Making things happen 2014–2015: implementing the European policy framework for health and well-being Health 2020 in the former Yugoslav Republic of Macedonia

M A K I N G T H I N G S H A P P E N 2 0 1 4 – 2 0 1 5 Implementing the European policy framework f o r h e a l t h a n d w e l l - b e i n g H e a l t h 2 0 2 0 in the former Yugoslav Republic of Macedonia Abstract: This publication provides an overview of the WHO activities and achievements in the former Yugoslav Republic of Macedonia in the period 2014-2015, focusing on the implementation at national level of Health 2020, the WHO European policy framework for health and well-being. Keywords: HEALTHY PEOPLE PROGRAMS HEALTH PLAN IMPLEMENTATION HEALTH POLICY GLOBAL HEALTH WORLD HEALTH ORGANIZATION - organization and administration Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City Marmorvej 51 DK-2100 Copenhagen Ø Denmark Alternatively, complete an online request form for documentation, health informa- tion, or for permission to quote or translate, on the Regional Office website (http:// www.euro.who.int/pubrequest). © World Health Organization 2015 3 Acknowledgements This publication presents the results of the joint work and collaborative efforts of all sectors of the Government, under the leadership of the Ministry of Health, in the areas of action scoped in the Biennial Collaborative Agreement 2014–2015 signed between the Ministry of Health of the former Yugoslav Republic of Macedonia and the World Health Organization Regional Office for Europe in September 2013. Local communities, civil society organizations, individuals, the United Nations and other international organizations in the country have also contributed to achieving these results. The work in the country has been coordinated by the WHO Country Office. © World Health Organization 2015 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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 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. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. 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The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. 54 The complex, interconnected world we now live in demands a new, more ambitious, more comprehensive, universal agenda for people, the planet and prosperity – and this is what the sustainable development agenda promises. One of the 17 new Sustainable Development Goals (SDGs) – goal 3 – is specific to health. It is to “ensure healthy lives and promote well-being for all at all ages”. This goal and its targets build on the Millennium Development Goals, with new priorities for health, such as addressing noncommunicable diseases (NCDs) and ensuring universal health coverage so that everyone has access to high-quality, affordable health and public health services. Achieving these new targets requires action by all of us – we are all making this journey together. Now more than ever before, we live in a world where we need global reach, legitimacy and an inspiring agenda that will remind us of our collective responsibility to build a healthier, fairer, safer world, where no one is left behind. Health 2020, the European policy for health and well-being, is fully aligned with the new sustainable development agenda. We in Europe are not starting from scratch. Europe is already well on its way to achieving its SDGs. Health 2020 has already been facilitating the change necessary for achieving the SDGs in the WHO European Region. The former Yugoslav Republic of Macedonia has made significant progress towards implementation of the European and global policies for health and well-being, by setting up its own national health and well- being agenda, Together for Health for All, focused on strengthening public health, addressing the burden of NCDs, and health and environment determinants of health, at its core. It builds on the achievements so far and continues the work on communicable diseases (CDs) and health system strengthening. This is a promising start. WHO will continue to support the country on its way towards achieving better health gains, through implementing the national Health 2020 agenda in the period to come. Dr Zsuzsanna Jakab WHO Regional Director for Europe Foreword Working for a healthier future The countries of the WHO European Region have been important advocates of health and its central role in the 2030 Agenda for Sustainable Development. Following the adoption of the 2030 Agenda in September 2015, its adaptation at country level and integration with national development planning, adopting national targets, has begun. This represents a unique opportunity to renew national commitments to health and seek intersectoral synergies to advance sustainable development goals and implement the priorities already endorsed through Health 2020. Health 2020, adopted by European Member States in 2012, strongly emphasizes improving health for all and reducing health inequalities, as well as working across sectors and government to improve leadership and participatory governance for health. A truly transformative shift would be required to implement an integrated approach to sustainable development, and to ensure that every person’s health and wealth and human rights are respected. The vision and objectives of the national health policy framework Together for Health for All reflect contemporary developments and have the potential to facilitate this transformative shift at country level. Built on and guided by the Health 2020 European policy framework, it positions the country on the right track to achieve the SDGs. Efforts in the WHO Country Office have focused on supporting the national authorities for health in taking a whole-of-government and whole- of-society approach to respond to social, economic and environmental challenges critical for health development. The country has made good progress in many areas, and yet there is still much to do, and partnerships are essential. The WHO Country Office will continue to support the country towards implementation of Health 2020 and the SDGs, and engage in a multisectoral response based on partnership. This will be the main reference point for further developing and implementing the national Health 2020. Snezhana Chichevalieva Head of WHO Country Office, Skopje Foreword Pursuing better health for Macedonians Launching the Health 2020 process at national level with full political support (left to right: Agis Tsouros, WHO Regional Office for Europe, Nikola Todor- ov, Minister of Health, Snezhana Chichevalieva, Head of WHO Country Office) © WHO/A.N. Bingol 76 What WHO does WHO works with national governments and international organizations, serving its 194 Member States by: • providing leadership on global health matters • shaping the health research agenda • setting norms and standards • articulating evidence-based policy options • providing technical support to countries • monitoring and assessing health trends. All of WHO’s actions are based on a set of shared values; key among them is the idea that health is a human right. WHO and you WHO’s work has a significant impact on all people’s lives. With help from WHO and its partners, a greater number of: • government policies are in place to ensure that all people have equal access to effective health care; • agreements have been reached to protect against shared health threats, such as tobacco, disease outbreaks or chemical pollution, as health risks can cross borders; • drugs are available for treating tuberculosis (TB), HIV/AIDS and many other killer diseases; • people are protected by life-saving vaccines against poliomyelitis (polio), measles, rubella, diphtheria, tetanus, pertussis and meningitis; • best practices for midwives, surgeons and other health workers have been developed; • sectors of public life — such as transport, agriculture, education and urban planning — take health into account; • diseases, including polio and leprosy, will soon be eliminated; and • well-targeted interventions are making environments healthier and preventing illnesses from unsafe water, air pollution and poor hygiene. BUT THERE IS STILL A LOT OF WORK TO BE DONE TO MAKE THE WORLD A HEALTHIER PLACE The WHO Country Office in Skopje was established in January 1996. Priorities for joint work are set out in the biennial collaborative agreement (BCA) between WHO Regional Office for Europe and the country for 2014–2015. Global direction: The BCA aligns with WHO’s Twelfth General Programme of Work for 2014–2019, which establishes priorities for the Organization’s work and an overall direction for the six-year period beginning January 2014. In so doing, it reflects the three main areas of WHO reform: programmes and priorities, governance, and management. Regional perspective: It reflects the European policy framework for health and well-being, Health 2020, adopted by the WHO Regional Committee for Europe at its 62nd session in 2012. National implementation: The aim of the BCA is to raise the level of health in the country and reduce inequity in the distribution of health within its population. The 2014–2015 priorities are placed within the programme categories of: CDs, NCDs, promoting health throughout the life-course, health systems and preparedness, surveillance and response. WHO Country Office WHO in numbers • Year founded: 1948 • Governance: WHO Constitution, elected Executive Board, World Health Assembly (of all Member States), regional committees for all regions • Member States: 194 • Regional offices: 6 • Country offices: 147 • WHO collaborating centres: 800 • NGOs in official relations with WHO: 183 WHO Country Office staff with the Minister of Health About WHO WHO was founded in 1948 to help people everywhere achieve the highest possible level of health. To provide tailor-made assistance to Member States on specific issues, WHO has six regions, including the European Region. © WHO/Predrag Kitanovski 9OUTWARD LOOKING Health as a goal, Health as an outcome Health 2020 is…. Health 2020 is a health policy framework that guides the 53 countries of the WHO European Region. It recognizes that good health benefits everyone, and that countries can reach the highest standards of health by working across government to pursue two strategic objectives: (i) improving health for all and reducing health inequalities; (ii) improving leadership and participatory governance for health. Achieving these objectives will take a combination of individual and collective efforts. Governments, nongovernmental organizations (NGOs), civil society, the private sector, academia, health professionals, communities and all individuals have a role to play in Health 2020, and all must work together. This was a guiding principle in developing the policy framework, which brought together input from all Member States as well as NGOs, professional associations and international partners, including the European Union. Health 2020 has four interconnected priority areas for policy action that are tailored to the particular health needs of the Region. While each country has a different starting point, as well as its own circumstances and capacities, these priority areas form the foundation for all work within Health 2020: (i) investing in health through a life-course approach and empowering people; (ii) tackling the Region’s major health challenges of NCDs and CDs; (iii) strengthening people-centred health systems, public health capacity and emergency preparedness, and surveillance and response; and (iv) creating resilient communities and supportive environments. With the coordinated common framework provided by Health 2020, all European countries can realize the benefits of good health, which in turn strengthens communities and society as a whole. Health 2020: the European policy framework for health and well-being Making a difference in the Region Health 2020: making a difference in the Region 11 FORWARD LOOKING Responding to contemporary Health challenges Health 2020 is… Recognizing the need for systematic action for better health of future generations, the Government initiated the development of the national Health 2020 policy for health and well-being framework at the start of 2014, using an open, consultative, participatory and inclusive process. Together for Health for All emphasizes the importance of achieving its vision, objectives and goals through the joint efforts of the whole of government and the whole of society. A national, intersectoral consultative process included use of contemporary media for strengthening the public consultation process, held also via an e-platform for Health 2020, hosted by the Ministry of Health (available at http://zdravstvo.gov.mk/health_2020/). The process, governed by the Government Committee of Environment and Health under the leadership of the Ministry of Health, involved: • people: over 400 experts, practitioners, individuals, citizens • institutions: over 60 government bodies, professional and civil society organizations, international and UN agencies • documents: over 300 documents gathered • meetings: over 70 meetings held • outcomes: development of Together for Health for All. Common vision: equitable society, healthier nation By 2020, the country will be a place where the health and well-being of the population is significantly improved, health inequalities reduced, public health strengthened and there is a people-centred health system that is universal, equitable, sustainable and of high quality, as a contribution to and a result of the country’s social and economic development. Together for Health for All National Health 2020 framework policy for health and well-being 1312 From gaining political support and momentum to intiating a national Health 2020 process, through gathering evidence and making the case for the first ever national health policy framework for health and well-being in the country, what was and remains important is gaining consensus and wider ownership. This is a prerequisite for both endorsement and implementation with adequate data and resources and putting in place proper accountability, follow-up and review mechanisms. The national health policy Together for Health for All, in line with Health 2020, encompasses all these and advocates for upstream approaches and work on all the determinants of health. Using contemporary media to facilitate the process, the Health 2020 e-platform has been established as an extraordinarily dynamic tool with complex possibilities and the following goals: ✓ to inform: over 200 national documents about or connected to health have already been placed on the portal. The goal is to create an e-library of national and international documents on health where all sectors, including the civil sector, as well as all citizens can contribute. For the first time, anyone can obtain information about the processes and documents on health (pupils, students, professionals, retired people – all interested citizens); ✓ to allow every citizen, group or organization to make a contribution (My contribution) by submitting their own assessments or ideas about specific problems, suggestions for resolving them or sharing their opinion (My opinion) in an online survey (What kind of health do I want in 2020?); ✓ to prompt all sectors, including the civil sector, to engage in the public debate concerning all the documents that will be placed on the platform before they are formally adopted. The Health 2020 policy framework, the draft of the Environment and Health 2020 Action Plan, and the draft of the Public Health 2020 Action Plan, which have been prepared in the country for the very first time, have already been published on the e-platform and they are open for public debate. The analysis of the health sector in terms of NCD management, which is currently being conducted by WHO and the national experts, will be placed on the platform soon; and ✓ to become a virtual space for gathering and informing every person who wants to engage or find information on health. Discussion between experts, the public and wider audiences continue in meetings, many of which have been convened by the WHO Country Office. E-platform for Health 2020 National Health 2020 process and elements Public health /life-course approach Environment & health CDs/ preparedness & response NCDs/risk factors Health system & resources Together for Health for All Together for Health for All Health and well-being as its core values Together for Health for All Whole-of-government and whole-of-society as its core principles 14 Together for Health for All Delivering on the SDGs SDGs have provided a new paradigm in taking health and development forward, emphasizing strongly the social, economic and environmental determinants of health that need to be tackled. The 17 SDGs recognize that eradicating poverty and inequality, creating inclusive economic growth and preserving the planet are inextricably linked, not only to each other but also to population health. Although many of the goals are interlinked and contribute to health, SDG 3: “ensure healthy lives and promote well-being for all at all ages” profiles health as a desirable outcome in its own right. Importantly, however, health is also presented as an input to other goals, and a reliable measure of how well sustainable development is progressing in general. Health targets are no longer focused just on saving lives in poor countries, but on creating healthier societies and promoting well-being for everyone worldwide. Implementing this new agenda at national level has already brought coherence to the approach. Together for Health for All Health as a goal, health as a target Together for Health for All Public health /life-course approach Environment and health CDs/ preparedness and response NCDs/ risk factors Health system and resources Together for Health for All embeds a whole-of-government and whole-of-society approach across its five pillars, as a prerequisite for delivering on the SDGs and the 2030 Agenda. National health policy and SDGs: health as a goal... ...health as a target 15 17 INNOVATIVE, FLEXIBLE, CREATIVE NCDs and promoting Health through the life-course Health 2020 is… World leaders have formally recognized NCDs as a major threat to health, economies and societies and placed them high on the development agenda. The current evidence indicates that four types of NCDs – cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – make the largest contribution to mortality in the majority of countries and require concerted, coordinated action. WHO Regional Office for Europe is committed to increasing support and offering a menu of policy options for all Member States to take coordinated and coherent action, at all levels (local to global), to strengthen their health systems for improved NCD outcomes (Health 2020). An evidence-gathering exercise to make a strong case for a national action plan on NCDs was supported by WHO. A multidisciplinary WHO team of experts conducted an assessment of NCDs from a health-system perspective in June 2015, to identify factors that limit the use of the health system to its full potential. Through this assessment, aimed at establishing a basis for pragmatic, contextualized policy recommendations for health-system strengthening and improvement of NCD outcomes, the country opened the door to addressing NCDs, their prevention and early detection, and reducing underlying risk factors. The new strategic framework and action plan for NCDs as part of Together for Health for All will be a multistakeholder platform of mechanisms for coordinated whole-of-society action to reduce the burden of NCDs and promote healthy lifestyles for improved economic development and well-being. Main causes of death as a percentage of the total number of deaths in the former Yugoslav Republic of Macedonia, 2012 1918 Advocacy and communication EPHO 9 Health protection EPHO 3 Disease prevention EPHO 5 Health promotion EPHO 4 Public health information and assessment EPHO 1 & 2 Planning and public health law EPHO 6 Structure and resources EPHO 8 Workforce EPHO 7 Research, evidence base and evaluation EPHO 10 Public health Self-assessment: reflecting on potentials and possibilities At national level, strengthening the public health process was initiated in 2013 through a series of expert missions and meetings, leading into a critical self-assessment of Essential Public Health Operations (EPHOs) in 2014. The resulting efforts, involving over 200 experts, national and local policy- and decision-makers, practitioners and civil society, have been converted into the first Public Health Action Plan 2020. Furthermore, the self-assessment results have been used to inform other policy development processes and to initiate intersectoral policy dialogues. The plan, in line with the WHO European Action Plan for Strengthening Public Health Capacities and Services, is in the pipeline for endorsement. Its implementation through multisectoral action will contribute to reducing health inequalities, through improving public health services. The vision “Better health and well-being through reducing health inequalities and establishing strengthened and sustainable public health services and capacities.” Public health is defined as the science and art of promoting health, preventing disease, and prolonging life through the organized efforts of society. The overall vision is to promote greater health and well-being in a sustainable way, while strengthening integrated public health services and reducing inequalities. In order to achieve this vision, the public health approach involves working with other sectors to address the wider determinants of health, and with health professionals: primary health-care professionals can play a key role in preventing illness and promoting health, as outlined in the Alma Ata Declaration. Self-assessment workshop, Skopje Self-assessment workshop, Ohrid © WHO/Margarita Spasenovska © WHO/Margarita Spasenovska 20 21 Acting upstream: tackling determinants of health Tobacco The WHO Framework Convention on Tobacco Control (FCTC), which entered into force in February 2005, was the world’s first global public health treaty, designed to tackle the devastating health, social, environmental and economic consequences of tobacco consumption and exposure. In 2015, ministers of health from the 53 Member States of the WHO European Region signed up to a roadmap that will make it possible for future generations to make tobacco a thing of the past, through setting national targets for reducing the use of tobacco by 2025 and promoting a cross- government approach to tobacco control involving ministries of health, finance, agriculture, education, environment, social affairs and trade. In 2014, the country vigorously promoted the “Raise tobacco tax, decrease death and diseases” motto on World No Tobacco Day, presenting key findings on the topic and calling other sectors to join the action, in support of the smoking ban introduced in 2010. “Genes load the barrel, but environment and lifestyle pull the trigger” (Dr Elliot Joslin) Visions for the future Support for research and evidence as well as health promotion will be provided as part of the implementation of the National Health 2020 Strategy and the NCD Action Plan. WHO will further support the efforts of the Government to achieve the objectives of the FCTC, with the participation of all relevant sectors, particularly health, finance, economy, education, environment and trade, as well as civil society. Nutrition The burden of disease associated with poor nutrition continues to grow in the WHO European Region. Unhealthy diets, overweight and obesity contribute to a large proportion of NCDs that are the main killers at regional and national level alike. WHO Regional Office for Europe works with Member States to develop and improve government-approved policies dealing with nutrition and food security. Policy developments indicate that these topics span different government sectors and involve both the public and stakeholders. In the country, childhood obesity is a growing problem and continuous policy measures are essential to prevent one of the principal risks for early development of chronic diseases. Community nutrition survey Initiated in 2014 in cooperation with the Ministry of Health and Institute of Public Health, the survey aimed to provide data on food consumption, eating habits and daily intake of contaminants through food. This and other surveys used as a basis for evidence-based policy-making are the main pillar of the work on prevention, early detection and management of NCDs, and thus to reducing their great burden on society as a whole. The recommendations are significant contributors to setting the strategic objectives of the strategic framework for NCDs. Visions for the future To promote healthy diets, it is necessary to provide support for the development, adaptation and updating of national guidelines and legislation on nutrition, based on the updated global norms, standards and guidelines, including, food-based dietary guidelines, guidelines on micronutrient supplementation and fortification. WHO Country Office regularly shares information in order to ensure technical guidance for the country. It is working on providing good content and promotional material for various stakeholders, which could be used as an awareness- raising tool. Повисоки такси за тутун = помалку пушачи, помала смртност и поздрави заедници.СВЕТСКИ ДЕН ПРОТИВ ПУШЕЊЕТО, 31 МАЈ www.who.int/world-no-tobacco-day Toba cc o T ax Raise Tobacco Tax Lower Death and Disease Death and Disease Higher tobacco taxes = fewer smokers, less death and healthier communities. WORLD NO TOBACCO DAY, 31 MAY www.who.int/world-no-tobacco-day © WHO/Franz Henriksen 2322 Violence and injuries are among the most pervasive yet silent undermining factors of health and well-being. Since 2002, systematic work on violence prevention has been implemented as a priority for collaboration at national level. The national policy framework for prevention of and protection from domestic violence 2012–2015 has been enacted; a unified protocol for cases of domestic violence has been prepared and launched for implementation, accompanied by capacity-building activities with WHO Country Office support. WHO has been providing assistance to the Government to develop the National Action Plan for the Prevention of and Protection from Child Abuse and Neglect 2013–2015, aimed at safety and well-being for children and effective prevention, detection, treatment, rehabilitation and protection of children from any form of abuse and neglect. Involvement in the policy dialogue at national level has been enriched with WHO technical and policy support, especially through promoting the European Action Plan on Child Abuse and Neglect, leading to adoption of a new law on domestic violence. Recognizing the importance of addressing violence on all levels, in 2015 WHO continued to support capacity- building activities on preventing intimate partner violence and child maltreatment. In 2013, the Ministry of Health, with WHO technical support, embarked on the preparation of a policy framework and Action Plan on Mental Health 2014–2020, adopting an integrated multisectoral approach. The document, prepared by the National Commission on Mental Health fully aligned with the principles of the European Mental Health Action Plan, is strategically oriented towards the development of a sustainable community mental health system. The community orientation and whole-of-society approach have strengthened the vision of the country of creating resilient communities for better mental health and well-being. Community mental health guidelines, developed with WHO technical support, have been provided as part of the policy framework, to boost the capacity of mental health professionals. At the same time, with the vision of strengthening human resources in health, training of trainers for diagnosis and treatment of depression and prevention of suicide was conducted in 2015 in Skopje, with WHO support in collaboration with the national professional associations and the Medical Faculty in Skopje. Visions for the future WHO County Office will carry on supporting the development of mental health capacities through endorsing and implementation of the National Health 2020 Strategy and the NCDs Action Plan. Specific areas of action include: • research for better understanding of the damaging links between mental health problems and social marginalization, unemployment, homelessness, alcohol and other substance use disorders; and • implementation of a human-rights approach to address social inequalities among patients, long- term care, poor and insufficient treatment in mental health institutions and reduction of stigma associated with mental health disorders and disability. Acting upstream: tackling determinants of health Mental health Violence and injuries Visions for the future Prevention of violence and injuries requires intersectoral action, which can be ensured through continued support to policy dialogue and implementation of adopted policies, through an integrated approach within the national health strategy Together for Health for All. Reducing health inequalities can be addressed through technical support for implementation of prevention programmes aimed at breaking the cycle of violence. Training for diagno- sis and treatment of depression and suicide prevention in Skopje Training workshop on preventing intimate partner violence and child maltreatment in Skopje © WHO/Predrag Kitanovski © WHO/Predrag Kitanovski 2524 COMMUNICABLE DISEASES Prevention and surveillance for Health Health 2020 is… Through its European Immunization Week, WHO promotes one of the world’s most powerful tools for health – vaccines – to protect people of all ages from disease. At national level, WHO is collaborating with the Government on promoting and strengthening the surveillance system for vaccine-preventable diseases, in order to maintain the recommended immunization coverage. Reduction of the number of cases of and deaths from vaccine-preventable diseases is evident and is a result of the vaccination efforts, guided by WHO recommendations. In 2014 and 2015, European Immunization Week was celebrated in accordance with the global campaign “Immunize for a healthy future: know, check, protect”. WHO supported the process of sharing experience regarding immunization trends among health professionals, as technical expertise to successful implementation of continuous immunization in the country. In 2015, with the combined efforts of the Ministry of Health and WHO, the inactivated poliovirus vaccine (IPV) was introduced into the national mandatory immunization calendar. WHO technical assistance was provided to ensure the sustainability of the IPV introduction plan at national level with affordable IPV products. WHO supported Immunization Week activities Vaccine-preventable diseases © WHO 2726 The HIV response has been a public health trailblazer in promoting human rights, mobilizing communities, contributing to health equity and addressing social determinants of health, which approach advocates for building strong and sustainable systems in line with the national Health 2020 policy framework. The prevalence of HIV in the country has remained low and concentrated mostly among populations with high-risk behaviour; therefore, the response to HIV has been focused on certain groups considered most vulnerable to HIV infection. A coordinated response to HIV/AIDS remains one of the biggest challenges for policy-makers and therefore WHO Country Office is implementing the most effective programme activities and creating a supportive environment for the sustainable development of a joint local and national response to HIV/AIDS. Campaigns play an essential role in reducing HIV vulnerability, reducing HIV-related stigmatization and discrimination, and removing structural barriers to accessing HIV services. Also, the production of two documentary films as part of the National HIV/AIDS Campaign provided an insight into the world of people who inject drugs, people living with HIV or TB, and expressing the complexity of living with these diseases. It deliberately provoked questions and initiated issues that would cause change. Qualitative field research conducted in Tetovo, Ohrid, Bitola, Strumica, Shtip and Skopje, to assess the needs, possibilities and degree of inclusion of services supported by the Global Fund to fight AIDS, Tuberculosis, Malaria (GFATM) for most-at-risk-populations within the communities, is leading to evidence for the creation of a tailored response to HIV. The WHO Country Office has responded to the GFATM request to the WHO Regional Office for Europe, for evaluation of the national HIV programme in the former Yugoslav Republic of Macedonia (epidemiological analysis; review of HIV treatment and care; HIV services for key populations; analysis of service delivery models for populations affected by the HIV epidemic from the perspective of the health system). These recommendations will inform the development of a sustainability plan for the country after GFATM’s involvement finishes. HIV/AIDS Continuing the fight against and surveillance of existing and emerging threats CDs remain a continuous challenge in the country, specifically for maintenance of high levels of immunization, optimizing response to HIV, preventing STIs, diagnosis, treatment and care and enhancing surveillance capacities. Visions for the future In order to contain the low HIV prevalence in the country, it is necessary to further strengthen advocacy and awareness-raising. Upholding a rights- and values-based approach to health and well-being to achieve universal access to HIV prevention, treatment and care, it is essential to support the sustainable, affordable and continuous access to services and treatment. With the above in mind, it is of utmost importance to strengthen the roles and contributions of creative partnerships and a whole-of-society approach. HIV/AIDS campaign, Skopje © WHO 2928 INCLUSIVE, RESPONSIVE Tackling Health inequalities Health 2020 is… Roma health WHO is committed to scaling up work on promoting better health for Roma in the European Region, guided by the values and principles of the European policy framework for health and well-being (Health 2020). Changing the lens on the approach to vulnerability, WHO has supported the interagency coordination initiative for scaling up action towards Millennium Development Goals 4 and 5, focusing on reorientation of strategies, programmes and activities for greater health equity for vulnerable groups, and in particular the Roma population. The reorientation, as a systematic evaluation process, will be further supported as a continuous cycle of improvement that could enhance the equity, effectiveness and quality of health programmes. Visions for the future Addressing inequities requires that health systems and public health governance embrace and put into action measures that ensure non- discrimination, cultural competence, participatory approaches and intersectoral action on the social determinants of health. The WHO Country Office emphasizes the need for reorienting strategies, programmes and actions for addressing social determinants of health and reducing health inequalities. 31 EVIDENCE-INFORMED Moving from data to information for Health Health 2020 is… The Ministry of Health’s 2011 initiative My appointment includes e-health records for all visiting patients, and its objective is to incorporate all health data, including national registries of diseases. My appointment is opening the pathway towards a better-integrated and coherent health information system (HIS). WHO provided technical support to assess the situation and technical guidance towards full integration of the national HIS, ensuring sustainability, comprehensiveness and comparability of the initiative, while bearing in mind the usefulness of the data at both individual and population levels. Looking forward, the focus is on developing evidence- informed policies to improve health system planning and management, as well as disease prevention, early detection and health promotion. New media as enablers of efficient resource use for health My appointment e-platform was introduced in the country in 2010, to improve the scheduling of clinical appointments and reduce long waiting times to see a doctor or for diagnostic tests. Initially it was used in three public institutions but soon expanded to public hospitals and primary care providers, and has continued to develop. It now covers over 5000 health-care providers and service points, integrating over 1000 applications and systems, including secure e-health records, pharmacy prescriptions, a performance-based pay module, automated provider credentialling, specialist referrals, ambulance service management, public booking interface for health interventions and medical equipment, etc. The system also has features for health policy and resource planning, tracking hospital patient workflow, service billing, health-care inventory management, general practitioner and specialist practice records management, etc. In a very short time, health system performance has improved; for example, the waiting time for radiology scans and specialist visits has been reduced from 15 months to less than 7 days. Currently under expansion, My appointment will integrate both curative and preventive services, screening outcomes and risk factors, and will be used for health resource planning and management and improvement of health- care access and quality. E-health and an integrated health information system 3332 Towards joining EVIPNet: evidence, analysis, informing policies With a vision of a Europe in which high-quality, context-sensitive evidence routinely informs health system decision-making, Evidence- informed Policy Network (EVIPNet Europe) supports governments to implement WHO’s new European policy framework, Health 2020, and its goals: reducing health inequalities and improving health for all by fostering and promoting a knowledge translation culture. The country has joined EVIPNet Europe, together with 12 other European countries, and with WHO technical support embarked on the process of structured and systematic evidence-gathering through scientifically sound processes. This produces policy briefs that inform policy- and decision-makers of the best practices and best buys to improve health and well-being and reduce inequalities, aimed at the realization of the Together for Health for All vision. Using regional expertise at national level: WHO supports the country in joining EVIPNet From information to evidence Prior to launching the EVIPNet process in the country, WHO supported the development of policy briefs, in order to strengthen the knowledge base, nurture the culture of translation of information to evidence and support use of evidence in policy- and decision-making. Throughout the process, over 20 policy briefs have been developed and published in a bilingual compendium of policy briefs, in the special edition of the Journal for European Issues “Evrodijalog”, issue 20/2015. Infant mortality: deaths per 1000 live births according to mother’s educational level, 2008–2014 Extreme events that have struck the country, 2010–2015 Using evidence and translating knowledge for setting priority and informing policies © WHO 35 COLLABORATIVE AND LINKING Intersectoral actions for Health Health 2020 is… Recognizing the need for integrated action by all sectors and entities in the field of the environment, where health threats persist, in 2013 the Government appointed the Committee of Ministers on Environment and Health, with a mandate on strategic and situational governing of environmental risk factors and their consequences, creating policies, improving legislation and applying current world experience and standards in the field of environment and health, with a unique goal of achieving better health and well-being of the population. In 2014, taking a whole-of-government approach, the Committee, chaired by the Prime Minister, enacted a resolution for preparing and adopting a strategic framework and action plan for improving environment and health by 2020. The appointed team, with a wide stakeholder participation and consultation process involving over 150 experts, policy- and decision- makers, practitioners and civil society, reiterated the process to prepare a national strategic framework and action plan of national and local ownership. Environment and health “The best way to predict the future is to design it.” (Buckminster Fuller) Environment and health launch, from left to right: Dr Srdan Matic, Coordinator, Environment and Health, WHO Regional Office for Europe; Ms Snezhana Chichevalieva, Head of WHO Country Office; Dr Jovanka Kostovska, Head of Preventive Health Care Sector, Ministry of Health; Mr Stevo Temelkovski, Deputy Minister for Environment and Spatial Planning; Dr Zoran Gjorgievski, Coordinator of the Parliamentary Committee for Health © WHO/Margarita Spasenovska 3736 Environment and health Strategic framework with action plan 2020 During 2014 and 2015, with political commitment and WHO technical support, the country embarked on the process of developing a strategic framework and action plan for improving environment and health by 2020. Air pollution, massive fires and floods have further strengthened the vision and the professional and political commitment to the whole- of-government and whole-of-society approaches, and underlined the necessity of coordinated intersectoral action, triggering situation analyses and assessments, from which data were gathered to define the strategic priorities and activities. The resulting Strategic Framework for Environment and Health with Action Plan by 2020, based on technical evidence, political commitment and national ownership, is the first such document of joint governance for health between two sectors, and exemplifies the modalities for future intersectoral collaboration, at both central and local levels, for creating and supporting healthy environments, and developing rural and sustainable urban areas and resilient communities. The strategic framework is in the pipeline for endorsement by the end of 2015, with implementation envisaged as commencing in 2016. The vision “To improve health through actions on all levels of the health care system and far beyond it, including assessment and management of health and environmental risks using an organized, strategic and intersectoral approach with specified activities and measures from the wide area of environment and health by 2020 in order to improve and protect the health of the population by creating and maintaining a healthy environment.” COMPELLING EVIDENCE Approximately 1350 lives are lost annually due to fine particulate matter air pollution, with thousands of days of production lost. Particulate matter air pollution cost the economy €253 million, or 3.2 percent of GDP, in 2011 (World Bank Study on Air Pollution) TRIGGERS FOR POLICY CHANGE Public and media pressure POLITICAL DECISION AND COMMITMENT Government Committee on Environment and Health BREAKING THE SILOS An exemplary intersectoral collaboration of health and environment sectors E&H PROCESS STARTED Working together, making the case – WHO full support of the process E&H PROCESS SUSTAINED E&H POLICY DRAFT Joint efforts, common gains “The best time to plant a tree was 20 years ago. The next best time is today.” (A proverb) Visions for the future The commitments to improving environment for better health are focused on delivering results through: • assuring the involvement of the health sector in implementation and development of environmental or infrastructural projects and policies; • placing greater emphasis on reducing health inequalities arising from different social and environmental determinants of health; and • providing technical support to implementation and policy-making for healthy environments towards developed rural and sustainable urban areas and resilient communities. The inclusive process for change is fully supported 3938 In addition to environmental concerns, climate change also raises health concerns, as it implies an increased burden of climate-sensitive diseases such as heat-related illnesses, vector- borne, diarrhoeal and respiratory diseases, as well as increased risk of injuries from extreme events. In the WHO European Region, health effects have already been observed from more frequent and intense extreme weather events as well as changes in the geographic range of some infectious disease vectors. Recognizing the magnitude of impact of climate change on health, since 2009 the country has implemented a wide range of activities with WHO support, including: development of the National Climate Change Health Adaptation Strategy in 2011; economic analysis of the impact of air pollution and heat-waves in the city of Skopje with WHO support as part of the Reconciling Adaptation, Mitigation and Sustainable Development for cities (RAMSES) project funded by the European Commission, in cooperation with the WHO Centre for Environment and Health in Bonn. Continuing its efforts, in 2015 WHO supported the Ministry of Health in the evaluation of the country’s climate change health adaptation policy framework and heat-waves action plan, drawing lessons on institutional capacities and highlighting future focus on collaboration and coordination among various stakeholders. Climate change Visions for the future Climate change requires intersectoral action and continued support in identifying policy options to prevent, prepare for and respond to its health impact. This will contribute to selecting and implementing the most suitable policies, measures and strategies in addressing climate change for long-term economic and societal benefits. Tackling the health risks of climate change − early-warning systems up and running An innovative contribution to adaptation has been developed, making use of the latest technology to provide the health sector with early warnings of heat risks. The systems are now functional and available at www.toplotnibranovi.mk and www.studenibranovi.mk. With these systems the health authorities receive SMS (short message service) and email alerts up to 48 hours in advance of the hazard, meaning they will be much better prepared to undertake the necessary actions. These contributions have helped to strengthen the country’s capacity to cope with the health risks of climate change, as well as raising awareness of the threats. Where people work defines one third of their health. Thus, monitoring, strengthening and improving occupational health is an important instrument to maintain a healthy workforce and a healthy nation. WHO is providing technical support at national level to implement the Global Plan of Action on Workers’ Health 2008–2017, and specifically to use the norms and standards in developing policies and plans for preventing and managing the health impacts of environmental and occupational risks. In this process, the WHO Country Office has supported the Ministry of Health and the Institute of Occupational Health (a WHO collaborating centre) which plays an important role in the educational, scientific and specific health care issues in the area of occupational health. The Protecting health from climate change project 2009– 2013 brought significant activities in the area of protection of workers’ health from heat-waves and cold-waves. With WHO support, the process of developing a national programme for elimination of asbestos-related diseases, and development of a platform for further intersectoral and multidisciplinary action, was initiated in 2014, and the process has been continuously supported with technical assistance in the form of preparation of policy briefs and discussion of specific policy options, focusing particularly on promoting safe removal and disposal of materials containing asbestos. WHO continues to support country actions and provide technical assistance in implementing the WHO Global Plan of Action on Workers’ Health and the International Labour Organization’s Promotional Framework for Occupational Safety and Health Convention. Occupational health Tenth anniversary of the WHO Collaborating Centre for Occupational Health © WHO 41 COMMUNICATIVE AND COMPREHENSIVE Exchanging opinions, gathering ideas for Health Health 2020 is… In the modern era of information explosion and large-scale availability of new media and communication technologies, knowledge is readily accessible and exchange is instantly available. The potential for use of new technologies for health and addressing health concerns – from emergency to chronic situations, from mainstream to rare conditions – is enormous, and thus inevitably affects the health landscape at global, regional, national, local or individual level. Recognizing this potential, the WHO Country Office has fully supported the use of new technologies for opening up policy dialogues with all stakeholders, to design optimal policies for improved health. Good communication is essential for better health National Health 2020 workshop © WHO 4342 Resistance to antibiotics is a growing global problem for public health. In the WHO European Region, the resistance of some pathogens now exceeds 50% in some countries, and new resistant mechanisms are emerging and spreading rapidly. Measures including good hygiene, rational use of antibiotics, surveillance and vaccination, as well as awareness-raising, are currently among the most efficient ways to prevent health-care-associated infections. At national level, joint efforts have been in place since 2008, with the establishment of the European Antibiotic Awareness Day. National campaigns and education events for professionals, students and the general public have been organized jointly by the Ministry of Health, Institute for Public Health, Medical Faculty in Skopje, and Studiorum Centre for Regional Policy Research and Cooperation, with WHO technical support. Awareness campaigns Antimicrobial resistance – everyone’s responsibility Awareness- raising campaign outreach Branding for awareness Online education Building capacities for extending the life of antibiotics In furthering the efforts to fight the global threat of reduced effectiveness of antibiotics, WHO has supported the piloting of the Antibiotic Stewardship Course for health professionals in the country. In 2015, understanding of the issue, so as to be able to address this global concern, has been greatly strengthened through an online accredited course for health professionals, aimed at improved implementation of clinical guidelines for the prudent use of antibiotics. Organized by the Medical Faculty of Skopje, together with the Studiorum Centre for Regional Policy Research and Cooperation, and with support from the University of Stanford and WHO, it educated 50 professionals on the latest advances in antimicrobial stewardship. Health professionals have received further capacity-building in diagnostics and surveillance, through the nationally organized workshop on CAESAR (Central Asian and Eastern European Surveillance of Antimicrobial Resistance), which the country joined with WHO support, for strengthening the surveillance and exchange of important data as part of regional efforts in the fight against antimicrobial resistance. Certification ceremony of WHO-supported Antibiotic Stewardship Course © WHO 45 ADAPTIVE AND REACTIVE Aligning responses for Health Health 2020 is… Migration is a high-priority issue for the political and policy agendas of most Member States of the WHO European Region. The complexity and increasing relevance of migration poses public health challenges which require a coordinated response of all sectors and stakeholders involved. In the context of Health 2020, the WHO Country Office in Skopje is assisting the Ministry of Health to provide appropriate care for refugees and migrants, with a particular focus on vulnerable individuals. This includes technical and on-site assistance, with assessment of and support to the country capacity to address the health needs of refugees and migrants, as well as policy advice and training of health personnel. Regular field visits have been put in place with the aim of identifying needs and providing sound recommendations to the national health authorities, as well as collecting information. Meetings have been organized with representatives of the Ministry of Health, health centres, public health centres, hospitals in Kumanovo and Gevgelija, United Nations agencies, NGOs and crisis management centres to identify the health needs of refugees and migrants and provide assistance in resolving problems. Crisis management training of health personnel from Gevgelija and Kumanovo regions was organized in September 2015, as well as training for Red Cross volunteers. In addition, medicines and medical supplies have been provided to cover the needs of the Vinojug transit centre in Gevgelija. Health and migration Visions for the future Recognizing the universal right to health, and at the request of the Government, WHO will continue to support action to: • support the preparation of intersectoral public health contingency plans for the management of CDs and NCDs and interventions to meet immediate mortality and morbidity needs; • support HIS relevant to migration and health through data collection, surveillance, evidence and research in the European Region and through interregional collaboration with the countries of origin and transit; and • foster collaboration on health and migration with national and international partners, particularly in the areas of public health risk analysis and the development of country profiles on migration and health. WHO visit to the transit centre in Gevgelija Health and migration workshop, Gevgelija © WHO © WHO 46 Developing adaptive policies, resilient structures and foresight to effectively anticipate and deal with public health emergencies is crucial for every country. The International Health Regulations (IHR) (2005) require countries to implement a multihazard, intersectoral and cross-border approach to public health emergencies and to be prepared to effectively manage health-related aspects of emergencies and humanitarian disasters. Recognizing such need, since 2004 the country has, with technical support from the WHO Country Office, been aligning its systems and capacities to implement emergency preparedness at national and local level, so as to be able to effectively implement the IHR following their entry into force in 2007. As preparedness is readiness for the unpredictable, the system has been tested in over five simulation exercises, technically supported by WHO, to enable diagnosis of gaps and potential improvements. The identified challenges to the preparedness and response have been addressed in the National Health Crisis Preparedness Plan updating process with wide stakeholder participation during 2014, resulting in full development and endorsement of the IHR protocols for points of entry, chemicals, ionizing and biological risks, with WHO technical support. Ebola simulation exercises at Skopje airport As part of preparation efforts to prevent, as well as manage, suspected cases of Ebola, a simulation exercise was organized during the Extraordinary Ministerial Conference of the South-eastern Europe Health Network (SEEHN) in November 2014, with the participation of high- level representatives from the SEEHN countries, Regional Cooperation Council and WHO Regional Office for Europe. The aim of the exercise was to test the IHR (2005) protocols for the designated point of entry, Skopje airport. It was organized as part of Ministry of Health capacity-building activities to prepare the health system for emergencies and outbreaks, with technical support and guidance from WHO. International Health Regulations Preparedness and response Crisis preparedness simulation exercises held in Skopje and Ohrid Simulation exercises were held to test the preparedness to respond to crisis situations at two hospitals and their emergency medical services: at the 8th of September City Hospital in Skopje in May 2014, and at the general hospital in Ohrid in December 2015. Health and emergency workers responded to a simulated traffic accident involving a bus carrying school children and an ensuing fire. These were the sixth and seventh such exercises organized by WHO, in close cooperation with health authorities in the country, to strengthen the health system’s capacity to plan for and respond to crisis situations. The exercises called for strong and coordinated multisectoral cooperation in the public health response to emergencies, in accordance with the principles of the WHO European policy framework Health 2020. Ebola simulation exercise, Skopje airport Simulation exercise, Skopje Simulation exercise, Ohrid 47 © WHO © WHO © WHO © WHO © WHO OPEN, INVITING AND SHARING Partnering for Health Health 2020 is… Ministry of Health, Ministry of Environment and Physical Planning, Health Insurance Fund, Cabinet of the Prime Minister Ombudsperson, local self-government units, Institute & Centres of Public Health, Crisis Management Centre, Road Safety Committee, civil society National and local institutions and agencies, academia, international community, civil society Whole-of- government Whole-of- society Leaders and partners Together for Health for All in numbers 49 5150 SEEHN was set up in 2001 as a political and institutional forum by the governments of the Republic of Albania, Bosnia and Herzegovina, the Republic of Bulgaria, the Republic of Croatia, Montenegro, the Republic of Moldova, Romania, the Republic of Serbia and the former Yugoslav Republic of Macedonia. WHO, as a founding partner, has been supporting SEEHN to promote peace, reconciliation and health in the region. Over the years, this partnership has reshaped the political commitment of its member states to extend subregional cooperation and enhance partnerships towards achieving equity and accountability in health, and promoting health as a contributor to economic growth and development. South–eastern Europe Health Network Bringing health to the economic growth and societal development agenda SEEHN ad-hoc ministerial meeting in Skopje Collaborative actions and higher political commitment for health Health partnerships are an effective means of streamlining efforts for health and responding to the challenges posed by modern life. The increased national and international commitment, resources and expertise invested in creative partnerships for health and well-being are a strong sign not only of their interdependence, but also of their complementarity for the achievement of common vision and goals for better health and well-being globally, regionally, nationally and locally. WHO is committed to supporting and participating in health partnerships, involving governments, civil society, international organizations, the private sector and affected communities, with the goal of achieving improvements in health that no organization could achieve alone. On the national level, partnerships for health have been an effective instrument in addressing multisector issues, bridging the gap between the systemic and individual levels, and enabling communication channels between knowledge and policy. In 2014, under the country’s Presidency of the Network, the Minister of Health, jointly with the WHO Regional Director for Europe, hosted a SEEHN ministerial meeting, to discuss strategic pathways to align the Network’s joint efforts in public health with the regional priorities and trends, to further strengthen its position, influence and relevance on the regional and global agenda. The ministers discussed the crisis preparedness and response capacity of the Network and the region, as well as the importance of human resources for health. In this context, a preparedness and response simulation exercise was held at Alexander the Great airport in Skopje. The meeting brought further political commitment on partnerships and regional collaboration through the Skopje statement that was endorsed, on the importance of health in overall economic and societal growth. Ministers pledged to take responsibility to aim to make health one of the key indicators for measuring prosperity and inclusive development of societies in the south-eastern European region and Europe as a whole. Recognizing whole-of-government and whole-of-society approaches as essential, ministers have committed to better regional collaboration, exchange of experience, expertise and human resources and intensified involvement of citizens and institutions as partners in identifying and implementing solutions for improved health and well-being. WHO and SEEHN co-organized ministerial meeting in Skopje, November 2014 WHO Regional Director for Europe supports the SEEHN © WHO © WHO 53 ACCOUNTABLE AND RESPONSIBLE Implementing for Health Health 2020 is… With health being a public good, and with its increasing recognition as a contributor to economic growth and societal development, accountability for health becomes even more important. The accountability landscape comprises a broad array of actors with multiple roles and responsibilities; WHO is committed to supporting the establishment of good governance structures and proper accountability and transparency mechanisms in health and other sectors, towards delivering for health, reducing health inequalities, and addressing social determinants of health in contributing to well-being for all. The health policy dialogues are breeding a culture and nurturing a process of exchange of opinions, ideas and experiences, expressing attitudes and interests to achieve common understanding while optimizing gains in a win- win outcome. WHO is offering a great deal of support to allow the voices of all stakeholders to be heard, and to encourage various forms of expression of such voices. The WHO Country Office has inspired the professional community and encouraged their stronger involvement in the policy- and decision- making processes through gathering and providing evidence that feeds health policy. A number of policy briefs on different, very relevant health issues have been produced, on subjects ranging from national health policy process to food safety and health and migration. These were streamlined through an open, consultative process as policy options for consideration. The policy briefs have been compiled into a compendium, in an effort to document the evidence-informed policy- making process, and to contribute to nurturing continuous health policy dialogue at national level. Health policy dialogues 55 MONITORING AND REVIEWING Sustainability for Health Health 2020 is… With the commitment for delivering on better health and well-being for all citizens through the implementation of Health 2020 at national level, the course of national health policy development has naturally included a dedicated process for determining the key indicators for monitoring achievements, as well as timelines for revisiting and reviewing the policy. Separate monitoring frameworks have been developed in an open consultative process of professionals, and using the data on citizens’ expectations collected through the survey “What kind of health do I want in 2020?”, while bearing in mind the the country’s reporting and monitoring obligations to the joint achievements of the WHO European Region. All separate monitoring frameworks have been assembled into the common monitoring framework of the national Health 2020 strategy Together for Health for All, aimed at delivering the overall results of the common and joint efforts of all sectors and stakeholders towards achieving better health and well-being, leaving no one behind. Quantitative outcome of activities implemented (number of preventive examinations, trees planted, filters installed, etc.) Cost–effectiveness of the activities implemented Planned activities Funds used Planned funds Monitoring of implementation: REPORTING Funds spent per outcome unit (output) Qualitative reporting Indexing activities implemented Narrative report Quantitative reporting Level of programme implementation Level of financial implementation 5756 Taking into account both the interdependence of the thematic plans and activities envisioned for the implementation of Together for Health for All, and the high level of intersectoral action anticipated, it will be extremely important to monitor the level of implementation in terms of activities, goals, and funds. Monitoring the level of implementation of the vision and strategic objectives of Together for Health for All requires a mechanism for regular annual reporting to the Assembly of the former Yugoslav Republic of Macedonia regarding the implementation of the strategic framework, as well as of the individual thematic action plans which are an integral part of the strategic framework. The draft report on the implementation of the strategy is reviewed by the Committee on Health and Environment which further gives proposals for submission to the Assembly for consideration, adoption, and recommendations for future implementation. Together for Health for All also proposes monitoring of the cost–effectiveness of the selected population-orientated interventions. A separate monitoring plan is being developed, as an online interactive database, in which all responsible ministries and agencies will be required to provide input for matrix-based correlative monitoring of progress. Also, by determining the health impact that social determinants have on certain population groups, Together for Health for All also envisions an analysis of the targeted activities regarding the reduction of health inequalities and the attainment of the highest possible standard of health for all. M A K I N G T H I N G S H A P P E N 2 0 1 4 – 2 0 1 5 Implementing the European policy framework f o r h e a l t h a n d w e l l - b e i n g H e a l t h 2 0 2 0 in the former Yugoslav Republic of Macedonia The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of the six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it services. 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