European Health for All Series No.

The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen , Denmark, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. World Health Organization 1998 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this publication are those that obtained at the time the original language edition of the book was prepared. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

Contents
World Health Declaration Foreword Summary Why HEALTH21? Solidarity and equity in health Better health for the people of WHOs European Region A multisectoral strategy for sustainable health Changing the focus: an outcome-oriented health sector Managing change for health The role of WHO and its partners for health Towards a better future 4 7 8 11 13

15 20

25 29 32 34

WHO Library Cataloguing in Publication Data HEALTH 21: an introduction to the health for all policy framework for the WHO European Region (European Health for All Series ; No. 5)

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European Health for All Series No. 5

An introduction to the health for all policy framework for the WHO European Region

World Health Organization Regional Office for Europe Copenhagen

World Health Declaration

Adopted by the world health community at the Fifty-first World Health Assembly, May 1998

I
We, the Member States of the World Health Organization (WHO), reaffirm our commitment to the principle enunciated in its Constitution that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being; in doing so, we affirm the dignity and worth of every person, and the equal rights, equal duties and shared responsibilities of all for health.

II
We recognize that the improvement of the health and well-being of people is the ultimate aim of social and economic development. We are committed to the ethical concepts of equity, solidarity and social justice and to the incorporation of a gender perspective into our strategies. We emphasize the importance of reducing social and economic inequities in improving the health of the whole population. Therefore, it is imperative to pay the greatest attention to those most in need, burdened by ill-health, receiving inadequate services for health or affected by poverty. We reaffirm our will to promote health by addressing the basic determinants and prerequisites for health. We acknowledge that changes in the world health situation require that we give effect to the Health-for-All Policy for the 21st century through relevant regional and national policies and strategies.1

Text not highlighted in original.

World Health Declaration

III
We recommit ourselves to strengthening, adapting and reforming, as appropriate, our health systems, including essential public health functions and services, in order to ensure universal access to health services that are based on scientific evidence, of good quality and within affordable limits, and that are sustainable for the future. We intend to ensure the availability of the essentials of primary health care as defined in the Declaration of Alma-Ata 2 and developed in the new policy. We will continue to develop health systems to respond to the current and anticipated health conditions, socioeconomic circumstances and needs of the people, communities and countries concerned, through appropriately managed public and private actions and investments for health.

IV
We recognize that in working towards health for all, all nations, communities, families and individuals are interdependent. As a community of nations, we will act together to meet common threats to health and to promote universal well-being.

V
We, the Member States of the World Health Organization, hereby resolve to promote and support the rights and principles, action and responsibilities enunciated in this Declaration through concerted action, full participation and partnership, calling on all peoples and institutions to share the vision of health for all in the 21st century, and to endeavour in common to realize it.

Adopted at the International Conference on Primary Health Care, Alma-Ata, 612 September 1978, and endorsed by the Thirty-second World Health Assembly in resolution WHA32.30 (May 1979).

Foreword The Member States of WHOs European Region 51 countries and their 870 million people
living within an area stretching from Greenland in the north, the Mediterranean in the south and the Pacific shores of the Russian Federation in the east have made remarkable progress in the health field. Since 1980, in spite of their many differences, they have come together and embraced a common policy framework for health development. This policy, based on a thorough analysis of the health problems of people in the Region, sets targets for their improvement and outlines strategies that countries, organizations and civil society can use to turn national policies into practical operational programmes at local level throughout this vast Region. his policy is not a one-off event: it is systematically monitored according to agreed indicators that all countries use, and it is updated at regular intervals to ensure that it reflects the changes in the countries and the most up-to-date scientific evidence collected by WHO and other authoritative sources. he current update was approved by the WHO Regional Committee for Europe in September 1998, and sets the agenda until the next revision planned for the year 2005. It is the result of very extensive scientific analysis and also a written consultation with all 51 Member States and some 50 major organizations in the Region. It represents the best and most comprehensive guidance available for countries on how to formulate national health policies, and how to create broad mobilization of societies through practical approaches that have proven effective in todays pluralistic and democratic countries in the European Region. his short introduction to the policy is first and foremost meant to inspire prime ministers, ministers of health and other ministers in the Member States of the Region to ensure that steps are taken to bring the health policies and strategies in their own countries in line with HEALTH21: the health for all policy framework for the WHO European Region. This, more than any other decision they can make, will help to ensure a better quality of life for the citizens of their countries as they enter the 21st century.

J.E. Asvall WHO Regional Director for Europe

WHO/CPA

Summary
Is it healthy? The question is simple but profound. By asking it, decision-makers can alter the course of human development. As the 21st century approaches, the people of Europe are searching for a more socially responsible and sustainable approach to development and growth. Very often this involves a trade-off: a resolution of the conflict between the pursuit of wealth and the protection and improvement of health. As stated in the 1998 World Health Declaration (see page 2), the enjoyment of health is one of the fundamental rights of every human being. Health is a precondition for wellbeing and the quality of life. It is a benchmark for measuring progress towards the reduction of poverty, the promotion of social cohesion and the elimination of discrimination. Good health is fundamental to sustainable economic growth. Intersectoral investment for health not only unlocks new resources for health but also has wider benefits, contributing in the long term to overall economic and social development. Investment in outcome-oriented health care improves health and identifies resources that can be released to meet the growing demands on the health sector. The HEALTH21 policy for WHOs European Region has the following main elements. The one constant goal is to achieve full health potential for all. There are two main aims:

The success of public policies can be measured by their impact on health

WHO/K. Oddoux

to promote and protect peoples health throughout their lives; and to reduce the incidence of the main diseases and injuries, and alleviate the suffering they cause.

Three basic values form the ethical foundation of HEALTH21:

health as a fundamental human right; equity in health and solidarity in action between and within all countries and their inhabitants; and participation and accountability of individuals, groups, institutions and communities for continued health development.

Summary
Four main strategies for action have been chosen to ensure that scientific, economic, social and political sustainability drive the implementation of HEALTH21:

multisectoral strategies to tackle the determinants of health, taking into account physical, economic, social, cultural and gender perspectives, and ensuring the use of health impact assessment; health-outcome-driven programmes and investments for health development and clinical care; integrated family- and community-oriented primary health care, supported by a flexible and responsive hospital system; and a participatory health development process that involves relevant partners for health at home, school and work and at local community and country levels, and that promotes joint decision-making, implementation and accountability.

Twenty-one targets for health for all have been set, which specifically spell out the needs of the whole European Region and suggest the necessary actions to improve the situation. They will provide the benchmarks against which to measure progress in improving and protecting health, and in reducing health risks. These 21 targets together constitute an inspirational framework for developing health policies in the countries of the European Region. HEALTH21 should be incorporated into the health development policy of every Member State of the Region and its principles should be embraced by all major European organizations and institutions. For its part, the WHO Regional Office for Europe should give strong support by playing the following five main roles: 1. act as a health conscience, defending the principle of health as a basic human right, and identifying and drawing attention to persistent or emerging concerns related to peoples health; 2. function as a major information centre on health and health development; 3. promote the health for all policy throughout the Region and ensure its periodic updating; 4. provide up-to-date evidence-based tools that countries can use to turn policies based on health for all into action; and 5. work as a catalyst for action by:

providing technical cooperation with Member States this can be strengthened through the establishment of a strong WHO function in every country, to ensure the mutually beneficial exchange of experience between the country and the regional health organization; exercising leadership in Region-wide efforts to eradicate, eliminate or control diseases that are major threats to public health, such as epidemics of communicable diseases and pandemics such as tobacco-related diseases;

10

Summary

promoting policies based on health for all with many partners through networks across the European Region; and facilitating the coordination of emergency preparedness for and response to public health disasters in the Region.

This book serves as a guide to the full regional health for all policy, which is described in detail in HEALTH21: the health for all policy framework for the WHO European Region (European Health For All Series No. 6).

Why HEALTH21?
The agenda for health The 870 million people of the 51 Member States of the European Region stand at a crossroads in history. Behind them lies the 20th century, its first half seared by two devastating world wars and its recent years disrupted by armed conflicts and growing inequities in health. However, as the 21st century approaches, armed conflicts are subsiding and the health crisis in the eastern part of the Region seems to have peaked. The 21st century may well be the first in the history of the Region where the prime focus of countries can be on human development. The European Region is one of great contrasts, where rich countries rub shoulders with the poorest of nations, and the latter struggle with the consequences of social and political change, economic transition and the building of new institutions. It is but one part of a world undergoing profound change, where increasing globalization of markets may widen the gap between rich and poor. The rapid development of science and of information technologies is spearheading further new developments, the full extent of which cannot yet be foreseen. To meet this new situation, a model of social policy development is needed, with health as a key contributory factor and outcome. Health for all provides such a policy framework. The global health for all policy The policy for health for all in the 21st century, adopted by the world community in May 1998, aims to realize the vision of health for all, which was a concept born at the World Health Assembly in 1977 and launched as a global movement at the Alma-Ata Conference in 1978. It sets out global priorities for the first two decades of the 21st century, and ten targets that aim to create the necessary conditions for people throughout the world to reach and maintain the highest attainable level of health. It is important to realize that health for all is not a single finite target. It is fundamentally a charter for social justice, providing a science-based guide to better health development and outlining a process that will lead to progressive improvement in peoples health. As emphasized in the World Health Declaration (see page 2) adopted by all WHOs Member States in May 1998, the realization of health for all depends on a commitment to health as a
WHO/APTN

11

The 21st century may well be the first in the history of the Region where the prime focus of countries can be on human development

Health for all is a mutually supportive framework of global, regional and national policies

12

Why HEALTH21?
fundamental human right. It involves strengthening the application of ethics and science to health policy and the provision of research and services. It also means implementing equityoriented and evidence-based policies and strategies that emphasize solidarity, and incorporating a gender perspective into such developments. As stated in the World Health Declaration, the global health for all policy for the 21st century should be given effect through regional and national policies and strategies, and HEALTH21 is the European Regions response to that call. HEALTH21, the WHO European Regions response to the global health for all policy Since it was introduced in 1980, health for all has provided a comprehensive framework for health improvement within the European Region of WHO and has had a major impact on health development. The present major revision, HEALTH21, gives effect to global health for all values, targets and strategies. It also reflects the Regions ongoing health problems, as well as its political, economic and social changes and the opportunities they provide. HEALTH21 gives an ethical and scientific framework for decision-makers at all levels to assess the impact on health of their policies, and to use health to guide development action in all sectors of society. HEALTH21 builds on the collective experience of the European Member States with their regional health for all approach, which for the past 15 years has made health outcomes in the form of aspirational targets the cornerstone of policy development and programme delivery. Refining the previous 38 regional health for all targets in the light of past achievements and new challenges, HEALTH21 defines 21 targets for the 21st century. They are not meant as a prescriptive list, but together they make up the essence of the regional policy. They provide a framework for action for the Region as a whole, and an inspiration for the construction of targets at the country and local levels.

Health for all gives an ethical framework for decision-makers at all levels to assess the impact on health of their policies, and to use health to guide development actions

WHO/Verbitski

Solidarity and equity in health

To foster stronger equity and solidarity in health development between Member States of the Region and better equity in health among groups within each country Closing the health gap between countries Poverty is a major cause of ill health and lack of social cohesion. One third of the population in the eastern part of the Region, 120 million people, live in extreme poverty. Health has suffered most where economies are unable to secure an adequate income for all, where social systems have collapsed, EU and where natural resources have 80 been poorly managed. This is clearly European Region demonstrated by the wide health gap CCEE between the western and eastern parts NIS of the Region. Infant mortality ranges from 3 to 43 deaths per thousand live births, and life expectancy at birth from 79 to 64 years.
75

13

One third of the population in the eastern part of the Region live in extreme poverty

In order to reduce these inequities and to maintain the security and cohesion of the European Region, a much stronger collective effort needs to be made by international institutions, funding agencies and donor countries to increase the volume, synergy and 70 effectiveness of health development support to the countries most in need. The 20/20 initiative, springing from the United Nations Social Summit held in Copenhagen in 1995, should now be Target 1. fully respected. That Solidarity for is, at least 20% of 65 overall development health in the assistance should be European Year allocated to social secRegion tor activities, and receiving countries should allocate at least 20% of their national budgets (net of aid) to basic social services. Furthermore, external support should be much better integrated through joint inputs into government health development programmes that are given high priority and are firmly based on a national health for all policy in the receiving country.
Life expectancy (years)

Life expectancy at birth in subregional groups of countries in the European Region, 19701996

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

14

Solidarity and equity in health

HEALTH21 provides the practical long-term framework of solidarity by which all Member States can contribute their own experience to the reduction of health gaps. Each can learn from the other through shared experience, and gain inspiration from outside initiatives. Each European Member State should have a WHO country function in order to profit from the technical advice emerging from global and regional health for all developments, and Target 2. be able to make its own contribution to this international body of knowledge.

Equity
Closing the health gap within countries in health Even in the richest countries in the Region, the better-off live several years longer and have fewer illnesses and disabilities than the poor. Poverty is the biggest risk factor for health, and income-related differences in health which stretch in a gradient across all levels of the social hierarchy are a serious injustice and reflect some of the most powerful influences on health. Financial deprivation also leads to prejudice and social exclusion, with increased rates of violence and crime. There are also great differences in health status between women and men in the Region. Educational levels produce a similar gradient of health risk to that produced by social class. Since levels of educational attainment are strongly related to levels of deprivation, a key strategy must be to remove the financial, cultural and other barriers that hinder equal access to education. This applies to women in particular, but also to poor children and other disadvantaged groups. It is also very important to introduce special programmes to help poor children overcome their initial handicaps. Increased equity leads to health gain and is associated with change and adaptation throughout society, higher productivity and sustained economic growth. For the same level of national wealth, those societies that reach out to and enable all their citizens to play a useful role in social, economic and cultural terms will be healthier than those where people face insecurity, exclusion and deprivation. It is therefore imperative that public policies address the root causes of socioeconomic inequities, and that fiscal, educational and social policies are designed to ensure a sustained reduction of health inequalities. All sectors of society should assume responsibility for the reduction of social and gender inequities, and the alleviation of their consequences on health. Disadvantaged groups must be ensured access to social welfare, through the provision of safety nets, and be given appropriate, acceptable and sustainable health care.

Income-related differences in health are a serious social injustice, and reflect some of the most powerful influences on health

WHO/APTN

Better health for the people of WHOs European Region

Strengthening health throughout life Life contains a series of critical transitions: emotional and material changes in early childhood, the move from primary to secondary education, starting work, leaving home and starting a family, changing jobs and facing possible redundancy, and eventually retirement. Each of these changes can affect health by pushing people on to a more or less advantaged path. Investing early in health typically pays off later in life. Important foundations of adult health are laid in a persons genetic endowment, in prenatal life and in early childhood. Low birth weight is a marker for indices of deprivation and represents accumulated risk factors. Slow growth and a lack of emotional support during this period can launch the child on a low social and educational trajectory, which increases the risk of poor physical and psychological Target 3. health. It can also reduce physical, intellectual and emotional functioning in Healthy adulthood.

15

Important foundations of adult health are laid in prenatal life and early childhood

start in life
Genetic and dietary counselling, a smoke-free pregnancy, and evidencebased prenatal care will help prevent low birth weight and congenital anomalies. Since early investment in health can compensate for a deprived start in life and produce later dividends, policies need to provide not only safety nets but also springboards to offset earlier disadvantage. Policies should therefore be implemented that create a supportive family, with wanted children and good parenthood capacity. Parents need the means and skills to bring up their children and care for them in a social environment that protects the rights of the child, and local communities need to support families by ensuring a safe nurturing environment and health-promoting child-care facilities. Health and social service personnel need training to recognize and treat cases of child abuse.

WHO/K. Oddoux

A good start in life means supporting parents and young children

WHO/Brad Stein

16

Better health for the people of WHOs European Region

If accidents, the harm done by drug use and unwanted pregnancies are to be reduced, public policies and programmes should help children and young people to make the healthy choice the easy choice. Therefore, all major public sector policy decisions should be reviewed to avoid any negative impact on the health of children and adolescents, Target 4. their families and carers. Education and employment policies need to enable Health of young people to get the best possible education and the most productive jobs. The provision of sex education and support to young people, plus ready access to young condoms, will reduce the risk of unplanned pregnancies and sexually transmitted people diseases, including HIV infection. A healthy working life. Both the quantity and quality of work have a strong influence on many health-related factors in adulthood, including income, social networks and self-esteem. Investing in secure employment can benefit health and thus long-term productivity. Stressful workloads and job insecurity incur unseen costs to industry, as well as to the workers involved. If these were included in analyses of economic performance, they would provide a more realistic picture. Stronger action needs to be taken to promote a healthier working environment through better legislation, standards and enforcement mechanisms. Companies should adopt a healthy company or enterprise concept with three elements: health promotion for their staff; making the companys products as health-supportive as possible; and, finally, being socially responsible by supporting local community or countrywide health programmes. Healthy aging. Health policies should prepare people for healthy aging by means of systematically planned promotion and protection of their health throughout life. Social, educational and occupational opportunities, along with physical activities, increase older peoples health, self-esteem and independence, and their active contribution to society. Innovative programmes to maintain physical strength and to corTarget 5. rect sight, hearing and mobility impairments before they lead to an older persons Healthy dependence are particularly important. Health and social services at community aging level should provide outreach services to support older people in their everyday lives. Their needs and wishes in relation to housing, income and other factors that enhance their autonomy and social productivity should be increasingly taken into account.

Investment in secure employment can benefit health and thus long-term productivity

WHO/Brad Stein

Better health for the people of WHOs European Region

To reduce the incidence and prevalence of diseases and other causes of ill health or death to the lowest feasible levels Reducing ill health and injury Determining where to invest in health is a challenge for all countries. Whatever approach is used, it should be based on an estimate of the health and economic burden of premature death and disability. Cardiovascular diseases represent the most frequent cause of death in virtually every Member State, with cancer ranking second. Infant and maternal mortality remain important concerns in many countries. Other key health burdens are mental health problems (almost 10% of the total disease burden), injuries and violence (over half a million deaths a year and a principal cause of death among young people) and once forgotten diseases like malaria, tuberculosis and syphilis, which have re-emerged. Reducing these burdens requires an integrated approach to health promotion, disease prevention, clinical treatment and rehabilitation. Mental health. Improving mental health and especially reducing suicide requires attention to the promotion and protection of mental health throughout life, particularly in Target 6. socially and economically disadvantaged groups. Well designed health Improving programmes for living and working mental environments can help people gain health a sense of coherence, build and maintain mutually supportive social relations, and cope with stressful situations and events. Suicide rates can be sharply reduced if health care providers are trained for the early detection of depression and if appropriate treatment is provided. In many countries, large mental health asylums need to be replaced by a well balanced network of departments of acute psychiatry in general hospitals, and a carefully constructed network of primary health care services and facilities. Stress at work plays an important role in contributing to the large differences in health, sickness absence and premature death that are related to social status. Improved conditions of work will lead to a healthier workforce which, in turn, will improve productivity. Unemployment puts psychological and physical health at risk. Because unsatisfactory or insecure jobs can be as harmful as unemployment, merely having a job is not enough to ensure physical or mental health; job quality is also important.
WHO/Brad Stein

17

Tobacco is responsible for over 14% of all deaths and costs the Region over US $100 billion a year

18

Better health for the people of WHOs European Region

Communicable diseases. Reducing communicable diseases requires an integrated approach combining health promotion, disease prevention and patient treatment. Improvement and maintenance of basic hygiene, water quality and food safety are essential, as are sustainable and effective immunization programmes and well directed treatment schedules. Efforts against communicable diseases can be directed towards eradication, elimination or control. Within the time span covered by HEALTH21, poliomyelitis, measles and neonatal tetanus should be eliminated from the Region (the first two as part of global eradication efforts) and congenital rubella, diphtheria, hepatitis B, mumps, pertussis and invasive 225 diseases caused by Haemophilus influenzae should be well controlled NIS 200 through immunization. In CCEE addition, tough, coordiTarget 7. 175 EU nated action is required Reducing to strengthen preven150 tion and treatment communicable programmes for tuberdiseases culosis, malaria, HIV/ 125 AIDS and sexually transmitted diseases. 100 Noncommunicable diseases. Cardiovascular diseases, cancer, diabetes, chronic obstructive lung disease and 50 asthma combine to create the greatest health problems in the Region. A large 25 part of these problems could be eliminated if all countries organized, both 0 at country level and in local communities, an integrated Year programme to reduce the risk facTarget 8. tors that are common to many of these diseases. These factors include Reducing smoking, unhealthy nutrition, lack of physical activity, use of alcohol and stress. The European Region has a good deal of experience in conducting noncommunicable diseases such integrated programmes: the CINDI approach, which should now be carried out in every local community in all Member States. Furthermore, diagnosis, treatment and rehabilitation services for these diseases including acute care facilities need improvement in many Member States. One important part of such an effort should be strong support for self-care, including the retraining of health professionals in this concept.
75
1990 1991 1992 1993 1994 1995 1996 New cases per 100 000 population

Syphilis incidence in subregional groups of countries in the European Region, 19901996

Better health for the people of WHOs European Region

Violence and accidents. Reducing injury from violence and accidents requires improved emergency services in many countries and stricter enforcement of the well known preventive measures that can cut accidents on the roads, at work Target 9. and in the home. Higher priority needs to be given to issues related to Reducing social cohesion and the major causes of violence including domestic injury from violence with particular attention to alcohol (see below).

19

violence and accidents

20

A multisectoral strategy for sustainable health

To create sustainable health through more health-promoting physical, economic, social and cultural environments for people Determinants of health Health results from the combined actions of society. Though many of the key health burdens are due to such risk factors as smoking and physical inactivity, poverty and socioeconomic deprivation are the major causes. It is important to note that for the same level of income, societies with less income inequality tend to have more social cohesion, less violent crime and lower death rates, particularly from heart diseases. It follows that enlightened economic policies, social support and good social relations can make an important contribution to health. An integrated multidisciplinary and intersectoral approach to health development is thus more effective, efficient and cost-effective than separate vertical approaches. It is not up to the health sector alone. Vital gains, both in health and in economic advancement, can be made through well designed policies for education, employment, industrial structure, taxation and social policy. Making the healthy choice the easy choice Environmental taxes promote Target 10. health by reducing pollution. A healthy and They shift the burden from income and savings to the ineffisafe physical cient and hazardous use of enenvironment ergy and resources, and so contribute to sustainable economic growth. The cost of cleaning up healthdamaging pollution is high. Investment in cleaner processes from the outset prevents pollution and makes for more efficient manufacturing, thus increasing profits. So changes in the way that industry does business can unlock resources that not only improve health but also increase profitability!

Many key health burdens are due to similar risk factors, of which poverty and socioeconomic deprivation are particularly important

Cycling and walking increase physical activity, reduce fatal accidents, increase social contact and reduce air pollution

WHO/Brad Stein

WHO/Brad Stein

A multisectoral strategy for sustainable health

Trade and agricultural policies should conTarget 11. tinue to be realigned to Healthier promote health, provide safe food and proliving tect the environment. Promoting more healthy eating and reducing obesity would result in considerable health gains, especially among vulnerable groups. This requires fiscal, agricultural and retail policies that increase the availability of, access to and consumption of vegetables and fruits and reduce the consumption of high-fat food, particularly for low-income groups. Health education alone is not sufficient to tackle health and food issues successfully. Safe food handling to reduce the risk of contamination should be applied throughout the entire food chain. It is important that policy-makers, especially those dealing with nutrition and food safety, strengthen cooperation between private and voluntary sectors.
110

21
Environmental taxes, by reducing pollution, promote health

105

Evin law

Units 109 (1 unit = 1 cigarette or 1 g of tobacco)

95

85

CIGARETTES

90

TOBACCO

100

80 The Evin law of 1991 placed a complete ban on tobacco advertising, banned smoking in public places and raised the retail price of tobacco products. 75 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Consumption of tobacco and cigarettes in France, 19751997

Source: DUBOIS, G. La ncessaire internationalisation de la lutte contre le tabagisme. Bulletin de lAcadmie nationale de mdecine, 182: 939953 (1998).

Cycling, walking and the use of public transport instead of cars all promote health by increasing physical activity and social contact. They also reduce fatal accidents and air pollution. Financial support for public transport, and the creation of tax disincentives for the business use of cars, can be a powerful stimulus for change. So can increasing the numbers of bus, cycle and walking lanes, and inhibiting the growth of low-density suburbs and out-of-town supermarkets, both of which increase the use of cars.

Year

Target 12. Reducing harm from alcohol, drugs and tobacco

Smoking is the biggest threat to health in the European Region. Implementation of the 1988 Madrid Charter against Tobacco and the Action Plan for a Tobacco-free Europe will lead to health and economic gain. Increasing taxes on tobacco products raises government revenue and saves lives. Tighter regulation of tobacco products and greater availability of treatment products and cessation advice, coupled with enhanced

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A multisectoral strategy for sustainable health

smoke-free environments and a ban on the advertising and sponsorship of tobacco products, will reduce the annual toll of up to 2 million deaths expected during the next 20 years. Effective legislation reduces tobacco consumption. Five years after the introduction of the Evin Law in France, which banned cigarette advertising, created smoke-free public places and increased prices, cigarette consumption had fallen by 16%. Alcohol-related harm, including accidents, represents a huge European health problem. There is substantial evidence that significant health and economic benefits may be achieved by taking action on alcohol. The European Charter on Alcohol (Paris, 1995) and the European Alcohol Action Plan outline the main public health and treatment strategies. They include taxation of alcoholic beverages, control of direct and indirect advertising, and treatment of hazardous and harmful alcohol consumption. All Member States should ensure that their policies and programmes are fully in line with the strategies of the European Charter. The number of heavy drug users in the European Region is estimated to be between 1.5 and 2 million. In addition to the direct health effects, drug use also contributes to the massive spread of HIV infection and hepatitis, especially in the southern and eastern parts of the Region. Treatment and prevention efforts have developed over the years, with wider acceptance of substitution treatment for those dependent on opiates. Evidence shows that societies that can mobilize extensive and innovative approaches to services for drug users can be very successful in reducing health-damaging behaviour, as well as in limiting antisocial and criminal activity among drug users. A settings approach to health action The past ten years of experience in the European Region has clearly revealed that informing, motivating and supporting individuals, groups and societies to lead a more healthy life can best be done by focusing systematically on the places where people live, work and play.

All children should have the right to be educated in a health-promoting school

Target 13. The home is the Settings for physical environment in which health people spend most of their time. In the context of urban and rural planning the home should be

WHO/CPA

A multisectoral strategy for sustainable health

designed and built in a manner conducive to sustainable health and the environment. The home is the primary unit of society, where family members can enact their own health policies such as a smoke-free and safe environment and healthy eating. Family health physicians and trained, home-visiting family health nurses can be very good catalysts for health action. In preschool settings, children can learn the basic values of healthy lifestyle, social interaction and teamwork, and be trained in issues such as accident prevention and a healthy diet. In schools, the pupils, teachers and parents working with local communities and supported by their health advisers should together analyse their health opportunities, design intervention programmes and evaluate the results. Smoke-free activities, for example, should include all three groups so as to reinforce all the main elements of the social networks that influence behaviour. All children should have the right to be educated in a health-promoting school that integrates health-related issues into a comprehensive approach, thus enabling schools to promote the physical, social and emotional health of students, staff, families and communities. Some 35% of GNP could be saved by making the working environment safe and healthy. The aim should be not just to reduce exposure to risks, but also to increase the participation of employers and employees in promoting a safer and healthier working environment and reducing stress. A company culture needs to be promoted that favours teamwork and open debate, on the understanding that better health for all staff and better social relationships at work will contribute to higher staff morale and productivity. At local community and city levels, and based on the 1998 Athens Declaration, the pioneering Healthy Cities network should reach out to every municipality in all Member States. It should embrace the political leadership, health and other sectors and major nongovernmental organizations in a structured, permanent partnership that addresses lifestyle, environment and health issues together through a local health for all plan. People and their living conditions should be the central consideration in town planning. Urban renewal projects that focus on improving the quality of urban life, reducing the use of water, energy and materials, and implementing programmes for separate waste collection, recovery and recycling can result in more sustainable cities.
WHO/APTN

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Health impact assessment should be applied to policies or programmes likely to have an effect on health

24
Accountability also rests with government leaders

A multisectoral strategy for sustainable health

Accountability for health impact An effective approach to health development requires all sectors of society to be accountable for the health impact of their policies and programmes and recognition of the benefits to themselves of promoting and protecting health. Target 14. Health impact assessment must therefore be applied to any social and ecoMultisectoral nomic policy or programme, as well as development projects, likely to have responsibility an effect on health.

for health

Accountability also rests with government leaders who create policy, allocate resources and initiate legislation. Mechanisms such as health policy audits, litigation for health damages and public access to reports on health impact assessments can ensure that both the public sector and private industry are publicly accountable for the health effects of their policies and actions. Countries should also aim to ensure that their foreign aid and trade policies are not detrimental to health in other countries, and that they contribute as much as possible to the development of disadvantaged countries. Closer cooperation between countries, and the development and implementation of international codes of conduct and regulatory mechanisms, can minimize such problems.

Changing the focus: an outcome-oriented health sector

To orient the health sector towards ensuring better health gain, equity and costeffectiveness Integrating health care Health services cost a lot of money and count among the Regions major employers. In many countries in the more eastern part of the Region, health expenditure today is too low. At the same time, increasing numbers of older people, rising levels of poverty and the introduction of new technologies all point to the need for more health spending in all Member States in the future. That is, if countries continue in the same way as now. Fortunately, however, solutions are available that can improve both the quality and the costeffectiveness of health systems. Moreover, they often do not require major investment, only a willingness to strengthen the overall design of the system and to sharpen the management focus on public health programmes and on patient care. In many Member States, a more integrated health sector is needed, with a much stronger emphasis on primary care. At the core should be a well trained family health nurse, providing a broad range of lifestyle counselling, family support Target 15. An integrated and home care services to a limited number of families. More specialized services should be provided by a family health physician who, together with health the nurse, would interact with local community structures on local health sector problems. Freedom of choice in selecting the two should be the prerogative of individual citizens, and actively supporting self-care should be one of the tasks of the nurse/physician team. A community health policy and programme should ensure systematic involvement of local sectors and nongovernmental organizations in promoting more healthy lifestyles, a healthier environment and an efficient health and social service system at local level. Such an approach would greatly enhance the prevention of illness and injury and ensure the early and effective treatment of all patients who clearly do not need hospital care. Nursing homes and similar long-stay institutions should have a stronger home atmosphere and be a local community responsibility. Secondary and tertiary care, which are largely provided in hospital, should be clearly supportive to primary health care, concentrating only on those diagnostic and therapeutic functions that cannot be performed well in primary care settings. If the above principles are followed, and flexibility in the development and deployment of hospital services becomes a stronger feature of hospital planning and management, hospitals will be better able to meet the future challenges of changing technologies and clinical practices. They will also be more responsive to the individual needs of their patients.

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Solutions are available that can improve both the quality and the costeffectiveness of health systems

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Changing the focus: an outcome-oriented health sector

Gain from quality health care A major problem in the overall design of todays health systems is that far too Target 16. little systematic effort is made to measure accurately and reflect on the Managing real value that alternative strategies and methods might have in reducing a for quality given health problem for the population. What is the relative effectiveness and cost of the different methods to prevent, diagnose and treat, for example, of care allergies, heart disease and depression? There is an urgent need to find a more unifying management concept one that will stimulate the search for better quality and reward innovations, not stifle them. The measurement of health outcomes using internationally agreed indicators at the level of populations offers such a unifying concept with which to compare the relative value of health promotion, disease prevention, treatment and rehabilitation programmes. The European health for all indicators and database provide a unique tool for comparing the relative success of all the 51 Member States attempts to strive towards the regional health for all targets. Nevertheless, much more should be done within countries to use this approach and refine it to suit local needs, as a tool for strategic decision-making.
WHO/APTN

Measurement of health outcomes identifies resources that can be released to meet the increasing demands on the health sector

A crucial problem in todays health care is that the outcome of clinical care for similar patients often shows large variations among countries, regions, hospitals and individual providers even when the material, financial and human resources employed are the same. A major reason for this is that such differences are not recognized because the data are not collected. There is great hidden potential for substantially improving the quality and costeffectiveness of patient care. So far, however, only a few systematic efforts are being made to ensure that such health outcome measurements are part of daily practice. The systematic measurement of health outcomes in clinical care using internationally standardized quality indicators, and with the results fed into databases whereby the outcomes can be compared with those of peers is an indispensable new tool for continuous quality development in patient care. Such health impact measurements, as a start to the process of quality of care development, together with greater emphasis on evidence-based medicine, can provide new tools for the assessment of technology and for more effective and efficient application of

Changing the focus: an outcome-oriented health sector

diagnostic and curative interventions. They can identify what works, what is necessary and what is not. This permits a scientific approach to identifying promising new interventions and to reducing any unnecessary procedures, pharmaceuticals and equipment. It can also identify resources that can be released to help meet some of the increasing demands on the health sector arising from an aging population, and the steady introduction of more complex health care technologies. Resources for health care The funding of health care should ensure equity and sustainability. Whatever system is used, governments must ensure that it provides universal coverage and access to health care, as well as containing overall costs. As concluded by the 1996 Ljubljana Conference on health care reform, there is no room for unreTarget 17. strained market activity in the funding or provision of a social good like Funding health health care. Moreover, market mechanisms targeting the individual or services and funding institutions have been notably less successful in terms of allocating equity and efficiency than those targeting hospitals and other health care providers. Payment systems for primary health care providers that resources combine elements of capitation, free choice of provider and fee-forservice, foster better possibilities for managing the system to achieve highquality, cost-effective use of resources, user and provider satisfaction, and a focus on health promotion and preventive services. Educational programmes for health care providers and managers should be based on the principles of the health for all policy. Technical and managerial capacity-building will need to be enhanced at

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The funding of health care should ensure equity and sustainability

Target 18. Developing human resources for health

WHO/B. Kinsella

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Changing the focus: an outcome-oriented health sector

all levels and across sectors, with emphasis on health impact and action. In most Member States, public health infrastructures and functions will require strengthening and modernization in line with HEALTH 21. The education and training of public health professionals needs to prepare them not only for their technical work, but also to act as enablers, mediators and advocates for health and populationbased action in all sectors. Educational programmes for professional groups, such as architects, engineers, economists, journalists and sociologists, need to provide the necessary knowledge, motivation and skills to support multisectoral action for health.

Clear mandates must exist for the work of public health professionals with an adequate infrastructure for their work

WHO/Verbitski

Managing change for health

To create a broad societal movement for health through innovative partnerships, unifying policies, and management practices tailored to the new realities of Europe Changing governance The collective power of the people of the European Region to shape the future is now more compelling than ever before. Governance is the sum of the many ways individuals and institutions, public and private, collectively solve problems and meet societys needs. It is a process through which conflicting or diverse interests may be accommodated Target 19. and cooperative action taken. It includes formal institutions empowered to Research and enforce compliance, and informal arrangements to which people and institutions have agreed. In the European Region today, the role of central governknowledge ment is changing in many countries. Governance based on health for all for health therefore involves not just governments but also nongovernmental organizations, civil society and the private sector in health development schemes. The role of research and information In many countries, health policies and programmes should be more clearly based on scientific evidence. Health research policies and strategies should be based on health for all principles and needs, striking a better balance between basic and applied research. Communication and cooperation between the scientific community and decision-makers for the application of new knowledge to health development needs to be strengthened in most countries. If all existing knowledge about which health approaches work and which do not were fully applied, this would have a major impact on improving health and protecting the environment. Each country should have a mechanism for systematically identifying, each year, the evidence of new successful methods produced by international or national research. A decision should then be made as to any changes that should be made in that countrys health sector as a result. National and local health information systems are a prerequisite for the development and monitoring of effective, efficient and equitable health policy. Evaluation and monitoring systems will determine whether the targets and objectives are being met and which issues require extra attention.

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Application of existing knowledge would have a major impact on improving health

WHO/Verbitski

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Managing change for health

Health information should be relevant for and easily accessible to politicians, managers, health and other professionals and the general public. At all levels, good governance for health requires transparency, accountability and incentives to promote participation. Engaging the resources and expertise of the media and communication sector, particularly the Internet and television, is a great opportunity to inform, educate and persuade all people of the individual and collective importance of health. It is important to monitor and assess the ethical, scientific and social implications of research in medical technology, and in particular those of research in genetic technology. Genetic knowledge can greatly improve preventive and therapeutic options, but its application should respect human dignity, autonomy and justice. Involving the public in the debate around genetics can ensure that democratic decisions form the basis for future policy choices. Health for all policies and partners Health for all is an integrated and forward-looking policy framework for setting priorities, choosing strategies and mobilizing resources for action for health throughout society. A national, targeted policy based on health for all values is the key to providing motivation and setting a framework for policies and action in regions, cities and local communities, and in settings such as schools and workplaces. By establishing values, setTarget 21. ting targets and mapping out strategies to achieve them, a health for all policy Policies and will guide and facilitate implementation. It is extremely important, when planning national policies and programmes, to engage those who are meant to strategies for implement the policy, that is senior leaders in, for example, health and other health for all ministries, national associations of health professionals, universities and national associations of local municipalities. A wide process of consultation, before final adoption by parliament, is a very good way of ensuring broad support from the whole of society. Similar principles should be applied to health for all programmes at subnational and local levels as demonstrated, for example, by members of the European Regions for Health and Healthy Cities networks. Encouraging all partners to adopt the health values outlined in HEALTH 21 will influence actions by individuals, organizations, businesses and households. Emphasis should be placed on building networks, alliances and partnerships for health at national, regional and local levels,

Target 20. Mobilizing partners for health

A health for all policy will guide and facilitate implementation

WHO/APTN

Managing change for health

and on empowering people to take action. By identifying and taking into account the mutual benefits of investment for health, all sectors stand to gain. However, integrative and participatory planning has implications for those governments that are not yet ready for such a holistic approach. Institutional reforms and mechanisms may be needed in a number of Member States to promote cooperation in implementing policies and plans, to facilitate the decentralization of structures, to involve different sectors, and to achieve better coordination within government.

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The role of WHO and its partners for health

The European Region of WHO has a formidable resource in the large number of organizations that can work with countries to support their efforts. The World Health Organization has as its major task to work for better health. The European Union, an integrational organization with a strong mandate for multisectoral action for health, has considerable potential for contributing to development. The Council of Europe is a major force in ensuring that the basic ethical values are defended, and the Organisation for Economic Co-operation and Development (OECD) provides important economic analyses for its Member States. These and other economic and political groupings, together with various United Nations agencies, major investment banks and international and nongovernmental organizations, contribute to regional governance for health.

WHO has a special mandate to promote closer cooperation for health development

Through its Constitution, WHO has a special mandate to promote closer cooperation for health development, both internationally and in its work to support individual countries. This task has to take into account the realities of the European Region as it enters the 21st century, and the need to establish cooperation with different partners based on mutual trust, a spirit of partnership among equals, and respect for each others specific mandates. On this basis, the Regional Office for Europe will work closely with WHOs Geneva headquarters and with other regional offices, as well as with its European partners, to provide maximum benefit to the European Member States from the wider experience and potential for action made possible by the global nature of WHO. Against this background, the Regional Office will have five roles to play in support of the policys implementation in individual countries. 1. Acting as the Regions health conscience to identify and draw attention to persistent or emerging health concerns, the Regional Office will protect the principles of health as a human right, promote regional health and advocate equity between and within countries. It will protect the health of the vulnerable and the poor, and identify policies and practices that benefit or harm health. 2. Providing a focus for information on health and health development, the Regional Office will maintain and keep up to date the regional health for all monitoring and evaluation systems (the next exercises will be carried out in 2001 and 2004, respectively) and serve as a centre for information on health status, health determinants, health systems and health developments in the Region. In so doing, the Regional Office will strive to optimize its cooperation with WHO headquarters and with its major partners in the Region the European Commission, OECD and other United Nations bodies in particular to promote the development of surveillance and other health information systems that combine ease of data collection and reporting for Member States with the technical requirements of standardization and responding to users needs.

The role of WHO and its partners for health

3. Analysing and advocating health for all policies, the Regional Office will provide guidance and support to Member States, to organizations and to its networks on health policy development at all levels. The Office will undertake health policy research, maintain the regional health for all policy and ensure its next update in 2005. 4. Providing evidence-based tools and guidelines for turning policies into action, the Office will identify innovative tools, approaches and methods for health development. This will be achieved through monitoring the results of international research, reviewing practical experience in Member States and, where necessary, promoting or undertaking special high-priority studies when these are not otherwise available. 5. Working as a catalyst for action, the Regional Office will have four main functions:

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technical cooperation with Member States; leadership in efforts to eliminate or control diseases that are major threats to public health, such as epidemics of communicable diseases and pandemics such as tobaccorelated diseases, trauma and violence; coordinated action with its partners through collaborative networks across Europe; and coordination of, and support to, emergency preparedness and response measures concerning public health disasters in the Region.

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Towards a better future

As we stand on the brink of the 21st century, we have a strong obligation to take action to improve the health of the 870 million people of the Region. HEALTH 21 provides the framework for accepting that challenge by applying the best strategies that have emerged from Europes collective experience during the past 1015 years. It is not a vision beyond our grasp it can be done! Experience has shown that countries with vastly different political, social, economic and cultural conditions can develop and implement health for all policies designed to put health high on the agenda, and when they do, they stand to gain from a fundamental change for the better. The major challenge for the 51 Member States in the Region is now to use the new regional health for all policy as an inspirational guide to update, as necessary, their own policies and targets. Throughout the Region, many local communities have shown great initiative and imagination in using the health for all ideas to mobilize people to promote and protect their health. The dynamic and rapidly expanding Healthy Cities movement, in particular, has demonstrated a formidable potential for systematic, sustainable and innovative mobilization of local communities in every Member State. Furthermore, excellent examples can be seen of the public and private sectors exploring the possibilities for health gain. Thousands of health professionals and many of their organizations have introduced innovative approaches to improving the quality of care and working more closely with other sectors to find new ways of meeting the challenges. Clearly focused and committed action is now needed to transform the vision of health for all into a practical and sustainable reality in every one of the 51 Member States in the Region. The experience, the know-how and many of the tools for influencing the determinants of health are all there. What is needed now is strong leadership and the political will to pick them up and use them!

Whether one is a government minister, city mayor, company director, community leader, parent or individual, HEALTH21 can help develop action strategies that will result in more democratic, socially responsible and sustainable development. Health is a powerful political platform. Those who implement HEALTH21 will be able to:

profit from greater equity in health strengthen health and productivity throughout life reduce the burden of ill health and injury unlock new resources from multisectoral action gain from quality and cost-effective health care take charge of health and its determinants.

ISBN 92 890 1348 6

Sw.fr. 15.

World Health Organization Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Denmark Telephone +45 39 17 17 17 Telefax: +45 39 17 18 18 Telex: 12000 who dk Electronic mail: Internet Userid: postmaster@who.dk World Wide Web Address: http://www.who.dk

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Slovakia Slovenia Spain Sweden Switzerland Tajikistan The Former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Yugoslavia