Report of the Regional Director: the work of the WHO Regional Office for Europe in 2023–2024

Report of the Regional Director The work of the WHO Regional Office for Europe in 2023–2024 Abstract This report covers the activities of the WHO Regional Office for Europe for the period 1 September 2023 to 31 August 2024. These activities are guided by the European Programme of Work, 2020–2025 – “United Action for Better Health” and the targets of the Thirteenth General Programme of Work, 2019–2025 (GPW 13). The report presents activities within the scope of each of the three pillars of the GPW 13: universal health coverage, health emergencies, and health and well-being, along with the supporting pillar of a more fit-for-purpose WHO. Keywords: EUROPE; UNIVERSAL HEALTH CARE; EMERGENCIE; WORLD HEALTH ORGANIZATION ISBN: 9789289061407 (PDF) ISBN: 9789289061414 (print) © World Health Organization 2024  Some rights reserved. 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In no event shall WHO be liable for damages arising from its use.   Cover photo: ©WHO/Sören Talu Designed by: Pointer Creative Report of the Regional Director The work of the WHO Regional Office for Europe in 2023–2024 ii Contents Abbreviations ..............................................................................................................................iv Foreword by the Regional Director ..............................................................................................vii Introduction ................................................................................................................................. 1 Core priority 1: moving towards UHC ........................................................................................... 5 Access to health care without financial hardship .......................................................................................................... 7 Access to medicines ........................................................................................................................................................ 8 PHC ................................................................................................................................................................................. 10 Patient-centred services delivered by well-supported health and care workers ........................................................ 11 Bringing quality to the heart of health care delivery ..................................................................................................... 14 Health through the life-course: from birth to healthy, active ageing ........................................................................... 15 Migration and health ...................................................................................................................................................... 16 Flagship initiative: the Pan-European Mental Health Coalition ................................................................................... 18 Flagship initiative: Empowerment through Digital Health ........................................................................................... 20 Flagship initiative: EIA2030............................................................................................................................................ 21 Core priority 2: protecting against health emergencies .............................................................. 25 Response to graded emergencies affecting the European Region ............................................................................. 27 Building country capacities in HEPR ............................................................................................................................. 36 Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 iii Core priority 3: promoting health and well-being ........................................................................ 47 Communicable diseases................................................................................................................................................ 49 NCDs ............................................................................................................................................................................... 53 Prison health ................................................................................................................................................................... 60 Environment, climate change and health ...................................................................................................................... 61 Healthy cities .................................................................................................................................................................. 66 Accelerated action against AMR ................................................................................................................................... 68 One Health ...................................................................................................................................................................... 71 Gender, rights, equity ...................................................................................................................................................... 73 Investment for health development .............................................................................................................................. 74 Flagship initiative: Healthier behaviours: incorporating BCI ........................................................................................ 75 Core priority 4: maintaining a fit-for-purpose WHO/Europe ........................................................ 79 Supporting health leadership at the country level and being relevant for all 53 Member States.............................. 80 Strengthening subregional and international partnerships ......................................................................................... 83 Transforming for impact and more accountability to Member States ....................................................................... 90 Financial, human, administrative resources managed in an efficient, effective, results-oriented and transparent manner ............................................................................................................................................... 100 Past forward: learning from yesterday to power tomorrow ....................................................... 111 Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024iv Abbreviations AMC antimicrobial medicines consumption AMR antimicrobial resistance BCI behavioural and cultural insights COP28 28th Conference of the Parties to the United Nations Framework Convention on Climate Change COP29 29th Conference of the Parties to the United Nations Framework Convention on Climate Change COVID-19 coronavirus disease CSOs civil society organizations ECDC European Centre for Disease Prevention and Control ECEH European Centre for Environment and Health EIA2030 European Immunization Agenda 2030 EIOS Epidemic Intelligence from Open Sources ELA Pan-European Leadership Academy EMTs Emergency Medical Teams EPW European Programme of Work, 2020–2025 – “United Action for Better Health” EU European Union GPW 13 Thirteenth General Programme of Work, 2019–2025 HEPR health emergency preparedness, response and resilience HERA Health Emergency Preparedness and Response Authority IHR International Health Regulations MHPSS mental health and psychosocial support Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 v NAHPS National Action Plan for Health Security NCDs noncommunicable diseases OECD Organisation for Economic Co-operation and Development PHC primary health care PHEIC public health emergency of international concern PHEOC public health emergency operations centre PHHE WHO European Centre for Preparedness for Humanitarian and Health Emergencies RC72 72nd session of the WHO Regional Committee for Europe RC73 73rd session of the WHO Regional Committee for Europe RC74 74th session of the WHO Regional Committee for Europe RCCE-IM risk communication, community engagement and infodemic management REECH Regional European Emergency Medical Team Capabilities Hub SCRC Standing Committee of the Regional Committee for Europe SDG Sustainable Development Goal TB tuberculosis UHC universal health coverage UNHLM United Nations High-Level Meeting WASH water, sanitation and hygiene WEU WHO Representation Office to the EU © W H O /H al ld or ss on Foreword by the Regional Director Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024viii Past forward: learning from yesterday to power tomorrow When I began my tenure as the WHO Regional Director for Europe in February 2020, it was difficult to imagine what lay ahead on the global public health stage: coronavirus disease (COVID-19) emerged as I began my first term. Some four and a half years later, the WHO European Region – encompassing 53 Member States in Europe and central Asia – is still recovering from the devastation of the COVID-19 pandemic. Conflicts in Ukraine and the Middle East have profoundly undermined health care delivery to millions in desperate need. Climate change continues to threaten our health and our health systems. And, as I write this foreword, mpox has been declared a public health emergency of international concern, for the second time in two years. Compounding these challenges are persistent health inequities across the Region, with the gap between wealthier and poorer populations widening every day. Yet throughout this permacrisis, our Region continues to show strength and leadership – as we work with our Member States to boost investments in health to benefit the nearly one billion people we serve. In such volatile times, both Member States and WHO/Europe need to follow a dual-track approach to health care, an approach which simultaneously strengthens health systems to anticipate and cope with the unexpected, and provides day-to-day essential health care. The European Programme of Work, 2020–2025 – “United Action for Better Health” has shown itself to be an effective and agile tool in implementing this approach. The European Immunization Agenda 2030 continues to help countries close the chasm of inequalities in vaccination coverage. With our assistance, 1.7 billion COVID-19 vaccines were administered between December 2020 and March 2023, saving 1.4 million lives. We have launched the Pan-European Mental Health Coalition to tackle the rising mental health challenges in the Region and since 2020, we have helped 42 countries develop and implement mental health policies and legislation, including in emergency settings. I am pleased that many Member States have made great progress on accelerating digital solutions to ensure better access to health care, including for long underserved groups and subpopulations and communities experiencing vulnerability. WHO/Europe has supported the development of 44 national digital health strategies or plans since 2020. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 ix And this year, we have seen more Member States using behavioural and cultural insights (BCI)  – an approach championed by WHO/Europe – to tackle and understand critical health challenges, such as low rates of breastfeeding or cancer screening uptake. Forty-eight Member States are now part of a dedicated BCI network we established last year. As I often mention, primary health care (PHC) is central to addressing our health and well-being priorities. I am delighted that Member States are taking action on strengthening multidisciplinary PHC models, bridging gaps in access, leveraging data and digital tools to reach people experiencing vulnerability, and enhancing community involvement. WHO/Europe has supported 23 countries with tailored technical support since 2020 in this regard. Looking back on the last year: September 2023–August 2024 This report lays out a snapshot of the multiple health achievements in the WHO European Region of the last year. Two more countries in the Region – Azerbaijan and Tajikistan – have eliminated malaria, following a century-long effort to do so. Malaria and other vector-borne diseases in our Region – for example, dengue, which is on the rise – are often linked to climate change. The health impacts of climate change, such as those from increasingly intense heat and cold, are being addressed by our Member States, building upon the Budapest Declaration on climate and health achieved last year. This year, during the Belgian presidency of the Council of the European Union, we launched a report on the commercial determinants of health. It highlighted that four industries, namely tobacco, alcohol, processed foods and fossil fuels, contribute to at least 7400 deaths per day in the Region. I am pleased that Member States are increasingly taking action to address the tactics of these industries, which are fuelling the ever-growing epidemics of noncommunicable diseases – including cardiovascular disease and cancer. We are also pushing forward our commitment to eliminate the burden of infectious disease, including multidrug-resistant tuberculosis (TB), HIV/AIDS, hepatitis and sexually transmitted infections, which all continue to steal far too many lives. In July, we joined Member States at the International AIDS Society Conference to step up efforts on the promise of ending AIDS, hepatitis and sexually transmitted infections by 2030. Additionally, In June in Tashkent, Uzbekistan, we gathered with the Stop TB Partnership and 13 countries from eastern Europe and central Asia to turbocharge political commitment towards ending TB. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024x Many of these abovementioned urgent challenges were discussed at our meeting on health innovation held in March 2024 in Copenhagen, Denmark. The meeting brought together the main innovation hubs in the Region and Member States to map out a collaborative plan to better use innovative solutions, such as remote monitoring, artificial intelligence, genomics and personalized medicine, and novel vaccination strategies. A draft plan will be ready for consideration at next year’s Regional Committee meeting. Furthermore, this year saw WHO/Europe launch the Pan-European Network for Disease Control, a crucial mechanism to boost regional health emergency preparedness and response, bringing Europe and central Asia closer together and aiming to deliver rapid and decisive action on health risks before they become regional or global health threats. Underpinning all of our efforts is the quest for universal health coverage. In June, we launched the first-ever Strategic Partners’ Initiative for Data and Digital Health, bringing together over 100 representatives from Member States and many related fields, including from the private sector and academic institutions. The partnership will identify and address gaps in data and digital health ecosystems with the overall aim of building safe and affordable health systems for everyone, everywhere. We must be encouraged by all these achievements. At the end of last year, we marked the 15th anniversary of the Tallin Charter, a blueprint that all Member States adopted with one clear objective in mind: that spending on health was an investment rather than a cost. Through co-creating solutions with frontline workers, patients and their families, Member States recommitted to work towards universal health coverage, to transform their health systems and to rebuild the trust that had been fractured in the wake of the pandemic. Ultimately, health is a political choice. And even while governments and policy-makers face a myriad of other complex challenges, it is up to them to make that choice. We need to break the cycle of panic and neglect that characterized the pandemic. Because without our health, societies, and we as individuals, have very little at all. We thank all Member States, all health workers, and all partners, especially in civil society, for your herculean work and your trust in WHO to leave no one behind. My colleagues and I count on your continued partnership as we look to the future, working closer together towards achieving health for all. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 xi © W H O /M uk hs in A bi dj an ov xii © W H O /M ar ie O le in ik Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 1 Introduction Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–20242 This report provides an overview of the main activities of the WHO Regional Office for Europe (WHO/Europe)1 between 1 September 2023 and 31 August 2024 at the regional, subregional, national and subnational levels. The report is not an exhaustive account of WHO/Europe’s activities and should be read in conjunction with the Regional Director’s verbal address at the 74th session of the Regional Committee (RC74) and with accompanying RC74 documents, including progress reports on programmatic activities. This report is also complemented by the WHO/Europe Accountability Report for 2024, which details WHO/Europe’s performance across the domains of the Programme budget, business operations, accountability and governance. Moreover, this year’s detailed country-impact report provides further insights into the activities WHO/Europe has undertaken to support Member States. This report marks the first year of activity under the regional plan for implementation of the WHO Programme budget 2024–2025, which serves as the primary means of reporting technical accountability and normative performance, with a focus on delivery to Member States. WHO/Europe’s work is driven by the European Programme of Work, 2020–2025 – “United Action for Better Health” (EPW), in the context of the global Thirteenth General Programme of Work, 2019–2025 (GPW 13) and its core priorities: 1) moving towards universal health coverage (UHC); 2) protecting against health emergencies; 3) promoting health and well-being; and 4) working towards a fit-for-purpose WHO. The core priorities serve as the backbone of this current report, under which all activities are presented. As two biennium programme budgets have concluded since 2020, which marked both the start of the Regional Director’s term and the EPW – now approaching its end date in 2025 – this year’s Report of the Regional Director also concludes with a short reflection on the lessons learned over the past four years. 1 WHO/Europe consists of the head office in Copenhagen, Denmark; field, liaison, representation and sub-offices including subregional WHO Health Emergencies Programme hubs; four geographically dispersed offices; one WHOhosted Partnership; one office for health systems financing (the regional level); 32 country offices (for Israel, host agreement is being finalized) (the country level); and the support of a broad partnership community, including 262 WHO collaborating centres. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 3 © W H O /H al ld or ss on © U ka B or re ga ar d Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 5 Core priority 1: moving towards UHC Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–20246 Member States continue to build on the lessons learned from the coronavirus disease (COVID-19) pandemic, working for stronger and more resilient health systems. Within core priority 1 – moving towards UHC – WHO/Europe has called for better health investment, and provided direct support to Member States through three main fronts: 1. the delivery of new, high-quality PHC services; 2. addressing well-being at the individual and societal levels; and 3. providing evidence and recommendations. This chapter of the report navigates activities through a range of topics under core priority 1, from access to health care and medicines without financial hardship, and the vital nature of a patient-centred PHC and a well-supported health workforce, through to quality care delivered throughout the life-course to all, including those migrating into and within the Region. To round off the chapter activities, the flagship initiatives – the Pan-European Mental Health Coalition, Empowerment through Digital Health, and the European Immunization Agenda 2030 (EIA2030) – are presented. In December 2023, the Government of Estonia and WHO/Europe co-hosted a high-level health systems conference celebrating the 15th anniversary of the Tallinn Charter: Health Systems for Health and Wealth. The conference, Trust and transformation: resilient and sustainable health systems for the future, held in Tallinn, Estonia, marked the culmination of a year of health systems-related events. During 2024, WHO/Europe has developed a  draft framework for resilient and sustainable health systems in the WHO European Region 2025–2030, which will be presented for consideration at RC74. This draft framework recognizes that health systems are key to the future cohesion of our societies and calls for people to trust that they will be able to receive the health care they need without facing financial hardship. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 7 Access to health care without financial hardship Access to health care is a fundamental right and UHC ensures that everyone is able to receive health care without suffering financial hardship. On UHC Day in December 2023, the WHO Barcelona Office for Health Systems Financing launched a landmark report, Can people afford to pay for health care? Evidence on financial protection in 40 countries in Europe. The findings of this report revealed significant challenges in health care access and affordability, which were also present in the Region’s richest countries. In response to the report’s findings, several countries have implemented policy changes to improve the affordability of health care, particularly for subpopulations experiencing vulnerability. Notably, reforms in Latvia, Ukraine and Uzbekistan aim to decouple entitlement to health care from the payment of contributions; Austria has integrated health care coverage expansion as a key metric into its social health insurance framework; and Estonia, Georgia, Ireland, Lithuania, Republic of Moldova and Slovenia have strengthened protection against user charges or abolished them. The WHO Barcelona Office for Health Systems Financing has directly supported over 20 countries with technical support based on the evidence gathered in the report, and training initiatives and health financing courses have reached 300 participants from 30 countries. The Barcelona Office has also facilitated dialogue events that have brought together senior health and finance officials, exemplified by the high-level meeting with Montenegro’s ministers of health and finance in July 2024. In the spirit of collaboration, WHO/Europe’s work towards financial protection for health care has been supported through grants from the Autonomous Community of Catalonia, Spain and the European Union (EU). Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–20248 Access to medicines The Region’s Member States have been raising concerns about shortages of medicines and rising prices, and the impact that paying for medicines has on health budgets. Several countries across the Region have reported difficulties in accessing medicines for cancers, tuberculosis (TB) and rare diseases. In the past year, the focus on this issue at the regional level has been the work carried out through the WHO/Europe Access to Novel Medicines Platform, complemented by providing specific, tailored technical support to countries. The WHO/Europe Access to Novel Medicines Platform, set up by a Member State mandate at RC72, has provided a neutral space for all stakeholders – patients, payers, policy-makers and industry – to discuss issues and to collaborate. The Platform has brought together 50 Member States, 25 nongovernmental organizations, 18 international partner organizations and six European-level industry representative organizations. Four working groups – on transparency, solidarity, sustainability and antimicrobial resistance (AMR) – have put forward 10 proposals, including proposals for dashboards, toolkits and demonstration projects. These proposals were discussed at the WHO/Europe Access to Novel Medicines Platform’s first inperson consensus-building meeting, which was held in Copenhagen, Denmark, on 2–3 July 2024. At this meeting, all stakeholders agreed that the Platform provides a unique opportunity to bring together all the parties involved in pharmaceutical procurement. The next steps for the Platform will involve tackling some of the most pressing issues preventing people’s access to novel medicines at regional and country levels. WHO/Europe has worked closely with WHO headquarters to support several countries to further develop their medicine regulatory systems to ensure the highest levels of quality and patient safety. Notably, in October 2023, Türkiye achieved maturity level 3 in WHO’s classification of regulatory authorities for medicines and vaccines. In 2023, the Swiss Agency for Therapeutic Products (Swissmedic) became the first regulatory authority in the Region to be recognized as a  WHO-Listed Authority. The European Medicines Regulatory Network, which comprises the European Commission, the European Medicines Agency and the medicines regulatory authorities of 30 European Region countries, was recognized as a WHO-Listed Authority in May 2024. Over the past year, WHO/Europe has continued supporting countries to combat the problems caused by substandard and falsified medical products and related crimes. A subregional workshop was held in Tashkent, Uzbekistan, with the participation of Kazakhstan, Kyrgyzstan and Uzbekistan in this regard. WHO/Europe also organized a workshop for central Asian countries and Armenia on the reimbursement of medicines for noncommunicable diseases (NCDs). Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 9 Access to medicines, including opioids such as morphine, for pain treatment and other symptoms, is vital for palliative care. In December 2023, WHO/Europe carried out a short assessment to document the procurement, registration and distribution of essential medicines for palliative care in central Asian countries. Also in central Asia, Kazakhstan piloted the surveillance of hospital antimicrobial medicines consumption (AMC) in 11 hospitals across the country, with technical support provided by WHO/Europe on methodology and training, based on WHO’s Global Antimicrobial Resistance and Use Surveillance System guidance. Tajikistan piloted a survey on the availability of essential in vitro diagnostics for AMR. This representative facility-based survey aimed to identify important gaps in the country’s ability to procure and provide these essential items. Furthermore, the first-ever high- level policy dialogue on the accessibility of medicines was held in Dushanbe, Tajikistan, in February 2024, based on the findings of an analysis of price dynamics and consumption patterns carried out in preparation for a pilot project on medicine reimbursement as part of PHC financing reform. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202410 PHC Access to essential quality care and treatment at the PHC level is crucial as it is the cornerstone of ensuring equitable and effective health care for all. In October 2023, WHO/Europe and the United Nations Children’s Fund (UNICEF), along with the Government of Kazakhstan, hosted the international conference, Primary Health Care Policy and Practice: Implementing for Better Results, in Astana, Kazakhstan. More than 600 delegates from over 70 countries convened to review the progress that has been made since the Declaration of Alma-Ata in 1978 and the Astana Declaration in 2018. The conference focused on practical steps to enhance PHC and to ensure UHC. Leading up to the event, a pre-conference interactive platform engaged 3365 participants globally with discussions and webinars. As a result of the conference, the Government of Kazakhstan has now launched the Coalition of Partners initiative to support PHC globally. The WHO Primary Health Care Demonstration Platform, which showcase proactive PHC and community health approaches, was expanded to include Spain. In the past year, WHO/Europe has also provided technical support to 16 countries and has intensified the support offered to nine UHC Partnership countries. Projects that received support included Albania’s network-based PHC model, Bosnia and Herzegovina’s multidisciplinary care policy dialogues and Czechia’s transformation of PHC provision towards multidisciplinary service delivery. In Georgia, WHO/Europe published a case study and implementation roadmap for PHC reform and in Tajikistan, support focused on its Districts of Excellence and the strengthening of its PHC workforce. WHO/Europe has also hosted several policy dialogues and continued with its monthly talk show, Let’s Talk Primary Health Care. Policy papers on the topics of population health management and PHC scaling, were published with detailed case studies taken from Georgia, Kazakhstan and Spain. In addition, WHO/Europe has partnered with the European Observatory on Health Systems and Policies to develop and launch the report, Implementing the primary health care approach: a primer, and has published a comment, Political economy dichotomy in primary health care: bridging the gap between reality and necessity, in The Lancet. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 11 Patient-centred services delivered by well-supported health and care workers The health and care workforce The Region currently faces significant health workforce challenges, including workforce shortages and an increasing number of personnel with mental health issues. Although there has been a 13.5% increase in doctors and an 8.2% increase in nurses during the past 10 years, there is a projected shortage of 4.1 million health workers by 2030, which will be exacerbated by an ageing workforce, as in 13 of the Region’s countries more than 40% of doctors are aged over 55 years. The Regional Director delivered a keynote speech on this topic at a special event held on 26 March 2024 in Brussels, Belgium, which was attended by the Deputy Prime Minister of Belgium and the European Commissioner for Health and Food Safety. In the speech, the Regional Director urged swift and specific actions to be taken to address the health workforce crisis. Although the Region’s Member States have among the highest numbers of health workers per capita in the world, Member States are still facing a shortage of health workers as the needs of the Region’s populations have grown without the same level of growth in health worker capacity. To address these challenges, WHO/Europe has supported 13 countries in implementing the new Framework for action on the health and care workforce in the WHO European Region 2023–2030, which was unanimously adopted at RC73 with a  call to action to “care for those who care for us”. Initiatives in countries have included health labour market analyses carried out in Tajikistan and Ukraine, the development of a nursing and midwifery roadmap for central Asian countries, and capacity-building workshops held in North Macedonia and Republic of Moldova. An executive training course on health workforce leadership and management has helped to enhance country leadership on building health workforce capacity. This initiative has already engaged 47 senior and mid-level policy- makers from 16 countries, and upcoming cohorts will mainly be drawn from small and central Asian countries. In June 2024, WHO/Europe launched the Network of Human Resources for Health Focal Points, with representatives from 38 countries, and has expanded the network of government chief nursing and midwifery officers to include officials from 39 countries. These networks foster collaboration on issues concerning health workforce challenges and policy solutions across the Region. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202412 People-centred, enabling health services Over the past year, WHO/Europe has conducted country assessments and provided technical support for providing rehabilitation and assistive technologies, and improving disability inclusion, in Armenia, Azerbaijan, Georgia, Kazakhstan, Republic of Moldova, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. This support involved developing national action plans and carrying out health equity assessments to ensure inclusive policies and services. Furthermore, as ageing populations increase the demands on health services, WHO/Europe has facilitated long-term care assessments and policy dialogues in Greece, Ireland and Lithuania. This work has engaged stakeholders to define the reforms needed and prioritize interventions in long-term care systems. WHO/Europe has expanded its work on improving palliative care to six countries and published the Policy brief on integrating rehabilitation into palliative care services. In addition, a summary report was produced on service delivery models for people with post COVID-19 conditions, providing insights from Israel, Italy and the United Kingdom of Great Britain and Northern Ireland, as well as from two autonomous regions of Spain: Aragon and Catalonia. The report offers recommendations for adapting health care services to meet patient needs. WHO/Europe has supported the transformation of hospitals in Albania, Estonia, Greece, Montenegro, North Macedonia, Republic of Moldova, Romania and Ukraine, with a  focus on enhancing patient-centredness, operational efficiency and the sustainability and resilience of hospital services. WHO/Europe’s support in Romania, in collaboration with the National Institute for Health Services Management, has also strengthened health care management, with the Institute establishing educational programmes and international partnerships. The European Hospital Transformation Alliance, led by WHO/Europe, has worked over the past year to ensure strategic alignment with international financing institutions to advance hospital roles to support and complement PHC-oriented systems and reduce the carbon footprint of health care. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 13 © W H O Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202414 Bringing quality to the heart of health care delivery Promoting people’s health and well-being relies on building open, trustworthy relationships between patients and health care workers. These relationships are essential to ensuring the highest quality of care and patient safety in all facilities and across every aspect of health care delivery. To this end, WHO/Europe established the WHO Office on Quality of Care and Patient Safety as part of the WHO Country Office in Greece. This Office puts quality at the centre of developing high-performing health systems that are focused on country capacity-building. The Office has supported Member States in the areas of care quality, patient safety and mental health services for children and adolescents. In Greece, new projects, such as the Development and Implementation of a Framework for Quality Care, have been launched to enhance national capacity for health intelligence and quality assurance. In addition, Armenia, Greece, Malta, Montenegro, North Macedonia and Republic of Moldova have all received support to develop their own national action plans on quality of care and patient safety. In Romania, WHO facilitated the development of a set of 25 quality monitoring indicators with financing incentives, with the help of the Organisation for Economic Co- operation and Development (OECD) and other national partners. Targeted support was provided to Albania, Greece, Latvia, North Macedonia and Serbia focused on improving mental health services for children and adolescents. In July 2024, WHO/Europe launched a  consultation on the quality standards for child and adolescent mental health services that it has developed; the first such consultation carried out by WHO/Europe in this area. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 15 Health through the life-course: from birth to healthy, active ageing In 2024, the Region saw a demographic shift, with the population of individuals aged over 65 years outnumbering those aged under 15 years. People’s health care needs are different across the life-course and children and young people have their own health priorities. WHO/Europe continues to work with its partners to improve and promote health in younger populations and has published seven reports based on the Health Behaviour in School-aged Children study, which indicated the need for a continuing focus on child and youth well-being across the Region. WHO/Europe has continued to support the reduction of the maternal and neonatal mortality gaps across the Region. Maternal mortality rates currently range from 2 to 56 per 100 000 live births, and neonatal mortality rates range from 2 to 35 per 1000 live births. Extensive support has been provided to Kyrgyzstan and Tajikistan to help these countries improve the quality of maternal and neonatal care that they provide. With regard to health ageing, from information gathered from 47 out of 53 Member States for the United Nations Decade of Healthy Ageing (2021–2030) collaboration, just over half of countries reported having sufficient political support for healthy ageing initiatives. Fewer than 60% of countries had conducted comprehensive surveys on ageing and health highlighting shortfalls in relevant political support and data collection. WHO/Europe’s Ageing and Health programme launched initiatives in several countries, enhanced data collection on ageing in Poland and supported Uzbekistan to develop a national strategy for healthy longevity. The programme has also supported Italy’s G7 presidency to promote investments in healthy ageing and has helped to develop national age- friendly programmes in Poland, Portugal and Slovenia. Forty new cities from 15 countries have joined the WHO Global Network of Age-friendly Cities and Communities. At the Regional summit on policy innovation for healthy ageing in the WHO European Region, held in Lisbon, Portugal, in October 2023, over 230 participants from 35 countries endorsed the Lisbon Outcome Statement, which highlighted prevention, health promotion, age-friendly environments and high-quality care for older people across all care settings. The Lisbon Outcome Statement has set the stage for the development of a  new framework for action on health throughout life in an ageing European Region by 2025. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202416 Migration and health Good health should not be determined by where someone comes from. Following the adoption of the new Action Plan for Refugee and Migrant Health in the WHO European Region 2023–2030 in October 2023, WHO/Europe has been accelerating this agenda. In December 2023, WHO/Europe, in collaboration with the International Organization for Migration and the EU, launched the joint project, Improving access to health care for refugees and people displaced from Ukraine benefiting from temporary protection in Member States (the EU4Health project), funded by the 2023 EU4Health Work Programme. The project has been guided by lessons learned and requests made by Member States, and focuses on priority areas in health care for refugees. These areas include the assessment undertaken in Estonia to gain a qualitative understanding of the barriers refugees from Ukraine face in accessing health services, and training and deploying health mediators in several countries to support access to health services. In March 2024, WHO/Europe participated in the regional review of the Global Compact for Safe, Orderly and Regular Migration. An important aim of this review was to improve migrant access to basic services including health care, discuss continuity of care and promote intercountry and interregional collaboration. WHO/Europe led the discussions focused on Objective 15 of the Global Compact, on access to basic services including health care. The discussions highlighted the role of migrants as key players in the provision of basic services, and the legal and practical barriers that they face when accessing basic services related to health, among other things. To address these challenges, further intercountry and interregional cooperation along migration routes is needed, with the collaboration of all Member States, United Nations entities, civil society representatives, relevant stakeholders and the migrants themselves. A new policy brief, published in August 2024, provides insights into how the WHO Global Code of Practice on the International Recruitment of Health Personnel can be applied in the context of conflict-related population movements. The policy brief underlines the importance of international cooperation and collaboration between destination and source countries so that both can derive benefits from the international migration of health personnel. In 2022, WHO/Europe established a  tri-regional partnership on health and migration to foster collaboration with Member States in the WHO African Region and the WHO Eastern Mediterranean Region, and to adopt a comprehensive approach towards migration. This collaboration is continuing at the technical level and facilitates productive discussions on whole-of-route strategies to address common cross-border challenges and promote interregional cooperation to tackle migration and health issues. In the future, WHO/Europe is planning to participate in a pilot project under the United Nations Network on Migration to find whole-of-route solutions to irregular migration from southern Asia to Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 17 Europe, using the route from Bangladesh to Italy, via Türkiye and the Western Balkans, as a case study, with the aim of generating knowledge and proven practice that can be scaled up and replicated on other routes. The first Knowledge Forum on Refugee and Migrant Health was held in Valetta, Malta, on 16–18 April 2024, and is an example of promoting these whole-of-route approaches. Over 30 Member States, partners, civil society organizations (CSOs) and other relevant stakeholders convened to exchange knowledge, share lessons learned, discuss and reflect on common challenges and opportunities, and identify key partnerships for joint interventions across the countries of origin, transit and destination. The event strengthened coordination among the beneficiary countries of the EU4Health project. The Forum will be convened again in the future and will serve as a platform to forge new initiatives to advance the implementation of the new Action Plan for Refugee and Migrant Health in the WHO European Region 2023–2030. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202418 Flagship initiative: the Pan-European Mental Health Coalition WHO/Europe is strengthening data and evidence to underpin its mental health policies and interventions. A survey carried out in EU countries, and Iceland and Norway, showed that 95% of these countries have mental health policies and two thirds (23) of these countries are updating or revising these policies. Since the COVID-19 pandemic began, 24 countries have started to reorganize their mental health services, with this reorganization making up part of larger reforms in 15 countries. The implementation of mental health policies in individual countries varies, while key areas that often need support include workforce planning, policy impact monitoring, mental health promotion, emergency response and reduction of stigma. To inform the work on combating the decreasing number of care professionals in the Region, the Health Workforce and Service Delivery team is surveying the mental health of the Region’s health workforce. WHO/Europe has also organized policy dialogues in Belgium, Bulgaria, Croatia, Cyprus, Czechia, Estonia, Finland, Hungary, Latvia, Lithuania, Luxembourg, Netherlands, Poland and Slovakia to explore how to tailor WHO support to national contexts, and countries expressed their needs for their mental health policies and services. Throughout 2023–2024, the Pan-European Mental Health Coalition has continued to build networks for effective knowledge sharing. The Coalition now has 330 members (Member State representatives, parliamentarians, civil society representatives, academic institutions and organizations representing people living with mental health conditions) and supporters (researchers, health care professionals and advocates) across all 53 Member States. The Coalition has advanced the work being carried out on reducing the stigma of mental health, improving child and adolescent mental health, expanding community-based care and leveraging digital tools, and has also reviewed mental health service strategies and WHO’s products on mental health leadership. Study visits to Denmark, Italy and the United Kingdom have supported Kazakhstan, Kyrgyzstan, Turkmenistan, Ukraine and Uzbekistan to adapt their community-based mental health services. WHO/Europe has mobilized and coordinated mental health and psychosocial support (MHPSS) for refugees and country local health systems in response to the many crises – from conflicts to natural disasters – that have destabilized health systems in the Region. In Ukraine, WHO/Europe supported MHPSS coordination and mental health service development, and in Armenia, Bulgaria, Czechia, Hungary, Israel, Poland, Republic of Moldova, Romania, Slovakia, Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 19 Türkiye and Ukraine, WHO/Europe deployed 16 MHPSS experts, aided over 700 humanitarian workers and trained over 2500 health workers in MHPSS. People with lived experience of mental health conditions are vital partners for effective policy-making. The Mental Health Coalition joined forces with the European Public Health Association, Mental Health Europe, the European Commission and people with lived experience of mental health conditions from countries including France, Ireland, Kazakhstan and Poland to hold webinars on co-creating effective mental health services and support. Over 300 mental health experts attended these webinars. WHO/Europe has been involved in other effective co-creative efforts in Member States, including developing a video case study on Denmark’s national anti-stigma programme, EN AF OS (ONE OF US). This case study highlighted how building trust between emergency care professionals and people with mental health conditions can transform services and reduce stigma. Most children grow up with digital devices that provide them with constant access to the internet. While this may bring benefits, it can also lead to significant harms for children’s development and physical and mental health. As part of the Health Behaviour in School-aged Children Study, a report on social media use and gaming among adolescents was published; the findings indicate that 11% of adolescents showed signs of problematic social media use (13% girls and 9% boys), and 12% of adolescents were found to be at risk of problematic gaming (16% boys and 7% girls). The results of the study suggest that the type of content consumed has a greater impact than simply the amount of time spent on the platforms. Digital marketing of unhealthy foods, alcohol and tobacco also impacts the health outcomes of children and adolescents. Furthermore, WHO/Europe has collaborated with people with lived experience of stigma and global anti-stigma experts to create a toolkit for reducing stigma. The WHO Mosaic toolkit to reduce stigma and discrimination in mental health will help policy-makers, service providers, civil society representatives and others to design evidence-based anti-stigma programmes and is scheduled for launch on World Mental Health Day in 2024. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202420 Flagship initiative: Empowerment through Digital Health The Second WHO Symposium on the Future of Health Systems in a Digital Era in the European Region was co-hosted with the Portuguese Government in Porto, Portugal, in September 2023 and attracted more than 1000 participants. A landmark report on the status of digital health in the Region was launched during the symposium. Of those Member States surveyed, 83% (44 out of 53) reported having a national digital health policy or strategy, 87% (45 out of 52) reported having either a national electronic health records system, interconnected regional electronic health records or a patient portal, and 77% (39 out of 51) reported using telemedicine or remote patient monitoring. However, only 52% of Member States (27 out of 52) reported having developed policies and strategies for digital health literacy and only 60% (30 out of 50) reported having developed an overarching national data strategy to regulate the use of big data and advanced analytics in the health sector. Guidance and tools have been developed to educate health workers on telehealth and cybersecurity and to address the digital determinants of health. Several important publications have been produced during the past year, including reports on the positive impact of digital health literacy to overcome barriers for health workers, the use of digital solutions to improve women’s health and promote equity, and the importance of having well-structured reimbursement methods in place to improve patient care and streamline administrative processes. Direct technical support has been provided to 16 Member States to strengthen health information systems, to enhance their health system responses and their cybersecurity, and to establish telemedicine services in rural areas that mitigate the disruption of services and that deliver high-quality PHC. Progress on building networks and promoting dialogue has also been made. A €12 million landmark donor agreement with the European Commission was signed to support the Region’s Member States to strengthen their health information systems and boost their health data governance. The WHO Health Information Network was established to continue strengthening data and health information systems across the Region. To facilitate advocacy and promote interregional, international and multisectoral collaboration, a regional digital health partnership forum was established in September 2023 and this forum now meets once every quarter. In addition, a transatlantic capacity-building workshop on the use of artificial intelligence in public health was jointly delivered with the WHO Regional Office for the Americas. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 21 Flagship initiative: EIA2030 EIA2030 is a  vision and strategy, designed and crafted by the Member States, for achieving the full benefits of vaccination in the WHO European Region for the next decade. In 2023, the Regional Verification Commission for Measles and Rubella Elimination concluded that 33 Member States had achieved, or sustained, measles elimination status for 2022. The Region’s countries responded to a 63-fold rise in measles cases during 2023, compared to the previous year, by scaling up catch-up vaccinations in accordance with WHO/Europe operational guidance, which resulted in a steady reduction in measles cases by February 2024. In September 2023, following an outbreak of vaccine-derived poliovirus in Ukraine, WHO/Europe and partners supported the Ukraine Ministry of Health to implement an accelerated immunization response and comprehensive poliovirus surveillance activities. To monitor the progress towards achieving the EIA2030 targets, and in line with the monitoring and evaluation framework endorsed by Member States, WHO/Europe has developed a compendium of indicators in consultation with Member States and partners. The first annual technical progress report of the compendium showed that the Region had made significant progress towards its disease control and elimination goals, but that limited progress had been made towards achieving immunization equity and strengthening PHC. WHO/Europe has supported Member States to implement the regional guidance on integrating COVID19 vaccination into routine immunization programmes, including reviewing and facilitating access to COVID-19 vaccines, reviewing vaccine safety monitoring systems, and managing the infodemic. For example, in North Macedonia and Ukraine, WHO/Europe supported the digitalization of immunization information systems to systematically identify areas of underperformance. Sustaining trust in vaccines and countering misinformation are critical to attain high vaccination coverage. Building upon the lessons learned from the roll-out of COVID-19 vaccines, WHO/Europe provided direct technical support to Armenia, Azerbaijan, Georgia, Hungary, Latvia, Republic of Moldova, Serbia, Tajikistan, Turkmenistan and Uzbekistan to conduct rapid qualitative research to gather insights on the drivers and barriers to vaccination. WHO/Europe also published a training module for health care workers about communication on immunization, and introduced a game- based education module for children (Immune Patrol) to engender knowledge and build health literacy on vaccinations. In alignment with the EIA2030’s partnership nature, a collaborative workshop, Force of the future: co-creating youth action on immunization, was held in Copenhagen, Denmark, in December 2023. Sixty-two young people, representing Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202422 44 organizations, participated in the workshop, which laid the ground for further collaborations to address topical issues on the implementation of EIA2030. European Immunization Week in April 2024 was used by all Member States to increase public awareness and counter misinformation about vaccines. During this Week, the 50th anniversary of the Expanded Programme on Immunization was commemorated. Member States, WHO/Europe and partners highlighted the Expanded Programme on Immunization’s remarkable achievements in protecting multiple generations from vaccine-preventable illnesses, while emphasizing the urgent need to achieve high and equitable vaccination coverage in every community. WHO/Europe has continued to monitor mpox and to advise countries on the implementation of the November 2022 immunization recommendations. On a country level, in Georgia and Republic of Moldova, approaches to increase the uptake of new vaccines that had been recently introduced were identified by using post-introduction evaluations. Evaluations to strengthen the technical advisory mechanisms for national immunizations took place in Bosnia and Herzegovina, Georgia and Serbia. In alignment with the EIA2030’s partnership nature, a collaborative workshop, Force of the future: co-creating youth action on immunization, was held in Copenhagen, Denmark, in December 2023. Sixtytwo young people, representing 44 organizations, participated in the workshop, which laid the ground for further collaborations to address topical issues on the implementation of EIA2030. European Immunization Week in April 2024 was used by all Member States to increase public awareness and counter misinformation about vaccines. During this Week, the 50th anniversary of the Expanded Programme on Immunization was commemorated. Member States, WHO/Europe and partners highlighted the Expanded Programme on Immunization’s remarkable achievements in protecting multiple generations from vaccine-preventable illnesses, while emphasizing the urgent need to achieve high and equitable vaccination coverage in every community. WHO/Europe has continued to monitor mpox and to advise countries on the implementation of the November 2022 immunization recommendations. On a country level, in Georgia and Republic of Moldova, approaches to increase the uptake of new vaccines that had been recently introduced were identified by using post-introduction evaluations. Evaluations to strengthen the technical advisory mechanisms for national immunizations took place in Bosnia and Herzegovina, Georgia and Serbia. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 23 © W H O /D an il Us m an ov © U ka B or re ga ar d Core priority 2: protecting against health emergencies Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202426 Multiple acute and protracted emergencies have continued to impact the Region over the past year, prolonging the state of permacrisis. The COVID-19 pandemic entered its fifth year, having claimed over 2.27 million lives in the Region. Ongoing recovery is continuing from the earthquakes in southern Türkiye and northwest Syrian Arab Republic, and complex emergencies, such as those affecting Armenia, Israel and Ukraine, also require response support. Global outbreaks of epidemic- and pandemic-prone diseases, such as dengue, measles and mpox, continue to affect the Region, and the impact of these diseases is already being felt in the Region’s health systems. Climate change is an emerging factor, and it is anticipated that the Region will see a shift in its risk profile with the occurrence of more natural disasters and epidemic threats. WHO’s response to a number of these emergencies is laid out in this chapter below. Supporting Member States to prepare for future health threats is the cornerstone of WHO/Europe’s efforts. Country capacity-building efforts in health emergency preparedness, response and resilience (HEPR) form the vital second part of this chapter, with WHO/Europe’s work to develop the comprehensive strategy on Health emergency preparedness, response and resilience in the WHO European Region 2024–2029: a new regional strategy and action plan (Preparedness 2.0) to help Member States become better prepared to protect their populations, at the forefront. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 27 Response to graded emergencies affecting the European Region During the reporting period, WHO/Europe provided strategic, technical and operational support to Member States in their response to 10 graded emergencies – of which six are expanded on below – ensuring that all countries and partners are prepared for, and can prevent, detect and respond to, health emergencies. COVID-19 In his first press conference of 2024, the Regional Director highlighted the results of a WHO-led study showing that safe and effective COVID-19 vaccines saved at least 1.4 million lives in the Region. Since January 2020, more than 270 million people have been infected by COVID-19 in the Region, and over 2.27 million people have died from the disease. Increased population immunity has resulted in a significant decline in hospitalizations and deaths caused by COVID-19, but the continued, widespread circulation of the virus means that thousands of people experiencing vulnerability remain at risk. Infection control strategies have been relaxed, even though the longer-term health consequences of infection and reinfection at both the individual and population levels remain poorly understood. The COVID-19 pandemic is no longer defined as a public health emergency of international concern (PHEIC); however, it continues to take a significant toll on health and recovery globally and, as such, is classified as a WHO Protracted Grade 3 emergency. The risk that new variants – that are more transmissible and/or more severe – emerge means that maintaining surveillance resources is critical. The plan for transitioning to the next stage of the COVID-19 pandemic, The transition from the acute phase of COVID-19: working towards a paradigm shift for pandemic preparedness and response in the WHO European Region, was formally launched in June 2023. Over the past year WHO/Europe has been implementing 13 strategic shifts to support countries and communities, with the overarching goal of enabling the Region to emerge stronger from the COVID-19 emergency. These strategic shifts are aligned with WHO’s proposed global health architecture for HEPR; and outline a comprehensive roadmap to allow countries to transition from the acute phase of the COVID-19 pandemic towards a sustained response and recovery phase, to strategically and sustainably invest in resilient health systems that are able to respond to emergencies, and to maintain essential health services at all times. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202428 A main challenge in implementing this plan has been the global focus shift away from the COVID-19 pandemic as other emergencies with more urgent needs, have appeared. This change has resulted in reduced funding to sustain both country support and the level of WHO-supported capacity-building that was provided throughout the COVID-19 response. Mpox outbreak Since May 2022, the world has been experiencing the largest ever outbreak of mpox. A total of 27 529 cases have been reported as of 19 August 2024 from 45 International Health Regulations (IHR) States Parties throughout the Region. The epidemic has been successfully controlled due to innovative and consolidated work, and strong engagement with the affected communities, in particular men who have sex with men. The impact of these efforts has been documented in a compendium of case studies on the mpox response. These studies showcase the central role that CSOs have played in every aspect of the response, from surveillance to testing, vaccination and health advice, which has ensured that communities have been at its heart. Although elimination of mpox in the Region has remained elusive so far, the relatively few cases that have been reported in 2024 indicate that this is an achievable goal. Between September 2023 and August 2024, WHO/Europe’s social media channels reached over 1 million people, with more than 140 postings about mpox across Facebook, Instagram, LinkedIn and X. The posts included information on the WHO Health Emergencies Programme evidence and data on the outbreak, public health advice, signposts to toolkits and guidance, and testimonials from mpox patients. A dedicated WHO/Europe mpox campaign page serves as a one-stop source of information, with links to the risk communication, community engagement and infodemic management (RCCE-IM) compendium and toolkit, and a  WHO/Europe press release, all of which have advice on controlling the disease for health authorities, event organizers and impacted communities. WHO/Europe remained vigilant during the 2024 spring and summer Pride celebrations, and with the many other scheduled mass gathering events (for example, the 2024 UEFA European Football Championship and the Paris 2024 Summer Olympics): actively engaging informal mpox CSO networks to gather insights into the opportunities and challenges associated with these events to ensure that the tools, and public health advice, available were informed by the latest risk assessments and used effectively to mitigate the risk of transmission. Clade I, a more severe form of the mpox virus is heavily impacting the WHO African Region and underlines the future need for more sustained mpox control and elimination plans. With one case of Clade I having recently been reported in the European Region, the experience of the African Region may encourage the European Region’s Member States and public health institutions to act, as making small investments to increase resources now will make significant differences to possible future Clade I outbreaks in Europe. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 29 War in Ukraine and the refugee humanitarian response WHO/Europe sincerely appreciates the determination, dedication and resilience of frontline health care workers in providing health services to people in Ukraine during the war. WHO/Europe also acknowledges the commitment of the staff of the WHO Country Office in Ukraine who take daily personal risks to ensure that the humanitarian response– recovery and reform continuum is fully operational. Since September 2023, there have been a total of 61 missions to Ukraine: five senior leadership-level missions; 56 technical-level missions; and 13 missions involving all three levels of WHO. Over the last year, WHO’s regular technical assistance and support to Ukraine has reached pre-pandemic engagement levels. Since the onset of the war in Ukraine in February 2022, the Regional Director has been the United Nations leader who has visited the capital and the war- affected regions most regularly. The co-signing of the Biennial Collaborative Agreement 2024–2025 between the Minister of Health of Ukraine and the Regional Director, in December 2023, and the agreement of the WHO Country Cooperation Strategy, Ukraine 2024–2030 underscore WHO/Europe’s long-term commitment to rebuilding Ukraine’s health system at the nexus of humanitarian support, development and peace. Since the beginning of the war, WHO/Europe has procured and distributed essential medicines, equipment and supplies worth over US$ 165.8 million across Ukraine. WHO/Europe coordinates 218 Health Cluster partners, offering technical expertise, capacity-building and advocacy for humanitarian health action. The WHO Health Emergency Appeal 2024, with an estimated requirement of US$ 75 million, aims to use the funds to strengthen Ukraine’s health care system to address health risks related to the ongoing war. In addition, WHO/Europe has coordinated RCCE-IM efforts with over 30 partners, aligning public health messages and strategies to tackle disease outbreaks. Ukraine continues to face severe damage to its energy infrastructure leading to critical energy shortages, frequent blackouts, disruptions in health and water supply services and changes in air quality, which have been further exacerbated by increasing numbers of targeted attacks in 2024. In October 2023, WHO/Europe transitioned the situation in Ukraine to a  Protracted Grade 3 emergency. WHO/Europe is prioritizing long-term planning and resource allocation and is maintaining around 300 staff on the ground to provide comprehensive health care services. As of July 2024, 1972 attacks on health facilities have been verified; these attacks resulted in 172 deaths and 541 injuries, and impacted 1680 facilities. Since the beginning of the war, the United Nations Office of the High Commissioner for Human Rights has recorded 35 160 civilian casualties, with 11 520 killed and 23 640 injured. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202430 A key priority is to align emergency action with health system developments. WHO/Europe has provided support for regions in Ukraine to maintain PHC services by installing prefabricated modular PHC units in areas that have been adversely affected. WHO/Europe is also improving communicable disease control, emergency medical services, access to genomic sequencing, immunization support (including an internally displaced persons vaccine outreach programme), laboratory strengthening and NCD management. Ukraine has major needs for trauma care, and care to manage burns, spinal cord injuries and complex limb injuries (including amputations). The availability of specialized rehabilitation services is currently limited. WHO/Europe has facilitated the establishment of rehabilitation centres, including a National Rehabilitation Centre for Spinal Cord Injuries, which provides training, equipment and the assistive technologies needed for rehabilitation. Working with the Ministry of Health of Ukraine, 4330 patients have been evacuated from Ukraine to date, with 3200 being supported via the EU Civil Protection Mechanism. WHO/Europe is supporting the MHPSS initiatives that are being led by First Lady Olena Zelenska by enhancing trainer capacities through programmes such as the WHO Mental Health Gap Action Programme (mhGAP), Self-Help Plus and Problem Management Plus. Over the last few years, more than 100 000 health care workers in PHC and other settings have been trained on mhGAP. This commitment was underscored by the inaugural Mental Health Forum, held in Kyiv, Ukraine, in October 2023, which convened key stakeholders to develop comprehensive mental health strategies. The Regional Director attended the Third Summit of First Ladies and Gentlemen dedicated to “Mental Health: Fragility and Resilience of the Future” in 2023, and the Fourth Summit, “Protecting Childhood: Ensuring a Safe Future,” in 2024. At the former summit, Dr Viktor Liashko, Minister of Health of Ukraine, launched the Medical Partnerships initiative to facilitate horizontal collaboration between health care facilities and health care workers. In September 2024, the Regional Director opened the first eHealth summit in Kyiv, bringing together stakeholders across sectors on digital health transformation. WHO/Europe, through a national dialogue on health sector recovery and reform has helped to estimate the damages and needs outlined in the Third Rapid Damage and Needs Assessment; has contributed to international dialogue, for example, as a  participant in the Ukraine Recovery Conference held in Berlin, Germany, in June 2024; and has collaborated with stakeholders to implement the Health Strategy 2030. Strategic policy interventions aim to align Ukraine’s health sector reforms with EU standards to support Ukraine’s strategic move towards EU accession, and include modernizing surveillance and diagnostics, ensuring sustainable health financing, and implementing PHC and workforce development, One Health and emergency preparedness. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 31 With more than 3.2 million refugees from Ukraine living under either the Temporary Protection Directive or other national schemes, WHO/Europe has been supporting health systems in host countries to meet the needs of refugees and host communities. Supplies and equipment worth over US$ 24.56 million have been delivered to refugee-hosting countries. Work has been carried out to address capacity gaps, ensure access to essential health services and enhance early warning systems. A subregional meeting, held in Prague, Czechia, in June 2024, focused on mid- to long-term solutions to meet the needs of both Ukrainian refugees and host country populations. Conflict in Israel and the occupied Palestinian territory On 7 October 2023, an unprecedented and brutal air, water and ground attack was launched in Israel, escalating the conflict and impacting both Israel and the occupied Palestinian territory. As hostilities intensified, deaths, injuries and displacements increased, with catastrophic humanitarian consequences in the area. WHO/Europe established an incident management support team, and the Regional Director coordinated the response closely with the Regional Director of the WHO Regional Office for the Eastern Mediterranean, Dr Hanan Balkhy and her team, and with the Executive Director of WHO’s Health Emergencies Programme and Deputy Director-General, Dr Mike Ryan and his team. In line with the WHO Director-General, Dr Tedros Adhanom Ghebreyesus, WHO/Europe has consistently advocated for the unconditional release of the hostages and their full access to medical care, a humanitarian ceasefire and scaled-up humanitarian assistance. WHO’s engagement with Israeli health counterparts was designed across four technical areas: surveillance for attacks on health; MHPSS; community engagement and resilience; and gender-based and sexual violence. The Regional Director for Europe engaged in extensive health diplomacy efforts with Member States in the Region, focusing on protecting the right to health for all. In collaboration with the Ministry of Health and Magen David Adom (Israel’s national emergency medical, disaster, ambulance and blood bank service), WHO supported the establishment of a surveillance system to document attacks on health. By August 2024, 68 attacks on health care in Israel had been verified, resulting in 24 deaths and 34 injuries of health workers and patients. The increased demand for MHPSS services has meant that addressing the mental health impact of the conflict became a major public health priority. In November 2023, WHO/Europe deployed experts to strengthen community resilience through mental health interventions and monitoring. WHO/Europe has developed recommendations for MHPSS, emergency communications and community engagement. WHO/Europe is also supporting the Mashiv Ha’Ruach Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202432 project, which is training 200 health care professionals and first responders in trauma processing and post-traumatic mental growth between May and November 2024. In collaboration with CSOs, WHO/Europe has assessed opportunities to improve outreach and access to mental health and other health services through trusted community influencers. Dialogues with key stakeholders, including a project with Mosaica, has trained religious leaders to support mental health services for victims of the 7 October 2023 attacks. In response to accounts of gender-based violence, including sexual violence during the attacks, WHO/Europe is working with the Israeli Ministry of Health to ensure that survivors have access to the necessary care, addressing both short- and long-term health consequences. WHO/Europe collaborated with the Ministry of Health of Cyprus to increase the readiness of the WHO Country Office in Cyprus to provide aid to populations in the Gaza Strip and Lebanon. The inflow and distribution of health and humanitarian supplies into, and within, the occupied Palestinian territory needs to be massively scaled up. WHO/ Europe has been supportive of all modalities to increase humanitarian aid into the area. In collaboration with the Government of Türkiye, WHO headquarters and the WHO Regional Office for the Eastern Mediterranean, WHO/Europe has made significant efforts to support the evacuation of injured and sick patients from the occupied Palestinian territory to countries in the European Region. With approximately 10 000 patients requiring health care that is not available in the area, the need to establish a sustained system to provide access to quality services has been at the forefront of the Regional Director’s personal health diplomacy efforts, with direct engagement with several Member States in the Region. These efforts have contributed to the activation of the EU Civil Protection Mechanism and timely commitments from several countries in the Region have been made to increase their involvement in medical evacuations of Palestinian patients, either through the reception of patients and their accompanying carers, the provision of transportation and other in-kind support, or through financing operations. As a result, by early October 2024, nearly 600 patients, mostly children and women, and their caregivers, had been evacuated to countries in the European Region, including Belgium, France, Italy, Romania, Spain, Switzerland and Türkiye. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 33 Earthquakes in Türkiye and Syrian Arab Republic On 6 February 2023, a 7.8 magnitude earthquake struck southern and central Türkiye and northern and western Syrian Arab Republic, followed by another of a similar magnitude later the same day. As of June 2024, the earthquakes in Türkiye and Syrian Arab Republic have affected 9.1 million people, displaced 3 million people, caused over 50 000 deaths and injured more than 107  000 people. Since then, WHO/Europe has scaled up response operations and deployed additional surge capacity by providing communication specialists, epidemiologists, logistics staff, public health advisers, trauma specialists and additional support for the WHO field office in Gaziantep, Türkiye. WHO/Europe has also provided public health information on 30 relevant topics and advice on information management. The response involved WHO/Europe initiating the largest deployment of Emergency Medical Teams (EMTs) to a  disaster zone in its 75-year history, with 38 EMTs being integrated into the ongoing health response to provide critical emergency care, surgery and access to primary care services, while also strengthening national capacities for preparedness and response. On 28 February 2023, the WHO Director-General and the Regional Director, accompanied by the WHO Representative to Türkiye, were invited by the Minister of Health to visit the provinces of Hatay and Gaziantep. They met with health officials, health workers, responders, and people affected by the earthquakes. Both the Director-General and the Regional Director reaffirmed the Organization’s solidarity and support for the recovery of earthquake survivors. They visited the Belgian Emergency Medical Team’s field hospital in Hatay’s Kırıkhan District. As part of the recovery from these earthquakes, WHO/Europe has worked to provide eight prefabricated PHC centres and 37 containers, which have been adapted for use by MHPSS and rehabilitation services in the four provinces that have been most affected: these facilities were completed in June 2024. Each prefabricated PHC centre is equipped to provide PHC services, maternal and child health care services, immunizations and laboratory services. WHO/Europe has supported several training sessions to enhance health care in the earthquake-affected regions. A PHC training session was attended by 152 personnel from the Ministry of Health of Türkiye, and covered topics such as breastfeeding, health information systems, reproductive health, water and sanitation. A Training of Trainers session on interpersonal communication and community engagement was held and attended by 72 health workers. Another training session focused on pre-hospital critical patient care and was attended by 142 frontline health care workers, Türkiye’s National Medical Rescue Team and ambulance staff, along with 25 academics, and covered topics including anaphylaxis, critical care and trauma management. Furthermore, an emergency obstetric care workshop to help Syrian refugees and affected provinces was attended by 30 obstetricians and gynaecologists. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202434 Refugee response in Armenia Since September 2023, WHO/Europe and the WHO Country Office in Armenia have been supporting the Government of Armenia, along with national and international health partners, to address the acute and long-term health needs of over 115 000 refugees who fled the Karabakh Region. A large fuel depot explosion during this population movement killed and injured many people, further straining Armenia’s health system. To address this, WHO/Europe immediately activated its emergency systems to initiate a  prompt response, which focused both on critical life-saving operations and the broader public health response, including enhanced event-based surveillance using the Epidemic Intelligence from Open Sources (EIOS) initiative. WHO facilitated the arrival of EMTs in the country shortly after, coinciding with a personal visit by the Regional Director. Subsequently, the Regional Director also visited neighbouring Georgia and Azerbaijan. WHO/Europe prioritized essential life-saving health services and mobilized funds from the Contingency Funding for Emergencies, which enabled the deployment of four EMTs to boost hospital capacity for surgery, wound management and rehabilitation for burn patients. As a result, numerous surgical procedures were completed and, in total, WHO training on rehabilitation has benefited over 56 specialists, including rehabilitation physicians, burn surgeons, nurses, and physical and occupational therapists. A key component of the response was to meet the mental health needs of the refugees. WHO/Europe scaled up MHPSS services by training over 300 psychologists, PHC workers and volunteers in psychosocial skills and psychological first aid. WHO trained 10 operators at a nationwide hotline, who responded to 4546 calls within the first six months. MHPSS mobile teams were supported and have conducted 540 consultations to bring direct support to communities. Significant progress has been made to implement the RCCE-IM plan for Armenian refugees, with a focus on youth and community engagement. WHO/Europe trained 50 youth volunteers to support health sector responses and share vital health information. Collaborative dialogues have been established with CSOs, including the Children of Armenia Foundation, Caritas, the New Generation Humanitarian, People in Need, the Red Cross and the Resource Centre for Women. WHO/Europe also delivered 1.7 tonnes of medical supplies, including NCD kits, with essential medicines for 50 000 people and critical supplies for treating burns patients. WHO/Europe facilitated the inclusion of refugees in vaccination campaigns, and produced information materials to help refugees navigate the Armenian health system. Paediatricians and immunization coordinators at 370 PHC centres were trained to prevent disease outbreaks by using immunization in the context of mass population movements. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 35 WHO/Europe has removed the emergency grade on the Armenian refugee response, as the refugees’ current needs can be met by WHO’s regular country operations, with additional support being provided, if needed. WHO/Europe continues to work with the Ministry of Health to address the health needs of both the refugees and the host communities, to support burn patients in their recovery and to strengthen the health care services being provided to the refugees and host communities as part of the broader refugee response. © W H O /N az ik A rm en ak ya n Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202436 Building country capacities in HEPR WHO/Europe has implemented a comprehensive programme of work to proactively build Member States’ capacities to prepare for, detect, respond to and recover from future emergencies in addition to its work in specific emergencies. Close collaboration with the International Health Regulations (IHR) National Focal Points is at the core of this partnership, and the first physical meeting of National Focal Points from all State Parties in the Region since 2019 was organized in September 2024 in Sofia, Bulgaria. WHO/Europe’s programme of work has been guided by the five “Cs” of the HEPR framework: 1) collaborative surveillance; 2) community protection; 3) safe and scalable care; 4) access to medical countermeasures; and 5) emergency coordination, which also serve as the framework for this current section, following the presentation of the new Preparedness 2.0 strategy, which will guide the vital work in this area. Preparedness 2.0 WHO/Europe has been working to develop the Preparedness 2.0 comprehensive strategy and action plan to help Member States be better prepared to protect their populations against all hazards. A process involving six meetings of the Technical Advisory Group on the development of Preparedness 2.0 and three Member State consultations culminated in the production of the draft strategy. Preparedness 2.0 is fully aligned with the evolving global health security architecture and will support Member States to adjust their national health security strategies and action plans by using the five subsystems (the five “Cs”) defined by the global framework for HEPR. Preparedness 2.0 also takes into account the approved package of amendments to the IHR (2005), the outcomes of the United Nations General Assembly High-level Meeting on Pandemic Prevention, Preparedness and Response and the ongoing negotiations being carried out by the Intergovernmental Negotiating Body on the new WHO Pandemic Agreement. If adopted by RC74, Preparedness 2.0 will serve as a single guiding document for the Region’s Member States as it contains a  menu of activities that Member States can carry out to strengthen their emergency preparedness. Preparedness 2.0 has an accompanying implementation support guide that outlines key support offers and includes references to critical tools and resources. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 37 Collaborative surveillance WHO/Europe has continued to support Member States by ensuring that they can detect, prevent and respond to health emergencies. Between September 2023 and August 2024, through all-hazards eventbased surveillance, 994 public health signals were detected and risk-assessed in the Region, of which 350 required action. During the reporting period, WHO/Europe responded to 54 acute public health events and 10 graded emergencies. WHO/Europe published more than 30 postings and announcements on the WHO Event Information Site and 15 public- facing Disease Outbreak News listings to inform policy and response in countries, as mandated by the IHR (2005). In October 2023, the European Respiratory Virus Surveillance Summary tool was launched jointly with the European Centre for Disease Prevention and Control (ECDC) to efficiently monitor the circulation, severity and characteristics of severe acute respiratory syndrome coronavirus 2, influenza and the respiratory syncytial virus. This initiative continues to be complemented by event-based surveillance which is run by WHO/Europe using the EIOS system to detect any unusual events or outbreaks in the Region. The latest training sessions related to EIOS held during the reporting period were conducted in Armenia, Greece, Israel and the Netherlands. WHO/Europe’s efforts to enhance health surveillance under the HEPR framework across the Region demonstrates a  focused commitment to collaborative surveillance mechanisms across various health domains using an early warning alert and response function. Initiatives such as the Food Safety and Zoonotic Disease programme have been used as a basis for training health care professionals in 10 countries, as well as Kosovo,[2] to carry out joint risk assessments of priority zoonotic diseases, and to enhance workforce capacity and multisectoral coordination. Fifteen Member States have been onboarded to the EIOS initiative to improve signal monitoring. Progress has been made in the integration of national food safety policies with Codex Alimentarius standards in central Asian countries, promoting standardized health regulations. National influenza centres have been strengthened in 15 countries, and, in 2023, the number of countries with these centres was increased to include Azerbaijan, Bosnia and Herzegovina and Tajikistan. 2 All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999). Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202438 From January 2024, WHO/Europe responded to the dengue emergency with global risk assessments and surveyed 30 IHR States Parties for evidence of autochthonous dengue cases. A new dengue and arbovirus surveillance protocol was launched in June 2024. This followed an Emergency Response Information Management System coordination workshop in November 2023, which had emphasized the importance of establishing robust, scalable systems integrated with national health information systems, involving WHO headquarters, WHO/Europe and the WHO Regional Office for the Eastern Mediterranean. In February 2024, a full-scale interregional field simulation exercise for rapid response mobile laboratories was held in Kachreti, Georgia, marking the successful completion of the first series of such exercises. The exercise was led by WHO/Europe and co-organized with the WHO Collaborating Centre for Global Outbreak Alert and Response, the International Federation of Red Cross and Red Crescent Societies, and the Robert Koch Institute. Moreover, a subregional workshop for Health Emergency and Disaster Risk Management was organized by the WHO Centre for Health Development, with support from the United Kingdom’s Health Security Agency, to meet the growing needs for research capacitybuilding and to provide guidance on the promotion of research at the country and regional levels. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 39 Based in Istanbul, Türkiye, the WHO European Centre for Preparedness for Humanitarian and Health Emergencies (PHHE) Centre continues to improve Member States’ preparedness through innovative and sustainable approaches, thereby strengthening the Member States of the Region’s capacities for humanitarian and health emergencies. The Centre has undertaken several key initiatives to strengthen health emergency preparedness and response throughout the Region. With robust support from the Turkish Government, and leveraging Istanbul’s strategic location, it has organized or supported 35 international WHO events in the city over the past two years, furthering regional cooperation and knowledge sharing. In May 2024, the first joint project between WHO and the Organization of Turkic States (OTS) was launched following the signing of a  Memorandum of Understanding between the two organizations in 2023. This initiative included a training course designed to enhance leadership skills in emergencies for Member States and WHO staff from the OTS countries, held in Istanbul. In November 2023, PHHE launched the WHO European Geospatial Coordination Hub to provide geographic information systems support to Member States. In the last year, the Hub has conducted 38 technical support activities, benefiting 22 Member States. Through the PHHE Centre, WHO/Europe has also supported the Ministry of Health of Türkiye in conducting an after-action review and two national meetings involving decision makers from all government sectors involved in earthquake response and frontline responders. This led to the revision of the National Disaster Health Action Plan, which will be tested in a simulation exercise later in 2024. To share lessons learned from the response to these major earthquakes and to strengthen and coordinate earthquake preparedness and response in the health sector among countries around the Mediterranean Sea and in the Balkans at high risk of future earthquakes, the PHHE Centre will jointly organize an international ministerial and technical conference in February 2025 with the Ministry of Health of Türkiye, and in collaboration with the WHO Regional Office for the Eastern Mediterranean. Box 1. The WHO European Centre for Preparedness for Humanitarian and Health Emergencies Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202440 Community protection WHO/Europe’s transformative shift has community protection as the end goal of Preparedness 2.0, with resilience as its foundation. This shift will be achieved by establishing equitable, community-centred emergency health systems. Preparedness 2.0 calls upon health authorities to collaborate closely with communities to build trust and accountability in health emergencies, with RCCE-IM being recognized as a critical public health intervention across the emergency cycle which lies at the heart of community protection. Between September 2023 and August 2024, WHO/Europe provided enhanced technical support on RCCE-IM to 19 countries, as well as Kosovo,[3] through 20 in-country/area missions. WHO/Europe has published guidance on engaging young people and guidance on managing false information, along with four investment advocacy brochures. Additionally, 286 risk communication messages were developed, which reached up to 12 000 social media users. Thirty-two social listening and infodemic management reports regularly monitored public sentiment on health risks to detect any false information that was circulating, and the information gathered was used to inform response interventions. Online social listening was enhanced by community feedback that was gathered through an informal working group of 30 CSOs, established by WHO/Europe to capture community insights on current and emerging hazards. The RCCE-IM Technical Advisory Group was established in April 2023 and has significantly advanced RCCE-IM research. The Group has been advising WHO/Europe on cutting-edge solutions and has positioned RCCE-IM into scientific forums and publications, including two return-on-investment studies, resulting in RCCE-IM being championed as an evidence-based public health intervention across the emergency cycle. The RCCE-IM Schools initiative, which aims to build capacity in countries, has benefited 496  participants from 30  countries and has provided guidance on a  wide range of RCCE-IM topics. The  innovative RCCE-IM Capability Mapping Tool and the RCCE-IM Plan Creator were launched in December 2023 and have already been implemented in five country workshops to support capacitybuilding tailored to individual country contexts. WHO/Europe have also supported 16 countries in three key areas of border health and points of entry readiness: planning for decision-making and consensus-building to implement international travel measures in the context of COVID-19; supporting the assessment and reporting of all-hazard emergency preparedness capacities at airports, ports and ground crossings; and strengthening capacity for health emergency preparedness and response at points of entry. 3 All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999). Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 41 Safe and scalable care Establishing robust, inclusive and agile national health care services is essential to ensuring timely, flexible and efficient emergency response. During an emergency response, maintaining essential services and supporting international surge responses when needed, is crucial to mitigating health consequences and saving lives, while contributing to future preparedness capacities: this is the dual-track approach. To ensure NCD care continuity during emergencies, WHO/Europe conducted operational reviews in Republic of Moldova, Türkiye and Ukraine to analyse NCD activities, identify good practices, document lessons and make recommendations for strengthening systems. These reviews also informed discussions on how WHO/Europe supports Member States at two meetings held in Copenhagen, Denmark; the Noncommunicable diseases in emergency preparedness and response regional consultation, in September 2023; and the Global high-level technical meeting on NCDs in humanitarian settings, in February 2024. Between September 2023 and August 2024, WHO/Europe invested in a number of activities to strengthen hospital resilience against emergencies, including running hospital safety assessments and training sessions in Albania, Lithuania, Montenegro, North Macedonia, Serbia and Tajikistan, as well as in Kosovo,[4] in which 28 hospitals were assessed using the Hospital Safety Index tool. A  subregional expert workshop was held in Bonn, Germany, in November 2023, on hospital response planning for chemical, biological, radiological and nuclear incidents. WHO/Europe, in close collaboration with the Integrated Health Services team from WHO headquarters, supported Armenia and Montenegro, as well as Kosovo,[1] to implement the Emergency Care Systems Assessment, using a  standardized online tool. Based on the country/area-specific action priorities for high-impact improvements to emergency care system processes and outcomes that were identified and agreed during the assessments, including for emergency preparedness and response, these countries/area will develop roadmaps to strengthen their emergency care systems. Since 2023, WHO/Europe has supported over 25 hospitals in eight countries and one area to revise their patient pathways, triage protocols and clinical standard operating procedures, and to integrate WHO clinical guidelines into national or equivalent practices. In addition, over 3500 health care workers have been trained in emergency and critical care using clinical simulation training and webinars. 4 All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999). Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202442 An assessment tool to evaluate laboratory sustainability has been piloted in five countries. Furthermore, the Global Laboratory Leadership Programme was developed, which has been implemented in three countries. This Programme is the result of a collaboration between the Association of Public Health Laboratories, the Centers for Disease Control and Prevention, the ECDC, the Food and Agriculture Organization of the United Nations, the World Organisation for Animal Health and WHO. To further laboratory preparedness and to enhance the financial sustainability of genomic surveillance, the Genomics Costing Tool was launched in December 2023 and has been piloted in two countries. The WHO Global Strategy for Food Safety 2022–2030 and the One Health Joint Plan of Action (2022–2026) are both initiatives that address foodborne and zoonotic diseases. Workforce capabilities and multisectoral coordination were strengthened using training and capacity-building for joint risk assessments in seven countries and one area to enhance surveillance and response mechanisms across the human–animal–environment interface in central Asia and the Western Balkans. Access to countermeasures Another pandemic is inevitable. WHO/Europe is working in all subregions to ensure that no country is left behind. Enhancing access to health countermeasures is crucial for strengthening health systems’ abilities to prepare for and handle emergencies. WHO/Europe is continuing to focus on strategic stockpiling, forecasting supply needs and anticipating gaps in equal access to vaccines and countermeasures as part of its pandemic prevention, preparedness and response efforts. WHO/Europe continues to collaborate with the European Commission’s Health Emergency Preparedness and Response Authority (HERA) through the EU4Health programme partnership. In this context, it was agreed that WHO/ Europe will, for the first time, second a senior staff to HERA. The EU4Health programme partnership continues to fund initiatives for epidemic intelligence, AMR, One Health, pathogen detection including wastewater surveillance, and increasing access to countermeasure tools, further strengthening capacities to address cross-border health threats. While the Central Asia Regional Economic Cooperation Health Strategy 2030 is strongly focused on countermeasures, WHO/Europe has continued to engage with Member States to increase planning and preparedness to import novel countermeasures. WHO/Europe’s collaboration with partners such as the Food and Agriculture Organization of the United Nations and the World Bank has resulted in projects being funded by the Pandemic Fund, which uses the One Health approach to strengthen pandemic prevention, preparedness and response. Examples of activities that have taken place include the regional Quadripartite One Health seminar held in Vienna, Austria, in June 2024, and the creation of strategic plans for embedding the One Health approach into health security management in alignment Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 43 with the multidisciplinary approach established by WHO/Europe. WHO/Europe, together with the Ministry of Health of Kyrgyzstan, organized the Central Asia International Health Investment Forum, held in Bishkek, Kyrgyzstan, in June 2024, underscoring its commitment to mobilizing financial and policy support for health emergency preparedness across the Region. Emergency coordination The launch of the Pan-European Network for Disease Control in April 2024 in London, United Kingdom, marked a significant milestone in improving emergency preparedness and response in the Region, implementing one of the key recommendations of WHO/Europe’s Pan-European Commission on Health and Sustainable Development. The Network, managed by the PHHE Centre in Istanbul and currently involving 31 subregional and national institutions from 17 Member States, aims to foster coordination and knowledge sharing among health stakeholders in the Region, focusing on collaborative surveillance, access to countermeasures and emergency coordination. Since the inaugural meeting, where Network members developed a one-year workplan, several activities have taken place, including two ad hoc virtual meetings on H5N1 and mpox. Providing support to the Region’s IHR States Parties to comply with and implement the requirements of the IHR (2005) and to maintain and strengthen IHR core capacities, stands at the core of WHO/Europe’s work. In 2023, 98% of the States Parties in the Region submitted the States Parties Self-Assessment Annual Report, which is the highest submission rate ever recorded in the Region for these mandatory reports. The data submitted in these reports are used to collect health emergency preparedness and response data through the IHR Monitoring and Evaluation Framework. WHO/Europe has continued to support Member States to take a risk-based approach to readiness and preparedness planning. Seven countries (Armenia, Bosnia and Herzegovina, Georgia, Republic of Moldova, Sweden, Tajikistan and Turkmenistan) and Kosovo[5] conducted strategic risk assessments to identify priority risks, taking an all-hazards approach. Six of these countries, as well as Kosovo,[1] used strategic risk assessments and lessons learned to develop their National Action Plan for Health Security (NAHPS) or equivalent, with a  further eight countries in the process of developing their NAHPS. In 2023, NAHPS were used in successful proposals to the Pandemic Fund, raising US$ 56.3 million for the Region’s Member States in the first round. 5 All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999). Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202444 The fourth Joint Assessment and Detection of Events tabletop simulation exercise held in Copenhagen, Denmark, in November 2023, reviewed and tested communication between national IHR (2005) focal points and WHO IHR (2005) regional contact points, and involved 150 participants from 43 States Parties. Joint external evaluations were conducted in three countries and two COVID-19 intra-and after-action reviews were facilitated or supported. Enhancing emergency coordination in the Region is crucial for an integrated health emergency response. Key initiatives include the Regional European Emergency Medical Team Capabilities Hub (REECH) and the Emergency Medical Teams regional action plan 2024–2030. Launched in 2023, and hosted by PHHE, REECH aims to strengthen regional EMTs and national health systems capacities, while the regional action plan, initiated in January 2024, focuses on improving Member States’ EMT responses by incorporating EMT norms and standards into national plans. From September 2023 to May 2024, WHO/Europe supported the deployment of four international EMTs to Armenia. In the first half of 2024, WHO/Europe, together with the ECDC, launched a regional forum of public health emergency operations centres (PHEOCs). A regional simulation exercise workshop on strengthening the functionality of PHEOCs took place in Istanbul, Türkiye, on 1–3 July 2024, organized by WHO/Europe and the WHO Health Emergencies Balkan Hub, in collaboration with the WHO Regional Office for the Western Pacific. The immersive workshop was the first of its kind and was carried out in two phases: a short series of online webinars followed by a three-day simulation exercise attended by 37 participants from 11 countries/areas of the Western Balkans and the Western Pacific Region. Participants successfully completed the new simulation exercise-based training that aimed to enhance technical capabilities, knowledge and skills of incident management teams working within a PHEOC. The upcoming WHO/Europe Regional PHEOC Network meeting will further unify regional emergency response management. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 45 © W H O /V ol od ym yr S hu va ye v © W H O /S ör en T al u Core priority 3: promoting health and well-being Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202448 Over the past year, through various prevention and health promotion programmes, WHO/Europe has scaled up its capacity and delivery to respond to the country-driven post-pandemic paradigm shift from reactive to preventive health care, and to promote healthier environments and behaviours using a One Health approach. The prevention and health promotion programmes involved include those on communicable diseases; NCDs; prison health; environment; climate change and health; healthy cities; AMR; One Health; gender equality; and investment for health development, as well as the Healthier behaviours: incorporating behavioural and cultural insights (BCI) flagship initiative, the activities of which are expanded on below. Through the dual-track approach of RACE to the Finish (accelerating progress towards Sustainable Development Goal (SDG) targets) and Vision 2050 (building an NCD-resilient Europe), WHO/Europe is aiming to meet the SDG targets for NCDs by 2030, while simultaneously championing the key generational shifts required to achieve a sustainably healthier Region. By fostering innovation in health, supporting Member States and addressing the commercial and environmental determinants of health, WHO/Europe is working towards ensuring healthy lives and promoting well- being for all at all ages in the European Region. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 49 Communicable diseases To support countries in their uptake of WHO guidelines and to align with regional priorities, WHO/Europe has extended technical support in response to country requests; reviewed national guidelines for HIV, TB and viral hepatitis; conducted programme reviews for HIV, TB and viral hepatitis; and carried out external reviews of country funding requests to the Global Fund to Fight AIDS, Tuberculosis and Malaria. All activities were delivered under the implementation of the Regional action plans for ending AIDS and the epidemics of viral hepatitis and sexually transmitted infections 2022–2030 and the Tuberculosis Action Plan for the WHO European Region 2023–2030. WHO/Europe, jointly with the ECDC, also published surveillance reports for TB and HIV as part of the Global hepatitis report 2024: action for access in low- and middle-income countries. TB The report, Tuberculosis surveillance and monitoring in Europe 2024 – 2022 data, published jointly in March 2024 by WHO/Europe and the ECDC, indicates that the burden of drug-resistant TB in new cases of TB (24%) and retreatment cases (54%) in the Region is still the highest in the world with the successful treatment of overall multidrug-resistant/ rifampicin-resistant TB cases at 57%. In 2021–2022, health service disruptions, due to the COVID-19 pandemic, resulted in nearly 7000 excess TB deaths in the Region, when compared with pre-pandemic trends. The escalating humanitarian crises in the Region highlight the ongoing importance of the efforts to control TB. In this regard, in September 2023, during the second United Nations General Assembly High-level Meeting on the Fight Against Tuberculosis (UNHLM on TB), held as part of the seventy-eighth session of the United Nations General Assembly, heads of state adopted the Political Declaration of the High-Level Meeting on the Fight Against Tuberculosis. This Declaration calls for accelerated efforts to end TB globally and sets ambitious targets to be reached by 2027. WHO/Europe contributed to the preparatory process for the UNHLM on TB, with Poland and Uzbekistan acting as co- facilitating countries during this event. To address the low uptake of TB preventive treatment, and to scale up efforts to prevent future TB epidemics, WHO/Europe launched a new initiative focusing on prevention and active targeted case-finding specifically targeting populations at high risk of developing TB. In October 2023, a new roster of experts on TB prevention and screening was formed, bringing together representatives from 18 TB high-priority countries in the European Region, to identify areas in the response that require support during 2024–2027, with the aim of accelerating the uptake of the latest WHO recommendations. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202450 Between September 2023 and August 2024, WHO/Europe reviewed the national TB programmes of six countries, allowing progress towards reaching national targets to be gauged. As part of the reviews, recommendations to improve the TB response were offered and areas needing tailored support in prevention, diagnosis, treatment and people- centred care were identified. A high-level regional dialogue on achieving the commitments and ambitious targets of the UNHLM on TB, was jointly organized with the Stop TB Partnership and with the participation of the Regional Director, and took place in Tashkent, Uzbekistan, in June 2024. The dialogue was pivotal in accelerating efforts towards achieving these commitments. Moreover, the TB-free Central Asia Initiative was announced at the Central Asia International Health Investment Forum held in June 2024 in Bishkek, Kyrgyzstan. The initiative is aligned with, and builds upon, the Roadmap for Health and Well-Being in Central Asia (‎2022–2025)‎, paving the way for TB eradication in this subregion by 2030. The recent introduction and use of the modified shorter treatment regimens for drug-resistant TB, under a regional operational research initiative led by WHO/Europe in 13 countries, showed a treatment success rate of more than 82% in a regional cohort and the initiative has enrolled more than 8600 patients. The results, which were published in Lancet Infectious Diseases, demonstrated a good safety profile for the treatment and enduring programmatic impact, and have resulted in a boost in the uptake of the shorter treatment regimens, which will help to provide strong, high-quality evidence to underpin the next generation of recommendations made by WHO on the treatment and programmatic management of drugresistant TB. It has been noted however, that TB elimination efforts in western and central Europe can be jeopardized by the high cost of the medicines required for the WHO-recommended drug-resistant TB regimens and by the procurement challenges for these drugs. A regional meeting to discuss improving access to drug-resistant TB medicines, organized jointly with Germany’s Ministry of Health, took place on 3–4 June 2024 in Berlin, Germany. The meeting assessed the priorities and the progress made, and proposed recommendations suggesting to accelerate the collective work towards producing effective national and supranational solutions to enhance access to, and availability of, medicines for TB and drugresistant TB. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 51 HIV The report, HIV/AIDS surveillance in Europe 2023 (2022 data), published jointly by WHO/Europe and the ECDC, indicates a 4% rise in HIV diagnoses across the Region in 2022 compared with 2021, with 16 countries recording the highest-ever number of diagnoses in a single year, which is a positive trend in reducing the numbers of undiagnosed people with HIV in the Region. Contributing factors to these results are the resumption of normal testing services after the COVID-19 pandemic, expanded and targeted HIV testing services, and new testing strategies. However, persistent stigma is still the cause of late presentations for treatment, often in people with advanced disease. The report underpins the policy shifts needed to achieve epidemic control for HIV in the Region. To accelerate implementation of the Regional action plans for ending AIDS and the epidemics of viral hepatitis and sexually transmitted infections 2022–2030, WHO/Europe, jointly with the Ministry of Health of Spain and partners, held a series of regional events to disseminate WHO guidelines and secure political engagement to eliminate discrimination. A ministerial session entitled, Keeping the promise on ending AIDS and the epidemics of viral hepatitis and sexually transmitted infections and held on 22 July 2024 in Munich, Germany, prior to the 25th International AIDS Conference, gathered ministers, decision-makers and CSOs from across the Region and beyond to renew commitments towards the 2025 targets of regional action plans. WHO/Europe also announced the triple elimination initiative at the Central Asia International Health Investment Forum in June 2024. The initiative encourages countries to simultaneously commit to the elimination of mother to child transmission of HIV, syphilis and the hepatitis B virus and aims to mobilize support to further push the agenda for integrated service delivery. Technical support was provided to 18 countries to review national guidelines and HIV, viral hepatitis and sexually transmitted infections programmes, to strengthen surveillance and data on key populations and to boost country capacity to proactively interpret and analyse data. Relevantly, the High-level Working Group on HIV, established with the Russian Federation, set priority actions for 2024 that include HIV data strengthening, joint reviews and drug-resistance laboratory work. WHO/Europe also helped countries apply for support from the Global Fund, with 10 successful applications raising US$ 337 million for 2024–2027. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202452 Viral hepatitis In 2023, WHO/Europe supported regional data collection for the Global hepatitis report 2024: action for access in low- and middle-income countries, which provides vital evidence for governments to understand and adapt policy to the viral hepatitis situation. In the Region, by the end of 2022, 8.6 million people were chronically infected with the hepatitis C virus, yet only 29% of people with hepatitis C were diagnosed and 9% were treated. Approximately 10.6 million people in the Region are infected with the hepatitis B virus of which, 16% have been diagnosed and 12% have been treated. With the aim of improving these statistics, WHO/Europe supported 15 countries in aligning their national viral hepatitis strategies and clinical guidelines with WHO recommendations; conducted programme reviews; supported capacity- building activities and strengthened the availability of strategic information. To date, 39 Member States have national viral hepatitis plans, 50 Member States have childhood hepatitis B vaccination programmes and nine (Belarus, Georgia, Italy, Kyrgyzstan, Netherlands (Kingdom of the), Republic of Moldova, Turkmenistan, United Kingdom and Uzbekistan) have achieved the hepatitis B control targets. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 53 NCDs NCDs and health determinants throughout the life-course In the European Region, the four major NCDs – cancers, cardiovascular diseases, chronic respiratory diseases and diabetes – account for 90% of deaths and 85% of years lived with disability and are the leading cause of premature mortality. Addressing NCDs and their risk factors – alcohol consumption, tobacco use, physical inactivity and unhealthy diets – is a necessary step for core priority 3 of the EPW: promoting health and well-being. Addressing NCDs and their risk factors also forms part of reaching SDG target 3.4: reduce by one third premature mortality from NCDs; SDG target 3.5: strengthen the prevention and treatment of substance abuse, and SDG target 3.8: achieving UHC by 2030. The Fourth UNHLM on NCDs, to be held in September 2025, will present Member States with a crucial opportunity to accelerate efforts to reduce the premature mortality caused by NCDs and save lives. Achieving the SDG targets for NCDs is critical: the progress in the Region is not on track to meet the targets, and immediate action is needed. The forthcoming UNHLM on NCDs underscores the urgency for targeted initiatives to address the political and health aspects of NCDs. Pandemics, earthquakes, wars and extreme weather events have further highlighted the vulnerability of those with underlying NCDs, necessitating that a dual-track approach for policy and health agendas be taken. One track of the dual-track approach, known as RACE to the Finish, aims to meet the 2030 SDG deadline by accelerating progress in reducing premature mortality from NCDs. Member States are encouraged to prioritize and implement strategies to reduce premature deaths, in particular those from cancers and cardiovascular diseases. WHO/Europe has worked with various countries, including Georgia and Germany, on ways to implement national NCD prevention agendas using the NCD “best buys” package. Efforts should also focus on improving country-level data on NCD risks and outcomes, to ensure a comprehensive approach to tackling NCDs. WHO/Europe is in the advanced stages of drafting a “quick buys” list, which is a list of the “best buys” that, when implemented correctly, lead to public health benefits within a period of five years. The second track, Vision 2050, urges Member States to integrate NCD policies into the broader generational agendas on ageing, climate change and health emergencies. Capitalizing on the co-benefits of an integrated approach will strengthen resilience in individuals, communities and systems. To achieve success in this track, the commercial determinants of health need to be addressed. The WHO/Europe report, Commercial determinants of noncommunicable diseases in the WHO European Region, published in June 2024, has paved the way for Member States to push back on Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202454 the concerted efforts of commercial actors to delay, amend or eliminate regulations that curb the harms from alcohol consumption, tobacco use, physical inactivity, unhealthy diets and the use of fossil fuels. If Member States act now, the burden of NCDs can be significantly reduced within the next five years, with resulting improvements in population health and a restart in progress made towards achieving the SDGs. Collaboration and innovation will be key, with international partners sharing knowledge and resources, and fostering innovation in health technology and community-based initiatives. These concerted efforts will enable Member States to effectively combat NCDs and create a healthier future for all. Progress towards global and SDG targets for NCDs Every fifth man and every tenth woman in the Region is currently dying before their 70th birthday from one of the four major NCDs. These deaths are largely avoidable – being both preventable and/or amenable to health care. The inequalities in premature NCD mortality rates between countries in the Region are substantial – up to nearly fourfold – and are driven mainly by circulatory diseases and excess male mortality. Progress towards the nine global NCD targets set forth in the NCD Global Monitoring Framework is lagging and uneven. It is unlikely that the Region will achieve the SDG target of a one third reduction in premature NCD mortality between 2015 and 2030, despite being the WHO Region that has made the most progress in reducing premature deaths from NCDs. The decreasing mortality trends have been accompanied by decreases in the levels of most risk factors, with the exception of obesity, which is rapidly increasing in many countries in the Region, making the prospect of achieving the global NCD target of no increase by 2025 unobtainable. Furthermore, the declines in other risk factors are insufficient to achieve the agreed targets and to have the desired impact on the reduction of premature mortality. Progress towards many important targets stalled during the COVID-19 pandemic, and consequently, the situation, for some indicators, actually worsened. The response to NCDs needs to be urgently intensified to meet the agreed EPW, NCD and SDG targets. Generally, costeffective policy interventions remain heavily underused. More specifically, although decreasing, the levels of tobacco and alcohol use in the Region are among the highest in the world, and it is unlikely that the Region will reach the target of a 30% reduction in tobacco use by 2025 if efforts are not intensified. The Region is on track to reach the target of a 20% reduction in alcohol per capita consumption by 2030, although progress has recently stalled and consumption is increasing in a number of EU countries. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 55 Hypertension is also decreasing in the Region but is still slightly off track to meet its target. The target will be within reach if the work to prevent and control hypertension is intensified, particularly through salt-reduction efforts, such as food reformulation and awareness campaigns. The implementation of the most cost-effective policies to prevent and control NCDs and the implementation of WHO’s “best buy” NCD interventions remains moderate. On average, countries in the Region are reporting implementation of around half of these policies at the highest level, with large differences between countries (ranging from 11% to 84%). The following policies have particularly low implementation rates: health examination surveys; measures to reduce the availability and affordability of alcohol; full enforcement of tobacco-free environments; elimination of all forms of tobacco advertising; and elimination of the marketing of breast milk substitutes. Improvements have been achieved in adapting management guidelines and treatment protocols and providing drug therapy for most common NCDs. During the reporting period, the work on data for impact and NCD surveillance has been intensified. Ten countries in central Asia, eastern Europe and the Western Balkans have been supported to implement the WHO STEPwise approach to NCD risk factor surveillance surveys to data-driven policy dialogue on NCDs. Data from electronic health records have been used to improve NCD prevention and control in numerous countries. Current data on the implementation of NCD policies and the availability of resources for NCD prevention and treatment have been collected from all 53 Member States in the Region through the WHO NCD Country Capacity Survey. In addition, assessments on progress towards the internationally agreed targets have been conducted along with situation analyses. Supporting countries to accelerate progress WHO/Europe has a critical role to play in formulating strategies to reduce premature mortality from NCDs in the Region: a number of examples of work done over the past year are presented below. WHO/Europe is developing a package of tools and approaches to facilitate accelerated action towards established NCD targets. This includes data visualization tools to indicate progress towards the targets and identification of the policies and interventions that will deliver results in the next five years, and to strengthen partnerships and multistakeholder engagement. In the Western Balkans, the regulatory measures on tobacco control have changed little since 2014, resulting in the consistently high prevalence of tobacco use. Since 2023, WHO/Europe has convened technical meetings, engagements with health authorities and wider stakeholder consultations, including joint activities with subregional partner organizations in the Western Balkans with the aim of reducing tobacco use. In March 2024, health ministers from Albania, Bosnia and Herzegovina, Montenegro, North Macedonia and Serbia achieved a significant milestone by agreeing to the declaration on protection from tobacco smoke. This declaration involves not only strengthening Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202456 existing smoke-free legislation, but also ensuring its rigorous enforcement and offering help to people to quit smoking. WHO/Europe is actively following up with individual countries, as well as the Western Balkan subregion as a whole, to offer support in strengthening tobacco control policies. In June 2024, a subregional technical workshop, held in in Skopje, North Macedonia, was organized for the Western Balkans to support in the planning of step-wise approaches to building comprehensive tobacco cessation services. Meaningful stakeholder engagement is crucial for achieving the SDGs and for reducing alcohol use. WHO/Europe exemplified this by bringing together the Evidence into Action Alcohol Project Youth Alcohol Network and focal points from 30 Member States in Madrid, Spain, in June 2024. Members of the Youth Alcohol Network shared the results of their ground-breaking work to unpack what lies behind the use of QR codes, an industry-favoured solution to avoid mandatory alcohol labelling. This collaborative meeting fostered dynamic exchanges, merging youth perspectives with policy-maker insights, resulting in specific ideas for policy recommendations and coordinated action at both the EU and national level. Such participatory approaches show that innovation in public health extends beyond technology to inclusive, codesigned strategies with tangible outcomes for the common good. In November 2023, in Belgrade, Serbia, WHO/Europe and the European chapter of the International Diabetes Federation jointly organized a high-level technical summit bringing together policy-makers, health professionals, academics, civil society representatives and people living with diabetes to consider accelerated action on diabetes in countries in line with existing commitments and, specifically, to achieve the global diabetes targets by 2030. Following the ensuing declaration, WHO is actively following up with individual countries to support them to self-assess their status against the targets, plan actions to address gaps, and use data to drive improvements in care. The Tallinn Charter 15th Anniversary High-level Conference, Trust and transformation: resilient and sustainable health systems for the future, co-hosted by the Government of Estonia and WHO/Europe, held in December 2023, served as an opportunity to showcase WHO/Europe’s work in supporting the Ministry of Health in Kyrgyzstan to transform diabetes care to be more people-centred, as part of a  three-year project co-funded by the World Diabetes Foundation; the project is also taking place in Uzbekistan. In Georgia, Kyrgyzstan and Uzbekistan, the implementation of WHO/Europe’s Therapeutic patient education: an introductory guide has been initiated to support self-management for people with chronic conditions. In Kyrgyzstan, the Russian Federation, Ukraine and Uzbekistan, there have been country-specific events to launch WHO/Europe’s report, Action on salt and hypertension: reducing cardiovascular disease burden in the WHO European Region, and to consider country-specific approaches to reduce the cardiovascular diseases burden and to reduce Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 57 premature mortality. Better management of hypertension and diabetes in people who are pregnant or have rheumatic heart disease has been a feature of WHO/Europe’s support in Kyrgyzstan and Tajikistan. In December 2023, a  Diet Impact Assessment tool was launched. This innovative and interactive modelling tool enables analysis of the health, environmental and affordability implications of diets and dietary change. The tool enables countries to analyse user-specific scenarios of dietary change, and to estimate the health, environmental and cost burden of each scenario in terms of diet costs, avoidable deaths, changes in resource use and compatibility with global environmental targets, including those associated with food-related greenhouse gas emissions, land use, water use and fertilizer application. NCDs and emergencies Given the current convergence of various hazards, combined with migration in the Region, robust health emergency response, preparedness, recovery and resilience measures are crucial. Such measures should prioritize the protection of subpopulations experiencing vulnerability, including people living with NCDs. For health systems, this situation represents a permacrisis – where disasters and conflicts exacerbate the already high risks associated with NCDs. Unfortunately, existing humanitarian systems often lack the capacity and resources to adequately address NCDs during emergencies. To address NCD challenges during emergencies and to facilitate the exchange of country experiences the following events were held during the reporting period: • a hybrid regional consultation, Noncommunicable diseases in emergency preparedness and response: from permacrisis to resilience, held in Copenhagen, Denmark, in September 2023; and • the Global high-level technical meeting on noncommunicable diseases in humanitarian settings, co-hosted by WHO and the Government of Denmark and held in Copenhagen, Denmark, in February 2024. During the high-level technical meeting, WHO/Europe co-organized two side events on research and innovation related to NCDs in emergencies. Country representatives and other stakeholders engaged in discussions about the current gaps, challenges and opportunities for harnessing and scaling up innovation and research in this area. In preparation for both the regional consultation and the global meeting, WHO/Europe conducted a landscape review of the existing evidence on NCD measures in different health emergencies. Three operational reviews were also carried Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202458 out: one on the general NCD response during the COVID-19 pandemic and during the war in Ukraine; another on cancer prevention and management in Republic of Moldova; and a third on the NCD response during the acute and recovery phases following the devastating earthquakes in Türkiye. Country experiences, findings and the recommendations from the meetings provided a solid basis for incorporating evidence-based NCD actions and lessons learned into Preparedness 2.0, and for producing an action plan to support Member States to be better prepared for current and future hazards and to build resilient health systems. Commercial determinants of NCDs Core priority 3 of the EPW – promoting health and well-being – requires WHO/Europe to support Member States by promoting initiatives that address social, economic and commercial determinants that shape health outcomes and inequities. In the Region, alcohol consumption, tobacco use, unhealthy diets and the use of fossil fuels are responsible for at least 7400 deaths a day. This is a conservative estimate, with the industries producing these products being responsible for 2.7 million deaths each year, or about one in four deaths. Harmful products from these industries hit low-income people harder, making existing health inequities even worse. Member States have reported struggles in dealing with the commercial determinants of health when developing and implementing public health policies. One prime obstacle in accelerating the implementation of NCD “best buy” policies is hampered political will that is greatly influenced by commercial industry. For example, only 19 countries in the Region have taxes on sugary drinks to reduce consumption and only 13 countries ban all forms of advertising, promotion and sponsorship of tobacco products (25% of countries at regional level compared with 34% at global level). Over the past year, WHO/Europe has taken several steps to support Member States to address the commercial determinants of health. The report, Commercial determinants of noncommunicable diseases in the WHO European Region, describes case studies illustrating key strategies and outcomes of industry influence on health policies in the Region, the solutions that countries have implemented and potential options for the future. The publication was launched on 12  June  2024 in Brussels, Belgium, during the WHO  European Forum on Commercial Determinants of NCDs, hosted by the Federal Public Service Health, Food Chain Safety and Environment of Belgium. The report was welcomed by the public health community and received significant media coverage, generating more than 1400 articles or references in major media outlets around the world. The report gives examples of positive stories of combating commercial determinants, including how tobacco laws were strengthened through new amendments by the Government of Slovenia with the support of civil society groups and health advocates; and how the Ministry of Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 59 Health of Estonia, with support from health advocacy groups, managed to gain political support to introduce a tax on sugary drinks. The report on the commercial determinants of NCDs connects well with WHO/Europe’s work on the well-being economy. The industry playbook identified in the report works to increase health and social inequities by concentrating wealth in, and giving disproportionate power to, a few corporations. WHO/Europe will provide practical and innovative (Box 2) ways in which civil society and academia can be mobilized, and that governments can use, to protect NCD policies from the undue influence of health-harming industries. In February 2024, WHO/Europe launched a consultation process with Member States on developing a strategy for harnessing innovation for public health in the WHO European Region for 2025–2030, recognizing gaps in addressing the complex health challenges facing the Region and the underuse of innovation to address public health issues. Momentum was generated in this regard through a  meeting entitled Building a  public health innovation ecosystem in the WHO European Region, held in Copenhagen, Denmark, by WHO/Europe in March 2024. The meeting brought together representatives from Member States, international organizations, foundations, CSOs and youth movements. Key outcomes highlighted the need for a holistic ecosystem approach to innovation that prioritizes equity, sustainability and value creation for people’s health and well-being, rather than economic profit alone and involving diverse stakeholders. Youth engagement was identified as particularly crucial, given their technological expertise and stake in future health outcomes. The meeting also stressed the critical role of user-centric innovation and the significance of global partnerships, with recommendations to work closely with innovation hubs and science parks to facilitate collaboration in responding to public health challenges. Box 2. Innovation for public health Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202460 Prison health As part of WHO/Europe’s efforts to leave no one behind and to bridge the health gaps observed within detention centres, and between detention centres and the general population across the European Region, WHO/Europe has held a number of events and activities in this regard. A two-day international conference on mental health and well-being in detention centres was held in April 2024 in Amsterdam, Netherlands. This conference was co-organized by WHO/Europe, Dutch partners and the Government of the Netherlands (Kingdom of the). WHO/Europe, together with the WHO Regional Office for the Americas and Yale University, United States of America, launched an e-learning course to train the prison health workforce on NCDs. The regional directors of WHO/Europe and the WHO Regional Office for the Americas presided over the launch. A mission was conducted to assess the status of HIV and viral hepatitis in key populations in Azerbaijan; this work was jointly carried out with WHO/Europe’s Joint Infectious Diseases team. The contribution of the WHO Collaborating Centre on Prevention and Control of Tuberculosis in Prisons in Baku was crucial to enabling the mission to take a holistic approach to health care and to include prisons, revealing several areas for improvement. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 61 Environment, climate change and health The Declaration of the Seventh Ministerial Conference on Environment and Health (the Budapest Declaration) was adopted at the Seventh Ministerial Conference on Environment and Health, Budapest, Hungary, in 2023 and endorsed through decision EUR/RC73/(7) at RC73. The Budapest Declaration embodies the strong political commitment of Member States of the Region tackle the health risks posed by the triple environmental crisis – climate change, environmental pollution and land degradation and biodiversity loss; to ensure that everyone has access to safe water, sanitation and hygiene (WASH); and to promote a clean, safe and healthy built environment, leaving no one behind by 2030. The launch of new partnerships led by Member States invigorated accelerated action to make progress in addressing these challenges by fostering collaboration and exchange of knowledge among Member States and by the strengthening of capacities in countries. The work of the WHO European Centre for Environment and Health (ECEH) in Bonn, Germany, has focused on supporting Member States to enhance their national policies on WASH, and on air quality and chemical safety; update their health impact assessment tools; build capacities, through transformative public health training; and forge new environment and health partnership networks. Advancing the implementation of the Budapest Declaration’s commitments Following the adoption of the Budapest Declaration in 2023, main developments have included: • setting in motion relevant partnerships including on: Ì human biomonitoring, co-led by Georgia and Germany; Ì health sector climate action, led by Ireland; Ì healthy and active mobility, co-led by Austria and the Netherlands (Kingdom of the); and Ì youth engagement in environment and health, led by Slovenia and the Youth Health Organization; • continuing the Bonn Dialogues on Environment and Health, highlighting the WHO report on the progress towards the SDG targets related to environment and health, and the application of BCI to environment and health challenges; and • convening the 14th meeting of the European Environment and Health Task Force, held in Utrecht, Netherlands on 26–27 June 2024, where two new partnerships were launched: poison centres, led by the United Kingdom; and indoor environments, led by Hungary. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202462 © M ic ha lis K ar ag ia nn is Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 63 Stepping up action on climate change and health With Europe becoming the fastest-warming continent on Earth, with temperatures rising at around twice the average global rate, WHO/Europe stepped up action in this regard. Of particular note was the European Regional Dialogue: accelerating action on climate and health at the 28th Conference of the Parties to the United Nations Framework Convention on Climate Change (COP28), held on 3  December  2023 in Dubai,  United Arab Emirates. The Dialogue provided an input to the COP28 climate-health ministerial segment, where 144 Member States, including 44 from the European Region, adopted a political declaration on climate change and health, which sets a call to action and represents a joint vision from countries, which is highly synergic to the Budapest Declaration. This Dialogue also acted as a robust springboard to action in 2024, and helped move forward the commitments agreed in Budapest. This action has included the start of activities of the newly established partnership on health sector climate action that, under the leadership of Ireland, convened for the first time in Bonn, Germany, on 13–14 May 2024. Other activities carried out by WHO/Europe in climate change and health over the past year are as follows: • A strategic round table, Increasing Resilience to Climate Change in the Water and Sanitation Sector was convened and held in Geneva, Switzerland, on 16 November 2023. • Member States were supported to strengthen their national preparedness to climate-induced extreme weather events. This included: Ì providing technical support for the development and implementation of WHOrecommended national heat health action plans (for example, in Tajikistan and Turkmenistan); Ì the launch of the annual #KeepCool campaign, with hands-on tips on how to behave during heat waves; and Ì advancing the update of the WHO normative guidance for heat health action plans, with support from the European Commission, with the publication of the new guidance expected in 2025. • The Climate Change Mitigation, Air Quality and Health tool was launched. • Partnerships with the European Commission Directorate-General for Climate Action, the European Climate and Health Observatory, the World Meteorological Organization and The Lancet Countdown on Health and Climate Change were strengthened. • The Hungarian presidency of the Council of the EU was supported on the core priorities for their 6-month term, including mental health, climate change and indoor air quality, with a focus on school environments. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202464 • A series of dialogues on climate change and health, in collaboration with the WHO Regional Office for the Americas, was launched as an input to COP29, with the first event held in July 2024 on the topic of extreme weather events. Environment and health emergencies Working with the WHO Health Emergencies Programme and the relevant country offices, the ECEH has strengthened preparedness and response to emergencies caused by extreme weather events. These efforts have focused on heat, which is estimated to claim more than 175 000 lives annually in the WHO European Region. In 2023, for the first time, the extreme heat reported during the summer was declared as a public health emergency to increase awareness and improve the public health response to heat, including by deploying the #KeepCool campaign, which is available in more than 20 languages. The ECEH has also responded to the environmental and health problems caused by the war in Ukraine, by addressing challenges related to the provision of safe water and sanitation services and those related to chemical pollution. Furthermore, the ECEH, in collaboration with the PHHE Centre and the WHO Country Office in Türkiye, has started to develop a training module on post-disaster environmental health services and resilience in the aftermath of the 2023 earthquakes in Türkiye, with the expectation that the training module will be completed during 2025. Strengthening capacities to address environment and health challenges The ECEH has worked closely with Member States on strengthening capacities to address environment and health challenges by organizing training initiatives addressing environmental health inequalities; WASH in schools and in health care facilities; drinking-water safety; air quality; chemical safety; and health impact assessments. The ECEH also published an educational package on the use of human biomonitoring to assess exposures to chemicals, and a set of policy briefs on incorporating health into environmental assessments, thereby ensuring that health is given due consideration in the mandatory assessment of the impacts of new policies, programmes and projects in countries. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 65 Addressing air pollution, chemical safety, and WASH Air pollution continues to pose a significant health threat, causing more than 500 000 deaths annually in the Region. Following the development of the WHO Air Quality Guidelines, the ECEH has continued to support Member States to address air pollution to protect health. The executive summary of the Guidelines is available in 14 languages and has been downloaded approximately 300 000 times. The Guidelines have been widely used in scientific and policy communities globally and have served as a  reference for the revision of the EU ambient air quality directives, with stricter regulations being adopted by the European Parliament in April 2024. The ECEH has continued to facilitate science policy dialogues and capacity-building; has developed resources, such as a compendium of air quality management tools; and offered practical advice on reducing personal exposure to ambient air pollution. WHO/Europe has supported Member States to promote the sound management of chemicals by establishing poison centres, using human biomonitoring to assess exposure and health risks, and phasing out mercury-containing products from health care. In June 2024, WHO/Europe convened a meeting to set regional priorities to facilitate the implementation of major chemical safety policies, including the Global Framework on Chemicals, the WHO Chemicals Road Map and the Minamata Convention on Mercury. In the European Region, approximately 33 500 acute respiratory and diarrhoea-related deaths annually can be attributed to inadequate WASH conditions and services. The ECEH has supported several countries in the Region to conduct comprehensive national assessments of WASH conditions and waste management practices in health care facilities, and to develop updated national standards in response to the findings of these assessments, contributing to improved infection prevention and control, better quality of care and working against AMR. The ECEH led work on wastewater- based public health surveillance for COVID-19 and other emergency-related and routine use cases. North Macedonia and Uzbekistan became the 28th and 29th countries, respectively, to join the Protocol on Water and Health, a unique legally binding instrument aiming to protect human health through better water management and by reducing water- related diseases. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202466 Healthy cities Cities are vital hubs for political, cultural and economic activity, and with rapid urbanization 80% of the Region’s population are anticipated live in cities by 2030. The WHO Healthy Cities Network consists of 90 flagship cities across eastern and western Europe and 20 national networks, spanning from Iceland to the Russian Federation and from Italy to the United Kingdom. The Network entered Phase VII (2019–2025) of its operation in January 2019, and has shown a strong commitment to building strategic partnerships and brokering solutions to address pressing urban health challenges. In 2023, the Network celebrated its 35th anniversary: uniting cities and national networks to advance regional and global development goals through local action since its inception. The Network has influence over 165 million people, and prioritizes health across political, social, economic and environmental agendas. The Network has had an impact on numerous EPW indicators, including decreasing road traffic injury mortality rates, improving air quality and decreasing air pollution mortality rates, and increasing access to safe drinking-water and safe sanitation, all through influencing local level policy and programming. To further strengthen its impact, the Network has developed a data visualization hub, which will be launched to provide cities with tools to track progress and share insights with other cities. In November 2023, the Network held its Annual Business Meeting and Technical Conference with the theme, Health and well-being for all: celebrating 35 years of the Healthy Cities movement. The Conference brought together over 350 participants to contribute to the ongoing conversation on how to create healthier, more equitable cities. A highlight was the adoption of the Political statement of the WHO European Healthy Cities Network: towards thriving societies - advancing health in the well-being economy, which had been drafted by 55 cities and 19 national networks in the Region. The statement featured 12 actionable recommendations to transform cities into healthier, more equitable places for all and which set a clear agenda for local governments to engage in intersectoral collaboration and drive innovation towards enabling an economy that works for everyone. To support the implementation of the statement, the Network, with the support of the WHO European Office for Investment for Health and Development, Venice, Italy, launched the pilot programme, Building a Well-being Economy: a pilot programme for Healthy Cities in Europe. The first phase of the pilot includes eight cities with results on track to be ready at the end of 2024, and the scale-up of the programme will include the national networks in the second phase. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 67 Partnerships and knowledge sharing are core to the Network. A study tour took place in Japan in November 2023, in which politicians, mayors and technical experts from six European cities observed successful policies and programmes in five Japanese cities, and best practices were shared on maintaining green and blue spaces and on healthy ageing, for potential adaptation to the European Region. The collaborative exchange fostered cross-cultural partnerships and effective strategies to enhance public health, which was highlighted during the Annual Business Meeting, and helped to sustain the momentum towards promoting healthier cities globally. The Network’s role extends to developing evidence-based guidance, exemplified by the How to develop and sustain healthy cities in 20 steps guide and an online capacity-building course, which was launched in April 2024 and which has more than 2000 enrolled learners. Throughout 2024, a  comprehensive evaluation of Phase VII of the Network is ongoing, emphasizing the need to digitalize and streamline city designation and network accreditation processes, and informing priorities for Phase VIII to meet the evolving health and well-being needs of communities across the Region. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202468 Accelerated action against AMR AMR is directly responsible for 133 000 deaths in the Region each year, which is equivalent to the combined burden of HIV/AIDS, influenza and TB. The cost of AMR in EU and European Economic Area countries amounts to nearly €11.7  billion every year as a  result of higher health expenditure and reduced workforce productivity. In addition to the strategic work being carried out at the regional level, WHO/Europe has provided support to Armenia, Georgia, Kazakhstan, Latvia, Tajikistan and Türkiye to develop or update their national AMR strategies and action plans. However, results from the latest Tracking AMR Country Self-Assessment Survey indicate that fewer than 25% of national AMR action plans in the Region have a dedicated budget to allow them to be implemented. In October 2023, the Roadmap on antimicrobial resistance for the WHO European Region 2023–2030 was endorsed at RC73 to accelerate action against AMR. The Roadmap is designed to support countries to prioritize interventions from 53 evidence-based interventions and to set targets to address AMR, and looks at health through a One Health lens, supports equity and a  people-centred approach, and adopts a  systems view. WHO/Europe’s support to the presidencies of the Council of the EU of Belgium, Spain and Sweden has provided opportunities to both obtain valuable input and raise awareness of the new AMR Roadmap. Strong leadership is important for creating an empowering and collaborative environment to implement policy interventions and technical solutions. In Slovenia, the three levels of WHO organized an AMR workshop to enhance leadership and multisectoral collaboration skills. Furthermore, a newly developed antimicrobial stewardship leadership course on broader clinical governance systems was piloted in North Macedonia for senior hospital leaders and policy- makers to enhance uptake of antimicrobial stewardship programmes in their facilities. Through applying the Tailoring Antimicrobial Resistance Programmes approach, WHO/Europe has supported countries to identify behavioural interventions to address AMR in their country contexts. These include ongoing projects in Greece and Malta addressing antibiotic prescribing; a project in Kazakhstan looking at over-the-counter sales of antibiotics; and one in Georgia to implement a surgical antibiotic prophylaxis programme in hospitals. Moreover, in close collaboration with the ECDC and partners, WHO/Europe has continued to strengthen surveillance of AMR and AMC according to international standards in an increasing number of countries, and is working towards obtaining a pan-European overview. Over the past year, data management and analysis training has been provided in Georgia, Tajikistan, Türkiye and Ukraine. For countries that do not have an AMR surveillance system, WHO/Europe is launching national AMR surveys to obtain reliable baseline information, while, at the same time, building the capacity to set up national systems. Kyrgyzstan is the first country in the world to undertake this national survey, and preparatory Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 69 So ur ce : S to rie s of A M R , p .1 9 © S tin e M ik ke ls en Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202470 work to carry out the survey has already been carried out in Azerbaijan. Lessons learned from this work will benefit many countries around the world that are embarking on similar endeavours. WHO/Europe and partners have also strengthened surveillance capacities for health care-associated infections to gather evidence to support decision-making, develop policy interventions and assess their impact. Armenia, Azerbaijan, Kazakhstan, Montenegro and Serbia, as well as Kosovo,[6] undertook point prevalence surveys in this regard, the results of which were used to develop health care-associated infection surveillance strategies and targets, update guidelines, prioritize infection prevention and control measures, and identify training needs. WHO/Europe also published a  report containing AMC data from 13 countries and an assessment of the possible impact of the COVID-19 epidemic on the consumption of antibiotics. Moreover, the second Surveillance of antimicrobial resistance in Europe report, published jointly by WHO/Europe and the ECDC, and its executive summary, was published during World AMR Awareness Week, containing data from 44 out of the 53 Member States, as well as from Kosovo. World AMR Awareness Week also marked the launch of a year-long social media campaign on Stories of AMR, which highlighted one story per week from all countries in the Region. Through country activities, such as the National Bridging Workshops in Romania, the workshop for evidence-informed policy-making for One Health in Croatia, the One Health Mechanism mission to Bulgaria, and supporting the AMR One Health conference in Latvia, WHO/Europe has been “walking-the-talk” in taking a One Health approach to tackling AMR. The One Health approach is strongly fostered in the publication Prevention and control of antimicrobial resistance in the food chain: guidance for food safety authorities in Europe. Together with the Global AMR Research and Development Hub, WHO/Europe is investigating the practical applications and current scientific evidence supporting the use of bacteriophages to treat bacterial infections – from a One Health perspective  – across the human, animal and environmental sectors and has setup a  Community of Practice as a platform for multidisciplinary engagement. 6 All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999). Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 71 One Health 7 All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999). In the face of interconnected crises spanning the health, environmental and social domains, WHO/Europe has embraced the One Health approach as a pivotal strategy to address complex challenges. In 2021, WHO/Europe made a commitment to use the One Health approach in all relevant policy settings, alongside increased investments in health and social care systems. Since then, significant progress has been made in operationalizing the approach, including the establishment in 2022 of the Technical Advisory Group for One Health, which identified six thematic areas for implementation aligned with international calls for preventive action. WHO/Europe’s work is supporting Member States to place health and well-being at the centre of government policies, especially in non-health sectors that impact health either directly or indirectly. This will be achieved using the One Health approach aligned with the One Health Joint Plan of Action (2022–2026) and its implementation guide, which was launched in December 2023. In June 2024, WHO/Europe co-organized the regional Quadripartite One Health seminar held in Vienna, Austria. This event provided a platform for cross-sectoral dialogue, enabling representatives from public health, animal health and environmental health sectors to exchange best practices and reinforce a collective commitment to the One Health approach. WHO/Europe has also been instrumental in shaping the global dialogue on One Health, in particular at prominent forums such as G7 and G20, and has offered strategic recommendations for key events, such as the G7 technical side event and the second G7 Health Working Group meeting, which was held on 3–4 May 2024, in Rome, Italy. Furthermore, WHO/Europe actively participated in the ECDC-Sciensano joint meeting on AMR during the Belgian presidency of the Council of the EU on 6–7 May 2024 and emphasized the importance of using a comprehensive One Health approach to address diverse health challenges, particularly in combating AMR and to address foodborne and zoonotic diseases. WHO/Europe has continued to provide inclusive, country/area-driven processes to expedite the implementation of the One Health approach and support national – or equivalent – and local entities to make it mainstream. Notably, over the past year, WHO/Europe has supported Turkmenistan to identify national priorities for embedding the One Health approach into its strategic planning for addressing potential health threats. Kosovo[7] was also supported to embed the One Health approach into its strategic planning for health security. Additionally, a One Health Symposium, attended by Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202472 multiple ministry stakeholders and partners, was held on 25 July 2024 in Baku, Azerbaijan, to explore the One Health approach in preparation for the upcoming COP29. The Pandemic Fund is a  significant investment initiative in the Region, through which WHO has secured funding to support the application of the One Health approach in central Asia. This initiative aims to strengthen pandemic prevention, preparedness and response in Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan. In 2023, WHO/Europe, together with the relevant country offices, actively implemented this initiative to address the synergies between strategies, structures, systems, legislation and financing to bolster health security. Overall, WHO/Europe’s commitment to One Health spans various initiatives within the Organization and across different sectors. Moving forward, sustained collaboration and innovation will be vital for leveraging these achievements to drive tangible advancements towards a healthier future for all. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 73 Gender, rights, equity Although life expectancies in the Region have increased over time, there remains a 6.2-year difference in life expectancies for women (81.8 years) and men (75.6 years). Men continue to have high rates of premature mortality, due primarily to higher rates of cardiovascular diseases and external causes of death, and higher exposure to NCD risk factors. Women, on the other hand are more likely to experience physical health conditions in early life, and depressive and anxiety disorders moving into adult life: in women, lower back pain, ischaemic heart disease and cancers are more prevalent at older ages. There is also a gender gap in the rates of poverty in later life, with 18% of women aged 65 years or older living in poverty compared with 13% of men. During the period under review, WHO/Europe has worked with 13 Member States to identify the effects of gender differences and inequalities on the health of women and men in individual countries, and to design policies and services that remove gender-based barriers to better health and well-being. For example, in Malta, recommendations have been integrated into government discussions on equity policy and reducing NCDs. WHO/Europe also published a  technical report on gender and digital health, The role of digital health technologies in women’s health, empowerment and gender equality: project report; and a  report on gender and the health and care workforce, Health and care workforce in Europe: time to act. These publications support the gender and equity recommendations and targets in the Regional digital health action plan for the WHO European Region 2023–2030 and in the Bucharest Declaration, which are intended to support 53 Member States to close the gender gap and improve working conditions for the 80% of care workers who are women, including protection from violence, discrimination and harassment. The manifestation of gender inequalities across the European Region creates access gaps to sexual and reproductive health services in many countries, as well as unacceptable rates of gender-based violence. In the Region, 26% of women aged 15–49 years have experienced intimate partner violence or non-partner sexual violence in their lifetimes. It has been estimated in the EU that the cost of gender-based violence amounts to €366 billion a year and the WHO European Office for Investment for Health and Development, Venice, Italy, is making the investment case with countries for gender equality and human rights as accelerators of UHC. WHO/Europe is continuing to address violence against women through a rights-based lens of universal access to health. WHO/Europe’s health response has supported investment in health systems in Ukraine and seven refugee-hosting countries (Czechia, France, Germany, Ireland, Norway, Portugal and Romania) to provide comprehensive health care to survivors and to strengthen provider capacity to identify and respond appropriately to signs of violence. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202474 Investment for health development Over the past year, key indicators of well-being in the Region continued to be a source of concern. • Economic well-being eluded 21% of the EU population: a population exposed to insecurities with respect to being able to afford essential goods such as food, shelter and medicine. • One in seven OECD residents aged over 65 years lived in relative poverty. • On a social level, 11.2% of young people aged 15–29 years faced exclusion from employment, education or training, which doubles their likelihood of reporting poor mental health. Accessing mental health services was a challenge for 50% of these young people. These disparities undermine health equity and economic opportunities. The WHO European Well-being Economy Initiative addresses these challenges by supporting countries with metrics, tools and capacity-building activities to invest in well-being policies for healthy ageing, youth mental health and marginalized regions. New evidence and options to implement national policies that increase health equity and well-being have been presented and discussed over the past year with over 900 policy-makers from more than 30  countries at seven WHO/Europe regional events and three global forums. These events included the G7 Health Working Group, held under the Italian presidency in Rome, in May 2024, and the Annual Dialogue on Tax and SDGs held in New York, United States, in December 2023. Furthermore, a high-level dialogue was held in Venice, Italy, on 9 April 2024 on Reimagining an economy for resilient and healthy societies that leaves no one behind. The event, which marked the 20th anniversary of the WHO European Office for Investment for Health and Development, Venice, Italy, was hosted by the Government of Italy (the Ministry of Health and the Veneto Region) and convened more than 200 participants from 12 countries representing health, economic and social sector ministers, and other stakeholders. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 75 Flagship initiative: Healthier behaviours: incorporating BCI Behaviours play an essential role in health, and the need for more evidence-based and peoplecentred approaches to support, enable and promote health-related behaviours is clear. Through the BCI flagship, WHO/Europe has provided extensive technical support to Member States to help them integrate evidence-based BCI approaches into their health efforts targeting priority health challenges and inequities. This support has included running a total of 22 BCI projects in 14 countries, along with 18 research studies and 17 strategy or stakeholder workshops. Examples of these projects include efforts to: improve the uptake of colorectal cancer screening in Croatia and the uptake of cervical cancer screening in Georgia; increase flu vaccination rates in health workers in Georgian hospitals; increase the rate of exclusive breastfeeding in Kyrgyzstan; decrease children’s consumption of sugary drinks in Kyrgyzstan and Tajikistan; improve emergency care in Republic of Moldova; advance smoking cessation in North Macedonia; scale up polio vaccination rates; apply prevention and control behaviours to combat AMR in hospital settings in Ukraine; and increase access to health services among Ukrainian refugees in five host countries. These projects have been carried out in collaboration with all three levels of WHO. The incountry work is further described in the Annual progress report 2023: Behavioural and cultural insights at the WHO Regional Office for Europe. This support has been underpinned by the BCI Community of Practice, established by the BCI flagship and involving ministerially nominated BCI focal points from 50 Member States. These focal points meet bimonthly online for intercountry sharing and learning. The BCI flagship has also delivered 13 online, incountry and regional training sessions – attended by 396 participants – for public health authorities to enable participants to integrate BCI into broader health efforts in their institutions and to initiate strategic discussions on the advanced use of BCI for health. Several tools and resources have been launched to support Member States’ BCI work. These have included a comprehensive how-to guide on applying BCI to health, a collection of 25 BCI case examples and an impact evaluation guide. These tools are all featured on the flagship’s knowledge repository – BCIHub.org – and are supported by the Technical Advisory Group on BCI and WHO collaborating centres. The BCI flagship has also launched an ambitious global project to explore the health benefits of engaging with the arts, including a commissioned series on the topic published in The Lancet. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202476 At regional level, noteworthy impacts of WHO/Europe’s BCI work have been reported by Member States, who have identified WHO/Europe as a driver of change in this critical, yet underfunded, area of work. This was documented through country reporting to WHO and a Member State interview study, conducted jointly with the ECDC, and was confirmed at a regional WHO meeting held in Copenhagen, Denmark, on 12–14 September 2023, attended by 112 participants from 48 Member States and nine partner organizations. Member States particularly highlighted the value of WHO/Europe’s technical support, advocacy, evidence for impact, intercountry exchange, guidance and capacity-building activities. These efforts will be sustained and accelerated over the coming years to achieve the targets of the resolution, European regional action framework for behavioural and cultural insights for equitable health, 2022–2027, adopted at RC72 in 2022. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 77 © W H O /M ik ha il G rig or ev © W H O /S pa rt ak A ve tis ya n Core priority 4: maintaining a fit-for-purpose WHO/Europe Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202480 Over the past year, WHO/Europe has continued to adapt and evolve in response to the changing health landscape. WHO/Europe remains dedicated to its core mission of promoting health and well-being across the European Region, while acknowledging the challenges and uncertainties that lie ahead. Work is ongoing to strengthen country focus, foster collaboration with Member States, and drive progress towards the EPW, GPW 13 and the SDGs. From piloting new leadership initiatives to scaling up country support teams, progress continues towards a more agile, effective and responsive Organization. This section of the report presents how WHO/Europe is making itself relevant and fit-for purpose for Member States. Supporting health leadership at the country level and being relevant for all 53 Member States Between September 2023 to August 2024, WHO/Europe has continued to focus on boosting support for health leadership at the country level, with the aim of being more relevant and impactful for all 53  Member States. This has been achieved through several key initiatives, one example of which is the PanEuropean Leadership Academy (ELA), which provides training for young professionals and mid-level officials from national administrations and public health institutions. WHO/Europe is working to strengthen country relevance by developing a standardized approach to engaging with countries, mapping health impact and promoting collaboration. This has been accompanied by a shift in resources to where they matter most: to the countries themselves. More than half of WHO/Europe’s human and financial resources are now located in countries, where they can have the greatest impact. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 81 ELA The ELA is a transformative initiative with a vision to support the current health leadership while enhancing the health leadership for tomorrow. The ELA aims to create a network of trained health professionals and leaders to advance the EPW priorities in the Region, while serving as a vehicle for practical dialogue and technical delivery in priority technical areas and for enhancing knowledge and insight into health system challenges and operations. The ELA is also tackling the critical issue of under-representation of some of the Region’s Member States in the United Nations system. By providing training and leadership opportunities, the ELA aims to elevate voices from these countries, ensuring that their perspectives and needs are considered in international health discussions and policy-making processes. The ELA offers learning opportunities and placements within WHO/Europe for early career public health and health professionals (Tier 1); a  peer-to-peer exchange for technical delivery to mid-career professionals in ministries of health and affiliated institutions (Tier 2); and support to high-level decisionmakers for the exchange and scaling up of nationwide and sustainable health systems and public health innovations (Tier 3). Between 2021 and 2023, nationals of 10 countries completed the ELA’s Tier 1 and Tier 2 demonstration projects. Following the successful evaluation of these projects, reported at RC73, WHO/Europe has moved forward with the full implementation of the ELA, with two cohorts – one Tier 1 and one Tier 2 – running simultaneously until early 2025. These cohorts comprise nominees working in ministries of health or affiliated institutions, health workforce educational institutions and organizations from six countries. Tier 3 is currently in the final phase of strategic development and will be launched in early 2025. As the ELA continues to grow, WHO/Europe will identify additional leadership opportunities, including in the field of transformational leadership capacities and competencies. Strengthening country relevance for all 53 Member States All three levels of WHO are making concerted efforts to strengthen the Organization’s relevance to – and the tangible impact that it has  – in countries. This pivots around Delivering United Action for Better Health  – a  strategy for collaboration between the WHO Regional Office for Europe and Member States in the WHO European Region, adopted at RC72, and which is in its second year of implementation, guided by the SCRC subgroup on WHO/Europe’s work at the country level. The subgroup convenes regularly to ensure that activities are developed together, and previous SCRC chairs are included in the meetings as observers to maintain continuity and leadership between standing committees. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202482 Work to map and document health impacts has focused on gathering recent examples of effective collaboration and on lessons learned. These examples have been compiled into a compendium of countryimpact stories building on insights from Member States and forming an accompanying volume to this current report. To provide opportunities for gaining insights into how WHO can become more relevant and responsive to Member States, an open session of the subgroup was held in July 2024 emphasizing WHO/Europe’s commitment to strengthen its country work. Over the past year, the Regional Director has prioritized maintaining close contact with all Member States through a comprehensive programme of high-level missions to 25 countries in the Region, and hosting five country delegations at the main office in Copenhagen to ensure that WHO/Europe maintains agile responses to constantly evolving country needs. WHO/Europe continues to shift the balance of its resources to countries, with more than half of its human and financial resources now being located within countries. The Action for Results Group, a global WHO initiative, comprised of two WHO representatives from each WHO Region, has identified, and is actioning, a set of proposals covering enhanced delegation of authority, sustainable core staff positions and seamless communications for country offices to build an effective and predictable WHO presence in countries. WHO/Europe is taking forward its commitment to ensure that all 53 Member States have a clear point of access for collaboration with WHO/Europe, either through a Country Office or a designated WHO/Europe country counterpart. For countries without a physical presence, WHO/Europe is mapping existing areas of collaboration both at the country and regional levels. This will inform a reflection session with Member States in early 2025, to better understand and address the domestic and international health needs of these countries. The new concept of country support teams, designed to provide short-term responses to requests from Member States, was mobilized for Germany and Malta over the reporting period, to provide advice on national health policy developments. Over the past year, a total of 12 country cooperation strategies, setting out long-term strategic priorities and collaboration objectives between WHO and Member States, have been developed and signed. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 83 Strengthening subregional and international partnerships To navigate the complexities of health in the Region, it is essential to recognize the power of collaboration and partnerships. During the period covered by this report, WHO/Europe has continued to work with countries, territories and areas; regional organizations; and international partners to drive progress towards better health and well-being. From the Roadmap for Health and Well-being in the Western Balkans (2021–2025) to the Regions for Health Network, partnerships are helping to strengthen health systems and promote health leadership at all levels. By fostering collaborative relationships with entities of the United Nations, non-State actors, CSOs and the EU, WHO/Europe continues to leverage collective expertise and resources to advance common goals and accelerate progress towards better health and well-being in the Region. Subregional collaboration Roadmap for Health and Well-being in the Western Balkans (2021–2025) WHO/Europe and the Central European Initiative have continued to implement the Roadmap for Health and Well-being in the Western Balkans (2021–2025) over the past year. This has involved co-organizing a policy dialogue on how to ensure access to safe, effective and quality medicines and protect populations from financial hardship; and organizing initiatives focusing on PHC, the workforce and palliative care. In November 2023, the Regional Director advocated for health at the annual Central European Initiative gathering of foreign ministers under the presidency of the Republic of Moldova. WHO/Europe has strengthened its collaborative efforts with the Regional Cooperation Council by assisting in the development of the Inclusive Growth Index of the Council’s South East Europe Strategy 2030, and by developing the health dimensions in the Council’s Securimeter survey, which collects citizens’ views on a large number of security related issues. WHO/Europe and the Regional Cooperation Council will also collaborate on organizing the pre-meetings being held with the ministries of environment and finance in the Western Balkans in preparation for the Berlin Process Summit being held in October 2024. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202484 Under the Belgrade Pledge 2022, which sets out joint action by the South-eastern Europe Health Network for 2022– 2026, specific initiatives have been promoted in collaboration with WHO/Europe on different topics, including nursing, mental health and quality of care. In March 2024, ministers of health from Albania, Bosnia and Herzegovina, Montenegro, North Macedonia and Serbia made a  landmark commitment to tobacco control in the Western Balkans, with the adoption of the Declaration on Protection from Tobacco Smoke. Other developments and achievements within the subregion over the past year have included support for updating policies and capacities related to climate change; strengthening service delivery capacity in human resources for health, mental health, PHC model development and health financing; and running catch-up activities for immunization and capacity-building in public health emergency management. Roadmap for Health and Well-Being in Central Asia (2022–2025) Endorsed by the presidents of Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan in September 2023, the Roadmap for Health and Well-Being in Central Asia (2022–2025) is a  strategic pathway to embed societal and intersectoral action for health at the heart of the central Asian economies. Its initiatives have been taken up by WHO/Europe and the Organization of Turkic States in a  joint action plan signed in November 2023 to advance the health agenda in Organization of Turkic States countries, central Asia and regionally. A further milestone to advance health in central Asia was the Central Asia International Health Investment Forum, held in Bishkek, Kyrgyzstan, in June 2024. This Forum was jointly organized by WHO/Europe and the Ministry of Health of Kyrgyzstan, under the patronage of His Excellency President of the Kyrgyz Republic Sadyr Japarov, and brought together representatives from the five central Asian countries and development partners with the goal of increasing investment in health and accelerating progress towards the SDGs. A new multistakeholder partnership group has been established to oversee this commitment. Small Countries Initiative The Small Countries Initiative comprises the 11 smallest countries in the Region, each with 2  million or fewer inhabitants – Andorra, Cyprus, Estonia, Iceland, Latvia, Luxembourg, Malta, Monaco, Montenegro, San Marino and Slovenia. These small countries play a pivotal role, both individually and collectively, in seizing opportunities through innovation, as highlighted in Limassol, Cyprus, in April 2024, where these Member States jointly committed to take stronger action to improve cancer care, and to improve their cooperation on, and implementation of, climate action plans. This unique meeting also welcomed a 12th Member State to the Small Countries Initiative: North Macedonia. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 85 The Small Countries Initiative, with support from WHO/Europe serves as a mechanism for accelerating learning and implementation. For example, six Member States from the Initiative have developed national plans for human resources for health during the past two years and will share their experiences on planning, forecasting and the policy-making process in 2024. Ten Initiative countries have joined the WHO/Europe Access to Novel Medicines Platform that is set to improve affordable and equitable patient access to effective, novel, high-cost medicines in the Region. Regions for Health Network The Regions for Health Network brings together 41 subnational authorities in 28 European countries. Subnational authorities are taking an ever-more prominent role in health policy implementation. The recent meeting, on 15–17 November 2023, hosted by Seville, Andalusia, Spain, focused on integrated care, Preparedness 2.0, cooperation with the EU, One Health and health financing. Members of the Regions for Health Network discussed the advancement of population health status across the Regions for Health and identified joint priorities. The Regions for Health Network is a  subnational technical and strategic collaborative platform of 41  subnational authorities and 10 associated partners from 26 countries. At its 28th meeting, hosted by the Regional Government of Andalusia, in Seville, Spain, on 15–17 November 2023, more than 100 participants discussed Health for all: addressing challenges, sharing experiences. Coalition of Partners on Health and Tourism The newly established Coalition of Partners on Health and Tourism, an initiative coordinated by WHO/Europe and United Nations Tourism, held its first meeting in Athens, Greece, in April 2024, and marks the first formal collaboration between the ministries of tourism and health in 24 Member States in the Region. This cross-sectoral initiative aims to support Member States to generate resilience, safety and security within health and tourism, while equipping health systems to shield tourists, host communities and the tourism workforce from potential health risks, especially in response to the COVID-19 pandemic and future emergencies. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202486 Collaborative relationships United Nations and international organizations Collaboration across the United Nations family has focused on regional coordination under the auspices of the United Nations Regional Collaborative Platform. This Platform is led by the United Nations Economic Commission for Europe and the United Nations Development Programme, and the United Nations issue-based coalitions on Environment and Climate Change, Gender Equality, Youth and Adolescents, Data, Social Protection and Sustainable Food Systems, of which the latter two are co-chaired by WHO/Europe. The Issue-based Coalition on Health and Well-being, led by WHO/Europe, has revised its workplan to focus on topics including One Health, ageing and migration. WHO/Europe will host the next meeting of the Regional Collaborative Platform for Europe and central Asia, bringing together the regional heads of United Nations entities to advance the 2030 Agenda for Sustainable Development. Globally, in the context of One WHO, WHO/Europe has contributed to the Organization’s engagement in the multilateral initiatives of G7, G20 and the BRICS. WHO/Europe also continues to support the delivery of the Global Action Plan for Healthy Lives and Well-being for All in seven countries in the Region: Albania, Azerbaijan, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkmenistan and Ukraine. Non-State actors Work has continued on increasing WHO/Europe’s engagement with non-State actors and on convening non-State actors in coordination mechanisms around the EPW flagships and priorities, collaborating with organizations representing patients, health workers and industry, and collaborating with young people. To streamline the collaboration methods, WHO/Europe developed a non-State actors engagement plan: a manual on how WHO/Europe engages with non-State actors at the regional and country levels. The plan sets out a more strategic approach than previously, and was created through a consultative process, engaging Member States and WHO staff, and in alignment with the global WHO Civil Society Commission and the Framework of Engagement with Non-State Actors, following feedback from non-State actors at an informal meeting at RC73. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 87 WHO collaborating centres There are 262 WHO collaborating centres located in 33 Member States in the European Region, globally, there are 812  centres in over 80 countries supporting WHO programmes. These centres provide invaluable support for the benefit of all Member States, with a  recent analysis indicating that 53% of collaborating centres deliver support at country level. The analysis also showed that each collaborating centre provides an annual average of US$ 200 000 of in-kind support. Regular, well-attended briefings are organized for the centres, and a community knowledge platform was launched in August 2024. New crosscutting networks on Preparedness 2.0 and One Health, and a greater focus on communicating about the activities of collaborating centres, is improving visibility and awareness. Youth4Health In September 2023, WHO/Europe launched the Youth4Health network during RC73. Currently, the network comprises 32 youth organizations and 155 individual representatives, from 35 countries across Europe and central Asia. Examples of network members engaging in WHO/Europe’s work include: a youth representative nominated as a member of the Healthy Cities Network Advisory Board; participation at the Force of the future: co-creating youth action on immunization event, held in December 2023; and youth organizations collaborating with WHO/Europe and WHO country offices in Albania and Armenia on a  range of activities, including podcasts and peer-to-peer education workshops for the European Immunization Week held in April 2024. The Youth Initiative Team continues to facilitate meaningful engagement with young people, including delivering online youth engagement training and coaching. Furthermore, a WHO youth engagement toolkit, summarizing everything WHO colleagues need to know about how to meaningfully initiate and design youth engagement, was published in March 2024. The team meets regularly with youth engagement focal points across the Region to discuss and coordinate youth engagement activities, in particular linkages between the WHO Youth Council and the Youth4Health network. WHO and the EU During the reporting period, the WHO Representation Office to the EU (WEU) continued to actively collaborate with EU institutions, focusing on strategically enhancing WHO’s health agenda within EU frameworks and fostering wider health cooperation at the country level, for the Region, and between the regions and globally. A prominent highlight of the past year has been the enhanced collaboration between the European Commission and WHO/Europe. A notable achievement in this regard included a Senior Official Meeting held between European Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202488 Commission and WHO/Europe senior management in February 2024, which fostered strategic cooperation and reiterated the joint commitment to prioritizing a  joint health agenda, guided by the priorities of the organizations involved. Strategic cooperation between the European Commission and WHO/Europe spanned various critical health domains, including health security, digital health, workforce capacity-building, combating AMR, supporting mental health initiatives and advocating for improved resilience for health care systems. To coordinate legislative work, ensure a  smooth transition and set the strategic direction for EU policies, three consecutive presidencies of the European Council  – Spain (July–December 2023), Belgium (January–June 2024) and Hungary (July–December 2024) – agreed on a common trio programme. WEU has worked closely with all three presidencies to ensure effective health-related outcomes. The Regional Director was present at all informal employment, social policy, health and consumer affairs meetings that were organized during the EU Council presidencies and shared WHO/Europe’s perspective on key EU health-related priorities. The Regional Director, along with his team, also contributed to – or was involved in – more than 30 health-related events and conferences that were organized during the three presidencies. Under the Spanish presidency, progress was made in the development of the new EU Global Health Strategy. The WEU was successful in influencing this Strategy, with WHO holding a prominent place in it and the key priorities of the EU and WHO aligned. WHO’s vision and guidance were also incorporated into the EU Council Conclusions on Mental Health, which was approved during this presidency. Furthermore, WHO/Europe joined forces with the Spanish presidency and other partners to fight the stigma and discrimination associated with HIV by contributing to the High-Level Meeting on HIV and Human Rights: Political action to achieve zero stigma, and by developing technical guidance on the topic. WHO/Europe’s vision was presented by the Regional Director to the European Parliament on 1 December 2023, on the occasion of World AIDS Day. Under the Belgian presidency, the focus within health was on a Europe that cares, prepares and protects. At the High- level Conference on the Future EU Health Union, held in Brussels, Belgium, the Regional Director gave the keynote address on the health workforce crisis, calling on more bold and common actions to be taken at the European level in this area, including action on better planning, training, working conditions, professional development and ethical recruitment. Moreover, WHO/Europe joined efforts with the Belgium presidency to further advance the NCD agenda. At the meeting on Europe’s Beating Cancer Plan – Joining Forces, held in Brussels, Belgium, the Regional Director underlined WHO/Europe’s contribution to the implementation of the EU’s Cancer Plan since its launch in 2021. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 89 In full alignment with the presidency’s commitment to global health and health equity, the Belgium presidency organized the High-level event on the EU–African Union partnership in global health for equitable access: Towards African health sovereignty, held in Brussels, Belgium, in March 2024. The event was attended by the Regional Director, together with the Director-General and the regional directors of the African and Eastern Mediterranean regions. The Regional Director participated in the roundtable discussion on One Health in Antwerp, Belgium, and gave a keynote speech on the importance of global health in the context of the 2030 Agenda and the new EU legislative term for foreign affairs and development attachés and diplomats. The Hungarian Council presidency is committed to the idea of a comprehensive EU strategy on cardiovascular health and the launch of a new action plan on organ donation and transplantation. WHO/Europe provided technical expertise to the conferences held on both these issues. During the HighLevel Ministerial Conference on Cardiovascular Health held in Budapest, Hungary, in July 2024, the Regional Director called for more bold actions to be taken in combating industry interference in health policy and reducing NCD risk factors. During the High-Level Conference on Organ Donation and Transplantation, WHO/Europe advocated for this area to be enhanced by strengthening health systems, using integrated data systems, scaling up professional training, running public awareness campaigns, and also by inviting countries to invest more in health prevention, and research and innovation to help close the gap in the demand for organ transplantation. WEU has actively fostered robust engagement with the European Parliament, with WHO/Europe experts having contributed to numerous sessions of the European Parliament subcommittee on Public Health and other parliamentary events over the past year. WHO/Europe also contributed to two reports produced by the Public Health subcommittee in October 2023 on the topics of mental health and NCDs. WEU has also continued to play a  pivotal role in driving global health diplomacy through the Action  for Health Engagement, Advocacy and Diplomacy Initiative. With a view to shaping a common approach to global health diplomacy and strengthening the regional capacity in this regard, WEU launched the WHO Leadership Dialogue on Global Health Diplomacy course in 2023, which was an opportunity for participants (WHO representatives and representatives from 25 Member States) to deepen their knowledge and competencies in health diplomacy; to improve their ability to navigate an ever-complex geopolitical landscape; to experience an interactive sharing of best practices on the topic; and to build a solid network of stakeholders involved in global health, including those from EU institutions. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202490 Transforming for impact and more accountability to Member States Over the past year, WHO/Europe has continued to make progress in transforming its governance, communications, staff development, resource mobilization and Programme budget management to better serve the health needs of Member States. Participatory governance Participatory governance is the bedrock on which Member State confidence in WHO is based and is essential to: • strengthen trust with Member States • ensure transparency and accountability • benefit from countries’ rich experiences to guide WHO policies. This close engagement with Member States is vital, not only to ensure transparency and accountability, but also to benefit from countries’ expertise and experiences to guide and inform WHO policies both at the regional and global levels, which as demonstrated by the COVID-19 pandemic are fundamentally interconnected. As reported in the governance review adopted at RC73, concerted efforts over the past 4 years have led to significantly stronger Member State engagement in the Region’s work and increased communication with partners. Under the guidance of the SCRC subgroup on WHO/Europe’s governance, a participatory approach was used in the development of the governance review in which Member States were involved through interviews, briefings and other methods to shape the content of the report and its 16 recommendations. WHO/Europe is committed to implementing the outcomes of this review, ensuring meaningful governance indicators in this year’s accountability report and beyond, and continuing efforts to engage Member States in the Region through governing bodies to ensure a resilient, responsive WHO/Europe for the future. Since RC73, the SCRC has proceeded with a full programme of work and has been instrumental in working with the WHO/Europe Secretariat to shape the programme and agenda for RC74. The SCRC subgroup on WHO/Europe’s work at the country level and the SCRC subgroup on WHO/Europe’s governance have each met more than six times over the reporting period, either in-person or virtually. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 91 The SCRC subgroup on WHO/Europe’s governance has prioritized the implementation of the recommendations of the comprehensive governance review and has delivered governance enhancements. The priorities included: • developing key performance indicators to further improve the accountability and transparency of governance processes for inclusion in the annual WHO/Europe Accountability Report (recommendation 1); • strengthening the role and purpose of the SCRC by exploring further measures to increase the visibility of the SCRC (recommendations 2–5); and • further improving transparency in the pre-assessment and selection process for the Executive Board and the SCRC, including by refining the assessment criteria for candidate countries (recommendations 7–8). Communications WHO/Europe Communications Unit has continued to build on the progress of recent years, with the Regional Director championing communications as an essential enabling function to be optimally resourced. With communications formalized as a core function for the new biennium (2024–2025), WHO/Europe divisions and country offices were tasked with focusing strategically on communications staffing, converting temporary positions into fixed-term positions and funding communications positions from country offices’ budgets rather than relying on the Regional Office. Although this transition to entrench communications staffing remains a work in progress, the move augurs well for stronger communications skillsets overall at WHO/Europe. A key recruitment was a  new communications strategy post based at the WHO/Europe Enabling Hub in Istanbul, Türkiye, with a focus on central Asian country offices and partners. The appointment has already resulted in a coherent and coordinated central Asian communications strategy, complemented by significant communications capacity- building at the five central Asian country offices. This contributed to the communications success of the Central Asia International Health Investment Forum held in Bishkek, Kyrgyzstan, in June 2024. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202492 Leadership communication has remained a  key pillar of external communications, with a  focus on the Regional Director as spokesperson-in-chief. From September 2023 to June 2024, the Regional Director was mentioned in at least 7000  media pieces globally and via major news outlets/publications, including the BBC, CNN, Al Jazeera, Euronews, Financial Times, Politico, The Guardian and many more. Notably, one story on measles generated more than 3000 media hits between December 2023 and January 2024, and accounted for more than 40% of the Regional Director’s media coverage in the reporting period. Comprehensive media support during the Regional Director’s country missions ensures strategic visibility for WHO/Europe in key media markets, including for recent visits to Cyprus, Italy, Kyrgyzstan, Spain and Uzbekistan. Another such example of impactful communication activity occurred in the recent mpox emergency (see Box 3). To meet the many demands of journalists, the WHO/Europe Communications Unit is expanding its spokesperson lists to include directors and technical officers, where feasible. This has led to a diversification of voices emanating from WHO/Europe, and provides much needed flexibility while also strengthening WHO/Europe’s credibility as a source of high-quality subject-matter experts. WHO/Europe’s use of social media and multimedia channels were further strengthened in 2023–2024, with steady audience growth across all platforms, including on LinkedIn (launched in late 2022), which has proven to be a highly versatile channel. As of end-June 2024, WHO/Europe had 744 000 followers on Facebook; 294 000 on Instagram; 214 200 on X; 35 000 on LinkedIn; and 17 000 on YouTube. Industry surveys have revealed that most media users access news and information from digital channels and products. While WHO/Europe has sought to provide audiences with what they want, currently available resources need to be significantly strengthened and ramped up to enable the consistent production of even more compelling content across existing platforms, before new platforms are introduced (for example, TikTok). The ongoing Health in Europe podcast series has demonstrated how a well-packaged product, such as the special podcast collection on health emergencies – Not If, But When – can appeal to multiple audiences. Using this and other examples, the WHO/Europe Communications Unit is poised to craft a multimedia strategy for the Region to reach wider – and younger – audiences with customized products. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 93 In addition to external communications, WHO/Europe has renewed its focus on internal communications, spurred on by the results of the 2023 staff health and well-being survey that revealed an urgent need to address various concerns and perceptions. With the establishment of the comprehensive Respectful Workplace Programme in December 2023, a  key component of an internal communications strategy is taking shape to enable senior management to better support staff across WHO/Europe, and for staff in turn to help enhance a collegial work environment underpinned by stronger empathy and a high emotional quotient. With the Publications Unit falling under the communications umbrella, a priority has been to start streamlining the current workflow to ensure that the Publications Unit is brought on board earlier in the processes of publication strategizing, commissioning and drafting. This has helped WHO/Europe divisions and units to better prioritize and plan when conceptualizing a publication and has resulted in the Publications Unit contributing to dissemination planning for various products. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202494 In August 2024, WHO declared mpox as a PHEIC for the second time in two years, triggered by the escalating outbreak of Clade I mpox in east and central Africa. In 2022, a Clade II mpox outbreak – initially centred in the WHO European Region and primarily found among men who have sex with men – prompted the first mpox PHEIC declaration. On both occasions, WHO/Europe demonstrated leadership via public health messaging aimed at both regional stakeholders and the world at large, seeking to reiterate the steps Member States should take in responding to the situation. The Regional Director’s August 2024 media briefing, delivered virtually via the United Nations Office in Geneva, emphasized three messages: • mpox is not the “new COVID”, to correct disinformation being spread via social media channels; • WHO/Europe knows how to control mpox and to move towards total elimination in the European Region; and • the need for a coordinated response is greatest in the African Region, and this response should have equity and solidarity at its heart. WHO/Europe’s media briefing and subsequent messaging generated significant regional and global coverage, with over 3000 media hits within the first week alone. Sound public health advice, delivered swiftly, has the ability to reassure and direct an appropriate response. Box 3. Communications and mpox Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 95 © W H O /H al ld or ss on Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202496 Staff development and learning As WHO advances the EPW, staff development and lifelong and lifewide learning in the Region have become central to its strategic approach. This aligns with the regional plan for implementation of the WHO Programme budget 2024–2025, which aims to make WHO/Europe both fit-for-purpose and an employer of choice. Through its learning and development governance policy, and by focusing on upskilling and staff development, WHO/Europe is committed to empowering its workforce to excel in a dynamic global environment. Embracing the Kaizen philosophy of continuous improvement, together with other enabling tools, WHO/Europe is committed to fostering staff development through ongoing training and skill enhancement. During the reporting period, WHO/Europe has offered a range of training programmes tailored to the diverse needs of its staff. Over 500 staff members were equipped with the skills and knowledge needed to fulfil their roles and advance the Organization’s mission. Staff training programmes over the past year have included: • Leadership for Health Diplomacy Skills to enhance diplomatic and leadership skills, which are essential for achieving public health goals and managing international relations; • Pathways to Leadership for Health Transformation, in collaboration with the WHO Regional Office for Africa and the WHO Regional Office for the Eastern Mediterranean, to cultivate leaders who can drive health improvements and address evolving challenges through innovative and collaborative approaches; • project management skills, anti-fraud and anti-corruption training and administrative roundtable training to foster a collaborative approach to addressing challenges and enhancing efficiency within WHO/Europe’s administrative framework; • mindfulness-based mental agility training, conflict resolution training and communications training; and • running several sessions of the Regional Induction Programme to introduce new staff to WHO/Europe’s culture and operations, preparing them to contribute effectively from the outset. Resource mobilization Resource mobilization efforts have continued since RC73 with a focus on increasing the flexibility and predictability of voluntary contributions to WHO/Europe and tackling underfunded areas of work – the socalled pockets of poverty – at both regional and country levels. The total amount of voluntary contributions that were mobilized increased from US$  227  million to US$  641  million between 2018–2019 and 2022–2023 when contributions from all segments Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 97 were combined. Between September 2023 and the end of July 2024, US$ 155 million of voluntary contributions to WHO/Europe had been secured, which includes US$  69  million for the base segment and US$  86  million for the emergencies segment. The pipeline for the current biennium contains an additional US$  98  million of voluntary contributions (US$ 38 million for the base segment and US$ 60 million for the emergencies segment) with varying degrees of certainty. Most of these opportunities should materialize before RC74. During the reporting period, a  focus has been put on accelerating the shift of the resource mobilization function from a reactive mode to a more proactive one, supporting country offices and technical programmes in their efforts to mobilize resources, while ensuring strong collaboration and alignment with resource mobilization efforts at the global level. Since RC73, new funding partners have been secured, nevertheless, WHO/Europe continues to face a challenging funding situation with the majority of voluntary contributions still earmarked for specific areas of work and having limited geographical scope. The level of thematic flexible funds available for the base segment of the GPW 13 to WHO/Europe decreased from US$ 58.4 million (or 22% of all funding received for the Region) in 2020–2021, to US$ 52.5 million (or 17% of total funding) in 2022–2023, with the downward trend to US$ 24.0 million (9% of all funding) at this stage of the 2024–2025 biennium. Pockets of poverty continue to be the norm in areas such as preparedness, detection and response to health emergencies; access to medicines, vaccines, diagnostics and devices for PHC; health workforce and service delivery; and AMR. The limited availability of voluntary contributions to support enabling functions makes them totally dependent on core flexible funding (including assessed contributions and programme support costs), leaving very little flexible resources available to support technical work and work at the country level. In this context, WHO/Europe is actively contributing to the broader corporate efforts to improve the financial sustainability of WHO, such as the upcoming WHO Investment Round in November 2024. A  regional consultation was organized with the Region’s Member States in December 2023. The Central Asia International Health Investment Forum, held in Bishkek, Kyrgyzstan, in June 2024, was another important milestone in improving WHO/Europe’s financial sustainability. WHO/Europe has established an EU team based in the Resource Mobilization Unit with the aim of building the capacity of WHO/Europe to manage EU-funded projects, which represent an increasingly important source of funding for WHO/Europe at both the country and regional levels. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–202498 Programme budget management Programme budget management refers to the end-to-end process of coordinating corporate planning, implementation, monitoring and budgeting processes at the regional level. Programme budget management involves making recommendations to senior management on the allocation of budget and resources, providing key inputs to WHO headquarters and implementing relevant decisions to ensure the effective use of resources in the support of organizational goals. Between September  2023 and August  2024, several key achievements have been made regarding programme and resources management in the Region. The regional plan for implementation of the WHO Programme budget 2022–2023 was successfully concluded, marked by its robust implementation and high levels of funding, as detailed in the Programme budget 2022–2023 results report that will be presented at RC74. During 2022–2023, the unprecedented volume of emergency operations and appeals, with the inherent complexity in terms of planning, budget and resource management, were implemented with minimal impact on the management of the base programme, in full support of the regional dual-track approach. The Programme budget 2024–2025 was developed with engagement from Member States in the prioritization process. WHO/Europe’s internal programme management systems and capacity were strengthened with the establishment of the WHO European Programme Committee. Furthermore, the recruitment of programme management officers for country offices will lead to a regional network of programme management officers being established. These initiatives are set to bring uniformity to programme management and, thus, enhance technical coherence in the Region, greater effectiveness and efficiency in using available resources, and better monitoring and evaluation, as well as ensuring the quality of timely reporting to donors. For the Programme budget 2022–2023, with an approved base of US$ 360.7 million (30% higher than the Programme budget 2020–2021), more than US$ 291 million was implemented (a 75% implementation rate). WHO/Europe had the second highest implementing rate among major offices and was well above the average of 68%. While the implementation level in 2020–2021 was 5 percentage points higher, in absolute terms WHO/Europe implemented an additional US$  75  million in its base budget. WHO/Europe ended the biennium as the second highest funded Regional Office (80% funded), with more than US$ 83 million than at the end of the previous biennium. The emergency operations and appeals segment reached an unprecedented level in 2022–2023, with its budget at US$ 588.8 million (more than double the amount in the previous biennium), US$ 406.2 million mobilized and, as of December 2023, US$ 292.2 million had been implemented through the emergency operations and appeals segment alone. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 99 In the first quarter of the 2024–2025 biennium there have been three notable trends: • there is a marked increase in flexible corporate funds that have been allocated to the Region, with the largest proportion of these funds earmarked for the Core Predictable Country Presence, which has resulted in the creation of an additional 51 long-term positions in the country offices with long-term pledged corporate funding, but which is insufficient to close the pockets of poverty in technical areas; • the significant decrease of thematic flexible funds (as described above); and • the decreasing amount of funds for emergency appeals and operations because of a decreasing number of graded emergencies (for example, the COVID-19 pandemic, mpox and the earthquake in Türkiye). To address these intertwined issues effectively will require not only strategic discussions but a genuine commitment to collaboration and joint accountability. The stakes have never been higher; success hinges on the willingness of all parties to come together, responsibly share their perspectives and forge innovative solutions that transcend borders. Looking to the future, this is a call to action for Member States and the Secretariat to unite efforts, navigate the complexities of the current landscape, work collectively towards a sustainable and equitable future, while being jointly accountable. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024100 Financial, human, administrative resources managed in an efficient, effective, results-oriented and transparent manner Business operations have shown resilience and adherence to a dual-track approach, by laying the foundations of the WHO/Europe Enabling Hub in Istanbul, Türkiye, which is an extension of the main office in Copenhagen, Denmark, and by supporting unprecedented levels of programme implementation. The shift in the operations model is a result of the growth in demand from the country offices as displayed by: 1) procurement values reaching US$ 177 million during 2023, compared with US$ 55 million in 2019; and 2) a workforce of 996 staff members driving the implementation of WHO’s mandate, compared with 643 staff members in 2019, with a majority of staff now serving in country offices. To accompany these shifts, an enhanced delegation of authority, in synergy with WHO headquarters, has been implemented, requiring considerable capacity-building of, and increased support to, country offices. Finance and accountability To ensure continuous improvement, and effective internal control and compliance, WHO/Europe has established a dedicated team for transactional assurance in the Finance Unit, within the Division of Business Operations. This team supports capacity-building in WHO country offices, through analysis, review of financial transactions and ensuring compliance with financial rules and regulations. For financial support provided to countries through grants to strengthen health development capacities, mainly in Ukraine and neighbouring refugee-hosting countries, one of the main audit recommendations for the Organization is to ensure that financial assurance is performed for these grants through audits and spot checks by implementing partners. This recommendation has been given the utmost priority by WHO/Europe, which has performed a number of successful assurance activities for projects, ensuring the use of funds for the required purposes, ensuring best value for money and maintaining donor trust in WHO. There has been a considerable increase in European Commission verifications for various projects and the results are positive, ensuring WHO/Europe’s accountability and credibility as a custodian of European Commission funding. From the 32 recommendations given by external auditors in 2022, three remain open and action is being taken to close them by the end of 2024. Following the successful audit of the WHO Country Office in Ukraine, all the recommendations have been implemented and accepted by the Office of Internal Oversight Service. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 101 Digital transformation To enhance productivity and drive efficiency, a digital transformation has been pursued through a charter on digital and technology governance and associated strategies. Successful migration from the on-premises infrastructure to the Cloud in December 2023 marked a  significant achievement in enhancing WHO/Europe’s operational capabilities and flexibility. This strategic shift improved resilience, disaster recovery and data security measures. Transitioning to a  Cloud-based infrastructure has reduced physical data centre costs, has allowed resources to be scaled dynamically in response to needs, and has fostered a more collaborative and agile working environment. This move has positioned WHO/Europe to better leverage advanced technologies, such as artificial intelligence and big data analytics, enhancing WHO/Europe’s capacity to respond to emerging challenges and opportunities. A strategy to enhance the digital capacities of country offices involved targeted support missions to strengthen connectivity and standardize information technology services to enhance operations and ensure consistent service delivery across the global network. During this period, information and communication technology missions were conducted in Armenia, Azerbaijan, Georgia, Romania among others. A comprehensive review of the digital health applications portfolio was conducted for all digital applications in use in WHO/Europe. This review identified key areas for integration and modernization, leading to a streamlined portfolio that aligns with WHO/Europe’s strategic health objectives and enhances overall operational efficiency. This initiative also paves the way for prioritizing upgrades and phasing out redundant systems, ensuring that WHO/Europe’s digital tools are more effective and fully supportive of its public health mission. The strategic incorporation of artificial intelligence and machine learning at WHO/Europe to enhance decision-making accuracy, streamline processes and boost operational efficiencies involves four elements, namely to: 1. strengthen artificial intelligence capabilities by creating a  new position for an artificial intelligence software engineer and creating a dedicated artificial intelligence team; 2. set up an artificial intelligence developers’ group, which is a specialized team under the Digital and Technology Steering Committee and which is tasked with spearheading artificial intelligence initiatives and fostering technological innovation across WHO/Europe; Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024102 3. deliver the first artificial intelligence/machine learning prototypes, from the successful deployment of large language models and the developed artificial intelligence prototype applications, which are designed to further integrate artificial intelligence into WHO/Europe operations, enhancing data analysis capabilities; and 4. promote understanding and education in WHO/Europe on using artificial intelligence-driven tools, setting the stage for broader adoption and integration into WHO/Europe’s business operations processes. The development of the 2024–2025 cybersecurity roadmap for WHO/Europe began in 2023 with a thorough assessment of WHO/Europe’s cybersecurity status, identifying areas of strength and opportunities for improvement. The roadmap strategically focuses on four critical domains: governance, prevention, detection and response and recovery. This plan outlines key initiatives and actions designed to enhance WHO/Europe’s cybersecurity position, ensure robust prevention measures, enable quick detection of threats and facilitate rapid recovery from security incidents. WHO/Europe Enabling Hub The WHO/Europe Enabling Hub in Istanbul, Türkiye, was established to expand the Region’s operational capacities and bring services closer to the eastern part of the Region, where many of the needs and workforce are located. The move, for all areas of business operations, away from the central and transaction-focused work environment in the main office in Copenhagen, Denmark, to the Hub has strengthened the professionalization of these services. Through a structured, values-based and consultative process in place since 2021 and led by the Regional Director in consultation with Member States, internal stakeholders and staff members, the Hub welcomed its first staff members in June 2023. Staff have been recruited with a clear mandate and direction to focus on efficiency, advance new ways of working and reduce the burden for country offices and for regional implementation efforts. In mid-2024, the Hub reached the milestone of welcoming its fiftieth team member and is growing into a diverse, dynamic, skilled and agile team of new and long-serving WHO staff members. The Hub offers new and enhanced services to WHO country offices throughout the Region and has expanded capacity in key areas to support technical health work. It has broadened WHO/Europe’s base of professionals who support risk mitigation and risk management in the areas of finance, security, legal advice and prevention of workforce misconduct. In attracting candidates and building a core team, attention was given to creating a pool of talented professionals, strengthened by their diverse nationalities – now from more than 25 countries – while maintaining a gender balance. To accompany the reshaping of the structure of the units in the main office in Copenhagen and the jobs that were affected, resources were directed to individual career management, relocation support and advocating a  “leave no Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 103 staff behind” approach, aiming for positive outcomes, in line with the duty of care and adherence to WHO Staff Rules. The job openings in Istanbul offer career progression opportunities for high-performing administrative staff, and talent was acquired from the United Nations common system, other international organizations and public/private sector employers. The Hub is supported by experienced WHO staff and managers who ensure quality monitoring and reinforce the culture of continuous improvement, seeking efficiencies and optimizing best practices. Expanding the number of functions being carried out in Istanbul has allowed a  redistribution and alleviation of the workload for the relevant enabling areas and is one of the effective means to address staff burnout and staff absences on leave. Discussions with the Government of Türkiye to host the Hub and other multilateral agencies in a United Nations City are ongoing. WHO/Europe has taken a leadership role in coordinating the United Nations common system to ensure space and financial sustainability in the longer term. Despite being in the early stages, the first year of operations at the Hub has been a success, not in the least due to improvements initiated in business operations. This significant accomplishment for WHO/Europe contributes considerably to the global corporate efficiency agenda. Procurement In 2023, emergency procurements reached 60% of the volume of transactions, totalling US$ 105.5 million. This is more than a twofold increase compared with the 2021 total of US$ 42.1 million, due to multiple unprecedented emergencies. Continuing the trend of prioritizing goods over services in emergency scenarios, 48% of the procurements in 2023 were for goods. Emergency situations necessitated buying non-standard items, such as shelters and prefabricated buildings for public health needs and paying for medical evacuations and repatriation of Ukrainian patients. To aid country offices impacted by emergencies, additional resources were secured at both the country and regional levels. A new long-term agreement has been established to enhance the quality assurance process for medical devices. Human resources and talent The dual-track approach was an important theme for human resource services in 2023. Alongside the requirement to continue expanding staff numbers to meet project demands, WHO/Europe began the process of strengthening the country offices for sustainable delivery of quality services. The focus on the Core Predictable Country Presence was initiated by prioritizing the advertisement of over half of the planned positions during the first quarter of 2024. The operationalization of the Delegation of Authority to WHO representatives enabled more effective delivery of Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024104 interventions at the country level. This was complemented by direct provision of human resource advisory interventions during country office visits to Armenia, Azerbaijan, Bulgaria, Republic of Moldova and Romania, and strategic reviews in Kyrgyzstan and Uzbekistan. Organizational effectiveness was facilitated by the timely and qualitative acquisition of talent, together with employer brand visibility, which was increased through outreach activities, job fairs and targeted postings on LinkedIn. Prevention of and response to sexual misconduct Over the past three years, guidance from Member States has led WHO/Europe to make significant progress in preventing and responding to sexual misconduct in the workplace and in the communities served. Member States have expressed their low risk-tolerance level for sexual misconduct and expect WHO/Europe to maintain the momentum and extend this commitment to our partners, as emphasized by the Regional Committee at RC73. The goal is to ensure that WHO/Europe’s partners who have direct contact with communities uphold the same standards in the prevention of and response to sexual misconduct. The support from Member States has allowed WHO/Europe to build capacity, hire human resources, prevent and respond early to risk, and enable incident reporting, with work being intensified by the implementation of the WHO Management Response Plan 2021–2022 and Preventing and responding to sexual misconduct: WHO’s threeyear strategy 2023–2025, with a commitment to cover all offices and divisions. Within WHO/Europe, two major advancements have been made in the risk management approach to the prevention of and response to sexual misconduct. First, improved information flow from junior- to senior-level staff (and vice versa) and across teams and divisions, has ensured that leaders can make informed decisions and respond early to emerging risks. The second is that all WHO country offices and liaison offices have completed annual sexual misconduct risk assessments, and the results have been analysed and discussed with leadership, WHO representatives and the focal points for the prevention of and response to sexual misconduct. Furthermore, the improved governance arrangements allow for effective oversight and robust decision-making, supported by the 43 focal points. Towards a healthy and respectful work environment During these demanding times, the pursuit of cohesion and collaboration would be impossible without a culture of respect and a working climate within WHO/Europe that values the mental well-being of its staff. Senior management continue to facilitate organizational surveys, coordinate initiatives and direct resources to help ensure a  robust environment of psychological safety for all staff, which enhances performance, innovation and impact. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 105 One of the priorities of the Regional Director is addressing the concerning rate of psychological risks in parts of the WHO/Europe workforce, as emphasized in the EPW’s regional implementation plan. Prevention of burnout among the workforce is a priority for staff health and well-being. The launch of the Respectful Workplace Programme by the Regional Director in December 2023, saw a turning point in ensuring safe working environments for all staff with the appointment of a full-time coordinator, in March 2024, to ensure full engagement, alignment and participation across the Region and with the task of developing an action plan through a participatory approach. To ensure coordinated action, a  Respectful Workplace Advisory Committee was created in which various stakeholders in WHO/Europe participate to support a  respectful workplace. The Respectful Workplace coordinator chairs this Committee, which include representation from the Staff Association, Staff Physician, Human Resources, Ombudsperson, Staff Development and Learning, Internal Communications, and focal points from ethics; diversity, equity and inclusion; and prevention and response to sexual misconduct. The Committee has engaged with the senior leadership team, managers and teams to facilitate discussions using evidence taken from the data analysis of workplace assessments, and which are focused on impact. Between November 2023 and January 2024, the survey, Towards a Healthy and Respectful Work Environment, was conducted for the third consecutive year. Workforce trust in this approach has been demonstrated by increased workforce participation in these respectful workplace surveys, from 38% in 2021 and 2022 to 67% in 2023. In addition to interventions at the team level, a series of direct confidential channels of communication with senior managers, led by the Regional Director, has allowed signals to be received on psychosocial risks and the rapid monitoring of improvement in the work environment. In collaboration with WHO headquarters staff physicians, individual support and consultations for physical and mental health of the workforce in the Region continues to be provided, including in emergency contexts. Risk factors related to the workload, its distribution, and the lack of work–life balance remain the most prominent causes of stress requiring organization-level interventions. The proportion of respondents (almost 30%) reporting burnout symptoms was the same as last year. Respondents indicated that a sense of community, the meaning of the work, role clarity, support from colleagues and support from the Unit head are the most positive aspects of their working lives. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024106 Results of the annual staff health and well-being survey were discussed by staff in two townhalls and across teams in all offices between March and July 2024. Teams larger than six people, and who had a response rate of more than 60% to the survey, received their own analysis, and all teams held team discussions, developed plans to improve their own work environments, and identified actions to be addressed at the organizational level. Team discussions were supported by the Respectful Workplace coordinator, the Staff Counsellor and a  team of coaches who were made available to support managers. The activities and recommendations from these discussions were collated by the Respectful Workplace Programme and were presented at the June townhall and posted on the WHO/Europe Intranet for consultation. This resulted in the Respectful Workplace Strategic Action Plan, a guiding document which aims to: • prevent and minimize psychosocial risks among staff; • promote a healthy working environment where staff thrive; and • protect and support individuals exposed to burnout or work environment conflicts, or who are feeling psychologically unsafe. The Respectful Workplace Strategic Action Plan includes a list of risk indicator factors that may impact on burnout and which can be monitored by every team to allow corrective measures to be adopted. A monitoring and accountability framework is used to follow up on the implementation of the Action Plan, which is regularly monitored by the Executive Council and team leads to build on progress and identify gaps. WHO/Europe continues to convene regular townhall meetings where issues of relevance and interest to staff are discussed, and the anonymous “Ask Hans” mailbox ensures that any member of the WHO/Europe workforce can contact the Regional Director directly on any matter of concern. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 107 © W H O Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024108 WHO/Europe unites regional partners, supports health leadership in Member States and works with partners on core health priorities and sharing country learning. Its membership of the European Observatory on Health Systems and Policies and its hosting of the Observatory partnership helps it to deliver on these goals. The Observatory generates evidence for policy and has contributed to WHO/Europe’s technical and country work over the last year in a variety of ways, including: • giving rapid responses to pressing country questions by assimilating evidence on issues such as health systems access for young people experiencing vulnerability (Switzerland), delayed discharges (England, United Kingdom), or the sustainability of the home health system (Ireland); • unpacking evidence to make it accessible through the Observatory webinar series which, once a  week, explains topics ranging from health security, hospital reform or public health to valuebased health care, with countries such as Slovenia and Spain sharing their experiences; • supporting Member States holding the presidency of the Council of the EU, including Belgium’s presidency in which the Observatory’s journal Eurohealth offered a platform for the Belgian theme (the EU Health Union) and evidence on prioritizing AMR; • making conceptual thinking practical by, for example, turning the global Health System Performance Assessment framework into a tool for tracing progress towards UHC or using the study on health for all policies to map out the tangible co-benefits of intersectoral action; and • signposting the link between evidence and action, exemplified by a study on the care dividend that looks at why and how countries should invest in long-term care, or the policy brief on governance and working with the private sector in the light of the lessons of COVID-19. Box 4. European Observatory on Health Systems and Policies Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 109 The Observatory is also closely aligned with WHO/Europe’s approach to partnership. It has supported a number of activities in this regard including: • co-working across technical divisions, by, for example, supporting the Division of Country Health Policies and Systems with the Tallinn Charter 15th Anniversary High-level Conference, held in December 2023, with the production of five policy briefs on trust and transformation and jointly updating the Health Systems in Action Insights series; • collaborating with WHO headquarters, including on: Ì the Primer on implementing PHC, produced with the WHO Special Programme on Primary Health Care and the WHO European Centre for Primary Health Care in Almaty, Kazakhstan; Ì the Eurohealth Special Issue; and Ì the side event on social participation for the Seventy-seventh World Health Assembly; and • cooperating with the European Commission, including on: Ì the State of Health in the EU Country Profiles 2023 with the Directorate-General for Health and Food Safety and the OECD; Ì a series of public consultations on the future health priorities of the EU; and Ì through work with Directorate-General for Health and Food Safety and the OECD on strengthening health systems, which produced a practical handbook for resilience testing. • At the end of 2023, WHO/Europe and the other Observatory partners (11 Member States, six leading regional/ national institutions and the European Commission) agreed to extend the partnership for 2024–2028. Box 4. contd. © W H O /H al ld or ss on Past forward: learning from yesterday to power tomorrow Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024112 This final chapter reflects on the past 4.5 years – since the beginning of the EPW – summarized in five key achievements (Box 5), and looks ahead to the future. As we continue our journey towards strengthening health systems and achieving UHC, PHC remains our cornerstone. Innovation should play a critical role, with a focus on four priority areas – national health security; NCDs and mental health; the climate crisis; health longevity – alongside a dedicated emphasis on addressing sexual violence and gender issues. © W H O /U ka B or re ga ar d Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 113 The principle of leaving no one behind has guided the dedicated WHO/Europe team over the past 4.5 years, transforming challenges into opportunities and leading to many key achievements. Five foundational accomplishments that will enhance WHO/Europe’s efforts moving forward are presented below. 1. Balanced response: WHO/Europe efficiently addressed health crises while maintaining focus on ongoing public health priorities. This dual-track approach has been crucial in building a resilient Region capable of managing unexpected challenges. 2. Close engagement: WHO/Europe’s commitment to maintaining close contact with Member States and partners across the Region has been essential. Understanding and responding to each country’s unique needs has strengthened WHO/Europe’s leadership and effectiveness. 3. Improved working conditions: WHO/Europe has tirelessly worked to enhance our staff’s working conditions, while adhering to strict financial management, as evidenced by the clean balance sheets from the last two biennium. 4. Participatory governance: over the past four years, WHO/Europe has strengthened participatory governance through transparent interactions between the governing bodies and the WHO/Europe Secretariat, ensuring that each entity effectively fulfils its role. 5. Organizational unity: by fostering harmonious collaboration at all levels and aligning with Member States’ aspirations, WHO/Europe has contributed to a cohesive One Health policy while respecting our regional specificities. These achievements lay a solid foundation for the future, guiding our actions and commitments as WHO/Europe navigates challenges and seizes opportunities to better serve our communities. Box 5. Learning from yesterday … Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024114 … to power tomorrow Building on these achievements, WHO/Europe can guide the Region’s future efforts and strategies with a continuous commitment to learning and improving, powering a better tomorrow. This strategy emphasizes a balance between continuity and innovation. The selection of themes for continuation and innovation will be determined through inclusive consultations with Member States. Four priority areas have thus far emerged based on ongoing interactions: 1. National health security: a steadfast commitment exists to alleviate the suffering caused by conflict in the Region. Regular visits to Ukraine will continue, with support for the Ministry of Health, including in frontline efforts. WHO/Europe will maintain its leadership role in the health cluster, operationalizing the humanitarian– development–peace nexus in Ukraine. In the occupied Palestinian territory, the focus will remain on advocating for an immediate and permanent ceasefire, the release of all hostages, and unrestricted humanitarian assistance. WHO/Europe will position itself as a key partner in the reconstruction of health facilities in both the occupied Palestinian territory and Ukraine. 2. Pandemic prevention and preparedness will remain central: Support will be provided to Member States in contributing to the Pandemic Treaty, harmonizing surveillance, improving alert systems and ensuring no country is left behind. Strengthening links with the African Region is also a priority, with a focus on addressing threats, such as AMR, multidrug-resistant TB and HIV. The approach to AMR will include reducing its burden, promoting a One Health approach and introducing an AMR accountability index. A multi-disease elimination initiative will be launched with one of its aims being to make the European Region the first malaria-free Region. 3. NCDs and mental health: the dual-track approach will continue: RACE to the Finish and Vision 2050. For mental health, efforts will be accelerated in 42 countries, building on the progress of the PanEuropean Mental Health Coalition. This will include practical tools for better financing, advocacy and integration of mental health into all national policies. 4. Climate crisis: the climate crisis must be recognized as a  health crisis. Last year, extreme heat caused 60 000 deaths in the Region. The Budapest Declaration set ambitious commitments to address climate change, air pollution and biodiversity loss. Climate change should be a key pillar of the next programme of work for the Region, with the launch of a Pan-European Commission on Climate Change and Health to enhance adaptation and resilience efforts across the Region. 5. Healthy longevity: with the demographic shifts in the Region, there is a  need for an approach centred on prevention, health literacy and healthy ageing throughout life. A strategy for healthy longevity and a regional child and adolescent health strategy should be developed. A Global Exhibition to be held in 2026 will showcase assistive technologies for healthy ageing. Report of the Regional Director  The work of the WHO Regional Office for Europe in 2023–2024 115 Addressing the health consequences of sexual violence and gender inequality is also a key focus, particularly against women and young girls. Gender-based violence is a significant human rights violation and public health issue. Efforts should be directed towards addressing this challenge and the broader issue of gender inequality, ensuring access to sexual and reproductive health services. PHC connects all these ambitious agendas. With high public trust in PHC providers, the strategy will continue to centre PHC, helping countries develop strong, tailored business cases for PHC investment. Equity will be the foundation of all efforts, ensuring that no one is left behind. To navigate the complex landscape of challenges, WHO/Europe’s modus operandi, built on strong political leadership, continuous engagement with Member States, and a  commitment to transparency and participatory governance, must continue. This approach, which includes Member State-specific and subregional interactions, ensures tailored responses and capacity-building through initiatives such as the ELA. The Respectful Workplace Programme and rigorous management of resources also continue to support staff well-being and alignment with organizational goals. This agile and collaborative framework remains crucial for driving progress and addressing key thematic areas effectively. The past few years have provided WHO/Europe with valuable lessons. While it is essential to continue building on these insights, it is equally important to remain prepared for new challenges by maintaining a dual-track approach. Moving forward, WHO/Europe will ensure continuity, while innovating, to remain responsive and resilient in the face of future uncertainties.

6 Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands (Kingdom of the) North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Türkiye Turkmenistan Ukraine United Kingdom Uzbekistan 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: eurocontact@who.int Website: www.who.int/europe 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.