Is the EU reaching SDG 3.3.? An interview with Andrew J. Amato-Gauci

“Tuberculosis is our shame; Elimination of viral hepatitis C is very possible and HIV/AIDS is more complicated.”

I have met Dr Andrew Amato at the main conference venue of the European Health Forum Gastein, which he attended for the first time. During an hour-long interview, we had an interesting and fairly open discussion on where European Union is now in reaching SDG 3.3, as well as what are the key reasons for that. I hope you would enjoy reading this article as much as I enjoyed talking to this passionate health care professional while drinking a coffee on a sunny terrace of a small café surrounded by the Alps.  

AT: The motto of this year EHFG opening plenary was “Let’s think big for Public Health in Europe”. What does it mean for you to think big?

AA: For me, it means that we should be more ambitious in our aims and our goals. Even if we know that we are being too ambitious, this is important as the political commitment to public health today is rather weak, so politicians do need aspirational goals. I don’t see a lot of public health champions among the politicians today. There is also a tendency towards adopting more populist policies. Unfortunately, this usually means the politicians will tend to only focus on policies and make promises that will provide short-term satisfaction. So, we, the public health activists, need to look at the big picture and set ourselves bigger goals that could inspire the politicians to follow suit and plan greater policies, rather than going for immediate and short-term outcomes.

For example, hepatitis C elimination in Europe is ‘easily’ achievable from a policy aspect – the only thing that needs to be done is testing of the at-risk populations and providing curative treatment, as simple as that. Of course, it would cost a lot of money initially, but the benefit such a plan is that it will have to be done only once on large scale.Obviously, I am oversimplifying to make a point, but it really can be done with the help of motivated and strong-willed politicians behind it.

Vaccination is a similar topic: we could do so much better with just a little bit more emphasis on the right legislation, a bit stricter enforcement and stronger advocacy strategies. By now, we were supposed to have eliminated measles in the EU: we have the tools, we have the money, and yet, for the lack of interest and political will, the campaigns have mostly faltered. I am convinced that a major campaign – and by “major”, I mean a suitably funded campaign with inspired leadership, which is run over 3 to 5 years,focusing only on measles –, would easily manage to eliminate measles in the EU. The USA had managed to come very close to achieving this, and then faltered for various reasons, which unfortunately include recurrent imported infections from the EU. That’s the kind of high-level policies we need, with countries coming together and agreeing that we need to work on this particular priority and putting sufficient resources there. The problem with this is that the health mandate of the EU Commission is still rather limited. Namely, there have been brave attempts in starting up major partnerships (e.g. against tobacco or cancer) and becoming more involved in public health, but it is still a work in progress. The organization of health services is still the mandate of Member States, so we have different health care services across the EU. For me, this is in a way against the spirit of the EU, which is all about crossing borders without any obstacles or differences. So, as long as health care services,disease prevention and health promotion services are different in every country, a citizen moving from one country to another will face differing services. We still have a long way to go for the EU to fix that. From the public health perspective, the DG SANTE is probably not the most influential sector of the Commission – it is nowhere near the Economics, the Finance, or the Foreign Affairs sectors, just to name a few. I think we should all work on raising the profile of health to a satisfying level.

AT: Turning to one of the SDGs, precisely to SDG 3.3 – what are the key priorities for Europe?

AA: Yes, the famous SDG 3.3…. It is unlikely that we will be able to achieve TB elimination in the EU within the target. This is a disease which is almost 100% curable with antibiotics, and yet, despite all the medical advances that we have made, we can’t seem to “fix” it in the EU. I don’t understand how we have found ourselves in this situation. It’s true that the numbers are decreasing, but the decline is very slow. We need to focus on the latent TB, especially because we have never given it the attention it deserves. MD RTB shouldn’t remain the problem it is now, there are new tools coming online quite soon which hopefully should make it less of an issue.

The SDG 3.3. refers to combating hepatitis.What does that mean? The UN has come up with numbers, planning a reduction of 90%, but I think that total elimination of HCV is what we should aim for at the EU. As I said before, we already have all the necessary tools in the EU, and we have good health care services, so why can’t we achieve that?

For HIV/AIDS, the SDG target is more complicated. We have at last begun to see a true reduction of incidence in the EU/EEA, first seen in the surveillance data of the last year, mainly in new cases of infection among men who have sex with men. This is largely thanks to the adoption of Test and Treat policies and the roll out of PrEP for at-risk populations. I think people began to realize that the more we adopt these ‘fast-track’ policies, the more we will see HIV coming down rapidly. Also, AIDS rates are dropping very fast because the treatment is working so well. On the other hand, we see epidemics of gonorrhea and syphilis in the EU. With further roll out of PrEP, we can expect to see more of these. Still, it will be hard to know whether this is due to more new infections actually happening, or because at-risk people are tested more often and thus are found to be infected. However, I think if PrEP is implemented properly, the highest-risk groups will likely attend services more often, both for their prescriptions and screening tests. This way, they will be tested and treated for syphilis and gonorrhea as well, possibly bringing these down in the longer term. So, there is a possibility of using PrEP to reach out to the most at-risk group and reduce their overall infection risks and exposure. The current rates of increase of STIs are concerning, and we are expecting to find out more about the rising rates of congenital syphilis in the USA. We haven’t seen it yet, but we can expect that this is going to happen in one- or two-year time. 

Of course, malaria is not that relevant in the EU for now, but if the rates of other vector-borne diseases are anything to go by, it is just a question of time. 

So, I believe HCV is where we could achieve the most. For TB we are not doing as well as we should, especially in the east of Europe. And as a side effect of PrEP we might be also combating STIs.

AT: I also wanted to talk about SDG 3.3. and migration. You have published several papers related to the issues of migration. Every now and then, something happens in the world and we have a new wave of migrants arriving to the EU, bringing new culture, traditions, languages, as well as new health-related problems. What do you think of that?

AA: Our work with migrants is limited, because ECDC’s focus lies within infectious diseases, which might not be the major public health problem for migrants. TB and, to a lesser extent, hepatitis may pose some problems, especially among irregular migrants coming from high-prevalence areas, but for HIV/AIDS this is much less of an issue. The problems for migrants go beyond infectious disease, and we don’t have a mandate there.  

A specific problem with migrants that I have is the word itself. We use “migrant” for a very broad phenomenon, and mostly synonymous with migration from outside of EU: there are people who are economic migrants, for example the North Africans, who are trying to get across in order to get work; there are war refugees like Syrians, and there are whole mix of central Asians, who are looking for a better life. Still, we tend to put all of them in one basket of “migrants”. They all have very different problems, very different issues, very different health needs. It’s such a complex issue, and our work has been very limited. Some policy advisers asked ECDC to define whether we should be testing “migrants” for certain diseases, for example. In response, we developed guidelines that specify what should be asked if a test is offered, and of course, stating that those tests should be provided only on voluntary basis. Also, if a test is provided, the treatment has to be made available, otherwise it is simply not ethical to test. TB in migrants is something that we focus more on, as many migrants come from high-prevalence areas, but hepatitis and HIV/AIDS are among the least health problems migrants face. HIV/AIDS, as we have found out, becomes a problem for the migrants after moving to the EU. There is good data showing they get infected more often after they had moved to the EU. It is quite the opposite to what right-wing politicians like to preach – that the migrants bring HIV/AIDS to the EU. Finally, as already mentioned, we use the term mostly synonymous with migration from outside of the EU, but we should also consider the impact of migrations within the EU, from Eastern European to Western European countries.

AT: To sum up, this is your first time at EHFG – what does it feel like?

AA: Yes, it is. So far, I have only seen the village (laughing) and the village is very cute and I love the mountains! So, I am very happy to be here. I am here with my director, we will have ECDC session tomorrow, and I am looking forward to our session, we will see how it goes.

This interview was conducted by a Young Gasteiner Anna Tokar

A new approach to NCD control in Europe

Quote

Interview with Marianne Takki, Policy Coordinator, DG Sante, European Commission

“I’m here to tell everyone about the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases, and explain to organisations and other health stakeholders how the approach works.”

At the European Health Forum Gastein 2018, Marianne Takki was present to discuss the activities and role of the European Commission in non-communicable diseases (NCDs) prevention and control.

MD: You mentioned that the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases[i], which the European Commission established this summer (2018), is a totally new approach. What is so different about this approach compared to how the Commission worked on NCDs earlier?

MT: Previously, there were several disease-specific expert groups at the Commission, such as on rare diseases, cancer control, and mental health. The outputs of these groups were not effectively taken forward. We [the Commission] realised that, for plans and recommendations to be useful to someone, implementation needs to be the focus of all planning. Now, with the new steering group that officially started in July 2018, the member states are involved from the beginning. The aim of the steering group is not to create aspirational statements, nor develop new policies: instead, the steering group will address what we already have. This approach puts health in all policies into practice.

“The Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases, which is established by the European Commission in July 2018, is a new approach to non-communicable disease control in Europe. This approach is about health in all policies being integrated into practice.”

Through the best-practices portal – which is a part of this new approach – we make sure that the member states know which NCD interventions are available and which can be implemented. Preferably, these practices are already implemented in a country or region and, with some adaptation, can be implemented in other places. The best practice portal is more than just a collection of best practices, it also includes an evaluation, for which the assessment criteria are established by the steering group. Finally, the Commission provides funding to member states for the implementation of best practices

MD: NCDs are now on the political agenda, but winds might change. How can we keep NCDs on the national and European agendas?

MT: Commitment of member states is realised by having regular prioritisation exercises, where member states prioritise their own needs. There are already many agendas out there, such as the sustainable development goals (SDGs), so the steering group aims to support member states in achieving the targets and goals that are most challenging for them.

MD: What can we expect from the steering group in the future?

MT: Until today, the Health Programme was the main funding for health projects. But now, while we are moving towards the next multi-annual financial framework of the EU (2021-2027), this will change. The steering group will be the main mechanism. I’m here [at the European Health Forum Gastein] to tell everyone about the steering group and to bring forward our approach, so that it becomes clearer to organisations and other health stakeholders. It is a new approach and we are taking baby steps in the beginning. The positive feedback that we have received from the member states since the launch of the steering group is a clear indicator that we are using the right approach.

In the next multi-annual financial framework, health is incorporated in the ESF+ programme, within the so-called health ‘strand’ or ‘cluster’. As stated in the proposal for the ESF + programme, article 29 in particular, the steering group would mainly be responsible for the health strand, including the work plans, prioritisation, strategy and implementation of the public health activities in the EU.[i] We are aiming for a more upstream decision-making process in the future. This would mean that the steering group can steer financial resources based on member states’ health objectives.

By the way, 7.7 billion euros are set for health research in Horizon Europe [the new research cluster]. I don’t think people see the opportunities here.

The first formal meeting of the steering group – chaired by Martin Seychell – was held on 6th of November 2018. We also plan a joint meeting between the steering group and the current Horizon 2020 research programme committee in Brussels in early spring 2019. This is to facilitate discussions between the stakeholders from research and health on ministerial level and the different Commission services on where the synergies are. This is one concrete future step in making sure that our policies are aligned, and our objectives are in synergy.

This interview was conducted by a Young Gasteiner Maaike Droogers

[i] Article 29 of ‘Proposal for a Regulation of the European Parliament and of the Council on the European Social Fund Plus (ESF+) COM/2018/382’ suggests that the steering group could have an important role in the future ESF+ health strand. Available here, https://eur-lex.europa.eu/resource.html?uri=cellar:a39e5630-640f-11e8-ab9c-01aa75ed71a1.0003.02/DOC_1&format=PDF.  

[i] Webpage of the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases is available here: https://ec.europa.eu/health/non_communicable_diseases/steeringgroup_promotionprevention_en

Long-term access to vaccination across Europe (L8)

The one with housemate Rich and vaccines

When I was given my working group for Young Gasteiners and saw ‘vaccines’ on our list of sessions to attend, I struggled to think of how I could link this to my interest area of mental health. As far as I was aware they haven’t yet made a vaccine they could’ve given me when born, to stop me freaking out with professional anxiety, have they? I wasn’t sure, but I was willing to find out…

I start by taking a photo and sending it to an old house mate ‘Rich’ who is just finishing a PhD in vaccine use across the UK to make him jealous.  The room starts half empty, I put that down to fact it was the last day of 3 intense days of networking, thinking, making ‘hmmm’ noises, nodding in agreement and … well late night networking, but it soon filled up as the session went on.

Natasha Azzopardi-Muscat moderating says EU is responding to growing concerns, and people’s imagination running wild, with measles outbreaks STILL HAPPENING in our day and age. I think of Rich and how this information would rile him mad, as he is a ‘pro-vaccine’ campaigner.

Kicking off, An Baeyens from the European Commission gave us a refresh on what procurement is at an EU level.  In a nutshell, it appears to be something that ensures all services that public authorities’ commission, have to meet the EU rules.  They are there to ensure best value for money happens….NOT to force member states to privatise healthcare services, so we are told.  Maybe Rich could enlighten me on this when I get home.

Italy in 2017 created a Compulsory Vaccination Law!!  This is a brave and bold step, and a hefty 500 euro fine for non-compliance after primary school age. Since it has started, there has been an obvious increase in vaccinations being had. Carlo Signorelli said that this is constantly on-going in the political realm and looks to stay that way for some time to come. I think Rich would definitely be happy to see something similar to this in the UK…maybe.

Radu Ganescu, in a stunning suit, told us that in Romania, they’ve actually put forward a very similar framework, but this has spurred 2 years of debate to this day.  One off the big debates going on was the idea to suspend healthcare compensation to those families/children who haven’t had a vaccination. Radu finished talking about Romania having the EU presidency next year, for which he simply stated:

“We should go together and push that everyone across Europe has access to vaccine.”

I think I’ll give Rich his details…

Purchasing & awarding are phrases I normally associate with me ‘purchasing’ a chocolate bar to ‘reward’ myself after my run, not in health care. I say this, but I am aware of health economics and financial procurement with Pharma companies, which we get quick tour de force about in relation to vaccine from Tim Wilsdon.

At the start of this session, due to Rich, I did have some baseline knowledge on this topic, but learning about Compulsory Vaccination and worryingly, how the lack of access to vaccinations, due to money and other political spheres is still a thing, further peaked my interest in this topic.

Sadly they still haven’t created a vaccine that would’ve stopped me freaking out at my age (maybe Rich can make one??  He should know how to do that by now??), but what’s exciting, especially with the EU presidency being with Romania soon, is that vaccine’s will get a deserved spotlight, Rich will love it.

This blog was written by the Young Gasteiner Nicholas Morgan

Thursday Plenary (P2)

Making the case for investment in health – but what is investment?

The Thursday plenary Talking so you’re heard – making the case for investment in health focused on the question of how to ensure we get more resources to be spent on health for improved health outcomes and wellbeing of the population. As Hans Kluge from the WHO Regional Office for Europe said in his opening address, improved health systems and spending in health systems do not only lead to better individual health and wellbeing, but also to inclusive economic growth. So, how hard can it be to get what we as health sector want – a bigger piece of the budget cake?

Throughout the debate, however, it became clear that behind this question, there are certain implicit assumptions that should be acknowledged and re-examined. A diverse mix of speakers ensured that we heard both the financial and the health perspective, and figure out where they differ.  Let’s look at some of those assumptions.

You are successful if you get more money to spend. Wilhelm Molterer, Managing Director at the European Fund for Strategic Investment and former Minister of Finance and Agriculture in Austria, urged us to rethink whether it could also be a success that we spend equally or less.  However, the question remains how much room for efficiency there is if the original amount of resources is low in the first place.

We need to increase the share of resources for health in the public budget. Additionally, Mr. Molterer pointed out that the health sector too often just aims at increasing their share of the budget in the public sector, but does not think about alternative forms of financing – for example by turning to the private sector and adopting a more entrepreneurial approach.

We have not been successful in achieving investment in healthcare. Jennifer Dixon from The Health Foundation challenged us by saying that perhaps we have been too successful in achieving investment in healthcare, but not in the areas such as public health, social care and wider social determinants of health. More leadership is needed, though, in order to shift the focus away from mere treatment towards targeting factors that will promote health.

We just have to make the case about the return on investment to the finance sector. While the finance perspective (besides Mr. Molterer also Matti Hetemaki from the Finnish Ministry of Finance,) emphasized that in order to be willing to provide the resources, a clear case has to be made on return on investment. Josep Figueras, Director of the European Observatory on Health Systems and Policies and Head of the WHO European Centre on Health Policy, pointed out that often the measures of efficiency in healthcare, as set by the ministries of finance, are too simplified and not nuanced enough to capture the actual outcomes. 

Health and finance sectors are speaking the same language. Despite using the same terms, during the panel it became clear that representatives from finance and health sectors did not always mean the same thing when they said, for example, “investment” or “healthcare” or even “health”. These issues should be considered when having a conversation with people from different backgrounds. If we want to have a common understanding of our objectives and targets, we first have to make sure we are talking about the same basic concepts.

It is definitely true that it is important to think about win-win strategies for all the sides and that we have to overcome the silo thinking, as it was pointed out throughout the plenary. At the same time however, the discussion showed that we have to make sure to keep on reconsidering and rethinking the assumptions behind our reasoning, or we will not keep up with the rapidly changing circumstances.

Written by a Young Gasteiner Daša Kokole

Economic strategies for health equality (L2)

Building bridges with business and economic development

We hear a common theme at the European Health Forum Gastein – that we need greater levels of multi-sectoral work to tackle health inequalities. This includes private businesses and the “wealth generators” in society, since they too have an influence over the health of populations. Today’s lunchtime session on economic strategies for health equality emphasised the importance of engaging with businesses and economic groups if we are serious about achieving the SDGs by 2030.

Emma Spencelayh from the Health Foundation kicked off this session by highlighting some stark health inequalities from the UK. Major gaps in life expectancy and high levels of childhood poverty were cited; these are issues we may be familiar with, but cannot afford to be complacent about. Clearly, economic growth in high-income countries does not always equate to inclusive growth where everyone benefits. Having a healthy working-age population contributes towards economic prosperity, but there is an onus on us to ensure that available work is fair and decent work, which recognises the labour rights of employees. A few eyebrows were raised when some modern-day workplaces were likened to “sweatshops” and “Victorian workhouses”, particularly in zero-hour contract settings. Calling a spade a spade, perhaps…? If we truly want a healthy and productive workforce, then surely we need to do more to engage with large-scale employers, and encourage them to end unsafe and unfair employment practices.

Fabrice Murtin of the OECD convincingly argued that we could only truly achieve inclusive economic growth, and the SDG targets, if our health policies respond to “deep drivers of inequalities”. Inequitable income distribution has become more and more entrenched in recent years and has occurred in parallel with disparities in educational opportunities and social mobility. But what’s the solution? He asserted that inclusive growth needs real investment in the vulnerable groups who have been ‘left behind’, and business dynamism needs to be supported. There were nods of approval from the audience at the need to challenge the “Winner takes all” mindset that prevails in so many countries. How can we expect to see population-level improvements in health if our financial resources continue to be so unfairly distributed?

Charlotte Ersbøll of UN Global Compact emphasised the need to support businesses in a practical way so that they view the SDGs as real opportunities for growth. As public health professionals, we need to work together with businesses so they consider the health impacts of their activities. We need to encourage and facilitate them to do this, rather than pointing the finger of blame when it doesn’t happen. Although “health is everyone’s business”, it’s unrealistic to expect the corporate world to tackle health-related issues independently. We all need to play a part in “connecting the dots” between relevant stakeholders: healthcare professionals, policy makers, business leaders, economists, marketing experts etc.

A lively discussion ensued on how we can build bridges with the business world, and what practical steps we can take to ensure that politicians respond to the call for more inclusive economic growth. My highlight in this session was learning about the work done by the OECD in developing modern metrics that capture wellbeing and social progress in a more holistic way. We are all too familiar with the challenge of advocating for public health and social interventions, which we can’t adequately evaluate. The OECD has been working to capture, and quantify, what we mean by improved ‘wellbeing’ and ‘social progress’ by developing new indicators such as the Multidimensional Living Standard and Better Life Index. These metrics will allow holistic cost-benefit analyses to be undertaken when new reforms are proposed, and may help to convince politicians and multi-sectoral partners of the true value of such reforms. This year’s conference is about making “bold political choices” to achieve the SDGs… maybe these tools will help us to convince politicians to do exactly that?

From left to right: Charlotte Ersbøll (Senior Advisor, UN Global Compact), Fabrice Murtin (Economist, OECD), Emma Spencelayh (Senior Policy Advisor, The Health Foundation), Fiona Adshead (Expert Advisor, The Health Foundation).

What can be done? Framework for Action on Inclusive Growth. Slide from presentation by Fabrice Murtin (Economist, OECD).

This blog was written by a Young Gasteiner Peter Barret