Fifteenth Standing Committee of the Regional Committee for Europe Third session Copenhagen, 14 January 2008 EUR/RC57/SC(3)/REP 15 January 2008 80147 ORIGINAL: ENGLISH Report of the third session W O R L D H E A L T H O R G A N I Z A T I O N • R E G I O N A L O F F I C E F O R E U R O P E Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark Telephone: +45 39 17 17 17 Fax: +45 39 17 18 18 Electronic mail: postmaster@euro.who.int World Wide Web address: http://www.euro.who.int
EUR/RC57/SC(3)/REP page 1 Opening by the Chairperson and Regional Director 1. The Fifteenth Standing Committee of the WHO Regional Committee for Europe (SCRC) held its third session at the WHO Regional Office for Europe in Copenhagen on 14 January 2008. 2. The Chairperson welcomed the alternate members for Kyrgyzstan and Serbia, noted with pleasure that the member for Switzerland was attending his first full meeting and was pleased to see that the member for Italy was returned to full health. 3. The WHO Regional Director for Europe informed the SCRC that, since its previous session, operational planning for the 2008–2009 biennium had been completed. The second preparatory meeting for the forthcoming WHO European Ministerial Conference on Health Systems, on performance and health service delivery, had been held in Bled, Slovenia in November 2007, and a Ministerial Forum on tuberculosis had taken place in Berlin in October 2007. Technical meetings had also been held on avian influenza and noncommunicable diseases. Adoption of the provisional agenda, the provisional programme and the report of the second session (London, 8–9 November 2007) 4. The provisional agenda and programme of the Fifteenth SCRC’s third session, and the report of the second session, were adopted without amendment. Review of the provisional agenda and provisional programme of the fifty- eighth session of the Regional Committee (RC58) 5. The Deputy Regional Director explained that the programme of RC58 had been arranged to allow for one major substantive topic to be taken up each day: the proposed programme budget 2010–2011 on the Monday afternoon, stewardship/governance of health on the Tuesday and public health strategies targeting behaviour on the Wednesday. 6. The Standing Committee was concerned at the possible overlaps between the agenda items on the Regional Director’s report and on follow-up to previous RC sessions. The Regional Director said he would make it clear, both in the letter of invitation to the session and in his address, which subjects would be taken up in the “follow-up” discussion. In any case, a number of them could be covered in writing only. 7. It was decided that the private meeting to agree on elections and nominations to various bodies would best be held on that Tuesday afternoon, to allow time for consultations on the Monday and avoid placing the Regional Committee in a situation where it had to make decisions at the last minute. 8. Under the agenda item on stewardship/governance of public health, the Regional Committee would be asked to adopt a resolution endorsing the Charter that was due to be approved at the WHO European Ministerial Conference on Health Systems . At the same time, the ethical framework on human resources migration for health that had been called for by RC57 and was being developed by a small working group for consideration at the Conference could also be submitted for endorsement if so agreed during the conference. In general, the process of working on health systems strengthening was an ongoing one that would continue beyond the Conference and discussions at RC58. 9. The Fifteenth SCRC accepted with gratitude the invitation by the member from Georgia to hold its fifth and final session in Batumi prior to RC58. EUR/RC57/SC(3)/REP page 2 Outlines of main policy/technical subjects for RC58 Stewardship/governance of public health in the WHO European Region 10. The Deputy Regional Director explained that, while the Ministerial Conference would consider the various dimensions of the triangular relationship between health systems, health and wealth, the agenda item at RC58 would be focused on the best ways for ministries of health to exercise their responsibility for health governance. In the light of the findings of recent research, which demonstrated that effective health care had a bigger influence on health status than previously expected, effective health systems governance was seen as a precondition for tackling key challenges such as globalization, migration and climate change. 11. There were remarkable variations in the ways in which experts understood the concepts of public health and stewardship. The paper for RC58 would accordingly revisit the definitions and address the main technical issues at stake, based on WHO policies and positions. In particular, it would examine how the stewardship function contributed to the attainment of better health by: (a) orienting personal health care in primary centres and hospitals towards effectiveness and health gain; (b) ensuring that non-personal health services (health promotion, disease prevention, etc.) were relevant and cost-effective; and (c) providing leadership and advocacy so that other areas of government and the private sector paid attention to the social determinants of health and the need to incorporate health in all policies. 12. The RC58 paper would accordingly identify and analyse the tools and instruments required to secure that contribution. They included refinements to epidemiological analysis, improved priority-setting and strategic planning; better communication with other stakeholders; negotiation techniques to build alliances; norms and laws that would protect the weakest members of society; schemes for empowering citizens and promoting behavioural changes; and mechanisms for monitoring and supervision, as well as legal instruments for enforcing sanctions, if required. 13. In conclusion, the paper would recognize that stewardship of public health alone was not the solution. Health system performance also depended on proper interaction between the other functions inherent in a system: resource generation (human resources, facilities, technologies, etc.), service delivery and financing. 14. As noted above (para 8), a draft resolution setting out the key conclusions of the Ministerial Conference and the RC paper would be submitted for adoption by the Regional Committee. 15. The SCRC called for the paper to include a short, practical glossary of the key terms used, so as to avoid having to engage in debates around terminology and to distinguish clearly between the broader perspective of health, on the one hand, which was the responsibility of the entire Government, and the areas which health ministries were directly accountable for, on the other. That, in turn, would help to clarify the issues and the extent to which the debate at the Regional Committee would be a continuation of discussions at the Ministerial Conference on Health Systems. The importance of inclusion of governance of the decentralized system, as well as steering of the private sector, was also agreed. The SCRC recommended that the paper for RC58 should take account of the conclusions reached at the Conference. In light of the above, it would therefore be relevant to amend the title of the session to “Stewardship/Governance of Health Systems”. In practical terms, it might be advisable to have a very short session of the SCRC in the afternoon following the closure of the Conference on 27 June 2008, to review the outcomes of the latter and see how best to take them forward to the Regional Committee. 16. The Deputy Regional Director reiterated that the proposed content of the RC paper would cover the health systems stewardship function in relation to the broader scope of improving the health of nations, EUR/RC57/SC(3)/REP page 3 where ministries of health would have a role to play and through explicit measures, be accountable for their own work, as well as for guiding work by other sectors and actors. Public health strategies targeting behaviour 17. The Acting Director, Division of Country Health Systems emphasized the fact that modifiable behavioural risk factors were the leading causes of mortality in the developed world. Individuals’ behaviour needed to be better understood if public health strategies were to have the desired effect. While it was known what results could be obtained through behavioural changes such as smoking cessation or adoption of healthy diets, much less was known about how to effect such changes sustainably and systemically at population and individual levels. 18. Mass public health campaigns often failed to achieve the desired results, particularly among those regarded as being most in need. While they were potentially cost-effective and generally raised awareness, such campaigns ran the risk of being poorly targeted and might contribute to widening the health gap between different groups. Interventions focused on individual behaviour on the other hand, could be better targeted and allowed for direct engagement and peer-to-peer spread of messages, but they were often not cost-effective or sustainable and generally did not yield results that were measurable in terms of life years saved or disability avoided. 19. The paper for RC58 would therefore address questions such as “How cost-effective are current public health campaigns?”, “What is the capacity of health systems to design, fund, deliver and measure the impact of behaviour change programmes?” or “Do behaviour change programmes increase health inequities in already vulnerable groups?” In so doing, it would refer to the scarce (although growing) evidence base on what worked in health behaviour change, possibly including case studies to capture intercountry differences in approaches. 20. The paper would provide guidance to ministries of health on how to design and deliver personal and population-based health services that incorporated a solid understanding of individual and group behaviour as developed by psychologists and other experts. While focusing on actions to be taken by ministries of health, it would also enable them to provide leadership for intersectoral programmes involving areas such as education, local government and the media. Lastly, the paper would examine the role to be played by WHO in order to better support Member States in that area. 21. The SCRC believed that the question of health promotion should be considered in conjunction with the effects of health determinants. A close review should be made of the evidence of what favoured changes in health behaviour. That review would require the involvement of scientists and social scientists, and the SCRC offered to provide links with national specialists, to feed into and build on the work being done by the Regional Office, together with its professional networks. SCRC welcomed the evident link of behavioural change policies to the stewardship role of governments. 22. While acknowledging the reservations about public health campaigns expressed in the outline of the RC58 paper, the SCRC felt that they could be valuable instruments if conducted in conjunction with other measures such as legislation and pricing. Some countries had experience of effective campaigns targeted at specific risk groups, such as people vulnerable to HIV/AIDS. More generally, the SCRC recommended that the paper should present case studies of successes (and failures) of interventions aimed at changing people's behaviour, differentiating between the various types (addictive/non-addictive, etc.), both within and outside the WHO European Region. The paper should not impose solutions but rather promote good practices and evidence on effective interventions through case studies, including the effectiveness of prevention laws in the European Member States. It would be desirable that the paper leads to some level of prioritization in terms of focusing resources on cost-effective interventions. Lastly, the SCRC suggested that the topic might lend itself to a panel discussion at the Regional Committee session, possibly involving representatives of other bodies such as the Organisation for Economic Co- operation and Development (OECD). EUR/RC57/SC(3)/REP page 4 Review of the process of reporting back to the Regional Committee on resolutions adopted at previous sessions 23. The SCRC welcomed the proposals contained in the working paper whereby an end date would be applied to a number of open-ended commitments on the part of the Regional Director to report back to the Regional Committee. It suggested that a shorter version of the working paper, possibly accompanied by a draft resolution, might be submitted to RC58. In addition, it recommended that resolutions adopted by the Regional Committee in the future should, where practicable, not contain such open-ended commitments. Regional suggestions for elective posts at the Sixty-first World Health Assembly in May 2008, including permanent membership of the General Committee and the Committee on Nominations 24. The SCRC confirmed that it had a legitimate role to play in advising the Regional Director on the names of individuals and countries that he would suggest for elective posts at the World Health Assembly, as it did on other matters. It acknowledged his suggestions for the positions of Vice-President of the Health Assembly and Chairman of Committee A. Equally, it agreed with his proposals for membership of the Committee on Credentials and the Committee on Nominations noting that the latter was due to be discontinued after the Sixty-first World Health Assembly (WHA61). 25. With regard to the arrangement whereby the three European permanent members of the United Nations Security Council traditionally enjoyed permanent membership of the Health Assembly’s General Committee, the SCRC appreciated the gesture of goodwill made by the United Kingdom in giving up its seat the previous two years. It asked the Chairperson to meet representatives of all three countries concerned (France, the Russian Federation and the United Kingdom) towards the end of the forthcoming session of the Executive Board, in order to draw their attention to that gesture and commend it to them as a good way of ensuring broad representation of European Member States on the General Committee. In effect, the continued permanent membership of those three countries, in conjunction with the practice of awarding the remaining fourth European seat on that committee to the country holding the presidency of the European Union (EU), “disenfranchised” the 25 European Member States of WHO that were not members of the European Union. Nominations to WHO bodies and committees: country groupings/ rebalancing of countries 26. As requested at the previous session, a small working group of the SCRC (consisting of members or alternate members from Georgia, the Netherlands, and Norway) had had two telephone conferences to evaluate whether the country groupings used for considering candidates for membership of the Executive Board should be adjusted as some of those groups (EU and European Free Trade Association (EFTA) countries (north), EU and EFTA countries (south) and Commonwealth of Independent States (CIS)) were related to political bodies, while the fourth (south-east) was based on purely geographical considerations. The working group recommended that the groupings should not be adjusted at present, because of current political dynamics within the CIS. 27. The SCRC noted that the geographic grouping as set out in the annex to resolution EUR/RC53/R1 made reference to the fact that the European Region (at the time of adoption of the resolution in 2003) had had seven seats on the Executive Board. Now that it had eight seats on the Board (and the arrangement was also applied, passim passu, to the SCRC, where nine seats were available), an explanatory paper and updated annex might need to be presented to RC58. The SCRC looked forward to reviewing a draft of that paper at its next session. EUR/RC57/SC(3)/REP page 5 Regional Search Group for candidates for the post of Regional Director 28. The Chairperson noted that the Organization’s Legal Counsel had advised that it was too late to make changes to Rule 47.1 of the Rules of Procedure of the Regional Committee and the Standing Committee, given that the Regional Director’s letter requesting nominations for various bodies, including the Regional Search Group (RSG) had already been sent out on 11 January 2008. In line with that rule, the RSG would consist of three members and three alternates. The SCRC recalled that meetings of previous RSGs had been attended by all members and alternates. It therefore suggested that balanced geographical representation of all European countries on the RSG could be secured by having the three members and the first of the alternates drawn from the four groupings being used for nominations to the Executive Board 29. The Chairperson of the SCRC also explained that Legal Counsel had confirmed that Rule 47.2(a) should also be interpreted to apply to ex officio and outgoing members of the SCRC1. 30. Given that the Standing Committee had a mandate from the Regional Committee to act on its behalf, and that the Regional Committee had the opportunity to comment on the work done by the Standing Committee, the SCRC saw no reason why it should not draw up a desired profile of the candidate for the post of Regional Director, to help the RSG in its task. The SCRC would consider, at its next session, the question of who would draw up such a profile, at the same time as it considered the list of candidates for membership of the RSG. Other matters Preparations for the 122nd session of the Executive Board 31. The SCRC recognized that, with Slovenia holding the presidency of the EU at the same time as it had a member of the Executive Board who also attended meetings of the Standing Committee as an observer, there was a unique opportunity for expressing consistent views of member countries of the EU in WHO’s various bodies. To that end, the Regional Director (or his representative) was willing to attend the coordination meetings of EU members of the Executive Board, if invited to do so. Nonetheless, the SCRC agreed to consider, at a future session, the question of how best to coordinate the views of EU and non-EU Member States. 32. The Executive President of the Regional Committee offered to share with the SCRC the draft resolution that the United Kingdom intended to submit to EB122 on climate change and health. WHO European Ministerial Conference on Health Systems, Tallinn, Estonia, June 2008 – progress report on preparations, including report on other activities in the area of health workforce 33. The Deputy Regional Director, having recalled the objectives of the forthcoming Conference, reported that work was well advanced on two commissioned studies on central Conference themes, as well as on a series of policy briefs on key health system strategies. In addition, relevant studies were under way in WHO and other organizations. The second pre-Conference meeting, on improving the performance of health service delivery and putting patients at the centre of health systems, had been held in Bled, Slovenia on 19 and 20 November 2007. A charter was being developed by a drafting group consisting of nominated representatives of 26 Member States and partner organizations, and the second meeting of the group was due to take place in Valencia, Spain on 8 and 9 February 2008. The third and final pre-Conference meeting, on health systems governance, would be held in Rome in April 2008. The Conference itself would be a two and a half day event, bringing together some 500 participants and 1 Legal Counsel has since confirmed that Rule 47.2(a) should be read to include any person belonging to a Member State’s delegation to the SCRC i.e. alternates and advisers as well as the designated member. EUR/RC57/SC(3)/REP page 6 attracting internationally renowned keynote speakers. A photograph competition was being organized to showcase contemporary images of health systems in the WHO European Region. A representative of the host country would attend the next session of the SCRC and report on the progress of preparations there. 34. In preparation for the First Global Forum on Human Resources for Health (Kampala, Uganda, 2–7 March 2008), the Acting Director, Division of Country Health Systems had attended a high-level meeting on scaling up health workforce education and training, hosted by the African Union in Addis Ababa, Ethiopia 8-10 January 2008. It had subsequently been agreed with the Executive Director of the Global Health Workforce Alliance (GHWA) that a keynote speaker from Norway would deliver an address on the theme of “Migration and retention” during the Action Conference component of the Forum on 4 March 2008, while a half-day “constituency meeting” in the morning of 6 March 2008 would be devoted to the same theme, with European and African ministers of health and/or country representatives participating in a round-table discussion, together with international experts on migration and representatives of the respective WHO regional offices. 35. The Vice-Chair of the SCRC and WHO Secretariat would attend the meeting in Kampala. It was also agreed for EURO Secretariat to facilitate a meeting with WHO/AFRO to discuss how best EURO Member States could support the needs of the countries in AFRO. 36. The SCRC agreed that it would be important for the WHO Secretariat as a whole to work closely on the issue of health workforce migration in preparation for the discussions at EB122 and WHA61. It noted with satisfaction that a WHO Regional Office for Europe technical group (including a representative of OECD) was working on an ethical framework on health workforce migration; the next meeting of the group would be in early February 2008 (after EB122), and the framework could be presented to the Health Systems Conference and subsequently perhaps to RC58 for endorsement. Council of Europe and blood transfusion/organ transplantation – update on recent developments 37. The Regional Director reported that he had had an informal meeting with the Secretary-General of the Council of Europe (CoE) at which the question of blood transfusion had been discussed. The SCRC urged the Regional Director to draw attention to all aspects of blood safety, and especially those related to hepatitis C. 38. The discussions with CoE would continue to produce a working arrangement. Geographically dispersed office in Athens – progress report on discussions 39. The Deputy Regional Director informed the SCRC that the first draft agreement on establishing a geographically dispersed office (GDO) in Athens had been sent to the government of Greece for comment. Both parties shared the view that the work of the Athens GDO should be focused on information generation, knowledge creation and technical support. In terms of logistics and financial arrangements, the Greek government was offering to pay some US$ 5 million per biennium over a period of 10 years, in addition to office premises and running costs; that would represent a valuable contribution to an area of work that was due to be funded to a total amount of US$ 28 million (including staff costs) in 2008–2009. The Regional Director reiterated that he would ask the SCRC for its views before he concluded the agreement.