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

2. 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

3. 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.

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

5. 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

6. 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

7. Health 2020 evidence base

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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)

17. 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).

18. 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

19. 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.

20. 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.

21. 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

22. 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

23. 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?

24. 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

25. 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?

26. 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

27. Thank you for listening!