How to improve the health of the Polish population

Health 2020 – the European policy framework

Zsuzsanna JakabWHO Regional Director for Europe

Health – a precious global good

• Higher on the political and social agenda of countries and internationally

• An important global economic and security issue

• A major investment sector for human, economic and social development

• A major economic sector in its own right• Health as a human right and a matter of

social justice

Health 2020 was adopted by the WHO Regional Committee in September 2012

Health 2020 aim: to significantly improve health and well-being of populations, to reduce health inequities and to ensure sustainable people-centred health systems

Why Health 2020?

Significant improvements in health and well-being but … uneven and unequal

Source: WHO Health for All database, August 2010

Overall health improvement (5 years’ life expectancygained) but with an important divide

CIS: Commonwealth of Independent StatesEU12: countries belonging to the European Union (EU) after May 2004 or 2007EU15: countries belonging to the EU before May 2004

Source: WHO European Health for All database

Life expectancy trends in Poland and European regions

Source: WHO European Health for All database

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

Life expectancy at birth, in years, male

60

65

70

75

80

85

90

Value

Life expectancy at birth, in years, male

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

Life expectancy at birth, in years, female

60

65

70

75

80

85

90

Value

Life expectancy at birth, in years, female

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

Life expectancy at age 65, in years, female

10

15

20

25

Value

Life expectancy at 65 years, in years, female

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

Life expectancy at age 65, in years, male

10

15

20

25

Value

Life expectancy at 65 years, in years, male

Country

EU 12 European Region Poland

Infant and maternal mortality in Poland and European regions

Source: WHO European Health for All database

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

Infant deaths per 1000 live births

0

5

10

15

20

25

30

35

40

45

50

55

60

Value

Infant deaths per 1000 live births

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

Maternal deaths per 100000 live births

0

5

10

15

20

25

30

35

40

45

50

55

60

Value

Maternal deaths per 100000 live births

EU 12

European Region

Poland

Year

Sta

ndard

ized d

eath

rate

, 0-6

4 p

er

100,0

00

0

20

40

60

80

100

120

140

1980 1985 1990 1995 2000 2005

Cause

Heart disease

Cancer

Injuries and violence

Infectious diseases

Mental disorders

Source: WHO European Health for All database

Trends in premature mortality by broad group of causes in the European Region, 1980–2008

Overall and premature mortality by groups of causes in Poland and European regions

Source: WHO European Health for All database

Indicator

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340 360 380 400 420 440

Value

Diseases of the circulatory system

Malignant neoplasms

Diseases of the respiratory system

External cause injury and poison

Diseases of the digestive system

Infectious and parasitic disease

SDR, all ages per 100000, by broad causes of death

Indicator

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340 360 380 400 420 440

Value

SDR, diseases of circulatory system,0-64, per 100000

SDR, malignant neoplasms, 0-64, per100000

SDR, external cause injury and poison,0-64 per 100000

SDR, diseases of the digestive system,0-64 per 100000

SDR, diseases of the respiratorysystem, 0-64 per 100000

SDR, infectious and parasitic disease,0-64 per 100000

SDR, 0-64 per 100000, by broad causes of death

EU 12 European Region Poland

Heart disease and stroke mortality trends in Poland and European regions

Source: WHO European Health for All database

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, ischaemic heart disease, 0-64 per 100000, ..

0

50

100

150

200

Value

SDR, ischaemic heart disease, 0-64 per 100000,male

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, ischaemic heart disease, 0-64 per 100000, f..

0

50

100

150

200

Value

SDR, ischaemic heart disease, 0-64 per 100000, female

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, cerebrovascular diseases, 0-64 per 100000, ..

0

20

40

60

80

100

Value

SDR, cerebrovascular disease, 0-64 per 100000, male

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, cerebrovascular diseases, 0-64 per 100000,f..

0

20

40

60

80

100

Value

SDR, cerebrovascular disease, 0-64 per 100000, female

EU 12 European Region Poland

Mortality from lung cancer in Poland and European regions

Source: WHO European Health for All database

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, trachea/bronchus/lung cancer, 0-64 per 100000, male

0

10

20

30

40

50

60

70

80

90

100

Value

SDR, trachea/bronchus/lung cancer, 0-64 per 100000, male

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, trachea/bronchus/lung cancer, 0-64 per 100000, female

0

10

20

30

40

50

60

70

80

90

100

Value

SDR, trachea/bronchus/lung cancer, 0-64 per 100000, female

EU 12 European Region Poland

Smoking prevalence, cigarette costs and lung cancer trends in Poland and European regions

Source: WHO European Health for All database

Year

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Indicator

% of regular daily smokers in the population, age ..

0

10

20

30

40

50

Value

% of regular daily smokers in the population, age 15+

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, trachea/bronchus/lung cancer, 0-64 per 100000

0

5

10

15

20

25

30

Value

SDR, trachea/bronchus/lung cancer, 0-64 per 100000

1 2 3 4 5 6 7 8 9 10 11 12

Price of a 20 cigarette pack in US$ in 2008

0

10

20

30

% regular daily smokers in the population, ages 15 +

PortugalKazakhstan

Israel

Denmark

Cyprus

Czech Republic

EstoniaFrance

Germany

GreeceHungary

Ireland

Italy

Kyrgyzstan

Latvia

Luxembourg

MaltaNorway

Poland

Slovakia

Spain

Sweden

Turkey

Turkmenistan

% of regular daily smokers aged 15+ and price of a 20 cigarette pack

EU 12 European Region Poland

Mortality from chronic liver disease and alcohol consumption in Poland and European regions

Source: WHO European Health for All database

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

SDR, chronic liver disease and cirrhosis, 0-64 per 100..

0

20

40

60

80

Value

SDR, chronic liver disease and cirrohsis, 0-64 per 100000, male

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

SDR, chronic liver disease and cirrhosis, 0-64 per 100..

0

20

40

60

80

Value

SDR, chronic liver disease and cirrhosis, 0-64 per 100000, female

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Pure alcohol consumption, litres per capita, age 15+

0

5

10

15

20

25

Value

Pure alcohol consumption, litres per capita, age 15+

0 5 10 15 20 25 30 35 40 45

Average price of 750ml of locally produced spirits, in US$, 2008

0

10

20

30

40

Percentage of heavy weekly drinkers

Netherlands

Croatia

Czech Republic

Estonia Finland

France

Hungary

Iceland

Ireland

Israel

Italy

Latvia

NorwaySwitzerland

% of heavy weekly drinkers and average price of locally produced spirits

EU 12 European Region Poland

Mortality from female cancers in Poland and European regions

Source: WHO European Health for All database

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, malignant neoplasm female breast, 0-64 per 100000

0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

Value

SDR, malignant neoplasm female breast, 0-64 per 100000

Year

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Indicator

SDR, cancer of the cervix, 0-64, per 100000

0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

Value

SDR, cancer of the cervix, 0-64 per 100000

EU 12 European Region Poland

In summary…• Life expectancy has risen steadily in Poland, in line with the European

average, to a large extent as a reflection of the declines in infant and maternal mortality.

• The principal causes of death are the “classics”, noncommunicable diseases such as cardiovascular diseases, cancers and injuries.

• In contrast to the European average for premature deaths, cancers predominate over cardiovascular diseases (which have declined), especially in women, with little decline over time (bronchial, cervical).

• Chronic liver disease has increased slowly over time, accompanied by increases in the consumption of alcohol.

• Mortality from suicides has increased in men, accompanied by a rise in unemployment rates.

• Human resources for health density is lower than the European average, as is health expenditure (although increasing over time).

Increasing attention to inequity

For richer, for poorerGrowing inequality is one of the biggest social, economic and political challenges of our time. But it is not inevitable …

The Economist, special edition, 13 October 2012

Why Health 2020?

Europe’s changing health landscape:new demands, challenges and opportunities

European Region landscape

• We are dealing with complexity and uncertainty• Health challenges are multifaceted and require active

involvement of all levels of government (international, national, and local)

People live longer and have fewer

children.

People migrate within and between

countries; cities grow bigger.

Health systems face rising costs.

Primary health care systems are weak

and lack preventive services.

Public health capacities are

outdated.

Infectious diseases, such as HIV and

tuberculosis, remain a challenge

to control.

Antibiotic-resistant organisms are

emerging.

Noncommunicable diseases dominate the disease burden.

Depression and heart disease are leading causes of healthy life-years

lost.

Why Health 2020?

Economic opportunities and threats:the need to champion public health values and approaches

The economic case for health promotion and disease prevention

Cardiovascular diseases (CVD)

Alcohol-related harm

Cancer

Road traffic injuries

Obesity-related illness (including

diabetes and CVD)

€169 billion annually in the EU, health care accounting for 62% of costs

€125 billion annually in the EU, equivalent to 1.3% of gross domestic product (GDP)

Over 1% GDP in the United States, 1–3% of health expenditure in most countries

6.5% of all health care expenditure in Europe

Up to 2% of GDP in middle- and high- income countries

Sources: Leal (European Heart Journal, 2006); DG Sanco (2006); Stark (The European Journal of Hospital Pharmacy: Science and Practice, 2006); Sassi (Organisation for Economic Co-operation and Development, 2010).

Austerity adds layer of complexity: lessons learned from past and present crises

•Associated with a doubling of the risk of illness and 60% less likelihood of recovery from disease*

•Strong correlation with increased alcohol poisoning, liver cirrhosis, ulcers, mental disorders**

•Increase in suicide incidence***: Greece and Latvia 17%, Ireland 13%

•Active labour market policies and well-targeted social protection expenditure can eliminate most of these adverse effects****

Unemployment

Sources: * Kaplan G (2012). Social Science & Medicine, 74:643–646.** Suhrcke M, Stuckler D (2012). Social Science & Medicine, 74:647–653.*** Stuckler D et al. (2011). The Lancet, 378:124–125.**** Stuckler D et al. (2009). The Lancet, 374:315–323.

Health impact of social welfare spending and GDP growth

•Each additional US$ 100 per capita spending on social welfare (including health) is associated with 1.19% reduction in mortality.

Social welfare

spending

•Each additional US$ 100 per capita increase in GDP is associated with only 0.11% reduction in mortality.

GDP

Source: Stuckler D et al. BMJ 2010, 340:bmj.c3311.

Health 2020 - reaching higher and broader

• Going upstream to address root causes, such as social determinants

• Investing in public health, primary care, health protection, health promotion and disease prevention

• Making the case for whole-of-government and whole-of-society approaches

• Offering a framework for integrated and coherent interventions

Working to improve health for all and reducing the health

divide

Improving leadership, and participatory governance for

health

Investing in health through a life-

course approach and empowering

people

Tackling Europe’s major health challenges of

noncommunicable diseases and communicable

diseases

Strengthening people-centred

health systems and public health

capacities, and emergency

preparedness, surveillance and

response

Creating resilient communities and

supportive environments

Health 2020: four common policy priorities for health

Health 2020 strategic objectives

The Health 2020 development journey – two years’ participatory process with countries and partners• Unprecedented evidence review • New evidence gathering• Solutions that work• Integrating and connecting• Stakeholder(peer)-reviewed

Building on public health history

• WHO Constitution• Alma-Ata Declaration• Health for All • HEALTH21• Tallinn Charter

Integrated policy frameworks can and have inspired health-generating actions on all levels.

New evidence informing Health 2020

• Governance for health in the 21st century• Supporting Health 2020: governance for health in the 21st

century• Promoting health, preventing disease: the economic case• Intersectoral governance for health in all policies:

structures, actions and experiences• Report on social determinants of health and the health

divide in the WHO European Region• Review of the commitments of WHO European Member

States and the WHO Regional Office for Europe between 1990 and 2010

The WHO European review of social determinants and the health divide: key findings and recommendations to improve equity in health

Policy goals • Improve overall health of the population • Accelerate rate of improvement for those with worst

health

Policy approaches• Take a life-course approach to health equity • Address the intergenerational processes that sustain inequities• Address the structural and mediating factors of exclusion

• Build the resilience, capabilities and strength of individuals and

communities The review was carried out by a consortium of over 80 policy researchers and institutions across Europe, and chaired by Professor Sir Michael Marmot (2012)

Assessment of health inequalities in Poland

• Recommendations for strategy and policy formulation, monitoring and coordination

• Recommendations for actions aiming to improve the socioeconomic status of the population

• Recommendations for targeted public health programmes

Improving governance for health

Source: I Kickbusch (2011)

Supporting whole-of-government and whole-of-society approaches

Learning from a wealth of experience with work on intersectoral action and health in all policies in Europe and beyond

Two governance for health studies led by Professor Ilona Kickbusch (2011, 2012)

Inter-sectoral governance for health in all policies, by Professor David McQueen et al. (2012)

The Health 2020 framework:

• recognizes that countries engage from a different starting point and have different contexts and capacities;

• recognizes that every country is unique and that countries will pursue common goals through different pathways and use different entry points and approaches but be united in purpose.

• is an adaptable and practical policy framework;

Noncommunicable diseases action plan 2012–2016

Planning and oversight

National plan

Health information system with

social determinants

disaggregation

Health in all policies

Fiscal policies

Marketing

Salt

Trans-fat

Healthy settings

Workplaces and schools

Active mobility

Secondary prevention

Cardio-metabolic risk assessment

and management

Early detection of cancer

European Action Plan

for Strengthening Public

Health Services and

Capacity

Supporting Member States to navigate the crisis is central to our work

• Strong economic case for health promotion and disease prevention, as economic cost of noncommunicable diseases extremely high (only 3% investment)

• Prevention one of most cost-effective approaches to improve health outcomes

• Use of fiscal policy such as by raising taxes on tobacco and alcohol

• Sin taxes have short-term benefits.

Supporting Member States to navigate the crisis is central to our work (2).

• Try to protect health budgets but, if cuts have to be made, avoid across-the-board budget cuts and target public expenditures more tightly on poor and vulnerable (avoiding or reducing out-of-pocket payments, which lead to impoverishment).

• Think long-term: save in good times and spend in bad times!

Year

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Indicator

Total government expenditure as % of GDP

0

10

20

30

40

50

Value

Total government expenditure as percentage of the gross domestic product

Country EU 12 European Region Poland

Year

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Indicator

..Total health expenditure as % GDP, WHO estim

0

2

4

6

8

Value

Total health expenditure as percentage of the gross domestic product

Year

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Indicator

..Private sector expenditure on health as % of total h

0

10

20

30

Value

Private households out-of-pocket payment on health as percent of private sector health expenditure

Year

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Indicator

.. ,Public sector expenditure on health as % TGE

0

2

4

6

8

10

12

Value

Public sector expenditure on health as percentage of total government expenditure

Health expenditure trends in Poland and European regions, by type

Source: WHO European Health for All database

Challenging the view of health as a cost to society: example from the United Kingdom

• Health and social care system in north- western region £8.2 billion (10% of regional total GDP of £88 billion): 60% on staff, with £2 billion on goods and services

• 340 000 people employed directly (12% of regional employment)

• 0.5% of regional businesses primarily in the health sector: 780 businesses

• 50% of health sector firms have turnovers of £100 000–499 000

• Capital spending on programmes for 5 years is £4.5 billion

The contribution of the health sector to the economy

Source: The King’s Fund (2002)

Health 2020 helps to rethink policies for health and approaches to stakeholder engagement, such as fiscal policy to control harmful use of alcohol

Alcohol-related harm

€125 billion annually in the EU, equivalent to 1.3% of GDP

Mapping allies and interests

Ministry of Justice and police

Employers and development sectors

Health

Transport

Local communities

Requires a healthy population and complementary policies among health,

development and social sectors.

Health as a contributor to public policies European targets to increase participation of older people in the workforce

Source: EUROSTAT

Dear prime minister, minister, mayor or member of parliament:

Good health underpins social and economic development and strengthens policies across all sectors. However, the economic and fiscal crisis facing many countries presents serious challenges and potentially risks undermining the positive progress that has been made. Nevertheless, it also presents an important opportunity to refocus and renew our efforts to improve the health of all people.

All sectors and levels of government and society contribute to health creation. Your leadership for health and well-being can make a tremendous difference for the people of your country, state, region or city and for the European Region as a whole.

Your support for Health 2020 is truly essential.

THANK YOU!