Whole of society approach for health and wellbeing Monika Kosińska Programme Manager Governance for Health WHO Regional Office for Europe Slovenia, 9 June 2015

Introduction Moving towards a new strategy and policy framework for Health in the European Region: the road to Health 2020 Implementing Health 2020: Governance for Health Whole-of-society approach to health and well-being

Part I Moving towards a new strategy and policy framework for Health in the European Region: the road to Health 2020 Implementing Health 2020: Governance for Health What next: strengthening intersectoral action in the European Region.

by average national income per capita Life expectancy at birth Life expectancy, by average national income per capita Average gross national income per capita

Review of social determinants and the health divide in the WHO European Region Avoidable health inequities exist within and between countries These health inequities have social, economic and environmental causes The wealth of a country is not the only factor in determining level of health Government choices can make positive difference, at any level of GDP

Key recommendations to improve equity in health Ensure the best start in life for every child – including early child education Improve employment levels and working conditions Promote equity through adequate social protection, taxes and transfers Work with local communities to make local environments healthier (homes, schools, streets, neighbourhoods) Address the structural and mediating factors of social exclusion Improve governance mechanisms to act on the social determinants of health “Do Something, Do More, Do Better” * The study was carried out by a consortium of over 80 policy researchers and institutions across Europe (2012), and led by Sir Michael Marmot. 6

Health 2020 evidence base

Health 2020: a strategy for Europe Working to improve health for all and reducing the health divide Improving leadership, and participatory governance for health Health 2020: four common policy priorities for health Investing in health through a life-course approach and empowering people Tackling Europe’s major health challenges: NCDs and communicable diseases Strengthening people-centred health systems, public health capacities and emergency preparedness, surveillance and response Creating resilient communities and supportive environments

New approach for new challenges Complexity, uncertainty, high stakes, and conflicting value Systems thinking used to analyse problems and devise solutions Policies to be implemented as large-scale experiments A commitment to learning from practice Monitoring and evaluation systems Policies adapted based on experience The right health policy decisions and system thinking have to go together. “It is the right policies that make health” and therefore have to be fully integrated within the health systems. Countries need a health policy which is coherent and simultaneously addresses all determinants that improve health and reduce inequities. Health 2020 is therefore meant as an inspiration for this. But the complexity of these problems also requires a systems approach, which reflects their inherent complexity, uncertainty and conflicting values. We need a commitment to learning and adapting from practice, with policies implemented as experiments. Again Health 2020 discusses what this means in practice.

Part II Moving towards a new strategy and policy framework for Health in the European Region: the road to Health 2020 Implementing Health 2020: Governance for Health Whole-of-society approach to health and well-being

Governance Governance is about how governments and other social organizations interact, how they relate to citizens, and how decisions are taken in a complex and globalized world. (Institute on Governance, Ottawa Policy Brief 15, 2003) New types of leadership New types of engagement New types of democratization Steering - diffusion

Governance for Health ‘The attempts of governments or other actors to steer communities, whole countries, or even groups of countries in the pursuit of health and wellbeing as a collective goal.’ (based on Bell/Hindmoor 2009) health is a human right health is essential to well being health is a global public good Health is social justice Political determinants: indicators of commitment of government and in many sectors of society

Improving governance for health and increasing participation Governing through: collaboration citizen engagement a mix of regulation and persuasion independent agencies and expert bodies adaptive policies, resilient structures and foresight If Health 2020 is to achieve its goals new forms of governance for health will be required, more coherent, inter-connected and participative. Because the determinants of non-communicable disease stretch across the whole of society and all its sectors, so must the response. We speak today of a whole of society and a whole of government responsibility and accountability for health. Health 2020 explores what this means in practical terms, and shows how this improved governance for health can actually be achieved. EXTRA NOTES (from Health 2020): Leadership from health ministers and public health agencies will remain vitally important to address the disease burden across the European Region. It needs to be strengthened. Health ministries and public health agencies are increasingly engaged in initiating intersectoral approaches for health and acting as health brokers and advocates. This includes highlighting both the economic, social and political benefits of good health and the adverse effects of ill health and inequalities on every sector, the whole of government and the whole of society. Exercising such a leadership role requires using diplomacy, evidence, argument and persuasion. The health sector also has a partnership role towards other sectors when strengthening health can contribute to achieving their goals. Governments at all levels are considering establishing formal structures and processes that support coherence and intersectoral problem-solving. This can strengthen coordination and address power imbalances between sectors. This approach advocates moving health up the policy agenda, strengthening policy dialogue on health and its determinants, and building accountability for health outcomes. Source: Kickbusch, 2011

New collaborative approaches Governance for health and wellbeing requires both a whole of government (WoG) and a whole of society (WoS) approach. Requires new processes and structures, both formal and informal, strengthening collaboration with existing partners and identifying new ones. It challenges health system boundaries It positions human health and well being as an over arching societal goal grounded in values such as human rights and equity It integrates good population health as a key feature of what constitutes a successful society in the 21st century. It requires a new role for ministers and ministries of health and health agencies at all levels

Whole of government Public services agencies working across portfolio boundaries to achieve a shared goal An integrated government response to particular issues. Approaches can be formal or informal. They can focus on policy development, program management, and service delivery. (Australian Management Advisory Committee, 2004) Includes multilevel activities: aiming for coherence between subnational, national and global levels Political commitment and support essential Builds on HiAP to beyond a health-centric approach

Whole of society Wicked problems need solutions that go beyond government and the public sector Involves stakeholders, particularly citizens, in an inclusive and participatory way on issues impacting on their health and their communities Requires expanded and new forms of communication and new participatory models of governance A form of collaborative governance that requires trust building (Kickbusch 2011)

Implementing Governance for Health The health sector should be considered “one of a number of intersectoral players in a ‘web’ that makes use of new kinds of leadership, skills, information and intelligence” (WHO, 1997).

Part III Moving towards a new strategy and policy framework for Health in the European Region: the road to Health 2020 Implementing Health 2020: Governance for Health Whole-of-society approach to health and well-being

Origins of WOS: changing political context Substantial shift in geopolitics marked the beginning of the trend towards new models and relationships in health. Traditional models of diplomacy, policy and politics – and in particular the power and responsibilities of the state – were challenged and revised Transfer of resources to private enterprise as well as a spirit of great collaboration between state and non-state actors The emergence of nonstate actors in the geopolitical arena and their influence on the need to move beyond traditional centralized or devolved governmental models in tackling health challenges.

Whole-of-society approach Extension of the whole-of-government approach to include the roles of the private sector and civil society Beyond institutions: Influences and mobilizes local and global culture and media, rural and urban communities Engages relevant policy sectors, such as the education system, the transport sector, the environment, urban design.

Participatory governance for health Thailand’s National Health Assembly Mechanism for opening up the debate on public health policy-making to citizens. Attended by over 1500 people, Discusses health and related issues (eg agriculture, food prices, economic crises, youth). Participating groups have equal speaking rights. Resolutions considered by the National Health Commission

Collaborative governance: involving citizens State Health Conferences in Germany Public health law 1997: health conferences should be held to debate and discuss solutions to health problems with local stakeholders and community Attended by local government, state health institutions, professionals, unions, NGOs, public Topic set in advance (eg healthy ageing, patient self-determination, healthy growing-up etc) Resolutions passed and must be followed up by government

The role of the private sector Corporate social responsibility and “inclusive capitalism”. Public private partnerships Self-regulation vs co-regulation vs regulation All private actors equal?

Key questions and challenges Purpose including ownership, priority setting, duration Governance including participation, representation, transparency and accountability Capacity including public sector as well as partners, for both implementation as well as governance Communication including new technologies, ethics and messages Trust amongst and between all actors involved

Summary Response to complex policy challenge Recognition of power/resources lying outside the realm of the traditional state Process is part of the outcome Justification for inaction in regulation? Replacement for lack of political will? Manifestation of public health governance where government cannot drive change for political/financial reasons?

Concluding comments Systematically strengthening partnerships is a key goal of the Health 2020 A partnership-based vision engaging governments, nongovernmental organizations, civil society, the private sector, science and academe, health professionals, communities – and every individual The importance of shared governance for health at all levels supporting whole-of-government and whole-of-society approaches Lastly WHO cannot achieve the aims of Health 2020 alone. These can only be made to happen through a combination of individual and collective efforts. Success requires common purpose and broad collaborative efforts by people and organizations across society in every country: governments, nongovernmental organizations, civil society, the private sector, science and academe, health professionals, communities – and every individual. Key to the success of Health 2020 will be Member States and WHO working closely together and reaching out to engage other partners in a systematic fashion. Close cooperation between the WHO Regional Office for Europe, WHO Headquarters and other regions lies at the core. This must be supported by building wider engagement across regional networks and entities such as the Commonwealth of Independent States, the Eurasian Economic Community, the countries in south-eastern Europe and the EU. It is with this message, that meeting the challenges of global health necessarily requires wide ranging engagement and partnership that I end my talk today. Thank you for your attention. 26

Thank you for listening!