Transformative approaches for equity and resilience: harnessing the 2030 agenda for health and well-being

Health in All Policies Eurohealth — Vol.23 | No.3 | 2017 16 TRANSFORMATIVE APPROACHES FOR EQUITY AND RESILIENCE – HARNESSING THE 2030 AGENDA FOR HEALTH AND WELL-BEING By: Monika Kosinska, Adam Tiliouine and Christoph Hamelmann Summary: Tackling pressing global public health challenges and meeting common goals requires commitment to strengthened intersectoral action for health and well-being for all. This poses governance challenges at the global, regional, national and sub-national levels. The adoption of the United Nations 2030 Agenda for Sustainable Development provides a renewed political impetus for tackling the determinants of health by all sectors and actors. The European Region has a long standing history of leadership and innovation in relation to intersectoral action for health and well-being for all, which provides an opportunity to bring about transformative change. Keywords: Intersectoral Action, Health 2020, Policy Framework, Whole-of- Government Approaches Well-being Monika Kosinska is Programme Manager, Governance for Health; Adam Tiliouine is Consultant; Christoph Hamelmann is Head of WHO European Office for Investment for Health and Development, World Health Organization (WHO) Regional Office for Europe, Copenhagen, Denmark. Email: kosinskam@who.int Introduction Intersectoral action is at the heart of the policy approaches currently being taken forward at national and sub- national level across the WHO European Region, as part of the concerted effort by countries to implement Health 2020, the European strategy and policy framework for health and well-being 1 and the transformative 2030 Agenda for Sustainable Development adopted by governments in September 2015. 2 The ambitious 2030 Agenda stresses that health is both an integral investment for social, economic and sustainable development as well as an outcome of good policies and actions across other sectors and by other actors. The indivisibility of the Sustainable Development Goals (SDGs) reinforce Health 2020 in both calling for inter- and multi-sectoral approaches to today’s challenges that influence health and well-being, as well as in their objective to address issues of equity and leaving no one behind. In 2015, the Regional Committee of the WHO European Region working paper, Promoting intersectoral action for health and well-being in the WHO European Region: health is a political choice, proposed four strategic intersectoral approaches for action on health and well-being; intersectoral action for > #EHFG2017 Forum 4 & 10: Transformative approaches for equity and resilience Health in All Policies Eurohealth — Vol.23 | No.3 | 2017 17 health; whole-of-government; Health in All Policies; and governance for health. 3 These four approaches are central to the implementation of Health 2020 and the 2030 Agenda. ‘‘ A good start in life generates significant dividends Tackling inequalities has been central to the improvement of health and well- being for the Region throughout the implementation of Health 2020, and has been given particular prominence since the publication of the review of social determinants and the health divide in the WHO European Region. 4 The WHO Regional Office for Europe is committed to supporting countries in their work to improve health and health equity through supporting the transfer of knowledge on the intersectoral approaches in the European Region. Preconditions and challenges to work across and between sectors The work to strengthen intersectoral action in the Region has highlighted a number of commonalities as preconditions and challenges: almost all countries report that political will is essential for the adoption of whole-of-government approaches, where health is a goal of overall government policy. Implementing whole-of-government approaches mean strengthening policy coherence between sectors. In addition to strong leadership from the Ministry of Health and excellent communication across sectors, providing a strong evidence base and an economic case for action can trigger and support the political choices to invest in intersectoral action. The experience of the European Region shows that intersectoral working is also possible where political will still needs to be fostered: time, buy-in from other sectors and partners, and capacity to take action forward are core criteria for success. A first step in this process is identifying co-benefits for joint working. In addition to the ongoing work of the WHO Regional Office for Europe to support and strengthen intersectoral action, three important developments have put intersectoral working as high level priorities for countries in the European Region: 1. the localisation of the 2030 Agenda; 2. the renewed commitment to the Environment and Health Process; and 3. the convening of the Regional Platform for Working Together for Better Health and Well-Being for All, focusing on bringing together the health, education and social sectors. All three mark important milestones in the journey to improved health and well-being for all in the European Region. Implementing the 2030 Agenda through intersectoral action The 2030 Agenda and its 17 SDGs present a significant opportunity for the public health community to step up intersectoral action on the various determinants of health, and through engagement with a wide range of stakeholders. The unprecedented political commitment to the SDGs – seen by global health being discussed during meetings of the G7 and G20 for example – together with the transformative demands of the 2030 Agenda give the public community impetus to innovate and adopt new and wider partnerships. Many countries have established inter- and multisectoral mechanisms to support action. However, more action is needed to tackle the burden of disease from environmental exposures, climate change and food systems; to address the risk factors for non-communicable diseases (NCDs); communicable diseases and antimicrobial resistance; and to strengthen the factors that support the social determinants of health and empower people through education and training. The adoption of the Roadmap to implement the 2030 Agenda for Sustainable Development, building on the Health 2020 policy framework, at the 67th session of the WHO Regional Committee for Europe in Budapest, Hungary in September 2017 marks an important milestone to support countries in their localisation of the 2030 Agenda and improving health and well-being for all. Tackling the environmental determinants of health The European Region has many years of experience and lessons learnt on intersectoral action for improved health and well-being. One key area of success is the work in the environment and health area, and this learning and experience needs to be transferred to other areas, including the social and economic determinants of health. In 1989, concerned about the growing evidence of the impact of poor environments on human health, the WHO Regional Office for Europe initiated the first ever international environment and health process for addressing environmental determinants of health. The European Environment and Health Process (EHP) is steered by ministerial conferences that bring together different sectors and stakeholders to agree on commitments and shape shared European policies and actions on environment and health. Despite the successes achieved since 1989, the environmental burden of disease is still stubbornly present in some geographic areas. There are many opportunities for progress; for example through changing production and consumption patterns and fostering healthy and environmentally friendly approaches in energy, transport, housing, urban management and agriculture, as well as in the health sector itself. In Ostrava, Czech Republic, in June 2017, the countries of the European Region adopted the Declaration of the Sixth Ministerial Conference on Environment and Health which recognises the inseparable link between development, environment, human health and well- being and resolves to fulfil the vision of a healthy planet and healthy people through partnership with relevant sectors and stakeholders. 5 Health in All Policies Eurohealth — Vol.23 | No.3 | 2017 18 Scaling up action on the social determinants of health The sustainable development of the WHO European Region and the implementation of the 2030 Agenda cannot be achieved without ensuring a sustainable and healthy future for future generations. This requires a renewed focus on children and adolescents, their families and communities: investment in people and human capital is at the heart of achieving health and well-being. Currently, inequalities among children exist between and within countries in the Region: disregarding these inequalities contributes to their perpetuation, to reduced social cohesion, and puts societies at risk of instability. ‘‘ the education and social sectors play a particularly important role A good start in life generates significant dividends for health and well-being. 6 Investing in all children early in their development provides the greatest return on investment at any point during the life-course: it is crucial to address inequalities early so they do not continue and perpetuate throughout generations as the earlier the investment during the life- course, the greater the benefits. While a number of determinants affect child and adolescent health and well- being, it is the education and social sectors that play a particularly important role. Educational settings, from child care and pre-schools in early years to school during later childhood and adolescence, promote cognitive, emotional and executive function, support social development and encourage participation in activities that build individual resilience. In the social sector, household income (through decent work and pay as well as social transfers, such as child or housing benefit) remains the strongest determinant of child health and well-being. 7 In December 2016, in Paris, France, the countries of the European Region came together as the health, education, social and other relevant sectors for the first time during the High Level Conference Promoting intersectoral and interagency action for health and well-being in the WHO European Region. They committed to tackling health inequalities and improving the health and well-being of all children in the Region, including through the establishment of the Regional Platform for Working Together for Better Health and Well-being, which brings together the health, education and social sectors. The evidence of policies that effectively work in addressing social determinants of health and health inequities is there 8 – it is urgently time to implement them coherently. Conclusion The development and implementation of policies to advance health and well-being in the 21st century cannot be achieved without breaking down silos between policies and sectors. It is crucial for allowing and encouraging health to make the maximum possible contribution to sustainable development. Although the experience of the European Region shows that sustained and consistent intersectoral action is not easy, there are many good examples in countries that can act as inspiration and lessons learnt on how to move forward. Intersectoral action calls for the strengthening of evidence-based approaches, development of economic cases for action, a better understanding of the co-benefits of joint action as well as strengthened approaches to governance for health and well-being. This includes the legislative and policy frameworks that support greater accountability and policy coherence for better health and well-being outcomes, as well as systematic approaches to addressing conflicts of interest and the commercial determinants of health. These issues become increasingly important as the complexity of governance of intersectoral action increases, with a plurality of stakeholders and actors at the decision-making table. Intersectoral action is not a universal panacea and it is imperative that the health sector leads by example, tackling the inequalities in access and barriers to universal health coverage, as well as the employment, social and environmental conditions affecting its own workforce. However, the current political environment provides a renewed mandate, impetus and direction to strengthen action between and across sectors. It is imperative, therefore, that all actors in public health look to their engagement and partnerships and to step up work to bring together the relevant stakeholders to allow us to meet our common goals and objectives. There is no alternative to intersectoral approaches and intersectoral working if the ambitious goals of Health 2020 and the 2030 Agenda are to be realised. References 1 WHO Regional Office for Europe. Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen, 2012 (EUR/RC62/9). Available at: 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 2 United Nations. Transforming our world: the 2030 agenda for sustainable development. New York, 2015 (A/RES/70/1). Available at: https://sustainabledevelopment.un.org/content/ documents/21252030%20Agenda%20for%20 Sustainable%20Development%20web.pdf 3 WHO Regional Office for Europe. Promoting intersectoral action for health and well-being in the WHO European Region: health is a political choice. Copenhagen, 2015 (EUR/RC65/16). Available at: http://www.euro.who.int/en/about-us/governance/ regional-committee-for-europe/past-sessions/65th- session/documentation/working-documents/ eurrc6516-promoting-intersectoral-action-for-health- and-well-being-in-the-who-european-region-health- is-a-political-choice 4 WHO Regional Office for Europe. Review of social determinants and the health divide in WHO European Region: final report. Updated reprint 2014. Copenhagen, 2014. Available at: http://www.euro. who.int/en/publications/abstracts/review-of-social- determinants-and-the-health-divide-in-the-who- european-region.-final-report 5 Declaration of the Sixth Ministerial Conference on Environment and Health. Available at: http://www. euro.who.int/__data/assets/pdf_file/0007/341944/ OstravaDeclaration_SIGNED.pdf?ua=1) 6 Dyakova M, Hamelmann, C, Bellis MA, et al. Investment for health and well-being: a review of the social return on investment from public health policies to support implementing the Sustainable Development Goals by building on Health 2020. Health Evidence Network (HEN) synthesis report 51. Copenhagen: WHO Regional Office for Europe, 2017. Health Systems Eurohealth — Vol.23 | No.3 | 2017 19 7 Institute of Education. Children’s well-being: does family income matter? Evidence from the UK millennium cohort. London: University of London, 2015. Available at: http://www.nuffieldfoundation. org/sites/default/files/files/Children_wellbeing_ income_summary_v_FINAL.pdf 8 Saunders MD, Barr B, McHale P, Hamelmann C. Key policies for addressing the social determinants of health and health inequities. Health Evidence Network (HEN) synthesis report 52. Copenhagen: WHO Regional Office for Europe, 2017. CONSIDERING THE FUTURE OF HEALTH SYSTEMS IN EUROPE By: Hans Kluge, Nick Fahy, Jo De Cock, Elke Jakubowski, Govin Permanand and on behalf of the WHO Regional Office Health Systems Foresight Group Summary: European health systems face challenges and financial pressures which threaten their long-term sustainability and the values of equity, universalism and solidarity which underpin them. Towards understanding potential future health system directions and how to plan for them, the WHO European Regional Office has established a Health Systems Foresight Group. The group will work with the Division of Health Systems and Public Health to develop scenarios and pragmatic and policy-oriented advice for policy-makers to address these challenges, also with the aim of ensuring that European health systems remain oriented around their shared values. Keywords: Health Systems, Values, Financial Sustainability, Future Hans Kluge is Director, Division of Health Systems and Public Health, World Health Organization (WHO) Regional Office for Europe, Denmark; Nick Fahy is Consultant, WHO Regional Office for Europe and Senior Researcher, University of Oxford, United Kingdom; Jo De Cock is Chief Executive Officer, National Institute for Health and Disability Insurance, Belgium; Elke Jakubowski is Programme Manager, Health Systems Governance and Govin Permanand is Senior Health Policy Analyst, WHO Regional Office for Europe, Denmark. Health decision-makers in Europe face a number of common challenges. Among the most notable are the increasing cost of health care, demographic change and population ageing, the changing burden of disease, concerns around the health workforce, and growing patient demand. These, in turn, raise broader health system issues around affordability and sustainable financing, adequate human resources for health (not just in numbers and distribution, but in training and quality), and systems’ ability to adapt to meet such challenges while still providing quality care. European health systems have long faced similar concerns. Researchers, experts and policy-makers have often sought to draw attention to unsustainable health care costs, changing patterns of disease and demographic change, and difficulties in meeting growing demands, and have called for sustainable forward-looking responses. What is perhaps different today, however, is the intensity of the challenges, particularly in view of the financial pressure on health systems also driven by medicines and technologies, where pharmaceutical spending is increasingly skewed towards high-cost products. 1 (See also the article by Edwards and Panteli in this issue). The result being that ensuring universalism and solidarity – the values that have traditionally under- pinned health systems in Europe – is potentially under threat. 2 The global economic crisis has served to worsen this, where progress towards universal health coverage (UHC) in some countries is being unpicked. 3 Also new