As discussed in Gastein...

EHFG 2018 Outcomes

Health and Sustainable Development -

Bold political choices for Agenda 2030

3 – 5 OCTOBER 2018, BAD HOFGASTEIN, AUSTRIA

Introduction: Health in Europe – Think big, be bold, be practical!

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Without health nothing is sustainableOpening the EHFG 2018, Gastein Forum PresidentClemens Auer addressed the importance of finallyconceding a more prominent role to health on theEuropean agenda, saying 'It would be a mistake to thinkthat the single market can work without a correspondinghealth and social policy'. He urged conferenceparticipants to “Think big, be bold and be practical”.Referring to European Commission President Juncker´smantra that the EC should be “big on big things andsmall on small things” (with health falling into the lattercategory under the principle of subsidiarity), the newlyelected EPHA President Freek Spinnewijn maintainedthat to some extent “big” has become a contaminatedexpression. He proposed that first and foremost weneed a new European Commission to be “effective onthe issues where it can add value”. Spinnewijncontinued that while the social rights pillar is currentlyjust a declaration, if effectively implemented it has hugepotential for advancing public health in Europe. Therewere some bolder calls for the rethinking the principleof subsidiarity, in recognition of the limitations of thisprinciple and the loss of momentum when continuing towork on problems in silos. Not only were the workings ofthe EU single market in respect to health outcomeshighlighted, but also the role of global capital flows.Given the significant health impacts of products fromthe global food, beverage and tobacco industries,delegates at the EHFG 2018 agreed that it was high timeto bring their discussion into the public healthmainstream and address issues around the commercialdeterminants of health.

Bold leaders and social innovatorsAgainst the backdrop of the Austrian Presidency of theCouncil of the EU, it was no coincidence that theconcept of leadership permeated discussions at theEHFG 2018. WHO Regional Director for EuropeZsuzsanna Jakab highlighted the SDGs as a fantasticopportunity to think big and outlined how the WHO isleading by example with a European roadmap to reachthe SDG targets, and will critically assess progress on anannual basis. “Things only evolve because bold leadersstand up and press for change”, articulated BronwynKing, Founder and CEO of Tobacco Free Portfolios, anext generation health promotion leader campaigningfor tobacco-free finance. She reminded us that changeis possible and that there are no inevitabilities - if we canescape the confines of our own mindsets. Recognisingher contribution as a social innovator, Filippo Addarii,Co-Founder of PlusValue, emphasised that we musthowever engineer a shift from leaders embodying greatpersonal bravery to an educational system embodyingfundamental social values, that equips people with theknowledge and tools to act socially in every facet oftheir lives – for example through introducing “social”business schools. The wider role of civil society as apolitical actor was determined to be crucial: “Everybodyneeds to be political. It is not just up to the politicians,we all need to play a role and advocate, and exertpressure for bold political choices to be taken” saidFanny Voitzwinkler, Deputy Executive Director at GlobalHealth Advocates. Effective collaboration asks forpolitical will, which comes with taking responsibility forengendering the right changes in the right places. Allsectors and actors carry responsibility for health systemsustainability. Without the genuine involvement ofeveryone, we cannot take the concrete and decisiveactions needed to ensure that Europe realises the SDGsby 2030.

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Reframing the inter-sectoral narrativeSeeing the SDGs as an opportunity to advance theconcept of intersectoral collaboration, and vice-versa,was an oft-mentioned theme of the EHFG 2018. In avideo message, EU Health Commissioner VytenisAndriukaitis stressed the need for multi-stakeholderapproaches to reach the goals, maintaining that “Healthis no longer the sole responsibility of those working inthe health sector”. DG SANTE Director John Ryanreminded us that the political arguments of bigbusiness have so far been far stronger than thosechampioning sustainable health, with employmentconcerns offering considerable political leverage. But abalance must be found if we want to achieve betterhealth for everyone. Some even argued that thehealthcare sector may have been too successful inclaiming resources, perhaps at the expense of othersectors linked to important determinants of health.“Invest in housing, not just hospitals”, implored JenniferDixon, Chief Executive, Health Foundation. Whilepartnerships with the private sector were debated as apossible solution at times, some offered words ofcaution. “Let us be precise, not everything is apartnership. WHO’s best buys to tackle NCDs requiregovernment action which many industries will not like,”affirmed Ilona Kickbusch, Director of the Global HealthCentre, Graduate Institute Geneva. Some advocatedintegrated action plans accounting for the localepidemiological context of each EU Member State - anSDG toolkit that could be tailored to a country-levelapproach.

Health in all policies and sectorsThe growing and important role of the Gastein Forumas a place to bring diverse actors together was alsohighlighted by many participants, with advances madethis year by involving actors from finance, procurementand the social sector. Zoltán Massay-Kosubek, PolicyManager for Health Policy Coherence at EPHA,highlighted the cross-sectoral levers of internationaltrade, the EU budget, national taxation policies andlocal and regional policies that all play a role inimproving the wellbeing of citizens. To effect fruitfulcollaboration, health actors must learn to speak thelanguage of their counterparts in other sectors and viceversa. ‘The health sector does not really speak thelanguage of finance ministers’, Jennifer Dixonreminded us – but needs to in order to engenderunderstanding of the importance of investment in andcollaboration on health. Amongst others, John Ryanreminded us of the main reason for really workingtogether across sectors: achieving the best possibleoutcomes for patients and people.

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A bold political choice we need to make now is...

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OUTCOMES EHFG 2018

Digital healthThe opportunities offered by block chain, big data andthe digitalisation of healthcare systems werediscussed, ranging from new ways of collaborationbetween countries to patient-centred care, availablecloser to the patient. Delivering care where the patientneeds it will result in better outcomes at lower costs,argued DG SANTE Deputy-Director General MartinSeychell. He highlighted some key priorities for theEuropean Commission in digital health: better accessto health data and using digital services for citizenempowerment and person-centered care; connectingand sharing health data for research, and betterdiagnosis. The potential advantage of digital health inreducing inequalities was also noted by several peopleacross sessions. One example highlighted by theEstonian Health Minister Riina Sikkut concerned theincreased uptake of subsidies for regular prescriptionswith a new digital solution. Digitalisation - not AI - is theclue to cost-savings in healthcare, argued Liisa-MariaVoipio-Pulkki, CMO, Ministry of Health of Finland,suggesting the cost-saving benefits of AI would onlybecome apparent in the long-term.

Artificial intelligence – hype or hope?There was both optimism and caution about theopportunities offered by Artificial Intelligence (AI). First,we need to be clear on what we mean by AI – there is ahuge difference between regression analyses andbasic algorithms offering decision support tools and farmore sophisticated “black-box” diagnostic tools. Someargued that AI will increase the accuracy, value andefficiency of healthcare services, others were moresceptical and cautioned against regarding it as a silverbullet E. g. in terms of supporting workforce issues,discussions highlighted how AI has the potential toease the burden of health professionals but cannotreplace their multi-faceted roles. “We need humans tocheck, challenge and provide care”, said LydiaMakaroff, Director, European Cancer Patient Coalition.Brian O´Connor, Chair of the ECHAlliance, added:“Algorithms will not dehumanise medicine, they canstrengthen the human factor by delivering more focuson personalised medicine”. While there wasunanimous agreement that measures to engender trustand ensure data safety are paramount, many thoughtthat potential safety risks should not serve as anargument against the adoption of AI. Yet, ClaytonHamilton, WHO Regional Office for Europe, stressedthat we must tread carefully and advocated for aprogressive but cautious approach to foster public trustconcerning key issues of data quality, sharing andgovernance, covering all dimensions from ethics tosafety and transparency. He suggested public healthsystems have an opportunity and duty to create

independent regulatory bodies ensuring that AIsolutions are developed in a rigorous manner, forexample. Overall there was optimism that if we carefullydesign, effectively regulate and apply a whole systemapproach to how these technologies are implementedand evaluated, we can mitigate many of the potentialdangers. And, it was argued, not using AI presents riskstoo. Rachel Dunscombe, CIO, Salford Royal NHSFoundation Trust, boldly argued “We have a duty ofcare to use AI. To fail to do so is to harm our patients.”

Innovative and personalised medicineEHFG 2018 participants agreed that it was time to dropthe “s” in “innovative medicines” and start talking about“innovative medicine”, i.e. taking an integratedapproach to healthcare delivery. A growingacknowledgment of the need for new business modelsand consistent approaches to make sure the medicalneeds of people are met, and innovations are madeaffordable, was once more the topic of a number ofpopular conference sessions. The commercialunattractiveness of certain medications due to smalltarget populations and short courses of curativetreatment were recognised as major issues underlyingthe limited access to these medicines. Somequestioned whether we have the courage to divestfrom ineffective medicines after they are authorised,while others advocated for mandatory and timely post-authorisation trials that use real world evidence. Therole of governments in adjusting the regulatory andincentive systems to drive positive change was alsodiscussed, as were responsibilities at EU level. Here, weneed to set new policy frameworks for increasedaccess to pharmaceuticals, for example by proposingnew criteria for the approval, designation, andreimbursement of medications. Thereby we can ensuregreater control of the innovation pathways in thepharmaceutical field, support the implementation of aneeds-led research strategy, and help secure fundingfor medications lacking commercial attractiveness. Theneed to increase research in areas other thanpharmaceuticals (e.g. prevention and early diagnosis)was also highlighted as a key element to innovatemedical care. Riina Sikkut gave an example, citing therecently-set target to sequence the DNA of over 10% ofthe Estonian population. The measure aims to gaininsights that will help improve health outcomes andstrengthen prevention and diagnostics - and would beimpossible without the digitalisation of Estonianhealthcare, she explained.

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The role of markets in healthThe role of global financial flows in relation to health, inparticular NCDs, was explicitly discussed. The financialmarkets are key to achieving the SDGs and the publichealth community needs to build its capacity onfinance issues, read the Financial Times as much asThe Lancet, and pro-actively enter finance negotiationsto tackle the challenge of NCDs, advocated IlonaKickbusch, fresh from the UN High Level Meeting onthe topic. “WHO should have a Chief Economist whocan actively engage and shape financial discussions –it cannot afford to be absent”, she stressed. Fromsmarter vaccine procurement and social impactinvesting as the main pay-off from big urban projects,to health bonds to drive better clinical management ofpatients with chronic diseases, the role of markets isclearly integral to health. Filippo Addarii emphasisedthat markets are social products and citizens have thepower to change them: “We are all shareholders andwe can no longer devolve decisions to others claimingthat we do not know - we have the technological toolsto make informed decisions about where to invest andto influence markets”, he exhorted. We should notforget, however, that the market power of citizensdiffers across different socio-economic strata and takesteps to redress these inequalities.

Economic strategies for health equityParticipants agreed on the need to move fromcorporate social responsibility to creating a sharedvalued approach, and through this change inphilosophical mindset put all our energies and weightin one direction. There is a need to not only engagebusinesses, but also involve shareholders andinvestors, requiring new narratives in advocacy tounderline that investing in health is money well spentand inclusive growth is a vital route to tacklinginequalities, precipitating a change in perspective fromseeing health spending as a financial ‘black hole’ to aproductive societal investment that provides tangiblereturns. As in other areas, for example innovativemedicines, it was agreed that the key principle forpartnering with the private sector in social impactinvestment is a fair profit. Investors get back theircapital and a reasonable surplus – this would mark anend to 'profiteering'. However, partnering with somesectors, particularly tobacco, was recognised to befutile and even dangerous. In such cases regulation isthe only option. Momentum has been gathering forsome time for a Framework Convention on AlcoholControl (FCAC) – and given the results of recentresearch on the impact of alcohol and health it wascommented that the time seems ripe to finally turn thisidea into reality.

Primary healthcareReforming primary healthcare (PHC) is a predominantconcern of most European countries, and commonissues highlighted included workforce challenges,chronic disease management, care coordination,prevention and investment. Contractual andorganisational matters form major obstacles to primarycare reform, because they are often GP-centric and donot support multidisciplinary team working. However,diverse solutions were offered, from making full use ofa multi-professional workforce to improvements inmedical training and more possibilities for careerdevelopment to increase the attractiveness of PHCamong young health professionals. The EU waschallenged to strengthen PHC by reducing thefragmentation of healthcare systems and by supportingthe continuation of care across the different MemberStates. Peter Smith, Emeritus Professor of Health Policyat Imperial College London, highlighted similar issuesacross Europe for the sustainability of healthcarefunding - demography, technology and publicexpectations - and asserted that essentially healthcarefunding remains a political choice.

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Smarter use of existing dataThe mere existence of evidence is by no means aguarantee for improved outcomes - how we employ itis key. At the EHFG 2018, we focussed not on howmuch evidence we have but on how smartly we areusing it. Obstacles to fruitful health research includemisalignment of goals between different stakeholders,like universities, pharmaceutical industries andhealthcare providers. Sometimes the problem is moreto do with evidence uptake. Peter Smith commentedthat while the quantitative data on health systemsustainability are clear calls to action for policymakers,straightforward data is not enough. What we need inaddition is a more profound sociological, cultural andorganisational understanding to ensure researchevidence successfully impacts the way the healthsystem operates.

Policymaking in practiceMaking better use of existing data was something thatresonated across EHFG sessions. “Policymakers areswimming in white papers, reports and studies” statedPaul Cairney, Professor, University of Stirling. Hedismissed the oft-cited “knowledge gap” betweenresearch and policy, suggesting policymakers wereforced to prioritise and thus ignore most evidence withwhich they were presented to make decisions. Thepolicymaking process is essentially complex andconvoluted, with multiple influencers and evidencesources, of which usually the most useful studies areresearch syntheses. There were suggestions that ratherthan being impartial knowledge-brokers, researchers’work was most fruitful when crossing the “objectivityline”, discussing policy implications and even givingadvice. Recognising windows of political opportunitysuch as events or sympathetic politicians was anotherkey recommendation for enabling the uptake ofevidence. Some found that bypassing centralgovernment and targeting information at more locallevels – for example giving municipalities specifichealth data about their population - has spurredpolitical leaders into action.

Disseminating best practice

Several new best practice tools were launched or

highlighted at the EHFG 2018, offering new solutions to

better translate knowledge into action. The new DG

SANTE Steering Group on Promotion and Prevention

could become a particularly useful tool, a hub for

consulting with Member States on spending priorities

and efficacy of EU funds and a cooperation space with

other EC DGs and the European Investment Bank. The

WHO Global Coordination mechanism on the

Prevention and Control of NCDs launched a

Knowledge Action Portal (KAP) – an interactive

platform and knowledge hub for multisectoral and

multi-stakeholder engagement. They also highlighted a

new Community of Practice on the commercial

determinants of health, an online network of experts

developing knowledge, sharing best practices and

country case studies on NCD prevention and control.

Martin Seychell related that despite a set of

challenging political circumstances there has never

been so much health collaboration between Member

States as now, pointing to the example of pandemic

vaccines, ERNs, HSPA, eHealth and HTA.

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Health inequalities: complex issues in complex systemsLeaving no-one behind is absolutely central to the2030 Agenda and was a key theme running throughEHFG 2018. Europe is generally considered a continentwhere great strides have been made in ensuringequitable chances of well-being and good health for allpeople. Yet, even though progress is visible, challengesremain – health inequalities continue to persist or evengrow between and within countries, regions andcommunities. People with lower socio-economicstatus experience cumulative inequalities, resulting in atoxic cocktail of high demands, low control and lowrecognition. This leads to powerlessness and, where itpersists, hopelessness. There were calls to fightlearned helplessness by using tried and testedapproaches, acting upon evidence instead of hand-wringing and theorising. Yvonne Doyle, RegionalDirector London, Public Health England, illustrated howthe London Health Inequalities Strategy was drawn upby bringing together deputy mayors from acrossdifferent policy areas and engaging them in evidence-based actions to address the challenge of healthinequalities. Social movements for health that invitepeople to join were acknowledged as having thepotential to empower and accelerate progress.

Let´s get political!Vaccination is another complex issue where inclusivityas well as recognising the value of investment are key.It remains high on the list of European priorities in 2018:“Vaccination may save societies approximately tentimes more than the original cost” John Ryan stressed.Discussions made clear that while improvedvaccination coverage and access throughout people’slives could contribute to progress on several SDGs, weneed to work harder to reach vulnerable and hard-to-reach groups. Speaking on the challenges surroundingHIV/AIDS, Hepatitis and Tuberculosis, Andrea Ammon,Director of the European Centre for Disease Preventionand Control, highlighted that both the complex natureof these epidemics and the nature of the SDG targetscall for a multisectoral, societal and integratedresponse. Reaching underserved populations howeverremains inextricably linked to political will, solidarityand commitment. “Let’s get political!” Ricardo BaptistaLeite, Member of Parliament, Portugal, challenged, andVinay P. Saldanha, Regional Director for Eastern &Central Asia, UNAIDS, added that we are in need of “anew sense of geographic solidarity - to work beyondborders limits and mandates.”

Systemic changes for a more equitable societyOne of the key challenges is that many of the causes ofhealth inequalities and therefore the solutions toaddressing them lie outside the health sector, in areassuch as employment, education and housing. Thisdraws attention once more to the necessity ofintersectoral collaboration, and the importance ofestablishing a coalition of leaders on the socialdeterminants of health across Europe. It was agreedthat interventions exclusively focussing on behaviouralchange are doomed to failure. Systemic change isneeded, and projects and their potential impact oninequalities across several key domains, for exampleliving, moving and consuming, were on the agenda.Yvonne Doyle, asserted that when taking decisions oractions we might not always get an answer to “Does itwork?” The question should rather be “(Who) does ithelp?” A way forward may be targeted investment inresearch that explicitly takes opportunities forvulnerable populations into account when formulatingresearch questions and strategy. Also, once asuccessful policy intervention has been identified,funding should be made available to transfer andupscale if appropriate. Sir Michael Marmot evenadvocated the concept of universal basic services. Weare already familiar with this concept when it comes toeducation and healthcare, but expanding the array ofservices to include transportation, nutrition, andcommunication (amongst others) has the potential tomake our societies more equitable. Another boldstrategy proposed was that the EU should adopt anapproach of an economy for the common good, whichwould connect many SDG themes and put humanwellbeing and the environment at the core of allpolicies.

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Conclusion: Courage and conviction to embrace disruption

A disruptive discourseThe current political discourse has been considerablyinfluenced by the biggest disruptions of our times – thehighly competitive global market economy, theinfluence of digitalisation on the job market, and thenational management of unpredictable migrationflows. In order to ensure social cohesion and wealthysocieties, politicians need to consider health as acrucial factor. Aligned to this, the health sector needs togrow in confidence as its purpose reaches far beyondproviding care. All this requires a dose of courage forrethinking health policy and a new narrative in health,with the SDGs providing a valuable, socially-orientedmodel. We would do well to implement the goals intosocial and health policies at national and Europeanlevels as quickly as possible, and to adopt them in ourdaily activities.

Trio 8 remaining EU presidenciesLooking to the future and the forthcoming leadershipof Romania and Finland as part of the Trio 8, Romaniastressed that the rotating EU Council Presidency isabout keeping legacies and putting things intoperspective, and that digital health will be a top priorityfor #ROEU2019. Finland trailed its welcome Presidencytheme of “the economics of a society based onwellbeing”, which was greeted with much enthusiasmby the Gastein conference community.

Gastein´s contributionAnd what of Gastein´s continuing contribution to thefield of health policy? The many professionals in healthand healthcare owe it to patients and society as awhole to bring a range of stakeholders from differentsectors together to think outside the box and have aclear and transparent debate that constructivelypinpoints the kind of decisions that need to be taken.The EHFG will continue to offer an open market spacefor new ideas and insights and a safe space forcontroversial debates and thought experiments, whichmay plant the seeds for creative restructuring anddisruptive ideas.

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European Health Forum Gastein

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Floris Oudshoorn

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30 October2018

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Infographic Naomi Fein, Think Visual