Final consultation meeting of the European Framework for Action on Integrated Health Services Delivery: Copenhagen, 2–3 May 2016: meeting report

MEETING REPORT Final consultation meeting of the European Framework for Action on Integrated Health Services Delivery Copenhagen, 2–3 May 2016

MEETING REPORT Final consultation meeting of the European Framework for Action on Integrated Health Services Delivery Copenhagen, 2–3 May 2016 Health Services Delivery Programme Division of Health Systems and Public Health Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2016 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Abstract On 2–3 May 2016, the WHO Regional Office for Europe hosted a final consultation meeting of the European Framework for Action on Integrated Health Services Delivery (EFFA IHSD) at UN City in Copenhagen, Demark. The event convened over 170 participants from more than 30 Member States in the WHO European Region, and representatives from professional associations, patient organizations and other special interest groups, as well as international experts, development partners and WHO staff. Over the two–day meeting, the Framework’s four domains focusing on populations and individuals, health services delivery, other health system enablers and change management were discussed in detail. Each domain was explored through expert presentations, country cases, panel discussions and comments from participants. This report provides an overview of the meeting and related discussions. These discussions inform the final review and revisions to the EFFA IHSD for presentation at the 66th session of the Regional Committee for Europe in September 2016. Keywords DELIVERY OF HEALTH CARE DELIVERY OF HEALTH CARE, INTEGRATED HEALTH SERVICES DISEASE MANAGEMENT EUROPE Document number: WHO/EURO:2016-6522-46288-66956 Table of Contents Acknowledgements ................................................................................................................ vii Abbreviations ....................................................................................................................... viii Table of figures .................................................................................................................... viii Executive summary ............................................................................................................. ix About the final consultation meeting ................................................................................... 1 Background ............................................................................................................................ 1 Rationale ................................................................................................................................ 2 Objectives .............................................................................................................................. 2 Outline ................................................................................................................................... 2 Participants ............................................................................................................................ 2 Day one: Opening and launch .............................................................................................. 3 Welcome and introduction ............................................................................................................ 3 Session one: Finding policy alignment across priorities: from Member States to partners, policies and practice .................................................................................................................... 4 Key note: Integrated service delivery: from framework to local action ........................................ 5 Illustrative country case: Spain ................................................................................................ 5 Illustrative country case: Tajikistan .......................................................................................... 5 Panel discussion: Finding policy alignment across partners ......................................................... 5 Session two: Addressing key challenges in health services delivery ................................................. 6 Panel discussion: Innovations in services delivery ...................................................................... 7 Day two: Consultation .......................................................................................................... 8 Session one: Populations and individuals domain ........................................................................... 8 Expert presentation: Making the case for a people-centred approach: evidence on improved performance and health outcomes .......................................................... 9 Panel discussion: Key considerations in working to put people first ............................................. 9 Illustrative country case: Kazakhstan ...................................................................................... 10 Illustrative country case: Slovenia .......................................................................................... 10 Session two: Services delivery processes domain ......................................................................... 11 Expert presentation: Making the case for transforming health services delivery: evidence on performance and health outcomes ....................................................................... 12 Panel discussion: Key considerations in transforming health services delivery ............................ 12 Illustrative country case: Denmark ......................................................................................... 13 Illustrative country case: Veneto Region, Italy ........................................................................ 13 Session three: System enablers domain ...................................................................................... 14 Expert presentation: Making the case for health system strengthening for improving outcomes and sustaining services delivery transformations .................................. 15 Panel discussion: Key considerations in enabling health system conditions ................................ 15 Expert intervention: Global perspective on health systems for people-centred and integrated health services ............................................................................................... 16 Illustrative country case: The Netherlands .............................................................................. 16 Illustrative country case: Scotland (United Kingdom) ............................................................... 16 Session four: Change management domain ................................................................................. 17 Expert presentation: Strategizing change for health system strengthening: from assessments to policy actions ....................................................................................... 18 Illustrative country case: Croatia ............................................................................................ 18 Illustrative country case: Republic of Moldova ......................................................................... 18 Panel discussion: Lessons from the perspectives of change agents ........................................... 18 Final remarks ..................................................................................................................... 20 Annex 1: Final programme .................................................................................................... 21 Annex 2: List of participants .................................................................................................. 27 Annex 3: List of available resources ....................................................................................... 39 Meeting report: Final consultation meeting of the EFFA IHSD Page vii Acknowledgements The final consultation meeting was organized by the Health Services Delivery Programme, a technical unit of the Division of Health Systems and Public Health directed by Hans Kluge, at the WHO Regional Office for Europe. The meeting’s technical organization was overseen by Juan Tello with the support of Erica Barbazza, together with other staff and consultants of the Health Services Delivery Programme, including Aliya Kosbayeva, Margrieta Langins and Altynai Satylganova. The meeting’s logistics were coordinated by Connie Petersen, with Susan Ahrenst, Gitte Andersen and Thomas Moore of the WHO Regional Office for Europe. All meeting material was translated to Russian by Vladimir Verbitske (TAIS) and Larisa Akhmadeeva (Consultant) and their respective teams. The Health Services Delivery Programme acknowledges the technical support of presenters and colleagues at the WHO Regional Office for Europe who participated in the meeting. This report has been drafted by the meeting rapporteur, Camilla Peterson (Consultant) and edited by Erica Barbazza and reviewed by Juan Tello (WHO Regional Office for Europe). All photos are by Jules Philips (Kiwi Photography), copyright to WHO. Meeting report: Final consultation meeting of the EFFA IHSD Page viii Abbreviations EFFA IHSD European Framework for Action on Integrated Health Services Delivery NCD noncommunicable disease OECD Organization for Economic Development and Cooperation WHO World Health Organization Table of figures Fig. 1. The European Framework for Action on Integrated Health Services Delivery .......................... 4 Fig. 2. Domain one areas for action ........................................................................................................ 8 Fig. 3. Domain two areas for action ...................................................................................................... 11 Fig. 4. Domain three areas for action .................................................................................................... 14 Fig. 5. Domain four areas for action ..................................................................................................... 17 Meeting report: Final consultation meeting of the EFFA IHSD Page ix Executive summary Since 2012, the WHO Regional Office for Europe has worked to advance the priority, set out by Health 2020, to strengthen people-centred health systems. To this end, in 2013, with a focus on transforming health services delivery, a process was launched for the development of an action- oriented framework as a resource for undertaking health services delivery transformations. In September 2016, the European Framework for Action on Integrated Health Services Delivery (EFFA IHSD) will be presented at the 66th session of the Regional Committee for Europe as an outcome of this process. In anticipation of this event, a consultation meeting was organized by the WHO Regional Office for Europe in May 2016, to facilitate a final technical and policy dialogue. Throughout the two-day meeting held in Copenhagen, Denmark on 2–3 May 2016, over 170 participants from more than 30 WHO European Region Member States, as well as international experts, WHO staff from the African, Eastern Mediterranean and European regions and headquarters, and representatives of professional associations, patient and carer organizations, special interest groups, insurers and hospitals, debated the specificities of health services delivery transformations. Specifically, the consultation meeting set out with the following objectives: 1. To inform and discuss the EFFA IHSD’s vision, strategic approach and priority areas of action in alignment with other Regional policies and commitments; 2. To discuss the areas for action and key strategies identified for accuracy and completion from the different perspectives of participants; and, 3. To share experiences of countries and stakeholders on health services delivery transformations in practice. The consultation programme took shape around the four key domains for health services delivery transformations put forward by the EFFA IHSD: populations and individuals, health services delivery, other health system enablers and change management. Key topics of discussions according to each included the following. Domain one: Populations and individuals ! Placing people at the centre of care was a recurrent topic. Proactive participation of people in their own health and initiatives to transform services delivery are essential for optimizing outcomes. ! Other stakeholders must also be included, and patients, carers, volunteers and peer groups should have a greater role in the process of delivering services. ! Systematically understanding the target population to assess the effects of socioeconomic status, gender, and other factors is important to understand how best to tailor services and work with individuals in the design of their care. ! Informal caregivers are an important part of the health workforce, yet much work remains to protect and promote their health and well-being. Meeting report: Final consultation meeting of the EFFA IHSD Page x Domain two: Services delivery processes ! Measuring health services delivery was discussed with regards to its importance as well as the challenges it implies. Specifically, the usefulness of reporting hospitalization for conditions requiring ambulatory care as a proxy of performance was recognized, allowing comparisons among countries and providing a measureable baseline for transformations. ! Integrated health services delivery relies on a primary health care approach for proactive care across the lifespan. No less important than continuing efforts to strengthen primary care are those measures taken to ensure hospitals fulfil their key role in supporting effective integration. ! Needs and demands on the health workforce are constantly changing, calling for transformations to strike a balance between skill mix, roles and team size, among other considerations, to best organize the workforce. Domain three: System enablers ! Many new applications of technology driving integrated care were described during the meeting. Participants emphasized the importance of maintaining focus on their usability and ensuring that technological advances and innovations are rooted in meeting people's needs. It was recommended that to achieve this, innovations should be advanced in a participatory manner, with the inclusion of key users from the outset to ensure relevance. ! Faced with increasing numbers of patients managing multiple medicines, ensuring the evidence- based selection of medicines as well as their overall quality, tailoring based on the preferences of patients and their responsible use, is critical. ! Incentive systems demand regular, reliable reporting of performance measures with defined targets (absolute, relative), levels (individual, group, institution) and form (bonus, penalty) to be determined at the outset. ! Conventional barriers between health and social care need to be challenged in order to foster the intersectoral actions called for to adequately respond to needs. Domain four: Change management ! Balancing need for evidence with an acceptable pace of change was raised in many discussions, along with putting a stronger focus on sustainability and scale up. ! Making a case for change was repeatedly raised as a challenge for policy-makers, hard-pressed to ‘sell’ integrated care as a priority. The continued implementation of research to further develop the evidence base on impact and outcomes of transformations is critical. Meeting report: Final consultation meeting of the EFFA IHSD Page 1 About the final consultation meeting Background WHO recognizes that well-performing health systems are critical to achieve population health and well-being. In the WHO European Region, Member States share a timeless commitment to health system strengthening. The European health policy, Health 2020, adopted by Member States in 2012, recognizes this priority and sets out a course of action for realizing the Region’s greatest health and well-being potential by year 2020. Within this policy, health system strengthening is firmly rooted as a core strategic priority, promoting people-centred health systems as a forward-looking approach for advancing overarching goals. Transforming health services for integrated delivery is pivotal to this and, subsequently, takes part in the implementation of Health 2020 as a key strategic lever. In this policy context and in alignment with guiding commitments, in 2013 the WHO Regional Office for Europe officially launched the development of an action-oriented framework to support services delivery transformations: the European Framework for Action for Integrated Health Services Delivery (EFFA IHSD). The EFFA IHSD is envisaged as a practical resource for Member States, supporting the process of services delivery transformations by calling attention to and organizing the associations between a core set of areas for strategic action. The process of developing the EFFA IHSD was defined in a planning document,1 working to ensure a participatory, evidence-based and practice-informed approach. Realizing this has included efforts such as establishing a forum of appointed technical representatives on integrated health services delivery across Member States, conducting topic-specific research and generating informative cases spanning all 53 countries of the European Region. Since 2013, partners have been convened in discussions, consultations and reviews of concepts and lessons learned while working towards an agreed upon framework of priority areas for action. Partners engaged throughout have included a forum of Member State technical focal points, an advisory team of international experts from academia and organizations at the forefront of work in this domain, public and professional networks representing patients, health and social care providers and special interest groups, and international development partners, as well as staff from the different technical units of WHO and its offices. Events have brought these partners together at several stages throughout the development of the EFFA IHSD, with workshops and consultations held in Istanbul (Turkey), Brussels (Belgium), and Copenhagen (Denmark). In preparation for the 66th session of the Regional Committee for Europe, the EFFA IHSD has undergone a series of final reviews. This has included presentations and requests for input from the Twenty-third Standing Committee of the Regional Committee according to the standard governing process and cycle of the Regional Office. An online consultation with Member States was launched in March 2016, requesting comments from appointed WHO National Counterparts on an advanced version of the EFFA IHSD document. Finally, in May 2016, keeping with the annual tradition of a 1 Roadmap: strengthening people-centred health systems in the WHO European Region. A Framework for Action towards Coordinated/Integrated Health Services Delivery. Copenhagen: WHO Regional Office for Europe; 2013. (http://www.euro.who.int/en/health-topics/Health-systems/health-service-delivery/publications/2013/strengthening-people- centred-health-systems-in-the-who-european-region-a-roadmap). Meeting report: Final consultation meeting of the EFFA IHSD Page 2 consultation event, a multi-stakeholder meeting was organized in Copenhagen, Denmark, as a final opportunity to meet, discuss and update the EFFA IHSD based on input from countries and partners. Rationale In finalization of the EFFA IHSD, a last consultation meeting was organized 2-3 May 2016. Hosted at UN City, this event set out to reconvene stakeholders engaged annually in the development of this work, in addition to WHO National Counterparts and national technical focal points from across the Region. The diversity of participants sought to facilitate both a technical and policy dialogue in preparation for the EFFA IHSD’s presentation at the 66th session of the Regional Committee for Europe in September 2016. The event also served as an opportunity to generate discussion on the dissemination, application and implementation in the Framework in the Region in alignment with partners. Objectives This meeting aimed to present and discuss the EFFA IHSD in the context of its finalization and sought endorsement by the European Regional Committee as well as onward implementation across the Region. To this end, the proceedings of the meeting were guided by the following objectives: ! To inform and discuss the EFFA IHSD’s vision, strategic approach and priority areas of action in alignment with other Regional policies and commitments; ! To discuss the areas for action and key strategies identified for accuracy and completion from the different perspectives of participants; and, ! To share experiences of countries and across stakeholders on services delivery transformations in practice. Outline Sessions throughout the two-day consultation took shape according to the EFFA IHSD’s four domains calling focus to populations and individuals, health services delivery, other health system enablers and change management. Key challenges pertaining to health services delivery were highlighted as pertinent topics and prioritized in the discussion of each domain. To support concepts advanced by the Framework, case presentations and interventions from Member States and invited country experts illustrated experiences and good practices, with expert panels, plenary discussions and opportunities for Member State interventions allowing numerous occasion for interaction and discussion among participants. The complete programme for the event can be found in Annex 1. Participants This event targeted a wide audience totalling over 170 participants. Participants represented more than 30 Member States, with representation including WHO National Counterparts, national technical focal points, and integrated health services delivery focal points. Also among participants were numerous invited experts, partner organizations, patient representatives, health and social care providers, civil society and special interest groups, as well as staff from WHO country offices, regional offices and headquarters, and programme managers from technical units in-house. A complete list of participants can be found in Annex 2. Meeting report: Final consultation meeting of the EFFA IHSD Page 3 Day one: Opening and launch Welcome and introduction Opening the consultation, the Director of the Division of Health Systems and Public Health at the WHO Regional Office for Europe challenged participants to consider their ‘ideal health system’. The reflection served as a reminder to keep perspective on the ultimate aim of services delivery transformations: working towards improved population and individual health. The EFFA IHSD emphasizes the importance of this perspective and has aimed, since the outset of its development, to put people at the heart of services delivery. Health systems have already demonstrated great resilience and innovation in the face of changing contexts, including changes in demographics, epidemiology, economics and the public’s expectations. Continuing to fine-tune health systems moving forward is imperative in order to ensure these systems continue to evolve according to populations’ needs. The EFFA IHSD has sought to develop a common and clear direction with which to move forward in this manner, finding alignment with priorities already advanced in Health 2020, the Tallinn Charter, the Sustainable Development Goals, the WHO global framework on integrated, people-centred health services, and other related policy documents. “Strengthening people-centred health systems. …requires reorienting health care systems to give priority to disease prevention, foster continual quality improvement and integrate service delivery, ensure continuity of care, support self-care for patients and relocate care as close to home as is safe and cost-effective.” Health 20202 To do so, the EFFA IHSD has identified a shortlist of areas that call for strategic action in working to transform health services delivery. These areas have been sequenced according to four domains, organized as shown in Fig. 1 to recognize their associations. Attention is called first to people to identify health needs and work in partnerships with populations and individuals; second to ensuring services delivery processes of designing, organizing, managing and improving services are in alignment; third, to ensuring the contributions of other health system functions support and promote the processes of services delivery and; finally, to the importance of strategically leading and managing transformations throughout. This year can be considered a landmark year for health services delivery, marked by the endorsement of the global framework for integrated, people-centred services in May and further, by the upcoming Regional Committee meeting also tabling services delivery as a key item. However, despite this momentum, speakers described the change process occurring as a marathon, rather than a sprint, calling for WHO’s commitment to the continuous implementation of health services delivery transformations and the importance of supporting changes through a comprehensive implementation 2 Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen: WHO Regional Office for Europe; 2013 (http://www.euro.who.int/en/publications/abstracts/health-2020-a- european-policy- framework-supporting-action-across-government-and-society-for-health-and-well-being). Meeting report: Final consultation meeting of the EFFA IHSD Page 4 package. Existing resources that are part of this package and already available online were referred to throughout the event.3 Fig. 1. The European Framework for Action on Integrated Health Services Delivery Source: WHO Regional Office for Europe From the perspective of Member States, a delegate from Belarus shared experiences from the Ministry of Health to address challenges such as maternal and child mortality and, more recently, chronic disease. For further improvements to be achieved, it was recognized that services need to be focused around people and their needs. It was described how changes in health services are inevitable; we live in a changing time. For this reason, the presented Framework is an important tool for shifting focus towards new challenges, helping to provide a clear understanding of what should be done and guide leaders towards more people-centred health systems. Session one Finding policy alignment across priorities: from Member States to partners, policies and practice Transforming health services delivery is a multistage, multimodal process, demanding broad collaboration among stakeholders. This first session of the consultation meeting aimed to explore the unique properties of this change process, as well as what it means to move from more conventional care to integrated health services delivery. Country case interventions aimed to illustrate this continuum of development in practice and a panel discussion probed further reflection on the different perspectives regarding integrated health services delivery. 3 Publications available online can be accessed through the health services delivery webpage of the WHO Regional Office for Europe at: http://www.euro.who.int/en/health-topics/Health-systems/health-service-delivery/publications. Meeting report: Final consultation meeting of the EFFA IHSD Page 5 Key note: Integrated service delivery: from framework to local action The importance of applying existing knowledge, bridging the gap between research and practice, and shifting towards local care that is more participatory and dynamic, was emphasized during this presentation. While the EFFA IHSD can serve as an important guide for transformations, context- specific adaptations were described as necessary at the national level, as well as in the specific regions, districts and other sub-national levels where reforms are applied. Research described in the Netherlands found many common themes for implementing integrated care, spanning phases of initial design, experimentation and execution, expansion and monitoring, and consolidation. Recognizing that each stakeholder brings a unique perspective was also a feature of discussion. Formation of networks, including patient and professional networks, was described as a useful strategy for managing these differences and increasing integration in the Netherlands. “I think that one of the major lessons is that we know and can also use the evidence that working on integrated care is difficult and it takes a long time, but also that it can deliver results and that you can measure it and you can show what it really means.” – Temporary Advisor Illustrative country case: Spain Spain has a national health system with a high level of decentralization. Integrated care is high on the government agenda, both at the national and regional levels, but achieving true cultural change in this area was recognized to take time. Key assets highlighted during the presentation as supporting integrated care in Spain included unique identification numbers for patients, electronic health records (regional-specific) and a strong primary care system that was credited as the starting point for integrated care in Spain. Due to the high level of autonomy, different regions can be seen to be taking different approaches to integrated care. The variability was noted as an important reminder of the delicate balance between bottom-up approaches (fostering tailored, local implementation) and top- down approaches (giving a common direction for transformations). Illustrative country case: Tajikistan In 2010, Tajikistan launched a national health strategy for the years 2010 to 2020. Significant work has been undertaken to strengthen family medicine, with actions aiming to sustainably develop primary care and health promotion services, improve the use of diagnostic and treatment services, increase the knowledge of health staff, and improve primary care performance. Changes have been supported by many national stakeholders as well as development partners. Over time, gains in population health outcomes show alignment with improvements in family medicine in areas including the prevention and control of tuberculosis and antenatal care. Opportunities to further scale up and roll out pilot projects have called for a focus on harmonizing institutional arrangements, roles and responsibilities of management across levels of the health system. The government plans to continue developing integrated family medicine-based primary care with a new strategic plan building upon achievements following the 2011-2015 national programme on the development of family medicine. Panel discussion: Finding policy alignment across partners This panel set out to discuss integrated health services delivery from the perspective of development partners, stakeholders and WHO headquarters in order to identify commonalities in priorities and Meeting report: Final consultation meeting of the EFFA IHSD Page 6 underscore key challenges faced by their respective Member States. Key questions considered were: i) what does it take to move from conventional care towards integrated care along a continuum of development and; ii) how do we ensure these changes are sustainable? The discussion raised the following key points: ! Many options to involve the public in health policy decisions exist and these should be accessed from the outset of changes to ensure relevant, people-focused transformations. Moreover, as patients become increasingly health literate and empowered; measures need to involve them in their care should be systematically taken. ! Incentives for providers to work in partnership with each other and patients are needed, along with clear goals, a strong organizational model, appropriate training, a strong information structure and aligned resources. In some cases, incentives can be as simple as uniting people who like working together. ! While supportive structures (such as electronic health records) are important nationally, integration must also happen locally. Local authorities need to be empowered and supported to implement mechanisms to increase integration subnationally. ! Measurement is important for ensuring progress towards integrated care. Although what indicators are best is open to debate, useful measures may include patient satisfaction and avoidable hospitalizations. The potential need for simpler measures to evaluate integrated care was also discussed. Session two Addressing key challenges in health services delivery This session explored integrated care in practice, highlighting different processes, organizational arrangements and resources for transforming services delivery at-scale and sustainably across the health system. Key considerations for the session included how systems move beyond pilot projects to establish sustainable reforms; differences between step-wise change and disruptive innovation; what it takes to innovate services and; what environmental conditions are needed for innovation in practice. Through the keynote presentation, expert interventions and illustrative country cases, evidence and first-hand experiences from practice were explored. Key note: Addressing key challenges in health services delivery: fostering innovation Participants were reminded that the concept of integrated care is not new, but rather that it is continuously being revisited and advanced. Likewise, many innovations (such as electronic health records) can no longer be considered new, but implementation of these is not always prevalent or optimally managed. Careful consideration needs to be taken in deciding whether disruptive innovation is beneficial, or if a more evolutionary approach is preferable. Six key pathbreakers for change were put forward: innovation funds supporting new initiatives, the inclusion of nonmedical professionals in the delivery of health services, digitalization of care and service processes, patient empowerment, the advent of Generation Y (a cohort increasingly familiar with digital and electronic technology), and big data (extensive datasets that allow predictive analytics or other advanced data methods). The example of innovation funds started in Germany was explored. Early on, these funds were successful in generating many new pilot projects in priority areas, but ultimately failed to develop sustainable initiatives. To address the problem of pilotitis, funds are now financed for a period of four years and laws require successful interventions to be taken to scale. While public funding was described as a good short-term solution for driving innovation, aligning Meeting report: Final consultation meeting of the EFFA IHSD Page 7 incentives to promote innovation is required in the long-term. The takeaway message for the presentation underscored the need to create an environment conducive to innovation, share successful strategies and learn from failed change attempts. Panel discussion: Innovations in services delivery This panel aimed to explore innovation in practice through illustrative country cases and interventions by associations on the delivery of services and the system conditions needed for putting new processes and resources into practice, reflecting also on different approaches and techniques for managing the change process itself. Importantly, discussions centred on both the successes and failures of interventions, seeing both as useful sources for lessons learned. The discussion raised the following key points: ! It is important to ensure both the health system and overall context support innovation. Implementing fundamental, cross-cutting tools for innovation will help maintain independence and sustainability vis-à-vis political change. ! Dialogue between different stakeholders helps to introduce, sustain and advance innovation. Working collaboratively brings different perspectives and skills to the table. When working with many stakeholders, it may be helpful to assign change champions as representatives for each group. ! Ensuring interconnectivity can help prevent failure and siloed implementation. Significant creativity and energy can be concentrated in start-ups, but these do not necessarily connect to the wider health system. It is important to avoid implementing technology just for the sake of it; implementation should be based on its usefulness and other properties, including usability. ! Innovations should be the result of co-creation between all stakeholders. Not everyone will support innovation, so focusing on designing practical, user-centric technologies is key. Gradual implementation and regular consultation with stakeholders can allow for challenges to be addressed early on. Meeting report: Final consultation meeting of the EFFA IHSD Page 8 Day two: Consultation Day two of the consultation was dedicated to a series of four sessions that explored each of the key domains put forward by the EFFA IHSD. The sessions followed a consistent format: an expert presentation on key evidence; discussions on a series of pertinent topics; illustrative country cases; and a summary of the areas for action put forward in the EFFA IHSD. Session one: Populations and individuals domain This session took an in-depth look at the first domain of the EFFA IHSD, calling for a focus on populations and individuals to identify health needs and work in partnership with people towards realizing their greatest health potential. Goal: To identify health needs and work in partnership with populations and individuals, as patients, family members, carers, members of their communities, civil society and special interest groups, to support health-promoting behaviours, skills and resources to ensure that people have the potential to take control of their own health, while also working to tackle the determinants of health and improve health across the life-course without discrimination by sex, gender, ethnicity and religion. Through expert presentations and country case examples, this session aimed to explore key considerations for putting people first in practice and the imperative of doing so at present. The session concluded with an overview of the first domain and its key areas for action: identifying health needs, tackling the determinants of health, empowering populations and engaging patients (Fig. 2). Fig. 2. Domain one areas for action Meeting report: Final consultation meeting of the EFFA IHSD Page 9 Being the first domain presented, the importance of making people a priority in discussions was apparent and people-centred care was a prominent theme recurring throughout the discussions. Putting people first is not a trivial principle; it is important for shifting the provision of services from confronting health needs with prescribed processes to more holistic delivery considering an individual’s health, over time and throughout the life course. As the session’s chair poignantly noted at the beginning of the session: “Everything starts with people. Without people there is no health system.” Expert presentation: Making the case for a people-centred approach: evidence on improved performance and health outcomes This first presentation described a people-centred approach as an evolving paradigm that seeks to improve the way that people (individuals, their families, carers and communities) interact and relate with their own health, health services, social care and their health determinants. The vision of a people-centred approach was described as moving from imposed curative and episodic disease- centred systems, to systems that support both the empowerment of communities and engagement of individuals. Key reasons given during the presentation for why a people-centred approach is important included: ! People have the right to exert control upon the decisions that affect their health and the care they receive. ! Self-care is the predominant way in which people manage and cope with their needs and this requires the ability to change health behaviours in evolving circumstances. ! People are a source of expert knowledge and should be treated as assets and co-producers of their care. ! Support needs to be tailored to different levels of empowerment, engagement and activation. ! People-centred services are linked to health outcomes, and in a similar way, families and carers that are not supported in their caring role can have poorer health outcomes as a result. “To have a people perspective means that providers can see a person as a whole, they can understand their health, goals in life and their level of contentment with how they live and try to build together some self-care skills so they can enjoy a better life and prevent diseases.” – Temporary Advisor Panel discussion: Key considerations in working to put people first Experts were invited to discuss topics pertinent to people-centred care with interventions focusing on the burden of disease and its effects on health and social needs, impact of gender, how to adapt programmes towards patients’ needs and the hidden burdens faced by informal carers. Questions following the discussion reinforced the need to address health inequalities, calling for further discussion on the changing role of professionals and queries on how people-centred systems will be resourced. ! Burden of disease on health and social needs. Ageing, chronicity and multi-morbidities are impacting services delivery and giving rise to new health system challenges. While health systems have been successful in coping with changes thus far, continuing increases in chronic care needs will require adjustments in the future, particularly for the management of long- term care. Health systems are largely successful in curing disease, but there is a need to expand beyond these boundaries to actively promote health. Meeting report: Final consultation meeting of the EFFA IHSD Page 10 ! Gender and health. Norms, roles and behaviours vary between people and services need to be designed with consideration of this. Understanding the target population and how different people will respond to interventions based on gender and other personal factors is important. For example, symptoms for cardiovascular disease are different for women; lack of recognition for these differences can lead to cardiovascular disease being less detectable in women, which in turn can lead to slower care-seeking behaviour and poorer health outcomes. ! Involvement of beneficiaries in services delivery: lessons from immunization programmes. Increases in vaccine-preventable diseases triggered the development of a tool to understand why people were not vaccinating. WHO’s Tailoring Immunization Programme guide helps diagnose factors behind vaccination patterns, identifying root causes and influences on vaccine uptake, on both the supply and demand side, and offers useful lessons for understanding individual preferences and fostering engagement. ! Engaging patients, carers and families in services delivery. Across Europe, unpaid informal carers are the largest providers of health and social care support. Demographic changes are found to place an increasing demand on informal care. As informal carers face significant challenges to maintain their own health and well-being, it is important they are provided with adequate support. Priority needs highlighted by carers include: financial support, flexible employment arrangements, pension credits for care-time, and skill-training to become more effective carers. Illustrative country case: Kazakhstan This illustrative case described the transition of a cardiologist to a family physician in the context of Kazakhstan’s shift towards a family medicine-based model of services delivery. Frustrated by seeing patients repeatedly return for specialist, cardiac care, the presenter described the development of family health centres able to manage and respond to the increase of cardiovascular diseases. Efforts to strengthen primary care-led services for cardiovascular disease included investments in basic equipment and medicines for managing needs (made possible through a grant funded by the local mayor), developing health information materials for patients, setting up patient schools on cardiovascular health and designing targeted programmes for vulnerable groups. Through extensive discussions with patients, it became clear that social issues were often the most pressing problem. While having limited means to influence these, collaborations with patients and volunteers have helped establish several support groups and programmes. Illustrative country case: Slovenia National strategies in Slovenia have long promoted the involvement of patients in their care. However, translating this into practice has proven to take time. A representative from the Ministry of Health in Slovenia presented the example of the national diabetes programme as a good practice in fostering greater patient involvement, with patients having a direct role in designing and reporting on the programme. Need assessments conducted with diabetic patients highlighted the importance of patients having more time with providers and receiving explanations of their needs and treatment plans. As a result, patient education was expanded into primary care and a dedicated chronic care nurse has been established in what are known as model primary practices. Health education centres have also been established to support lifestyle changes and provide diabetes counselling to patients and a peer-to-peer support project has been developed to empower patients and reach those not accessing traditional provider-led services. Changes were described as a never-ending process that will be monitored and built upon with the support of patient associations. Meeting report: Final consultation meeting of the EFFA IHSD Page 11 Session two: Services delivery processes domain This session looked in-depth, through presentations, discussions and country examples, at the second domain of the EFFA IHSD on health services delivery processes. This service-focused domain sets out areas for action with the goal of ensuring that the processes of selecting, designing, organizing, managing and improving services to optimize the performance of health services delivery are in alignment with the health needs of the population and individuals that health services delivery aims to serve. Goal: To ensure that the processes of designing care are matched by organizing, managing and improving services accordingly in order to optimize the performance of health services delivery in alignment with the health needs of those populations and individuals it aims to serve. Taking an integrated approach to services delivery is founded on the same principles as put forth in a primary care approach for the delivery of comprehensive, coordinated, effective and patient-centred care. While the services delivery function is closely woven into and heavily determined by the other health system functions, a number of unique processes can be acted upon to strengthen the performance of health services delivery. This session aimed to explore the different entry points and key areas for action for transforming service delivery: designing care across the care continuum, organizing providers and settings of care, managing services delivery, and improving performance (Fig. 3). Fig. 3. Domain two areas for action Meeting report: Final consultation meeting of the EFFA IHSD Page 12 Expert presentation: Making the case for transforming health services delivery: evidence on performance and health outcomes This presentation looked to examine the contribution of health services transformations on performance and health outcomes. While many factors impact improvements in care, evidence supports, to some degree, that integrated care strategies can improve care coordination, quality and health outcomes, although evidence on the economic impact of integrated care is less clear. Effective interventions appear to include those based on communication and collaboration (case conferences, virtual consultations, and multidisciplinary teams), standardization mechanisms (guidelines accompanied with relevant training and feedback) and targeted disease or case management programmes. Successful implementation of interventions has been shown to rely on training, organizational changes (including adequate working conditions, resources and incentives) and contextual adaptations. Panel discussion: Key considerations in transforming health services delivery Experts were invited to discuss topics pertinent to transforming health services delivery with themes focusing on avoidable hospital admissions, primary care strengthening, the role of hospitals in integrated care and the role of the health workforce. Interventions following the discussion brought up the need to share decision-making with patients and the increasing role pharmacists play in providing health services. ! Avoidable hospital admissions as a measure of performance. The measure of health outcomes has evolved over time, from mortality rates to disease rates, and now delving into measures of disability and discomfort. Avoidable hospital admissions began to be used approximately 10 years ago as a proxy indicator for the performance of primary care because, if primary care is strong, admissions for largely-controllable chronic diseases should be minimal. Avoidable hospital admissions provide a good starting point for determining how to prevent people with chronic diseases from requiring hospital-based care. A growing number of Member States are now using this data and, consequently, more collaborations and comparisons using this measure as an indicator of overall services delivery performance are increasingly possible. ! Primary care strengthening. Primary care has strengthened over time in order to deliver an increasingly comprehensive and holistic package of services. An integrated approach to services delivery relies heavily on the strength of primary care. Although trends in primary care continue to extend and broaden the scope of services offered, more can still be done to promote and maintain health, rather than treat advanced disease. Primary care should be in the driving seat for taking proactive action to improve health. Without strong primary care, health systems are at risk of compromised performance contributing to higher costs and inefficiencies. ! Hospitals’ role for integrated care. Hospitals have a key role to play in supporting integrated care. To fulfil their potential, hospitals should adapt their internal processes and practices, as well as their interactions with other providers, to expand their ability to deliver integrated health services; leverage their technical, economic and organizational capacities to support implementation of integrated health services delivery areas and; adjust their mission and strategies to make integrated health services a priority. While the importance of hospitals was the main topic of this discussion, it was also noted that health providers working across levels and settings of care have a role to play and an integrated model cannot be achieved without involving the health workforce at large. Meeting report: Final consultation meeting of the EFFA IHSD Page 13 ! Role of the health workforce in transforming services. Needs and demands on the health workforce are constantly changing. Effective management is needed for engaging the workforce in transformations and ensuring a balanced skill mix and team size is important for being both effective and efficient in caring for patients. This presentation positioned family physicians as central to both the primary care team and the care of patients. However, the changing role of physicians, rise of other professions and increasing role of patients were also touched on throughout this session. Particularly, health workers are facing new challenges in satisfying the modern, empowered patient. “More access, more services, like more drugs, do not necessarily mean better care. It is coordinating the care; it is giving sense to what we are proving for the patients and protecting the frail because they are the prominent benefactors of integrated care, whilst being at risk of our current fragmented system of care. So, it is to their [patients’] benefit.” – Temporary advisor [reflecting on the meaning of integrated care] Illustrative country case: Denmark This case offered an overview of the national hospital reform taking place in Denmark. Since the mid- 2000s, it became increasingly recognized among policy-makers that Danish hospitals were at risk of becoming unfit for purpose. For a more sustainable structure to be achieved, a vision for a centralized, consolidated model for hospitals was put forward. Knowing that halving the number of hospitals in Denmark (from 40 to 20) and reducing the number of hospital beds would be politically unpopular, the government allocated a total of 6 billion kroner in long-term funding for the project as a means to incentivize change across the regions in Denmark. In exchange for closing hospitals and developing plans for improved hospital services, each region in Denmark is eligible to receive funding. While encouraging change has not been a politically easy task, there is a strong belief that pursuing this approach will create a more sustainable structure for the future. Illustrative country case: Veneto Region, Italy Although Italy’s Veneto Region generally benefits from above-average health outcomes, recent trends in population ageing and increasing morbidity became cause for concern. In response, the regional government undertook several reforms to reduce multimorbidity and address care fragmentation. The region introduced adjusted clinical groups as a means to proactively identify high-risk patients for targeted health interventions and personalize health coaching. General practitioners are central implementers of this initiative, along with newly-established case-manager nurses. Although still small in scale and with the long-term impact on health outcomes pending, patients report a high level of satisfaction with the new programme. Meeting report: Final consultation meeting of the EFFA IHSD Page 14 Session three: System enablers domain The third domain aims to align health services delivery with the health system functions of governing, financing and resourcing in order to establish the conditions necessary to allow services delivery to perform optimally and enable sustainable system-wide change. Finding alignment between policy, institutional and regulatory conditions, financing arrangements and resources has proven vital for overcoming persisting bottlenecks that contribute to the suboptimal performance of services delivery. Goal: To align the contributions of other health system functions in order to support the conditions required for services delivery by arranging accountability mechanisms, aligning incentives, preparing a competent workforce, promoting the responsible use of medicines, innovating technologies and rolling out e-health. Exploring the system enabling factors for integrated health services delivery, this session aimed to flag the key interdependencies between health services delivery and the broader health system towards a prioritized list of areas to be activated in working to transform care. To conclude, the session provided an overview of the system-focused domain and its key areas for action: rearranging accountability, aligning incentives, ensuring a competent health workforce, promoting the responsible use of medicines, innovating health technologies and rolling out e-health (Fig. 4). Fig. 4. Domain three areas for action Meeting report: Final consultation meeting of the EFFA IHSD Page 15 Expert presentation: Making the case for health system strengthening for improving outcomes and sustaining services delivery transformations This session opened with a reflection on the trade-offs when strengthening health systems, recognizing that there is a value-laden political element that cannot be ignored. Should patient choice be limited to improve health outcomes? Would greater responsiveness be worth trade-offs in efficiency? How should reforms that may run counter-intuitively against integrated care, such as encouraging competition, be managed? These are some of the issues that need to be resolved when designing integrated, people-centred health systems. Panel discussion: Key considerations in enabling health system conditions Experts were invited to speak on topics pertinent for enabling the health system conditions for integrated health services delivery with discussions focusing on responsible use of medicines, aligning governance frameworks and financial incentives, developing a health workforce and integrating health and social care. Interventions following the discussion touched upon potential tensions between competition, choice and integration; the need for more resources for social care; and the need to invest in management of health systems as well as health services. ! Ensuring access and the responsible use of medicines. An increasing number of patients are required to take multiple medicines for longer durations to manage their chronic conditions. With some stakeholders standing to profit from prescribing medicines, ensuring their responsible use is an important consideration for the health system. Selection of medicines should be evidence-based, resources should be used optimally, the quality of medicines (especially less-costly generics) should be ensured and patient preferences (in terms of cost, regimens and monitoring of side-effects, for example) must be considered. ! Aligning institutional frameworks and financial incentives. Ideally, provider payment mechanisms are administratively simple and work to encourage providers to achieve optimal outcomes, avoid incentives that lead to risk selection of patients, and contribute to efficiency gains. Different payment mechanisms each hold advantages and disadvantages. For example, pay for coordination is relatively easy to implement but lacks incentives to reduce costs, whereas shared savings or bundle payments allow for efficiency gains but are considerably more complex to implement. In order for incentives to be optimally applied, meaningful indicators must be collected, targets must be defined and the level (individual, group, institution-based) and form (bonus, penalty) of the incentive, determined. Having strong information systems and institutional frameworks is paramount to the effective application of incentives. ! Fostering intersectoral actions between health and social sectors. As populations age, social care needs are growing. However, social care remains largely under-recognized and the level of integration between health and social sectors is often weak. Yet, the barrier that exists between health and social care is, arguably, an artificial one. Key factors for fostering better integration include developing a shared vision with better focus on service integration along pathways, attention to differences in culture through effective leadership, care coordination undertaken by a case coordinator, multi-disciplinary teams and integrated information systems. ! Developing a competent health workforce for integrated services delivery. Health services must be prepared to accommodate a competent workforce, while health systems Meeting report: Final consultation meeting of the EFFA IHSD Page 16 should support the health workforce to update and maintain necessary competencies. Key policy levers for strengthening the health workforce include regulating, coordinating, managing, and organizing competencies. Innovating health workforce governance to strengthen competencies across sectors, organizations, professions and settings of care is needed for enabling integrated care. Expert intervention: Global perspective on health systems for people-centred and integrated health services At the Sixty-ninth World Health Assembly in May 2016, Member States endorsed a global framework for integrated, people-centred health services. Reflecting on the EFFA IHSD and global framework, the alignment in the vision, principles and strategies of these frameworks was underscored, noting the EFFA IHSD as an extension of the global framework adapted to the European Region. Since 2013, coordinated efforts in the development of these frameworks have entailed common collaborations with leading experts in the field, the exchange of background material, mutual participation in technical consultations and the peer review of draft documents at each stage of development. These close collaborations are expected to continue through the implementation phase. Turning to a new phase of implementation, the newly-launched integratedcare4people web platform aims to serve as a resource for further expanding implementation research. The website can be accessed at: http://integratedcare4people.org. Illustrative country case: The Netherlands The Ministry of Health, Welfare and Sport in the Netherlands has put focus on facilitating a shift in the organization of long-term care at the local level to encourage and enable people to live at home longer, delaying the need for institutionalization. Various innovative initiatives are being undertaken to explore new technologies and, in parallel, revised care guidelines and protocols are being developed for primary care and website improvements are being undertaken in order for patients to receive information on available treatment options. Illustrative country case: Scotland (United Kingdom) Prior to reforms, oversight for health services and social care fell under the purview of different organizations, contributing to inefficiencies and fragmentation in the provision of services. Capitalizing on the readiness for a more integrated model following the implementation of a smaller- scale integrated care programme, greater alignment between health and social governance structures was sought. Joint boards were set up and the initiative has now progressed further to integrate budgets. A strong focus on what matters to patients was used as the lever to initially move away from professional siloes. Portal technologies are being incrementally introduced to facilitate data sharing and leaders are working to develop an ethos on the safety and security of information sharing. Currently at a mid-way point in this long-term change process, positive results can already be seen as elderly people are spending more days at home. Meeting report: Final consultation meeting of the EFFA IHSD Page 17 Session four: Change management domain This final session explored the cross-cutting change management domain of the Framework, aiming to take stock of lessons learned from initiatives to transform services delivery across the Region. The change management domain ultimately aims to facilitate the process of transformations, recognizing the contribution of the process of change itself to the overall success of initiatives. Viewing health services delivery transformations as a process also recognizes that change is more likely to occur as incremental adjustments in a step-wise process along a continuum, rather than immediately through large-scale sweeping reform. Goal: To lead and manage the process of change strategically at the different stages of transforming health services delivery by setting a clear direction, developing and engaging partners and piloting innovations to ensure transformations are tailored to the needs of the population and rolled out and sustained over time. Through presentations and discussion with expert panellists, key considerations for strategizing change, implementing transformations and enabling sustainable system-wide improvements were explored. To conclude, the session provided an overview of the system domain and its key areas for action: strategizing change with people at the centre, implementing transformations, and enabling system-wide change (Fig. 5). Fig. 5. Domain four areas for action Meeting report: Final consultation meeting of the EFFA IHSD Page 18 Expert presentation: Strategizing change for health system strengthening: from assessments to policy actions This session presented a national assessment tool for noncommunicable diseases (NCDs) developed by the WHO Regional Office for Europe. The assessment aims to apply a systematic approach for identifying health system challenges and opportunities as a starting point for change by supporting evidence-informed priority-setting and strategic decision-making. To date, 12 country assessments have been conducted, with the documents developed through this process serving as an entry point for policy dialogue about what can and should be done to improve NCD outcomes. As a result of these assessments, countries have been empowered to take a variety of follow-up actions, including developing national NCD plans, implementing new care guidelines, and adopting new tobacco legislation, among other interventions. Illustrative country case: Croatia NCDs account for the majority of deaths in Croatia and represent a major burden of disease. After participating in the country assessment process described above, Croatia utilized the information provided by the assessment report to enact health system improvements. A whole-of-society approach was adopted in developing an action plan. Following this, a number of actions are being taken to address NCDs, including adopting a healthy living strategy and developing electronic health records. Illustrative country case: Republic of Moldova Over the past decade, the Republic of Moldova has undertaken a number of broad health system reforms, including implementing a mandatory health insurance system and introducing payment-for- performance in primary care and diagnosis-related groups in hospital care. Addressing NCDs is currently a political priority and a strategy for the prevention and control of NCDs has been put in place. Under this plan, stricter tobacco and alcohol legislation is being phased in, limiting smoking in public places and restricting advertising, for example. Panel discussion: Lessons from the perspectives of change agents During this session, the perspectives of different change agents from across a wide variety of stakeholder groups were explored. Key topics of discussion included the need to generate sustainable change, the importance of community and patient engagement, the value of teamwork and the necessity of considering contextual factors when implementing interventions. ! Policy makers. Integrated care was described as a challenge for policy-makers to push high on the policy agenda. Consequently, it is of critical importance to enlarge the evidence base that speaks to policy-makers on the expected improvements that can be achieved with strategic actions, in order to allow integrated care to gain political attention and resources. Integrated care is rewarding and this needs to come across better at the policy-level. The lack of national plans for dealing with multimorbidities was also noted. ! Regional health authorities. There is no one-size-fits-all for transformations sub-nationally. Regions and municipalities vary greatly in size, structure and capacity. Consequently, there is a wide variety of experience in integrated care at the sub-national level that can be leveraged Meeting report: Final consultation meeting of the EFFA IHSD Page 19 and shared. Learning from the experiences of others was described as very important. The need to more deeply root changes into the cultural makeup of society was also raised as a means to avoid political overhauls and ensure sustainability. ! Public. More needs to be done to translate the priority of engaging patients into practice. Attention was called to the importance of recognizing that patient involvement may be disruptive. Patients should be involved in their care and throughout the change process from the outset, not once changes have been decided on. Patient engagement should occur not only at the service level, but also the policy level. Developing strong patient organizations and change processes that are transparent and open towards the engagement of society is recommended. The European Patients’ Forum has developed guidance on how to work with and include patient organizations in this process. ! Nurses. The concept of nurses as the foundation of the health workforce for integrated care was put forward, underscoring in particular the role of primary care and community care nurses. The importance of nurses working in teams with other providers was also recognized, calling for open-mindedness among providers and multidisciplinary teams to achieve common goals. ! Other primary care providers. As with nurses, the importance of working with a wide range of other health and social care providers, including therapists, pharmacists and midwives, was highlighted. These professionals, as well as patients, each bring different perspectives to care. Taking a community-oriented approach is also important for considering interactions with culture and context. Meeting report: Final consultation meeting of the EFFA IHSD Page 20 Final remarks Echoed throughout keynote presentations, illustrative country cases and expert interventions during this final consultation meeting of the EFFA IHSD was the sentiment that "everything starts with people." A diverse range of topics were explored, with the experiences shared by Member States and other stakeholders resonating similar key messages, indicating the relevance of the EFFA IHSD in its ability to capture the most pertinent areas for strategic action in transforming services delivery. Discussion highlights included: ! The importance of placing people at the centre of care, while also balancing individual preferences with clinical effectiveness, system efficiency and long-term sustainability. ! The need to continue to invest in transformations in health services delivery and work to make integrated care more appealing to decision-makers through evidence that makes the case for change. ! The need to avoid “reinventing the wheel” by capitalizing on the wealth of information and experiences already available and fostering an understanding, dialogue and collaboration between sectors and different actors both within and across countries. ! Balancing the need for evidence with an acceptable pace for change, with greater consideration to ensure sustainability and scale up. ! Exploring potential applications for technology in driving integrated care through a participatory process, incorporating key users from the outset to ensure relevance. Closing comments emphasized the need for each participant to continue to focus on what they can contribute to the change process moving forward. The level of progress already achieved towards more integrated, people-centred care inspires further change. A package of available resources (Annex 3) has been made available to aid implementation of the EFFA IHSD. Included in this package is the recently published compendium of initiatives to transform services delivery, detailing case profiles from all 53 Member States as a starting point for sharing ideas across the Region. The global "integratedcare4people" web-based platform, launched during the Sixty-ninth World Health Assembly in May 2016, provides another means for networking and information-sharing. “The idea of integrated care or integrated patient-centred care is very abstract and different countries perceive this idea from different perspectives which leads to a variety of confusing acts, legislations or projects. This Framework document could help to streamline these areas and highlight what is actually bringing value and what does and what does not work and how to proceed when preparing individual action plans or activities.” – Country participant The validated EFFA IHSD resulting from this consultation will be presented at the 66th session of the WHO Regional Committee for Europe in September 2016, marking a significant milestone in strengthening integrated, people-centred health systems in the European Region, as set out in Health 2020. The WHO Regional Office for Europe looks forward to taking this ambitious, transformative Framework onwards for the benefit of all WHO European Region Member States. Meeting report: Final consultation meeting of the EFFA IHSD Page 21 Annex 1: Final programme Day one: opening and launch Welcome and introduction 13:00–13:30 Opening presentation. Strengthening people-centred health systems: a European framework for action on integrated health services delivery (EFFA ISD) Hans Kluge, Director, Division of Health Systems and Public Health, WHO Regional Office for Europe Member State opening. Elena Bohdan, Chief of Department of Medical Sciences, Ministry of Health, Belarus Session one 13:30–15:30 Finding alignment: from Member States to partners, policies to practice Member State chair: Christiaan Decoster, President a.i., Director-General, Department of Healthcare, Federal Public Service of Health, Food Chain Safety and Environment, Belgium 13:30–13:50 Keynote presentation. Integrated service delivery: from framework to local action. Mirella Minkman, Director Innovation and Research, Vilans, Centre of Expertise for Long- Term Care, Netherlands 13:50–14:00 Illustrative country cases: Spain and Tajikistan ! Spain. Antoni Dedeu, Director, Agency for Healthcare Quality and Evaluation of Catalonia, Spain ! Tajikistan. Shaidullo Sharipov, Head of Service Delivery Department, Ministry of Health and Social Protection of the Population, Tajikistan 14:00–15:00 Panel discussion: finding policy alignment across partners Moderator. Josep Figueras, Director, European Observatory on Health Systems and Policies ! Patient-perspective for integrated health services. Kaisa Immonen- Charalambous, European Patients’ Forum ! Integrated care and the health workforce. Pascal Garel, HOPE, European Hospital and Health care Federation ! Integrated care for health and development. Fend Zhao, Programme Leader for Ukraine, Belarus and Moldova, World Bank ! Integrated care in the European Union: learning from each other to improve performance. Federico Paoli, Policy Officer, European Commission ! Quality health services. Niek Klazinga, Head of Health Care Quality Programme, Organization for Economic Co-operation and Development ! Health system strengthening for better NCD outcomes. Gauden Galea, Director, NCDs and Promoting Health through the Life Course, WHO Regional Office for Europe ! People-centred and integrated health services. Edward Kelley, Director, Service Delivery and Safety, WHO Headquarters 15:00–15:30 Plenary discussion 15:30–16:00 Break Meeting report: Final consultation meeting of the EFFA IHSD Page 22 Session two 16:00–17:30 Addressing key challenges in health services delivery Member State chair: Daniel Reynders, Head of Service, International Relations and Public Health Emergencies, Belgium 16:00–16:20 Keynote presentation. Addressing key challenges in health services delivery: fostering innovation Volker Amelung, President, German Managed Care Association, Professor for International Health System Research, Medical School of Hannover 16:20–17:10 Innovations in services delivery: interventions and illustrative country cases Moderator. Ellen Nolte, Coordinator, European Observatory on Health Systems and Policies ! Empowering patients through e-health and other innovations. Nick Guldemond, European Health Futures Forum ! Rolling out new technologies for information connectivity in Ireland. Michelle Kearns, Caredoc, Ireland ! Integrating services delivery in Azerbaijan. Zakiya Mustafayeva, Chief of Staff of the Ministry of Health, Azerbaijan ! Delivering a comprehensive package of services: perspective of occupational therapy. Stephanie Saenger, Council of Occupational Therapists from European Countries ! Innovating processes: integrated care pilots in Poland. Tomasz Pawlega, Deputy Director, Department of Healthcare Insurance, Ministry of Health, Poland ! Innovating policy: a national strategy for integrated care in Slovakia. Martin Smatana, Project Manager, Ministry of Health, Slovakia 17:10 – 17:30 Plenary discussion 17:30 Closing Reception 17:30–18:30 Toast to a vision for integrated services delivery in the Region Zsuzsanna Jakab, WHO Regional Director for Europe Meeting report: Final consultation meeting of the EFFA IHSD Page 23 Day two: consultation Session one 9:00–10:30 Populations and individuals domain Member State chair: Yann Bourgueil, Research Director, Institute for Research and Information in Health Economics, France 9:00–9:05 Expert presentation. Making the case for a people-centred approach: evidence on improved performance and health outcomes Lourdes Ferrer, Director of Programmes, International Foundation for Integrated Care 9:05–9:45 Pertinent topics. Key considerations in working to put people first Moderator. Juan Tello, Programme Manager, WHO Regional Office for Europe ! Burden of disease on health and social care needs in the WHO European Region. Kai Leichsenring, Executive Director, European Centre for Social Welfare Policy and Research ! Gender and health. Isabel Yordi, Technical Officer, Gender and Health, WHO Regional Office for Europe ! Involvement of beneficiaries in services delivery: lessons from vaccine programmes. Robb Butler, Programme Manager, Vaccine-preventable Diseases and Immunization, WHO Regional Office for Europe ! Engaging patients, their carers and family members in services delivery. Stecy Yghemonos, Executive Director, Eurocarers – European Association Working for Carers 9:45–9:55 Illustrative country cases: Kazakhstan and Slovenia ! Kazakhstan. Roza Abzalova, Family Health Centre “Demeu”, Kazakhstan ! Slovenia. Vesna-Kerstin Petrič, Head, Division for Health Promotion and Prevention of Noncommunicable Diseases, Ministry of Health, Slovenia 9:55–10:05 Presentation of EFFA IHSD: people domain Juan Tello, Programme Manager, WHO Regional Office for Europe 10:05–10:30 Interventions by Member States 10:30–11:00 Break Meeting report: Final consultation meeting of the EFFA IHSD Page 24 Session two 11:00–12:30 Services delivery processes domain Member State chair: Martin Dolezal, Director of Concepts and Strategies Department, Ministry of Health, Czech Republic 11:00–11:05 Expert presentation. Making the case for transforming health services delivery: evidence on improved performance and health outcomes María Luisa Vázquez, Health Policy Research Unit Head, Consortium for Health Care and Social Services of Catalonia 11:05–11:45 Pertinent topics. Key considerations in transforming health services delivery Moderator. Juan Tello, Programme Manager, WHO Regional Office for Europe ! Avoidable hospital admissions for quality of care. Niek Klazinga, Head of Health Care Quality Programme, OECD ! Primary health care reforms. Salman Rawaf, Director, WHO Collaborating Centre for Public Health Education and Training, Imperial College London ! Hospitals and integrated care. Anna Riera, International Hospital Federation ! Role of the health workforce in transforming services. Anna Stavdal, Vice President, WONCA Europe 11:45–11:55 Illustrative country cases: Denmark and Italy ! Denmark. Nanna Skovgaard, Ministry of Health, Denmark ! Italy. Maria Chiara Corti, Area Santita e Sociale, Regione Veneto, Italy 11:55–12:05 Presentation of EFFA IHSD: services domain Juan Tello, Programme Manager, WHO Regional Office for Europe 12:05–12:30 Interventions by Member States 12:30–13:30 Lunch Meeting report: Final consultation meeting of the EFFA IHSD Page 25 Session three 13:30–15:30 System enablers domain Member State chair: Triin Habicht, Head of the Health System Development Department, Ministry of Social Affairs, Estonia 13:30–13:35 Expert presentation. Making the case for health system strengthening for improving outcomes and sustaining services delivery transformations Josep Figueras, Director, European Observatory on Health Systems and Policies 13:35–14:25 Pertinent topics. Key considerations in enabling health system conditions Moderator. Juan Tello, Programme Manager, WHO Regional Office for Europe ! Access to and the responsible use of medicines. Jane Robertson, Technical Officer, Health Technologies and Pharmaceuticals, WHO Regional Office for Europe ! Aligning institutional frameworks and financial incentives. Ewout van Ginneken, Berlin University of Technology, Germany ! Fostering intersectoral actions between health systems and social care. Aparnaa Somanathan, Senior Economist, World Bank • Developing a health workforce for integrated services delivery. Ellen Kuhlmann, Institute of Economics, Work and Culture, Goethe-University Frankfurt, Germany 14:25–14:30 Expert intervention. Global perspective to health systems for people-centred and integrated health services. Hernan Montenegro, Coordinator, Services Organization and Clinical Interventions Unit, WHO Headquarters 14:30–14:40 Illustrative country cases: Netherlands and Scotland ! Netherlands. Margoleen Honcoop, Policy Advisor, Ministry of Health, Welfare and Sport, Netherlands ! Scotland. Anne Hendry, Clinical Lead for Integrated Care, Scotland 14:40–14:50 Presentation on EFFA IHSD: system domain Juan Tello, Programme Manager, WHO Regional Office for Europe 14:50–15:30 Interventions by Member States 15:30–16:00 Break Meeting report: Final consultation meeting of the EFFA IHSD Page 26 Session four 16:00–17:30 Change management domain Member State chair: Milena Vasic, Head, Department for European Integrations, Institute of Public Health of Serbia 16:00–16:10 Expert presentation. Strategizing change for health system strengthening: from assessment to policy actions Anne Johansen, Senior Global Health Policy Advisor 16:10–16:20 Illustrative country cases: Croatia and Republic of Moldova ! Croatia. Tatjana Prenda Trupec, Director, Croatian Health Insurance Fund ! Republic of Moldova. Rodica Scutelnic, Head of Department for Hospital Care, Ministry of Health, Moldova 16:20–17:10 Panel discussion. Lessons from the perspective of change agents Moderator. Viktoria Stein, Head of Education and Training, International Foundation on Integrated Care ! Policy makers. Franςois Schellevis, ICARE4EU Project ! Regional health authorities. Antoni Dedeu, European Association for Regional and Local Health Authorities ! Primary care providers. Sally Kendall, European Forum for Primary Care ! Nurses. Graça Silveira Machado, European Forum of National Nursing and Midwifery Associations ! Public. Kaisa Immonen-Charalambous, European Patients’ Forum 17:10–17:15 Communities of practice. Web platform for the global framework on integrated people-centred health services Nuria Toro, Consultant, Services Organization and Clinical Interventions Unit, WHO Headquarters 17:15–17:20 Presentation on EFFA IHSD: change domain Juan Tello, Programme Manager, WHO Regional Office for Europe 17:20–17:30 Interventions by Member States Closing remarks: next steps and thanks 17:30 Hans Kluge, Director, Health Systems and Public Health, WHO Regional Office for Europe Meeting report: Final consultation meeting of the EFFA IHSD Page 27 Annex 2: List of participants Country participants Albania Romeo Zegali Head, Directory of European Integration and Donors Information Ministry of Health Austria Herwig Ostermann Head, Department of Health Economics Gesundheit Österreich GmbH Azerbaijan Zakiyye Mustafayeva Chief of Staff Ministry of Health Belarus Elena Bohdan Chief of Department of Medical Services Ministry of Health Marina Schaveleva Head, Department of Public Health and Health Care Belarusian Medical Academy of Post-diploma Education Tamara Sharashakova National focal point - Horizon 2020 Gomel State Medical University Belgium Christiaan Decoster President a.i., Director-General, Department of Healthcare Federal Public Service of Health, Food Chain Safety and Environment Saskia Van den Bogaert Head of Cell, Organization of Care Federal Public Service of Health, Food Chain Safety and Environment Daniel Reynders Head of Service, International Relations and Public Health Emergencies Federal Public Service of Health, Food Chain Safety and Environment Bosnia and Herzegovina Drazenka Malicbegovic Assistant Minister, Department of Health Ministry of Civil Affairs of Bosnia and Herzegovina Meeting report: Final consultation meeting of the EFFA IHSD Page 28 Alen Seranic Senior Technical Officer, Public Health Ministry of Health and Social Welfare of the Republika Srpska Croatia Tatjana Prenda Trupec Managing Director Croatian Health Insurance Fund Cyprus Martin Douglas Rayner Press Officer Embassy of the Republic of Cyprus Czech Republic Martin Dolezal Director, Concepts and Strategies Department Ministry of Health Denmark Nanna Skovgaard Chief Health Economist Ministry of Health Sven Erik Bukholt Senior Adviser Ministry of Health Estonia Triin Habicht Head, Health Systems Development Department Ministry of Social Affairs Jürgen Ojalo Chief Specialist, European and International Coordination Department Ministry of Social Affairs Finland Taina Mäntyranta Medical Counsellor Ministry of Social Affairs and Health France Yann Bourgueil Research Director Institute for Research and Information in Health Economics Georgia Mzia Jokhidze Chief Specialist, Health Care Department Ministry of Labour, Health and Social Affairs Meeting report: Final consultation meeting of the EFFA IHSD Page 29 Greece Eleni Sourani Ambassador Extraordinary and Plenipotentiary Embassy of Greece Lamprini Koleidou Embassy of Greece Hungary Judit Pako Ministry of Human Capacities Israel Niva Azuz Assistant to the Director of Medical Affairs Ministry of Health Lithuania Rima Vaitkienė Head, Strategic Health Development Division Ministry of Health Montenegro Natasa Terzic Director, Centre for Health System Development Institute of Public Health Netherlands Margoleen Honcoop Policy Advisor Ministry of Health, Welfare and Sport Norway Maren Skaset Deputy Director General Royal Ministry of Health and Care Services Poland Tomasz Pawlęga Deputy Director, Department of Healthcare Insurance Ministry of Health Republic of Moldova Rodica Scutelnic Head, Ministry of Health Department of Hospital and Emergency Care Serbia Natasa Djurasinovic International Cooperation Group Manager Ministry of Health Meeting report: Final consultation meeting of the EFFA IHSD Page 30 Milena Vasic Head of Department for European Integrations, International Cooperation and Project Management Institute of Public Health of Serbia Slovakia Martin Smatana Project Manager, Institute of Health Policy Ministry of Health Slovenia Vesna-Kerstin Petrič Head, Division for Health Promotion and Prevention of Noncommunicable Diseases Ministry of Health Mircha Poldrugovac Health System Policy Analyst National Institute of Public Health Switzerland Ljubisa Stojanovic Deputy Head of International Affairs Division Swiss Federal Office of Public Health Stefanie Johner Scientific Adviser Swiss Federal Office of Public Health Tajikistan Shaidullo Sharipov Head, Health Care Services Delivery Department Ministry of Health and Social Protection Ilkhom Bandaev Director, Republican Family Medicine Center Takhmina Dzhabarova Vice Rector, Tajik State Postgraduate Institute Turkey Seçil Özkan Professor, Department of Public Health Gazi University Medical Faculty Hülya Şirin Advisor of President Public Health Institute of Turkey Turkmenistan Jennet Adakova Head, Ashgabat Health Department Meeting report: Final consultation meeting of the EFFA IHSD Page 31 Maral Gujikova Lead Specialist, Department of Educational Facilities, Science and Human Resources Ministry of Health and Medical Industry Observers Rumbidzi Gondo MSc Global Health Student Irma Matuleviciute University of Copenhagen Signe Smith Jervelund Associate Professor, Research Director Department of Public Health, Section on Health Services Research University of Copenhagen Associations and Special Interest Groups Caredoc Dorcas Collier Director, Caredoc Community Intervention Team Margaret Curran Director Phonsie McCarron General Manager Council of Occupational Therapists from European Countries (COCTEC) Stephanie Saenger President Eurocarers Stecy Yghemonos Executive Director EuroHealthNet Caroline Costongs Managing Director European Brain Council Vinciane Quoidbach Project Management, Public Health and Policy European Consumer Organisation/Danish Consumer Council Sine Jensen Senior Health Advisor Meeting report: Final consultation meeting of the EFFA IHSD Page 32 European Federation of Nurses Associations Marianne Schulz Consultant, Danish Nurses' Organization European Federation of Pharmaceutical Industries and Associations (EFPIA) Thomas Allvin Director European Forum for Primary Care Sally Kendall Professor of Community Nursing and Public Health University of Kent European Forum of National Nursing and Midwifery Associations (EFNNAMA) Rui Lopes Gonçalves Member of EFNNMA’s Steering Committee Graça Silveira Machado Member of EFNNMA’s Steering Committee European Health Futures Forum Nick Guldemond Associate Professor, Integrated Care and Technology University Medical Centre Utrecht European Network of Occupational Therapists in Higher Education Marie-Antoinette Minis HAN University of Applied Sciences European Patients´ Forum Kaisa Immonen-Charalambous Director of Policy International Hospital Federation Anna Riera Membership Director Jaspers, European Investment Bank Adam Kozierkiewicz Analyst National Health Fund in Poland Katarzyna Wiktorzak Head, Strategy and Development Projects Section Department of Analysis and Strategy Netherlands Institute of Primary Health Care (NIVEL) Francois Schellevis Senior Researcher Meeting report: Final consultation meeting of the EFFA IHSD Page 33 Organisation for Economic Co-operation and Development (OECD) Niek Klazinga Head, Health Care Quality Indicator Project Health Division Pharmaceutical Group of European Union Jamie Nathan Wilkinson Director of Professional Affairs Senior Italia Federanziani Giuseppe Pozzi Vice President World Organization of Family Doctors (WONCA) Anna Stavdal Vice-President for European Region WHO Collaborating Centre for Public Health Education and Training, Imperial College Salman Rawaf Director Sondus Hassounah Teaching Fellow Federica Amati Research Postgraduate and Research Assistant Temporary Advisors Roza Abzalova Doctor of Medical Science Center of Family Medicine Volker Amelung President, German Managed Care Association Professor for International Health System Research, Medical School of Hannover Liesbeth Borgermans Professor, Department of Family Medicine Vrije Universiteit Brussel Maria Chiara Corti Medical Director Area Santia e Sociale, Regione Veneto, Italy Antoni Dedeu Director, Agency for Healthcare Quality and Evaluation of Catalonia European Association for Regional and Local Health Authorities Meeting report: Final consultation meeting of the EFFA IHSD Page 34 Joâo Diogo Da Rocha Fernandes Health Economist International Diabetes Federation Lourdes Ferrer Managing Director International Foundation for Integrated Care Anne Hendry National Clinical Lead for Integrated Care The Scottish Government Arnoldas Jurgutis Professor, Public Health Department, Faculty of Health Sciences Klaipeda University Michelle Kearns Chief Information Officer Caredoc Ellen Kuhlmann Senior Researcher, Institute of Economics, Work and Culture Goethe-University Frankfurt Kai Leichsenring Executive Director European Centre for Social Welfare Policy and Research Alisher Makhmundov Health Systems Expert Human Development Support Program II Mirella Minkman Director, Innovation and Research Vilans, Centre for Expertise for Long-term Care Ilaria Mosca Senior Consultant Ecorys Research and Consulting Firm Camilla Peterson Consultant Joao Sarmento Universidade Nova De Lisboa Escola Nacional de Saude Publica Viktoria Stein Head, Integrated Care Academy International Foundation for Integrated Care Anne Stœhr Johansen Senior Health Policy Advisor Meeting report: Final consultation meeting of the EFFA IHSD Page 35 Ewout van Ginneken Senior Researcher, Health Care Management, Faculty of Economics and Management Berlin University of Technology Elena Varavikova Lead Researcher, Human Resources in Health Analysis Federal Research Institute for Health Organization and Informatics Ministry of Health of the Russian Federation Maria Luisa Vázquez Health Policy Research Unity Head Consortium for Health Care and Social Services of Catalonia Sina Waibel Health Policy and Health Services Research Unit Consortium for Health Care and Social Services of Catalonia UN Agencies, World Bank and European Commission Basil Rodriques Regional Adviser, Health System & Policy UNICEF Regional Office for Central and Eastern Europe, Commonwealth of Independent States Federico Paoli Policy Coordinator European Commission Directorate-General for Health and Food Safety Feng Zhao Program Leader for Ukraine, Belarus and Moldova The World Bank in Ukraine Aparnaa Somanathan Senior Health Economist The World Bank WHO Country Offices, Regions and Headquarters Country Offices Gazmend Bejtja National Professional Officer Albania Henrik Khachatryan National Professional Officer Armenia Valiantsin Rusovich National Professional Officer Belarus Meeting report: Final consultation meeting of the EFFA IHSD Page 36 Nino Mamulashvili National Professional Officer Georgia Paulina Karwowska Head of Country Office Poland Zinaida Bezverhni National Professional Officer Republic of Moldova Zulfiya Pirova National Professional Officer Tajikistan Oleksandr Martynenko National Professional Officer Ukraine Zakir Khodjaev National Professional Officer Uzbekistan Ardita Tahirukaj National Professional Officer Kosovo Regional Office for Africa Martin Ekeke Mononou Regional Adviser, Health Systems and Services Unit Regional Office for Eastern Mediterranean Mohammad Assai Ardakani Regional Adviser, Health Information and Statistics Headquarters Edward Talbott Kelley Director, Service Delivery and Safety Hernan Julio Montenegro Coordinator, Services Organization and Clinical Interventions Nuria Toro Polanco Consultant, Services Organization and Clinical Interventions Meeting report: Final consultation meeting of the EFFA IHSD Page 37 Evgeny Zheleznyakov Technical Officer, Office of the Assistant Director General Regional Office for Europe Erica Barbazza Technical Officer, Health Services Delivery Josep Figueras Director, European Observatory on Health Systems and Policies Gauden Galea Director, Division NCDs and Promoting Health through the Life-Course Manfred Huber Coordinator, Healthy Ageing, Disability and Long-term Care Zsuzsanna Jakab Regional Director Hans Kluge Director, Division of Health Systems and Public Health Aliya Kosbayeva Technical Officer, Health Services Delivery Monika Kosinska Programme Manager, Governance for Health Tanja Kuchenmüller Technical Officer, Evidence and Intelligence for Policy-making Margrieta Langins Consultant, Health Services Delivery Gunta Lazdane Programme Manager, Sexual and Reproductive Health Srdan Matic Coordinator, Division of Policy and Governance for Health and Well-being Matthijs Muijen Programme Manager, Division NCDs and Promoting Health through the Life-Course Åsa Nihlén Technical Officer, Equity, Social Determinants, Gender and Human Rights Ellen Nolte Coordinator, European Observatory on Health Systems and Policies Govin Permanand Health Policy Analyst, Division of Health Systems and Public Health Meeting report: Final consultation meeting of the EFFA IHSD Page 38 Jane Robertson Technical Officer, Health Technologies and Pharmaceuticals Altynai Satylganova Consultant, Health Services Delivery Juan Tello Programme Manager, Health Services Delivery Isabel Yordi Aguirre Technical Officer, Equity, Social Determinants, Gender and Human Rights Interpreters Evgeny Sinelschikov Lyudmila Yurastova Meeting report: Final consultation meeting of the EFFA IHSD Page 39 Annex 3: List of available resources Background documents Tello, J. and Barbazza, E. (2015). Health services delivery: a concept note. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0020/291611/Health-Services-Delivery-A-concept- note-301015.pdf?ua=1 Langins, M. and Borgermans, L. (2015). Strengthening a competent health workforce for the provision of coordinated/integrated health services. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0010/288253/HWF- Competencies-Paper-160915-final.pdf Suter, E. and Mallinson, S. (2015). Accountability for coordinated/integrated health services delivery. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0003/286149/Accountability_for_coordinated_integra ted_health_services_delivery.pdf Ferrer, L. (2015). Engaging patients, carers and communities for the provision of coordinated/integrated health services: strategies and tools. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0004/290443/Engaging- patients-carers-communities-provision-coordinated-integrated-health-services.pdf Edwards, N. (2015). Improving hospitals and health services delivery: A report on the priorities for strengthening hospital and health services delivery in the WHO European Region. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0007/167569/Improving-hospitals-report-FINAL- B.pdf WHO Regional Office for Europe. (2014). Strengthening people-centred health services delivery in the WHO European Region: concept note. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0005/258224/Strengthening-people- centred-health-services-delivery-in-the-WHO-European-Region-concept-note.pdf?ua=1 WHO. (2015). WHO global strategy on people-centred and integrated health services: interim report. Geneva: World Health Organization. Retrieved from http://www.who.int/servicedeliverysafety/areas/people-centred-care/global-strategy/en/ Evidence WHO Regional Office for Europe. (2016). Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0014/303026/Lessons- HSD-compendium-initiatives.pdf?ua=1 WHO. (2015). People-centred and integrated health services: an overview of the evidence: interim report. Geneva: World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/155004/1/WHO_HIS_SDS_2015.7_eng.pdf?ua=1&ua=1 Meeting report: Final consultation meeting of the EFFA IHSD Page 40 Tools WHO Regional Office for Europe. (2016). A step-by-step guide for developing profiles on health services delivery transformations. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0010/298297/Step-by-step-guide-developing-profiles- HSD-transformations.pdf?ua=1 WHO Regional Office for Europe. (2016). Assessing health services delivery performance with hospitalizations for ambulatory care sensitive conditions. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0010/305875/Assessing- HSD-performance-with-ACSH.pdf Advocacy Barbazza, E., Langins, M., Kluge, H., and Tello, J. (2015). Health workforce governance: Processes, tools and actors towards a competent workforce for integrated health services delivery. Health Policy; 119(12):1645–1654. doi:10.1016/j.healthpol.2015.09.009. Retrieved from http://www.healthpolicyjrnl.com/article/S0168-8510(15)00246-8/abstract Barbazza, E. and Tello, J. (2014). A review of health governance: definitions, dimensions and tools to govern. Health Policy; 116(1):1–11. doi: 10.1016/j.healthpol.2014.01.007. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24485914 Stein, VK., Barbazza, E., Tello, J., and Kluge, H. (2013). Towards people-centred health services delivery: a Framework for Action for the World Health Organisation (WHO) European Region. Int J Integr Care; 13(4). doi: 10.5334/ijic.1514. Retrieved from http://www.ijic.org/index.php/ijic/article/view/1514/2358 Tello, J., Barbazza, E., and Kluge, H. (2013). Coordination and governance mechanisms to enable the conditions for integrated care of chronic conditions. Int J Integr Care; 13(5): Annual Conf Suppl. doi: 10.5334/ijic.1243. Retrieved from http://www.ijic.org/index.php/ijic/article/view/1243/2078 Barbazza, E., Stein, VK, Bengoa, R., Borgermans, L., Kluge, H., and Tello, J. (2014). Initiatives to strengthen the coordination/integration of health services delivery in the WHO European Region: a synthesis of lessons from implementation. Int J Integr Care; 14(6). doi: 10.5334/ijic.1622. Retrieved from http://www.ijic.org/index.php/ijic/article/view/1622/2450 Capacity building and networks WHO Regional Office for Europe. (2014). Coordinated/integrated health services delivery (CIHSD) kick-off technical meeting: Istanbul, 3–5 February 2014. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0007/246256/Coordinated-Integrated-Health- Services-Delivery-CIHSD-Kick-off-Technical-Meeting.pdf?ua=1 WHO Regional Office for Europe. (2014). Coordinated/integrated health services delivery (CIHSD) stakeholder consultation: Brussels, 1 April 2014. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0018/251082/Coordinated- Integrated-Health-Services-Delivery-CIHSD-Stakeholder-Consultation.pdf?ua=1 Meeting report: Final consultation meeting of the EFFA IHSD Page 41 WHO Regional Office for Europe. (2015). Second annual technical meeting on coordinated/integrated health services delivery (CIHSD): Istanbul, 17–18 February 2015. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0005/275972/II-CIHSD-Meeting-Report-Istanbul- 150415pm.pdf WHO Regional Office for Europe. (2015). Delegate briefing note: Second technical meeting on coordinated/integrated health services delivery: developing the framework for action in the context of Health 2020: Istanbul, 17–18 February 2015. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0003/270192/CIHSD- Istanbul-mtg-briefing-note-040215f.pdf?ua=1 Country work WHO Regional Office for Europe. (2015). Ambulatory care sensitive conditions in Germany. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0004/295573/ASCS-Germany-2015-rev1.pdf?ua=1 WHO Regional Office for Europe. (2015). Ambulatory care sensitive conditions in Kazakhstan. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0003/294402/Ambulatory-care-sensitive-conditions- Kazakhstan-en.pdf?ua=1 WHO Regional Office for Europe. (2015). Ambulatory care sensitive conditions in Latvia. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0008/284192/Ambulatory-care-sensitive-conditions- Latvia.pdf?ua=1 WHO Regional Office for Europe. (2015). Ambulatory care sensitive conditions in the Republic of Moldova. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0009/276813/Ambulatory-care-sensitive-conditions- in-the-Republic-of-Moldova-final-report.pdf?ua=1 WHO Regional Office for Europe. (2016). Ambulatory care sensitive conditions in Portugal. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/en/countries/portugal/publications2/ambulatory-care-sensitive-conditions-in- portugal-2016 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. 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