Equity and sustainable development – keeping people at the centre: Sixth high-level meeting of the small countries: San Marino, Republic of San Marino, 31 March–2 April 2019

Equity and sustainable development – keeping people at the centre Sixth high-level meeting of the small countries San Marino, Republic of San Marino 31 March–2 April 2019

Equity and sustainable development – keeping people at the centre Sixth high-level meeting of the small countries San Marino, Republic of San Marino 31 March–2 April 2019 Abstract The Small Countries Initiative is a platform through which 8 Member States in the WHO European Region with populations of less than 2 million (Andorra, Cyprus, Iceland, Luxembourg, Malta, Monaco, Montenegro and San Marino) can share their experiences in implementing Health 2020 and the 2030 Agenda. At the Sixth high-level meeting of the Small Countries held in San Marino, Republic of San Marino, on 31 March–2 April 2019, they were joined by Estonia, Latvia and Slovenia. The meeting provided the small countries with the opportunity to share their experiences in tackling health equity and using participatory approaches to implement the Sustainable Development Goals (SDGs), as well as their challenges in addressing issues related to human resources for health in small-country contexts. The San Marino Statement adopted at the meeting shows the commitment of the small countries to reducing inequities, and emphasizes that governments, health systems and public authorities, at all levels, have a role to play in ensuring that health equity is central to their policies, strategies and plans. 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 web site (http://www.euro.who.int/ pubrequest). © World Health Organization 2019 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. 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Edited by Anna Müller Book design by Marta Pasqualato Printed in Italy by AREAGRAPHICA SNC DI TREVISAN GIANCARLO & FIGLI Cover © WHO Document number: WHO/EURO:2019-3535-43294-60679 CONTENTS Executive summary .......................................................................................................................... iv Introduction ....................................................................................................................................... 1 The economic and social impact of health systems in small countries ........................................ 3 How health systems can contribute ................................................................................................ 3 Key messages. The economic and social impact of health systems in small countries.............. 4 Accelerating progress towards health equity................................................................................. 5 Health Equity Status Report Initiative ............................................................................................. 6 How environment can impact environmental health inequalities ................................................ 8 Key messages. Accelerating progress towards health equity ...................................................... 9 Small-country perspectives on equity, environmental sustainability and urban health ............ 10 Small-country challenges to achieving equity .............................................................................. 12 Key messages. Small-country perspectives on equity, environmental sustainability and urban health .................................................................................................................................... 13 The global agenda on sustainable development and the small countries ............................... 14 Small-country participatory approaches to achieving the SDGs ................................................ 15 Communications, civil society and the SDGs ............................................................................... 16 Key messages. The global agenda on sustainable development and the small countries ..... 18 Addressing health-workforce challenges in small countries ....................................................... 19 HRH-related challenges in small countries ................................................................................... 20 Key messages. Addressing health-workforce challenges in small countries ............................. 21 References ....................................................................................................................................... 22 Annex 1. Programme ...................................................................................................................... 24 Annex 2. Leaving no one behind: the San Marino Statement .................................................... 27 Annex 3. Participants ...................................................................................................................... 29 iii iv Executive summary The Small Countries Initiative (SCI) (1) is a platform through which 8 Member States in the WHO European Region with populations of less than 2 million can share their experiences in implementing Health 2020 (2), the 2030 Agenda for Sustainable Development (3) and the the WHO Roadmap to implement the 2030 Agenda for Sustainable Development (hereafter, the SDG Roadmap) (4). The countries participating in the Initiative are Andorra, Cyprus, Iceland, Luxembourg, Malta, Monaco, Montenegro and San Marino. At the Sixth high-level meeting of the small countries in San Marino, Republic of San Marino, on 31 March–2 April 2019, they were joined by Estonia, Latvia and Slovenia (Annex 3). The Initiative seeks to foster political commitment to, and the development of, good practices in the implementation of Health 2020 and the 2030 Agenda in small countries (1,2,3). The theme of the Sixth high-level meeting of the Small Countries was equity and sustainable development – keeping people at the centre. Its main objectives were to: • discuss the main findings of the Economic and social impacts and benefits of health systems report and related opportunities for small countries (5); • present the preliminary findings of the Health Equity Status Report initiative (HESRi) (6) and their relevance to small countries, and identify key areas for action; • strengthen the commitment of small countries to placing equity at the centre of all policies; • discuss the human resources for health (HRH) action framework (7) and its applicability to small countries, building on the recommendations of the Expert meeting on human resources for health held in Venice, Italy, on 18–19 December 2018 (8); • review the experiences of small countries in implementing the 2030 Agenda (3) and adopting a participatory process, involving the general public and civil society; and • discuss environmental sustainability, focusing on urban health and equity (Annex 1). Country experiences in tackling health equity and using participatory approaches in implementing the Sustainable Development Goals (SDGs) (3) and their challenges in addressing HRH in small-country contexts were amply shared. The following key messages derived from the meeting will guide the work of HESRi (6) in the coming year. The San Marino Statement (adopted at the meeting) (Annex 2) shows the commitment of small countries to reducing inequities through efforts to close the coverage and access gaps, enhance people’s participation in decisions pertinent to their health, and reduce exposure to discrimination and stigma, as well as differential exposure to commercial pressures that polarize inequities in health. The Statement (Annex 2) emphasizes that governments, health systems and public authorities, at all levels, have a role to play in ensuring that health equity is central to their policies, strategies and plans. Investment in a country’s well-being is not an economic burden but a contributor to the growth and stability of the economy. Key figures can be used to show policy-makers that it is possible to do even more, even better. For example: • in 2017, in northern, southern and western Europe, employment in health and social work accounted for over 12% of all jobs, reflecting a large number of people in secure positions; • in Preston, United Kingdom, the City Council increased local procurement by 13% over a period of 4 years, which translated into £4 million more spent in the local community; and • 14% of the gross domestic product (GPD) of the European Union (EU) (representing € 2 trillion) is spent on public procurement every year, which can be considered an investment (5). vHESRi is relevant to small-country contexts. It will help shift policy, increase investment in the health sector and, through other sectors, demonstrate the bidirectional importance of health, that is, how health is affected and how health can contribute. It will also “achieve, accelerate and influence” by focusing on five conditions that are essential to living a healthy life: • access to health services; • income security and social protection; • adequate living standard; • social and human capital; • employment and work (6). Small countries recognize that environment goes beyond physical agents and risk factors. Its impact on health equity is well documented and should be considered in planning and implementing action to reduce inequities. Tackling environmental issues embraces the need for a broader health model with strong links to the SDGs (3) and great potential for equity gains. Salutogenic models for promoting health, which consider the effects of green and blue spaces in cities, complete this holistic approach. Equality for health and environment calls for cross-cutting action and a change in mind set. A sustainable model for economic development is needed, which makes it possible to slow down urbanization and climate change while helping people make a decent living. © W H O The health sector can take the lead in providing a straightforward, practical explanation of what is required to achieve the SDGs (3). It can help non-health sectors become advocates by illustrating the impact of their “sector specifics” on health and well-being. The participation of a broad range of stakeholders is needed to make progress towards the SDGs (3). Civil society, the private sector, youth and non-health actors can all play important roles, each bringing a richness that complements the contributions of the others. Their participation can be assured through different mechanisms, depending on the context, starting from awareness-raising to engagement in partnerships for the co-creation of plans and strategies. vi © W H O Addressing the challenges of the health workforce in small countries can be done collectively. An ad hoc working group on HRH challenges will be established, with modality options for countries to work together on strengthening HRH. Its aim will be to foster the exchange of information and ideas, document experiences, consider how best to address health- professional mobility, and map available policy-support tools. Events held under the auspices of the Sixth high-level meeting of the small countries The following events took place on 2 April 2019 after the closure of the meeting: • Fifth meeting of the focal points of the Small Countries Health Information Network (SCHIN); • Engaging citizens in the SDGs: a workshop for communications professionals. 1Introduction SCI (1) is a platform through which the 8 Member States in the WHO European Region with populations of less than 2 million are able to share their experiences in implementing Health 2020 (2), the 2030 Agenda for Sustainable Development (3) and the WHO roadmap to implement the 2030 Agenda, building on Health 2020 (4). The countries participating in the Initiative are Andorra, Cyprus, Iceland, Luxembourg, Malta, Monaco, Montenegro and San Marino. At the Sixth high-level meeting of the small countries in San Marino on 31 March–2 April 2019, they were joined by Estonia, Latvia and Slovenia (Annex 3). SCI seeks to foster political commitment to, and the development of, good practice in the implementation of Health 2020 and the 2030 Agenda in small countries (1,2,3). Small countries share unique contexts and needs. Their multifaceted similarities, including size, enable them to navigate the increasingly complex and turbulent global environment better than larger countries. Thanks to a shared sense of purpose, it is easier for small countries to set and implement policies quickly and effectively. It is this strategic agility that renders small countries ideal settings for policy experimentation and innovation. The theme of the Sixth high-level meeting of the small countries was equity and sustainable development – keeping people at the centre. Its main objectives were to: • discuss the main findings of the Economic and social impacts and benefits of health systems report and relevant opportunities for small countries (5); • present the preliminary HESRi findings (6) and their relevance to small countries, and identify key areas for action; • strengthen the commitment of small countries to placing equity at the centre of all policies; • discuss the HRH action framework (7) and its applicability to small countries, building on the recommendations of the Expert meeting on human resources for health held in Venice, Italy, on 18–19 December 2018 (8); • review the experiences of small countries in implementing the 2030 Agenda (3) and adopting a participatory process, which involves the general public and civil society; and • discuss environmental sustainability, focusing on urban health and equity. This high-level meeting of the small countries differed from previous ones in that Dr Tedros Adhanom Ghebreyesus, WHO Director General, opened it and that its timing coincided with a key event in San Marino, namely, the Investiture Ceremony during which the Captains Regent (heads of state elected every six months) take office (9). Dr Tedros expressed his appreciation to the San Marino leadership for establishing SCI (1) and confirmed the view that such a platform could be of benefit to other small countries outside the WHO European Region. He referred to SCI’s (1) timeliness in addressing various issues over the years, such as universal health coverage (UHC), health inequities, obesity, climate change and water, SDG implementation and HRH, to name a few. Dr Tedros emphasized the importance of the 13th General Programme of Work 2019–2013 (GPW 13) (WHO’s new 5-year strategic plan) and its triple billion goals to achieving the SDGs (3,10). He commended the small countries for their achievements in this area so far and encouraged them to continue their efforts. Dr Franco Santi, Minister of Health and Social Security, National Insurance, Family and Economic Planning of San Marino, also welcomed the participants to the meeting. He stressed its importance in gathering the participants in San Marino, SCI’s starting point in 2013 (1). Since then, the yearly high-level meetings and their resulting statements and follow-up activities have provided a mechanism whereby small countries with similar challenges and strengths can to continue to learn from one another. SCI (1) is unique in that it has the unique quality of pioneers searching for innovation and solutions. Introduction 2 Sixth high-level meeting of the small countries © W H O 3The economic and social impact of health systems in small countries The economic and social impact of health systems are poorly understood and often overlooked in mainstream development processes at the local, national and European levels. The dominant debate is about the cost of health systems with the result that, in many countries, public expenditure on health is being challenged and at risk of being reduced. Furthermore, the economic and social impact of health systems on local communities, being regarded only as a cost – a drain on the economy, is often overlooked when development and investment decisions are being made. Nowadays, ministries of finance pressurize health ministries to do more with less money. The small countries were presented with three key figures that could help challenge the notion that health systems drain the economy. Work around these issues is being by the WHO European Office for Investment for Health and Development. 1. 12% This is the average proportion of people working in health and social care in countries in the WHO European Region. It represents a large number in higher-paid positions and with full-time contracts, including a fair number of women and older people. • Health systems are important components of every economy and a major source of employment. • In most countries, the size of the health and care workforce is significant and growing (5). 2. 13% This percentage reflects a movement towards strategic social purchasing around the world. A study carried out in Preston, United Kingdom, showed that an increase in local procurement over a period of four years had added £ 4 million to the local economy (5). Since 2013, the City Council has increased the proportion of the local economy spent on procurement from 14% to 28%. Today, 20% of suppliers are based in Preston, 73% of which pay their staff a living wage and, in the past year, an estimated 801 jobs and 483 apprenticeships have been created (11). Despite these figures, the lowest price is still used as the only award criterion in 55% of public procurement procedures (5). 3. 14% This is the average proportion of GPD that is being spent on public procurement in European Union (EU) countries. The figure is in the billions and can be considered an investment (5). Changes are coming about in the EU. In 2014, new rules were introduced to ensure the efficient and effective spending of public funding, as well as a “greater inclusion of common societal goals in the procurement process” (12). In 2018, the EU stated that contracting authorities can and should apply “other criteria than only lowest price or cost effectiveness, including qualitative, environmental and/or social aspects”. Such actions mark the beginning of an important move to tag a value on other aspects of health systems that impact on health (12). How health systems can contribute The health sector is essential to maintaining a stable, functioning economy in all countries of the WHO European Region and, in this respect, small countries have important strengths. They can set and implement policy quickly and effectively and their size allows them to be agile and innovative, which is much more difficult for larger countries. The 12, 14 and 13 percentages described above prove that it is possible to do even more, even better (5). One of the triple The economic and social impact of health systems in small countries 4 Sixth high-level meeting of the small countries billion goals of GPW 13 (10) is to ensure that 1 billion more people benefit from UHC by 2023. Users should have access to the health services they need without suffering financial hardship. This can be achieved by: increasing employment opportunities; implementing inclusive employment policies (hiring locally); improving the skills base towards a more educated workforce; targeting investments in deprived areas or places with low economic input; and increasing the use of micro, small and medium-sized enterprises (MSMEs). These seemingly “non-health” measures can play an important role in improving equality and strengthening social cohesion. When a health system contributes to increasing household incomes, it becomes an important stabilizing factor for the environment. Spending on health systems is not a cost, it is an investment. Health systems can transform local economies into economies that work for everyone and not only for the few. They create jobs, drive productivity and stimulate inclusive growth. Investment in UHC improves population health and strengthens local and national economies. Rather than being a burden on the national economy, investing in well-being contributes to the growth and stability of a country. Investment in health systems has a positive impact both at the national level through economic development and at the community level where it provides social benefits, such as quality jobs and goods and services procured from local businesses. Thus, health systems have powerful economic and social roles to play at the national and local- community levels. Key messages. The economic and social impact of health systems in small countries Investment in a country’s well-being is not an economic burden but a contributor to the growth and stability of the economy. By demonstrating their value to local economies, health systems can become leading contributors to economic development at both the national and local levels. The health sector is essential to creating a stable, functioning economy in all countries of the WHO European Region and, in this regard, small countries have important strengths. Data can be used to explain to policy-makers that it is possible to do even more, even better. For example: • 12% represents the average number of people working in health and social care in countries in the WHO European Region, illustrating a large proportion in secure employment; • 13% reflects a movement towards strategic social purchasing in countries around the world, which can boost the local economy; and • 14% represents the average proportion of GPD spent on public procurement in countries in the WHO European Region, which can be considered an investment (5). 5Accelerating progress towards health equity Leaving no one behind is at the heart of Health 2020, the 2030 Agenda and GPW 13 (2,3,10) and health equity and UHC are at the core of these commitments. Ensuring that health systems do not unintentionally contribute to health inequities is key. The Declaration of Astana, adopted in 2018, stresses the critical role of primary health care in ensuring that everyone is able to enjoy the highest attainable standard of health (13). The WHO European Region has seen overall success: for example, nearly 1 billion people living in the Region – both women and men – have an average life expectancy of 78 years (14). Despite this, health inequities in and among the countries are of an unacceptable magnitude and the gap between the richest and poorest in society remains unchanged, or has increased. In all countries, including the small countries, the noticeable gaps in health and well-being follow a social gradient. Between 2005 and 2017, the gap in self-reported health between the most and least educated in society remained the same, or increased (14). In countries across the Region, there are discrepancies in life expectancy, marked by sex, income level and number of years of education. Increasing health equity must remain a central goal and whole-of-government, whole-of-society approaches are key to achieving it. The WHO high-level meeting on health equity, which will take place in Ljubljana, Slovenia, on 11–13 June 2019, will bring together representatives of Member States, international organizations and civil society to take stock of progress and set the European action agenda on health equity for the next 10 years. The outcome statement of the meeting will be used as the basis of a proposed resolution on health equity to be presented for the consideration of the WHO Regional Committee for Europe at its 69th session in September 2019. The San Marino Statement on leaving no one behind (Annex 2) will support discussions at the meeting and the drafting of the proposed resolution. It will ensure that small countries remain central to current and future efforts to accelerate progress towards health equity in Europe and inspire other small countries globally. © W H O Accelerating progress towards health equity 6 Sixth high-level meeting of the small countries Health Equity Status Report Initiative While many countries, regions and communities have taken action to address health inequities, the rate of reducing avoidable gaps in health is both lower and slower than could be expected, given existing knowledge and commitments. This work is being led by the WHO European Office for Investment for Health and Development. The challenges faced are: • the notion that the issue is too complex to leverage political commitment and policy action; • uncertainty about which policies and investments to prioritize; • failure over time to implement the optimal mix of policies and approaches on the scale and with the intensity needed; • lack of metrics and data to measure and monitor progress; • lack of understanding of the reality of the lives of people who are being left behind, or are at risk of falling behind; • the need to find ways of anticipating and responding to health-equity threats, and of building alliances, advocating, mediating and being accountable for equity. Inequity gaps arise as a result of: • unequal access to and quality of health care; • financial insecurity and the inability to make ends meet; • poor housing and neighbourhood environments; • higher levels of social exclusion among the more disadvantaged groups; • a lack of decent work and poor working conditions. HESRi (6), work led by the WHO European Office for Investment for Health and Development, monitors well-being, morbidity and mortality and aims to bring about a shift from describing the problem to implementing solutions by: • setting a baseline for monitoring health status and policy progress in Europe; • providing user-friendly tools and guidance to drive health equity forward, for example, in relation to monitoring policy action and advocacy; • giving a stronger voice to, and including action for, health equity in national and local development plans and UN country plans, and mainstreaming acceleration and policy- support (MAPS) missions (6,15); • increasing public and government attention to, and accountability for, health equity at the national and local levels (6). HESRi aims to create a new big-data set, capturing 3 types of indicators needed to measure and drive action for health equity: 1. health and well-being data (self-reported); 2. essential conditions needed to live a healthy and prosperous life; 3. policies based on strong evidence (6). HESRi aims to “achieve, accelerate and influence” health by focusing on 5 conditions that are essential to living a healthy life, namely: 1. access to health services; 2. income security and social protection; 3. adequate living standard; 4. social and human capital; 5. employment and work (6). 7These 5 conditions are reflected in over 100 indicators, disaggregated by age, sex and socioeconomic status (Fig. 1). They show how security and insecurity shape differential opportunities, risks, exposure and effects (consequences) (Box 1). Fig. 1. Five conditions needed to live a healthy life Achieve Accelerate Influence + 100 indicators measuring 5 essential conditions needed to live a healthy life disaggregated by age, sex and socioeconomic status Source: Healthy, prosperous lives for all. Interim Report. WHO European Health Equity Status Report Initiative (6). Box. 1. What does it mean to achieve, accelerate and influence? ACHIEVE by creating the conditions necessary for all to prosper and flourish in health and in life and remove the barriers to doing so. An essential set of conditions is needed for all to be able to lead a healthy life. These conditions represent the foundation of effective and sustainable progress. ACCELERATE by implementing a basket of policies built on inclusive and empowering approaches to reducing health gaps. Shifting from fragmented and short-term interventions to a comprehensive and coherent set of solutions is key to creating and sustaining the essential conditions for all to be able to lead a healthy life. INFLUENCE by putting health equity at the centre of sustainable development and inclusive economies. Eradicating health inequities and strengthening sustainable development for all is a bold, but achievable, ambition. New partnerships and instruments are needed to advocate, enable, motivate and show the importance of health equity in benefitting the future of countries and communities alike. Source: Healthy, prosperous lives for all. Interim Report. WHO European Health Equity Status Report Initiative (6). HESRi is trying to shift policy, increase investment in the health sector and, through other sectors, demonstrate the bidirectionality of health, namely, how it is affected and how it can contribute. In providing data to illustrate this bidirectionality, HESRi will facilitate cross- government discussion (6). This will in turn allow the development of better tools for ensuring that no one is left behind within context of the SDGs (3) and national development plans. Non-health sectors can help by addressing the following factors: • poor housing contributes to 29% of the health gap between the top and bottom levels of society (6); • 19% of the health gap is attributable to a lack of trust in and sense of belonging to the agencies, as well as to insecure environments (6); • 53% of countries have disinvested in policies that have an impact on housing and community facilities (6). Accelerating progress towards health equity 8 Sixth high-level meeting of the small countries Inequities can be reduced within a period of 2–5 years through investment in active labour- market programmes. How environment can impact environmental health inequalities Environmental factors also shape human health. Exposure to air pollution, noise, unhealthy built environments and the effects of climate change all occur in cities, which is where most people live. Each year, around 23% of global deaths are linked to the environment, equivalent to 12.6 million, including 1.4 million in the WHO European Region (16). Air pollution is responsible for 50% of the morbidity impact, costing the WHO European Region approximately US$ 1.6 trillion (17), and 50 million years of life are lost due to environmental risk factors (18). The Ostrava Declaration of the Sixth Ministerial Conference on Environment and Health (2017) (19) set the following priority areas for Europe in the coming years: • air quality; • drinking-water, sanitation and hygiene; • chemicals; • waste and contaminated sites; • climate change mitigation and adaptation; • city- and regional-level action for the environment; • environmental sustainability of health systems. Interest is shifting to a positive or, so-called, salutogenic model of promoting health. The positive effect of green spaces (parks, woods, trails) and blue spaces (water bodies) on health within the context of cities is now being examined through the BlueHealth programme (20). This programme aims to: gain an understanding of the relationships between exposure to blue space and health and well-being; map and quantify the public health impacts of changes to both natural blue spaces and associated urban infrastructure in Europe; and provide policy- makers with evidence-based information on how to maximize health benefits associated with interventions in and around aquatic environments. Environment is no longer only a collection of physical agents and risk factors viewed vertically; it embraces a broader health model with strong links to the SDGs (3) and great potential for equality gains. So far, these gains remain untapped, for example, in the areas of transport, housing, green and blue spaces, and climate change and adaptation. Linked to cities is architecture, a field in which equality must be considered in the light of the heavy industrialization that took place around the world in the 1970s and the resulting problems related to urban living conditions. Today, cities consume 70% of the world’s resources, whereas wooded areas and forests occupy only 30% of its surface (21). Nonetheless, city architecture and design can help slow down climate change and reduce poverty. A handful of cities around the world are taking action towards becoming greener and more sustainable: Shanghai, China, has designated areas for urban agriculture and is planning to build new “green” cities; the 2030 Master Plan of Tirana, Albania, includes the creation of an urban forest; and Milan, Italy, now has several vertical forests. Regarding the reduction of poverty, Sao Paolo, Brazil, and Nairobi, Kenya, are building gardens to generate work for people living in cities. All these efforts actively increase the absorption of carbon dioxide from the environment. Cities can also revive no-longer inhabited areas by turning them into parks to benefit the well-being of their residents. A model for sustainable economic development is needed, which makes it possible to slow down urbanization and climate change while helping people make a living at the same time. Equality for health and environment calls for cross- cutting action and a change in mindset. 9An example of such action can be seen in San Marino’s intersectoral collaboration on addressing inequalities, actively led by the sector for agriculture. San Marino is a leader in terms of biodiversity of flora and fauna, production of organic crops and food products, and elimination of pesticides from vegetable gardens and parks. San Marino has recently established a task force on safe streets and accessible tourism for everyone. This intersectoral group will be instrumental in achieving the SDGs (3). © W H O Key messages. Accelerating progress towards health equity HESRi (6) aims to shift policy, increase investment in the health sector and, through other sectors, demonstrate the bidirectionality of health – how it is affected and how it contributes. Inequities can be reduced within a period of 2–5 years through investment in active labour programmes. HESRi will “achieve, accelerate and influence” by focusing on 5 conditions that are essential to living a healthy life, namely: 1. access to health services; 2. income security and social protection; 3. adequate living standard; 4. social and human capital; 5. employment and work (6). Environment is no longer only a collection of physical agents and risk factors viewed vertically. It embraces a broader health model with strong links to the SDGs (3) and great potential for equity gains. Interest is also shifting to positive, or salutogenic, models for promoting health, which consider the effects of green and blue spaces in cities. Equity in health and environment calls for cross-cutting action and a change in mind set. A model of sustainable economic development is needed, which makes it possible to slow down urbanization and climate change and helps people make a living at the same time. Accelerating progress towards health equity 10 Sixth high-level meeting of the small countries Small-country perspectives on equity, environmental sustainability and urban health Despite advances in policy and research, progress to reduce health inequities has not been as fast as expected. This is explained partly by the global financial crisis and subsequent policy responses, which continue to influence health and well-being. In the last 10 years, the number of people at risk of poverty or social exclusion has increased, as has in-work poverty. Furthermore, income inequalities have remained stable (22,23). Thus, despite an increase in policies and research on health inequities, people on low incomes and those who have fewer years of education, or are unemployed, continue to live in worse conditions and be in worse health than those living in more favourable socioeconomic conditions. HESRi recognizes and stresses that equity in living conditions – including housing, public transportation, urban design, air quality and access to green spaces – is an essential part of enabling people to live equitably healthy lives. Part of its mandate is to track comprehensive and coherent policies on reducing health inequities that work across all areas of government (6). During the meeting, representatives of the small countries shared examples of action taken in their countries to reduce health inequities. © W H O Cyprus In June 2017, passing legislation towards the 100% implementation of a UHC system by the year 2020 was a milestone in a country, which did not have a national health system previously. UHC will help to ensure that everyone has access to the health system and eliminate social inequalities. Estonia Estonia has developed a specific national action plan with the objective of reducing health inequities. 11 Digital solutions to covering 50% of a person’s annual pharmaceutical expenses in excess of € 100 have been implemented. The health gains resulting from this action, namely, the removal of barriers to treatment, will be examined. Iceland Iceland has introduced a payment participation system, according to which high users pay less and low users pay more, thus encouraging access to health services. The country is aiming for out-of-pocket expenses of no more than 15% (currently they are at 17%) and to set up mechanisms to ensure that poorer people and vulnerable groups are able to access health services. Luxembourg A national strategy for providing housing solutions for everyone in the country is in place, with a focus on vulnerable groups. Registration in the country’s social-security system gives everyone equal access to its services. Often, however, the homeless are not registered, which prevents them from receiving benefits. These people need to be reached. Immigrants in Luxembourg are offered a national transportation card so they can travel with public transport all over country. This provides them with opportunities to move around for work, or pleasure. From 2020, everyone will have free access to public transport. Malta With the support of a EU structural funds project, Malta has been able to quantify the effects of social determinants of health and social barriers with the engagement of public officials from ministries across the board. Work to determine the effect of social determinants of health on children has given the best results. The two examples shared related to the establishment of a primary school for children with developmental delays in one village, and the passing of the Healthy Lifestyle Act (through the Office of the Prime Minister), which is being implemented in school settings. The Act stresses the benefits of physical activity and a balanced diet. Monaco Efforts to ensure equitable housing and public transport are ongoing. While inequality in Monaco is low, the price of housing is very high, and the local population often seeks affordable accommodation outside the country. The Government is keen to improve this situation: the Prince Albert’s national housing plan will enable more than 75% of households to live in a government-owned apartment within the next 15 years. To maintain a middle class in the country, Monaco has introduced fixed rent for those who cannot afford to pay a lot for housing. The country also ensures that retirees are not required to spend more than 10% of their incomes on rent. Montenegro For Montenegro, sustainable development means achieving equitable access to water. Despite having an abundance of water resources, inequalities between rural and urban areas persist and need to be addressed. Safe water and sanitation in schools is another issue that will need more attention. Slovenia In Slovenia, examples of multisectoral action to mitigate health inequities include setting up robust social- and financial-protection programmes, providing community support for decent housing, facilitating access to health-supportive neighbourhoods, and ensuring the quality and safety of consumer products, to name a few. Examples of health-sector-specific policies Small-country perspectives on equity, environmental sustainability and urban health 12 Sixth high-level meeting of the small countries include those related to UHC and strengthening the primary-care system, with a focus on health promotion and disease prevention. Multisectoral responses to existing health inequities are delivered at the community level, mostly by regional public health institutions, social-service institutions and civil society. Tailored approaches are being used to ensure that preventive and screening programmes are accessible to vulnerable populations. In this connection, the key challenge is to identify those who do not participate. Small-country challenges to achieving equity The countries shared their main obstacles to achieving equity. These were: the absence of policies on equity and (for many countries) an information system to monitor such policies (see Box 2 on SCHIN developments); resistance to change in the face of new policies; lack of a coordinated approach to helping vulnerable groups, such as migrants, and people not accessing services at the community level; the need for strong central-government support/ leadership of equity-related initiatives that would encourage non-health ministries to become involved; the absence of impact measurement to show how the country is performing; and finally, the need for measures to ensure that the livelihoods (jobs) of young people are secure since they represent future society. Box 2. SCHIN’s work is moving forward The Fifth meeting of the focal points of the Small Countries Health Information Network (SCHIN) was held in San Marino on 2 April 2019 under the auspices of the Sixth high-level meeting of the small countries. The participants discussed the following topics: • recent developments in health information in the Region (including the Joint monitoring framework. the GPW 13 impact framework, big data, and implementation of the 11th revision of the International Classification of Diseases (ICD 11); • progress in the use of rolling averages (including calculation and reporting); • the establishment of a joint set of indicators for the small countries; • the work plan related to the joint statement of small countries presented at the 68th session of the WHO Regional Committee for Europe and the responses of the Committee. The meeting provided comments on recent developments, identified next steps towards establishing a joint set of indicators, and reviewed and updated the SCHIN work plan. In response to the need for further commitment in the area of health equity, the small countries endorsed the San Marino Statement (Annex 2). The Statement emphasizes that governments, health systems and public authorities, at all levels, have roles to play in ensuring that health equity is central to their policies, strategies and plans. Through the Statement, the small countries committed to: closing the coverage and access gaps; enhancing people’s participation in decisions that affect their health; and reducing exposure to discrimination, stigma and commercial pressures that polarize inequities in health. 13 Key messages. Small-country perspectives on equity, environmental sustainability and urban health By virtue of their size, small countries a have a strong potential to function as incubators, providing an understanding of how things work. Coupled with a common framework for action, their size allows them to take action more quickly and with greater focus than bigger countries. In terms of issues related to the environment and closing the gaps, equality has moved up on national development agendas. It is no longer an issue to be tagged on, but one which governments and society recognize that they need to deal with. Intersectoral collaboration can play an important role in mitigating health inequities. Therefore, whole- of-government commitment is needed in addressing the social and commercial determinants of health. It is imperative that sectors work together, pool resources and utilize each other’s experiences, knowledge and assets. It is necessary to ensure the availability of data and map policies to gain an understanding of population needs in, and policy impact on, reducing the gap between the poorest and richest within a period of 2–5 years. It is important that policy-makers understand the significance of investing in public health. This can be achieved by examining factors, such as often impoverishing out-of-pocket payments and health and well-being among vulnerable groups. Small-country perspectives on equity, environmental sustainability and urban health 14 Sixth high-level meeting of the small countries The global agenda on sustainable development and the small countries Achievement of the SDGs (3) is still distant. While progress has been made in the WHO European Region with regard to increasing life expectancy and reducing premature mortality, too many people are still being left behind. Although success rates in reducing the burden of noncommunicable diseases in the Region have given rise to cautious optimism, progress is uneven both among and within countries and across risk groups, tobacco use is not decreasing fast enough, the rates of overweight and obesity are increasing, and the prevalence of alcohol consumption is the highest among all WHO Regions. In 2016, more than 550 000 deaths in the Region were attributable to the joint effects of household and ambient air pollution (24). Unacceptable numbers of women and children are still exposed to violence. Far too many people cannot access the health-care services they need, or risk falling into poverty in doing so by paying out of pocket. These complex challenges require transformative approaches that will support shifting the trajectory. The WHO SDG roadmap features a set of strategic priority areas for action, which – when implemented in an integrated and indivisible manner – open opportunities for realizing co-benefits and magnifying impact towards achievement of the SDGs (3). These priority areas are: • governance and leadership for health; • leaving no one behind by addressing health inequities; • preventing disease and addressing health determinants; • establishing healthy places; • strengthening health systems for UHC; • investing for health and well-being; • building multipartner cooperation; • promoting health literacy, research and innovation; • monitoring and evaluation (4). The above priority areas are in line with the GPW 13 triple billion goals: “1 billion more people benefitting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being” (10). To tackle them, the WHO Regional Office for Europe is developing a resources guide relevant to implementation of the health-related SDGs in the Member States. A high level of political commitment is essential to accelerate progress towards achieving the SDGs (3) and ensuring consideration of health in all policies. This requires identifying and effectively communicating to multiple sectors the co-benefits of addressing health and well- being for all at all ages. Based on Voluntary National Reviews (VNRs) submitted to the High- Level Political Forum on Sustainable Development (HLPF), most countries have made an effort to improve access to health care, education and social benefits. These VNRs did not, however, identify benefits to non-health sectors of investments in health and well-being or, conversely, benefits to health of action taken in non-health sectors. A key issue related to the effective implementation of action towards achieving the SDGs (3) is the need to ensure adequate financing. The overall funding gap ranges from 20% to 30% across countries. Government budgets are the main source of SDG funding in the Region and are expected to remain so. Another important flow in some countries in the Region comprises remittances from migrant workers. Progress towards the SDGs (3) depends not only on improving the mobilization of domestic resources, but also on how these resources are distributed. 15 © W H O Small-country participatory approaches to achieving the SDGs The small countries are using participatory approaches to achieving the SDGs (3). Those presented at the meeting are described below; others can be accessed on the website of the WHO Regional Office for Europe (25). Andorra has been working to raise awareness about the SDGs (3) and submitted a VNR to HLPF in 2018. Real ownership of the review was only possible with the full participation of the Andorran society, which the Government facilitated by launching a web-based public consultation on the SDGs (3). The VNR shows that the country has been working hard to address the problem of overweight and obesity with the involvement of central Government, the Ministry for Health, the mass media, health providers and civil society. Cyprus’s recent SDG-related efforts have focused on UHC and leaving no one behind through the establishment of a national health-insurance system. The SDG framework (3) helps Cyprus to continue working on issues, such as: the reduction of road-traffic accidents; inclusion in the school system (including private schools) of addressing children’s health from an early age; vaccination coverage; and the comprehensive tracking of mental- and physical-health issues. Iceland has set up an interministerial working group, comprising representatives of all ministries, the local authorities and a youth council (ages 13–18 years). This group will analyze Iceland’s performance with regard to the SDGs (3) and a VNR will be available in summer 2019. The Government has set up 65 priority targets to guide action towards achieving the SDGs (3). Iceland is integrating this action into the national budgetary process to map progress and funding allocated. In Luxembourg, the SDGs (3), which fall under the Ministry of Sustainable Development, still represent a topic that is distant to many people. Initially, the SDGs (3) were not well understood but now that people have a better grasp of what they mean, the time has come to bring others on board. SDG strategies need to be available for all social groups. Engaging the media is a challenge as they tend to focus on specific goals and not the big picture. The global agenda on sustainable development and the small countries 16 Sixth high-level meeting of the small countries In Malta, a predominant challenge in relation to the SDGs (3) has been that they are often looked upon as being very abstract. In the course of a few years, Malta has become one of the leading countries in lesbian, gay, bisexual, transgender and queer (LGBTQ) rights. The country’s experience in the participatory development of policy on health services for transgender people is very concrete. Having the political will and relevant legislation in place was, however, not enough to initiate work on developing transgender health services. A key change came about when the Government was persuaded to dedicate a budget line for these services (which remained under the auspices of the Ministry of Health). The biggest challenge was to gain a clear understanding of the existing legal and social contexts and what needed to be done to address the needs of the target group This was a topic that went beyond the realms of traditional medical training. The country learned how important it is to work closely with users and lobby groups to achieve a common language that allows the development of a new service based on the principles and mentality of the users. San Marino has established an intersectoral, intergovernmental commission to orient the Government towards the SDGs (3). Up to now, the work has focused on the “analyze” and “align” components of the SDG Roadmap (4). San Marino is also preparing a VNR for submission to HLPF. The country has the tradition of using working groups to move intersectoral initiatives forward and cited their Health and School Working Group as having brought together all those involved in working to enhance collaboration on improving children’s lifestyles. © W H O Communications, civil society and the SDGs The roles of civil society and communications in connection with the SDGs (3) were also a matter of interest to the small countries. Civil-society organizations are fundamental to ensuring that no one is left behind since many people often remain in the margins of society. The motto of the San Marino Commission for Disability, “You can do nothing about us without us”, indicates a commitment to breaking 17 down barriers that people with disabilities face every day. Due to its small size, San Marino has been able to fully get to know the needs of this population group. People with disabilities are represented by associations, nongovernmental organizations and charities, and they have dedicated mentors to help them achieve their goals. The country offers accessible tourism and has recently opened a new tactile museum in the city centre. Helping people with disabilities, both residents and visitors, is considered a measure of equity. Communications to obtain civil-society buy-in is indispensable for achievement of the SDGs (3). The single biggest communications-related problem is the illusion that a communication has taken place. The small countries were reminded that, if the general public and civil society do not know what the SDGs (3) are, they will not be interested in how action to achieve them is being implemented, thus diminishing its impact. Communications can be used as a tool to help countries account for their SDG journeys. They represent a way of reporting to the people to whom the public sector is accountable. When planning action towards the SDGs (3), countries could consider breaking it down into practical steps, taking the need for communication into consideration at every one. Issues related to communications on the SDGs were discussed at the SCI communications workshop that took place after the meeting (Box 3). Box 3. Engaging citizens in the SDGs: a workshop for communications professionals, 2 April 2019 This year’s SCI communications workshop focused on ways of communicating information related to the 2030 Agenda for Sustainable Development and the SDGs (3), with an emphasis on engaging civil society and citizens in achieving the latter. The workshop gathered approximately 25 participants, including journalists and communications staff operating in small countries and WHO representatives. The aim was to present examples of concrete tools, resources and strategies, which could render SDG-related communications more effective. Presentations and hands-on interactive group work were combined to enhance the participants’ engagement in the topic of SDG-related communications. An overview of the 2030 Agenda was presented in connection with which the importance of the role of civil society and citizens as partners in attaining the SDGs (3) was stressed. Presentations also covered the fundamentals of tailoring SDG-related communications strategies to specific audiences and using story-telling techniques to bring the SDGs (3) to life and highlight their relevance to real issues and real people. Examples of communications strategies used by the WHO European Office for Investment for Health and Development, Venice, Italy, of the WHO Regional Office for Europe, in connection with the Regions for Health Network (RHN) and SCI (1) were shared. These include Facebook and Twitter accounts, the RHN newsletter and a weekly news digest. All sessions were informal and encouraged interactive participation. Many participants shared ideas and presented examples of their countries’ experiences in communicating about the SDGs (3). During the latter part of the workshop, the participants broke up into small groups to work on a scenario exercise, allowing them to put into practice many of the communications strategies, approaches and resources presented. At the end of the workshop, several participants expressed their appreciation of a useful, well- organized programme from which they had gained knowledge that could be applied in their daily work. Several of them felt that those participating in the workshop could serve as a valuable network through which people from different countries could share ideas, or become inspired, about SDG- communications activities. The global agenda on sustainable development and the small countries 18 Sixth high-level meeting of the small countries © W H O Key messages. The global agenda on sustainable development and the small countries It is important to prioritize SDG-related action that is based on information and evidence. The focus should be on selecting those areas that will accelerate progress across the Goals (3). To this end, a broad remit of stakeholders is needed, including civil society and the private sector whose participation, depending on the context, can be assured through different mechanisms, from raising awareness to engaging in partnerships for the co-creation of plans and strategies. Factors for success include involving all levels of governance, empowering people and involving them early, and ensuring effective financing and monitoring measures. The health sector can take the lead in providing a straightforward, practical explanation of what is required to achieve the SDGs (3). It can help non-health sectors become advocates of SDG-related action by illustrating how their sectors could make an impact. Multipartner and multisectoral cooperation is essential to ensuring delivery of the many-faceted services. The inclusion of all relevant ministries and civil society in planning and designing services for a target audience makes it possible to meet the needs of that audience in an interdisciplinary manner. A balanced input from all parts of the population and society is also needed in the decision-making process to ensure that no one is left behind. The opinions of children and young people are valuable, but often unheard. Involving this segment of the population is central to the goal of leaving no one behind. Establishing a youth council and a working group on health and education are just two of the ways in which the small countries are involving children and young people in working towards the SDGs (3). Surveys can reveal vulnerable groups and demographic change – data speak. Only by monitoring progress in improving health and well-being can countries really know how they are doing, and whether or not they are on track to achieving the SDGs (3). 19 Addressing health-workforce challenges in small countries Small countries in the WHO European Region face the same range of HRH-related challenges as the other Member States in the Region. In planning and developing policy related to HRH, they need to take the specific and unique characteristics of their small-country contexts and dynamics into consideration to ensure that policy responses to HRH challenges will be effective in achieving the broader UHC-related policy objectives. The HRH-related challenges and potential solutions applicable to small countries were discussed at the Expert meeting on human resources for health in small countries in the WHO European Region, held in Venice, Italy, on 18–19 December 2018, at which 12 Member States were represented. The meeting provided the opportunity to share HRH policy and planning approaches and innovative solutions to HRH challenges across four domains: education and performance; planning and investment; building capacity; analysis and monitoring (8). Priority focus areas arising from the meeting werethe following. 1. HRH • developing the use of the WHO labour market framework for UHC in Member States (26) to identify and implement the most effective mix of HRH polices across short-, medium- and long-term priorities; • effective HRH planning and forecasting; 2. Post-graduate training for health professionals • examining and improving ways in which small countries deal with this critical issue; 3. Continuing professional development • renewing emphasis on this and other forms of in-service training as the most effective way to improve and adapt the current workforce to best meet the challenge of changing population-health priorities; 4. Workforce mobility • monitoring and management (8). The meeting proposed the establishment of an ad hoc expert working group on HRH in small countries, comprising representatives of Member States with populations of less than 2 million and selected regions (subnational level) with characteristics similar to those of small countries. The working group would be supported on a collaborative basis by the Division of Health Systems and Public Health and the WHO European Office for Investment for Health and Development of the WHO Regional Office for Europe (8). In bringing forward the above recommendations, the participants sought ways of moving forward to strengthen HRH in small countries, one of which was to endorse the establishment of the proposed ad hoc expert working group on HRH in small countries (8). Representatives of the small countries briefly described the situations in their countries. Health systems are changing very rapidly and they are often faced with sudden and dramatic challenges (8). Addressing health-workforce challenges in small countries 20 Sixth high-level meeting of the small countries Five years ago, small countries faced challenges, such as: • lack of capacity (particularly in specialized services); • dependence on larger, neighbouring countries for self-sufficiency; • medical paternalism (weak civil society); and • lack of peer reviews/little opportunity for internal mobility (8). Today, some of these challenges still persist and have been joined by the following: • limited capacity due to population size, preventing the provision of a full range of services (self-sufficiency); • limited capacity for analysis, evaluation and research; • quality-related issues in treating rare diseases due to low patient numbers; • lack of competition and choices (jobs, advancement, etc.), due to small market; • high prices for medicines and technology due to the small volumes required, which is linked to difficulties in accessing new technology; • high overhead costs and the administrative burden of regulation; • lack of accreditation processes at the national level, due to insularity; • professional and career stagnation due to limited opportunities for internal mobility; • loss of health workforce due to external migration; • governance issues related to difficulties in role differentiation; • challenges in implementing reform due to the strength of vested interests in small-country health systems • lack of active patient and public participation in decision-making processes; and • lack of institutional capacity, financial and technical resources and robust data (intelligence) (8). © W H O HRH-related challenges in small countries The small countries shared some of their HRH-related challenges. Many are struggling to attract or retain medical professionals and have difficulties in dealing with competing labour markets. The migration of health professionals to other sectors is commonplace. It is often a challenge to promote multidisciplinary work, for example, through the integration of hospital- based work in the communities. Small countries are often dependent on larger ones for access 21 to health-professional education. This is especially true where there is no national medical school, in which case they are faced with possible brain drain if health professionals who leave to study abroad do not return. Small countries have adopted some strategies for dealing with these challenges. These include: passing legislation that offers medical professionals stability; introducing incentives (such as higher salaries) to work in rural areas, or outside the capital; helping health-care staff achieve a work–life balance by providing child day care; ensuring and financing post-graduate training for nurses and doctors; recognizing the credentials of professionals from other countries so that they are encouraged to stay in the health sector; and ensuring decent work conditions and sufficiently challenging opportunities for career progression. It was evident that the challenges small countries face can be overcome. The meeting endorsed the establishment of the ad hoc expert working group on HRH in small countries as an effective point of departure in moving forward. In the midst of these challenges, it is important not to lose sight of the ultimate goal of improving population health and achieving UHC; this will not be possible without investment in the health workforce. It is also important to find a structured way of dealing with the many challenges related to delivering a health workforce and bringing about sustainable improvement. Developing the use of the WHO labour market framework for UHC (26) could be a convening mechanism in different countries. A systematic approach to a multifaceted challenge is needed and a set of policies should be identified and given priority. Steps in this direction were taken at the Expert meeting on human resources for health held in Venice, Italy, on 18 December 2018 (8) and it is now imperative to decide on future action. The creation of momentum and a community of practice could push this work forward. An observatory approach whereby small countries come together to provide the necessary resources to address this should be explored. Digital health systems should also be considered in terms of the traditional versus the evolving work force. Key messages. Addressing health-workforce challenges in small countries Small countries could take a collective approach to moving forward, using the mechanism of the agreed ad hoc expert working group on HRH challenges in small countries, with modality options for collaboration on strengthening HRH. These include: • exchanging information about and ideas on HRH issues in small countries; • taking a structured approach to capturing knowledge on what has worked and what could be of potential benefit, including networking, involving the development of case studies and the documentation of experiences; • taking an analytical approach by documenting experiences related to, and considering ways of, addressing the issue of health-professional mobility and improving understanding of the situation on hand; and • assessing/mapping existing policy-support tools that might be useful to small countries in planning HRH. 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Programme Sunday, 31 March 2019 Opening of the meeting: Franco Santi, Minister of Health and Social Security, National Insurance, Family and Economic Planning, San Marino. Tedros Adhanom Ghebreyesus, WHO Director General. Piroska Östlin, Acting WHO Regional Director for Europe. Session 1 (informal session). The economic and social impact of health systems: why it matters to small countries. Tammy Boyce, WHO Consultant, WHO European Office for Investment for Health and Development, Venice, Italy. Monday, 1 April 2019 Investiture Ceremony of the Captains Regent: − assembly of participants at Palazzo Pubblico for the official start of the Ceremony; − procession of the Captains Regent to Basilica del Santo and Mass; − procession of the Captains Regent to Palazzo Pubblico; − keynote speech: Tedros Adhanom Ghebreyesus, WHO Director General; − end of Ceremony. Session 2. Accelerating progress towards health equity: − preliminary findings from the Health Equity Status Report; − focus on the environmental domain and living conditions in cities. Moderator: Francesco Zambon, Coordinator, Investment for Health and Development in Healthy Settings, WHO European Office for Investment for Health and Development, Venice, Italy. Piroska Östlin, Acting WHO Regional Director for Europe. Chris Brown, Head, European Office for Investment for Health and Development, Venice, Italy. Marco Martuzzi, Acting Head, European Centre for Environment and Health, Bonn, Federal Republic of Germany. Stefano Boeri, Founding Partner, Stefano Boeri Architetti, San Marino. Augusto Michelotti, Minister of Environment and Tourism, San Marino. Session open to representatives of civil society, government, equal opportunities and youth policies commissions, architects, engineers, and Department of Engineering and Design, University of San Marino. (Simultaneous interpretation English–Italian and vice versa available.) 25 Session 3. Open discussion among delegates of Member States on equity, environmental sustainability and urban health Moderators: Chris Brown, Head, WHO European Office for Investment for Health and Development, Venice, Italy. Francesco Zambon, Coordinator, Investment for Health and Development in Healthy Settings, WHO European Office for Investment for Health and Development, Venice, Italy. Tour de table with representatives of Cyprus, Estonia, Iceland, Luxembourg, Malta, Monaco, Montenegro, Slovenia. Session open to representatives of civil society, government, equal opportunities and youth policies commissions, architects, engineers, and Engineering and Design, University of San Marino. (Simultaneous interpretation English–Italian and vice versa available.) Closed meeting between the Acting WHO Regional Director for Europe and ministers/heads of delegations. Tuesday, 2 April 2019 Session 4. The global agenda on sustainable development: how to make it a reality in everyone’s life Moderators: Emilia Aragon de Leon, Consultant, Health and Development, WHO Regional Office for Europe; Francesco Zambon, Coordinator Investment for Health and Development in Healthy Settings, WHO European Office for Investment for Health and Development, Venice, Italy. − The global agenda on sustainable development: how far did we get in implementation? Bettina Menne, Coordinator, Division of Policy and Governance for Health and Well-being. Tour de table with representatives of Andorra, Cyprus, Iceland, Luxembourg, Malta and San Marino. Maurizio Ceccoli, President of the San Marino Commission for Disability (representative of civil society in San Marino). Chelsea Hedquist, Information and Communications Officer, WHO Regional Office for Europe. Session open to representatives of Government, Equal opportunities and Youth Policies Commissions, Department of Human Sciences, University of San Marino, and voluntary associations in the health and social sectors. (Simultaneous interpretation English–Italian and vice versa available.) Session 5. Addressing 21st-century health workforce challenges in small countries Chair: Gabrielle Jacob, Programme Manager, Division of Health Systems and Public Health, WHO Regional Office for Europe. James Buchan, WHO Consultant, Division of Health Systems and Public Health, WHO Regional Office for Europe. Natasha Azzopardi Muscat, WHO Collaborating Centre on Health Systems and Policies in Small States. Annex 1. Programme 26 Sixth high-level meeting of the small countries Tour de table with representatives of Andorra, Cyprus, Estonia, Iceland, Latvia, Monaco, Montenegro and San Marino. Session open to representatives of civil society, government, equal opportunities and youth policies commissions, architects, engineers, and Engineering and Design, University of San Marino. (Simultaneous interpretation English–Italian and vice versa available.) Session 6. Adoption of the San Marino Statement and closure of the meeting Franco Santi, Minister of Health and Social Security, National Insurance, Family and Economic Planning, San Marino. Piroska Östlin, Acting WHO Regional Director for Europe. Fifth meeting of focal points of the Small Countries Health Information Network (SCHIN) Small Countries Initiative (SCI) workshop for communications officers © W H O 27 Annex 2. Leaving no one behind: the San Marino Statement © W H O Annex 2. Leaving no one behind: the San Marino Statement Andorra Cyprus Iceland Estonia Luxembourg Latvia Malta Monaco Montenegro San Marino Slovenia Ensuring no onE is lEft bEhind: thE san Marino statEMEnt sixth high-level meeting of the small countries, san Marino, republic of san Marino, 31 March–2 april 2019 We, the Ministers and delegates of the 11 Member States in the WHO European Region with populations of less than two million inhabitants, met in San Marino, Republic of San Marino, on 31 March–2 April 2019, to participate in the Sixth high-level meeting of the small countries: “Equity and sustainable development: keeping people at the centre”. We reconfirm our previous commitments to implementing the core principles, approaches and values of the WHO European policy framework for health and well-being, Health 2020, the United Nations 2030 Agenda for Sustainable Development and WHO’s 13th General Programme of Work 2019–2023. We recognize that health equity is a core value in these interconnected frameworks, emphasizing the right to the highest attainable state of health for all and the importance of equitable access to universal health coverage for all. We also recognize that inequities in health are caused by the systematic influence of adverse social, economic, environmental and commercial determinants that are unevenly distributed across populations. The resulting disadvantage is compounded by cumulative unhealthful exposures that perpetuate the existing health inequities. Progress will only be achieved if we act upon all these determinants in a collaborative, coherent manner. It is our joint responsibility to achieve health equity and we will work wholeheartedly to ensure that everyone realizes their right to health. We emphasize that governments, health systems and public authorities, at all levels, have a role to play in ensuring that health equity is central to their policies, strategies and plans. It is our joint responsibility to close the coverage and access gaps, enhance people’s participation in decisions that affect their health, reduce exposure to discrimination and stigma, and reduce differential exposure to commercial pressures that polarize inequities in health. We recognize that the strategies on the health and well-being for every human being in the WHO European Region provide a strong framework for addressing health inequities driven by the interrelationships between gender norms and roles and other determinants of health. Making progress towards ensuring healthy, prosperous lives for all requires systematic action, including scaling up and adapting what works. It also involves generating alliances and solutions that accelerate change and remove barriers to progress. Measuring and monitoring health equity is key to speeding up progress towards inclusive development and prosperity in the WHO European Region. Data that can identify inequities in our small countries can enable, motivate and empower decision-makers and the public to support meaningful policy dialogue and evidence-informed policy-making where equity is central to sustainable growth and development. It is a priority in our countries to adequately invest in health-information systems and monitoring processes as they are the foundations of our health systems’ ability to address health inequities. We commit to providing access to universal health coverage with an emphasis on supporting populations and people who traditionally experience barriers to accessing such coverage so that no one is left behind. These accelerated actions are essential to reducing inequities in health and well-being. We recognize that health systems have a crucial role to play in driving sustainable development at the local and national levels. We note that health systems can use socially responsible approaches to employment and procurement practices to improve the communities in which they are based. Building safe and resilient communities is part of sustainable and inclusive development and is crucial to accelerating progress towards health and prosperity for all. At the Sixth high-level meeting of the small countries, we agreed on the importance of: • addressing the causes of health inequities and the pathways that lead to them – the “drivers” of health inequity; • ensuring a minimum set of conditions needed to be able to live a healthy life; • progressing towards healthy, prosperous lives for all; • improving living conditions for all through a basket of universal and targeted measures that match the scale and the level of disadvantage. With this statement, we, the Ministers and high-level delegates of the small countries, commit to: • leaving no one behind and supporting each other through enhanced intersectoral cooperation and coordination; • strengthening our policy and governance for health and well-being; • working across sectors and adopting whole-of-government and whole-of-society approaches; • leading by example and investing in expanding partnerships and bringing different sectors and stakeholders together to address health inequities; • working in partnership to create healthy places for life, where all people feel safe, and have a sense of hope and belonging in their neighbourhoods and shared spaces; • engaging citizens to help them understand the health inequities existing in their own countries, and how to reduce them; • adequately invest in health information systems and monitoring processes to address health inequalities. We commit to supporting the creation of a new European equity alliance in the European Region where countries, regions and municipalities can participate in dialogues, test new solutions, develop innovation sites and exchange best practice in improving health equity. Equity is central to sustainable development. In implementing the 2030 Agenda for Sustainable Development, we, the Ministers and high-level delegates of the small countries, commit to placing equity at the centre of all our policies. © World Health Organization 2019 29 Annex 3. Participants Sixth high-level meeting of the small countries Andorra Mr Joan Antoni Leon Peso Secretary of State, Ministry of Health Email: Joan_Leon@govern.ad Mr Josep Romagosa Massana Public Health Officer Promotion, Prevention and Health Surveillance Unit, Ministry of Health Statistics Department, Ministry of Finances Email: josep_romagosa@govern.ad Cyprus Mrs Angeliki Protopapa Administrative Officer, Ministry of Health Email: aprotopapa@moh.gov.cy Mrs Despo Chrysostomou Health Services Officer, Ministry of Health Email: dchrysostomou@moh.gov.cy Estonia Ms Riina Sikkut Minister of Health and Labour, Ministry of Social Affairs Email: tervisejatoominister@sm.ee, triin.uusberg@sm.ee Dr Maris Jesse Deputy Secretary General on Health, Ministry of Social Affairs Email: maris.jesse@sm.ee Ms Eva Lehtla Media Adviser Communications Department, Ministry of Social Affairs Email: eva.lehtla@sm.ee Iceland Ms Ásthildur Knútsdóttir Deputy Director General, Ministry of Health Email: asthildur.knutsdottir@hrn.is Dr Sigríður Haraldsdóttir Head of Division, Health Information, Directorate of Health Email: shara@landlaeknir.is Latvia Ms Līga Šerna Director of the Healthcare Department, Ministry of Health Email: Liga.Serna@vm.gov.lv Luxembourg Dr Robert Goerens Chief Physician, Health Directorate Ministry of Health Email: robert.goerens@ms.etat.lu Andorra Cyprus Iceland Estonia Luxembourg Latvia Malta Monaco Montenegro San Marino Slovenia Ensuring no onE is lEft bEhind: thE san Marino statEMEnt sixth high-level meeting of the small countries, san Marino, republic of san Marino, 31 March–2 april 2019 We, the Ministers and delegates of the 11 Member States in the WHO European Region with populations of less than two million inhabitants, met in San Marino, Republic of San Marino, on 31 March–2 April 2019, to participate in the Sixth high-level meeting of the small countries: “Equity and sustainable development: keeping people at the centre”. We reconfirm our previous commitments to implementing the core principles, approaches and values of the WHO European policy framework for health and well-being, Health 2020, the United Nations 2030 Agenda for Sustainable Development and WHO’s 13th General Programme of Work 2019–2023. We recognize that health equity is a core value in these interconnected frameworks, emphasizing the right to the highest attainable state of health for all and the importance of equitable access to universal health coverage for all. We also recognize that inequities in health are caused by the systematic influence of adverse social, economic, environmental and commercial determinants that are unevenly distributed across populations. The resulting disadvantage is compounded by cumulative unhealthful exposures that perpetuate the existing health inequities. Progress will only be achieved if we act upon all these determinants in a collaborative, coherent manner. It is our joint responsibility to achieve health equity and we will work wholeheartedly to ensure that everyone realizes their right to health. We emphasize that governments, health systems and public authorities, at all levels, have a role to play in ensuring that health equity is central to their policies, strategies and plans. It is our joint responsibility to close the coverage and access gaps, enhance people’s participation in decisions that affect their health, reduce exposure to discrimination and stigma, and reduce differential exposure to commercial pressures that polarize inequities in health. We recognize that the strategies on the health and well-being for every human being in the WHO European Region provide a strong framework for addressing health inequities driven by the interrelationships between gender norms and roles and other determinants of health. Making progress towards ensuring healthy, prosperous lives for all requires systematic action, including scaling up and adapting what works. It also involves generating alliances and solutions that accelerate change and remove barriers to progress. Measuring and monitoring health equity is key to speeding up progress towards inclusive development and prosperity in the WHO European Region. Data that can identify inequities in our small countries can enable, motivate and empower decision-makers and the public to support meaningful policy dialogue and evidence-informed policy-making where equity is central to sustainable growth and development. It is a priority in our countries to adequately invest in health-information systems and monitoring processes as they are the foundations of our health systems’ ability to address health inequities. We commit to providing access to universal health coverage with an emphasis on supporting populations and people who traditionally experience barriers to accessing such coverage so that no one is left behind. These accelerated actions are essential to reducing inequities in health and well-being. We recognize that health systems have a crucial role to play in driving sustainable development at the local and national levels. We note that health systems can use socially responsible approaches to employment and procurement practices to improve the communities in which they are based. Building safe and resilient communities is part of sustainable and inclusive development and is crucial to accelerating progress towards health and prosperity for all. At the Sixth high-level meeting of the small countries, we agreed on the importance of: • addressing the causes of health inequities and the pathways that lead to them – the “drivers” of health inequity; • ensuring a minimum set of conditions needed to be able to live a healthy life; • progressing towards healthy, prosperous lives for all; • improving living conditions for all through a basket of universal and targeted measures that match the scale and the level of disadvantage. With this statement, we, the Ministers and high-level delegates of the small countries, commit to: • leaving no one behind and supporting each other through enhanced intersectoral cooperation and coordination; • strengthening our policy and governance for health and well-being; • working across sectors and adopting whole-of-government and whole-of-society approaches; • leading by example and investing in expanding partnerships and bringing different sectors and stakeholders together to address health inequities; • working in partnership to create healthy places for life, where all people feel safe, and have a sense of hope and belonging in their neighbourhoods and shared spaces; • engaging citizens to help them understand the health inequities existing in their own countries, and how to reduce them; • adequately invest in health information systems and monitoring processes to address health inequalities. We commit to supporting the creation of a new European equity alliance in the European Region where countries, regions and municipalities can participate in dialogues, test new solutions, develop innovation sites and exchange best practice in improving health equity. Equity is central to sustainable development. In implementing the 2030 Agenda for Sustainable Development, we, the Ministers and high-level delegates of the small countries, commit to placing equity at the centre of all our policies. © World Health Organization 2019 Annex 3. Participants 30 Sixth high-level meeting of the small countries Malta Dr Neville Calleja Director, Department for Policy in Health – Health Information and Research Ministry for Health Email: neville.calleja@gov.mt Ms Sina Bugeja Director, Special Projects, Ministry for Health Email: sina.bugeja@gov.mt Monaco Ms Isabelle Rosabrunetto Vice-Minister Director-General, Department of External Relations and Cooperation Ministry of State Email: irosabrunetto@gouv.mc Mr Alexandre Bordero Director, Department of Health Affairs, Ministry of Health and Social Affairs Email: abordero@gouv.mc; dass@gouv.mc Montenegro Dr Kenan Hrapovic Minister of Health, Ministry of Health Email: kenan.hrapovic@mzd.gov.me; mzdravlja@mzd.gov.me Ms Mirjana Djuranovic Head, Directorate for International Cooperation and International Relations Ministry of Health Email: mirjana.djuranovic@mzd.gov.me Professor Vesna Miranovic Director, Quality Control and Improvement of Human Resources for Health Ministry of Health Email: vesna.miranovic@mzd.gov.me Ms Natasa Terzic Director, Center for Health System Development, Institute of Public Health Email: natasa.terzic@ijzcg.me San Marino Dr Franco Santi Minister of Health and Social Security, National Insurance, Family and Economic Planning State Secretariat for Health and Social Security, Ministry of Health and Social Security Email: franco.santi@gov.sm Dr Augusto Michelotti Minister of Territory and Environment, Agriculture and Tourism Ministry of Territory and Environment, Agriculture and Tourism Email: augusto.michelotti@gov.sm Mr Simone Bacciocchi Expert, Data Management, Institute for Social Security Email: simone.bacciocchi@iss.sm Mr Giacomo Barducci Press Officer, San Marino RTV Email: barduccigiacomo@gmail.com 31 Mr Franco Cavalli Press Officer, Institute for Social Security Email: franco.cavalli@iss.com Mr Maurizio Ceccoli President of the San Marino Commission for Disabiliy Email: commissione.sammarinese.disabilita@istituzioni.sm Ms Elisa Gianessi Press Officer, Government of San Marino Email: gianessielisa@libero.it Mr Davide Giardi Press Officer, Government of San Marino Email: davidegiardi1@gmail.com Dr Andrea Gualtieri Chief, Institute of Social Security Email: andrea.gualtieri@iss.sm Dr Mara Morini Health Director, Institute for Social Security Email: mara.morini@iss.sm Dr Gabriele Rinaldi Director, Health Authority, Ministry of Health and Social Security Email: gabriele.rinaldi@pa.sm Ms Micol Rossini Officer, State Secretariat for Health and Social Security Email: micol.rossini@gov.sm Ms Elena Sacchini Health Statistics Expert, Health Authority Email: elena.sacchini.authority@pa.sm Dr Micaela Santini Institute for Social Security Email: referente.oms@iss.sm Ms Stefania Stefanelli Head, Public Relations Office, Institute for Social Security Email: stefania.stefanelli@iss.sm Slovenia Ms Liza Zorman Undersecretary, Ministry of Health Email: Liza.Zorman@gov.si Ms Nuša Kerč Communications Officer, National Institute of Public Health Email: nusa.kerc@nijz.si Dr Pia Vračko National Institute of Public Health Email: Pia.Vracko@nijz.si Annex 3. Participants 32 Sixth high-level meeting of the small countries Invited speaker Mr Stefano Boeri Founding Partner, Stefano Boeri Architetti San Marino Email: studio@stefanoboeriarchitetti.net Accompanying Mr Stefano Boeri: Mr Corrado Longa Coordinator, Urban Design Division, Stefano Boeri Architetti Email: c.longa@stefanoboeriarchitetti.net Ms Maria Lucrezia De Marco Personal Assistant to Mr Boeri Email: l.demarco@stefanoboeriarchitetti.net Invited guests H.E. Luigi Cerboni Italian Ambassador, San Marino Ambasciata.sanmarino@esteri.it Temporary Adviser Mr Marius I. Ungureanu Division of Information, Evidence, Research and Innovation Email: m.i.ungureanu@gmail.com WHO Collaborating Centre Dr Natasha Azzopardi Muscat Co-Head, WHO Collaborating Centre on Health Systems and Policies in Small States University of Malta Email: natasha.muscat@gov.mt Observers Dr Nedret Emiroglu Candidate for WHO Regional Director for Europe Turkey Dr Pirous Fateh-Moghadam Health Observatory, Department of Health and Social Solidarity Representative of the WHO Regions for Health Network Email: pirous.fatehmoghadam@provincia.tn.it Dr Hans Kluge Candidate for WHO Regional Director for Europe Belgium Dr Gianna Zamaro Chief, Social Policies Sector Representative of the WHO Regions for Health Network Email: gianna.zamaro@regione.fvg.it World Health Organization Regional Office for Europe Dr Emilia Aragon de Leon Consultant, Health and Development (SDG) Division of Policy and Governance for Health and Well-being Email: aragondeleonm@who.int 33 Dr Tammy Boyce Consultant, Footprint initiative WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: boycet@who.int Ms Mina Brajovic Head of Country Office, Montenegro Email: brajovicm@who.int Ms Chris Brown Head, WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: brownc@who.int Professor Jim Buchan WHO Consultant, Division of Health Systems and Public Health E-mail: James_buchan@hotmail.com Ms Annalisa Buoro Secretary, WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: buoroa@who.int Ms Chelsea Britannia Hedquist Communications Officer (Multimedia) Corporate Communications, Office of the Regional Director Email: hedquistc@who.int Mrs Gabrielle Jacob Programme Manager, Division of Health Systems and Public Health Email: jacobg@who.int Ms Emmanuelle Jouy Desk Officer, Country Support and Communications Email: jouye@who.int Dr Lucianne Licari Director, Country Support and Communications Special Representative of the Regional Director to the South-eastern Europe Health Network Email: licaril@who.int Dr Brigida Lilia Marta WHO Consultant, WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: martab@who.int Dr Marco Martuzzi Acting Head of Office, WHO European Centre for Environment and Health Division of Policy and Governance for Health and Well-being Email: martuzzim@who.int Dr Bettina Menne Coordinator, Division of Policy and Governance for Health and Well-being Email: menneb@who.int Annex 3. Participants 34 Sixth high-level meeting of the small countries Ms Leda Nemer WHO Consultant (Rapporteur) WHO European Office for Investment for Health and Development Division of Policy and Goverance for Health and Well-being Email: nemerl@who.int Dr Piroska Ostlin Acting Regional Director for Europe Director, Division of Policy and Governance for Health and Well-being Email: ostlinp@who.int Mrs Marge Reinap Head of Country Office Country Office, Estonia Email: reinapm@who.int Ms Cristina Da Rold WHO Consultant, Social Media WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: dac@who.int Dr Aiga Rurane WHO Representative and Head of Country Office in Slovenia Acting Head, WHO Country Office in Latvia Email: ruranea@who.int Mr Martynas Satinskas Secretary, Country Office, Lithuania Email: satinskasm@who.int Ms Mary Ann Stewart Secretary Division of Information, Evidence, Research and Innovation Email: stewartm@who.int Dr Francesco Zambon Coordinator, Investment for Health and Development in Healthy Settings WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: zambonf@who.int WHO Headquarters Dr Tedros Adhanom Ghebreyesus Director-General Mrs Elena Altieri Technical Officer (Communications) NCDs, Disability, Violence and Injury Prevention Ms Shenaaz El-Halabi Director Office of the Director General 35 Fifth meeting of the Small Countries Health Information Network (SCHIN), 2 April 2019 Andorra Mr Josep Romagosa Massana Public Health Officer, Promotion, Prevention and Health Surveillance Unit Ministry of Health Statistics Department, Ministry of Finances Email: josep_romagosa@govern.ad Cyprus Mrs Despo Chrysostomou Health Services Officer, Ministry of Health Email: dchrysostomou@moh.gov.cy Iceland Dr Sigríður Haraldsdótti Head of Division, Health Information, Directorate of Health Email: shara@landlaeknir.is Luxembourg Dr Robert Goerens Chief Physician, Health Directorate, Ministry of Health Email: robert.goerens@ms.etat.lu Malta Dr Neville Calleja Director, Department for Policy in Health, Health Information and Research Ministry for Health Email: neville.calleja@gov.mt Montenegro Ms Natasa Terzic Director, Center for Health System Development, Institute of Public Health Email: natasa.terzic@ijzcg.me San Marino Dr Gabriele Rinaldi Director, Health Authority, Ministry of Health and Social Security Email: gabriele.rinaldi@pa.sm Observers Mr Simone Bacciocchi Data Management Expert, Institute for Social Security Email: simone.bacciocchi@iss.sm Ms Elena Sacchini Health Statistics Expert, Health Authority Email: elena.sacchini.authority@pa.sm Temporary Adviser Mr Marius I. Ungureanu Division of Information, Evidence, Research and Innovation Email: m.i.ungureanu@gmail.com Annex 3. Participants 36 Sixth high-level meeting of the small countries World Health Organization Regional Office for Europe Ms Mary Ann Stewart Secretary, Division of Information, Evidence, Research and Innovation Email: stewartm@who.int Engaging citizens in the SDGs: a workshop for communications professionals, 2 April 2019 Andorra Mr Joan Antoni Leon Peso Secretary of State, Ministry of Health Email: Joan_Leon@govern.ad Cyprus Mrs Angeliki Protopapa Administrative Officer, Ministry of Health Email: aprotopapa@moh.gov.cy Estonia Ms Eva Lehtla Media Adviser, Communications Department, Ministry of Social Affairs Email: eva.lehtla@sm.ee Iceland Ms Ásthildur Knútsdóttir Deputy Director General, Ministry of Health Email: asthildur.knutsdottir@hrn.is Italy Ms Anna Lisa Bonfranceschi Freelance Journalist, La Republicca Email: a.bonfranceschigmail.com Mr Ruggerio Corcella Health Senior Editor, Corriere della Sera Email: rcorcellarcs.it Mr Marco Motta Journalist, Rai Radio 3 Scienza Email: marco.mottarai.it Latvia Ms Līga Šerna Director of the Healthcare Department, Ministry of Health Email: Liga.Serna@vm.gov.lv Malta Ms Sina Bugeja Director, Special Projects, Ministry for Health Email: sina.bugeja@gov.mt Montenegro Ms Mirjana Djuranovic Head, Directorate for International Cooperation and International Relations Ministry of Health Email: mirjana.djuranovic@mzd.gov.me 37 San Marino Mr Giacomo Barducci Press Officer, San Marino RTV Email: barduccigiacomo@gmail.com Mr Franco Cavalli Press Officer, Institute for Social Security Email: franco.cavalli@iss.com Ms Elisa Gianessi Press Officer, Government of San Marino Email: gianessielisa@libero.it Mr Davide Giardi Press Officer Email: davidegiardi1@gmail.com Ms Micol Rossini Officer, State Secretariat for Health and Social Security Email: micol.rossini@gov.sm Ms Stefania Stefanelli Head, Public Relations Office, Institute for Social Security Email: stefania.stefanelli@iss.sm Slovenia Ms Nuša Kerč Communication Officer, National Institute of Public Health Email: nusa.kerc@nijz.si Observer Dr Pirous Fateh-Moghadam Health Observatory, Department of Health and Social Solidarity Representative of the WHO Regions for Health Network Email: pirous.fatehmoghadam@provincia.tn.it World Health Organization Regional Office for Europe Dr Emilia Aragon de Leon Consultant, Health and Development (SDG) Division of Policy and Governance for Health and Well-being Email: aragondeleonm@who.int Ms Mina Brajovic Head of WHO Country Office, Montenegro Email: brajovicm@who.int Ms Annalisa Buoro Secretary, WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: buoroa@who.int Ms Chelsea Britannia Hedquist Communications Officer (Multimedia), Corporate Communications Office of the Regional Director Email: hedquistc@who.int Annex 3. Participants 38 Sixth high-level meeting of the small countries Dr Brigida Lilia Marta WHO Consultant, WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: martab@who.int Ms Leda Nemer (Rapporteur) WHO Consultant, WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: nemerl@who.int Mrs Marge Reinap Head of WHO Country Office, Estonia Email: reinapm@who.int Ms Cristina Da Rold WHO Consultant, Social Media, WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: dac@who.int Dr Aiga Rurane WHO Representative and Head of WHO Country Office in Slovenia Acting Head, WHO Country Office in Latvia Email: ruranea@who.int Dr Francesco Zambon Coordinator, Investment for Health and Development in Healthy Settings WHO European Office for Investment for Health and Development Division of Policy and Governance for Health and Well-being Email: zambonf@who.int

World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan WHO/EURO:2019-3535-43294-60679