Quarterly of the European Observatory on Health Systems and Policies

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] Learning how to mind the gap
Volume 21 | Number 1 | 2015

• Public health monitoring

:: Special Issue ::

] Glasgow Declaration
& reporting

PULX\HSP[PLZ ] Migrant & ethnic minority

• Developing public health
workforce
PUOLHS[OHUK populations
] Health information
• Learning from each other

OLHS[OJHYL • Building sustainable &

resilient health systems
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Quarterly of the
European Observatory on Health Systems and Policies
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Email: info@obs.euro.who.int
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:,5069,+0;690(3;,(4
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Anna Maresso: a.maresso@lse.ac.uk
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,+0;690(3(+=0:69
Willy Palm: wpa@obs.euro.who.int

-6<5+05.,+0;69
Elias Mossialos: e.a.mossialos@lse.ac.uk

LSE Health, London School of Economics

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,+0;690(3(+=0:69@)6(9+
Paul Belcher, Reinhard Busse, Josep Figueras,
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*65;,5;:


3PZ[VM*VU[YPI\[VYZ
Margaret M. Barry Š School of Health Sciences,
National University of Ireland Galway, Ireland.
Vesna Bjegovic-Mikanovic Š School of
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.
2 4HY[PU4J2LLHUK+PULRLALLNLYZ7HNL[
Public Health, Belgrade University, Serbia.
Raj Bhopal Š Centre for Population Health
Sciences, University of Edinburgh, Scotland.
Marine Buissonniere Š Public Health Program,
Open Society Foundations, New York, USA.
Eurohealth Observer Jonathan Cohen Š Public Health Program,
Open Society Foundations, New York, USA.
Valerie Curtis Š Hygiene Centre, The

3 HEALTH INEQUALITIES:3,(9505./6>;6
¸405+;/,.(7¹¶1VOHU74HJRLUIHJO
London School of Hygiene & Tropical
Medicine, London, United Kingdom.
Judith de Jong Š NIVEL, The Netherlands
 LASGOW DECLARATION¶º(33/(5+:65+,*2»;6
7 G
*36:,;/,/,(3;/05,8<(30;0,:.(7
Institute for Health Services Research,
Utrecht, The Netherlands.
Irina Dinca Š Public Health Capacity and
3,(+,9:/07-964>0;/05!ROMA COMMUNITIES
8
Communication Unit (PHC), European
Centre for Disease Prevention and
RESPONDING TO HEALTH INEQUALITY05,<967,¶ Control (ECDC), Stockholm, Sweden.
4HYPUL)\PZZVUUPLYLHUK1VUH[OHU*VOLU Karl Ekdahl Š Public Health Capacity and
Communication Unit (PHC), European
Centre for Disease Prevention and
Control (ECDC), Stockholm, Sweden.

Eurohealth International Anders Foldspang Š Department of Public

Health, Aarhus University, Aarhus, Denmark.
Peter Groenewegen Š NIVEL, The
 3,(9505.-964,(*/6;/,9!>/,9,HEALTH
13 PROMOTION MEETS INFECTIOUS DISEASES¶
,YPR*9\SHUK0YPUH+PUJH=HSLYPL*\Y[PZ4HYNHYL[4)HYY`
Netherlands Institute for Health Services
Research, Utrecht, The Netherlands.
Johan Hansen Š NIVEL, The Netherlands
Institute for Health Services Research,
2HYS,RKHOSHUK(\YH;PTLU Utrecht, The Netherlands.
Elke Jakubowski Š Division of Health
 PUBLIC HEALTH MONITORING AND REPORTING!
17 4(05;(0505.(5+04796=05.;/,,=0+,5*,)(:,¶
5PJVSL9VZLUR€[[LYHUK4HYQH]HU)VU4HY[LUZ
Systems and Public Health, WHO Regional
Office for Europe, Copenhagen, Denmark.
Allan Krasnik Š Department of Public Health,
University of Copenhagen, Denmark.
Alistair Leyland Š MRC/CSO
 CHANGING YOUR HEALTH BEHAVIOUR!9,.<3(;,
21 6956;&¶,SZ4HLJRLSILYNOLHUK4HY[PU4J2LL
Social and Public Health Sciences,
University of Glasgow, Scotland.
Johan P. Mackenbach Š Department
+
 ,=,36705.;/,7<)30*/,(3;/>692-69*,¶
24
of Public Health, Erasmus MC,
Rotterdam, The Netherlands.
=LZUH)QLNV]PJ4PRHUV]PJ(UKLYZ-VSKZWHUN,SRL Elis Maeckelberghe Š Institute for
1HR\IV^ZRP1HJX\LSPUL4 SSLY5VYKOVYU9VILY[6[VR Medical Education, University Medical
Centre Groningen, The Netherlands.
HUK3V\PZL:[QLYUILYN
Erika Marek Š University of Pécs
Medical School, Hungary.
Martin McKee Š The London School

Eurohealth Systems and Policies of Hygiene & Tropical Medicine and

European Observatory on Health Systems
and Policies, United Kingdom.
 BUILDING SUSTAINABLE AND RESILIENT HEALTH Jacqueline Müller-Nordhorn Š Berlin School
28 CARE SYSTEMS!/6>,9(5,;:05/690A65*(5
/,37¶1VOHU/HUZLU1\KP[OKL1VUN7L[LY.YVLUL^LNLU
of Public Health – Charité, Berlin, Germany.
Robert Otok Š ASPHER Office,
Brussels, Belgium.
HUK>HS[LY9PJJPHYKP Walter Ricciardi Š Catholic University
of the Sacred Heart, Rome, Italy.
Nicole Rosenkötter Š NRW Centre for
Health, Bielefeld, Germany and Faculty of
Eurohealth Looking Forward Health, Medicine and Life Sciences, CAPHRI,
Maastricht University, The Netherlands.

 LEAVING A LEGACY05GLASGOW ¶+PULRLALLNLYZ Erik C. Ruland Š Department of Infectious

32 7HNL[
Diseases Control, Municipal Health Service
(Utrecht region), Zeist, The Netherlands.
Louise Stjernberg Š Department
,
 <967,»:*/(33,5.,05REDUCING HEALTH AND
34 HEALTH CARE INEQUITIES ¶>HS[LY9PJJPHYKP
of Health, Blekinge Institute of
Technology, Karlskrona, Sweden.
Aura Timen Š National Coordination
Quarterly of the European Observatory on Health Systems and Policies
Centre for Communicable Disease Control
,<96/,(3;/ (LCI), RIVM-Centre for Communicable

Eurohealth Monitor
PUJVYWVYH[PUN,\YV6IZLY]LY
9,:,(9*/‹+,)(;,‹7630*@‹5,>:
Diseases, Bilthoven, The Netherlands.
Marja van Bon-Martens Š Trimbos
7th European Public Health Conference

Institute, Netherlands Institute of Mental

 NEW PUBLICATIONS
38 Health and Addiction, Utrecht, and Tranzo,
Scientific Centre for Care and Welfare,
Tilburg University, The Netherlands.
© Jack Sullivan – Alamy

 NEWS Dineke Zeegers Paget Š European

i9LK\JPUN
] Learning how to mind the gap

39 Public Health Association (EUPHA)

Volume 21 | Number 1 | 2015

• Public health monitoring

:: Special Issue ::

] Glasgow Declaration
& reporting

PULX\HSP[PLZ
PUOLHS[OHUK
] Migrant & ethnic minority
populations
] Health information
• Developing public health
workforce
• Learning from each other
Utrecht, The Netherlands.
OLHS[OJHYL • Building sustainable &
resilient health systems

,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

 

,KP[VYPHS!/LHS[OPULX\HSP[PLZHYL\UULJLZZHY`HUK\UQ\Z[
Inequalities in health exist both within and between countries. They systems. Rosenkötter and van Bon-
Martens discuss the state of national
are both unnecessary and unjust. They also create a great cost
health information systems throughout
to societies, not only through the direct costs of providing health Europe in a time of austerity and,
in particular, focus on the need for
care for those with avoidable illness but also the costs of reduced
much better data on morbidity from
participation in the workforce and lower productivity. In November specific diseases and external causes.
Maeckelberghe and McKee argue in favour
2014, these issues were brought to the fore when Glasgow hosted
of “progressive universalism” – public
the 7th European Public Health Conference with the theme “Mind the health policy directed at improving the
health of all but with increased emphasis
Gap: Reducing Inequalities in Health and Health Care”. It was fitting
placed on improving the health of those
for such a conference to be held in Glasgow given that the World in greatest need, thereby reducing
health inequalities. They provide many
Health Organization report of the Commission on Social Determinants
examples of the successes that can be
of Health had contrasted the very low life expectancy in one part of achieved when necessary governmental
regulation is accompanied by measures
the city (Calton – 54 years) with that in a more affluent area nearby
empowering individuals and communities
(Lenzie North – 82 years). Even more shocking, it showed that life and an increase in the accountability
of policy-makers. The World Health
expectancy in Calton lagged behind the average experience of some
Organization has recognised the need
low income countries (India – 62 years, Philippines – 64 years). to develop the public health workforce,
and Bjegovic-Mikanovic and colleagues
The conference, organised by the then show how Roma communities have describe the current state of education
European Public Health Association taken the lead in initiatives to improve the and training across Europe concluding
and the UK’s Society for Social health of their communities, so that they with specific recommendations to policy-
Medicine, provided an opportunity for have not only reduced the health gap makers and Schools of Public Health.
researchers, practitioners and policy- with non-Roma communities but also
makers to exchange opinions and contributed to improving the health of In the Systems and Policies section
examples of best practice, to improve the overall population. These examples, Hansen and colleagues describe the
our understanding of the nature, extent whereby Roma have increased social development of a European Research Area
and causes of inequalities and to share accountability, improved access to health network in health services and systems
ideas and experiences regarding the care, and challenged beliefs about the research. This network will concentrate
means to reduce inequalities. This issue place of Roma within the public health on the transferability of successful
of Eurohealth highlights some of the system, illustrate how empowered health care models from one country
main contributions to the conference communities can bring about change. to another, identifying the necessary
and provides a timely update of current This section also contains a description of preconditions for successful transfer of
knowledge and areas for action in Europe. a meeting that examined the adaptation policies or the arrangement of services.
of interventions designed to improve the Ricciardi concludes this issue by providing
Mackenbach opens the Observer conditions of migrant and ethnic minority a summary of some of the lessons
section and talks of the shift in research populations, drawing on nine invited learned at the conference. Bringing
on inequalities, moving from a focus presentations and summarising the together over 1500 participants from so
on description to explanation and on lessons learned for intervention research. many countries undoubtedly provided a
to intervention. Both the increase in learning opportunity for all constituents
knowledge as to what works to reduce In the Eurohealth International section, of the public health community –
inequalities, made possible in part Ruland and colleagues discuss the researchers, practitioners and policy-
by concerted action by the European potential contribution of behaviour-centred makers. The Glasgow Declaration is a
Commission, and the evidence that design to improved health promotion part of making sure that reducing health
some inequalities in health are starting and infectious disease control. They go inequalities remains high on the agenda
to decrease are to be welcomed. This on to highlight the need for more and of the EU and all Member States.
research has informed the Glasgow better formative research, particularly
Declaration: a call for “all hands on deck” in response to emerging diseases. (SHZ[HPY/3L`SHUK>HS[LY9PJJPHYKP
to reduce health inequalities, suggesting 4HY[PU4J2LLHUK+PULRLALLNLYZ7HNL[
that this is not just a problem for the public Evidence-informed policy-making
health community but one for the wider all (including policy to reduce inequalities) Cite this as: ,\YVOLHS[O 2015; 21(1).


of society. Buissonniere and Cohen is dependent on high quality information

,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

,\YVOLHS[O6):,9=,9 

HEALTH INEQUALITIES:
3,(9505./6>;6¸405+;/,.(7¹
By: Johan P. Mackenbach

Summary: Recent years have seen progress on tackling inequalities

in health between socioeconomic groups in Europe on two fronts:
several studies exploiting natural policy experiments have generated
new knowledge on the effectiveness of interventions and policies to
reduce health inequalities; and trend data on health inequalities show
that some inequalities, particularly absolute inequalities in mortality
among men, are becoming smaller instead of larger. Nevertheless,
health inequalities remain unacceptably large, and it will require
“all hands on deck” to close the health inequalities gap.

.H\ZRUGV+HDOWK,QHTXDOLWLHV1DWXUDO3ROLF\([SHULPHQWV7UHQGV5HVHDUFK

Johan P. Mackenbach is
Professor, Department of Public
Health, Erasmus MC, Rotterdam,
The Netherlands. Email:
j.mackenbach@erasmusmc.nl
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,\YVOLHS[O6):,9=,9 

Figure 1: Changes in educational inequalities in mortality between the 1990s and 2000s, by country/region and sex

a. Relative inequalities, men b. Absolute inequalities, men

Rate Ratio Mortality Rate Ratio, Men Deaths per 100,000 Mortality Rate Difference, Men
3.5 2000
1990s 1990s

3.0 2000s 2000s

1500
2.5

2.0
1000
1.5

1.0
500

0.5

0.0 0
Finland

Sweden

Norway

Denmark

England & Wales

Belgium

France

Switzerland

Barcelona

Basque C

Madrid

Turin

Hungary

Lithuania

Estonia

Finland

Sweden

Norway

Denmark

England & Wales

Belgium

France

Switzerland

Barcelona

Basque C

Madrid

Turin

Hungary

Lithuania

Estonia
c. Relative inequalities, women d. Absolute inequalities, women
Rate Ratio Mortality Rate Ratio, Women Deaths per 100,000 Mortality Rate Difference, Women
3.0 800
1990s 1990s

700
2.5 2000s 2000s

600

2.0
500

1.5 400

300
1.0
200

0.5
100

0.0 0
Finland

Sweden

Norway

Denmark

England & Wales

Belgium

France

Switzerland

Barcelona

Basque C

Madrid

Turin

Hungary

Lithuania

Estonia

Finland

Sweden

Norway

Denmark

England & Wales

Belgium

France

Switzerland

Barcelona

Basque C

Madrid

Turin

Hungary

Lithuania

Estonia

Rate Ratios and Rate Differences calculated from age-standardised all-cause mortality rates of those with no, primary or lower secondary education versus those with tertiary education.
Source: 

OLWWOHWRGRZLWKHDFKRWKHU7KHGHFOLQH HQRUPRXVDFKLHYHPHQWRIPDQ\:HVWHUQ References

RIDEVROXWHLQHTXDOLWLHVLQPRUWDOLW\VHHQ
LQVRPHFRXQWULHVZDVQRWGXHWRWKH
LPSOHPHQWDWLRQRISROLFLHVDLPLQJWR
UHGXFHKHDOWKLQHTXDOLWLHVEXWUHSUHVHQWV
JHQHUDOSURJUHVVLQUHGXFLQJPRUWDOLW\
(XURSHDQFRXQWULHVZKLFKZRXOGQRWKDYH  Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P,
EHHQSRVVLEOHZLWKRXWVRPHGHJUHHRI Consortium for the European Review of Social
HTXDOLW\RIDFFHVVWRKHDOWKFDUH Determinants of Health. WHO European review of
social determinants of health and the health divide.
1HYHUWKHOHVVPXFKUHPDLQVWREH The Lancet 2012;380(9846):1011 – 29.

ZKLFKZDVVKDUHGPRUHRUOHVVHTXDOO\ GRQHSDUWLFXODUO\LIZHDLPDWUHGXFLQJ 

Mackenbach JP, Bakker MJ. Tackling
EHWZHHQVRFLRHFRQRPLFJURXSV UHODWLYHLQHTXDOLWLHVLQKHDOWK+HDOWK socioeconomic inequalities in health: analysis
LQHTXDOLWLHVUHPDLQXQDFFHSWDEO\ODUJH of European experiences. The Lancet 2003;
362(9393):1409 – 14.
2QHH[DPSOHLVWKHGHFOLQHLQPRUWDOLW\ ERWKLQDEVROXWHDQGUHODWLYHWHUPVDQG
IURPFDUGLRYDVFXODUGLVHDVHZKLFKKDV ZKLOHHYLGHQFHRQWKH LQ HIIHFWLYHQHVVRI

Reeves A, McKee M, Mackenbach JP, et al.
EHHQODUJHULQDEVROXWHWHUPVDPRQJWKH SROLFLHVDQGLQWHUYHQWLRQVWRUHGXFHKHDOWK Introduction of a National Minimum Wage reduced
depressive symptoms in low-wage workers: a
ORZWKDQDPRQJWKHKLJKHGXFDWHGLQPDQ\ LQHTXDOLWLHVLVDFFXPXODWLQJWKHSROLWLFDO natural experiment in the UK. Manuscript submitted
:HVWHUQ(XURSHDQFRXQWULHVSUREDEO\ ZLOOWRLPSOHPHQWWKHVHSROLFLHVDQGWR for publication.
DVDUHVXOWRIDGYDQFHVLQSUHYHQWLRQDQG DOORFDWHWKHUHVRXUFHVQHFHVVDU\WRDFKLHYH 
Mehdipanah R, Rodríguez-Sanz M, Malmusi D,
WUHDWPHQWRIWKHVHFRQGLWLRQVZKLFKKDYH SRSXODWLRQOHYHOHIIHFWVLVRIWHQODFNLQJ et al. The effects of an urban renewal project on
EHQHILWHGDOOVRFLDOVWUDWD6XFKEHQHILWV $VWKH*ODVJRZGHFODUDWLRQULJKWO\VWDWHV health and health inequalities: a quasi-experimental
WRORZHUVRFLRHFRQRPLFJURXSVGRQRW LWLV³DOOKDQGVRQGHFN´WRFORVHWKHKHDOWK study in Barcelona. Journal of Epidemiology and
FRPHDXWRPDWLFDOO\EXWUHSUHVHQWDQ LQHTXDOLWLHVJDS Community Health. 2014:jech-2013-203434.

,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

 ,\YVOLHS[O6):,9=,9

Some tweets from the Conference #ephglasgow


Wahrendorf M, Siegrist J. Proximal and distal
determinants of stressful work: framework and
analysis of retrospective European data.
BMC Public Health 2014;14(1):849.

Kuipers MA, Nagelhout GE, Willemsen MC, 3URI:KLWHKHDGJRYHUQPHQWVVKRXOG
Kunst AE. Widening educational inequalities in LQYHVWLQVRFLDOSURWHFWLRQRYHUDXVWHULW\
adolescent smoking following national tobacco PHDVXUHVWKDWKLWKDUGWKHPRUH
control policies in the Netherlands in 2003: a time
GLVDGYDQWDJHGHSKJODVJRZ
series analysis. Addiction 2014; 109(10):1750– 9.

Herttua K, Mäkelä P, Martikainen P. The effects of
a large reduction in alcohol prices on hospitalizations
related to alcohol: a population-based natural $FFHVVWRFDUHNH\LQGHFUHDVLQJ
experiment. Addiction 2011;106(4):759 – 67. PRUWDOLW\DPRQJORZHUVRFLRHFRQRPLF

JURXSVHSKJODVJRZ
Mackenbach JP, Kulhánová I, Menvielle G, et al.
Trends in inequalities in premature mortality: a study
of 3.2 million deaths in 13 European countries.
Journal of Epidemiology and Community Health.
2014:jech-2014-204319.
.DUO(NGDKOLVZDUQLQJWKDWKHDOWK
 
Harper S, King NB, Meersman SC, et al. Implicit SROLWLFLDQVDUHQRWDZDUHRIORZHUDFFHVV
value judgments in the measurement of health WRKHDOWKFDUHIRUYXOQHUDEOHJURXSV
inequalities. The Milbank Quarterly 2010;88(1):4 – 29.
HSKJODVJRZ
Epub 2010/04/10.

Mackenbach JP. Should we aim to reduce relative
or absolute inequalities in mortality? European
Journal of Public Health 2015 (in press).
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,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

,\YVOLHS[O6):,9=,9
.3(:.6>+,*3(9(;065
‘ALL HANDS ON DECK’ TO CLOSE THE HEALTH INEQUALITIES GAP
0U[YVK\J[PVU
Glasgow welcomed Europe and
beyond to the 7th European Public
Health (EPH) Conference between 19th
and 22nd November 2014. Sixty-
five countries were represented by
over 1500 delegates, who gathered to
discuss and debate the knowledge and
practice of reducing health inequalities.
Over the course of the conference,
which included seven plenary
sessions, over 100 parallel sessions,
about 300 posters and six films,
delegates had the opportunity to share
findings from research and experiences
with innovation in all fields of public
health and health services.
Researchers, educators, policy-makers,
community representatives and health
managers from Europe and beyond
shared new information and insights from
their experiences with interventions to
reduce health inequalities, the theme of
the conference, and developed a deeper
understanding of the urgency to address
this issue.
This Declaration summarises broad
ranging discussions over the three
days of the conference, drawing
upon rapporteurs’ notes across all
the sessions.
;OLMHJ[Z
Health inequalities exist not only between
countries but also within countries.
Health inequalities refer to differences in
people’s health and life chances. Health
inequalities are strongly related to the
conditions in which people live, such
as their income, employment status or
the area they reside in. In the UK, for
example, those living in the richer areas
will live, on average, seven years longer
than those who live in poor and deprived
areas. Priority areas in health inequalities
are tobacco, alcohol, addictive drugs
and poor diet.
While there are some welcome
indications that inequalities have
started to narrow in recent years, at
least on an absolute scale, they are still
unacceptably large.
The evidence presented at the
EPH Conference in Glasgow was
overwhelming:
• Health inequalities between countries
amount to a gap of 8.9 years of
life expectancy between Latvia
(74.1 years in 2012) and Iceland
(83.0 in 2012)
• Health inequalities within countries
systematically favour the well off. In
Glasgow, for examples, there is a
nine-year gap in male life expectancy
between neighbourhoods.
At the conference, several promising
examples were presented, including:
• Involving peer groups (professional
sports clubs willing to ‘buy in’ to
health improvement programmes for
their fans) has a positive effect on
lifestyle changes
• Green spaces in urban environments
have a positive effect on mental health
• Regulation by authorities having a
positive impact on healthy choices
(e.g. Danish fat tax and potential UK
sugar tax)
• Organising better access to health
care by making ethnic/migration
status a routine part of policy.
Even though there have been successes,
health inequalities are still unacceptably
large. Recent trends, for example in
cardiovascular disease mortality, suggest
that reducing health inequalities is
indeed feasible. National programmes
in various European countries to tackle
health inequalities have so far been only
partly successful, and have shown that
we need to re-think what is needed to
measurably reduce health inequalities
at the population level. The focus going
forward should be on a reduction of
absolute and relative health inequalities.
,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015
;OLZVS\[PVUZ
Glasgow 2014 has made us aware
that we not only have to ‘mind the
gap’ in health inequalities, we need
to go much further than that. It is ALL
HANDS ON DECK! The whole public
health community and the whole of
society needs to get involved in reducing
health inequalities.
We need to:
• Increase the available data and also
studies on how to achieve population
wide impact
• Translate research/evidence to policy
consistently and at all levels
• Understand what works to reduce
health inequalities, for whom, and why
• Ensure that policies are based on
established models of good practice
and evaluated both in terms of
economic and health benefits
• Exchange best practice (international,
national) to learn from each other
• Think outside the box: topics to be
covered include poverty reduction,
improving employment and working
conditions, tobacco and alcohol
control and urban renewal
• Foster public engagement and
solidarity
• Increase personal engagement
• Develop the commitment of the public
health community
• Obtain a commitment from the
community
;OLUL_[Z[LWZ
At the 8th European Public Health
Conference, in October 2015, in Milan,
Italy, we will evaluate what processes
have been put in place that can reduce
health inequalities. We encourage
researchers, governments, NGOs
and funders to attend Milan 2015 and
contribute towards this vision.

3,(+,9:/07-964>0;/05!ROMA
COMMUNITIES RESPONDING TO
HEALTH INEQUALITY05,<967,
By: Marine Buissonniere and Jonathan Cohen
Marine Buissonniere is
Director and Jonathan Cohen
is Deputy Director of the Public
Health Program, Open Society
Foundations, New York, USA.
Email: marine.buissonniere@
opensocietyfoundations.org
,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015
,\YVOLHS[O6):,9=,9
Summary: The economic crisis disproportionately impacted
on European Roma’s access to health care, with health status
deteriorating further. While state efforts have produced limited results
to address social exclusion in health facing Roma, Roma communities
themselves are leading on solutions that can lead to better health for
Roma and beyond. Whether using social accountability methods to
hold authorities to account for health-related commitments; working
with paralegals to overcome obstacles to care; or changing the system
from within by becoming medical professionals, Roma communities
are challenging the prevailing narrative of Roma as burdens on – to
become leaders of – Europe’s health systems.
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have begun this process but it has been difficult to reach

Assessing chronic disease conclusions about the best approach to take: care models are
management in European highly context-dependent and scientifically rigorous evaluations
have been lacking.
health systems
Assessing chronic disease management in European health
Edited by: E Nolte, C Knai & RB Saltman. systems explores some of the key issues, ranging from
interpreting the evidence base to assessing the policy context
Copenhagen: World Health Organization / European
for, and approaches to, chronic disease management across
Observatory on Health Systems and Policies, 2014
Europe. Drawing on twelve detailed country reports (available
Number of pages: 97, ISBN: 978 92 890 5030 2, in a second, online volume), the
37
Observatory Study Series 37
37
se ss ing ch ronic study provides insights into the
As
Studies Series
Observatory

gement
ASSESSING CHRO

disease mana
in Eu rop ea n range of care models and the
Freely available for download at: http://www.euro.who. health systems
Concepts
people involved in delivering these;
NIC DISE

int/__data/assets/pdf_file/0009/270729/Assessing-chronic- and approache

s
payment mechanisms and service
Saltman
ASE MANAGEM

Edited by
disease-management-in-European-health-systems.pdf?ua=1 Ellen Nolte
Cécile Knai
user access; and challenges faced
Richard B. Saltm
an

by countries in the implementation

ENT IN EURO

The rising burden of chronic illness, in particular the rapid

and evaluation of these novel
increase in the number of people with multiple health problems,
PEAN HEALTH

approaches.
is a challenge to health systems globally. Associated premature
SYSTEMS

mortality and reduced physical functioning, along with higher This book builds on the findings
use of health services and related costs, are among the key of the DISMEVAL project
concerns faced by policy-makers and practitioners. (Developing and validating
DISease Management
There is a clear need to redesign delivery systems in order to
EVALuation methods for European health care systems),
better meet the needs created by chronic conditions, moving
led by RAND Europe and funded under the European Union’s
from the traditional, acute and episodic model of care to one
(EU) Seventh Framework Programme (FP7) (Agreement
that better coordinates professionals and institutions and
no. 223277).
actively engages service users and their carers. Many countries

,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

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Adaptation of health promotion and disease prevention interventions for

migrant & ethnic minority populations: policy, practice and research
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3,(9505.-964,(*/6;/,9!
>/,9,HEALTH PROMOTION
MEETS INFECTIOUS DISEASES
By: Erik C. Ruland, Irina Dinca, Valerie Curtis, Margaret M. Barry, Karl Ekdahl and Aura Timen

Summary: Communicable disease control can benefit from the

transfer of knowledge on health promotion. Behaviour change
interventions are more effective if they incorporate recent insights
on formative research and emotional drivers. By mapping current
health communication activities in Europe, a range of perceived needs
and a wealth of opportunities emerged. Furthermore, successful
interventions in non-communicable disease have shown that political
commitment is essential to develop public health policies. In order
to get these policies adopted, health professionals need to develop
vision, strategy and effective action. As public health budgets are
limited ‘smart collaboration initiatives’ are needed to drive
capacity development.

Erik C. Ruland is Senior Expert,

Department of Infectious Diseases
Control, Municipal Health Service
Utrecht region (GGD regio Utrecht),
Zeist, The Netherlands; Irina Dinca
is Senior Expert and Karl Ekdahl
is Head, Public Health Capacity
and Communication Unit (PHC),
European Centre for Disease
Prevention and Control (ECDC),
Stockholm, Sweden; Valerie Curtis
is Director of the Hygiene Centre,
London School of Hygiene &
Tropical Medicine, London, United
Kingdom; Margaret M. Barry is
Head, World Health Organization
Collaborating Centre for Health
Promotion Research, School
of Health Sciences, National
University of Ireland Galway,
Galway, Ireland; Aura Timen
is Head, National Coordination
Centre for Communicable Disease
Control (LCI), RIVM-Centre for
Communicable Diseases, Bilthoven,
The Netherlands and President
of the Section Infectious Disease
Control of the EUPHA.
Email: eruland@ggdru.nl
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,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

,\YVOLHS[O05;,95(;065(3 


Sixsmith J, Doyle P, D’Eath M, Barry MM. Health
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Academic Collaborative Centres Public Health
[web site]. Available at: http://www.zonmw.nl/en/
programmes/academic-collaborative-centres-public-
By: Nicole Rosenkötter and Marja van Bon-Martens
health/programme/

Academische Werkplaatsen Publieke Gezondheid
in kaart gebracht; samenwerken aan lokaal
gezondheidsbeleid [Academic Collaborative Centres
for Public Health mapped; working together to
improve public health at the local level]. ZonMw,
2012 (in Dutch)]. Available at: http://www.zonmw.nl/ Summary: It is undisputed that reliable and comprehensive health
fileadmin/documenten/AWPG/AWPG_IN_KAART_
GEBRACHT_KLEIN2_.pdf information is needed to support evidence-informed policy-making.
This article gives an overview of the drivers and actions that aim to
improve the health information infrastructure in Europe. In addition to
outlining the status quo of international infrastructure development,
Acknowledgement: We would this article highlights existing gaps in monitoring health inequalities
like to thank the presenters and
participants of the EPH Conference and in data sources for monitoring morbidity. A sustainable health
workshops co-organised by the
EUPHA Public Health Monitoring information infrastructure in Europe, a feasible legal framework,
and Reporting section for sharing
their thoughts and information. as well as opportunities for good-practice exchange, would help
to overcome information gaps and improve the possibilities for
evidence-informed decision making.
Nicole Rosenkötter is President of
the EUPHA Public Health Monitoring
and Reporting (PHMR) section,
Research Associate at NRW Centre .H\ZRUGV3XEOLF+HDOWK0RQLWRULQJDQG5HSRUWLQJ+HDOWK,QIRUPDWLRQ6\VWHP+HDOWK
for Health, Public Health Reporting ,QHTXDOLWLHV0RUELGLW\6WDWLVWLFV
Group, Bielefeld, Germany and
Faculty of Health, Medicine and Life
Sciences, CAPHRI, Department of
International Health, Maastricht
University, The Netherlands;
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WHO Regional Office for Europe. Partnerships
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 Have you ever wondered why some
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lead to higher expenditures?

Council of the European Union. Council
Join the WE CARE Conference:
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responsive and sustainable health systems”. Pan-European Road Towards
Brussels: Council of the European Union, 2013. Future Healthcare to find out!
Available at: http://www.consilium.europa.eu/
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When: 14th – 15th April 2015

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listen to, debate and influence future
 
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,\YVOLHS[O05;,95(;065(3
CHANGING YOUR HEALTH
BEHAVIOUR!9,.<3(;,6956;&
By: Els Maeckelberghe and Martin McKee
Elis Maeckelberghe is Senior
Lecturer in ethics at the Institute
for Medical Education, University
Medical Centre Groningen, The
Netherlands and Martin McKee is
Professor of European Public Health
at The London School of Hygiene
& Tropical Medicine, and Director
of Research at the European
Observatory on Health Systems and
Policies, United Kingdom. Email:
e.l.m.maeckelberghe@umcg.nl

Summary: The overwhelming message of the EPH-conference is that
taking health inequalities seriously demands a portfolio of approaches.
Regulating health behaviour is neither a choice for liberalism (self-
regulation) nor for paternalism (interventionism). Regulation and fiscal
policies are essential but they must be accompanied by measures to
empower people and to hold accountable those (policy-makers at local,
national and European levels) who may make populations vulnerable.
These policy-makers would have benefited greatly from listening to the
discussions among public health researchers at the EPH in Glasgow.
It is now our task to take these messages to them.
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References

Understanding Glasgow. Available at: www.
understandingglasgow.com/films/understanding_
glasgow_film_series/young_mums
political writings. Vol 2. New York, NY: Vintage Press,
1974:143–249.

Leichter HM. Free to Be Foolish: Politics and Health
Promotion in the United States and Great Britain.
Princeton NJ: Princeton, 2014.
BMJ 2012;345:e8082.

Taylor G, Hawley H. Health promotion and the
freedom of the Individual. Health Care Analysis

Mackenbach J. Kos, Dresden, Utopia … A Journey
through idealism past and present in Public Health.
European Journal of Epidemiology 2005;20:817 – 26.

Powers M, Faden R. Social Justice: The Moral
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Oxford: Oxford University Press, 2005.

Goodin RE. Protecting the Vulnerable. Chicago:

DEVELOPING THE PUBLIC
HEALTH WORKFORCE
By: Vesna Bjegovic-Mikanovic, Anders Foldspang, Elke Jakubowski, Jacqueline Müller-Nordhorn,
Robert Otok and Louise Stjernberg
Vesna Bjegovic-Mikanovic is
Professor, School of Public Health,
Belgrade University, Belgrade,
Serbia; Anders Foldspang is
Professor, Department of Public
Health, Aarhus University, Aarhus,
Denmark; Elke Jakubowski
is Head of the Public Health
Services Programme, Division
of Health Systems and Public
Health, WHO Regional Office for
Europe, Copenhagen, Denmark;
Jacqueline Müller-Nordhorn is
Professor, Berlin School of Public
Health – Charité, Berlin, Germany;
Robert Otok is Director, ASPHER
Office, Brussels, Belgium; Louise
Stjernberg is Associate Professor/
Docent, Department of Health,
Blekinge Institute of Technology,
Karlskrona, Sweden.
Email: bjegov@med.bg.ac.rs
,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015
,\YVOLHS[O05;,95(;065(3
Summary: The development of the public health workforce is a
cornerstone in WHO’s Action Plan for Strengthening Public Health
Services and Capacities. Public health education shall combine
Essential Public Health Operations – surveillance; monitoring; health
protection and promotion; disease prevention; service delivery;
communication and research – with the competences needed within:
public health methods; population health and its social, economic
and environmental determinants; and man-made systems and
interventions to improve population health. An authorised public
health profession founded on graduation from comprehensive public
health education is needed. The capacity and standards of Schools
of Public Health should accordingly be continuously developed.
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Table 1: Chapters of WHO Europe’s Essential Public Health Operations SXEOLFKHDOWKLQWHUYHQWLRQV3XEOLFKHDOWK

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1. Surveillance of population health and well-being
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4. Health promotion including action to address social determinants and health inequity 7KHFUHDWLRQRID(XURSHDQQHWZRUN
5. Disease prevention, including early detection of illness LQUHVHDUFKWUDLQLQJDPRQJ$63+(5
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7. Assuring a sufficient and competent public health workforce
8. Assuring sustainable organisational structures and financing
9. Advocacy, communication and social mobilisation for health
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,\YVOLHS[O05;,95(;065(3
Table 2: Chapters of European Core Competences for Public Health Professionals and
for MPH Education
Chapter content/theme
Methods in public health
Population health and its social and economic determinants
Population health and its material – physical, radiological, chemical and biological –
environmental determinants
Health policy; economics; organisational theory and management*
Health promotion: health education, health protection and disease prevention
Ethics
* Including leadership
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References

Whitehead M, Povall S, Loring B. The equity
Guidance for addressing inequities in health.
Copenhagen: WHO Europe, 2014.

WHO Regional Office for Europe. European Action
http://www.euro.who.int/en/health-topics/Health-
systems/public-health-services/publications2/2012/
health-capacities-and-services

Martin-Moreno JM. Self-assessment tool for the
evaluation of essential public health operations in the
WHO European Region. Copenhagen: WHO Europe,
2014.
,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015


Foldspang A, Otok R, Czabanowska K,
Bjegovic-Mikanovic V. Developing the Public
Health Workforce in Europe: The European
Public Health Reference Framework (EPHRF):
It’s Council and Online Repository. Concepts
and Policy Brief. Brussels: ASPHER, 2014.
Available at: http://www.aspher.org/repository/
index.php?get_action=open_file&repository_
id=0&file=%2FASPHER%2FASPHER%20
Positions%2FEPHRF_Concept_and_Policy_Brief.pdf

Bjegovic-Mikanovic V, Czabanowska K,
Flahault A, et al. Addressing needs in the public
health workforce in Europe. Policy Summary 10.
Copenhagen: European Observatory on Health
Systems and Policies, 2014. Available at: http://www.
euro.who.int/_ _data/assets/pdf_file/0003/248304/
Addressing-needs-in-the-public-health-workforce-in-
Europe.pdf?ua=1

Birt C, Foldspang A. European Core
Competences for Public Health Professionals
(ECCPHP). ASPHER’s European Public Health
Core Competences Programme. ASPHER
Publication No. 5. Brussels: ASPHER, 2011.
Available at: http://www.aspher.org/repository/
index.php?get_action=open_file&repository_
id=0&file=%2FASPHER%2FPublic%20Health%20
Competences%2FEPHCCP_ECC_PH-Professionals.
pdf

ASPHER Working Group on Innovation and Good
Practice in Public Health Education. Survey of the
European Schools and Departments of Public Health
and the Employers of Public Health Professionals.
Report. Brussels: ASPHER, 2012.

ASPHER Working Group on Undergraduate
Programmes. Undergraduate Education in Public
Health in Europe. Report. Brussels: ASPHER, 2014.
 
Bjegovic-Mikanovic V, Vukovic D, Otok R,
Czabanowska K, Laaser U. Education and training of
public health professionals in the European Region:
variation and convergence. Int J Public Health
2013;58(6):801-10. DOI: 10.1007/s00038-012-0425-
2

SPHER Working Group on Doctoral Programmes
and Research Capacities. Recommendations for PhD
Programmes in Public Health. Brussels: ASPHER,
2013.

Vukovic D, Bjegovic-Mikanovic V, Otok R,
Czabanowska K, Nikolic Z, Laaser U. Which level
of competence and performance is expected?
A survey among European employers of public health
professionals. Int J Public Health 2014;59(1):15 – 30.
DOI: 10.1007/s00038-013-0514-x

Working Group on Innovation and Good Practice
in Public Health Education (WGIGP). Modern
Teaching – Distance Learning, a guide to online and
blended learning – with case studies from public
health. Brussels: ASPHER, 2013.
 ,\YVOLHS[O:@:;,4:(5+7630*0,:
BUILDING SUSTAINABLE AND
RESILIENT HEALTH CARE
SYSTEMS!/6>,9(5,;:05
/690A65*(5/,37
By: Johan Hansen, Judith de Jong, Peter Groenewegen and Walter Ricciardi
Johan Hansen is senior researcher
at NIVEL, The Netherlands Institute
for Health Services Research,
Utrecht, The Netherlands and
project coordinator of HRS Europe;
Judith de Jong is programme
coordinator at NIVEL and
President of the EUPHA Section
on Health Services Research;
Peter Groenewegen is director at
NIVEL and Lead of the Research
Pillar, EUPHA; Walter Ricciardi
is Past President, EUPHA and
Professor of Hygiene and Public
Health, Catholic University of the
Sacred Heart, Rome, Italy.
Email: J.Hansen@nivel.nl
,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015
Summary: Currently, a European Research Area network (ERA-NET)
research programme – within Horizon 2020 – is being developed in
the area of health services and systems research. It focuses on two
meta-questions 1) under what conditions can health care innovations
be effectively transferred to other countries and 2) how can this
enhance health systems performance? In terms of substantive topic
areas, ERA-NET will focus on the organisation of services throughout
the entire chain of care, ranging from public health and prevention to
hospital and long-term care. This article identifies the programme’s
focus and how it can build on existing initiatives.
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year 2014 (n=26 countries)*

Note: * Countries that provided a response report in English, either for 2014 or the latest available year

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European Commission. Mission Letter of President
of the European Commission, Jean-Claude Juncker to
the Commissioner for Health and Food Safety, Vytenis
P. Andriukaitis. Sent on 10 September 2014. Available
at: http://ec.europa.eu/about/juncker-commission/
docs/andriukaitis_en.pdf

References 
Rose R. Lesson Drawing in Public Policy: A Guide

to Learning Across Time and Space. Chatham, N.J:
Maresso A, Wismar M, Greer S, Palm W.
Chatham House, 1993.
What makes health systems resilient and innovative?

Voices from Europe. Eurohealth 2013;19(3):3 –7. Figueras J. Transferring health reform innovation.

How to ensure effective cross fertilisation?
European Commission. Horizon 2020 –
Presentation at Preconference meeting on Health
The Framework Programme for Research and
Systems Research, European Public Health
Innovation. COM(2011) 808 final. Brussels,
Conference, Glasgow, 19 November 2014.
30.11.2011. Available at: http://ec.europa.eu/
Available at: http://tinyurl.com/pb74h9t
research/horizon2020/index_en.cfm
 

Nolte E. Transferability of health services and
Walshe K, McKee M, McCarthy M, et al. Health
policies. Learning from international experience.
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The Lancet 2013;382(9893):668-69.
Systems Research, European Public Health

Azzopardi-Muscat N, Clemens T, Stoner D, Brand Conference, Glasgow, 19 November 2014.
Helmut H. EU Country Specific Recommendations for Available at: http://tinyurl.com/pb74h9t
health systems in the European Semester process: 
European Commission. Communication from the
Trends, Discourse and Predictors. Health Policy,
Commission, On effective, accessible and resilient
2015. Available at: http://dx.doi.org/10.1016/j.
health systems. COM(2014) 215 final. Available
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at: http://ec.europa.eu/health/healthcare/docs/

Thomson S, Figueras J, Evetovits T, et al. com2014_215_final_en.pdf
Economic crisis, health systems and health
in Europe: impact and implications for policy.
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Organization on behalf of the European Observatory
on Health Systems and Policies, 2014. Available
at: http://www.euro.who.int/_ _data/assets/pdf_
file/0008/257579/12-Summary-Economic-crisis,-
health-systems-and-health-in-Europe.pdf?ua=1

remains substantial. The government has implemented a basic

New HiT on Uzbekistan benefits package, but, for most people, this does not include
secondary or tertiary care and outpatient pharmaceuticals.
By: M Ahmedov, R Azimov, Z Mutalova, S Huseynov,
E Tsoyi, B Rechel This new health system review (HiT) on Uzbekistan examines
the changes and reforms that have taken place and the
Copenhagen: WHO Regional Office for Europe
challenges that still remain.
Number of pages: 168, ISSN: 1817-6119

Freely available for download at: http://www.euro.who.

int/__data/assets/pdf_file/0019/270370/Uzbekistan-HiT-web. in Transition
Health Systems
pdf?ua=1 Vol. 16 No. 5 2014

Since the country’s independence in 1991, Uzbekistan has Uzbekistan

review
Health system
embarked on several major health reforms, which included
changes to health financing and the primary health care
system. The country has also retained some features of the
Soviet period, as most health care providers are still publicly Mohir Ahmedov
ov
U Ravshan Azim ynov
Huse
lova U Shahin
Zulkhumor Muta
Bernd Rechel
owned and administered and health workers are government Elena Tsoyi U

employees.

Health expenditure is comparatively low when compared to

the rest of the WHO European Region. The government has
increased public expenditure on health in recent years, but
private expenditure in the form of out-of-pocket payments

,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

 ,\YVOLHS[O366205.-69>(9+

LEAVING A LEGACY05GLASGOW
By: Dineke Zeegers Paget

The European Public Health conferences have been organised for over
20 years now – first as the annual European Public Health Association
(EUPHA) conference and, since 2009, as the European Public Health
(EPH) Conference. The conference combines networking, knowledge
exchange and capacity building between more than 1500 public health
professionals worldwide and several international institutes and NGOs
are partners in this venture. However, in the past, the Conference
did not include activities aimed at the population of the city where
the conference was being organised. That is, not until Glasgow in
2014. At the initiative of the Glasgow City Marketing Bureau (GCMB),
EUPHA and the EPH Conference decided to get active for Glaswegians
and organise, together with the GCMB and the University of Glasgow,
some activities to leave a tangible and meaningful legacy in the city.

Dineke Zeegers Paget is Executive
Director, European Public Health
Association (EUPHA) and Director
of the European Public Health
(EPH) Conference office, Utrecht,
The Netherlands.
Email: office@eupha.org
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The high levels of health care resources and utilisation, in

New HiT on Iceland the context of an ageing population and other public health
challenges (such as obesity), as well as the continued impact
By: S Sigurgeirsdóttir, J Waagfjörð, A Maresso
of the country’s financial collapse in 2008, have been
Copenhagen: WHO Regional Office for Europe particularly challenging for the financial sustainability of
the current system, which is
Number of pages: 182, ISSN: 1817-6119 in Transition
Health Systems increasingly shifting costs from
Vol. 16 No. 6 2014

Freely available for download at: http://www.euro.who. public coverage to private

int/__data/assets/pdf_file/0018/271017/Iceland-HiT-web. land
households.
Ice
pdf?ua=1 Health system
review

The most important reform

challenge is to change the
Average life expectancy at birth is high in Iceland: 81.6 years
pattern of health care utilisation,
for men and 84.3 for women in 2012. As measured in healthy
steering it away from the most
geirsdóttir U
life years (HLY), the health status of the Icelandic population Sigurbjörg Sigur
Jónína Waagfjör
ð U Anna Mare
sso

expensive end of the health

is better than the European average.
services spectrum towards
The small, state-centred, publicly funded health system more cost-efficient and effective
guarantees universal coverage with the state as payer and alternatives. To a large degree,
provider of most health care services. However, since 1990, this will involve renewed
the number and scope of private non-profit and for-profit attempts to prioritise primary care as the first port of call for
providers has increased, especially through a rapid growth patients, and possibly to introduce a gate-keeping function for
in private specialist care at the expense of more developed GPs in order to moderate the use of specialist services.
(and publicly provided) primary care services.

,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

 ,\YVOLHS[O366205.-69>(9+

,<967,»:*/(33,5.,05
REDUCING HEALTH AND HEALTH
CARE INEQUITIES
)`! Walter Ricciardi

Summary: The European Public Health (EPH) Conference was

about promoting excellence in public health in Europe. Europe is
a tremendously rich place for health research and this conference
was an opportunity to bring everyone up to the level of the best, as
well as creating the opportunity for networking and bringing people
together to exchange ideas on good practices and on further research
and collaboration. Inspired by the exclamation “mind the gap”, the
conclusions of the 7th EPH Conference provided governments with
real policy options to address the challenge of reducing inequalities
in health and health care.

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Walter Ricciardi is Past President,
European Public Health Association
and Professor of Hygiene and Public
Health, Catholic University of the
Sacred Heart, Rome, Italy.
Email: wricciardi@rm.unicatt.it
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DQGHQHUJ\RIWKHFRPPXQLWLHVLQ References 

ILQGLQJVROXWLRQVWRWKHDERYHPHQWLRQHG  Mackenbach JP, Meerding W, Kunst A. Economic
SUREOHPV,QIDFWFRPPXQLWLHVRIWHQNQRZ implications of socio-economic inequalities in health
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DUHQHFHVVDU\7KHSULQFLSDOUHVSRQVLELOLW\
IRUDFWLRQLQDGGUHVVLQJKHDOWKLQHTXDOLWLHV
UHVWVZLWKWKH0HPEHU6WDWHVEXW(8
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WRRYHUFRPHVRPHRIWKHFXUUHQWREVWDFOHV
WRDFWLRQ
Busse R, Blümel M, Scheller-Kreinsen D, Zentner
A. Tackling chronic disease In Europe. Strategies,
interventions and challenges. Copenhagen: European
Observatory on Health Systems and Policies, 2010.
in the European Union. Brussels: Directorate-General
Available at: http://www.euro.who.int/_ _data/
assets/pdf_file/0008/96632/E93736.pdf
ec.europa.eu/health/ph_determinants/socio_

economics/documents/socioeco_inequalities_en.pdf European Roma Rights Centre. Hidden Health
Crisis. A Report by the European Roma Rights Centre.

WHO. World Health Report 2013. Available at:
Health Inequalities and Disaggregated Data, 2013.
http://www.who.int/whr/en/
Available at: http://www.errc.org/cms/upload/file/

Lim SS, Vos T, Flaxman AD, et al. A comparative hidden-health-crisis-31-october-2013.pdf
risk assessment of burden of disease and injury  
Makara P. Policy actions to tackle health
attributable to 67 risk factors and risk factor clusters
inequalities in Hungary arising from the economic
in 21 regions, 1990–2010: a systematic analysis for
the Global Burden of Disease Study 2010. The Lancet
crisis. Measuring and tackling health inequalities
2012;380(9859):2224–60.
across Europe. Eurohealth 2009;15(3):28 – 9.
Available at: http://www.euro.who.int/_ _data/assets/
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Moodie R, Stuckler D, Monteiro C, et al. Profits
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file/0005/171770/RC62wd12rev1-Eng.pdf?ua=1

Each year the Avedis Donabedian Foundation honours leaders

International Award to Professor
Martin McKee
Martin McKee, Professor of European Health Policy at the
London School of Hygiene & Tropical Medicine, Research
Director of the European Observatory on Health Systems
and Policies and president-elect of the European Public
Health Association has been awarded the 2015 Donabedian
International Award.
in the field of quality in health care, both individuals and
institutions, which have made a substantial contribution to
health care excellence.
The Foundation notes how Professor McKee has an impressive
record in health systems analysis and evaluation, especially in
drawing attention to the challenges that all countries in Europe
face in integrating health and social care and the responses
that will be needed in the future.
Professor McKee is a world leader in health systems
and his leadership is evident in his crucial contributions
that have provided new insights into the adverse health
consequences of rapid social transition and his major
research activities on the health effects of the financial
crisis. His contributions on strategies for changing health
care enlighten quality programmes all over the world,
making him an outstanding leader and advocate for
quality in health care.

Many congratulations to Martin!

,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

 ,\YVOLHS[O4650;69

5,>7<)30*(;065:
What do we know about the strengths and weakness Cross-border health care in Europe
of different policy mechanisms to influence health
Edited by: K Footman, C Knai, R Baeten, K Glonti and M McKee
behaviour in the population?
Copenhagen: World Health Organization / European Observatory
on Health Systems and Policies, 2014
By: D McDaid, A Oliver and S Merkur
Number of pages: 41; ISSN: 2077-1584, Policy Summary 14
Copenhagen: World Health Organization / European Observatory
on Health Systems and Policies, 2014 Freely available for download at: http://www.euro.who.int/__
data/assets/pdf_file/0009/263538/Cross-border-health-care-in-
Number of pages: 36; ISSN: 2077-1584, Policy Summary 15
Europe-Eng.pdf?ua=1
Freely available for download at: O[[W!^^^L\YV^OV
Patient mobility is high on the political agenda in the European
PU[FFKH[HHZZL[ZWKMFMPSL7:^LIWKM&\H$
Union, with increasing numbers of people crossing European
With health care systems under increasing pressure the borders. Issues relating to health professional mobility have received
development of a well-defined and effective public health strategy less attention, yet this is an
has never been more important. Many health problems are important policy issue for the
potentially avoidable and EU considering the scale of
governments have long had 1%6=
and reliance on professional
430-'=791
tools at their disposal to mobility between countries,
1%6 =
influence population health 'VSWWFSVHIV and existing variations in
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and change individual educational and professional
[ MR)YVSTI
;LEXHS[IORS RH  behaviours, directed both standards.
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 health, as well as at
FILEZMSYVMRXLI patient and professional
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mobility, and what are the
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7LIVV]1IV OYV implications for access and
behaviours are already
quality of health services?
manifest. But how effective eu

are these different actions?
This policy summary
briefly maps out what is
known about some of
these mechanisms, including approaches that have come to
recent prominence from behavioural economics and psychology.
Combinations of taxation, legislation and health information remain
the core components of any strategy to influence behavioural
change. There remain many unanswered questions on how best to
design new innovative interventions that can complement, and in
some instances augment, these well-established mechanisms.
*VU[LU[Z! Background; Focus of the policy summary; What factors
influence why people do or do not change their behaviour?; What
mechanisms have been used to help influence health behaviours?;
What do we know about the effectiveness and cost effectiveness of
these mechanisms?; How can the evidence base, including different
modes of implementation, be strengthened?; Conclusions and
summary of key themes; References.
Is greater coordination
needed, or do calls for
increasing integration
reflect a political agenda for increasingly competitive markets
in health care?
Recent legislative changes which clarify patient entitlements to
cross-border care will have important impacts on national and
EU-wide health policies. This policy summary provides a review of
the current state of issues relating to cross-border health care in
Europe. It combines a literature search with evidence gathered by
the Evaluating Care Across Borders Project to provide an update
on the 2005 ‘Policy Brief on Cross-Border Health Care in the
European Union’.
*VU[LU[Z! Introduction; Who is moving?; Patients treated across
the border; Professional mobility; The EU legal framework;
EU mechanism to fund cross-border care; Organisation of cross-
border care; Quality of cross-border care; Disease management;
Continuity of care; Telemedicine across borders; Professional
standards; Conclusions.

,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

,\YVOLHS[O4650;69
5,>:
International
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å states ability to run their public services…
SPMLZ[`SLZWH[PLU[ZHML[`HUKX\HSP[`
Writing in The Parliament Magazine,
Latvia’s health minister Guntis Bel ēvi čs
set out the Latvian Presidency’s priorities
for health. These include working towards
agreement on new EU rules for medical
devices and in-vitro diagnostic medical
devices to help promote patient safety
and quality care. Promoting healthy
lifestyles, particularly for children and
young people are another priority, with a
focus on nutrition and physical activity. The
Presidency will also host the first ministerial
conference on tuberculosis and its multi-
drug resistance on 31 March in Riga, while
eHealth week in Riga in May will focus on
ways to improve the uptake of eHealth
and mHealth technologies by patients.
The Presidency will also host a conference
on deinstitutionalisation and the further
development of social care policy in Europe
on 15 June.
Minister Belēvi čs’ article in The Parliament
Magazine can be read at: http://tinyurl.
com/mz3l2b9
;YHUZH[SHU[PJ[YHKLHUKPU]LZ[TLU[
WHY[ULYZOPW!L_[YHZHMLN\HYKZWYVTPZLK
In an interview with The Guardian
newspaper in the UK, Cecilia Malmström,
the EU’s trade commissioner, is stated
to be planning to rework key areas of
the Transatlantic Trade and Investment
Partnership (TTIP) agreement to allay
fears that US companies could use the
deal to unfairly obtain health service
contracts and undermine national health
services. In the article Commissioner
Malmström states that US multinationals
must only have a “limited possibility” of
winning compensation in behind-closed-
doors investor to state dispute settlement
(ISDS) procedures if governments cancel
privatisations or award public contracts to
in-house bids.
At a recent meeting at Europe House
in London the Commissioner stated
categorically that the UK’s National Health

Service will not be threatened by TTIP The report combined data from five
saying that it “will not hinder EU member European monitoring networks that
gather information from European Union
nothing will prevent outsourced services Member States, as well as Iceland,
being brought back into public ownership.” Norway and Switzerland. The aim was
to make better use of existing data and
The NHS Confederation’s European Office
strengthen coordinated surveillance
has also produced a report on how the deal
systems on antimicrobial consumption
could impact on the NHS in the UK. One
and antimicrobial resistance in human
key worry concerns the ISDs procedures –
and veterinary medicine. It identifies data
the Confederation states that if American
limitations that need to be addressed to aid
corporations challenge domestic health
in future analyses; these include additional
policy measures through ISDs arbitration
data on antimicrobial consumption by
procedures this could potentially result
animal species, data on antimicrobial
in “policy freeze” in the future, as UK
consumption in hospitals in more European
governments might think twice about
countries and monitoring of resistant
introducing new policy if they fear potential
bacteria in the normal flora from both
challenges. They point to recent experience
healthy and diseased people.
with other international trade agreements
noting that tobacco giant Philip Morris has The first in a series of planned reports
now for several years been challenging the that will look at data collected by various
Australian Government on their introduction monitoring networks, the report will inform
of cigarette plain packaging. the European Commission’s action plan
against the rising threats from antimicrobial
The Guardian article is available at:
resistance.
http://tinyurl.com/kjx23ll
The report is available at: http://tinyurl.com/
The NHS Confederation briefing on TTIP
ldk9uh8
is available at: http://tinyurl.com/kxy9jra
AZ\aZHUUH Jakab appointed WHO
5L^,<YLWVY[VUHU[PTPJYVIPHSHNLU[Z
Regional Director for Europe for
HUKYPZRVMHU[PTPJYVIPHSYLZPZ[HUJL
second term
Access to accurate data on the use of
In January WHO’s Executive Board, in
antimicrobials and the occurrence of
its 136th session in Geneva, appointed Dr
antimicrobial resistance is an essential
Zsuzsanna Jakab, WHO Regional Director
step to develop and monitor policies that
for Europe, for a second term. This follows
minimise the development of resistance
her nomination in September last year
and keep antimicrobials effective for future
by the Regional Committee for Europe,
generations. A new report concludes that
which comprises the health ministers
the use of certain antimicrobials in animals
of the Region’s 53 Member States.
and humans is associated with resistance
Dr Jakab started her new five-year term in
to these antimicrobials in bacteria from
February 2015. “In my second mandate,
animals and humans. There are also
I will give priority to linking health to
important differences in the consumption
sustainable development in order to ensure
of antimicrobials in animals and in humans
greater equity in health in the European
between European countries. These
Region. It’s not only about making health
are just some of the findings of the first
better; it’s about ensuring more equitable
integrated analysis of data from humans,
and sustainable health for Europe,” said
animals and food in Europe published
Dr Jakab.
jointly by the European Centre for Disease
Prevention and Control (ECDC), the
European Food Safety Authority (EFSA) and
the European Medicines Agency (EMA).
,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015

WHO launches tool to help countries
reduce marketing of foods with too
much fat, sugar and salt to children
Unhealthy diets are a leading factor
affecting health and well-being in every
European country; rising overweight and
obesity among children are particular
concerns. Affecting up to 27% of 13-year-
olds and 33% of 11-year-olds, overweight
risks becoming the new norm in the
WHO European Region. Robust evidence
points to a link between exposure to food
marketing and unhealthy diets, while
obesity in children and brand recognition
starts in early childhood. Children who
recognise multiple brands by the age
of 4 years are more likely to eat unhealthily
and be overweight.
Across the WHO European Region,
children are still regularly exposed to
marketing that promotes foods and drinks
high in energy, saturated fats, trans-fatty
acids, free sugars or salt. Despite progress
in some countries, government action to
restrict such marketing remains less than
optimal. One of the reasons for this is
the challenge of identifying foods whose
marketing should be restricted. A first step
in developing policies to restrict marketing
to children is to establish the criteria that
identify such foods and drinks. To meet this
need, the WHO Regional Office for Europe
has developed a nutrient profile model for
countries to adapt and use to classify foods
according to their nutritional composition.
The model is largely based on Danish
and Norwegian models which are used to
restrict food marketing to children. Health
authorities developed the Norwegian
model, while the Danish model was
developed by the Forum for Responsible
Food Marketing Communication (a trade
association) but endorsed for use by the
Danish Government.
The model is available at: http://tinyurl.
com/k2vpm2g
Country News
0YLSHUK!Z[YVUNUL^TLHZ\YLZ[V[HJRSL
HSJVOVSTPZ\ZLWSHUULK
On 3 February the Irish Cabinet signed
off on proposals to reduce alcohol
consumption and tackle alcohol misuse
,\YVOLHS[O incorporating Euro Observer — Vol.21 | No.1 | 2015
which are intended to help Ireland cut
alcohol consumption to the OECD average
of 9.1 litres per person per annum by 2020
and reduce the harm associated with
alcohol misuse. Minister for Health Leo
Varadkar said the proposed Public Health
(Alcohol) Bill 2015 is part of a suite of
measures designed to reduce alcohol
consumption and limit the damage to the
nation’s health, society and economy.
The proposed bill will include provisions
to prevent the sale of very cheap alcohol,
health labelling, as well as warnings on
products including calorie counts. The
minimum price will be set when the bill is
published and will be at a level that the
evidence shows will reduce the burden of
harm from alcohol. The sale price of the
alcohol product, in both the on-trade (e.g.
pubs) and off trade (e.g. off-licenses and
supermarkets) sectors, could not be below
this minimum unit price.
New enforcement powers for environmental
health officers to police and enforce the
separation of alcohol within stores are
planned. They will also be empowered
to police minimum unit pricing, health
labelling, marketing and advertising and
other measures of the Bill.
New measures regarding marketing,
advertising and sponsorship will be subject
to a three year review to gauge their
effectiveness. These will include restrictions
on the advertising and marketing of alcohol
from 2016 including a broadcast watershed
on television and radio, with further
restrictions due on cinema and outdoor
advertising.· It will also be illegal to market
or advertise alcohol in a manner that is
appealing to children. There will also be
legal regulation of sports sponsorship for
the first time.
Ireland is no stranger to taking tough public
health actions. On 3 March, following
Australia, Ireland became only the second
country to pass standardised packaging
legislation which will remove all tobacco
industry marketing from cigarette packets.
The brand will be printed on the packet in
a standardised font and colour. The size
of the warning will also be doubled on the
front of the packet (to 65% of the packet)
and it will feature a graphic picture warning.
More information at: http://tinyurl.com/
l6cbh9a
,\YVOLHS[O4650;69
-YHUJL!:P_[OLKP[PVUVMOLHS[OZ[H[\Z
VM[OLWVW\SH[PVUW\ISPZOLK
On February 12 the sixth edition of the
health status of the French population
was published by DREES (Direction de la
recherche, des études, de l’évaluation et
des statistiques) at the Ministry of Health.
The report shows that the French are
generally healthier than their European
neighbours, but that they also face
three major challenges. One challenge,
paradoxically, is increasing life expectancy,
as this inevitably means a need for care
better tailored to the needs of an ageing
population. With increased life expectancy
comes an increase in the incidence of
chronic disease, for instance there are now
more than three million people in France
living with diabetes. Another challenge
is the persistence of social and health
inequalities. One example highlighted in
the report is that the children of executive
level employees are ten times less likely
than the children of blue collar workers to
become obese. Moreover, life expectancy
differences between senior managers and
blue collar workers can be as much as
ten years.
To meet these challenges the government
plans to reform the health care system to
put more focus on prevention and improve
access to care as early as possible. A new
health law will be discussed by the National
Assembly in April. Among the proposed
measures are better nutritional information
on food packaging, combating underage
drinking and potentially making public
outdoor sporting venues smoke free.
The report on the health status of the
population (French only) is available at:
http://tinyurl.com/kfear8o
Additional materials supplied by:
EuroHealthNet Office
67 rue de la Loi, B-1040 Brussels
Tel: + 32 2 235 03 20
Fax: + 32 2 235 03 39
Email: r.rollet @ eurohealthnet.eu
 6):,9=(;69@
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IL`VUK[OLYOL[VYPJ¹

26th July – 1st August 2015
Isola di San Servolo, Italy
;OLTLHUKVIQLJ[P]LZ
Building on participants’ own
knowledge and expertise, the
School will:
• Provide a state of the art account
of the effectiveness and economic
impacts of integrated care
• Discuss a range of concrete examples The School will guide participants to:
of integrated care programmes
and strategies that have been
implemented across Europe and
elsewhere, stretching from individual
pilot programmes to regional and
national integrated care strategies
• Interpret how different integrated
care options can be operationalised
considering resource, infrastructure
and technology constraints in
different settings
• Discuss in a critical manner the place
and usefulness of integrated care
in a modern health and social care
system
• Draw practical policy and
implementation lessons to inform
better decision-making on delivery
system reform that will positively
impact the quality of care given
resource constraints.
(WWYVHJO /V^[VHWWS`
Submit your CV and registration form
before 31 May 2015.
• Critically appraise options for the
development of integrated care
Summer School’s fee: EUR 2,200
programme strategies, focussing
(teaching material, accommodation,
on implications for efficiency, access
meals and social programmes included)
and cost
• Understand the nature of the policy More information and on-line
debate around integrated care and application are available
what has been achieved so far on our web-site: www.
theobservatorysummerschool.org
• Apply tools and frameworks to help
design, implement and evaluate
We are waiting for you in Venice!
integrated care programmes and
strategies to inform decision-making
Organised by the European Observatory
• Investigate the various levers needed on Health Systems and Policies, the
to ‘make integrated care work’, Veneto Region of Italy, the European
including regulatory, financing and Commission and the World Health
governance strategies to redesign Organization
service delivery towards more people-
centred care
• Hypothesise what people-centred care
policy will look like in the future.