WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE COPENHAGEN REGIONAL COMMITTEE FOR EUROPE Fiftieth session, Copenhagen, 11 – 14 September 2000 Provisional agenda item 3(c) EUR/RC50/10 + EUR/RC50/Conf.Doc./9 8 August 2000 00983 ORIGINAL: FRENCH THE WHO REGIONAL OFFICE FOR EUROPE’S COUNTRY STRATEGY “MATCHING SERVICES TO NEW NEEDS” The attached document describes the main lines of the WHO Regional Office for Europe’s new strategy for work with countries. It should be read in conjunction with the report on the evaluation of the EUROHEALTH programme (EUR/RC50/4) and the proposed programme budget for 2002–2003 (EUR/RC50/7 and /7 Add.1). A draft resolution (EUR/RC50/Conf.Doc./9) is attached, for the consideration of the Regional Committee.
CONTENTS Page Post-EUROHEALTH....................................................................................................................................1 Principles of a country strategy.....................................................................................................................1 Consider all the countries in their diversity ........................................................................................1 Strengthen international partnerships for health .................................................................................2 Be part of WHO’s global country strategy .........................................................................................2 Incorporate the experience gained by the Regional Office.................................................................2 Making the Regional Office’s services available to countries......................................................................3 The content of services for countries ..................................................................................................3 The delivery of services to countries ..................................................................................................5 Reorganization of the Regional Office .........................................................................................................6 The four functions of the new organizational structure ......................................................................6 Preparatory work ................................................................................................................................7 Resource allocation.............................................................................................................................7
EUR/RC50/10 page 1 POST-EUROHEALTH 1. In the early 1990s the threats to people’s health as a result of the political, economic and social upheavals that had occurred in the countries of central and eastern Europe led WHO’s Regional Office for Europe to adopt a priority programme, EUROHEALTH, specifically for that part of the Region. Its principal purpose was to offer the 26 countries concerned a common framework for tackling the main health problems they were facing, notably infectious diseases, noncommunicable diseases, poor maternal and child health, and environmental hazards. EUROHEALTH also emphasized the development of national policies for health for all and the broad outlines of health system reform. 2. The EUROHEALTH programme represented a radical change in the Regional Office’s priorities, working methods and modes of intervention. Until then, the political and health situation in the European Region had allowed the Office to propose projects and programmes that were common to all the countries. 3. In order to carry out the new programme, a department for country health development was set up. A liaison office was opened in each of the countries concerned. The budget for WHO’s activities in these 26 countries, although clearly inadequate, was steadily increased and the funds were structured in two- year contracts with the countries (known as medium-term programmes of cooperation or MTPs). 4. This change enabled the Regional Office to build up experience and acquire new skills for its work at country level. It also provided the opportunity for it to work more closely and in a more practical way with many national and international organizations, especially since during the same period the Office had to carry out major humanitarian assistance operations (which were also a new undertaking) to respond to the upsurge of conflict and civil disorder in the countries of the Region. 5. In 1998, the Regional Committee called for an in-depth, external evaluation of the EUROHEALTH programme to be made in 2000, so as to assess its achievements, identify the lessons to be learned, and align the Regional Office’s intervention strategies with the current needs of the countries in the Region. 6. The evaluation concludes that the EUROHEALTH programme “has been successful in meeting its objectives given the limited resources at its disposal and the difficult political and economic situation in the countries concerned”. However, the evaluation report also draws attention to a number of weaknesses. In particular, it stresses the need for better coordination of programmes within the Regional Office, in order to increase their effectiveness on the ground. 7. The purpose of the present document is therefore to propose to the Regional Committee, at its request and following discussion within the Standing Committee, new approaches to the strategy for working with the countries of the Region and the changes that will need to be made to the Regional Office to give effect to them. PRINCIPLES OF A COUNTRY STRATEGY 8. The principles put forward below result from an analysis of certain determining factors in the current political and health context. Consider all the countries in their diversity 9. During the ten years of the EUROHEALTH programme, the 51 Member States have developed in different ways and at different speeds. As a result, the Regional Office’s activities must now take account of the diversity of political and health situations encountered in the countries of the Region. This approach represents the main strategic evolution for the Regional Office towards the countries. Of course, EUR/RC50/10 page 2 it will always be possible and desirable to respond in a coordinated way to the common needs of several Member States, and to group them as required. But the Office’s activities will always be guided by the specific features of each country. This approach corresponds to one of the conclusions from the evaluation of the EUROHEALTH programme, i.e. the suggestion to terminate a programme that is limited to a single part of the Region. Instead, it is recommended that a new intervention strategy should be designed to meet the needs of all the countries. Strengthen international partnerships for health 10. In its work with countries, the Regional Office must also encompass the growing interest in health matters expressed by many international organizations. Their interventions deal either with health system reforms and financing, or with more specific technical issues such as the prevention of infectious diseases or health and safety matters. This applies in particular to the European Union, which is currently examining a public health policy for its member states and candidate countries, as well as to the World Bank, which is setting up a framework for support to each country that integrates social dimensions with interventions in the economic and institutional sectors. United Nations bodies, and in particular the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA) and the Food and Agriculture Organization (FAO), are also becoming increasingly visible in the health sector. This general trend must be seen as extremely positive, rather than felt to be dangerous for the Regional Office, provided of course that complementary action and partnerships are thereby strengthened. The current process of reform of the United Nations is proceeding along these lines, encouraging cooperation between its agencies in the field. There are still many obstacles to be overcome, however. The evaluators of the EUROHEALTH programme cite instances where the advice given by different organizations was contradictory and their activities very uncoordinated, placing countries in a “situation which is intolerable”. So partnership with other organizations will be an essential strategic principle of the Regional Office’s work with countries. Some contexts are particularly well suited to this type of partnership. Examples include the mechanism of accession to membership of the European Union, and the grouping of certain countries within the Stability Pact. The Regional Office will rapidly take initiatives to mobilize the international community, help countries themselves to coordinate the interventions by different organizations, and ensure that these interventions result in progress for the health systems of the countries concerned and, ultimately, in better health for their people. The limited resources available to the Regional Office and to the health sector in all countries, especially the poorest ones, make these partnerships even more necessary. They are the only realistic solution to the problems of obtaining funds and ensuring that they are used efficiently. 11. Globalization is another major feature of the current international context. While it is difficult to foresee all of its health repercussions, this trend must be monitored and analysed to ensure that economic interests are not pursued at the cost of serious harm to people’s health. The clear stance of WHO in general and of the Regional Office in particular, enriched by partnerships with organizations sharing their values and missions, will enable the health sector to benefit from the positive aspects of globalization. Be part of WHO’s global country strategy 12. The Regional Office’s strategy for its work with countries is in line with the spirit and approaches laid down for the Organization as a whole in the Country Cooperation Strategy (CCS). It is based not only on an analysis of the needs and aspirations of the country in question, but also on an assessment of its own capacities and possibilities for involvement. It takes account of the values and principles of WHO as “one Organization”. It is designed in a spirit of cooperation and mutual respect, and advocates an integrated approach to health development. Incorporate the experience gained by the Regional Office 13. Since it was set up, and especially in the past decade, the Regional Office has expanded its technical knowledge and its networks of experts in all the priority areas of public health. Its skills are useful both to the countries who need them and to the many organizations with which it works. The EUR/RC50/10 page 3 Office has also built up more detailed knowledge of health systems and fuller information on the health situation in the different countries. Lastly, under the EUROHEALTH programme and through its humanitarian assistance work, it has acquired practical experience of intervening at country level. This know-how is a major asset for the Regional Office’s country strategy. However, it must be made more operational and better coordinated, as recommended by the EUROHEALTH evaluators: they consider that there is insufficient coordination between technical programmes and those focused on country work. MAKING THE REGIONAL OFFICE’S SERVICES AVAILABLE TO COUNTRIES 14. Giving effect to the principles outlined above entails developments in both the content and delivery of the Regional Office’s services. The content of services for countries Health policy and health system reform 15. The development of national health policies is certainly one of WHO’s most significant contributions in recent decades. The Health for All policy has undoubtedly acted as a stimulus in this regard, and it has also provided the broad outlines for such policies. Many countries in the Region have now adopted genuine health policies which lay down medium- and long-term objectives and priorities. In some cases, these policies have been ratified by parliament, thereby gaining greater legitimacy and continuity. Other countries are currently establishing such policies, while still others are revising theirs. Some have not yet started the process. The Regional Committee, by endorsing HEALTH21, reaffirmed that each country would benefit from having such a policy framework. The Regional Office will therefore maintain and step up its support to Member States in this area. It will do so, of course, on a case-by-case basis, responding to the interest expressed by the country itself, taking account of the country’s capacity for implementation, and adapting the services it offers to the country’s political and economic situation. In addition to the advantages it offers to the country itself, the adoption of a coherent and intersectoral health policy constitutes an effective framework for the services which the Regional Office can provide. For those countries of the Region which need bilateral and multilateral international support, the policy framework ensures that such support, often accompanied by the allocation of financial resources, is aligned as closely as possible on national objectives. This aspect is also stressed in the evaluation of the EUROHEALTH programme, which points out that international support must be based on a national document setting out a health policy and be coordinated by the ministry of health, supported by WHO. 16. Virtually all the countries of the Region are reforming their health systems. Here, too, the situations are very varied: in some cases, fundamental reform of the system is being undertaken, while in others circumstantial adjustments are being made. There are clearly very close links between health policy and health system reform. In effect, it is difficult to carry out a reform without a policy framework which enables informed technical choices to be made. Even if they differ in intensity and nature from one country to another, these reforms almost always have the same objectives: • to promote universal access to the health system, in order to reduce the very marked inequities that still exist, even in the richest countries; • to improve the quality of the health system, in order to provide users with good services despite limited resources; • to strengthen respect for patients and their rights and to promote democracy in health based on clear information and greater public participation in decisions concerning health; • to rationalize the use of human and material resources, while ensuring respect for ethical and social dimensions. EUR/RC50/10 page 4 17. Health professionals have a vitally important role to play in the reform of health systems. Nurses, for instance, are becoming increasingly involved in primary care and public health, with the support of the Regional Office. 18. In these areas of health policy and system reform, the services offered by the Regional Office must help the countries to base their choices on reliable information, comparative analyses, evaluations of their own situations, specific case studies, and contacts between officials with complementary experience. These services will therefore be strengthened and improved, because they can be of use to all Member States, albeit at different levels. Lastly, it should be noted that work on analysing and improving health systems can usefully draw on the new perspectives opened up by The world health report 2000.1 Technical programmes 19. The Regional Office for Europe provides countries with a wide variety of technical programmes covering the main fields of public health. It does this both through its own units and via a network of experts and collaborating centres. There is currently a good match between the Regional Office’s technical skills and the priority health problems which the Member States are having to face. These priorities also reflect those identified for the Organization as a whole: prevention of communicable diseases and the main chronic diseases, health promotion, and the control of risk factors and health hazards related to the environment. Some fields will receive special attention in the light of particular circumstances, which will give countries intensified services and the possibility of greater participation. Examples of such areas include the poliomyelitis eradication programme, the tobacco convention, and the action plans on alcohol and on food and nutrition policy. Mental health should also be mentioned in this context: it is a growing concern in all countries, both in terms of psychiatric care and with regard to the prevention of mental disorders that are often the result of modern-day lifestyles (difficulties of communication and lack of social contact). In 2001, World Health Day and The world health report will be devoted to this problem. 20. Some areas will be the subject of new, more coherent and concerted approaches. This will apply notably to health determinants and the question of health throughout the life course, in particular during pregnancy and childhood. 21. In order to increase the technical effectiveness of its interventions, the Regional Office is currently reviewing each of its programmes. These reviews are looking at the scientific evidence on which its recommendations and actions are based; the skills of its networks of experts and collaborating centres, and their ability to mobilize themselves; the priorities and actions of other bodies active in the area; and, of course, the best strategies to propose to the countries. Health crises 22. One of the characteristic features of the end of the twentieth century has been the increase in the number of crises that have had an unexpected and brutal impact on the health field. Obvious examples include AIDS and blood contamination, bovine spongiform encephalitis (BSE), environmental disasters, and outbreaks of chemical and food poisoning. These crises have caused considerable public anxiety. Governments often find it very difficult to resist economic, political and media pressure groups. In order to prevent the risks involved and to reduce their harmful repercussions on health, the countries of the Region are setting up monitoring and observation mechanisms. Many organizations are taking initiatives in this area. The Regional Office must contribute to this effort by disseminating independent scientific information. In partnership with other bodies in the Region, notably the European Union, it will ensure that the Member States have rapid access to a summary of scientific knowledge in the area in question. This service, too, will be supported by the network of experts and collaborating centres. 1 The world health report 2000: health systems: improving performance. Geneva, World Health Organization, 2000. EUR/RC50/10 page 5 23. Humanitarian assistance is another example of a service provided to countries in times of crisis. The Regional Office will of course continue its work in this field. But it is now facing the problem of continuity, since the plentiful resources that are often available in the initial, acute phase are not forthcoming at the later stage of reconstruction of a health system. A strategy for continuity must therefore be worked out, taking account of the investments already made, the results of the action taken, and the country’s needs in the long term. “Futures fora” 24. One of the missions which WHO is expected to perform is to enable Member States to share their visions, experience and concerns. This function has now become more important owing to the increasing pace of political, social and technical change, especially in the area of communications. Forecasting the repercussions which these changes will have on health, exerting influence over them, and taking decisions now to make them as favourable or harmless as possible are very onerous tasks for health decision-makers at all levels. The Regional Office will gradually set up a service to provide “futures fora”, in the shape of working groups bringing together decision-makers and experts in a given subject. The time-limited mission of each group will be to explore a new field and to derive guidance and recommendations, not only for the Member States but also for the development of the Regional Office. Subjects that could be taken up would include bioethics; alternative medicine; the influence of the new electronic media on the use of medical and pharmaceutical services; crisis communication; telemedicine; the impact of economic change and poverty on health systems; and the health challenges of globalization. Information and knowledge 25. This field, which is regarded as essential for progress in public health, is one where the Regional Office’s competence, legitimacy and credibility are most widely acknowledged. The services provided by the Office will focus mainly on the development, in close cooperation with the countries, of modern systems for information and knowledge management. In addition, the Office will strengthen its capacity for analysing data in support of decision-making. Regrettably, there is a certain amount of duplication, inconsistency and investment that yields little benefit for users, so the Office will also foster partnerships and coordination with the many bodies that are taking initiatives in this sector. Lastly, the Office will help to develop a more scientific approach to public health, by collecting and analysing information and by making use of the new information and communication technologies, in particular the Web, to disseminate it. The delivery of services to countries 26. It is up to each country, in consultation with the Regional Office, to choose those services which it most needs and to participate in those activities which it feels are most important both for itself and as a contribution to regional development. 27. Ideally, the Regional Office should have a liaison office in each country. Unfortunately, the limited resources available preclude attainment of this objective. The experience gained in humanitarian operations has demonstrated the value and the effectiveness of a strong presence in the field, therefore it is realistic and necessary to maintain liaison offices in those countries where they already exist. Moreover, their role of representing WHO and coordinating its actions in the country will be strengthened, in particular by clarifying their status. The principle of a contractual mechanism with these countries will be maintained, but it will be improved by expanding its scope, strengthening its coherence and ensuring greater continuity. The liaison offices will be given more responsibility for negotiating and concluding contracts, managing the resources allocated to them, carrying out activities in partnership with other organizations active in the country, and evaluating the results achieved. 28. To ensure that the Member States have access to high-quality services, the Regional Office will continue (as resources permit) to call on the most competent external experts and collaborating centres, but the missions of these centres will have to be redefined. It is not feasible or desirable to have, in the Regional Office itself, a permanent staff of experts in each area of public health. On the other hand, all EUR/RC50/10 page 6 units and programmes must develop their capacity to mobilize expertise as and when required, and to energize and manage networks. Increasingly, therefore, they will have to act as a mediator between experts and decision-makers. A new form of expertise will be used by the Regional Office for its services to Member States. This will consist in calling on advisers who themselves have recently been involved in reform and public health action in their own countries. Areas such as health system reform and financing are particularly well suited to this mechanism, which brings together technical knowledge and real-life experience. Preparations are currently being made to run a trial of this mechanism. 29. Disseminating case studies is another way in which the Office can ensure that its advice and recommendations are practicable and realistic. It will do this for decision-makers, in particular, in forms and language that are clear and accessible, while maintaining a systematic and rigorous scientific approach. A collection of these case studies will therefore be launched in the near future. It will form one of the elements of the Office’s new communication and publication policy, the main aim of which will be to tailor its communication products more closely to selected target audiences, notably decision-makers, health professionals and the scientific community. 30. More generally, the Regional Office will improve its capacity to respond to the questions raised by its many constituents. It will do this either directly or by facilitating contact with other sources of expertise, both within and outside the Organization. It will organize itself so that it can respond more quickly and more accurately, and it will make more professional and systematic use of electronic media that enable the rapid, individualized exchange of both technical knowledge and specific, practical experience. 31. Even though the situation in some countries will require priority investments by the Regional Office, its services are, as mentioned above, aimed at all the Member States in the Region. In order to make these services more specific, more appropriate and more operational, the Office has launched an exercise (initially on an internal basis) to analyse its information on the countries and the priorities for its present and future cooperation with each of them. REORGANIZATION OF THE REGIONAL OFFICE 32. These changes in the approaches adopted by the Regional Office, which are designed to improve the services offered to Member States, are currently taking the form of a reorganization of its structure and the gradual evolution of its methods of intervention. The priority given to services for countries does not, however, preclude the Office’s involvement in “intercountry” projects, which will be maintained but limited to scientific projects with a recognized operational potential. The four functions of the new organizational structure 33. In order to support the new strategic approaches and the changes in the services offered by the Regional Office, a new organizational structure has been adopted. It is aligned on functions, whereas the previous one was based on the various branches of public health. Four functions have been defined, each of which corresponds to a division of the Office: • A country function – responsible for coordinating action in the countries, including humanitarian assistance, partnerships with other organizations, health policy and health systems. • A technical function – bringing together all the technical units and programmes. • A function of information and communication – responsible for the collection, internal consistency, analysis, presentation and dissemination of information. • A function of operational support – responsible for administration, budget and finance. Its new title reflects the way in which its mission has evolved towards servicing the Office’s interventions and actions, while retaining a control function. EUR/RC50/10 page 7 34. The new organizational structure incorporates immediate changes in such areas as health system organization and financing; health determinants; health impact assessment; the evidence base for public health action; and the training of Regional Office staff. The organizational structure is also forward- looking, in that it indicates which fields are to be considered as a priority once the necessary funds become available, in areas which are not yet covered, such as health of the elderly, accident prevention, and disease surveillance. Preparatory work 35. In addition to updating its information, analysing its cooperation with countries and reviewing its technical programmes, the Regional Office is considering what mechanisms to put in place in order to make its interventions more coherent and consistent and to reduce fragmentation. This “cross-cutting” work is being carried out in five areas: services to countries; partnership with other organizations; resource mobilization; information management; and communication policy. Resource allocation 36. The European Region’s proposals for the 2002–2003 budget reflect the priority given to activities for countries. This trend builds on the one already apparent in previous budgets, and especially that for 2000–2001. During the current biennium, the available funds are being used as a priority to support the reorganization process and those sectors that require an immediate involvement. 37. The main elements of the current reorganization will be completed by the end of the year, but there will be room for continuing improvements based on regular evaluations.