Foreign experience. Health for all in the 21st century: challenges to the global strategy of the World Health Organization (WHO) Reducing the burden of disease
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The Health 2020 policy framework includes four priority areas for strategic action:
Social inequalities account for a large proportion of the disease burden in the European Region. The difference between countries in the Region with the lowest and highest life expectancy at birth is 16 years, and there are also differences between the life expectancies of men and women. In terms of maternal mortality, the countries with the lowest and highest rates differ by 42 times. This distribution of health and life expectancy across the Region suggests that there are significant, persistent and avoidable differences in the ability to be healthy and in the risk of illness and premature death. Social determinants underlie many of these differences. Unfortunately, social inequalities in health within and between countries continue to persist and, in most cases, are increasing. Extreme health inequalities also exist within countries. These inequalities are also driven by people's health behaviours, including smoking and drinking, diet and physical activity levels, and mental health conditions. With the adoption of Health 2020, countries are making a strong commitment to eliminating this completely unacceptable state of affairs in the health sector and in other areas of life. Many of these inequities can be addressed by addressing the social determinants of health.
The Health 2020 policy framework reaffirms WHO and Member States' commitment to universal health coverage, including access to high-quality, affordable health services and medicines. |
Maintaining long-term resilience to the negative impacts of financial cycles, containing supply-driven price increases and combating waste of resources is critical. Health technology assessment and quality assurance mechanisms are critical to health system transparency and accountability and are an integral part of a culture of patient safety. In 2012, the WHO Regional Committee for Europe adopted two versions of Health 2020. Both of these options are presented in this publication. A shortened version of the framework, aimed at European policy-makers, outlines the core values and principles of Health 2020 and provides key policy recommendations for action for the health and well-being of populations. The extended version of the policy and strategy framework contains more regarding evidence and action.
This policy has two strategic objectives, based on the principles of social justice, gender equality and human rights, and improved governance for health. The policy is intended to be a tool for promoting people's health and well-being and improving health equity, taking into account the specific context of each country and its political and organizational circumstances. It is a flexible, "living" guide to policy and strategy.
Achieving such goals requires political and scientific efforts in equal measure, and Health 2020 therefore places great emphasis on political commitment, expert expertise and civil society participation. Focused on finding “solutions”, this framework offers policy options that are both achievable and practical, yet flexible and can be successfully implemented in the changing context of any country.
INTRODUCTION
HEALTH 2020: A EUROPEAN POLICY FRAMEWORK TO SUPPORT GOVERNMENTAL AND SOCIETY ACTION FOR HEALTH AND WELLBEING
Preface
Health is the most important social resource
A strong value basis: achieving the highest possible level of health
A strong social and economic case for improving people's health
Strategic objectives of Health 2020: improving equity and governance for health
Improving health for all and reducing health inequalities
Improving leadership and participatory governance for health
Working together on shared strategic health priorities
Priority area 1. Investing in health at all stages of human life and empowering citizens
Priority area 2: Addressing Europe's most pressing health challenges: non-communicable and infectious diseases
Priority area 3: Strengthening people-centred health systems, public health capacity, and emergency preparedness, surveillance and response
Priority area 4: Strengthening local communities and creating a supportive environment
Working together: increasing total contribution through partnerships
Health 2020 - common goals and shared responsibility
HEALTH 2020: POLICY FRAMEWORK AND STRATEGY
Preface
Health 2020 - introduction
Part 1: Health 2020: reinvigorating health and well-being - the landscape and drivers
Ensuring broad coverage: why health matters across society and across government
Values underpinning Health 2020
Emerging drivers, demographics and epidemiology, and the social, technical and economic arguments for action
Part 2: Health 2020: applying evidence-based policies that deliver results and key stakeholders
Introduction
Targets
Addressing interacting determinants of health
Improving health for all and reducing health inequalities
Reliance on facts - an integrated approach that involves the search for new knowledge
Integrating new thinking based on advances in social and behavioral sciences and strategic social marketing
Governance for health in the 21st century
Working together to address shared health priorities
Investing in health at all stages of human life and empowering citizens
Taking action to reduce the burden of major diseases in Europe
Strengthening people-centred health systems, developing public health capacity, and improving preparedness and surveillance and emergency response
Public Health Security, International Health Regulations, Public Health Emergency Preparedness and Response
Ensuring strong communities and creating supportive environments for health
Part 3. Health 2020: improving implementation efficiency - requirements, approaches and continuous learning
Introduction
Making it happen: The challenges facing policymakers
Leadership, including strengthening the role of health ministers and the health sector
Design, implementation and evaluation of national and subnational programs, strategies and plans using input from various sectors
Increasing total contribution through partnerships for health
Formation of responsibility of the entire state and society for work on health protection
Monitoring, evaluation and priority areas scientific research in public health
Health protection - at the crossroads of the challenges of the 21st century
The active role that WHO has to play
A look into the future
Bibliography
Application. Glossary of key concepts and terms used in Health 2020: working definitions and explanatory comments
The “Health for All” strategy once again confirms the inalienable human right to health, the responsibility of the individual and the entire society for the real provision of this right, the systematic development of healthcare on a national and departmental level, the development of cooperation in the formation of a global healthcare system, as well as monitoring progress towards this long-term goal.
Significant changes in the twentieth century occurred in such important areas as medical science and health care, medical law and ethical traditions.
In medical science, the twentieth century is associated with a deepening understanding of the essence of health and disease, advances in general biology, microbiology, virology, immunology, the study of nervous and endocrine regulation, heredity and genetics; with the spread of the achievements of the scientific and technological revolution to biology and medicine. Scientific and technological revolution has led to the re-equipment of medical science and practice with fundamentally new methods of studying, diagnosing and treating diseases. Progress was especially striking in the methodology for studying all biomedical problems.
In medical practice, fundamentally new methods of prevention, diagnosis and treatment of many diseases have appeared, enormous achievements have been achieved in the fight against epidemics and infectious diseases, scientists and practitioners have achieved significant success in surgery, oncology, and cardiology.
In the organization of health care, the main results of the twentieth century were:
Recognition of health as a social human right;
Awareness of the social system of healthcare and its multi-scale problems;
Cardinal reforms in the management and self-government of this system;
Development of international cooperation in this area.
Currently global community poses new challenges:
Sustainable development of society in harmony with nature;
Formation of a humanistic paradigm;
Protecting and ensuring human rights and peoples around the world;
Achievements in the 21st century "Health for all".
The policy of achieving health for all in the 21st century represents a forward-looking vision of this problem. This policy sets out global priorities for the first two decades of the 21st century. In accordance with them, objectives are formulated, which, on the one hand, define specific goals, and on the other, the conditions for achieving and maintaining the highest possible level of health. Thus, Health for All is not a one-time goal. This is an ideology, a scientific justification for those practical actions that should and can lead to a consistent improvement in people's health.
The goal of “Health for All” was confirmed by the 51st World Health Assembly, which formed the corresponding report (A51/5) as the basis for the development of future policies of WHO and countries.
The World Health Organization has formulated 10 main goals (global objectives) within the framework of the “Health for All in the 21st Century” program:
Strengthening health equity;
Improving opportunities for survival and quality of life;
Reversing global trends in the five major pandemics (communicable diseases, non-communicable diseases, injuries and violence, alcoholism and drug addiction, tobacco smoking);
Complete or partial elimination of certain diseases (poliomyelitis, etc.);
Improving access to water, sanitation, food and housing;
Promoting healthy and counteracting unhealthy lifestyles;
Improving access to comprehensive, quality health care;
Supporting health research;
Implementation of global and national health information and epidemiological surveillance systems;
Development, implementation and monitoring of policies to achieve "Health for All" in countries.
Ultimately, the idea and strategy of “Health for All” once again confirms the inalienable human right to health, the responsibility of the individual and the entire society for the real provision of this right, the systemic development of healthcare on a national and departmental level, the development of cooperation in the formation of a global healthcare system , as well as monitoring progress towards this long-term goal.
The global policy to achieve health for all for the twenty-first century must be implemented through appropriate regional and national strategies. For our country, which gravitates towards the European Region, it is the European experience in developing and implementing a unified strategy for “achieving health for all in the European Region” that is of the greatest interest.
Since its introduction in 1980, the health-for-all policy has provided a comprehensive framework for action to improve health in the European Region and has had a very significant impact on health action. The response to the demands of the 21st century, formulated in the World Health Declaration, is the adoption of a new European strategy for achieving health for all - “Health 21”. Reviewing and refining the previous 38 regional targets for health for all in the light of past experience and new targets, Health 21 sets and defines 21 targets for the 21st century. They are not a rigid list of prescriptions, but together they define the essence of the regional strategy. This document reflects issues related to global values, goals and strategies for Health for All, current health issues in the Region, as well as political and socio-economic changes and opportunities presented by them. Health 21 provides decision-makers at all levels with an ethical and scientific basis for assessing the health impact of their policies. Thus, health requirements are formulated for any social activity of any sectors and layers of society.
The key goal of Health21 in the European Region is for all people to achieve their full “health potential”.
It can be achieved by:
Ensuring equality in health care through solidarity of action;
Strengthening and protecting people's health throughout their lives;
Reduce the prevalence and suffering caused by major diseases, injuries and disabilities.
The specification of these goals is contained in the tasks aimed at:
Achieving solidarity for health among European countries(task 1);
Achieving equality in health care within European countries (task 2);
Ensuring a healthy start in life (objective 3);
Strengthening the health of young people (task 4);
Maintaining health in old age (task 5).
This means it should be:
The mental health situation has been improved (task 6);
The prevalence of infectious diseases has been reduced (task 7);
The prevalence of non-communicable diseases has been reduced (target 8);
Injuries resulting from acts of violence and accidents have been reduced (task 9).
To achieve these goals, strategies have been developed in the following areas:
a) Taking into account the multifactorial nature of health, strategies that ensure positive changes in this regard should contribute to the formation of physical, economic, social and cultural “environmental” conditions for the population that are favorable to health, i.e., be multisectoral.
Creating a healthy and safe physical environment (task 10);
Ensuring healthier lifestyles (target 11);
Reducing the harm caused by alcohol, addictive drugs and tobacco (target 12);
Ensuring healthier environments where people live, work and play (target 13);
Strengthening the responsibility and accountability of various sectors for activities that impact health (target 14).
b) Given the role of health care in achieving health and the rising cost of health services worldwide, the health sector's focus on achieving outcomes must change.
This strategy can be implemented by:
Formation of an integrated health sector, meaning strengthening the interaction of various structures, with an emphasis on the role of an integrated primary health care system (task 15)
Improving governance and ensuring the quality of health care (target 16);
Health services financing and resource allocation (target 17);
Development of human resources for health care (task 18).
c) Change management and regulation for health must be ensured, taking into account multisectoral participation and responsibility for achieving the goals of Health for All.
The strategy can be implemented by:
Conducting research and providing information support on health issues (task 19);
Involvement of partners in action for health at all levels: families, schools, workplaces, local communities, region and country as a whole (target 20);
Adopt and implement policies and strategies to achieve health for all (target 21).
Challenges facing Russia
In order to determine the directions of a possible national strategy “Health for all Russians,” we can consider our achievements in comparison with the three main goals recommended by WHO as universal guidelines for achieving health for all. These tasks can be divided into three categories:
1. The first category includes two objectives that address the fundamental orientation of the health-for-all policy: achieving equity and equity in health and improving health and quality of life.
(The selection of these groups as requiring special attention was influenced by the fact that in each of these groups people are relatively vulnerable in terms of their health and social status; maintaining health in these groups has its own unique characteristics and needs, finally, it is these groups in benefits are maximized by establishing effective cross-sectoral links).
3. The third category includes tasks that address specific health problems: cancer and cardiovascular diseases, other chronic diseases, infectious diseases, accidents, mental health problems and suicide.
It is advisable to begin the analysis of the situation in the Russian Federation with the third category of tasks, since the tasks of the second and especially the first category are their unique generalization for specific groups of the population (second category) and for the entire population (first category).
Improved mental health
2020 should see improvements in people's psychosocial well-being and the availability of comprehensive services to help people with mental health problems.
In Russia in the second half of the 90s, about 6 million people (42 out of every 1000 population) used the services of psychiatrists. During the year, an average of 7 people are newly diagnosed with a mental disorder, and 8 out of every 1,000 people are hospitalized for a mental illness. For the first time, 1 person out of 1000 people is recognized as disabled due to mental illness. The population of people using psychiatric care has expanded significantly, but at the same time it has become significantly easier. The nosological appearance of the contingent has undergone significant changes. The number of patients with psychosis increased by 1.5 times, non-psychotic disorders - by 3.1 times, mental retardation - by 3.8 times, and alcoholism - by 8.7 times. Thus, if in 1965 the nosological portrait of the average mentally ill person was determined by severe psychotic disorders, then 30 years later it was alcoholism.
A comparative analysis of the registered levels of the population seeking psychiatric help indicates a significant underreporting (by 5 times) of mental disorders in the population. Thus, the recorded prevalence of mental disorders in Russia provides an idea of only the tip of the iceberg, describing only the most general contours of the problem of mental health of the population. The “price” of poor mental health is very high. A tenth of the population's life expectancy consists of losses associated with mental illness, including - 2 years - due to premature death and about 5 years - due to deterioration in the quality of life.
In Russia, there are two large groups of territories that are fundamentally different in terms of the state and trends of mental health, the resulting socio-demographic damage and the nature of its social determination, and, consequently, ways of reduction:
the first group includes mainly regions of the European part of Russia;
the second - the territories of the Volga region, regions and territories of the North Caucasus, the Urals and Western Siberia.
In terms of the mental health of the population, the situation is more favorable in the European part of Russia. Among the factors determining the situation with mental health, a more prosperous socio-economic background, characterized by the level and differentiation of income, the level of unemployment and tension in the labor market, comes first. The essence of this relative well-being is that economic motives have not become the dominant factors in the incapacity and disability of mentally ill people in the territories of the European part of Russia. Thus, mental health is increasingly becoming a socio-economic phenomenon, the scale of which is decisively determined by economic disadvantage, and itself, in turn, generates disadvantage due to the increase in the number of people in need of social protection and support.
Thus, the duration and quality of life of the population in connection with the state of its mental health directly depends on the choice of strategies for reforming health services, and, more broadly, on strategies for reforming society, which determine “the price of a person, his life and health.”
Reducing the prevalence of infectious diseases
By 2020, there should be a significant reduction in the prevalence of infectious diseases through systematic programs for partial and complete elimination, as well as control of infectious diseases of public health concern
The problem of infectious diseases is also acute for Russia. It is known that during periods of acute social cataclysms, the incidence of so-called social diseases (tuberculosis, syphilis, etc.) sharply increases. The incidence of infectious diseases in the Russian population varies greatly due to the intensification or attenuation of the influenza epidemic. A particular problem in Russia (as in many other countries) is AIDS. In recent years, the number of outbreaks of acute intestinal infections and waterborne hepatitis A has increased. The greatest epidemiological danger is posed by disturbances in the centralized water supply system, which are responsible for up to 80% of outbreaks of infectious diseases of water origin. The forecast of epidemiologists about the increase in the incidence of hemorrhagic fever with renal syndrome (HFRS) in the territories of its natural foci has come true. For a number of regions of the forest zone, the problem of tick-borne spring-summer encephalitis is relevant. Over the past years, the epidemiological situation regarding the incidence of malaria has been deteriorating. The unfavorable situation with the prevalence of helminthiases in the population, especially diphyllobothriasis and opisthorchiasis, does not change.
Thus, in recent years, the epidemiological situation in Russia has sharply worsened; a comparison of Russia with other countries in terms of mortality from infectious diseases indicates a more complex sanitary and epidemiological situation in our country.
Reducing the prevalence of noncommunicable diseases
By 2020, morbidity, disability and premature mortality associated with major chronic diseases should be reduced. The main chronic diseases that determine the increased mortality of the Russian population are diseases of the circulatory system. The mortality rate from this class of diseases is largely determined by both factors affecting the population as a whole (natural-climatic, environmental and socio-economic), as well as by the established habits of the population, cultural and ethnic traditions and way of life.
Reducing injuries from violence and accidents
By 2020, there should be a significant and sustained reduction in the number of injuries, disabilities and deaths due to accidents and violence in the Region
Injuries are the third leading cause of death and the first among the causes determining the loss of labor potential of the country's population. The number of crimes, terrorist acts, attacks on the life and health of citizens with the use of firearms and explosive devices is growing. More than 500 road accidents are recorded every day, in which more than 100 people die and more than 600 are injured. The number of deaths in road accidents in just three days exceeds the number of deaths in aviation, maritime and maritime accidents throughout the year. river transport generally. Up to 60% of all deaths are people aged 16 to 40 years. The number of child deaths increases by 15% annually. More than 80% of affected children become disabled. Another one characteristic, inherent in this class of causes of death, is the extremely high excess mortality rate of men. Data for Russia indicate the relevance of these observations for our country, because the mortality rate of men here is 3-4 times higher than that of women.
Each cause of death has its own “sphere of greatest influence” on the age scale. For accidents, poisonings and injuries, these are people of working age. It is at this age that the difference in mortality between the Russian population and the population of developed countries is maximum. Thus, the specificity of mortality from injuries and poisonings lies in its almost complete dependence on social factors.
Healthy start in life
By 2020, all newborns, toddlers and school-age children in the Region should be healthier, giving them a healthier start in life
Thus, congenital anomalies in children, approximately a quarter is due to genetic abnormalities and environmental conditions, important factor mother's abuse of alcohol and drugs. After the first month of life, the main cause of death becomes sudden death syndrome associated with smoking, drug addiction, adolescence of postpartum women, infections in the second half of pregnancy, the burden of this pathology in the mother's medical history increases potential danger HIV infection and drug addiction in newborns.
Youth health
By 2020, the region's youth should be healthier and better prepared to take on their responsibilities in society
The structure of morbidity among adolescents and young men (aged 15-24 years) in Russia is dominated by diseases of the respiratory system, nervous system and sensory organs, and digestion, which total almost 62%. According to epidemiological studies, no more than 14% of high school students are healthy. Up to 60% of school graduates suffer from at least one chronic disease. In high school, the prevalence of visual impairment and digestive diseases increases by up to 15%. The main causes of death in this group are accidents, murders and suicides. Injuries are largely caused by road traffic accidents and are often associated with intoxication. Murders are also committed in more than half of cases while intoxicated.
Another group of problems is associated with the formation of a lifestyle that will affect later years. This group includes alcoholism, drug addiction, and early sexual intercourse. At the same time, the number of births at 15-17 years of age is increasing. Up to half of pregnancies have complications. Young mothers experience psycho-emotional difficulties, often do not complete their education, are more likely to become unemployed, are more likely to give birth to premature children and do not have parenting skills. The health of young women is deteriorating. Disorders of menstrual function are noted by 1206.2 teenage girls per 100 thousand of this group, 599.2 - inflammatory diseases of the tubes and ovaries. Up to 23% of young women (18-23 years old) suffer from chronic gynecological diseases. Early sexual activity contributes to the spread of sexually transmitted diseases.
Thus, in adolescence, attitudes towards nutrition, physical exercise, smoking are formed, lifestyle, sexual behavior are formed, and at the same time risk factors for chronic diseases of older age appear. The structure of health threats is changing dramatically, including alcohol and drugs, physical inactivity, crime, gang violence and unwanted pregnancy.
Maintaining health in old age
By 2020, people over 65 years of age should be able to achieve their full health potential and play an active social role in society. Elderly and senile people (60 years and older) in Russia are socially the most vulnerable and disadvantaged. A negative trend in Russia is the increase in the number of pensioners receiving a disability pension. The increase in disability growth rates may be due to a combination various factors. It should be noted that in the last five years, despite the deep socio-economic crisis, a number of legislative decisions aimed at social support for people with disabilities were adopted. An increase in pension provision and an expansion of benefits for various categories makes disability more “attractive” for persons with persistent health problems and significant limitations in their ability to live. Thus, the increase in the growth rate of disability over the last five years may be a largely stimulated process.
Half of all primary disability of the adult population is caused by diseases of the circulatory system, another 10% - by malignant neoplasms, 4-6% of new disabled people are added annually by diseases of the nervous system, injuries, mental disorders, respiratory diseases and diseases musculoskeletal system The main cause of disability in people of retirement age is diseases of the circulatory system, accounting for about 75% of cases.
In Russia, there is a significant regional variation in life expectancy in a state of disability: from 1.4 years in the Sakhalin region to 6.4 years in Belgorod region, i.e., differs by 4.5 times. The current risk of disability in Russia reduces the hypothetical life expectancy of the population by 7.5 years. Another 3.7 years are losses due to deterioration in the quality of life. Thus, the risk of disability turns out to be twice as significant as a factor in preserving life itself than as a factor in maintaining activity throughout life.
If we consider disability as an indicator of population health, then it would be fair to expect that the level of disability, and, consequently, life expectancy in a state of disability, is higher in areas characterized by high mortality and, accordingly, low life expectancy of the population. However, the situation in Russia is not so clear. Moreover, the opposite pattern is quite clearly visible. The higher the life expectancy, the greater the proportion of it will be lived in a state of disability, and the less - in healthy condition. And vice versa. Thus, for Russian territories the following ratio is true: the higher the mortality rate, the lower the disability. In Russia, people die before they become disabled. Within the logic of a civilized community, these ratios are clearly negative characteristics of health.
Thus, the key problem of the elderly is their functional dependence on outside help and the closely related issues of physical activity. The “attractiveness” of disability in Russia is growing as the standard of living of the population deteriorates and tension in the labor market increases, as a result of which the disability pension and the benefits accompanying this status become the only source of livelihood for previously socially adapted persons with persistent health problems.
Solidarity for health in the European Region
By 2020, the current health gap between Member States of the European Region should be reduced by at least one third. This goal is a key pillar of the Health for All strategy. By the mid-60s, Russia had reached life expectancy levels comparable to those of major developed countries. With regard to women, this thesis is fully true; the life expectancy of men was somewhat behind the average European level (the gap was 2-5 years). Over the next two decades, the mortality situation in Russia can be characterized by the term “stagnation” with an increasing tendency towards regression. More at a fast pace The situation worsened for men, whose initial positions regarding “European mortality” were already worse. Against the backdrop of positive dynamics in life expectancy in European countries, Russia's lag in terms of life expectancy has noticeably increased. In the 70s, the gap was 2.5-3.5 years for women and 5-9 years for men. In the 80s it increased to 3-5 years for women and 9-11 years for men.
In the mid-80s, the evolutionary trend of mortality in Russia was interrupted. Partly as a result of the anti-alcohol campaign in Russia, the maximum value of life expectancy was achieved (64.9 years for men in 1986 and 74.6 years for women in 1988). From this time until 1995, the average life expectancy decreased steadily. In 1993, the decline in this indicator can be called catastrophic: in one year, the average life expectancy of men decreased by 3.1 years, of women - by almost 2 years. In general, since the recorded maximum of this indicator, average life expectancy has decreased by 7.3 years for men and by 5.5 years for women. Data from 1995 showed no further decline in life expectancy. 1996 was even marked by a slight increase (by 1.6 years for men and 0.4 years for women). These are certainly positive signs, especially against the backdrop of the previous catastrophic dynamics. This happened partly because we have reached the “natural limits” of life expectancy, determined by the existing age structure of the population and, accordingly, by the structure of causes of death. At the same time, compared to the previous fall, the situation remains fundamentally the same. As a result of the 8-year (1986-1994) decline in life expectancy, the gap in life expectancy between Russia and European countries increased to 7-10 years for women and 14-17 years for men. Behind these quantitative assessments there are profound qualitative changes. We can assume that we have a life expectancy that is adequate to our standard of living.
According to the results of research by the Institute of Sociology of the Russian Academy of Sciences, in the system of personal values, after “work” and “family,” “health” in the minds of Russian citizens occupies a high third place in importance. However, at the same time, health does not have an independent value, but is considered as a means of achieving other goals and needs of the individual, for example, higher income, an apartment, etc. This behavior indicates that people have no choice in the means of achieving the necessary benefits of life, and health in such conditions becomes a kind of bargaining chip, a subject of rather harsh exploitation, especially in today’s economic and social reality. Thus, the problem of improving the health of the population is, first of all, the problem of changing the value of health, both in the value system of the entire society and in the value system of the individual.
Thus, the gap in life expectancy between Russia and European countries has increased for women to 7-10 years and 14-17 years for men, only the transformation of “health” from a means into an end, i.e. acquiring the status of a fundamental value creates the necessary prerequisites for the development, adoption and practical implementation of an adequate policy to protect public health.
Health equity
By 2020, the health gap between socioeconomic groups within countries should be reduced by at least one quarter in all Member States by significantly improving the health of underserved populations. This goal is also a key pillar of the Health for All strategy. Drawing conclusions about the mortality situation in Russia based on average data for the Russian Federation is only possible as a first approximation, since data from more than 80 constituent entities of the Russian Federation demonstrate extreme diversity in the achieved levels of life expectancy. The variation in average life expectancy for men in different regions is more than 16 years, for women - 17 years. These differences are huge. They even exceed those that separate Russia from the developed countries of the world. Thus, not only does Russia as a whole live in a different historical dimension relative to Europe (in terms of health and mortality), but in Russia itself there are parallel enclaves belonging to qualitatively different types of medical and demographic situation.
It is characteristic that even territories with maximum levels of life expectancy are extremely far from achieving the central goal of achieving “health for all,” according to which life expectancy at birth in the countries of the region should be at least 75 years for both sexes. It is important to emphasize that the life expectancy level of 75 years is formulated by WHO as achievable goal for the entire European Region, and not just for a group of developed countries. In Russia, only in three republics of the North Caucasus, and only for the female population, life expectancy has reached this level, and if for women in life expectancy the lag behind the European benchmark is about 10 years, then for men it is close to 20-25 years.
Several key features can be identified that characterize qualitatively heterogeneous types of regional mortality in Russia.
The first is the age specificity of mortality. The main and practically the only factor in the heterogeneity of Russian territories in terms of life expectancy is the significant differences across the territories in mortality in working age, and mainly in young ages. The risk of death of men aged 15-44 years varies across Russian territories by more than 4 times, and the risk of death of women by more than 6 times. Differences in the magnitude of this risk at ages 45-64 decrease by more than 1.5 times. The variation in the risk of death in the interval from 0 years to 1 year is 24.3%, and the variation in the risk of death before the age of 15 years is 36.0%. In principle, this corresponds to the usual idea that in relation to infant mortality Russian territories relatively homogeneous, which cannot be said about mortality in children and working ages.
The second characteristic feature is the ratio of life expectancy of men and women. Currently, only in a few countries (Nigeria, Upper Volta, Liberia, etc.) men live longer on average than women, and some excess of women's life expectancy over men is characteristic of almost all countries. Data on the magnitude and differences in life expectancy across different countries of the world support the assertion that there is a direct and positive relationship between the level of life expectancy and the size of the gap in life expectancy between men and women. Every 10 years of increase in life expectancy for women corresponds to 9 years of increase in life expectancy for men, i.e. increase the mentioned gap by 1 year. These differences are interpreted to mean that the progress of civilization obviously gives women greater advantages than men. Russian data show a completely different pattern: the increase in life expectancy for women is slower than for men (for every 10 years of increase in life expectancy for women, there is 16 years of increase in life expectancy for men). The interpretation of the resulting pattern will also be completely different: if life expectancy in Russia decreases, the gap in life expectancy between men and women will increase - a trend that has no analogues in Peaceful time in no country in the world.
Conclusion
The presented data indicate that all the tasks to achieve health for all, formulated in the WHO European Strategy as certain universal guidelines, are relevant for Russia. Moreover, in many areas the dynamics of health indicators in Russia are opposite to global trends. Thus, the situation objectively requires the adoption and implementation of reasonable measures to improve the health of the population.
When planning such a large-scale work, it is important to formulate the basic principles and conditions on compliance with which its effectiveness will largely depend. One of these conditions is the compliance of the ideological principles of the “Health for All” concept with the methodological and organizational conditions of its development, implementation and monitoring. The idea of an intersectoral approach to population health problems requires the creation of an adequate organizational structure- possibly in the form of the National Institute of Health, the main tasks of which may be: development of evidence-based policies in the field of strengthening and protecting public health, taking into account the regional specifics of the situation; development, in accordance with WHO recommendations, of a national program “Health for all Russians”, combining the efforts of various industries and departments according to health criteria; creation of a population health monitoring system; objective information governing bodies countries (President, Government, Parliament, Security Council, Heads of administrations of the constituent entities of the Russian Federation) about the state, trends and forecasts of public health, about the necessary measures to improve the situation. A national health agenda is urgently needed today. It should be based on a clear concept of protecting people's health and a unified strategy.
The publication was prepared based on the materials of an analytical report on the problems of the WHO global strategy to achieve health for all in the 21st century (Venediktov D.D., Ivanova A.E., Maksimov B.P.).
The right to health remains far from reality, however, a certain historical logic emerged in the reforms of the world's health care systems, and their most important stages were 1918, 1948, 1971, 1978 and 2000. WHO and UNICEF began not only to expand technical assistance to developing countries, but also to play an increasingly noticeable informational and scientific coordinating role in ensuring the health and sanitary well-being of countries and peoples.
T. Tulchinsky et al. share the opinion that the “sanitary revolution”, improved housing conditions, nutrition and the spread of education made a huge contribution to the victory over mass diseases.
According to the testimony of the Dutch scientist B. Tobes , at the international level the term “right to health” is most often used. To prove the legality of use the term “right to health” She gives three reasons:
This term is the best in terms of compliance with international documents and agreements;
It is generally used more often than others at the international level;
It helps to understand that we are talking not only about health protection, but also about the right to a number of conditions without which health is impossible, such as access to clean drinking water and a healthy environmental situation
The phrase “right to health” is closest to the “right to the highest attainable standard of health” referred to in Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR). , the most famous treaty dealing with the right to health. The right to protection of health can be considered to coincide with the right to health. Like the latter, it can cover a wide range of problems. However, here too there can be confusion when referring to the word “protection”, which can easily be interpreted too narrowly.
Throughout its history, WHO has been an initiator of health policy reforms. In the 1970s, WHO developed two programs: “Health for all by the year 2000” and “Primary health care”.
In 1973, the World Health Organization came up with the idea of “primary health care (PHC)”, which was understood as “the zone of first contact between a person (family, community) and national health systems”, as their “integral part”, “main function” and “central link”.
In 1977, the Health for All program strategy was approved. It was stated that the fundamental social objective for WHO and its members over the coming decades should be for all the world's people to achieve a level of health that would enable them to lead socially and economically productive lives...” A year later, at the international conference on primary health Health, in Almaty (USSR), a declaration was adopted in which primary health care was considered “the key to achieving universal health by the year 2000.”
The WHO/UNICEF International Conference on Primary Health Care, with the participation of delegations from 134 countries and representatives of 67 international organizations, was held in Almaty (6-12 September 1978). It approved in its final documents the position that primary health care, including preventive programs, are a key element in achieving health and a healthy lifestyle.
As a result, the Alma-Ata Declaration (see Appendix 1) and 22 recommendations were adopted. They became a major turning point in the development and reform of the entire healthcare system in the world.
The most important task of governments, international organizations and the entire world community was proclaimed to achieve by the year 2000. all peoples of the world with a high level of health.
The declaration once again confirmed responsibility of states for the health of their citizens. Primary health care was considered as assistance “substantial, integral, available equally to individuals and entire families, available to everyone without exception, to the extent determined by the capabilities of a particular state.” Such health care should exist in all countries, although it may take different forms depending on political, economic, social and cultural circumstances.
The primary health care program addresses social health problems through promotional, preventive, curative and rehabilitative medical services and, for this reason, primary health care should be the basis of all health systems:
1) health is a fundamental human right and a global social challenge; 2) health is an integral part of the development of societies; 3) there are huge inequalities in people's health, which is a matter of common concern for all countries; 4) people have the right and obligation to participate on an individual and collective basis in the planning and implementation of medical and social services; 5) governments are responsible for the health of their people; 6) the world's resources should be better used to promote health.
The setting of this task marked review of the basic principles of health policy in WHO European Region.
This culminated in the adoption in 1984 of the regional health-for-all strategy and its 38 national targets. In this case, the main emphasis was placed on four of particular concern areas:
Lifestyle and health;
Risk factors affecting public health and the environment;
Reorientation of the healthcare system;
Mobilize political, managerial and technological support to bring about the necessary changes.
The “health for all” strategy is based on 6 principles:
1. ensuring equal opportunities to maintain and improve health
2. disease prevention;
3. broad cooperation between government organizations and public associations to address health and environmental issues; ,
4. participation of the entire population in solving the problems of achieving health for all;
5. orientation of the health care system towards providing adequate and accessible primary medical care;
6. establishing international cooperation to solve health problems that cross national borders.
The most correct and far-sighted conclusions from the Almaty conference were made by countries Western Europe, who seriously took up both the “Health for All by 2000” strategy and the criteria for organizing primary health care, clearly ahead of not only developing countries, but also the United States, as well as Russia and the CIS.
Unfortunately, the significance and relevance of the Alma-Ata Declaration and other decisions were not understood by the top leadership of the USSR:
1) the achievement of Soviet healthcare was taken for granted as evidence of this task supposedly already being resolved;
2) due to the arms race and increasing difficulties in the economy, the country's leadership simply could not find additional finances for the needs of the social sphere.
After the collapse of the USSR, the situation became a crisis and now to overcome it, it is necessary to literally have a nationwide awareness of the impending danger to the health of modern and future generations, “political will” and determination to get out of the abyss.
Taking into account the multifactorial nature of health, strategies that ensure positive changes in this regard should contribute to the formation of physical, economic, social and cultural “environmental” conditions for the population that are favorable to health, i.e., be multisectoral.
Change management and regulation for health must be ensured by taking into account multisectoral participation and responsibility for achieving the goals of Health for All. In this regard, we should once again return to the essence of the concept of human lifestyle (HOL). OZ depends mainly on those values, priorities, practical possibilities and difficulties that are an integral part Everyday life people and are formed as a result of repeated stereotypes of actions, forms of behavior, abilities and skills, views on ongoing changes in society and personal life. It was necessary to accept "Ottawa Charter for Health Promotion (Charter)" for consistency of opinion on health.
The Charter, firstly, expanded the content of the concept of “health promotion”, which is now defined as “creating the opportunity to control one’s health and improve it.” Secondly, it played a significant role in shaping the methodology of the “health for all” concept.
The Charter's methodology was distinguished by three main features:
The goal is to help people realize their full health potential;
They are encouraged to act in the interests of health protection;
The health sector is trying to take on mediation functions aimed at reconciling conflicting interests in society in order to support health development .
Of interest Charter methodology, which is based on five principles:
1) promotion of policies focused on public health;
2) formation of a favorable living environment;
3) support for public participation;
4) reorientation of medical care services;
5) advanced training of medical personnel.
It also included a number of aspects of health policy:
1) creation of health-oriented public policy;
2) creation of a favorable social environment;
3) strengthening action at the local level;
4) development of personal skills;
5) reorientation of existing medical services.
If all of the listed areas, principles and strategies for improving public health work together, then the main motto of healthcare - “Health for all” will take on real meaning.
Thus, The Health for All policy is based on three fundamental values: which are its ethical basis:
1) recognition of health as the most important human right;
2) equity in matters of health and its protection and effective solidarity of countries and population groups within countries in these matters;
3) participation in health care activities and a responsible attitude towards it by all layers and sectors of society.
Currently, the world community is putting forward new tasks: the sustainable development of society in harmony with nature, the formation of a humanistic paradigm, the protection and provision of human rights and peoples around the world, the achievement of “Health for All” in the 21st century.
The Jakarta Declaration identified the main priorities for promoting health in the 21st century. In the World Health Declaration adopted on May 16, 1998, the 51st World Health Assembly solemnly reaffirmed its commitment to humanistic principles. Now “the enjoyment of the highest attainable standard of health” is considered one of the fundamental rights of every person and in relation to health everyone has equal rights, equal duties and equal responsibilities.
In accordance with global priorities, on the one hand, goals and objectives were formulated for the first two decades of the 21st century. And, on the other hand, the necessary specific conditions for achieving and maintaining a higher level of health have been identified (see Appendix 2).
The response to the challenges of the 21st century, formulated in the World Health Declaration, is adoption of a new European strategy to achieve health for all – “Health 21”.
The key goal of Health21 in the European Region is for all people to achieve their full “health potential”.
For Russia, all the tasks to achieve health for all, formulated in the WHO European Strategy as certain universal guidelines, are relevant.
Health21 is based on the collective experience of WHO Member States. This experience clearly demonstrates that countries with very different socio-political, economic and cultural conditions can develop and implement policies to achieve health for all.
Yu.E. Abrosimova et al. believe that sustainable improvements in health can only be expected if targeted and coordinated intersectoral actions are organized (including socio-economic issues and safety, the state of the environment and the improvement of habitats, the development of transport and the quality of medical care, culture and education). This approach is consistent with the social model of health, the implementation of which involves the development and implementation of health-oriented interdepartmental plans. There is no doubt that this approach is broader than what the health sector can do, as meaningful agency involvement requires efforts at a higher political level. The implementation of these interdepartmental programs uses the approach of setting specific quantitative goals.
The social approach to healthcare has been known for a long time, since the end of the 14th century, but it is most holistically manifested as a scientific theory of public health in the already named WHO strategy “Health for All”, as well as in the “Healthy Cities” project, and in other WHO programs ( School of Health Promotion, Healthy Workplace and others).
The WHO health (social) strategy was continued in the document “WHO Global Strategy on Diet, Physical Activity and Health”. The overall goal of this strategy, in the context of “risk theory,” is to develop sustainable actions aimed at only two risk factors (RFs).
The strategy suggests that protecting and promoting health can be achieved by providing family, community, national and global guidance on unhealthy diets and physical inactivity. These actions together will lead to a reduction in morbidity and mortality rates. It fully complies with the principles of healthcare laid down in Almaty and develops them.
Thus, “Health for all” is not a single, one-time goal. This is an ideology, a scientific justification for those practical actions that should and can lead to a consistent improvement in people's health. For our country, which is gravitating towards the European Region, it is the European experience in developing and implementing a unified strategy to “achieve health for all in the European Region” that is of the greatest interest.
1. What scientific theories can be classified as general theories of public health and healthcare?
2. Three stages of general adaptation syndrome?
3. Causes of “distress”?
4. Name the main urban-ecological factors!
5. The rational grain of the theory of “diseases of civilization”?
6. Three options for the harmful (medical) impact of “civilization”?
7. What are risk factors or medical and environmental factors according to Yu.P. Lisitsyn?
8. Epidemiological aspects of RF?
9. Medical and ecological set of factors that determine morbidity?
10. The connection between human needs and the multiplicity of urban RFs?
11. What is the essence of the optimistic concept of “lifestyle (WL)” in healthcare?
12. What unites the concept of “lifestyle (WW)” and the theory of “diseases of civilization” and social maladjustment?
13. The concept of human behavior and lifestyle?
15. What strategy does the medical behavioral model primarily use?
16. Give arguments that reduce the impact of individual lifestyle on health!
17. What does the strategy of personal responsibility for your health state?
18. What do the numerous forms of so-called “self-destructive” behavior indicate?
19. Why do traditional medical, socially neutral recommendations represent yesterday’s science?
20. The concept of “healthy lifestyle (HLS)” according to Yu.P. Lisitsyn?
21. The main directions of activities to improve the “lifestyle (WW)” (according to R. G. Oganov)?
22. The main postulates of the classical theory of T. Malthus?
23. Arguments against F. Hayek’s “demographic alarmism”?
24. The main conclusions of the physicist S.P. Kapitsa on the demographic process in the world?
25. The role of the “sanitary revolution” in improving the health of the world population?
26. The Thirtieth World Health Assembly in May 1977 and the idea of “health for all”?
27. The four areas of the European regional strategy for health for all, adopted in 1984?
28. Six principles of the “health for all” strategy?
29. When, in the context of the WHO Ottawa Charter of 1986, does the fundamental health motto of “Health for All” take on real meaning?
30. Key goal of Health21 in the European Region?
Consultations held last year emphasized international role WHO in strengthening health systems in a changing world. In working to improve health systems that do not yet deliver adequate, equitable health services to all people, WHO faces many of the same challenges that countries face:
how to ensure that the program of this work is clear and specific;
how to create better functional links between programs, partners, donors, aid organizations and countries; And
how to provide the capacity to address current issues and identify future challenges.
The following four principles underpin WHO's response to this problem:
a single Program of Action with six building blocks;
health systems programs that focus on results;
a more effective role for WHO at country level;
WHO's role in the international health systems programme.
The main goal The Action Program is to promote a common understanding of what a health system is and what it means to strengthen health systems. It also provides a framework to support countries in scaling up health systems and services using a “diagonal” approach: collaborative, coordinated action to overcome barriers to achieve desired health outcomes and sustainable gains across the system. To be most effective, the process must be country-focused and based on the priorities set in comprehensive national health plans.
There is no single set of best practices that can be used to improve performance. The Four Fundamental Principles and the WHO Program of Action chart a course that must be given the highest international priority. Working with countries and international health partners, WHO will use its strengths to immediately strengthen health systems and services and save millions of lives.
"Health for everyone" is the World Health Organization's (WHO) global strategy for health development, adopted in 1980 by all 189 WHO member countries.
In 1998 it was adopted a new version strategy - "Health for all in the 21st century", the main goal of which is to achieve the highest possible level of health for all residents of the regions of the world.
One ongoing goal is for all people to achieve their full “health potential.”
Two main goals:
strengthening and protecting people's health throughout their lives;
reducing the prevalence and suffering caused by major diseases, injuries and disabilities.
Three fundamental values as the ethical basis of Health-21:
health as one of the most important human rights;
equity in health and health and effective solidarity between countries, groups and populations within countries and between both sexes;
health participation and ownership/accountability of individuals, groups, populations (communities) and institutions, organizations and sectors.
Four main action strategies have been selected to ensure scientific, economic, social and political sustainability as an ongoing prerequisite and driving factor in the implementation of the Health 21 goals:
Multisectoral strategies to address the determinants of health, taking into account physical, economic, social, cultural and gender perspectives and to ensure the use of health impact assessments:
results-based programs and investments to advance health care and clinical care;
a comprehensive primary health care system focused on family and community-based care, supported by a flexible and responsive hospital system and, finally,
collaborative health action, with broad participation and involvement of relevant health partners at all levels - home/family, school and workplace, local/community and country - and promoting shared processes of decision-making, enforcement and accountability.
solidarity for health in the European Region;
health equity;
healthy start in life;
youth health;
maintaining health in old age;
improved mental health;
reducing the prevalence of infectious diseases;
reducing the prevalence of non-communicable diseases;
reducing injuries from violence and accidents;
healthy and safe physical environment;
healthier lifestyle;
reducing the harm caused by alcohol, addictive drugs and tobacco;
healthy environment conditions;
multisectoral commitment to health;
integrated health sector;
governance issues and quality assurance of health care;
health services financing and resource allocation;
development of human resources for health;
research and health information;
policies and strategies to achieve health for all;
mobilizing partners for health.
The current burden of disease is driven by highly complex and interconnected factors (aging, migration, the spread of noncommunicable diseases and mental health disorders, remaining infectious disease challenges, efficiency and financial challenges of health systems, poor public health in many areas). However, it is possible to find cost-effective ways to implement policies that will improve the health and well-being of populations. Health 2020 was developed through extensive consultation within and outside the WHO Regional Office for Europe, as well as a range of new research studies. Health 2020 aims to “significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health, and ensure universal, equitable, sustainable and high-quality people-centred health systems.” The article highlights the main principles of the Health 2020 policy, the values underlying this policy, and its main provisions. It is emphasized that the Health 2020 policy is aimed at solving two interrelated tasks: improving health for all and reducing inequalities in health indicators; improving leadership and participatory governance for health. In addition to these two objectives, the Health 2020 policy framework contains four interconnected, interdependent and mutually supportive priority areas for strategic action: investing in health across the life-course and empowering citizens; solving the most pressing problems of the European region related to non-communicable and infectious diseases; strengthening people-centred health systems, public health capacity, emergency preparedness, surveillance and response; ensuring the strength of local communities and creating a supportive environment. It concludes that Health 2020 provides a powerful incentive for collective action across the WHO European Region to seize opportunities to improve the health and well-being of current and future generations.
Introduction
Health and well-being are universal humanitarian values, which today are also considered as inalienable human rights; they are essential components of equitable human, economic and social development and resources in everyone's daily lives. The goals of health and well-being are increasingly considered fundamental as a key driver of human development and security. Health is no longer seen merely in terms of consumption to be financed, but as a capital asset to be maintained, enhanced and improved in an equitable manner, and as a positive concept emphasizing social and individual resources as well as physical potential. In this context, we are talking about the lives of 900 million people living in the 53 countries of the WHO European Region, and the challenge before us today is to increase the impact of the above principles so that we achieve equitable improvements in health outcomes in all these countries. Given existing knowledge and technological advances, we can and must achieve better results.
Today, health issues are receiving more attention than ever before. Among the many determining factors are, for example, the impact of the forces of globalization and the increasing possibility of the rapid spread of infectious diseases. Health is a significant topic raised in discussions of trade, diplomacy and security. The healthcare sector is the most important independent sector of the economy, a source of many jobs, and a stimulus for the development of science and technology. Human rights aspects of health and healthcare play a significant role, but are often ignored. For example, problems of mobility and migration develop into prejudice and stigma. These are just some of the factors that confirm the critical importance of health issues.
Therefore, to meet people's expectations, it is necessary to actively address health and its determinants within existing political, social, economic and infrastructural conditions. This impact contributes to community development and improved health outcomes. The wide range of determinants of health means that it cannot be the sole responsibility of the health sector, although the sector and its systems undoubtedly play a very significant role. Models should be actively built collaboration with other sectors, based on shared priorities. Addressing the determinants of health directly associated with these sectors results in additional societal benefits, including economic benefits.
The current burden of disease is driven by highly complex and interconnected factors, such as aging, migration, the spread of noncommunicable diseases and mental health disorders, remaining infectious disease challenges, efficiency and financial challenges of health systems, and poor public health in many areas. However, strong evidence suggests that cost-effective policy options can be found to improve the health and well-being of populations. Such pathways are based on approaches that combine government leadership, creating a supportive environment, developing a sense of control and ownership, and the empowerment of all stakeholders. A new type of governance for health is needed for the 21st century, based on the following principles: a social determinants of health approach; equity and sustainability; achieving global and social goals through interconnected forms of formal and informal governance and new strategic relationships; increasing the role, voting rights and active participation of people. This is both a serious challenge and an opportunity.
Health 2020
The European region is made up of 53 countries with a rich diversity of culture, historical heritage, level of development, material security and resources. Despite their differences, these countries, which came together at the annual session of the WHO Regional Committee for Europe in September 2012, unanimously endorsed the framework of the new European health policy, Health 2020, and committed to implementing it. Health 2020 was developed through extensive consultation within and outside the WHO Regional Office for Europe, as well as a range of new research studies.
Thus, a fundamental review of the social determinants of health and the health gap in the WHO European Region was commissioned to make evidence-based policy recommendations to reduce social inequalities in health in the Region, and to develop a framework for subsequent action. The review was compiled under the direction of Michael Marmot as part of a two-year project divided into two phases. The full text of the final report was published in September 2013. It analyzes the levels of health disparities between and within countries in the European Region and examines policy options to reduce such inequalities. It drew on the work of 13 task forces, as well as the findings and recommendations of the global Commission on Social Determinants of Health, which contain the critical message that social inequities in health are rooted in the conditions in which people are born, grow, live, work and age , as well as the inequalities of power and resource distribution that give rise to these conditions. Based on this evidence and analysis, the review authors formulated specific practical recommendations on strategic interventions to be implemented across different age groups and generations that have the potential and capacity to reduce social inequalities in health.
A second set of fundamental reviews on principles and processes for implementing improved governance for health was prepared under the leadership of Ilona Kickbusch. These reviews were directly used in the development of Health 2020. The keynote address examines new approaches to governance as a result of the changing nature of the challenges of the 21st century. Its content is supplemented by a number of reference and analytical documents containing an in-depth analysis of the issues raised. The study revealed an ongoing process of dispersal of strategic leadership with a transition to a collaborative model, in which leadership is the product of the joint activities of a wide range of entities operating at the state level (ministries, parliaments, departments, government bodies, commissions, etc.), at the societal level (commercial enterprises , citizens, local communities, global funds mass media, including networked social media, foundations, etc.) and at the supranational level (European Union, UN, etc.).
The results of this work were also used to prepare a section of the European Review of Social Determinants and the Health Gap.
In September 2012, an analysis of resolutions adopted by the WHO Regional Committee for Europe over the previous 10 years, as well as World Health Assembly resolutions and ministerial conference declarations, was published. The results of this review of previous commitments suggest that Health 2020 will redefine and bring together many of them in a coherent and innovative approach, breaking down fragmentation and promoting successful implementation of its goals. However, there are a number of issues, such as the health of older people, the provision of care for some non-communicable diseases and the economic aspects of health and disease, that require greater attention today. The review also points to the need for better articulation and careful development of mechanisms and principles for implementing integrated strategies. Finally, it proposes that WHO Regional Committee for Europe resolutions should contain a summary of progress in meeting previous commitments.
A review of lessons learned in intersectoral work was published in 2012. This paper documents experience with health-in-all-policies and assesses the evidence and benchmarks the effectiveness of different governance frameworks in addressing the social determinants of health and, ultimately, population health outcomes. The publication presents research showing how best to establish, use and strengthen cross-sectoral governance structures. It also provides illustrative examples of available strategic leadership tools and techniques.
A work devoted to the economic aspects of disease prevention is being prepared for publication. It will analyze the growing body of reliable evidence that shows economic efficiency increasing investment in health promotion and disease prevention.
Member States of the WHO European Region have adopted Health 2020, set out in two separate formats. Health 2020: a European policy framework to support whole-of-government and societal action for health and well-being provides policymakers and policymakers with key values and principles in the form of strategic recommendations for implementation. implementation of approaches within the framework of the Health 2020 policy. The longer version, Health 2020: policy framework and strategy, provides much more detail on the evidence and practice in health and well-being, and is intended for those involved in policy making and implementation at operational levels. This document is intended to be a continually updated guide to policy and strategy, reflecting ongoing changes in evidence and practice. It is not prescriptive but provides a practical framework for use in each country, taking into account its circumstances, needs and aspirations.
The underlying data that informed the development of Health 2020 reflects the profound disparities in health outcomes across the WHO European Region. The health of the population as a whole is improving, but deep inequalities remain. There are sharp differences between countries, with a marked deterioration in performance from west to east. Here are other stark figures: a child born in the CIS is three times more likely to die before reaching age five than one born in the European Union, and maternal mortality rates in some countries in the Region are 43 times higher than others.
These countries undoubtedly differ in terms of the quality of health services and access to them. However, all available evidence indicates that the above inequalities are largely due to differences in social and economic conditions. They are also associated with behavioral factors, including tobacco and alcohol use, diet and physical activity levels, as well as mental disorders, which in turn reflect stress and distress in people's lives.
Health 2020 is a response to these challenges. Its goal is to “significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health, and ensure universal, equitable, sustainable and high-quality people-centred health systems.” Health 2020 is based on the values founded in the WHO Constitution, which states that the enjoyment of the highest attainable standard of health is a fundamental right of every person, regardless of ethnicity, gender, age, social status or ability to pay for services. Other important values are fairness, sustainability, quality, transparency and accountability, the right to participate in decision-making and the protection of human dignity.
To summarize the above, the following basic principles can be identified in the policy framework:
Close attention to health and well-being as indicators of socio-economic development;
A comprehensive approach to the full range of determinants of health;
Taking into account the Region's key public health priorities and effective practical solutions;
Adopting bold, innovative approaches to developing collective leadership to bring together multiple partners and mobilize broad political and public support for protecting and improving people's health to collaboratively determine the best solutions;
Identification and practical consideration of the necessary prerequisites for the implementation of positive changes;
Finding ways to formulate the economic case for investing in health, including objective justification of benefits and effective approaches to implementing the principle of health in all policies;
Finding ways to empower citizens and patients as key conditions for improving health outcomes, the functioning of health systems and increasing satisfaction with the quality of services;
Introducing effective ways to take advantage of opportunities, including new technologies, for networking, partnerships and communications;
Establishment of a common mechanism throughout the WHO European Region to ensure and maintain unity and consistency of voices within the health community;
Identifying knowledge gaps and identifying priority areas for research;
Establish an ongoing communication platform for the exchange of practical experience among policymakers and public health advocates across the Region.
The values underlying Health 2020 and its key messages
The dominant components of the current burden of disease are noncommunicable diseases and mental health conditions. Their causes are rooted in the social and economic conditions of people's lives and in lifestyle characteristics that are themselves socially mediated. These diseases arise as a result of an individual's interactions with multiple determinants of health throughout the lifespan. Evidence clearly shows that strong preconditions for health include equitable access to early childhood development opportunities, quality education and employment, and decent housing and income.
Health 2020 argues for the need to go to the roots of problems and address their underlying causes. Modern economic research not only reveals the economic burden that disease brings, but also shows that these problems can be solved with much greater emphasis on health promotion, disease prevention, and public health. This requires efforts to reduce health inequalities across the social gradient and target support to those who are most vulnerable and excluded. However, in many countries, policies outside the health sector currently do not pay sufficient attention to health or equity issues.
In most of them, the share of government budgets spent on health is large, but the cost of health care services is rising faster than national income. Many cost items are also increasing due to increased supply from providers, particularly as new treatments and technologies become available, and as people increasingly expect protection from health risks and access to high-quality health care services. Health systems, like other sectors, need to adapt and change, particularly in matters related to health promotion and disease prevention. Particular attention should be paid to the development of people-centred and participatory services, as well as integrated care delivery, such as primary and secondary care or health and social care. Reviews have shown that reductions in mortality from coronary heart disease in several high-income countries are due to more than half a reduction in population levels of exposure to risk factors such as smoking. The remainder of the reduction in mortality is due mainly to clinical prevention measures, and this proportion appears to be growing. These reviews provide a strong rationale for a combination approach that combines population-based risk reduction and high-quality clinical care for patients with existing diseases. Despite this, the OECD estimates that countries in the WHO European Region spend on average only 3% of their health budgets on health promotion and disease prevention.
Main strategic goals, objectives and content of the Health 2020 policy
Improving health for all and reducing health inequalities;
Improving leadership and participatory governance for health.
In addition to these two objectives, the Health 2020 policy framework contains four priority areas for strategic action that are interconnected, interdependent and mutually supportive:
Investing in health at all stages of human life and empowering citizens;
Solving the most pressing problems of the Region related to non-communicable and infectious diseases;
Strengthening people-centred health systems, public health capacity, emergency preparedness, surveillance and response;
Ensuring the strength of local communities and creating a supportive environment.
Work in all four priority areas includes actions to wide range interdisciplinary issues. The new type of governance for health needed to achieve this will be built on the following principles: social determinants of health, equity and sustainability; achieving global and social goals through interconnected forms of formal and informal governance and new strategic relationships; increasing the role, voice and active participation of people.
Governments achieve greater health benefits when they link policies, investments and services and focus on reducing inequalities. On organs government controlled responsibility for developing and implementing national cross-sectoral strategies that combine planning and control elements with goals and objectives for key areas of action, such as caring for people's health throughout the life course, strengthening health systems and public health, and empowering citizens . Such cross-sectoral strategies include, for example, the use of fiscal measures, the implementation of interventions in specific settings such as schools or workplaces, and the promotion of secondary prevention measures, including risk assessment and screening.
Mental health disorders, which are one of the the most important reasons long-term stress and disability. One in four people in the European Region will experience some type of mental health problem at some point in their life. Research evidence is providing insight into the destructive links between mental health disorders and social marginalization, unemployment, homelessness, and alcohol and other substance abuse. Particularly pressing but challenging challenges are improving early diagnosis of depression and suicide prevention through community-based interventions. This problem has acquired particular significance during the recent economic crisis, when the rate of suicide increased, for example, in Greece by 17%, in Ireland by 13%. Evidence suggests that the rise in suicides, like other Negative consequences the health costs associated with the economic downturn can be significantly reduced through well-targeted social protection measures and active labor market policies.
Health 2020 is fully consistent with WHO's General Program of Work and other international processes and instruments. This policy fully supports growing global efforts to combat noncommunicable diseases, as reflected in documents such as the UN Political Declaration on Noncommunicable Diseases (2011), the WHO Framework Convention on Tobacco Control and the WHO Global Strategy on Diet and Physical Activity and health. There is still a need to continue the fight against infectious diseases, in particular to achieve full implementation of the International Health Regulations, improve information exchange and improve mechanisms for joint epidemiological surveillance and infection control.
Working to address complex and interconnected determinants of disease in today's context requires making strategic decisions despite uncertainty and incomplete scientific knowledge. Under these conditions, the approaches of narrowly rational, linear thinking are not applicable. In situations where it is impossible to fully predict the broad systemic effects of multiple interventions, expertise related to synergetics and complex systems theory is required. In practical terms, to cope with the challenges of uncertainty, there is an increasing emphasis on small-scale interventions that allow for learning from experience and adjustments to be made.
Health 2020 prioritizes strengthening patient-centred health systems and increasing their capacity to deliver high-quality and effective services. These systems must be viable and financially sustainable, fully consistent with their purpose and based in their work on objective scientific knowledge. A reorientation is needed to prioritize disease prevention, integrated service delivery, continuity of care, continuous quality improvement, support for self-care, and bringing services as close to the community as possible in a safe and cost-effective manner. patients' residence. Health 2020, like WHO globally, remains a priority for universal access to health care and a commitment to primary health care as the cornerstone of health systems in the 21st century. All of these processes at the health and public health systems level require a more flexible, diverse and team-oriented workforce.
A significant contribution to the creation of Health 2020 is associated with the development of the European Action Plan for Strengthening Public Health Capacity and Services, which was endorsed by the WHO Regional Committee for Europe in 2012 as one of the fundamental elements of the implementation of this policy. The action plan aims to improve public health services and infrastructure, including public health aspects of health care services. It contains a set of 10 horizontally linked core public health operational functions to provide a unifying and guiding framework for European health authorities to develop, monitor and evaluate policies, strategies and interventions to reform and improve public health. To improve health outcomes, action is needed in the following areas: significantly strengthening public health functions and capacities; development of organizational mechanisms in the field of public health protection; scaling up measures to protect and promote health and prevent disease.
Building resilience is seen as a key factor in protecting and promoting health and well-being at both the individual and societal levels. Strong and resilient communities have the resources that allow them to proactively respond to emerging, including adverse, circumstances, or are able to quickly increase such resources. They also show readiness for economic, social and environmental changes, and are more effective in confronting crises and overcoming difficulties.
One of the most important determinants of health is environmental hazards; Many types of health problems are associated with exposure to such factors, including, for example, air pollution and the effects of climate change. These factors also interact with social determinants of health.
Policy implementation process and work ahead at country level
There is no doubt that countries embarking on Health 2020 for health development are in different contexts and have different capabilities. However, the policy framework is intended to remain relevant and practical regardless of differences in countries' starting positions. Specific goals for countries include securing strong political commitment to improve health and placing health at the forefront of the strategic agenda, mainstreaming health in all policies, enhancing policy dialogue on health and its determinants, and increasing accountability for final health indicators.
Health 2020 provides evidence-based pathways to achieve these goals. To support collaboration with countries and the implementation of Health 2020, the WHO Regional Office for Europe is putting together a package of services and tools to systematically support Member States in addressing horizontal policy issues that are key to the policy, as well as to establish programmatic linkages and entry points for implementation of the policy framework. For each component of the package, a list of priority high-impact services, guidelines and techniques will be provided. The package will be updated regularly to reflect progress made in countries and to include promising practices and expertise.
As an initial step, countries should develop national health policies with associated strategies and plans. Based on the results of a thorough needs assessment, the following questions should be answered: “What results does the country hope to achieve in terms of improving health outcomes while respecting the principle of social equity?” “What multisectoral policies and programs will be implemented, for example, in relation to noncommunicable diseases?” The Health 2020 toolkit will help you find the best answers. For public health, a useful guide is the European Action Plan for Strengthening Public Health Capacities and Services and its accompanying self-assessment tool. The Health 2020 policy is not for theoretical study, and its documents should not gather dust on shelves, but serve as a guide to action!
Valuable tools for determining the potential health benefits of specific strategies and social justice are techniques such as health impact assessment and economic analysis. Both qualitative and quantitative health data can be used.
It is encouraging that development is already underway in a number of countries. national policy Health 2020 with supporting programs and plans. Other countries use elements of the Health 2020 framework in accordance with its values and principles. The WHO Regional Office for Europe has begun systematically supporting countries in their efforts to implement Health 2020 during 2014–2015. As another initiative, the Regional Office will help develop new forms of networking between countries, institutions and citizens, including online collaboration mechanisms.
Implementation of Health 2020 will require the active participation of many organizations and structures throughout Europe with an interest in the development of health care and public health. In particular, cooperation with the EU will be a solid foundation and a source of new opportunities and additional benefits. Many other organizations and networks must be similarly involved; they are so numerous that it is impossible to list them by name. Opinions vary regarding private sector involvement, but private participation, when ethically required, can make a significant contribution to achieving Health 2020 goals.
An example of an active network that can significantly advance the implementation of Health 2020 is the WHO European Healthy Cities Network. Cities are home to around 69% of the European Region's population, and urban environments can provide citizens and families with great opportunities for success and well-being. A city can drive economic prosperity and provide healthy environments through improved access to services, cultural and recreational facilities. However, cities are also often sites of poverty and ill health. Certain circumstances of urban life, particularly segregation and poverty, contribute to and exacerbate these inequalities, contributing to the disproportionate impact of health-damaging and socially undesirable patterns of response to economic and social deprivation.
Cities and city governments can have a significant impact on people's health and well-being through a range of policies and interventions, including in the areas of addressing social exclusion and providing support, promoting healthy and physically active lifestyles, safety and the environment , working conditions, preparedness to cope with the consequences of climate change, elimination of harmful impacts and household inconveniences, urban planning and design taking into account the interests of health, active involvement and wide participation of citizens in collective processes. The WHO European Healthy Cities Network provides many examples of good practice across the WHO European Region and will act as a strategic driver for the implementation of Health 2020 at local level.
The WHO Regional Office for Europe will support effective collaboration with all such partners and networks across the Region, based on the following principles: engaging a wide range of stakeholders; helping to improve policy coherence; exchange of statistical health data; joining forces in surveillance; participation in the development and implementation of common strategic platforms, as well as in the conduct of assessment missions, workshops, individual consultations, technical dialogues and case studies.
Accountability and targets
Political commitment to the entire process described above at the global, regional, national and subnational levels is essential. At the 2013 WHO Regional Committee for Europe, countries endorsed the following overarching or core targets:
1. By 2020, reduce premature mortality among the European population.
2. Increase life expectancy in Europe.
3. Reduce inequities in Europe (social determinants benchmark).
4. Increase the level of well-being of the European population.
5. Universal coverage and the “right to health”.
6. National targets/targets set by Member States.
Conclusion
In today's environment, efforts to improve people's health must carefully consider a wide and complex range of determinants and influences, as well as the multisectoral and multidisciplinary nature of policies and interventions. Health 2020, with its goal of radically prioritizing and resourcing efforts to address social determinants, health promotion and disease prevention, fully reflects this reality. The complex nature of the determinants of health in modern societies, characterized by a wide variety of characteristics, an abundance of horizontal connections and massive flows of information, requires a whole-of-government and whole-of-society approach to be mandatory for any policy.
The current body of scientific knowledge is sufficient to improve people's health and reduce inequities in this area. WHO strives for a world in which health gaps are reduced and health care is universally accessible; in which countries have sustainable and strong health systems, based on primary health care and responsive to people's expectations and needs; internationally agreed health targets achieved; non-communicable diseases are under control; countries are successfully managing disease outbreaks and weathering natural disasters.
Health 2020 can help achieve all of these goals. It provides a powerful impetus for collective action across the WHO European Region to seize emerging opportunities to improve the health and well-being of current and future generations. The WHO Director-General said in the foreword to Health 2020: “The framework is a synthesis of what we have learned in recent years about the role and meaning of health. Achieving the highest level of health at all stages of life is the fundamental right of everyone, not the privilege of a select few. Good health people is a valuable resource and a source of economic and social stability. It plays a key role in poverty reduction and also contributes to sustainable development and at the same time enjoys its fruits.” Accordingly, Health 2020 provides a powerful impetus for collective action across the WHO European Region to seize opportunities to improve the health and well-being of current and future generations.
Authors: Zsuzsanna Jakab, WHO Regional Director for Europe, WHO Regional Office for Europe, Copenhagen, Denmark; Agis D. Tsouros, Director, Division of Policy and Governance for Health and Well-Being, WHO Regional Office for Europe, Copenhagen, Denmark.
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