civil unrest in some countries aggravates the situation. Acute shortages of vaccines, essential drugs and finan- cial resources are further damaging health, at least in some vulnerable groups and particularly in some of the NIS. New role for the Regional Office The new con- ditions in and the unprecedented problems of these countries call for new responses from the Re- gional Office. With a staff of under 250 and a regular annual budget of US $23 million, its strength is in its extensive relationships with peo- ple and organizations in the health field. It has therefore developed new tools and working rela- tionships, with both new and familiar partners, to help channel funds into health work and narrow the health divide. Strategy for the CCEE The importance of equity and the need to reduce the health divide between eastern and western Europe have led the Regional Office to give first priority to improving health in the CCEE through the EUROHEALTH programme. The governments of these countries risk losing sight of health in trying to meet a host of crying needs. International agen- cies may forget that health is vital to development. The Regional Office's aim is to be the advocate for health. Change in the Region has begotten change in the Regional Office. It is establishing links with new countries and coping with fundamental and rapidly changing needs in others. To tackle these tasks, the Regional Office has adapted its methods and created new structures, most notably a Coun- try Health Development Department to manage, coordinate and evaluate its activities in countries, helped by a new network of liaison offices in the CCEE. Principles The Regional Office bases its assist- ance on solid information. This means not only collecting and disseminating data, but a great em- phasis on analysis and evaluation. Assistance must be based on a knowledge of conditions in the area concerned, the groups and organizations involved, and the action already taken. This indicates the action most likely to be effective in the circum- stances. Such knowledge is offered to users within and outside the Regional Office. International aid to the CCEE must be well coordinated to make the best use of the resources available. The Regional Office has a unique pos- ition in the Region: political neutrality, long- standing links with and knowledge of these countries, and considerable experience with health activities and the building of consensus. Its aim is to become the preferential health agency in the international com- munity. This means pursuing closer cooperation with funding institutions, nongovernmental and intergovernmental organizations, other United Nations agencies and WHO headquarters. Assistance from the Regional Office aims to reinforce countries' capacities, and thus reduce their need for international aid. In other words, its activities will lead to institution building and to sustainable social and economic development in the CCEE. Developing human resources is essen- tial to this process. WHO can help through its networks of experts, collaborating centres and fellowships programme. The Regional Office works with countries on their immediate health problems, while supporting them in the longer process of developing policies and programmes for health, using the framework of the regional policy for health for all. An important way to do this is to help their officials and experts to take part in international networks and activities. This permits a two -way exchange, in which people from the CCEE both learn from and teach their counterparts in other countries. Tools Both familiar and new tools are used: not only the Health for All Database, other Regional Office databases, and networks of collaborating centres and national counterparts, but also liaison offices, country missions and the MS clearing- house. The Regional Office negotiates two -year col- laborative agreements with each of the countries in the CCEE. Since the NIS are new countries and the situation is pressing, missions have been organized to the NIS: to negotiate an agreement; to begin to influence the country's health strat- egy; to identify technical counterparts and liaison officers; and to promote contact with other key people, in- stitutions and organizations in the country. At the behest of the international community, the Office has set up a clearing -house to collect and disseminate information on health assistance to the NIS. Its main task is to record donor activity in the area and ensure timely and coordinated help where most needed. Initially, it is concentrating on supplies of vaccines, pharmaceuticals and small medical supplies. By mid -1993, the Regional Office had liaison offices in Albania, Bosnia and Herzegovina, Bul- garia, Croatia, the Czech Republic, Georgia, Hun- gary, Kazakhstan, Latvia, Poland, Romania, the Russian Federation, Slovakia and Slovenia; more are being established. They allow permanent con- tact and information exchange between the Re- gional Office and countries, and better coordi- nation with the other organizations présent in the countries. The main tasks of locally recruited liaison officers are to collect information on health status and needs, and help the country to make the best use of Regional Office resources. 3 WHO reports on its missions to the NIS Some young boys in Kyrgyzstan, a new Member State in WHO's European Region Refugees wait anxiously for evacuation A UN convoy brings food and medical supplies to besieged Bosnians Humanitarian aid programme in the former Yugoslavia Nowhere is a new response from the Regional Office more needed than in the new independent republics that have emerged from the former Yu- goslavia. In these countries, hundreds of thou- sands have been killed, wounded or disabled and millions have fled their homes. Hospitals are tar- gets for artillery, food and water supplies are used as a weapon, humanitarian aid workers are at- tacked, women are raped and children are tar- geted victims. Such conditions have elicited an unprecedented response from the entire United Nations family. Public health adviser The Regional Office's role in Bosnia and Herzegovina is to act as the public health adviser to the United Nations, and to work in partnership with many other agencies to meet the health needs of over 4 million people. This means on -the -spot assessment of medical and nu- tritional needs, and carrying out public health measures in the field. The food and medical sup- plies in the white UN lorries that have reached the besieged areas of Bosnia and Herzegovina are selected on the basis of WHO advice, as were the supplies dropped by helicopter over eastern Bosnia and Herzegovina in March. Since aid workers risk their lives to ensure delivery, supplies must be strictly related to need. Therefore, WHO experts carry out health and nutritional surveys in the field throughout Bosnia and Herzegovina in very dangerous situations. WHO has also secured donations of large amounts of medical supplies, in the form of standard kits (such as for anaesthetics, special hygiene kits, basic medical kits, kits for chronic diseases and mental health kits) and arranged for their delivery. A small number of experienced and resource- ful WHO field staff has spearheaded this wide range of humanitarian operations. But success is largely attributable to the will of the population, which has enabled them to withstand winter cold, famine and war injuries. The health sector has continued to function despite being under fire and without medical supplies, while families without enough food for themselves have opened their doors to refugees. The average weight loss in adults over the winter has been 12 kg, women losing most since they have been giving their food to their children. The spring and summer bring worsening con- ditions. Water supplies become contaminated through cracked pipes and diseases spread through a population weakened by poor hygiene, malnu- trition, and stress. Perhaps, the women suffer the most as they undergo the stress of not knowing the fate of their fathers, husbands and sons, and many have been subjected to rape and violence. Joint appeal Needs must continue to be met. The United Nations humanitarian aid programme is funded from voluntary donations. The first joint appeal was launched in September 1992 to raise US $250 million. Of the US $40 million compo- nent intended specifically for WHO, just over US $15 million was actually raised and has been spent in the period up to the end of March 1993. Major contributors were the European Commu- nity, Canada, Denmark, Germany, the Nether- lands, Sweden, the United Kingdom and the United States. A second appeal for US $42 million was made to cover operations until the end of 1993. It had been hoped that this work would have been moving on to reconstruction. But as long as the conflict drags on, only humanitarian assistance can be provided. To run its humanitarian assistance programme, WHO now has some 50 people in the field. The hub is the area office in Zagreb, Croatia, with field offices in Belgrade (in Serbia), Split (in Croatia), Sarajevo, Tusla and Zenica (in Bosnia and Herzegovina) and Skopje (in The Former Yugo- slav Republic of Macedonia). Like all the United Nations personnel involved in The programme, they have displayed more than professional ex- pertise. They show political sensitivity, initiative and great personal courage. New trouble spots The future looks bleak as other trouble spots rumble. Social, economic and politi- cal changes, often exacerbated by internal con- flicts, are weakening the fabric of many of the NIS. Under the United Nations humanitarian aid programme, interagency teams have completed missions to assess needs in Armenia, Azerbaijan, Georgia, Tajikistan and Uzbekistan. In mid -1993, a WHO staff member was coordinating health assist- ance in Tajikistan, but appeals have been launched to meet the needs of the other countries, too. Women's and children's health Childhood is a most vulnerable period of life and birth can be the most dangerous episode of all. But immunization against the major childhood dis- eases and improvements in birth practices greatly increase the chances for the survival of babies and children and their mothers. Immunization and vaccines Immunization is one of the most cost -effective weapons in public health. The WHO Expanded Programme on Immuniz- ation (EPI) uses it to eliminate the main childhood diseases - polio, diphtheria, neonatal tetanus, measles, mumps and congenital rubella. The Eu- ropean Advisory Group, set up to guide the imple- mentation of the EPI in the Region, has drawn up operational targets for the 1990s. They cover: immunization coverage, surveillance of target dis- eases, and outbreak investigation and response. Immunization coverage is generally high and stable in the Region and diseases are on the decline. Coverage is now reported from the dis- trict level and upwards in most countries, how- ever, revealing that districts often fall below the target level of 90 %. The level of immunization coverage as a national average must be a mini- mum of 95% to ensure good protection in a country. As to levels of illness, measles has de- clined by a dramatic 75% since the introduction of the umbrella vaccination against measles, mumps and rubella. Polio continues to decline steadily and neonatal tetanus is very low, though persistent in 3 -4 countries. Nevertheless, pockets of non -immunization in the Region can lead to dangerous outbreaks of disease. The polio outbreak in the Netherlands in 1992 cost millions of dollars to contain. Outbreaks also result from declines in the overall rates of immunization coverage in some CCEE. Diphthe- ria has reappeared. By 1992, nearly 6000 cases had occurred in the Russian Federation and Ukraine, a level not seen in the Region for 20 years. Vaccines are now in short supply, par- ticularly in some parts of the NIS, and infant and child mortality are rising. Two things are urgently needed: a guaranteed supply of vaccines in the short term, and improve- ments in the quality of locally produced vaccines in the long term. The Regional Office has launched a programme to address both these needs. Both donations and expert advice are being provided, much of it through this programme. As to vaccine supply, UNICEF, Canada, Japan, USAID and the European Community Humani- tarian Office are planning ways to meet the needs of the NIS for the next few years. Denmark, Finland, Iceland, Norway and Sweden have committed funds for adequate supplies for 1993 to Estonia, Latvia and Lithuania. The Regional Office is assisting work to im- prove vaccine production in the CCEE. The Netherlands may support its project in Albania. Experts recruited by the Regional Office (from Canada, Denmark, Germany and the Netherlands) are advising on modernizing production in Roma- nia. The other partners in this work are the Institut Pasteur (Paris), the World Bank and the European Community PHARE project. Similar advice is planned for other CCEE, including the Russian Federation and Ukraine. The Regional Office is seeking further re- sources so that it can organize regional training programmes for vaccine production scientists and those responsible for vaccine registration and qual- ity control. Women and children Maternal mortality need not be high in any country of the Region. In most, it is well below the target level of 15 per 100 000 live births. In some CCEE, however, it is not only higher but rising. The Russian Federation is a case in point. St Petersburg, for example, has a maternal mortality rate of 60 per 100 000, some 10 times higher than rates in the west. Twice as many newborn babies have low birth weight as in western countries, and intrauterine and neonatal infections are rising. St Petersburg St Petersburg has reviewed its health needs as part of WHO's Healthy Cities project. One priority is better health services to improve the health of its women and children. The Regional Office has worked with the people of the city in drawing up recommendations on the devel- opment of their maternal, neonatal (including breastfeeding) and family planning services. An action plan based on these recommendations was launched in early 1993, with indicators of out- come and level of services to monitor its progress. The review was supported by a donation from Sweden, matched three times over by contribu- tions from other members of the Healthy Cities project (Hamburg, Milan, Rotterdam, Stockholm, Turku) and Indianapolis. The work in St Petersburg will make an equally valuable contribution to the exchange of experiences with other cities in the Healthy Cities project. Cases 1 000 000 800 000 600 000 400 000 200 000 NM I 111111 11111111 1111111 g F., A g 5 The outbreak of diphtheria in the Russian Federation and Ukraine Vaccine supplies must be safeguarded if immunization cam- paigns such as this one in Kyrgyzstan are to succeed The dramatic fall in measles in the Region This report outlines the policy framework for CINDI countries to use in the prevention of noncommunicable disease Preventing noncommunicable disease Noncommunicable diseases - cardiovascular disease, cancer, respiratory diseases and cirrho- sis - cause three quarters of all deaths in the Re- gion. They have certain risk factors in common, such as smoking, poor nutrition, alcohol abuse, physical inactivity and psychosocial stress. Clearly these risk factors are rooted both in individual lifestyles and in environmental and social condi- tions. An integrated approach appears to be the most efficient way of tackling them all. The countrywide integrated noncommunicable disease interven- tion (CINDI) programme was launched just over 10 years ago to link partners from both the health and non -health sectors, action both within and between sectors, and work to prevent disease and to promote health. A wide range of European countries" partici- pate in the CINDI programme (and several others are joining). This entails setting up both demon- stration programmes and national activities. The demonstration programmes are vital. They are small enough, for instance, to show how people in a community have understood and reacted to in- formation they have been given, how their behav- iour has changed and why. They show decision - and policy -makers how prevention is possible. Such projects may involve a community (such as in Lithuania, where five small rural areas are involved), a region (such as Setubal in Portugal or Chelyabinsk in Russia) or an entire country (such as Malta). The CINDI programme has been adopted equally enthusiastically in both the east and the west of the Region. The upheavals in the CCEE have recently revealed a lack of consensus about what precisely should be done to prevent noncommunicable dis- eases. What issues should be addressed and what strategies should be used to deal with them? A recent review of the CINDI programme has answered some of these questions. Seven of the CINDI countries looked at the progress they have made in the last 10 years. They identified the key programme issues that face the CINDI member countries in the next five years and the collabor- ative strategies to address these issues. They also set out a clear -cut policy framework. The countries participating in the CINDI pro- gramme have been so enthusiastic that the Re- gional Office has only had to provide seed money. a Austria, Bulgaria, Canada, the Czech Republic, Fin- land, Germany, Hungary, Israel, Lithuania, Malta, Poland, Portugal, the Russian Federation and the United Kingdom (Northern Ireland). It is very much their programme, and they have given both money and time to make it succeed. Collaborating centres in Heidelberg and Moscow have also supported the programme with special- ist help. CINDI recently received an additional boost from substantial donations from Canada and Austria. Canada will support the CINDI programmes in the Czech Republic, Hungary, Lithuania, Po- land, the Russian Federation and Slovakia, while Austria will concentrate on a project in the Rus- sian Federation. Canada is the only country out- side the Region involved in the programme, but one of its most active proponents. The Canadian Heart Health Initiative is the result of extensive cross -pollination of ideas between Canada and the Regional Office about the concept and application of health promotion and disease prevention. The CINDI programme is one of the cogs in the partner- ship model that the Initiative has developed. The Canadian cooRDINAnNGHeart Health Initiative- coMMrn ES A Partnership Model °ONWMUNITIES HEART & STROKE FOUNDATIONSPRIVATE SECTOR COPI PROVINCIAL HEART HEALTH PROGRAMS PROVINCIAL .) HEALTHIIW CANADIAN HEART HEALTH NEIIVORKINfERNAT1oNAL CINDI SCIENTIFIC COMMUNITY HEART HEALTH INTERNATIONAL CONFERENCE NETWORKS PROFESSIONAL ASSOCIATIONS GOVERNMENT DEPARTMENTS CANCER FOUNDATIONS CINDI as a tool The CINDI approach to tackling the risk factors for noncommunicable diseases has resulted in its becoming a tool that could well be applied to different but analogous situations. For instance, Croatia recently asked the Regional Office to assess whether the method can be ap- plied to the health and social problems facing displaced persons, of which Croatia has some half million at present. The Russian Federation and Belarus are considering using the method to deal with the problems of radiation resulting from the accident at Chernobyl, as well as a nuclear acci- dent over 30 years ago in the Urals. CINDI is an excellent vehicle for delivering the health for all message in both the European Re- gion and Canada. It has sensitized health pro- fessionals to the principles of health for all and mobilized them to participate in debates and in networking. It has also shown the feasibility of building and maintaining an evaluation system as an intrinsic part of the programme. As more coun- tries express an interest in joining the programme, the time has probably come to turn CINDI into a European coordinated policy, geared to diminish- ing the burden of noncommunicable disease in every country in the Region. Developing quality of care People are taking greater responsibility for their health, so they expect to have greater choice in health care. They want more say in choosing their options for treatment. They demand more accountability from the health professionals who treat them. And this sharpens everyone's focus on the outcomes of treat- ment and the most appropriate use of resources. Pilot studies have shown that the differences in outcomes cannot be blamed on lack of resources, poor professional skill or low professional ethics. The cause is a lack of awareness that these differ- ences are occurring. Health professionals are not motivated to evaluate their work or improve it. They need mechanisms to help them monitor the services they provide and to ensure their quality. The Regional Office has been developing out- come indicators to measure the quality of care. In the past, most quality assurance activities defined and introduced standards to control the way care was given. But WHO' s new indicators measure the outcome of the care, rather than the process. They are yardsticks against which professionals and institutions can continuously measure their performance. In this way, centres of excellence can easily be identified and their experience quickly disseminated to teach others. This becomes a dy- namic process that continuously strives to identify the best solutions and make the most constructive use of them. Dramatic improvements WHO has used this proc- ess in several areas such as the management of diabetes, the prevention of surgical wound infec- tions and oral health care to reduce caries. The results of these demonstration projects have been very promising. For example, the number of sick days and stays in hospital for diabetic patients in Moscow fell by 80% after they had taken part in a pro- gramme developed by a WHO collaborating cen- tre in Düsseldorf. It mainly taught them to monitor their blood glucose levels regularly to improve their metabolic control. A DiabCare centre set up in Munich will eventually monitor the quality of diabetic care across Europe and help diabetes centres compare their performances. Infections from surgical wounds have been cut by 25 - 50% in some hospitals in Denmark and Italy, saving bed days and enormous costs. Five years ago, only a few surgical departments in Den- mark performed this kind of self -evaluation and comparison of results. Surgeons resisted such ac- tivities. Over the last few years, however, their view and understanding of the importance of evalu- ation has changed. Today, nearly 80% of all surgi- cal departments in Denmark actively monitor the quality of their care. A similar movement has begun in Belgium and the Netherlands. In oral health, the number of decayed, miss- ing and filled teeth (DMFT) has been used as an outcome indicator, to measure the results of d 7- Number ô of DMFT ô o ä Outcome curve 1987 ® Outcome curve 1991 d g m < n v é n preventive oral health care services, especially in children. This field has had a long- standing tradition of reporting and comparing results be- tween different intervention programmes. Over the last ten years, this has resulted in quite dra- matic changes for the better. The idea of measuring the quality of care with outcome indicators is being explored in various new areas such as mental illness, acute respiratory diseases, maternal and child care, cardiovascular disease including stroke, and the whole area of the care of the elderly. For instance, stroke is a major health problem in the Region, mostly affecting people over the age of 60. Though rates of stroke are dropping in some areas, the number of elderly people is grow- ing so fast that the numbers of stroke victims are actually increasing. In the CCEE, rates of stroke are 2.5 times higher than in the west, while tradi- tions of care and rehabilitation vary throughout the Region. This area would therefore benefit from the development of better quality in care. In practice, setting up a quality of care process has several phases. First, the outcome indicators for stroke are chosen, on the basis of a consensus on which indicators are relevant, valid and obtain- able as measurements of good practice in stroke care. Then, health professionals can collect and analyse their own data consistently, with a spe- cially developed, user -friendly information sys- tem. In this way, they can begin to evaluate their own performances in comparison with their peers and improve the quality of the care they give. Finally, international comparative databases can be set up that highlight the best performing cen- tres. Information about the practices that are shown to be the most successful can be widely dissemi- nated and their application promoted. Through this process of learning by feedback, health pro- fessionals can take more responsibility for the quality of care. Everyone has the right to the best obtainable level of health. This means not only reducing inequities but also continuously improving the quality of care. By enabling health professionals systematically to monitor the quality of care they deliver and by making assessment a permanent part of their activities, shortcomings can be iden- tified, good practices rewarded and quality of care improved. 7 How better care improved the dental health of Danish children between 1987 and 1991 Improving outcome of patient care 6110 1 Success and problem identification Quality assessment Action for improvement A World No- Tobacco Day poster in Kaunas, Lithuania, offering the choice between tobacco or health The emblem of the newly launched European alcohol action plan Tobacco and alcohol The health hazards of using tobacco are indisput- able, and public opinion is turning against its production and use. In 1987, WHO launched a Region -wide action plan to promote these changes throughout society. The first action plan for a tobacco -free Europe ran to 1991. The second will run until 1996. Tobacco -free Europe The first action plan showed that comprehensive policies implemented through multisectoral action will prevent tobacco use and reduce disease and death. But the target of 80% of the population being nonsmokers will not be achieved without stronger Region -wide action. The new action plan has three aims - to help smokers quit, to prevent young people from taking up the habit, and to protect people from involuntary exposure to tobacco smoke. In essence, measures to combat the use of tobacco are of three types: those that make money (taxation), those that cost money (health edu- cation) and those that are free (advertising bans and laws for smoke -free public and work places). The new plan advocates all three, and recom- mends that tobacco taxation be used to finance the most expensive form of dissuasion: health edu- cation. This has been successful in the Australian State of Victoria, in California and in Finland. It will be increasingly attractive as health care bud- gets shrink. It also makes sense. Action on to- bacco works better if a combination of measures is used synergistically. The first action plan showed the need for wide social and political support to achieve a tobacco - free Europe. This requires both stronger commit- ment and greater capacity, secured through alli- ances among all possible partners and more staff and funds. The new action plan will involve na- tional policy -makers in the field of tobacco or health, and programme implementers and people outside government. The WHO projects for healthy cities, healthy workplaces, health promoting schools and health promoting hospitals also work for a tobacco -free society. With the European Community as a key actor and ally in the first action plan, the Regional Office is building a strong alliance with the World Bank, UNICEF, the United Nations Development Programme, the Council of Europe, the Nordic Council and others. Already some international agencies and national governments have decided to stop giving development aid and subsidies that encourage tobacco growing, production and trade. The sporting community and the media are also vital allies. The Olympics in Barcelona and Albertville were smoke -free, conveying a posi- tive message to the audience. While smoking rates in western countries have peaked, they are still high (in men) and rising (in women) in the CCEE and in southern countries. The international tobacco industry is taking ad- vantage of the vulnerability of the CCEE to put pressure on their governments to allow the indus- try to expand. To help them resist these aggressive promotional and economic pressures, the Regional Office has set up a special task force of experts from various European countries and organiz- ations. They are conducting country missions and organizing consensus conferences, to assist these countries to develop a strategy for tobacco -free societies. European alcohol action plan Learning from the tobacco action plan, the Regional Office launched the European alcohol action plan in 1992. Of course, people regard alcohol and tobacco very differently. While tobacco is dangerous at any level of consumption, some say that alcohol is mildly beneficial in low doses. Yet this distinction must not hide the very real harm that alcohol consumption causes. The European Region has the world's highest level of production of and trade in alcohol. In the CCEE, alcohol consump- tion and its ill effects have risen sharply. Like the tobacco industry, the alcohol industry has aggres- sively moved into these new markets. The action plan has two aims: an overall re- duction of 25% in alcohol consumption and a specific reduction in harmful alcohol use. The first aim is based on the general agreement that the higher the consumption level in a population, the higher the number of problems caused. There is less agreement about the level below which no harm is done. Cultural attitudes towards alcohol differ widely, so the action plan recognizes the need for diverse approaches. Nevertheless, price and tax increases, and controls on availability and advertising, are universally effective. The second aim is more widely accepted across the Region: the reduction of alcohol consumption in specific groups (such as young people) and situations (such as driving). Consumption by young people can lead them to have accidents, commit crimes, have unsafe sex and miss out on edu- cation. Car accidents are closely associated with excessive drinking. The first phase of the action plan will run until 1995, concentrating on developing the support necessary to implement it. Threat of AIDS to CCEE While the AIDS epidemic continues in the Region (reaching over 90 000 cases by mid - 1993), the number of new cases no longer doubles annually in the west. In the CCEE, on the other hand, it is comparatively rare, and could still be kept that way. Yet barriers are falling across the Region, and the CCEE are beginning a process of rapid social change. People's growing mobility and other factors linked to change increase the potential for a rapid growth in HIV transmission. This remark- able opportunity for prevention must not be lost. The painful lessons of other countries teach that safer sex must be promoted to help reduce high -risk behaviour, and harm- reduction strategies must be introduced among people who inject drugs. Health workers must have adequate equipment and training to avoid transmitting HIV infection. The Riga Initiative The Riga Initiative calls for comprehensive AIDS programmes to prevent HIV and AIDS in the CCEE. The Initiative was launched at a meeting held in Riga, Latvia, in early 1993. It assesses the action needed to prevent HIV infec- tion, reduce its personal and social impact, and mobilize and unify national and international ef- forts against HIV /AIDS. It also estimates the funds needed for the first three years, until sustainable programmes have been established. These funds will launch well targeted and timely action and develop technical cooperation and institution build- ing in countries. They will increase coordination between countries and international donor agen- cies. The participants agreed: "We need to act now on the lessons learned worldwide, before the epidemic becomes established." Reform in the CCEE demands a truly multisectoral approach. The Riga meeting, aptly entitled "Investment in health ", was an important landmark not just for AIDS but for health policy development in general. It was attended by minis- ters of health and of finance from all over the Region, and was organized with the World Bank. The central theme of AIDS in the CCEE was the entry point to examine the range of policy chal- lenges facing these countries as they remodel their health and social systems. Concrete examples were given of how various policies and programmes could work. Finally, the participants' Riga Statement set out the principles of action for working together to meet the challenge of HIV and AIDS in the CCEE: Coordination of investment in health Social and political commitment Health promotion Respect for human dignity Safe health care settings Monitoring the epidemic Health promotion Much recent WHO work in the CCEE has concentrated on preventing HIV and AIDS in vulnerable groups (such as women, men who have sex with men, people who inject drugs, sex workers and their clients, and migrants) as well as young people, prisoners, tourists, busi- ness travellers, seafarers, people with sexually transmitted diseases or living with HIV, and the general public. This means almost everyone, but the approach required for each target group dif- fers with their risk of infection and their attitudes towards that risk. Nongovernmental organizations Self -help organ- izations - of people living with HIV or at particu- lar risk of HIV infection - have burgeoned all over the Region, vigorously meeting the challenge of AIDS. The active involvement of such community and nongovernmental organizations is the key to success in prevention, care and the advocacy of human rights. The Regional Office works closely with these organizations, promoting their full par- ticipation at all levels in national AIDS programmes and actively supporting their pan- European net- working activities. Some of these networks con- centrate on specific problems, such as access to treatment and trials, home care, information and resource mobilization. Others represent and ad- dress the needs of vulnerable groups and commu- nities, as reflected in the theme of World AIDS Day 1992, "AIDS - a community commitment ". Obviously, nongovernmental organizations, particularly those representing stigmatized and marginalized communities, are new to the CCEE. The Regional Office has successfully supported the creation and mobilization of organizations active against AIDS. This support includes promot- ing twinning programmes to forge links with west- ern organizations, arranging training workshops, mobilizing resources, and advocating human rights and legal emancipation. A dangerous and widespread belief is the idea that violation of the human rights of the few can save the many. While many countries, particu- larly in the CCEE, initially introduced coercive measures such as mass screening, obligatory test- ing and contact tracing, quarantine and travel restrictions, significant progress has been made in overturning them. 9 The Riga Initiative: a call for action to prevent HIV and AIDS in the CCEE Number of new cases of AIDS each year <1985 1985 1986 1987 1988 1989 1990 1991 1992 Cases I AIIIIIIMINI CCEE 5 000 10 000 0 Western Europe 15 000 20 000 Estimated 10 An elderly participant at the Copenhagen Healthy Cities Sympo- sium dons a Healthy Cities T -shirt to exercise her way to health Healthy Cities The Healthy Cities project is proving to be one of the most effective vehicles for conveying the mes- sage of health for all. By reaching into the settings where people live and work, it aims to help people take action to improve the physical, mental and social environments that affect their health. The first phase The project has just completed its first five -year phase. It has grown to include a WHO network of 35 European cities and 19 na- tional networks (incorporating some 500 cities and towns). They are committed to building sup- port for a new kind of public health, based on the willingness of all sectors to adopt policies that promote health. This means creating and promot- ing safer and more supportive environments and services in the community, with an explicit empha- sis on promoting wellbeing. To this end, the WHO network of cities has helped decision -makers, pro- fessionals and communities agree on how to apply the principles of health for all through health promotion strategies. The project's main achievement has been to create the organizational structures that will per- mit change. These include task forces and con- sultative bodies that enable different parts of the public sector to collaborate on healthy public policy. As a result, the health departments of about half the cities have drawn up city health plans jointly with some or all of the other public sector departments, for example, on environmen- tal issues, health promotion or HIV /AIDs preven- tion. These are the first steps towards comprehen- sive city health plans that involve all sectors. As the cities' mayors said at the close of the annual Healthy Cities Symposium in Copenhagen in 1992: The WHO project has widened our understanding of health and its determinants at the local level ... Our involvement ... has high- lighted the need to overcome sectoral separation in order to respond to new health challenges. In particular, the project has confirmed to us the need to involve partners throughout the city in health, above all the citizens themselves. Action centred on people is particularly impor- tant. This may involve, for example, children and old people in decision -making on health or taking comprehensive action in a deprived area. Demon- strating the immediate action that people can take to solve seemingly intractable problems catches the imagination both of policy- makers and of the public. For example, membership of the WHO net- work has enabled St Petersburg to tackle the health of women and infants. WHO mobilized the tech- nical support and other project cities gave practi- cal assistance. Groups of cities have developed multicity ac- tion plans on common problems, such as tobacco (coordinated by Belfast), the Baltic region (Turku), city health indicators (Nancy), and AIDS (Liver- pool). The city of Pécs, Hungary has started major environmental initiatives on water, sanitation and waste disposal, partly in collaboration with Horsens, Denmark. The WHO network has given many kinds of support to cities in special need. For instance, Horsens, Sandnes, Mechelen, Eindhoven and other cities gave assistance and support worth over US $9 million in response to an appeal from the Regional Office to support Zagreb, Croatia. The Horsens contribution alone was worth US $7 mil- lion. The Healthy Cities project approach is in- valuable not just to help cities carry out their health care reforms, but also to mobilize commu- nity participation. The second phase The next five -year phase of the Healthy Cities project will consolidate and extend the progress made. The WHO network will promote action on healthy public policies based on the health for all strategy, the creation of city health plans, and the introduction of mechanisms to ensure accountability for health. It will also promote action on such pressing issues as in- equity, social disadvantage, health -damaging behaviour and how to create sustainable economic structures. The aim will be to create a vision of a healthier city and to mobilize public support to realize this vision. The new phase begins with a review of the membership of the WHO network. Some 80% of the existing cities will become part of a new network. It will also take in new members, mostly from the CCEE. National networks will be strengthened and extended to countries where none yet exist, and a new Region -wide organization will link them together. European Centre for Environment and Health The WHO European Centre for Environment and Health was established in 1990, as an immediate follow -up to the 1989 European Conference on Environment and Health in Frankfurt. Its job is to strengthen collaboration on the health aspects of environmental protection and to improve under- standing of the relationships between environ- mental conditions and human health and well- being. One of its most pressing tasks is to gather data on the nature and extent of environmental health problems throughout the European Region, to be published as a report entitled Concern for Eu- rope's tomorrow. By drawing conclusions about the quality and availability of data and identifying priorities for future action, this report will form the basis of an action plan to be presented at the Second European Conference on Environment and Health, in Helsinki in June 1994. The project has entailed close collaboration with both coun- tries and intergovernmental organizations such as the European Community and the Economic Com- mission for Europe. Over 30 countries have al- ready established national focal points for infor- mation on environmental health. Concern for Eu- rope's tomorrow is the beginning of a long -term project to strengthen the environment and health database in the Region. In addition, the Centre is involved in a wide spectrum of technical cooperation activities, for both the Region as a whole and in individual CCEE. The Centre is coordinated from the Regional Office in Copenhagen, which also deals with over- all policy, strategies and planning. There are oper- ating divisions in Rome and in Bilthoven, and a project office in Nancy. The governments of Italy, the Netherlands and France have provided basic funding. The Centre already employs 38 staff, and experts are recruited for particular tasks. Bilthoven division The Bilthoven division has programmes on descriptive epidemiology, toxi- cology and the health impact of air pollution. A priority is the updating of the air quality guide- lines for Europe, which are widely used by gov- ernmental and other bodies as a basis for assess- ment and control. The European Community is also using them in developing its framework di- rective, which will provide the monitoring criteria for mandatory national surveys of pollution levels and for the setting of objectives for air quality. Work is also proceeding to develop guidance for the protection of people's health in both smog episodes and chemical accidents. The Bilthoven division has started a series of projects, funded by the Netherlands Government, in the Czech Republic, Hungary, Poland and Slovakia. They work to strengthen institutions, develop human resources, assess health hazards and control specific hazards. Projects are also being developed in Bulgaria and Romania. Rome division The Rome division has units re- sponsible for radiation protection, food safety, water, analytical epidemiology and data science. The radiation unit is developing follow -up studies of the health consequences of the Chernobyl nu- clear accident. It is also planning a project in the area affected by nuclear testing in Kazakhstan. The food safety unit is collaborating on the European Community ENs /CARE project, part of an ambitious plan to revolutionize the use of tele- communications in the Community. The ENs /CARE project is intended to improve the efficiency and effectiveness of national public health adminis- trations by the use of telecommunications systems and technology. Drawing on its wide network of WHO collaborating centres and other expert part- ners, the Rome division is leading the food safety part of the project. Four databases are being de- veloped: on foodborne infections, dietary expo- sure to potentially hazardous substances, food safety services and legal limits in food legislation. Three are based on existing Regional Office net- works. The water unit is advising Latvia on water supply and quality control issues, and developing guidelines for the use of recreational waters throughout the Region. In addition, it will embark on a rolling revision of the drinking -water guide- lines, using the most recent available scientific information, and will be involved in applying the existing WHO guidelines in the CCEE. Nancy project office The Nancy project office, which began operations in the second half of 1992, specializes in the public health engineering aspects of water supply and sanitation, waste man- agement and urban development. It will concen- trate almost exclusively on country projects in the CCEE. Its first project is to advise the city of Moscow on the restructuring of its water quality control operations. 11 The Nancy project office, the most recent addition to the European Centre for Environment and Health 12 Environmental degradation is a serious threat to people's health in the CCEE European Charter on Environment and Health The most significant result of the European Con- ference held in 1989 was the adoption of the European Charter on Environment and Health. It is now available in 18 languages and has been widely adopted as a basis for action by central, provincial and local governments and non- governmental organizations. It continues to influ- ence decision -makers throughout the Region. Gov- ernments have referred to it when drawing up national plans on the environment and health. It has also sparked lively debate among European parliamentarians at a Council of Europe confer- ence in Vienna in 1990, at a 1991 meeting of the International Union of Local Authorities in Oslo, and at the International Congress on Environmen- tal Health in Brighton in 1991. The implementation of the Charter by organ- izations and population groups was reviewed at a workshop organized by the Regional Office in Düsseldorf in August 1990. Since then, two subregional meetings have shown how the Char- ter can be applied in particular geographical areas. Baltic Sea countries The first of these was a workshop for countries surrounding the Baltic Sea, held in Stockholm in November 1991. These countries have many common features and close cultural and historical links. Those that, until re- cently, had centralized socialist economies are suffering from severe environmental degradation, which has harmed people's health. Natural re- sources had been seriously misused and little at- tempt had been made to alleviate industrial pollu- tion and decay. Inevitably, the impact of some of the resulting problems has spread beyond national frontiers. For example, heavy metals and toxic organic materials have contaminated the Baltic Sea. The workshop brought together representatives from Denmark, Estonia, Finland, Germany, Latvia, Lithuania, Norway, Poland, the Russian Feder- ation and Sweden. They reviewed the problems they face and decided how to tackle them to- gether, in the spirit of the Charter. They also gave clear descriptions of the environmental conditions in each country and their effect on people's health. The depressing stories of the eastern Baltic coun- tries spell out a clear need for urgent action. The burning of low- quality fossil fuels for heating and energy production pollutes the air, while untreated municipal and industrial wastewaters pollute both surface and groundwaters. Large areas of land are so contaminated with deposited wastes that they are a public health hazard. The western Baltic countries were willing to help resolve these problems, by using their own long experience in dealing with similar issues. They agreed to make special efforts to provide technical and financial support to improve the monitoring of environmental conditions and the evaluation of their effects on health, particularly among vulnerable groups such as workers, preg- nant women and children. CCEE The second workshop was organized in collaboration with the World Bank, the United Nations Environment Programme and the Gov- ernment of Switzerland, as part of the preparations for an intergovernmental conference to be held in Lucerne. The theme of this workshop, held in Copenhagen in early 1993, was the importance that should be given to environmental protection in the CCEE because of its effect on health. Clearly, these countries have much in com- mon, with conditions resulting from a long period of neglect and abuse of natural resources. A major difficulty now is the absence of adequate data on which to base rational decisions. An environmen- tal action programme for these countries is being developed for the Lucerne conference, and the workshop put the health considerations of such a programme in a proper perspective. Represen- tatives from ministries both of the environment and of health in eight of the CCEE took part in the workshop, demonstrating the growing cooperation between the two sectors in the spirit of the Euro- pean Charter. The participants described the extent of the dangerous environmental degradation in their countries and they agreed on mechanisms to ad- dress both national and international issues. In accordance with the European Charter, they rec- ognized the need to give high priority to the inter- action of environment, health and economics when addressing the problems of the CCEE. This issue is receiving particular attention in the preparations for the Second European Conference on Health and the Environment, to be held in 1994. The aftermath of Chernobyl The accident to reactor No. 4 at the Chernobyl nuclear power plant in Ukraine in 1986 produced a radioactive plume that trailed across Europe. Up to half the 10 million inhabitants of neighbouring Belarus may have been exposed to the plume and many still live in areas contaminated by fallout. They are now beginning to witness one of the first late effects of this exposure: an increase in thyroid cancer in children. Thyroid cancer in children Although increases were expected, the early appearance of relatively large numbers took a sceptical scientific commu- nity by surprise. Thyroid cancer is very rare in young children, so, however few the cases, they are much more numerous than would be expected naturally. This may indicate a much larger prob- lem to come. Though some experts still disagree about the cause, WHO has taken up the challenge of relieving the suffering and learning from the situation. The Regional Office sponsored a mission to Minsk, Belarus in June 1992, to investigate local physicians' claims of sharp increases, particularly in the Gomel region closest to Chernobyl. The mission confirmed the claims and the Regional Office launched a project to help Belarus improve the diagnosis, treatment and monitoring of the disease, and determine the origin, nature and likely extent of the outbreak. The project will be run from the Rome division of the WHO European Centre for Environment and Health. A WHO collaborating centre in Minsk is planned, to conduct research and training and coordinate all the activities in Belarus. An inter- national network of WHO collaborating centres will be set up in centres of excellence in the relevant disciplines. Belarus physicians will col- laborate in research with these centres, and re- ceive technical assistance and training from them through exchange visits. The project has received donations from the Government of Switzerland and may be implemented as part of the Inter- national Programme on Health Effects of the Chernobyl Accident coordinated by WHO. Fur- ther funds are needed. Childhood thyroid cancer need not be fatal but the prognosis depends on diagnosis and treatment. The aggressive nature of the disease means that early diagnosis is essential, yet screening the en- tire population is out of the question. The project must identify the people most at risk, to make screening more effective. Thyroid cancer is so rare that experience in treating it is scarce. The project will draw on worldwide experience to define the best treatment regime and help make it available in Belarus. In addition to thyroid cancer, the Regional Office is concerned about possible breast cancer in young women and the effects of the hot par- ticles that fell on southern Belarus. Reliable epi- demiological surveys of the populations are ur- gently needed. Clean -up workers The population around Chernobyl is not the only one at risk. Many of the 400 000 people brought in to clean up the accident site were exposed to high levels of radiation and may also be suffering the effects. Many were army conscripts, now dispersed to their homes throughout the former republics of the USSR. At the urging of the Baltic states, the slow process of tracing and studying the clean -up work- ers has begun. The Rome division held a meeting in May 1992, with the support of the Government of Switzerland; it revealed that studies of clean-up workers and sometimes their offspring have be- gun in Estonia, Latvia, Lithuania, Belarus, the Russian Federation and Ukraine. The International Agency for Research on Cancer is planning a feasibility study on the most affected countries (Belarus, the Russian Federation and Ukraine) but still lacks funds. Accurate and reliable dose estimates may be impossible to obtain but the consequences of the Chernobyl accident demand study. Only coordi- nated studies, however, using compatible proto- cols will produce comparable results and provide the public with the information that it needs and will believe. A committee of Baltic country rep- resentatives has been created to carry out this work. Meanwhile the time bomb continues to tick. The remains of reactor No.4 at Chernobyl present a serious hazard of further contamination. The existing containment could collapse, injecting sev- eral tons of radioactive dust into the atmosphere. Many Soviet -designed reactors are still in use throughout the CCEE. As the Chernobyl accident has shown, radiation respects no boundaries. We are all at risk. 13 Belarus Gomel Region O Estimated The sharp rise in childhood thyroid cancer in Belarus Clean -up workers brought in to Chernobyl were exposed to high levels of radiation 14 Health care reform Europe is changing rapidly. What was thought to be stable and predictable until a few years ago is now insecure and in constant turmoil. The health sectors in rigid, centrally planned economies have had to get used to raging market forces and gallop- ing inflation. In pluralistic societies, hospitals have suddenly been awakened from their Sleeping Beauty dreams to deal with contracting and com- petition for scarce funds. Even in affluent so- cieties, citizens have been horrified to learn that the heavy taxes they pay do not automatically give them access to every scientifically possible form of technical care, because funds are lacking. Medi- cal personnel are graduating with high qualifi- cations only to hear that society does not need their expertise or that they have studied the wrong subjects. What went wrong, during the last dec- ade, despite all the good intentions and the poli- cies for health for all? EUROCARE project Nothing has gone wrong. The world is just changing, as it always does, and we Discussion of the pertinent issues by the First Working Party on Health Care Reforms in Europe, Madrid, 1992 To have a common goal and to work towards it in a coordinated way - that's what reform is about must change with it as fast as we can. WHO's response has been to go into the reform process by launching the EUROCARE project. It has provided a forum for top -level decision -makers (ministers of health, first secretaries and directors -general) and their advisers from both east and west to discuss how to handle the process of change. In 1992, the WHO working party on health care reforms held its first meeting in Madrid, where members ex- changed their experiences and evaluated the vari- ous options open to them. But theory and words are no longer enough in a Europe where health conditions are in many ways beginning to resemble those in the third world. Through its EUROCARE project, WHO can play a significant role in helping its Member States halt this decline. Since the meeting in Madrid, WHO has been drawing on the project's networks in the fields of financing, management, hospitals and training, and setting up think tanks of key players to debate the issues in depth. WHO soon realized that, despite the vast amount of information available, no one knew enough about the actual health care reforms tak- ing place in the Region. Now the EUROCARE project is building up a monitoring system to track them. It aims to keep all parties informed of these events, and their outcomes, in a pragmatic way. The re- sulting health in transition (or HIT) profiles will be available on Belarus, Hungary, Kazakhstan, Latvia, Poland and Uzbekistan by the end of 1993. They will be supplemented by some 15 reform overviews (or Rovers). Experience counts In the present climate of de- centralization and decreasing ministerial control, the EUROCARE project cannot reach its goals sim- ply by working through top -level decision -makers and by imposing legislative measures. A powerful tool is to influence the reform process through local projects on health care development. For example, in Austria, several experiments have helped to improve the collaboration between health professionals and social workers for the benefit of their clients. In the Czech Republic, a town of 100 000 people has introduced a new information system to tailor the health services more closely to the needs of the population. In Finland, the system of having a personal physician has been introduced and the physicians' salary system changed accordingly. In a district of Mos- cow, the health services aimed to improve their efficiency and quality by identifying external funds and putting more emphasis in the budget system on results. In the United Kingdom, a workshop brought together 40 health care providers, pur- chasers and consumers to simulate a model for a better local health care system. Through these local examples, brought together by the EUROCARE project, innovations in the prac- tical implementation of health care reforms can be shared with the whole population of the Region. Health information Countries need to share information about health and related issues. Learning both from their own experience and from that of other countries will help them update their health policies and track their progress towards health for all. The Regional Office acts as a catalyst, a facilitator and a clear- ing- house: a European health information centre. The Office takes two approaches to this role. First, it collects, maintains, interprets and dissemi- nates information about people's health through- out the Region. Its main tool is the triennial Regionwide monitoring and evaluation of progress towards health for all. The feedback from such international comparisons enhances countries' own efforts on issues ranging from health policy to service delivery. It also highlights some of the dramatic differences between countries and groups of countries. The Regional Office's second ap- proach is to help countries strengthen their own information systems. This has the additional ben- efit of improving their contribution at the inter- national level. International exchange For the past seven years, the Office has developed and maintained the Health for All Database. It contains readily accessible and coordinated comparative information about health, gleaned from the Member States of the Region. A user -friendly PC version of the data- base is in great demand and a new Windows version was developed in 1992. The Office also regularly meets requests for information on vari- ous other topics (including nutrition, quality as- surance systems and health documentation). This wealth of information is updated periodically, en- abling the Office to measure and analyse the health situation in the Region. The reform of health care in the CCEE re- quires detailed knowledge of the existing systems and health in these countries. In March 1992, the Regional Office extended its database to include data on the NIS. Many donors and other agencies are commit- ted to assisting reform in the CCEE. Their de- mands for information are growing rapidly. To meet this demand, the Regional Office started to produce highlights on health for these countries. The highlights are an extract and analysis of the most important information held by the Office. The Regional Office also produces more detailed profiles for these countries in specific areas such as nursing and health care reform. Better country information The Regional Office helps countries strengthen their health information systems, which improves the quality and compar- ability of the health data they collect. For exam- ple, guidelines have been drawn up on conducting health interview surveys that will comparably measure health for all indicators. This will help harmonize health monitoring in the Region. Simi- larly, guidelines on producing public health re- ports are intended to improve international stand- ards of health reporting. Another aim is to help countries make better use of health data in planning and management. A major project has begun to help the CCEE develop a system of health service indicators, similar to the one used in the United Kingdom. So far, Bulgaria, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania and Slovakia have joined the project. To help the CCEE make better use of available mortality data, an atlas of avoidable mortality is being prepared in collaboration with the Hungar- ian Central Statistical Office. The atlas will help health administrators in planning and in assessing health care quality. Finally, the Regional Office coordinates a longi- tudinal study on risk factors in children, ac- cumulating valuable epidemiological data. In the United Kingdom, for instance, these data have been used to monitor the results of a campaign to prevent cot deaths. Though a slow process, it is vital to study today's children in order to help tomorrow's. Documentation Units throughout the Regional Office collect, analyse and disseminate information in many forms. Much of it appears in publications and documents, which are distributed through net- works, sold in bookshops, displayed in libraries, and widely translated into the many languages of the Region. Details of this documentation are available on the Regional Office bibliographic database, EuaoDOC, which will soon become pub- licly accessible. Over 20 libraries and health documentation centres in 20 countries have been officially ap- pointed as Regional Office documentation cen- tres. They ensure that documents and publications of the Regional Office are prominently displayed and easily available. Liaison offices in the CCEE have been given ready -to -use WHO reference libraries. These will soon be available to the MS. Comparative health information at inter- national, national and subnational levels is essen- tial in the drive to improve health. The objective of the Regional Office as a European health infor- mation centre is to help countries to share and learn from each other's experience. 11111111 IIiIIIIII I! ._ '1:114111.10111111401.1 15 As a European health information centre, the Regional Office disseminates vital information on health, through such reports as these The Health of Europe offers a wider public access to Region -wide information collected by experts 16 Family health The policy of health for all rests on primary health care: essential care that is available to everyone and easily accessible from homes and workplaces. It gives people the information they need to lead healthier lives. It treats common diseases before they get worse. It gives individuals and families control over their lives and their health. Every country in the Region adopted this ideal over 15 years ago. Putting it into practice has been less easy. The need to reform health care systems throughout the Region and particularly in the CCEE, however, makes it all the more urgent and relevant today. Basing a health care system on pri- mary health care requires health pro- fessionals (nurses, midwives, general practitioners and others) to work to- gether as a team in the community. Countries therefore allocated budgets to fund teams and set up local health care centres where they could work. But somehow, the awaited transfor- mation did not happen. The Regional Office therefore re- assessed the assumption that setting up the right organization will ensure that the right jobs are done in the best poss- ible way. The aim now is to identify the key functions whose performance is critical to a good health care system. By focusing on the function instead of the performer, one can separate the two. What matters is what is done well, not who does it. The function may be carried out effectively by differ- ent people or services in different settings, such as schools, workplaces or homes. A good health care system defines its effec- tiveness by the outcome of patients' contact with it. The more their health improves, the better the system. To change the way they work, health profes- sionals must first know more about their current practices. With the support of WHO, general practitioners and nurses have begun to describe what they do and to try new approaches that might work better. They are identifying models of good practice: those that lead to a measurable improvement in health outcome. This approach has a number of benefits, chief among them flexibility. Countries may choose the models that suit them best. These models can answer questions, such as what makes an interdisciplinary team function well and what are the roles of different health care providers. They can show how different sectors of the health system can cooperate best. Finally, they contribute to the general review of health care systems, by showing the effects of different health Primary health care workers hold the key to family health This report will help nurses create a new role as autonomous, skilled professionals care policies (including financing systems) on health and the health care system. General practitioners To help general prac- titioners break out of their traditional mould, WHO is promoting the development of a Charter of General Practice. It will not only define what general practitioners already do well, but also indicate what more they could do, particularly in prevention. WHO has also become a partner in a new project, the Integrated System Architecture for Advanced Primary Care (Isaac), launched by the European Community in 1992. The project investigates the information needs that general practitioners share with other health professionals in the primary health care field. Both the Charter and Isaac will lead to new definitions of general practice and show its place within primary health care. The CCEE are also learning about the role of general practice from the experiences of southern Europe. Since 1986, WHO has held regular meet- ings on the development of primary health care in southern European countries. The 1993 forum reviewed the relevance of these discussions to the CCEE. This tied in with various WHO reviews of the development of primary health care in indi- vidual CCEE. Nurses Nurses and midwives also need to work in new ways. As the largest occupational group working in the health services, they are a major force in the development of primary health care. The entire nursing infrastructure needs to be im- proved, particularly in the CCEE. Apart from drawing up models of good practice to learn from, their priorities are to reform basic nursing edu- cation, and develop management and leadership. The changes that result will enable nurses to take up their role as partners in the primary health care team. WHO has launched the learning materials on nursing (LEMON) project to supply nurses and mid- wives with the modern, high -quality educational materials they urgently need. The WHO Nursing in Action project brings together the nurse leaders of the Region to discuss national action plans for nursing and how to link them to national health policies. Clinical nurse leaders have been trained . in project management. Projects that improve the outcome for patients are being studied to identify models of good practice. Family health Nurses and general practitioners are the two main agents of primary health care. By addressing the family and taking their work to people's homes, they may learn to share their functions more efficiently and ultimately bring better health to everyone in the community. Conclusion How healthy could Europe be? In general, the Region has moved towards better health. Healthy lifestyles and environ- mental issues are gaining ground. Reforms in health services are begin- ning. Countries, regions, provinces, cities and even neighbourhoods are adopting health for all as a policy basis. But this overall progress hides a widening gap in health status between the northern and western and the central and eastern parts of the Region. The changing political map of Europe, increasing migration, slow economic develop- ment, high unemploy- ment and the aging of the population are formidable challenges for the European Region and the Regional Office. Yet progress can continue, and the health divide can be narrowed, if we are prepared to learn from experience. Advances in health are slow and require sustained and cumulative effort. But health development on the basis of the principles of health for all is the most economical way of maintaining and promoting health. Health and welfare, after all, are resources, not just areas of expenditure. Policy -makers at national, regional and local levels must accept their social responsibility by being aware that every decision they make may affect people's health. Health is not the sole concern of governments and health professionals: it depends on the creativity, resources and commitment of a wide range of other people and social groups, including those in business and industry, the law, education and the media. Putting these lessons into practice is our task for the coming decades. 17 World Health Organization Regional Office for Europe Copenhagen WHO Regional Publications European Series No. 50 ISBN 92 890 1314 1 Sw.fr. 12.-