Health in the well-being economy: background paper: working together to achieve healthy, fairer, prosperous societies across the WHO European Region

Health in the well-being economy Background paper: working together to achieve healthy, fairer, prosperous societies across the WHO European Region

Health in the well-being economy Background paper: working together to achieve healthy, fairer, prosperous societies across the WHO European Region Document number: WHO/EURO:2023-7144-46910-68439 © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/ by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Abstract This is the main evidence synthesis paper for the WHO European Regional High-level Forum on health in the well-being economy. It sets out why we need to shift to well-being economies and the role that can be played by many different stakeholders, as well as outlining several examples already being implemented. Keywords SOCIAL DETERMINANTS OF HEALTH ECONOMIC DEVELOPMENT HEALTH INEQUITIES ENVIRONMENT QUALITY OF LIFE The WHO European Well-being Economy Initiative is led by the WHO European Office for Investment for Health and Development of the WHO Regional Office for Europe, based in Venice, Italy. Contents iii Contents List of tables, figures and boxes iv Tables iv Figures iv Boxes iv Abbreviations v Acknowledgments vi Executive summary vii 1. On the road to well-being economies in the WHO European Region 14 1.1 Pressing challenges threaten health and social cohesion 14 1.2 Why is well-being a priority for decision-makers? 17 1.3 What is a well-being economy? 19 1.4 The emerging global movement towards well-being economies 21 2. The health sector and a healthy population as a driver of well-being economies 24 2.1 The health sector as a well-being economy sector 24 2.2 The role of health care in improving human, social, planetary and economic well-being 25 2.3 Well-being economies invest in health 27 3. Health as a co-creator and partner in producing well-being capitals 28 4. Better health and health equity as an outcome: putting well-being economies into practice 30 4.1 Countries 30 4.2 Private and social economy sectors 32 4.3 International and intergovernmental organizations 33 4.4 NGOs 34 5. Health and well-being as a measure of social progress 35 6. Illustrative examples 36 6.1 Protecting investment in well-being during the cost-of-living increases 36 6.2 Mental health and the inclusion of young people 37 7. Outcomes from the Regional High-level Forum 39 8. References 40 HealtH in tHe Well-being eConomy iv Table 1 Stakeholders and potential actions Fig. 1.1 Underlying causes of pressing challenges for the WHO European Region Fig. 1.2 Well-being capitals with examples in each domain Fig. 1.3 Action areas for creating the conditions for dignity, to thrive and to contribute to society Fig. 1.4 Interconnections between health and well-being economies Fig. 1.5 Timeline of key commitments, commissions and declarations relevant to well-being economies and investment for health box 1.1 The importance of the well-being capitals: human, social, planetary and economic well-being box 1.2 Well-being economy key terms and concepts box 1.3 Examples of policy directives and political actions box 2.1 Examples of how health care is contributing to well-being economies box 2.2 Benefits of investing in health and risks of inaction box 3.1 Health sector as co-creator and partner in producing well-being capitals box 4.1 Illustrative examples of approaches to delivering well-being capitals in the shift towards well-being economies box 4.2 Examples of approaches to shaping markets box 4.3 Example activities and initiatives by international and inter-governmental organizations box 4.4 Examples of NGO activities aiming to develop the well-being economy approach box 5.1 Examples of well-being measurement frameworks box 6.1 Examples of approaches to tackling the cost-of-living increases box 6.2 Examples of approaches to tackling mental health and inclusion issues across Europe Tables Figures Boxes List of tables, figures and boxes abbreviations v ACE adverse childhood experience ADB Asian Development Bank CMHA City Mental Health Alliance COVID-19 coronavirus disease 2019 DEAL Doughnut Economics Action Lab EIGE European Institute for Gender Equality ESG environmental, social and governance EU European Union EPW European Programme of Work, 2020–2025 – “United Action for Better Health” ESCAP United Nations Economic and Social Commission for Asia and the Pacific FAO Food and Agriculture Organization GDP gross domestic product HESRi WHO Health Equity Status Report initiative IBRD International Bank of Reconstruction and Development IHE Institute of Health Equity ILO International Labour Organization IMF International Monetary Fund NGO nongovernmental organization OECD Organisation for Economic Co-operation and Development OOP out-of-pocket SCI Small Countries Initiative SDC Swiss Agency for Development and Cooperation SDG Sustainable Development Goal UHC universal health coverage UNDP United Nations Development Programme UNWTO United Nations World Tourism Organization WEAll Wellbeing Economy Alliance WEGo Wellbeing Economy Governments partnership WHO World Health Organization Abbreviations HealtH in tHe Well-being eConomy vi This report was developed under the overall strategic guidance of Natasha Azzopardi-Muscat (WHO Regional Office for Europe), and the technical leadership of Chris Brown (WHO European Office for Investment for Health and Development). The main contributors were Yannish Naik, Amanda Shriwise, Tahnee Ooms, Anna Stielke, Jasmina Cunmulaj (WHO European Office for Investment for Health and Development), Govin Permanand and Gabriele Pastorino (WHO Regional Office for Europe), and Emma Wright (University of Liverpool). WHO Regional Office for Europe is grateful to the following experts for their guidance and comments in the drafting of the paper: Benjamin Barr (University of Liverpool), Mark Bellis (Public Health Wales and Liverpool John Moores Univesity), Luigi Bertinato (Italian National Institute of Health), Tatjana Buzeti (Ministry of Agriculture, Forestry and Food, Slovenia), Francois Cohen (University of Barcelona), Jon Cylus (WHO Barcelona Office for Health Systems Financing and European Observatory on Health Systems and Policies), Antoni Dedeu (WHO European Centre for Primary Health Care), Carrie Exton (Organisation for Economic Co-operation and Development), Mojca Gabrijelčič (National Institute of Public Health, Slovenia), Tural Gulu (WHO Country Office, Azerbaijan), Heli Hatonen (Ministry of Social Affairs and Health, Finland), Heikki Hiilamo (University of Helsinki), Timotej Jagrič (University of Maribor), Martin McKee (London School of Hygiene and Tropical Medicine), Bettina Maria Menne (WHO European Office for Investment for Health and Development), Sinaia Netanyahu (WHO European Centre for Environment and Health), Cathal O’Donoghue (National University of Ireland), Aaron Reeves (University of Oxford), Jolanta Reingarde (European Institute for Gender Equality), Marc Suhrcke (University of York), Dina von Heimburg (Norwegian University of Science and Technology), and Isabel Yordi Aguirre (WHO European Office for Investment for Health and Development). The WHO Regional Office for Europe is grateful to the following members of the Country Advisory Group for their guidance and feedback in drafting the paper: Tit Albreht (National Institute of Public Health, Slovenia), Tracey Cooper (Public Health Wales), Dóra Guðrún Guðmundsdóttir (Directorate of Health, Iceland), Taru Koivisto (Ministry of Social Affairs and Health, Finland), Marija Palibrk (Ministry of Health, Montenegro), Mojca Presečnik (Institute of Public Health, Slovenia), Robert Velickovski (Ministry of Health, North Macedonia), and Ed Wilson (Welsh Government). Acknowledgments exeCutive summary vii A growing list of challenges, including cost-of-living increases, conflict and climate change are all damaging trust in institutions and social cohesion, and placing health and welfare systems under strain. These are exacerbating existing pressures, such as an ageing population, insufficient numbers of health workers and unmet health needs. Data show a drop in life expectancy, worsening mental health, decreasing trust in institutions, environmental issues and widening inequalities. These challenges have led to significant thinking, know-how and experience around how to respond to these crises while future-proofing societies and policies in ways that build resilience and enable us to thrive and prosper fairly. New and deepening health inequities reflect avoidable fractures within society, threatening cohesion and trust. It will not be possible to achieve healthy, safe and resilient societies and economies with so many being left behind. Equity and inclusion are critical to fair and stable recovery. There is a growing interest in and recognition of the necessity of economic models that focus on fiscal resilience that is fair, and which unlock investments and policies to deliver healthier, fairer societies for the next generation. In this context, human, social, planetary and economic well-being have emerged as key cross-cutting policy priorities. These can be considered the “well-being capitals” – important assets such as trust, social cohesion, participation, our environment, equity and people’s well-being – that are all crucial for developing healthy, fairer and prosperous societies where people can thrive. There are also mutually reinforcing linkages between these dimensions. The focus on well-being as a driver of policy and development both nationally and locally has emerged more strongly since the 2008 financial crisis and in growing recognition that this is vital to secure sustainable health and welfare services. The well-being economy agenda has at its heart the idea of reshaping the economy to secure equitable well-being for people and planet, with underpinning goals of equity, inclusion and sustainability through: • using public and private investment, spending and resources to improve human, social, planetary and economic well-being in a way that is fair and equitable; • recognizing that investing in well-being delivers co-benefits across sectors, and therefore optimizing co-benefits from any decision or investment while minimizing any negative impacts; • delivering public health goods and policies that create the conditions for healthy lives for all and enable people to thrive, such as accessible and high-quality health services, and secure and affordable housing; • recognizing that the solutions for producing well-being lie with different sectors of government and society and therefore engaging a broad range of stakeholders, including the population, as part of implementing the solutions through dialogue. Executive summary HealtH in tHe Well-being eConomy viii A movement of governments, businesses, international institutions and civil society actors across the WHO European Region are aiming to develop well-being economies. Many international organizations have initiatives that can support the well-being economy approach, such as the European Union (EU), World Bank, Organisation for Economic Cooperation and Development (OECD), and other international development institutions. Healthier societies and well-being economies are interconnected agendas. Health status is a crucial determinant of well-being and health systems are a key economic sector. Universal health coverage (UHC) – “all people having access to the full range of quality health services they need, when and where they need them, without financial hardship” (the widely accepted WHO definition) – plays a key role in healthy, fairer and prosperous societies. The health sector is uniquely placed to contribute to well-being economies and is already doing so. This includes, for example, the conscious use of health care employment and procurement to optimize well-being benefits, and transforming health care to promote the four well-being capitals, for example by contributing to delivering environmentally sustainable health services and/or community development. Health services can also address wider social and economic population needs through integration with other services and can limit the use of out-of-pocket (OOP) payments, while also ensuring those most at risk of financial hardship are exempt from these. Investing in health is a vital, with positive returns to societies and economies. The health sector is also a key partner in tackling wider challenges that cannot be solved by any sector alone, such as implementing the One Health approach, or the inclusion of young people and their mental health. Well-being economies are particularly significant for health given the crucial importance of the economic determinants of health. Countries can implement legislation, determine their spending priorities through the national budget, develop new models of governance and implement policies to deliver well-being economies. Fair taxation can be used to increase the available fiscal space, and there are many tools to optimize the use of this fiscal space, such as well-being budgeting and gender budgeting. Innovative instruments can also be used, for example to link social and environmental outcomes with government debt. While countries may face constraints on their ability to identify new resources, they may also redirect existing resources or review how existing services contribute to promoting the well-being capitals. Central banks can also play a role, for example through assessing health risks to the economy and using levers such as monetary policy to improve well-being. As market-driven economic models can lead to negative impacts on people and environments, there is a need to promote private sector activities that improve health while reducing those that negatively affect health. Markets can be shaped through regulation, legislation, incentives and disincentives. This includes the development of investor frameworks that consider health. International and intergovernmental organizations play key roles in supporting national policy- and decision-making; they also direct international funding. More will be required to secure countries’ ability to invest in well-being and there have been calls to change the global financial architecture. Many nongovernmental organizations (NGOs) continue to play an active role in developing the well-being economy approach, including through developing innovative policy proposals, sharing evidence and connecting people and organizations. exeCutive summary ix Going beyond gross domestic product (GDP) to measure the well-being capitals along with public health goods and services (including health services) will be vital in supporting policy-making and investment to promote these well-being capitals. It is important to measure inequalities as well as population averages. Developing comparable metrics and integrating them with decision-making will be critical to their uptake and use in decision-making. This background paper provides a range of examples and prompts to invite delegates to engage in dialogue at the Regional High-level Forum on health in the well-being economy, to be held in Copenhagen, Denmark, 1–3 March 2023. It outlines what a well-being economy is and why a well-being economy approach is needed, now. It provides some preliminary framing of the role to be played by the health sector in supporting well-being economies. It also considers how health can be improved and health inequalities reduced through a wider well-being economy approach. The paper includes evidence and case studies, supporting exchange between countries and experts, and collaboration with other international institutions. The Regional High-level Forum is a way to demonstrate WHO Regional Office for Europe’s leading role in this endeavour, and to answer a need from the countries involved – both big and small – for concrete steps forward. Based on the evidence in the paper and the expert consultation that informed it, Table 1 summarizes some of the steps that stakeholders can take in promoting action towards well-being economies. HealtH in tHe Well-being eConomy x Stakeholders Potential actions SEE SECTIONS Ministry of Health and health sector senior managers Drive well-being through employment and training, by: • investing in the well-being of the workforce and healthy working conditions, including minimum wages, health insurance and pensions for health workers; • employing locally and from underrepresented groups, contributing to income security and human capital development; • addressing inequities in employment (such as the gender pay gap), as well as wider equality and well-being issues among staff, supporting staff progression; • preparing the health workforce for dealing with current and future challenges, for example in preparing them to use a One Health approach and addressing climate change; • ensure sufficient health care staff are trained and recruited to meet current and future demands. Drive well-being through procurement practices, such as: • routine use of social and environmental assessment criteria in tenders; • routine procurement of goods and services from local suppliers, maximizing local returns on investment and contributing to stable local economies. Integrate disaggregated indicators of population well-being into routine data collection, monitoring and reporting of health status and health equity, by: • conducting well-being surveys; • disaggregating data, for example by age, gender, ethnicity, place and socioeconomic status; • increasing compatibility of existing data from health and non-health sectors to assess progress on implementing policies and investments that protect and promote public health goods across the population. Design and implement health and care services that increase well-being, as well as evaluating and reporting impact on health and development goals. This includes: • implementing robust measures to strengthen UHC; • ensuring primary care supports community development and engagement to promote empowerment and inclusion; • delivering health care that is environmentally stable, such as through green hospitals and green procurement; • providing integrated services that meet the health, social, livelihood and well-being needs of the population, including those relating to primary care, legal services, job-seeking and housing; • rural-proofing health services, contributing to improved human development in regions that are falling behind; • limiting the use of OOP payments and ensuring those most at risk of financial hardship are exempt from these; • supporting informal carers to reduce the burden of unpaid care; • future-proofing health and care services to ensure they are able to cope with the challenges of ageing populations; • investing in health emergency preparedness and response systems as an insurance policy against future health threats. Implement joint action with other sectors to tackle large challenges that cannot be solved in silos, such as youth inclusion, mental health issues, and One Health. This includes: • conducting joint problem assessment and solution design; • engaging the population, especially those underrepresented in service design and evaluation. Ensure access to health care is appropriately distributed to address health and health equity needs across geographical (specifically rural) areas, including targeted approaches to recruitment and retention in rural areas. 2 - 3 - 5 - 6 Table 1 Stakeholders and potential actions exeCutive summary xi Stakeholders Potential actions SEE SECTIONS National and regional governments Prioritize well-being through core governance instruments, such as: • laws and regulations; • taxes and fiscal instruments • political bodies, e.g. cross-party committees and steering groups; • political mandates; • ministerial portfolios for well-being and future generations; • public consultations and dialogue to develop locally tailored visions of well-being and to empower the population; • accountability mechanisms that take into account data on well-being outcomes. Ensure that key democratic processes work to include everyone, creating a better society for all. Prioritize well-being across government economic and development policies, including: • monitoring the impact of fiscal and monetary policies on population well-being and equity; • routinely incorporating macroeconomic analysis of well-being into fiscal policy and modelling; • shaping industrial sectors through regulation to support healthy food systems, sustainable travel and sustainable energy. Adopt indicators of well-being as key markers of social progress, incorporating the four well-being capitals, as well as indicators of public health policies and health systems. Develop the conditions for people to lead healthy lives equitably, by: • investing in health and public health systems that are sustainable and able to meet future needs; • prioritizing public health-oriented goods and policies, such as social protection, affordable housing and decent employment; • adopting laws and policies that enable people to thrive, such as minimum wage legislation. Protect national solidarity through redistributive policies. This includes: • using methods to assess the distributional impacts of policies and investments, such as distributional impact assessment tools; • involving the population in assessing the impacts of policies. Support international, cross-sector collaboration between health, economy and finance sectors to work towards a well-being economy. Use public sector procurement to strengthen local supply chains and equitable employment. Develop cross-sector plans to address key priorities, such as increases in the cost of living and the mental health of young people. 4.1 - 5 - 6 Economic and finance policy-makers and ministers Design economic and fiscal policies with a well-being, equity and sustainability lens, by: • investing in producing equitable human, social, economic and planetary well-being, by adopting relevant tools such as well-being budgeting and gender budgeting; • considering the well-being of future generations as part of investments and policies; • developing and implementing analytical methods and tools to measure the likely impacts on human, social, planetary and economic well-being of any investments and policies, while maximizing the co-benefits, for example through national accounts; • investing in health and public health systems, especially health services that deliver well-being, such as community-focused primary care; • developing, appraising, implementing and evaluating innovative policy proposals towards well-being economies; • strengthening health considerations within trade policy; • ensuring improved working conditions and minimum wages. Implement fair taxation to maximize available fiscal space, by: • considering innovative taxes, such as windfall taxes; • eliminating subsidies on products and activities which cause harm to health. Implement market shaping through regulation, incentives, disincentives and investment frameworks, including setting standards for business and investment. 4.1 - 5 - 6 HealtH in tHe Well-being eConomy xii Stakeholders Potential actions SEE SECTIONS Public health institutions and health professional associations Develop training programmes, research and guidance to enable health professionals to take a more holistic approach towards well-being in their practices and services. Engage directly with economic and finance policy-makers on policies that can be shaped jointly to deliver well-being. Focus leadership towards well-being economies, through: • research, sharing evidence and contributing to designing policies to deliver equitable well-being; • data-gathering and analysis, including measures of well-being, public health goods and policies and distributional aspects of these; • evaluation of the impacts of well-being policies and interventions. 2 - 3 - 4 - 5 - 6 Development institutions and international financial institutions Adopt development models and instruments which ensure countries can make investments to promote well-being capitals, such as debt-for-health swaps and bonds. Develop the collaboration mechanisms to embed health and well-being at the heart of international processes. Shape the policy agenda to support countries in implementing well-being economies and delivering public health goods and policies, ensuring equity, inclusion and sustainability are at the heart of policy-making. Make direct investments that promote and protect well-being capitals, including in: • health services that promote well-being, such as those that integrate with other services to meet economic and social needs; • public health goods, such as affordable housing, decent employment and healthy living environments. 4.3 - 5 - 6 Central banks Analyse macro-critical economic health risks, such as population ill-health and pandemics, as part of assessing economic trends. Consider how to promote equitable well-being using monetary policy and through regulation. Consider strengthening/increasing the inclusion of equity and well-being in economic analysis. 4.1 Civil society Continue to advance dialogue, innovation and knowledge exchange to develop the well-being economy approach, including developing resources and educational tools or programmes to support people in implementing well-being economy approaches. Contribute to placing the people’s voice at the centre of policy-making. 4.4 - 6 Research funders and donors Fund international collaborative efforts to inform policy and practice between the health, economy and finance sectors. Support the development of investment frameworks and mechanisms for well-being to be prioritized. Fund research to assess the impacts of innovative interventions. 2 - 3 - 4 - 5 - 6 Investors Prioritize investments that protect and promote well-being capitals. Incorporate health more strongly into investment frameworks. 4.2 Research institutions and universities Strengthen the evidence base around well-being economies to support policy-makers in implementing evidence-based solutions, especially around innovative policies and investments, and the causal chains linking human, social, planetary and economic well-being. Develop innovative methods that allow forecasting and dynamic assessment of return on investment across human, social, planetary and economic well-being. Embed well-being economy concepts within university training programmes. 2 - 3 - 4 - 5 exeCutive summary xiii Stakeholders Potential actions SEE SECTIONS Employers and businesses Prioritize employee well-being and equity in human resources policies. Adopt business models and practices that protect and promote well-being capitals, such as employee-owned businesses. 4.2 WHO Develop tools that can support Member States in applying a well-being economy approach in decision-making and investment, including measurement frameworks and optimizing co-benefits. Shape the agenda around the role of the health sector in developing a well-being economy. Convene dialogues with key stakeholders. 2 - 3 - 4 - 5 - 6 HealtH in tHe Well-being eConomy 14 Europe faces a growing list of connected and pressing challenges. Less than 15 years since the last recession, the region faces the prospect of another recession alongside sharp increases in the cost of living. Alongside this, the region is experiencing the impacts of climate change and environmental damage, continuing conflicts and the risk of worsening social fractures. The novel coronavirus disease 2019 (COVID-19) pandemic led to high excess mortality (2020–2021) and a drop in life expectancy between 2019 and 2021 across most of the WHO European Region (1). The most disadvantaged groups in society have experienced the worst impacts – the gap in levels of well-being between those on low incomes and those on high incomes has increased by 50% since the pandemic (2). 600 000 excess deaths in the WHO European Region during the pandemic can be attributed to low levels of investment in health systems and human development, with higher mortality affecting the poorest countries the most. This builds on pre-existing social inequities and has exacerbated the numbers of children and adults with poor health, living insecure lives, affecting their future opportunities and the capability of countries to recover fairly and safely. Health and welfare systems are under severe strain to cope with the effects of people living insecure lives. United Nations General Assembly Resolution 66/290 highlights that “human security is an approach to assist Member States in identifying and addressing widespread and cross-cutting challenges to the survival, livelihood and dignity of their people” (3). The 2021 Pan-European Commission on Health and Sustainable Development recognized the key role that factors such as worsening wealth and income inequalities, insecure employment, and insufficient investments in social protection play in driving inequalities in health (4,5). These inequalities are exacerbated by significant cost-of-living increases, including increases in the cost of fuel and food, which have led to the highest inflation rates in decades in many countries across the various regions. In the EU, inflation is calculated to have led to around 2% higher levels of deprivation and a 5% higher rate of absolute poverty since 2021 (6). 1.1 Pressing challenges threaten health and social cohesion On the road to well-being economies in the WHO European Region 1 1. on tHe road to Well-being eConomies in tHe WHo european region 15 The pandemic has led to decreased trust in governments – particularly among the unemployed – which was 40% lower after the pandemic (7). The gap is also widening in terms of trust in others, with those earning low incomes reporting 50% lower trust in others than those with high incomes. The European Institute for Gender Equality (EIGE)’s gender equality index shows a decrease in several domains for the first time (8). Climate change is increasing the risk of extreme weather events, such as heatwaves and floods. At least 15 000 people died in Europe in 2022 due to heatwaves, with people’s livelihoods severely affected (9). There are likely to be 5 million internal climate migrants in eastern Europe and central Asia by 2050 (10). Biodiversity loss increases the risk of emerging infectious diseases; biodiversity is in strong decline in the region (11,12). These issues present significant risks for future stability and prosperity. These complex challenges threaten progress towards the Sustainable Development Goals (SDGs) (13). They also create significant pressures on health systems, especially in the context of other issues, such as rising unmet needs, long waiting lists and the burden of the condition known as Long COVID. These exacerbate pre-existing pressures, such as the rising proportion of older people in many countries; for example, by 2050, those aged 65 years and over are expected to make up one quarter of the population in the WHO European Region (14). Many countries in the WHO European Region had insufficient numbers of health and care workers prior to COVID-19; the resulting pressures on this workforce following the pandemic and the cost-of-living increases have led to the risk that existing shortages will be amplified. With many countries having more than 30% of doctors aged 55 years or over and more than 20% of nurses in the same age group, investment is needed to secure a workforce that can meet the population’s ongoing need for health care (15). Many of these pressures are underpinned by an undervaluation of the role the public sector plays in ensuring the stability of economies and societies. New and deepening health inequities reflect avoidable factures within society, threatening cohesion and trust. It will not be possible to achieve healthy, safe and resilient societies and economies when so many are being left behind. Widening inequalities between regions within countries since the turn of the century represent further key challenges, as regions are key drivers of national prosperity (16). Areas within countries with higher levels of disadvantage had on average 20% fewer doctors than the national average, prior to the pandemic (2). These inequities between regions are underpinned by a lack of attention to equity and distribution as part of policies to pursue economic growth. Equity and inclusion are critical to fair and stable recovery – and especially to addressing growing concerns about civic unrest, the erosion of democracy and solidarity, and economic resilience. Many of these challenges share common underlying causes, such as economic models that focus on profit over people and planet, unequal distribution of resources, the privatization of public assets and weakened public services (see Fig. 1.1). Whereas, historically, economies and societies have pursued increases in GDP as a key focus for development, there is a growing realization that these significant challenges cannot be solved through markets that only pursue profits. GDP measures important economic factors that have a strong impact on people’s well-being – such as income – but also activities which have a negative impact on health and well-being, such as industrial activities that release pollutants. HealtH in tHe Well-being eConomy 16 Buying back well-being that has been lost or weakened by economic models driven only by profits is not only unethical but also inefficient and ineffective. There is increasing agreement around the need to refocus on protecting and promoting equitable well-being. As this paper seeks to demonstrate, well-being is vital to producing peace and security, as well as resilient people, economies and societies that are more prepared for future crises. Promoting population well-being is also key to reducing the burden on health systems, to enable sustainable and resilient health care. This cannot be achieved in silos, and a new approach is needed to deliver healthy, fairer, prosperous societies (17). Intensive production and consumption of goods contribute to pandemic risks, ecological degradation and NCDs Structural factors affecting ability to buy and access goods and services create inequities in risk of NCDs and vulnerability to health harms Deepening gaps in society affecting social, economic and environmental determinants of health Less public accountability harms service standards, as well as equality of access and care, maintenance and investment The big challenges of our time, including those related to health and well-being, share common underlying causes linked to: Sources: WHO Regional Office for Europe, 2023 (2); WHO, 2022 (17); Shannon et al., 2022 (18); WHO, 2021 (19); Lawler et al., 2021 (20); Allen, Hatefi & Feigl, 2019 (21); Weaver & Fasel, 2018 (22); Guivarch, Taconet & Méjean, 2021 (23); ShareAction, 2022 (24). Fig. 1.1 Underlying causes of pressing challenges for the WHO European Region Underestimation of the importance of public servicesInequitable distribution of opportunities and resources Economic development models focusing on profit over people Producing public value from private assets is underdeveloped and unsystematic 1. on tHe road to Well-being eConomies in tHe WHo european region 17 Well-being is the ability of individuals and society to thrive. It includes elements such as people’s sense of belonging and mattering, and social cohesion, in addition to more direct measures of health status that assess physical and mental health. Different dimensions of well-being exist that are vital to achieving inclusive and sustainable development – these are: social, human, planetary and economic well-being (see Fig. 1.2). These can be thought of as the well-being capitals – important assets such as trust, social cohesion, participation, our environment, equity and people’s well-being that are all crucial for developing healthy, fairer and prosperous societies where people can thrive. Each of these dimensions is made up of several components, which are critical to addressing today’s challenges while developing cohesive, resilient and prosperous societies. In particular, addressing these dimensions of well-being is key to managing long-term pressures on health systems. Box 1.1 provides an overview of why each of these well-being capitals matters. There are important connections between these capitals too – as investing in one can have benefits and negative impacts for another sector – known as co-benefits and co-costs. In some cases, this can lead to greater returns than invested, known as a multiplier effect (25). Given the vital importance of these four well-being capitals, developing a well-being economy involves protecting, promoting and innovating to develop them. 1.2 Why is well-being a priority for decision-makers? Fig. 1.2 Well‑being capitals with examples in each domain POLICY & GOVERNANCE Planetary well-being Human well-being Economic well-being Social well-being Good air & water quality Healthy & sustainable living environment Sustainable public transport & active travel Access to safe green space Stable climate Biodiversity & natural capital Circular economy & green technology Living wage Universal social protection through the life‑course Decent, psychologically safe work Gender‑responsive employment Social dialogue & collective bargaining Economic cohesion & balanced development Healthy life expectancy Mental health & well‑being Ability to carry out daily activities free from illness Universal Health Coverage Quality & non‑discriminatory health & social care Universal policies for housing, food & fuel security Early childhood development Lifelong learning & literacy Safe, orderly & regular migration Living in safety & free from violence Sense of belonging (“Mattering”) Social cohesion & embracing diversity Perceived ability to influence politics & decisions (“Agency”) Social support & protection Building trust in others & in institutions Public spending on communities Participation in volunteering Source: adapted from the OECD well-being framework (26). HealtH in tHe Well-being eConomy 18 Why is human well-being important? People’s health and their subjective well-being are closely linked; both are drivers of economic prosperity. Well-being makes fundamental contributions to health, such as greater life expectancy, increased likelihood of adopting healthy behaviours, reduced incidence of serious health conditions and improved outcomes of existing conditions (27). Health also plays a key role in economic development: for example, reduced mortality is calculated to have contributed 11% of economic growth in low- and middle-income countries in recent years (28). Globally, depression and anxiety lead to around US$ 1 trillion of productivity losses each year (29). Avoidable health inequities across the majority of EU countries are estimated to lead to welfare losses of €980 billion a year (30). Education and health services are drivers of health and economic outcomes (31). Early childhood interventions can improve education levels and employment opportunities with an eightfold economic return (32). Affordable, accessible and high-quality integrated health services are key enablers of human capital across the life-course. See Chapter 2 (Box 2.2) for more details on the return on investment of health services. Why is social well-being important? Trust, participation and social cohesion make significant contributions to health and well-being, including health equity, as well as being vital to prosperous and resilient societies. Life expectancy gaps between the richest and poorest parts of a country are lower in countries with strong democracies (33). Democratization can also lead to increases in GDP per capita of approximately 20% (34). Why is planetary well-being important? The environment is key to human well-being and economic prosperity (35). The World Bank estimates that droughts and floods – both made more likely by climate change – could cause damage of up to 1.3% of GDP each year in central Asia and extreme weather could cost the EU €170 billion by 2100 (36). 58% of the world’s infectious diseases have been exacerbated by climate change (37). Natural capital accounted for 23% of the wealth of low-income countries in 2018, down from 39% in 1995 (38). Green spaces make key contributions to physical and mental health – areas with accessible green space have significantly lower inequalities in mortality (39). In 2020, exposure to fine particulate air pollution led to at least 238 000 deaths across the EU, and air pollution makes significant contributions to the burden of chronic disease (40). Why is economic well-being important? Workforce well-being increases performance, decreases staff turnover, and has positive outcomes for employees, employers and the overall economy (41). The economic cost of absence related to ill-health and inability to work is over £100 billion annually in the United Kingdom (42). The well-being of health care staff is vital – it can improve patient safety and is also important for the long-term capacity of the health workforce, where addressing issues of burnout and staff retention are key (43). High levels of inequality can damage trust, increase the risk of conflict, reduce economic prosperity and increase the severity of recessions (44–48). The International Monetary Fund (IMF) has recognized that increases in income share for the 20% at the top of the income distribution ultimately lead to decreases in GDP, whereas for all other groups increases in income share lead to increases in GDP (49). Improving gender equality could lead to increases in GDP of 6.1–9.6% by 2050 for EU countries and of 1.5% by 2035 in the Western Balkans (50–52). box 1.1 The importance of the well‑being capitals: human, social, planetary and economic well‑being 1. on tHe road to Well-being eConomies in tHe WHo european region 19 The policy focus on a well-being economy has emerged strongly since 2008 and the financial crisis. It builds on decades of thinking and action across domains, including health systems, economics, international development, environmental sustainability, and the social determinants of health (53–56). A well-being economy approach provides an important pathway for implementing inclusive and sustainable development. There is no single definition of a well-being economy but certain themes recur in interpretations of it; whether as the goal itself – that is, what a well-being economy aims to achieve – or as the approach – that is, how to deliver it. These concepts are summarized in Box 1.2. A well-being economy as a goal is an economy which secures well-being for all people today and for future generations, and includes the well-being of the planet as an overarching goal. • Equity – equality across domains, including gender, ethnicity and age. • Inclusion – people participating in society and having a voice in decision-making. • Sustainability – including addressing climate change and biodiversity loss. A well-being economy approach is a combination of ways of working that contribute to achieving the above goals (equity, inclusion and sustainability). • Investing in and producing the four well-being capitals involves using public and private investment, spending and resources to improve human, social, planetary and economic well-being in a way that is fair and equitable. • Optimizing co-benefits from the four well-being capitals entails explicitly considering in policy design and investment decisions the benefits and risks to the four capitals. • Creating the conditions for people to lead healthy lives means delivering policies, essential goods and services that enable people to live in dignity, to thrive and contribute to society – also known as public health goods and policies (see Fig. 1.3 for the relevant action areas) (57). • Recognizing that the solutions to produce well-being lie with different sectors of government and society is key, and therefore engaging a broad range of stakeholders including the population as part of implementing the identified solutions through dialogue. 1.3 What is a well-being economy? box 1.2 Well‑being economy key terms and concepts HealtH in tHe Well-being eConomy 20 The well-being economy approach can be taken in all countries across the WHO European Region, irrespective of the size of the country or type of economy. However, the approach needs to be adapted in response to country-specific assets (such as existing economic sectors) and the cultural context (such as people’s aspirations); different economic sectors will require different approaches. Healthier societies and well-being economies are interconnected agendas (see Fig. 1.4). With economic, social and environmental factors having a critical influence on health outcomes, achieving the goals of a well-being economy is highly likely to benefit people’s health. Equally, a well-being economy will not be achievable without addressing health inequalities and recognizing that the health sector has a key role to play in improving well-being. HEALTH & INCOME SECURITY AND SOCIAL PROTECTION Unemployment insurance HEALTH & LIVING CONDITIONS Secure and affordable housing HEALTH & SOCIAL AND HUMAN CAPITAL Trust in institutions and in others HEALTH & EMPLOYMENT AND WORKING CONDITIONS Working conditions; active labour market programmes Universal Health Coverage HEALTH & HEALTH SERVICES Fig. 1.3 Action areas for creating the conditions for dignity, to thrive and to contribute to society Source: adapted from the work of the WHO Health Equity Status Report Initiative (HESRi). 1. on tHe road to Well-being eConomies in tHe WHo european region 21 A growing movement of governments, businesses, research organizations, financial institutions and civil society actors is seeking to develop well-being economies. This includes commitments from across the WHO European Region as well as more widely, from other regions. Action to develop well-being economies is already advancing, including strategic commitments, laws, changes to how budget decisions are made, new monitoring systems and international collaboration efforts. WHO has a clear mandate to support this work. This includes: • the Global Programme of Work 2019–2023 target of 1 billion more people enjoying better health and well-being and highlighting of the social, environmental and economic determinants of health, as well as 1 billion more people benefiting from UHC – implementing the Health in the Well-being Economy approach provides a way to meet both goals (58); • the European Programme of Work (2020–2025 – “United Action for Better Health”) (EPW), which includes specific mention of initiatives to “address local determinants of health with green deal investments into a future economy of well-being” (59); • the WHO Geneva Charter for Well-being (2021), which builds on the Ottawa Charter for Health Promotion and nine global conferences on health promotion – it highlights the need for a just transition to a low-carbon economy and to an equitable economy that serves human development within ecological boundaries (19); • the 2021 Pan-European Commission on Health and Sustainable Development, which made the case for a paradigm shift in thinking around the relationship between health, environment and the economy, and the need to prioritize investments that enable people to thrive equitably while building resilience (4,5). 1.4 The emerging global movement towards well-being economies Fig. 1.4 Interconnections between health and well‑being economies Source: authors’ own compilation. EQUALLY HEALTHY PEOPLE EQUITABLE HEALTH SYSTEMS EQUITABLE PUBLIC HEALTH POLICIES WELL-BEING ECONOMY WELL-BEING CAPITALS Human well‑being Planetary well‑being Social well‑being Economic well‑being HealtH in tHe Well-being eConomy 22 The well-being economy approach – and especially its alignment with the health agenda – builds on multiple international declarations and commitments. There are also accelerating commitments to further action to support the well-being economy approach across the WHO European Region. Fig. 1.5 summarizes key commitments, commissions and declarations underpinning the movement towards well-being economies, including WHO’s mandate. Box 1.3 provides examples of policy directives and political actions under way in the same field. Fig. 1.5 Timeline of key commitments, commissions and declarations relevant to well‑being economies and investment for health Source: authors’ own compilation. EU Council Porto Declaration (2021) welcomes measures of economic, social and environmental progress to supplement GDP Geneva Charter for Well-being (2021) draws attention to the need for a just transition to a low-carbon economy and to an equitable economy that serves human development within ecological boundaries EU Council conclusions on the Economy of Wellbeing (2019) were adopted in 2019, which included inviting stakeholders to strengthen the work around economies of well-being WHO Europe Regional Committee Resolution on increasing equity in health (2019) highlights that stronger partnerships and alliances are needed to bring the social values of solidarity, equity, social justice, inclusion and gender equality into mainstream fiscal and growth policies 2030 Agenda (2015) is the overarching framework for sustainable development until 2030, with SDGs that include health, equity and decent work Commission on the Measurement of Economic Performance and Social Progress (2008) explored measurement of social progress beyond GDP Rio Declaration (1992) establishes collaborative commitments towards sustainable development, linking with economic development Tallinn Charter (2008) through which WHO European Region Member States committed to investments in health and in other sectors that influence health Addis Ababa Action Agenda (2015 ) comprises a set of policies to transform the global economy and meet the SDGs, with a global framework to finance sustainable development Global Action Plan for Healthy Lives and Wellbeing for All (2019) is a global, multistakeholder plan, which includes strengthening the use of fiscal measures and national investment to address the determinants of health WHO Global Programme of Work (2019) sets the goal of 1 billion more people enjoying better health and well-being, highlights the need to address the social, environmental and economie determinants of health through a multisectoral approach WHO European Programme of Work (2020) incorporates the promotion of initiatives to address local determinants of health with green deal investments into a future economy of well-being WHO Council on the Economics of Health for All (2020) aims to reframe health for all as a public policy objective, and ensure that national and global economies and finance are structured in such a way to deliver on this ambitious goal Pan-European Commission on Health and Sustainable Development (2021) calls for a paradigm shift around the relationship between health, environment and the economy, and prioritizing investments that enable people to thrive equitably while building resilience 1. on tHe road to Well-being eConomies in tHe WHo european region 23 National actions • Finland, Iceland, New Zealand, Scotland and Wales are part of the Wellbeing Economy Governments (WEGo) partnership initiative to advance collaboratively their shared goal of developing well-being economies (60). Two concrete examples are outlined here. °Building on a public consultation process to understand the future desired by Welsh citizens, Wales created the Well-being of Future Generations Act (61), which places a duty on all public bodies to consider the well-being of future generations when developing public policies. ° Iceland has developed an indicator framework bringing together indicators of social, economic and environmental progress, including health measures; then developed well-being priorities and used these to guide its fiscal strategy (62). Since the 2008 recession, Iceland brought about a decrease in financial hardship and more equal income distribution through changes to tax policy and labour market policies, and support for people with lower incomes, including those with debts (63). Iceland has seen high rates of GDP growth – often above 4% – since 2013 and often the highest employment rate among EU countries (64,65). International examples • The EU legislative programme to embed an economy that works for people includes legislation on minimum wages, sustainable corporate governance and minimum corporate taxes (66). There are a number of other initiatives at the European level, including the European Pillar of Social Rights and major investments in a green transition through the European Green Deal Investment Plan (67,68). • The Central Asia Regional Economic Cooperation (CAREC) Institute is implementing a programme on green, inclusive and sustainable recovery (69). • The Economic and Social Commission for Asia and the Pacific (ESCAP), the Asian Development Bank (ADB) and the United Nations Development Programme (UNDP) have reported on promoting inclusive recovery from COVID (70). box 1.3 Examples of policy directives and political actions HealtH in tHe Well-being eConomy 24 Healthy people and the health sector play key roles in a well-being economy. Health status is strongly linked to people’s well-being (71), making important contributions to livelihoods, people’s agency and their contribution to society. The distribution of physical and mental health in a population is another key factor – for example, reducing inequities in life expectancy between groups by 50% could lead to benefits of 0.3–4.3% of GDP (72). UHC – “that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship” – is a vital component of a well-being economy (73). One of the key ways in which health systems can prevent households from experiencing financial hardship is by limiting the use of OOP payments to finance health care, and by putting protective coverage policies in place to ensure those households most at risk of financial hardship are exempt from making OOP payments (74). The health sector is a key economic sector with a large employment and procurement footprint, which impacts on communities as well as making wider contributions to economies and societies (75). In 2020, health and social work accounted for on average 10% of total employment across the WHO European Region, although data were not available for all countries (15). Effective investment into the health and care workforce results in positive returns for societies and economies (76). Health systems can produce the well-being capitals through procurement that incorporates social and environmental considerations or that develops local supply chains, as well as decent, inclusive employment. It is also important for the health system to address inequities in employment, such as the gender pay gap, which is calculated to be 20% in the health and care sector, compared with 12% in other sectors (15), to address wider equality issues such as the prevention of violence and harassment of employees, as well as promoting staff well-being. Accessible health services are increasingly seen to be a key part of rural policy, in particular because they can create additional jobs (77,78). The stability of the health sector ensures continuity as well as livelihood opportunities in places where health services exist. Primary care is particularly important in this respect, as it is often a significant employer in rural areas. 2.1 The health sector as a well-being economy sector The health sector and a healthy population as a driver of well-being economies 2 2. tHe HealtH seCtor and a HealtHy population 25 Health systems can also make other key contributions to well-being economies, according to how care is delivered. It is important to develop health services that prioritize prevention, community development and integration with services to meet people’s wider economic and social needs, such as employment services and social care. This includes strengthening primary care services to address community needs through public engagement and mental health care. It is also essential to ensure that any private care provision enhances public health care. It is also important to support unpaid, informal carers who currently carry out the majority of long-term care in Europe, with a higher proportion of women than men undertaking this role (79). To provide 10% of older people who receive informal care with formal care instead would require a doubling of expenditure on long-term care in EU countries. Health care results in considerable carbon emissions (80). Achieving environmentally sustainable health care will require a significant transformation of health care delivery to minimize its environmental impact, spanning medicines, facilities, travel, equipment, care pathways and many other domains. This will become increasingly important as part of actions needed to tackle climate change. Box 2.1 provides examples of how health care contributes to well-being economies. Employment and procurement levers • The region of Utrecht added a social return clause to all public tenders, with contracts over €100 000 requiring 5% of the contract value to be spent adding social value, for example on education or employment for people removed from the labour market (81). • The West Belfast and Greater Shankill Health Employment Partnership promoted opportunities for people who were economically inactive and lower paid workers. This led to unemployed people finding employment, lower paid staff obtaining promotions and savings on unemployment benefits (81). • The NHS in England has a target of net zero by 2045 for emissions influenced through suppliers and partners (82). Since 2022, NHS procurement in England is to include a 10% net zero and social value weighting. From 2023, contracts above £5 million per annum will require a carbon-reduction plan from suppliers; this will be extended to all suppliers from 2024. By 2030, only suppliers that can demonstrate progress around carbon emissions will qualify for contracts. Community services • Caring neighbourhoods is an initiative in the Flanders region in Belgium, which aims to develop the conditions for all people to live comfortably in their homes and neighbourhoods, encompassing aspects such as safety, social connectedness and informal care, alongside formal, integrated health services. 133 projects had been started by 2022 (83). • Men’s sheds are community-based initiatives that provide the opportunity for men to take part in social activities in the community. The “Sheds for life” programme in Ireland showed increases in self-rated health and life satisfaction, sense of belonging and trust, among other positive outcomes (84). • The cottage hospital model from southern Lapland, Sweden, builds on cross-sectoral collaboration between key stakeholders with the community for providing primary care in remote, rural and sparsely 2.2 The role of health care in improving human, social, planetary and economic well-being box 2.1 Examples of health care’s contribution to well‑being economies HealtH in tHe Well-being eConomy 26 populated areas (85). This collaboration – bridging the gaps between the voices of clinical practice, policy, innovators, and the community – has resulted in industrial innovation and its adoption in health care. Cottage hospitals apply innovative and remote health care delivery solutions, including drone technology and digital solutions, along with a wide range of telemedicine applications. • In Kyrgyzstan, Village Health Committees were set up. Local residents select priorities and elect representatives to the committee, which then play a key role in delivering health-related activities. The programme has been scaled up nationally. Over two years, the programme led to the detection of over 180 000 people with high blood pressure, as well as helping individuals to feel enabled to be more involved in health improvements (86). Redesigning mental health services • Czechia has been reforming mental health care – moving away from a focus on long-stay facility-based care towards a model that addresses the psychosocial environment. Social workers support social rehabilitation including the allocation of social housing and connections to other services (87). • Triple P is a multi-level approach including media campaigns and intensive support for families who are deemed high risk, focusing on children aged under 12 years. By promoting positive parenting, the programme also promotes social competence and emotional self-regulation in children. It has been found to positively impact maltreatment and injuries resulting from maltreatment, as well as out-of-home-placements, thus contributing to a reduced risk of adverse childhood experiences (ACEs) (88). Environmentally sustainable health care • Innovations in environmentally sustainable health care in the Nordic countries are supporting the delivery of health services – one such example is the use of battery-powered drones to increase the speed of transfer of blood samples (89). • The University Hospital of South Manchester in the United Kingdom decreased its reliance on non-renewable energy sources by 36% through a combination of technical and behavioural changes (90), while also reducing carbon emissions by 28% and generating savings of £390 000 a year. • Ospedale dell’Angelo Mestre is a technologically advanced hospital in Venice-Mestre, surrounded by a landscape garden (91). It also has various roof gardens, abundant gardens connecting the buildings and green roofs, contributing to water drainage and bringing important benefits to patients’ well-being. Integration with other services • Health justice partnerships are partnerships between health care services and legal services to provide support on a range of issues, such as housing and debt. Evidence suggests that these partnerships can improve the life circumstances of people accessing the service, as well as promoting mental well-being (92). • Kazakhstan has moved towards multidisciplinary primary care, with an emphasis on stronger social care and mental health care, leading to reduced use of specialized and hospital services (93). 2. tHe HealtH seCtor and a HealtHy population 27 Efforts to protect and improve health and health systems are not costs, but are core investments in producing peace and security, as well as resilient people, economies and societies (94,95). Box. 2.2 outlines some of the benefits of investing in health, along with some of the risks of inaction. • Investment in health systems has a multiplier effect – for every €100 000 invested, on average four new jobs are created elsewhere in the economy (in some countries this can be as high as 10 new jobs). The employment multiplier for the health sector is higher than the average across all economic sectors (81). • Public health interventions have been found to have an average return on investment ratio of 14 to 1 (96). Many health interventions also deliver wider social returns, such as social prescribing, which delivers 3.5 times the benefit for every unit invested, including benefits in terms of educational outcomes and volunteering (97). UHC has an expected return of US$ 1.4 for every dollar invested (98). • Resilient health and public health systems can help to protect the economy and other social systems from shocks. The health sector is one of the most stable industries during economic recessions. The IMF has estimated the impact of COVID-19 on the global economy to be in excess of US$ 12.5 trillion (99). Yet we also know that health systems are often under-provisioned and face significant workforce challenges (100). Investment needs to focus on both long-term improvements in well-being and in the resilience of health and public health systems to ensure society can respond effectively to future pandemics and other health crises. 2.3 Well-being economies invest in health box 2.2 Benefits of investing in health and risks of inaction HealtH in tHe Well-being eConomy 28 Health stakeholders are increasingly acting as partners to tackle wider challenges that no single sector can tackle alone. For example, One Health is an approach that aims to sustainably optimize the health of people, animals and ecosystems by virtue of their interdependence (101). The approach is important because 60% of emerging infectious diseases come from animals, and there are many stresses on ecosystems – such as loss of habitats – which increase the likelihood of new diseases emerging. This involves health stakeholders, animal health stakeholders and environmental stakeholders working together across and between their individual goals, to prevent outbreaks of emerging diseases, improve food safety, reduce AMR and protect biodiversity (102). Health stakeholders can support the creation of conditions for healthy living by supporting wider policy-making and collaborating with the economic and finance sectors. The pandemic has already led to the emergence of such collaboration. Box 3.1 provides several examples where the health sector has partnered with other sectors. • Tobacco-free farms is a joint initiative by WHO, the Food and Agriculture Organization (FAO), and the World Food Programme to support tobacco farmers in Kenya in switching from labour-intensive tobacco farming to alternative crops that have fewer health, socioeconomic and environmental risks (103). To date, the initiative has supported 1413 farmers to switch to alternative livelihoods, covering 806.5 acres of land; as a result, 481.4 tonnes of high-iron beans were sold in the first season. Harvesting and aggregation for the most recent season are ongoing at the time of writing.1 • Healthy Working Wales (104) is a programme supporting employers to improve the health and well-being of staff employed in Wales, including through creating healthy working environments and engaging with employees. The programme delivers advice and support, and operates an awards scheme, among other activities. Employee engagement and well-being contribute to beneficial outcomes for employers, such as increased productivity and workforce retention. • The importance of multisectoral collaboration on health and tourism is increasingly recognized. Elaborating on the lessons learned from the COVID-19 pandemic and the need for multi-level cooperation between the health and the tourism sectors, countries of the Small Countries 1. Data provided with permission to share by WHO’s Tobacco Free Initiative on 11 January 2023. box 3.1 Health sector as co‑creator and partner in producing well‑being capitals Health as a co-creator and partner in producing well-being capitals 3 3. HealtH as a Co-Creator and partner in produCing Well-being Capitals 29 Initiative (SCI) recognized at the 8th High-level Meeting of the SCI in Montenegro that the reopening of travel and tourism is crucial for economic recovery, jobs and livelihoods. Based on the SCI Montenegro Statement (105) and a policy brief on health and tourism (106), a Coalition of Partners on Health and Tourism will be created, jointly coordinated by the WHO European Office for Investment for Health and Development (Venice Office) and the United Nations World Tourism Organization (UNWTO). Its aim is to prepare health systems across the WHO European Region for promoting the health of tourists, host communities, tourism workers and the environment, and making health and well-being a priority for resilient, inclusive and sustainable tourism development. • WHO Regional Office for Europe has launched the Pan-European Mental Health Coalition as a flagship initiative to promote mental health across the Region (107). In bringing together a diverse group of members with a shared interest in improving mental health across Europe, the Coalition represents a recognition of the need for multisectoral stakeholder engagement to drive priority actions for the Region, including: raising awareness and reducing stigma; expanding community-based delivery of mental health services; strengthening the mental health workforce; and building capacity in community settings (such as schools and workplaces) to promote and protect mental health throughout the life-course. The #Youth4Health Tirana 2022 Health and Well-being Forum for Youth brought together young people, public health experts and partners from the WHO European Region to network and discuss current health and well-being issues. The Forum created space for dialogue with young people around how mental health challenges can be addressed through intersectoral collaboration (108), with the goal of shaping policies to have more impact in terms of supporting inclusion, trust and livelihood security. • The European Environment and Health Process (109) is designed to enable cross-sectoral work towards eliminating environmental threats to human health. Every 5–7 years, a ministerial conference brings together the environment and health sectors to shape relevant policies and actions. The last Environment and Health Ministerial declaration – the Ostrava Declaration – summarizes priorities for the WHO European Region, with a commitment to develop national portfolios for action that should address the need to accelerate progress on health and environment and, in particular, address the relevant goals and targets of the 2030 Sustainable Development Agenda. A new institutional framework was agreed to ensure appropriate coordination and collaboration between the national, subnational and international levels, the proper level of monitoring and implementation, and the necessary political drive (110). HealtH in tHe Well-being eConomy 30 A substantial evidence base has developed around the wide range of economic factors and policies that impact health and well-being (111). These provide solid foundations for developing well-being economies, spanning a number of topics, such as working conditions, trade, and taxes on unhealthy products. In terms of several promising innovative interventions – from circular economies to universal basic incomes – the evidence is complex, and more research is required (112,113). Yet the scale and urgency of many current challenges implies that interventions will need to be tested and scaled up rapidly. Action is already being taken at country level, as well as by businesses, the social sector, international institutions and NGOs. The following subsections provide a brief overview of the roles some of these organizations can play. Countries can take a whole-of-government approach – including by developing political bodies such as cross-party committees or steering groups – to take forward shared action on well-being. They can create clear political mandates for well-being through, for example, a Ministerial portfolio for well-being or by having independent commissioners tasked with embedding well-being into thinking and policies. They can also put people’s voices at the heart of decision-making, though consultations or public dialogues. Further actions include implementing laws and regulations, determining spending priorities through the national budget using tools such as gender or well-being budgeting, and implementing policies designed specifically deliver well-being economies. According to the IMF, as of 2021, all G20 countries had implemented fiscal approaches focusing on gender, although the “tools to operationalize these policies [were] far less established” (114). Crucially, countries can implement a combination of hard measures (such as laws and investment frameworks) and soft measures (such as participatory problem analysis, involving various stakeholders) to deliver well-being economies. National governments can raise revenue through fair taxation, increasing the fiscal space available to them (115) as well as boosting the benefits of this fiscal space through approaches to optimize co-benefits across sectors. There are many tools that can help with embedding a well-being economy approach in budgeting – from methods to appraise the value of the multiple benefits of investments to budget tools such as gender budgeting. 4.1 Countries Better health and health equity as an outcome: putting well-being economies into practice 4 4. better HealtH and HealtH equity as an outCome 31 A wide range of taxes have been used or proposed as means to generate revenue, and there is an increasing recognition of the importance of fair taxation in driving equity and economic resilience. Recently, increasing attention is being paid to innovative taxes such as windfall taxes – where a single tax is raised from companies who have generated profits that are felt to be unreasonable due to unusually favourable markets, but at the expense of wider society (116). Alternatively, subsidies on fossil fuels have been identified as an ideal target for reduced spending, representing US$ 5.9 trillion globally (117). A number of innovative instruments also exist, such as linking government debt with social and environmental outcomes, debt cancellations conditional on other investments, and social impact bonds (118–120). Countries can contribute to well-being economies by investing in sustainable travel and energy systems, developing healthy and sustainable food systems, and promoting initiatives that combine sustainable resource management with improving livelihoods. Countries may still face constraints on their ability to spend and there is ongoing debate about how these constraints can be eased (121). So, if countries are unable to identify new resources they may be able to redirect existing resources or review existing services to ensure they derive the most benefit. Whatever stage Member States are at with budget planning for 2023–2024, there are likely to be opportunities to shift towards investing in well-being in both the short and long term. The public sector can also play a role in shifting investment towards well-being, for example through procurement strategies. Regions can also play a key role, including by investing locally, hiring locally, collaborating across sectors and budget lines, and knowing and involving people as partners in solutions for healthier societies. Central banks are increasingly responding to climate change (122,47), including by assessing risks, developing standards for green finance and issuing green bonds. There is increasing interest in how central banks can address inequality (47). Central banks can go further to address population health issues, for example by assessing public health risks, incorporating health issues in modelling and using available levers – such as monetary policy and regulation – to contribute to improving well-being. Illustrative examples of approaches to delivering well-being capitals are provided in Box 4.1. Whole-of-government approaches and public engagement • In Finland, a cross-sector model of governance is being developed to steer the economy of well-being (123). This Finnish example is a local-to-global approach – it includes local government action as well as international leadership, through the country’s Presidency of the EU. • Scotland is engaging the population in decisions around public spending with plans for at least 1% of local government budgets to be subject to participatory budgeting (124). Scotland also has a Cross-Party Group on Health Inequalities, which works with parliamentarians and policy-makers to tackle health inequalities (125). Shifting investment and resources • New Zealand’s Public Finance (Wellbeing) Amendment Bill requires the Government to report annually on budgetary well-being objectives and the Treasury to report on the state of well-being (126). The Treasury’s Living Standards Framework is a holistic, locally relevant measurement box 4.1 Illustrative examples of approaches to delivering well‑being capitals in the shift towards well‑being economies HealtH in tHe Well-being eConomy 32 framework that captures relevant capitals and is used to consider the impacts of policy decisions (127). • In Austria, gender budgeting is required by the Constitution at every level of government, including reporting of gender equality achievements and outcomes, and auditing of budget programme impacts (114). The EIGE has published a set of tools to support gender budgeting (128). • Community wealth building is a public sector approach using procurement and employment levers to improve residents’ economic circumstances. In Preston (United Kingdom) (129) this has been found to be associated with an 11% improvement in mental health and 11% increase in median wages, compared with expected trends. Innovative instruments and approaches • Debt2Health is a scheme whereby debts are cancelled in return for investment in health (130). To date, over US$ 350 million in debt has been cancelled, with over US$ 220 million invested in health programmes. • The EU has plans to raise €140 billion from producers of electricity from sources other than gas, which are making higher than usual profits due to current demand (131). Purely profit-driven markets can lead to negative impacts on people and environments. There is therefore a need to promote activities in the private sector that improve health, while reducing those that negatively affect health. This includes their role in improving the health of consumers, employees and the community (132), and social economy business models which are likely to improve health, such as employee-owned organizations (133). Managing conflicts of interest is also key when addressing private sector activities that harm health. There are many examples of private companies taking innovative approaches to promote well-being capitals as part of their business activities, including actions taken across their business models, employment practices and supply chains. However, there is still room for many more businesses to act as a force for good. Charities and foundations are acting as a bridge to shape the world of business (see, for example, the “Long-term investors in people’s health initiative” in Box 4.2). Markets can be shaped through regulation, legislation, incentives and disincentives. Countries can look to WHO for guidance on effective interventions to prevent noncommunicable diseases through market regulation around unhealthy goods, including laws and pricing strategies (134). By 2026, it is forecast that investors will use frameworks to assess the environmental, social and governance (ESG) impacts of companies for around a fifth of all assets under management (135). Efforts are under way to improve how health is measured as part of these frameworks. However, these approaches also come with challenges, such as data and monitoring difficulties in the central Asian region (136,137). It will be important to engage with emerging evidence from the field of market design, along with evidence from experiments to change key economic sectors, such as food distribution (138). Box 4.2 includes selected examples of efforts to shape markets and support the private sector, which have potential to improve well-being. 4.2 Private and social economy sectors 4. better HealtH and HealtH equity as an outCome 33 • The “Long-term investors in people’s health initiative” aims to include health considerations in investor decision-making, supported by investors managing US$ 5.7 trillion in assets (139). • The European Commission has adopted a proposal for a Directive on corporate sustainability due diligence, which aims to embed human rights and environmental considerations as part of business activities and governance in the corporate sector (140). • The Biscay model proposes favourable tax treatment for companies addressing the SDGs (141). • The United Nations hosts several relevant projects, including the United Nations Global Compact, a major initiative that aims to deliver the SDGs through accountable companies (142). International and intergovernmental organizations play key roles in supporting national policy- and decision-making; they also direct international funding. Many initiatives led by international and intergovernmental organizations are aligned to the goals and principles of a well-being economy. Achieving sufficient financing for sustainable development will require efforts to address challenges related to countries’ debt, combined with the alignment of all financial flows with sustainable development, and better quality data paired with effective monitoring (143). Box 4.3 provides examples of relevant activities by international and intergovernmental organizations. International investments • The ADB is investing in health systems, promoting well-being across the life-course and addressing COVID-19, as well as social protection, poverty reduction and inclusion (144,145). In 2021 the bank reported 28.8 million people with improved living standards, 30 million benefiting from better health, education or social protection, and 1.8 million jobs created. • The IMF allocated Special Drawing Rights (a unique asset) to countries to support the response to the COVID-19 pandemic (146) and recently launched plans for a Resilience and Sustainability Trust to help low-income and vulnerable middle-income countries build resilience to achieve sustainable growth (147). • The Green Climate Fund supports design and implementation of projects in the field of climate change mitigation and adaptation, with themes that include health and livelihoods. To date over US$ 11 billion has been committed, with over US$ 30 billion in co-financing (148). • During the fiscal year 2021, Sustainable Development Bonds worth US$ 68 billion issued by the International Bank of Reconstruction and Development (IBRD) have enabled social safety net coverage for an additional 7 million people, essential services for 4.4 million people, the training or recruitment of nearly 500 000 teachers, savings of 3.5 million tonnes of greenhouse gas emissions and have improved urban conditions for 3.4 million people (149). Shaping and influencing • The International Labour Organization (ILO) is implementing its centenary initiatives around the future of work, and ensuring decent work as part of the green transition and women at work (150). box 4.2 Examples of approaches to shaping markets 4.3 International and intergovernmental organizations box 4.3 Example activities and initiatives by international and intergovernmental organizations HealtH in tHe Well-being eConomy 34 • The World Bank’s report The changing wealth of nations considers the wider well-being capitals (38); the institution also hosts the Human Capital Project, which aims to encourage investments in people (151). • The OECD’s “Beyond Growth” initiative brought together new thinking around economic policy and the measurement of social progress (152). Many NGOs continue to play an active role in developing the well-being economy approach, including by developing innovative policy proposals, sharing evidence, and connecting people and organizations. Philanthropic organizations are also playing key roles in driving a research and practice agenda around the well-being capitals. Box 4.4 provides examples of ongoing activities in this field. • The Finnish Federation for Social Affairs and Health (SOSTE), along with other relevant NGOs was key in driving the early adoption of the economy of well-being concept in Finland (153). • The Wellbeing Economy Alliance (WEAll) is a global project connecting people and organizations working towards well-being economies. Among other outputs, WEAll has published a well-being economy policy design guide (154). • The Doughnut Economics Action Lab (DEAL) has published a guide to help with redesigning businesses to promote equity and improve the environment around us (155). • The Robert Wood Johnson Foundation has conducted extensive work on the social determinants of health, including investments to develop affordable housing, to explore the role of municipal bonds in promoting equity, and research into policies that can tackle health inequalities, such as minimum wages (156). • Wellcome is investing £16 billion by 2023 across a range of research fields, with priorities around climate and health, infectious diseases and mental health (157). 4.4 NGOs box 4.4 Examples of NGO activities aiming to develop the well‑being economy approach 5. HealtH and Well-being as a measure of soCial progress 35 Measuring a wide range of factors that influence well-being is now widely seen as a promising way forward for measuring social progress, and many efforts have been made to develop such indicator sets (see Box 5.1). Yet to date no well-being measurement framework has gained the same level of international agreement as GDP or the same level of application to decision-making. In addition, data collection is far from standardized. • The OECD’s Framework for Measuring Well-being and Progress (26) includes health and other determinants of current well-being, along with natural, economic, social and human capital as resources for future well-being • The UNDP developed the Human Development Index to measure people’s capabilities as a measure of development, rather than assessing only economic growth (158). • Scotland, Iceland and Wales have all developed national measurement frameworks that measure a range of indicators across the well-being capitals (159–161). • The SDG indicators comprise 231 different indicators spanning the 17 SDGs (162). Health outcomes other than life expectancy and self-reported health are not reported consistently in many well-being measurement frameworks. The lack of monitoring around public health goods and policies, including access to health services, could lead to continued underinvestment in these areas. Finance stakeholders may be concerned about the use of self-reported measures, although they are widely accepted in the health field (72). Measures such as healthy life expectancy and the Human Development Index provide important indicators to assess progress towards productive and caring societies, particularly when disaggregated to understand inequalities. Well-being measurement frameworks can strengthen measurement across the human, social, planetary and economic well-being capitals, including public health goods and policies. To track inequalities, indicators should measure a range of domains of inequality, including gender, ethnicity, migrant status, sexual orientation and disabilities. Separating spending on prevention from other more reactive expenditure can help to address long-term issues. It may be necessary for some purposes to create composite indicators or to collect detailed data from individuals –through surveys, for example. Developing comparable metrics and integrating them with decision-making will be critical to their uptake and use in decision-making (163). box 5.1 Examples of well‑being measurement frameworks Health and well-being as a measure of social progress5 HealtH in tHe Well-being eConomy 36 The highest inflation rates in decades are putting pressures on budgets across households, the public sector and businesses, which will have significant impacts on people’s health and well-being. While there is variation in the magnitude of inflation rates across European countries, they share many similar challenges in ensuring their populations’ needs are met. While there has been a reduction in living standards thus far during the cost-of-living increases, the economic outlook for the year ahead is worse, with poor consumer confidence and slower economic growth (164). Those in the bottom and middle of the income distribution, which includes most people with poor health, are less financially resilient owing to a lack of savings and are thus less able to absorb sudden price changes without having to make stark choices about their consumption priorities. The policy challenge with the cost-of-living increases is how to protect the most vulnerable from the worst impacts of the current crisis, mitigating impacts on well-being social solidarity and minimizing further macroeconomic and political instability. Well-being economy approaches can guide us towards a range of approaches that can support people through cost-of-living increases, safeguarding lives and livelihoods. Examples of such approaches are listed here. • Addressing relevant economic, social and environmental issues inspires thinking around holistic policy responses – not just addressing inflation through monetary policy but also equitable approaches to support people to meet their basic needs. • The health sector can support the response to the cost-of-living increases by considering the wages of its workforce, reducing out-of-pocket payments, and by referring individuals with complex needs to additional services, such as social protection, financial support services or energy efficiency services. • Promoting sustainable solutions to meeting basic needs is essential, including in such areas as housing, water and sanitation, or energy provision. • Insight into the impacts of the cost-of-living increases on people can help guide the response: this can include data that track the impacts on vulnerable groups, as well as lived experience and participation approaches that put the voices of those most affected at the centre of decision-making. Analysis from Public Health Wales describes what a whole-system public health response to the cost-of-living increases would look like (165). The 2022 paper proposes short-term responses, such as mental health support, debt support, efforts to reduce fuel poverty or prevent homelessness, support for employees and safeguarding against violence. 6.1 Protecting investment in well-being during the cost-of-living increases Illustrative examples6 6. illustrative examples 37 In the long term, proposals include increased energy efficiency, efforts to improve the supply of affordable high-quality housing and the promotion of fair work. A recent WHO briefing around inequalities in keeping warm highlighted some potential solutions (166), including: • financial mechanisms, such as regulating fuel, increasing minimum wages and implementing benefits to alleviate energy poverty; • targeted financial support, such as heating grants and social tariffs for those most at risk; • investments in energy-efficient housing; • requiring housing to be upgraded to minimum standards; and • social tariffs for energy supply, as well as potentially banning households in arrears from being disconnected from their energy supply. Box 6.1 provides examples of approaches taken across Europe to tackling the cost-of-living increases. • Many countries in Europe have already implemented packages to support their populations with rising costs. For example: ° in Germany, a range of measures are planned, including increased rental subsidies, a cap on gas prices, and national public transport for €49 a month (167); °Spain has implemented a law preventing people with severe health problems from being disconnected from their electricity supply (168). • Time to Talk Public Health in Wales is a representative panel of residents in Wales supporting engagement to underpin public health policy and practice. 2000 people took part in the first phase, with results indicating that 38% of people had worried a lot about the cost of living in the week before the survey, with cost of living being one of the top five priorities reported to Public Health Wales (169). • In Ireland, policies during the COVID-19 pandemic helped households in the bottom 70% of the income distribution to improve their financial situation on average, whereas households in the top 30% of the income distribution were recorded to have experienced financial losses (170). Significant concern has arisen regarding job losses and mental health in young people during the COVID-19 pandemic (171). This presents a significant challenge for policy-makers. Data from 2021 suggest that 64% of young people aged 18–34 years in the EU had a low WHO-5 score2 and were therefore considered at risk of depression (7) and that over 300 million people in Europe were thought to have suffered ACEs; that is, intensive stress in childhood that can have long-term impacts on health and socioeconomic outcomes during a person’s lifetime (88). Addressing ACEs requires a holistic response across sectors to prevent the risk of these events occurring. Failing to invest in young people will result in the accumulation of adverse experiences as well as challenges in addressing the intergenerational care burden. More work is clearly needed to address the scale of the challenge, including: 2 The WHO-5 is a commonly used tool to assess well-being through five questions that assess how the respondent has felt over the prior two weeks (172). box 6.1 Examples of approaches to tackling the cost‑of‑living increases 6.2 Mental health and the inclusion of young people HealtH in tHe Well-being eConomy 38 • universal and equitable mental health support and mental health services, in conjunction with wider services to support employment and universal social protection to prevent income, housing, food and fuel insecurity; • promoting safe physical and virtual environments to enable participation in education and employment, supporting smooth transitions between education, employment and training; • bringing together employers, young people, labour policy-makers and other alliances to ensure that young peoples’ needs are at the centre of policy-making; • addressing stigma, discrimination and bullying; stopping and preventing the accumulation of adverse experiences. Box 6.2 provides examples of approaches to tackling these issues. • Accelerate Estonia is a platform supported by the Government which partners with entrepreneurs to convert global problems (such as poor mental health) into economic opportunities. Those who secure support from the programme receive up to €300 000 in funding, access to policy-makers and advice from diverse sectors (173). • Ritineitis – an NGO in Latvia – has set up a project which encourages young people to participate in civic life by developing ideas to help improve the quality of life in their country (174). • Thriving from the start is a network hosted by the City Mental Health Alliance (CMHA), working to improve the mental health of people who are early in their career or who are in education and seeking work (175). box 6.2 Examples of approaches to tackling mental health and inclusion issues across Europe 7. outComes from tHe regional HigH-level forum 39 Outcomes from the Regional High-level Forum7 Health is essential to a developing a well-being economy and a well-being economy approach can improve health outcomes while contributing to inclusive and sustainable development. Now is the time to capitalize on the global momentum towards developing well-being economies. This will require collaboration between the health, economic development and finance sectors. It will be important to build on existing mechanisms of international collaboration, such as the processes developed and managed by the United Nations agencies (among others). Health stakeholders will need support to be able to fulfil their potential role in a well-being economy approach. Shifting towards well-being economies will no doubt involve a substantial shift in policy and practice. Building on the Forum themes, two main next steps are proposed. • A country policy initiative is needed, to provide Member States with the know-how, example investment cases and modelling of the return on investment from building well-being economies. • A regular forum is required to encourage dialogue between ministries of health, finance and economic development to assess progress, overcome barriers, and set the agenda for how the health sector can serve as a driver, ally and co-creator in the shift towards well-being economies that deliver better health for all. Following endorsement by the attendees of the Regional High-level Forum, the WHO Regional Office for Europe will advance the work outlined in the document, with a more formal presentation of the agenda, workstream and preliminary outputs to be presented at the 73rd session of the WHO Regional Committee for Europe in 2023. The Regional Office will engage with partners to implement the actions agreed. 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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. WHO/EURO:2023-7144-46910-68439 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 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 North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan

Health in the well-being economy Background paper: working together to achieve healthy, fairer, prosperous societies across the WHO European Region Corrigendum Health in the well-being economy Background paper: working together to achieve healthy, fairer, prosperous societies across the WHO European Region WHO/EURO:2023-7144-46910-68439 1. On page 15 Previously: “The pandemic has led to decreased trust in governments – particularly among the unemployed – which was 40% lower after the pandemic (7). The gap is also widening in terms of trust in others, with those earning low incomes reporting 50% lower trust in others than those with high incomes. Now: “The pandemic has led to decreased trust in other people and in government, with widening gaps. People on low incomes report 40% lower trust in others compared with those on a high income, and those who are out of work report 40% lower trust in 2022 than before the pandemic.” 2. On page 32 Previously: “In Preston (United Kingdom) (129) this has been found to be associated with an 11% improvement in mental health and 11% increase in median wages, compared with expected trends.” Now: “In Preston (United Kingdom) (129), this has been found to be associated with reduced antidepressant prescribing and prevalence of depression compared with controls, along with a 9% increase in life satisfaction and 11% increase in median wages compared with expected trends.” Reference changed to Rose TC, Daras K, Manley J, McKeown M, Halliday E, Goodwin TL, Hollingsworth B, Barr B. The mental health and wellbeing impact of a Community Wealth Building programme in England: a difference- in-differences study. Lancet Public Health. 2023 Jun;8(6):e403-e410. doi: 10.1016/S2468-2667(23)00059-2. Epub 2023 Apr 21. PMID: 37094594. These corrections were incorporated into the electronic file on 29 August 2023. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Abstract This is the main evidence synthesis paper for the WHO European Regional High-level Forum on health in the well-being economy. It sets out why we need to shift to well-being economies and the role that can be played by many different stakeholders, as well as outlining several examples already being implemented. Keywords SOCIAL DETERMINANTS OF HEALTH ECONOMIC DEVELOPMENT HEALTH INEQUITIES ENVIRONMENT QUALITY OF LIFE The WHO European Well-being Economy Initiative is led by the WHO European Office for Investment for Health and Development of the WHO Regional Office for Europe, based in Venice, Italy. Contents iii Contents List of tables, figures and boxes iv Tables iv Figures iv Boxes iv Abbreviations v Acknowledgments vi Executive summary vii 1. On the road to well-being economies in the WHO European Region 14 1.1 Pressing challenges threaten health and social cohesion 14 1.2 Why is well-being a priority for decision-makers? 17 1.3 What is a well-being economy? 19 1.4 The emerging global movement towards well-being economies 21 2. The health sector and a healthy population as a driver of well-being economies 24 2.1 The health sector as a well-being economy sector 24 2.2 The role of health care in improving human, social, planetary and economic well-being 25 2.3 Well-being economies invest in health 27 3. Health as a co-creator and partner in producing well-being capitals 28 4. Better health and health equity as an outcome: putting well-being economies into practice 30 4.1 Countries 30 4.2 Private and social economy sectors 32 4.3 International and intergovernmental organizations 33 4.4 NGOs 34 5. Health and well-being as a measure of social progress 35 6. Illustrative examples 36 6.1 Protecting investment in well-being during the cost-of-living increases 36 6.2 Mental health and the inclusion of young people 37 7. Outcomes from the Regional High-level Forum 39 8. References 40 HealtH in tHe Well-being eConomy iv Table 1 Stakeholders and potential actions Fig. 1.1 Underlying causes of pressing challenges for the WHO European Region Fig. 1.2 Well-being capitals with examples in each domain Fig. 1.3 Action areas for creating the conditions for dignity, to thrive and to contribute to society Fig. 1.4 Interconnections between health and well-being economies Fig. 1.5 Timeline of key commitments, commissions and declarations relevant to well-being economies and investment for health box 1.1 The importance of the well-being capitals: human, social, planetary and economic well-being box 1.2 Well-being economy key terms and concepts box 1.3 Examples of policy directives and political actions box 2.1 Examples of how health care is contributing to well-being economies box 2.2 Benefits of investing in health and risks of inaction box 3.1 Health sector as co-creator and partner in producing well-being capitals box 4.1 Illustrative examples of approaches to delivering well-being capitals in the shift towards well-being economies box 4.2 Examples of approaches to shaping markets box 4.3 Example activities and initiatives by international and inter-governmental organizations box 4.4 Examples of NGO activities aiming to develop the well-being economy approach box 5.1 Examples of well-being measurement frameworks box 6.1 Examples of approaches to tackling the cost-of-living increases box 6.2 Examples of approaches to tackling mental health and inclusion issues across Europe Tables Figures Boxes List of tables, figures and boxes abbreviations v ACE adverse childhood experience ADB Asian Development Bank CMHA City Mental Health Alliance COVID-19 coronavirus disease 2019 DEAL Doughnut Economics Action Lab EIGE European Institute for Gender Equality ESG environmental, social and governance EU European Union EPW European Programme of Work, 2020–2025 – “United Action for Better Health” ESCAP United Nations Economic and Social Commission for Asia and the Pacific FAO Food and Agriculture Organization GDP gross domestic product HESRi WHO Health Equity Status Report initiative IBRD International Bank of Reconstruction and Development IHE Institute of Health Equity ILO International Labour Organization IMF International Monetary Fund NGO nongovernmental organization OECD Organisation for Economic Co-operation and Development OOP out-of-pocket SCI Small Countries Initiative SDC Swiss Agency for Development and Cooperation SDG Sustainable Development Goal UHC universal health coverage UNDP United Nations Development Programme UNWTO United Nations World Tourism Organization WEAll Wellbeing Economy Alliance WEGo Wellbeing Economy Governments partnership WHO World Health Organization Abbreviations HealtH in tHe Well-being eConomy vi This report was developed under the overall strategic guidance of Natasha Azzopardi-Muscat (WHO Regional Office for Europe), and the technical leadership of Chris Brown (WHO European Office for Investment for Health and Development). The main contributors were Yannish Naik, Amanda Shriwise, Tahnee Ooms, Anna Stielke, Jasmina Cunmulaj (WHO European Office for Investment for Health and Development), Govin Permanand and Gabriele Pastorino (WHO Regional Office for Europe), and Emma Wright (University of Liverpool). WHO Regional Office for Europe is grateful to the following experts for their guidance and comments in the drafting of the paper: Benjamin Barr (University of Liverpool), Mark Bellis (Public Health Wales and Liverpool John Moores Univesity), Luigi Bertinato (Italian National Institute of Health), Tatjana Buzeti (Ministry of Agriculture, Forestry and Food, Slovenia), Francois Cohen (University of Barcelona), Jon Cylus (WHO Barcelona Office for Health Systems Financing and European Observatory on Health Systems and Policies), Antoni Dedeu (WHO European Centre for Primary Health Care), Carrie Exton (Organisation for Economic Co-operation and Development), Mojca Gabrijelčič (National Institute of Public Health, Slovenia), Tural Gulu (WHO Country Office, Azerbaijan), Heli Hatonen (Ministry of Social Affairs and Health, Finland), Heikki Hiilamo (University of Helsinki), Timotej Jagrič (University of Maribor), Martin McKee (London School of Hygiene and Tropical Medicine), Bettina Maria Menne (WHO European Office for Investment for Health and Development), Sinaia Netanyahu (WHO European Centre for Environment and Health), Cathal O’Donoghue (National University of Ireland), Aaron Reeves (University of Oxford), Jolanta Reingarde (European Institute for Gender Equality), Marc Suhrcke (University of York), Dina von Heimburg (Norwegian University of Science and Technology), and Isabel Yordi Aguirre (WHO European Office for Investment for Health and Development). The WHO Regional Office for Europe is grateful to the following members of the Country Advisory Group for their guidance and feedback in drafting the paper: Tit Albreht (National Institute of Public Health, Slovenia), Tracey Cooper (Public Health Wales), Dóra Guðrún Guðmundsdóttir (Directorate of Health, Iceland), Taru Koivisto (Ministry of Social Affairs and Health, Finland), Marija Palibrk (Ministry of Health, Montenegro), Mojca Presečnik (Institute of Public Health, Slovenia), Robert Velickovski (Ministry of Health, North Macedonia), and Ed Wilson (Welsh Government). Acknowledgments exeCutive summary vii A growing list of challenges, including cost-of-living increases, conflict and climate change are all damaging trust in institutions and social cohesion, and placing health and welfare systems under strain. These are exacerbating existing pressures, such as an ageing population, insufficient numbers of health workers and unmet health needs. Data show a drop in life expectancy, worsening mental health, decreasing trust in institutions, environmental issues and widening inequalities. These challenges have led to significant thinking, know-how and experience around how to respond to these crises while future-proofing societies and policies in ways that build resilience and enable us to thrive and prosper fairly. New and deepening health inequities reflect avoidable fractures within society, threatening cohesion and trust. It will not be possible to achieve healthy, safe and resilient societies and economies with so many being left behind. Equity and inclusion are critical to fair and stable recovery. There is a growing interest in and recognition of the necessity of economic models that focus on fiscal resilience that is fair, and which unlock investments and policies to deliver healthier, fairer societies for the next generation. In this context, human, social, planetary and economic well-being have emerged as key cross-cutting policy priorities. These can be considered the “well-being capitals” – important assets such as trust, social cohesion, participation, our environment, equity and people’s well-being – that are all crucial for developing healthy, fairer and prosperous societies where people can thrive. There are also mutually reinforcing linkages between these dimensions. The focus on well-being as a driver of policy and development both nationally and locally has emerged more strongly since the 2008 financial crisis and in growing recognition that this is vital to secure sustainable health and welfare services. The well-being economy agenda has at its heart the idea of reshaping the economy to secure equitable well-being for people and planet, with underpinning goals of equity, inclusion and sustainability through: • using public and private investment, spending and resources to improve human, social, planetary and economic well-being in a way that is fair and equitable; • recognizing that investing in well-being delivers co-benefits across sectors, and therefore optimizing co-benefits from any decision or investment while minimizing any negative impacts; • delivering public health goods and policies that create the conditions for healthy lives for all and enable people to thrive, such as accessible and high-quality health services, and secure and affordable housing; • recognizing that the solutions for producing well-being lie with different sectors of government and society and therefore engaging a broad range of stakeholders, including the population, as part of implementing the solutions through dialogue. Executive summary HealtH in tHe Well-being eConomy viii A movement of governments, businesses, international institutions and civil society actors across the WHO European Region are aiming to develop well-being economies. Many international organizations have initiatives that can support the well-being economy approach, such as the European Union (EU), World Bank, Organisation for Economic Cooperation and Development (OECD), and other international development institutions. Healthier societies and well-being economies are interconnected agendas. Health status is a crucial determinant of well-being and health systems are a key economic sector. Universal health coverage (UHC) – “all people having access to the full range of quality health services they need, when and where they need them, without financial hardship” (the widely accepted WHO definition) – plays a key role in healthy, fairer and prosperous societies. The health sector is uniquely placed to contribute to well-being economies and is already doing so. This includes, for example, the conscious use of health care employment and procurement to optimize well-being benefits, and transforming health care to promote the four well-being capitals, for example by contributing to delivering environmentally sustainable health services and/or community development. Health services can also address wider social and economic population needs through integration with other services and can limit the use of out-of-pocket (OOP) payments, while also ensuring those most at risk of financial hardship are exempt from these. Investing in health is a vital, with positive returns to societies and economies. The health sector is also a key partner in tackling wider challenges that cannot be solved by any sector alone, such as implementing the One Health approach, or the inclusion of young people and their mental health. Well-being economies are particularly significant for health given the crucial importance of the economic determinants of health. Countries can implement legislation, determine their spending priorities through the national budget, develop new models of governance and implement policies to deliver well-being economies. Fair taxation can be used to increase the available fiscal space, and there are many tools to optimize the use of this fiscal space, such as well-being budgeting and gender budgeting. Innovative instruments can also be used, for example to link social and environmental outcomes with government debt. While countries may face constraints on their ability to identify new resources, they may also redirect existing resources or review how existing services contribute to promoting the well-being capitals. Central banks can also play a role, for example through assessing health risks to the economy and using levers such as monetary policy to improve well-being. As market-driven economic models can lead to negative impacts on people and environments, there is a need to promote private sector activities that improve health while reducing those that negatively affect health. Markets can be shaped through regulation, legislation, incentives and disincentives. This includes the development of investor frameworks that consider health. International and intergovernmental organizations play key roles in supporting national policy- and decision-making; they also direct international funding. More will be required to secure countries’ ability to invest in well-being and there have been calls to change the global financial architecture. Many nongovernmental organizations (NGOs) continue to play an active role in developing the well-being economy approach, including through developing innovative policy proposals, sharing evidence and connecting people and organizations. exeCutive summary ix Going beyond gross domestic product (GDP) to measure the well-being capitals along with public health goods and services (including health services) will be vital in supporting policy-making and investment to promote these well-being capitals. It is important to measure inequalities as well as population averages. Developing comparable metrics and integrating them with decision-making will be critical to their uptake and use in decision-making. This background paper provides a range of examples and prompts to invite delegates to engage in dialogue at the Regional High-level Forum on health in the well-being economy, to be held in Copenhagen, Denmark, 1–3 March 2023. It outlines what a well-being economy is and why a well-being economy approach is needed, now. It provides some preliminary framing of the role to be played by the health sector in supporting well-being economies. It also considers how health can be improved and health inequalities reduced through a wider well-being economy approach. The paper includes evidence and case studies, supporting exchange between countries and experts, and collaboration with other international institutions. The Regional High-level Forum is a way to demonstrate WHO Regional Office for Europe’s leading role in this endeavour, and to answer a need from the countries involved – both big and small – for concrete steps forward. Based on the evidence in the paper and the expert consultation that informed it, Table 1 summarizes some of the steps that stakeholders can take in promoting action towards well-being economies. HealtH in tHe Well-being eConomy x Stakeholders Potential actions SEE SECTIONS Ministry of Health and health sector senior managers Drive well-being through employment and training, by: • investing in the well-being of the workforce and healthy working conditions, including minimum wages, health insurance and pensions for health workers; • employing locally and from underrepresented groups, contributing to income security and human capital development; • addressing inequities in employment (such as the gender pay gap), as well as wider equality and well-being issues among staff, supporting staff progression; • preparing the health workforce for dealing with current and future challenges, for example in preparing them to use a One Health approach and addressing climate change; • ensure sufficient health care staff are trained and recruited to meet current and future demands. Drive well-being through procurement practices, such as: • routine use of social and environmental assessment criteria in tenders; • routine procurement of goods and services from local suppliers, maximizing local returns on investment and contributing to stable local economies. Integrate disaggregated indicators of population well-being into routine data collection, monitoring and reporting of health status and health equity, by: • conducting well-being surveys; • disaggregating data, for example by age, gender, ethnicity, place and socioeconomic status; • increasing compatibility of existing data from health and non-health sectors to assess progress on implementing policies and investments that protect and promote public health goods across the population. Design and implement health and care services that increase well-being, as well as evaluating and reporting impact on health and development goals. This includes: • implementing robust measures to strengthen UHC; • ensuring primary care supports community development and engagement to promote empowerment and inclusion; • delivering health care that is environmentally stable, such as through green hospitals and green procurement; • providing integrated services that meet the health, social, livelihood and well-being needs of the population, including those relating to primary care, legal services, job-seeking and housing; • rural-proofing health services, contributing to improved human development in regions that are falling behind; • limiting the use of OOP payments and ensuring those most at risk of financial hardship are exempt from these; • supporting informal carers to reduce the burden of unpaid care; • future-proofing health and care services to ensure they are able to cope with the challenges of ageing populations; • investing in health emergency preparedness and response systems as an insurance policy against future health threats. Implement joint action with other sectors to tackle large challenges that cannot be solved in silos, such as youth inclusion, mental health issues, and One Health. This includes: • conducting joint problem assessment and solution design; • engaging the population, especially those underrepresented in service design and evaluation. Ensure access to health care is appropriately distributed to address health and health equity needs across geographical (specifically rural) areas, including targeted approaches to recruitment and retention in rural areas. 2 - 3 - 5 - 6 Table 1 Stakeholders and potential actions exeCutive summary xi Stakeholders Potential actions SEE SECTIONS National and regional governments Prioritize well-being through core governance instruments, such as: • laws and regulations; • taxes and fiscal instruments • political bodies, e.g. cross-party committees and steering groups; • political mandates; • ministerial portfolios for well-being and future generations; • public consultations and dialogue to develop locally tailored visions of well-being and to empower the population; • accountability mechanisms that take into account data on well-being outcomes. Ensure that key democratic processes work to include everyone, creating a better society for all. Prioritize well-being across government economic and development policies, including: • monitoring the impact of fiscal and monetary policies on population well-being and equity; • routinely incorporating macroeconomic analysis of well-being into fiscal policy and modelling; • shaping industrial sectors through regulation to support healthy food systems, sustainable travel and sustainable energy. Adopt indicators of well-being as key markers of social progress, incorporating the four well-being capitals, as well as indicators of public health policies and health systems. Develop the conditions for people to lead healthy lives equitably, by: • investing in health and public health systems that are sustainable and able to meet future needs; • prioritizing public health-oriented goods and policies, such as social protection, affordable housing and decent employment; • adopting laws and policies that enable people to thrive, such as minimum wage legislation. Protect national solidarity through redistributive policies. This includes: • using methods to assess the distributional impacts of policies and investments, such as distributional impact assessment tools; • involving the population in assessing the impacts of policies. Support international, cross-sector collaboration between health, economy and finance sectors to work towards a well-being economy. Use public sector procurement to strengthen local supply chains and equitable employment. Develop cross-sector plans to address key priorities, such as increases in the cost of living and the mental health of young people. 4.1 - 5 - 6 Economic and finance policy-makers and ministers Design economic and fiscal policies with a well-being, equity and sustainability lens, by: • investing in producing equitable human, social, economic and planetary well-being, by adopting relevant tools such as well-being budgeting and gender budgeting; • considering the well-being of future generations as part of investments and policies; • developing and implementing analytical methods and tools to measure the likely impacts on human, social, planetary and economic well-being of any investments and policies, while maximizing the co-benefits, for example through national accounts; • investing in health and public health systems, especially health services that deliver well-being, such as community-focused primary care; • developing, appraising, implementing and evaluating innovative policy proposals towards well-being economies; • strengthening health considerations within trade policy; • ensuring improved working conditions and minimum wages. Implement fair taxation to maximize available fiscal space, by: • considering innovative taxes, such as windfall taxes; • eliminating subsidies on products and activities which cause harm to health. Implement market shaping through regulation, incentives, disincentives and investment frameworks, including setting standards for business and investment. 4.1 - 5 - 6 HealtH in tHe Well-being eConomy xii Stakeholders Potential actions SEE SECTIONS Public health institutions and health professional associations Develop training programmes, research and guidance to enable health professionals to take a more holistic approach towards well-being in their practices and services. Engage directly with economic and finance policy-makers on policies that can be shaped jointly to deliver well-being. Focus leadership towards well-being economies, through: • research, sharing evidence and contributing to designing policies to deliver equitable well-being; • data-gathering and analysis, including measures of well-being, public health goods and policies and distributional aspects of these; • evaluation of the impacts of well-being policies and interventions. 2 - 3 - 4 - 5 - 6 Development institutions and international financial institutions Adopt development models and instruments which ensure countries can make investments to promote well-being capitals, such as debt-for-health swaps and bonds. Develop the collaboration mechanisms to embed health and well-being at the heart of international processes. Shape the policy agenda to support countries in implementing well-being economies and delivering public health goods and policies, ensuring equity, inclusion and sustainability are at the heart of policy-making. Make direct investments that promote and protect well-being capitals, including in: • health services that promote well-being, such as those that integrate with other services to meet economic and social needs; • public health goods, such as affordable housing, decent employment and healthy living environments. 4.3 - 5 - 6 Central banks Analyse macro-critical economic health risks, such as population ill-health and pandemics, as part of assessing economic trends. Consider how to promote equitable well-being using monetary policy and through regulation. Consider strengthening/increasing the inclusion of equity and well-being in economic analysis. 4.1 Civil society Continue to advance dialogue, innovation and knowledge exchange to develop the well-being economy approach, including developing resources and educational tools or programmes to support people in implementing well-being economy approaches. Contribute to placing the people’s voice at the centre of policy-making. 4.4 - 6 Research funders and donors Fund international collaborative efforts to inform policy and practice between the health, economy and finance sectors. Support the development of investment frameworks and mechanisms for well-being to be prioritized. Fund research to assess the impacts of innovative interventions. 2 - 3 - 4 - 5 - 6 Investors Prioritize investments that protect and promote well-being capitals. Incorporate health more strongly into investment frameworks. 4.2 Research institutions and universities Strengthen the evidence base around well-being economies to support policy-makers in implementing evidence-based solutions, especially around innovative policies and investments, and the causal chains linking human, social, planetary and economic well-being. Develop innovative methods that allow forecasting and dynamic assessment of return on investment across human, social, planetary and economic well-being. Embed well-being economy concepts within university training programmes. 2 - 3 - 4 - 5 exeCutive summary xiii Stakeholders Potential actions SEE SECTIONS Employers and businesses Prioritize employee well-being and equity in human resources policies. Adopt business models and practices that protect and promote well-being capitals, such as employee-owned businesses. 4.2 WHO Develop tools that can support Member States in applying a well-being economy approach in decision-making and investment, including measurement frameworks and optimizing co-benefits. Shape the agenda around the role of the health sector in developing a well-being economy. Convene dialogues with key stakeholders. 2 - 3 - 4 - 5 - 6 HealtH in tHe Well-being eConomy 14 Europe faces a growing list of connected and pressing challenges. Less than 15 years since the last recession, the region faces the prospect of another recession alongside sharp increases in the cost of living. Alongside this, the region is experiencing the impacts of climate change and environmental damage, continuing conflicts and the risk of worsening social fractures. The novel coronavirus disease 2019 (COVID-19) pandemic led to high excess mortality (2020–2021) and a drop in life expectancy between 2019 and 2021 across most of the WHO European Region (1). The most disadvantaged groups in society have experienced the worst impacts – the gap in levels of well-being between those on low incomes and those on high incomes has increased by 50% since the pandemic (2). 600 000 excess deaths in the WHO European Region during the pandemic can be attributed to low levels of investment in health systems and human development, with higher mortality affecting the poorest countries the most. This builds on pre-existing social inequities and has exacerbated the numbers of children and adults with poor health, living insecure lives, affecting their future opportunities and the capability of countries to recover fairly and safely. Health and welfare systems are under severe strain to cope with the effects of people living insecure lives. United Nations General Assembly Resolution 66/290 highlights that “human security is an approach to assist Member States in identifying and addressing widespread and cross-cutting challenges to the survival, livelihood and dignity of their people” (3). The 2021 Pan-European Commission on Health and Sustainable Development recognized the key role that factors such as worsening wealth and income inequalities, insecure employment, and insufficient investments in social protection play in driving inequalities in health (4,5). These inequalities are exacerbated by significant cost-of-living increases, including increases in the cost of fuel and food, which have led to the highest inflation rates in decades in many countries across the various regions. In the EU, inflation is calculated to have led to around 2% higher levels of deprivation and a 5% higher rate of absolute poverty since 2021 (6). 1.1 Pressing challenges threaten health and social cohesion On the road to well-being economies in the WHO European Region 1 1. on tHe road to Well-being eConomies in tHe WHo european region 15 The pandemic has led to decreased trust in other people and in government, with widening gaps. People on low incomes report 40% lower trust in others compared with those on a high income, and those who are out of work report 40% lower trust in 2022 than before the pandemic. The European Institute for Gender Equality (EIGE)’s gender equality index shows a decrease in several domains for the first time (8). Climate change is increasing the risk of extreme weather events, such as heatwaves and floods. At least 15 000 people died in Europe in 2022 due to heatwaves, with people’s livelihoods severely affected (9). There are likely to be 5 million internal climate migrants in eastern Europe and central Asia by 2050 (10). Biodiversity loss increases the risk of emerging infectious diseases; biodiversity is in strong decline in the region (11,12). These issues present significant risks for future stability and prosperity. These complex challenges threaten progress towards the Sustainable Development Goals (SDGs) (13). They also create significant pressures on health systems, especially in the context of other issues, such as rising unmet needs, long waiting lists and the burden of the condition known as Long COVID. These exacerbate pre-existing pressures, such as the rising proportion of older people in many countries; for example, by 2050, those aged 65 years and over are expected to make up one quarter of the population in the WHO European Region (14). Many countries in the WHO European Region had insufficient numbers of health and care workers prior to COVID-19; the resulting pressures on this workforce following the pandemic and the cost-of-living increases have led to the risk that existing shortages will be amplified. With many countries having more than 30% of doctors aged 55 years or over and more than 20% of nurses in the same age group, investment is needed to secure a workforce that can meet the population’s ongoing need for health care (15). Many of these pressures are underpinned by an undervaluation of the role the public sector plays in ensuring the stability of economies and societies. New and deepening health inequities reflect avoidable factures within society, threatening cohesion and trust. It will not be possible to achieve healthy, safe and resilient societies and economies when so many are being left behind. Widening inequalities between regions within countries since the turn of the century represent further key challenges, as regions are key drivers of national prosperity (16). Areas within countries with higher levels of disadvantage had on average 20% fewer doctors than the national average, prior to the pandemic (2). These inequities between regions are underpinned by a lack of attention to equity and distribution as part of policies to pursue economic growth. Equity and inclusion are critical to fair and stable recovery – and especially to addressing growing concerns about civic unrest, the erosion of democracy and solidarity, and economic resilience. Many of these challenges share common underlying causes, such as economic models that focus on profit over people and planet, unequal distribution of resources, the privatization of public assets and weakened public services (see Fig. 1.1). Whereas, historically, economies and societies have pursued increases in GDP as a key focus for development, there is a growing realization that these significant challenges cannot be solved through markets that only pursue profits. GDP measures important economic factors that have a strong impact on people’s well-being – such as income – but also activities which have a negative impact on health and well-being, such as industrial activities that release pollutants. HealtH in tHe Well-being eConomy 16 Buying back well-being that has been lost or weakened by economic models driven only by profits is not only unethical but also inefficient and ineffective. There is increasing agreement around the need to refocus on protecting and promoting equitable well-being. As this paper seeks to demonstrate, well-being is vital to producing peace and security, as well as resilient people, economies and societies that are more prepared for future crises. Promoting population well-being is also key to reducing the burden on health systems, to enable sustainable and resilient health care. This cannot be achieved in silos, and a new approach is needed to deliver healthy, fairer, prosperous societies (17). Intensive production and consumption of goods contribute to pandemic risks, ecological degradation and NCDs Structural factors affecting ability to buy and access goods and services create inequities in risk of NCDs and vulnerability to health harms Deepening gaps in society affecting social, economic and environmental determinants of health Less public accountability harms service standards, as well as equality of access and care, maintenance and investment The big challenges of our time, including those related to health and well-being, share common underlying causes linked to: Sources: WHO Regional Office for Europe, 2023 (2); WHO, 2022 (17); Shannon et al., 2022 (18); WHO, 2021 (19); Lawler et al., 2021 (20); Allen, Hatefi & Feigl, 2019 (21); Weaver & Fasel, 2018 (22); Guivarch, Taconet & Méjean, 2021 (23); ShareAction, 2022 (24). Fig. 1.1 Underlying causes of pressing challenges for the WHO European Region Underestimation of the importance of public servicesInequitable distribution of opportunities and resources Economic development models focusing on profit over people Producing public value from private assets is underdeveloped and unsystematic 1. on tHe road to Well-being eConomies in tHe WHo european region 17 Well-being is the ability of individuals and society to thrive. It includes elements such as people’s sense of belonging and mattering, and social cohesion, in addition to more direct measures of health status that assess physical and mental health. Different dimensions of well-being exist that are vital to achieving inclusive and sustainable development – these are: social, human, planetary and economic well-being (see Fig. 1.2). These can be thought of as the well-being capitals – important assets such as trust, social cohesion, participation, our environment, equity and people’s well-being that are all crucial for developing healthy, fairer and prosperous societies where people can thrive. Each of these dimensions is made up of several components, which are critical to addressing today’s challenges while developing cohesive, resilient and prosperous societies. In particular, addressing these dimensions of well-being is key to managing long-term pressures on health systems. Box 1.1 provides an overview of why each of these well-being capitals matters. There are important connections between these capitals too – as investing in one can have benefits and negative impacts for another sector – known as co-benefits and co-costs. In some cases, this can lead to greater returns than invested, known as a multiplier effect (25). Given the vital importance of these four well-being capitals, developing a well-being economy involves protecting, promoting and innovating to develop them. 1.2 Why is well-being a priority for decision-makers? Fig. 1.2 Well‑being capitals with examples in each domain POLICY & GOVERNANCE Planetary well-being Human well-being Economic well-being Social well-being Good air & water quality Healthy & sustainable living environment Sustainable public transport & active travel Access to safe green space Stable climate Biodiversity & natural capital Circular economy & green technology Living wage Universal social protection through the life‑course Decent, psychologically safe work Gender‑responsive employment Social dialogue & collective bargaining Economic cohesion & balanced development Healthy life expectancy Mental health & well‑being Ability to carry out daily activities free from illness Universal Health Coverage Quality & non‑discriminatory health & social care Universal policies for housing, food & fuel security Early childhood development Lifelong learning & literacy Safe, orderly & regular migration Living in safety & free from violence Sense of belonging (“Mattering”) Social cohesion & embracing diversity Perceived ability to influence politics & decisions (“Agency”) Social support & protection Building trust in others & in institutions Public spending on communities Participation in volunteering Source: WHO analysis, building on OECD well-being framework (26). HealtH in tHe Well-being eConomy 18 Why is human well-being important? People’s health and their subjective well-being are closely linked; both are drivers of economic prosperity. Well-being makes fundamental contributions to health, such as greater life expectancy, increased likelihood of adopting healthy behaviours, reduced incidence of serious health conditions and improved outcomes of existing conditions (27). Health also plays a key role in economic development: for example, reduced mortality is calculated to have contributed 11% of economic growth in low- and middle-income countries in recent years (28). Globally, depression and anxiety lead to around US$ 1 trillion of productivity losses each year (29). Avoidable health inequities across the majority of EU countries are estimated to lead to welfare losses of €980 billion a year (30). Education and health services are drivers of health and economic outcomes (31). Early childhood interventions can improve education levels and employment opportunities with an eightfold economic return (32). Affordable, accessible and high-quality integrated health services are key enablers of human capital across the life-course. See Chapter 2 (Box 2.2) for more details on the return on investment of health services. Why is social well-being important? Trust, participation and social cohesion make significant contributions to health and well-being, including health equity, as well as being vital to prosperous and resilient societies. Life expectancy gaps between the richest and poorest parts of a country are lower in countries with strong democracies (33). Democratization can also lead to increases in GDP per capita of approximately 20% (34). Why is planetary well-being important? The environment is key to human well-being and economic prosperity (35). The World Bank estimates that droughts and floods – both made more likely by climate change – could cause damage of up to 1.3% of GDP each year in central Asia and extreme weather could cost the EU €170 billion by 2100 (36). 58% of the world’s infectious diseases have been exacerbated by climate change (37). Natural capital accounted for 23% of the wealth of low-income countries in 2018, down from 39% in 1995 (38). Green spaces make key contributions to physical and mental health – areas with accessible green space have significantly lower inequalities in mortality (39). In 2020, exposure to fine particulate air pollution led to at least 238 000 deaths across the EU, and air pollution makes significant contributions to the burden of chronic disease (40). Why is economic well-being important? Workforce well-being increases performance, decreases staff turnover, and has positive outcomes for employees, employers and the overall economy (41). The economic cost of absence related to ill-health and inability to work is over £100 billion annually in the United Kingdom (42). The well-being of health care staff is vital – it can improve patient safety and is also important for the long-term capacity of the health workforce, where addressing issues of burnout and staff retention are key (43). High levels of inequality can damage trust, increase the risk of conflict, reduce economic prosperity and increase the severity of recessions (44–48). The International Monetary Fund (IMF) has recognized that increases in income share for the 20% at the top of the income distribution ultimately lead to decreases in GDP, whereas for all other groups increases in income share lead to increases in GDP (49). Improving gender equality could lead to increases in GDP of 6.1–9.6% by 2050 for EU countries and of 1.5% by 2035 in the Western Balkans (50–52). box 1.1 The importance of the well‑being capitals: human, social, planetary and economic well‑being 1. on tHe road to Well-being eConomies in tHe WHo european region 19 The policy focus on a well-being economy has emerged strongly since 2008 and the financial crisis. It builds on decades of thinking and action across domains, including health systems, economics, international development, environmental sustainability, and the social determinants of health (53–56). A well-being economy approach provides an important pathway for implementing inclusive and sustainable development. There is no single definition of a well-being economy but certain themes recur in interpretations of it; whether as the goal itself – that is, what a well-being economy aims to achieve – or as the approach – that is, how to deliver it. These concepts are summarized in Box 1.2. A well-being economy as a goal is an economy which secures well-being for all people today and for future generations, and includes the well-being of the planet as an overarching goal. • Equity – equality across domains, including gender, ethnicity and age. • Inclusion – people participating in society and having a voice in decision-making. • Sustainability – including addressing climate change and biodiversity loss. A well-being economy approach is a combination of ways of working that contribute to achieving the above goals (equity, inclusion and sustainability). • Investing in and producing the four well-being capitals involves using public and private investment, spending and resources to improve human, social, planetary and economic well-being in a way that is fair and equitable. • Optimizing co-benefits from the four well-being capitals entails explicitly considering in policy design and investment decisions the benefits and risks to the four capitals. • Creating the conditions for people to lead healthy lives means delivering policies, essential goods and services that enable people to live in dignity, to thrive and contribute to society – also known as public health goods and policies (see Fig. 1.3 for the relevant action areas) (57). • Recognizing that the solutions to produce well-being lie with different sectors of government and society is key, and therefore engaging a broad range of stakeholders including the population as part of implementing the identified solutions through dialogue. 1.3 What is a well-being economy? box 1.2 Well‑being economy key terms and concepts HealtH in tHe Well-being eConomy 20 The well-being economy approach can be taken in all countries across the WHO European Region, irrespective of the size of the country or type of economy. However, the approach needs to be adapted in response to country-specific assets (such as existing economic sectors) and the cultural context (such as people’s aspirations); different economic sectors will require different approaches. Healthier societies and well-being economies are interconnected agendas (see Fig. 1.4). With economic, social and environmental factors having a critical influence on health outcomes, achieving the goals of a well-being economy is highly likely to benefit people’s health. Equally, a well-being economy will not be achievable without addressing health inequalities and recognizing that the health sector has a key role to play in improving well-being. HEALTH & INCOME SECURITY AND SOCIAL PROTECTION Unemployment insurance HEALTH & LIVING CONDITIONS Secure and affordable housing HEALTH & SOCIAL AND HUMAN CAPITAL Trust in institutions and in others HEALTH & EMPLOYMENT AND WORKING CONDITIONS Working conditions; active labour market programmes Universal Health Coverage HEALTH & HEALTH SERVICES Fig. 1.3 Action areas for creating the conditions for dignity, to thrive and to contribute to society Source: adapted from the work of the WHO Health Equity Status Report Initiative (HESRi). 1. on tHe road to Well-being eConomies in tHe WHo european region 21 A growing movement of governments, businesses, research organizations, financial institutions and civil society actors is seeking to develop well-being economies. This includes commitments from across the WHO European Region as well as more widely, from other regions. Action to develop well-being economies is already advancing, including strategic commitments, laws, changes to how budget decisions are made, new monitoring systems and international collaboration efforts. WHO has a clear mandate to support this work. This includes: • the Global Programme of Work 2019–2023 target of 1 billion more people enjoying better health and well-being and highlighting of the social, environmental and economic determinants of health, as well as 1 billion more people benefiting from UHC – implementing the Health in the Well-being Economy approach provides a way to meet both goals (58); • the European Programme of Work (2020–2025 – “United Action for Better Health”) (EPW), which includes specific mention of initiatives to “address local determinants of health with green deal investments into a future economy of well-being” (59); • the WHO Geneva Charter for Well-being (2021), which builds on the Ottawa Charter for Health Promotion and nine global conferences on health promotion – it highlights the need for a just transition to a low-carbon economy and to an equitable economy that serves human development within ecological boundaries (19); • the 2021 Pan-European Commission on Health and Sustainable Development, which made the case for a paradigm shift in thinking around the relationship between health, environment and the economy, and the need to prioritize investments that enable people to thrive equitably while building resilience (4,5). 1.4 The emerging global movement towards well-being economies Fig. 1.4 Interconnections between health and well‑being economies Source: authors’ own compilation. EQUALLY HEALTHY PEOPLE EQUITABLE HEALTH SYSTEMS EQUITABLE PUBLIC HEALTH POLICIES WELL-BEING ECONOMY WELL-BEING CAPITALS Human well‑being Planetary well‑being Social well‑being Economic well‑being HealtH in tHe Well-being eConomy 22 The well-being economy approach – and especially its alignment with the health agenda – builds on multiple international declarations and commitments. There are also accelerating commitments to further action to support the well-being economy approach across the WHO European Region. Fig. 1.5 summarizes key commitments, commissions and declarations underpinning the movement towards well-being economies, including WHO’s mandate. Box 1.3 provides examples of policy directives and political actions under way in the same field. Fig. 1.5 Timeline of key commitments, commissions and declarations relevant to well‑being economies and investment for health Source: authors’ own compilation. EU Council Porto Declaration (2021) welcomes measures of economic, social and environmental progress to supplement GDP Geneva Charter for Well-being (2021) draws attention to the need for a just transition to a low-carbon economy and to an equitable economy that serves human development within ecological boundaries EU Council conclusions on the Economy of Wellbeing (2019) were adopted in 2019, which included inviting stakeholders to strengthen the work around economies of well-being WHO Europe Regional Committee Resolution on increasing equity in health (2019) highlights that stronger partnerships and alliances are needed to bring the social values of solidarity, equity, social justice, inclusion and gender equality into mainstream fiscal and growth policies 2030 Agenda (2015) is the overarching framework for sustainable development until 2030, with SDGs that include health, equity and decent work Commission on the Measurement of Economic Performance and Social Progress (2008) explored measurement of social progress beyond GDP Rio Declaration (1992) establishes collaborative commitments towards sustainable development, linking with economic development Tallinn Charter (2008) through which WHO European Region Member States committed to investments in health and in other sectors that influence health Addis Ababa Action Agenda (2015 ) comprises a set of policies to transform the global economy and meet the SDGs, with a global framework to finance sustainable development Global Action Plan for Healthy Lives and Wellbeing for All (2019) is a global, multistakeholder plan, which includes strengthening the use of fiscal measures and national investment to address the determinants of health WHO Global Programme of Work (2019) sets the goal of 1 billion more people enjoying better health and well-being, highlights the need to address the social, environmental and economie determinants of health through a multisectoral approach WHO European Programme of Work (2020) incorporates the promotion of initiatives to address local determinants of health with green deal investments into a future economy of well-being WHO Council on the Economics of Health for All (2020) aims to reframe health for all as a public policy objective, and ensure that national and global economies and finance are structured in such a way to deliver on this ambitious goal Pan-European Commission on Health and Sustainable Development (2021) calls for a paradigm shift around the relationship between health, environment and the economy, and prioritizing investments that enable people to thrive equitably while building resilience 1. on tHe road to Well-being eConomies in tHe WHo european region 23 National actions • Finland, Iceland, New Zealand, Scotland and Wales are part of the Wellbeing Economy Governments (WEGo) partnership initiative to advance collaboratively their shared goal of developing well-being economies (60). Two concrete examples are outlined here. °Building on a public consultation process to understand the future desired by Welsh citizens, Wales created the Well-being of Future Generations Act (61), which places a duty on all public bodies to consider the well-being of future generations when developing public policies. ° Iceland has developed an indicator framework bringing together indicators of social, economic and environmental progress, including health measures; then developed well-being priorities and used these to guide its fiscal strategy (62). Since the 2008 recession, Iceland brought about a decrease in financial hardship and more equal income distribution through changes to tax policy and labour market policies, and support for people with lower incomes, including those with debts (63). Iceland has seen high rates of GDP growth – often above 4% – since 2013 and often the highest employment rate among EU countries (64,65). International examples • The EU legislative programme to embed an economy that works for people includes legislation on minimum wages, sustainable corporate governance and minimum corporate taxes (66). There are a number of other initiatives at the European level, including the European Pillar of Social Rights and major investments in a green transition through the European Green Deal Investment Plan (67,68). • The Central Asia Regional Economic Cooperation (CAREC) Institute is implementing a programme on green, inclusive and sustainable recovery (69). • The Economic and Social Commission for Asia and the Pacific (ESCAP), the Asian Development Bank (ADB) and the United Nations Development Programme (UNDP) have reported on promoting inclusive recovery from COVID (70). box 1.3 Examples of policy directives and political actions HealtH in tHe Well-being eConomy 24 Healthy people and the health sector play key roles in a well-being economy. Health status is strongly linked to people’s well-being (71), making important contributions to livelihoods, people’s agency and their contribution to society. The distribution of physical and mental health in a population is another key factor – for example, reducing inequities in life expectancy between groups by 50% could lead to benefits of 0.3–4.3% of GDP (72). UHC – “that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship” – is a vital component of a well-being economy (73). One of the key ways in which health systems can prevent households from experiencing financial hardship is by limiting the use of OOP payments to finance health care, and by putting protective coverage policies in place to ensure those households most at risk of financial hardship are exempt from making OOP payments (74). The health sector is a key economic sector with a large employment and procurement footprint, which impacts on communities as well as making wider contributions to economies and societies (75). In 2020, health and social work accounted for on average 10% of total employment across the WHO European Region, although data were not available for all countries (15). Effective investment into the health and care workforce results in positive returns for societies and economies (76). Health systems can produce the well-being capitals through procurement that incorporates social and environmental considerations or that develops local supply chains, as well as decent, inclusive employment. It is also important for the health system to address inequities in employment, such as the gender pay gap, which is calculated to be 20% in the health and care sector, compared with 12% in other sectors (15), to address wider equality issues such as the prevention of violence and harassment of employees, as well as promoting staff well-being. Accessible health services are increasingly seen to be a key part of rural policy, in particular because they can create additional jobs (77,78). The stability of the health sector ensures continuity as well as livelihood opportunities in places where health services exist. Primary care is particularly important in this respect, as it is often a significant employer in rural areas. 2.1 The health sector as a well-being economy sector The health sector and a healthy population as a driver of well-being economies 2 2. tHe HealtH seCtor and a HealtHy population 25 Health systems can also make other key contributions to well-being economies, according to how care is delivered. It is important to develop health services that prioritize prevention, community development and integration with services to meet people’s wider economic and social needs, such as employment services and social care. This includes strengthening primary care services to address community needs through public engagement and mental health care. It is also essential to ensure that any private care provision enhances public health care. It is also important to support unpaid, informal carers who currently carry out the majority of long-term care in Europe, with a higher proportion of women than men undertaking this role (79). To provide 10% of older people who receive informal care with formal care instead would require a doubling of expenditure on long-term care in EU countries. Health care results in considerable carbon emissions (80). Achieving environmentally sustainable health care will require a significant transformation of health care delivery to minimize its environmental impact, spanning medicines, facilities, travel, equipment, care pathways and many other domains. This will become increasingly important as part of actions needed to tackle climate change. Box 2.1 provides examples of how health care contributes to well-being economies. Employment and procurement levers • The region of Utrecht added a social return clause to all public tenders, with contracts over €100 000 requiring 5% of the contract value to be spent adding social value, for example on education or employment for people removed from the labour market (81). • The West Belfast and Greater Shankill Health Employment Partnership promoted opportunities for people who were economically inactive and lower paid workers. This led to unemployed people finding employment, lower paid staff obtaining promotions and savings on unemployment benefits (81). • The NHS in England has a target of net zero by 2045 for emissions influenced through suppliers and partners (82). Since 2022, NHS procurement in England is to include a 10% net zero and social value weighting. From 2023, contracts above £5 million per annum will require a carbon-reduction plan from suppliers; this will be extended to all suppliers from 2024. By 2030, only suppliers that can demonstrate progress around carbon emissions will qualify for contracts. Community services • Caring neighbourhoods is an initiative in the Flanders region in Belgium, which aims to develop the conditions for all people to live comfortably in their homes and neighbourhoods, encompassing aspects such as safety, social connectedness and informal care, alongside formal, integrated health services. 133 projects had been started by 2022 (83). • Men’s sheds are community-based initiatives that provide the opportunity for men to take part in social activities in the community. The “Sheds for life” programme in Ireland showed increases in self-rated health and life satisfaction, sense of belonging and trust, among other positive outcomes (84). • The cottage hospital model from southern Lapland, Sweden, builds on cross-sectoral collaboration between key stakeholders with the community for providing primary care in remote, rural and sparsely 2.2 The role of health care in improving human, social, planetary and economic well-being box 2.1 Examples of health care’s contribution to well‑being economies HealtH in tHe Well-being eConomy 26 populated areas (85). This collaboration – bridging the gaps between the voices of clinical practice, policy, innovators, and the community – has resulted in industrial innovation and its adoption in health care. Cottage hospitals apply innovative and remote health care delivery solutions, including drone technology and digital solutions, along with a wide range of telemedicine applications. • In Kyrgyzstan, Village Health Committees were set up. Local residents select priorities and elect representatives to the committee, which then play a key role in delivering health-related activities. The programme has been scaled up nationally. Over two years, the programme led to the detection of over 180 000 people with high blood pressure, as well as helping individuals to feel enabled to be more involved in health improvements (86). Redesigning mental health services • Czechia has been reforming mental health care – moving away from a focus on long-stay facility-based care towards a model that addresses the psychosocial environment. Social workers support social rehabilitation including the allocation of social housing and connections to other services (87). • Triple P is a multi-level approach including media campaigns and intensive support for families who are deemed high risk, focusing on children aged under 12 years. By promoting positive parenting, the programme also promotes social competence and emotional self-regulation in children. It has been found to positively impact maltreatment and injuries resulting from maltreatment, as well as out-of-home-placements, thus contributing to a reduced risk of adverse childhood experiences (ACEs) (88). Environmentally sustainable health care • Innovations in environmentally sustainable health care in the Nordic countries are supporting the delivery of health services – one such example is the use of battery-powered drones to increase the speed of transfer of blood samples (89). • The University Hospital of South Manchester in the United Kingdom decreased its reliance on non-renewable energy sources by 36% through a combination of technical and behavioural changes (90), while also reducing carbon emissions by 28% and generating savings of £390 000 a year. • Ospedale dell’Angelo Mestre is a technologically advanced hospital in Venice-Mestre, surrounded by a landscape garden (91). It also has various roof gardens, abundant gardens connecting the buildings and green roofs, contributing to water drainage and bringing important benefits to patients’ well-being. Integration with other services • Health justice partnerships are partnerships between health care services and legal services to provide support on a range of issues, such as housing and debt. Evidence suggests that these partnerships can improve the life circumstances of people accessing the service, as well as promoting mental well-being (92). • Kazakhstan has moved towards multidisciplinary primary care, with an emphasis on stronger social care and mental health care, leading to reduced use of specialized and hospital services (93). 2. tHe HealtH seCtor and a HealtHy population 27 Efforts to protect and improve health and health systems are not costs, but are core investments in producing peace and security, as well as resilient people, economies and societies (94,95). Box. 2.2 outlines some of the benefits of investing in health, along with some of the risks of inaction. • Investment in health systems has a multiplier effect – for every €100 000 invested, on average four new jobs are created elsewhere in the economy (in some countries this can be as high as 10 new jobs). The employment multiplier for the health sector is higher than the average across all economic sectors (81). • Public health interventions have been found to have an average return on investment ratio of 14 to 1 (96). Many health interventions also deliver wider social returns, such as social prescribing, which delivers 3.5 times the benefit for every unit invested, including benefits in terms of educational outcomes and volunteering (97). UHC has an expected return of US$ 1.4 for every dollar invested (98). • Resilient health and public health systems can help to protect the economy and other social systems from shocks. The health sector is one of the most stable industries during economic recessions. The IMF has estimated the impact of COVID-19 on the global economy to be in excess of US$ 12.5 trillion (99). Yet we also know that health systems are often under-provisioned and face significant workforce challenges (100). Investment needs to focus on both long-term improvements in well-being and in the resilience of health and public health systems to ensure society can respond effectively to future pandemics and other health crises. 2.3 Well-being economies invest in health box 2.2 Benefits of investing in health and risks of inaction HealtH in tHe Well-being eConomy 28 Health stakeholders are increasingly acting as partners to tackle wider challenges that no single sector can tackle alone. For example, One Health is an approach that aims to sustainably optimize the health of people, animals and ecosystems by virtue of their interdependence (101). The approach is important because 60% of emerging infectious diseases come from animals, and there are many stresses on ecosystems – such as loss of habitats – which increase the likelihood of new diseases emerging. This involves health stakeholders, animal health stakeholders and environmental stakeholders working together across and between their individual goals, to prevent outbreaks of emerging diseases, improve food safety, reduce AMR and protect biodiversity (102). Health stakeholders can support the creation of conditions for healthy living by supporting wider policy-making and collaborating with the economic and finance sectors. The pandemic has already led to the emergence of such collaboration. Box 3.1 provides several examples where the health sector has partnered with other sectors. • Tobacco-free farms is a joint initiative by WHO, the Food and Agriculture Organization (FAO), and the World Food Programme to support tobacco farmers in Kenya in switching from labour-intensive tobacco farming to alternative crops that have fewer health, socioeconomic and environmental risks (103). To date, the initiative has supported 1413 farmers to switch to alternative livelihoods, covering 806.5 acres of land; as a result, 481.4 tonnes of high-iron beans were sold in the first season. Harvesting and aggregation for the most recent season are ongoing at the time of writing.1 • Healthy Working Wales (104) is a programme supporting employers to improve the health and well-being of staff employed in Wales, including through creating healthy working environments and engaging with employees. The programme delivers advice and support, and operates an awards scheme, among other activities. Employee engagement and well-being contribute to beneficial outcomes for employers, such as increased productivity and workforce retention. • The importance of multisectoral collaboration on health and tourism is increasingly recognized. Elaborating on the lessons learned from the COVID-19 pandemic and the need for multi-level cooperation between the health and the tourism sectors, countries of the Small Countries 1. Data provided with permission to share by WHO’s Tobacco Free Initiative on 11 January 2023. box 3.1 Health sector as co‑creator and partner in producing well‑being capitals Health as a co-creator and partner in producing well-being capitals 3 3. HealtH as a Co-Creator and partner in produCing Well-being Capitals 29 Initiative (SCI) recognized at the 8th High-level Meeting of the SCI in Montenegro that the reopening of travel and tourism is crucial for economic recovery, jobs and livelihoods. Based on the SCI Montenegro Statement (105) and a policy brief on health and tourism (106), a Coalition of Partners on Health and Tourism will be created, jointly coordinated by the WHO European Office for Investment for Health and Development (Venice Office) and the United Nations World Tourism Organization (UNWTO). Its aim is to prepare health systems across the WHO European Region for promoting the health of tourists, host communities, tourism workers and the environment, and making health and well-being a priority for resilient, inclusive and sustainable tourism development. • WHO Regional Office for Europe has launched the Pan-European Mental Health Coalition as a flagship initiative to promote mental health across the Region (107). In bringing together a diverse group of members with a shared interest in improving mental health across Europe, the Coalition represents a recognition of the need for multisectoral stakeholder engagement to drive priority actions for the Region, including: raising awareness and reducing stigma; expanding community-based delivery of mental health services; strengthening the mental health workforce; and building capacity in community settings (such as schools and workplaces) to promote and protect mental health throughout the life-course. The #Youth4Health Tirana 2022 Health and Well-being Forum for Youth brought together young people, public health experts and partners from the WHO European Region to network and discuss current health and well-being issues. The Forum created space for dialogue with young people around how mental health challenges can be addressed through intersectoral collaboration (108), with the goal of shaping policies to have more impact in terms of supporting inclusion, trust and livelihood security. • The European Environment and Health Process (109) is designed to enable cross-sectoral work towards eliminating environmental threats to human health. Every 5–7 years, a ministerial conference brings together the environment and health sectors to shape relevant policies and actions. The last Environment and Health Ministerial declaration – the Ostrava Declaration – summarizes priorities for the WHO European Region, with a commitment to develop national portfolios for action that should address the need to accelerate progress on health and environment and, in particular, address the relevant goals and targets of the 2030 Sustainable Development Agenda. A new institutional framework was agreed to ensure appropriate coordination and collaboration between the national, subnational and international levels, the proper level of monitoring and implementation, and the necessary political drive (110). HealtH in tHe Well-being eConomy 30 A substantial evidence base has developed around the wide range of economic factors and policies that impact health and well-being (111). These provide solid foundations for developing well-being economies, spanning a number of topics, such as working conditions, trade, and taxes on unhealthy products. In terms of several promising innovative interventions – from circular economies to universal basic incomes – the evidence is complex, and more research is required (112,113). Yet the scale and urgency of many current challenges implies that interventions will need to be tested and scaled up rapidly. Action is already being taken at country level, as well as by businesses, the social sector, international institutions and NGOs. The following subsections provide a brief overview of the roles some of these organizations can play. Countries can take a whole-of-government approach – including by developing political bodies such as cross-party committees or steering groups – to take forward shared action on well-being. They can create clear political mandates for well-being through, for example, a Ministerial portfolio for well-being or by having independent commissioners tasked with embedding well-being into thinking and policies. They can also put people’s voices at the heart of decision-making, though consultations or public dialogues. Further actions include implementing laws and regulations, determining spending priorities through the national budget using tools such as gender or well-being budgeting, and implementing policies designed specifically deliver well-being economies. According to the IMF, as of 2021, all G20 countries had implemented fiscal approaches focusing on gender, although the “tools to operationalize these policies [were] far less established” (114). Crucially, countries can implement a combination of hard measures (such as laws and investment frameworks) and soft measures (such as participatory problem analysis, involving various stakeholders) to deliver well-being economies. National governments can raise revenue through fair taxation, increasing the fiscal space available to them (115) as well as boosting the benefits of this fiscal space through approaches to optimize co-benefits across sectors. There are many tools that can help with embedding a well-being economy approach in budgeting – from methods to appraise the value of the multiple benefits of investments to budget tools such as gender budgeting. 4.1 Countries Better health and health equity as an outcome: putting well-being economies into practice 4 4. better HealtH and HealtH equity as an outCome 31 A wide range of taxes have been used or proposed as means to generate revenue, and there is an increasing recognition of the importance of fair taxation in driving equity and economic resilience. Recently, increasing attention is being paid to innovative taxes such as windfall taxes – where a single tax is raised from companies who have generated profits that are felt to be unreasonable due to unusually favourable markets, but at the expense of wider society (116). Alternatively, subsidies on fossil fuels have been identified as an ideal target for reduced spending, representing US$ 5.9 trillion globally (117). A number of innovative instruments also exist, such as linking government debt with social and environmental outcomes, debt cancellations conditional on other investments, and social impact bonds (118–120). Countries can contribute to well-being economies by investing in sustainable travel and energy systems, developing healthy and sustainable food systems, and promoting initiatives that combine sustainable resource management with improving livelihoods. Countries may still face constraints on their ability to spend and there is ongoing debate about how these constraints can be eased (121). So, if countries are unable to identify new resources they may be able to redirect existing resources or review existing services to ensure they derive the most benefit. Whatever stage Member States are at with budget planning for 2023–2024, there are likely to be opportunities to shift towards investing in well-being in both the short and long term. The public sector can also play a role in shifting investment towards well-being, for example through procurement strategies. Regions can also play a key role, including by investing locally, hiring locally, collaborating across sectors and budget lines, and knowing and involving people as partners in solutions for healthier societies. Central banks are increasingly responding to climate change (122,47), including by assessing risks, developing standards for green finance and issuing green bonds. There is increasing interest in how central banks can address inequality (47). Central banks can go further to address population health issues, for example by assessing public health risks, incorporating health issues in modelling and using available levers – such as monetary policy and regulation – to contribute to improving well-being. Illustrative examples of approaches to delivering well-being capitals are provided in Box 4.1. Whole-of-government approaches and public engagement • In Finland, a cross-sector model of governance is being developed to steer the economy of well-being (123). This Finnish example is a local-to-global approach – it includes local government action as well as international leadership, through the country’s Presidency of the EU. • Scotland is engaging the population in decisions around public spending with plans for at least 1% of local government budgets to be subject to participatory budgeting (124). Scotland also has a Cross-Party Group on Health Inequalities, which works with parliamentarians and policy-makers to tackle health inequalities (125). Shifting investment and resources • New Zealand’s Public Finance (Wellbeing) Amendment Bill requires the Government to report annually on budgetary well-being objectives and the Treasury to report on the state of well-being (126). The Treasury’s Living Standards Framework is a holistic, locally relevant measurement box 4.1 Illustrative examples of approaches to delivering well‑being capitals in the shift towards well‑being economies HealtH in tHe Well-being eConomy 32 framework that captures relevant capitals and is used to consider the impacts of policy decisions (127). • In Austria, gender budgeting is required by the Constitution at every level of government, including reporting of gender equality achievements and outcomes, and auditing of budget programme impacts (114). The EIGE has published a set of tools to support gender budgeting (128). • Community wealth building is a public sector approach using procurement and employment levers to improve residents’ economic circumstances. In Preston (United Kingdom) (129), this has been found to be associated with reduced antidepressant prescribing and prevalence of depression compared with controls, along with a 9% increase in life satisfaction and 11% increase in median wages compared with expected trends. Innovative instruments and approaches • Debt2Health is a scheme whereby debts are cancelled in return for investment in health (130). To date, over US$ 350 million in debt has been cancelled, with over US$ 220 million invested in health programmes. • The EU has plans to raise €140 billion from producers of electricity from sources other than gas, which are making higher than usual profits due to current demand (131). Purely profit-driven markets can lead to negative impacts on people and environments. There is therefore a need to promote activities in the private sector that improve health, while reducing those that negatively affect health. This includes their role in improving the health of consumers, employees and the community (132), and social economy business models which are likely to improve health, such as employee-owned organizations (133). Managing conflicts of interest is also key when addressing private sector activities that harm health. There are many examples of private companies taking innovative approaches to promote well-being capitals as part of their business activities, including actions taken across their business models, employment practices and supply chains. However, there is still room for many more businesses to act as a force for good. Charities and foundations are acting as a bridge to shape the world of business (see, for example, the “Long-term investors in people’s health initiative” in Box 4.2). Markets can be shaped through regulation, legislation, incentives and disincentives. Countries can look to WHO for guidance on effective interventions to prevent noncommunicable diseases through market regulation around unhealthy goods, including laws and pricing strategies (134). By 2026, it is forecast that investors will use frameworks to assess the environmental, social and governance (ESG) impacts of companies for around a fifth of all assets under management (135). Efforts are under way to improve how health is measured as part of these frameworks. However, these approaches also come with challenges, such as data and monitoring difficulties in the central Asian region (136,137). It will be important to engage with emerging evidence from the field of market design, along with evidence from experiments to change key economic sectors, such as food distribution (138). Box 4.2 includes selected examples of efforts to shape markets and support the private sector, which have potential to improve well-being. 4.2 Private and social economy sectors 4. better HealtH and HealtH equity as an outCome 33 • The “Long-term investors in people’s health initiative” aims to include health considerations in investor decision-making, supported by investors managing US$ 5.7 trillion in assets (139). • The European Commission has adopted a proposal for a Directive on corporate sustainability due diligence, which aims to embed human rights and environmental considerations as part of business activities and governance in the corporate sector (140). • The Biscay model proposes favourable tax treatment for companies addressing the SDGs (141). • The United Nations hosts several relevant projects, including the United Nations Global Compact, a major initiative that aims to deliver the SDGs through accountable companies (142). International and intergovernmental organizations play key roles in supporting national policy- and decision-making; they also direct international funding. Many initiatives led by international and intergovernmental organizations are aligned to the goals and principles of a well-being economy. Achieving sufficient financing for sustainable development will require efforts to address challenges related to countries’ debt, combined with the alignment of all financial flows with sustainable development, and better quality data paired with effective monitoring (143). Box 4.3 provides examples of relevant activities by international and intergovernmental organizations. International investments • The ADB is investing in health systems, promoting well-being across the life-course and addressing COVID-19, as well as social protection, poverty reduction and inclusion (144,145). In 2021 the bank reported 28.8 million people with improved living standards, 30 million benefiting from better health, education or social protection, and 1.8 million jobs created. • The IMF allocated Special Drawing Rights (a unique asset) to countries to support the response to the COVID-19 pandemic (146) and recently launched plans for a Resilience and Sustainability Trust to help low-income and vulnerable middle-income countries build resilience to achieve sustainable growth (147). • The Green Climate Fund supports design and implementation of projects in the field of climate change mitigation and adaptation, with themes that include health and livelihoods. To date over US$ 11 billion has been committed, with over US$ 30 billion in co-financing (148). • During the fiscal year 2021, Sustainable Development Bonds worth US$ 68 billion issued by the International Bank of Reconstruction and Development (IBRD) have enabled social safety net coverage for an additional 7 million people, essential services for 4.4 million people, the training or recruitment of nearly 500 000 teachers, savings of 3.5 million tonnes of greenhouse gas emissions and have improved urban conditions for 3.4 million people (149). Shaping and influencing • The International Labour Organization (ILO) is implementing its centenary initiatives around the future of work, and ensuring decent work as part of the green transition and women at work (150). box 4.2 Examples of approaches to shaping markets 4.3 International and intergovernmental organizations box 4.3 Example activities and initiatives by international and intergovernmental organizations HealtH in tHe Well-being eConomy 34 • The World Bank’s report The changing wealth of nations considers the wider well-being capitals (38); the institution also hosts the Human Capital Project, which aims to encourage investments in people (151). • The OECD’s “Beyond Growth” initiative brought together new thinking around economic policy and the measurement of social progress (152). Many NGOs continue to play an active role in developing the well-being economy approach, including by developing innovative policy proposals, sharing evidence, and connecting people and organizations. Philanthropic organizations are also playing key roles in driving a research and practice agenda around the well-being capitals. Box 4.4 provides examples of ongoing activities in this field. • The Finnish Federation for Social Affairs and Health (SOSTE), along with other relevant NGOs was key in driving the early adoption of the economy of well-being concept in Finland (153). • The Wellbeing Economy Alliance (WEAll) is a global project connecting people and organizations working towards well-being economies. Among other outputs, WEAll has published a well-being economy policy design guide (154). • The Doughnut Economics Action Lab (DEAL) has published a guide to help with redesigning businesses to promote equity and improve the environment around us (155). • The Robert Wood Johnson Foundation has conducted extensive work on the social determinants of health, including investments to develop affordable housing, to explore the role of municipal bonds in promoting equity, and research into policies that can tackle health inequalities, such as minimum wages (156). • Wellcome is investing £16 billion by 2023 across a range of research fields, with priorities around climate and health, infectious diseases and mental health (157). 4.4 NGOs box 4.4 Examples of NGO activities aiming to develop the well‑being economy approach 5. HealtH and Well-being as a measure of soCial progress 35 Measuring a wide range of factors that influence well-being is now widely seen as a promising way forward for measuring social progress, and many efforts have been made to develop such indicator sets (see Box 5.1). Yet to date no well-being measurement framework has gained the same level of international agreement as GDP or the same level of application to decision-making. In addition, data collection is far from standardized. • The OECD’s Framework for Measuring Well-being and Progress (26) includes health and other determinants of current well-being, along with natural, economic, social and human capital as resources for future well-being • The UNDP developed the Human Development Index to measure people’s capabilities as a measure of development, rather than assessing only economic growth (158). • Scotland, Iceland and Wales have all developed national measurement frameworks that measure a range of indicators across the well-being capitals (159–161). • The SDG indicators comprise 231 different indicators spanning the 17 SDGs (162). Health outcomes other than life expectancy and self-reported health are not reported consistently in many well-being measurement frameworks. The lack of monitoring around public health goods and policies, including access to health services, could lead to continued underinvestment in these areas. Finance stakeholders may be concerned about the use of self-reported measures, although they are widely accepted in the health field (72). Measures such as healthy life expectancy and the Human Development Index provide important indicators to assess progress towards productive and caring societies, particularly when disaggregated to understand inequalities. Well-being measurement frameworks can strengthen measurement across the human, social, planetary and economic well-being capitals, including public health goods and policies. To track inequalities, indicators should measure a range of domains of inequality, including gender, ethnicity, migrant status, sexual orientation and disabilities. Separating spending on prevention from other more reactive expenditure can help to address long-term issues. It may be necessary for some purposes to create composite indicators or to collect detailed data from individuals –through surveys, for example. Developing comparable metrics and integrating them with decision-making will be critical to their uptake and use in decision-making (163). box 5.1 Examples of well‑being measurement frameworks Health and well-being as a measure of social progress5 HealtH in tHe Well-being eConomy 36 The highest inflation rates in decades are putting pressures on budgets across households, the public sector and businesses, which will have significant impacts on people’s health and well-being. While there is variation in the magnitude of inflation rates across European countries, they share many similar challenges in ensuring their populations’ needs are met. While there has been a reduction in living standards thus far during the cost-of-living increases, the economic outlook for the year ahead is worse, with poor consumer confidence and slower economic growth (164). Those in the bottom and middle of the income distribution, which includes most people with poor health, are less financially resilient owing to a lack of savings and are thus less able to absorb sudden price changes without having to make stark choices about their consumption priorities. The policy challenge with the cost-of-living increases is how to protect the most vulnerable from the worst impacts of the current crisis, mitigating impacts on well-being social solidarity and minimizing further macroeconomic and political instability. Well-being economy approaches can guide us towards a range of approaches that can support people through cost-of-living increases, safeguarding lives and livelihoods. Examples of such approaches are listed here. • Addressing relevant economic, social and environmental issues inspires thinking around holistic policy responses – not just addressing inflation through monetary policy but also equitable approaches to support people to meet their basic needs. • The health sector can support the response to the cost-of-living increases by considering the wages of its workforce, reducing out-of-pocket payments, and by referring individuals with complex needs to additional services, such as social protection, financial support services or energy efficiency services. • Promoting sustainable solutions to meeting basic needs is essential, including in such areas as housing, water and sanitation, or energy provision. • Insight into the impacts of the cost-of-living increases on people can help guide the response: this can include data that track the impacts on vulnerable groups, as well as lived experience and participation approaches that put the voices of those most affected at the centre of decision-making. Analysis from Public Health Wales describes what a whole-system public health response to the cost-of-living increases would look like (165). The 2022 paper proposes short-term responses, such as mental health support, debt support, efforts to reduce fuel poverty or prevent homelessness, support for employees and safeguarding against violence. 6.1 Protecting investment in well-being during the cost-of-living increases Illustrative examples6 6. illustrative examples 37 In the long term, proposals include increased energy efficiency, efforts to improve the supply of affordable high-quality housing and the promotion of fair work. A recent WHO briefing around inequalities in keeping warm highlighted some potential solutions (166), including: • financial mechanisms, such as regulating fuel, increasing minimum wages and implementing benefits to alleviate energy poverty; • targeted financial support, such as heating grants and social tariffs for those most at risk; • investments in energy-efficient housing; • requiring housing to be upgraded to minimum standards; and • social tariffs for energy supply, as well as potentially banning households in arrears from being disconnected from their energy supply. Box 6.1 provides examples of approaches taken across Europe to tackling the cost-of-living increases. • Many countries in Europe have already implemented packages to support their populations with rising costs. For example: ° in Germany, a range of measures are planned, including increased rental subsidies, a cap on gas prices, and national public transport for €49 a month (167); °Spain has implemented a law preventing people with severe health problems from being disconnected from their electricity supply (168). • Time to Talk Public Health in Wales is a representative panel of residents in Wales supporting engagement to underpin public health policy and practice. 2000 people took part in the first phase, with results indicating that 38% of people had worried a lot about the cost of living in the week before the survey, with cost of living being one of the top five priorities reported to Public Health Wales (169). • In Ireland, policies during the COVID-19 pandemic helped households in the bottom 70% of the income distribution to improve their financial situation on average, whereas households in the top 30% of the income distribution were recorded to have experienced financial losses (170). Significant concern has arisen regarding job losses and mental health in young people during the COVID-19 pandemic (171). This presents a significant challenge for policy-makers. Data from 2021 suggest that 64% of young people aged 18–34 years in the EU had a low WHO-5 score2 and were therefore considered at risk of depression (7) and that over 300 million people in Europe were thought to have suffered ACEs; that is, intensive stress in childhood that can have long-term impacts on health and socioeconomic outcomes during a person’s lifetime (88). Addressing ACEs requires a holistic response across sectors to prevent the risk of these events occurring. Failing to invest in young people will result in the accumulation of adverse experiences as well as challenges in addressing the intergenerational care burden. More work is clearly needed to address the scale of the challenge, including: 2 The WHO-5 is a commonly used tool to assess well-being through five questions that assess how the respondent has felt over the prior two weeks (172). box 6.1 Examples of approaches to tackling the cost‑of‑living increases 6.2 Mental health and the inclusion of young people HealtH in tHe Well-being eConomy 38 • universal and equitable mental health support and mental health services, in conjunction with wider services to support employment and universal social protection to prevent income, housing, food and fuel insecurity; • promoting safe physical and virtual environments to enable participation in education and employment, supporting smooth transitions between education, employment and training; • bringing together employers, young people, labour policy-makers and other alliances to ensure that young peoples’ needs are at the centre of policy-making; • addressing stigma, discrimination and bullying; stopping and preventing the accumulation of adverse experiences. Box 6.2 provides examples of approaches to tackling these issues. • Accelerate Estonia is a platform supported by the Government which partners with entrepreneurs to convert global problems (such as poor mental health) into economic opportunities. Those who secure support from the programme receive up to €300 000 in funding, access to policy-makers and advice from diverse sectors (173). • Ritineitis – an NGO in Latvia – has set up a project which encourages young people to participate in civic life by developing ideas to help improve the quality of life in their country (174). • Thriving from the start is a network hosted by the City Mental Health Alliance (CMHA), working to improve the mental health of people who are early in their career or who are in education and seeking work (175). box 6.2 Examples of approaches to tackling mental health and inclusion issues across Europe 7. outComes from tHe regional HigH-level forum 39 Outcomes from the Regional High-level Forum7 Health is essential to a developing a well-being economy and a well-being economy approach can improve health outcomes while contributing to inclusive and sustainable development. Now is the time to capitalize on the global momentum towards developing well-being economies. This will require collaboration between the health, economic development and finance sectors. It will be important to build on existing mechanisms of international collaboration, such as the processes developed and managed by the United Nations agencies (among others). Health stakeholders will need support to be able to fulfil their potential role in a well-being economy approach. Shifting towards well-being economies will no doubt involve a substantial shift in policy and practice. Building on the Forum themes, two main next steps are proposed. • A country policy initiative is needed, to provide Member States with the know-how, example investment cases and modelling of the return on investment from building well-being economies. • A regular forum is required to encourage dialogue between ministries of health, finance and economic development to assess progress, overcome barriers, and set the agenda for how the health sector can serve as a driver, ally and co-creator in the shift towards well-being economies that deliver better health for all. Following endorsement by the attendees of the Regional High-level Forum, the WHO Regional Office for Europe will advance the work outlined in the document, with a more formal presentation of the agenda, workstream and preliminary outputs to be presented at the 73rd session of the WHO Regional Committee for Europe in 2023. The Regional Office will engage with partners to implement the actions agreed. 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