1. 3rd Medical Faculty - Department of Preventive Medicine WHO Programs and Strategies of Public Health Alena Šteflová, M.D.,Ph.D. 2009/2010

2. WHO/ specialised UN agency WHO established in 1948 - 7 April ( World health Day) – after ratication of 23 countries Target: to promote technical cooperation for health among nations, to carry out programmes to control and eradicate disease, and to improve the quality of life.

3. World Health Organization Specializovaná agentura OSN " Health is a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity " Definition of Health Preambule of Constitution „Its objective is the attainment by all people of the highest possible level of health“ Constitution, 1948

4. Structure of WHO Headquarter (HQ): Geneve, general director Dr. Margaret Chan ( previous GD LeeJong-wook died 2006) -WHA – World Health Assembly / the governing body of the organization/ meeets annually / in 2009 62nd WHA in Geneva -Executive Board consists from 32 experts, elected for 3years – preparatory of strategies and resolutions WHO includs 194 member states, divided into 6 geographical regions -AFRO Brazzaville/Congo - Africa -EMR Cairo/Egypt – Middle-East -AMR Washington/USA – South and North America -SEAR New Delhi/India – South-East Asia -WPR Manila/Philippines – West Pacific

5. Structure of WHO European region EURO Copenhagen/Denmark – Europe RD Zsuzsana Jakab since 1st Feb 2010 ( former Marc Danzon) - Over 870mil inhabitens ( including all countries of former Soviet Union) -Diversities within the region: industrial societies, agriculture, new democracies in East and Central Europe -Regional Committee – once per year ( Standing Committee) -Related strategies for the regions are adopted by member states Country offices of WHO (Liaison Office) in 142 member states -for the Czech Republic / Prague -Participation of the Czech Republic since 1948 (figures separatly since 1993)

6. The main tasks of the WHO -Coordination and solution of the main acute health problems with the impact on global health -Preparedness of potential global pandemy ( SARS, Avian Influenza, Swine Influenza); the struggle with HIV/AIDS, Malaria, TB -Humanitarien help and crises management (disasters, political conflicts) -Health policy- support to member states/assistance, consultancy -Monitoring, assessment, HFA Database - reports, campaigns, printing documents, etc.

7. Transnational strategies of Health Policy European Union – does not have united strategy of health policy/health care mandatory implemented by member states Harmonization of legislation, support of preventive programs and health promotion policy: Communitarian Program 2007-2013, 7 th framework program – medical research WHO – creates frame for health policy as well as partial technical recommendations, guidelines, strategies in three main areas: Lifestyl conductive to health A healthy environment Appropriate services for prevention, treatment and care;

8. The Health for All Policy Framework for the WHO European Region The basic conceptional programmes for implementation in respective countries accordingly to their conditions and priorities: Health for All to 2000 Health 21 – adopted at the 51st WHA, May 1998; supposed to be implemented through relevant regional ant national policies

9. Health 21 – the Health for All Policy Framework for the WHO European Region -The one constant goal is to achieve full health potential for all -Two main aimes for better health towards this goal – promoting and protecting people’s health throughout the course of their lives - reducing the incidents of the main diseases and injuries -Three basic values form the ethical foundation - health as a fundamental human right - equity and solidarity in health - participation of individuals, groups and communities

10. Health 21 - Four Main Strategies for Action -Multisectorial strategies to tackle the determinants -Health outcome driven programs and investments for health -Integrated family and community oriented primary health care, supported by a flexible and responsive hospital system -Involvement of relevant partners for health at all levels – home, school and worksite, local community and country that promotes joint decision making and implementation of action

11. Solidarity and Equity in Health Closing the health gap between countries -Target 1- Solidarity for health in the European region -Target 2 - Equity in health

12. Better Health for People Strengthening health throughout life -Target 3 - Healthy start in life -Target 4 - Health of young people -Target 5 - Healthy ageing -Target 6 - Improving mental health -Target 7 - Reducing communicable diseases -Target 8 - Reducing non-communicable diseases (CVD, cancers, DM, chronic respiratory and musculoskeletal disorders, teeth caries) -Target 9 - Reducing injury from violence and accidents

13. A Multisectoral Strategy for Sustainable Health To create sustainable health through more health-promoting physical, economic, social and cultural environments for people -Target 10 - A healthy and safe physical environment -Target 11 - Healthier living -Target 12 - Reducing harm from alcohol, drugs and tobacco -Target 13 - Settings for health (at home, school, workplace and in the local community) -Target 14 - Multisectorial responsibility for health

14. Changing the Focus: an Outcome- Oriented Health Sector To orient the health sector towards ensuring better health gain, equity and cost-effectiveness -Target 15 - An integrated health sector -Target 16 – Managing for quality of care -Target 17 – Funding health services and allocating resources -Target 18 - Developing human resources for health

15. Managing Change for Health To create a broad societal movement for health through innovative partnerships, unifying policies, and management practices tailored to the new realities -Target 19 - Research and knowledge for health -Target 20 - Mobilizing partners for health -Target 21 - Policies and strategies for health for all

16. National Health Programs of the Czech Republic HFA -The National Program of Health Restoration and Promotion in the Czech Republic – approved by the government in April 1992 -National program of health – long term strategy – approved by the government in 1995 (successful community projects Healthy Cities, Health Promoting Schools, Healthy Workplaces, Regions for Health); state budget for the implementation of the national health program H21 -The Czech version - A long-term Program for Improving the Health of the Czech Republic – Health for All in the 21st Century Approved by the Government of the CZH in 2002 –Resolution 1046

17. The global perspective

18. 75% 50% 25% AFRAMREMREURSEARWPR 2001 Communicable disease Non/ communicable diseases injuries Zdroj: WHR 2002

19. Sources: For cause-specific mortality: EIP/WHO. For undernutrition: Pelletier DL et al. American Journal of Public Health 1993, 83:1130–1133 Diarrhoea 12% Other 29% Pneumonia 20% Malaria 8% Measles 5% HIV/AIDS 4% Perinatal 22% Deaths associated with undernutrition 54% Worldwide, about 10 million children died per year Major causes of death among children under five years

20. WHO global priorities EPIDEMY OF COMMUNICABLE DISEASES HIV/AIDS MALARIA TB Preparedness on potential global pandemy (SARS,ic influenza EPIDEMY NON – COMMUNICABLE DISEASES TABACCO ALCOHOL, DRUGS NUTRITION INJURIES

21. The WHO European Region Child and adolescent health – emerging issues HIV/AIDS Obesity Mental health Injuries

22. Western Europe Eastern Europe Central Europe HIV infections newly diagnosed in children, 1997–2002 – Europe Source: EuroHIV 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 199719981999200020012002 Year of report Cases

23. Prevalence of overweight children in 31 countries grouped by region Source: HBSC Overweight Prevalence (%) North America Scandinavia United Kingdom (South) Western Europe (Central) Western Europe (Northwest) Eastern Europe (Southwest) Eastern Europe 0 5 10 15 20 25 United States Canada Malta Spain Portugal Italy Greece Wales England Scotland Slovenia Hungary The former Yugoslav Republic of Macedonia Croatia Finland Norway Denmark Sweden Austria Belgium (French) France Germany Belgium (Flemish) Switzerland Netherlands Czech Republic Poland Estonia Ukraine Russian Federation Latvia Lithuania Overweight Prevalence (%) North America Scandinavia United Kingdom (South) Western Europe (Central) Western Europe (Northwest) Eastern Europe (Southwest) Eastern Europe

24. 0 5 10 15 20 25 30 19701980199020002010 Prevalence % IOTF estimates. Increasing prevalence of overweight children in Europe

25. Youth and depression Four percent of 12–17 years old and nine percent of 19 years old suffer from depression, making it one of the most prevalent disorders with wide-ranging consequences.

26. Youth and depression Depression is associated with youth suicide and is the third leading cause of death in young people. Source: World Health Report 2001

27. Road Traffic Injuries: a huge global public health problem  1.2 million die a year  Up to 50 million are injured or disabled injured or disabled  11th leading cause of death of death  3rd cause of death and disability and disability in 2020 in 2020  account for 2.1% of all deaths globally of all deaths globally

28.  127,000 die a year  2.4 million more are injured or disabled  One out of three deaths involve young people under 29 (about 43 800).  Of these, nearly 80% are males (about 33 600)  Over 2 million crashes happen every year  65% crashes occur in towns (over 1.3 million)  One out of three deaths involves a pedestrian or a cyclist  Costs (in the EU15):about 180 € billion/year (equivalent to 2.0 % GDP) RTIs: a huge European public health problem

29. Source: WHO, Health for All database, June2004 Childhood (0-14) injury mortality is unequally distributed across Europe: highest and lowest in the world (2002) People in low- middle income countries are at 4 times the risk of dying from injuries than people in high income countries (HIC). Many cost- effective strategies exist as in HIC, which are among the safest in the world.

30. Global/regional strategies Frame Convention of Tobacco Control (FCTC) European Action Plan against Alcohol Strategy of Environment and Health of Children / Budapest Conference Declaration of mental health, Action plan / Helsinky 2005 Global strategy of healthy nutrition, physical activities and health - Ministerial Conference in Istanbul – 2006 European Charter on Counteracting Obesity Ministerial Conference on Health Systems in Tallin 2008

33. COMMISSION ON SOCIAL DETERMINANTS OF HEALTH Sir Michael Marmot Chair of the Commission on Social Determinants of Health Professor of Epidemiology and Public Health, Royal Free and University College Medical School, London

34. What are the social determinants of health? "The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon….Together, the structural determinants and conditions of daily life constitute the social determinants of health."

35. Why treat people… then send them back to the conditions that made them sick?

36. Life expectancy at birth (men) Glasgow, Scotland (deprived suburb)54 India61 Philippines65 Korea65 Lithuania66 Poland71 Mexico72 Cuba75 US75 UK76 Glasgow, Scotland (affluent suburb)82 (WHO World Health Report 2006; Hanlon,P.,Walsh,D. & Whyte,B.,2006)

37. Inequalities: Between Countries Life expectancy at birth (men and women): selected countries Japan Hong Kong Iceland Switzerland Australia China Brazil Russia Federation India Mozambique Sierra Leone Angola Zimbabwe Zambia National LE data HDP 2007/2008, Glasgow data: Hanlon et a l. 2006 Glasgow Calton 54 (men) Glasgow Lenzie 82 (men)

38. Preston Curve in 2000 (Deaton, 2004)

39. Trends in life expectancy (Human Development Report, 2005)

40. Under 5 mortality (per 1000 live births) by wealth group (Houweling et al, 2007)

41. Mortality over 25 years according to level in the occupational hierarchy: Whitehall (Marmot & Shipley, BMJ, 1996)

42. Life expectancy of Indigenous Peoples (Bramley et al, 2005)

43. (Pinto da Cunha, 1997) Infant mortality in Brazil by race and mother's education, 1990

44. Poverty is an issue throughout the Region Percent of children living below national poverty lines Source: UNICEF Innocenti Research Centre, Child poverty in rich countries

45. The widening trend in mortality by education in Russia,1989-2001 (probability of living to 65 yrs when aged 20 yrs) (Murphy et al, 2005)

46. What are the social determinants of health?

47. Why emphasize social determinants? Social determinants of health have a direct impact on health Social determinants predict the greatest proportion of health status variance (health inequity) Social determinants of health structure health behaviours Social determinants of health interact with each other to produce health

48. Social justice Empowerment as a means – material, psychosocial, political Creating the conditions for people to take control of their lives www.who.int/social_determinants

49. 28 August 2008

50. World Health Assembly Resolution May 2009 All member states: –Tackle health inequities through action on the social determinants of health –Impact of polices and programmes on health inequities; –Health equity in global development goals

51. "Public health can be grateful for backing from the Commission on Social Determinants of Health. I agree entirely with the findings. The great gaps in health outcomes are not random. Much of the blame for the essentially unfair way our world works rests at the policy level." Dr Margaret Chan, 62 nd World Health Assembly, May 2009 Photos:WHO/Cédric Vincensini

52. Framework for action on tackling social determinants of health inequities

53. 1. Improve Daily Conditions Improve the well-being of girls and women and the circumstances in which their children are born –Major emphasis on early child development and education for girls and boys Manage urban development –Greater availability of affordable housing –Invest in urban slum upgrading especially water and sanitation, electricity, paved streets Ensure urban planning promotes healthy and safe behaviours equitably –Active transport –Retail planning to manage access to unhealthy foods –Good environmental design and regulatory controls e.g. number of alcohol outlets Ensure policy responses to climate change consider health equity Full and fair employment made a shared objective of international institutions and a central part of national policy agendas and development strategies –Strengthened representation of workers in the creation of employment policy, legislation, and programmes

54. 1. Improve Daily Conditions International agencies should support countries to protect all workers –Implement core labour standards for formal and informal workers –Develop policies to ensure a balanced work–home life –Reduce negative effects of insecurity among workers in precarious work arrangements Progressively increase social protection systems –Ensure systems include those in precarious work, including informal work and household or care work Build quality health-care services with universal coverage, focusing on Primary Health Care –Strengthen public sector leadership in equitable health-care systems financing, ensuring universal access to care regardless of ability to pay –Redress health brain drain, focusing on investment in increased health human resources and training and bilateral agreements to regulate gains and losses.

55. 2. Tackle the Inequitable Distribution of Power, Money and Resources Place responsibility for action on health and health equity at the highest level of government, and ensure its coherent consideration across all policies Strengthen public finance for action on the social determinants of health Increase global aid to the 0.7% of GNP commitment and expand the Multilateral Debt Relief Initiative Institutionalize consideration of health and health equity impact in national and international economic agreements and policy-making Reinforce the primary state role for basic services essential to health (such as water/sanitation) and regulation of goods and services with a major impact on health (such as tobacco, alcohol, and food)

56. 2. Tackle the Inequitable Distribution of Power, Money and Resources Create and enforce legislation that promotes gender equity and makes discrimination on the basis of sex illegal Increase investment in sexual and reproductive health services and programmes, building to universal coverage and rights Strengthen political and legal systems –Protect human rights –Assure legal identity and support the needs and claims of marginalized groups, particularly Indigenous Peoples Ensure fair representation and participation of individuals and communities in health decision-making Enable civil society to organize and act to promote and realize political and social rights affecting health equity Make health equity a global development goal

57. 3. Measure and Understand the Problem and Assess the Impact of Action Ensure routine monitoring systems for health equity locally, nationally, and internationally –Ensure all children registered at birth –Establish national and global health equity surveillance systems Invest in generating and sharing new evidence on social determinants and health equity and on effectiveness of measures –Create dedicated budget for generation and global sharing of evidence Provide training on the social determinants of health to policy actors, stakeholders, and practitioners and invest in raising public awareness –Incorporate the social determinants of health into medical and health training –Train policy-makers and planners in health equity impact assessment –Strengthen capacity within WHO to support action on social determinants

58. Information about WHO www.who.int.www. who.dk Country Office in the Czech Republic www.who.cz