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.

 

 

Data protection as an added value

Leonardo Cervera Navas, Director at the European Data Protection Supervisor (EDPS) in an interview for the magazine “Healthy Europe” on the protection of health data and the challenges of sharing them within and between countries. A short version of the interview is part of an article on page 8 of the print magazine “Healthy Europe”.

Director Cervera Navas, what has to be done generally to guarantee data security and ethical usage of data? How can the tasks of the European Data Protection Supervisor in that context be described shortly?

Leonardo Cervera Navas:

The fundamental rights to privacy and to the protection of personal data have become more important for the protection of human dignity than ever before. Such rights are enshrined in the EU Treaties and in the EU Charter of Fundamental Rights. The General Data Protection Regulation (GDPR), now applicable since two months, lays down, under its Article 5, the data protection principles(lawfulness, fairness and transparency, purpose limitation, data minimisation, accuracy, storage limitation, integrity and confidentiality)that apply to all processing of personal data.Indoing so, the GDPR expressly reinforces the data protection principles that guarantee, among others, data security.

However, in today’s digital environment, we also have to consider the ethical dimension of the processing of data. We should address deeper questions as to the impact of new technologies in data driven society on dignity, individual freedom and the functioning of democracy. The possible solutions relate tomanifold aspects and have engineering, philosophical, legal and moral implications.We needa collective effort, underpinned by ethical considerations in order to respond to these challenges.

In this context, in theEDPS Strategy 2015-2019, we have outlined as one of our priorities the assessment of an ethical dimension that, as said above, goes beyond the application of data protection rules and encourages a multi-stakeholders and informed conversation and knowledge-sharing on the impact ofbig data and the internet of things on digital rights.

In September 2015, the EDPS issued an Opinion, Towards a New Digital Ethics, in which we urged the EU and the internationally responsible entities to promote an ethical dimension in future technologies to preserve the value of human dignity. The EDPS also created anEthics Advisory Group (EAG)with the aim of helping the EDPS to better assess the ethical implications of how personal information is defined and used in the digitalised world. As outcome of its work, the EAG issued a Final Report, which is available on our website.

This year the EDPS willbe hosting the International Data Protection and Privacy Commissioners Conference. The main theme of the Conference is:“Debating Ethics: Dignity and Respect in Data Driven Life”, focusing on the impact of digital technologies on our lives.

Let me recall that the European Data Protection Supervisor (EDPS) is the data protection authority for the European Union institutions, bodies and agencies. Among these institutions and bodies, the EDPS supervises the European Medicine Agencies (EMA)andclosely follows the work of EMA’s Technical Anonymisation group (TAG) with the key objective to further develop best practices for the anonymisation of clinical reports.The TAG group involves members from Europe and the US with significant experience in the area of anonymisation and clinical trials, coming from the academia, the public authorities – DPAs, the private sector, and other research institutions.

In addition to our supervision of the EU institutions, the EDPS also has a role as advisor on data protection issues in a wide range of policy areas and all matters concerning the processing of personal data, including health research policies.

HEALTHY EUROPE:

Standardized surveys and usage of health data could bring benefits for patients by improving treatments and enabling more personalized medicine. On the other hand health data are especially sensitive. What has to be done to guarantee data security and ethical usage of data especially regarding health data? What are the most important measures?

Leonardo Cervera Navas:

It is widely acknowledged that standardized surveys and use of health data can bring benefits for patients by improving their treatments. In this regard, I would like to underline that data protection shouldnot to be considered as an obstacle, but as an added valuein order to improve the usage of health data, while keeping it safe and respecting the ethical dimension.

As provided by EU legislation, certain categories of personal data, including health data, are considered as particularly sensitiveandcannot be processed unless the ‘controller’ can rely on a specific legal ground (as specified under Article 9 of the GDPR) and specific safeguards are applied to the processing.

One of the legal grounds for the processing of health data is the explicit consent of the data subject (the person that can be identified, directly or indirectly, via the personal data).  Consent is a key condition,also from the ethical viewpoint,for the processing of personal data in the context of health research projects.However, it should be considered that consentis not, in all circumstances, the appropriate legal basis for all the types of processing of personal data.In addition to allowing researchers to process sensitive data where the data subject explicitly consents or makes her data public, the GDPR also permits a controller to process sensitive data when processing is necessary for the purposes of “preventive or occupational medicine”; for reasons of public interest in the area of public health”; and for research purposes where “processing is necessary for [research] purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.”

We also note that it is often difficult to fully identify the purpose of personal data processing for scientific research purposes at the time of data collection. Therefore, data subjects should be allowed to give their consent to certain areas of scientific research.

Let me also flag that Article 89 of the GDPR allows the EU or Member States to limit certain individual rights, when necessary for scientific research. As an exception, it should however be strictly interpreted and applied.

The GDPR introduces safeguards which, even though also applying to ‘non-health data’, are particularly relevant to the processing of health data:

  • The principle of privacy by design and by default: this important principle, initially established only ‘in practice’, is now codified by the GDPR. Privacy shall be embedded in the design phase of the processing of data.
  • The principle of data minimisation and data quality: these are ‘sides of the same coin’. A large amount of data are available in the real world, but not all of them are of good quality. The GDPR introduces the concept of data minimisation (use just what you need). As minimisation is implemented, there is a greater incentive to select data of good quality. Data quality is crucial in healthcare (e.g. clinical trials, therapy evaluation, etc.).
  • The principle of accountability: the GDPR introduces a shift in paradigm about compliance. The controller has to adopt suitable measures to ensure and demonstrate compliance  and to continuously assess, manage and minimize risk associated to processing.

A non-exhaustive list of appropriate measures includes: documentation,implementing security requirements , Data Protection Impact Assessment (DPIA)  anddesignation of a Data Protection Officer (DPO).

HEALTHY EUROPE:

Should information sharing of health data within and between countries be enhanced, especially for the aim of improving diagnoses and treatments? What are the challenges doing this?

Leonardo Cervera Navas:

The increasingly international dimension of scientific research requires the sharing of health data at the EU and at the international level toenhance diagnoses and treatments.

At the same timethe sharing of information may bring to an increased risk for the protection of data subjects. For this reason, the GDPR lays down a number of grounds, subject to specific conditions, for the transfer of personal data to third countries and international organizations. Such ‘legal grounds’ include: transfers to Countries recognized by the European Commission as providing an adequate level of protection by so-called adequacy decisions and appropriate safeguards provided by the controller or processor (legally binding agreements between public authorities, binding corporate rules, standard data protection clauses, approved codes of conduct or certification mechanism).

We note that the GDPR, also referring to codes of conduct or certification mechanism, extends the possibility for data transfers, also having regard to the exchange of health data for research purposes.

HEALTHY EUROPE:

The General Data Protection Regulation, which has become law across the EU in May 2018, has been criticised as being over-regulative by health researchers and practitioners. Should it be attenuated regarding the purposes of health research and treatment?

Leonardo Cervera Navas:

As already mentioned, Article 9 of the GDPR provides for legal grounds other than consent allowing the processing of sensitive data in the context of research, in particular when necessary for reasons of public interest in the areas of public health, such as for public health surveillance activities and epidemiological studies.

The GDPR also offers new opportunities for standardizationof data protection practices in the field of scientific research, in particular with reference to codes of conduct, binding corporate rules and certification mechanisms. Such harmonisation (a ‘common playing field’) would facilitate the exchange of health related data (across health operators within EU Member States and with third countries) and hence the medical and scientific work.

As a general remark, let me stress that in the future, we expect that privacy is increasingly perceived as a quality feature of products and services lubricating the flow of information.

Let me finally add that the EDPS will soon publish a background paper on research and data protection in the European Union, as a first stage in stimulating an informed discussion on data protection law and related ethical issues in the field of research, having regard in particular to health research.

 

Include, invest, innovate – Health Systems for Prosperity and Solidarity: leaving no one behind

WHO high-level regional meeting, Tallinn 2018

In June 13th-14th three Young Gasteiners were dispatched to Tallinn to help disseminate outputs from the WHO high-level conference organised to reaffirm the principles signed by WHO members in the 2008 Tallinn Charter. It provided a forum to discuss challenges facing these principles of health for prosperity and solidarity: present and predicted political and financial headwinds.

The conference sought to reaffirm, through new evidence, that health systems based on solidarity are the most efficient means of facing these challenges.

It was split into three themes:

  • Include – The ethical arguments of improving coverage, access and financial protection for everyone (universal health coverage) are well trodden. However, the conference highlighted the economic case and the huge increases in expenditure amongst poorer WHO European region (+/-10% increase in annual expenditure) for these reasons.
  • Invest –the case for investing in health systems was further stressed for ensuring a productive workforce and longer labour-market participation, amongst other reasons. The importance of value-based healthcare in providing tangible economic evidence towards investing in health systems was provided. Communication on returns on investment over different timescales was also found to be key to persuading finance ministries.
  • Innovate – experience of harnessing and spreading innovations were elaborated. The conference converged on the need for multi-stakeholder visions for innovative healthcare systems. These visions must provide the pathway and incentives for scaling up and spreading innovation. Innovation should be a tool to shrink, not widen health differences between and within countries. Participants were honest and clear that health systems based on solidarity need to be efficient, responsive and require reform. Innovation was viewed as key to these requirements and thus key to safeguarding the solidarity underlying our systems of universal healthcare.

Conclusion: Currently expenditure in health systems is seen as a black hole. The forecasted growth in expenditures to around 14% GDP by 2060 requires a stronger case being made of this expenditure as an investment. Innovation in HTA/pharmaceuticals are a good example with their value-metrics. However, the low hanging fruit seems to reside in health services innovation and spread. It is here where the efforts of the WHO and OECD are focussed.

Check out the blogs on:

Include written by the Young Gasteiner Karolina Mackiewicz: here

Invest written by the Young Gasteiner Dimitra Panteli: here

Innovate written by the Young Gasteiner Philip Hines: here

The three Young Forum Gastein authors together with their fellow Young Gasteiner Gabriele Pastorino (left)

Innovation to protect solidarity – WHO high-level meeting “Health Systems for Prosperity and Solidarity: leaving no one behind”

One of the key themes coming out of the -high-level meeting was the need for innovation, not only for progresses’ sake, but to protect solidarity.

Health systems have changed since 2008 and the difference between the have and the have nots has never been wider: according to Oxfam >80% of wealth generated goes to the top 1%. This threatens solidarity. But there is also good news, both in development and health, with life expectancy having increased rapidly across the European region. Nevertheless, the challenges of equity, demographics and AMR, amongst the myriad others, remain. And on recent projections, the OECD estimates that, without adequate action, 14% of GDP will be spent on health amongst its members by 2060.

But this expenditure, whilst often framed as a cost, has a strong potential to be seen as an investment. Indeed, the conference made a clear financial case for expenditure in public health, but also a detailed case for the need to innovate; innovation encompassing both health technologies and services.

Whilst innovation occurs in a context specific manner, the participants were clear on the requirement for sharing best practices across countries. It was even suggested that collaborative efforts to promote innovation across the region should be sold as the Marshall Plan was: that it is better to have wealthy neighbours than poor neighbours.

Currently, the European region’s ecosystem already performs well in producing innovation, but is hampered when it comes to spreading it. There was much discussion of the barriers for this diffusion, which have been extensively studied by the Innovate plenary session keynote speaker, Professor Greenhalgh.  The desirability politically, in the clinic, and from patients, can aid or hamper an innovation. Other panellists added more traditional examples to the growing mountain of barriers discussed, with geographical, language and historical barriers mentioned. One key finding was that these challenges correlate with the complexity of the innovation, and its business case. For example, the interdependent routines of daily practice prevent the introduction of new innovations, such as telemedicine which can disrupt the flow of the waiting room and prescribing patterns etc. For the above reasons, creating an innovation ecosystem for clinical practice equivalent to that of the pharmaceutical sector is very challenging, principally due to the complex, cross-cutting nature of healthcare services.

Despite these challenges there are of course best practices. One way of ensuring innovation is to reduce their complexity. Spreading innovation has also required high-level political buy in, a strategy and having the resources set aside to bring them from pilots to the market. In Finland this buy-in has been sought with an inter-ministerial agreement, enabling a one-stop-shop for Ehealth data-access, benefiting both patients and researchers.  Beyond the political and financial buy in, there is also the need for a “quadruple-helix” approach to early stakeholder engagement and early due diligence in assessment to ensure a “fail-fast fail-early” mentality is not punished, but encouraged.

Other practices to reduce human resource barriers were shared, such as the provision for professional residencies within and between countries. Or to provide financial incentives where, for example, Belgium offers premiums to clinics which use certified, innovative software. Italy, on the other hand, has legislated that doctors must follow guidelines, which can incorporate innovation.

The depth of experience and scale of these challenges oblige international cooperation, and this was further highlighted through the experience Kazakhstan has had in bringing innovation into its healthcare system – establishing an inclusive health technology assessment (HTA) process, based in part on Germany’s model. For HTAs in particular, there was agreement on the need for international cooperation in the assessment of real-world data. Here, Sweden is using registries to conduct real-world studies on pharmaceuticals and France has adopted pay-for-performance practices. It was suggested that EUneHTA should go further towards cooperating on the value side of technology assessment.

With the future in mind, innovations were seen as increasingly involving software, which update faster than we can assess, or that existing hardware and software can handle. Yet, we need to ensure their appropriate assessment and transparency. And, although the potential benefits on inclusivity of eHealth were recognised, digital literacy is affected by age, education and social class – posing worrying equity questions. These questions were highlighted as requiring greater attention.

Whilst the European region may already be competent at producing many small-scale innovations, there needs to be large-scale international efforts in implementing them. Innovation should be a tool to shrink, not widen health differences between and within countries. Participants were honest and clear that health systems based on solidarity need to be efficient, responsive and require reform. Innovation was viewed as key to these requirements and thus key to safeguarding the solidarity underlying our systems of universal healthcare.

 

This Blog was written by the Young Gasteiner  Philip Hines

Investing in health systems is one of the cornerstones of the Tallinn Charter – but how do we make it work?

Last week’s 10th anniversary meeting for the signing of the Tallinn Charter, which back in 2008 put a commitment to investing in sustainable health systems that are inextricably embedded in overall policy formation and responsive to people’s needs firmly on the international agenda, strongly and enthusiastically reinforced the importance of investing in a healthy society by ensuring that health systems have enough resources to achieve their goals (a short overview of selected related passages from the Charter and the Outcomes Statement of the anniversary meeting is in the table, below).

Tallinn Charter, 2008 Tallinn10 Outcome statement
Therefore we, the Member States and partners, believe that

  • Investing in health is investing in human development, social well-being and wealth; (…)
  • Heath systems are more than health care and include disease prevention, health promotion and efforts to influence other sectors to address health concerns in their policies; (…)
  • Health systems need to demonstrate good performance.

We, the Member States commit ourselves to:

  • (…) invest in health systems and foster investment across sectors that influence health, using evidence on the links between socioeconomic development and health; (…)
  • Engage stakeholders in policy development and health; (…)

Countries shall pursue (…) performance goals to the greatest extent possible given their means. This requires efficiency: making the best use of available resources. (…)

The overall allocation of resources should strike an appropriate balance between health care, disease prevention and health promotion to address current and future health needs. (…)

In a rapidly globalizing world, generation of knowledge, infrastructure, technologies, and, above all, human resources with the appropriate skills and competence mix requires long-range planning and investment to respond to changing health care needs and service delivery models.

(…) We will thus:

i.        continue to strive to secure and sustain adequate resources through greater public investment, make use of efficiency gains and ensure a redistribution of resources to meet health need, especially towards poorer people and regular users of health care, for whom the economic gain is most evident;

ii.      intensify efforts to bring health and finance decision-makers together around shared goals by taking note of public finance objectives and correspondingly demonstrating the economic and social returns of investing in health systems; and

iii.     elevate our efforts to enact cost-effective and evidence-based public health approaches, services and interventions by improving cooperation with key stakeholders inside and outside the health system; by improving human resource policies through training and broadening the range of professionals and skills; by introducing financial mechanisms to increase the share of resources to public health; and by adapting the organization of public health services with better population-based health needs assessment and coordination with primary health-care services.

(…)We (…) further commit to scaling up work on health system transformation, and will invest in mechanisms and processes to manage the transformational change required of our health systems. (…)

We, the participants of this high-level meeting, call upon European leaders to recognize the centrality of strong health systems based on the need to include, invest and innovate, where healthy populations are the bedrock of delivering on governmental and social commitments, and to pursue these policy directions.

 

During the meeting, discussions often focused on the fact that despite a wide recognition of the importance of safeguarding and improving the health of populations, health policy-makers often find it difficult to ensure funding for reforms, additional initiatives or ad-hoc responses to short-term needs. Prepared specifically for the meeting, a video starring Geert van Maanen, who has served as the Secretary General of both the Ministries of Health and Finance in the Netherlands (and who should definitely consider an acting career in subtle comedy) aptly put the issue in context. Finance Ministers, and, in consequence, governments, need to see that existing funds are used wisely before they will consider committing even more to the health system. Beyond ideological conviction, they do not necessarily always see how health systems can be of value to the overall economy.

 

Indeed, while statutory health spending per capita shows shallow upwards trends in the majority of EU countries since the signing of the Tallinn Charter (see OECD data for 2008-2016), the breakdown of contributor to the phenomenon (e.g. high-priced innovations and inefficiencies) requires more granular analysis. Having said that, there seems to be sufficient data to suggest that higher per capita spending corresponds to lower amenable mortality rates – if only Health Ministers readily had such evidence at hand when speaking with their counterparts in Finance!

This is the gap a new policy brief by the European Observatory on Health Systems and Policies (www.healthobservatory.eu) aims to bridge. Authors Jonathan Cylus, Govin Permanand and Peter Smith systematically examine the barriers health policy-makers can face when trying to “make the case” for (further) investing in the health system. They identify the reasons for resistance on behalf of governments to prioritize health as a sector for investment (e.g. the major role of factors outside the influence of the health care system in determining overall health outcomes, perception of widespread inefficiency, low prospects of productivity growth etc.) and provide hands-on advice for health policy-makers to overcome them.

So what could matter to Ministers of Finance? The authors organize the main messages of the brief around four key areas of interest in resource allocation:

  • Is spending on health systems a good use of government resources and how can health systems demonstrate that they use public resources responsibly?
  • Are health systems an important driver of macroeconomic growth?
  • Do health systems support societal well-being?
  • How does the health system influence overall fiscal sustainability?

The brief will be available online soon, but here’s a sneak peek into what we can argue to convince those with the power to act on it that sufficiently funding the health care system is a sound investment: there is good evidence that spending on the health systems contributes to better health outcomes (not to mention, out of potential contributors, it’s the one we can control the easiest) and, while we may not be able to fully eliminate inefficiencies, we can show that we are committed to value for money by monitoring performance and acting on identified waste and misuse. From the macroeconomic perspective, health systems are not only major employers but also very important for the productivity of the labor force overall. Health systems´ contribution to societal well-being is increasingly discussed in the context of “morbidity compression”, which can be directly influenced by concerted efforts. Finally, by adjusting to epidemiologic trends and focusing on keeping older people active and able to contribute to society, health systems can be a boost and not a threat to fiscal sustainability. [For the types and sources of evidence to support these assertions, seek out the full text of the brief soon!]

As Hans Kluge, the Director of the Division of Health Systems and Public Health at WHO Europe, clearly and resoundingly reiterated in his inspiring summation speech on June 14th, if we are going to stay true to the investment goal of the Tallinn Charter “we need to show that we know what we want and that we have our house in order”. [Slovenian Health Minister Milojka Kolar Celarc added another important tenet for health policy-makers when addressing those deciding on funding: persistence. “You throw me out the door, I come in the window!” is the attitude that has proven the most successful in her experience (fellow policy-makers at the meeting agreed)]. An important point to remember here: as the Tallinn Charter explicitly described (and the name of Hans’ Division fittingly reminds us), “what we want” should not limit itself to investment for the provision of health care services – public health with all its facets equally merits a place on the agenda of health policy-makers. However, securing funding for public health initiatives can be even more challenging – making sure that sufficient evidence is generated and organized in a way that is conducive to “making the case” for public health investments is another imperative. [A separate Observatory policy brief, this one by David McDaid, takes a closer look at how this can be addressed, drawing on a number of successful initiatives from a number of countries. Both policy briefs will be appearing soon on the WHO and Observatory websites. Stay tuned!]

 

This Blog was written by the Young Gasteiner  Dimitra Panteli