Current Structure of the EUSBSR Action Plan

NCD&OSH_4_joint-session-6./Info 1

NCD EG on Non-Communicable Diseases related to Lifestyles and Social and Work Environments

4th NCD EG meeting 23-25 May 2012 in Helsinki, Finland (24-25 May jointly with NDPHS/ OSH TG (Occupational Safety & Health Task Group)

Reference NCD&OSH_4_joint-session-6./Info 1 Title Review of the EUSBSR Action Plan – proposal by the Northern Dimension Partnership in Public Health and Social Well-being (NDPHS) (input proposed by the NCD EG)

Submitted by NCD-Secretariat Summary / Note NCD EG secretariat sent 08.05.2012 this requested feed-back to NDPHS Secreatariat.

Requested action For reference and information on NCD EG position

1 NCD&OSH_4_joint-session-6./Info 1

Review of the EUSBSR Action Plan – proposal by the Northern Dimension Partnership in Public Health and Social Well-being (NDPHS)

Current structure Proposed new structure

Priority Area 12. Priority Area xxx (a separate PA). To maintain and reinforce attractiveness of To improve and promote people’s health the Baltic Sea Region in particular through (public and individual) , including its social education and youth, tourism, culture and aspects health Coordinated by Coordinated by Northern Dimension Partnership in Public 1) Tourism: Mecklenburg-Vorpommern Health and Social Well-being (Germany) 2) Health: Northern Dimension Partnership in Public Health and Social Well-being 3) Education and youth: Hamburg

Presentation of the issue: Do you think the description of the issue is still relevant? Based on the implementation up to now and your experience, would you like to update it, to modify it, to narrow it down, to highlight some specific aspects?

Unlike other Priority Areas included in the current EUSBSR Action Plan, Priority Area 12 covers four different sub-areas, health being one of them. The description of the health component in itself is still relevant. However, the approach of combining four different issues in the Priority Area 12 needs to be revised. The NDPHS’ view is that the four issues do not have much in common to substantiate combining them. Furthermore, this approach is misleading in various respects and undermines their value, visibility and importance vis-à-vis other sectors. Despite this, the NDPHS together with other stakeholders engaged was able to make good progress in the health sub-area. Furthermore, as the coordinator of the health component in the EUSBSR Action Plan, the NDPHS plans to put more emphasis on social aspects and wellbeing linked to health. In this effort it will engage regional stakeholders having specialist expertise in this area, among them the BSN-ESF, the network of the Managing Authorities for the ESF between the Member States concerned. This will help address issues such as social exclusion, inequity and combating poverty, which often are root-causes of ill-health. At the same time, poor health can cause exclusion and poverty, and lead into a viscious circle , which becomes very expensive to society. In focusing on public health and investing in human capital recognizing health as a resource and prerequisite for economic growth, we can better contribute to the implementation of the new Europe 2020 Strategy.

Considering the above, the NDPHS requests that public health (including its social aspects) be made a separate Priority Area in the upcoming, reviewed version of the EUSBSR Action Plan.

The “Presentation of the issue” does not require substantial modifications, as compared to the current text in the description of the health sub-area in the Priority Area 12. The most important proposed addition, however, is an explicit reference to the challenges posed by the ageing society and the crucial role that health plays in overcoming those challenges. Furthermore, the role of health in promoting prosperity and the social dimension need to be emphasized.

If so, please suggest a new drafting of it. To which objective (1. to save the Sea; 2. to connect the Region; 3. to increase prosperity) should it be linked?

It is proposed that the new text of the “Presentation of the issue” within the (separate) Priority Area “To improve and promote people’s health (public and individual), including its social aspects” (linked to the objective “to increase prosperity”) would read as follows:

“ The prosperity of the region is based on human capital; consequently a healthy population is a critical factor behind sustainable economic development of enterprises and societies. 1Improvement of people’s health and social well-being is particularly important in the context of the ageing society, one of the greatest regional challenges in the 21st century. Unless counteracted, a decline in the working age population and a higher number of people with chronic non-communicable diseases will put an immense pressure on the national budgets and will lead to loss of productivity in the decades to come. By investing in health improvement and promotion, the economic gain will be two-fold: (i) healthy people are more likely to stay at the labour market longer and remain productive and (ii) reduced spending on treatment of ill health.

Currently the Baltic Sea Region is an area of considerable disparities in health and social conditions. It features places where social and economic problems lead to high levels of mortality due to non-communicable diseases, violence, alcohol- and drug- abuse and the spreading of infectious diseases. Social exclusion and poverty are not unheard problems either. Further, growing cross-border movement of people need to be paralleled by actions addressing inequalities in health status and in the level of health protection.

Consequently, this priority area focuses on improving and promoting health of people in the Baltic Sea Region, including social aspects of health, as an important precondition for ensuring sustainable and healthy societies enjoying economic growth and for containing future health and social care related costs.”

Baltic Sea Region added value: some partners have suggested removing this section. In any case, can you explain, how according to you, the EUSBSR has best addressed the issues identified in your priority area? What are these issues? What are the "success stories", the "good practices" and the "good outcomes" which are linked to the implementation of the Strategy (process-related and content-related)?

The cross-cutting dimension of the Strategy may appear to be one prominent element of value added. Have you experienced it in your priority area? If so, in what way? Have you developed contacts in other priority areas, with whom? Have you set-up cross-cutting working groups, organisations, have you designed and/or implemented projects with a cross- cutting dimension? If not, do you intend to do it? Could you identify actions and/or projects, or areas where you would think it advisable to work more closely with other priority area coordinators/partners? If so, what are they?

1 Our societies are aging, which is the positive outcome of our previous successful work on public health and economic and social developments. In our region there are still many countries where improvements in life expectancy are badly needed. Having more older people is not the problem per se. On average, the most expensive time in life is our last year, no matter at which age it occurs. Reorganizing our societies and supporting elderly people to maintain their functionality can turn them into a resorce rather than a burden. The biggest risk to our human capital is caused by increasing unhealthy lifestyles leading into early loss of health and work ability due to hazardous and harmful alcohol consumption, use of tobacco, overweight and obesity and low physical activity (sedentary lifestyle), accidents and violence , and mental ill-health, which cause aover 80 per cent of our disease burden.

NCD Expert Group’s suggested input: .”To improve and promote people’s health (public and individual) , including its social aspects”: 3. References

The key landmarks in the healthy lifestyle promotion and non-communicable disease prevention and control are the following documents of the World Health Organization and UN, which all Northern Dimension Partnership countries have endorsed:  The WHO Framework Convention on Tobacco Control (FCTC) by the World Health Assembly in 2003 (http://www.who.int/tobacco/framework/fi nal_text/en/ ) ;  The Global Strategy on Diet, Physical Activity and Health endorsed by the World Health Assembly in 2004 (http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf) ;  The Global Plan of Action on Workers’ Health 2008-2017 endorsed by the World Health Assembly in 2007 (http://www.who.int/occupational_health/WHO_health_assembly_en_web.pdf)  The Resolution 61.17 on the Health of Migrants by the World Health Assembly in 2008 (http://apps.who.int/gb/ebwha/pdf_files/A61/A61_R17-en.pdf) ;  The 2008–2013 Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases endorsed by the World Health Assembly in 2008 (http://www.who.int/nmh/publications/9789241597418/en/index.html ) ;  The Global Strategy to Reduce the Harmful Use of Alcohol adopted by the World Health Assembly in 2010 (http://www.who.int/substance_abuse/msbalcstragegy.pdf) ;  The report of the 1st Global Ministerial Conference on Healthy Lifestyles and Non- communicable Diseases Control including the Moscow Declaration of the above mentioned Conference (http://www.euro.who.int/moscow-declaration-ob-healthy- lifestyles-and-ncds ) ;  Action plan for implementation of the European Strategy for the Prevention and Control of Non-communicable Diseases 2012-2016 (http://www.euro.who.int/ncd-actionplan ) ;  Political declaration adopted at the UN General Assembly - 19 September 2011 on the Prevention and Control of Non-communicable Diseases (http://www.un.org/ga/search/view/doc.asp?symbol=A%2F66%2FL.1&Lang=E) ;  European action plan to reduce the harmful use of alcohol 2012-2020 ( http://www.euro.who.int/en/who-we-are/ governance ) Due to the present very active period (see above) on global and European level to overcome modern-day plague, namely lifestyle related chronic diseases, disability and premature mortality, the EUSBSR can bring a strong booster to developments of the Baltic Sea area and Northern Dimension region. Innovations are needed on policy and practical levels, and they need to be adapted and tested in national circumstances through flagship projects and lessons be learned from each orthers’ successes and failures.

Main problems: Based on your evaluation of the two previous points (presentation of the issue and BSR added value), do you think the description of the main problems is still relevant? If not, please suggest a new drafting, highlighting what the main problems that should be focused on are.

NCD Expert Group’s suggested input: The main problems are viewed in a narrow way through the argumentation of environmentalists (water, air, transport and climate change. In principle, theree is nothing wrong with it, except that if the human health and social aspects are neglected, the problem statement provides a biased view.

The importance of public health gets a new basis if we view it in the light of economic losses through causes that could prevent premature loss of life. In the Baltic Sea Region countries loose human capital in the range of 9000 – 3000 years per 100.000 inhabitants. Considering that in the Baltic Sea Region live about 60 million people it can be estimated that we loose at least ca. 66 billion euro every year due to premature loss of life of preventable causes 2. Just if we could reduce preventabler mortality by 10 per cent, the annual gain would be about 6-7 billion euro. An this is only the top of the iceberg, as on top of it we would need to calculate the expenses caused by morbidity, invalidity and human suffering. Changing the trend would give a strong booster to economic development which would allow better invetments to other sectors including education, culture and environment

Actions: There is a strong consensus that the distinction between "strategic actions" and "cooperative actions" should be removed. They will all be called: actions and they should provide an appropriate reply to the focused problems identified.

Can you analyse all the existing actions (strategic and cooperative) mentioned in the current version of the action plan and indicate which ones should be updated, modified, reinforced, reworded, removed (you will find in annex 2 a list of actions and projects that might be taken out, because to our knowledge, nothing has happened so far as regards their implementation, unless there are good reasons not to do so)? Please suggest a new drafting.

NCD Expert Group’s suggested input: Strategic and cooperative actions can be pooled under one heading without major problem. When it comes to actions and projects focusing on public health and social well-being they should not be removed. On the contrary, they should be strengthened. Until now the problem has been that public health and social well-being, especially focusing on lifestyle related issues, have had very poor project funding opportunities. There has simply not been an address to focus applicatons on. In addition, public health initiatives are not well suited for economic activity, because preventive health action is not a market produc on individual demand. Therefore, in order to implement them, funding must continue to come to a great extent in grants. Projects on curative services are not needed under EUSBSR, as they are well funded by pharmaceutical and insurance companies, in addition large research funds.

Flagship projects: The list of flagship projects mentioned in the current action plan should be carefully scrutinised. Can you list those that:  should be taken out (while explaining why),  are up and running in a satisfactory way,  did not manage to secure financing (and explain why, and what should be done),  have other problems (describe which problems)  have been completed (and what the results are)?

Each project (except those that must be taken out) should be filed under the action it directly or more directly relates to. It could also be decided that those that have been completed will be filed in an annex to the action plan with a short paragraph describing the achievements and results and with a hyperlink to a relevant website.

As for new ideas or flagship projects to be inserted in the reviewed action plan, they should follow the criteria that have been agreed upon in the taskforce on roles and responsibilities (see fiche in annex 3). If the project fulfils all criteria listed in this annex and if the procedure described has been followed, it could be considered as a flagship project and associated to one of the actions of the priority area.

2 the cost of one lost year according to national economic principle is the same amout as GNP per capita., which ranges in our region (2010) between 11.000 USD (Latvia) to 48.000 USD (Sweden).

If it does not fulfil all criteria and has complied with the procedure, it should be inserted in the action plan as an idea (related to one of the actions) that is likely to become a flagship project when all criteria have been fulfilled.

NCD Expert Group’s suggested input: The following two Flagship projects have not been funded as no source for tesources has been available. Both topics are extremely timely and efforts continue to identify necessary funding source. The fact that public health would have a stronger status in EUSBSR could be an important additional positive factor. a) Prevention of over-weight and obesity among schoolchildren (ages 7-15) b) Effective and efficient implementation of national NCD- prevention strategies

Funding sources: if you have identified or even secured funding sources (European, national, regional, local, other) for your actions or projects in the current or future period, please mention them in this section.

NCD Expert Group’s suggested input: Healthier people: management of change through monitoring and action St. Petersburg/ Kalininsky district 2012-2013 (total budget 250 000 Euro of which 200.000 Euro EU grant)

Indicators and targets: Please indicate in this new section the indicators and targets that illustrate best, according to you, the main objectives and achievements you want to reach in your priority area (for the record, what is the objective, the indicator related to it, the baseline situation and its year of reference, the target and its deadline (and intermediate targets and deadlines when you find them useful), and the reliable source(s) of information and statistics).

NCD Expert Group’s suggested input: The potential years of life lost (PYLL) rate describes life lost due to premature death in a population. From a social point of view, this is equal to loss of human capital. The rate is calculated on the basis of the difference between the age at death and the expected length of life, and it is determined by the cause of death according to the ICD-10. The method reviews the time of death in relation to pre-defined life expectancy. The rate is age- standardized and expressed as a sum of all deaths per 100,000 person- years.

The PYLL rate provides comparable information about the wellbeing of a population concerning all death causes. It provides supplementary information for planning and decision-making for health policies. In the Baltic Sea Region countries the PYLL-indicator ranges from about 9000 – 3000 years per 100.000 inhabitants. Considering that in the Baltic Sea Region live about 60 million people it can be estimated that we loose at least ca. 66 billion euro every year due to premature loss of life of preventable causes. Just if we could reduce preventabler mortality by 10 per cent, the annual gain would be about 6-7 billion euro.

The target for progress can be set to 10 per cent reduce premature avoidable mortality (PYLL) in NDP countries’ populations. Additional target could be 10 per cent reduction in the DIFFERENCE of premature avoidable mortality (PYLL) between BSR countries’ populations. As an economic idicator the amount of annual financial benefit to national economies can be calculated. In the same way we can calculate the price of non-action (= “laissez- faire”) .

Any other suggestions or comments: In case you would need to add further elements.

NCD Expert Group’s suggested input: An additional important fact to strengthen the role of public health and social inclusion in the EUSBSR is that in the Northern Dimension Countries some EU free-market polcies have in fact brought with them considerable additional burden and negatve health related side effects. As alcohol has been handled as a normal market good and nor a potentially hazardous and harmful addictive substance, European deregulation of import in recent years has increased alcohol related mortality, morbidity and social harm (child neglect, violence and accidents) . Hence new action to overcome the caused harm is needed and in fact a moral oblication for EU. In nutrition policies the causal links are not as clear, but nevertheless through sensible nutrition policies we could increase fruit and vegetable intake at the same time while reducind obesitogenic and biabetogenic high caloey and sugar content products.

Conclusions of your analysis

Status of the priority area: Based on your review of all the points abovementioned, can you draw some conclusions on how your priority area could/should evolve? In particular, will it be or does it need to be more focused? Can it be merged with one or more priorities, and if so how and with which ones? Can some actions be transferred to other priority areas? Do you have any other suggestions?

One of the conclusions drawn by the NDPHS from the first two years of the coordination of the implementation of the health sub-area in the EUSBSR Action Plan is that the idea of combining education, tourism, culture and health in one Priority Area has been wrong and does not work. These four sectors do not have much in common (and certainly vastly less than some other, currently separate, PAs) to substantiate combining them into one Priority Area. Keeping health as a sub-area not only does not support efforts of organizations and people engaged in this component of the Strategy but just the opposite – it undermines the value and importance of these efforts as well as sends misleading signal and causes confusion among actors not engaged in the coordination of the Strategy.

To that end, on 18 November 2011, following the respective decision by the NDPHS Committee of Senior Representatives, the NDPHS Secretariat sent a letter to the DG REGIO (cc. to the EUSBSR NCPs) with a request to include health (and social matters, if possible) as a separate Priority Area (PA) in the EUSBSR Action Plan. Furthermore, the ministerial-level Partnership Annual Conference held on 25 November 2011 emphasised that “both health and social dimension should be given in the EUSBSR Action Plan a status adequate to their role and importance in the region’s societies.”

Although organization and delivery of health care is a national competence, regional cooperation in health is advantageous and essential. The main health-related challenges (including those regarding social issues linked to health), that the Baltic Sea Region countries are currently facing, are the same. Consequently, it is only logical to coordinate the responses to common challenges, in order to bridge gaps and speed up innovation processes, avoid duplication of efforts and limited resources, and allow for well-informed policy and decision making. The ongoing process of the review of the EUSBSR Action Plan provides an opportunity to recognize a key role of health and social well-being in contributing to smart and inclusive growth, thereby making it an important component in the implementation of the EU 2020 Strategy.