Presentation delivered by Dr Zsuzsanna Jakab, Regional Director, WHO Regional Office for Europe (30 October 2015, Ljubljana, Slovenia)

1. Health 2020 and
health systems
strengthening
Dr Zsuzsanna Jakab
Regional Director
WHO Regional Office for Europe
Ljubljana, Slovenia, 30 October 2015

2. Contents
From the Ljubljana Charter to Health 2020
Health situation in Slovenia
Investing in health
Slovenia health system review
Refugee and migrant health
Preparedness and response (Ebola)
Content

3. Long history of excellent collaboration

4. Ljubljana charter
Driven by values
Targeted on health
Oriented towards primary care
Based on sound financing
Centred on people

5. Alma-Ata Declaration;
Ljubljana Conference on
Reforming Health Care
1978-96
Introduced core health system functions:
governance; services delivery; financing;
resource generation
2000
Tallinn Charter:
health systems
for health and wealth
2008 and 2013
Oslo conference:
Impact of crisis
2009 & 2013
2012
Health 2020 priority area:
strengthening people-centred
health systems and public health
From the Ljubljana Charter to Health 2020

6. New vision for health systems strengthening
reaches out to people

7. Health system strengthening priorities:
starting from the values

8. Two important measures for
universal health care
Unmet
need
Financial
protection
against the costs
of ill health

9. Slovenia is a top performer in
universal health care
Unmet need for a medical examination for financial or other reasons by
income group in the European Union, EU-SILC data for 2012

10. Financial protection is excellent: out-of-pocket
payment <15%
Out-of=pocket payment as a share (%) of total expenditure on health
ranked from low to high by income (high, upper-middle, lower-middle, low)
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
Netherlands
Monaco
France
UK
Luxembourg
Slovenia
Germany
SanMarino
Denmark
Norway
Croatia
CzechRepublic
Ireland
Austria
Sweden
Andorra
Iceland
Estonia
Finland
Belgium
Italy
Spain
Poland
Slovakia
Israel
Hungary
Switzerland
Lithuania
Greece
Portugal
Malta
RussianFederation
Latvia
Bulgaria
Cyprus
Turkey
Belarus
Romania
BosniaandHerzegovina
TFYRM
Montenegro
Turkmenistan
Serbia
Kazakhstan
Albania
Azerbaijan
Kyrgyzstan
Ukraine
Uzbekistan
RepublicofMoldova
Armenia
Georgia
Tajikistan
Source: WHO Global Health Expenditure Database for 2011
Alarming zone

11. 15%
A number to remember: keep out-of-
pocket payment low

12. The share of public expenditure for health spending is
lower in Slovenia than in many comparable countries
IE
NL
HU
AT
HR
SK
EE
CZ
FI
DE
WHO Europe: European Health for All database
60
65
70
75
80
85
90
95
1995 2000 2005 2010
EU15
SI
EU13
WHO/Europe
% of all health expenditure

13. Total health expenditure (as % of GDP) is
lower in Slovenia than the EU15 average
IE
NL
HU
AT
HR
SK
EE
CZ
FI
DE
WHO Europe: European Health for All database
4
5
6
7
8
9
10
11
12
13
1995 2000 2005 2010
EU15
SI
EU13
WHO/Europe
% GDP

14. 60
65
70
75
80
85
Life expectancy is increasing and the gap
between Slovenia and EU15 is closing!
EU15
SI
EU13
WHO/Europe
DE
1980 1990 2000 2010
60
65
70
75
80
85
IENL
HU
AT
HR
SK
EE
FI
CZ
1980 1990 2000 2010
years years
males females
NL
FI
EE
HUAT
CZIE
HR
WHO Europe: European Health for All database

15. Maximum
value
Regional
average
Minimum
value
Inequality in life expectancy: declining, but gap persists

16. Maximum
value
Regional
average
Minimum
value
Inequality in life expectancy is decreasing, but the gap
persists

17. Gap in life expectancy at 30 years of
age by education level, Slovenia, 2010

18. East–west: gap in mortality
Mortality due to circulatory
system diseases
Source: National Institute of Public Health

19. High impact of mother‘s level of education
on stillbirths and perinatal mortality
Source:NationalInstituteofPublicHealth

20. The Region is on track to reducing premature mortality
Maximum
value
Regional
average
Minimum
value

21. Premature mortality in Slovenia is
decreasing
EU15
SI
EU13
WHO/Europe
1980 1990 2000 2010
100
200
300
400
500
600
700
IE
NL
HU
AT
HR
SK
EE
CZ
FI
DE
age-standardized death rate - all causes, 0-64, per 100000
WHO Europe: European Health for All database

22. litres of pure alcohol are
drunk per person per year
of the population is
overweight or obese
of the population
uses tobacco

23. Alcohol consumption remains a problem.
IE
NL
HU
ATHR
SK
EE
CZ
FI
1980 1990 2000 2010
5
7
9
11
13
15
17
19 EU15
SI
EU13
WHO/Europe
DE
Pure alcohol consumption, litres per capita, age 15+
WHO Europe: European Health for All database

24. Overweight and obesity are risk factors for
various chronic diseases and conditions.

25. 0%
5%
10%
15%
20%
25%
30%
35%
40%
čisto spodnji in
delavski sloj
srednji sloj višji srednji in
zgornji sloj
Delež(%)
TRENUTNI KADILCI
2001
2004
2008
2012
Comprehensive legislation on tobacco
control is needed.
Current smokers
Source: National Institute of Public Health
Lower social
class
Middle social
class
Higher/highest
social class

26. Noncommunicable diseases – by far the first cause of
mortality – are the key challenge in Slovenia
Source: WHO mortality database
With continued good
work in monitoring
communicable
diseases, work must
be strengthened in
all sectors working in
noncommunicable
diseases, especially
cancer, suicide and
injuries.

27. Acute respiratory
infections, pneumonia and
influenza in children <5y
Traffic accidents
Suicide
Cervical cancer
Breast cancer
Lung cancer
Cerebrovascular
disease
Heart disease
0 10 20 30 40
Standardized death rate per 100,000 population
EU13
EU15
European Region
Slovenia
Diseases that represent the highest burden
of premature mortality in Slovenia
Source: WHO Europe: Mortality indicator database.
Standardized premature
mortality (age 0–64 years)
due to selected diseases,
2010

28. The mortality rate from cancer is high,
and lung cancer is in the lead
EU15
SI
EU13
WHO/Europe
1980 1990 2000 2010
WHO Europe: European Health for All database
IE
NL
HU
AT
HR
SK
EE
CZ
FI
DE
130
150
170
190
210
230
250
270
290
age-standardized death rate – number of deaths per 100.000

29. Mortality from diseases of the circulatory system
has been effectively reduced in Slovenia
EU15
SI
EU13
WHO/Europe
1980 1990 2000 2010
IE
NL
HU
AT
HR
SK
EE
CZ
FI
DE
100
200
300
400
500
600
700
800
age-standardized death rate – number of deaths per 100.000
WHO Europe: European Health for All database

30. Slovenia has some of the best results in
reducing infant deaths
IE
NL
HU
AT
HR
SK
EE
CZFI
EU15
SI
EU13
WHO/Europe
1980 1990 2000 2010
Infant deaths per 1000 live births
0
5
10
15
20
25
DE
WHO Europe: European Health for All database

31. The percentage of the population ≥ 65 years
in Slovenia is rising rapidly.
8
10
12
14
16
18
20
22
SK
IE
HU
AT
EE
FI
NL
CZ
EU15
SI
EU13
WHO/Europe
DE
HR
1980 1990 2000 2010
% of population aged 65+ years
WHO Europe: European Health for All database

32. Investing in health pays off
Photos: Malin Bring

33. Health is an investment - not an expense:
we should invest more in health.

34. Health is a political choice.
64th session of the Regional Committee
for Europe, Denmark

35. European countries are strengthening their health
policies
.all answers (n=31 and 36 for 2010 and 2013, respectively)
No,butplanned forthefuture
Yes,anotherstrategy
Yes,comprehensivehealthpolicy
NationalhealthpolicyisalignedwithH2020
Allanswers(n=31and36for2010and2013,respectively)
2013
2010
Yes, comprehensive health
policy
Yes, another strategy
0% 10% 20% 30% 40% 50% 60% 70%
Noandnotplannedforthefuture
No,butplanned forthefuture
Yes,anotherstrategy
2013
2010
2013
2010

36. Health 2020: the right political choices for health
Increase
healthy life
expectancy
.
Enhance
well-
being
Reduce
inequity
Reduce
premature
mortality
Support
upstream
approaches to
governance
and
determinants
of health and
universal
health
coverage
Establish
national
targets in
health
policies, and
monitor

37. Transforming our world: the
2030 agenda for sustainable
development

38. Global goals for sustainable development

39. Health targets and health as a target in other
goals

40. Slovenia’s health system:
review

41. Slovenia’s health system – a collaborative
effort
Five technical
assistance
work
packages
Generating
evidence to
support process
in Slovenia
Collaboration
between WHO,
the European
Observatory and
more than 50
Slovene experts

42. Generating evidence
Five work packages covering a range of health system areas:
1. New, fully updated “Health systems in transition” profile
for Slovenia
2. Health system expenditure
3. Health system funding
4. Purchasing and payment
5. Optimizing service delivery

43. Benefits of a health system review
• Focus on the performance of the health system
• Provide detailed evidence on key challenges
• Identify areas amenable to reform
• Ensure consistency with Slovenia’s health
system values: sustainability, efficiency, equity
and quality

44. Health financing policy objectives and
performance
Financial protection
• Does use of health services cause
financial hardship?
Equity in financing
• Who bears the financial burden of
health services?

45. Adequate funding levels
Stable revenue flows
Administrative efficiency
Health financing policy objectives and
performance

46. Enhancing health system efficiency
• More efficient use of health resources is a pillar of
successful health system reform.
• Purchasing and payment functions must be well
designed and implemented.
• Health system review provides evidence on:
- the benefits of a health technology assessment
- strategic purchasing of goods and services
- equitable payment systems for health providers

47. Some indicators already show excellent
efficiency
IE
NL
HU
AT
HR
SK
EE
CZ
FI
DE
WHO Europe: European Health for All database
EU15
SI
EU13
WHO/Europe
Average length of stay in hospital – number of days
6
10
14
18
1980 1990 2000 2010

48. Admissions for inpatient care could be
reduced
IE
NL
HU
AT
HR
SKEE
CZ
FI
DE
WHO Europe: European Health for All database
EU15
SI
EU13
WHO/Europe
In-patient care admissions per 100
9
12
15
18
21
24
27
30
1980 1990 2000 2010

49. Outpatient contacts
NL
HU
AT
HR
SK
EE
CZ
FI
DE
3
5
7
9
11
13
15
EU15
SI
EU13
WHO/Europe
Outpatient contacts per person per year
WHO Europe: European Health for All database
1980 1990 2000 2010

50. Density of doctors
IE
NL
HU
AT
HR
SK EE
CZ
FI
1980 1990 2000 2010
Source: European database on human and technical resources for health.
200
250
300
350
400
450
500
EU15
SI
EU13
WHO/Europe
DE
Physicians per 100000

51. Density of nurses
IE
NL
HU
AT
HR
SK
EE
CZ
FI
DE
1990 2000 2010
EU15
SI
EU13
WHO/Europe
Nurses (PP) per 100000
400
500
600
700
800
900
1000
1100
1200
1300
1400
European database on human and technical resources for health.

52. Ensuring effective service delivery
The health system review explores opportunities to
optimize the delivery of health services, including:
- building on model family medical practices to meet the
needs of people with chronic and multiple conditions
- supporting coordination and decision-making between
levels of care
- moving care out of hospitals when appropriate
- strengthening information technology
- model practices = referenčne ambulante

53. Evidence-based policy-making
The health system review highlights Slovenia’s
commitment to evidence-based policy-making.
A basis for further discussion and consensus-
building on priorities for health system reform
Continued support from WHO

54. Refugee and migrant health

55. Refugee and migrant health, a challenge
for the WHO European Region
1 out of 12 residents is a migrant
77 million migrants are living in the WHO European Region, which
represent 8% of its population.
Ensuring adequate standards of care for
refugees and migrants is essential:
 For population health.
 For the protection and promotion of
human rights of refugees, migrants and
the resident population.
This is aligned with the fundamental
values of Health 2020, such as health
as a human right, solidarity and
protection of the vulnerable.
Almost 600,000 refugees and migrants have crossed the
Mediterranean in 2015 so far.
Increase of arrivals in Slovenia, with peaks of over
10,000 migrants entering on daily basis.

56. Demystifying refugee and migrant health
There is no systematic
association between
migration and the
importation of infectious
diseases.

57. The public health aspects of migration are influenced by policies
and interventions run by stakeholders outside the health sector,
which do not always take into account the health implications of
their actions.
Ministry
of Interior
Ministry
of Labour
Ministry of
Social
Affairs
Ministry of
Foreign
Affairs
Ministry of
Education
Ministry of
Health
Refugee and migrant health,
a multisectoral agenda

58. Adapting to diversity: towards migrant-
sensitive health systems
Refugees/migrants = heterogeneous group
 need to respond to diverse health
needs:
 Sexual reproductive health and
rights
 Mother and child health
 Diabetes
 Cardiovascular diseases
 Mental health
 Emergency care and protection
 Protection against vaccine-
preventable diseases

59. 2015 Goal: achieve zero human-to-human Ebola transmission
• The outbreak is not over: sporadic cases still reported in Guinea:
3 new confirmed cases reported in the week of 18 October.
• Robust surveillance remains essential..
• Vaccination trial continuing in Guinea; positive outcome, may play
a key role in ending the outbreak.
2016 Goal: sustain a resilient zero by rapidly detecting & stopping
new emergences
Ebola situation as of 21 October 2015

60. A unified
WHO
programme
for outbreaks
and
emergencies
Priority to
core
capacities of
the
International
Health
Regulations
A global
health
emergency
workforce
Improved
functioning,
transparency,
effectiveness
and
efficiency
of
International
Health
Regulations
Accelerated
research and
development
in epidemics
or health
emergencies
WHO
Contingency
Fund for
Emergencies
Reform of WHO’s Work in Outbreaks and Emergencies
with Health and Humanitarian Consequences

61. Overseen by WHO Director General, supported by:
– An Advisory Group on Reform of WHO’s Work in Outbreaks and
Emergencies with Health and Humanitarian consequences
• 19 high-level experts in large-scale emergency response, disaster preparedness, disease
outbreak control and crisis coordination. Chaired by UNSG SE on Ebola, David Nabarro. .
– A Project Team at WHO
Fed by other processes such as:
– An IHR Review Committee on the Role of the IHR(2005) in the Ebola
Outbreak and Response
• 16 experts from the IHR Roster of Experts. Chaired by Pr. Didier Houssin
Reform of WHO’s Work in Outbreaks and Emergencies
with Health and Humanitarian Consequences

62. Hvala