Forty-eighth Regional Committee for Europe: Copenhagen, 14-18 September 1998: proposed programme budget 2000–2001: and preliminary orientations for 2002 -2003

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE T O ® ™ COPENHAGEN PROPOSED PROGRAMME BUDGET 2000-2001 AND PRELIMINARY ORIENTATIONS FOR 2 0 0 2 -2 0 0 3 Document EUR/RC48/8 as at 15 June 1998 CONTENTS Page Introduction................................................................................................................................................................ 1 General situation in the Region............................................................................................................................... 1 Policy fram ework...................................................................................................................................................... 1 Priority-setting............................................................................................................................................................2 Priorities.............................................................................................................................................................. 2 Lower priority areas.......................................................................................................................................... 3 Programme budget allocations 2000-2001 ........................................................................................................... 4 Programme strategies................................................................................................................................................4 The health outlook in the European Region................................................................................................. 4 W HO’s role in promoting health through the HFA targets........................................................................ 5 Country health development.....................................................................................................................................6 National health policy development...............................................................................................................7 Health o f women and children.........................................................................................................................8 Infectious diseases.............................................................................................................................................8 Noncommunicable diseases and health promotion...................................................................................... 8 Environment and health....................................................................................................................................9 Changes in orientation...................................................................................................................................... 9 Reform, cost-containment and efficiency measures at the Regional Office................................................... 11 Organizational reform.....................................................................................................................................11 Global change.................................................................................................................................................. 11 Cost-containment and efficiency m easures................................................................................................ 11 Office-wide evaluation - main achievements and constraints................................................................. 11 1. GOVERNING BODIES................................................................................................................................ 23 Policy orientation and strategic priorities...........................................................................................23 1.1 Governing bodies....................................................................................................................................24 1.1.1 Regional committees................................................................................................................... 25 2. HEALTH POLICY AND MANAGEMENT.............................................................................................. 27 Policy orientation and strategic priorities...........................................................................................27 2.1 General programme development and management.........................................................................28 2.1.1 Executive Management...............................................................................................................31 2.1.2 Managerial process for WHO’s programme development...................................................31 2.1.3 Management and support to information system s................................................................. 32 2.1.4 Regional Director’s Development Programme.......................................................................32 2.1.5 Coordination with other organizations. Mobilization o f external health resources..........33 2.2 Health, science and public policy......................................................................................................... 34 2.2.1 Health and socioeconomic developm ent.................................................................................37 2.2.2 Research policy and strategy coordination............................................................................. 38 Forew ord 2.3 National health policies, and programme development and management.....................................39 2.3.1 Technical cooperation with countries.......................................................................................42 2.3.2 Collaboration with countries and peoples in greatest need................................................... 42 2.3.3 Emergency and humanitarian action, relief and rehabilitation operation and emergency preparedness programme..............................................................................43 2.4 Biomedical and health information and trends.................................................................................. 44 2.4.1 Epidemiology, statistics, trend assessment and country health information...................... 46 2.4.2 Publishing, language and library services................................................................................ 46 3. HEALTH SERVICES DEVELOPMENT................................................................................................... 49 Policy orientation and strategic priorities........................................................................................... 49 3.1 Organization and management o f health systems based on primary health care..........................50 3.1.1 Health systems research and developm ent..............................................................................53 3.1.2 National health systems and policies........................................................................................54 3.1.3 District health systems................................................................................................................ 56 3.2 Human resources for health .................................................................................................................. 57 3.2.1 Human resources for health....................................................................................................... 59 3.2.2 Fellowships................................................................................................................................... 60 3.3 Essential d rugs.........................................................................................................................................61 3.3.1 Action programme on essential drugs.......................................................................................62 3.4 Quality o f care and health technology..................................................................................................64 3.4.1 Technology for health ca re .........................................................................................................65 4. PROMOTION AND PROTECTION OF HEALTH................................................................................. 67 Policy orientation and strategic priorities........................................................................................... 67 4.1 Reproductive, family and community health and population issu es ........................................... 69 4.1.1 Reproductive health.....................................................................................................................72 4.1.2 Child health................................................................................................................................... 73 4.1.3 Adolescent health......................................................................................................................... 74 4.1.4 Women’s health........................................................................................................................... 74 4.1.5 Aging and health.......................................................................................................................... 75 4.1 .6 Occupational health .....................................................................................................................75 4.2 Healthy behaviour and mental health................................................................................................... 76 4.2.1 Mental health ................................................................................................................................79 4.2.2 Substance abuse including alcohol and tobacco.....................................................................80 4.2.3 Health promotion......................................................................................................................... 80 4.2.4 Communications and public relations.......................................................................................81 4.3 Nutrition, food security and safety....................................................................................................... 82 4.3.1 Nutrition........................................................................................................................................ 83 4.3.2 Food safety.................................................................................................................................... 83 4.4 Environmental health ............................................................................................................................. 84 4.4.1 Water supply and sanitation in human settlements................................................................ 88 4.4.2 Environmental health in urban development...........................................................................89 4.4.3 Assessment of environmental health hazards and risks.........................................................90 4.4.4 Promotion of chemical safety .................................................................................................... 91 4.4.5 Incorporation of health concerns into environmental management.....................................92 5. INTEGRATED CONTROL OF DISEASES AND INJURY.................................................................. 95 Policy orientation and strategic priorities...........................................................................................95 5.1 Eradication/elimination of specific communicable diseases............................................................96 5.1.1 Global eradication and elimination o f poliomyelitis..............................................................97 5.1.2 Regional elimination o f measles............................................................................................... 97 5.2 Control of other communicable diseases............................................................................................98 5.2.1 Vaccine-preventable diseases................................................................................................. 100 5.2.2 Diarrhoeal and acute respiratory disease control................................................................. 100 5.2.3 Tuberculosis............................................................................................................................... 100 5.2.4 Emerging diseases surveillance and control......................................................................... 101 5.2.5 Other communicable diseases..................................................................................................101 5.2.6 Control of tropical diseases (malaria).................................................................................... 102 5.3 Control of noncommunicable diseases.............................................................................................. 103 5.3.1 Control of noncommunicable diseases..................................................................................105 6 . ADMINISTRATIVE SERVICES..............................................................................................................107 Policy orientation and strategic priorities.........................................................................................107 Shift of resources................................................................................................................................. 107 6.1 Personnel................................................................................................................................................108 6.2 General administration.........................................................................................................................110 6.3 Budget and finance............................................................................................................................... 112 6.3.1 Budget and finance................................................................................................................... 112 Annex 1. Abbreviations........................................................................................................................................ 115 FOREWORD The present programme budget proposals for the European Region for the biennium 2000-2001 have been prepared in accordance with resolution EUR/RC47/R9, i.e. following the principles used for presentation o f the global programme budget, “thus permitting the greatest possible comparability and compatibility between the regional and global budgets ... while at the same time highlighting the exclusively regional health priorities and the response to the regional HFA policy and targets approved by the Regional Committee.” The detailed programme framework as used in this draft, which differs significantly from the structure applied to earlier programme budgets, was endorsed by the Standing Committee o f the Regional Committee at its meeting in December 1997. At the time these proposals were being prepared, the increased budgetary allocation to the European Region for 2000-2001, as provided for in resolution W HA51.31, could not be taken into account since the exact figures were still not known. Consequently, the total allocation, at zero real growth, is shown as being the same as that for 1998-1999, i.e. US $49 490 000. It is expected that the additional allocation to the European Region for 2000-2001 will be available exclusively for activities at country level. At the forty-eighth session of the Regional Committee, I will present an addendum to this document setting out detailed plans for my proposals regarding this additional allocation. Finally, the new Director-General elect, Dr Gro Harlem Brundtland, outlined a number o f her priority orientations both to the Fifty-first World Health Assembly and to the Executive Board at its 102nd session in May 1998. On the latter occasion, she also announced her intention to set up a task force which will, from July to October 1998, review in-depth all global as well as regional budget proposals, in order to make those adjustments she considers necessary. Needless to say, this review may also entail changes to the proposals contained in the current draft for the European Region. It is expected, however, that further details o f the shifts and reallocations which may become necessary as a result o f this policy review will be announced by Dr Brundtland when she attends the Regional Committee session in September 1998. Copenhagen, 23 June 1998 J.E.Asvall, M.D. Regional Director for Europe o f the World Health Organization EUR/RC48/8 page 1 INTRODUCTION G e n e r a l s i t u a t i o n i n t h e R e g i o n The European Region o f WHO now numbers 51 Member States. These include some of the richest countries in the world and others which are extremely poor and face serious health challenges. In the late 1990s, per capita GNP ranged from a few hundred to over forty thousand US dollars, a fact which is reflected in the wide range o f variations in many of the health indicators in the Region. The huge economic upheavals in the countries o f central and eastern Europe (CCEE) and the newly independent states (NIS) during the 1990s have increased the gap in health status between countries in the Region. At the threshold o f a new millennium, average life span varies by 15.3 years between the best country (Iceland, 79.3 years) and the least fortunate (Turkmenistan, 64 years). Furthermore, there is no sign that these disparities will narrow in the near future. According to the United Nations Development Programme’s (UNDP) Human development report 1997,1 “Eastern Europe and the countries o f the Commonwealth o f Independent States (CIS) have seen the greatest deterioration in the past decade. Income poverty has spread from a small part of the population to about a third - 120 million people live below a poverty line o f US $4 a day”. Extreme poverty has a profound influence on health. People cannot afford basic necessities and are unable to take part in community life, leading to social isolation and lack o f self-esteem. As income differentials widen, the risk o f ill health increases. As a result of this vicious circle, a major public health crisis in the more eastern part of the Region continues to affect some 300 million people, who previously enjoyed the security and stability in public health services that can no longer be guaranteed. Public health achievements built up over decades are being lost, and a resurgence of communicable diseases such as diphtheria, cholera and tuberculosis have been major manifestations o f this decline. WHO’s European Region is one family o f countries. The persistence and even growth o f variations in health status and the quality of life enjoyed by different members o f that family calls for much stronger emphasis to be placed on promoting equity in health in the twenty-first century. P o l i c y f r a m e w o r k WHO’s Ninth General Programme o f Work (9GPW) covering the period 1996-2001 will continue to be the policy framework for preparation o f the programme budget for 2 0 0 0 - 2 0 0 1 . As agreed by the Standing Committee o f the Regional Committee (SCRC), the proposed programme budget for 2000-2001 has been based on the 38 regional targets for health for all (HFA), as contained in the approved 1991 version o f the health policy for the European Region of WHO. However, since a renewed policy with a reduced number of targets is expected to be approved by the Regional Committee for Europe in September 1998, implementation of the approved programme budget for 2000-2001 will be based on the 1998 version o f the regional targets. The four policy orientations outlined in 9GPW will provide the framework for WHO’s work during the period. They are: (i) integrating health and human development in public policies; (ii) ensuring equitable access to health services; (iii) promoting and protecting health; (iv) preventing and controlling specific health problems. 1 United Nations Development Programme. Human development report 1997. Cary, NC, Oxford University Press, 1997. EUR/RC48/8 page 2 The criteria for resource allocation in the European Region are set out in the regional contribution to 9GPW. High priority is given to: • support to development o f HFA policies at national, subnational and city levels; • areas where WHO cooperation can make a difference (giving priorities to countries most in need); • fields where the Regional Office has a comparative advantage and could have a significant impact; • areas identified by Member States and where there is a manifest demand for W HO’s cooperation; • activities most likely to produce results in view of projected future developments. So far as specific programme priorities for the biennium 2000-2001 are concerned, the Executive Board, at its 101st session in January 1998, confirmed that these should be the same as those approved for the 1998— 1999 biennium. It will be recalled that these programme priorities are covered by the following five areas: (i) eradication of specific communicable diseases; (ii) prevention and control of specific communicable diseases; (iii) reproductive health, women’s health, and family health; (iv) promotion of primary health care and other areas that contribute to primary health care such as essential drugs, vaccines and nutrition; (v) promotion of environmental health, especially community water supply and sanitation. With regard to this policy framework, it is important to keep in mind the fact that a new Director-General will take office in July 1998; it is to be expected that some shifts in relative emphasis may well be proposed to the Board and the World Health Assembly as a result. Dr Brundtland has already outlined to the World Health Assembly and the Board her initial plans regarding a revised policy framework, including a strengthening o f health sector development issues. The precise manner in which new proposals from the incoming Director-General for a revised policy framework will affect the proposed programme budget for the European Region for 2000-2001 is not clear at the time o f drafting these proposals. Further guidance on this matter will no doubt be provided when the Regional Committee comes to review the budget proposals at its forty-eighth session in September 1998. P r i o r i t y - s e t t i n g Priorities In addition to the five broad programme areas outlined above, the Regional Committee for Europe has repeatedly requested that priority should also be given in Europe to the prevention and control of noncommunicable diseases. The specific priorities for the Region for 2000-2001 will therefore emphasize the following technical areas: (i) eradication o f specific communicable diseases, i.e. poliomyelitis, and prevention and control of other communicable diseases, including emerging diseases; (ii) prevention and control o f the most burdensome chronic noncommunicable diseases; (iii) promotion of primary health care, including women’s health, essential drugs, vaccines and nutrition, improvement o f the quality o f care and health care reform; (iv) promotion of healthy behaviour with emphasis on specific settings such as cities, regions, hospitals, schools and workplaces; (v) promotion o f environmental health. EUR/RC48/8 page 3 In order to stimulate some important new initiatives and foster multisectoral cooperation and interdepartmental collaboration, four specific areas have also been singled out for the financial period 2000-2001. Primary health care is still the tool to achieve HFA, and this area was very much endorsed by the SCRC in April 1998. The opportunity will be taken to test and work towards a new HFA target, “a healthy start in life”. The health and work initiative, as a follow-up measure to the Fourth International Conference on Health Promotion, is an opportunity to launch a new “healthy company” network in the Region. Action at the local level is an essential component o f any national or subnational health strategy or programme. Urban health is, therefore, an increasingly relevant and challenging field for the European Region. These “project” areas are to be financed through a reallocation o f 10% of the totality of intercountry funds, as shown below: Primary health care A healthy start in life Health and work Urban health Low er priority areas In order to allow adequate resources to be channelled towards the above priorities, the Regional Office has decided to scale down action in those areas which, although meritorious in themselves, are not considered fundamental to attainment o f the main aims and objectives o f the biennium. These so-called “posteriorities” have been identified for successive biennia since 1994-1995, a process which has been acknowledged by the SCRC as being of crucial importance in times of budgetary constraints. The SCRC has endorsed the following criteria for ending WHO’s involvement in a specific activity as a means o f identifying areas of lower priority: • the problem has ceased to be o f major public health importance or countries can deal effectively with the problem; • a review of WHO’s involvement reveals diminishing returns for efforts expended; • a review of WHO’s involvement reveals that it is not possible to sustain an effective level of activities within the resources available. As a result, the following lower priority areas will continue to apply in 2000-2001: • medical education at undergraduate level • cancer control • health legislation • disability and rehabilitation. The issue o f research coordination and development, which was categorized as a lower priority in 1998— 1999, will be taken up again with the reconstitution o f the European Advisory Committee on Health Research (EACHR). Likewise, the health o f migrants and refugees will be covered under the Regional Office’s planned programme for equity and health. Stress prevention, again a lower priority in 1998-1999, will be an integral part o f the re-established mental health programme, and it is planned to cover the question o f healthy aging through more active use o f collaborating centres. The identification o f lower priority areas should be seen as a dynamic process extending from one biennium to the next; a similar exercise will accordingly be carried out for the biennium 2002-2003. Furthermore, it should be noted that the priorities identified apply to the Region’s intercountry programme and do not necessarily affect WHO’s technical cooperation with individual countries, as identified through the respective medium-term programmes. (GPW 3.1.3.) (GPW 4.1.2) (GPW 4.1.7) (GPW 4.4.2) US$150 000 US$150 000 US$100 000 US$100 000 EUR/RC48/8 page 4 P r o g r a m m e b u d g e t a l l o c a t i o n s 2000-2001 In recent years, the Regional Committee has repeatedly expressed its frustration with the fact that, despite the dramatic geopolitical changes which affected the Region in the 1990s (including a marked increase in the number o f Member States), regular budget allocations to regions have remained unchanged. As such, they have been based not on objective criteria but rather on history and previous practice. In successive resolutions (EUR/RC42/R6, EUR/RC45/R10 and EUR/RC47/R3) the Regional Committee accordingly called for the European Region to receive a fairer share o f the global budget of the Organization, calculated on the basis o f equity and support to countries in greatest need. The Regional Director is pleased to draw the attention o f all European Member States to the fact that these initiatives have finally borne fruit. In January 1998, the Executive Board at its 101st session adopted resolution EB101.R10, outlining a new budget allocation model to regions which: • is based on UNDP’s Human Development Index • incorporates countries’ population statistics • will be implemented gradually over three biennia starting with the financial period 2 0 0 0 - 2 0 0 1 . Following complex and difficult negotiations between all parties concerned, the Fifty-first World Health Assembly adopted a landmark resolution, W HA51.31, largely reflecting the Board’s resolution. Under the provisions of the Assembly resolution, which was referred to by delegations as both an historic decision and a prime example of effective United Nations reform, additional funds will be allocated to the European Region for the biennium 2000-2001; all o f this money will be channelled exclusively towards activities at country level. These additional funds have not, however, been included in the present draft, since the exact amounts were not known at the time o f despatch. As stated by the Regional Director in the Foreword, an addendum will be prepared for presentation to the Regional Committee at its forty-eighth session, setting out detailed proposals in this regard. P r o g r a m m e s t r a t e g i e s T he health outlook in the European R egion When the Regional Committee for Europe adopted the 38 HFA targets in 1984, target 1 called for a reduction o f 25% in the prevailing levels o f inequality in health, both between and within Member States. Since then, there have been considerable gains in health due to advances in science, technology, public health and medicine and owing to expanded infrastructures, rising incomes and levels o f education, and improved nutrition, housing and sanitation. For Europe as a whole, the incidence o f infectious diseases has declined, greatly reducing childhood mortality and morbidity. People are living longer and on the whole enjoying a more healthy life. These benefits have not, however, been experienced by everyone. The health outlook for Europe at the start o f the new millennium therefore presents a mixed picture: inequalities in health status continue to exist both between countries and between different socioeconomic groups within countries. At the close o f the 1990s, the resurgence o f diseases such as diphtheria, poliomyelitis, malaria and even cholera has become a very serious problem for certain Member States, mainly CCEE and (particularly) NIS countries. The diphtheria epidemic in the Region, which erupted in the 1990s, was quelled as a result o f intensive vaccination programmes in all fifteen NIS, which probably prevented several hundred thousand new cases. None the less, that epidemic caused more than 170 000 cases o f diphtheria and more than 4000 deaths, representing about 95% o f all diphtheria cases reported worldwide. On the other hand, great progress was made in poliomyelitis eradication in the late 1990s. Operation MECACAR continued, with national immunization days attaining on average 90% coverage. New, improved and combination vaccines have been introduced, although mainly in western European countries - the lack o f financial resources made it difficult to purchase such vaccines in other countries. EUR/RC48/8 page 5 Sexually transmitted diseases have increased dramatically in almost all NIS and some other eastern European countries. While rates o f new cases o f human immunodeficiency virus (HIV) infection are levelling off or decreasing in western Europe, recent outbreaks o f HIV infection - especially among drug users and prostitutes - in some NIS are alarming. Endemic malaria, eradicated in Europe more than five decades ago, has re-emerged in the south-eastern part of the Region. Diarrhoeal diseases kill 100 times as many children under five years of age in many of the more eastern European countries as in western European ones. A particular concern is the spread of infectious agents resistant to antimicrobial drugs: this mainly threatens the treatment o f bacterial diseases such as tuberculosis, pneumonia and gonorrhoea. On the noncommunicable disease front, smoking has been paid increasing attention by the Regional Office in the 1990s, and a third five-year European Action Plan was approved by the Regional Committee in 1997. An encouraging trend in the European Region has been the support provided by a European Commission-funded centre to national medical associations in their anti-tobacco activities. W H O ’s role in promoting health through the H FA targets Health for all in Europe is a shared policy framework that is designed to inspire and motivate countries, regions, cities and civil society to formulate policies for health that suit their particular people and circumstances while being based on the values and principles o f HFA. Since they were first launched in 1984 and then updated in 1991, the European HFA policy and targets have had an impressive impact on the development and direction of health policies at all levels in the European Region. At the same time, it must be acknowledged that the political will which has been shown has not always been converted into practical action, and that the new strategies for more effective implementation (which have been developed in recent years) must therefore now be more forcefully explored. The Regional Office for Europe (EURO) will: • promote the development o f policies, plans and thinking at national, subnational and local/city levels, as well as across sectors, in line with the European HFA policy for the twenty-first century; • carry out and promote research and development in support o f policy implementation, developing better tools for strengthening decision-making through appropriate health information systems, establishing active surveillance systems, promoting health, supporting the prevention and control of diseases and health risks o f importance, and guiding health sector development; and • cooperate with Member States most in need on implementing specific programmes and action. A number o f interactive collaborative networks support countries and stimulate “ local” HFA action in a catalytic way, by linking both country and intercountry actions and initiatives. These networks focus on: • “settings” at national, subnational and city/local levels (notably schools, hospitals, prisons and - a new approach in the biennium 2 0 0 0 - 2 0 0 1 - companies); • health problems (such as communicable diseases, diabetes, stroke, maternal and child health, environmental risks, etc.); • health professionals (including national medical associations, pharmacists, nurses and midwives); and • geographically defined groups of countries (including networks o f central Asian republics and of central, southern and eastern European countries for health sector development). Action by all Member States to attain the goals o f HFA needs to be guided by two policy objectives: making health central to human development, and developing sustainable health systems to meet people’s needs. EUR/RC48/8 page 6 C O U N T R Y H EALTH D E V E L O P M E N T Pursuing the extensive development o f country work in the European Region, EURO will, in the biennium 2000-2001, maximize its impact in countries through the EUROHEALTH programme. During 1996-1997 a number o f challenges and opportunities were taken up in the Region; these will be built on, in the next biennium, in the following areas: • there is a growing need for more systematic collaboration with western Europe and to establish pilot projects on simple and cost-effective ways o f ensuring W HO’s country presence; • the United Nations reform process has gained momentum in selected countries and EURO will continue to take part in this process, putting health in the context o f overall socioeconomic development and identifying the role which WHO can best play in order to support countries (i.e. through the United Nations Development Assistance Framework - UNDAF); • integration in Europe will continue and a number o f central European countries will become member states o f the North Atlantic Treaty Organization (NATO) or the European Union (EU) in 2000-2001. Strategic partnerships will have to be developed between WHO, EU and their member states in order to identify the necessary improvements in the field o f health; • WHO’s impact in countries needs to be further strengthened: steps will be taken to ensure active follow-up by Member States o f the agreed global/regional targets and resolutions; strategic alliances will be forged with other agencies; and WHO’s policy and programmes will be more closely integrated with national health policy development; • country allocations in the Region may increase, which will give a fresh impetus to all these developments. Between 1991 and 1997, the main emphasis in country health development was on the EUROHEALTH programme, originally launched following a decision by the Regional Committee in 1991 to respond to the considerable needs of the CCEE. In 1995, following an in-depth external evaluation, the Regional Committee endorsed an update o f the EUROHEALTH programme until the year 2000. Twenty-six countries are covered by the EUROHEALTH framework programme for the period 1995— 2000. They include 14 CCEE: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia, Slovenia and The Former Yugoslav Republic of Macedonia. There are also 12 NIS: Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic o f Moldova, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. In addition, EURO has specific collaborative agreements with Israel, Malta and Turkey. Specific targets for the countries covered by the EUROHEALTH programme are: • By the year 2000, at least 80% of the EUROHEALTH countries shall have formulated national HFA policies and at least half of those will have made a plan for health system development on that basis. • By the year 2000, the EUROHEALTH programme shall have assisted at least 80% of the target countries in modifying their health care systems towards a more rational hospital infrastructure and family- and community-oriented primary health care, with at least one national health programme managed in accordance with the concept o f health gain and using measurable quality indicators. • By the year 2000, infant mortality and maternal mortality in at least 90% of the EUROHEALTH countries should be no more than 15 per 1 0 0 0 and 15 per 1 0 0 0 0 0 , respectively. • By the year 2000, all poliovirus transmission will have ended in the EUROHEALTH countries, programmes under the Expanded Programme on Immunization (EPI) will routinely reach at least 90% of the target population, and a permanent solution will have been found to the problems of vaccine provision for all the EUROHEALTH countries. All EUROHEALTH countries will have EUR/RC48/8 page 7 begun implementation o f a national plan for tuberculosis control. The EUROHEALTH countries should be self-reliant insofar as AIDS prevention and control are concerned, in accordance with international principles and standards. • By the year 2000, all EUROHEALTH countries will have re-established public health systems that ensure epidemiological surveillance and control o f communicable diseases. • By the year 2000, each o f the EUROHEALTH countries will have included health promotion as a specific part o f its national policy, and at least 90% of those countries will have specific programmes based on the principles o f the regional tobacco and alcohol control programmes. • By the year 1997, in accordance with the Helsinki Declaration on Action on Environment and Health in Europe, EUROHEALTH countries should have developed national environment and health action plans. • By the year 2000, a national road traffic safety programme should have been developed in at least 80% of EUROHEALTH countries and be in the implementation phase; projects should be under way to improve drinking-water quality for a great part o f the 1 0 0 million people currently in need o f this; and all EUROHEALTH countries will have adequately strengthened their institutional capacity for management o f the environment and health at national and local levels. These targets are expected to be updated following the adoption o f the revised HFA targets for the European Region by the Regional Committee in September 1998 and the evaluation o f the EUROHEALTH programme which is expected to take place in 2000. The above priorities and targets are followed in the bilateral collaborative agreements with countries. Growing economic and social inequities continue to have a negative impact on the health status of populations in the European Region. Major political, social and economic changes have continued to take place in the Region. The health situation in NIS and some CCEE has not improved significantly over the past years, whereas the first signs of recovery are to be seen in some central European countries. Widening social and economical gaps among countries, demographic changes, the re-emergence of communicable diseases, global environmental threats, and unfavourable lifestyles are likely to continue to interact and strongly influence the health o f populations in the Region in the beginning o f the next century. In 1996-1997, the country health development work concentrated mainly on the EUROHEALTH countries. Particular attention was paid to the six priority areas as identified by the Regional Committee in 1995, in order to reach the aims o f the EUROHEALTH programme through two approaches: linking EUROHEALTH countries to intercountry programmes and Europe-wide networks; and country-specific activities. This was done by implementing biennial collaborative agreements with the EUROHEALTH countries in the priority areas identified. WHO liaison offices - which are operational in 25 out o f the 26 countries - assisted EURO to implement joint activities, and they also played a leading role in work on United Nations reform at country level. In line with the thinking behind this reform, it was decided in September 1998 to close the WHO representative’s office in Turkey and to transform it into a liaison office. As a result of the above endeavours, good progress was made in a number o f areas, as outlined below. N a tio n a l h e a lth policy d eve lopm en t The aim here is to help countries formulate policies based on the principles o f HFA. Good progress was made both in CCEE and NIS. In some countries, where a political commitment to develop policy had already been made, advice was given on policy options and the policy-making process. The target set by the Regional Committee in 1995 will be reached prior to the next EUROHEALTH evaluation. EUR/RC48/8 page 8 The countries’ health care reform activities were supported in three complementary ways, as a follow-up to the WHO Conference on European Health Care Reforms, at which a set o f principles (the Ljubljana Charter) and action strategies were agreed upon. • A knowledge base for health care reform was constituted (the “Health Care in Transition” or HiT profiles). This guarantees the availability o f up-to-date, accurate and comprehensive information on almost all EUROHEALTH countries as well as on those in western Europe. • Within various networks (MIDNET, EASTNET, CARNET and SOUTHNET) the participating (mainly EUROHEALTH) countries shared experience and discussed current issues in health care reform. • Advisory support was provided to EUROHEALTH countries that expressed their willingness to follow the values and principles of the Ljubljana Charter. H ealth o f w om en and children In all CCEE/NIS, efforts were made to create integrated programmes on women’s health, family planning, safe motherhood (conception, pregnancy, delivery and postnatal care), early and exclusive breastfeeding, and proper weaning practices. The knowledge base is being improved through country profiles on women’s health (now available for 39 countries). Capacity-building is continuing as an important part of this activity in most EUROHEALTH countries, first and foremost in the CARAK (Central Asian Republics, Azerbaijan and Kazakhstan) project. The EUROHEALTH targets for infant and maternal mortality have already been reached in CCEE, and efforts will be made to achieve the same results in the NIS during the biennium 2000-2001. Infectious diseases The eradication of poliomyelitis is one of the top priorities globally, and regionally Europe is close to achieving the target by 2000. In HIV/AIDS comprehensive workplans have been produced in a great number of countries, to raise awareness of and political commitment to tackling the problem. Programmes for the surveillance, prevention and control o f infectious diseases are quite well developed in all CCEE and have been further strengthened in the NIS. The same applies to the immunization programmes, which were well implemented before the political changes. Although some discrepancies and inequities occurred as a result o f the economic transition, most o f these have now been overcome and the situation has stabilized, even if some countries are still not self-sufficient in vaccines, reagents, tests and modern equipment. Despite the fact that tuberculosis continues to be a threat in some countries, many have - with WHO’s assistance - developed modem tuberculosis control strategies during the biennium. N oncom m unicable diseases and health prom otion In collaboration with the United Kingdom Health Education Authorities, EURO offers a programme of technical assistance which comprises a range o f services in planning, implementing policies, strengthening infrastructures, and building capacity. Almost all CCEE have been covered, and activities are starting up in NIS. The European Network o f Health Promoting Schools (ENHPS) - in 38 European countries - provides methods and techniques o f implementing and sustaining a whole-school approach to health promotion. A new service was introduced during the 1996-1997 biennium: at the request o f the parliament and government, two countries were provided with an expert appraisal o f their capacity to develop and maintain a comprehensive health promotion programme. To tackle the prevention o f noncommunicable diseases, the countrywide integrated noncommunicable diseases intervention (CINDI) programme is being implemented in 24 countries. EURO also supported the development o f food-based dietary guidelines and breastfeeding promotion strategies. EUR/RC48/8 page 9 WHO has focused attention on the implementation o f tobacco policy by sending policy missions to a number o f countries. Training is taking place as integral part o f these activities. As a follow-up of the Alcohol Conference in 1995, special policy development meetings have been held with the EUROHEALTH countries, and policy development will follow. Activities in drug addiction and mental health have also been taking place. Environm ent and health Following the Second Ministerial Conference on Environment and Health (Helsinki, 1994), countries have been drawing up National Environment and Health Action Plans (NEHAPs) as a key instrument for introducing integrated policies on environment and health, developing legislation and building appropriate institutions. All CCEE and NIS are either in the process o f developing their NEHAPs or have finalized development and started with implementation. Changes in orientation In 2000-2001, work on country health development will cover the whole Region. There will be increased emphasis on and more systematic collaboration with western Europe, while special attention will continue to be paid to countries most in need. In the latter, W HO’s activities will continue to be governed by the six medium-term priorities for EUROHEALTH collaboration, i.e. communicable diseases, women’s and children’s health, health policies, health care reform, environmental health, and noncommunicable diseases and the promotion of better health. These EUROHEALTH priorities are broadly consistent with the global priorities endorsed by the Executive Board, as referred to in the section on “Policy framework” above. While the most needy part o f the Region is well covered by the work o f the Regional Office, the renewed European HFA policy and the public health problems in western Europe will call for more systematic and intensified collaboration. During 1996-1997, only a few countries in the western part of the Region had direct or systematic collaboration with the Regional Office. In 1998-1999 the number increased, and the intention is to cover all European countries with systematic collaboration and a country function during the biennium 2 0 0 0 - 2 0 0 1 . While priority will continue to be given to intensifying cooperation with populations in greatest need, Europe-wide core functions will be protected: seeking a quantified reduction in the burden o f disease in Member States; aiming for impact by concentrating human and programme resources in a limited number o f focused areas; giving primacy to access to health systems based on primary health care; helping countries address the health problems o f poverty; and strengthening countries’ capacity to move from absorption o f emergency assistance to self-sufficient redevelopment. The EUROHEALTH programme will continue to be based on an analysis of the problems o f the target countries, an assessment o f the relevance of the HFA strategy to solving them, and an understanding o f EURO’s potential to deliver the action required. This involves reconciliation o f the priority needs o f these countries and the Regional Office’s capacities. Should additional regular budget resources materialize in the biennium 2000-2001 as a result o f revised regional allocations, as recommended by resolution W HA51.31, this fact, together with the need to expand the network o f country health development to the whole Region, will necessitate a strategic repositioning of EURO’s country focus. Two components of the country work will none the less continue: country-specific collaboration with individual countries in their priority areas (i.e. health policy development in line with the updated European HFA policy, formulation o f health care reforms, and other specific health issues) and a strong country focus on intercountry work, but better linked to and integrated with national policy-making processes. These two broad components will complement each other and will both be integrated into national health policy development. EUR/RC48/8 page 10 Table 1. Country programme allocations under the regular budget (US$ nominal amounts, excluding cost increase factors) Country 2000-2001 1998-1999 1996-1997 Albania 130 000 130 000 130 000 Andorra 0 0 Armenia 130 000 130 000 130 000 Austria 0 0 0 Azerbaijan 130 000 130 000 130 000 Belarus 130 000 130 000 50 000 Belgium 0 0 0 Bosnia and Herzegovina 130 000 130 000 130 000 Bulgaria 50 000 50 000 50 000 Croatia 130 000 130 000 130 000 Czech Republic 50 000 50 000 50 000 Denmark 0 0 0 Estonia 50 000 50 000 50 000 Finland 0 0 0 France 0 0 0 Georgia 130 000 130 000 130 000 Germany 0 0 0 Greece 0 0 0 Hungary 50 000 50 000 50 000 Iceland 0 0 0 Ireland 0 0 0 Israel 0 25 000 50 000 Italy 0 0 0 Kazakhstan 130 000 130 000 130 000 Kyrgyzstan 130 000 130 000 130 000 Latvia 50 000 50 000 50 000 Lithuania 50 000 50 000 50 000 Luxembourg 0 0 0 Malta 0 25 000 25 000 Monaco 0 0 0 Netherlands 0 0 0 Norway 0 0 0 Poland 50 000 50 000 50 000 Portugal 0 0 0 Republic of Moldova 130 000 130 000 50 000 Romania 50 000 50 000 50 000 Russian Federation 200 000 200 000 200 000 San Marino 0 0 0 Slovakia 50 000 50 000 50 000 Slovenia 50 000 50 000 50 000 Spain 0 0 0 Sweden 0 0 0 Switzerland 0 0 0 Tajikistan 130 000 130 000 130 000 The Former Yugoslav Republic of Macedonia 130 000 130 000 50 000 Turkey 200 000 200 000 200 000 Turkmenistan 130 000 130 000 130 000 Ukraine 130 000 130 000 50 000 United Kingdom 0 0 0 Uzbekistan 130 000 130 000 130 000 Yugoslavia8 50 000 50 000 0 Total country allocations 2 900 000 2 950 000 2 605 000 * If the World Health Assembly has in the meantime agreed to normalization of official membership status. EUR/RC48/8 page 11 R e f o r m , c o s t - c o n t a i n m e n t a n d e f f i c i e n c y m e a s u r e s a t t h e R e g i o n a l O f f i c e O rganizational reform A number o f organizational reform measures were instituted at the Regional Office over the past two biennia, and these will continue to affect the way in which EURO manages its programmes in the biennium 2000-2001. Considerable authority for handling day-to-day operational and administrative matters has been delegated to unit level following the reorganization o f Executive Management, which can now give the Regional Director better support in discharging his directing, managerial and coordination responsibilities. The rest of the secretariat has also been streamlined. An in-depth review of the multi-professional units within each department was carried out in 1997, and the lessons learned in terms o f rationalization o f support services will also continue to affect the departments and units into 2000- 2001. Furthermore, the Regional Director ordered an extensive management review by a professional management consulting company, Deloitte & Touche Consulting Group, covering Executive Management and Administration and Finance, the outcome o f which was implemented in 1998. G lobal change As part o f overall reform at the Regional Office, significant attention was paid, over the past three biennia, to full implementation of all the recommendations made by the Executive Board Working Group on the WHO Response to Global Change. A comprehensive status report on implementation was provided to the Regional Committee at its forty-seventh session in September 1997, and the actions referred to in that report will govern the work o f the Office in 2000-2001. C ost-containm ent and efficiency m easures In response to Executive Board resolution EB99.R13 and World Health Assembly resolution WHA50.26, an efficiency plan was drawn up for the 1998-1999 biennium, in order to shift 3% of the total regular budget from administrative areas and reallocate these amounts to high-priority health programmes. EURO’s efficiency plan generated US $1.6 million (3.2%) savings in administrative areas, which has strengthened the Regional Office’s capacity in the following technical areas: • STD/AIDS (part-financed with WHO headquarters) • other communicable diseases • mental health • sexual and family health • pharmaceuticals • resource mobilization. While both o f the above resolutions refer to efficiency shifts applied to the 1998-1999 biennium, the savings and shifts have been carried forward into 2 0 0 0 - 2 0 0 1 and as such are reflected in the budgetary tables in the following chapters. O ffice-w ide evaluation - m ain achievem ents and constraints At its 101st session, the Executive Board adopted resolution EB101.R1, calling for an evaluation methodology which permits comparisons of expenditures and trends with budgetary allocations, in line with previous Board and Assembly resolutions on budgetary reform. The resolution specifically requests the Director-General to present an interim report on the result o f such an evaluation to the Board at its 103rd session in January 1999, as a means o f complementing the Board’s discussion o f the proposed programme budget for 2 0 0 0 - 2 0 0 1 . EUR/RC48/8 page 12 The Regional Office is already doing such an analysis: it presented comprehensive budget implementation reports for both the 1992-1993 and the 1994-1995 biennia to the Regional Committee, providing a detailed analysis o f actual expenditure versus budgetary provisions, including explanations o f variances. The Regional Director will be presenting the third report on implementation o f the 1996-1997 programme budget to the Regional Committee in September 1998. The 1996-1997 programme evaluation was carried out in November 1997. The purpose was to examine whether EURO had delivered what it had promised to the Member States, in the approved programme budget and workplans. The exercise reviewed achievement against operational plans and thus allowed EURO to measure and document the progress made towards the expected outcomes o f programme activities. The evaluation highlighted the need for more cross-departmental collaboration; the need to better integrate health care reform and health policy into departmental activities; and the fact that medium-term programmes should cover a longer period than two years. The evaluation also brought into focus the need to streamline with other agencies the collection and analysis o f health information at country level, with a view to avoiding duplication of efforts. The ongoing UNDAF process, in which the Regional Office actively participates, will provide opportunities to further this work. EUR/RC48/8 page 13 EUR/RC48/8 page 14 Table 2. Proposed program m e budget 2000-2001 Share of budget by m ajor programme No. G P W Area Programme t it le PB 2000-2001 Total S taff (2) IC P /3 ; CP Regional (3) programme P GS S Total SO) 1 1. G O V E R N IN G BODIES T O T A L S E C T IO N 1 624 400 524 400 1.0 291 000 815 400 2. H E A L T H P O L IC Y A N D M A N A G E M E N T 2.1 General programme development and management Total section 2.1 1 380 000 1 243 700 2 623 700 8.0 10.0 3 527 000 6 150 700 2.2 Health, science and public policy Total section 2.2 245 500 357 000 602 500 2.0 2.0 836 000 1 438 500 2.3 National health policies and programme development and management Total section 2.3 235 000 2 495 000 2 730 000 4.0 9.0 2 314 000 5 044 000 2.4 Biomedical and health information and trends Total section 2.4 316 500 172 000 421 000 909 500 12.5 19.5 5 864 000 6 773 600 T O T A L S E C TIO N 2 2 177 000 3 024 000 1 664 700 6 865 700 26.5 40.5 12 541 000 19 406 700 3. H E A L T H S ER VIC ES D E V E L O P M E N T 3.1 {Organization and management of health systems !based on prim ary health care i Total section 3.1 742 000 565 000 1 307 000 5.0 3.0 1 873 000 3180 000 3- L Human resources for health Total section 3.2 189 500 69 000 258 500 4.0 4.0 1 652 000 1 910 500 1 3.3 Essential drugs Total section 3.3 115 000 114 000 229 000 2.0 1.0 413 000 642 000 3.4 Quality of care and health technology Total section 3.4 176 200 54 000 230 200 2.0 2.0 , 765 000 995 200 1 T O T A L S E C T IO N 3j 1 222 700 802 000 2 024 700 13.0 10.0! 4 703 0001 6 727 700 | 4. P R O M O T IO N A ND P R O T E C T IO N O F H E A L T H 4.1 j Reproductive, family and community health land population issues 1 Total section 4.1 536 000 267 000 803 000 2.0 1.5 785 000 1 688 000 1 4.2 Healthy behaviour and mental health Total section 4.2 558 600 227 700 786 300 5.0 3.0 1 841 000 2 627 300 4.3 Nutrition, food security and safety Total section 4.3 130 400 42 000 172 400 1.0 1.0 433 000 605 400 4.4 Environmental health Total section 4.4 840 000 333 000 1 173 000 7.0 6.5 2 892 000 4 065 000 T O T A L S E C TIO N 2 065 000 869 700 2 934 700 15.0 12.0 5 951 000 8 885 700 5. INTEGRATED C O N T R O L O F DISEASE 5.1 Eradication/elimination of specific communicable diseases Total section 5.1 90 000 20 000 110 000 110 000 S.2 Control of other communicable diseases Total section 5.2 196 900 377 000 673 900 4.6 2.5 1 676 000 2 249 900 5.3 Control of noncommunicable diseases Total section 5.3 243 800 192 300 436 100 1.0 1.0 433 000 869 100 T O T A L S E C T IO N 5 530 700 589 300 1 120 000 6.5 3.5 2 109 000 3 229 000 6. A D M IN IS T R A T IV E SER VIC ES 6.1 Personnel (■>) Total section 6.1 218 000 218 000 1.0 8.0 1 205 000 1 423 000 6.2 General administration (4) Total section 6.2 64 000 2 956 500 3 010 600 3.0 24.0 3 863 000 6 873 500 6.3 | Budget and finance (4) ! Total section 6.3 58 000 58 000 3.0 11.0 2 071 000 2 129 000 1 T O T A L S E C T IO N 6 54 000 3 232 600 3 286 500 7.0 43.0 7 139 000 10 425 500 G R A N D T O T A L 6 049 400 5 285 000 6 421 600 16 756 000 68.0 109.0132 734 0001 49 490 000 Notes: 1. The total proposed programme budget for 2000-2001 has been reduced by US S333 000 from the approved level for 1998-1999 as a result o f the reallocation of 1 professional post to headquarters. 2. The total number of professional and general service posts has been decreased from 183.5 to 177 as a result o f the reallocation o f 1 professional post to headquarters and implementation o f “efficiency shifts” from administrative services to technical programmes. EUR/RC48/8 page 15 Table 2. Proposed program m e budget 2000-2001 Share o f budget by m ajor programme PB 1998-1999____________________________________________________ 1996-1997 Expenditures_________ Total ________ S t a f f s ________ Total Total 1CP (3)_______ CP Regional (3) programme P GS_______ $__________ $ (I)_______ IC P (3)_______ CP Regional (3) programme 15 000 516 400 631 400 1.0 285 200 816 600 8 734 476 445 485 179 I 1 364 000 1 098 500 2 462 500 8.0 9.5 3 804 600 6 267 000 636 370 448 944 1 085 314 275 000! 305 000 5 000 585 000 2.0 2.0 818 500 1 403 600 427 536 31 265 458 801 207 000 2 172 000 210 000 2 589 000 6.0 8.0 2 159 600 4 748 600 371 300 3 054 282 3 425 582 347 600 191 400 410 000 949 000 13.5 21.5 6 366 800 7 315 800 375 100 166 740 354 408 896 248 2 193 600 2 668 400 1 723 500 6 585 500 28.5 41.0 13 149 400 19 734 900 1 810 306 3 252 287 803 352 6 865 945 723 000 571 000 40 000 1 334 000 5.0 3.0 1 923 900 3 257 900 691 445 462 423 1 153 868 25 000' 105 000 11 000 141 000 4.0 5.0 1 506 300 1 647 300 230 911 126 348 357 259 110 000 94 000 5 000 209 000 1.0 1.0 417 100 626 100 191 065 103 374 294 439 160 000 70 000 5 000 235 000 2.0 2.0 846 700 1 081 700 176 357 63 055 239 412 1 018 0001 840 000 61 000 1 919 000 12.0 11.0 4 694 000 6 613 000 1 289 778 755 200 2 044 978 643 400 172 500 8 000 823 900 1.0 1.6 488 200 1 312100 311 401 177 196 488 697 463 300 376 700 15 000 855 000 4.0 3.0 1 555 500 2 410 600 686 516 206 288 9 876 902 680 139 000 251 900 5 000 395 900 1.0 1.0 422 600 818 500 194 813 43 024 237 837 695 000 401 000 60 000 1 146 000 7.0 6.6 2 931 700 4 077 700 969 148 310 236 1 279 384 1 940 700 1 202 100 78 000 3 220 800 13.0 12.0 5 398 000 8 618 800 2 161 878 736 744 9 876 2 908 498 100 000 100 000 10 600 210 600 210 500 91 691 91 591 272 900 334 400 36 000 643 300 3.0 2.0 1 274 800 1 918 100 702 433 331 730 1 034 163 260 000 140 000 5 000 405 000 2.0 1.0 421 000 826 000 236 716 179 869 416 685 632 900! 574 400 51 500 1 258 800 5.0 3.0 1 695 800 2 954 600 1 030 740 611 599 1 642 339 6 000 6 000 1.0 8.0 1 213 800 1 219 800 4 516 4 515 65 000 3 372 800 3 437 800 3.0 30.0 4187 800 7 625 600 84 010 4 681 646 4 765 656 15 000 5 000 20 000 3.0 12.0 2 219 700 2 239 700 8 632 4 689 13 321 80 000 3 383 800 3 463 800 7.0 50.0 7 621 300 11 085100 92 642 4 690 850 4 783 492 5 880 200! 5 284 9001 5 814 200! 16 979 300! 66.5 117.01 32 843 700 49 823 000 6 394 078 6 255 830 6 980 523! 17 630 431 3. Duty travel was previously included entirely under “regional” activities. For 2000-2001 duty travel provision has been reclassified into intercountry and regional based on the programme area 4. Some activities previously included under General administration (6.2) have been reclassified, resulting in an increase in Personnel (6.1) and Budget and finance (6.2). Share of budget by specific programme 50 00 Table 3. Proposed programme budget 2000/2001 ** o GPW PB 2000-2001 PB 1998-1999 No Area Programme title IC P (3) CP Total Staff Total Regional (3) programme P GS $ 9(1) Total Staff (2) Total IC P (3) CP Regional (3) programme P GS $ 9(1) I 1. GOVERNING BODIES 1.1.2 Global Governing Bodies and External Relations 1.1.3 Regional Committee 524 400 524 400 1.0 291 000 815 400 15 000 516 400 531 400 1.0 285 200 816 600 TO TAL SECTION 1 524 400 524 400 1.0 291 000 815 400 15 000 516 400 531 400 1.0 285 200 816 600 2. HEALTH POLICY AND MANAGEMENT 2.1 General programme development and management 2.1.1 Executive management 235 700 235 700 1.0 1.0 484 000 719 700 145 000 145 000 2.0 1.0 822 600 967 600 2.1.2 Managerial process for WHO's programme development 266 000 200 000 466 000 2.0 5.0 1 234 000 1 700 000 265 000 147 500 412 500 2.0 4.5 1 434 900 1 847 400 2.1.3 Management and support to information systems 54 000 80S 000 862 000 3.0 3.0 1 105 000 1 967 000 7 000 800 000 807 000 3.0 3.0 1 130 800 1 937 800 2.1.4 Regional Director's Development Programme 900 000 900 000 900 000 936 000 936 000 936 000 2.1.5 Coordination with other organizations. Mobilization of external health resources 160 000 160 000 2.0 1.0 704 000 864 000 156 000 6 000 162 000 1.0 1.0 416 200 578 200 Total section 2.1 1 380 000 1 243 700 2 623 700 8.0 10.0 3 527 000 6150 700 1 364 000 1 098 500 2 462 500 8.0 9.5 3 804 500 S 267 000 2.2 Health, science and public policy 2.2.1 Health in socioeconomic development 245 500 357 000 602 500 2.0 2.0 836 000 1 438 500 275 000 305 000 5 000 585 000 2.0 2.0 818 500 1 403 500 2.2.2 Research policy and strategy coordination Total section 2.2 245 500 357 000 602 500 2.0 2.0 836 000 1 438 500 275 000 305 000 5 000 585 000 2.0 2.0 818 500 1 403 500 Table 3. Proposed programme budget 2000/2001 Share of budget by specific programme GPW PB 2000-2001 PB 1998-1999 Area Total Staff Total Total Staff (2) Total No Programme title ICP (3) CP Regional (3) programme P GS i t ( V IC P (3) CP Regional (3) programme P GS $ i d ) I I I 2.3 National health policies and programme development and management 2.3.1 Technical cooperation with countries 101 000 2 495 000 2 596 000 3.0 4.0 1 413 000 4 009 000 52 000 2 172 000 210 000 2 434 000 4.0 4.0 1 360 000 3 794 000 2.3.2 Collaboration with countries and peoples in greatest need 2.3.3 Procurement services (excluding drugs, biologicals and contraceptives) 2.0 244 000 244 000 2.0 244 200 244 200 2.3.4 Emergency & humanitarian action; relief & rehabilitation operation & emergency preparedness programmes 134 000 134 000 1.0 3.0 657 000 791 000 155 000 155 000 1.0 2.0 555 400 710 400 Total section 2J 235 000 2 495 000 2 730 000 4.0 9.0 2 314 000 5 044 000 207 000 2172 000 210 000 2 589 000 5.0 8.0 2159 600 4 748 600 2.4 Biomedical and health information and trends 2.4.1 Epidemiology, statistics, trend assessment and country health information 258 000 172 000 430 000 3.0 4.0 1 361 000 1 791 000 243 600 191 400 5 000 440 000 3.0 4.0 1 391 100 1 831 100 2.4.2 Publishing, language and library services 58 500 421 000 479 500 9.5 15.5 4 503 000 4 982 500 104 000 405 000 509 000 10.5 17.5 4 975 700 5 484 700 Total section 2.4 316 500 172 000 421 000 909 500 12.5 19.5 5 864 000 6 773 500 347 600 191 400 410 000 949 000 13.5 21.5 6 366 800 7 315 800 TOTAL SECTION 2 2 177 000 3 024 000 1 664 700 6 865 700 26.5 40.5 12 541 000 19 406 700 2193 600 2 668 400 1 723 500 6 585 500 28.5 41.0 13149 400 19 734 900 3. HEALTH SERVICES DEVELOPMENT 3.1 Organization and management of health systems based on primary health care 3.1.1 Health systems research and development 31 500 31 500 31 500 90 000 16 000 106 000 106 000 tn c 'O OO Table 3. Proposed programme budget 2000/2001 Share of budget by specific programme GPW Area No Programme title PB 2000-2001 PB 1998-1999 Total Staff Total ICP (3) CP Regional (3) programme P GS i $ (V Total Staff (2) Total IC P (3) CP Regional (3) programme P GS $ $ (1) 3.1.2 National health systems and policies 375 300 415 000 790 300 3.0 2.0 1 169 000 1 959 300 478 000 435 000 35 000 948 000 3.0 2.0 1 170 000 2 118 000 3.1.3 District health systems 335 200 150 000 485 200 2.0 1.0 704 000 1 189 200 155 000 120 000 5 000 280 000 2.0 1.0 753 900 1 033 900 Total section 3.1 742 000 565 000 1 307 000 5.0 3.0 1 873 000 3 180 000 723 000 571 000 40 000 1 334 000 5.0 3.0 1 923 900 3 257 900 3.2 Human resources for health 3.2.1 Human resources for health 189 500 64 000 253 500 4.0 2.0 1 408 000 1 661 500 25 000 105 000 11 000 141 000 4.0 2.0 1 140 000 1 281 000 3.2.2 Fellowships 5 000 5 000 0.0 2.0 244 000 249 000 3.0 366 300 366 300 Total section 3.2 189 500 69 000 258 500 4.0 4.0 1 652 000 1 910 500 25 000 105 000 11 000 141 000 4.0 5.0 1 506 300 1 647 300 1 3.3 Essential drugs 3.3.1 Action programme on essential drugs 115 000 114 000 229 000 2.0 1.0 413 000 642 000 110 000 94 000 5 000 209 000 1.0 1.0 417 100 626 100 3.3.2 Procurement of drugs, biologicals and contraceptives Total section 3J 115 000 114 000 229 000 2.0 1.0 413 000 642 000 110 000 94 000 5 000 209 000 1.0 1.0 417 10Q 626 100 3.4 Quality of care and health technology 3.4.1 Technology for health care 176 200 54 000 230 200 2.0 2.0 765 000 995 200 160 000 70 000 5 000 235 000 2.0 2.0 846 700 1 081 700 3.4.2 Drugs and biologicals, quality, safety and efficacy 3.4.3 Traditional medicine Total section 3.4 176 200 54 000 230 200 2.0 2.0 765 000 995 200 160 000 70 000 5 000 235 000 2.0 2.0 846 700 1 081 700 TOTAL SECTION 3 1 222 700 802 000 2 024 700 13.0 10.0 4 703 000 6 727 700 1 018 000 840 000 61 000 1 919 000 12.0 11.0 4 694 000 6 613 000 4. PROMOTION AND PROTECTION OF HEALTH 4.1 Reproductive, family and community health and population issues 4.1.1 Reproductive health 89 000 90 000 179 000 1.0 0.5 372 000 551 000 16 000 5 000 21 000 0.5 69 200 90 200 4.1.2 Child health 207 500 135 000 342 500 1.0 1.0 413 000 755 500 89 000 45 000 3 000 137 000 1.0 1.0 419 000 556 000 4.1.3 Adolescent health 18 000 26 000 44 000 44 000 30 000 10 500 40 500 40 500 4.1.4 Women's health 99 000 11 000 110 000 110 000 458 400 100 000 558 400 558 400 4.1.5 Aging and health 5 000 5 000 5 000 Table 3. Proposed programme budget 2000/2001 Share of budget by specific programme GPW Area No Programme title PB 2000-2001 PB 1998-1999 Total Staff Total IC P p ; CP Regional (3) programme P GS $ t ( V Total Staff (2) Total IC P (3) CP Regional (3) programme P GS $ $ (V 4.1.6 Special programme of research, development and research training in human reproduction 4.1.7 Occupational health 122 500 122 500 122 500 50 000 17 000 67 000 67 000 Total section 4.1 536 000 267 000 803 000 2.0 1.5 785 000 1 588 000 643 400 172 500 8 000 823 900 1.0 1.5 488 200 1 312100 4.2 Healthy behaviour and mental health 4.2.1 Mental health 143 000 15 000 158 000 1.0 291 000 449 000 115 300 47 000 162 300 162 300 4.2.2 Substance abuse including alcohol and tobacco 172 600 137 400 310 000 2.0 1.0 724 000 1 034 000 165 000 35 000 7 000 207 000 2.0 1.0 724 200 931 200 4.2.3 Health promotion 208 000 67 300 275 300 1.0 1.0 413 000 688 300 125 000 170 000 5 000 300 000 1.0 1.0 414 500 714 500 4.2.4 Communications and public relations 35 000 8 000 43 000 1.0 1.0 413 000 456 000 58 000 3 000 61 000 1.0 1.0 416 800 477 800 4.2.5 Rehabilitation 124 700 124 700 124 700 Total section 4.2 558 600 227 700 786 300 5.0 3.0 1 841 000 2 627 300 463 300 376 700 15 000 855 000 4.0 3.0 1 555 500 2 410 500 4 J Nutrition, food security and safety 4.3.1 Nutrition 85 400 42 000 127 400 1.0 1.0 433 000 560 400 39 000 240 000 5 000 284 000 1.0 1.0 422 600 706 600 4.3.2 Food safety 45 000 45 000 45 000 100 000 11 900 111 900 111 900 4.3.3 Food aid Total section 4.3 130 400 42 000 172 400 1.0 1.0 433 000 605 400 139 000 251 900 5 000 395 900 1.0 1.0 422 600 818 500 4.4 Environmental health 4.4.1 Water supply and sanitation in human settlements 49 500 70 000 119 500 20 000 139 500 60 000 47 000 107 000 107 000 4.4.2 Environmental health in urban development 390 500 37 000 427 500 2.0 2.0 826 000 1 253 500 180 000 55 000 5 000 240 000 2.0 2.0 845 000 1 085 000 4.4.3 Assessment of environmental health hazards 87 000 38 500 125 500 3.0 2.5 1 178 000 1 303 500 125 000 119 000 5 000 249 000 3.0 2.5 1 183 700 1 432 700 4.4.4 Promotion of chemical safety m C VO oo •o mU3 o q b :fD W © ^ Table 3. Proposed programme budget 2000/2001 2 Share of budget by specific programme So GPW PB 2000-2001 PB 1998-1999 Area Total Staff Total Total Staff (2) Total No Programme title ICP (3) CP Regional (1) programme P GS $ i ( V IC P (3) CP Regional (3) programme P GS $ t(1 ) 4.4.5 Incorporation of health concerns into environmental management 313 000 187 500 500 500 2 0 2.0 868 000 1 368 500 330 000 180 000 40 000 550 000 2.0 2.0 903 000 1 453 000 Total section 4.4 840 000 333 000 1 173 000 7.0 6.5 2 892 000 4 065 000 695 000 401 000 50 000 1 146 000 7.0 6.5 2 931 700 4 077 700 TOTAL SECTION 4 2 065 000 869 700 2 934 700 15.0 12.0 5 951 000 8 885 700 1 940 700 1 202 100 78 000 3 220 800 13.0 12.0 5 398 000 8 618 800 | S. INTEGRATED CONTROL OF DISEASES 5.1. Eradication/elimination of specific communicable diseases 5.1.1 Global eradication or elimination 90 000 20 000 110 000 110 000 100 000 100 000 5.1.2 Regional eradication and elimination 100 000 10 500 110 500 110 500 Total section 5.1 90 000 20 000 110 000 110 000 100 000 100 000 10 500 210 500 210 500 5.2. Control of other communicable diseases 5.2.1 Vaccine-preventable diseases 63 900 127 000 190 900 2.0 1.5 785 000 975 900 110 000 91 400 6 000 207 400 1.0 1.0 524 000 731 400 5.2.2 Diarrhoeal and acute respiratory disease control 27 000 17 500 44 500 44 500 10 900 20 000 30 900 30 900 5.2.3 Tuberculosis 27 000 105 500 132 500 132 500 10 600 23 000 33 600 33 600 5.2.4 Emerging diseases including cholera and other epidemic diarrhoeas, zoonoses and antimicrobial resistance 36 000 37 000 73 000 73 000 56 400 90 000 146 400 146 400 5.2.5 Other communicable diseases 43 000 90 000 133 000 2.5 1.0 891 000 1 024 000 85 000 110 000 30 000 225 000 2.0 1.0 750 800 975 800 5.2.6 Control of tropical diseases 5.2.7 Special programme for research and training in tropical diseases T otal section 5.2 196 900 377 000 573 900 4.5 2.5 1 676 000 2 249 900 272 900 334 400 36 000 643 300 3.0 2.0 1 274 800 1 918100 Table 3. Proposed programme budget 2000/2001 Share of budget by specific programme GPW Area No Programme title PB 2000-2001 PB 1998-1999 Total Staff Total ICP (3) CP Regional (3) programme P GS $ * (1) Total Staff (2) Total IC P (3) CP Regional (3) programme P GS $ i (V I 5.3. Control of noncommunicable diseases 5.3.1 Control of noncommunicable diseases 243 800 192 300 436 100 1.0 1.0 433 000 869 100 260 000 140 000 5 000 405 000 2.0 1.0 421 000 826 000 5.3.2 IARC Total section 5.3 243 800 192 300 436 100 1.0 1.0 433 000 869 100 260 000 140 000 5 000 405 000 2.0 1.0 421 000 826 000 TOTAL SECTION 5 530 700 589 300 1 120 000 5.5 3.5 2 109 000 3 229 000 632 900 574 400 51 500 1 258 800 5.0 3.0 1 695 800 2 954 600 6. ADMINISTRATIVE SERVICES 6.1 Personnel (4) 6.1.1 Personnel services and administration 218 000 218 000 1.0 8.0 1 205 000 1 423 000 6 000 6 000 1.0 8.0 1 213 800 1 219 800 Total section 6.1 218 000 218 000 1.0 8.0 1 205 000 1 423 000 6 000 6 000 1.0 8.0 1 213 800 1 219 800 6.2. General administration (4) 6.2.1 Administrative support to technical programmes w 54 000 2 956 500 3 010 500 3.0 24.0 3 863 000 6 873 500 65 000 3 372 800 3 437 800 3.0 30.0 4 187 800 7 625 600 total section 6.2 54 000 2 956 500 3 010 500 3.0 24.0 3 863 000 6 873 500 65 000 3 372 800 3 437 800 3.0 30.0 4 18 7 800 7 625 600 63. Budget and finance (4) 6.3.1 Budget and finance 58 000 58 000 3.0 11.0 2 071 000 2 129 000 15 000 5 000 20 000 3.0 12.0 2 219 700 2 239 700 Total section 6.3 58 000 58 000 3.0 11.0 2 071 000 2129 000 15 000 5 000 20 000 3.0 12.0 2 219 700 2 239 700 TO TAL SECTION 6 54 000 3 232 500 3 286 500 7.0 43.0 7 139 000 10 425 500 80 000 3 383 800 3 463 800 7.0 50.0 7 621 300 11 085100 GRAND TOTAL 6 049 400 5 285 000 5 421 600 16 756 000 68.0 109.0 32 734 000 49 490 000 5 880 200 5 284 900 5 814 200 16 979 300 66.5 117.0 32 843 700 49 823 000 1. The total proposed programme budget for 2000-2001 has been reduced by $333,000 from the approved level for 1998-1999 as a result o f the reallocation o f 1 professional post to headquarters. 2. The total number o f professional and general service posts has been decreased from 183.5 to 177 as a result o f the reallocation o f 1 professional post to headquarters and implementation o f "efficiency shifts" from administrative services to technical programmes. 3. Duty travel was previously included entirely under “regional” activities. For 2000-2001 duty travel provision has been reclassified into intercountry and regional based on the programme area. 4. Some activities previously included under General administration (6.2) have been reclassified, resulting in an increase in Personnel (6.1) and Budget and Finance (6.2). EUR/RC48/8 page 2 2 EUR/RC48/8 page 23 1. GOVERNING BODIES Policy orientation and strategic priorities According to the WHO Constitution, the Health Assembly is the highest legislative and policy organ of WHO. It determines the Organization’s policies, gives directives to the Executive Board and the Director- General, and monitors and evaluates the implementation o f policies. In accordance with Article 28 o f the WHO Constitution, the Executive Board will act as the executive organ o f the Health Assembly to give effect to the decisions and policies of that body. On the regional level, and in accordance with Article 50 o f the Constitution, the Regional Committee will formulate policies o f a regional character and will supervise the activities o f the Office, monitor and evaluate the way in which resolutions o f the Assembly and the Board are being implemented, and provide information on its findings to the Board. As far as strategic priorities are concerned, a major policy review was undertaken in 1993 by the Executive Board through its Working Group on the WHO Response to Global Change. The Regional Office has worked intensively to implement and follow up all the forty-seven recommendations made by the Executive Board Working Group, and a comprehensive status report on the implementation was provided to the Regional Committee at its forty-seventh session in September 1997. Implementation of those recommendations will continue to affect the interface between the Regional Office and its governing bodies in the biennium 2 0 0 0 - 2 0 0 1 . Another major policy initiative by the governing bodies o f the European Region concerns the repeated call by the Regional Committee for a higher percentage allocation of the Organization’s global regular budget, as expressed through successive resolutions culminating with resolution EUR/RC47/R3 of September 1997. Following extensive debate on this issue by the Executive Board’s Special Group on the Review o f the Constitution and Regional Arrangements, the Board adopted resolution EB101.R10 on the subject in January 1998. The latter was subsequently endorsed by the World Health Assembly in resolution WHA51.31. EUR/RC48/8 page 24 1.1 G o v e r n in g b o d ie s Regional situation and targets In addition to the mandate o f the Regional Committee outlined above, it also has an important role to play in carrying out such functions as may be delegated to it by the Health Assembly, the Executive Board or, indeed, the Director-General. The Regional Committee advises the Regional Director on regional matters and, through the Director-General, tenders advice to the Organization as a whole on international matters that have wider than regional significance. Thus, in taking an active part in the work of the Organization as a whole, it will submit to the Executive Board its recommendations and concrete proposals on matters o f both regional and global interest. In order to strengthen the links between the Regional Committee and the Secretariat, the SCRC was established in 1993, with a basic mandate to act for and represent the Regional Committee, and to counsel the Regional Director as and when appropriate, between sessions o f the Regional Committee. It is beyond doubt that the formal sessions o f the Standing Committee, convened four to five times per year, have been instrumental in fostering a much closer relationship between the M ember States and the Regional Office staff, giving better effect to decisions and policies o f the Regional Committee and guiding the work o f the Regional Office. Evaluation - main achievements and constraints As part o f the work o f the Special Group for the Review o f the Constitution o f WHO, the Regional Office prepared a paper on the Mission and functions o f regional committees -frequency o f regional committee sessions. The paper reviewed the functions o f regional committees as set out in Article 50 o f the Constitution and recalled Health Assembly resolution WHA33.17, adopted in May 1980, which listed eight specific additional functions which the Health Assembly urged the regional committees to take on. At its 101st session in January 1998, the Executive Board welcomed and endorsed that paper. The Board also considered the pros and cons o f annual versus biennial meetings o f regional committees and confirmed its recommendation to the World Health Assembly that sessions of regional committees should continue to be annual. Proposed resources by source of funds: 1.1 Governing Bodies Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources8 Regular Budget Other Sources3 Regular Budget Other Sources3 Intercountry - 15 000 Country - - Regional 524 400 250 000 516 400 246 000 485 179 175 800 Total: 1.1 524 400 250 000 531 400 246 000 485 179 175 800 Amounts to be received from countries hosting sessions of the Regional Committee. EUR/RC48/8 page 25 Budgetary comments and trends The SCRC, at its meeting in Istanbul in September 1997, was presented with a detailed analysis o f the costs o f holding meetings o f the governing bodies in the European Region, which showed that (even after many cost-containment measures had been taken) the real costs2 amounted to some 5% of the regular budget allocation for the Region. The SCRC decided that the expenditure incurred represented good value for money. None the less, the quality and length o f documentation for governing bodies, and associated costs, are under continuous review with the aim of achieving savings without prejudicing quality. 1.1.1 R egional com m ittees WHO targets by end 2001 • Efficient organization and conduct o f meetings o f governing bodies through timely preparation and production o f short, readable working papers and reports 2000-2001 Products Projections for 2002-2003 Annual meetings of the Regional Committee for Europe Meetings of other statutory committees, and ad hoc meetings of the Member States in connection with World Health Assemblies Continued 2 Both direct costs budgeted under this programme, as well as all indirect costs incurred in convening meetings of the governing bodies but budgeted under programmes 2.4 and 6.2, i.e. those associated with editorial and translation services, text processing, printing and despatch (for a detailed analysis of direct and indirect costs see document EUR/RC46/SC(5)/6 Cost o f meetings o f the governing bodies). EUR/RC48/8 page 26 2. HEALTH POLICY AND MANAGEMENT Policy orientation and strategic priorities The changes now occurring throughout Europe call for a review o f agendas. The challenge is how to put public health more visibly on the political agenda and promote the notion o f public health as a “common good”. WHO is the only agency in the health field in Europe with the technical background and track record to push for forward-looking policies targeted on equity, improved quality o f life, sound ecology and a continually improving quality o f care. Such revisiting o f European health policy will be carried out in addition to responding to demands from Member States for practical solutions to immediate problems arising in an environment o f crisis. There is strong consensus among decision-makers throughout the Region, in both donor and EUROHEALTH countries, that the long-range regional HFA strategy is the path not only to lead citizens o f central and eastern Europe out of their current predicament in the health sector but also to bring further improvements in health to western Europe. Massive pollution of the environment, unhealthy lifestyles and insufficient resources for health services infrastructure are the underlying causes o f poor health for too many o f Europe’s citizens. The Regional Office will support all countries o f the Region in their health developments but it will give priority to countries most in need. Work will be focused on six specific priorities, adapted to the needs of each individual country (see Introduction). Other important priority areas for the Office will be the new HFA policy, to be adopted by the Regional Committee at its forty-eighth session as the guidance for policy development in countries, the Regional Office’s role as the European health information centre, and the development o f partnerships with other organizations interested in health improvement in Europe. EUR/RC48/8 page 27 EUR/RC48/8 page 28 2.1 G e n e r a l p r o g r a m m e d e v e l o p m e n t a n d m a n a g e m e n t Regional situation and targets By the year 2000, in all Member States, a wide range o f organizations and groups throughout the public, private and voluntary sectors should be actively contributing to the achievement o f health fo r all. The rapid socioeconomic changes in Europe and the increase in health needs call for a quick response by all actors in the health field; this in turn entails planning and managing EURO’s resources in a flexible way, including evaluation o f programme implementation, and ensuring cost-effective and efficient delivery o f programmes, among other things by streamlining management processes and making full use of modern computer technology. W H O ’s role The Regional Office’s organizational developm ent strategy aims to ensure programme s ta ffs full participation in and ownership o f programme activities through more decentralization o f decision­ making. Management will foster communication, teamwork, a shared sense o f purpose and flexibility. Continuous efforts are being made to improve management procedures and to introduce new tools for promoting managerial efficiency. The S taff Development and Training program m e will continue to reinforce people’s skills and fill in gaps in their knowledge and ability, so that fixed-term personnel and the increasing number o f short-term and outposted staff, both national and international, can perform effectively in their assigned tasks. Areas to which particular attention will be paid include computer and language training; on-entry and continuing briefing on WHO policies and procedures; consultative and interpersonal skills; management skills, and effective communication. As part o f the staff development process, updating people’s technical capacities will also be a priority. This will be done through planned work assignments, job exchanges and releases for study purposes, and extension o f the international health training programme started in 1998-1999. A key activity in 2000-2001 will be the submission o f the 2002-2003 program m e budget to the Regional Committee. Efforts to improve an understanding o f the use o f the GPW structure in strategic budgeting will continue. Other activities will include evaluation and operational planning. Since W HO’s new Activity Management System (AMS) for computerized programme management information will be fully implemented as from 2 0 0 0 , the necessary support will be provided to technical staff during the transition. In health inform atics, telemedicine and telecom m unications, the opportunities for global connectivity and widespread use of globally distributed knowledge have never been greater. The challenge is to ensure the local adaptability and application o f such global knowledge and information. Three main categories of applications include: • systems that provide electronic communications and advanced support for management and administrative purposes, as well as a flow of technical data; • applications and information services for professionals and the general public which offer access to data and knowledge bases, e.g. the World Wide Web and the Internet; • applications oriented towards communications support for health care tasks and clinical activities, including telemedicine. One o f the paramount aims o f the policy for health informatics and health telematics within the HFA framework is to use information and education as a tool to enable people to improve and maintain their own health. Health telematics should strengthen the capacities o f all relevant health care providers and EUR/RC48/8 page 29 permit them to network in a cooperative way. This includes the long-distance provision o f information and advice on health care by health professionals in different institutions. The Regional D irector’s Development Program m e will be used to ensure flexibility in programme implementation, in order to respond to a continuously changing European environment. In this respect, the enhancement of cooperation with countries most in need in the Region remains a high priority (resolution EUR/RC40/R8). The Regional Director will also continue to use the Programme as a contingency fund for tackling emerging priorities or emergencies. In 1996-1997 an Office-wide strategy for resource m obilization was implemented, based on clearly expressed goals and objectives. The Regional Office will capitalize on the successes of this strategy and the wealth o f experience and skills it has available to strengthen its capacity for coordination, monitoring and delivery o f support and for focusing efforts more sharply on priority areas defined by Member States. The Regional Office will seek partnership agreements with key organizations interested in health, both at regional level and in countries (with the latter facilitated by the integrated United Nations approach). As the lead agency for health matters in both development and humanitarian assistance programmes, WHO has long cooperated with other parts of the United Nations system. This approach will be intensified in the context o f the United Nations reform process and will be increasingly concentrated on unified country programmes and activities. To play its role as lead agency in the field of health, the Regional Office will continue to build and expand partnerships and networks within the context o f the regional HFA policy. High priority will be given to developing collaboration with the European Commission (EC), the Council o f Europe (CE) and the World Bank, seeking to extend this from an individual, project-by-project basis to more systematic programmatic and policy development. To this end, strategies for cooperation will be developed and applied, focusing on increasingly collaborative project identification, development and implementation. With the EC in particular, joint work will take account o f the context of their developing public health competence. To respond to the changing situation in the Region, efforts are also being directed towards those actors outside the health sector whose decisions have a major impact on health. The groups particularly aimed at are public health leaders, parliamentarians and professional associations. Other target groups include health care financing experts, consumer organizations, nongovernmental organizations and self-help groups. Closer collaboration at subnational level will be sought through the Centre for Urban Health, the Regions for Health Network, the new Healthy Company network, other European networks and the EC’s Regional Development Fund. In CCEE/NIS, it is essential for the various agencies of the United Nations system to work closely and create synergy. This has not always been the case, however. None the less, there is already good cooperation with UNDP in Kyrgyzstan, Turkmenistan and Uzbekistan, and WHO has been involved in the coordination o f United Nations activities in Kazakhstan. A collaboration agreement was signed with the World Bank in Turkmenistan. Close cooperation has been established with the Know-How Fund in a number o f projects. WHO has also worked together with the Danish International Development Agency (DANIDA) and the Swiss Federal Office for Foreign Economic Affairs (FOFEA) on several projects. The UNDAF pilot projects in Romania and Turkey may be expanded to other countries in 2000-2001, if the outcome o f these two projects is encouraging. Evaluation - main achievements and constraints Regular internal reviews to monitor progress and evaluate programme implementation have ensured accountability. As agreed with the SCRC, a selected programme is reviewed each year by external evaluators, while regional evaluation o f all programmes is done through an internal mechanism at the end of each biennium. EUR/RC48/8 page 30 In the interests o f cost-effectiveness and consumer satisfaction, EURO has decided to integrate staff posts for the coordination o f technical database development and continued maintenance. The telecommunications link with Member States o f the Region, particularly those in eastern Europe and central Asia, is vitally important in terms o f speed and cost. During the biennium 1998-1999, automated systems were developed and introduced, both in the Administration and Office-wide, to offset the lack of human resources and reduce the amount of staff time spent on routine, repetitive tasks. Outposted offices were given access to all the information available on the Regional Office’s local area network (LAN) by means o f new technologies. During 1996-1998 (and continuing into 1999), extensive use was and is being made o f netw orks such as CINDI, Healthy Cities, Health Promoting Schools, the European Forum of Medical Associations, the European Forum of Pharmaceutical Associations, central and eastern European countries (MIDNET, SOUTHNET and EASTNET), central Asian republics (CARNET) and Regions for Health. The strategy of using national, subnational, local and area-specific networks to promote and disseminate WHO products is considered to be a very cost-effective method of reaching a large audience, stimulating and catalysing HFA-oriented work at many levels throughout the Region. This strategy will be further pursued in 2000-2001, when a new Healthy Company network is also expected to be functioning. Such networks should gradually move towards being self-financing. Collaboration with the CE and EC intensified, notably in the areas o f emergency response, health- promoting schools, information, and environmental action. The World Bank also collaborated on several projects such as participation in the European Environment and Health Committee, the MANAS health care reform project in Kyrgyzstan, the financing and development o f regional health care waste treatment facilities across Romania, the Observatory on Health Care Systems and Reform project, and a public health advisory project in Hungary. Annual meetings o f the various professional fora (the EuroPharm Forum, the European Forum of Medical Associations and the European Forum o f National Nursing and Midwifery Associations and WHO) have proved successful and will continue to be organized. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium To strengthen interdepartmental collaboration in EURO, four cross-departmental projects are being established, on urban health, primary health care, health and work, and a healthy start in life. The intention is to develop a broader, more integrated Office-wide effort, incorporating strategic collaboration with key partners. Strategies are being developed for collaboration with the European Union, the World Bank and nongovernmental organizations (NGOs), building on already successful collaboration with the technical units and programmes. Partnerships to support HFA will be promoted, with the objective of intensifying collaboration within a more structured and sustained policy context. Efforts will be made to increase the Office’s capability to develop and deliver attractive and consistent products in the context o f resource mobilization. More briefing and tra in ing is required to fill the gap created by the abolition of senior administrative posts in technical departments and to meet the needs o f the growing body o f short-term staff. EURO was the first Region to move from a majority o f fixed-term to a majority o f short-term staff. EUR/RC48/8 page 31 Proposed resources by source of funds: 2.1 General programme development and management Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources® Regular Budget Other Sources8 Regular Budget Other Sources3 Intercountry 1 380 000 1 364 000 636 370 - Country - - Regional 1 243 700a 300 000 1 098 500a 894 900 448 944 10 393 Total: 2.1 2 623 700 300 000 2 462 500 894 900 1 085 314 10 393 * Includes the Regional Director’s Development Programme. Budgetary comments and trends Targeted public information has been instrumental in raising funds for humanitarian assistance and immunization campaigns. The amount o f voluntary funds in 1996-1997 was nearly equal to the level of regular budget funds. It is anticipated that this balance will remain more or less the same in 2000-2001. 2.1.1 E xecutive M anagem ent WHO targets by end 2001 • Effective leadership will have been provided to control the process o f reform and to prepare fo r implementation o f the GPW 2000-2001 Products Projections for 2002-2003 Policy development Review o f regional priorities Transparent management, budget and financial information for Member States Strengthen collaboration with Member States Global/regional reform General management and supervision o f Regional Office 2.1.2 M anagerial process for W H O ’s program m e developm ent WHO targets by end 2001 • S ta ff time monitoring developed • Timely reports and analyses o f implementation o f the regional programme • Timely production and Regional Committee endorsement o f the programme budget • Cost-efficient management o f resources • Comprehensive briefing on WHO policies and practices fo r all newly recruited sta ff Continued Continued Continued Continued Continued EUR/RC48/8 page 32 2000-2001 Products Projections for 2002-2003 Strategic programme budget 2002-2003 developed on the basis o f the Programme Budget Tenth General Programme o f Work 2004-2005 Operational plans, 2002-2003 Biennial evaluation, 2001 Biennial evaluation, 2003 Implementation o f WHO activity management system (WHO/AMS) Further refinement in EURO Regional Director’s biennial report and an information document in Report on 2000-2001 2000 on work done in 1998-1999 A staff development and training programme with special focus on Continued enhancing communication skills, including language acquisition, PC updating, project management and interpersonal skills 2.1.3 M a n ag e m en t a n d s u p p o r t to in fo rm a tio n system s WHO targets by end 2001 • Provide health information to Member States fo r planning and monitoring • Information exchange, interactive use o f databases fo r continuous quality o f care development 2000-2001 Products Projections for 2002-2003 Updates of HFA policy database Internet enabling o f EURO’s databases Communicable Diseases and Immunization database Telematics Informatics support Informatics support Support to AMS implementation Continued 2.1.4 R eg ional D ire c to r ’s D evelopm en t P ro g ra m m e WHO targets by end 2001 • Systematic criteria used in disbursement o f funds 2000-2001 Products Projections for 2002-2003 Allocation of Regional Director’s development funds to technical Continued priorities and emerging developments, supporting flexibility in shifting priorities within the approved programme Rapid and effective response to emergencies Continued EUR/RC48/8 page 33 2.1.5 C oordination w ith other organizations. M obilization o f external health resources WHO targets by end 2001 • Increase in number o f formal agreements with key partners • 25% increase in volume o f resources mobilized 2000-2001 Products Projections for 2002-2003 Formal agreements with key partners to enable WHO to fulfil its role as a public health leader in support o f HFA Continued Wide range o f partners and projects, with particular emphasis on those of EU Continued Networks o f nongovernmental organizations, in particular national medical, nursing and pharmaceutical associations Continued Cooperation agreements with UNDP: Continuation in Kazakhstan, Continuation in Kazakhstan, Kyrgyzstan and Turkmenistan and start in Tajikistan Kyrgyzstan, Tajikistan, Turkmenistan and start in Azerbaijan and Uzbekistan Cooperation agreements with the World Bank: Continuation of Continuation of cooperation strategic cooperation in Kyrgyzstan and Turkmenistan. Initiation of in Azerbaijan, Kazakhstan, cooperation in Azerbaijan, Kazakhstan, Tajikistan and Uzbekistan Cooperation with United Kingdom Department for International Development (DFID): Continuation o f strategic cooperation in CARNET process Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan Cooperation agreements with the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) Continued Cooperation agreements with the International Federation o f Red Cross and Red Crescent Societies: Continuation o f cooperation in Kazakhstan and Kyrgyzstan, start o f one further country project Continued Private sector: Improvement o f relations and resource mobilization for CARNET and country-specific projects Continuation Resource mobilization for country-specific projects and intercountry projects (CARNET, EASTNET, etc.) (see also 2.3.2) Continuation EUR/RC48/8 page 34 2.2 H e a l t h , s c i e n c e a n d p u b l i c p o l i c y Regional situation and targets By the year 2000, the differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level o f health o f disadvantaged nations and groups. By the year 2000, health research should strengthen the acquisition and application o f knowledge in support o f health fo r all development in all Member States. By the year 2000, all Member States should have developed and be implementing policies in line with the concepts and principles o f the European health fo r all policy, balancing lifestyle, environment and health service concerns. By the year 2000, management structures and processes should exist in all Member States to inspire, guide and coordinate health development, in line with health fo r all principles. By the year 2000, all Member States should have mechanisms in place to strengthen ethical considerations in decisions relating to the health o f individuals, groups and populations. From the launch of the HFA policy, greater equity in health has been the desired outcome of most o f the regional targets. Many o f the socioeconomic policies and health care reforms implemented in many countries in the Region in the late 1990s, however, put the principle o f equity at risk. There was a considerable expansion of research in this area, and a number o f countries, particularly in western Europe, improved their information base to reflect possible inequities. A clearer picture o f the situation has been obtained in about half the Member States, but increasing gaps are being seen both within and between countries. Despite determined efforts by a small number o f countries, there is still very little evaluation of what does or does not work in closing the gaps, and of the impact on equity resulting from changes in health care organization and financing. Changes in global patterns of production and conditions in the labour market and their possible effects on health are giving rise to growing concern. The effects o f increasing numbers o f the very old who need constant care, long-term unemployment and the health situation o f migrants, refugees and ethnic minorities also continue to cause concern. Despite some noteworthy exceptions to achieve greater transparency in decision-making, policy-makers and the public are still not always fully aware o f the ethical issues involved when critical decisions have to be taken. At the same time, technological advances and the vastly expanded availability o f information offer new opportunities to meet the challenges. There is, however, a danger o f creating two-tier societies o f those with access to such technology and those who are excluded from the advances. None the less, some o f the challenges are so acute that people are more disposed to enter into dialogue with other sectors to find common objectives. The health sector will have an important role to play in providing the information and public health expertise necessary to support this dialogue, and in looking for more flexible ways o f meeting the challenges and providing choice for a more selective and demanding public. Countries need to involve the research community in developing strategies and evaluating HFA achievements. The potential that exists in universities and research institutions has not been fully utilized. On the one hand, available scientific knowledge is far too rarely applied in decision-making and, on the other, there is not yet sufficient willingness to listen to the views o f the citizen or consumer. The long term vision o f the H ealth for All policy for Europe needs to be adapted and implemented at all levels o f society. Major components will be values, evidence, targets, strategies, advocacy and EUR/RC48/8 page 35 capacity-building. Especially important is the development and use o f economic arguments, to make non­ health sectors understand the issues and the benefits to be gained. W HO’s role A Regional Committee resolution in 1997 (EUR/RC47/R2) invited all countries to further enhance their own capacities to analyse health-relevant policies and to share their knowledge and expertise, and requested the Regional Director to strengthen capacity to carry out and promote health policy analysis. In accordance with that resolution, the Regional Office, in collaboration with a number of Member States, intends to establish a European Centre for Health Policy Analysis in 1998. Through this initiative, the available information base will be greatly improved, and the groundwork laid for greater collaboration with sectors other than health and with other international organizations, associations and networks to make intersectoral action for health a reality. During 2000-2001, the role o f the Organization as the conscience for equity in health will be strengthened. Stronger links will be forged with other networks, the business community, parliamentarians and local decision-makers to help achieve equity-related targets. Using the expertise built up through the Centre for Health Policy Analysis, direct support will continue to be given to countries for the development o f intersectoral policies for health gain, with emphasis on tackling the causes o f inequities in health. The renewed regional HFA policy presented to the Regional Committee in 1998 provides the framework and fresh impetus for intersectoral action at all levels. Tools are being developed to assess the health impact o f socioeconomic development, and new methods are being worked out to ensure more effective collaboration with other sectors. Synergy is being promoted between WHO networks. The issues related to health ethics have continued to gain prominence in Europe and have led to wide public discussion and debate, pointing to the need for citizen participation and openness. Emphasis is being placed not only on patients’ rights and the ethical aspects of various health care reforms and technologies, but also on broader issues associated with the critical choices to be made. The Declaration on the Promotion o f Patients’ Rights in Europe (Amsterdam 1994) has enhanced the determination in all Member States to work concretely on patients’ rights. It is increasingly evident that economic development and the related public and private policies are fundamental determinants o f a population’s health status. Economic development underlies both disease risks and opportunities for health. A “marriage” o f economics and public health (among other disciplines) is required to bring together evidence o f the impact o f policies on health status. This evidence in turn needs to be used in mobilizing partnerships with industry and public sectors. The European Advisory Committee on Health Research (EACHR) will continue to implement its action plan. This will include promoting a research agenda supportive o f HFA, engaging in dialogue with the scientific community, taking steps to build research capacity in the eastern part o f the Region, and bringing relevant research findings to the attention o f senior decision-makers. U rban health is an area of increasing relevance to the entire European Region. There is no shortage o f studies and reports stressing the growing health challenges in cities related to poverty, violence, social exclusion, pollution, sub-standard housing, the unmet needs o f the old and the young, the poor and migrants, the lack o f participative practices and the need to address inequalities and sustainable development in a serious way. The Healthy Cities project in the European Region has shown the value of a holistic approach to such problems. With ten years’ experience, it has developed the awareness, the political commitment and the know-how to promote innovation and change. Action at the local level is an essential component of national health policies. Furthermore, local governments have a key role in establishing intersectoral partnerships for health and sustainable development. The EURO Centre for Urban Health will develop the tools for implementation o f HFA-based strategies at the city/local level. The priorities for the urban health/healthy cities programme are to attain the goals o f phase III o f the Healthy Cities project (with emphasis on city health development strategies, equity, accountability, urban EUR/RC48/8 page 36 planing, poverty and lifestyles impact assessment); to expand the Healthy Cities programme into all the countries not so far involved (NIS and the Balkan Region); to strengthen and support national networks throughout Europe; and to develop partnerships with other EURO technical programmes for action at the local level, as well as international cooperation with EC and key agencies in the field of urban development. The strategic priorities o f phase III (1998-2002) o f the u rban health/healthy cities program m e cover five main areas: 1 ) development of urban health policy and planning tools; 2 ) networking for innovation and implementation HFA21-based policies at the local level; 3) strengthening the local/urban action dimension in EURO programmes; 4) developing strategic partnerships with international agencies; and 5) resource development and capacity-building for urban health development in the European Region (see section 4.4.2 for milestones and products related to urban health). Evaluation - main achievements and constraints Comparative analysis o f the process o f health policy development in countries indicated that, although commitment to the HFA approach was strengthened towards the end of the 1990s, the types o f policy tools used to implement this approach were still rather traditional. Although the renewal o f the global and regional HFA policies reaffirmed the commitment o f Member States, there was still a need to shift the way in which partnerships with other sectors are built, and to enhance the capacity for working intersectorally. By the end of the 1990s, more than half the Member States had formulated national HFA policies, and many regions and cities had followed suit or, in some cases, were leading the way. There was still a gap between theory and practice, however. Health policy development is a never-ending process. The situation can change as political leaders change, and even with political stability there is a need for constant review. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium Regional networks such as CARNET have been increasingly active in building leadership capacity for health and health policy. Increasing interest in developing policies at subnational level was met through the Regions for Health Network (RHN) and the Healthy Cities project. With greater decentralization in Member States, these and similar networks hold the key to future action. Collaboration with CE and EC will be intensified in the area o f health ethics. Patients’ and consumers organizations are showing great interest in the work done in this area. There is a need to devote sufficient resources to this issue so as to retain WHO leadership. During the period 2000-2001 the urban health/healthy cities programme will place emphasis on: implementing the HFA action plan; strategies for health and sustainable development; policies for equity; healthy lifestyles and prevention of violence; addressing the needs o f migrants and youth; local capacity- building for public health; infrastructures for social support; healthy urban planning; promoting national/local cooperation; developing and consolidating healthy cities networks in eastern Europe; setting up the evaluation process o f phase III; developing systems for monitoring and reporting on urban health conditions; strengthening the resource base; and consolidating the role o f the Urban Health Centre in the European Region (see section 4.4.2 for milestones and products related to urban health). EUR/RC48/8 page 37 Proposed resources by source of funds: 2.2 Health, science and public policy Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 245 500 30 000 275 000 234 000 427 536 160 552 Country 357 000 305 000 31 265 Regional - 5 000 Total: 2.2 602 500 30 000 585 000 234 000 458 801 160 552 2.2.1 H ealth and socioeconom ic developm ent WHO targets by end 2001 • Increase in the number o f Member States developing health policy • Thirty countries with HFA-basedpolicies at national, regional or city level • Thirty-five regions participating in the Regions fo r Health Network (RHN). Adoption o f overall HFA policy models in at least 5 regions, adoption o f regional-level policies fo r tobacco control in at least 5 regions andfor alcohol control in at least 3 regions • Forty WHO project cities to have made significant progress towards implementing integrated health development strategies • Thirty-five countries with national healthy cities networks • Ten institutions/networks linked to the European Centre fo r Health Policy, Analysis (ECHPA) in a "virtual network”fo r HFA • Parliamentarians actively participating in the RHN and several E U parliamentarians collaborating with the ECHPA • Five countries with improved legislation on patients ’ rights • Increase in the number o f CCEE/NIS advocating the HFA policy • Agreement o f EC and CE to the essentials o f the new HFA policy • Mobilization o f a critical mass o f relevant NGOs, networks, countries, regions, cities, professions and sectors fo r strengthening citizens ’ voice and position in health care, both as patients and as “owners ” o f services • Initiation o f dialogue with industry regarding accountability fo r the healthiness o f consumer products 2000-2001 Products Projections for 2002-2003 Public health leadership seminar, 2000, 2001 2002, 2003 Joint policy workshops with major economic organizations (including Continued EC, CE, CIS) HFA policy documents, CD-ROMs, etc., targeted at specific Distribution of such material audiences (sectors, settings, issues, actors) EUR/RC48/8 page 38 Biennial European status reports on patients’ rights, citizens’ participation and professional rights: five country reports in each two- year period Patients’ rights network: annual meetings and follow-up on developments of patients’ rights in Europe. Intensified collaboration with NGOs and IGOs Seminars to identify common economic interests for intersectoral action for health Analysis of evidence about the health effects o f economic development strategies in public and private sectors A database on the cost-effectiveness of actions to promote and maintain health Case studies on the use of economic incentives and measures to promote the healthiness of consumer goods Training of senior officials in economic advocacy for health Guidelines setting out general recommendations and guidelines on structures, mechanisms and processes to develop effective programmes for equity in health (in collaboration with ECHPA) Guidelines on areas of collaboration with at least two non-health sectors related to the prevention of certain specific risk factors in equity (in collaboration with ECHPA) Improved methodology for assessing the impact o f socioeconomic development policies on equity in health (in collaboration with ECHPA) Short-term intensive training for key decision-makers at national, regional and city levels (in collaboration with ECHPA) A network o f parliamentarians, including EU parliamentarians, who are sufficiently well briefed to become advocates for health Active network o f regions for mutual support in HFA policy development Continued Continued Continued Continued Continued Network o f “healthy product’' companies Continued Continued Agreement with other IGOs, NGOs and the Regional Committee on protocols for collaborating for health gain in two non-health sectors Testing of methodology in at least two countries and two regions. “Cascading” o f training in at least three countries. Establishment o f national groups o f “Parliamentarians for Health” in at least four countries Expansion o f work o f RHN to “cross-country” regions 2.2.2 Research policy and strategy coordination WHO targets by end 2001 • Mobilization o f the scientific community fo r HFA throughout Europe 2000-2001 Products Projections for 2002-2003 EACHR meeting Continued Strengthening o f research capacity in NIS and CCEE Continued _ . EUR/RC48/8 page 39 2 .3 N a t io n a l h e a l t h p o l i c ie s , a n d p r o g r a m m e d e v e l o p m e n t a n d M A N A G E M E N T Regional situation and targets By the year 2000, injury, disability and death arising from accidents should be reduced by at least 25%. The changes in Europe’s political, economic and social structures have had a major impact on health. The major pan-European issue o f the 1996-1997 biennium continued to be the west-east health divide. As national and personal incomes in the east declined, health inequalities widened. The western part of the Region showed signs o f economic recovery as economic integration made progress in the European Union. CCEE displayed a wide range o f transition patterns: negative economic growth was experienced by the majority o f countries in the eastern part, whereas signs of a stabilization o f economic activity appeared in some countries in central Europe. The political and economic scene was dominated by freer flows o f information, goods and services and people across the Region as economic globalization continued. Conflicts over ethnic and border issues have erupted in several countries in the Region in recent years, most notably the wars in Croatia, Bosnia and Herzegovina, Chechnya and Tajikistan. Although it is expected that armed conflicts will substantially decrease, certain areas in the Region will remain unstable owing to social unrest, ethnic tensions or political upheaval. For some countries, the transition to a market economy will cause a further deterioration o f the social sector, at least in the initial stages. The consequence of all these factors is a continued demand for humanitarian assistance well into the next biennium. The Region will have to face a number o f other challenges and opportunities in 2000-2001 such as participation in the UNDAF exercise, a possible increased country allocation for the most needy countries of the Region, and certain political developments (expansion of EU, NATO). The effect of these developments is that the scope o f country health development work will be extended to cover the whole of Europe, but with special emphasis on countries most in need. As part o f this work, the intercountry programmes with a strong country component will continue, country-specific advisory activities in countries’ high priority areas will be strengthened, and WHO’s country presence will be further enhanced. While the most needy part o f the Region is well covered by the work o f the Regional Office, the renewed European HFA policy and the public health problems in western Europe call for more systematic and intensified collaboration. During 1996-1997 only a few countries in the western part o f the Region (e.g. Israel, Malta and Turkey) had direct or systematic collaboration with the Regional Office. By 2 0 0 0 - 2 0 0 1 it is envisaged that systematic collaboration will also have been instituted with many western European Member States. Country offices might be established in some western European countries. Between 1990-1997 a country presence (in the form o f WHO liaison offices) was established in CCEE/NIS as part o f the EUROHEALTH programme. With the increased regional allocation and the severity o f health problems in the most needy parts o f the Region, this country presence will have to be strengthened in countries most in need by establishing new entities as and when applicable. WHO representative posts could perhaps be established in one or two countries most in need. In expanding its activities to cover the whole Region and to handle the increased regional allocation as o f 2000-2001, the Country Health Development programme will have to be rethought and strategically repositioned. Two components o f country work will continue: ( 1 ) a strong country component to intercountry work, but better linked to and integrated with national policy-making processes; EUR/RC48/8 page 40 (2 ) country-specific collaboration with individual countries in their high priority areas, in order to provide support for: (a) health policy development in line with the updated European HFA policy, strengthened by the work of the newly established ECHPA (see 2.2 above); (b) formulation of health care reforms; and (c) development of major health issues. These two components o f country work will complement each other, and both will be integrated in national policy development efforts. WHO’s role WHO coordinates its cooperation with countries according to their needs, focusing attention on those with the greatest needs. This includes the provision of objective information and the assessment and delivery o f appropriate technical support. It also includes joint planning, implementation and evaluation o f cooperative programmes with Member States, where applicable. WHO will continue to play a dual role in countries: performing “representational” functions (to promote policies, strategies and programmes), and engaging in technical cooperation to advise on the development o f national policies, strategies and programmes. EURO will further improve its capacity to analyse countries’ needs and forge strategic partnership with other agencies, taking better account o f the collaboration already developed in countries. Member States o f the European Region renewed their support to the EUROH EALTH program m e at the forty-fifth session o f the Regional Committee in 1995 (resolution EUR/RC45/R6). The priority areas outlined in the EUROHEALTH programme are: health policies; health care reform; communicable diseases; women’s and children’s health; noncommunicable diseases and the promotion o f better health; and environmental health. They form the basis for the medium-term cooperative programmes with the EUROHEALTH countries. WHO will continue to respond to demands arising from emergency situations. Work will focus on developing competence in emergency preparedness, especially in the CCEE/NIS (this will include training liaison officers and working more closely with collaborating centres) and on extending humanitarian health assistance to countries suffering from major natural disasters or complex emergency situations, including possible armed conflicts. Evaluation - main achievements and constraints Cooperation between country and intercountry programmes clearly improved during the 1996-1997 biennium, but it could be further improved by better integration of programme delivery at country level, with more strategic support from the Regional Office and its networks and increased collaboration at country level with other agencies. The work o f the Regional Office needs to be made better known. The Regional Office must maintain its capacity to address new developments in western European countries as well. Up to 70% o f EURO’s total resources (slightly more than anticipated) were spent on EUROHEALTH countries in the biennium, with the major emphasis placed on NIS. The Organization’s country presence has been strengthened by increasing the number o f WHO liaison offices, as well as by establishing time-limited public health adviser posts in Armenia, Georgia, Tajikistan and Uzbekistan, with the aim of advising the government on key health policy and programme developments. That country presence has helped to improve cooperation with international organizations such as the World Bank, UNDP, UNFPA and the EC. Thanks to substantial voluntary donations, emergency relief and hum anitarian assistance was provided to Bosnia and Herzegovina, Croatia, the Federal Republic o f Yugoslavia (Serbia and Montenegro), The Former Yugoslav Republic of Macedonia, and, on a smaller scale, to Albania, Armenia, Azerbaijan, EUR/RC48/8 page 41 Georgia, the Republic o f Moldova, Ukraine and in the regions surrounding Chechnya (Russian Federation) and some central Asian republics, especially Tajikistan. The close cooperation with different donor agencies in humanitarian assistance has led to a strengthening o f the Regional Office’s relations with donors in general. As part of the follow-up to deal with the health consequences of the Chernobyl accident, a project office was opened in Minsk. A handbook on nuclear emergencies was produced and distributed to Member States. As to chemical accidents, the emphasis has been on clarifying the epidemiological strategies to be adopted following such events. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1997-1999 biennium During the biennium 1996-1997, activities shifted significantly from basic humanitarian aid to development assistance. In Bosnia and Herzegovina, for example, emphasis was placed on health service reconstruction and reform, post-conflict resolution and utilizing health as a vehicle for the promotion of dialogue and reconciliation. Considerable experience was gained from working with other partners towards these objectives. In the coming biennia, the emphasis will be on developing an integrated approach to the delivery o f humanitarian assistance within a sustained development context. The fundamental objective will be to see humanitarian and development assistance contributing in an integrated way to sustainable development within countries. To achieve these ends, WHO will work in partnership with donor and recipient countries, other development and humanitarian organizations in the United Nations system and NGOs. In future emergencies, the longer-term perspective o f development and capacity-building will be built into W HO’s response from the outset. Proposed resources by source of funds: 2.3 National health policies and programme development and management Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 235 000 207 000 371 300 339 852 Country 2 495 000 7 000 000 2 172 000 5 978 000 3 054 282 19 374 701 Regional - 210 000 Total: 2.3 2 730 000 7 000 000 2 589 000 5 978 000 3 425 582 19 714 553 Budgetary comments and trends More than two thirds of the Regional Office’s regular budget resources were directed to CCEE/NIS in 1996-1997 and 1998-1999. Despite the decrease in regular budget resources in later years, EURO has made continuous efforts to protect (and even increase) country-level activities. Voluntary donations are still expected to be received for the countries most in need, as well as for humanitarian assistance and emergency relief activities. 2.3.1 Technical cooperation w ith countries- WHO targets by end 2001 • Pilot project on "essential country presence ” • Strategies fo r additional support to western Europe • Simple and cost-effective form o f country presence in western Europe • Strengthened EURO capacity to analyse country needs • WHO's presence in major health developments and integrated support through its dual functions • Strategic partnership with agencies in the United Nations system as part o f the UN reform process and with EC within the context o f the accession o f new members EUR/RC48/8 page 42 2000-2001 Products Projections for 2002-2003 Collaborative agreements (medium-term programmes - MTPs) with Evaluation of pilot studies countries to be made with a 2 + 2 year, rolling-plan principle for and possible expansion o f the country presence and activities in western Europe; pilot studies in two mechanism to other countries Member States Internal task force on country health development Continued Evaluation of EUROHEALTH programme (2000) Database of technical and basic non-technical information on Continued countries Strengthening o f EURO capacity to collect, analyse, interpret and Continued disseminate health information on countries in the Region 2.3.2 C ollaboration w ith countries and peoples in greatest need WHO targets by end 2001 • Strategies fo r resource mobilization, management and coordination in countries in greatest need 2000-2001 Products Projections for 2002-2003 EURO task force on development for countries in greatest need Continued Strengthened WHO presence in such countries (WHO representatives’ Continued offices as funds permit) Participation in UNDAF process Expanded to more countries National coordination committees in countries Expanded to more countries EUR/RC48/8 page 43 2.3.3 E m ergency and hum anitarian action, re lief and rehabilitation operation and em ergency preparedness program m e WHO targets by end 2001 • Reduction o f death and disabilities due to accidents • Integrated policies fo r accident prevention, control and monitoring • Effective emergency/contingency plans in at least five countries exposed to natural or man-made disasters • Up-to-date Regional Office emergency response system 2000-2001 Products Projections for 2002-2003 Contingency plans for handling emergency situations, including nuclear accidents or others contaminating the environment EURO’s strengthened capacity to manage emergencies Keep updated EUR/RC48/8 page 44 2.4 B i o m e d i c a l a n d h e a l t h i n f o r m a t i o n a n d t r e n d s Regional situation and targets By the year 2000, health information systems in all Member States should actively support the formulation, implementation, monitoring and evaluation o f health fo r all policies. During the 1990s European Member States became increasingly aware o f the need for adequate information as a basis for formulating and implementing their own health policies and evaluating progress towards attainment of the European HFA targets. However, in some CCEE/NIS the economic transition also had adverse effects, albeit indirect, on health information systems. In some countries the traditionally strong elements o f data collection were also disrupted, at times due to the effects o f health care reforms. During the biennium 2000-2001 there will be an even greater need to assess progress towards HFA and for support to strengthening information systems. WHO’s role In order to help Member States evaluate and monitor progress towards health for all, there is a critical need for appropriate and relevant health and health-related information systems, so that knowledge can be shared within and among Member States. In this respect, EURO has to be a catalyst, a facilitator and a clearing house - a European health information centre to enable existing knowledge to be more widely known and used. To achieve this, comparative information is needed at international, national and subnational levels, in every part of the health service, for a variety o f purposes and for many “end-users” . The overall objective is to tap and share evidence o f successes (and failures), in order to initiate the practice-oriented exchange o f experience. Recent events in Europe and the experience of the economies in transition emphasize the need to do this. The further development o f EURO as a European health information centre is the key to helping to make existing knowledge better known. All countries’ capacity to analyse and use health information needs to be strengthened, so that major health problems, trends and areas for public health action can be pinpointed. Universal access to WHO information through both electronic and traditional means is the aim. Information is a priority in countries in transition and a continuing requirement in developed countries. W HO’s programmes cannot achieve maximum impact if their products are not accessible. Translation into official and other languages is a necessity. A range o f media will be used including books (produced in-house and co-published), CDs and the Internet information highway. Partnership with the national WHO documentation centres will be enhanced, as will that with the European Association for Health Information Libraries. Evaluation - main achievements and constraints The results of the 1996-1997 HFA evaluation were published in 1998. The HFA statistical database was further improved (with a new Windows version) and access continued to be provided via the Internet. It continues to be the most widely used and accessible international database on health in Europe. The Regional Office also produced, together with the Central Statistical Office, Hungary, an atlas o f avoidable mortality for CCEE/NIS. The Regional Office continued to actively support EC in its efforts to develop a system o f health data and indicators for EU countries. The European health interview survey (EUROHIS) project to develop common methods and instruments for health interview surveys in Europe obtained funding from EC’s BIOMED2 programme over three years, starting in 1998. The application was based on the experience already gained by this project, which was started jointly with Statistics Netherlands in 1987. The project will develop common European instruments for such indicators as physical activity, alcohol consumption, mental disability, chronic physical conditions, use o f medicines and medical services, preventive care, and quality o f life. It will also process readily available survey data in the Member States to harmonize this for cross-national activities. The project collaborated with many other EUR/RC48/8 page 45 EURO programmes, e.g. the Health Behaviour o f School Children study, the Quality o f Care and Pharmaceuticals programme, etc. The “Country highlights on health” continued to be updated as resources permitted, and those for the EU countries were finished with support from EC. Health service indicators were developed and national HFA databases established by many countries. The Health for All/Health Service Indicator (HFA/HSI) project for CCEE was the main vehicle for this. It was further extended to all NIS during 1997 and 1998. The European Public Health Information Network for Eastern Europe (EUPHIN-EAST) project aims to develop a European public health information network for eastern Europe that telematically interconnects distributed databases on servers based in the individual countries that host health data and indicators. The purpose is to exchange data and indicators between Member States, so that they can use international comparisons o f their statistics to pinpoint areas for public health action and to facilitate reporting to WHO and international agencies. The EUPHIN-EAST project is based on EURO’s (1992-1994) experience of an EC statistics pilot project (ENS/CARE) and its participation (1995-1996) in a project to develop a similar network for the G7 countries. EUPHIN-EAST is initially (1997-1998) being implemented for 23 countries o f central and eastern Europe, with the support o f EU’s INCO-COPERNICUS programme. EUPHIN-EAST has been designed and is being implemented with the aim o f interconnecting to a similar network being developed for the EU countries (Interchange o f data between administrations - Health indicators exchange and monitoring systems (IDA-HIEMS)). Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium In spite o f considerable progress, information support in many countries still needs strengthening through increased analytical capacity and advisory services. Therefore, in 1998-1999 emphasis is being placed on strengthening the Regional Office’s role as the health information centre of Europe by building on earlier work and obtaining information on, and monitoring progress towards, HFA in Europe. Joint work continues to be strengthened with EC and with other partners. The Health Interview Survey project was launched in 1998 with the support of EC’s BIOMED2 programme and will continue until 2001. Support continues to be given to the development o f country health information systems, in the case of CCEE/NIS through the EUPHIN-EAST project, supported by the EU INCO-COPERNICUS programme. The “Country highlights on health” for NIS/CCEE are being updated with the support of Finland and additional funds are being sought. In 1998, the second “Information for Health for Europe” meeting is bringing together the main providers and users o f health information from all 51 Member States. It is part o f the statutory UN/ECE/WHO meeting on health statistics and will be also attended by representatives of the World Bank, the Organisation for Economic Co-operation and Development (OECD), UNICEF, UNFPA, EC and CE. One of the aims o f this meeting is to start a process o f international collaboration and cooperation, so as to lessen the burden o f multiple reporting by Member States. Other areas with related information components are directed towards: 1. health care reforms following the Ljubljana Conference, through the establishment o f a European Health Care Reform Observatory; 2. communicable disease (CD) surveillance through the establishment o f an Internet-based CD surveillance and reporting network; 3. HFA policy development through the establishment o f the ECHPA; 4. quality o f care and outcomes through the development o f clinical outcome databases that enable local clinicians and policy-makers to compare outcomes and effectiveness o f clinical practices and procedures. EUR/RC48/8 page 46 Proposed resources by source of funds:. 2.4 Biomedical and health information and trends Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 316 500 150 000 347 600 312 000 375 100 176 641 Country 172 000 191 400 - 166 740 Regional 421 000 410 000 - 354 408 Total: 2.4 909 500 150 000 949 000 312 000 896 248 176 641 2.4.1 Epidem iology, statistics, trend assessm ent and country health inform ation WHO targets by end 2001 • Coordinated development work on EURO information systems; access to them by Member States; and promotion o f their use in an efficient way • Support to countries in their efforts to establish countrywide HFA databases, production o f national public health reports and other information products that identify action towards HFA in Europe • Preparation and dissemination o f the 1999-2000 monitoring report on progress towards HFA in Europe 2000-2001 Products Projections for 2002-2003 Production and dissemination of the 1999-2000 HFA monitoring Available on the World Wide report Web Regular updates on the health situation in countries and Country Public Health Reports Country highlights on health, for all countries Distribution of revised HFA indicators for the HFA policy for the Assistance re their twenty-first century implementation in Member States Up-to-date HFA statistical database Keep updated Advisory services and support for CCEE/NIS in the development of health information systems Telematic reporting from Member States to WHO Display systems for regional, national and subnational HFA data Appropriate definitions and standards o f health information in Europe Completed Health Interview Surveys project (2001) 2.4.2 Publishing, language and library services WHO targets by end 2001 • Universal access to WHO documents through the Internet EUR/RC48/8 page 47 2000-2001 Products Projections for 2002-2003 Production and dissemination o f health publications, documents and Continued translations Regional Office’s “home page” on the World Wide Web Continued Strengthening o f WHO information and documentation centres Continued EUR/RC48/8 page 48 EUR/RC48/8 page 49 3. HEALTH SERVICES DEVELOPMENT Policy orientation and strategic priorities In the past decade, a number o f health system pressures have led many governments in the European Region to review their systems and explore new approaches to the financing, organization and delivery of health services. In many cases, health system models and ideas have been transferred across national boundaries. There is, however, very little evidence about the actual impact o f these reform policies on a series o f fundamental societal objectives such as health gain, solidarity and quality, which are embodied in the HFA policy. This process o f health system change is set to continue into the beginning o f the next century. Contextual factors such as macroeconomic constraints, demographic changes and globalization will play an increasingly important role in determining the shape o f health care systems. The paradigm shift illustrated by the crisis of the welfare state and the increasing role o f market incentives in the social and health fields will continue to affect the financing and organization o f health care systems. Public health infrastructures, skills and capacities, both within and outside the health sector, are key elements for delivering the new agenda o f HFA in the twenty-first century in Member States. Reforming and reorienting health systems towards health gain, equity and high quality care require the backing o f a strong population-based public health. Particular emphasis should be placed on developing the advocacy and leadership role o f public health, and also on training public health professionals and the wide range of actors within and outside the health sector. The wave o f reforms o f health care systems in Europe in the 1990s has re-emphasized the important position o f primary health care (PHC) in the development of accessible and efficient health care systems in an increasing number o f Member States. PHC systems have been reorganized, training and retraining schemes for family practitioners and nurses have been introduced, and moves towards decentralizing the management o f PHC have been seen. In this context, EURO will stimulate a PHC initiative that will focus on capacity-building and implementation at country level, building on the knowledge already gained through projects such as CINDI and capitalizing on the networks and achievements of PHC in a number o f Member States. To support this effort, a systematic review will be made of the current status o f PHC development in Europe and of the available evidence o f the impact of PHC approaches, and the resulting findings will be actively disseminated. Major challenges will include strengthening the development o f public health systems and of comprehensive and family-oriented care, and continuous development o f the quality o f care by mobilizing all the key partners involved in the care process and in managing and assessing clinical work and health care priorities, practices and institutions. EUR/RC48/8 page 50 3 .1 O r g a n iz a t io n a n d m a n a g e m e n t o f h e a l t h s y s t e m s b a s e d o n PR IM A R Y H EALTH CARE Regional situation and targets By the year 2000, all Member States should have developed, and be implementing, policies that ensure universal access to health services o f quality, based on primary care and supported by secondary and tertiary care. By the year 2000, health service systems in all Member States should be managed cost- effectively, with resources being distributed according to need. By the year 2000, primary health care in all Member States should meet the basic health needs o f the population by providing a wide range o f health-promotive, curative, rehabilitative and supportive services and by actively supporting health-help activities o f individuals, families and groups. By the year 2000, hospitals in all Member States should be providing cost-effective secondary and tertiary care and contribute actively to improving health status and patient satisfaction. By the year 2000, people in all Member States needing long-term care and support should have access to appropriate services o f a high quality. By the year 2000, management structures and processes should exist in all Member States to inspire, guide and coordinate health development, in line with health fo r all principles. European countries in both west and east are in the midst o f health care reforms. It has become clear that health care reform is a difficult and ongoing task, for which no one standard solution is available. Intensive efforts to reform or modernize European health care systems will continue to be high on the public policy agenda. Renewed attention to PHC and to citizens’ participation are shaping these health care reform efforts. However, PHC has been viewed by many in a very narrow way and often interpreted as primary medical care. Over the past two decades, initiatives with regard to PHC have been fragmentary and carried out in isolation. There is a recognized need to integrate and coordinate more closely activities related to PHC. Few countries in Europe have a national policy on quality indicators, evidence-based medicine and outcome measurements. Although some attempts have been made to introduce benchmarking procedures, the definition o f policies in this area often creates opposition among the professionals involved who fear that they will be seen as a system for exercising control. National strategies should focus on: • defining common minimum requirements for the operation o f health services; • introducing standard quality indicators, appropriate information systems and benchmarking; • adopting the necessary legislative measures to ensure the delivery o f appropriate integrative services, including home health services; • introducing health promotion as an integral part o f health care services. Under health care reform strategies (e.g. substitution policies), the delivery o f effective, evidence-based nursing and midwifery services is increasingly being targeted at the community and home settings. The family nurse and the family physician will be important ways o f focusing attention on the health needs of families, as well as o f more vulnerable groups in society. Together, they will place particular emphasis on EUR/RC48/8 page 51 health promotion and disease prevention, as well as on dealing with chronic disease and rehabilitation. The family nurse will advise on lifestyle and behavioural risk factors, assist families with health-related matters, and ensure the early detection of health problems in families and early treatment as required. The family nurse will also be in a position to identify the effects of socioeconomic factors on a family’s health and to refer family members to the appropriate agencies. Not least, the family nurse and family physician, working in partnership, will ensure the seamless care required at the primary location in cases o f early discharge from hospital. Hospitals in Europe are having to respond to major challenges such as the rapid development of technology, the need to reduce costs, the new market orientation and the higher demands and expectations o f the population. The development of high technology for diagnosis and treatment is changing the face o f the hospitals and increasing hospital expenditures. “Hospitals without walls”, “hospitals without beds”, “day care hospitals” and “hospitals at home” are some developments that indicate the direction in which health care is shifting. Such developments require strong coordination between the different levels of care (health and social care) and calls for a multiprofessional approach. The increasing demands o f the population and the requirements for information and participation in the decision-making process entail changes in the relationship between health care practitioners, managers and administrators, and patients. These demands also stimulate the development o f information systems based not only on the cost o f interventions, but also on measurable results, including consumer satisfaction. The importance of health systems research has grown as the quest for greater cost-effectiveness has moved on to the political agenda. We still know too little about the complicated interrelationships between service production, financial inputs and health outputs. Health services research therefore has an important role to play in injecting clarity into evidence-based health care reforms. Policy-makers in the field o f health care reform are preoccupied with effecting change in health care financing and payment systems. There is a need to exchange experience, to assist countries in need, and to link financing and economic aspects more systematically to health outcomes. WHO's role WHO will continue to play a central role by providing information on health care systems, and in particular by disseminating examples o f good practice, monitoring reform developments and assessing these developments against HFA principles. WHO should continue to build on its unique position of working with both policy-making and academic constituencies. This involves obtaining information, analysing it in a way that is relevant to policy-makers, and developing policy options and recommendations. WHO will enhance its support for the development o f health and health care policies by stepping up its country projects, especially for those countries most in need. The task o f managing change will be made easier by building up countries’ capacity for policy-making and strategic planning. These projects will also offer a forum for donor coordination and resource mobilization. Emphasis will be placed on shifting resources towards PHC and strengthening the organizational, managerial and administrative structures that reinforce the delivery o f promotive, preventive and curative care. Policies that build up the capacities o f the health professionals providing PHC, in particular general/family practitioners and nurses, will be encouraged. The Regional Office will also take the lead in spreading innovative practices that are based on methods for assessing the needs o f the population and the outcomes o f interventions, as well as those aimed at populations with special needs (such as refugees, migrants, the unemployed and marginalized social groups). EUR/RC48/8 page 52 Interdepartmental project on primary health care Areas that will be emphasized include: repositioning PHC within broader health policies; building skills in disease prevention and health promotion and in support o f multidisciplinary approaches; pilot projects which incorporate the principles o f PHC, e.g. integration o f health promotion, disease prevention, curative and rehabilitative services through supportive planning, managerial and evaluation mechanisms around priority health issues in Member States; development of PHC indicators to support quality management processes and monitor progress; and the use of telematics to facilitate communication, both among PHC providers and with the community. The proposed regular budget allocation to this project is US $150 000. Activities to strengthen general practice and nursing and to establish training structures for nursing and general practice/family medicine (GP/FM) in CCEE and NIS will also be stepped up. More work will be done on sharing experience o f innovative practices in PHC related to the assessment of needs, the implementation of outreach programmes and the evaluation o f outcomes. Evaluation - main achievements and constraints The Ljubljana Conference on European Health Care Reforms (1996) produced a policy consensus on the role of health care financing and payment systems. During the 1998-1999 biennium guidelines are being developed on specific issues such as privatization, the macroeconomic aspects o f health insurance, the role o f economics in health care development, priority-setting and decentralization. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium As a result of the analytical and normative products generated by the Ljubljana Conference, the Office has taken centre stage in the reform and health care policy debate. The establishment o f the European Health Care Reform Observatory during the 1998-1999 biennium constitutes a major step towards consolidating this role. This effort will have to be maintained in the next biennium. PHC has been the focus in district health systems, but a lot more work needs to be done - especially in Europe - before duplication o f administrative functions, parallel health care services and unnecessary specialist services are eliminated and decision-making structures and services are secured at the lowest effective level. Many WHO collaborating centres and other research institutes and universities have actively improved their capacity to conduct health systems research. W HO’s role will be to support them in their work, identify pertinent research questions and encourage governments to enhance their activities. Furthermore, there is a lot of work to be done on disseminating good quality research findings to all Member States, especially CCEE and NIS. Proposed resources by source of funds: 3.1 Organization and management of health systems based on primary health care Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 742 000 1 100 000 723 000 3 047 200 691 445 1 516 330 Country 565 000 571 000 - 462 423 Regional - 40 000 - Total: 3.1 1 307 000 1 100 000 1 334 000 3 047 200 1 153 868 1 516 330 EUR/RC48/8 page 53 Budgetary comments and trends In this biennium, funds will be reallocated to strengthen reviews and analysis o f health care reform, to support demonstration and pilot projects (with implementation o f research and dissemination o f findings), and to strengthen capacity in countries to manage change processes and give effect to reform strategies focusing on PHC. The magnitude of the reallocation will be determined at the time o f operational planning. It is expected that voluntary donations will be required to support many activities in this programme. 3.1.1 H ealth system s research and developm ent WHO targets by end 2001 • The European Health Care Reform WHO Observatory to be fu lly operational and at the centre o f the health systems debate in the Region • The Observatory to have accurate and timely information on individual country health systems, as well as on main health care innovations • The information and analytical products o f the Observatory to be widely used by policy-makers and analysts in countries and organizations • Increased input from the findings o f health system research into the implementation o f health care reform in Europe • Increased number o f Members States committed to strengthening public health practice • Action plan fo r strengthening the leadership, authority and advocacy role o f public health • Public health capacity at national and local levels built up through established WHO networks • Close cooperation established with the Association o f Schools o f Public Health in the European Region (ASPHER), the European Public Health Association (EUPHA), public health professional associations and EC • Collaborating centre(s) designated fo r monitoring public health practice and systems development • Economically sound PHC policies and practices being implemented in five Member States • At least five new research findings which have relevance to health care reforms in countries identified and disseminated widely through country work and networks 2000-2001 Products Projections for 2002-2003 Analytical studies with policy options and lessons for eight key health Continued system development areas in Europe Advice to Member States to strengthen public health practice Ongoing Methodology for needs and outcomes assessment in PHC Up-to-date HiT profiles for all countries in the Region Up-to-date subregional comparative analysis o f reform trends, obstacles and lessons in western Europe, CEE, NIS and CAR A fully functioning clearing house for health care reform (the To be confirmed “Observatory”) EUR/RC48/8 page 54 Development o f guidance and identification o f good practice demonstration projects covering the following topics: template for assessing public health practice; options for systems development; tools for population-based public health; developing capacity for implementation; public health leadership and advocacy; infrastructures for local-level public health National- and local-level public health capacity-building activities (integrated planning, workshops) through established WHO networks (health care/subregional, Healthy Cities, CINDI, Regions for Health, settings) Dissemination o f innovative methodologies for outreach programmes based on assessment o f needs and outcomes in PHC Pilot project to test the concept o f the family doctor and the family nurse in six Member States People’s needs for nursing care - a multinational study Inclusion in nursing and midwifery curricula of competencies for nursing within the context of health services research (including the ability to understand informatics and information systems) Guidance on selected economic and operational aspects o f PHC organization and financing. Databases and publication o f results Analysis of innovations in hospital management, evaluation of outcomes and development of systems to improve hospital performance Analysis of systems for coordination o f the different levels of care, focusing on emergency services. Exchange o f information on examples o f good practice Analysis of home health services Completion o f resource tool kit, translation into local languages, dissemination Continued Continued Continued Continued Technical cooperation Continued Continued Continued 3.1.2 National health system s and policies WHO targets by end 2001 • Strengthened policy advice in the four subregional networks (MIDNET, CARNET, EASTNET andSOUTHNET) • Assistance to at least two more central Asian republics with the development o f health care policy and capacity-building • Strengthened capacity fo r change management in CARNET countries • Quality o f care elaborated as a component o f health policy in one CARNET country • Ability to appreciate and apply health economics built up in at least six countries • Assistance to at least five countries on policy issues related to health care financing and economics • Availability o f tools fo r appraisal o f options and evaluation o f economic strategies • Evidence-based guidance on national health system development • Mechanisms fo r sustainable financing o f health care systems that support the development o f PHC to be in place in five Member States EUR/RC48/8 page 55 2000-2001 Products Projections for 2002-2003 Regional network of health economics experts and collaborating centres Continued Position paper on the implications o f changing the private/public mix Technical cooperation re in health care financing and delivery implementation Tools for managing appropriate change in the health economy Technical cooperation Economic incentives for improving the quality o f care: case studies Dissemination Development of outcome-oriented payment mechanisms in CARNET Implementation o f outcome- countries oriented payment mechanisms in at least one country Learning material and seminars for health department officials responsible for financing and economics Continued Advisory support to countries with developing strategies and policies for benchmarking in health services Continued Consensus on common strategies for outcome measurement in hospitals Continued Health and health care policy developed in Armenia, Georgia and Health and health care policy Kazakhstan development in Azerbaijan and Uzbekistan Implementation o f health care reform in Turkmenistan (LUKMAN Implementation o f health care project) and Kyrgyzstan (MANAS project) policy in Kazakhstan and Tajikistan. Implementation continued in Kyrgyzstan and Turkmenistan Continuation o f established networks (EASTNET, MIDNET, Strengthened and reoriented CARNET, SOUTHNET) towards the management of change Compendium of examples o f successful management o f change to community-based practice in nursing and midwifery services Continued Guidelines on innovative practices in community and home care nursing and midwifery, including appropriate skill mix requirements Continued Publication on the role o f nursing and midwifery in public health, Strengthen competencies in including analysis and policy recommendations policy development and public health Analysis and computer displays o f information on health care reform for service development (4-5 new or updates per biennium) Continued Health care management manuals and advice for selected countries at local, regional and national levels (two per biennium) Continued Evaluation of developments on the fifth anniversary o f adoption o f the Ljubljana Charter and dissemination and country implementation of the principles o f the revisited Charter Completed Country-specific programmes for the development o f national health systems Continued Dissemination and country application o f the outcome o f the health Monitoring o f ongoing care contracting study implementation EUR/RC48/8 page 56 3.1.3 D istrict health system s WHO targets by end 2001 • Increase in the number o f countries giving high priority to continuity o f care through appropriate referral mechanisms, including support to home care • Community care (nursing and general practice) and intersectoral collaboration at district level strengthened in at least five Member States • Five countries to be implementing programmes fo r strengthening horizontally integrated PHC services 2000-2001 Products Projections for 2002-2003 Strategies to strengthen the delivery o f horizontally integrated PHC services, in which the citizens’ role in promoting their own health and self-care is fully acknowledged Continued Analysis of and support to community care as part of health care reforms in five countries Continued Analysis of and support to regionalized referral systems as part of health care reforms in five countries Continued Assessment tool (including quality indicators) to identify gaps in Development o f innovative community-based services for the most vulnerable population groups approaches to rectify gaps in community-based services for the most vulnerable population groups Guidance on benchmarking and quality improvements, including Manual on quality evidence- development o f a set o f relevant quality indicators and databases for based nursing practice in evidence-based nursing practice within the community community and home care Expanded network o f health-promoting hospitals Continued Encouragement and support for the implementation o f substitution policies, introduction of day care facilities and patient education units, and coordination of different levels of care, based on the results of research Continued EUR/RC48/8 page 57 3 .2 H u m a n r e s o u r c e s f o r h e a l t h Regional situation and targets By the year 2000, primary health care in all Member States should meet the basic health needs o f the population by providing a wide range o f health-promotive, curative, rehabilitative and supportive services and by actively supporting self-help activities o f individuals, families and groups. By the year 2000, education and training o f health and other personnel in all Member States should actively contribute to the achievements o f the health fo r all. Family physicians, nurses and midwives are key health care providers and must now refocus their activities to provide services which are sensitive to the needs o f patients and which give quantifiable health outcomes. To achieve this, they will need to have appropriate competencies to operate in more complex health care systems and deal effectively with the effects of, for example, war, new public health challenges and environmental issues. Efforts need to be directed towards creating a quality culture in the profession and promoting accountability for their practice. Many o f the countries in the subregional networks (CARNET, MIDNET, EASTNET, SOUTHNET) are in the process of reforming their health systems. The changes already made have generated a need for new types o f human resources and new skills, and the success o f strengthening PHC will be dependent on the human resources available. One of the main policy aims in these countries is to strengthen PHC, with a trend towards introducing family physicians and family nurses. Since medical education has been based on training specialists rather than generalists, this trend has serious implications for medical education. Many countries are revising their education systems and are introducing the discipline o f general practice. The same implications apply to nursing: nurses are being given more responsibilities. This will entail adapting the training of nurses so that they acquire the new knowledge, skills and attitudes as required. There is a lack o f public health specialists in the CARNET countries. This need has been recognized by Kazakhstan and a school of public health has been set up to train specialists in line with the concept o f the “new public health”. Human resources planning and management are also becoming important issues. In many countries in these networks, health personnel suffer from low salaries and a lack o f motivation. Excess numbers of health personnel give rise to the need for rationalization. All in all, this leads to a need for better planning o f future supply and better human resources management policies. The Avicenna programme in CARNET countries explores the human resources requirements for PHC and develops policies and strategies for ensuring that the human resources have the required skills. W HO's role The rapid development o f technology, the new arrangements for delivery o f health care, the need to use appropriate technology and information systems, to ensure that activities are quality-oriented and evidence-based, and to provide integrated and comprehensive care, as well as the new relationships between professionals and patients/consumers based on partnership are: • challenging the traditional role o f health professionals; • underlining the need for a multidisciplinary and multisectoral approach to health care; • indicating the need for a different mix o f health professionals, with a more prominent role for nurses; EUR/RC48/8 page 58 • questioning whether the curricula for nurses and physicians can cope with the demands o f the new - situation and the focus on PHC, home health care provision and integrated care; • pointing out the need for new skills in management, communication, problem-solving, ethics, health promotion, etc. There are large variations in the level o f education in nursing and midwifery, and a common strategy across the Region is needed to reduce them. New roles for the profession, especially with respect to family health-oriented, integrated care, will require skills in policy development, advocacy and negotiation. It will be important for nursing and midwifery personnel to become involved in policy development with respect to the public health agenda and emergency humanitarian assistance, for instance. This will entail strengthening the current curricula in several areas, as well as legislative and regulatory frameworks to support the changing role o f nursing and midwifery in all countries. Revisiting the Vienna Conference on Nursing in the year 2000 will provide an opportunity to reflect on the profession’s contribution over the past decade, as well as to plan systematically for the future. Within the changing context o f health care delivery, several countries are now facing shortages o f nursing and midwifery personnel, among other care providers. To plan for the future workforce, new tools (e.g. to ascertain skill mix requirements) must be designed to calculate the size o f the workforce required to meet the population’s needs. The aim of the Regional Office is to help countries to develop the personnel to meet their special needs. The Fellowships programme is an important component of WHO’s strategy for the development of human resources. In past biennia collaboration was focused on the EUROHEALTH countries; these countries will continue to be the priority for the biennium 2000-2001, but western European countries will also be more involved in the Fellowships programme’s activities. Evaluation - main achievements and constraints In view of EURO technical programmes’ special mandate to support CCEE/NIS, the nursing and midwifery programme focused on the development o f national action plans for nursing and midwifery as well as on the LEMON (LEaming Material On Nursing) project, which made basic information and a support network available to the nursing community in CCEE/NIS. The workplan for the 1996-1997 biennium broadened the scope o f nursing and midwifery activities to the entire European Region, to strengthen the profession in many western European countries where it is currently weak. In the area of practice, efforts are being made to develop clinical indicators for chronic diseases and care o f the elderly, to ensure that the effectiveness o f nursing interventions can be measured. The European Forum o f National Nursing and Midwifery Associations and WHO is proving an important channel of communication and action to ensure that the profession embraces the new health agenda. Work that had already started on strengthening GP/FM within PHC was expanded. Consultations on laying down guiding principles for GP/FM development continued, as did the expert network for family medicine development strategies in CCEE, while a new network was launched for GP education and training in the NIS. Member States continued to receive support for developing national local PHC services. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium Work has started on exploring innovative practices in the implementation o f PHC in Member States. In addition, the newest subregional network, SOUTHNET, will be focusing on PHC as a major component o f health care reform. EUR/RC48/8 page 59 Proposed resources by source of funds: 3.2 Human resources for health Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 189 500 330 000 25 000 312 000 230 911 173 180 Country 69 000 105 000 126 348 Regional - 11 000 Total: 3.2 258 500 330 000 141 000 312 000 357 259 173 180 Budgetary comments and trends Given the need to link up with major NGOs’ and professional associations’ efforts to facilitate training programmes that support multidisciplinary approaches to PHC, it will be necessary to reallocate funds to support intercountry activities. The magnitude o f the reallocation will be determined at the time of operational planning. As human resources for health are an important area for technical cooperation with Member States, country-level activities have been protected. Furthermore, it is expected that voluntary donations will be received for many o f the activities in this programme. 3.2.1 H um an resources for health WHO targets by end 2001 • National strategies fo r nursing and midwifery education in 80% o f Member States • Legislation and regulatory frameworks to support the new roles o f health personnel and to ensure protection o f the public • Increased involvement o f the profession in policy development, public health and primary prevention • Strengthening existing and establishing new schools o f public health, giving priority to the development o f HFA21-based curricula • A European strategy fo r nursing and midwifery education to be translated into national strategies. Legislative and regulatory frameworks in 50% o f Member States 2000-2001 Products Projections for 2002-2003 Strengthened programmes on human resources development in public Continued health and multiprofessional training. Strengthened links between the three levels o f the continuum of education - undergraduate, postgraduate (vocational/specialist) and continuing Strengthened modules for public health, health promotion and the Continued environment in training programmes for health professionals Change management training package for health professionals Continued Network of medical schools for PHC Continued EUR/RC48/8 page 60 Strategies for curriculum development for general practice/family medicine, with special emphasis on GP/FM as member o f a multidisciplinary team New roles for nursing and midwifery in public health, including policy analysis and recommendations Analysis of people’s needs and development o f a model to ascertain skill mix requirements and o f guidelines on best practice in the nursing profession to meet these needs Second European Conference on Nursing and Midwifery (“Vienna revisited”) in 2 0 0 0 Revised and updated training programmes in CARNET countries Direct support for public health training at the Kazakhstan School of Public Health. The School has been established and short courses started in 1998. Short courses will continue and the M.Sc. courses will be initiated in 2 0 0 0 Continued Dissemination Continued Follow-up activities Public health training programme started Avicenna programme will ensure technical cooperation among CARNET countries on policy development in reforming medical and nursing education Monitoring and evaluation in pilot countries. Implementation o f policies in the others 3.2.2 Fellow ships WHO targets by end 2001 • Increase in voluntary donations in order to place more fellows • Improvement and development o f partnerships with EU RO ’s technical units in the area o f fellowships • Strengthening o f national capacity-building 2000-2001 Products Projections for 2002-2003 Improvement and development o f fellowships strategies and Continued methodologies Strengthening o f the programme in the areas o f assessment and Continued follow-up Further development o f the fellowships database Continued EUR/RC48/8 page 61 3 .3 E s s e n t ia l d r u g s Regional situation and targets By the year 2000, there should be structures and processes in all Member States to ensure continuous improvements in the quality o f health care and appropriate development and use o f health technologies. While the basic problem in the NIS is the lack o f access to and affordability o f safe and effective drugs of good quality, in CCEE affordability and inefficiencies in the pharmaceutical sector are of prime concern. Western European countries are focusing attention on the quality of drug use and cost-containment, but are also concerned with securing access to new drugs. During the transition process in CCEE/NIS substantial progress has been made, but affordability continues to be the great problem. In many countries, drug expenditures have become the responsibility of patients as government budgets have been depleted or spent inefficiently, with the risk o f increasing inequities affecting the most vulnerable. Many CCEE/NIS lack clearly defined drug policies and objectives and legislative frameworks, and their drug regulatory authorities need to be further strengthened. Drug reimbursement schemes are still underfinanced and often non-operational. Rational drug use remains a problem for all countries and leads to waste o f scarce resources. New approaches to and tools for training and continuous education and the feedback o f information on prescriptions and outcomes are needed, in order to improve the use o f drugs. There is great potential for pharmacists to play an increased role in health promotion efforts. W HO’s role In order to meet the needs o f CCEE/NIS, EURO has since 1995 facilitated and provided direct country and intercountry technical assistance to Member States for the development o f pharmaceutical sector reforms. Collaboration with Member States will continue, giving priority to formulation and implementation o f national drug policies in the least developed countries, as part o f their endeavours to reform their health policies and health services. External assistance will be sought in order to ensure the availability, access to and appropriate use o f essential drugs. WHO will expand its role in monitoring and analysing the outcomes o f pharmaceutical policies and disseminating and discussing its findings with Member States. The following strategic shifts will be made in the role played by WHO assistance: strengthen W HO’s role as a facilitator for the implementation o f drug policies in Members States and the promotion o f innovative strategies; continue to focus attention on the least developed countries in the Region; intensify the synergy between country and intercountry work and step up subregional activities; expand networking and partnerships with experts, collaborating institutions, international agencies and NGOs (with increased participation o f actors from western European countries); pay more attention to data collection, analysis and monitoring; link activities more closely with overall health care policy and reforms; and apply and evaluate measurable indicators o f the implementation o f drug policies. Evaluation - main achievements and constraints Several NIS and CCEE have adopted national drug policies and are in the process o f carrying them out. Technical assistance has focused on the development o f national drug policies, drug regulation, economic aspects o f drug supply and rational drug use, including development of the role o f the pharmacist and good pharmacy practice. Networking, also among western European countries, in the different drug- related areas has increased considerably. Obstacles include a general lack o f funding in the health care sector, strong private interests and the often unclear directions o f health care reform. EUR/RC48/8 page 62 The continuity and consistency o f country support and the use o f a limited number o f key consultants with increasingly good knowledge o f the countries has been a crucial factor in the success o f the programme. The EuroPharm Forum network is tapping the huge potential o f the pharmacists’ contribution to health promotion. Cross-linkage with health promotion programmes has created “win-win” situations, and this approach therefore needs to be stepped up. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium On the basis o f the experience gained in country support and intercountry work, the programme will intensify the cross-fertilization of these approaches. This can be summarized as generating knowledge through country work, analysing and synthesizing the positive approaches and experiences at intercountry level, and then feeding back the conclusions into country support. In view of the forthcoming accession o f some CCEE to membership o f the EU, the latter’s pharmaceutical legislation and policies will become the driving force behind pharmaceutical developments in CCEE. The programme will therefore need to intensify its already good cooperation with the EC. At the same time, western European countries are facing many controversial issues in the drug sector that fall outside the scope and competence o f the EU; through its networks and collaborating centres, the programme can provide the analysis and synthesis o f countries’ experiences. Especially in NIS, after the first years o f strong advocacy for and laying the foundation o f the new pharmaceutical sector, there is now a clear need for better data on the drug situation in the countries from the patients’ point of view, in order to monitor improvements. There is also a need to provide better tools for management o f the drug sector that are suitable for use in the NIS. The programme will therefore need to incorporate the development of operational research methodologies and suitable tools. Proposed resources by source of funds: 3.3 Essential drugs Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 115 000 2 000 000 110 000 936 000 191 065 - Country 114 000 94 000 103 374 2 125 531 Regional - 5 000 - Total: 3.3 229 000 2 000 000 209 000 936 000 294 439 2 125 531 Budgetary comments and trends The regular budget is still insufficient to meet the needs o f the programme, and voluntary donations will be required for many activities. 3.3.1 Action program m e on essential drugs WHO targets by end 2001 • 15 countries, in priority the least developed countries in the Region, will be implementing national drug policies and promoting the rational and efficient use o f drugs • system fo r monitoring drug policies to be operational EUR/RC48/8 page 63 2000-2001 Products Projections for 2002-2003 Promoting rational and efficient drug use Continued Policies on efficient use o f drugs Guidelines and tools for rational drug use A system for monitoring of, and training in, prescribing Support to rational drug use network Analysis o f and training in economic aspects o f drug supply Development work with EuroPharm Forum Development and implementation o f national drug policies through Continued country support Development of national drug policies Strengthened national drug regulatory systems National drug lists and formularies Guidelines for, and training in, rational drug use Analysis of drug financing; support to development o f drug financing schemes, pricing and reimbursement mechanisms EUR/RC48/8 page 64 Regional situation and targets By the year 2000, there should be structures and processes in all Member States to ensure continuous improvement in the quality o f health care and appropriate development and use o f health technologies. Managing the quality o f care is important because quality can influence health outcomes, because poor quality may damage health, and because quality influences the effectiveness o f the care provided and the cost o f treatment. Management of health care is the merger of continuous quality o f care development (QCD) and the tools for monitoring and assessing the outcome of health service activities. A model of quality management for specific diseases and conditions has been developed and tested by EURO and is being implemented, to various degrees, in virtually all European Member States The basic concept of QCD has been developed as a structural framework and is the basis for national QCD policies endorsed by government in a number o f Member States. WHO's role QCD is based on the classification of quality through a number o f multi-layered indicators for specific diseases and conditions. These quality indicators are agreed by consensus among health care authorities, professionals and financing bodies throughout Europe and become part o f core quality data sets, which provide the frameworks for data collection, analysis, evaluation and feedback. Work will continue on (a) reaching a European consensus on additional sets o f quality indicators; (b) testing indicators through demonstration projects in Member States; (c) implementation o f QCD in Member States; and (d) promotion of national QCD policies by individual Member States. Evaluation - main achievements and constraints A series of “tools” - either population-based (aggregate, anonymous data to be used by decision-makers for optimal allocation of available resources) or individual-based (for the health care provider to monitor, assess and reorient his or her clinical practice) - have been developed. Quality indicators have been developed for diabetes mellitus, surgical wound infections, oral health care, orthodontics, depression care/prevention o f suicide, and perinatal/obstetric care. Changes made as a result o f the evaluation, with emphasis on the 1996-1997 biennium Work will continue on developing additional core data sets and testing indicators through demonstration projects in Member States. The possibility o f establishing a EURO network o f databases will be explored. 3.4 Q u a l i t y o f c a r e a n d h e a l t h t e c h n o l o g y Proposed resources by source of funds: 3.4 Quality of care and health technology Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 176 000 270 000 160 000 517 300 176 357 - Country 54 000 70 000 63 055 707 666 Regional - 5 000 - Total: 3.4 230 200 270 000 235 000 517 300 239 412 707 666 EUR/RC48/8 page 65 Budgetary comments and trends Despite the fact that the regular budget remains at practically the same level, voluntary donations have increased over the past biennia, and it is hoped that this trend will continue. 3.4.1 Technology for health care WHO targets by end 2001 • A t least one third o f Member States to have developed, endorsed and be implementing national QCD policies as part o f their health care reforms • Tools fo r QCD policy implementation to be available to all Member States at the various levels o f technology required by their various settings • At least ten major health conditions to be covered by quality indicators and core data sets and data banks • A t least five QCD “templates " for specific diseases and conditions to be available to Member States 2000-2001 Products Projections for 2002-2003 Tools for monitoring, evaluation and feedback o f data, based on Assessment o f the impact o f common European quality indicators and core data sets data collection, evaluation and feedback on the health of populations in Member States A basic framework and specific “template” components for a national Assessment o f the impact of QCD policy implementation o f QCD policy in Member States Tools for data collection and analysis on the Internet for immediate evaluation of the outcome of health care Continued EUR/RC48/8 page 66 EUR/RC48/8 page 67 4. PROMOTION AND PROTECTION OF HEALTH Policy orientation and strategic priorities The Organization’s Ninth General Programme of Work (1996-2001), the renewal of the HFA policy and the 1997 Jakarta Declaration on leading health promotion into the twenty-first century all emphasize the importance o f influencing the social, economic and other factors that play such a large part in determining people’s health. Since the adoption o f the Ottawa Charter in 1986, awareness and knowledge o f the importance of health promotion has increased in all Member States. At the same time, considerable social and economic changes have taken place within Europe, and the conditions affecting people’s lives have also altered greatly. It is imperative to examine these new circumstances and devise the kinds o f strategy that are best suited to dealing most effectively with them. Since the health o f the population can be maximized only by investing in areas that influence the key determinants o f health, there is a need to focus attention more sharply on the underlying social, economic and environmental processes that create health. It is, therefore, crucially important to sustain health-promoting action by a wide range o f means, including educational, legislative, fiscal and organizational measures. In order to achieve this, the institutional capacities for health promotion and protection will need to be broadened, developed and strengthened at policy-making and operational levels in most Member States. For such an approach to succeed, health must increasingly be seen as a sound social investment. The promotion and protection o f the health of the population requires an approach through which diverse or conflicting interests can be accommodated and cooperative action taken. It includes formal institutions empowered to enforce compliance and involves nongovernmental organizations, civil society, the public and private sectors and the media working together for health. Integrated activities to increase opportunities for a healthy start in life (by means o f health promotion and protection programmes and policies for children and young people) will be a major priority area in the biennium 2000-2001. Action to protect and enhance the health o f adults will also be pursued through a range o f programmes and technical support delivered within the so-called “ life-cycle” approach. In the past, health development policies and programmes often tended to look at the population’s health needs in a too fragmented way. By choosing life-long intervention strategies directly linked to key determinants of health affecting the social, economic and physical environment, this approach can have more sustained and fundamental impact. The strategy is one that naturally can be adapted to the specific requirements of different age groups. It will also be possible to include lifestyles and social issues relevant to promoting and protecting the population’s health. EUR/RC48/8 page 68 Interdepartmental project - Health and work Under the umbrella o f “Health and Work”, various activities will be strengthened in the biennium 2000-2001. The project will include three interrelated elements; the first two (occupational health and health promotion at the worksite) will be further integrated, to yield the greatest health gain in the working population and foster good practice in health management at work. The third element, under the title “Healthy Company”, will aim to ensure that organizations, both private and public, become more and more health-promoting. Health-promoting enterprises will have an impact on increasing social and health gain in the population outside the working premises, and they will foster economic, social and community development in an equitable, sustainable and health-promoting way. There is an increasing amount o f evidence to show that organizations can play a major role in increasing community access to the determinants o f health, strengthening social cohesion and social capital, improving and increasing the community’s coping resources and improving the local environment. By subscribing to these goals, organizations can become health-promoting enterprises. All these factors are related to opportunities for health development. As such, the health-promoting enterprise initiative is a major follow-up o f the Fourth International Conference on Health Promotion: New Players for a New Era (Jakarta, 1997). The interdepartmental project will also build on and ensure implementation o f the outcome document from the Third European Ministerial Conference on Environment and Health (London, 1999) on good practice in health and environment management in industrial and other enterprises. This project has been allocated US $100 000. EUR/RC48/8 page 69 4.1 R e p r o d u c t i v e , f a m i l y a n d c o m m u n i t y h e a l t h a n d p o p u l a t i o n i s s u e s Regional situation and targets: By the year 2000, the health o f all children and young people should be improved, giving them the opportunity to grow and develop to their fu ll physical, mental and social potential. By the year 2000, there should be sustained and continuing improvement in the health o f all women. By the year 2000, accessible and effective education and training in health promotion should be available in all Member States, in order to improve public and professional competence in promoting health and increasing health awareness in other sectors. By the year 2000, life expectancy at birth in the Region should be at least 75 years and there should be a sustained and continuing improvement in the health o f all people aged 65 years and over. By the year 2000, the health o f workers in all Member States should be improved by making work environments more healthy, reducing work-related disease and injury, and promoting the wellbeing o f people at work. A sense o f coherence, where life is experienced as comprehensible, manageable and meaningful, is a great health resource for all people. Health is created if people are confident that life makes sense emotionally, and if they have adequate resources (mental, physical, emotional, social and material) to meet whatever demands are placed on them. As outlined above, this sense o f coherence must be built up from infancy and childhood through a range o f family, kindergarten and health care experiences. Policies that have an immediate effect on young people, as well as on the settings in which they learn, work, live or spend leisure time, should be oriented towards strengthening this sense o f coherence. Eating habits are determined in infancy and childhood, so food and nutrition policies should include strategies to promote breastfeeding and complementary feeding and to improve children’s diets, thus supporting health and preventing nutritional deficiencies. Many women face a great burden o f ill health since they often fulfil multiple roles as worker, home­ maker and informal carer. The health o f women can be improved if social policies support them in carrying out their multiple roles and encourage men to share the duties o f family life; and if Member States and other actors promote a gender perspective in all policies and programmes so that, before decisions are taken, an analysis is made o f the effects they may have on both women and men. Population aging is the most significant demographic trend worldwide and is particularly pronounced in the European Region. Eighteen out o f the 20 countries in the world with the highest percentages o f older people are in the European Region, and the elderly themselves are growing older. In 1993, people aged 80 years and above constituted 16% of the elderly over 65 in the developing countries. This proportion is expected to increase to over 30%. These changes obviously have ramifications for public health. Cardiovascular diseases are the main causes o f death in old age, followed by neoplasms and respiratory diseases. The last years o f life are frequently accompanied by an increase in disability and sickness, including dementia, one o f the main reasons for institutionalization. The elderly take more than 50% of all drugs prescribed. Health in old age is determined by patterns o f living, exposure to health hazards and opportunities for health protection over the life course. Member States need to develop and promote the notion of EUR/RC48/8 page 70 disability-free or active life expectancy and to focus on functional status and active living.-Although - about one third o f patients in PHC facilities in many countries are elderly, the curricula for GPs do not include geriatrics and geriatric psychiatry. Work-related ill health causes a significant burden to national economies in all Member States and accounts for much preventable suffering, illness, premature retirement and death. Indicators of occupational health used in most countries reflect neither the importance o f the role and impact o f the workplace as a setting for people’s health nor the need for change in occupational health practice. Part of the east-west health gap in Europe may be related to differences in working cultures, the quality of occupational health care provision and workplace health promotion. WHO’s role Activities will focus on improving the health care o f neonates, infants, children and young people, with specific action in the field o f appropriate medical technology, nutrition and health information and education. The concept o f a holistic approach to birth and perinatal care will continue to be promoted. The development o f indicators o f the quality o f perinatal care and measures to improve the quality of maternal and child care will be continuously reviewed. Further training will be organized on assessment of appropriate technology in child care, particularly for early neonatal and infant care but also with regard to WHO concepts and standard practices in child health. Interdepartmental project—A healthy start in life An integrated project entitled “A Healthy Start in Life” will be developed. It will draw together partners from different areas in the Departments o f Health Promotion and Disease Prevention, Health Policies and Services, Environment and Health, and Country Health Development, including the programme on quality o f care and technologies (QCT) and taking account o f genetic components. The focus will be on integrating and orienting policy-making structures towards promoting the health of children. The provision o f supportive environments will play a crucial role in disease prevention, as will training programmes for professionals, trainers o f trainers and local community activists. One innovative method used will be the introduction o f participatory and interactive means o f communicating, learning and informing. Reorienting health services to meet the needs o f the target age group and act in a more effective way will be another focus o f the project. This will include action with other sectors which have a direct or indirect impact on children’s health, such as welfare and social services, education, leisure and recreation. In addition, activities will be included which encourage more effective use o f health services by the age group and their carers. This project has been allocated US $150 000. WHO will provide leadership, policy advice and country support for effective investment in adolescent health. An integrated approach, offering an extensive support infrastructure is needed to help countries, regions and groups be more effective in addressing the health and wellbeing o f young people. This integrated approach will involve collaboration between programmes already targeted at young people, as well as between international organizations working in relevant areas, and it will also bring in public and private sectors as well as NGOs. Activities will be based on the ideas and principles o f the updated HFA policy. The regional HFA target set for wom en’s health by the year 2000 was not reached, mainly because o f the socioeconomic transition in eastern Europe and the NIS. Women’s health will therefore remain one o f the priority areas in 2000-2001, not only with respect to technical assistance to CCEE/NIS but also for Member States in western Europe. The networks o f women’s health institutions, multi-city action groups EUR/RC48/8 page 71 and collaborating centres on women’s health created in the past biennium will continue to remain important vehicles for promoting the implementation o f comprehensive women’s health policies. The joint WHO/UNFPA projects on reproductive health/family planning in CCEE/NIS will be progressively implemented. The findings of surveys o f the reproductive health o f adolescents will be further disseminated and accompanied by strategic guidelines for Member States. Appropriate information targeted at adolescents will be developed and distributed to young people in all Member States. WHO’s role regarding aging has been laid down in resolution WHA32.25: to promote health and wellbeing throughout the entire lifespan and to assist Member States in developing strategies to ensure the availability and provision o f comprehensive and holistic health care to elderly populations. In close cooperation with WHO headquarters, a EURO programme on Aging and health will be established. Its overall aims will be to help people maintain their autonomy in old age, to encourage solidarity between generations, to enhance the role o f older people as a resource for their families and the community, to promote programmes o f community-based health care for aging individuals, with particular emphasis on health promotion and self-care, and to create more opportunities for rehabilitation. Encouraging countries to develop and implement policies for healthy aging along these principles is the goal o f the programme. This will be done through information and advocacy for healthy aging as an integral part of public health and social development. An essential component will be upgrading the competence o f care providers within the health and social welfare system to respond and deal appropriately with the changes that occur as part o f the normal process o f aging. WHO will initiate and support a financially self-sustained, collaborative network within European industry and other workplaces/enterprises aimed at promoting a “Healthy Company” approach. This will tackle health promotion and disease and accident prevention, encourage assessment o f the health impact o f industrial products, and foster the role o f private industry as an active partner in local HFA- oriented community projects. In collaboration with EU and the International Labour Organization (ILO), WHO will also support the development o f occupational health information systems. Evaluation - main achievements and constraints In 1998-1999, WHO is continuing to advocate the integrated management o f childhood illness (IMCI) in selected countries, to promote breastfeeding and to introduce baby-friendly hospital initiatives (BFHI), as well as the principles o f perinatal care and appropriate technology in neonatal care. The aim o f the OBSQID project (obstetrical quality development through the integrated use o f telematics) has been to identify a set of quality indicators for perinatal care that are acceptable to as many centres, regions and countries as possible. The indicators served as a basis for the collection of data in 1994-1999, and this in turn has triggered technical cooperation between a number o f Member States. The project has been instrumental in compiling a picture of health care needs in this area and will be essential for continuous quality o f care development. The biennium 1996-1997 also saw increased investment in improving the reproductive health of women in all countries of the Region, and especially in central and eastern Europe and the NIS, both from WHO as well as from other agencies o f the United Nations system, notably UNFPA, UNICEF and the Joint United Nations Programme on HIV/AIDS (UNAIDS). The achievements o f 1998-1999 will be built on in the next biennium. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium The genetic determinants o f health tend to have their most marked effects in early and middle life, making a major contribution to infant and childhood mortality, chronic morbidity and premature onset o f common disorders. Among these, the most achievable targets are those related to prevention o f a measurable proportion o f cases o f severe congenital malformations, Down’s syndrome, haemoglobin disorders and cystic fibrosis. Although the new breakthroughs in genetic research have not been generally EUR/RC48/8 page 72 accepted, they open up very important new public health approaches in European Member States, and a programme component to look at these issues now is called for. Over the past two biennia the programme on the Elderly, Disability and Rehabilitation has been classified as a lower priority, but it will be re-established in 2 0 0 0 - 2 0 0 1 in view o f the recommendations o f an advisory group. Contacts with collaborating centres will be revitalized and other potential partnerships will be identified. Since 1999 has been designated the International Year o f Older Persons, this will give impetus to the establishment o f a programme on aging and health in the year 2 0 0 0 . The high-risk period for mortality and morbidity o f young children is when complementary foods are introduced. The aim here is therefore to focus on the weaning period and ensure that strong policy guidelines exist to promote the development of good dietary habits at a young age. Other elements contributing to morbidity o f young children are accidents and battering. Industry and other enterprises will increasingly be invited to exchange experience and develop a European health and environment management strategy. The strategy will stress economic appraisal and be based on integration of all approaches used to achieve a health gain at work, particularly occupational health, rehabilitation and workplace health promotion. Proposed resources by source of funds: 4.1 Reproductive, family and community health and population issues Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 536 000 1 400 000 643 400 4 504 100 311 401 Country 267 000 172 500 177 196 2 343 833 Regional - 8 000 Total: 4.1 803 000 1 400 000 823 900 4 504 100 488 597 2 343 833 Budgetary comments and trends Extrabudgetary funds will have to be found for implementation of the Aging and Health programme. The network of WHO collaborating centres will be mobilized to contribute to the programme. 4.1.1 R eproductive health WHO targets by end 2001 • Majority o f countries in the Region to have adopted and implemented comprehensive reproductive health policies and strategies • A t least five countries to show a decrease in teenage pregnancy and abortion rates • Increased use o f modern, effective methods offam ily planning in all Member States • Increased use o f comprehensive sexual health education strategies in all Member States 2000-2001 Products Projections for 2002-2003 Reproductive health strategies, policies and improved services, as well Continued as promotion o f sexual health based on the recommendations o f the relevant international conferences EUR/RC48/8 page 73 Implementation o f country projects in reproductive health, in close cooperation with UNFPA Issue o f the newsletter Entre nous Annual consensus meetings o f focal points on regional reproductive health priorities Annual meetings of the scientific advisory group on training in reproductive health Symposium on women’s health priorities in EU Development o f an outline for a programme on genetics Continued Continued Continued Continued Follow-up 4.1.2 Child health WHO targets by end 2001 • 25% increase in the number o f countries with perinatal care services • 25% increase in the number o f countries using new WHO indicators fo r infant, child and adolescent health • 25% increase in the number o f designated baby-friendly hospitals • 30% increase in the number o f countries showing increased breastfeeding rates • 30% increase in the number o f countries with high infant and child mortality rates due to infectious diseases and malnutrition using IM CI approach • ten countries to have included child protection in their public health policies and have strategies to implement child protection • ten countries to have established nutrient reference standards and translated them into practical recommendations 2000-2001 Products Projections for 2002-2003 Extension o f the European Longitudinal Survey on Pregnancy and Childhood (ELSPAC) to include additional CCEE/NIS Continued Extension o f implementation of the IMCI approach in pilot areas and review of the experience gained Continued Review o f appropriate methods for implementing perinatal care principles and ensuring a provide holistic approach to birth and infant care Continued Set o f indicators for monitoring infant, child and adolescent health, morbidity and mortality Continued Priority actions within national environment and health action plans (NEHAPs) to reduce and prevent exposure o f children to environmental health risks (water- and food-related diarrhoea, respiratory disease due to air pollution) in all Member States with high infant mortality Continued Practical implementation of European strategies on child protection and review of the experience gained Continued EUR/RC48/8 page 74 4.1.3 A dolescent health WHO targets by end 2001 • Trends in adolescent health reviewed through surveys and European comparative research • Policies developed which will create a supportive family, social and community environment fo r adolescents and young people 2000-2001 Products Projections for 2002-2003 Cross-national study o f health behaviour in school-aged children (HBSC) Pilot approaches to dialogue with young people on sexual health and Continued reproduction in selected European countries Review of appropriate methods to reach young people and to provide Continued information and support with regard to health needs, including mental health and social support Special reproductive health services for young people within the Continued framework o f country projects co-executed with other United Nations agencies (in particular UNFPA, UNICEF and UNAIDS) 4.1.4 W o m e n ’s h ea lth WHO targets by end 2001 • Active safe motherhood programmes in 25% o f European countries • A t least five countries with decreased maternal mortality and morbidity rates • Increase in number o f countries participating in WHO data collection efforts • Violence against women included in national agendas on wom en’s health 2000-2001 Products Projections for 2002-2003 National databases on obstetrics and perinatal care (based on W HO’s Continued OBSQID indicators), to identify best practices. Evaluation o f the impact of changes in obstetric practice and introduction o f the holistic approach to birth Periodic meetings o f a women’s health forum that links Continued representatives o f Member States, o f bodies implementing strategies such as multi-city action plans for women’s health, and o f the European network o f women’s health institutions Technical assistance with the implementation o f Safe Motherhood Continued programmes Technical assistance with the development o f programmes for the Continued prevention of violence against women EUR/RC48/8 page 75 WHO targets by end 2001 • A t least five countries to be introducing or strengthening intersectoral policy development on healthy aging, ensuring equitable access to health services and promoting and protecting the health o f older people 4.1.5 A ging and health 2000-2001 Products Projections for 2002-2003 Information on and analysis o f intersectoral policies on healthy aging Continued in European countries Strategies for advocating healthy aging Continued Model community-based programmes for service delivery and Promotion o f training strengthened family care and self-care packages on care for healthy aging Development o f quality o f care indicators, databases, feedback Quality pilot projects for information systems aging and health 4.1.6 O cc u p a tio n a l h ea lth WHO targets by end 2001 • A t least five pilot countries to be implementing good practice in health and environment management, including chemical safety at work, as a follow-up o f the Third European Ministerial Conference on Environment and Health in 1999 • At lease five pilot countries implementing guidelines on quality management in occupational health services • Improvement in occupational health and workplace health promotion information system using Internet and other means o f information exchange 2000-2001 Products Projections for 2002-2003 Assessment of the incidence and prevalence of diseases and accidents Broadened scope and related to the working environment in selected Member States coverage o f the assessment Occupational health indicators and country profiles on Additional countries join the World Wide Web home pages o f WHO collaborating centres telematic network EUR/RC48/8 page 76 4 .2 H e a l t h y b e h a v i o u r a n d m e n t a l h e a l t h Regional situation and targets By the year 2000, the health-damaging consumption o f dependence-producing substances such as alcohol, tobacco and psychoactive drugs should have been significantly reduced in all Member States. By the year 2000, accessible and effective education and training in health promotion should be available in all Member States, in order to improve public and professional competence in promoting health and increasing health awareness in other sectors. By the year 2000, there should be a sustained and continuing reduction in the prevalence o f mental disorders, an improvement in the quality o f life o f all people with such disorders and a reversal o f the rising trends in suicide and attempted suicide. By the year 2000, all settings o f social life and activity, such as the city, school, workplace, neighbourhoods and home, should provide greater opportunities fo r promoting health. There is currently a significant gap between the eastern and western parts o f the continent in the amount o f curative and preventive care provided to individuals with psychiatric problems, and in the philosophy behind that care. The resources o f communities, e.g. families and neighbourhoods, in opening roads to social participation for individuals affected by mental disorders remain underutilized. M ental health reforms should critically reappraise beliefs about mental illness, suicides and depression. In many Member States, primary health care does not consider mental health its responsibility. Because o f this, new approaches to diagnosis and treatment, designed for use in general health settings, remain unused. The use of alcohol, illicit drugs and tobacco are among the most important risk factors for ill health in the Region. Together they account for 24% of the disease burden. During the mid-1990s, the use of alcohol, illicit drugs and tobacco remained largely stable or decreased in the western part o f the Region but increased in the eastern part. In two thirds o f countries, cigarette use was increasing among young people who, along with women, continue to be a target group o f the tobacco industries. Alcohol-related harm is particularly high in the eastern part of the Region and is responsible for a large proportion of the reduced life expectancy in the countries o f the former Soviet Union. Forty per cent o f all AIDS cases in the European Region result from intravenous drug use. Despite a general acceptance o f the key importance o f a strong health prom otion strategy, very few countries have implemented robust programmes and policies. The growing awareness that the promotion o f people’s health cannot depend upon the health care sector alone has not yet resulted in a systematic harnessing of the sectoral and intersectoral potential for health development. Legislative, financial, educational, organizational and managerial support to health promotion should therefore be strengthened and investment for health increased. In achieving this target, participatory mechanisms should be used at national, regional and local levels to involve people in policy-making, implementation and evaluation. Securing the political, social and economic commitment to creating conditions that are conducive to good human health depends greatly on people having access to health information that is accurate, relevant, readily available and impartial. Rapidly expanding telecommunication capacities are increasingly shaping health behaviour and opinions about and responses to new health laws, regulations, and risks at local, national, regional, and global levels. Mechanisms and strategies are needed that can effectively EUR/RC48/8 page 77 communicate health policy and promote informed debate among both technical and non-technical audiences throughout Europe. Cities represent an ideal level o f decision-making for developing and supporting the whole range o f health-promoting settings. Local governments can catalyse intersectoral cooperation and community participation and create the awareness, the organizational preconditions and the political climate to promote health in various settings o f everyday life such as schools, workplaces, health centres, hospitals, food markets, prisons and universities. WHO’s role The Regional Office will continue to play its role o f catalyst in bringing together the numerous groups, bodies and networks active in the field o f mental health. The review of psychiatric services in European countries, which will be published in the biennium 1998— 1999, will recommend the continuation o f data collection and the maintenance and further development o f the regional database. A EURO conference on mental health, to be held in 2001, will attempt to challenge the view prevailing in political circles o f Europe that investment in mental health brings no returns. The conference will argue that mental health care reforms yield considerable returns in terms of reduced mortality and morbidity, and especially in the form of better quality of life, protection o f human rights, enhanced community resilience in the face o f adversity, and savings on the direct and indirect costs o f care. The implementation, monitoring and evaluation o f intercountry and country-based activities related to the European Network o f Health Promoting Schools (ENHPS), a joint initiative o f EC, CE and the Regional Office, will be strengthened. The new interdepartmental initiative on healthy companies will also be a main target area for EURO work. The Regional Office, acting in collaboration with Member States, will develop methods for making the transition from centralized service-led planning to needs-led planning. Instruments for classifying care in mental health, for monitoring progress in action and for measuring trends in the mental health status of the general population are top priorities. The Action Plan for a Tobacco-free Europe and the European Alcohol Action Plan will continue to be the main vehicles for introducing stronger measures to promote Europe-wide intersectoral action against alcohol and tobacco. The creation o f a Committee for a Tobacco-free Europe will bring together a number o f international partners. A EURO conference on tobacco is to be held in 2001. A second phase of the European Alcohol Action Plan will be prepared for the five-year period 2000-2004. The Regional Office will continue its work on illicit drugs, in close cooperation with other international partners and with greater emphasis on harm reduction strategies. WHO is assuming a strong leadership role in placing health at the heart o f development. The renewal of the HFA policy has provided the opportunity to reflect and build on the achievements o f health prom otion in the European Region. The role o f WHO is to provide and strengthen its leadership in policy development for health promotion. The urban/local policy dimension is an essential aspect o f health promotion. Fostering integrated approaches to introducing initiatives which promote health in specific settings at the local level could maximize the impact of W HO’s efforts. The Regional Office has established the European Health Communications Network to: (a) recognize and promote awareness of the importance o f health communication; (b) bring communication professionals into the health sector and improve the relationship between health professionals, government and the media, particularly television; (c) support skills development and highlight good practice; and (d) make health EUR/RC48/8 page 78 information available through the media which is ethically and scientifically sound, relevant to current health concerns, reliable and understandable by target audiences. Evaluation - main achievements and constraints Although the vast majority o f countries in the European Region have some elements o f policy on addictive drugs, in many countries there is still a lack o f commitment and failure to implement comprehensive policy. Some countries in the eastern part o f the Region have recently re-established effective legislative frameworks. Transnational alcohol and tobacco companies have paid particular attention to countries in the eastern part of the Region, not just in terms o f advertising and promotion but also in the form o f investment in their manufacturing sectors. Compounding the problem for many of these countries has been a failure to regulate smuggling and collect taxes on all alcohol and tobacco products. In 1996, however, the World Health Assembly by resolution WHA49.17 called for the development o f an international framework convention for tobacco control. Activities, programmes and projects have been conducted in a variety o f regional and social settings such as cities, schools and workplaces. European and global networks like Health Promoting Schools, Healthy Cities and Health Promoting Hospitals have provided a context in which health promotion experience has been gained and shared. Scientific understanding o f the determinants o f health has increased. At the same time, considerable social and economic changes have taken place within Europe and the conditions affecting people’s lives are altering dramatically. In October 1996 a new regional comm unication strategy (entitled “Good work alone is not enough”) was formulated and adopted. It calls for the establishment o f organizational, regional and national policies for communication, and the targeting o f both technical and non-technical audiences with proactive communication. Activities have included the production and distribution o f a new regional newsletter {Health catalyst), use of electronic communication technologies (Internet/World Wide Web), the making o f new partnerships (with the BBC World Service and Worldwide Televison News), the development of a European health communication network (EHCN) and capacity-building seminars at country level. At the first meeting o f the EHCN in 1997, recommendations focused on developing the network and moving it in new directions, such as giving regional guidance for policy communicators and support to health broadcasters, particularly in CCEE. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium Greater emphasis is being placed on the development o f intersectoral coordinating committees to draw up national action plans on alcohol, illicit drugs and tobacco as part o f intersectoral public health and health promotion strategies. Other sectors, such as finance, judiciary, agriculture and transport are thus to be involved in the development and implementation o f public policy on alcohol and tobacco. Major lessons have been learned in the implementation o f WHO projects focusing on schools, cities, workplaces and health care settings, and on investment for health. EUR/RC48/8 page 79 Proposed resources by source of funds: 4.2 Healthy behaviour and mental health Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 558 600 1 172 500a 463 300 1 352 000 686 516 1 850 839 Country 227 700 376 700 206 288 - Regional - 15 000 9 876 - Total: 4.2 786 300 1 172 500 855 000 1 352 000 902 680 1 850 839 a Includes US $500 000 for a tobacco conference. 4.2.1 M ental health WHO targets by end 2001 • A t least six countries with strategic goals fo r mental health in terms o f improving health and reducing disability, mortality and suicide • A t least three countries with mental health policies outlining necessary service inputs, processes and links with other sectors • At least five countries with an operating mechanism fo r evaluating their mental health programme, based on WHO recommendations • A t least one country with strategic goals and a policy document on mental health promotion • At least three countries with demonstration projects o f care programmes fo r specified mental health problems based on primary care settings 2000-2001 Products Projections for 2002-2003 Position papers on methods for supporting countries in carrying out Development and distribution mental health care reforms, including monitoring and evaluation of of instruments mental health programmes Recommendations on mental health care modules o f demonstrated Follow-up with survey on efficacy for use in primary care settings and in health promotion response and impact on programmes in the Region countries’ policy Recommendations on community-based modules for psychosocial Follow-up with wider variety rehabilitation of patients with social dysfunction o f approaches and modifications Support for mental health care reforms at country level: training modules for reorientation o f curricula to community-based care and mental health promotion Preparation for a ministerial conference on mental health: the returns Ministerial conference on o f mental health care reforms mental health, 2 0 0 2 4.2.2 Substance abuse including alcohol and tobacco WHO targets by end 2001 • A t least 12 countries with effective well balanced policies on alcohol, based on the European Alcohol Action Plan • A t least 12 countries with effective well balanced policies on tobacco, based on the Action Plan fo r a Tobacco-free Europe • At least 12 countries with effective harm reduction policies in relation to illicit drugs • Reduced levels o f harm related to alcohol, drugs and tobacco in at least 20 countries EUR/RC48/8 page 80 2000-2001 Products Projections for 2002-2003 Action Plans for (a) a Tobacco-free Europe (third phase: 1997-2002); Fourth phase of Action Plan (b) tobacco-free cities; and (c) a strong Region-wide tobacco control (2003-2007) developed and network being implemented Committee for a Tobacco-free Europe Conference WHO European Conference on Tobacco (2001) Follow-up activities Six publications on action on tobacco Extended and updated European Alcohol Action Plan (third phase: 2000-2004). A strong Preparations for fourth phase Region-wide network for action on alcohol. Municipal action plans (2005-2009) Prevention of harm done by illicit drugs, joint action with the Greater emphasis on European Monitoring Centre for Drugs and Drug Abuse, the United implementation o f harm- Nations Drug Control Programme and CE reduction strategies Assistance in the prevention of drug use and concomitant HIV Continued, with emphasis on infection, especially in NIS harm reduction Regional information bases on tobacco and alcohol Continued and updated European Network on Health in Prisons Continued and extended 4.2.3 Health promotion WHO targets by end 2001 • Full involvement o f at least 80% o f Member States in the activities o f the European Committee fo r Health Promotion Development (ECHPD) • Monitoring o f the coverage o f health promotion development in 80% o f Member States • Investment appraisal and audit o f health promotion capacity in four Member States • Demonstration projects to test investment fo r health approaches in three Member States • 85% o f Member States covered by the European Network o f Health Promoting Schools • 65% o f Member States covered by the sixth WHO/EURO survey on Health Behaviour in School-aged Children (HBSC) • Establishment o f the European Network o f Health Providing Companies/Enterprises EUR/RC48/8 page 81 2000-2001 Products Projections for 2002-2003 Recommendations, standard-setting and networking for health Continued promotion through the ECHPD Regular update o f package o f policy tools, including national audit Continued reports and guidelines on key organizational, managerial and financial issues related to health promotion Database on health promotion policies in Member States Continued Methods for investment for health, including an integrated approach Continued, with both national to adolescent health and subnational focus Package for national dissemination o f information on the Continued Health Promoting School International report on the (fifth) Health o f Youth survey (2000) International report on the sixth survey (2 0 0 2 ) Criteria and protocol for a “Healthy Company” Network o f at least 100 healthy companies WHO/EURO Forum of Healthy Companies Health-promoting settings initiatives in selected project and national Evaluation and expansion network cities Biannual meetings of national network and multi-city action plan Continued (MCAP) coordinators. Monitoring and review of progress. Support for coordination o f the Health Promoting Universities MCAP 4.2.4 C o m m u n ica tio n s a n d p u b lic re la tio n s WHO targets by end 2001 • Adoption by 75% o f Member States o f EURO guidelines on public policy communications, disaster communications, and ethical media standards • Involvement o f all Member States in the activities o f the WHO European Health Communication Network (EHCN) • Establishment o f national health communication networks, starting with five countries • Production and distribution o f a regular (monthly) regional television and radio documentary series with partners 2000-2001 Products Projections for 2002-2003 Communication policy guidelines for Member States (2000) Further development o f guidelines Communication management for WHO events Communication training for staff, networks, collaborating centres and Continued EHCN Networking with media, policy communicators, health and Continued environment educators, activists and advertisers, through EHCN WHO Europe web site, regional newsletter, television and radio series Continued EUR/RC48/8 page 82 Regional situation and targets By the year 2000, there should be continuous efforts in all Member States to actively promote and support healthy patterns o f living through balanced nutrition, appropriate physical activity, healthy sexuality, good stress management and other aspects o f positive health behaviour. By the year 2000, health risks due to micro-organisms or their toxins, to chemicals and to radioactivity in fo o d should have been significantly reduced in all Member States. Food policy is determined in sectors such as agriculture, trade and industry, and finance, often with little thought to the impact on public health. Comparison o f diets in northern and southern Europe shows remarkable convergence, with a rapid rise in the consumption of meat, milk and sugar in the south so that the traditional “Mediterranean diet” is disappearing. Similar trends are apparent between east and west. With the enlargement o f the EU, it is vital that Member States collect information on the food intake and nutritional status o f their populations. The incidence of food contam ination is unacceptably high, even in the most highly developed countries, and foodbome diseases have reached epidemic proportions in several countries. New emerging problems, such as bovine spongiform encephalopathy (BSE), are creating additional concern among the public and the decision-makers. At national level, comprehensive food policies are needed, involving education and training and intersectoral collaboration to ensure effective food safety measures, in order to link food safety and food quality and to take nutritional aspects into consideration. WHO’s role WHO will encourage the development o f comprehensive food and nutrition policies based on data on nutritional status and food intake. WHO provides assistance to Member States concerning health information systems and recommends unbiased information from independent sources. WHO will provide normative standards, facilitate the sharing o f ideas between central, eastern and western Europe and promote healthy alliances between the voluntary and private sectors. There is a need to ensure that information on food safety is properly collected and circulated, to provide the basis for policy-making and monitoring. Health-oriented guidelines need to be constantly updated. There is a clear need for an international independent body to play a public health advocacy role vis-a-vis the strong economic forces acting within the food safety area. Implementation o f food safety policies in an intersectoral approach should help countries in their process o f accession to membership o f EU. Evaluation - main achievements and constraints The main emphasis has been on shaping food and nutrition policy and on strengthening national institutions so that they can build up public health policies, often with input from other agencies in the United Nations system (UNICEF and Food and Agricultural Organization (FAO)). Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium It is increasingly difficult for the health sector to influence the policies developed by the agri-business and food production sectors, which have a short-term vested interest in profit rather than a long-term perspective on health. There is, therefore, a need to develop an action plan on nutrition and food security, similar to those for alcohol and tobacco, and to have it ratified by the Regional Committee. 4.3 N u t r i t i o n , f o o d s e c u r i t y a n d s a f e t y The food safety programme, which was not operational during the biennium 1996-1997, restarted in June 1998. EUR/RC48/8 page 83 Proposed resources by source of funds: 4.3 Nutrition, food security and safety Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 130 400 50 000 139 000 520 000 194 813 Country 42 000 251 900 43 024 367 986 Regional - 5 000 Total: 4.3 172 400 50 000 395 900 520 000 237 837 367 986 4.3.1 N utrition WHO targets by end 2001 • A t least ten countries to be regularly producing nutrition information on the population and using this to update their fo o d and nutrition policies 2000-2001 Products Projections for 2002-2003 Review of nutrition policy status in Europe European Nutrition and Food Security Action Plans Workshops on food and nutrition policy development Training modules for PHC workers in nutrition and physical activity Continued 4.3.2 Food safety WHO targets by end 2001 • Development o f food safety information fo r public health policy • Development o f risk assessment methodology and principles fo r control o ffood contamination 2000-2001 Products Projections for 2002-2003 Recommendation on food safety surveillance and control Support to integrated policy development incorporating food safety and nutritional aspects in an intersectoral approach Health impact assessment among children of selected pathways of exposure to food contaminants and o f allergies related to contaminants in food Continuation o f activities Implementation o f these policies in support o f Member States’ process o f accession to EU Continued EUR/RC48/8 page 84 4 .4 E n v ir o n m e n t a l h e a l t h Regional situation and targets By the year 2000, all Member States should have developed, and be implementing, policies on the environment and health that ensure ecologically sustainable development, effective prevention and control o f environmental health risks and equitable access to healthy environments. By the year 2000, injury, disability and death arising from accidents should be reduced by at least 25%. By the year 2000, there should be effective management systems and resources in all Member States fo r putting policies on environment and health into practice. By the year 2000, all people should have access to adequate supplies o f safe drinking-water and the pollution o f groundwater sources, rivers, lakes and seas should no longer pose a threat to health. By the year 2000, cities, towns and rural communities throughout the Region should offer physical and social environments supportive to the health o f their inhabitants. By the year 2000, air quality in all countries should be improved to a point at which recognized air pollutants do not pose a threat to public health. By the year 2000, public health risks caused by solid and hazardous wastes and soil pollution should be effectively controlled in all Member States. The T hird European M inisterial Conference on Environm ent and H ealth (London, 1999) focuses on actions to be initiated to improve living and health conditions in Europe. Ministers o f health and o f the environment are expected to act on their commitments in six strategic priority areas: prevention, reduction and control o f water-related diseases; transport, environment and health; implementation o f NEHAPs; environment and health economics; involvement o f the public and NGOs; and good practice in health and environment management for industry and other workplaces. The biennium 2000-2001 will be the first o f several in which attention will be focused on taking action in these priority areas in cooperation with a wide range of partners (governmental, intergovernmental, nongovernmental and professional organizations; industry and the business community; the media; and the public). Considerable progress has been made in developing NEHAPs in almost all European Member States during the past three years, as a key mechanism for implementing environmental health policies. The programme will concentrate on developing a strategy to actively involve other sectors such as energy, transport, industry and agriculture. The public is an important partner in implementing the decisions taken at the Conference in London. The NEHAP implementation process will be a main instrument for giving effect to the Convention on public information and public participation in the environmental health decision-making process. Improvement o f policy instrum ents (e.g. the legal framework, the enforcement system and related environmental health services), education and training o f professionals, and environmental health economics will be the main areas o f activity by central government authorities such as ministries o f health and o f the environment. Driven by these broad policy concerns within and among Member States, action on sustainable, health outcome-oriented development will be directed towards a number o f key areas. These are outlined below. EUR/RC48/8 page 85 W ater and sanitation have a considerable impact upon health. Technical, financial and administrative solutions to problems of water management are available. Although progress has been made in providing access to adequate and continuous supplies o f safe drinking-water that meet the WHO Guidelines for Drinking-Water Quality in some countries, more than 100 million citizens in the Region still lack a safe and adequate water supply. New and re-emerging environm ental health hazards pose or are expected to pose serious problems to most European countries, especially in CCEE and NIS. The far-reaching and long-term potential health effects o f these environmental threats are particularly relevant to children. Regarding environment and health data, the challenge is to develop national and international health and environm ent geographical inform ation systems (HEGIS) capable o f relating the quality o f environment to the health status of the population, weigh its significance and measure the respective impact o f different hazardous factors on health and wellbeing. Environmental health situation analysis yields an overview of the main problems and dominant patterns and helps in selecting priority areas and issues where future action at local, national and international levels should be concentrated. T ransport continued its relentless development in the European Region, and especially in CCEEC/NIS. A number o f initiatives have been taken at the international level (e.g. Agenda 2000 and Trans-European Networks, the United Nations Economic Commission for Europe (UN-ECE) Regional Conference on Transport and the Environment, OECD initiatives on environmentally sustainable transport), but too little emphasis has been given to full integration of health arguments in the formulation o f transport policies. Such action is to be taken in follow-up to the Conference in London. Providing guidance on improving a ir quality and on preventing exposure to persistent environmental pollutants remains an important issue. Guidelines need to be issued on the use o f health risk evaluations for forming the basis o f national and international legislation, the capability for environmental health risk assessment in the Region requires strengthening and trends in exposure to environmental pollutants must be identified. Three long-term problems in environm ental radiation will continue to be health issues after the year 2000: the public health impact o f the Chernobyl accident, and in particular the International Thyroid Project; preparedness for and response to nuclear emergencies (the REMPAN project); and the public health impact o f exposure to radon in the domestic environment. Management o f municipal, industrial and healthcare wastes poses serious problems, both technically and financially, in many cities. The amount o f municipal waste generated in Europe is increasing each year, and in rural areas soil pollution is a growing concern. The problem is particularly acute in the CCEE/NIS. The WHO European Centre for Environment and Health, established in accordance with the recommendations o f the First European Conference in 1989 and with the support o f France, Italy and the Netherlands, is located in Nancy, Rome and Bilthoven respectively. The Nancy Project Office focuses on technical support to the CCEE and NIS in water supply, solid waste management and urban development. With a host agreement in place through 2001, the Rome Division covers environmental epidemiology; food safety; transport, environment and health; water and wastes; and radiation protection. The Bilthoven Division, with the host agreement running through 2000, concentrates on occupational health, chemical safety, and environmental health information systems and situation analysis. WHO’s role Three specific areas of ongoing activity at the Regional Office are o f particular relevance: • collaboration with other United Nations agencies to strengthen environmental health management practice in all Member States, with special emphasis on the expanding role and mandate o f EC in the Region; EUR/RC48/8 page 86 • implementation o f NEHAPs in follow-up to the Second European Conference on Environment and Health (1994); • development and implementation o f a WHO/UN-ECE “protocol on water and health” to the UN- ECE Transboundary Water Convention in Europe, as a major product of the Third European Ministerial Conference on Environment and Health (1999). The Third Environment and Health Conference is expected to give renewed impetus to activities designed to bring about environmental health improvements at local level. One aspect of local implementation will be the development of pilot studies on selected “demonstration” municipalities. WHO will concentrate on giving effect to the decisions taken at the Third Conference, working both with Member States and in cooperation with a wide range o f organizations, the media and the public. The European Environment and Health Committee has a special role to play here, building up partnerships between the environment and health sectors and international organizations and institutions. Synergistic planning o f environmental protection by social, health, education and economic sectors is a major component of regional planning. Urban planning should be based on participative processes and should not transfer environmental problems to rural areas. WHO will advocate a balanced approach to creating physical and social environments that are conducive and supportive to health and wellbeing. The main focus of the NEHAP programme will be to support the ongoing reforms, with emphasis on improving the main policy instruments, reforming professional education and training, and introducing better financing systems. WHO will also continue its programme on public information and communication in environmental health. The NEHAP Task Force will have a central role in leading this process. W HO’s European C entre for U rban H ealth will provide leadership and support to Member States to implement HFA-based policies and strategies at the city/local level through a process o f political commitment, networking, tool development and capacity-building. (The focus and goals o f phase III (1998-2002) of the urban health/healthy cities programme are described in section 2.2.) The NEHAP process has been identified as one o f the areas where EURO will support countries in their process of accession to membership o f EU, with NEHAP implementation linked to complying with the legal requirements laid down by EU legislation. To fight inequalities and protect vulnerable groups, especially children, from environm ental health hazards, WHO will support countries by providing methods, developing guidelines and tools and building capacity in environmental epidemiology and communication o f environmental health risks. It will also promote the formation of independent scientific fora to identify and fill existing gaps in the understanding of emerging environmental health issues, in close cooperation with other international agencies, NGOs, universities and national institutions, and it will advocate the importance o f health- promoting and sustainable policies in key economic sectors such as agriculture and tourism. The “vertical” programmes described below should all be supported at country level by the mechanism of NEHAP implementation. • WHO will further develop databases on environment and health, and help coordinate and consolidate the efforts o f different international and national organizations dealing with statistical information. Based on this information, WHO will evaluate the situation at regional level. The methodology developed by WHO, or its collaborators, will be widely disseminated through publications and workshops. WHO will also perform local situation analyses, assisting national authorities and providing a forum for exchange o f expertise. • WHO will develop health-based guidelines for w ater supply and sanitation and help to put them into practice through the “protocol on water and health”. EUR/RC48/8 page 87 • Information collected on a ir quality and exposure to environmental pollutants will be widely distributed in the form o f WHO publications or in electronic form, as an essential tool for international and national regulators in the field o f environmental health. Workshops and training sessions will also be organized. • In cooperation with other key international agencies, WHO will develop analytical tools to carry out integrated health impact assessment o f tran spo rt alternatives, conduct policy analyses and identify strategies with greatest overall benefits. By implementing a “Charter on Transport and Health” EURO will, together with pilot countries, create the conditions for promoting healthy and sustainable transport alternatives and ensuring that transport policies fully incorporate health considerations. • With regard to environm ental radiation, WHO acts as a facilitator and capacity-builder. More specifically, EURO will promote the communication o f reliable data and public health advice in case o f a radiation emergency, in the framework o f the REMPAN project and in close cooperation with the International Atomic Energy Agency (IAEA) and collaborating centres. • H ealth care waste and industrial waste management projects will be implemented to complement pilot projects on municipal solid waste. Between six and ten pilot studies o f solid waste management are envisaged, depending on the degree of intradepartmental coordination. Implementation at local level will concentrate on improving project design, project execution and the delivery of improved waste collection and disposal services to “at risk” population groups. Interdepartmental Project on Urban Health The main goals of the urban health project are: (1) to facilitate and promote in-house and country-level integrated approaches to HFA21-based urban health development; and (2) to accelerate and demonstrate the implementation o f such approaches in groups of committed countries/cities. Priority areas envisaged for the project include: • urban challenges and concerns: poverty and vulnerability; equity; health through economic regeneration; empowerment • policy processes and integration: health development/Agenda 2 1 planning; implementation o f the Environmental Health Action Plan for Europe (EHAPE) through urban planning; integrated development o f health-promoting settings Other key themes will be lifestyles, young people, and violence, while capacity-building will focus on national/local cooperation; local capacity for public health; and organized social support. This work wfllbe implemented in partnership with in-house units/programmes, collaborating centres and institutions, subregional project offices and WHO networks, on the basis o f Member States’ decisions in their NEHAPs. This project has been allocated US $100 000. Evaluation - main achievements and constraints In the biennium 2000-2001, EURO will reorient all programmes focusing on water issues towards implementation o f the WHO/UN-ECE protocol on water and health. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium In the area of environm ental epidemiology, higher priority will be given to issues requiring better scientific understanding (e.g. climate change, health effects o f the environment on children) and to the integration of health considerations in the complex system o f different social and economic interests. EUR/RC48/8 page 88 Work to give effect to WHO'recommendations on environm ental health hazards will be focused not - only on regional and national levels, but also on the local level. To guarantee adequate implementation of the programme on air quality in CCEE and NIS, international collaboration with UN-ECE has been formalized (through the Convention on Long-Range Transboundary Air Pollution). Fund raising for the In ternational Thyroid P ro ject cannot be sustained at the necessary level, and WHO may therefore facilitate the establishment o f a foundation to handle this aspect, restricting itself to handling the technical issues. Considerable efforts also need to be made to promote a quick and reliable response to nuclear emergencies (the REMPAN project). Based on the positive experience from 1996/1997, intercountry and country activities will be fully integrated, and country operations will rely much more on the principle o f “W HO’s essential presence”. An effort will be made to link country operations more closely with financing institutions and the technical programmes; to this end, different “instruments” will be tested, such as a Steering Committee for NEHAP implementation, an “implementation consortium”, and the United Nations Development Assistance Framework (UNDAF). Finally, steps will be taken to capitalize on the success o f subregional collaboration in sharing experience and conducting capacity-building exercises. T ransport activities result directly from one o f the lessons o f the biennium 1996-1997, that higher priority should be given to issues o f general relevance to the Region. Proposed resources by source of funds: 4.4 Environmental health Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 840 000 11 000 000 695 000 10 901 800 969 148 11 262 062 Country 333 000 401 000 310 236 Regional - 50 000 Total: 4.4 1 173 000 11 000 000 1 146 000 10 901 800 1 279 384 11 262 062 4.4.1 W ater supply and sanitation in human settlements WHO targets by end 2001 • WHO/UN-ECE “Protocol on water and health ” ratified by all Member States • Integration o f environment and health concerns in international/interagency programmes on international water bodies • Expansion o f the environmental health component o f the Mediterranean Strategic Action Programme so that (1) at least three international water body programmes have a specific health component and (2) the programme addresses pollution from land-based activities • Sustainable water supply and water resources/water services management projects implemented in up to ten demonstration cities or regions in CCEE/NIS EUR/RC48/8 page 89 2000-2001 Products Projections for 2002-2003 Water-related guidelines and models o f good practice Integration of “protocol on water and health” in the NEHAPs o f EU accession countries Establishment o f joint secretariat functions with UN-ECE, including monitoring, coordination and support for implementation o f the “protocol on water and health” Expanded Mediterranean Action Plan Water-related guidelines, including guidelines on safe recreational- water environments, jointly with WHO headquarters Seminars, workshops and study tours to demonstration cities 4.4.2 Environmental health in urban development WHO targets by end 2001 • Forty WHO Healthy Cities project cities committed to implementing an HFA-based health development plan: - Support to and consolidation o f national, subregional, metropolitan and thematic healthy cities networks. A t least 35 national networks to be operational in the European Region involving more than 2000 cities and towns - Policy and planning tools, training materials, and impact assessment procedures developed to facilitate attainment and evaluation ofphase III goals o f the Healthy Cities and interdepartmental urban health projects • Strategic/technical guidance fo r national and international multi-city action plans (MCAPs) on Agenda 21 and health: - Mediterranean network o f healthy cities established (EURO-EMRO cooperation) and working links developed with networks in other Regions - Three to four subregional support and coordination structures fo r healthy cities and urban health development established - Two pilot projects being implemented that focus on improvements to health protection from better health care waste management - Sustainable air, urban water and solid waste projects being implemented in up to ten CCEE/NIS and three non-CCEE/NIS demonstration cities or regions - A t least one interdepartmental activity launched with each Healthy City project, Health Promoting Schools project and Healthy Industries initiative Implementation o f “protocol on water and health” in all EU accession countries and EU member states Implementation o f the “protocol o f water and health” as part of an action plan for sustainable development in the Aral Sea basin and implementation o f NEHAPs in central Asian republics EUR/RC48/8 page 90 2000-2001 Products Projections for 2002-2003 Guidelines on housing and construction, indoor air contamination and health effects from construction materials, furniture and fuel Guidelines on healthy urban planning; demonstration projects in WHO project and national network cities; forum of city urban planners for training and exchange o f information Continued Regular meetings o f Agenda 21 city coordinators Continued Policy, decision-making and planning tools, training materials and Testing, translation, demonstration projects in the following areas: integrated approaches dissemination. Work on to health development and Agenda 21, equity, social exclusion, violence, migration and health, healthy youth, engaging the business sector, empowerment, accountability, health through economic regeneration, local public health infrastructures, urban indicators further development o f tools Mid-term review of phase III o f the Healthy Cities project; Completion of phase III identification and dissemination o f good practices; Healthy Cities evaluation. Open conference technical symposium (2 0 0 0 ) to mark completion of phase III (2003) Strategy for national/local cooperation on healthy and sustainable urban development, integrating and/or based on Member States’ priorities as defined in the NEHAP Implementation continued Regular meetings o f the forum of local directors o f public health: awareness-raising, capacity-building, exchange o f information Continued 4.4.3 Assessment o f environmental health hazards and risks WHO targets by end 2001 • Training in surveillance o f Creutzfeldt-Jakob disease (CJD) implemented in at least eight countries, including non-EU countries • Monitoring o f the early effects o f climate change on health implemented in at least eight countries • Minimum set o f indicators developed fo r conducting environmental performance reviews • Environmental performance reviews completed in at least seven CCEE/NIS • Methodology fo r assessment o f exposure to air pollution tested and implemented in at least three pilot countries • Impact o f classical air pollutants estimatedfor at least one third o f the population in the Region • Burden o f three groups ofpollution-related diseases analysed in one third o f the population o f the Region • Health and Environment Geographical Information System operational fo r at least three quarters o f the Member States EUR/RC48/8 page 91 2000-2001 Products Projections for 2002-2003 Indicators to assess the burden of tourism activities on public health Set of guidelines on assessing the environmental health impact of climate change Guidelines on healthy and sustainable tourism in the Mediterranean area Training package on CJD surveillance Training package on good practices in risk communication, incorporating the basic documents provided by EU member countries Report on monitoring the early effects o f climate change on health Reviews and conduct of environmental health impact assessments among children for selected environmental risks and indicators Indicators o f and training packages on the effects o f environmental hazards on children’s health Environmental health reviews o f selected CCEE and NIS Updated 1995-1996 database on mortality at subnational level to include environment situation, together with European Environment Agency (EEA) and EUROSTAT Geographically linked information at subnational level (including outbreaks o f communicable diseases and incidence o f notifiable diseases) on Internet Pilot project on assessing population exposure to air pollutants in selected European populations Health impact assessment o f air pollution and its use in pollution reduction programmes in selected populations Two pilot projects focusing on improvements to health protection from better health care waste management Implementation Implementation Follow-up activities Continue assessments Implementation Complete first round of reviews European Atlas on Environment and Health (1994/1995) supplemented with forecasting trends for the beginning o f the twenty-first century Improvement o f exposure/ response estimates based on new epidemiological studies Replication o f successful approaches in medical institutions 4.4.4 Promotion o f chemical safety WHO targets by end 2001 • Exposure to persistent environmental pollutants estimated in one third o f the population o f the Region • Use o f WHO air quality guidelines fo r standard-setting in CCEE and NIS in support o f the process o f accession to membership o fE U EUR/RC48/8 page 92 2000-2001 Products Projections for 2002-2003 A method for assessing exposure to persistent environmental pollutants Risk communication and risk reduction methods for CCEE and NIS Implementation Emergency management plans for major chemical accidents in selected countries, particularly in CCEE and NIS Implementation 4.4.5 Incorporation o f health concerns into environmental management WHO targets by end 2001 • All Member States to be implementing environmental health policies that ensure sustainable development and effective prevention and control o f environmental health hazards • Methods fo r integrated environmental health impact assessment and economic evaluation o f transport to be implemented in at least four countries • National networks o f environment and health NGOs established in five countries • Local environment and health projects in selected industries in at least three countries • Guidelines fo r environment and health (EH) services accompanied by capacity-building exercises involving the environment, health and economic sectors in five pilot countries 2000-2001 Products Projections for 2002-2003 NEHAP implementation strategy for achieving sustainable development through an intersectoral approach Framework for a transatlantic environmental health initiative WHO/EU/UN-ECE strategy for environmental health action plan for key economic sectors: transport, energy, agriculture, industry and tourism Framework for WHO/EU/World Bank (WB) public health reform in Europe with emphasis on the main policy instruments: legal system, enforcement and professional profiles Framework for WHO/WB/OECD/UN-ECE international programme on environmental health financing WHO/EEA strategy and guidelines for public information and participation in environmental health decision-making WHO/WB/UNDAF pilot project on NEHAP implementation Guidelines on health-promoting sustainable transport Training package on best practices in health-promoting transport policies Methods of integrated environmental health impact assessment and economic evaluation for transport WHO/EU/UN-ECE programme on NEHAP implementation Continued Continued Continued Implementation o f training packages EUR/RC48/8 page 93 International network o f NGOs in environment and health, consisting o f national networks in Member States Sustainable development plans integrating environment, health and economic concerns adopted by respective policy bodies in five countries EUR/RC48/8 page 94 5. INTEGRATED CONTROL OF DISEASES AND INJURY Policy orientation and strategic priorities Since the beginning o f the 1990s, a serious re-emergence o f communicable diseases has threatened the Region, affecting mainly CCEE and particularly NIS. The resurgence o f diseases such as diphtheria, sexually transmitted diseases (STDs), tuberculosis, malaria and even, at times, cholera has become a very serious problem in many countries. The diphtheria epidemic caused more than 170 000 cases and over 4000 deaths in the NIS between 1990 and 1996, representing about 95% of all diphtheria cases reported worldwide. HIV infection is falling significantly in western Europe but it continues to affect drug users and prostitutes in several countries of eastern Europe. Another major burden o f illness in the European Region is from cardiovascular diseases, cancer, chronic respiratory diseases, diabetes and accidents: these are responsible for three quarters o f all deaths and a large proportion o f morbidity and disability. The prevention and control o f communicable and noncommunicable diseases will remain major priority areas for the Regional Office, with focused in particular on the eradication o f poliomyelitis and its certification. EUR/RC48/8 page 95 EUR/RC48/8 page 96 5.1 E r a d i c a t i o n / e l i m i n a t i o n o f s p e c i f i c c o m m u n i c a b l e d i s e a s e s Regional situation and targets By the year 2000, indigenous measles, mumps, congenital rubella, diphtheria, poliomyelitis and neonatal tetanus should be eliminatedfrom the Region WHO's role Emphasis will be placed on making the European Region polio-free and on implementing the measles elimination strategy in all countries. WHO has to heighten the political commitment o f all Member States to attaining these goals and, for measles elimination, help find the necessary managerial and financial resources and work closely with other governmental and NGOs. Evaluation - main achievements and constraints Due to the huge political and socioeconomic changes in eastern Europe during the 1990s and the lack of political commitment in some western European countries, the goals of eliminating diphtheria, congenital rubella, measles and mumps could not be achieved. Neonatal tetanus, however, has been eliminated as a public health problem. Thanks to a sharp rise in polio control activities in the Region - mainly operations MECACAR (1995- 1997) and MECACAR Plus (1998-2000) - the eradication o f poliomyelitis from the Region is expected to be achieved by the year 2000. As a result o f successful polio immunization campaigns, only seven cases were reported from two countries in the Region in 19973. Surveillance o f acute flaccid paralysis (AFP) has greatly improved and, on average, reached the recommended level o f 1 AFP case per 100 000 population in at least 30 countries in the Region. However, most western European countries are not yet using AFP surveillance; instead they are employing alternative methods such as enterovirus surveillance. In 1996, a regional commission for the certification of polio eradication was established; since then, all European countries have initiated or completed the establishment o f national commissions for this purpose. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium As the measles elimination programme cannot reach its target by the year 2000, the situation has been carefully reviewed and a new target has been proposed for the year 2007. The strategic plan for measles elimination, as well as the plan of operations, the timetable and the resources required, have all been revised. The situation with regard to mumps, diphtheria and congenital rubella has also been reviewed. Proposed resources by source of funds: 5.1 Eradication/elimination of specific communicable diseases Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 90 000 3 000 000 100 000 91 591 790 880 Country 20 000 6 000 000 100 000 10 400 000 - Regional - 10 500 - Total: 5.1 110 000 9 000 000 210 500 10 400 400 91 591 790 880 3 By 1 April the 1998 figure was one case. EUR/RC48/8 page 97 Budgetary comments and trends The level o f budgetary and extrabudgetary funding for the biennium 1996-1997 was sufficient to support the most important activities and was increased for the biennium 1998-1999. The eradication of poliomyelitis in the European Region by the year 2000 was made possible through a collaborative effort with partners such as Rotary International, United States Agency for International Development (USAID), the US Centers for Disease Control (CDC) and UNICEF. A similar collaborative effort is needed to attain the goal of measles elimination, but it is uncertain if the desired level of extrabudgetary donations can be achieved. 5.1.1 Global eradication and elimination o f poliomyelitis WHO targets by end 2001 • No poliovirus transmission in the European Region • Poliomyelitis eradication certified in the western and central parts o f the Region 2000-2001 Products Projections for 2002-2003 Poliomyelitis eradication Continuation o f the certification process to declare the European Region polio-free Maintenance o f high quality o f surveillance for AFP/polioviruses in Continued all European Member States, with good laboratory support Mopping-up operations if and where needed Continued (if need be) Immunization activities: Immunization activities: - high level of routine coverage - maintain high level of routine coverage - mopping-up operations where appropriate - implement mopping-up operations where appropriate 5.1.2 R eg iona l e lim in a tio n o f m easles W H O targets by e n d 2001 • All Member States to have measles elimination plans 2000-2001 Products Projections for 2002-2003 Measles elimination Continued A laboratory network covering the majority o f Member States A functioning surveillance mechanism in all Member States Immunization activities: Continued - high-level o f routine coverage in all Member States (over 80%) - implementation o f elimination strategies Building o f a consortium Fund-raising for measles eradication EUR/RC48/8 page 98 5.2 C o n t r o l o f o t h e r c o m m u n i c a b l e d i s e a s e s Regional situation and targets By the year 2000, there should be no indigenous cases o f poliomyelitis, diphtheria, neonatal tetanus, measles, mumps and congenital rubella in the Region and there should be a sustained and continuing reduction in the incidence and adverse consequences o f other communicable diseases, notably H IV infection. While the aggressive measures to control epidemic diphtheria taken by countries and the international donor community have slowly brought the epidemic under control, other diseases have re-emerged and require increased attention. Sexually transmitted diseases have increased dramatically in almost all NIS and some other eastern European countries. While incidence rates o f AIDS cases are levelling off or decreasing in western Europe, recent outbreaks o f HIV infection among drug users in some NIS are alarming. The extensive spread o f HIV infection in the NIS started in 1996 and will continue to increase. There are dangerous contributing factors such as the high incidence o f tuberculosis. Extensive control efforts are required to control the spread o f other sexually transmitted infections, such as syphilis, gonorrhoea and chlamydia, which facilitate the spread o f HIV infection. The incidence o f and mortality due to tuberculosis are rapidly increasing in many eastern European countries, and the decline of tuberculosis in western Europe has levelled off, with immigrants mainly accounting for new cases. Immunization coverage for most childhood diseases is still at a level of 80%, and international assistance to the NIS has helped to re-establish immunization programmes. In some countries, diseases such as measles, mumps and rubella are close to elimination. However, there are still western and eastern European countries with insufficient vaccination coverage (below 80%). New vaccines have been introduced, mainly in western European countries. Endemic malaria, previously forgotten in Europe, re-emerged in the south eastern part o f the Region. A particular concern is the worldwide spread o f infectious agents resistant to antimicrobial drugs. This issue will be given more prominence and proposals will be made to tackle it with the help o f WHO headquarters. WHO's role WHO will assist Member States in strengthening national laboratory-based infectious diseases surveillance programmes to monitor diseases of public health importance and to detect emerging and re- emerging diseases. Such programmes should monitor new developments with regard to resistance to antibiotics and ensure rapid exchange o f information between Member States, regional networks, WHO collaborating centres and the Regional Office. Emphasis will be placed on helping Member States to sustain high immunization coverage for diseases covered by the Expanded Programme on Immunization (EPI), on achieving self-sufficiency in the supply o f vaccines, and on implementation o f hepatitis B, rubella, mumps and Haemophilus influenzae type B (Hib) immunization in all European Member States. WHO will also support the introduction o f new vaccines, such as rotavirus vaccine and pneumococcal and conjugated meningococcal vaccines, as well as combination vaccines. Evaluation - main achievements and constraints The intensive diphtheria control efforts - which prevented some 500 000 cases and 10 000-15 000 deaths - and the success o f polio eradication activities have been the main achievements. In addition, it was possible to ensure primary immunization in the NIS, to achieve self-sufficiency in vaccine supply in some NIS, and to initiate activities aimed at self-sufficiency in many other NIS. Universal immunization against hepatitis B and HiB was implemented in most western European countries, and improved combination vaccines have been introduced. In EURO, the human and financial resources for communicable diseases control have been increased and the necessary action could be taken - or at least EUR/RC48/8 page 99 initiated - in all programme areas. The main constraints were limited resources at national level in many of the countries in economic transition. International collaboration has been very much strengthened as a precondition for efficient work: the Interagency Immunization Coordinating Committee (IICC) is a good example o f this. An international task force for STD prevention and control was established, on the IICC model, in 1998. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium The proposed changes for the biennium 2000-2001 take into consideration the changing priorities described below. (a) Current priorities whose importance will increase: - To make the surveillance and control o f infectious diseases effective, particularly in the NIS and selected other eastern European countries - HIV/AIDS - support will be provided at country level through the regional component of UNAIDS - Implementation o f existing vaccines not yet widely used and introduction o f newly developed vaccines - countries most in need have only partly introduced the hepatitis B, rubella and Hib vaccines. (b) Current priorities whose importance will remain the same: - tuberculosis control - certification of poliomyelitis eradication and high quality surveillance for AFP and suspected polio - routine immunization programmes in all European Member States - control o f diarrhoea! diseases and acute respiratory infections (CDD/ARI) - malaria control. (c) Current priorities whose importance may decrease: - control o f other STDs - there is real hope that changes in policies and control measures now being put into effect can help to halt the spread o f syphilis and other STD in eastern European countries (in the other countries of the Region, STDs are not a priority problem) - self-sufficiency in vaccine supply - four NIS have already achieved this goal, and at least three others will achieve it by the year 2 0 0 0 . (d) No longer a priority - diphtheria control. Proposed resources by source of funds: 5.2 Control of other communicable diseases Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 196 900 1 500 000 272 900 1 756 300 702 433 2 386 962 Country 377 000 2 000 000 334 400 331 730 Regional - 36 000 Total: 5.2 573 900 3 500 000 643 300 1 756 300 1 034 163 2 386 962 Budgetary comments and trends - Regional budget resources have been planned to increase in the biennium 1998-1999. However, there is some uncertainty whether the requested extrabudgetary donations will materialize, and special resource mobilization efforts will therefore be made. 5.2.1 Vaccine-preventable diseases WHO targets by end 2001 • Reduction o f diphtheria incidence to pre-epidemic levels EUR/RC48/8 page 100 2000-2001 Products Projections for 2002-2003 Strengthed immunization programmes Campaigns for the elimination o f measles and routine immunization Implementation o f WHO recommendations on CDD/ARI 5.2.2 D ia rrh o e a l an d a cu te r e s p ira to ry d isease co n tro l WHO targets by end 2001 • Implementation o f WHO recommendations on CDD/ARI in leading paediatric institutions in all countries 2000-2001 Products Projections for 2002-2003 Implementation o f WHO strategies for the control of diarrhoeal and Sustain and reinforce acute respiratory diseases through support to national CDD/ARI established CDD/ARI programmes activities in the Region Health professionals skilled in management o f diarrhoeal and acute Continued promotion o f the respiratory diseases. Training programmes for integration of Integrated Management of CDD/ARI programmes with other child health interventions Childhood Illness (IMCI) Implementation of “Protocol on Water and Health” in order to control Continued water-related diarrhoeal diseases 5.2.3 Tuberculosis WHO targets by end 2001 • National tuberculosis control policies and programmes based on WHO recommendations in priority countries • Reduction in the morbidity and mortality associated with tuberculosis EUR/RC48/8 page 101 2000-2001 Products Projections for 2002-2003 Support to national programmes, including programme monitoring, Continued assessment, evaluation, surveillance Training programmes for national and district-level TB programme Continued managers, laboratory technicians and heads o f laboratories Tools for TB control (guidelines, translations o f advocacy materials) Continued development of tools for TB control Adult lung health initiative Establishment o f laboratory support network International fora on TB control, including surveillance 5.2.4 Emerging diseases surveillance and control WHO targets by end 2001 • National laboratory-based infectious disease surveillance programmes capable o f monitoring diseases o f public health importance and detecting emerging and re-emerging diseases, including new developments in resistance to antibiotics, in the majority o f Member States 2000-2001 Products Projections for 2002-2003 Assistance with strengthening national laboratory-based infectious Rationalization o f laboratory- diseases surveillance and control programmes through electronic based infectious diseases exchange of information between national programmes, regional surveillance networks, WHO collaborating centres and WHO Improved resistance monitoring programmes and implementation of Upgrade o f electronic resulting measures information systems to incorporate improved techniques Assessment of implementation o f the revised International Health Regulations 5.2.5 Other communicable diseases WHO targets by end 2001 • A sustained and continued reduction in the rate o f transmission o f H IV infection and STDs in all countries 2000-2001 Products Projections for 2002-2003 Support to national programmes for the prevention o f HTV infection Continued Assistance to countries with STD control Continued Stabilization o f STD incidence Continued EUR/RC48/8 page 10 2 Comprehensive care for HIV-infected people and those with AIDS Continued Integration o f HIV/AIDS care in the existing health system Continued infrastructure WHO integrated approach to control HIV/AIDS and STD epidemics Continued Reliable and effective surveillance for HIV/AIDS and other sexually Continued transmitted diseases Establishment o f a consortium for mobilization and coordination of Continued responses to the rapidly evolving STD crisis 5.2.6 C o n tro l o f tro p ic a l d iseases (m a la ria ) WHO targets by end 2001 • Incidence and adverse consequences o f malaria reduced in endemic countries o f the Region 2000-2001 Products Projections for 2002-2003 Support malaria control activities in endemic countries, including Maintain control activities in human resources development countries still in need Strengthen malaria surveillance in south/eastern parts o f the Region Certification o f malaria elimination in selected countries Implement water management strategies to reduce and control Implement as appropriate in Anopheles breeding sites and vector distribution (in Turkey) Azerbaijan, Tajikistan, Turkmenistan EUR/RC48/8 page 103 5.3 C o n t r o l o f n o n c o m m u n i c a b l e d i s e a s e s Regional situation and targets By the year 2000, there should be a sustained and continuing reduction in morbidity and disability due to chronic disease in the Region. By the year 2000, mortality from diseases o f the circulatory system should be reduced, in the case o f people under 65 years by at least 15%, and there should be progress in improving the quality o f life o f all people suffering from cardiovascular disease. By the year 2000, mortality from cancer in people under 65 years should be reduced by at least 15% and the quality o f life o f all people with cancer should be significantly improved. The World Health Report 1997 and the latest evaluation o f the health status o f populations o f Member States o f the European Region show that the rates of mortality, morbidity and disability from major noncomm unicable diseases (NCD) are high and a number of countries are experiencing upward trends. NCD include cardiovascular diseases (CVD), lung and some other cancers, chronic nonspecific disease of the respiratoiy system, diabetes mellitus, obesity, selected chronic musculoskeletal disorders and oral diseases, that share one or more risk factors. In the Region as a whole, CVD account for nearly half o f all deaths, a considerable proportion of them premature. In CCEE the level o f CVD is two/three times higher: there, they are responsible for nearly two thirds of all deaths (again, a considerable proportion of which are premature). This is the most important reason for the wide health gap between western and central and eastern Europe. There is much evidence available about the causal factors in NCD; as many o f them are related to lifestyles, they are amenable to modification through concerted public health action. Management o f diabetes mellitus became a WHO action programme in 1991. The St Vincent Declaration, setting targets for the reduction o f complications due to diabetes, was endorsed in 1989. All 51 European Member States are at various stages of the implementation o f the St Vincent programme, which also is a pilot programme for Quality o f Care Development (QCD). There is a need for oral health care reforms, particularly in CCEE and NIS where standards have deteriorated. Oral health promotion and preventive care programmes are required at the community level; QCD programmes to monitor, evaluate and assess oral health status at the provider and the health authorities level need to be expanded. Systematic data collection has been initiated in CCEE, and the first results have been analysed. W H O ’s role Evaluation o f work done in the biennium 1996-1997 confirmed that NCD prevention has great potential for yielding major health gains, and that the concept o f integration is central to NCD prevention and control. WHO coordinated programmes, such as CINDI, are concrete examples o f effective activities for the reduction of NCD. Community-based health promotion and disease prevention measures remain a key element in the prevention and control o f NCD. Appropriate early case detection and the management of chronic conditions should be ensured. In 2000-2005, international collaboration should be encouraged with the aim of strengthening integrated health promotion and disease prevention action in order to prevent and control NCD. Essential public health action and the integration of preventive measures within the functions o f the health sector, especially in PHC services, will contribute to the reduction o f NCD risk factors. New approaches to the management o f chronic diseases, especially o f CVD, should be sought through identification o f best practices and operational research. NCD and their risk factors should be better monitored and evaluated, EUR/RC48/8 page 104 in order to assess the progress made and to identify optimal strategies. Monitoring o f scientific data and operational research should be supported. In order to improve the quality o f life o f people with NCD, it is important to design and implement strategies o f disease management that reduce case fatality, morbidity and disability. To this end, the Helsingborg Declaration on Stroke Management was formulated in 1985 and a follow-up process of implementation of the Declaration was launched by the Regional Office. Promotion of the implementation o f national diabetes programmes will also continue, in accordance with the European Diabetes Action Plan. Specific projects on securing better outcomes at local and/or regional level, which have proved effective in previous biennia, will continue to be developed. A “template” will be available for management o f diabetes mellitus within the framework o f national QCD policies. Oral health care reforms will continue to be promoted in CCEE and NIS, concentrating on schoolchildren (through the Healthy Schools programme) but also including better community-based dental care for adults. Achievement o f the target o f < 3 decayed, missing or filled teeth (DMFT) by age 12 for oral health care, developed for the year 2000, will continue to be fostered. A “template” will be available for QCD in oral health care, within the framework o f national policies. The WHO health information system (Oral Status East) will support the continuous development o f oral health care. Evaluation - main achievements and constraints Countries participating in the CINDI programme actively implemented measures and local projects aimed at improving primary NCD prevention. Analysis o f the results o f intervention and o f risk factor trends was carried out in a number o f countries, revealing different degrees o f success. The most impressive positive trends were achieved in Finland, which noted a 72% reduction in coronary heart disease (CHD) mortality over a 25-year period. Support was given to countries in the following areas: improving CVD and risk factor monitoring; improving hypertension prevention and control (a number o f countries launched specific projects); and stroke management with the aim of improving the quality o f care (a consensus document was produced, disseminated and translated into various languages, and a steering group and working groups were established to work towards the goals in the Helsingborg Declaration). Measures to improve stroke care outcomes were identified, intercountry networks o f health professionals were formed, and partnerships between people with stroke and health professionals have been improved. With the help o f several donors, the International Thyroid Project was established in Belarus. The Regional Office conducts on-the-spot research and supports services for thyroid cancer caused by the Chernobyl accident through a WHO collaborating centre in Minsk and a network o f international collaborating centres. A project office has been established in Minsk to facilitate follow-up of the accident and to coordinate activities. One or more o f the targets set out in the St Vincent Declaration (reduced mortality and morbidity due to late complications o f diabetes) have been reached in at least 18 Member States, at either the local, regional or national levels. The availability o f information tools for the collection o f data has led to the identification of best practices and their dissemination. The oral health target for the year 2000 (< 3 DMFT at age 12) has been achieved in at least 19 Member States. The network o f oral health care providers involved in data collection for the purposes o f comparing outcomes and identifying and disseminating best practices is gradually expanding, while national health authorities are increasingly aware o f the need for better oral health status. Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium Evaluation of programmes related to NCD prevention and control demonstrate that Member States, especially in central and eastern Europe, are increasingly concerned with the burden o f NCD and are EUR/RC48/8 page 105 seeking experience and examples o f practical action and programmes aimed at community-based health promotion and disease prevention. At the same time, now that the proportion o f elderly people is increasing and new treatments are becoming available, the issues of reducing morbidity and disability caused by NCD and o f improving, in a cost-effective way, the quality o f life o f those suffering from NCD are also the focus of attention. More emphasis will be placed on promoting the implementation o f national diabetes programmes in 95% of Member States, as stipulated in the European Diabetes Action Plan. Specific projects will continue to be developed to ensure better outcomes at local and/or regional level. Guidelines and pilot projects on stroke management and rehabilitation will be applied and implemented in at least three countries. Budgetary comments and trends Despite the decrease in regular budget resources, country-level activities have been protected as much as possible. Intercountry programme activities concerning cancer have been considerably scaled down owing to a lack o f funds. It is expected that voluntary donations will be received for many of the activities under this programme. Proposed resources by source of funds: 5.3 Control of noncommunicable diseases Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 243 800 260 000 364 000 236 716 463 839 Country 192 300 140 000 179 869 Regional - 5 000 Total: 5.3 436 100 405 000 364 000 416 585 463 839 5.3.1 C ontrol o f noncom m unicable diseases WHO targets by end 2001 • Integrated NCD intervention programmes in 50% o f Member States • NCD prevention policies in at least three countries • NCD prevention guidelines in at least eight countries with integrated NCD intervention programmes • Analysis o f trends o f major NCD and risk factors in at least three countries with integrated NCD intervention programmes • Survey ofpublic health services fo r NCD prevention in countries participating in the CINDI programme • Guidelines fo r stroke management and rehabilitation applied in at least three countries • National diabetes programmes in 95% o f Member States, with two thirds in an advanced stage o f implementation • Documented reduction in diabetes-related complications at local, regional or national level in 75% o f Member States • Documented reduction in the level and severity o f oral diseases, with particular reference to dental caries/periodontal disease/tooth loss, in at least 50% o f CCEE and NIS EUR/RC48/8 page 106 2000-2001 Products Projections for 2002-2003 Expansion of networks - both for the CINDI programme and those within and between countries Continued Further development o f policy on NCD prevention and control and building o f capacity for integrated intervention Continued Dissemination of experience of and knowledge about integrated Continued. Wide application preventive intervention (e.g. multidisciplinary and community-based prevention o f hypertension, “quit and win” campaigns) o f telematics Database on measurement o f the burden of disease and intervention practices (quantitative and qualitative analysis and evaluation o f e.g. CHD, stroke and lung cancer) Continued Updated intervention packages for primary prevention and control of major risk factors o f NCD Continued Mechanisms for dissemination and implementation of NCD Continued. Wide application prevention guidelines, with emphasis on primary health care (PHC) of telematics Interdisciplinary partnerships to enhance disease prevention in PHC, strengthening of cooperation betweeen complementary approaches to health promotion and disease prevention Further developed Models for appropriate case detection and management o f chronic Continued. Management of diseases (with emphasis on CHD) heart failure will become more important Implementation o f the Helsingborg Declaration (pilot stroke care projects; guidelines on stroke care and rehabilitation; indicators of quality o f stroke care) Continued Monitoring o f CVD trends and updating o f strategies Continued National programmes for management o f diabetes at local, regional Assessment o f the impact of and national levels national programmes on the level o f diabetes-related complications Availability of data on diabetes outcomes; databases for exchange of Assessment of the impact of such data among health care providers data collection, evaluation and feedback on the level o f diabetes-related complications at all levels Evaluation, assessment, identification and dissemination o f best practices in oral health Continued Promotion o f programmes for the prevention o f dental disease and Assessment o f the impact o f improved oral health status in both children and adults, especially in activities on the level o f oral CCEE/NIS disease at national level EUR/RC48/8 page 107 6. ADMINISTRATIVE SERVICES Policy orientation and strategic priorities Administration’s role is to support delivery o f the technical programmes through effective management of resources, both human and financial (regular budget and other sources), maintenance o f buildings, communications services and networks, the provision o f supplies, and the production, packaging and dissemination in many languages o f the health information which the technical units generate. There is a service function and an oversight function inherent in administration, and the challenge is to marry the two. Priorities for 2000-2001 will be to build up the country programmes in a way which allows the smoothest application o f the products of the intercountry programmes in accordance with expressed national needs. Shift o f resources An external management survey in 1997 resulted in recommendations that some functions should be transferred between units within the Administration and in principle also from Executive Management Coordination to the Administration, including proposals for outsourcing some functions. It confirmed the cost-effectiveness o f the printing unit. EUR/RC48/8 page 108 6.1 P e r s o n n e l Regional situation The trends evident in recent biennia will probably continue, and staff may be located outside Copenhagen. The majority o f those employed will be working on short-term contracts, probably o f no more than 11 months’ duration. With the increased activity at country level, the need for more widespread delegation of authority will be apparent. In order to achieve this, there will need to be greater simplification of work procedures, more extensive briefing o f staff and the identification o f criteria to facilitate accountability. This will have to be achieved within clearly defined policies common not only to WHO but to many agencies in the United Nations system. The United Nations system as a whole will need to develop policies for the recruitment and retention o f young professional women o f childbearing age. Priorities in the Personnel area will include: support to staff based outside the Regional Office; the design and implementation o f a more effective briefing package; greater cooperation with other United Nations bodies at local level - this will include the sharing o f facilities with other agencies (e.g. FAO in Rome and UNICEF in Copenhagen); more attention to career planning and counselling; delivery o f the Staff Health Promotion programme. The biennium should see the first fruits of the reform of Personnel policy, which began in 1998-1999. Evaluation - main achievements and constraints The introduction o f automated systems has increased the management and analytical capacity o f the Personnel Unit. Supervisors pay too little attention to the development o f their staff; and staff are not sufficiently concerned with self-development. Incentives need to be offered to promote cross- departmental project delivery. Proposed resources by source of funds: 6.1 Personnel Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry - - Country - - Regional 218 000 6 000 122 100 4 515 Total: 6.1 218 00(f 6 000 122 100 4 515 a Some activities previously included under general administration (6.2) have been reclassified, resulting in an increase in allocations for Personnel (6.1.) and Budget and Finance (6.2). WHO targets by end 2001 • Preparation o f a human resources plan with a five-year rolling horizon • Appointment o f highly qualified and skilled women to 50% o f internationally recruited posts • Clear, concise guidelines fo r programme managers on human resources practices EUR/RC48/8 page 109 2000-2001 Products Projections for 2002-2003 Human resource strategy for EURO Criteria for better targeting o f candidates for internationally recruited posts, with particular emphasis on the recruitment o f highly qualified and skilled women Continued Greater devolution o f responsibility for human resource issues to line managers based on clear guidelines and accountability (for information on Staff Development and Training (SDT), see section 2 . 1 .) Continued EUR/RC48/8 page 110 6 .2 G e n e r a l a d m in is t r a t io n Regional situation Considerable attention will be paid to cost-containment in administrative services, as well as to improved support services to technical units and to country programmes. Communications links and supplies to country programmes will take priority. At the Regional Office, the maintenance of a healthy and user-friendly environment is the continuing aim. The administrative staff will ensure that the Organization’s procedures, designed to guarantee ethical business practice, are followed. Ongoing activities include the maintenance o f the Regional Office complex (buildings and equipment), provision and maintenance o f an adequate communications network (telephone, telefax, courier and postal links), purchase and distribution o f supplies for both the Regional Office and field offices, and provision o f cafeteria, travel and conference services. Evaluation - main achievements and constraints Significant reductions were achieved in the cost o f communications and building maintenance; travel costs were 40% lower than the official entitlement, for the same number o f miles flown. Cafeteria management needs review to increase consumer satisfaction. Conference arrangements should be streamlined. Proposed resources by source of funds: 6.2. General administration Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry 54 000 65 000 84 010 Country - - Regional 2 956 500 3 372 800 2 977 300 4 681 646 1 694 660 Total: 6.2 3 010 500 3 437 800 2 977300 4 765 656 1 694 660 WHO targets by end 2001 • 15% reduction in travel costs while maintaining quality o f service • Ensure routine maintenance o f buildings and equipment • Ensure that supplies are purchased at competitive prices, with specifications met and an inventory maintained to safeguard the investment • All communication services to operate internationally • Ensure that requirements fo r each meeting and conference are met at economical prices 2000-2001 Products Projections for 2002-2003 M aintenance: Keep all buildings and equipment in a functioning Ongoing condition, in line with the maintenance schedule set in consultation with the Danish Government EUR/RC48/8 page 111 Com m unications: Upgrading and maintenance o f communications systems, ensuring quality services at competitive prices (communications include telephone, telefax, postal and courier services) Supplies: Purchase o f supplies for the Regional Office, field projects and, where necessary, declared emergencies Canteen: Provision o f safe and satisfactoiy food services to the Regional Office Travel: Provision o f an economical and responsive travel service to the Region through the duly appointed travel agent at the Regional Office Conferences and Printing: Provision o f an advisory and technical service (including printing of material) in connection with meetings and conferences Ongoing Ongoing Continued Ongoing EUR/RC48/8 page 112 6 .3 B u d g e t a n d f in a n c e Regional situation Within the policy framework provided by the Financial Regulations and the Financial Rules o f the Organization, the unit aims to provide efficient and effective services in accordance with the needs o f the Organization, its Member States and donors. The restructuring o f units in Budget and Finance as a result o f the Management Survey report o f December 1997 was implemented during the biennium 1998-1999. This was undertaken in conjunction with a complete review o f general office procedures, after the introduction o f new computer system applications linked to the Administrative and Financial Information (AFI) system and designed to minimize the duplication o f input at both technical and administrative levels o f the Organization. The implications of the increase in the regional allocation for the European Region to benefit country programmes (as decided by the World Health Assembly in May 1998) will include the need to review the delegation of authority to country level and the systems and staff required to support it. An increased effort will be made to follow trends and developments in the banking sector in the eastern part of the Region, to enable the timely transfer o f funds. Evaluation - main achievements and constraints During 1996-1997 there were three audit visits, two by the Office of Internal Audit and one by W HO’s External Auditors, all with completely satisfactory results. The transfer to the new regional version o f the AFI system entailed considerable reprogramming and delayed normal services. Any new global development in computerized financial and management information systems must be significantly better integrated than in the past and oriented more towards regional and country operations. Proposed resources by source of funds: 6.3 Budget and finance Strategic Budget 2000-2001 Approved Budget 1998-1999 Expenditure 1996-1997 Regular Budget Other Sources Regular Budget Other Sources Regular Budget Other Sources Intercountry - 15 000 8 632 - Country - - Regional 54 000 5 000 122 100 4 689 - Total: 6.3 54 00(f 20 000 122 100 13 321 - 3 Some activities previously included under general administration (6.2) have been reclassified, resulting in an increase in allocations for Personnel (6.1.) and Budget and Finance (6.2). 6.3.1 B udget and finance WHO targets by end 2001 • Prepare annual expenditure reports fo r management • Ensure all budget and finance services are provided in a timely manner EUR/RC48/8 page 113 2000-2001 Products Projections for 2002-2003 Budgetary aspects o f the proposed regional programme budget for 2002-2003 Continued Financial activities for all funds monitored Continued EURO contribution to the Organization’s financial report for the biennium 1998-1999 and the interim report for 2000 Continued Facilities to assist technical programmes in the management o f their financial resources and to provide administrative and financial data Continued EUR/RC48/8 page 114 Annex 1 A b b r e v ia t io n s AFI Administrative and Financial Information AFP Acute flaccid paralysis AIDS Acquired immunodeficiency syndrome AMS Activity Management System ASPHER Association of Schools o f Public Health in the European Region BFHI Baby-friendly hospital initiatives BSE Bovine spongiform encephalopathy CARAK Central Asian Republics, Azerbaijan and Kazakhstan CARNET Health care reform network for central Asian republics CCEE Countries o f central and eastern Europe CD Communicable disease CDC US Centers for Disease Control CDD/ARI Diarrhoeal diseases and acute respiratory infections CE Council o f Europe CINDI Countrywide integrated noncommunicable diseases intervention CJD Creutzfeldt-Jakob disease CVD Cardiovascular diseases DANIDA Danish International Development Agency DFID Department for International Development (United Kingdom) DMFT Decayed, missing or filled teeth EACHR European Advisory Committee on Health Research EACHR European Advisory Committee on Health Research EASTNET Health care reform network for eastern European countries EC European Commission ECHPA European Centre for Health Policy, Analysis ECHPD European Committee for Health Promotion Development EEA European Environment Agency EH Environment and Health EHAPE Environmental Health Action Plan for Europe EHCN European Health Communication Network ELSPAC European Longitudinal Survey on Pregnancy and Childhood ENHPS European Network o f Health Promoting Schools EPI Expanded Programme on Immunization EU European Union EUPHA European Public Health Association EUPHIN-EAST European Public Health Information Network for Eastern Europe EURO WHO Regional Office for Europe EUROHIS European health interview survey FAO Food and Agricultural Organization FOFEA Federal Office for Foreign Economic Affairs (Switzerland) GNP Gross national product GP/FM General practice/family medicine GPW General Programme o f Work HBSC Health Behaviour in School-aged Children HEGIS Health and environment geographical information system HFA Health for all HFA/HSI Health for All/Health Service Indicator Hib Haemophilus influenzae type B HiT Health care in transition profile EUR/RC48/8 page 116 HIV Human immunodeficiency virus IAEA International Atomic Energy Agency IDA-HIEMS Interchange o f data between administrations - Health indicators exchange and monitoring systems IGO Intergovernmental organization IICC Interagency Immunization Coordinating Committee ILO International Labour Organization IMCI Integrated Management o f Childhood Illness LAN Local area network LEMON (LEaming Material On Nursing) MCAP Multi-city action plan MECACAR Mediterranean and Caucasian countries and central Asian republics (Mass vaccination campaign against poliomyelitis in) MIDNET Health care reform network for central European countries MTP Medium-term programme NATO North Atlantic Treaty Organization NCD Noncommunicable diseases NEHAP National environment and health action plan NGO Nongovernmental organization NIS Newly independent states OBSQID Obstetrical quality development through the integrated use o f telematics OECD Organisation for Economic Co-operation and Development PHC Primary health care QCD Quality o f care development QCT Quality o f care and technologies RHN Regions for Health Network SCRC Standing Committee o f the Regional Committee SDT Staff Development and Training SOUTHNET Health care reform network for southern European countries STD Sexually transmitted disease UNAIDS Joint United Nations Programme on HIV/AIDS UNDAF United Nations Development Assistance Framework UNDP United Nations Development Programme UN-ECE United Nations Economic Commission for Europe UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development WB World Bank

ekxv W ORLD HEALTH ORGANIZATION 1 9 4 8 Regional O ffice for Europe S L .............. C o p e n h a g e n REGIONAL COMMITTEE FOR EUROPE Forty-eighth session, Copenhagen, 14 - 18 September 1998 Provisional agenda item 3(b) EUR/RC48/8 Corr. 1 10 September 1998 09938 ORIGINAL: ENGLISH Pr o p o s e d P r o g r a m m e B u d g e t 2 0 0 0 - 2 0 0 1 C o r r ig e n d u m For Read Contents 1.1.1 Regional Committees 1.1.3 Regional Committees Contents 2.3.3 Emergency and ... 2.3.4 Emergency and... Contents 4.1.6 Occupational Health 4.1.7 Occupational Health Page 7 Last sentence, paragraph 8 In line with the thinking behind this reform, it was decided to close the WHO representative’s office in Turkey in September 1998 and to transform it into a liaison office. Pages 15 and 21 Footnote 4 Some activities previously included under General administration (6.2) have been reclassified, resulting in minor changes to Personnel (6.1) and Budget and finance (6.3). Page 25 Second heading 1.1.3 Regional Committees Page 41 First heading Changes made as a result o f evaluation and lessons learned, with emphasis on the 1996-1997 biennium Page 43 First heading 2.3.4 Page 69 End ninth paragraph In 1993, people aged 80 years and above constituted 16% of the elderly over 65 in the developed countries. This proportion is expected to increase to over 30% by the year 2020. These changes obviously have ramifications for public health. Page 75 4.1.6 Occupational health 4.1.7 Occupational Health Page 77 Fifth paragraph A EURO conference on mental health, to be held in 2002, will ... Page 80 Projections for 2002-2003 Committee for a Tobacco Free Europe - Continued Page 104 Fourth and ninth paragraphs .. <3 . < 2 Pages 108 and 112 Footnote a Some activities previously included under General administration (6.2) have been reclassified, resulting in minor changes to Personnel (6.1) and Budget and finance (6.3).