“Ministry of Finance needs to be a good listener” – Interview with Corina Pop, former Romanian State Secretary for Health

Corina Pop

Corina Pop (CP) served as Romanian State Secretary for Health from 2015 to October 2018. She coordinated the Project Implementation and Coordination Unit. At the EHFG plenary, she gave her perspective on “making the case for investment in health”. This interview is a follow-up on the heated plenary debate.

NP: During the plenary, you talked about the issue of ‘silo thinking’ and how to better understand the dialogue between health and finance decision-makers. We, as public health professionals, are sometimes in the position of having plans for a health project which we need to pitch to the finance ministry to convince them to allocate a budget for it. We would be interested to hear your take on such situations from the health perspective – how do you approach this challenge?

CP: First of all, I am a doctor, and I am not political. I am rather strictly a doctor in the position of the Ministry of Health. When I arrived at the MoH, one of the most important problems that I faced, and which is of particular interest to me, was that the doctors didn’t want to be involved in the projects. They are not interested in projects because running a project is very difficult. It is not like clinical or surgical medicine, or dentistry. It requires a type of work done by a civil servant. This means that you need to have a team, ideas, and you to spend a lot of time writing mails and talking about money and administration – this is why doctors do not want to be involved. I called everyone I know asking to help me run these projects because we had a reasonable amount of money at our disposal. For me, as a health system policy-maker, it means that you have to find both the resources and the beneficiaries. In order to promote your interests and projects, you need to convince not only the Ministry of Finance, but also the promoters who are the doctors, the managers of the hospitals etc. The promoters are especially interested in research and not in public health-related projects.

For example, I have an important project for Romania that I care about a lot. It is about health economics. As there is no specialist for health economics in Romania, I said ‘look we have to prepare a project: first, we need a curriculum and a methodology, then we need to find the professors, the teachers, the speakers, the experts, and finally we need to train and pilot the first 20-30 doctors or economists’. Even though I have written the guidelines and the programme, no one wants to run the project. And this is not only about the funding, it is also about the interest in public health.

BF: How do you think you could adjust this and make public health a more attractive specialty for doctors in Romania?

CP: It has to be specifically promoted during the undergraduate studies. What we need is for students to start learning about the importance of public health and health of the population as soon as they start studying medicine. It is important to talk about public health when talking about epidemiology in the first year. This way, the students have more options before they go the common way of choosing the surgical specialty which is associated with fame and lots of money. However, no one wants to talk about epidemiology, you know (laughs).

NP: Mr Hetemäki from Finland mentioned the issue of trust being a key factor for collaboration, which can only be based on a common understanding. Now adding that you also have to convince the promoters, how do you actually achieve this? 

CP: There are two dimensions. First, the evidence. Just saying ‘look I have a lot of evidence here, please give me the money’ is not enough to gain trust. Rather, you need to approach it by providing the evidence, i.e. number of saved women’s lives with cervical cancer. It is not like in a Disney cartoon in which you can achieve anything by repeating ‘please trust in me, trust in me’ (laughs). The second dimension is the team that will implement what you promise to do. However, I recently had a case of a very difficult and complex project in which the professionals were simply not able to promise to deliver a certain number of services. That is why the budgeting official said ‘OK, if you are not able to, you will not get the money’. It is very difficult to fight with the Ministry of Finance for trust. It is about the capacity-building and it is about the health workforce. That is why I said, ‘my wish for the Ministry of Finance is to be a good listener’, to have patience to explain that there is so much we can do, and this is not at all because we are unable. It is because health services are too complex. We have to be very patient and listen to the process. It should not be like in a marketplace: ‘how much do you want?’ ‘health spending is this much’, ‘which are the metrics?’, ‘OK, I won’t give any money’. This is impossible.

NP: Are there any tools to support you in convincing them?

CP: Yes, there are two partners you need. One of them is a very good journalist, always capable of presenting the problem. The second is the civil society, especially patient associations. Together with journalists and patient societies/associations, we can convince the Ministry of Finance. Not only with evidence, but with real life examples.

NP: I understand. We frequently hear the financial sustainability of healthcare systems being questioned due to challenges such as the aging population, unhealthy lifestyles and high prices of new medicines and technologies. In your view, what needs to be done to successfully address these challenges?

CP: The problems that require a lot of attention are related to innovation, ageing and costs of healthcare delivery. It should be taken case by case, though. Depending on the country, I can provide you with different answers. Regarding Romania, and the low-income countries, I have told you that it’s always about choosing between either prevention or treatment and diagnosis because all of these fall under the same budget. It is up to you to keep explaining the importance of keeping prevention high, because prevention will decrease the spending in the next 10 years. But the Ministry of Finance does not care about the next 10 years, especially if the elections are in 2 years. At the same time, you have to explain that it is impossible to spend only on prevention, because you have cases of cervical cancer that are happening right now, and need radiotherapy.

The problem is that they are not interested in prevention of lifestyle-associated diseases, because they do not understand the process from smoking and cancer to spending and expenditure. This is the process that we, as specialists, know all too well.

The budgeting officials are interested in taxing alcohol and smoking, but this money does not go to health. It means that you have to explain that we raise the taxes not only to gain more money, but also to prevent people form buying and consuming tobacco products, as well as to use that money to cure the already existing cancer. There needs to be a communication, one needs a lot of time to explain things that seem so trivial for us in public health.

BF: You were mentioning that these things are sometimes hard to explain. Do you think that the direct benefits that the health system has, such as contributing to people having longer lives and healthier lives, are measured enough in the current system? And do we communicate these benefits enough?

CP: Surely it is not communicated enough. And I think that everybody talks about aging, but everybody talks about what problems you have when you are elderly. No one talks about how beautiful it is to have your grandchildren and to be healthy at the same time. It means to explain that good health gives you the gift to be healthy when you are elderly. It means that you are healthy enough to help your family and community. We have to live well and have a high quality of life.

BF: This leads me on to the next question. Public health is actively working on well-being and safety of the entire population. Do you think that the entire health system takes this into account? Sometimes I feel we have a system that is geared around the financial aspect and doesn’t take into account the things which we cannot quantify.

CP: Yes, it’s interesting, we just discussed this one two hours ago. I think that the Sustainable Development Goals address exactly these ‘uncountable’ aspects. If we talk about any of the SDGs, none of them is only about numbers: they talk about quality, well-being, air, nutrition, communicable diseases, safety, patient safety, water, transport… So, yes, it’s exactly about the SDGs.

BF: So you see the SDGs as a useful tool to help you?

CP: Very useful, but they are not promoted enough by the policymakers. They understood they would need to take care about the SDGs, to fulfil the targets, but they don’t really care. If the policymakers were to read, but really read the SDGs, they would understand they are faced with a complete political programme, and a very beneficial one. It is so complete, it is so about people, it’s so social, at the same time addressing health, economy and inequalities.

BF: Is there any way that the SDGs have influenced or inspired you in the way you’re tackling certain health issues in Romania?

CP: Yes, we had a lot of meetings. We had a meeting with Zsuzsanna Jakab in July about SDGs, it was very important for Romania, because she has the power to bring the politicians to the same table.

NP: Who participated, only health policymakers?

CP: No, the president of the country, the directors of the whole university, the rectors of the universities.

BF: Did she help you to get other people on board?

CP: Yes, certainly, she has the power to do that. She’s wonderful in doing something to get all the policymakers on the same table, and without punishing any, she convinced them that was important to work for health.

This interview was conducted by the Young Gasteiners Beatrice Farrugia (BF) and Nataša Peric (NP).

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

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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

It is clear that something needs to change

Hans Kluge, Director of the Division of Health Systems and Public Health at the World Health Organization Regional Office for Europe, in an interview for the magazine “Healthy Europe” on how the economy affects our health. A short version of the interview is part of an article on page 12 of the print magazine “Healthy Europe”.


HEALTHY EUROPE

Mr Kluge, are health and economy in opposition to one another and do the two sectors collide? If yes, how can we make them dovetail?

Hans Kluge:

  • I’m not sure that they collide per se, but it is clear that many in finance circles view health as a ‘black hole’; where money is poured in but with little in the way of return on investment.
  • We know, however, that this is something of a simplistic caricature of the situation.
  • There is an increasing body of evidence, building already on the compelling work profiled at the 2008 Tallinn Ministerial Conference which led to the Tallinn Charter on Health and Wealth, that the health system contributes economically, and that healthy populations provide a boost to the economy.
  • It is precisely for this reason that, along with the European Observatoryon Health Systems and Policies, my division at the World Health Organization (WHO) Europe has developed a workstream to firstly strengthen the evidence base, and secondly to explore how best to get these important messages across.
  • Messages such as the fact that health systems contribute to human capital at all ages; that the health system is an industry in its own right and major source of employment; and that, as we learned from the initial and spin-off work of the Commission on Macroeconomics and health, good population health allows for more people in employment, greater individual and collective productivity in employment, and more people investing in education, retirement and the economy itself.
  • Nonetheless, we often hear financial decision-makers talk about waste and inefficiency in the health sector as a reason for not investing in health, and it is important to not simply dismiss these accusations but to engage with them – for it is only by doing so that we can better understand why they are made and what type of information is needed to counter them.
  • In this regard, we are working to examine ways to improve the dialogue between health and finance decision-makers and to see how best they can work together when it comes to budget and spending decisions around health.
  • In saying this, I must admit that while I understand that we in the health community need to do better in speaking the language of the economists – they are after all the ones holding the purse-strings – I nonetheless would argue that as health has an intrinsic value of its own and should not necessarily be defined economically.
  • And I do think that other sectors are wasteful, perhaps in some cases more so, and we should not always be as defensive as we are here.

HEALTHY EUROPE

What is the impact of economic development on health?

Hans Kluge:

  • We know that people who are employed and earn more are in the main healthier than those who do not.
  • The reasons for this are many, some relating to socio-economic factors and the social determinants of health – so difficult for individuals to change themselves – some to education and access to information, and some to ability to pay for health services or health insurance etc.
  • So at a micro- or individual level, a better economic standing has a positive impact on health.
  • At a more macro-level, however, the picture is less clear.
  • Economic development and growth would suggest benefits across the population such that everyone’s standard of living is raised and that households have more disposal income, ideally to be spent on health.
  • But individuals may choose to spend any additional income or wealth on non-health related commodities; some of which might even worsen their health status beyond what being poorer might have done.
  • Economic development would also suggest that the social safety net can be drawn wider and strengthened, providing greater health coverage and health for more people.
  • But again, it depends where any additional money is spent – we know that even in richer countries, the amount spent on public health is far lower than it ought to be.
  • So while economic development should suggest greater health, it always comes down to choices and where resources are distributed.

HEALTHY EUROPE

Do we need a different, new form of economic development to get more health for all?

Hans Kluge:

  • This is of course a more philosophical issue than I am usually asked in my capacity as Director of Health Systems and Public Health at WHO Europe.
  • And I’m not sure that I am qualified to answer this!
  • What I can say is that with the Sustainable Development Goals (SDGs) of United Nations and the growing attention given to economic and social disparities worldwide, including in Europe, thinking about people’s access and right to health is coming to the forefront of discussions even those about the economy.
  • The push for sustainable development suggests an alternative to current models of economic development, re-emphasising the need for solidarity and looking out for the needs of the many rather than the few.
  • It is difficult to understand how we can be generating so much wealth across the globe, and yet in many cases we see inequality rising rather than falling.
  • It is clear that something needs to change, and a clear focus on redistributive models under the SDGs is a step in this direction, and with a positive effect on our pursuit of health for all.

HEALTHY EUROPE

What has to be done to ensure good health of the workforce?

Hans Kluge:

  • I’m not sure that anything specific needs to be done for the workforce as opposed to those not working – at WHO Europe, we of course subscribe to the health for all view.
  • This is not intended to be reductionist or a lowest common denominator approach, rather it is the opposite.
  • It’s about everyone attaining their own highest possible level of health.
  • So everyone, not just those in the workforce or of working age, should benefit for universal health coverage and have affordable access to the highest quality care that they need.
  • Yes, of course, in different professions there are important occupational health guidelines which should be adhered to, and WHO has helped developed guidelines here.
  • But what is important is that workers have health coverage and financial protection – these are key issues particularly in the WHO European Region where access to care, and access to quality care is generally better for most people when compared to other regions; not everyone, of course, but our populations in Europe are generally better off than elsewhere.
  • Ensuring a strong people-centred health system will generate and maintain a healthy workforce, with a consequent benefit for the economy.

A Unique Momentum for Public Health

Zsuzsanna Jakab, WHO Regional Director for Europe, on the importance of the 17 Sustainable Development Goals for the health sector, why we are currently living at the expense of the present and future generations and for which reason health diplomacy is critical to lead us through a period of considerable uncertainty. A short version of the interview is part of an article on page 10 + 11 of the print magazine “Healthy Europe”.


HEALTHY EUROPE

Director Jakab, the 17 Sustainable Development Goals (SDGs)of the 2030 Agenda for Sustainable Developmentof United Nations are meant to end all forms of poverty, fight inequalities and tackle climate change over the next 15 years while ensuring that no one is left behind. What is the importance of the SDGs asa whole for the health sector?

Zsuzsanna Jakab:

The adoption of the 2030 Agenda and the universal commitment to the SDGscreateunique momentum for public health. The implementation of the SDGs will contribute to the full realization of human rights and fundamental freedoms for all, including the right of everyone to the highest attainable standard of physical and mental health.

Also, the adoption of the 2030 Agenda has clearly shown that the vision of the international community is converging, and that there are growing signs of solidarity in the world. We have unprecedented political determination to strengthen health systems towards universal health coverage, strengthen primary health care, combat major diseases and address the multiple determinants of health through the achievement of all SDGs. With these essential elements in place, we have an excellent opportunity to make major progress in achieving better health and well-being for all people at all ages. The point is that now we have to act together to live up to the pledges we all made in 2015.

HEALTHY EUROPE

What can the health sector contribute to reaching all the SDGs together?

Zsuzsanna Jakab:

Obviously,its main contribution is the implementation of SDG 3, the “health goal”, which is the most powerful tool for operationalizing health in all policies. This is underpinned by universal health coverage, which is the flagship of the new global vision for WHOapproved by Member States at the World Health Assembly in May this year.But health targets are not limited to SDG 3– almost all of the other 16 goals are directly related to health or contribute to health indirectly, reflecting the complex pattern of health contributions to SDG implementation.

If I have to pick a few key elements that have a strong impact on the implementation of the 2030 Agenda, I would like to highlight the main elements of the SDG roadmapendorsed by European Member States. The first is strengthening health systems towards universal health coverage. By building strong health systems we contribute to reducingpovertyand toincreasing social cohesion and inclusive economic growth.

Another isadvancing governance for health.Implementing the 2030 Agenda requires a high level of political commitment and a whole-of-government, whole-of-society approach. Health ministers and public health authorities play key roles in setting agendas, providing evidence and proposing policies. They can, for example, seek the commitment of heads of state and leaders of other sectors to improve population health and well-being by considering investments in public health, health in all policies and equity.

Ensuring that no one is left behindisanother major focus area.The health sector itself can ensure that everybody has access to quality care and that it does not discriminate against anybody, but it can also lobby for universal social protection, for example.

In addition, advocating forimproving the environmental, social, economic, commercial and cultural determinants of health through a health-in-all-policiesapproachandembedding health promotion and disease prevention in communitiescan probably reduce half of our burden of disease.It is particularly necessary, for example, to tackle the burden of disease from environmental exposures, climate change and unhealthy food systems; to address the risk factors for noncommunicable diseases; to meet the challenges of emergencies, communicable diseases and antimicrobial resistance; to strengthen the factors that promote social protection; and to empower people through education and training.

Plus, the health community can offer expertise, evidence and tools to assessthe effects of health and health equity policies, programmes and processes.

HEALTHY EUROPE

The health sector and health promotion are connected to all other societal sectors, such as agriculture, infrastructure, education, city planning and landscape architecture. Should health therefore be an overarching goal in the context of the SDGs?

Zsuzsanna Jakab:

Health is an overarching goal. Without health we cannot achieve the SDGs, and to achieve health we need to accomplish all of the SDGs. The SDGs have strong interconnections that extend to all sectors. If properly implemented, actions to achieve the SDGs should span many spheres of governance (such as legal, institutional, technical and fiscal realms) and many sectors (such as those focused on agriculture, transport, energy, justice, welfare, education, security, industry and housing). Ultimately, this will improve people’s living conditions; increase capacity; improve social, environmental and financial protection; create a greener society; and increase security at all levels.

Yet, effective multisectoral action also requires policy coherence across sectors as well as effective multistakeholder governance for health. This means that actors across health and other areas must regularly engage with each other in structured dialogue and, where appropriate, plan and act jointly to maximize shared gains and minimize tradeoffs.

Let me offer an example to show that allSDGs are strongly interconnected and indivisible, meaning that each depends on the success of the others.Poverty (which SDG 1 specifically addresses) is linked to poor health, low salaries, unemployment and low educational outcomes. Without effective and universal education, health coverage and social protection, the risk of poverty is passed from one generation to the next. The implementation of social protection floors that provide universal access to basic social guarantees such as healthcare, disability benefits, unemployment benefits and old-age pensions reduces the risk of poverty and social exclusion.These are specific targets of SDG 1 and SDG 10, but strongly connected to target 3.8 of universal health coverage.

Similarly, out-of-pocket payments for health care(addressed in SDG 3) can have detrimental effects on families, individuals and society by contributing toimpoverishment. Out-of-pocket payments as a proportion of total health expenditure are still high in many countries of the WHO European Region, ranging from 11% to 49% (our benchmark goal is 15%). The outcome statement “Health systems for prosperity and solidarity: leaving no one behind”,adopted by all 53 Member States in Tallinn, Estonia, in June this year, stresses that in order to include everybody, we need to extend coverage to the whole population, improve access to medicines and carefully redesign policies on user charges to protect all households from financial hardship. This has to be addressed throughout a whole-of-the-government approach.

One more example of the interconnectivity of the SDGs involves preserving Earth’s ecosystems on which human societies depend. Climate change and environmental degradation are increasing the risk of extreme weather events and creating greater food and water insecurity, all of which contribute to a higher burden of disease. Approximately 16% of all deathsin the Regionare attributable to environmental factors that could have been prevented and/or eliminated. Much progress could be achieved by focusing on strengthening the implementation of the many national and international commitments that Member States have already made in these areas. In our Region, we have the Ostrava Declarationon environment and health, the implementationof which will contribute to achieving SDGs 3, 6, 7, 9, 11, 12, 13, 14 and 15.

HEALTHY EUROPE

Sustainability means not living at the expense of future generations. Is this currently the case – in Europe and globally?

Zsuzsanna Jakab:

Let me clarify: sustainability means not living at the expense of future or present generations. How societies live, consume and produce continues to be disconnected from natural environments as a result of long-standing patterns and practices in policies, institutions, technologies and lifestyles. Despite improvements in the last decades, Europe’s ecological footprint is large. If everyone on the planet had the same ecological footprint as the average resident of the European Union, we would need approximately 2.6 Earths to support our demands on nature.

We are living not only at the expense of future generations, but also at the expense of the present generation. Climate change already contributes significantly to the global burden of disease, and its health effects are projected to increase in all countries and regions. The rising numbers of deaths and losses from more frequent heat waves, floods and wildfires that we are already observing are related to our unsustainable lifestyles.

Every year, at least 1.4 million premature deaths in the Region are attributable to environmental risk factors – especially air pollution – and 14 people every day die from diarrhoeal disease due to inadequate water supplies, sanitation and hygiene. This situation is worrisome and the challenges are multifaceted, since the systems that account for a large proportion of our environmental pressures are also linked in complex ways to benefits and interests such as jobs, investments, lifestyles and values.

Yet,the future is hopeful. Europe has some of the world’s highest environmental standards and has set a vision to “live well, within the planet’s ecological limits” by 2050.Adequate investments in environmental and climate policies can generate innovations and sustainable solutions, which can be implemented and exported to help address international environmental and climate challenges more effectively.

Unsustainable lifestyles are damagingto health in various ways. For example, rising rates of obesity, physical inactivityand consequent noncommunicable diseases are results of these health-damaging lifestyles. More than 50% of adults (in 46 countries accounting for 87% of the Region) are overweight or obese, and in several of these countries the rate is close to 70%. Of particular concern are high rates of childhood obesity.Preliminary unpublished data from the WHO European Childhood Obesity Surveillance Initiative (COSI) reveals that in some countries almost 50% of 8-year-old boys were overweight and more than 25% were obese in 2016. Regional estimates for 2016 show that more than 40 million and 5 million of disability-adjusted lifeyears lost per year are attributable to dietary risks and low levels of physical activity, respectively. Based on trends from surveys of adolescents and adults, the Region is unlikely to achieve a 10% relative reduction in prevalence of insufficient physical activity.

HEALTHY EUROPE

Which aspects of sustainability should have priority? Where should we start?

Zsuzsanna Jakab:

The SDGs are indivisible. This makes prioritizinga single SDG difficult. But a range of so-called accelerators can help to achieveone SDG with multiple benefits for all other SDGs. I will mention just a few.

The first is collective action to achieve shared goals. The 2030Agenda provides the opportunity to strengthen intersectoral and multistakeholder cooperation. The good news is that extensive coordination efforts are scaling up to, for example: meet specific health priorities (such as disease outbreaks);ensure more effective emergency responses; standardize data collection; increase access to priority medicines through joint work on product development, registration, approval, prequalification and distribution; and support universal health coverage. 

At this early stage in the implementation of the SDGs, the health community faces a critical opportunity to capitalize on this growing momentum. Our United NationsIssue-based Coalition on Health and Well-being provides a good example: more than 20 United Nations agencies work together in European countries to implement country health priorities through multistakeholder action.

Also, to achieve long-term sustainability and address sustainability challenges, we need fundamental transformations in how we produce and consume; inthe commercial determinants of innovative health technologies andregulations;in ourpractices and behaviours; and in our beliefs and values. For example, addressing the consumption ofultra-processed foods, sugar-sweetened beverages and tobacco requires multisectoral responses involving a range of public- and private-sector actors working in health, industry, finance, environment, media and other areas.

From the health perspective, major investments in health promotion and early disease detection and prevention will allow countries to limit the rising costs of health systems and enable savings if disease can be avoided. Member States are called to place a spotlight on people-centred primary health care as the means to move towards universal health coverageand serve the most disadvantaged, marginalized, stigmatized and hard-to-reach populations. We must carefully considereffectiveness, safety and efficiency; ensurethe continuity, integration and coordination of care; and fosterrespectful and compassionate relations between people and their health-care workers.

We must also ensure that more people are better protected from emergencies. Every country is vulnerable to epidemics and emergencies – these threats are universal. Global and regional earlywarningand event-based surveillance systems are now in place. Early detection, risk assessment, information-sharing and rapid response are essential to avoid illness, injury, death and economic losses on a large scale. However, not all countries have the same risk-preparedness and -management capacities for health emergencies. The implementation of the International Health Regulationsand the Sendai Framework for Disaster Risk Reduction 2015–2030will address this.

HEALTHY EUROPE

The SDGs are not legally binding, but governments are expected to take ownership and establish national frameworks for their achievement. What importance do the SDGs have in the realpolitik, the practical policy of nations?

Zsuzsanna Jakab:

The fact that the 2030 Agenda is universal, for high- and low-income countries alike, provides an unprecedented opportunity for global governance. Although it is not legally binding, we see more and more countries, international actors and stakeholders engaged in implementing and contributing to the2030 Agenda and achieving the SDGs.

We can see this commitment in, for example, the annual reporting of more than 100 countries worldwide and 36 countries in the Region at the United Nations High-level Political Forum on Sustainable Development. TheForum isan important process for strengthening assessment, review, dialogue, mutual learning and the science–policy interface. Development partners are more engaged in financing solutions for sustainable development, and countries are more and more interestedin aligning national priorities with sustainability principles.

Our analysis of the voluntary national reviews published until 2017 shows that, generally, countries show a willingness to address challenges relating to governance, leadership and engagement. Many countries state commitments to improve energy efficiency, reduce emissions, improve air quality, support renewables, reduce waste, improve recycling, develop information technology, and develop knowledge-based or green economies. However, countries have struggled to apply the broad principles of intersectoral work and to integrate the three dimensions of sustainability – environmental, social and economic – and have engaged in even less discussion on the potential health benefits of wider action on sustainability.

HEALTHY EUROPE

In Europe and globally, we are currently experiencing a conflict between sociopolitical concepts of nationalism and national self-interest and concepts that attach more importance to solidarity within and between nations. Are we currently standing at a crossroads in this regard? What does that mean for the health sector? 

Zsuzsanna Jakab:

We are definitely in a time of emerging challenges, and these challenges are not unique to the health sector. We can be proud of the attributes we assign to European health systems: solidarity, equity and universalism – but, indeed, these are at risk.

The political and public debate is increasingly polarized on climate change, the globalization of hazardous products, terrorism, civil conflicts, vaccination, etc.These complex and sometimes interconnected problems require systemic approaches that involve a wide range of society and multiple levels of governance, from local to global – with recognition of the increasing relevance of regional and local levels.The biggest challenge in this context, however, is to nurture leaders with a strategic vision, technical knowledge, political skills, and an ethical orientation to lead the complex processes of policy formulation and implementation.

Health diplomacy is critical to lead us through this period of considerable uncertainty in Europe and the wider world. Meeting and working together to achieve the SDGs and the European policy framework for health and well-being Health 2020require more and more expertise from Member States and from many state and non-state actors. These efforts require close cooperation on health matters with the European Union and other European organizations. Public health professionals increasingly need a better understanding of the mechanisms of diplomacy, and diplomats engaged in health-related negotiations must be informed of the challenging dimensions of today’s public health.

WHO is committed tocontinue promoting the vital role of health in human development at all levels of government, as well as within the United Nations system and among a range of non-state actors and citizens. We must continue to use human rights-based principals to argue for public health measures to address issues ranging from climate change to tobacco control toadequate standards of living, and to ensurea wide range of civil, political, economic, social and cultural rights.