health 2020 and health system strengthening

Health 2020 and

health systems

strengthening

Dr Zsuzsanna JakabRegional Director

WHO Regional Office for Europe

Ljubljana, Slovenia, 30 October 2015

Contents

From the Ljubljana Charter to Health 2020

Health situation in Slovenia

Investing in health

Slovenia health system review

Refugee and migrant health

Preparedness and response (Ebola)

Content

Long history of excellent collaboration

Ljubljana charter

Driven by values

Targeted on health

Oriented towards primary care

Based on sound financing

Centred on people

Alma-Ata Declaration;

Ljubljana Conference on

Reforming Health Care

1978-96

Introduced core health system functions:

governance; services delivery; financing;

resource generation

2000

Tallinn Charter:

health systems

for health and wealth

2008 and 2013

Oslo conference:

Impact of crisis

2009 & 2013

2012

Health 2020 priority area:

strengthening people-centred

health systems and public health

From the Ljubljana Charter to Health 2020

New vision for health systems strengthening

reaches out to people

Health system strengthening priorities:

starting from the values

Two important measures for

universal health care

Unmet

need

Financial protection

against the costs of ill health

Slovenia is a top performer in

universal health careUnmet need for a medical examination for financial or other reasons by

income group in the European Union, EU-SILC data for 2012

Financial protection is excellent: out-of-pocket

payment <15%Out-of=pocket payment as a share (%) of total expenditure on health

ranked from low to high by income (high, upper-middle, lower-middle, low)

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

Ne

therl

and

sM

onaco

Fra

nce

UK

Lu

xe

mbo

urg

Slo

ven

iaG

erm

any

San M

arin

oD

enm

ark

No

rwa

yC

roa

tia

Czech R

epu

blic

Irela

nd

Austr

iaS

wede

nA

ndo

rra

Icela

nd

Esto

nia

Fin

land

Belg

ium

Ita

lyS

pain

Pola

nd

Slo

vakia

Isra

el

Hu

nga

ryS

witzerl

and

Lithu

ania

Gre

ece

Port

ug

al

Ma

lta

Ru

ssia

n F

ed

era

tion

La

tvia

Bulg

aria

Cypru

s

Turk

ey

Bela

rus

Ro

man

iaB

osnia

an

d H

erz

eg

ovin

aT

FY

RM

Mo

nte

ne

gro

Turk

men

ista

nS

erb

iaK

azakhsta

nA

lba

nia

Aze

rbaija

n

Kyrg

yzsta

nU

kra

ine

Uzbe

kis

tan

Re

pub

lic o

f M

old

ova

Arm

enia

Geo

rgia

Tajik

ista

n

Source: WHO Global Health Expenditure Database for 2011

Alarming zone

15%

A number to remember: keep out-of-

pocket payment low

The share of public expenditure for health spending is

lower in Slovenia than in many comparable countries

IE

NL

HU

AT

HR

SK

EE

CZ

FIDE

WHO Europe: European Health for All database

60

65

70

75

80

85

90

95

1995 2000 2005 2010

EU15

SI

EU13

WHO/Europe

% of all health expenditure

Total health expenditure (as % of GDP) is

lower in Slovenia than the EU15 average

IE

NL

HU

AT

HR

SK

EE

CZ

FI

DE


4

5

6

7

8

9

10

11

12

13

1995 2000 2005 2010

EU15

SI

EU13

WHO/Europe

% GDP

60

65

70

75

80

85

Life expectancy is increasing and the gap

between Slovenia and EU15 is closing!

EU15

SI

EU13

WHO/Europe

DE

1980 1990 2000 2010

60

65

70

75

80

85

IENL

HU

AT

HR

SK

EE

FI

CZ

1980 1990 2000 2010

years years

males females

NL

FI

EE

HUATCZ

IEHR


Maximum value

Regional average

Minimum value

Inequality in life expectancy: declining, but gap persists

Maximum value

Regional average

Minimum value

Inequality in life expectancy is decreasing, but the gap

persists

Gap in life expectancy at 30 years of

age by education level, Slovenia, 2010

East–west: gap in mortality

Mortality due to circulatorysystem diseases

Source: National Institute of Public Health

High impact of mother‘s level of education

on stillbirths and perinatal mortality

So

urc

e: N

atio

na

lIn

stitu

te o

fP

ub

licH

ea

lth

The Region is on track to reducing premature mortality

Maximum value

Regional average

Minimum value

Premature mortality in Slovenia is

decreasing

EU15

SI

EU13

WHO/Europe

1980 1990 2000 2010

100

200

300

400

500

600

700

IE

NL

HU

AT

HR

SK

EE

CZ

FIDE

age-standardized death rate - all causes, 0-64, per 100000


litres of pure alcohol are

drunk per person per year

of the population is

overweight or obese

of the population

uses tobacco

Alcohol consumption remains a problem.

IE

NL

HUATHR

SK

EECZ

FI

1980 1990 2000 2010

5

7

9

11

13

15

17

19 EU15

SI

EU13

WHO/Europe

DE

Pure alcohol consumption, litres per capita, age 15+


Overweight and obesity are risk factors for

various chronic diseases and conditions.

0%

5%

10%

15%

20%

25%

30%

35%

40%

čisto spodnji indelavski sloj

srednji sloj višji srednji inzgornji sloj

Del

ež (%

)

TRENUTNI KADILCI

2001

2004

2008

2012

Comprehensive legislation on tobacco

control is needed.Current smokers

Source: National Institute of Public Health

Lower social

class

Middle social

class

Higher/highest

social class

Noncommunicable diseases – by far the first cause of

mortality – are the key challenge in Slovenia

Source: WHO mortality database

With continued good

work in monitoring

communicable

diseases, work must

be strengthened in

all sectors working in

noncommunicable

diseases, especially

cancer, suicide and

injuries.

Acute respiratory infections, pneumonia and

influenza in children <5y

Traffic accidents

Suicide

Cervical cancer

Breast cancer

Lung cancer

Cerebrovascular disease

Heart disease

0 10 20 30 40

Standardized death rate per 100,000 population

EU13

EU15

European Region

Slovenia

Diseases that represent the highest burden

of premature mortality in Slovenia

Source: WHO Europe: Mortality indicator database.

Standardized premature

mortality (age 0–64 years)

due to selected diseases,

2010

The mortality rate from cancer is high,

and lung cancer is in the lead

EU15

SI

EU13

WHO/Europe

1980 1990 2000 2010


IENL

HU

AT

HR

SKEE

CZ

FI

DE

130

150

170

190

210

230

250

270

290age-standardized death rate – number of deaths per 100.000

Mortality from diseases of the circulatory system

has been effectively reduced in Slovenia

EU15

SI

EU13

WHO/Europe

1980 1990 2000 2010

IE

NL

HU

ATHR

SK

EE

CZ

FIDE

100

200

300

400

500

600

700

800age-standardized death rate – number of deaths per 100.000


Slovenia has some of the best results in

reducing infant deaths

IE

NLHU

AT

HR

SK

EE

CZFI

EU15

SI

EU13

WHO/Europe

1980 1990 2000 2010

Infant deaths per 1000 live births

0

5

10

15

20

25

DE


The percentage of the population ≥ 65 years

in Slovenia is rising rapidly.

8

10

12

14

16

18

20

22

SK

IE

HU

AT

EE

FINL

CZ

EU15

SI

EU13

WHO/Europe

DE

HR

1980 1990 2000 2010

% of population aged 65+ years


Investing in health pays off

Photos: Malin Bring

Health is an investment - not an expense:

we should invest more in health.

Health is a political choice.

64th session of the Regional Committee

for Europe, Denmark

European countries are strengthening their health

policies

.all answers (n=31 and 36 for 2010 and 2013, respectively)

0% 10% 20% 30% 40% 50% 60% 70%

No and not planned for the future

No, but planned for the future

Yes, another strategy

Yes, comprehensive health policy

National health policy is aligned with H2020All answers (n=31 and 36 for 2010 and 2013, respectively)

2013

2010

Yes, comprehensive health

policy


0% 10% 20% 30% 40% 50% 60% 70%

No and not planned for the future

No, but planned for the future


Yes, comprehensive health policy

National health policy is aligned with H2020All answers (n=31 and 36 for 2010 and 2013, respectively)

2013

2010

2013

2010

Health 2020: the right political choices for health

Increase

healthy life

expectancy

.

Enhance

well-

being

Reduce

inequity

Reduce

premature

mortality

Support

upstream

approaches to

governance

and

determinants

of health and

universal

health

coverage

Establish

national

targets in

health

policies, and

monitor

Transforming our world: the

2030 agenda for sustainable

development

Global goals for sustainable development

Health targets and health as a target in other goals

Slovenia’s health system:

review

Slovenia’s health system – a collaborative

effort

Five technical assistance

work packages

Generating evidence to

support process in Slovenia

Collaboration between WHO, the European

Observatory and more than 50

Slovene experts

Generating evidence

Five work packages covering a range of health system areas:

1. New, fully updated “Health systems in transition” profile

for Slovenia

2. Health system expenditure

3. Health system funding

4. Purchasing and payment

5. Optimizing service delivery

Benefits of a health system review

• Focus on the performance of the health system

• Provide detailed evidence on key challenges

• Identify areas amenable to reform

• Ensure consistency with Slovenia’s health

system values: sustainability, efficiency, equity

and quality

Health financing policy objectives and

performance

Financial protection

• Does use of health services cause financial hardship?

Equity in financing

• Who bears the financial burden of health services?

Adequate funding levels

Stable revenue flows

Administrative efficiency

Health financing policy objectives and

performance

Enhancing health system efficiency

• More efficient use of health resources is a pillar of

successful health system reform.

• Purchasing and payment functions must be well

designed and implemented.

• Health system review provides evidence on:

- the benefits of a health technology assessment

- strategic purchasing of goods and services

- equitable payment systems for health providers

Some indicators already show excellent

efficiency

IE

NL

HU

AT

HR

SK

EE

CZ

FI

DE


EU15

SI

EU13

WHO/Europe

Average length of stay in hospital – number of days

6

10

14

18

1980 1990 2000 2010

Admissions for inpatient care could be

reduced

IE

NL

HU

AT

HR

SKEE

CZFI

DE


EU15

SI

EU13

WHO/Europe

In-patient care admissions per 100

9

12

15

18

21

24

27

30

1980 1990 2000 2010

Outpatient contacts

NL

HU

AT

HR

SK

EE

CZ

FI

DE

3

5

7

9

11

13

15

EU15

SI

EU13

WHO/Europe

Outpatient contacts per person per year


1980 1990 2000 2010

Density of doctors

IE

NLHU

AT

HR

SK EE

CZ

FI

1980 1990 2000 2010

Source: European database on human and technical resources for health.

200

250

300

350

400

450

500

EU15

SI

EU13

WHO/Europe

DE

Physicians per 100000

Density of nurses

IE

NL

HU

AT

HR

SKEE

CZ

FI

DE

1990 2000 2010

EU15

SI

EU13

WHO/Europe

Nurses (PP) per 100000

400

500

600

700

800

900

1000

1100

1200

1300

1400

European database on human and technical resources for health.

Ensuring effective service delivery

The health system review explores opportunities to

optimize the delivery of health services, including:

- building on model family medical practices to meet the

needs of people with chronic and multiple conditions

- supporting coordination and decision-making between

levels of care

- moving care out of hospitals when appropriate

- strengthening information technology

- model practices = referenčne ambulante

Evidence-based policy-making

The health system review highlights Slovenia’s commitment to evidence-based policy-making.

A basis for further discussion and consensus-building on priorities for health system reform

Continued support from WHO

Refugee and migrant health

Refugee and migrant health, a challenge

for the WHO European Region

1 out of 12 residents is a migrant

77 million migrants are living in the WHO European Region, which

represent 8% of its population.

Ensuring adequate standards of care for

refugees and migrants is essential:

For population health.

For the protection and promotion of

human rights of refugees, migrants and

the resident population.

This is aligned with the fundamental

values of Health 2020, such as health

as a human right, solidarity and

protection of the vulnerable.

Almost 600,000 refugees and migrants have crossed the

Mediterranean in 2015 so far.

Increase of arrivals in Slovenia, with peaks of over

10,000 migrants entering on daily basis.

Demystifying refugee and migrant health

There is no systematic

association between

migration and the

importation of infectious

diseases.

The public health aspects of migration are influenced by policies and interventions run by stakeholders outside the health sector, which do not always take into account the health implications of

their actions.

Ministry

of Interior

Ministry

of Labour

Ministry of

Social

Affairs

Ministry of

Foreign

Affairs

Ministry of

EducationMinistry of

Health

Refugee and migrant health,

a multisectoral agenda

Adapting to diversity: towards migrant-

sensitive health systems

Refugees/migrants = heterogeneous group

need to respond to diverse health

needs:

Sexual reproductive health and

rights

Mother and child health

Diabetes

Cardiovascular diseases

Mental health

Emergency care and protection

Protection against vaccine-

preventable diseases

2015 Goal: achieve zero human-to-human Ebola transmission

• The outbreak is not over: sporadic cases still reported in Guinea:

3 new confirmed cases reported in the week of 18 October.

• Robust surveillance remains essential..

• Vaccination trial continuing in Guinea; positive outcome, may play

a key role in ending the outbreak.

2016 Goal: sustain a resilient zero by rapidly detecting & stopping

new emergences

Ebola situation as of 21 October 2015

A unified WHO programme for outbreaks and emergencies

Priority to core capacities of the International Health Regulations

A global health emergency workforce

Improved functioning, transparency, effectiveness and efficiency of International Health Regulations

Accelerated research and development in epidemics or health emergencies

WHO Contingency Fund for Emergencies

Reform of WHO’s Work in Outbreaks and Emergencies

with Health and Humanitarian Consequences

Overseen by WHO Director General, supported by:

– An Advisory Group on Reform of WHO’s Work in Outbreaks and

Emergencies with Health and Humanitarian consequences

• 19 high-level experts in large-scale emergency response, disaster preparedness, disease

outbreak control and crisis coordination. Chaired by UNSG SE on Ebola, David Nabarro. .

– A Project Team at WHO

Fed by other processes such as:

– An IHR Review Committee on the Role of the IHR(2005) in the Ebola

Outbreak and Response

• 16 experts from the IHR Roster of Experts. Chaired by Pr. Didier Houssin

Reform of WHO’s Work in Outbreaks and Emergencies

with Health and Humanitarian Consequences

health 2020 and health system strengthening

Health & Medicine