High-level regional meeting: Health systems respond to NCDs: experience of the European Region: Sitges, Spain, 16–18 April 2018: briefing note for presenters and panellists

High-level regional meeting Health systems respond to NCDs: Experience of the European Region Sitges, Spain 16–18 April 2018 Briefing note for presenters and panellists Document number: WHO/EURO:2018-3031-42789-59707 © World Health Organization 2018 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. 2 This briefing note is prepared for presenters and panellists at the High-level regional meeting on “Health systems respond to NCDs: the European experience”, to be held in Sitges, Spain on 16– 18 April 2018. The objectives of the High-level regional meeting are:  to discuss policy directions and country experiences for a comprehensive and aligned health system response to noncommunicable diseases (NCDs);  to highlight the equity and gender dimensions of health system transformation for better NCD outcomes, including those left behind by traditional, mainstream approaches;  to explore the possibility of accelerating health system transformation for faster reductions in premature NCD mortality (leapfrogging); and  to tease out factors that have enabled successful, large-scale health system transformations. This note provides background information for the above and summarizes the policy directions proposed for discussion by the WHO Regional Office for Europe. These policy directions are based on five years of multidisciplinary and contextualized country work in the WHO European Region. Country-based good practices feature extensively at the meeting and in the regional synthesis report. The note is organized around the following topics: (1) NCD trends in the WHO European Region; (2) the status of core NCD interventions and services; (3) a comprehensive and aligned health system response to NCDs; (4) equity-enhancing policies in the health system response to NCDs; (5) opportunities and challenges for leapfrogging in the health system response to NCDs; and (6) leading large-scale system transformation. 1. NCD trends in the WHO European Region: time for ambition NCDs are the most important public health problem in the European Region, responsible for the vast majority of deaths and the largest disease burden. This results in important health system costs and has wider implications for the economy and society. Important gains have been made in the European Region, with inspiring success stories. In practically all countries, there has been a clear decline in premature NCD deaths in the past decade. If current trends continue, the commitment in the Sustainable Development Goals of reducing premature mortality from NCDs by one third by 2030 will be met by the Region as a whole. The challenge remains, however, of how to accelerate this decline and reduce inequalities across countries. If the countries of the Commonwealth of Independent States (CIS) continue on their present trajectory, it will take them around 50 years to achieve the current mortality levels of the 15 countries that were members of the EU before May 2004 (EU15). The Member States who joined the EU since May 2004 (EU 13) are 25 years behind the EU15 in terms of avoidable NCD 3 mortality. This lag raises the possibility that, should the middle-income countries in the Region more fully exploit the better knowledge to which they now have access, they can accelerate their achievements and leapfrog the prolonged period of slow decline seen in the EU15. 2. The status of core NCD interventions and services There is now a great opportunity to accelerate gains in NCD outcomes by aggressively scaling up core NCD interventions and services, or best buys. Policy-makers today live in a fortunate age of knowing with great certainty what works for NCDs. However, despite unequivocal evidence, cost- effective interventions remain underimplemented in the Region. The failings that limit a health system’s performance in tackling NCDs primarily result not from a lack of knowledge but from not fully applying what is already known. Without doubt, political barriers continue to undermine progress, especially in scaling up population interventions for tobacco, alcohol and nutrition policies, where public health goals and commerical interest are not aligned. On the other hand, a weak – fragmented and poorly aligned – health system response fails to overcome the barriers to scaling-up the core interventions and services. While lack of funding is often an important constraint, it cannot be assumed that progress will be assured if more money becomes available. Without a health system that can use money well, spending will not merely be inefficient, it may conceivably be counterproductive. 3. A comprehensive and aligned health system response to NCDs Health systems have an important role to play in leading and coordinating the fight against NCDs. By addressing the important barriers that stand in the way of scaling up core interventions and services, health systems can indeed accelerate improvements in NCD outcomes, saving the lives of millions of people and improving the lives of those living with – often multiple – chronic conditions. A comprehensive and aligned health system response based on nine cornerstones is essential (Figure 1). Effective health system stewardship for NCDs requires stronger governance arrangements to ensure coherence across the different settings where NCD policies are developed, whether inside or outside the health system. Better governance is also essential for sustained sectoral and intersectoral health action with an institutionalized focus on outcomes. In order to scale up core NCD interventions and services in a people-centred manner, there is a need for an ambitious transformation in how we deliver public health, primary care and specialist services, with a sharpened focus on outcomes, coordination, continuity, comprehensiveness and change management strategies. This service delivery transformation can be further supported through aligned strategies related to four health system functions: the health workforce, health financing, medicines policy and information solutions. 4 Figure 1 The nine cornerstones of a comprehensive and aligned heath system response to NCDs  Strengthened governance ensures coherent policy frameworks and sustainable intersectoral action on NCDs, connecting national, regional and local levels (Chapter 6)  Well resourced public health services lead health promotion and disease prevention activities with an focus on equity (Chapter 7)  Multiprofile integrated primary health care proactively manages community health and well- being (Chapter 8)  Adequately regionalized specialist services provide efficient and timely care for acute conditions (Chapter 9)  People-centredness is reflected in all health system functions (Chapter 10)  A fit-for-purpose health workforce delivers people- centred interventions and services based on evidence (Chapter 11)  Adequate and prioritized health financing ensures that coverage of important services and incentives are aligned with service delivery goals (Chapter 12)  Access to quality medicines is ensured through reliance on comprehensive coverage and pricing policies and on promotion of generics (Chapter 13) Information solutions serve population health management, condition management in primary care, coordination across providers for seamless care, and self-management (Chapter 14) #1. Effective governance arrangements can produce coherent multilayered policies related to NCDs with accountability frameworks connecting different levels of government and creating bridges across sectors. Intersectoral action is a cornerstone of the effective health system response to NCDs and can be catalyzed through leveraging knowledge, evidence and information in the areas of nutrition, tobacco and alcohol. Well functioning governance arrangements contribute to navigating complex relationships with important stakeholders, including the private sector and non-state actors, towards public health goals, bridging regulation, incentives through fiscal policies, and voluntary approaches. While political leadership and the driving force for any of these areas may lie outside the health system, an NCD policy hub in the health system (Ministry of Health, public health agency) can be helpful in connecting these important axes of policy development and implementation and stewarding them to move synchronously towards policy goals. (Chapter 6) #2. Well resourced and appropriately staffed public health services can drive the policy agenda for NCDs in a technical sense. They can provide policy-relevant information about mortality and morbidity throughout the policy cycle, putting the spotlight on equity dimensions. They can spearhead efforts on health promotion and disease prevention in the areas of obesity and 5 inactivity, alcohol and substance abuse, tobacco use, mental health, depression and violence. They can also work closely with communities and primary care providers to identify locally relevant solutions for early detection of cardiovascular disease, diabetes and cancers, and engine with high-risk and/or otherwise vulnerable populations. Well functioning public health agencies can catalyse intersectoral action as the cornerstone of an NCD prevention strategy with strategic use of information, evidence and knowledge. (Chapter 7) #3. Multiprofile integrated primary care embedded in communities can provide timely and effective first-line care in a broad spectrum, including health promotion, disease prevention, counselling, early detection and diagnosis, condition management – including of multimorbidity – in a one-stop manner, referral if needed, follow-up and rehabilitation. These services matter for the full range NCDs, such as cardiovascular disease, diabetes, lung diseases, cancers and mental disorders. The service basket of multiprofile teams should be based on and vary with a sophisticated picture of population health needs. Equitable expansion of access to services should be matched with available resources, including funding, staff, medicines, technology and supplies. By working more closely together, clinical medicine in primary care and public health can help each other improve health maximally — and emphasize society’s responsibility to promote both healthy environments and consistent, high-quality care. Similarly, integrated approaches between primary care and specialists provide a seamless experience for patients, improve outcomes and spare resources. (Chapter 8) #4. Appropriately regionalized specialized care can provide timely referral and acute care, improving NCD outcomes as well as health care efficiency, responsiveness and accountability. A nuanced, flexible, evidence-informed model for organizing hospital services, which carefully considers the case for centralization or decentralization in light of the nature of the service and patients’ needs, is essential. To be executed successfully, regionalization requires skilful management of the process, along with dialogue with the public, high-level support and buy-in from policy-makers and leaders of the medical profession. For optimal performance of the model, new ways of working must be found and new relationships forged across the different parts and levels of the health system, embracing new or redesigned systematic processes of care. (Chapter 9) #5. People-centred health systems not only provide people with a more responsive experience (a goal in itself) but also contribute to better outcomes. People with NCDs now turn to health systems for help with a much wider variety of problems and expectations than before. Empowerment and health literacy of people and families are central themes in people-centred approaches and are made possible through health education, informed consent processes, shared clinical decision-making and self-management. Community empowerment calls for community-delivered care and community health workers, development of civil society and strengthened social participation in health, as well as community participation in policy formulation and evaluation. Reaching out to the underserved or marginalized is critical in people- centred care and is made possible by, for instance, the provision of outreach services for the underserved, including mobile units, transport systems and telemedicine, as well as outreach programmes for disadvantaged/marginalized populations. (Chapter 10) 6 #6. A health workforce ‘fit for purpose’ can deliver people-centred interventions and services based on evidence and tailored to the individual. Human resources for health meet NCD demands since new workers are trained in the correct skills and competences, thanks to reformed and updated curricula and scaled-up production capacity of educational institutions; and current personnel are utilized more effectively through continuous retraining activities and the promotion of task-shifting from doctors to nurses and other professionals. Easily accessible and qualified personnel providing timely long-term treatment and monitoring are available even in rural and underserved areas through a bundle of effective recruitment and retention policies, enhanced by appropriate information solutions. Workforce policy and planning, regulation and management are aligned with service planning and delivery, and support integrated teams rather than isolated individual health professionals, effectively addressing NCDs at all levels of service. #7. Health financing strategies ensure adequate resources for health through an effective fiscal dialogue. Those representing the health system powerfully make the case for investing in NCDs while highlighting potential efficiency gains. Through a transparent prioritization process, resources are allocated to those interventions and services that matter for improving NCD outcomes. Public health services, health promotion, disease prevention and primary care are thus adequately funded to deliver the comprehensive range of services expected of them. Incentives are effectively used to encourage the right behavior and service delivery configuration. (Chapter 12) #8. Access to quality medicines for people with NCDs is ensured in a well functioning health system through the careful selection of cost-effective, prioritized medicines, preferential prescribing of these medicines in clinical practice, efficient procurement and distribution systems for pharmaceuticals to ensure that they reach the patients who need them, and subsidized access through public funding of coverage. To ensure the greatest chance of successful treatment outcomes, patients adhere to an agreed care plan, including taking medicines as recommended by their health care professionals. (Chapter 13) #9. Information solutions help overcome policy problems previously thought intractable. More sophisticated population health information systems and communications technologies across the whole range of functions (from clinical consultations to macro-level resource allocation) improve outcomes for NCDs. While health system digitalization is complex, and can be costly, the potential longer-term benefits in promoting efficiency gains must be considered. These include improved quality of care, better planning and resource allocation, and an enhanced evidence base for health service delivery and policy-making. (Chapter 14) 4. Equity-enhancing policies in the health system response to NCDs The social determinants of NCDs play an important role in how the NCD best buys reach and affect the health and well-being of different social groups within different populations. Therefore, strengthening the equity orientation of health system policies and embedding health equity considerations in public health action is important in order to leave no one behind. This includes the need for the appropriate design and implementation of equity-enhancing health system strategies for NCDs, which intervene at various stages along the causal pathway in order 7 to address the inequalities in NCD-related mortality and morbidity that exist between, and within, all countries in the Region. A comprehensive health system response to NCDs needs to ignite action to address both upstream and downstream sources of health inequalities. There are three types of actions, implying three different roles for the health system:  Strengthening intersectoral action to address inequalities in the upstream determinants of NCDs. Sectors other than the health sector take the lead in addressing the root causes of health inequalities originating from socioeconomic and structural determinants of health. With increasing evidence of the connections between NCDs and early childhood development, education, labour market participation and urban planning, the case is mounting for the health system to take a stronger role in advocating for action. In these areas, the health system plays a role in making and building the case and catalysing action in other sectors.  Strengthening intersectoral action to address inequalities in the downstream, more immediate determinants of NCDs, including tobacco use, alcohol use, unhealthy diets and physical inactivity. This can be supported through ensuring a balance between the implementation of universal strategies to improve average population health, but on a scale and at an intensity proportionate to the level of disadvantage within each population/society (universal proportionalism). For example, universal smoking bans are implemented in public places but with an additional focus on prioritizing workplace interventions on smoking cessation in low-income and less secure areas of employment, with heavily subsidized nicotine replacement therapy. The health system plays a role in catalysing action across sectors, ensuring that universal public policies are accompanied by complementary equity-sensitive approaches, perhaps delivered through public health action or individual services; synthesizing and providing evidence for action; proposing joint policies to relevant sectors; taking stock of progress; evaluating impact; and keeping the policy cycle going.  Reducing inequalities within the health system. Delivery of individual services can help attenuate some health inequalities through ensuring access to services upon need without the risk of financial ruin. The main sources of inequalities in the delivery of individual NCD services include the underutilization of primary care by men, leading to late detection and poor management of health conditions, large variations in geographical access to rapid response to acute cardiovascular events and specialized cancer services, and a high financial burden associated with chronic conditions, especially for out-of-pocket payments for medicines. Addressing these sources of health inequalities can go a long way to closing the health equity gap within countries. Embedding equity and gender sensitivity in public health action and service delivery policies are critical areas for reducing inequalities in outcomes. 8 5. Opportunities and challenges for leapfrogging in the health system response to NCDs Overall, the European Region is doing relatively well in addressing some of the health determinants that can cause NCDs, as well as in managing chronic conditions. Even though high- burden countries are catching up, projections show that it will take another six decades to close this gap. This is why we need to find ways to accelerate progress, to leapfrog over these decades of continuous yet slow decline in mortality, and to achieve a sharp improvement in NCD outcomes, both within and between countries in the Region. Leapfrogging in the health system response to NCDs would mean skipping inferior, less efficient or more expensive ways of generating improved NCD outcomes; moving directly to more advanced approaches representing today’s good practices in delivering NCD-relevant core population interventions (on tobacco, alcohol, nutrition and physical activity, for instance) and individual health services (such as for early detection and high-quality management of cardiovascular diseases, diabetes, lung diseases and cancer). Leapfrogging implies a large-scale qualitative change that is driven by innovation. However, here we are not restricted to technological innovation alone. There is also a great potential for organizational innovation, for example in the way in which public health services can be dynamically engaged with intersectoral action to address social determinants of NCDs, or through organizing health service delivery in a more people-centred way, or in using financial incentives as well as deploying the health workforce, redistributing tasks and changing the skill mix. There are exciting leapfrogging opportunities along each of the nine cornerstones presented above, but this entails overcoming many technical and political economy challenges and managing a complex transformation process in a short time-frame. Leapfrogging does not imply single-policy solutions. Comprehensive concerted action is needed to align specific policies with interlinked and enabling health system functions. For example, strengthening the public health orientation and moving towards multiprofile primary health care requires a rethink of the health workforce, including the types of health workers needed, the duration and depth of their training, as well as the ways of collaboration between them. In the same way, a rethink of financial incentives is needed to achieve the desired results in many of the policy areas using leapfrogging. The playfulness of the word “leapfrogging” masks the seriousness and the rigour needed to implement large-scale systemic transformation. Any reform will need to take due account of the political context and path dependency that will also largely determine the options and the level of resistance to change. In particular, disruptive innovations – which are likely to displace older organizational structures, workforce, processes, products, services and technologies – can face fierce opposition and important barriers. Not only professionals but also citizens and patients may refuse to engage with these changes. 9 This is why it is time to act now. Ultimately, there is no escape from the complexity of an aligned approach to comprehensively strengthening the health system response to NCDs. 6. Leading large-scale system transformation What needs to be done to strengthen health systems for NCD prevention and control is clear. The main ingredients are to give higher priority to promoting health and well-being while addressing widening inequalities, to integrate health and social care, to give patients and citizens a greater voice, to adopt a whole-of-government approach in policy-making, and to align health financing and health workforce strategies to support these agendas. Transforming health systems in a way that can successfully meet the urgent needs posed by NCDs demands continuity, consistency and constancy of purpose, combined with communicating the early ‘wins’ to demonstrate what is possible. There can be no blueprint, manual or prescription to ensure that the health system transformations of the type needed to tackle NCDs, and as set out in this and the previous chapters, will succeed. Context is all-important. These are not always easy or welcome messages for policy-makers to acknowledge or assimilate, when they are impatient to introduce reforms quickly within a short-term electoral cycle. Nevertheless, it is possible to identify a number of factors that need to be in place if change is to occur and be sustained over time. These key ingredients are:  creating strategic alignment: without a vision, there can be no alignment and hence no change;  acknowledging the interconnections between the ’whys’, ‘whats’ and ‘hows’ of change;  working with professional cultures, particularly (although not exclusively) the clinical culture, which remains a powerful determinant of change (or the lack of it) in health systems;  creating enabling environments that allow change to flourish, through adopting plan-do- study-act (PDSA) approaches;  nurturing new leadership approaches based on a system approach;  increasing patient and public engagement so they become co-producers of health;  supporting evidence-informed policy that is timely and relevant. The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Document number: WHO/EURO:2018-3031-42789-59707 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int