The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan HEALTH SYSTEMS STRENGTHENING IN THE CONTEXT OF HEALTH 2020: CHALLENGES AND PRIORITIES IN THE WHO EUROPEAN REGION Division of Health Systems and Public Health Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region Expert meeting Barcelona, Spain, 3–4 November 2014 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region Expert meeting Barcelona, Spain, 3–4 November 2014 ABSTRACT From November 3-4, 2014, the Division of Health Systems and Public Health (DSP), the WHO Regional Office for Europe, brought together senior staff in the Division of Health Systems and Public Health of the WHO Regional Office for Europe and external experts who have worked closely with WHO Europe on health systems strengthening to identify priority areas for health systems strengthening. The meeting was the first step in identifying priorities for health systems strengthening from 2015 to 2020 for a draft resolution to be submitted to the RC65. The meeting was also an opportunity to discuss the content of the upcoming WHO Regional Office’s draft strategic document which will inform the positioning of the Regional Office’s priorities in strengthening people-centered health systems for the next five years, to realize the goals of Health 2020. In identifying priorities, the group discussed key constraints and challenges health systems are likely to face in the next five to ten years, taking into account the diversity of countries in the European Region. The group identified ways in which WHO can best support member states (at country and regional level) to make progress in the priority areas and identified priorities for generating the evidence needed to support member states in health systems strengthening. Keywords DELIVERY OF HEALTH CARE HEALTHCARE SYSTEMS MEETING REPORTS PUBLIC HEALTH UNIVERSAL COVERAGE 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 information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © 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. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Document number: WHO/EURO:2015-6488-46254-66905 CONTENTS Page Background ....................................................................................................................... 1 Health systems strengthening: past and future ..................................................................... 3 Health systems frameworks ........................................................................................ 3 Fiscal sustainability, efficiency and universal health coverage (UHC) ............................... 3 The important role of case studies ............................................................................... 4 Maintaining a country-specific approach ....................................................................... 4 Shared learning and building networks ........................................................................ 5 The Tallinn Charter .................................................................................................... 5 The challenges and priorities facing Member States and the WHO Regional Office in health systems strengthening ........................................................................................................ 6 Integrated health services delivery .............................................................................. 6 Public Health ............................................................................................................. 7 Skill mix and human resources for health ..................................................................... 7 Seeking innovative information systems and health technologies ................................... 7 Working with limited resources ................................................................................... 8 Communication with multiple audiences ....................................................................... 8 Unpacking people-centred health systems ............................................................................ 8 Managing transformation of health systems .......................................................................... 9 The comparative advantage of the WHO Regional Office in the field of health systems strengthening .................................................................................................................. 10 Conclusions ..................................................................................................................... 11 References. ..................................................................................................................... 12 Annex 1. Provisional Programme ............................................................................... 13 Annex 2. List of participants ...................................................................................... 15
Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 1 Background A WHO/Europe expert meeting on ‘Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region’ was held 3–4 November 2014 in Barcelona, Spain. The meeting was attended by senior staff in the Division of Health Systems and Public Health (here on referred to as DSP) and a number of external experts who have worked closely with WHO/Europe on health systems strengthening activities. Through DSP, the Regional Office has been instrumental in providing guidance and technical assistance to its Member States on strengthening and improving the performance of their health systems. These activities have drawn inspiration from the Tallinn Charter ‘Health systems for health and wealth’,1 which was endorsed by the Regional Committee in resolution EUR/RC58/R4 (WHO, 2009). Building on this, and developing it further, the strengthening of people-centred health systems is one of the four priority areas of WHO/Europe’s Health 2020 policy framework and strategy for the 21st century.2 At the 2013 WHO high-level meeting marking the 5 year anniversary of the Tallinn Charter, ‘Health systems for health and wealth in the context of Health 2020: Follow-up to the 2008 Tallinn Charter’, it was proposed that, following approval by the Standing Committee of the WHO Regional Committee for Europe (SCRC), a draft resolution setting out the priorities for Health Systems Strengthening (HSS) in the WHO European Region 2015–2020 would be submitted to the Regional Committee (RC65) in September 2015 for adoption. The proposal received strong support by Member States at RC64 in September 2014 emphasizing the importance of the Regional Office’s work on health systems strengthening. The expert meeting in Barcelona was the first step in identifying priorities for health systems strengthening from 2015 to 2020 in the context of Health 2020 for the draft resolution to be submitted to the RC65. The focus of the meeting was on the role of health systems in improving health and well-being, with particular attention on tackling inequities, and had four key components: • to identify the key constraints and challenges health systems are likely to face in the next five to ten years, taking into account the diversity of countries in the European Region; • to identify priority areas for health systems strengthening building upon the Division’s current and planned work on health systems strengthening; • to identify ways in which WHO can best support Member States (at country and regional level) to make progress in the priority areas; and 1 The seven commitments outlined in the Tallinn Charter are to: (1) promote shared values of solidarity, equity and participation; (2) invest in health systems and foster investment across sectors that influence health; (3) promote transparency and accountability; (4) make health systems more responsive; (5) engage stakeholders in policy development and implementation; (6) foster cross-country learning and cooperation; and (7) ensure that health systems are prepared and able to respond to crises. 2 The European policy Health 2020 has two strategic objectives: to improve health for all and reduce health inequalities, and to improve leadership and participatory governance for health. The policy delineates four pillars for action to achieve these objectives: 1) investing in health through the “life course” approach; 2) tackling Europe’s major disease burdens of NCD and communicable diseases; 3) strengthening people-centred health systems and public health capacity; and 4) creating supportive environments and resilient communities. The DSP works primarily under pillar three to revitalize public health services and to transform health systems in the region towards a more people-centred focus. Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 2 • to identify priorities for generating the evidence needed to support Member States in health systems strengthening. The operational approach of the DSP is set out in the document Towards people-centred health systems: An innovative approach for better health outcomes.3 This approach represents a paradigm shift towards focusing on desired health outcomes and strengthening systems accordingly. Such an outcome-focused approach has been put into practice for a number of tracer diseases including the control and prevention of noncommunicable diseases4, multidrug-resistant tuberculosis (MDR TB) and anti-microbial resistance (AMR). These approaches and the recent work on greening health services has been an effective way of promoting inter-divisional work within the Regional Office, and is one that has been very well received by Member States, who commented on the benefits of such collaboration at the recent Regional Committee (RC64). In 2013, there have been three important WHO/Europe health systems strengthening-related meetings in the context of Health 2020: • the 2nd Oslo Conference on the Impact on economic crisis on health and health systems in the region (17–18 April 2013); • the WHO high-level meeting on ‘Health systems for health and wealth in the context of Health 2020: Follow-up to the 2008 Tallinn Charter’, which marked the 5th anniversary of the Tallinn Charter: Health Systems for Health and Wealth (17–18 October 2013); and • the 35th anniversary of the Alma Ata Declaration on primary health care (PHC) in Almaty (5–6 November 2013). The meeting, therefore, built on the operational approach set out by the DSP, the outcomes of the above-mentioned three meetings and a background paper5 prepared by Professor Peter Smith which proposed a range of priorities for health systems strengthening priorities for each of the health system building blocks and the two cross cutting issues of efficiency and context. As participants embarked on narrowing the priorities for the next five years and addressing the implementation gaps in the region, the challenge for the Division, Dr Kluge urged, was to address these implementation gaps with excellence and relevance assuming leadership in health systems strengthening in a way that is responsive to Member State needs and respected by partners. The division remains ambitious but is also realistic in the face of daily tensions between ever increasing demands and limited resources. Constraints can serve to push the Regional Office to be more creative in implementing its ambitions. Finally, the division’s role is to advocate for solidarity and equity. The office ensures that human rights to health do not disappear from the discussions. This is of utmost importance especially when health outcomes or gains are subsumed within the economic perspective on health. 3 http://www.euro.who.int/__data/assets/pdf_file/0006/186756/Towards-people-centred-health-systems-an- innovative-approach-for-better-health-outcomes.pdf 4 http://www.ndphs.org///documents/3965/NCD_8-9- 5__HSS%20NCD%20Country%20Assessment%20Guide_v7.pdf 5 Smith, Peter. Unpublished. “HSS Meeting Discussion Paper: Some reflections on priorities for health system strengthening”. Copenhagen: WHO Regional Office for Europe. Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 3 Health systems strengthening: past and future The participants identified various areas of development that have characterized the field of health systems strengthening in the European Region over the past few years. Health systems frameworks One of the main developments in health systems strengthening has been the development of frameworks which represent a move away from fragmented approaches and analyses to ones that are integrated and systemic (systems thinking). Since then, the DSP has also developed a country assessment guide identifying 15 challenges and opportunities for tackling noncommunicable diseases (HSS-NCD country assessment guide). Most importantly these frameworks assist policy-makers and analysts to think systematically about health systems strengthening. Selecting the framework to be used is secondary to consistency in using it. Fiscal sustainability, efficiency and universal health coverage (UHC) Developing the concepts of fiscal sustainability and efficiency in health care, especially in distinguishing between efficiency and cost containment has been another major development in health systems strengthening (Fig. 1). The office has been instrumental in advocating to Ministers of Health, Finance and multilateral organizations (as the Troika) that cuts may undermine efficiency and there are limits to how far efficiency gains can be relied on to address gaps in public funding for health systems, particularly over a sustained period of time, as the work on the economic crisis has shown.6 It is crucial that WHO continues to be involved in discussions around efficiency and cost-containment as it has the expertise and resources to shape this discussion to one that is evidence based and maintains the focus on improving health. Fig. 1: Savings are not the same as efficiency gains Source: Thomson et al 2014 Experts in health systems strengthening are increasingly recognizing and addressing unintended consequences of measures taken to enhance efficiency. It is increasingly apparent that attempts to do more with less must not exacerbate or create new inefficiencies such as access barriers and 6 Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, Cylus J, Karanikolos M and Kluge H (2014). Economic crisis, health systems and health in Europe: impact and implications for policy, Copenhagen: WHO/European Observatory on Health Systems and Policies. Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 4 lower quality of services or coverage. The implementation of reforms during the financial crisis has left several pockets of populations without coverage in eastern and western European countries alike. It is clear that countries cannot simply cut services and still maintain effective coverage. The conversations around UHC have in this regard also been an increasingly unifying concept and the WHO cube (Fig. 2) and has been helpful in conveying key messages. These tools are for example helpful when meeting with policy makers to communicate that some but not all parts of benefit packages can be cut while still maintaining appropriate access and effective services. Fig. 2: Universal Health Coverage – A unifying concept Source: Adapted from WHO, 2010 The important role of case studies The Ebola crisis has reminded Member States of the important role of public health capacity. Several Member States have expressed concern that they are not prepared to tackle an epidemic and are therefore seeking help from the WHO in implementing for example, the International Health Regulations and building institutional health capacities. Here preparing some vignettes or case studies to expose the challenges faced by different health systems in dealing with Ebola could be useful. Case studies have been important in the recent work conducted by the human resources for health program on good practices in nursing and midwifery to inform policy makers on the potential roles of nurses and midwives. It is important to ensure that case studies are useful to the larger group of constituents as well as for policy makers. Case studies can, however, be very time consuming. The burden of case study work can perhaps be assumed by outside institutions if more sustained investment in research is provided to countries. Engaging expatriates living abroad is another way to rectify the challenges facing countries which do not have this capacity in place. Maintaining a country-specific approach WHO/Europe’s work on health systems has gone beyond description and comparative analysis across countries. The Regional Office has taken an important strategic approach in arguing that HSS is very country context specific. The Regional Office has worked closely with national policy-makers and has enabled better implementation of specific policies and wider reforms in a manner sensitive to local requirements and needs. WHO has also conducted institutionalized performance assessments in countries focusing on the impact of reforms in countries and performance improvements over time. The country focus in WHO’s technical work on HSS has for example proved to be a successful strategy with high impact. Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 5 Shared learning and building networks Countries have responded positively to the opportunity to share experience with other Member States. Learning from mistakes by others is just as important as learning from successes. The generation of networks is also a way of sustaining the work. Member States also like networks for the opportunities these networks offer in learning about how to prioritize and how to problem solve. Focusing on thematic networks (e.g. health workforce, medical products, public health, CIHSD) is a practice that the Regional Office has been pursuing through its vast networks of Collaborating Centres and proves to be a very useful strategy that should be continued. The regional training courses and high level policy dialogues initiated by the Barcelona Office and the European Observatory have also been a particular success. These courses have created alumni that are going to be in the ministries for longer than ministers themselves. Several experts suggested this model be extended to other areas of health systems. The idea of a virtual campus such as PAHO has done could also be explored. The Tallinn Charter Finally, an important area of development was the signing of the Tallinn Charter by all Member States in 2008. The Charter marked a landmark contribution in the area of health systems and has proved to be a powerful tool in pitching the case for the virtuous cycle of health, health systems and wealth. The health-health systems-wealth relationship put forward in the Tallinn Charter, however, still requires work (Fig. 3). The participants agreed that, in addition to continuing the work on revealing the important links between health and economic policies, more attention needs to be devoted to communication strategies in order to increase engagement with people but also between the ministries of health and finance on the values of the Tallinn Charter. An important development that emerged from the Tallinn Charter was the health systems performance assessments (HSPAs). The Regional Office now needs to emphasize that the HSPAs are used as part of the process of policy-making, basing priority setting on these HSPAs and not just using HSPAs as a measurement for which there is no follow up. Also important is to clarify linkages between HSPA and the Health 2020 policy. This clarification will benefit discussions between the Regional Office and the European Commission, which has recently identified HSPAs as a top priority area. Fig. 3: The Tallinn Charter Triangle “health systems for health and wealth” Societal well-being Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 6 The challenges and priorities facing Member States and the WHO Regional Office in health systems strengthening Participants differentiated activities in health systems strengthening as either easier to implement –‘low hanging fruit’- or more difficult to implement – ‘higher hanging fruit’ (Fig. 4). During the financial crisis the tendency has been towards reaching for the ‘low hanging fruit’. The ‘high hanging fruit’ are those activities where implementation strategies and tools are weakest. The challenges in reaching these ‘high hanging fruit’ are exacerbated by the lack of information and evidence, suboptimal management, leadership and political commitment. These ‘high hanging fruit’ and the exacerbating factors should inform the region’s long-term priorities. Fig. 4: Low-hanging fruit and more complex actions Source: Based on Bengoa and Repullo, 2013 Integrated health services delivery Since the Tallinn Charter and with the re-orientation towards people-centred care, integrated care has become an increasingly important area of interest for Member States. In order for this to take place, particular emphasis needs to be placed on ensuring that no health system function or programme operates in isolation. New accountability mechanisms will need to be in place for services, incentives will be key for integrating services, as will the definition of workforce competencies and new means of communication between technologies, services and /or Integrated Care Skill Mix Public Health Hospital Rationalization Clinical Guidelines Payment for Performance Innovation ICT E Health HTA Benefit Packages User Charges Staff Cuts Salary Reductions Population Exclusions Delayed Investments Rationing Benefits Training & Research Cuts Price Controls Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 7 providers. The Regional Office will have a key role to play in supporting countries in the implementation of integrated health services. Public Health The WHO has demonstrated progress and success in several areas of public health including the setting of targets and priorities, monitoring and assessing population health, defining public health strategies, policies and plans and assuring funding. In order to scale up successful programmes and improving delivery of services at the individual and population level the Regional Office developed the ten essential public health operations (EPHOs). This work is accompanied by a public health assessment tool. The Regional Office will now be instrumental in supporting countries with the implementation of the EPHOs. The current trend of integrating public health into primary care also needs to be reflected on carefully however so that public health services do not lose their population health focus. Governments must continue to address the determinants of health at this broader level. Skill mix and human resources for health Experts agreed that there are a number of key and pressing issues around human resources for health, specifically in relation to information on health workforce numbers and needs. These cross cut other sectors including education, labour and finance. Several participants recounted their frustration over the lack of capacity for health workforce research and information systems to direct decision-making. The politics around accepting new professional task profiles and skill mixes also needs to be addressed in order to enable the various areas of innovation to take place. While costly, the training of clinical professionals and the organization of providers is only partially amenable to short term reform and requires long term thinking and increased investments in line with the principles put forward by the Lancet Commission on transformational education.7 Seeking innovative information systems and health technologies The crisis has caused policy-makers to take a closer look at medicine prices in respect of addressing efficiency and spending concerns. The time is ripe for re-thinking strategies to achieve sustainability in the introduction of innovations in health both in approach and products. There is room for a lot of change where shortages are rare but underutilization, particularly of pharmacists and pharmacies, is pervasive. This has to do with the fact that for many years, medical products have lied outside of the health system. Other trends in the region include a net rise in out of pocket expenditures since the financial crisis, rising costs for medical products and heavy focus on noncommunicable diseases and rare diseases without transparent mechanisms to demonstrate evidence-based decision making. Work must be focused on increasing sustainable access not only to essential medical products but also on technologies and devices. The Regional Office can work with countries to help develop in priority setting. Some of the challenging actions that need to take place include establishing government vision/policy for medical products, conducting price reviews, making changes to co-payment and financing structures, revision of existing pharmaceutical and regulation policies, increased transparency, and as these 7 Frenk, J. Chen, L., Bhutta, Z., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimsah, S., Sepulveda, J., Serwadda, D, Zurayk, H. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. Vol. 376: 1923-1958. Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 8 changes are made it is important to support countries in developing indicator systems to monitor the impact of these changes. Working with limited resources The group agreed that DSP has undertaken a lot of hard work on a range of extremely relevant issues. While the division’s desire to be ambitious and effective is commendable, DSP has very limited resources and this requires better priority-setting. DSP needs to focus on the activities with greatest impact. Communication with multiple audiences An overarching challenge for the WHO Regional Office is communicating with multiple audiences, including health policy makers, policy makers in other sectors and the population at large. Broader communities of policy makers and the public often have very different levels of understanding from health sector policy makers. It is therefore important for the Regional Office to be clear and targeted in its dialogue with these audiences so that expectations are not unrealistic. Speaking to multiple audiences has the benefit of securing input and insights. This could also be particularly valuable in mobilizing public support for key agendas to building health system resilience. Ensuring sustainability of HSS relies on linking health to broader policies and being inclusive of a broader range of stakeholders and sectors. It requires being able to ‘speak’ not just in health terms, but to find ways of engaging with non-health interests. For example, dialogue with the ministry of finance involves talking about efficiency or pensions and the effects that decision- making around pensions have on health financing (i.e. later or earlier retirement ages means more or less financial contributions to health), or the health-wealth link under the Tallinn Charter (i.e. healthier populations contribute to greater employment). Nevertheless, it still remains a challenge for health systems strengthening activities. The WHO Regional Office needs to be able to help policy makers achieve structural reforms. The biggest gap in this regard seems to be in mobilizing tools for stronger leadership and better governance. Helping Member States articulate their priorities in a national health strategy, and overcome the barriers they face when it comes to operationalizing the strategy, is an important area to invest in. Unpacking people-centred health systems Key to realizing the goal of people-centred health systems, will be unpacking the concept of people-centredness since as of yet there is no consensus on what this means. National and international policy statements use the term in very different and diverse ways. There are several dimensions to people centredness including strengthening health literacy, defining patient care pathways, encouraging more self-management among patients, advocating for shared decision making with patients, and patient empowerment. Discussions on what is meant by people centred health systems allowed the group to identify several important questions that will need to be answered: What should health systems look like in 5 years? What do we mean by people-centred systems and care? How can the health system functions be aligned towards serving the goal of people centred health systems? Where does delivery of people-centred health services take Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 9 place? Who should provide the services? How to involve people in people-centred services in a meaningful way? Managing transformation of health systems Participants closed the meeting with a discussion on managing change and transformation of health systems. Health systems in the Region can be characterized along a spectrum that involves reactive medical care systems at one end of the spectrum and broader multi-sectoral health care systems at the other end of the spectrum. See Fig. 5. Change becomes more challenging and leadership more vital as one moves along this spectrum from left to right. Countries on the left side of the spectrum focus efforts on maintaining the status quo and traditional medical models of care, which are reactive in nature. Such countries are often challenged by innovation and change including new health services delivery models, new financing schemes, acquiring new technologies, or hiring new staff and task re-profiling. Moving out of this “reactive state” requires very realistic assessments of what countries can and cannot do. For the past 25 years, the WHO has invested a lot of efforts in providing new solutions to health and healthcare, characterizing ideal health systems at the right end of the spectrum without a clear theory of change or road map on the steps required to achieve a transformation of the health system. Discussions around WHO reform have also emphasized that the WHO is too medicalized. This discussion about change management is therefore timely and extremely relevant. Moreover, the high level ministerial meeting in Tallinn in 2013 also resulted in a proposal to bring together high level policy makers to discuss leadership and stories from peers who have first-hand experience in negotiating with power interest groups and making politically unpopular decisions. Fig. 5: Change model for health systems Source: Rafael Bengoa Change Leadership Reactive medical care Proactive accountable care Broader multi- sectoral response Resist stage Transform stage Supertransform stage Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 10 Overall, the group agreed that the visualization, represented in fig. 5, of a spectrum for change management is useful for providing countries with a sense of direction despite its simplification of the complexities involved in HSS. Participants proposed various ways by which change management can take place in order to more effectively move countries along the spectrum of change. These include: • focusing on breaking down silos between professional groups; • working with the education sector; • facilitating multi-professionalism; • working with change agents who may exist outside of ministries of health; • focusing efforts and discussions on how to deal with powerful political interests (i.e. doctor lobbies, pharmaceutical companies); • developing leadership among clinicians as well as policy makers; and • tailoring language for policy makers. The group agreed that the WHO should use its convening power to create opportunities for member states to exchange experiences in managing change. It was proposed that these discussions are informed by the problems that countries are facing and accompanied by structured decision making frameworks to address key questions. Facilitating external reviews on what countries are doing with their peers could also be helpful. Given that some countries (7 were identified) have already thrust themselves into the super transformation stage, these opportunities would not need WHO to generate new evidence. The group agreed that local context continues to be important in deciding what exact tools for convening countries for experience sharing works best. The comparative advantage of the WHO Regional Office in the field of health systems strengthening Participants agreed that the Regional Office has a comparative advantage over other players in the health field on several fronts. WHO is the organization whose mandate is to coordinate and convene around international public health around values. Countries rely on the WHO to help with structural reforms and with help in articulating their vision and values when it comes to health. The WHO offers a forum where countries can be honest about the challenges their health systems face and share experiences on how to improve their health systems. The WHO has played an instrumental role in generating and disseminating evidence. This dissemination of evidence is not only valuable to ministries of health but also needed and requested by other ministries and actors. The WHO’s convening power enables peer knowledge exchange through policy dialogue and maintains credibility in engaging with health professionals. Its ability to organize peer review between countries, identify bottlenecks in health systems, frame concerns in terms of process rather than technical issues e.g. how do policy makers make difficult decisions, what are the gravity of issues and provide the vision for change are all dimensions of the strength of the organization. Help with implementation was identified as an area in which WHO has also been instrumental as is its role in holding countries to account to their populations, and building capacity at regional and country level. Participants agreed that WHO has therefore both a normative and Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 11 interventionist function. In its interventionist function, the WHO has played a critical role in leveraging funds from other organizations in countries such as Greece and Cyprus. In its normative function, the WHO is important for navigating the current landscape whereby countries are being forced to be selective in their health priorities. Conclusions The Expert meeting in Barcelona was the first step in identifying priorities for health systems strengthening from 2015 to 2020 for a background paper and draft resolution to be submitted to the RC65. The focus of the meeting was on the role of health systems in improving health and well-being with due attention to equity. Among the most notable outcomes of the meeting were: • identification of key constraints and challenges for health systems in Europe and for the WHO Regional Office; • proposals for strategic priority areas and approaches of work by the DSP and Regional Office on health systems strengthening up to 2020; • identification of the Regional Office’s key and most valuable operational approaches; • sharing of inspiring good practices of ways to strengthen health systems; and • to start the process of agreeing on future directions for health systems up to 2020. The meeting underscored the importance of making health systems people-centred and finding new ways of engaging civil society. Participants re-enforced that there is no single best model so tailoring assistance to a specific context is critical and something WHO already does well. Turning single ‘control knobs’ is also not enough. Clearly action is usually required on multiple fronts. The importance of ensuring that these actions are themselves aligned and aim to secure greater alignment across the health system is necessary. And while the desire for WHO to be relevant, effective and ambitious is one all participants share, there was widespread recognition that in order to do this the WHO will need to prioritise and be systematically selective. The meeting confirmed that Health 2020 and the Tallinn Charter have been synergistic in their aims - of improving people’s health and reducing health inequalities. WHO/Europe has an important role in asserting the values that underlie Health 2020 and the Tallinn Charter, which articulate that: effective health systems promote both health and wealth; that investment in health is an investment in future human development; and that well-functioning health systems are essential for any society to improve health and attain equity. The priority now lies in achieving the Health 2020 goal of making health systems more people-centred. The WHO maintains a comparative advantage in this regard on several fronts. The operational ways in which WHO has worked to date continue to be relevant and valuable. Recognizing the points of comparative advantage and challenge areas will be important to leverage as the WHO works with Member States to tackle a number of key priority areas in health systems strengthening in Europe. Several strategic priority areas of work were proposed for DSP and Regional Office’s health systems strengthening activities up to 2020. Understanding what is meant by people centred health systems will be central to the WHO’s work moving forward. Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 12 References Smith, Peter. (2014). Unpublished. “HSS Meeting Discussion Paper: Some reflections on priorities for health systems strengthening”. Copenhagen: WHO Regional Office for Europe. Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, Cylus J, Karanikolos M and Kluge H (2014). Economic crisis, health systems and health in Europe: impact and implications for policy. Copenhagen: WHO/European Observatory on Health Systems and Policies. Available at: http://www.euro.who.int/en/about- us/partners/observatory/publications/policy-briefs-and-summaries/economic-crisis,-health- systems-and-health-in-europe-impact-and-implications-for-policy. WHO (2000). The World Health Report 2000. Health Systems: Improving Performance. Geneva: World Health Organization. Available at: http://www.who.int/whr/2000/en/ WHO (2007). Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes, WHO’s Framework for Action. Geneva: World Health Organization. Available at: http://www.who.int/healthsystems/strategy/en/ WHO Regional Office for Europe (2008a). Stewardship/governance of health systems in the WHO European Region. In: Fifty-eighth Session of the Regional Committee for Europe. Copenhagen: World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0016/70243/RC58_eres04.pdf WHO Regional Office for Europe (2008b). The Tallinn Charter: Health Systems for Health and Wealth. Copenhagen: World Health Organization Regional Office for Europe. Available at: http://www.euro.who.int/document/e91438.pdf WHO (2010). Financing for Universal Health Coverage. Geneva: World Health Organization. Available at: http://www.who.int/healthsystems/topics/financing/healthreport/en/ WHO Regional Office for Europe (2012a). Health 2020: the European policy for health and well-being. Copenhagen: World Health Organzation Regional Office for Europe. Available at: http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for- health-and-well-being/publications/2013/health-2020-a-european-policy-framework-and- strategy-for-the-21st-century WHO Regional Office for Europe (2013). Towards people-centred health systems: An innovative approach for better health outcomes. Copenhagen: World Health Organization Regional Office for Europe. Available at: http://www.euro.who.int/__data/assets/pdf_file/0006/186756/Towards- people-centred-health-systems-an-innovative-approach-for-better-health-outcomes.pdf Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 13 ANNEX 1. PROVISIONAL PROGRAMME Monday, 3 November 2014 10:00-10:10 Welcome and introduction 10:10–10:20 Context and rationale for the meeting - Hans Kluge 10:20–10:40 Health systems strengthening: past and future – Tamás Evetovits and Josep Figueras Objective: short overview of the work on health systems by WHO Europe and the European Observatory 10:40-11:30 Challenges and priorities for health systems strengthening – introductory presentation by Peter Smith Objective: to set the scene and propose a structure for the discussion on current challenges health systems face and priority areas for health systems strengthening 11:30-12:00 Break 12:00–13:30 Experts’ contributions and discussion– facilitated by Nigel Edwards Objective: to discuss key constraints and challenges for HSS in Europe and seek experts’ views on strategic directions and priorities for HSS up to 2020 13:30–14:30 Lunch break 14:30–15:30 People-centred health systems: Brief overview of ongoing HSS work by DSP – Hans Kluge Objective: to inform experts about the current activities on HSS by the Division of Health Systems and Public Health 15:30-16:00 Break 16:00–17:30 Experts’ contributions and discussion – facilitated by Wim Van Lerberghe Objective: to seek experts’ proposals to complement WHO’s work on HSS to enhance relevance to new challenges and exploit WHO’s comparative advantage 17:30-17:45 Wrap up – Sarah Thomson 17:45 Closure of the day – Hans Kluge Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 14 Tuesday, 4 November 2014 9:00-11:00 Unpacking people-centred health systems – facilitated by Juan Tello with contributions from all experts Objective: to unpack people centredness and discuss implications for health systems strengthening 11:00-11:30 Break 11:30–12:30 Managing transformation of health systems - Rafael Bengoa with contributions from all experts Objective: to discuss health system reform implementation experience and the importance of managing the change process 12:30-13:00 Comparative advantage of WHO in the field of health systems strengthening. Gaining leadership – Rafael Bengoa 13:00–13:30 Wrapping up messages of the meeting - Sarah Thomson Summary and closure – Hans Kluge Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 15 ANNEX 2. LIST OF PARTICIPANTS Prof. Volker Amelung President German Managed Care Association Dr. Rafael Bengoa Director Deusto Business School Health Mr. Nigel Edwards Chief Executive The Nuffield Trust Dr. Josep Figueras Director European Observatory on Health Systems and Policies Prof. Martin McKee Professor of European Public Health London School of Hygiene and Tropical Medicine Prof. Elias Mossialos Professor of Health Policy London School of Economics and Political Science Ms. Liis Rooväli Acting Head E-Health Department at Ministry of Social Affairs of Estonia Prof. Wim Van Lerberghe Senior Advisor WHO Athens Project Office WHO Regional Office for Europe Ms. Susan Ahrenst Administrative Assistant (Director’s Office) Division of Health Systems and Public Health WHO Regional Office for Europe Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 16 Ms. Hanne Bak Pedersen Programme Manager Health Technologies and Pharmaceuticals Division of Health Systems and Public Health WHO Regional Office for Europe Dr. Tamás Evetovits Head of Office a.i. Barcelona Office for Health Systems Strengthening Division of Health Systems and Public Health WHO Regional Office for Europe Dr. Melitta Jakab Senior Health Economist Barcelona Office for Health Systems Strengthening Division of Health Systems and Public Health WHO Regional Office for Europe Dr. Elke Jakubowski Programme Manager, Public Health Services Division of Health Systems and Public Health WHO Regional Office for Europe Dr. Hans Kluge Director Division of Health Systems and Public Health Special Representative of the Regional Director on MXDR-TB WHO Regional Office for Europe Ms. Margrieta Langins WHO Technical Consultant Division of Health Systems and Public Health WHO Regional Office for Europe Dr. Belinda Loring Technical Officer Division for Non communicable Diseases and Life-course WHO Regional Office for Europe Dr. Galina Perfilieva Programme Manager, Human Resources for Health Division of Health Systems and Public Health WHO Regional Office for Europe Dr. Govin Permanand Senior Health Policy Analyst Division of Health Systems and Public Health WHO Regional Office for Europe Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region page 17 Dr. Maria Skarphedinsdottir Technical Officer, Health Services Delivery Division of Health Systems and Public Health WHO Regional Office for Europe Dr. Juan Tello Programme Manager, Health Services Delivery Division of Health Systems and Public Health WHO Regional Office for Europe Dr. Sarah Thomson Senior Health Financing Specialist Barcelona Office for Health Systems Strengthening Division of Health Systems and Public Health WHO Regional Office for Europe Rapporteur Ms Margrieta Langins The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan HEALTH SYSTEMS STRENGTHENING IN THE CONTEXT OF HEALTH 2020: CHALLENGES AND PRIORITIES IN THE WHO EUROPEAN REGION Division of Health Systems and Public Health Health systems strengthening in the context of Health 2020: challenges and priorities in the WHO European Region Expert meeting Barcelona, Spain, 3–4 November 2014 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int