November 2013

Health Systems Strengthening in the WHO European Region – Putting the values and commitments of the Tallinn Charter into action through Health 2020 and a people-centred approach

In 2013, the WHO Regional Office for Europe convened 2 High Level Meetings on Health System Strengthening:

1. Health in times of global economic crisis: implications for the WHO European Region, 17-18 April 2013, Oslo, Norway; and

2. Health systems for health and wealth in the context of Health 2020: High level Tallinn Charter 5 year anniversary meeting, 17-18 October 2013, Tallinn, Estonia.

1. Health in times of global economic crisis: implications for the WHO European Region, 17-18 April 2013, Oslo, Norway.

WHO Europe has engaged extensively with Member States since the beginning of the financial crisis to help the Ministers of Health making effective policy decisions. Examples include support to Ireland, Cyprus, Portugal, Hungary and the Baltic States to maintain Universal Health Coverage but also our joint work with OECD on the Senior Budget Official Network convening Senior Budget Officials from health and finance.

In April 2009 the Government of Norway hosted a WHO high-level meeting on “Health in times of global economic crisis: implications for the WHO European Region”.  Since then, the crisis has deepened across the Region, with a damaging impact on the public finances of many Member States and consequent health outcomes. 

Given the fast-moving economic and political environment, the WHO Regional Office for Europe convened a follow-up meeting, again held in Oslo on 17–18 April 2013, generously hosted by the Norwegian Directorate of Health, with the following objectives:

• to review the impact of the ongoing economic crisis on health and health systems in the WHO European Region;
• to draw policy lessons around three broad themes: maintaining and reinforcing equity, solidarity and universal coverage; coping mechanisms, with a focus on improving efficiency; improving health system preparedness and resilience; and
• to identify policy recommendations for consideration by Member States and possible future political commitments.

The meeting also served to intensify the dialogue with Ministers of Finance and the multi-lateral organizations (ECFIN, IMF, World Bank, OECD etc).

The meeting was informed by a raft of evidence produced jointly by the Regional Office and the European Observatory on Health Systems and Policies, based on 2 regional surveys, a literature review (both health and fiscal), detailed country case studies and our direct technical assistance work with countries on the impact of the crisis on health and health systems as for example Greece, Ireland Portugal, the Baltic States etc

The evidence and meeting emphasized that even with a restricted budget envelope, Governments and Ministers of Health do have a choice and can focus on areas and services that encourage economic growth and reinforce equity. Furthermore, maintaining and improving population health is an investment which contributes to a healthy workforce, economic growth and human and social development. Fiscal policy should therefore consider explicitly taking into account of the likely impact on population health and there is now ample evidence that long term unemployment is associated with higher levels of disease, especially mental health and increased mortality from suicides, especially among the poor and vulnerable. Fiscal policy should therefore avoid prolonged and excessive cuts in health budgets except where downward budget adjustments do not threaten population access to needed services which is at the heart of the WHO European Health Policy H2020.   Jonas Gahr Støre, Minister of Health Norway; Zsuzsanna Jakab, RD WHO Europe; Hans Kluge, Director Health Systems and Public Health, WHO Europe at the Oslo Meeting

Much of this evidence is available on the conference website. http://www.euro.who.int/en/media-centre/events/events/2013/04/oslo-conference-on-health-systems-and-the-economic-crisis.

A crucial outcome of the Oslo meeting was the elucidation of a series of 10 key policy lessons and recommendations.  These offer a way forwards for Member States in terms of navigating the crisis while mitigating the impact on health outcomes; and proved already to serve as a powerful negotiation tool for Ministers of Health in their dialogue with the Ministers of Finance and Prime Ministers (as for example, in the case of Ireland).  They were subsequently put to a regional consultation in July and August 2013, resulting in some revisions and reflecting wider regional inputs.  A resolution on health responses to the financial crisis was then tabled at the 63rd European Regional Committee meeting in Izmir, Cesme, and endorsed by all 53 Member States¹.  The 10 policy lessons/ recommendations are:

• Policy lesson 1: It is critical to keep in mind the longer-term challenges to health systems while navigating the crisis

¹ http://www.euro.who.int/__data/assets/pdf_file/0005/217733/63rs05e_HealthSystems.pdf

• Policy lesson 2: Fiscal policy should explicitly take account of the probable impact on population health
• Policy lesson 3: Social safety nets and labour market policies are intersectoral actions that can mitigate the negative health effects of the financial and economic crises
• Policy lesson 4: Health policy responses influence the health effects of financial and economic crises
• Policy lesson 5: Adequate funding for public health services must be ensured
• Policy lesson 6: Fiscal policy should avoid prolonged and excessive cuts in health budgets
• Policy lesson 7: High-performance health systems are more resilient during times of crisis
• Policy lesson 8: Deeper structural reforms require more time to deliver savings
• Policy lesson 9: Safeguarding access to services requires a systematic, reliable information and monitoring system
• Policy lesson 10: Prepared, resilient health systems are primarily the result of good governance

The future priorities for the Regional Office in this area are:

• Facilitating dialogue between health and finance officials (with OECD and the World Bank)
• Further evidence generation for cross-country learning with the European Observatory
• Improve systems to monitor the health impact of economic crisis in a more timely manner (with the Division of Information, Evidence and Research).

2. Health systems for health and wealth in the context of Health 2020: High level Tallinn Charter 5 year anniversary meeting, 17-18 October 2013, Tallinn, Estonia.

Marking the five year anniversary of the signature of the Tallinn Charter, a high level technical meeting on “Health Systems for Health and Wealth in the Context of Health 2020” was convened by WHO Europe and generously hosted by the Ministry of Social Affairs in Estonia.   The Tallinn high level meeting provided a platform to understand new frontiers to improve population health, exchange inspiring examples of health system strengthening, and agree on future directions weaving together the commitments in the Tallinn Charter and the Health 2020 policy framework.

The WHO European Ministerial Conference on Health Systems, held in Tallinn in 2008, was a milestone signalling the importance that Member States placed on improving the performance of their health systems.   Their political commitment was marked by the signing of the Tallinn Charter: Health Systems for Health and Wealth, and its later endorsement in a Regional Committee resolution. (EUR/RC58/R4)

The Tallinn Charter highlighted a number of themes central to health system strengthening and its signatories pledged to “invest in health systems and foster investments across sectors that influence health, using evidence on the links between socioeconomic development and health“.  The Charter places strong emphasis on value-driven policy design reaffirming solidarity and equity as core values.  This commitment is embodied in the strong statement of the Charter related to universal health coverage: “Today, it is unacceptable that people become impoverished because of ill health”.

Ministers, experts and delegates from 38 Member States and representatives of key partners – including the European Commission, the Organisation for Economic Co-operation and Development (OECD), the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria – were in attendance to explain the steps they had taken to implement the Tallinn Charter, and move towards providing universal health coverage.

Keynote addresses, ministerial panels and plenary discussions over the two-day meeting aimed to take stock of the implementation of the Tallinn Charter and to map a way forward for efforts to strengthen health systems through the lens of Health 2020.  Discussions during these sessions highlighted various themes.

• A whole-of-government, whole-of-society approach is important to ensure transparency, accountability, shared political and civic commitment. A common vision needs to be communicated to lay the foundation for all initiatives for health-system strengthening.
• The changing health needs across the Region, as the burden of chronic diseases increases with the growing rate of multi-/co-morbidities, demand treatment that is more continuous and proactive in addressing people’s health status.
• The organization of health services needs to be transformed to offer more coordinated/integrated pathways for the provision of care along the full continuum of services, according to a patient’s needs and preferences.
• Greater commitment to public health – of key relevance for promoting health and reducing inequalities – is needed to point out the role of public health in primary health care as a unique niche for strengthening services and securing gains in societal, community, family and individual health.
• Modern technology needs to be used to support improved communication, strengthen data collection and empower patients to manage their health needs. Participants from the host country shared the experience of the Estonian health system as a strong example of using e-health to engage patients.
• New and innovative approaches to health-system financing are needed that are aligned to service-delivery models necessitated by health trends and applicable in the economic climate.

• In discussing these themes, participants acknowledged key cross-cutting challenges, including:

• strengthening human resources for health, aligning skills and competencies to secure more coordinated/integrated approaches to services delivery; and
• modernizing information systems and knowledge transfer, an area that needs attention owing to the continuously increasing volume of data that can be supplied through modern technologies.

In addition, interventions from Member States reported measures to improve accountability and governance through, for example, assessing the performance of their health systems.  Tobacco and alcohol control were identified as areas in which effective, evidence-based cross-sectoral policies exist, and mutual sharing of experiences and expertise were highlighted as ways to promote learning and longer-term collaboration.

The outcomes of the high level meeting will feed into the final report of the Tallinn Charter implementation and a Resolution on the main health systems strategic directions 2015-2020 within the context of Health 2020 to be presented at the regional Committee in 2015.

Day 2 of the high level meeting, the Regional Director launched the work plan for the development of the European Framework for Action towards Coordinated/ Integrated Health Service Delivery at a session chaired by the Director-General of HealthCare, Ministry of Health, Belgium.

The Framework’s goal is to support countries with policy options and recommendations that target key areas for strengthening the coordination/integration of health services. These changes are in line with the vision of Health 2020 and the values of universal health coverage, as the delivery of care must be of high quality and people centred to secure improvements in health and equity.
Discussions throughout the conference called attention to the importance of moving health-service delivery towards more people-centred care, with the coordination/integration of delivery being a key approach.

A WHO/Europe roadmap explains the process of developing the Framework for Action towards CIHSD, setting out the phases from now to 2016. It gives particular attention to ensuring the participation of partners, including a network of focal points in Member States, external experts and leading organizations in the field, such as the International Foundation for Integrated Care.

For the final Roadmap document see: http://www.euro.who.int/__data/assets/pdf_file/0005/231692/Strengthening-people-centred-health-systems-in-the-WHO-European-Region,-Roadmap.pdf