Performance Assessment Report 2012–2013

Appendix:OWER indicators and Detailed Outcome Assessment Sheets

1862014

© World Health Organization 2014. All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Part 1: Regional Office achievement of indicators of Organization-wide expected results in the global context

SO OWER Indicator Text Organization-wide (Global) EURO List of countries (Member States Indicator only), which achieved the indicator Baseline Target 2013 Achieved Baseline Target 2013 Achieved 2012 2012

01 1.1.1 Number of Member States with at least 90% 130 135 131 48 50 50 ALB, AND, ARM, AZE, BLR, BEL, BIH, national vaccination coverage (DTP3) BUL, CRO, CYP, CZH, DEN, EST, FIN, FRA, GEO, DEU, GRE, HUN, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MON, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UNK, UZB

01 1.1.2 Number of Member States that have 169 180 184 51 52 52 ALB, AND, ARM, AUT, AZE, BEL, BIH, introduced Haemophilus influenzae type b BUL, CRO, CYP, CZH, DEN, EST, FIN, vaccine in their national immunization FRA, GEO, DEU, GRE, HUN, ICE, IRE, schedule ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MON, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB

01 1.2.1 Percentage of final country reports 80% 100% 59% 100% 100% 100% demonstrating interruption of wild poliovirus transmission and containment of wild poliovirus stocks accepted by the relevant regional commission for the certification of poliomyelitis eradication

01 1.2.2 Percentage of Member States using 0% 75% 67% 37% (7 out 50% 53% ALB BIH BLR KAZ MNE POL RUS SRB trivalent oral poliovirus vaccine that have a of 19 TUR UKR timeline and strategy for eventually stopping countries) its use in routine immunization programmes

01 1.3.1 Number of Member States certified for 180 183 184 1 4 4 BIH, Territories of Denmark, Norway, eradication of dracunculiasis UNK

01 1.3.2 Global reduction of Grade 2 Disabilities in 2.21 2 2.5 NA NA NA new cases of leprosy/million population at risk. SO OWER Indicator Text Organization-wide (Global) EURO List of countries (Member States Indicator only), which achieved the indicator Baseline Target 2013 Achieved Baseline Target 2013 Achieved 2012 2012

01 1.3.3 Number of reported cases of human African 8000 7500 6500 NA NA NA trypanosomiasis for all endemic countries

01 1.3.4 Number of Member States having achieved 23 25 28 2 countries: 5 countries: 7 countries: STH TJK, KGZ, KAZ, ARM, GEO, MDA, AZE: the recommended target coverage of STH control STH control control STH control population at risk of lymphatic filariasis, schistosomiasis and soil-transmitted helminthiases through regular anthelminthic preventive chemotherapy

01 1.4.2 Number of Member States for which 151 165 154 VPI: 18 VPI: 53 (+1 VPI: 17 ROM IRA SWE CYP NET ARM LTU WHO/UNICEF joint reporting forms on KOS) UZB AZE CZH EST KGZ LVA POR RUS immunization surveillance and monitoring SMR SVK are received on time at global level in accordance with established time-lines

01 1.5.1 Number of new and improved tools or 0 4 13 NA NA NA implementation strategies, developed with significant contribution from WHO, introduced by the public sector in at least one developing country

01 1.5.2 Proportion of peer-reviewed publications 71% 60% 67% n/a n/a n/a based on WHO-supported research where the main author’s institution is in a developing country

01 1.6.1 Number of Member States that have 129 193 141 0 53 42 ARM, AUT, AZE, BLR, BEL, BIH, BUL, completed the assessment and developed a CRO, CZH, DEN, EST, FIN, FRA, DEU, national action plan to achieve core GRE, HUN, ICE, IRE, ITA, KAZ, KGZ, capacities for surveillance and response in LVA, LTU, MAT, NOR, POL, POR, line with their obligations under the ROM, RUS, SMR, SRB, SVK, SVN, International Health Regulations (2005) SPA, SWE, SWI, TJK, MKD, TUR, TKM, UNK, and UZB

01 1.6.2 Number of Member States whose national 121 180 163 47 47 47 ALB, ARM, AUT, AZE, BLR, BEL, BIH, laboratory system is engaged in at least one BUL, CRO, CZH, DEN, EST, FIN, FRA, external quality-control programme for GEO, DEU, GRE, HUN, ICE, IRE, ISR, epidemic-prone communicable diseases ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SRB, SVK, SVN, SPA, SWE, SWI, MKD, TUR, UKR, UNK, UZB

01 1.7.1 Number of Member States having national 158 185 181 3 35 38 AUT, AZE, BEL, BIH, BUL, CRO, CYP, preparedness plans and standard operating CZH, DEN, EST, FIN, FRA, DEU, GRE, procedures in place for readiness and HUN, ICE, IRE, ITA, LVA, LTU, LUX, response to major epidemic-prone diseases MAT, MNE, NET, NOR, POL, POR, MDA, ROM, SMR, SVK, SVN, SPA, SWE, SWI, MKD, TUR, UNK

01 1.7.2 Number of international coordination 8 9 9 n/a n/a n/a mechanisms for supplying essential vaccines, medicines and equipment for use in mass interventions against major epidemic and pandemic-prone diseases

01 1.7.3 Number of severe emerging or re-emerging 8 10 10 n/a n/a n/a diseases for which prevention, surveillance and control strategies have been developed

01 1.8.1 Number of WHO locations with the global 129 140 104 n/a n/a n/a event-management system in place to support coordination of risk assessment, communications and field operations for headquarters, regional and country offices

01 1.9.1 Proportion of Member States' requests for 99% 99% 99% 100% 100% 100% ALB, AND, ARM, AUT, AZE, BLR, BEL, assistance that have lead to effective and BIH, BUL, CRO, CYP, CZH, DEN, EST, timely interventions by WHO, delivered FIN, FRA, GEO, DEU, GRE, HUN, ICE, using a global team approach, in order to IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, prevent, contain and control epidemic and LUX, MAT, MON, MNE, NET, NOR, other public health emergencies POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB

02 2.1.1 Number of low and middle income countries a) 8 and b) a) 35 and b) a) 15 and b) a) 0 and b) a) 10 and b) a) 0 and b) 25 b) ARM, AZE, BLR, BIH, BUL, CRO, that have achieved 80% coverage for (a) 13 45 38 14 20 CZH, EST, GEO, KAZ, KGZ, LVA, LTU, antiretroviral therapy and (b) the prevention MDA, MKD, MNE, POL, ROM, RUS, of mother-to-child transmission services SRB, SVK, SVN, TJK, UKR, UZB

02 2.1.2 Proportion of endemic countries that have 50% 60% 64% 10 11 11 GEO, AZE, ARM, TUR, TJK, TKM, KAZ, achieved their national intervention targets RUS, KGZ, UZB and GRE for malaria

02 2.1.3 Number of Member States that have 45 50 41 10 29 10 ALB, AND, BUL, CRO, MNE, ROM, achieved the targets of at least 70% case SRB, SVK, MKD, TUR detection and 85% treatment success rate for tuberculosis

02 2.1.4 Number of countries among the 27 priority 5 10 10 3 9 5 EST, LVA, LTU, BLR, KAZ ones with high burden of multidrug-resistant tuberculosis that have detected and initiated treatment under the WHO-recommended programmatic management approach, for at least 70% of estimated cases of multidrug- resistant tuberculosis

02 2.1.5 Proportion of high burden Member States Not 90% 89% n/a n/a n/a n/a that have achieved the target of 70% of available persons with sexually transmitted infections diagnosed, treated and counselled at primary point-of-care sites

02 2.2.1 Number of targeted Member States with HIV: 158 HIV1: 160 HIV: 85 HIV: 10 HIV: 15 HIV: 20 HIV: AZE, BLR, BIH, BUL, CRO, CZH, comprehensive policies and medium-term TB: 119 TB: 148 TB: 133 TB: 53 TB: 51 EST, GEO, KGZ, LVA, MDA, MKD, plans in response to HIV, tuberculosis and Malaria: 81 Malaria: 85 Malaria: 81 MAL: 11 MAL: 11 MNE, POL, ROM, SRB, SVK, SVN, TJK, malaria UKR TB: 39 TB: ALB, AND, ARM, AUT, AZE, BLR, MAL: 10 BEL, BIH, BUL, CRO, CYP, CZH, DEN, EST, FIN, FRA, GEO, DEU, GRE, HUN, ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB Malaria: GEO, AZE, ARM, TUR, TJK, TKM, KAZ, RUS, KGZ, UZB and GRE

02 2.2.2 Proportion of high-burden countries Not 75% 68% n/a n/a n/a monitoring provider initiated HIV testing and available counselling in sexually transmitted infection and family planning services

02 2.2.3 Number of countries among the 63 ones 43 45 49 3 3 3 EST,RUS,UKR with a high burden of HIV/AIDS and tuberculosis that are implementing the WHO 12-point policy package for collaborative activities against HIV/AIDS and tuberculosis

02 2.3.1 Number of new or updated global norms 41 105 50 new or n/a n/a n/a and quality standards for medicines and updated diagnostic tools for HIV/AIDS, tuberculosis standards = and malaria 91

02 2.3.2 Number of priority medicines and diagnostic 300 400 416 n/a n/a n/a tools for HIV/AIDS, tuberculosis and malaria that have been assessed and pre-qualified for United Nations procurement

02 2.3.3 Number of targeted countries receiving HIV/AIDS: HIV/AIDS: HIV: 82 HIV: 4 HIV: 5 HIV: 5 HIV: ARM, GEO, KGZ, MDA, UKR support to increase access to affordable 73 80 TB: 116 TB: 5 TB: 8 TB: 16 TB: ARM, AZE, BLR, BUL, GEO, KAZ, essential medicines for HIV/AIDS, TB: 111 TB: 116 Malaria: 74 MAL:10 MAL:10 MAL:10 KGZ, LVA, LTU, MDA, ROM, RUS, TJK, tuberculosis and malaria whose supply is Malaria: 64 Malaria: 77 TUR, UKR, UZB integrated into national pharmaceutical MAL: GEO, AZE, ARM, KGZ, TJK, UZB, systems (the number of targeted countries TKM, KAZ, RUS, TUR is determined for the six-year period)

02 2.3.4 Number of Member States implementing 109 125 125 53 53 53 ALB, AND, ARM, AUT, AZE, BLR, BEL, quality-assured HIV/AIDS screening of all BIH, BUL, CRO, CYP, CZH, DEN, EST, donated blood FIN, FRA, GEO, DEU, GRE, HUN, ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MON, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB

02 2.3.5 Number of Member States administering all 180 193 194 n/a n/a n/a medical injections using sterile single use syringes

02 2.4.1 Number of Member States providing WHO HIV: 157 HIV: 130 HIV: 131 HIV: 51 HIV: 53 HIV: 51 HIV: ALB, AND, ARM, AUT, AZE, BLR, with annual data on surveillance, monitoring TB: 208 TB: 182 TB: 189 TB: 52 TB: 53 TB: 50 BEL, BIH, BUL, CRO, CYP, CZH, DEN, or financial allocation data for inclusion in Malaria: Malaria: 107 Malaria: 102 MAL: 53 MAL: 53 MAL: 53 EST, FIN, FRA, GEO, DEU, GRE, HUN, the annual global reports on control of 105 ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, HIV/AIDS, tuberculosis or malaria and the LTU, LUX, MAT, MON, MNE, NET, achievement of targets NOR, POL, POR, MDA, ROM, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, TB: ALB, AND, ARM, AUT, AZE, BLR, BEL, BIH, BUL, CRO, CYP, CZH, DEN, EST, FIN, FRA, GEO, DEU, GRE, HUN, ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, UKR, UNK, UZB MAL: ALB, AND, ARM, AUT, AZE, BLR, BEL, BIH, BUL, CRO, CYP, CZH, DEN, EST, FIN, FRA, GEO, DEU, GRE, HUN, ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MON, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB

02 2.4.2 Number of Member States reporting drug HIV: 61 HIV: 75 HIV: 67 HIV: 0 HIV: 3 HIV: 2 HIV: RUS, UKR resistance surveillance data to WHO for TB: 127 TB: 130 TB: 136 TB: 51 TB: 53 TB: 48 TB: ALB, AND, ARM, AUT, AZE, BLR, HIV/AIDS, tuberculosis or malaria Malaria: 73 Malaria: 107 Malaria: 102 MAL:n/a MAL:n/a MAL:n/a BEL, BIH, BUL, CRO, CYP, CZH, DEN, EST, FIN, GEO, DEU, HUN, ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, UKR, UNK, UZB MAL:n.a

02 2.5.1 Number of Member States with functional HIV: 152 HIV: 152 HIV: 164 HIV: 41 HIV: 53 HIV: 52 HIV: HIV: All EURO Member States coordination mechanisms for HIV/AIDS, TB: 122 TB: 124 TB: 130 TB: 35 TB: 53 TB: 36 havefunctional coordination mechanisms tuberculosis and malaria control Malaria: 72 Malaria: 76 Malaria: 76 MAL: 10 MAL: 11 MAL: 11 for HIV/AIDS control. With the exception of TKM reporting no HIV cases TB: BEL, BUL, CZH, EST, ICE IRE, LVA, LTU, LUX, MAT, NET, POR, ROM, SVK, SVN, SPA, ALB, AND, ARM, AZE, BLR, BIH, GEO, ISR, KAZ, KGZ, MKD, MDA, MNE, RUS, SRB, TJK, TUR, UKR, UZB MAL: GEO, AZE, ARM, TUR, TJK, TKM, KAZ, RUS, KGZ, UZB and GRE

02 2.5.2 Number of Member States involving HIV: 147 HIV: 150 HIV: 157 HIV: 51 HIV: 53 HIV: 52 HIV: ALB, AND, ARM, AUT, AZE, BLR, communities, persons affected by the TB: 100 TB: 107 TB: 107 TB: 12 TB: 18 TB: 19 BEL, BIH, BUL, CRO, CYP, CZH, DEN, diseases, civil-society organizations and the Malaria: 76 Malaria: 76 Malaria: 76 MAL: 10 MAL: 11 MAL: 11 EST, FIN, FRA, GEO, DEU, GRE, HUN, private sector in planning, design, ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, implementation and evaluation of HIV/AIDS, LTU, LUX, MAT, MON, MNE, NET, tuberculosis and malaria programmes NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, UKR, UNK, UZB TB: ARM, AZE, BLR, BIH, BUL EST, GEO, KAZ, KGZ, LTU, MNE, MDA, ROM, SRB, TJK, MKD, TUR, UKR, UZB MAL: GEO, AZE, ARM, TUR, TJK, TKM, KAZ, RUS, KGZ, UZB and GRE

02 2.6.1 Number of new and improved tools or 0 13 29 0 1 1 ARM, AZE, BLR, GEO, KAZ, KGZ, implementation strategies for HIV/AIDS, MDA, RUS, TKM, UKR UZB tuberculosis or malaria implemented by the public sector in at least one developing country

02 2.6.2 Proportion of peer-reviewed publications 61% 60% 66% n/a 100% 100% BLR, MDA, UZB arising from WHO-supported research on HIV/AIDS, tuberculosis or malaria and for which the main author’s institution is based in a developing country

03 3.1.1 Number of Member States whose health 164 170 175 14 17 17 BEL, MDA, SWE, CYP, FIN, LTU, ITA, ministries have a focal point or a unit for NOR, NET, EST, POR, TUR, UNK, injuries and violence prevention with its own BLR,CZH, LVA, MKD budget

03 3.1.3 Number of Member States with a mental 100 110 Data not 53 53 53 ALB, AND, ARM, AUT, AZE, BLR, BEL, health budget of more than 1% of the total available BIH, BUL, CRO, CYP, CZH, DEN, EST, health budget FIN, FRA, GEO, DEU, GRE, HUN, ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MON, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB

03 3.1.4 Number of Member States with a unit in the 165 185 176 41 46 46 ALB, AND, ARM, AUT, BEL, BUL, CRO, ministry of health or equivalent national CYP, CZH, DEN, EST, FIN, FRA, DEU, health authority, with dedicated staff and GRE, HUN, IRE, ISR, ITA, KAZ, KGZ, budget, for the prevention and control of LVA, LTU, LUX, MTA, MON, NET, NOR, chronic noncommunicable diseases POL, POR, MDA, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB.

03 3.2.1 Number of Member States that have 133 140 144 17 20 20 RUS, TKM, UKR, CYP, DEU, FIN, LTU, national plans to prevent unintentional MDA, ITA, NET, EST, NOR,TUR, UNK, injuries or violence CZH, LVA, MKD, ROM, KGZ, POR

03 3.2.2 Number of Member States that have 56 64 64 2 5 5 AZE, ROM, KGZ, TUR, MDA initiated the process of developing a mental health policy or law

03 3.2.3 Number of Member States that have 121 165 136 0 5 36 ARM, AZE, BEL, BUL, CZH, EST, FIN, adopted a multisectoral national policy on FRA, DEU, HUN, ICE, IRE, ISR, ITA, chronic noncommunicable diseases KGZ, LVA, LTU, LUX, MAT, MNE, NET, NOR, POR, MDA, RUS, SMR, SRB, SVK, SPA, SWE, TJK, MKD, TKM, UKR, UNK, UZB.

03 3.2.4 Number of Member States that are 59 130 74 n/a n/a n/a implementing comprehensive national plans for the prevention of hearing or visual impairment

03 3.3.1 Number of Member States that have 175 180 181 3 6 6 CZH, TUR, RUS, ROM, CYP, MKD submitted a complete assessment of their national road traffic injury prevention status to WHO during the biennium

03 3.3.2 Number of Member States that have a 193 179 179 1 2 2 TKM, TJK published document containing national data on the prevalence and incidence of disabilities

03 3.3.3 Number of low- and middle-income Member 110 120 Data not 22 22 22 ALB, ARM, AZE, BLR, BIH, BUL, GEO, States with basic mental health indicators available HUN, KAZ, KGZ, LTU, MNE, POL, MDA, annually reported RUS, SRB, TJK, MKD, TKM, TUR, UKR, UZB

03 3.3.4 Number of Member States with a national 101 155 101 42 48 47 AND, ARM, AUT, AZE, BEL, BUL, CRO, health reporting system and annual reports CYP, CZH, DEN, EST, FIN, FRA, DEU, that include indicators for the four major GRE, HUN, ICE, IRE, ISR, ITA, KAZ, noncommunicable diseases KGZ, LVA, LTU, LUX, MAT, MON, MNE, NET, NOR, POL, POR, MDA, RUS, SMR, SRB, SVK, SVN, SPA, SWE, TJK, MKD, TUR, TKM, UKR, UNK, UZB.

03 3.3.5 Number of Member States documenting, 47 66 57 n/a n/a n/a according to population-based surveys, the burden of hearing or visual impairment

03 3.4.1 Availability of evidence-based guidance on 12 14 Published and 0 2 2 N.a the effectiveness of interventions for the intervention interventions disseminated management of selected mental, s published published for 19 behavioural or neurological disorders and and interventions including those due to use of psychoactive disseminat disseminate substances ed d

03 3.4.2 Availability of evidence-based guidance or 6 8 Published and 0 3 0 N.a guidelines on the effectiveness or cost- intervention interventions disseminated effectiveness of interventions for the s published published for 8 prevention and management of chronic and and interventions noncommunicable diseases disseminat disseminate ed d

03 3.5.1 Number of guidelines published and widely 15 18 19 3(European 5 5 N.a (1. European facts and global status disseminated on multisectoral interventions report on report on road safety 2013; 2. European to prevent violence and unintentional child injury report on preventing child maltreatment.) injuries prevention, European report on preventing violence and knife crime among young people, and European report on preventing elder maltreatmen t)

03 3.5.2 Number of countries whose Health 8 20 47 12 16 16 UNK, NOR, NET, ITA, FIN, DEN, FRA, Ministries have begun scaling up services SWE, POR, SPA, ISR, AUT, KGZ, MDA, for mental neurological and substance use MNE, TUR disorders.

03 3.5.3 Number of Member States implementing 78 130 93 n/a n/a n/a strategies recommended by WHO for the prevention of hearing or visual impairment

03 3.6.1 Number of Member States that have 70 80 80 13 16 16 AZE, BLR, BUL, CRO, KGZ, LVA, LTU, incorporated trauma-care services for SRB, SVK, MKD, TUR, ITA, SWE, UNK, victims of injuries or violence into their KAZ, ROM health-care systems using WHO trauma- care guidelines

03 3.6.2 Number of Member States implementing 34 41 42 0 3 3 TJK, TUR, UKR community-based rehabilitation programmes

03 3.6.3 Number of low- and middle-income 80 88 88 11 11 11 ALB, ARM, GEO, AZE, KGZ, LVA, MDA, Member States that have completed an MKD, TJK, UKR, UZB assessment of their mental health systems using the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS)

03 3.6.4 Number of low- and middle-income Member 36 55 82 0 2 2 TJK, UZB States implementing primary health-care strategies for screening of cardiovascular risk and integrated management of noncommunicable diseases using WHO guidelines

03 3.6.5 Number of Member States with tobacco 65 67 86 30 30 30 AUT, BLR, BEL, BUL, CRO, CZH, DEN, cessation support incorporated into primary FIN, FRA, IRE, DEU, FRA, ISR, ITA, health care LVA, LTU, LUX, MAT, NET, POL, HUN, ROM, POR, SRB, SVN, SPA, SWE, TKM, TUR, UNK

04 4.1.1 Number of targeted Member States that 72 75 100 12 20 18 HUN, SVN, TJK, ARM, UZB, GEO, have an integrated policy on universal ROM, UNK, KAZ, MDA, IRE, SVK, ALB, access to effective interventions for KGZ, AZE, UKR, TKM, RUS improving maternal, newborn and child health

04 4.1.2 Number of Member States that have 63 75 73 14 20 18 TJK, MDA, MNE, TKM, ROM, UZB, developed, with WHO support, a policy on KGZ, AZE, SPA, RUS, KAZ, ARM, LVA, achieving universal access to sexual and BLR, UKR ,IRE, SWI, ALB reproductive health

04 4.2.1 Number of research centres that have 12 14 14 2 2 2 LTU, TJK received an initial grant for comprehensive institutional development and support

04 4.2.2 Number of completed studies on priority 60 62 62 4 6 5 ROM, MDA, UKR, RUS, KGZ issues that have been supported by WHO

04 4.2.3 Number of new or updated systematic 89 92 94 7 8 8 KGZ, UKR, TJK, LTU, EST, LVA, KAZ, reviews on best practices, policies and UZB standards of care for improving maternal, newborn, child and adolescent health, promoting active and healthy ageing or improving sexual and reproductive health

04 4.3.1 Number of Member States implementing 66 75 103 11 13 15 ALB, UZB, TJK, MDA, KAZ, KGZ, TKM, strategies for increasing coverage with ARM, BUL, AZE. LVA, UKR, SRB, BLR, skilled care for childbirth MKD

04 4.4.1 Number of Member States implementing 56 65 104 10 13 15 ALB, UZB, TJK, MDA, KAZ, KGZ, TKM, strategies for increasing coverage with ARM, BUL, AZE. LVA, UKR, SRB, BLR, interventions for neonatal survival and MKD health

04 4.5.1 Number of Member States implementing 79 75 84 10 12 12 ALB, ARM, AZE, GEO, KAZ, KGZ, MDA, strategies for increasing coverage with child TJK, UZB, UKR, TKM, SRB health and development interventions

04 4.5.2 Number of Member States that have 54 65 72 8 10 10 ARM, KGZ, MDA, KAZ, TKM, UZB, expanded coverage of the integrated GEO, AZE, TJK, SRB management of childhood illness to more than 75% of target districts

04 4.6.1 Number of Member States with a 74 75 85 9 12 12 TKM, BLR, ALB, KAZ, TUR, MDA, UKR, functioning adolescent health and TJK, KGZ, UZB, ARM, SRB development programme

04 4.7.1 Number of Member States implementing the 60 62 66 18 20 25 ALB, BLR, BUL, IRE, ROM, AZE, CRO, WHO reproductive health strategy to LVA, MKD, TKM, ITA, SPA, DEN, MDA, accelerate progress towards the attainment LUX, TUR, KAZ, KGZ, TJK, ARM, FIN, of international development goals and GEO, NOR, POR, SWI targets related to reproductive health agreed at the 1994 International Conference on Population and Development (ICPD), its five-year review (ICPD+5), the Millennium Summit and the United Nations General Assembly in 2007

04 4.7.2 Number of targeted Member States having 20 22 22 6 7 7 MDA, TJK, MKD, AZE, SPA, UKR, TUR reviewed their existing national laws, regulations or policies relating to sexual and reproductive health

04 4.8.1 Number of Member States with a 33 30 66 14 15 17 DEN, FIN, FRA, DEU, ISL, ISR, LUX, functioning active healthy ageing MAT, NET, NOR, POL, POR, SVK, programme consistent with WHA58.16 SVN, SPA, SWE, UNK “Strengthening active and healthy ageing”

05 5.1.1 Percentage of countries that have 47% 60% 40% 65% 70% 70% (12* out of ALB, ARM, CZH, KAZ, KGZ, MDA, completed a health risk assessment and 20 EURO MKD, MNE, RUS, TJK, UKR, TUR. have, at a minimum, initiated the safe countries) hospitals component of a national risk reduction programme for health.

05 5.1.2 Percentage of countries that have Not 50% 31% 15% 20% 20% (4 out of 20 MKD, MDA, SRB, TJK conducted an emergency health response available EURO simulation at least once during the countries) biennium..

05 5.1.3 Percentage of WHO country offices that Not 20% 5% 0% 15% 15% (3 out of 20 SRB, KGZ, TJK conducted an emergency health response available EURO simulation according to a written countries) contingency and business continuity plan at least once during the biennium.

05 5.7.1 Percentage of acute humanitarian 70% 80% 67% 100% 100% 100% emergencies with a coordinated risk assessment and initial health sector response strategy within 72 hours of onset.

06 6.1.1 Number of countries that have been 5 6 76 5 6 6 IRE, RUS, TUR, NOR, CZH, ITA supported to build capacity to strengthen multi-sectorial action for health.

06 6.1.2 Number of cities that have implemented 34 40 61 34 40 40 healthy urbanization programmes aimed at reducing health inequities

06 6.2.1 Number of Member States with a 94 105 102 1 5 5 KGZ, TKM, UZB, MDA, GEO functioning national surveillance system for monitoring major risk factors to health among adults based on the WHO STEPwise approach to surveillance

06 6.2.2 Number of Member States with a 72 83 83 32 32 32 UNK, UKR, TUR, SWI, SWE functioning national surveillance system for SPA, SVN, SVK, RUS, ROM, POR monitoring major risk factors to health POL, NOR, NET, MKD, LUX, LTU, LVA among youth based on the Global school- ITA, IRE, ICE, HUN, GRE, DEU, FRA, based student health survey methodology FIN, EST, DEN, CZH, CRO, BEL, AUT

06 6.3.1 Number of Member States having 78 92 94 5 6 6 GRE, RUS, POL, UKR, TUR, CZH comparable adult tobacco prevalence data available from recent national representative surveys, such as the Global Adult Tobacco Survey (GATS) or STEPS

06 6.3.2 Number of Member States with 31 33 42 5 10 9 UKR, BUL, TKM, ALB, IRE, UNK,TUR, comprehensive bans on smoking in indoor MAT, SPA public places and workplaces

06 6.3.3 Number of Member States with bans on 20 21 24 2 10 7 UKR, TKM, TUR, NOR,FIN, ALB, SPA tobacco advertising, promotion and sponsorship

06 6.4.1 Number of Member States that have 57 60 67 20 35 37 ALB, BLR, BEL, BIH, CRO, CYP, CZH, developed, with WHO support, strategies, FIN, FRA, DEU, GRE, ICE, IRE, ISR, plans and programmes for combating or ITA, LVA, LTU, MNE, NET, NOR, POL, preventing public health problems caused POR, MDA, ROM, RUS, SMR, SVK, by alcohol, drugs and other psychoactive SVN, SPA, SWE, SWI, TJK, MKD, TUR, substance use TKM, UNK and UZB

06 6.4.2 Number of WHO strategies, guidelines, 16 17 17 0 3 4 n/a standards and technical tools developed in order to provide support to Member States in preventing and reducing public health problems caused by alcohol, drugs and other psychoactive substance use

06 6.5.1 Number of Member States that have 73 79 90 23 26 26 AUT, BEL, DEN, FIN, IRE, ISR, MAT, adopted multisectoral strategies and plans NET, NOR, POR, SPA, SWE, SWI, for healthy diets or physical activity, based UNK, TJK, UZK, ALB, SRB, BUL, CRO, on the WHO Global Strategy on Diet, EST, HUN, MNE, POL, ROM, UKR Physical Activity and Health

06 6.5.2 Number of WHO technical tools that provide 22 24 24 3 3 3 n/a support to Member States in promoting healthy diets or physical activity

06 6.6.1 Number of Member States generating 22 32 34 8 10 10 KGZ, UKR, TJK, DEU, MNE, ROM, IRE, evidence on the determinants and/or RUS, MKD, LVA consequences of unsafe sex

06 6.6.2 Number of Member States generating 5 7 7 n/a n/a n/a comparable data on unsafe sex indicators using WHO STEPS surveillance tools

07 7.1.1 Number of WHO regions with a regional 5 6 6 1 1 1 strategy for addressing social and economic determinants of health as identified in the Report of the Commission on the Social Determinants of Health endorsed by the Director-General

07 7.2.1 Number of published country experiences 28 38 72 12 17 17 FIN, NET, NOR, SWE, SVN, UNK, LTU, on tackling social determinants for health SVK, SPA, MKD, DEN, POL, SVN, SRB, equity MNE, HUN

07 7.3.1 Number of country reports published during 46 50 52 17 20 24 EST, NOR, RUS, SWE, UNK, KAZ, the biennium incorporating disaggregated KGZ, ALB, ARM, BLR, DEU, FIN, GEO, data and analysis of health equity MDA, TJK, UKR, DEN, ITA, LTU, POL, SWE, SVN, SPA, HUN

07 7.4.1 Number of tools produced for Member 37 45 66 1 2 2 States or the Secretariat giving guidance on using a human rights-based approach to advance health

07 7.4.2 Number of tools produced for Member 16 19 19 n/a n/a n/a States or the Secretariat giving guidance on use of ethical analysis to improve health policies

07 7.5.1 Number of WHO tools, documents 98 108 180 8 14 14 (developed or updated) and joint activities with WHO technical units to promote gender responsive actions into the work of WHO

07 7.5.2 Number of gender mainstreaming activities 189 199 284 12 19 16 CRO, MDA, POR, TJK conducted in Member States supported by WHO

08 8.1.1 Number of Member States with proven 67 81 84 38 38 38 AND, AUT, BLR, BEL, BIH,CRO, CYP, capacity to conduct assessments of specific DEN, EST, FIN, FRA, GEO, DEU, GRE, environmental threats to health, in order to ICE, IRE, ISR, ITA, KGZ, LVA, LTU, quantify, with WHO support, the LUX, MAT, MON, MNE, NET, NOR, environmental burden of disease so as to POR, SMR, SRB, SPA, SWE, SWI, add sustainability to MDGs 4, 5 and 6 MKD, TUR, UKR, UNK, UZB achievements.

08 8.1.2 Number of new or updated WHO norms, 21 25 25 0 2 2 n/a standards or guidelines on occupational or environmental health issues published during the biennium

08 8.2.1 Number of Member States implementing, 92 106 109 32 38 38 AND, AUT, BLR, BEL, BIH, CRO, CYP, with WHO technical support, primary DEN, EST, FIN, FRA, DEU, GRE, ICE, prevention interventions to reduce IRE, ISR, ITA, LVA, LUX, MAT, MON, pneumonia in children, diarrhoea and NET, NOR, POR, ROM, SMR, SPA, noncommunicable diseases in at least one SWE, SWI, MKD, UKR, UNK,SRB, KAZ, of the following settings: workplaces, homes TUR, MNE, ALB, BUL or urban settings.

08 8.3.1 Number of Member States that have 88 103 103 38 41 41 ALB, AND, AUT, BEL, BIH, CRO, CYP, implemented national action plans/policies DEN, FIN, FRA, GEO, DEU, GRE, for the management of occupational health ICE, IRE, ISR, ITA, KAZ, LVA, LTU, risks, such as in relation to the Global Plan LUX, MAT, MON, MNE, NET, NOR, of Action on Workers’ Health (2008–2017). POL, POR, ROM, SMR, SRB, SPA, SWE, SWI, MKD, TUR, UKR, UNK, EST, BUL, HUN

08 8.4.1 Number of Member States implementing Not 86 86 10 12 12 ALB, EST, HUN, KAZ, KGZ, LVA, LTU, WHO-supported initiatives to reduce measured MDA, MNE, SVN, SVK,TUR noncommunicable and communicable previously diseases through healthy agriculture, energy and transportation policies.

08 8.5.1 Number of studies or reports on new and re- 21 25 28 32 62 69 n/a emerging occupational and environmental health issues published or co- published by WHO

08 8.5.2 Number of reports published or jointly 10 12 14 2 4 4 n/a published by WHO on progress made in achieving water and sanitation objectives of major international development frameworks, such as the Millennium Development Goals

08 8.5.3 Number of high-level regional forums on 11 13 33 5 10 10 n/a environment and health issues organized or technically supported by WHO biennially

08 8.6.1 Number of studies or reports on the public 35 40 46 4 11 13 ALB, MKD, KGZ, KAZ, RUS, TJK, UZB, health effects of climate change published HUN, TUR, MAT, ITA, SPA, SWE or co- published by WHO

08 8.6.2 Number of countries that have implemented 48 68 72 30 37 37 ALB, AND, AUT, BLR, BEL, CRO, CYP, plans to enable the health sector to adapt to CZH, FIN, FRA, DEU, DEN, GRE, ICE, the health effects of climate change IRE, ISR, ITA, LUX, MAT, MON, MNE, NET, NOR, POR, MDA, SPA, SWE, SWI, MKD, UNK, KAZ, KYG, LTU, RUS, TJK, TUR, UZB

09 9.1.1 Number of Member States that have 128 100 183 48 50 50 All except MDA, AZE, UKR functional institutionalized coordination mechanisms to promote intersectoral approaches and actions in the area of food safety, food security or nutrition

09 9.1.2 Number of Member States that have 117 35 117 n/a n/a n/a included nutrition, food-safety and food- security activities and a mechanism for their financing in their sector-wide approaches or Poverty Reduction Strategy Papers

09 9.2.1 Number of new nutrition and food-safety 88 and 557 90 and 600 231 and 1,482 n/a n/a n/a standards, guidelines or training manuals Codex Codex Codex produced and disseminated to Member standards standards standards States and the international community

09 9.2.2 Number of new norms, standards, 20 30 30 n/a n/a n/a guidelines, tools and training materials for prevention and management of zoonotic and non-zoonotic foodborne diseases

09 9.3.1 Number of Member States that have 115 125 128 34 39 39 ALB, ARM, AUT, BEL, BUL, CRO, CYP, adopted and implemented the WHO Child CZH, DEN, EST, FIN, MKD, FRA, GRE, Growth Standards HUN, IRE, ISR, ITA, KAZ, LVA, LTU, LUX, MAT, MDA, MNE, NET, NOR, POL, POR, ROM, RUS, SVK, SVN, SPA, SRB, SWI, TJK, TUR, UZB, UKR

09 9.3.2 Number of Member States that have 142 130 148 50 51 51 ALB, AND, ARM, AUT, AZE, BEL, BLR, nationally representative surveillance data BUL, BIH, CRO, CYP, CZH, DEN, EST, on major forms of malnutrition FIN, MKD, FRA, DEU, GEO, GRE, HUN, ISL, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MDA, MNE, NET, NOR, POL, POR, ROM, RUS, SVK, SVN, SPA, SRB, SWE, SWI, UNK, TJK, TUR, UZB, UKR, MON

09 9.4.1 Number of Member States that have 117 105 128 32 40 40 ALB, AUT, BEL, BUL, CRO, CYP, CZH, implemented at least three high- priority DEN, EST, FIN, MKD, FRA, DEU, GRE, actions recommended in the Global HUN, ISL, IRE, ISR, ITA, KAZ, LVA, Strategy for Infant and Young Child Feeding LTU, MAT, MDA, MNE, NOR, POL, POR, ROM, RUS, SVK, SVN, SPA, SRB, SWE, CHE, UNK, TJK, TUR, UZB, UKR

09 9.4.2 Number of Member States that have 119 80 120 39 51 51 ALB, AND, ARM, AUT, AZE, BEL, BLR, implemented strategies to prevent and BUL, BIH, CRO, CYP, CZH, DEN, EST, control micronutrient malnutrition FIN, MKD, FRA, DEU, GEO, GRE, HUN, ISL, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MDA, MNE, NET, NOR, POL, POR, ROM, RUS, SVK, SVN, SPA, SRB, SWE, CHE, UNK, TJK, TUR, UZB, UKR, MON

09 9.4.3 Number of Member States that have 138 80 131 31 41 41 ALB, AUT, BEL, BUL, CRO, CZH, DEN, implemented strategies to promote healthy EST, FIN, MKD, FRA, DEU, GRE, HUN, dietary practices for preventing diet-related ISL, IRE, ISR, ITA, KAZ, LVA, LTU, chronic diseases LUX, MAT, MDA, MNE, NET, NOR, POL, POR, ROM, RUS, SVN, SPA, SRB, SWE, CHE, UNK, TJK, TUR, UZB, UKR

09 9.4.4 Number of Member States that have 25 65 79 n/a n/a n/a included nutrition in their responses to HIV/AIDS

09 9.4.5 Number of Member States that have 47 50 61 n/a n/a n/a national preparedness and response plans for nutritional emergencies

09 9.5.1 Number of Member States that have 105 80 132 48 50 50 All but GEO, MDA, UKR established or strengthened intersectoral collaboration for the prevention, control and surveillance of foodborne zoonotic diseases

09 9.5.2 Number of Member States that have 85 86 102 42 48 48 All but AZE, GEO, KGZ, MDA,TKM initiated a plan for the reduction in the incidence of at least one major foodborne zoonotic disease

09 9.6.1 Number of selected Member States 85 90 71 12 8 8 AZE, BLR, KGZ, MLD, ROM, TJK, TKM, receiving support to participate in UKR international standard-setting activities related to food, such as those of the Codex Alimentarius Commission

09 9.6.2 Number of selected Member States that 177 80 183 52 53 53 ALB, AND, ARM, AUT, AZE, BLR, BEL, have built national systems for food safety BIH, BUL, CRO, CYP, CZH, DEN, EST, with international links to emergency FIN, FRA, GEO, DEU, GRE, HUN, ISL, systems IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MON, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, CHE, TJK, MKD, TUR, TKM, UKR, UNK, UZB

10 10.1.1 Number of Member states that have 73 90 90 n/a n/a n/a regularly updated databases on numbers and distribution of health facilities and health interventions offered

10 10.2.1 Number of Member states that have in the 108 115 126 29 33 31 ALB, ARM, AZE, AND, BiH, DEN, EST, last five years developed comprehensive DEU, FIN, FRA, GEO, HUN, ISL, IRE, national health planning processes in ITA, KAZ, KGZ, LTU, MDA, MAT, NET, consultation with stakeholders NOR,POL POR, SVN, SRB, SWE, TJK, TUR, UNK, UZB

10 10.2.2 Number of Member states that conducted a 69 75 79 16 20 19 ALB, DEN, EST, DEU, FIN, FRA, GEO, regular or periodic evaluation of progress, ITA, KGZ, LTU, MDA, NET, NOR, POR, including implementation of their national SPA, SWE, TJK, TUR, UNK health plan, based on a commonly agreed performance assessment of their health system

10 10.3.1 Number of Member states where the inputs 52 60 60 4 5 3 KGZ, TJK, MDA of major stakeholders are harmonized with national policies, measured in line with the Paris Declaration on Aid Effectiveness

10 10.4.1 Proportion of low- and middle-income 48% 60% 60% 50% 65% 65% KGZ, KAZ, RUS, SRB, TJK, TKM, UZB countries with adequate health statistics and monitoring of health-related Millennium Development Goals that meet agreed standards

10 10.5.1 Proportion of countries for which high 98% 98% 98% 90% 95% 95% ALB, ARM, AUT, AZE, BLR, BEL, BIH, quality profiles with core health statistics are BUL, CRO, CYP, CZH, DEN, EST, FIN, available from its open-access databases FRA, GEO, DEU, GRE, HUN, ICE, IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB

10 10.5.2 Number of countries in which WHO plays a 36 45 45 13 17 17 ALB, ARM, AZE, BiH, GEO, HUN, KAZ, key role in supporting the generation and KGZ, MDA, MNE, ROM, RUS, SVK, use of information and knowledge, including TJK, TUR, UKR, UZB primary data collection through surveys, civil registration or improvement or analysis and synthesis of health facility data for policies and planning

10 10.5.3 Effective research for health coordination Global Mechanisms Global 80% of 100% of 100% of n/a and leadership mechanisms established research operating at research for appropriate appropriate appropriate and maintained at global and regional levels for health global and health strategy functioning functioning functioning strategy all regional established at established levels WHO HQ. at WHO Regional HQ. strategies Regional established in strategies AFRO, AMRO, established EMRO and in AFRO, SEARO AMRO, EMRO and SEARO

10 10.6.1 Proportion of low- and middle-income 40% 60% 57 of 144 n/a n/a n/a n/a countries in which national health-research LMIC systems meet internationally agreed countries minimum standards namely 40%

10 10.7.2 Number of Member States with access to 162 180 167 48 51 n/a n/a electronic international scientific journals and knowledge archives in health sciences as assessed by the WHO Global Observatory for eHealth biannual survey

10 10.7.3 Proportion of Member States with eHealth 75 90 85 5 5 5 AZE, KGZ, TJK, TKM, UZB policies, strategies and regulatory frameworks as assessed by the WHO Global Observatory for eHealth biannual survey

10 10.8.1 Number of countries reporting two or more 127 130 122 53 53 53 ALB, AND, ARM, AUT, AZE, BLR, BEL, national data points on human resources for BIH, BUL, CRO, CYP, CZH, DEN, EST, health within the past five years, reported in FIN, FRA, GEO, DEU, GRE, HUN, ICE, the Global Atlas of the Health Workforce IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, LUX, MAT, MON, MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SMR, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB

10 10.8.2 Number of Member states with an national 90 95 107 n/a n/a 23 AUT, BEL, DEN, EST, FIN, FRA, DEU, policy and planning unit for human HUN, ICE, IRE, ISR, ITA, LTU, NET, resources for health NOR, POL, POR, SVN, SPA, SWE, SWI, TUR, UNK *

10 10.9.1 Proportion of 57 countries with critical 61% 68% 68% n/a n/a n/a n/a shortage of health workforce, as identified in The world health report 2006 with a multi- year HRH plan

10 10.9.2 Proportion of 57 countries with critical 35% 40% 53% n/a n/a n/a n/a shortage of health workforce, as identified in The world health report 2006 which have an investment plan for scaling up training and education of health workers

10 10.10.1 Number of Member States provided with 77 20 during 89 during the 20 20 20 ARM, BIH, BLR, BUL, EST, GEO, GRE, technical and policy support to raise the biennium biennium HUN, IRE, KAZ, KGZ, LTU, LVA, MDA, additional funds for health; to reduce MNE, POL, SPA, SVN, TJK, TUR financial barriers to access, incidence of financial catastrophe, and impoverishment linked to health payments; or to improve social protection and the efficiency and equity of resource use

10 10.10.2 Number of key policy briefs prepared, 24 15 technical 25 technical 9 technical 12 technical 17 technical disseminated and their use supported, technical briefs briefs, 35 briefs briefs briefs which document best practices on revenue- briefs, over additional raising, pooling and purchasing, including 75 information contracting, provision of interventions and information products services, and handling of fragmentation in products of systems associated with vertical other types programmes and inflow of international funds

10 10.11.1 Key tools, norms and standards to guide Tools and Tools and WHO- Tools and Tools and New system of ALB, AND, ARM, AUT, AZE, BLR, BEL, policy development and implementation frameworks frameworks CHOICE & frameworks frameworks health accounts BIH, BUL, CRO, CYP, CZH, DEN, EST, developed, disseminated and their use modified, modified, OneHealth modified, modified, developed and FIN, FRA, GEO, DEU, GRE, HUN, ICE, supported, according to expressed need, updated updated and joint UN cost updated and updated and disseminated IRE, ISR, ITA, KAZ, KGZ, LVA, LTU, that comprise resource tracking and and disseminate and impact disseminate disseminate jointly with LUX, MAT, MON, MNE, NET, NOR, allocation, budgeting, financial disseminat d as tool updated, d as d as OECD and POL, POR, MDA, ROM, RUS, SMR, management, economic consequences of ed as necessary SHA2011 necessary necessary EUROSTAT. SRB, SVK, SVN, SPA, SWE, SWI, TJK, disease and social exclusion, organization necessary rolled out with MKD, TUR, TKM, UKR, UNK, UZB and efficiency of service delivery, including new contracting, or the incidence of financial production tool catastrophe and impoverishment

10 10.11.2 Number of Member States provided with 70 20 additional Participant 12 12 12 ARM, BLR, EST, GEO, HUN, IRE, KGZ, technical support for using WHO tools to during the from 62 MDA, POR, TJK, UKR, UZB track and evaluate the adequacy and use of biennium countries funds, to estimate future financial needs, to manage and monitor available funds, or to track the impact of financing policy on households

10 10.12.1 WHO presence and leadership in WHO WHO WHO 3 3 3 KGZ, MDA, TJK international, regional and national participatio participation participation in partnerships and use of its evidence in n in 4 5 global or order to increase financing for health in low- in 5 partnerships regional income countries, or provide support to partnership partnerships countries in design and monitoring of s and Poverty Reduction Strategy Papers, sector- support on wide approaches, medium-term expenditure long-term frameworks, and other long-term financing financing mechanisms capable of providing social options health protect consistent with primary health provided to care 46 countries

10 10.12.2 Number of Member States provided with Annual Annual Annual 27 30 32 ALB, ARM, AZE, BEL, BIH, BLR, BUL, support to build capacity in the formulation updates of updates of updates of CZE, EST, FIN, GEO, HUN, ICE, ISR, of health financing policies and strategies health health health ITA, KAZ, KGZ, LVA, LTU, MDA, MKD, and the interpretation of financial data, or expenditure expenditures expenditures MNE, POR, ROM, RUS, SPA, SRB, with key information on health expenditures, s produced for all provided after SWI, TJK, TUR, UKR, UZB financing, efficiency and equity to guide the after Member country process consultatio States. consultation. n with Capacity Capacity Member building in building States. financial participation Capacity policy and from 116 building in analysis in countries one or 20 countries more of the WHO tools provided to 67 countries

10 10.13.1 Key tools, norms and standards to guide 6 standards 4 global 6 global 5 8 8 (various BUL, CZH, KAZ, KGZ, LVA, POL, SVK, policy development, measurement and and 15 safety clinical degrees) MDA implementation disseminated and their use tools standards standards and supported and 40 45 supporting major tools supporting tools

10 10.13.2 Number of Member States participating in 69 90 90 32 35 35 AUT, ALB, BEL, BIH, BUL, CRO, CZH, global patient safety challenges and other DEN, FRA, FIN, GEO, GER, ICE, IRE, global safety initiatives, including research ITA, KAZ, KGZ, LVA, LTU, MDA, MKD, and measurement MAT, MNE, NOR, POL, ROM, SWE, SWI, SRB, SVN, SPA, TJK, TKM, TUR, UZB

11 11.1.1 Number of Member States receiving support 118 136 99 15 17 17 ALB, ARM, CRO, EST, GEO, HUN, to formulate and implement official national KGZ, KOS*, LVA, MAT, MDA, MKD, policies on access, quality and use of MNE, ROM, SRB, TJK, TUR essential medical products or technologies

11 11.1.2 Number of Member States receiving support 68 84 66 6 6 6 AZE, MDA, BLR, UKR, KGZ, TKM to design or strengthen comprehensive national procurement or supply systems

11 11.1.3 Number of Member States receiving support 68 71 84 42 49 49 ALB, ARM, AUT, AZE, BLR, BEL, BIH, to formulate and/or implement national BUL, CRO, CYP, CZH, DEN, EST, FIN, strategies and regulatory mechanisms for FRA, GEO, DEU, GRE, HUN, ICE, IRE, blood and blood products or infection ISR, ITA, KAZ, KGZ, LVA, LTU, MAT, control MNE, NET, NOR, POL, POR, MDA, ROM, RUS, SRB, SVK, SVN, SPA, SWE, SWI, TJK, MKD, TUR, TKM, UKR, UNK, UZB

11 11.1.4 Publication of a biennial global report on 1 1 1 reported n/a n/a n/a n/a medicine prices, availability and report report published affordability, based on all available regional published published (2013) and national reports (2011) (2013)

11 11.2.1 Number of new or updated global quality Additional 30 per 30 per n/a na n/a n/a standards, reference preparations, 61 biennium biennium guidelines and tools for improving the provision, management, use, quality, or effective regulation of medical products and technologies

11 11.2.2 Number of assigned International 8 552 8 750 8900 n/a na n/a n/a Nonproprietary Names for medical products

11 11.2.3 Number of priority medicines, vaccines, 320 300 583 n/a n/a n/a n/a diagnostic tools and items of equipment that (274 medicines; are prequalified for United Nations medicines; 40 APIs; procurement 35 APIs ; 15 11 diagnostic diagnostic tools; tools; 140 134 vaccines vaccines)

11 11.2.4 Number of Member States for which the 102 125 125 25 26 25 ALB, ARM, AZE, BLR, BIH, HUN, CRO, functionality of the national regulatory GEO, EST, KAZ, KGZ, LVA, MDA, MKD, authorities has been assessed or supported MNE, POL, ROM, RUS, SRB, SWI, TJK, TKM TUR, UKR, UZB

11 11.3.1 Number of national or regional programmes 78 97 83 16 18 18 ARM, AZE, BLR, BIH, HUN, CRO, GEO, receiving support for promoting sound and EST, KAZ, KGZ, MDA, MKD, MNE, cost-effective use of medical products or ROM, TJK, TKM, UKR, UZB technologies

11 11.3.2 Number of Member States using national 94 120 80 17 20 20 ARM, ALB, AZE, BLR, BIH, CRO, EST, lists, updated within the past five years, of GEO, KAZ, KGZ, LVA, MDA, POL,SPA, essential medicines, vaccines or SRB, SVK, TKM, TJK, UKR, UZB technologies for public procurement or reimbursement

12 12.1.1 Proportion of documents submitted to 95% 95% 95% 60% 75% 75% n/a governing bodies within constitutional deadlines in the six WHO official languages

12 12.2.1 Number of Member States where WHO is 33 38 38 of the 145 29 32 31 ALB, ARM, AZE, BLR, BIH, BUL, CRO, aligning its country cooperation strategy county of the 145 country CZH, EST, GEO, HUN, KAZ, KGZ, LVA, with the country’s priorities and cooperation country cooperation LTU, MAT, MNE, KOS, POL, MDA, development cycle and harmonizing its work strategies cooperation strategies ROM, RUS, SRB, SVK, SVN, SWI, TJK, with the United Nations and other strategies updated/revise MKD, TUR, TKM, UKR, UZB development partners within relevant updated/revi d frameworks, such as the United Nations sed Development Assistance Framework, Poverty Reduction Strategy Papers and Sector-Wide Approaches

12 12.2.2 Proportion of WHO country offices which 77% 80% 80% 0% 100% 100% ALB, ARM, AZE, BLR, BIH, BUL, CRO, have reviewed and adjusted their core CZH, EST, GEO, HUN, KAZ, KGZ, LVA, capacity in accordance with their country LTU, MAT, MNE, KOS, POL, MDA, cooperation strategy ROM, RUS, SRB, SVK, SVN, SWI, TJK, MKD, TUR, TKM, UKR, UZB.

12 12.3.1 Number of health partnerships in which 45 45 45 not not not applicable not applicable WHO participates that work according to the applicable applicable best practice principles for Global Health Partnerships

12 12.3.2 Proportion of health partnerships managed 100% 100% 100% 100% 100% 100% by WHO that comply with WHO partnership policy guidance

12 12.3.3 Proportion of countries where WHO is 80% 90% 90% 75% 85% 85% ALB, ARM, AZE, BLR, BIH, BUL, CRO, leading or actively engaged in health and GEO, KAZ, KGZ, LVA, LTU, MNE, MDA, development partnerships (formal and ROM, RUS, SRB, TJK, MKD, TUR, informal), including in the context of reforms TKM, UKR, UZB of the United Nations system

12 12.4.1 Average number of page views/visits per 7 million 7 million More than 7 not not N/A month to the WHO headquarters’ web site million available/11 available/12 7000 0000 528000/164000

12 12.4.2 Number of pages in languages other than More than 80 000 More than 17879 23000 23488 N/A English available on WHO country and 80 000 80000 regional offices’ and headquarters’ web sites

13 13.1.1 Proportion of country workplans that have 0% 100% 100% 100% 100% 100% been peer reviewed with respect to their technical quality, that they incorporate lessons learnt and reflect country needs

13 13.1.2 Office Specific Expected Results (OSERs) 85% 90% 92% 86% 90% 99% for which progress status has been updated within the established timeframes for periodic reporting

13 13.2.1 Degree of compliance of WHO with Systems First fully First fully Systems First fully To be reported International Public Sector Accounting and compliant compliant and opening compliant by HQ Standards opening IPSAS IPSAS annual accounts IPSAS accounts annual financial fully annual fully financial statements compliant financial compliant statements presented to statements presented to the Sixty-sixth presented to the Sixty- World Health the Sixty- sixth Assembly in sixth World May 2013 World Health Health Assembly in Assembly in May 2013 May 2013

13 13.2.2 Amount of voluntary contributions that are US$ 235 US$ 400 US$ 264 US$ 15.2 US$ 30 US$ 13.4 million classified as fully and highly flexible million million million million million

13 13.3.1 New human resources policies implemented 5 7 8 100% 100% 100% in line with the United Nations General Assembly and World Health Assembly resolutions.

13 13.3.2 Number of staff assuming a new position or 0 400 113 26 40 moving to a new location during a biennium

13 13.3.3 Proportion of staff in compliance with the 63% 100% 86% 51% 51% 62% cycle of the Performance Management Development System

13 13.4.1 Number of information technology 5 7 7 5 7 6 disciplines1 implemented Organization-wide according to to industry-best-practices benchmarks

13 13.4.2 Proportion of offices using consistent real- Headquarte All relevant All relevant Headquarter All relevant All EURO offices time management information rs, WHO WHO s, WHO are using 5 regional locations, locations, 5 regional locations, corporate offices and including including offices and including connectivity associated sub country subcountry associated sub country solution and country and field and field country and field Global offices offices, offices, where offices offices, Management where appropriate where System. appropriate appropriate

13 13.5.1 Proportion of services delivered by the 85% 100% 90% 85% 100% n/a n/a global service centre according to criteria in service-level agreements

13 13.5.2 Percentage of transactions rejected. 3.5% 3% 2.5% 3.5% 3% To be reported by HQ

13 13.6.1 The percentage of offices which are MOSS 70% 95% 85% 70% 95% 95% ALB, ARM, AZE, BIH, BLR, BUL, CRO. compliant. CZE, DEN, EST, GEO, HUN, KAZ, KGZ, LTU, LVA, MDA, MKD, MNE, POL, ROM, RUS, SRB, SVK, SVN, TKM, UKR, UZB

13 13.6.2 Level of funding and execution of the 70% 95% Funding 33% 70% 95% 95% biennial Capital Master Plan Implementatio n 88%

Part 2: Regional Office Outcome Assessment Sheets 2012–2013 Outcome 01 Assessment (KPO)

SO.01.001 Member States develop, implement, and maintain policies to achieve OSER Achievement elimination of measles and rubella in the European Region by 2015 Fully 17 through strengthening the quality of disease surveillance and delivery Partially Not‐achieved of immunization services. Not‐reported Total 17 Outcome responsible: Dr Dina Pfeifer General narrative on Outcome achievement: Increasing population immunity through routine and supplemental immunization; increasing acceptance/demand for immunization by improved advocacy and communication. The Regional Verification Commission for measles and rubella elimination has been established, and 44 MS established the National Verification Committees; All 53 MS organized activities during the EIW. Out of 68 measles rubella reference laboratories, 64 have been accredited and 4 accreditations are in the process. Contribution to public health impact: 36 national Annual Status Reports were received in 2013, and the RVC conclude on absence of endemic measles in 16 and on absence of endemic rubella in 19 MS. Activities towards measles and rubella immunization increased capacities of national immunization programmes and surveillance systems in regards to all VPDs, and increased awareness of elimination goal’s importance for the Region and globally.

Evt. Examples of outstanding Outcome achievements in one or two countries: • Germany – dedicated work of national technical experts resulted with increased commitment of the Government. In 2013 Germany introduced national comprehensive rubella case‐based surveillance. • Sustainable, high quality immunization and surveillance systems allowed achieving and documenting absence of endemic measles or rubella in some MS (16 and 19 MS, consequently), making them beacons of the elimination in the Region. Evt. Supportive documentation for Outcome achievement: • Germany (Reference: page 581 at http://www.bgbl.de/Xaver/start.xav?startbk=Bundesanzeiger_BGBl#__Bundesanzeiger_BGBl__%2F%2F*%5B%40attr_id%3D'b gbl113s0566.pdf'%5D__1388328867667 • Report of the 2nd RVC Meeting, CPH, Oct 2013 – in preparation General narrative on deliverable (Output) Technical support was provided by the Secretariat to all MS, and in particular to 14 MS with BCA in strengthening measles and rubella surveillance and its laboratory component; Links to supportive documentation for deliverables

Challenges: Decision makers in the MS have to confirm their commitment to elimination goals by practical actions, that will result in implementation of recommended and in general accepted Regional strategies. Due to significant number of susceptibles to measles and rubella in population, outbreaks are still burden to some MS, threatening the Regional elimination goal. Lessons learned: High level advocacy and involvement of stakeholders (international and national) enabled active implementation of elimination strategies. New approaches to advocacy, including involvement of professional associations and global champions of measles and rubella elimination, may present “game changers” in some countries. Plans for 2014‐2015: Implementation of activities stated in Accelerated package of action for the elimination of measles and rubella, accepted by MS at RC63, is the main task. Continuing with high political level advocacy meetings, we expect that MS will follow WHO Europe guides and example, and create their own accelerated plans towards elimination goal by 2015.

Outcome 02 Assessment (KPO)

SO.01.006 Member States have made an initial assessment of the epidemiological OSER Achievement situation of antibacterial resistance, antibiotic usage in all sectors Fully 20 (including food and agriculture) and have established a national Partially 1 Not‐achieved coordination mechanism and have developed national action plans based Not‐reported on the seven strategic objectives of the regional plan on the containment Total 21 of antibiotic resistance. Outcome responsible: Dr Danilo Lo Fo Wong General narrative on Outcome achievement: Some countries have national coordination mechanisms (e.g. BLR, MNE, TUR) dedicated to AMR, while others have existing infectious diseases coordination structures which could include AMR with some adjustments (e.g. MKD, GEO, SRB) or the intention to establish such a mechanisms (e.g. KGZ, UZB). Many Member States seek further support to develop their national AMR action plan. Contribution to public health impact: Data on antimicrobial consumption and resistance highlights the need for public health intervention and monitors the impact. In the absence of this data, most MS in the non‐EU part of our Region are still at the very beginning of a long journey towards public health action and impact. Our efforts on surveillance, coordination and awareness campaigns aim to support MS to achieve public health impact through AMR stewardship. Evt. Examples of outstanding Outcome achievements in one or two countries: • Turkey has established AMR surveillance and two national workshops were conducted to streamline national data collection and analysis. Turkey contributes national data to the WHO surveillance networks. • Montenegro appointed a National AMR Focal Point, established an Intersectoral Coordination Committee (NIKRA) and developed a national AMR action plan. Twinning is in place with the Swedish National Reference laboratory. Evt. Supportive documentation for Outcome achievement: http://www.mzdravlja.gov.me/ResourceManager/FileDownload.aspx?rid=162669&rType=2&file=2012‐ 226135%20Final%20AMR%20Strategy%20submitted%20to%20MoH%20for%20adoption%20MNE.pdf General narrative on deliverable (Output) Six initial assessments were done through country missions in ARM, AZE, BLR, GEO, KGZ, UZB, during which the available information available on antibiotic usage and resistance was discussed. 10 technical workshops were conducted to assess and improve the country capacity to address antibiotic resistance and to advise on follow‐up activities. WHO and partners initiated regional networks for the surveillance of antimicrobial consumption and resistance, closely coordinated with ECDC. Materials were developed and distributed for awareness campaigns. Links to supportive documentation for deliverables (examples) • http://www.euro.who.int/en/health‐topics/disease‐prevention/antimicrobial‐ resistance/news/news/2012/11/antibiotic‐resistance‐surveillance‐network‐extended‐throughout‐ european‐region • http://www.euro.who.int/en/health‐topics/disease‐prevention/antimicrobial‐ resistance/news/news/2014/01/initiating‐a‐response‐to‐antibiotic‐resistance‐in‐turkey • http://www.euro.who.int/en/countries/montenegro/sections/news/2012/11/national‐conference‐ in‐montenegro‐promotes‐action‐to‐combat‐antibiotic‐resistance • http://www.euro.who.int/en/health‐topics/disease‐prevention/antimicrobial‐ resistance/news/news/2013/12/marking‐european‐antibiotic‐awareness‐day‐in‐georgia • http://www.euro.who.int/en/countries/belarus/news/news/2012/06/assessing‐antibiotic‐ resistance‐in‐belarus

• http://www.euro.who.int/en/health‐topics/disease‐prevention/antimicrobial‐ resistance/news/news/2013/11/antibiotics‐awareness‐day‐activities‐in‐the‐former‐yugoslav‐ republic‐of‐macedonia

Challenges: Involve all relevant sectors, bringing laboratory methods in line with international standards, setting up an infrastructure for central data collection at a national reference laboratory and changing antimicrobial consumption behaviour. Lessons learned: Some countries lack fundamental laboratory capacity to perform surveillance, doctors are not relying on diagnostics for treatment and patients can obtain antibiotics without prescription. Intersectoral coordination is vital. Plans for 2014‐2015: Continued support to countries to develop and implement comprehensive national AMR action plans. We will address the fundamental need for laboratory capacity‐building through training and twinning in collaboration with technical partners and slowly build up the infrastructure for data collection through sentinel surveillance initially. The AMR problem is closely linked to health systems strengthening and will be addressed in partnership with dedicated programmes.

Outcome 03 Assessment (KPO)

S0.01.006 In support to national and regional health security, Member States have OSER Achievement developed policies and national plans to implement the IHR, including Fully 22 strengthening their core public health capacities for disease surveillance Partially 3 and response, as well as preparedness for epidemic‐prone diseases (such Not‐achieved Not‐reported 1 as influenza). Total 26 Outcome responsible: Dr Jukka Tapani Pukkila General narrative on Outcome achievement: Three Member states developed draft laboratory policies (Republic of Moldova), or are in process of doing so (Tajikistan and Uzbekistan). Lab policies; Capacities in MSs for early detection and response to public health events (including those of potential international concern) caused by any health hazards improved. Information sharing on PH events strengthened. Contribution to public health impact: Importation of MERS‐CoV cases from Middle East to five EURO Member States (France, Germany, Italy, Spain and United Kingdom) occurred in 2012‐13. All these Member States were able to promptly detect secondary cases and exclude any further human to human transmission of MERS‐CoV in their territories. Evt. Examples of outstanding Outcome achievements in one or two countries: • “Country 1 – REPUBLIC OF MOLDOVA: Active IHR National Focal Point with political support and multidisciplinary and multisectoral cooperation developed. NFP translated WHO Risk Assessment manual and acted as a facilitator in subregional RA trainings in Russian. • “Country 2 – UNITED KINGDOM: After the UNK reported their first MERS CoV case in a Qatari patient refererred for treatment in the UNK in 2012, they have greatly contributed to the diagnostics and treatment of this new disease with their vigorous scientific laboratory work and facilitation and leadership of the work of international clinical networks (especially the ISARIC network).

Evt. Supportive documentation for Outcome achievement: Public Health England Genetic sequence information for scientists about the novel coronavirus 2012: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/MERSCoV/respPartialgeneticsequenceofno velcoronavirus/

Public Health England PHE MERS‐CoV CASE ALGORITHM: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317136270914 General narrative on deliverable (Output): IHR core capacity development continued. First EURO IHR meeting since 2008 in Luxembourg, Feb 2013. Numerous IHR WSs held. European pandemic guide finalized. Training materials on CM of flu, RA, response etc. developed and translated. IHR CP EURO fully functional 24/7. Links to supportive documentation for deliverables IHR meetings in EURO http://www.euro.who.int/en/health‐topics/emergencies/international‐health‐ regulations/activities/past‐meetings ; WHO RRA manual for acute public health events (English http://www.who.int/csr/resources/publications/HSE_GAR_ARO_2012_1/en/index.html and in Russian http://www.who.int/csr/resources/publications/HSE_GAR_ARO_2012_1/ru/index.html ).

Challenges: The voluntary donations from a number of Member States were essential to allow for organizing IHR core capacity activities and EURO participation in IHR and public health event management – related networks. The availability of training materials and publications in Russian is still not sufficient.

Lessons learned: Involvement of partners in IHR core capacity building and public health event management is essential. It is also crucial to ensure that the processes and systems, including content of various training activities are coordinated with the requirements of IHR.

Plans for 2014‐2015: Close cooperation between the European Commission Health Security Committee (HSC), ECDC with WHO Regional Office for EURO (ARO and relevant other technical units, especially Food Safety and Environment and Health) is required to prevent overlaps and ensure complementarity between IHR operations and the newly adapted EC Serious Cross Border Threats to Health –legislation (Decision 1082/2013/EU). Support in maintenance of IHR core capacities in States Parties after June 2014 will be required throughout the biennium.

Outcome 04 Assessment (KPO)

SO.02.001 Member States adopt policies and strategies for strengthening health system OSER Achievement and implementing public health approaches for prevention and control of Fully 6 HIV/AIDS, including programmes linked to TB control, drug dependence Partially (including opioid substitute therapy) and sexual and reproductive health, to Not‐achieved 4 halt the rise of HIV epidemic in Europe. Not‐reported Total 10 Outcome responsible: Mr Martin Christopher Donoghoe

General narrative on Outcome achievement:

All 53 Member States endorsed the European Action Plan on HIV/AIDS 2012‐2015 and, with the support of the Secretariat, 20 targeted low and middle income countries have adopted comprehensive policies, strategies and medium‐term plans that increasingly recognize a public health/health systems approach; targeting key populations at higher risk and integrating services to prevent and control HIV epidemics.

Contribution to public health impact:

In 2012‐2013 these policies and strategies contributed to 80% coverage for prevention of mother‐to‐child HIV transmission services in 25 targeted low‐ and middle‐income countries and only 1% of new HIV cases reported in 2012 in the Region were due to mother to child transmission.

Evt. Examples of outstanding Outcome achievements in one or two countries:

Integration models and linkages with other health programmes showed encouraging results in the Region. For example, progress in integrating HIV prevention with TB and/or drug dependence services was evidenced in Portugal and Ukraine.

Evt. Supportive documentation for Outcome achievement:

Accessibility and integration of HIV, tuberculosis and harm reduction services for people who inject drugs in Portugal 2012 http://www.euro.who.int/__data/assets/pdf_file/0005/165119/E96531‐v6‐Eng.pdf

HIV/AIDS treatment and care in Ukraine evaluation report 2012 http://www.euro.who.int/__data/assets/pdf_file/0004/194071/Evaluation‐report‐on‐HIV‐AIDS‐treatment‐and‐ care.pdf

General narrative on deliverable (Output)

While Regional guidance on TB/HIV and hepatitis/HIV continued to inform global efforts; global HIV/AIDS treatment guidelines have increasingly replaced Regional normative guidance. Regional office role increasingly focussed on supporting development of the global guidelines, ensuring that regional context and needs are addressed and on supporting implementation and roll‐out at the national level. Implementation of global consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection (2013) started in 11 targeted low and middle income EURO countries.

Links to supportive documentation for deliverables

Management of TB/HIV co‐infected patients (joint HSV/TBM revision) 2013 http://www.euro.who.int/en/health‐topics/communicable‐diseases/hivaids/publications/2012/hivaids‐treatment‐ and‐care.‐clinical‐protocols‐for‐the‐who‐european‐region.‐2012‐revisions/2013‐revision‐protocol‐4.‐management‐ of‐tuberculosis‐and‐hiv‐coinfection

Training manual on developing TB services for people who use drugs (2013) http://www.euro.who.int/__data/assets/pdf_file/0019/234352/EHNR‐manual‐Eng.pdf

Management of hepatitis B and HIV co infection (Revision) 2012 http://www.euro.who.int/en/health‐ topics/communicable‐diseases/hivaids/publications/2012/hivaids‐treatment‐and‐care.‐clinical‐protocols‐for‐the‐ who‐european‐region.‐2012‐revisions/2012‐revision‐protocol‐7.‐management‐of‐hepatitis‐b‐and‐hiv‐coinfection

Quality in HIV prevention in the European Region (jointly with the German Federal Centre for Health Education BZgA and AIDS Action Europe) 2012 http://www.euro.who.int/en/health‐topics/communicable‐ diseases/hivaids/news/news/2012/9/new‐report‐second‐conference‐on‐quality‐in‐hiv‐prevention‐in‐the‐european‐ region

Workshop on how to scale‐up and implement OST in Europe : Vilnius, Lithuania 22‐23 May (2012)http://www.euro.who.int/en/health‐topics/communicable‐diseases/hivaids/activities/scaling‐up‐access‐to‐ high‐quality‐harm‐reduction/key‐outputs/meetings‐and‐events/report‐workshop‐on‐how‐to‐scale‐up‐and‐ implement‐opioid‐substitution‐treatment‐based‐on‐the‐experiences‐of‐selected‐eu‐member‐states

Tuberculosis and harm reduction service integration and advocacy (in Ukraine for Moldova, Russia, Ukraine and Uzbekistan) 2012 http://www.euro.who.int/en/health‐topics/communicable‐ diseases/hivaids/news/news/2012/10/training‐in‐ukraine‐tuberculosis‐and‐harm‐reduction‐services‐integration‐ and‐advocacy Challenges:

Lack of integration and linkages between HIV, TB and drug dependence programmes persists in some countries in the Eastern part of Region and challenges progress in the prevention and control of HIV and related epidemics in the region.

Lessons learned:

The success of integration models and linkages between HIV, TB and drug dependence services in some countries has not been replicated in all countries across the region. Evidence for the effectiveness does not always inform policies and strategies.

Plans for 2014‐2015:

Progress on the implementation of the European Action Plan on HIV/AIDS 2012‐2015 will be reported at RC64 in 2014 together with specific recommendations for integration and linkages between HIV and other health programmes. Monitoring of progress will continue in 2014‐2015 and final implementation report at RC66 in 2016.

Outcome 05 Assessment (KPO)

SO.02.001 Member States adopt policies and strategies for prevention and control OSER Achievement of M/XDR‐TB through strengthened health systems and public health Fully 21 approaches Partially 1 Not‐achieved Not‐reported Total 22 Outcome responsible: Dr Masoud Dara General narrative on Outcome achievement: With technical assistance and advocacy work of the Secretariat, the Member States developed and adopted National MDR‐TB plans in line with Consolidated Action Plan to Prevent and Combat M/XDR‐TB. Contribution to public health impact: Treatment coverage for MDR‐TB increased from 63% to 97% in 2012‐ 2013. Default rate is decreasing in most Member States. With early detection and adequate treatment, transmission cycle will be broken. Evt. Examples of outstanding Outcome achievements in one or two countries: • Armenia embarked on patient friendly models of care with ambulatory, home‐based and outreach work with rational use of hospital, with WHO (RO and CO) support, along with reaching Universal Access to MDR‐TB diagnosis and treatment. • Uzbekistan adopted a unified TB guideline in line with WHO recommendations. In the meantime the Member State rapidly scaled up molecular diagnosis and treatment of MDR‐TB patients. This was facilitated through intensive WHO RO and CO assistance. Evt. Supportive documentation for Outcome achievement: Compendium of Best Practices in drug resistant tuberculosis, WHO 2013 WHO Europe Consolidated Action Plan to prevent and Combat Multidrug and Extensively Drug‐resistant Tuberculosis: cost‐effectiveness analysis, Z Jakab, C D. Acosta, H H. Kluge, M Dara, Journal of Tuberculosis, 2013 http://www.euro.who.int/__data/assets/pdf_file/0020/216650/Best‐practices‐in‐prevention,control‐and‐ care‐for‐drugresistant‐tuberculosis‐Eng.pdf

Diagnostic and treatment policies for childhood tuberculosis in high‐TB priority countries in Eastern Europe, C.D Acosta, M. Dara et al, Lancet Global Health, 2013 http://download.thelancet.com/pdfs/journals/langlo/PIIS2214109X13701530.pdf

BCG vaccination: where are we in Europe? M Dara, C Acosta et al, European Respiratory Journal, 2013 http://erj.ersjournals.com/content/43/1/24.full.pdf+html

General narrative on deliverable (Output): Through interdivisional work with the health system division, health system barriers to MDR‐TB control identified and appropriate guidance and support for sustainable improvement provided Links to supportive documentation for deliverables • Compendium of Best Practices in drug resistant tuberculosis, WHO 2013 http://www.euro.who.int/__data/assets/pdf_file/0020/216650/Best‐practices‐in‐ prevention,control‐and‐care‐for‐drugresistant‐tuberculosis‐Eng.pdf

• WHO Europe Consolidated Action Plan to prevent and Combat Multidrug and Extensively Drug‐ resistant Tuberculosis: cost‐effectiveness analysis, Z Jakab, C D. Acosta, H H. Kluge, M Dara, Journal of Tuberculosis, 2013 • Diagnostic and treatment policies for childhood tuberculosis in high‐TB priority countries in Eastern

Europe, C.D Acosta, M. Dara et al, Lancet Global Health, 2013 http://download.thelancet.com/pdfs/journals/langlo/PIIS2214109X13701530.pdf

• BCG vaccination: where are we in Europe? M Dara, C Acosta et al, European Respiratory Journal, 2013 http://erj.ersjournals.com/content/43/1/24.full.pdf+html

Challenges: Limited access to rapid diagnosis of MDR‐TB and low detection of second‐line drug‐resistance, lack of availability of all second line drugs, modest MDR‐TB treatment success (same as global level). Lessons learned: High level policy dialogue, government commitment with adoption of evidence based interventions, intensive work of skilled Regional and Country staff is leading to control of drug‐resistant TB in increasing number of countries.

Plans for 2014‐2015: Health system barriers/stigma addressed, National TB Strategic Plans finalized, molecular diagnosis scaled up, new medicines introduced and used rationally, national electronic surveillance expanded, Global TB strategy adapted to country context.

Outcome 06 Assessment (KPO)

SO2.001 Remaining affected Member States are implementing strategy that lead OSER Achievement to malaria elimination by 2015 and will sustain malaria‐free status Fully 6 Partially Not‐achieved Not‐reported Total 6 Outcome responsible: Dr Mikhail Nicolaevich Ejov General narrative on Outcome achievement:

Malaria remains a health challenge in the WHO European Region, where 253 cases of locally acquired Plasmodium vivax malaria were reported in Azerbaijan, Georgia, Greece, Tajikistan and Turkey in 2012, an increase from 2011. At present, in Europe, Plasmodium vivax is the only malaria parasite species present in local transmission but infected travellers or migrants can also carry the other forms, most frequently P. falciparum.

Welcoming the substantial progress made towards eliminating malaria from Europe, WHO/Europe urges all affected countries to boost their efforts to achieve this historic regional elimination target and sustain successes. WHO Europe continues to provides technical assistance to certify malaria elimination whenever possible. Contribution to public health impact: Work to eliminate the disease from the Region by 2015 remains on track: only 37 cases of locally acquired P. vivax malaria were reported in Turkey, Tajikistan and Greece in 2013 as compared with the 253 authochthonous cases reported in Azerbaijan, Georgia, Greece, Tajikistan and Turkey in 2012.

Nevertheless, malaria’s potential to return and settle again in formerly free areas is real, owing to increased importation from endemic countries as a result of constant and massive travel and migration. Recent outbreaks of malaria in Greece and Turkey, successfully contained, show that particular attention should be paid to setting up and maintaining effective surveillance systems with full coverage across all geographical areas, as well as capacity for the early detection of and rapid response to outbreaks.

Eliminating the disease from Europe would contribute to the achievement of Millennium Development Goal (MDG) 6 (on combating HIV/AIDS, malaria and other diseases) and ensure the attainment of MDGs 4 and 5 (on reducing infant and maternal mortality).

Evt. Examples of outstanding Outcome achievements in one or two countries: • AZE: In line with the 2015 regional elimination goal the malaria transmission has been interrupted in the country in 2013, and at present the issues related to prevention of re‐introduction of malaria are being addressed • KGZ: In line with the 2015 regional elimination goal the country was able to interrupt the transmission of malaria in 2011 and had zero locally acquired malaria cases for the following three years. In the end of 2013 the country officially requested the DG WHO to initiate the certification process, and WHO provides the necessary support to certify its malaria‐free status Evt. Supportive documentation for Outcome achievement: Mission and technical reports, scientific publications etc.. (www.euro.who.int/en/health‐topics/communicable‐diseases/vector‐borne‐and‐parasitic‐ diseases) General narrative on deliverable (Output) –The requested assistance has been provided to countries to

10 eliminate malaria, in order to achieve the stated national and regional malaria elimination goals. A number of sub‐regional meetings, training courses on malaria elimination were organized. Cross‐border collaboration on malaria control and elimination between countries of WHO/Europe and EMRO was promoted, and cross‐border meetings took place. Links to supportive documentation for deliverables Missions and technical reports, HQ and regional publications, scientific publications etc. (www.euro.who.int/en/health‐topics/communicable‐ diseases/vector‐borne‐and‐parasitic‐diseases) Challenges: Although progress to eliminate the disease from the European Region by 2015 remains on track the probability of malaria becoming re‐established in a malaria‐free area represent a concern that malaria may come back and settle again in formerly free areas, related to increased importation of the disease from endemic countries. Lessons learned: The regional experience has shown that elimination of malaria is feasible in the regional context. Stark examples of recent outbreaks of malaria in Greece and Turkey ‐ that were successfully contained ‐ have shown that particular attention should be paid to setting up/maintaining a proper malaria surveillance system with full coverage of all geographical areas and adequate capacity for early detection of and rapid response to outbreaks. Plans for 2014‐2015: The Regional Office continues supporting countries to reach the agreed targets and goals and providing technical assistance to certify malaria elimination whenever it is possible.

Outcome 07 Assessment (KPO)

SO.03.004 Member States apply principles and evidence based interventions OSER Achievement according to the European Mental Health Strategy and Action Plan and Fully 20 mhGAP (with the aim of improving mental wellbeing of the population Partially and quality of life of people with mental disorders). Not‐achieved Not‐reported Total 20 Outcome responsible: Dr Matthijs Frederik Muijen General narrative on Outcome achievement: The preparation of drafts and the subsequent adoption of the European Mental Health Action Plan has raised awareness in MSs of the importance of applying principles and interventions proposed by the Plan (as well as other WHO MNH related documents such as mhGAP). This resulted in national assessments of challenges and necessary actions, including the drafting of policies to improve mental health services and the quality of care for people with mental health problems and reduce suicides in many countries across the Region such as KGZ, TKM, UZB, GEO, MDA, ROM, POR, TUR and SEE countries. mhGAP has been used for primary care training in TJK, aiming to improve quality of assessment and treatment of people with depression.

Contribution to public health impact: The WHO activities have improved competence of primary care, resulting in reduced suicide rates in many countries, although in some this has been partly reversed due to recent public spending cuts. Many countries, inspired by WHO objectives, have reduced bed numbers in institutions and improved community capacity, supported by a more competent workforce, offering social inclusion and an improved quality of life to thousands of people with long term mental health problems.

Evt. Examples of outstanding Outcome achievements in one or two countries: • TUR: WHO supported the establishment and staff training of about 70 community mental health centres, reducing the need for hospital admissions and improving the functioning of about 5000 people with severe mental health problems. The need assessment of mental hospitals and their residents encouraged the shift to community based homes, improving living conditions and quality of life of about 50 residents in the first instance in line with the European Action Plan. • KGZ: Continuing training of about 300 primary care staff in priority conditions, aiming to prevent the development of severe mental disorders and reduction of suicide. Evt. Supportive documentation for Outcome achievement: General narrative on deliverable (Output) 1) The European Mental Health Action Plan has been developed in close consultations with the Member States and relevant stakeholders. It is in line with the Global MNH Action Plan while reflecting the need of the Region. The Action Plan was adopted the Regional Committee in September 2013. 2) Political consultations with all Member States on both the Global and European Action Plans were held in Oslo in 2012. A discussion with relevant WHO CCs on contribution to implementation of the Action Plan took place. 3) There was a bilateral collaboration with 18 countries on this outcome, successfully implemented. It is worth to mention MDA that received substantial technical support through a process of developing a national mental health strategy and a process of fundraising as well as sub‐regional networks that were used to support effectively SEE countries and CAR countries. Links to supportive documentation for deliverables http://www.euro.who.int/__data/assets/pdf_file/0004/194107/63wd11e_MentalHealth‐3.pdf

Challenges: Limited technical capacity of secretariat, although alleviated by use of external consultants and highly competent country staff, particularly in Turkey. Economic challenges in Member States causing cuts in mental health budgets reversing progress in some countries such as Greece, Romania, Serbia, Bulgaria and Portugal.

Lessons learned: Inclusive and intensive consultative process of the Action Plan development as well as its link to existing major WHO/EURO policies and strategies could be seen as a successful ground for the forthcoming implementation. Effective groupings of countries and development of joint activities will be replicated across the region.

Plans for 2014‐2015: KPO 7 will be EURO Regional outcome 7: Member States offer evidence based interventions to improve mental wellbeing of the population and the quality of life of people with mental disorders by applying the Global and European Mental Health Action Plans. It is linked to Global Outcome 2.2. Increased access to services for MNH & substance use disorders. The large number of countries committed to mental health reform will mean a greater emphasis on partnership between countries, but also joint activities with collaborating centres and agencies (EC, SDC, World Bank, OECD) that have been initiated in 2013.

Outcome 08 Assessment (KPO)

SO.03.002 Evidence based programming increased in Member States to reduce the OSER Achievement burden from violence and injuries Fully 17 Partially 3 Not‐achieved Not‐reported Total 20 Outcome responsible: Dr Dinesh Sethi General narrative on Outcome achievement: 1) National prevalence surveys of adverse childhood experiences conducted held in ALB, CZH, LVA, LTU, MKD, MNE, ROM, TUR, RUS 2) Policy dialogues have been held which have advocated the use of evidence based measures and these have been available for policy makers and practitioners in the form of the European report on preventing child maltreatment. Though there is yet no evidence of improved programme implementation to reduce maltreatment, discussions have been had about the importance of implementing them with key policy makers. These policy dialogues are achievements in harnessing political will. 3) Assessments have been conducted on road safety in TUR, RUS and plans developed for the Decade of Action for Road Safety. Contribution to public health impact:

Evt. Examples of outstanding Outcome achievements in one or two countries: • MKD has developed national action plan to prevent child maltreatment with evidence based programming to reduce maltreatment and with monitoring of actions. • RUS has developed an action plan for the Decade of Action for Road Safety and has achieved seatbelt wearing rates of 80% in 2 implementation oblasts as part of the Road Safety in 10 countries Project. Turkey has achieved seat belt wearing rates of 50% and 30% in implementation provinces. It is estimated that such improvements will lead to saving lives and reducing severe road traffic injuries. Evt. Supportive documentation for Outcome achievement: http://www.who.int/violence_injury_prevention/road_traffic/countrywork/rs10_turkey_en.pdf http://www.who.int/violence_injury_prevention/road_traffic/countrywork/rus/en/index.html

General narrative on deliverable (Output) 2) European report on child maltreatment prevention developed and being disseminated. Presented at technical briefing at RC63. Emphasis on social determinants 3)Policy dialogue workshops held in ALB, CZH, LVA, LTU, MKD, MNE, ROM to strengthen child maltreatment prevention programmes 4)Network meeting of national focal points of VIP held in Antalya in 2012 5)Capacity building using TEACH‐VIP and a train the trainer approach held in BLR, KGZ, TJK, KAZ, UZB, CZH, LTU 6)Regional policy briefing European facts and Global status report on road 2013 developed and policy workshops held in selected countries to promote road safety and to support 2nd UN Global Road Safety Week with a focus on pedestrian safety.

Links to supportive documentation for deliverables http://www.euro.who.int/en/publications/abstracts/european‐report‐on‐preventing‐child‐maltreatment http://www.euro.who.int/en/media‐centre/sections/latest‐press‐releases/road‐traffic‐deaths‐down‐by‐25‐ but‐92‐000‐still‐die‐each‐year‐in‐the‐who‐european‐region

Challenges: resource constraints and harnessing political will for health systems to engage in multisectoral prevention

Lessons learned: Critical to convince health policy makers that violence and injuries are a public health threat and that they need to own it and coordinate it.

Plans for 2014‐2015: Road safety and child maltreatment prevention will be part of deliverable 2.3.1 and 2.3.3 respectively. European action plan to prevent child maltreatment being developed for RC64. These will involve engaging policy makers and practitioners in evidence based prevention.

Outcome 09 Assessment (KPO)

SO.03.002 Member States adoption of a priority list of evidence‐ based actions OSER Achievement for prevention and control of NCDs consistent with the European NCD Fully 20 Action Plan. These actions could include (1) integrating surveillance Partially 1 systems, (2) using fiscal measures, (3) product formulation and (4) Not‐achieved 5 control of marketing to promote healthier consumption, (5) promoting Not‐reported wellness in workplace, (6) managing cardiometabolic risk, and/or (7) Total 26 stepwise approaches to cancer‐control Outcome responsible: Ms Frederiek Mantingh General narrative on Outcome achievement: Several countries in the region have strengthened their work on NCDs by implementation of evidence‐ based actions in line with the European NCD Action Plan. The strengthening of health information systems by for example implementation of the WHO STEPS survey was achieved in multiple countries. At a seminar on working across sectors, with special attention to fiscal policy, member states worked on future steps in the area of fiscal policies related to tobacco, alcohol or nutrition. Guidance for cardio‐ metabolic risk assessment and management have been implemented through implementation of the PEN package (the Package of Essential NCD interventions for primary health care). National cancer control programmes with an emphasis on the early detection of cancers are strengthened through for example imPACT missions, direct support of a NCD consultant on an assessment or representation of WHO at a conference. Contribution to public health impact: To measure public health impact of interventions in the area of NCDs, policy makers need to have information. This requirement is being met through the work on strengthening integrated NCD surveillance systems. In addition, in the area of cardiometabolic risk assessment and management, evidence shows that early identification and modification of cardio‐metabolic risk factors is an effective intervention to prevent the development of hyperglycemia, type 2 diabetes mellitus, hypertension and hyperlipidemia. Emphasis should be placed on overall assessment of a number of risk factors, rather than on a strategy aimed at a single disease or single risk factor. This important public health intervention is at the core of the PEN‐package which was implemented in several countries. In the area of cancer‐control the focus of the work was on early detection. Where resources and health systems are limited, and where the majority of the cancers amenable to early detection are diagnosed in late stages, the establishment of an early diagnosis programme may be the most feasible strategy to reduce the proportion of patients presenting with late stage cancer (“downstaging”) and to improve survival rates. Therefore, the early detection of cancer programmes were being strengthened in the member states. Evt. Examples of outstanding Outcome achievements in one or two countries: Turkmenistan has strengthened the response to NCDs in preparation for the Ministerial Conference on NCDs in the context of Health 2020, hosted by the respective country in December 2013. The areas of work were strengthening monitoring and surveillance of NCDs through implementation of the WHO STEPS survey, development of a National Tobacco Control Action Plan including action to change existing laws and regulations in this area, an assessment of the current status in Turkmenistan with respect to the early detection of breast cancer and a consideration of perspectives for further improvement, and an overall assessment of the health system reorientation towards prevention and care for NCDs including recommendations. Evt. Supportive documentation for Outcome achievement: Strengthening the response to noncommunicable diseases in Turkmenistan. WHO Regional Office for Europe. 2013. http://www.euro.who.int/__data/assets/pdf_file/0004/235894/Strengthening‐the‐ response‐to‐NCDs‐in‐Turkmenistan.pdf

General narrative on deliverable (Output): The NCD Global Monitoring Framework was adopted in May 2013, aligned with the H2020 targets and indicators. The input of European Member States was maximized through consultations. The integrated WHO STEPS survey was implemented in Azerbaijan, Kyrgyzstan, Turkey and Uzbekistan. Participating countries at the seminar on working across sectors with a special attention to fiscal policy, were Albania, Bulgaria, Croatia, Estonia, Hungary, Lithuania, Poland, Slovakia and the Ukraine. The PEN package (the Package of Essential NCD interventions for primary health care) was implemented in Tajikistan and Uzbekistan. And imPACT missions were organized to Armenia, Montenegro, Republic of Moldova, Romania, and Tajikistan. Links to supportive documentation for deliverables: NCD Global Monitoring Framework: http://www.who.int/nmh/global_monitoring_framework/en/

STEPwise approach to surveillance: http://www.who.int/chp/steps/en/

Marketing of foods high in fat, salt and sugar to children: update of recent policy actions of European Member States. http://www.euro.who.int/__data/assets/pdf_file/0019/191125/e96859.pdf

Package of supporting documents on fiscal policies: http://www.euro.who.int/en/health‐ topics/noncommunicable‐diseases/sections/news/2012/10/can‐fiscal‐policies‐reduce‐noncommunicable‐ diseases2

Package of essential noncommunicable disease interventions for primary health care in low‐resource settings: http://www.who.int/cardiovascular_diseases/publications/pen2010/en/

Prevention and control of noncommunicable diseases in the European Region: a progress report. WHO Regional Office for Europe. 2013. http://www.euro.who.int/en/health‐topics/noncommunicable‐ diseases/cancer/publications/2013/prevention‐and‐control‐of‐noncommunicable‐diseases‐in‐the‐ european‐region‐a‐progress‐report Challenges: Due to the high amount of actions in countries, some countries choose to give other action areas priority, or merge deliverables. Therefore in some countries the NCD part of the BCA was not (fully) delivered. A challenge at the secretariat to deliver the Outputs is the low amount of human resources which led to less focussed and in depth support than we would wish for. Lessons learned: It is good to organize intensive support to a country. When in a country multiple areas are being strengthened at the same time, as was done for example in Turkmenistan, changes are more receptive to sustain. Also, this leads to clear results and shows the impact WHO can have in a country. Plans for 2014‐2015: Work in this area will be continued through EURO Outcome 9, Output 2.1.1 on development of national multisectoral policies and plans, 2.1.2 on including NCDs in development agendas, and 2.1.3 on monitoring and surveillance. In the coming biennium a few countries will be chosen for intensive support in line with the work implemented in Turkmenistan.

Outcome 10 Assessment (KPO)

SO.04.008 An increasing proportion of the older population are covered by public OSER Achievement initiatives of healthy aging, disability policy and services in Member Fully 5 States Partially Not‐achieved Not‐reported Total 5 Outcome responsible: Mr Manfred Huber General narrative on Outcome achievement: Evaluation of the European Healthy Cities Network for 2012‐2013 revealed that 80% of cities now have initiatives or actions on healthy ageing and that “age‐ friendly environments” is the topic that was reported most frequently as “having the most impact” in cooperation with WHO/Europe. Contribution to public health impact: Continuing implementation of an increasing number of National Strategies and Plans on Healthy Ageing was essential to counter negative health impacts on the situation of older persons that are due to the economic and fiscal crisis in many European countries. Life‐ expectancy at age 65 continues to increase, but the evidence on trends in life expectancy at 65 in good health is mixed. Evt. Examples of outstanding Outcome achievements in one or two countries: Finland (2013) Act on Supporting the Functional Capacity of the Older Population and on Social and Health Care Services for Older Individuals; Germany (2012): National Health Goal “Healthy Ageing” Evt. Supportive documentation for Outcome achievement: http://www.finlex.fi/en/laki/kaannokset/2012/en20120980 http://www.bmg.bund.de/gesundheitssystem/gesundheitsziele.html

General narrative on deliverables (Output) Three outputs were instrumental to establish the ageing programme: (1) World Health Day 2012 events; (2) Strategy and action plan for healthy ageing in Europe, 2012‐2020; and (3) Regional meeting in Utrecht, 2013, with national counterparts. Links to supportive documentation for deliverables Strategy and action plan for healthy ageing in Europe, 2012‐2020; http://www.euro.who.int/en/health‐ topics/Life‐stages/healthy‐ageing/publications/2012/eurrc6210‐rev.1‐strategy‐and‐action‐plan‐for‐healthy‐ageing‐ in‐europe,‐20122020 Challenges: Requests from Member States and from international partners exceeded the capacity of the Regional Office due to limited human and financial resources. Lessons learned: Mainstreaming of healthy ageing in WHO work should more fully include eHealth and health information in general, as well as topics of human resources for health. Between international organizations, there remains some fragmentation of work on healthy ageing that needs to be addressed in the 2014‐2015 biennium.

Plans for 2014‐2015: Develop tools and guides on Age‐Friendly Environments in Europe (AFEE) in cooperation with the European Commission, for publication in 2015. Support to Member States with national healthy ageing strategy development and with implementation of the Strategy and action plan on healthy ageing for Europe; in‐depth country capacity assessments for 3 to 5 countries. Development of monitoring and evaluation tools in cooperation with WHO Geneva and international partners. These tasks will include the areas listed under “Lessons learned”. The Healthy Ageing work programme has secured solid funding from voluntary donations for 2014‐2015.

Outcome 11 Assessment (KPO)

SO04.001 Evidence‐based gender responsive practices for improving maternal, OSER Achievement perinatal, new‐born, and child health adopted (or adapted) and Fully 19 implemented by Member States. Partially Not‐achieved Not‐reported Total 19 Outcome responsible: Mrs Vivian Birgitte Barnekow/Dr Gunta Lazdane General narrative on Outcome achievement: Six Member states (ARM, KAZ, MDA, KGZ, TJK, TKM, UZB started in 2012‐2013 implementing new or revised evidence‐based gender responsive policies and practices for improving maternal, perinatal, new‐born and child health Contribution to public health impact: Decreased under‐five mortality in all countries linked to improvement of services. Increased resources channelled to maternal, child and adolescent health in some countries linked to strategy development. Evt. Examples of outstanding Outcome achievements in one or two countries: Improving hospital care for children project started in KGZ and TJK in 2012 Kyrgyzstan–. Paediatric hospital care and outpatient antenatal and postpartum care for women and new‐ borns improved due to country effort of adaptation and wide dissemination of clinical guidelines, trained staff and teaching faculty, development of monitoring and supportive supervision program, and assessment of child rights. Tajikistan ‐ The national advisory board for improving hospital care for children initiated an assessment of the quality of paediatric hospital care and out‐patient antenatal and postpartum care for women and new‐ borns . The board used the outcomes of the assessment to develop recommendations for improvement of hospital care. Training and dissemination of updated WHO Pocket Book, “Beyond the numbers” approach, regular monitoring and supportive supervision, and assessment of child rights was part of recommended activities in improving quality of care for mothers and children. Evt. Supportive documentation for Outcome achievement: N:\DNP\CAH\Child rights\Child Rights KGZ TJK\Report\Final reports

General narrative on deliverable (Output): The secretariat has supported countries to adopt a comprehensive approach on assessment of the quality of maternal, newborn and child health care, identification of existing gaps by using the WHO methodology on maternal mortality and morbidity audit “Beyond the numbers”. In support for meeting the MDG 4, 14 countries have received support for improving child health services, including a major focus on improving quality of paediatric care, where two countries have received intensive support (see examples below). A training tool on managing child health programmes using an e‐ learning based platform, to support the strengthening of health system and the process of improving quality of and access to child health care is at the point of being finalized. Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/Life‐stages/child‐and‐adolescent‐health/child‐health/children‐ in‐hospitals/new‐project‐to‐support‐improved‐quality‐of‐pediatric‐care‐in‐kyrgyzstan‐and‐tajikistan; technical reports on training and supervision results available in CAH program http://www.euro.who.int/en/health‐topics/Life‐stages/maternal‐and‐newborn‐health

Challenges: Countries have found both the CAH strategy framework and the tools very useful, however

19 final results of country processes are often more health care focussed than planned from the beginning. National leadership is one of the main factors in making progress – in some countries the leadership has changed during the process, and therefore priorities have changed as well thus delaying the process in some countries Requests from the MS to receive support for developments within this outcome exceed the capacity of the Regional office as there are very limited financial and human resources available so it has been difficult to provide the support needed. Lessons learned: Maternal child and adolescent health remains a priority in many countries, however it is an area where it has been difficult to obtain adequate financial Plans for 2014‐2015: Development of European regional child and adolescent health strategy with focus on investment in early child development and life‐course approach‐ to be presented in RC 2014. Assisting countries in achieving MDG 4 and 5 through regional and national activities in collaboration with partners. Increased efforts to mobilize resources for activities as well as for staff are needed – management support from highest level is needed for success.

Outcome 12 Assessment (KPO)

SO.05.001 Enhanced preparedness and response capacities of Member States to OSER Achievement emergencies and disasters through all‐hazard risk management Fully 15 programmes, in line with humanitarian needs and also IHR Partially requirements Not‐achieved Not‐reported Total 15 Outcome responsible: Dr Gerald Rockenschaub General narrative on Outcome achievement: The WHO “toolkit for assessing health system capacity for crisis management” was further rolled out to comprehensively assess health system preparedness capacities in targeted countries, to identify capacity gaps and to address them through targeted capacity building efforts. Hospital resilience was reinforced through the application of the Hospital Safety Index as a tool to conduct hospital assessments in 23 hospitals in Kazakhstan (5), Montenegro (11) and Ukraine (6). Emergency medical services systems were reinforced in KOS, MDA, MKD and TJK through trainings and simulation exercises of local health care providers together with police, fire fighters and other local stakeholders, and through development of guidelines and recommendations as part of respective national projects. Contribution to public health impact: Through those activities the generic health system preparedness of selected MSs has been reinforced by identifying gaps and weaknesses, addressing them and enhancing collaboration within and beyond the health sector through application of an all‐hazard approach. MSs are now better prepared for any type of emergencies and their emergency medical system is functioning more effective. Evt. Examples of outstanding Outcome achievements in one or two countries: • KGZ updated the health system assessment for crisis preparedness, organized the first regional public health and emergency management (PHEM) training in Russian language, and assessed and improved 25 hospitals in the country. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/health‐ topics/emergencies/disaster‐preparedness‐and‐response/publications/2013/assessment‐of‐health‐ system‐crisis‐preparedness‐kyrgyzstan General narrative on deliverable (Output): Five health system capacity assessments for crisis management and re‐assessments were carried out, preparedness gaps were identified and recommendations agreed to implement targeted capacity building to address identified gaps. Two regional and five national public health emergency management (PHEM) trainings conducted.

Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐ response/publications

Challenges: Scarce human and financial resources of many MoHs and limited intersectorial and interdisciplinary collaboration in countries remain challenges for effective emergency preparedness in transition countries.

Lessons learned: To overcome the limited resources of MoHs and therefore limited response capacity better planning and preparedness of national and local health systems in collaboration with other partners is crucial. That is addressed by the development and update of national guidelines and strategies as well as by assisting MoHs to train more personnel in emergency risk management, including through regular drills and exercises. The assessments of health system crisis management capacities are a crucial

21 step to trigger continuous planning and updating of preparedness and response capacities in MS. Plans for 2014‐2015: To further continue assessments, training and capacity building for health system preparedness and emergency risk management in selected MSs and to encourage MoHs to implement assessment recommendations in close collaboration with other key partners. To introduce risk, vulnerability and health capacity mapping as new GIS supported tools for MoHs.

Outcome 13 Assessment (KPO)

SO.06.004 Member States have strengthened their national programmes to reduce OSER Achievement the harmful use of alcohol in line with European Alcohol Action Plan Fully 14 2012‐2020 Partially Not‐achieved Not‐reported Total 14 Outcome responsible: Dr Lars Moller General narrative on Outcome achievement: Following endorsement of the European action plan to reduce the harmful use of alcohol 2012−2020, an increasing number of countries are in the process of either developing or reformulating a national alcohol policy. Of the 53 Member States which provided information to the Secretariat by December 2013, 37 have developed a written national policy on alcohol and 20 of these are currently in the process of updating their national policies. Of the 16 Member States without a national policy on alcohol, 10 are in the process of developing a national policy. Since 2012, 10 Member States have adopted a new national alcohol policy in line with the European action plan to reduce the harmful use of alcohol 2012−2020. Contribution to public health impact: Harmful use of alcohol is one of the main risk factors for death and disability in the WHO European Region. The European Region has the highest alcohol consumption among adults of all WHO regions and almost double the world average. In western Europe the overall consumption is declining but in central and eastern Europe consumption is raising. Evt. Examples of outstanding Outcome achievements in one or two countries: Moldova adopted in 2012 a new national alcohol programme where most of the recommendation by WHO was used and WHO played a vital role in the drafting process. The implementation process started in 2012 and continued in 2013 where WHO facilitated drafting of new laws on alcohol policy. Montenegro adopted in 2012 a new alcohol strategy and action plan on alcohol using almost all the recommendations from the European action plan. The process was guided with inspiration and help from EURO. A number of laws and activities have been implemented since 2012 and will continue in the coming years. Evt. Supportive documentation for Outcome achievement: Governmental Decision No 369: Approval of the Pentru aprobarea Programului național privind controlul alcoolului pe anii 2012‐2020/об утверждении Национальной программы по контролю за алкоголем на 2012‐2020 годы [National Programme on Alcohol Control over the period of 2012–2020] (http://lex.justice.md/index.php?action=view&view=doc&lang=1&id=343538).

Workshop on alcohol policy in Moldova (http://www.euro.who.int/en/health‐topics/disease‐ prevention/alcohol‐use/news/news/2013/11/national‐workshop‐on‐alcohol‐control‐policies‐in‐the‐ republic‐of‐moldova). Development and publication of the National strategy to prevent harmful use of alcohol and alcohol-related disorders in Montenegro 2013–2020 ((http://www.mzdravlja.gov.me/en/library/strategije).

General narrative on deliverable (Output): The Secretariat has issued and widely distributed the European action plan with the texts of the associated resolution EUR/RC61/R4 and a list including definitions of all indicators related to the 10 action areas in English and Russian languages. The action plan

23 follows the five objectives and 10 action areas of the Global strategy to reduce the harmful use of alcohol (WHA63.13).1 The action plan and a report published in 2012 in 2012 (Alcohol in the European Union ‐ Consumption, harm and policy approaches2) has been used for hand‐on guidance on alcohol policy in MS. The secretariat has guided a number of countries in the drafting process of a national plan on alcohol.

The process is monitored in the European Information System for Alcohol and Health and reported in the European Status report on alcohol and health published in 20133.

Links to supportive documentation for deliverables In the European Status report on alcohol and health an annex on policy changes in MS has been included giving references to all documents, reports, etc. by country and year4 .

Challenges: There are still 16 Member States without a national plan on alcohol and some of the countries with an existing plan have not renewed it for many years. Of these are 7 from western, 3 from central and 6 from eastern European

Lessons learned: With the access to new and relevant data on alcohol consumption, harm and policies, the regular reports and the guidance developed by EURO there is an excellent platform for putting alcohol on the agenda in countries and for providing evidence based guidance. Plans for 2014‐2015: It is important to keep alcohol on the agenda especially in countries without a national plan on alcohol but also in countries with an old or less comprehensive plan. Therefore, EURO has decided to develop an alcohol policy scoring system using the most important indicators on alcohol policy. Furthermore, the Regional Office will collect information on alcohol policy developments in Member States since 2006 with links to documents, publications and websites in order to facilitate knowledge and information sharing of good practice in Member States. For 2014‐2015, 14 Member States have asked for guidance on substance abuse policies including a few MS where there so far is no national plan on alcohol.

1 European action plan to reduce the harmful use of alcohol 2012–2020. Copenhagen, WHO Regional Office for Europe, 2012 (http://www.euro.who.int/__data/assets/pdf_file/0008/ 178163/E96726.pdf, accessed 6 November 2013). 2 WHO Regional Office for Europe (2012). Alcohol in the European Region. Consumption, harm and policy approaches. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0003/160680/e96457.pdf, accessed 6 November 2013). 3 WHO Regional Office for Europe (2013). Status report on alcohol and health in 35 European countries 2013. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0017/190430/Status‐Report‐on‐Alcohol‐and‐Health‐in‐35‐ European‐Countries.pdf, accessed 6 November 2013). 4 WHO Regional Office for Europe (2013). Status report on alcohol and health in 35 European countries 2013. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0017/190430/Status‐Report‐on‐Alcohol‐and‐Health‐in‐35‐ European‐Countries.pdf, accessed 6 November 2013).

Outcome 14 Assessment (KPO)

SO.06.005 Obesity prevention and control Action Plans, including healthy diet and OSER Achievement physical activity, developed and implemented in Member States based on Fully 17 the principles of the European Charter to Counteract Obesity and the Partially Vienna Declaration. Not‐achieved Not‐reported Total 17 Outcome responsible: Dr Joao Breda General narrative on Outcome achievement: Member States have adopted a new political framework for obesity (Vienna Declaration) based on Health 2020 strategic dimensions (equity and governance. 23 countries involved in WHO Childhood Obesity Surveillance Initiative (COSI).Member States updated their data on diet, physical activity and obesity including the dimensions of epidemiology and policy developments as part of NOPA information system. Member States produced an update on the situation of marketing of foods to children in the Region.

Contribution to public health impact: The establishment of ground breaking and innovative information systems involving diet and physical activity policies together with a unique surveillance system like the Childhood Obesity Surveillance Initiative will contribute to public health gains. In some countries that adopted the mix of policies and actions prescribed by WHO guidance tools childhood obesity seems to be levelling off.

Evt. Examples of outstanding Outcome achievements in one or two countries: • Malta: with WHO support Malta has developed during the biennium both a new obesity strategy and a new food and nutrition action plan. The country is one of the “founders” of COSI having collected data already for several rounds. With the help of the Regional Office Malta prepared the first National Nutrition Survey following internationally recommended standards. • Turkey: with WHO support effectively performed its National Childhood Obesity Surveillance Initiative as part of the National Plan on Obesity also revised during the biennium. Turkey launched National action plan for salt reduction, issued report on population salt consumption, published the WHO report on marketing of foods HFSS to children and held Meetings of the respective Action Networks. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/health‐topics/disease‐prevention/nutrition/activities/monitoring‐and‐ surveillance/who‐european‐childhood‐obesity‐surveillance‐initiative‐cosi

General narrative on deliverable (Output): Ministerial Conference Nutrition NCD in Context of Health 2020 successfully organized with participation 48 MS. Vienna Declaration revisited the commitments of Istanbul Charter and established five priority areas. Draft FNAP was prepared. Support was provided to MS on development, implementation and evaluation of National Plans. A set of workshops organized to prepare roadmaps. Links to supportive documentation for deliverable http://www.euro.who.int/__data/assets/pdf_file/0003/234381/Vienna‐Declaration‐on‐Nutrition‐and‐ Noncommunicable‐Diseases‐in‐the‐Context‐of‐Health‐2020‐Eng.pdf http://www.euro.who.int/__data/assets/pdf_file/0004/235975/Prevention‐and‐control‐of‐ noncommunicable‐diseases‐in‐the‐European‐Region‐A‐progress‐report‐Eng.pdf

25 http://www.euro.who.int/__data/assets/pdf_file/0019/191125/e96859.pdf http://onlinelibrary.wiley.com/doi/10.1111/j.2047‐6310.2012.00090.x/abstract

Challenges: Low level of funding of many activities particularly in countries was an enormous challenge for the achievement of goals and objectives however most barriers were overcome based on a very fruitful collaboration between the three levels of the organization: CO, RO and HQ.

Lessons learned: Strength of the collaboration with the MoH and other national authorities as well as the leadership of Country Offices when applicable was crucial for the successful implementation of activities. The collaboration and mutual support at the three levels of the organization was a major element for success.

Plans for 2014‐2015: Follow‐up of the on‐going activities in Member States is important to ensure sustainability. Capacity in the COs is important notably in the countries with highest burden of diet and PA related NCDs. Submit to the governing bodies a proposal for a new food and nutrition action plan (2014) and a physical strategy (2015). Report on Vienna Declaration commitments implementation.

Outcome 15 Assessment (KPO)

SO.06.003 Multi‐sectoral policies and strategies established within Member States to OSER Achievement increase the level of implementation of the WHO FCTC by using the Fully 17 MPOWER framework Partially Not‐achieved Not‐reported 1 Total 18 Outcome responsible: Mrs Kristina Mauer‐Stender General narrative on Outcome achievement: Number of countries adopted new or revised existing intersectoral tobacco control policies to align them with the WHO FCTC and good practices. In several countries evidence indicated clearly that strong policies work and bring health results in a shirt timeframe. At the European Union level, good progress was made towards a strong new Directive on packaging and labelling with clear impact on 28 EU countries but also beyond.

Contribution to public health impact: Effective implementation of the WHO FCTC and awareness built around the tobacco control leads to the less young people taking up smoking and becoming addicted as well as more smokers to quit smoking or smoke less. Advances in tobacco control lead the way to effective solutions for other NCDs related risk factors. Evt. Examples of outstanding Outcome achievements in one or two countries: Russian Federation adopted in spring 2013 one of the strongest tobacco control laws in the Region despite of heavy influence from the tobacco industry. The adopted law is fully in line with the WHO FCTC and sets an example to other countries in terms of a strong law and process leading to it. Kazakhstan adopted and uses from summer 2013 the strongest pictorial health warnings in the European Region. It was decided to use Thai warnings being one of the strongest and most effective globally to discourage young people to take up smoking and encourage smokers to quit smoking. Evt. Supportive documentation for Outcome achievement: Available on homepage: Russia: http://www.euro.who.int/en/health‐topics/disease‐ prevention/tobacco/news/news/2013/03/putin‐signs‐law‐banning‐smoking‐in‐public‐in‐the‐russian‐ federation Kazakhstan: http://www.euro.who.int/en/health‐topics/disease‐ prevention/tobacco/news/news/2013/05/kazakhstan‐to‐start‐graphic‐warning‐labels‐on‐cigarette‐packs‐ in‐july‐2013 General narrative on deliverable (Output): Policy tools: At the request of countries, a technical inter‐country working group on taxes was established and met 3 times during biennium to discuss various aspects related to tobacco taxes, related challenges and good practices in countries. A country case study on tobacco taxes and their impact on health as well as country revenues were published. Technical advise: European Tobacco Control Report 2013 was launched analysing the status of the WHO FCTC implementation in the Region and ways forward towards further actions in countries. Technical support provided to approx 25 countries on bilateral bases with tangible policy and health outcomes Best practices: Latest evidence and good practices were disseminated through regional focal points meeting, sub‐regional trade meeting and tobacco control leadership course. 4 country case studies were published in view to provide some hands‐on advise to other countries. Political support: Political support was provided at several occasions at the RD level to the EU Directive revision process with a strong outcome for final decisions in 2014. Links to supportive documentation for deliverables

European Tobacco Control Status Report 2013: http://www.euro.who.int/en/health‐topics/disease‐ prevention/tobacco/publications/2013/who‐european‐tobacco‐control‐status‐report‐2013 4 country case studies: http://www.euro.who.int/en/health‐topics/disease‐ prevention/tobacco/publications/2012/tobacco‐control‐in‐practice Challenges: limited human capacity at WHO Regional and Country Offices to react very quickly and at the highest level to requests for support; limited funding to ensure proper follow‐up actions at country level; active engagement with other sectors such as Ministries of Finance and Economy for tobacco tax work has proved to be very challenging Lessons learned: strong commitment of country leadership can make substantial difference; highest importance of timely political support from WHO Regional Office at the level of RD in addition to technical support has be proven to be highly relevant for strong outcomes; high relevance and strong impact on countries from learning from each other and bringing the change Plans for 2014‐2015: In the given limitations by the limited human and funding sources, further prioritization is needed in the beginning of biennium to leave more space for country requests for advice and support. It is important to see what can be done more at horizontal level in the NCD cross‐risk factor setting at country level. Continue to engage with RD at her political level by seeking opportunities for her high‐level interventions calling for a change. Role of the Regional Office should be linking up countries who have something to offer and those who need support.

Outcome 16 Assessment (KPO)

SO.07.002 Greater capacity and commitment among Member States to better OSER Achievement meeting the right to health and health needs of poor, vulnerable and Fully 10 socially excluded groups (VGs) with particular emphasis on action for Partially migrants and Roma populations and addressing inequities in progress Not‐achieved Not‐reported towards the MDGs. Total 10 Outcome responsible: Dr Piroska Östlin General narrative on Outcome achievement: Significant progress has been made to strengthen capacity of health professionals and ministries of health to review and reorient health strategies related to MDG 4 and 5 towards greater health equity with focus on Roma populations and to strengthen migrant health information management and migrant health capacity building in MS most affected by large influx of migrants.

Contribution to public health impact: The achievements of this outcome, e.g. national health strategies and programmes towards greater health equity, and health systems that are sensitive to the health needs of Roma and migrants, will likely to have a major impact on the distribution of health in the population.

Evt. Examples of outstanding Outcome achievements in one or two countries: As a result of multi‐ country capacity building training events, The Former Yugoslav Republic of Macedonia has reorienteded its Programme for active maternal and child health care towards greater health equity with explicit but nor exclusive focus on the Roma population. The reoriented Programme includes activities that address the needs of vulnerable groups of women – or those who are most in need in order to bring the interventions closer to the marginalized and rural women, including adolescents and facilitate health equity as a way of achieving MDGs 4 and 5.

As a result of WHO‐Ministry joint Assessment in Italy the Sicily Region has programmed the creation of a Contingency Plan on health and migration building on the assessment report recommendations.

Evt. Supportive documentation for Outcome achievement:

Presentations on reoriented strategies at the UNFPA/WHO Workshop on ”Strategies to reduce health inequities with focus on Roma”, Istanbul, 24 October 2013:

• Dr Katerina Stavrikj (on behalf of the MKD Review Working Team): Integrating Equity into the Programme for Active Maternal and Child Health Care with focus on Roma in tfYR of Macedonia. • Dr Neliya Mikushinska (on behalf of the BUL Review Working Team): Integrating Equity into the Programme on Sexual and Reproductive Health with focus on Roma in Bulgaria. • Dr Gordana Vukčević (on behalf of the MNE Review Working Team): Integrating Equity into the Strategy for Maintenance and Improvement of Reproductive and Sexual Health in Montenegro 2013‐2020 • Dr Bosiljka Djikanovic (on behalf of the SRB Review Working Team)Integrating Equity into the National Program for Screening on Cervical Carcinoma with focus on Roma in Serbia http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2013/11/strategies‐to‐reduce‐health‐inequities‐with‐focus‐on‐roma

General narrative on deliverable (Output): Multi‐country trainings and development of resource packages and health systems assessment tool‐kits have been developed to build greater capacity and

29 commitment of MS in this area. Two WHO CC established. Resource package on Roma health and Health Systems assessment toolkit for migrant health are being developed. Roma health case study series created and case studies from Romania and Spain have been published. Five issues of Roma Health Newsletters, scientific papers on Roma health published. Multi‐country trainings for four pilot countries organized in Belgrade and Skopje. Technical assistance on Roma and migrant health in more than 10 countries. Several activities has been devoted to assess the capacity of health sectors to deal with large influx of migrants in the Mediterranean Countries mostly influenced by the migration phenomenon; coordination to strengthen response increased in Italy, Malta, Portugal and Greece. Coordination of the Interagency Coordination Initiative. Co‐organization of numerous workshops, expert meetings and consultations on Roma and migrant health. Supportive documentation for deliverables

WHO Collaborating Centres: http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2012/02/vulnerability‐and‐health‐who‐opens‐new‐collaborating‐centre‐in‐ hungary http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2012/10/who‐opens‐new‐collaborating‐centre‐on‐social‐inclusion‐and‐health http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2013/10/who‐collaborating‐centre‐on‐social‐inclusion‐and‐health‐celebrates‐ first‐anniversary

Resources, publications, reports:

Publication on “Potential Criteria for the Review of the HEALTH COMPONENT of the National Roma Integration Strategies”http://www.euro.who.int/en/what‐we‐do/health‐topics/health‐ determinants/social‐determinants/publications/potential‐criteria‐for‐the‐review‐of‐the‐health‐ component‐of‐the‐national‐roma‐integration‐strategies

5 issues of Roma Health Newsletters http://www.euro.who.int/en/what‐we‐publish/newsletters/roma‐ health‐newsletter

Roma health mediation in Romania (case study): http://www.euro.who.int/en/publications/abstracts/roma‐health‐mediation‐in‐romania

Integration of SDH in health policies in Spain (case study) http://apps.who.int/iris/bitstream/10665/85689/1/9789241505567_eng.pdf

A scientific journal paper, “Risk factors for low vaccination coverage among Roma children in disadvantaged settlements in Belgrade, Serbia”, authored by WHO staff, has been accepted for publication in “Vaccine”. http://www.sciencedirect.com/science/article/pii/S0264410X1200953X

Training, capacity building: http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2013/03/the‐former‐yugoslav‐republic‐of‐macedonia‐hosts‐multi‐country‐

30 training‐on‐how‐to‐achieve‐greater‐health‐equity‐for‐roma http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2012/11/training‐focuses‐on‐ensuring‐greater‐equity‐in‐policies‐for‐roma‐ population

Coordination, workshops, expert meetings, consultations: http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2013/11/strategies‐to‐reduce‐health‐inequities‐with‐focus‐on‐roma http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2013/07/significant‐progress‐in‐implementing‐activities‐for‐roma‐health http://www.euro.who.int/en/health‐topics/health‐determinants/social‐ determinants/news/news/2012/03/scaling‐up‐action‐for‐roma‐health‐in‐serbia‐and‐beyond

• Italy hosts expert consultation on pubic health aspects of migration in Europe: http://www.euro.who.int/en/health-topics/health-determinants/social- determinants/news/news/2013/06/italy-hosts-expert-consultation-on-public-health-aspects-of- migration-in-europe

• Improving and coordinating the public health response to migration: http://www.euro.who.int/en/health-topics/health-determinants/social- determinants/news/news/2013/10/improving-and-coordinating-the-public-health-response-to- migration

• Assessing the public health capacity for migration in Portugal: http://www.euro.who.int/en/health-topics/health-determinants/social- determinants/news/news/2013/11/assessing-the-public-health-capacity-for-migration-in-portugal Challenges: The Secretariat’s ability to deliver outputs is challenged by the fact that there is no technical officer available for Roma health work. All technical work is done by the Programme Manager of the Vulnerability and Health Programme, who needs also to support the work of the Health2020 secretariat 20% or more of her time. This means that there is not much time for the PM for more strategic work, such as fundraising activities or coordination of Roma work within and outside WHO. The implementation of the migration and health project started only in April 2013 due to the lengthy process for the appointment of the Project Coordination. Uptake of outcome achievements may be affected in MS by lack of political will for implementation and lack of human and/or financial resources for implementing proposed actions.

Lessons learned: Ensuring the participation of representatives of Roma and migrant associations in multi‐ country trainings, workshops and consultations is crucial for outcome achievements. Investing in the establishment of intersectoral coordination mechanism and collaboration on Roma and migrant health activities will increase the possibility of outcome achievement.

Sudden influx of migrants often overstretched health sector capacity of high performing Countries. Contingency plans and preparedness is necessary to strengthen the response to migrants’ health specific needs.

Plans for 2014‐2015: Multi‐country trainings (including six MS) and publication of Roma health newsletters will continue in 2014‐2015; Publication of Roma participation tool‐kit: Launch of WHO Roma

31 health website; 3‐4 case studies to be published in the new Roma health case study series; publication on policy brief on Violence against women with focus on migrants and ethnic minorities; continued coordination of activities of the Interagency Coordination Initiative on Roma Health; organizing workshops and conferences with Interagency partners; contributions to Health 2020 implementation package. The Health and migration project has in this biennium been moving to greater integration with the health area, and also with the social determinants and health equity area of work. This is the outcome of Health 2020 development and implementation In 2014‐15, Health and Migration project together with equity, rights and SDH, in particularly considering that migration will be a priority for the Greek and Italian EU presidency will function as a platform for these cross‐cutting issues.

Outcome 17 Assessment (KPO)

SO.07.001 Member States develop comprehensive national (NHP) and sub‐ OSER Achievement national policies, strategies and plans for health and wellbeing based Fully 11 on/or aligned with the Health2020 policy framework and develop Partially capacity to implement whole of government and multi‐stakeholder Not‐achieved governance processes and mechanisms for Health 2020 Not‐reported implementation. Total 11 Outcome responsible: Dr Agis Tsouros General narrative on Outcome achievement: Ireland, Turkey, Switzerland, Lithuania, Latvia Bulgaria and Kyrgyzstan have either completed or are well advanced in processes for developing national health policies that are aligned with Health 2020. Several other countries have also initiated such processes including Armenia, Spain, Portugal, Austria, Norway, Poland and Moldova. The Regions for Health and the Healthy Cities Networks endorsed in 2012, Health 2020 including the development of sub‐national policies and plans as the basis for their goals and commitments to action. The South Eastern European Health Network is also aligned with the policy objectives of Health 2020. Contribution to public health impact: Developing Health 2020 based, aligned or inspired policies and strategies creates preconditions and commitments for public health impact in addressing key issues such as health inequalities, social determinants, tackling NCDs, strengthening public health and especially prevention and focusing on people. Too early to talk about measurable impact. Evt. Examples of outstanding Outcome achievements in one or two countries: Healthy Ireland proposes a vision where “everyone can enjoy physical and mental health and wellbeing to their full potential, where wellbeing is valued and supported at every level of society and is everyone’s responsibility”. This vision is almost identical to the vision behind Health 2020. Healthy Ireland is based on the following goals: Increase the proportion of people who are healthy at all stages of life, Reduce health inequalities, Protect the public from threats to health and wellbeing and Create an environment where every individual and sector of society can play their part in achieving a healthy Ireland. The 4 main goals of Healthy Ireland also reflect H2020 as does the framework for action to roll out the policy. These elements in the Irish policy have been identified as follows:Governance and Policy, Partnerships and Cross‐Sectoral Working, Empowering People and Communities, Health and Health Reform, Research and Evidence, Monitoring, Reporting and Evaluation

Turkish policy reflects several of the Health 2020 principles and approaches. The current strategic health plan has a strong emphasis on using a whole of government and whole society approaches. The strategic health plan has 4 main goals: To protect the individual and community from health risks and foster healthy lifestyles; To provide accessible, appropriate, effective and efficient health services to individuals and the community; to respond to health needs and expectations of individuals on a human centred and holistic approach and to continue to develop Health Systems as a means to contribute to the economic and social development of Turkey and to global health. Evt. Supportive documentation for Outcome achievement: IRE: http://www.dohc.ie/publications/pdf/HealthyIrelandBrochureWA2.pdf?direct=1 TUR: http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/stratejikplaning.pdf General narrative on deliverable (Output): Completion of the Health 2020 policy framework and strategy and the three supporting studies on SDH, governance and economics. Promoting political commitment; aligning the work of the European Office to and framing BCAs on Health 2020; developing capacity for implementation and supporting member states and networks developing Health 2020 policies.

Links to supportive documentation for deliverables

Health 2020, Governance for Health in the 21st century, European Social Determinants and Health divide review. Challenges: The main challenge is to develop adequate capacity and resources to meet the demand from member states and networks for support to develop Health 2020 aligned policies, strategies and plans.

Lessons learned: Having an overarching policy framework/strategy provides enormous impetus for change because it gives legitimacy, inspiration, and a focus on values and approaches that work. The importance of leadership for health.

Plans for 2014‐2015: A series of initiatives including establishing a roster of accredited Health 2020 policy consultants; organizing integrated missions to countries for cost efficiency purposes; mobilizing resources; and organizing inter‐country capacity building and awareness events which are also cost effective, for instance on health leadership.

Outcome 18 Assessment (KPO)

SO.08.005 Member States implement evidence‐based intersectoral policies and OSER Achievement strategies at regional and national level to meet Parma Declaration Fully 3 commitments with effective new governance for the European Partially Environment and Health Process (EEHP) Not‐achieved Not‐reported Total 3 Outcome responsible: Dr Srdan Matic General narrative on Outcome achievement: Member States in the European Region made progress and reported on it towards meeting their commitments under the Parma Declaration. This was achieved through their active engagement in the governance of the Environment and Health Process, relevant multilateral environmental agreements, monitoring mechanisms, such as the Joint WHO/UNICEF Monitoring Programme, and participation in capacity building activities to enhance knowledge on the interaction of environment and health risks and the application of intersectoral approaches to address them. Contribution to public health impact: Public health achievements under this outcome contribute to reducing exposures of the general population and of vulnerable groups, such as children and socio‐ economic disadvantaged groups, to multiple risk factors present in different settings, including occupational ones, and environmental media (water, food, air, soil and physical agents, such as noise and ionizing and non‐ionizing radiations), including under emergency conditions (natural or man‐made). Evt. Examples of outstanding Outcome achievements in one or two countries:. SLOVENIA: Through its participation in a multi‐country project on "Capacity Building in Environment and Health (CBEH)", Slovenia took part in international activities and organized two national workshops (in February and June 2012) tp strengthen national capacities to apply multisectoral approaches to address environment and health challenges, with a special emphasis on implementing the Parma Declaration commitments and enhancing integration of health (equity) in environmental impact assessments and strategic environmental assessments. A country‐specific proposal for development of a continuous training framework through the inclusion of certain environment and health training modules will be developed. Slovenia also supported the governance of the European Environment and Health Process as a member of the European Environment and Health Ministerial Board. Evt. Supportive documentation for Outcome achievement: Strengthening health in environmental assessments in Slovenia. Gap analysis and way forward (http://www.euro.who.int/en/countries/slovenia/publications3/strengthening‐health‐in‐environmental‐ assessments‐in‐slovenia.‐gap‐analysis‐and‐way‐forward)

General narrative on deliverable (Output) – Highlights on progress on the four main outputs planned under this KPO include the following: 1) WHO Secretariat supported the European Environment and Health Process (EEHP) through the organization of meetings of the European Environment and Health Task Force (June 2012 and December 2013) and Ministerial Board (February 2012; November 2012 and April 2013), consultations with Member States and stakeholders and EHMB alternates and the development of an inter‐sessional programme of work. Reporting to the RC and to the United Nations Economic Commission for Europe (UNECE) took place in fall 2013. The WHO also provided secretariat services and/or technical expertise to multilateral agreements and processes, notably the Protocol on water and health, the Convention on Long Range Transboundary Air Pollution, the Protocol on Strategic Environmental Assessment and the Transport, Health and Environment Pan European Programme; 2) WHO developed new tools for evidence based policy and strategies including guidelines, policy

guidance and advice on multiple environmental exposures and risks, including extreme weather events and the effects of air pollution on health, and standardized methodologies for monitoring the commitments taken in the Parma Declaration; It also supported global monitoring efforts such as the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) and the Global Analysis and Assessment of Sanitation and Drinking Water (GLAAS). 3) Capacity building tools/activities were conducted under intercountry (Bonn, and Riga) and country‐specific workshops (Slovenia), with a focus on strengthening capacities for health impact assessments and multisectoral approaches, as well as supporting the development of national plans for the elimination of asbestos‐related diseases . 4) Technical assistance for implementation of the European Framework for Action on protecting health under a changing climate was provided both at intercountry level, through the exchanges within the Health in Climate Change (HIC) group, and in‐country, notably through the provision of support to 18 countries that developed heat health action plans. Links to supportive documentation for deliverables • Reports of the European Environment and Health Ministerial Board and Task Force meetings at: http://www.euro.who.int/en/health‐topics/environment‐and‐health/pages/european‐process‐on‐ environment‐and‐health/governance • Health and Environment in the WHO European region: Creating resilient communities and supportive environments at: http://www.euro.who.int/en/health‐topics/environment‐and‐ health/pages/european‐process‐on‐environment‐and‐health/health‐and‐environment‐in‐the‐ who‐european‐region‐creating‐resilient‐communities‐and‐supportive‐ environmentsEUR/RC63/Inf.Doc./6 Progress report on the WHO European Centre for Environment and Health, Bonn, Germany (WHO/ECEH) (http://www.euro.who.int/en/about‐ us/governance/regional‐committee‐for‐europe/sixty‐third‐session/documentation/information‐ documents/eurrc63inf.doc.6‐progress‐report‐on‐the‐who‐european‐centre‐for‐environment‐and‐ health,‐bonn,‐germany‐whoeceh) • EUR/RC63/10 Report of the European Environment and Health Ministerial Board to the WHO Regional Committee for Europe and the United Nations Economic Commission for Europe Committee on Environmental Policy (http://www.euro.who.int/en/about‐us/governance/regional‐ committee‐for‐europe/archive/advance‐copies‐of‐documents/eurrc6310‐report‐of‐the‐european‐ environment‐and‐health‐ministerial‐board‐to‐the‐who‐regional‐committee‐for‐europe‐and‐the‐ united‐nations‐economic‐commission‐for‐europe‐committee‐on‐environmental‐policy); • Documentation on the 3rd Meeting of the Parties to the Protocol on Water and Health (http://www.unece.org/env/water/3rd_mop_protocol_water_and_health_2013.html) • Documentation on THE PEP Activities in 2012: http://www.unece.org/index.php?id=2506) • Documentation on THE PEP Activities in 2013: (http://www.unece.org/index.php?id=2506 ) • Biomonitoring‐based indicators of exposure to chemical pollutants (2012) (http://www.euro.who.int/en/data‐and‐evidence/environment‐and‐health‐information‐system‐ enhis/publications/meeting‐reports/biomonitoring‐based‐indicators‐of‐exposure‐to‐chemical‐ pollutants‐2012) • Review of evidence on health aspects of air pollution – (REVIHAAP project: final technical report http://www.euro.who.int/en/health‐topics/environment‐and‐health/air‐ quality/publications/2013/review‐of‐evidence‐on‐health‐aspects‐of‐air‐pollution‐revihaap‐project‐ final‐technical‐report) • Health risks of air pollution in Europe – HRAPIE project Recommendations for concentration– response functions for cost–benefit analysis of particulate matter, ozone and nitrogen dioxide http://www.euro.who.int/en/health‐topics/environment‐and‐health/air‐ quality/publications/2013/health‐risks‐of‐air‐pollution‐in‐europe‐hrapie‐project‐ recommendations‐for‐concentrationresponse‐functions‐for‐costbenefit‐analysis‐of‐particulate‐

matter,‐ozone‐and‐nitrogen‐dioxide; • Protecting health from climate change: A seven‐country initiative http://www.euro.who.int/en/health‐topics/environment‐and‐health/Climate‐ change/publications/2013/protecting‐health‐from‐climate‐change‐a‐seven‐country‐initiative • Infectious diseases in a changing climate http://www.euro.who.int/en/health‐topics/environment‐ and‐health/Climate‐change/publications/2013/infectious‐diseases‐in‐a‐changing‐climate • Floods in the WHO European Region: health effects and their prevention http://www.euro.who.int/en/health‐topics/environment‐and‐health/Climate‐ change/publications/2013/floods‐in‐the‐who‐european‐region‐health‐effects‐and‐their‐ prevention Challenges: The voluntary and intersectoral nature of the European Environment and Health Process (EHP) make it highly vulnerable to changes in political priorities in countries, which may result in country disengagement and in volatile commitments, as well as in the need to maintain high relevance to the agenda of two different sectors within governments. It also has an impact on the sustainability and predictability of resources available for implementation. In particular, after the first three years of implementation of the new governance mechanism for the EHP, it became clear that there is a strong need to ensure greater continuity and stability in political leadership of the process, as well as greater coordination and integration between the agendas of the European Environment and Health Task Force and of the Ministerial Board, that are two independent bodies.

Lessons learned: Development of an institutional process, such as EHP, takes a lot of effort, sustained commitment and resources from its stakeholders. Its success is also dependent on WHO’s ability to properly resource, provide leadership and support the efforts of Member States and other stakeholders

Plans for 2014‐2015: Work on this outcome will continue under the new deliverable 3.5.3 – WHO providing leadership and support to intersectoral governance for environment and health. . The lessons learned through the first years of implementation of the new governance mechanism of the European Environment and Health will guide the discussions and proposals for action of the Mid‐term review of the Parma Declaration implementation, which will take place in fall 2014, and the preparations of the 6th Ministerial Conference on Environment and Health, to be held in 2016.

Outcome 19 Assessment (KPO)

SO.09.004 Member States develop, implement and evaluate National plans and OSER Achievement strategies for the promotion of appropriate nutrition in accordance Fully 9 with the "WHO European Action Plan for Food and Nutrition Policy", Partially prioritizing the areas of nutritional status surveillance and monitoring Not‐achieved Not‐reported of the population with a focus on children. Total 9 Outcome responsible: Dr Joao Breda General narrative on Outcome achievement: Member States developed with WHO a first draft of the new Food and Nutrition Action Plan for the Region and discussed and adopted a Declaration on Nutrition and Noncommunicable Diseases. A set of Member States evaluated their recent year’s nutrition policies with the support of the secretariat and a other Member States both revised or developed brand new nutrition action plans.

Contribution to public health impact: One of the most significant achievements known to improve public health was the scaling/up of the nutrition information system notably by establishing a remarkable surveillance system for the assessment of children nutritional status which is the most relevant of its kind in all WHO Regions, involving already 36 Member States at different levels of engagement. The support to the evaluation of National frameworks in the area will enable the creation of supportive environments to the adoption of appropriate nutrition and better diets and fine‐tuning of existing policies.

Evt. Examples of outstanding Outcome achievements in one or two countries: • Norway: WHO conducted an extensive and very comprehensive evaluation of the Norwegian nutrition policies including obesity. It was performed under a partnership with Institutions of the Ministry of Health and with the support of an elite group of National and International experts. The analysis engaged a whole array of Institutions and stakeholders including several levels of the administration. • Albania: Under WHO leadership a new Food and Nutrition Policy was developed with the collaboration of several UN organizations especially UNICEF and FAO. Stakeholders at different levels were involved in the process whose epilogue was the adoption and publication of the FNAP. Albania was also one of the most successful newcomers to COSI having already published the report of its first survey. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/__data/assets/pdf_file/0003/234381/Vienna‐Declaration‐on‐Nutrition‐and‐ Noncommunicable‐Diseases‐in‐the‐Context‐of‐Health‐2020‐Eng.pdf http://www.euro.who.int/__data/assets/pdf_file/0003/192882/Evaluation‐of‐the‐Norwegian‐nutrition‐ policy‐with‐a‐focus‐on‐the‐Action‐Plan‐on‐Nutrition‐20072011.pdf http://www.fao.org/fileadmin/user_upload/Europe/documents/Events_2013/ICN2TA/9p.pdf http://www.euro.who.int/en/countries/albania/news/news/2013/11/capacity‐building‐workshop‐on‐ school‐based‐prevention‐of‐childhood‐obesity‐in‐albania

General narrative on deliverable (Output): Country profiles as the progress report on the Implementation of FNAP prepared. Development of a draft of the new WHO European Region Food and Nutrition Action Plan in line with the Global Strategy on Diet and Physical Activity and the Global Strategy IYC. Technical Assistance to Member States for the implementation of the National Surveillance Systems particularly COSI

38 was provided.

Links to supportive documentation for deliverables http://www.euro.who.int/__data/assets/pdf_file/0009/217728/63rs04e_ViennaDeclaration.pdf http://www.euro.who.int/__data/assets/pdf_file/0010/195958/63wd18e_Progress‐reports‐2.pdf

Challenges: Lack of funding for activities and to the improvement of capacity at national level was challenging but a good collaboration between the three levels of the organization: CO, RO and HQ made implementation possible. Lessons learned: Very good relationship and collaboration with Ministries of Health as well as other national authorities. In many instance colleagues at CO showed great leadership of Country Offices. The interaction, collaboration and joint work between the three levels of the organization was important for achieving high levels of implementation.

Plans for 2014‐2015: This line of work will be important to the fulfilment of category 2 main objectives therefore it was included as part of the new biennium workplan. It is advised to support on‐going activities in Member States to ensure they are not discontinued. Capacity in the CO is important notably in the countries with highest burden of diet and PA related NCDs. Submit to the governing bodies a proposal for a new food and nutrition action plan (2014) and COSI report.

Outcome 20 Assessment (KPO)

SO.09.006 Member states enhance their capacities and resource allocations for OSER Achievement addressing food safety, foodborne diseases and food hazards Fully 1 Partially Not‐achieved Not‐reported Total 1 Outcome responsible: Dr Hilde Kruse

General narrative on Outcome achievement: In Central Asian Republics (CAR) and South Eastern European (SEE)countries, awareness on food safety has been raised and understanding of the importance of food safety has increased, in particular in regard to Codex Alimentarius work and how countries can better detect and respond efficiently to food safety emergencies.

Contribution to public health impact: The strengthening of the detection, prevention and control of foodborne diseases generally has a positive impact on public health by reducing the morbidity and mortality due to foodborne diseases. However, one cannot provide evidence for the effect of this particular outcome as there are multiple factors that impact on the incidence of foodborne disease.

Evt. Examples of outstanding Outcome achievements in one or two countries: Albania: Methods for 6 important public health hazards in the food chain has been accredited at the central laboratory in Tirana.

Turkmenistan: In 2012 TKM became a Member of Codex Alimentarius in 2012 and at the 50 years anniversary of Codex Alimentarius Commission in FAO, Rome, July 2013 TKM gave an opening speech as the newest Member State of Codex.

Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/countries/albania/areas‐of‐work/strengthening‐food‐control‐institutions‐in‐ albania http://www.codexalimentarius.org/50th‐anniversary/opening‐speeches

General narrative on deliverable (Output): WHO/FAO sub‐regional training on Codex held for CAR and SEE, respectively. Sub‐regional training on detection, prevention and control of foodborne disease held for CAR. Sub‐regional training on AMR from a food safety perspective was held for SEE countries. Development, promotion and distribution of food safety risk communication materials at the national level. Technical support provided to countries during food safety emergencies. Successful finalization of a 4 year (2009‐2013) food safety project in Albania.

Links to supportive documentation for deliverables http://www.euro.who.int/en/countries/albania/news/news/2013/06/balkan‐countries‐improve‐ knowledge‐of‐international‐food‐standards‐setting.‐zagreb,‐croatia,‐4‐6‐june‐2013 http://www.euro.who.int/en/countries/turkmenistan/sections/news/2013/10/integrated‐foodborne‐ infections‐surveillance‐training‐in‐turkmenistan

40 agriculture/veterinary sectors, which is crucial for cost‐effective prevention and control of foodborne diseases.

Lessons learned: Often intersectoral collaboration and communication on food safety is not the best at the national levels. Ensuring inter‐sectoral participation in the food safety activities that WHO is organizing, helps strengthening the intersectoral cooperation at the national level. Partnership between WHO and FAO can is often helpful in this respect.

Plans for 2014‐2015: Continue the good food safety capacity building that has taken place in SEE countries and CAR during the last biennium, and also engage in Ukraine and Turkey, with particular focus on the importance of strengthening inter‐sectoral collaboration and communication in line with the H2020 and the “One health” approaches.

Outcome 21 Assessment (KPO)

SO.10.002 Member States have applied a systematic approach to governance with OSER Achievement the aim of strengthening health systems by developing, evaluating and Fully 20 supporting alignment to national and/or sub‐national health plans and Partially strategies and by assessing the performance of their health system. Not‐achieved Not‐reported Total 20 Outcome responsible: Dr Juan Tello General narrative on Outcome achievement: Member States have embarked upon various means to strengthen health systems and to enhance accountability for the performance of their health systems some with, and some without direct WHO support. A number of countries have introduced new national health strategies and have incorporated health system performance frames within their strategies. Some countries have introduced or updated their national health system monitoring schemes. Others have strengthened pre‐existing systems for health system performance assessment or introduced new health system performance assessment and reporting arrangements. Contribution to public health impact: Allowed for more transparent accountability mechanisms in line with Tallinn Charter 2008. Evt. Examples of outstanding Outcome achievements in one or two countries: • TUR. This country developed a NHS but also HSPA and a monitoring framework to monitor reforms. Currently, cooperation has moved to support implementation and but the presence of the Division in the country accompanying the above mentioned process has facilitated the dialogue to move forward the cooperation agenda. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/__data/assets/pdf_file/0008/168875/Case‐Studies‐for‐HSPA‐ENG.pdf

General narrative on deliverable (Output) ICP. Mainly, 1. Development of a concept note identifying the subfunctions of the HGO function. 2. Development of a training module and web platform for at distance learning and self assessment tool. 3. Draft paper on HGO for TB/MDR‐TB 4. Scoping review on the HGO. 5. Accountability paper for report to Tallinn. 6. Technical organization and coordination of the Tallinn event. 7. Presentation in Gastein of HGO for Patient Safety 8. Publication of HSPA country guide CSP: Assessment of the UKR CDC on merging TB and HIV programmes. Support to evidence to policy and NHS (UKR, ARM, MAT) and HSPA in EST, MAT. Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/Health‐systems/health‐systems‐governance/publications

Challenges: Health governance entails, among other things, strengthening policy formulation, evaluation and transparency. But it also requires that MSs apply rigorous procedures that are to be developed and framed in a consistent framework. Lessons learned: The HGO aspects of HS are still a priority to be addressed if sustainable changes are to take place at country level. Plans for 2014‐2015:

Outcome 22 Assessment (KPO)

SO.10.001 Member States improve the performance of public health OSER Achievement services and operations by developing, implementing, Fully 22 evaluating evidence-informed public health policies. Partially Not‐achieved 3 Not‐reported Total 25 Outcome responsible: Dr Hans Kluge General narrative on Outcome achievement: With the support of WHO, about 28 Member States have improved performance on public health (PH) services by undertaking public health assessments; defining public health strategy/public health plans; endorsing new public health laws; reorganizing public health services; and redefining funding mechanisms. Contribution to public health impact: Some Member States including Kyrgyzstan, Slovenia, Slovakia, Armenia, Moldova and Greece have reported on improved public health services as a proxy for improved public health and population health status. Evt. Examples of outstanding Outcome achievements in one or two countries: Greece: recent decision to introduce 25 Euro co‐payment in hospitals was waved for an increase of tobacco taxation instead. Slovenia: Reorganised public health institutions as of 1st January 2014 onwards. Evt. Supportive documentation for Outcome achievement: (http://www.euro.who.int/en/health‐topics/Health‐systems/public‐health‐ services/news/news/2013/10/public‐health‐consensus‐meeting‐in‐slovenia) General narrative on deliverable (Output): Mostly due to outputs of PH reviews: 1. Integrated and modernized public health services, Slovakia; 2. Merged public health institutions, Slovenia; 3. Draft Public health action plan, Armenia; 4. New PH law, Kyrgyzstan; 5. New PH Plan, Moldova; 6. Action Plan for PH reform in Greece; 7. 2 new WHO Collaborating Centres (Durham, UK; Russian Federation). Links to supportive documentation on deliverables Example Moldova health operations review http://www.euro.who.int/en/countries/republic‐of‐moldova/publications2/health‐policy‐paper‐series‐ no.‐8‐analysis‐of‐public‐health‐operations,‐services‐and‐activities‐in‐the‐republic‐of‐moldova Challenges: • External: Financial crisis, change of governments, change of counterparts • Internal: Change in implementation capacity (reduction of HR)

Lessons learned: Strengthening Public Health services requires strong government commitment, a robust assessment process of public health services, a dialogue by stakeholders at all levels and a national action plan or roadmap in order to prioritize and guide activities.

Plans for 2014‐2015: Further Implementation of the EAP on PHS with a definition of a maximum of 6‐7 priority countries.

Outcome 23 Assessment (KPO)

SO.10.004 Increased quality of and capacity for health OSER Achievement situations analysis, including collection, use of Fully 15 standards, analysis and dissemination of health Partially information in Member States Not‐achieved Not‐reported Total 15 Outcome responsible: Dr Enrique G. Loyola Elizondo

General narrative on Outcome achievement: Using guidelines and standards provided by WHO, at least 15 Member States have carried assessments of their health information systems and data produced by them, particularly civil registration and vital statistics and cause of death statistics, allowing action on issues and improving the overall quality of their health information. In addition, EURO capacity building efforts contributed to analytical skills of staff, which also allowed countries to generate and disseminate more health information and analyses.

Contribution to public health impact: Enhanced health monitoring and situation analyses are essential public health functions playing an important role orienting policy. However, sound reports have to be based on quality information and analyses to provide the right answers. Developing analytical skills through training and providing guidance and tools in Russian language for conducting assessments of information quality is allowing to increase monitoring and reporting capacities of Ministries of Health in priority countries. This helps them to identify and address main health issues and monitor progress of their strategies and interventions.

Evt. Examples of outstanding Outcome achievements in one or two countries: • Turkey shows significant progress establishing a population based mortality system and submitting data to WHO; this milestone effort meant that for the first time national statistics with full coverage were achieved. Health information has been used in different reports to orient and monitor policy at highest levels. Country is a champion supporting health information improvement actions. • The Netherlands has set a good example of cooperation with the preparation of public health monitoring and reporting at the National Institute of Public Health and Environment in response to the policy information needs of the Dutch Ministry of Health. The approach provides robust, quality and independent information and evidence and serves other purposes of informing the public and other stakeholders.

Evt. Supportive documentation for Outcome achievement: Ministry of Health of Turkey. Health statistics yearbook 2012. http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/hsy2012.pdf. Ministry of Health of Turkey. Strategic Plan 2013‐2017. http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/stratejikplaning.pdf. Turkish Statistical Institute. Mortality and cause of death statistics 2010, 2011 and 2012. http://www.turkstat.gov.tr/PreTabloArama.do?metod=search&araType=vt and http://www.turkstat.gov.tr/PreHaberBultenleri.do?id=15847 Dutch National Institute of Public Health and Environment, Ministry of Welfare and Sport. http://www.rivm.nl/en/Documents_and_publications/Common_and_Present/Newsmessages/2013/Thema tic_report_Public_Health_Status_and_Forecast_2014, http://www.zorgatlas.nl/object_binary/o15736_Kartograpische‐Nachrichten‐2013.pdf and http://www.rivm.nl/en/Documents_and_publications/Scientific/Reports/2013/oktober/Diet_of_communit

44 y_dwelling_older_adults_Dutch_National_Food_Consumption_Survey_Older_adults_2010_2012

General narrative on deliverable (Output): Efforts to improve health information in Member States have included the provision of guidelines and tools for implementation of standards, assessments of information systems and data quality produced by them, situation analysis and interpretation and public health monitoring and reporting. Dissemination of information products in English and Russian helped to increase uptake in the Region. The Autumn School on Health Information and Evidence provided a capacity building opportunity with participation of nationals from nearly 20 Member States. Links to supportive documentation for deliverables World Health Organization. Strengthening civil registration and vital statistics for births, deaths and causes of death: resource kit. http://www.who.int/healthinfo/CRVS_ResourceKit_2012.pdf, Improving the quality and use of birth, death and cause‐of‐death information: guidance for a standards‐based review of country practices http://www.who.int/healthinfo/tool_cod_2010.pdf and Analysing mortality level and cause‐of‐death data (ANACoD). http://www.who.int/healthinfo/topics_standards_tools_data_collection/en/

Challenges: Limited funding and staff resources at RO and no technical presence in countries made it more difficult to implement and follow up activities RDO and SRC plan to expand public health functions in WHO country offices, including strengthening health information, are envisioned for 2014; this is a very welcomed proposal.

Lessons learned: To deal with limited HMA staffing capacity, mobilizing support from WHO Headquarters, WHO Collaborating Centres and external experts has proven essential to meet commitments. In addition, establishing partnerships with Member States (e.g. the Netherlands), national institutions (e.g. RIVM) and other international organizations (e.g. HMN and UNESCAP) has contributed further with funding and direct technical cooperation to carry out some of the above mentioned activities (e.g. guideline translations, assessments and training) to improve different areas of health information

Plans for 2014‐2015: There are a number of guidelines and tools already available to improve assessment, quality, analysis, monitoring and reporting of health information, with emphasis on priority mandates, in countries. They have been particularly applied in Central Asian and Caucasus countries in this biennium. However, due to needs in other countries (e.g. other CIS and SEEHN), further dissemination, implementation and capacity building is warranted.

Outcome 24 Assessment (KPO)

SO.10.004 A common European health information system agreed and framework OSER Achievement established jointly with the EC for harmonized health information and Fully 13 evidence used for decision making at regional and Member State levels. Partially Not‐achieved 1 Not‐reported Total 14 Outcome responsible: Dr Enrique G. Loyola Elizondo General narrative on Outcome achievement: Jointly with EC and OECD, progress made on roadmap for a common health information system. To date, three stages of the agreed roadmap have been achieved, including the preparation of the framework for the common information system; an inventory of basic information of institutional databases and information systems available in all three organizations, and the identification of potential shared contents for the information system In this regard, a WHO list of indicators to monitor Health 2020 progress approved by Member States will also be used as input for the discussion on the common system; in turn, EC has proposed to use the ECHI indicators and OECD the health care indicators of the Eurostat/OECD/WHO joint data collection. A matrix has been prepared and shared by all institutions for further discussion and agreement on the selected set. Contribution to public health impact: A core set of agreed and harmonised high quality indicators available in a common information system will allow for improved health monitoring and situation analyses to inform policy at the Member States’ and European region levels, including aspects of the Health 2020 policy, the NCD monitoring framework and MDGs monitoring mandates. In addition to reducing discrepancies of indicator values that confuse information users, the joint standardised indicators proposal of the three international organizations will reduce the burden of data collections on Member States, an issue that is highly appreciated.

Evt. Examples of outstanding Outcome achievements in one or two countries: Several Member States have contributed to this initiative, among them Austria, Belgium, Finland, Germany, the Netherlands, Spain and the United Kingdom, who have supported the views of WHO for continuing the information system developments. Their joint experience with health indicators development (ECHI) and an information system (EUPHIX and HEIDI) and their continuation with national processes have been used to orient further course of action.

Evt. Supportive documentation for Outcome achievement:

Ministry of Health if the Netherlands. Public health indicators for the EU: the joint action for ECHIM (European Community Health Indicators & Monitoring) http://download.springer.com/static/pdf/187/art%253A10.1186%252F0778‐7367‐71‐ 12.pdf?auth66=1389897656_09b33197b3762832b0a419807c00ca53&ext=.pdf and ECHI indicators development and documentation http://www.nationaalkompas.nl/object_binary/o14707_ECHIM‐final‐ report_Part‐II_PDF.pdf

General narrative on deliverable (Output): In addition, under the Health Information Initiative, a Health Information and Evidence portal is being developed jointly with the National Institute of Public Health and the Environment will help to integrate quantitative and qualitative information, while contributing also to the common European information system. Also, tool for developing national Health Information Strategy will be presented to SCRC for consideration and further development. Links to supportive documentation for deliverables WHO Health Information and Evidence portal, soon to be available at the WHO Europe public web site.

46 http://www.euro.who.int/en/countries/netherlands/sections/news/2013/03/how‐good‐is‐our‐ information‐on‐health‐and‐well‐being

Challenges: During 2013, the team leader of the Monitoring, information systems and databases left the organization, creating a vacuum that has affected the progression of the information system developments. Also, recruitment has been slow and will have to wait until next year. The diverse and vast area of health information covered in the portal will demand additional staffing time contributions for its regular update and sustainability. Lessons learned: Linking with major international partners and Member States and agreeing on the development of the common European information system is a requisite for success. However, different institutional mandates, priorities and policies of EC and OECD have contributed to slowing the development of a rather ambitious process. The complex situation confronted needed to be taken into account and, thus, more pragmatic and simple approaches were proposed, such as starting with a short list of core health indicators that could be used as pilot testing while the system and its development matures. The original proposal of a common information system involves EU and WHO and more recently OECD. However, given its broader constituency, a large section of non‐EU and non‐OECD Member States look towards WHO for strategic and technical advice and to being involved in decisions on the health information system development. In turn, this provides additional leverage to WHO in the discussions with EC and OECD. Given their interest in strengthening health information, special funding contributions within the Health Information Initiative from the Dutch Ministry of Health and joint technical work with the National Institute of Public Health and the Environment have made some of these developments possible. Plans for 2014‐2015: Strong political support from RD and Member States for the initiative and continuous engagement with EC and OECD, particularly during their constituents’ technical and strategic meetings, are essential to continue the development of the common health information system. The additional roadmap stages (where the technical aspects of the systems will be addressed) and high level WHO‐DG SANCO/EC officers meetings are providing additional support to this effort. A plan to expand the contributions to the Health Information Initiative is taking place with other Member States indicating interest. The work on the Health 2020 indicators will continue to include wellbeing, while portal development and launching should occur early next year.

Outcome 25 Assessment (KPO)

SO.10.001 Member States implemented health financing policies to make progress OSER Achievement towards, or sustain existing achievements of, universal health coverage, Fully 11 with attention to minimizing the negative effects of the financial crisis Partially 4 on the health sector and ensuring that financing arrangements are well Not‐achieved 1 Not‐reported aligned to priority health care and public health services. Total 16 Outcome responsible: Mr Tamas Evetovits General narrative on Outcome achievement: Member States have made strong commitments to mitigate the negative health and financial protection effects of the financial and economic crisis at the Oslo Conference, and formalized their commitment through a resolution at the 63rd Regional Committee. The resolution remains a bedrock commitment guiding health financing policy for several years to come in the region. Several Member States have begun to better align their health financing arrangements with public health priorities e.g. for NCDs or TB to accelerate health outcome gains. Contribution to public health impact: Member States have recognized the impact of drastically cutting public health budgets across the board and many have introduced corrective measures or altered their policy course towards protecting cost‐effective and equity enhancing expenditures. Better aligned health budgets allow achieving greater health gain for the investment and there is increasing evidence of mis‐ alignment of funding and cost effective interventions and services for major conditions such as NCDs and TB. Evt. Examples of outstanding Outcome achievements in one or two countries: • Ireland: Several policy decisions on navigating the crisis were identified following a multidisciplinary joint international and national assessment (e.g. budget allocation, salary of health personnel, efficiency gains, etc.) leading to the publication of a report completed jointly with the European Observatory. • Turkey: After a decade of impressive reforms to introduce family medicine with a focus on maternal and child health, Turkey has begun to expand the scope of family medicine to better include NCDs and align financing and staffing accordingly. This is in line with the epidemiological data suggesting a fast growing NCD burden. This decision follows a multi‐disciplinary joint international and national expert assessment that has put forward policy recommendations through an influential report. Evt. Supportive documentation for Outcome achievement:

RC resolution http://www.euro.who.int/en/about‐us/governance/regional‐committee‐for‐europe/sixty‐third‐ session/resolutions‐and‐decisions/eurrc63r5‐health‐systems‐in‐times‐of‐global‐economic‐crises‐an‐ update‐of‐the‐situation‐in‐the‐who‐european‐region

Ireland http://www.euro.who.int/en/health‐topics/Health‐systems/health‐systems‐financing/country‐ work/ireland

General narrative on deliverable (Output): Technical work focused on the impact of the economic crisis in Europe and analysis of the policy responses, culminating in Oslo High Level meeting and 10 policy lessons and recommendations adopted by the Regional Committee. HSS NCD work program has been developed and assessment guide was launched at Ministerial Conference.

Links to documentation for deliverables Oslo Conference on Financial crisis http://www.euro.who.int/en/media‐centre/events/events/2013/04/oslo‐conference‐on‐health‐systems‐ and‐the‐economic‐crisis/about‐the‐conference

Challenges: Fiscal pressures often lead to rushed and misguided policy responses with adverse effects on universal health coverage. For some countries this meant moving away from progress achieved in the past. Lessons learned: Timely monitoring of health system performance including progress towards universal coverage is vital to provide evidence informed support to health financing policy. Dialogue with finance ministries has to be improved. Plans for 2014‐2015: Regional overview of financial risk protection as one of the pillars of UHC, focused technical support to selected member states hit by the economic crisis, continued support to MSs to better align health financing arrangements and public health priorities.

Outcome 26 Assessment (KPO)

SO.10.005 Member States request and use policy briefs and evidence syntheses for OSER Achievement the translation of evidence into policy at country level AND participate Fully 16 in capacity building workshops and in the development of tools for Partially evidence informed policy‐making. Not‐achieved Not‐reported Total 16 Outcome responsible: Ms Tanja Kuchenmüller General narrative on Outcome achievement: 1. 13 Member States participated in the first EVIPNet Europe multi‐country capacity building workshop in October 2013, increasing participants’ understanding of, commitment to and skills in supporting evidence‐informed health policy‐making. Member States are now in the process of setting up country‐specific knowledge translation platforms. 2. Member States are sensitized to the issue of research and development through the activities of CEWG and EACHR. Contribution to public health impact:

Since EVIPNet Europe is still in its infancy, public health impact is expected in the coming biennia.

Activities of CEWG and EACHR are equally in its early stages, and impact will be demonstrated in the upcoming biennia.

Evt. Examples of outstanding Outcome achievements in one or two countries: EST convened health policy‐makers and researchers at the first national EVIPNet Europe capacity building workshop, enhancing participants’ skills in identifying, appraising, and packaging research related to a health policy issue, as well as conducting policy dialogues. Evt. Supportive documentation for Outcome achievement: “Reference / link to documents, reports, publications, etc.” EVIPNet Europe multi‐country capacity building workshop: http://www.euro.who.int/en/data‐and‐ evidence/news/news/2013/10/evipnet‐multi‐country‐workshop‐on‐using‐research‐evidence‐for‐policy‐ making

CEWG: http://www.who.int/phi/implementation/phi_cewg_meeting/en/

General narrative on deliverable (Output) 1. EVIPNet Europe: the network was launched in October 2012 as a public health network to promote EIP capacity building at country level, in support of the implementation of Health 2020. The network currently comprises 13 member countries. National EIP roadmaps were jointly developed by the HoCOs and national EIP champions at the 1st EVIPNet Europe capacity building workshop. 2. CEWG: regional consultation held and demonstration projects collated and proposed to HQ. 3. EACHR: Two meetings of the group held with clear recommendations made to RD and action plan for next biennium devised. 4. HEN: Two major reviews commissioned (chronic diseases and health information systems). Links to documentation for deliverables: Information on the 2012/13 CEWG work can be found at http://www.euro.who.int/en/who‐we‐ are/governance/regional‐committee‐for‐europe/sixty‐second‐session/documentation/technical‐ briefingsministerial‐lunches/web‐based‐consultation‐on‐the‐report‐of‐the‐consultative‐expert‐working‐

50 group‐cewg‐on‐research‐and‐development‐financing‐and‐coordination The EACHR report of September 2012 can be accessed at http://www.euro.who.int/en/data‐and‐ evidence/evidence‐informed‐policy‐making/sections/news/2013/02/european‐advisory‐committee‐on‐ health‐research‐eachr‐meeting‐report‐published The HEN database website can be accessed at http://data.euro.who.int/HEN/

Challenges: The “Mission critical" EIP P1 position is not appointed, and position of unit leader EIP vacant for the last 8 months (new unit leader will commence his work on 1 January 2014). In addition, a high political visibility of CEWG work has led to challenging situations with some Member States. The process was, moreover, not coordinated well at HQ‐level leading to disparate approaches in the regions. Lessons learned: Global issues require global coordination and acting as one WHO. Plans for 2014‐2015: EVIPNet Europe will continue organizing capacity building workshops to its member countries, with a particular focus on its pilot countries. EACHR will continue to organize two meetings each year. EURO maintains its support to the global CEWG work. HEN will coordinate the two major reviews commissioned at the end of 2013. A key activity for HEN will be to conduct a programmatic evaluation and impact assessment.

Outcome 27 Assessment (KPO)

SO.11.001 Member States improve equitable access to good quality medical OSER Achievement products (medicines, vaccines, blood products) and technologies. Fully 13 Partially 1 Not‐achieved Not‐reported Total 14 Outcome responsible: Hanne Bak Pedersen General narrative on Outcome achievement: Many countries are concerned about the high costs of medical products and some have procurement and supply related problems. Managing medicine costs is central to equitable and affordable access. This includes both management of medicines prices and volumes of medicines used. Issues of health financing and in particular adequate financing for essential medicines are key challenge for countries. Access and affordability of medicines can be enhanced though evidences based decision making and by the use of generic medicines when possible. 16 countries have taken steps to improve equitable access by improving selection and use of medical products. Outcomes include medicines policy updates (5), review of pricing and reimbursement strategies(all but detailed in 2), up‐dates of national list of essential medicines ( 5 ); procurement and supply management reviews including national action plans for improvement (6) as well as a Procurement and Supply Management training seminar in Belarus; Contribution to public health impact: Access to medical products is a key component of access to health care. Pharmaceutical expenditure has risen in many countries and it has been challenging for countries to sustain and increase access. The strategies on access to essential medical product developed are based on the principles of evidence‐based selection of a limited range of medicines, efficient procurement, affordable prices and distribution systems, and rational use of medicines. Outcomes achieved have provided a better basis for management of medical products so that product selection is more cost effective and use of products is increasingly more rational.

Evt. Examples of outstanding Outcome achievements in one or two countries: Countries have had very different means to pursue equitable access to good quality medical products (medicines, vaccines, blood products) and technologies; however achievements have been good in most countries and linked to resources available. Azerbaijan, Estonia, Greece, Hungary, Kazakhstan, Kyrgyzstan, Moldova, Tajikistan, and Turkey have in the biennium substantially developed their pharmaceutical sector to support increase in equitable access to good quality medical products.

Evt. Supportive documentation for Outcome achievement:

General narrative on deliverable (Output): WHO has a pivotal role in supporting countries to develop transparent systems for selection and use as well as implement financing and pricing strategies to support UHC. HTP/DSP/WHO Europe has with WHO Collaborating Centres and other technical partners created networks across Europe on key topics such a medicines policy, pricing and reimbursement, HTA and evidence based selection and use of medical products. This work has contributed to development of transparent systems at country level that facilitate access to quality essential medical products. Comparative medical product value estimation, pricing and reimbursement have been key topics to facilitate introduction and management of new medical products in the health care systems. 4 country reviews on access to medicines for treatment of noncommunicable diseases (NCD) took place in the framework of WHO NCD assessments with focus on health system barriers to support incorporation of ‘Best Buys’ in the area of NCD medicines. Work with National TB and HIV/AIDS programme on

52 identification of the gaps in access to the priority essential medicines has been undertaken. In the TB area a joint monitoring mission to Moldova; a joint GDF and GLC mission to Kyrgyzstan and a PSM trainings in Donetsk, Ukraine, were carried out. Pharmaceutical sector country profiles for 24 countries have been prepared along with an analytical report of the finding. Development of comprehensive national policies on access, quality and use of essential medical products and technologies has been supported as well as systems for monitoring impact. For specific details see below links: Links to supportive documentation for deliverables HTP annual report 2012: http://www.euro.who.int/en/health‐topics/Health‐ systems/medicines/publications2/2012/health‐technologies‐and‐pharmaceuticals‐annual‐report‐2012;

WHO/Europe Regional pharmaceutical situation report http://www.euro.who.int/__data/assets/pdf_file/0014/237011/WHO‐EURO‐Regional‐Pharmaceutical‐ situation‐Report.pdf;

“Availability and affordability of medicines and assessment of quality systems for prescription of medicines in the Republic of Moldova” http://www.euro.who.int/en/health‐topics/Health‐ systems/medicines/publications2/2012/availability‐and‐affordability‐of‐medicines‐and‐assessment‐of‐ quality‐systems‐for‐prescription‐of‐medicines‐in‐the‐republic‐of‐moldova Challenges: Limited HR and financial resources for the technical area of work means that few direct country specific programmes have been possible but good progress has been achieved though inter‐ country work processes and networks with regular meetings and workshops to address specific topic. Lessons learned: Evidence based selection and use of medical products is key to sustain and increase access to good quality medical products (medicines, vaccines, blood products) and technologies. Plans for 2014‐2015: Continue support to policy frameworks and systems for evidence based decision making in support of increasing / sustaining access to essential health product in the European countries. More focus on HTA and capacity support, as per country requests. Assist countries with NCD related medicines issues linking the increasing NCD burden and cost implication in the relation.

Outcome 28 Assessment (OPO)

SO.01.001 Member States able to strengthen immunization systems in the context OSER Achievement of health systems strengthening in order to maximize equitable access of Fully 17 all people to vaccines of assured quality, including new or underutilized Partially immunization products and technologies, and to integrate other essential Not‐achieved Not‐reported family and child health interventions with immunization. Total 17 Outcome responsible: Dr Dina Pfeifer General narrative on Outcome achievement: All set targets against two indicators reflecting accessibility of immunization services (at least 90% coverage with DTP3 in 50 out 53 MS by end of the biennium; baseline value 48 out 53 MS), successful expansion of national immunization programmes through introduction of new vaccines (countries with Haemophilus influenza type b vaccine; 52 out of 53 MS have introduced Hib vaccine by end of the biennium, baseline value 50 MS). Contribution to public health impact: Protecting children against more vaccine‐preventable diseases by introduction of new vaccines to national immunization programmes – After introduction of rotavirus vaccine in Republic of Moldova, the number of hospitalizations due to overall diarrhoea among children under one year of age decreased 30% and the number of hospitalizations due to rotavirus related diarrhoea decreased by 77%. Evt. Examples of outstanding Outcome achievements in one or two countries: Armenia and Republic of Moldova made an evidence‐based decision and successfully introduced universal vaccination against rotavirus diarrhoeas during the biennium. Based on the technical support provided by the WHO, national immunization programmes in both countries implemented innovative strategies to overcome resistance to the new vaccination among medical workers and the public and to timely deliver rotavirus vaccine to infants within restricted age interval. As a result, both countries achieved planned coverage rates within short period of time after the introduction. The national specialists managed to demonstrate an impact of the recently introduced vaccine on rotavirus disease burden. The data from rotavirus sentinel surveillance in Armenia and Moldova verified that vaccination significantly decreased hospitalizations due to diarrhoeas in children under two years of age and reduced related health care expenditures. Evt. Supportive documentation for Outcome achievement: Rotavirus vaccine post‐introduction evaluation, Armenia” N:\DCE\VPI\10 NUVI\~Country Work\ARM\2013 rotavirus PIE\Report\Final Rotavirus vaccine post‐introduction evaluation, Republic of Moldova”, N:\DCE\VPI\10 NUVI\~Country Work\MDA\2013 rotavirus vaccine PIE\Report\Final

(Both documents are not available in public domain – can be obtained from the technical unit upon request.) General narrative on deliverable (Output): The Secretariat provided technical assistance to MS in strengthening evidence‐based decision making process (by providing capacity building activities for national immunization technical advisory groups), conducted post introduction evaluations to assess the new vaccine introduction process and provided recommendations to improve delivery of new vaccines. Links to supportive documentation for deliverables Same documents listed above

Challenges: Although the vaccination coverage is quite high at national level for new vaccines, existence of vaccine hesitancy and anti‐vaccination movements challenge the access to all eligible. If not addressed, it may jeopardize introduction of new vaccines and threaten the expected public health impact. Lessons learned: More efforts required in intensifying community advocacy and social mobilization

54 activities and training of health care workers to tackle with vaccine refusal problem. Plans for 2014‐2015: Providing technical assistance to MS in responding to negative public sediment, vaccine scares. Developing guidelines and training materials for health care workers.

Outcome 29 Assessment (OPO)

SO.01.002 Member States maintain high quality surveillance and high coverage OSER Achievement with polio vaccine to maintain polio‐free status leading to global Fully 19 Partially polio eradication. Not‐achieved Not‐reported Total 19 Outcome responsible: Dr Dina Pfeifer General narrative on Outcome achievement: Based on the evidence presented to the Regional Certification Commission, including results from poliovirus surveillance and routine immunization programme in all European Member States, the region remains polio‐free since 2002. Risk assessment is being used as a main tool to facilitate targeted activities to mitigate risks of poliovirus spread following importation. Contribution to public health impact: Sustaining polio free status in the WHO European Region means that over 900 million people leaving in the Region’s 53 Member States do not need to fear contracting endemic poliovirus any more. Moreover, positive synergies exist between polio eradication and general health systems. The eradication of polio has had impact on primary health care systems in many countries improving cooperation among public health institutions, clinicians and laboratories, facilitating linkages between health workers and their communities, and increasing routine immunization coverage. Evt. Examples of outstanding Outcome achievements in one or two countries: • Israel faced with insidious introduction of wild polio virus introduction in highly immunized population with inactivated polio vaccine with no clinical cases. Its environmental surveillance system established 25 years ago served as a successful early warning and provides many lessons learned for the Global Polio Eradication Initiative and end phase of the eradication. Evt. Supportive documentation for Outcome achievement: Reports of the European Regional Certification Commission for Poliomyelitis Eradication http://www.euro.who.int/en/health‐ topics/communicable‐diseases/poliomyelitis/activities/polio‐certification‐activities/european‐regional‐ commission‐for‐the‐certification‐of‐poliomyelitis‐eradication General narrative on deliverable (Output) – To achieve the documented absence of endemic wild poliovirus technical support was provided to MS to ensure capacity to sustain polio‐free status by maintaining high‐quality surveillance and immunization coverage. Additionally, technical support was provided to MS to initiate shifting from OPV to IPV. Links to documentation for deliverables Centralized information system for infectious diseases (CISID): http://data.euro.who.int/CISID/

WHO EpiBrief and WHO EpiData periodical reports: http://www.euro.who.int/en/health‐topics/disease‐ prevention/vaccines‐and‐immunization/data‐and‐statistics/who‐epibrief‐and‐who‐epidata

Reports of the European Regional Certification Commission for Poliomyelitis Eradication http://www.euro.who.int/en/health‐topics/communicable‐diseases/poliomyelitis/activities/polio‐ certification‐activities/european‐regional‐commission‐for‐the‐certification‐of‐poliomyelitis‐eradication

Challenges: Since wild poliovirus continues to circulate outside of the Region, existing immunity gaps in four high risk countries (Bosnia and Herzegovina, Georgia, Romania and Ukraine) and a declining quality of surveillance in a number of Member States pose a risk of polio outbreak in case of wild poliovirus importation Lessons learned: Countries with high vaccination coverage using only IPV may still be vulnerable to wild poliovirus importation and subsequent circulation. Proper risk analysis and risk mitigation measures

56 should be in place to prepare and respond to possible importations and outbreaks. Plans for 2014‐2015: Work is planned with all Member States to sustain polio‐free status, including high quality surveillance and high vaccination coverage with special emphasis on countries of high risk as per country‐specific recommendations of the Regional Certification Commission.

Outcome 30 Assessment (OPO)

SO.01.004 Member States equipped to carry out communicable diseases OSER Achievement surveillance and response, including laboratory, as part of a Fully 13 comprehensive surveillance and health information system Partially 2 Not‐achieved Not‐reported Total 15 Outcome responsible: Dr Caroline Brown General narrative on Outcome achievement: About 45 countries regularly shared influenza surveillance data with WHO and about 30 countries shared influenza viruses with WHO; 16 countries routinely conducted surveillance of severe disease due to influenza. About 33 countries established laboratory capacity to detect emerging respiratory viruses causing severe disease in humans ((Middle East Respiratory Syndrome Coronavirus (MERS‐CoV) and avian influenza A(H7N9)). Within 2 months of the first reported case of MERS‐CoV and A(H7N9), respectively 23 and 33 countries established capacity to confirm cases by laboratory testing. Contribution to public health impact: The timing, spread and severity of two influenza seasons were tracked allowing MS to tailor their national influenza prevention, control and treatment programmes to target groups at risk of severe disease due to influenza. Evt. Examples of outstanding Outcome achievements in one or two countries: • MDA: the National Influenza Centre complies with WHO terms of reference and was formally recognized by WHO Evt. Supportive documentation for Outcome achievement: • The MoH of MDA has received a letter from the RD stating that the National Influenza Centre was formally recognition by WHO; • An article regarding laboratory capacity achievements for MERS‐CoV has been published (see http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20335 ) and an article regarding laboratory capacities for A(H7N9) is in press (see meeting abstract at http://ecdc.europa.eu/en/ESCAIDE/Materials/Documents/ESCAIDE‐2013‐abstract‐ book.pdf#page=80 ) General narrative on deliverable (Output): The status of influenza vaccination policies and uptake in the Region has been established through two Regional surveys; 8 countries have received training in data management and assisted with an influenza risk factor study; advice on improvements to national influenza surveillance systems has been provided to 6 countries; laboratory external quality assessment programs have been provided to 47 countries. Links to documentation for deliverables http://www.euro.who.int/en/health‐topics/communicable‐ diseases/influenzahttp://www.cdc.gov/flu/international/program/eur.htm Challenges: Standardization of sentinel influenza surveillance data from hospitals is needed in order to monitor country and regional level trends in severity of influenza seasons and determine burden of disease. A second challenge is the poor integration of new sentinel systems with existing influenza surveillance systems. Lessons learned: There is a need to improve the capacities of national influenza focal points in monitoring and evaluation of their influenza surveillance systems. Plans for 2014‐2015: Intensive review is needed of the recently established sentinel hospital surveillance in 12 countries. This will require the development of standardized influenza surveillance assessment tools and training of national influenza focal points in their use. This work will be implemented under the PIP Framework partnership contribution implementation plan.

Outcome 31 Assessment (OPO)

SO.01.007 Member States able to detect, assess, respond and cope with major OSER Achievement epidemic and pandemic‐prone diseases in collaboration and partnership Fully 2 with the international community (e.g. influenza, meningitis, yellow fever, Partially hemorrhagic fevers, plague and smallpox) with effective prevention, Not‐achieved detection, surveillance, preparedness and intervention tools, Not‐reported Total 2 methodologies, practices, networks and partnerships. Outcome responsible: Dr Caroline Brown General narrative on Outcome achievement: 6 MS have updated their pandemic plans (4 are published). 33 countries established laboratory capacity to detect emerging respiratory viruses causing severe disease in humans ((Middle East Respiratory Syndrome Coronavirus (MERS‐CoV) and avian influenza A(H7N9)). Contribution to public health impact: Using the newly established laboratory capacity, 29 countries reported to WHO to have tested 523 suspected cases of MERS‐CoV in pilgrims returning from the Hajj in 2013. No cases were confirmed. This contributed to the global risk assessment that MERS‐CoV has so far not spread beyond the Arabian peninsula. Evt. Examples of outstanding Outcome achievements in one or two countries: • TJK is the only NIS country that has revised its’ national pandemic plan since the 2009 pandemic Evt. Supportive documentation for Outcome achievement: An article regarding laboratory capacity achievements for MERS‐CoV has been published (see http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20335 ) and an article regarding laboratory capacities for A(H7N9) is in press (see meeting abstract at http://ecdc.europa.eu/en/ESCAIDE/Materials/Documents/ESCAIDE‐2013‐abstract‐book.pdf#page=80 ) General narrative on deliverable (Output): 23 MS participated in a workshop on pandemic preparedness in 2012 and 40 MS participated in a joint workshop with ECDC on pandemic and generic preparedness in 2013; 47 MS continue to provide weekly influenza surveillance data to EuroFlu; The UNK pandemic plan is considered an example of good practice in strategic planning in line with the updated WHO pandemic influenza risk management guidance. Links to supportive documentation for deliverables Workshop on pandemic preparedness for countries of eastern and southeastern Europe, Israel and Switzerland, 5–7 December 2012 http://www.euro.who.int/en/health‐topics/communicable‐ diseases/influenza/publications/2013/workshop‐on‐pandemic‐preparedness‐for‐countries‐of‐eastern‐and‐ southeastern‐europe,‐israel‐and‐switzerland,‐57‐december‐2012 European meeting on generic and pandemic preparedness http://www.euro.who.int/en/media‐centre/events/events/2013/11/european‐meeting‐on‐generic‐and‐ pandemic‐preparedness UK Influenza Pandemic Preparedness Strategy 2011 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213717/dh_131040.pdf EuroFlu bulletin http://www.euroflu.org/cgi‐files/bulletin_v2.cgi Challenges: Insufficient political commitment in countries to complete the process of pandemic plan revision taking into account the gaps identified in preparedness. Lessons learned: As it will be difficult for countries to find resources to revise their pandemic plans, the focus of the work will be to improve critical components of pandemic preparedness at the operational level (outbreak response, routine surveillance, etc). Plans for 2014‐2015: Publish the revised WHO/Europe‐ECDC pandemic guidance. Focus on operational

59 aspects of pandemic preparedness by providing training and guidance for outbreak response and conducting exercises. Start implementation of the PIP Framework partnership contribution implementation plan in 4 priority countries.

Outcome 32 Assessment (OPO)

SO.01.009 Member States and the international community implement effective OSER Achievement and timely responses to declared emergency situations due to epidemic Fully 1 and pandemic prone diseases. Partially Not‐achieved Not‐reported Total 1 Outcome responsible: Dr Jukka Tapani Pukkila General narrative on Outcome achievement: During the biennium 2012‐13, member states in the WHO European Region handled over 700 public health events that came to WHO’s attention. 90 of these events had at least some potential to become public health events of international concern, and in all these events the affected member states consulted WHO through IHR or technical networks in order to manage these events.

Contribution to public health impact: Outbreaks were detected, investigated and controlled by the member states during the 2012‐13, and none of them developed into actual public health emergencies of international concern (PHEIC), as defined by IHR. In doing this, the member states cooperated with each other, WHO and other key partners, especially ECDC. Five member states in the WHO European region contributed significantly to understanding of the new MERS‐CoV outbreak.

Evt. Examples of outstanding Outcome achievements in one or two countries: • SERBIA: Serbia detected and responded effectively to a Q‐fever outbreak in Vojvodina province in February 2012, with support from WHO/Europe, as requested by Serbia. This work was published as an investigation report in EuroSurveillance in April 2012 • UNITED KINGDOM: The first MERS‐CoV infection in Europe was reported to WHO (ARO/EURO) on 22 Sep 2012 by the UNK. Since then, UNK has significantly and continuously contributed to MERS‐ CoV investigations and to development diagnostic and treatment procedures for this new disease, and provided reference laboratory services under WHO umbrella to other member states. Evt. Supportive documentation for Outcome achievement: EuroSurveillance article on Q‐fever outbreak in Serbia published on 12 April 2013 at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20143. By mistake, the ARO contributor Dennis Faix was not included among the authors, even though he contributed substantially to the outbreak investigation and documentation. General narrative on deliverable (Output): In 2012‐13, over 700 PH events recorded and analysed by ARO, and 90 events entered into EMS, leading in most cases to communication with the affected MSs. Technical support was always provided as required and requested (guidance docs, expert consultations and field missions). MERS‐CoV in EURO MSs generated much work. Outbreaks were detected, investigated and controlled by ARO EURO with other TUs. EURO contributed much to understanding of the MERS‐CoV outbreak. Outside EMRO, cases were detected/ managed only in EURO member states. It is not clear of MERS‐CoV cases did not occur at all in the other four WHO Regions (AFRO, AMRO, SEARO and WPRO), or if the member states in these regions were just unable to detect possible sporadic imported cases. Links to supportive documentation for deliverables IHR meetings in EURO http://www.euro.who.int/en/health‐topics/emergencies/international‐health‐ regulations/activities/past‐meetings ; WHO RRA manual for acute public health events (English http://www.who.int/csr/resources/publications/HSE_GAR_ARO_2012_1/en/index.html and in Russian http://www.who.int/csr/resources/publications/HSE_GAR_ARO_2012_1/ru/index.html

61 http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317136270914

Challenges: The human resources in ARO/EURO in 2012‐13 (3 P staff) have been just sufficient to allow for field work. However, ARO is losing the US secondee in Feb 2014, and no replacement has been identified‐

Lessons learned: Cooperation with Technical Units both in EURO and in HQ, and with key partners (especially ECDC and DG SANCO) is essential to ensure successful response to PH events of potential international concern caused by any hazard.

Plans for 2014‐2015: ARO will continue managing PH events of potential international concern caused by any hazard with other TUs and partners. It is crucial to ensure sufficient human and financial resources under Category 5 OCR programme area.

Outcome 33 Assessment (OPO)

SO.01.003 Member States possess policies, increased technical capacity and OSER Achievement effective collaboration to control and prevent neglected, tropical and Fully 4 zoonotic diseases Partially Not‐achieved Not‐reported Total 4 Outcome responsible: Dr Mikhail Nicolaevich Ejov General narrative on Outcome achievement: To assist Member States in reducing the risks of re‐emergence of vector‐borne infectious diseases, the WHO Regional Office for Europe has developed a Regional Framework for Surveillance and Control of Invasive Mosquito Vectors and Re‐emerging Vector‐borne Diseases 2014–2020.

Furthermore, these risks are addressed in Protecting Health in an Environment Challenged by Climate Change: European Regional Framework for Action and the “Commitment to act” of the Fifth Ministerial Conference on Environment and Health.

WHO/Europe supports MSs in their efforts towards surveillance and control of invasive mosquitoes species and re‐emerging vector‐borne diseases; control of leishmaniasis; control and prevention of soil‐transmitted helminthiases, and promotion of the use of sustainable vector‐control alternatives to persistent insecticides based on the principles of integrated vector management, by providing strategic guidance and technical assistance, building capacity, strengthening operational research, promoting cross‐border cooperation (involving WHO/Europe and the WHO Regional Office for the Eastern Mediterranean) and enhancing intersectoral collaboration. It supports the development and scaling up of strategies and partnerships to achieve these goals at the regional and national levels

Contribution to public health impact: By reducing the burden of vector‐borne and parasitic diseases, and eliminating them where feasible, WHO/Europe seeks to contribute to the achievement of the Millennium Development Goals and specifically Goal nr. 6. Furthermore, this work supports the implementation of World Health Assembly resolutions WHA54.19, WHA55.17 and WHA60.13 on the prevention and control of soil‐transmitted helminthiases, dengue and leishmaniasis. It also directly conrtibutes to the implementation of the International Health Regulations by strengthening surveillance and response capacity for some important epidemic‐prone and vector borne diseases such as dengue, Chikungunya, West Nile fever, malaria and CCHF. Evt. Examples of outstanding Outcome achievements in one or two countries: • GEO: operational research leishmaniasis was conducted, and the national programme to control leishmaniasis was revised to address the present situation and existing challenges and problems • TJK: national‐wide assessment of the STH situation and associated problems was conducted, the national programme to control and prevent was developed and a national preventive campaigns were carried out Evt. Supportive documentation for Outcome achievement: www.euro.who.int/en/health‐topics/communicable‐diseases/vector‐borne‐and‐parasitic‐diseases

General narrative on deliverable (Output): To assist Member States in reducing the risks of re‐emergence of vector‐borne infectious diseases, the WHO Regional Office for Europe has developed a Regional Framework for Surveillance and Control of Invasive Mosquito Vectors and Re‐emerging Vector‐borne Diseases 2014–2020.

The requested technical assistance to countries has been delivered by WHO/Europe in collaboration with NTD HQ . The joint EMCA/WHO guidelines for the control of invasive mosquitoes and associated vector‐ borne diseases on the European continent are also finalized and published. A draft of strategic framework to control and prevent STH in the Region is being developed, and national‐wise assessment of STH situations and problems has conducted in several countries.

Links to supportive documentation for deliverables 1. http://www.euro.who.int/en/health‐topics/communicable‐diseases/vector‐borne‐and‐parasitic‐ diseases/publications/2014/strategic‐framework‐for‐leishmaniasis‐control‐in‐the‐who‐european‐ region‐20142020 2. http://www.euro.who.int/en/health‐topics/communicable‐diseases/vector‐borne‐and‐parasitic‐ diseases/publications/2013/regional‐framework‐for‐surveillance‐and‐control‐of‐invasive‐mosquito‐ vectors‐and‐re‐emerging‐vector‐borne‐diseases,‐20142020 3. http://emca‐online.eu/documents/visitors/EMCA_guidelines_Speyer_2011.pdf

Challenges: New vector‐borne diseases are emerging in the WHO European Region and diseases considered to have been eliminated are returning. Population movement, rapid urbanization, ecological, climatic and environmental changes, the deterioration of political and socioeconomic situations, and the interruption of action to prevent and control transmission are central to this renewed public health problem.

The incidence and distribution of vector‐borne diseases such as leishmaniasis, Crimean‐Congo haemorrhagic fever, tick‐borne encephalitis, West Nile fever, Lyme disease and imported Chagas disease are significantly increasing in the Region.

The recent outbreaks or autochtonous cases of dengue and chikungunya in countries where these diseases had not occurred before, signal the potential threats associated with travel and trade, their potential economic impact, notably on tourism, and their possible association with environmental and climatic changes.

Lessons learned: It is essential to raise awareness on the problem and provide advice and technical assistance to public health authorities in order to strengthen prevention, preparedness and control activities.

The WHO Regional Office for Europe works in partnership with other institutions and agencies Such as the European Commission, the European Centre for Disease Prevention and Control and the European Mosquito Control Association to anticipate potential risks from the introduction of invasive mosquitoes and re‐emergence of vector‐borne diseases, particularly at the animal‐human‐ecosystem interface.

Plans for 2014‐2015 WHO Regional Office for Europe is pursuing an active role in reducing the risks of re‐emergence of vector‐ borne infectious diseases, and will continue to provide assistance in the following areas: • anticipation of risks:

• international Health Regulations • Sharing of methods • partnerships

Outcome 34 Assessment (OPO)

SO.02.002 Member States progress towards optimizing HIV, STIs and viral OSER Achievement hepatitis (B&C) prevention, diagnosis, treatment and care outcomes Fully 15 and progress towards building strong and sustainable systems for HIV, Partially STIs viral hepatitis prevention and control Not‐achieved 3 Not‐reported Total 18 Outcome responsible: Mr Martin Christopher Donoghoe General narrative on Outcome achievement: All Member States (to varying degrees) have increased access to HIV prevention and treatment and made limited progress towards building strong and sustainable systems. Building stronger and more sustainable systems for STIs and viral hepatitis presents opportunities for further integrated service provision; particularly for key populations at higher risk. Contribution to public health impact: Although no low‐ and middle‐income Member States achieved 80% coverage for HIV antiretroviral therapy (ART), Regional ART coverage increased from to 23% in 2010 to 35% in 2012 and 62, 000 additional patients in low and middle income‐countries received ART in 2012 (199 000) compared to 2011 (137 000). In Western and Central Europe 560 000 received ART in 2012 and treatment coverage was high. All countries in the WHO European Region continued to offer HIV testing and counselling services, but substantial variations in their availability, accessibility, affordability and quality continued. 14 targeted low‐ and middle‐income countries monitor provider initiated HIV testing and counselling in sexually transmitted infection and family planning services and two reported HIV/AIDS drug resistance surveillance data to WHO.

Evt. Examples of outstanding Outcome achievements in one or two countries: Best practice models from countries in the Region; for example: on expansion of access to HIV testing, treatment and care, particularly for key populations at higher risk (Ukraine); strengthening STI surveillance (Republic of Moldova) and increasing access to hepatitis C treatment for people who inject drugs (United Kingdom) were assessed, evidenced and shared in efforts to improve coverage, programmes and policies. Evt. Supportive documentation for Outcome achievement:

HIV/AIDS treatment and care in Ukraine (2013) http://www.euro.who.int/en/health‐topics/communicable‐diseases/hivaids/publications/2013/hivaids‐treatment‐ and‐care‐in‐ukraine

Strengthening of STI surveillance in the Republic of Moldova (2013) http://www.euro.who.int/__data/assets/pdf_file/0011/195482/Moldova‐STI‐surveillance‐report.pdf

Barriers and facilitators to hepatitis C treatment for people who inject drugs (2012) http://www.euro.who.int/en/health‐topics/communicable‐diseases/hivaids/publications/2012/barriers‐and‐ facilitators‐to‐hepatitis‐c‐treatment‐for‐people‐who‐inject‐drugs.‐a‐qualitative‐study

General narrative on deliverable (Output): HIV surveillance, evaluation and monitoring conducted and reported and hepatitis B and C infections prevalence estimated and reported for all Member States. HIV and/or STI treatment evaluation missions and national programme reviews conducted in AZE, GRE, KAZ, KGZ, MDA, RUS, TJK, UKR and UZB. Implementation of EAP supported by Secretariat through technical guidance and support. WHO EURO made major contribution to the development of Global consolidated

66 guidance for ART 2013 and to the related global treatment progress report 2013.

Links to supportive documentation for deliverables

HIV/AIDS surveillance in Europe reports 2011 and 2012 (jointly with ECDC) http://www.euro.who.int/en/health‐topics/communicable‐diseases/hivaids/publications/2013/hivaids‐surveillance‐in‐ europe‐2012

Prevalence and estimation of hepatitis B and C infections in the WHO European Region (2013) http://journals.cambridge.org/download.php?file=%2FHYG%2FS0950268813000940a.pdf&code=3b4854e2e942e2e94 579326df0a7aa58

2011 Progress report: HIV/AIDS in Europe and central Asia UNAIDS and WHO (2012) http://www.unaids.ru/sites/default/files/eca_regional_report_on_ua_to_hiv_programsl.pdf

Joint technical mission: HIV in Greece (with ECDC) 2012 http://ecdc.europa.eu/en/publications/Publications/hiv‐joint‐technical%20mission‐HIV‐in‐Greece.pdf

Patient evaluation and antiretroviral treatment for adults and adolescents (protocol revision 2012) http://www.who.int/hiv/pub/guidelines/9789241501972/en/index.html

Prevention of HIV transmission from HIV‐infected mothers to their infants (protocol revision 2012) http://www.euro.who.int/en/health‐topics/communicable‐diseases/hivaids/publications/2012/hivaids‐treatment‐ and‐care.‐clinical‐protocols‐for‐the‐who‐european‐region.‐2012‐revisions/2012‐revision‐protocol‐10.‐prevention‐of‐ hiv‐transmission‐from‐hiv‐infected‐mothers‐to‐their‐infants

HIV treatment and care for children (protocol revision 2012) http://www.euro.who.int/en/health‐ topics/communicable‐diseases/hivaids/publications/2012/hivaids‐treatment‐and‐care.‐clinical‐protocols‐for‐the‐who‐ european‐region.‐2012‐revisions/2012‐revision‐protocol‐11.‐hiv‐treatment‐and‐care‐for‐children

WHO Guidance on couples HIV testing and counselling ‐ recommendations for a public health approach (contribution) 2012 http://www.who.int/hiv/pub/guidelines/9789241501972/en/index.html

Coverage estimates of services for people who inject drugs in WHO European Region (2012) http://www.euro.who.int/__data/assets/pdf_file/0010/183970/Harm‐Reduction‐coverage‐estimates‐WHO‐European‐ Region‐final.pdf

WHO regional technical consultation on the use of antiretroviral drugs (Istanbul 2013) http://www.euro.who.int/en/health‐topics/communicable‐diseases/hivaids/news/news/2013/11/who‐regional‐ technical‐consultation‐on‐the‐use‐of‐antiretroviral‐drugs‐arvs Draft unpublished report available at: Q:\PUBLIC\HSV Reports 2012‐13\WHO_CG consultation_Istanbul_4Dec2013Laz (IER) 23 Jan

Challenges: Coverage of HIV treatment and other services increased and is accelerating in most eastern Europe and central Asian countries; however data analysed and published in 2012‐13 suggests that the response remained insufficient as treatment is not keeping pace with new infections and those most vulnerable to HIV, STIs and viral hepatitis face structural barriers to accessing services.

Lessons learned: Efforts to address structural barriers and strengthen health systems through integrated services, good governance and an intersectoral approach have resulted in treatment and prevention gains across the Region.

Plans for 2014‐2015: Treatment and prevention will be further scaled up to achieve 80% coverage for HIV antiretroviral therapy (ART); to reduce the burden of HIV and viral hepatitis co‐infection and progress towards elimination of mother to child transmission of HIV and congenital syphilis. Implementation of the European Action Plan and progress towards optimizing HIV, STIs and viral hepatitis (B&C) prevention, diagnosis, treatment and care outcomes (universal access) will be reported back to the Regional committee at its sixty‐fourth and sixty‐sixth sessions in 2014 and 2016.

Outcome 35 Assessment (OPO)

SO.02.005 Member States reduce vulnerability and structural barriers to OSER Achievement accessing HIV, STIs viral hepatitis and other essential services Fully 2 Partially (including through addressing social determinants of health) Not‐achieved 1 Not‐reported Total 3 Outcome responsible: Mr Martin Christopher Donoghoe

General narrative on Outcome achievement: The majority of Member States have progressed in reducing vulnerability; for example through explicitly addressing or reflecting human rights in national AIDS strategies and consulting and involving civil society in formulating HIV and viral hepatitis policy and decision‐making.

Contribution to public health impact: There is evidence from some countries that have reduced vulnerability and acted to address structural barriers on the rate of new infections. Modelling illustrates the potential impact on HIV incidence and prevalence in other countries.

Evt. Examples of outstanding Outcome achievements in one or two countries: WHO reviewed and accessed: the accessibility of HIV treatment for people who inject drugs (PWID) in Estonia; tuberculosis related services needs and accessibility of HIV/TB integrated service provision for PWID in Portugal and the accessibility of hepatitis C treatment for PWID in the United Kingdom. Each study identified structural barriers and environmental risk factors.

Evt. Supportive documentation for Outcome achievement: Social contexts of access to treatment and care for HIV, hepatitis C and tuberculosis among people who inject drugs in European cities (2012) http://www.euro.who.int/__data/assets/pdf_file/0018/183231/Scaling‐up‐ access‐to‐high‐quality‐harm‐reduction,‐treatment‐and‐care‐for‐injecting‐drug‐users‐in‐the‐European‐Region‐ final.pdf

General narrative on deliverable (Output) WHO and the World Bank have identified and assessed vulnerability to HIV and structural barriers to key vulnerable populations accessing HIV (and to a lesser extent viral hepatitis and other) services for all 53 Member States.

Links to supportive documentation for deliverables HIV epidemics in the European Region: Vulnerability and Response (jointly with the World Bank and the

London School of Hygiene and Tropical Medicine) 2013

HIV/AIDS stigma and discrimination in the health care sector in Belarus (2013) http://www.euro.who.int/en/health‐topics/communicable‐diseases/hivaids/news/news/2013/10/hivaids‐stigma‐ and‐discrimination‐in‐the‐health‐care‐sector‐in‐belarus

Jolley E, Rhodes T, Platt L, Hope V, Latypov A, Donoghoe M & Wilson D (2012) HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy BMJ Open. http://bmjopen.bmj.com/content/2/5/e001465.full

Challenges: Key challenges are the laws and regulations that are obstacles to an effective response; stigma and discrimination and relative weakness of community systems in some countries.

Lessons learned: WHO has identified structural barriers to accessing HIV, STIs viral hepatitis and other essential services (including through addressing social determinants of health) but has only limited, but increasing, influence outside the health sector. Strong partnership with civil society and state actors is essential to the response.

Plans for 2014‐2015 To further promote and support implementation of the European Action Plan on HIV/AIDS 2012‐2015 with increased focus and prioritisation on interventions that reduce vulnerability and reduce structural barriers for key populations at highest risk (in particular people who inject drugs) under the supportive framework of Health 2020.

Outcome 36 Assessment (OPO)

SO.02.005 Member States through national and international partnership OSER Achievement adopted the measures to identify and address determinants of TB Fully 13 and improved collaborative TB/HIV activities Partially Not‐achieved Not‐reported Total 13 Outcome responsible: Dr Pierpaolo de Colombani General narrative on Outcome achievement: Member States are revising their policies in documenting TB determinants and more concretely addressing TB risk factors, including childhood, urban residence, imprisonment, HIV infection, alcohol abuse. This under the context of the annual meetings of the National TB Programme Managers in The Hague in 2012 and 2013. Examples can be taken from Bulgaria and Belarus, where TB determinants were included in the national anti‐TB drug resistance surveillance; the Republic of Moldova, who revised the national guidelines on TB in adults (including TB/HIV) and in children; Estonia, where a specific framework was developed for a newly established collaboration between TB and alcohol services. Contribution to public health impact: Specific target populations have improved their access to early diagnosis and complete treatment of TB and MDR‐TB Evt. Examples of outstanding Outcome achievements in one or two countries: • Estonia – A framework for collaboration between TB, alcohol and social services was developed and tested in Estonia; these integrated services are now listed under the national insurance scheme Evt. Supportive documentation for Outcome achievement: Collaborative action on tuberculosis and alcohol abuse in Estonia: first report of a demonstration project (http://www.euro.who.int/__data/assets/pdf_file/0006/237516/WHO‐AUD‐TB‐project‐report_10‐ final‐edited‐with‐PCO_5Dec‐2013_NS_kujundatud_koos_TjaK_2.pdf). Multidrug resistant tuberculosis in Belarus: the size of the problem and associated risks factors (http://www.who.int/bulletin/volumes/91/1/12‐104588/en/index.html) General narrative on deliverable (Output): Minimum package for cross border TB control published. Main TB determinants included in country drug resistance surveys, country operational research and regional task force established. TB/HIV technical assistance provided in countries and regional clinical protocol published. Imprisonment and migration discussed during annual meetings Links to supportive documentation for deliverables Minimum package for cross‐border TB control and care in the WHO European Region (http://erj.ersjournals.com/cgi/pmidlookup?view=long&pmid=22653772) 2013 Revision – Protocol 4. Management of tuberculosis and HIV coinfection (http://www.euro.who.int/__data/assets/pdf_file/0004/218515/Management‐of‐tuberculosis‐and‐HIV‐ coinfection‐Eng.pdf Challenges: The implementation of cross border TB control has political sensitivities and requires intercountry funding; best practices in addressing social determinants of TB have limited documentation Lessons learned: Consistency in technical assistance and follow up were keys for success at both regional and country levels; important is taking the advantage of the commitment that Member States took in implementing the Regional Plan to Prevent and Combat M/XDR‐TB 2011‐2015 and the renewed collaboration between WHO programmes under the Health 2020 corporate efforts Plans for 2014‐2015: Same outcome is included in 2014‐2015 to ensure consistency with the Regional Plan

71 to Prevent and Combat M/XDR‐TB 2011‐2015 and the Health 2020 framework. A regional working group with other partners has been established in June 2013 to document interventions addressing TB social determinants; there is a concrete negotiation with the Global Fund to support cross border TB control and care in CAR; it is expected that cross border communication related to TB cases will improve in future under the current agreement of collaboration between WHO and the European Respiratory Society

Outcome 37 Assessment (OPO)

SO.02.003 Member States provided equitable and universal access to quality OSER Achievement assured laboratory diagnosis and quality medicines for treatment Fully 6 of TB Partially Not‐achieved 1 Not‐reported Total 7 Outcome responsible: Dr Masoud Dara General narrative on Outcome achievement: Access to treatment is reaching the universal coverage of notified MDR‐TB patients. Rapid Molecular diagnosis is being introduced across the Region. Contribution to public health impact: With rapid diagnosis and full treatment coverage of notified MDR‐ TB patients, transmission cycle will be broken and TB and MDR‐TB burden will decrease.

Evt. Examples of outstanding Outcome achievements in two countries: • Introduction of bedaquiline in Armenia sets a new era in TB treatment. • New diagnostic algorithm with including of the new diagnostics tools decreased significantly the diagnostic delay in Moldova Evt. Supportive documentation for Outcome achievement: Compendium of Best Practices in drug resistant tuberculosis, WHO 2013 http://www.euro.who.int/__data/assets/pdf_file/0020/216650/Best‐practices‐in‐prevention,control‐ and‐care‐for‐drugresistant‐tuberculosis‐Eng.pdf

General narrative on deliverable (Output): European Laboratory Initiative established. Countries receive TA support on lab and medicines with GDF support and close collaboration of TBM at DCE and HTP at DSP. Three regional workshops on pharmaceutical and laboratory conducted. Links to supportive documentation for deliverables Launch of European tuberculosis laboratory initiative: http://www.euro.who.int/en/health‐ topics/communicable‐diseases/tuberculosis/activities/european‐tuberculosis‐laboratory‐initiative Challenges: Access to all second line medicines for full treatment is still not available in some member states. Delay in getting a GDF Europe focal point in EURO has delayed our support to MSs on drug management. Lessons learned: Dutch Secondment of Laboratory scientist has proved as a successful element of addressing the laboratory needs for TB and AMR. Decentralization of GLC to Europe as the first region with GLC has been a success to increased access to treatment. Plans for 2014‐2015: Recruiting TB laboratory and drug management at EURO, intensifying country capacity building on lab diagnosis, drug management and pharmacovigilance.

Outcome 38 Assessment (OPO)

SO.02.004 Member States monitor progress in TB prevention and control and OSER Achievement use surveillance data for improving TB services Fully 7 Partially Not‐achieved Not‐reported Total 7 Outcome responsible: Dr Masoud Dara General narrative on Outcome achievement: 44 Member States have significantly improved their surveillance as indicated by timeliness and quality of their recording and reporting. Electronic surveillance is being introduced and scaled up. Contribution to public health impact: TB data permitted to prioritize interventions to achieve a wider TB care coverage and equity, including vulnerable and at high risks groups and monitor progress in addressing drug‐resistant TB with the support from national and international partners Evt. Examples of outstanding Outcome achievements in two countries: • Tajikistan monitors progress in TB prevention and control and uses surveillance data for improving TB services • Belarus – achieved full reporting and recording coverage of the detection, treatment enrolment and outcomes monitoring. • M&E framework of the national M/XDR‐TB Action Plans developed in Azerbaijan. Evt. Supportive documentation for Outcome achievement:

Epidemiology of tuberculosis in WHO European Region and public health response. Dara M, Dadu A, Kremer K, Zaleskis R, Kluge HH. 2013. Eur Spine J 22 Suppl 4:549‐455 (http://link.springer.com/article/10.1007%2Fs00586‐012‐2339‐3/fulltext.html) General narrative on deliverable (Output): Monitoring framework for Berlin declaration and MDR‐TB Action was developed. Data was collected, analysed and published annually. New case definitions piloted, surveillance meetings organized in collaboration with ECDC. Links to documentation for deliverables Tuberculosis surveillance and monitoring in Europe 2013, (http://www.euro.who.int/__data/assets/pdf_file/0004/185800/Tuberculosis‐surveillance‐and‐ monitoring‐in‐Europe‐2013.pdf)

Challenges: Surveillance on second line drug resistance in the Eastern‐ and treatment outcome monitoring in the Western‐ European countries remain challenges due to inadequate capacity. High turnover of country staff requires continued technical support in using data for decision making. Lessons learned: Inter‐country and partners collaboration is important to avoid duplication of efforts mechanism and help strengthen the surveillance and M&E country systems. Established group of inter‐ country surveillance consultants has increased the visibility and credibility of the Secretariat. Building local capacity is a cornerstone in transparency and continuity of TB surveillance. Plans for 2014‐2015: Detailed analysis of trends and determinants of MDR‐TB. Continuous monitoring of the implementation of the Regional M/XDR‐TB Action Plan and the Berlin Declaration . Regional and country specific capacity building activities.

Outcome 39 Assessment (OPO)

SO2.001 Member States certify malaria elimination through normative and OSER Achievement technical guidance and engage in this process Fully 2 Partially Not‐achieved Not‐reported Total 2 Outcome responsible: Dr Mikhail Nicolaevich Ejov General narrative on Outcome achievement: Kazakhstan was acknowledged by WHO as a malaria‐free country and Kyrgyzstan has requested the DG WHO to initiate the certification process Contribution to public health impact: Certification of malaria elimination is the international recognition that the country became free from malaria, and the countries in question could become more attractive from economic investments and developing tourism Evt. Examples of outstanding Outcome achievements in one or two countries: • KAZ: the country was acknowledged by WHO as the malaria‐free one • KGZ: the country has initiated the process of certification Evt. Supportive documentation for Outcome achievement: HQ and regional publications, (www.euro.who.int/en/health‐topics/communicable‐diseases/vector‐borne‐and‐parasitic‐diseases)

General narrative on deliverable (Output) The regional framework on prevention of malaria re‐ introduction and certification of malaria elimination is being finalized, and will be published in early 2014. The necessary strategic guidance and technical assistance on prevention of malaria reintroduction were provided to countries in need. The eligible countries were supported technically and financially to initiate and complete the certification process.

Links to supportive documentation for deliverables Regional framework, HQ and regional publications, mission and technical reports, scientific publications (www.euro.who.int/en/health‐topics/communicable‐ diseases/vector‐borne‐and‐parasitic‐diseases)

ChallengesThe transmission of malaria has been interrupted in almost all formerly malaria‐affected countries of the Region, and countries in question have moved into the phase of prevention of malaria reintroduction. There is a need to assist them in maintaining a malaria‐free status and in certification of malaria elimination. Lessons learned: The resumption of malaria transmission in areas/countries which were free from malaria has been reported in recent years, and the necessary assistance has been provided by WHO/Europe to contain introduced cases and localized outbreaks Plans for 2014‐2015: To continue assisting eligible countries in maintaining malaria‐free status and certification of malaria elimination, if requested

Outcome 40 Assessment(OPO)

SO.03.001 Member States develop and implement best practices based on OSER Achievement international good evidence and innovative services in mental Fully 3 health. Partially Not‐achieved Not‐reported Total 3 Outcomeresponsible: Dr Matthijs Frederik Muijen General narrative on Outcome achievement: Practice was improved by identifying problems in quality of service delivery, ability to evaluate outcome and involvement of patients and families. WHO supported the development and implementation of expertise in these areas.

Contribution to public health impact: Ability of primary care to diagnose and treat people with mental health problems improves their functioning and productivity and prevents admission. Indicators of quality care will allow assessment of impact of service reform on health and wellbeing. Involvement of patients and families in assessing service quality and outcomes is a component of the evaluation cycle, demonstrating empowerment.

Evt. Examples of outstanding Outcome achievements in one or two countries: • BIH has improved the effectiveness of its community mental health teams by involving users and families in planning and monitoring, disseminating the experience around SE Europe through the Regional Mental Health Development Centre.

Evt. Supportive documentation for Outcome achievement: N:\DNP\MNH\4.Country_networks\SEE\RHDC\RHDC‐ACTION PLAN DRAFT_ BIH‐WHO report 25th Sept 2013.doc N:\DNP\MNH\4.Country_networks\SEE\Newsletters\Newsletter Issue 2_RHDCMNH_Final.pdf

General narrative on deliverable (Output) 1) In order to back up the European MNH Action Plan,6 expert technical papers on relevant mental health issues have been drafted and are currently in the process of external review. Subjects include awareness by using web based technologies, and provide examples of good practice. They will be a good guidance / reference points for policy makers, MoH and MNH specialists. 2) TKM mental health service assessment requested by MOH contributed to awareness raising and is a good foundation for future strengthening of mental health services in TKM. Links to supportive documentation for deliverables ..\0.MNH_ overviews_briefings\Strategy\BackgroundPapers for Action Plan\Final‐041113\EDIT Preventing depression_20131015.docx Draft experts papers are available upon request.

Challenges: It proved difficult to gain acceptance for an assessment report in a country that was reluctant to accept any criticism of its services and human rights record. Changes at the MOH also caused a lack of organization memory, hindering the establishment of agreed partnerships. Implementation in a network of countries was difficult because level of representation was too low.

Lessons learned: Messages need to be carefully geared towards the willingness and ability of countries both to accept them politically and implement them technically. Success was achieved when strengths as perceived by the country were used as a starting point, rather than imposing external models. Limited

76 gain starting from a limited national model is better than a failed attempt to replicate international best practice.

Plans for 2014‐2015: Use the SEE mental health network for implementation across countries, agreeing a work plan based on the European Mental Health Action Plan using local expertise, models and motivation. Involving leaders from these countries, bringing on board technical focal points. Producing technical papers that will increase awareness, also developing web based technology on the mental health programme.

Outcome 41 Assessment(OPO)

SO.03.002 Member States implement activities to improve the quality of life OSER Achievement and social inclusion of children with Intellectual Disabilities (ID) and Fully 3 their families. Partially 1 Not‐achieved Not‐reported Total 4 Outcome responsible: Dr Matt Muijen General narrative on Outcome achievement: Needs of people with intellectual disabilities have been assessed, and services developed according to the declaration ‘better health, better lives’. Social inclusion has been encouraged by the closure or reduction in size of large institutions and the establishment of small residential homes. Family support has been assessed, and recommendations made about community services that offer incentives for strengthening the capacity of family support, reducing demand for institutionalization. Contribution to public health impact: This outcome improves quality of life and social integration and reduces mortality of people with intellectual disabilities by offering living in community settings and providing health care, equal to that of the general population and proportionate to needs. Evt. Examples of outstanding Outcome achievements in one or two countries: • TUR has improved quality of life of children with intellectual disabilities by shifting them from large institutions back to families or placing them in small residential homes, offering opportunities for community integration according to need and potential. This was initiated by an institutional assessment of needs and quality of care, inspiring the Turkish Ministry to change policy and set up small scale services. It has been strongly supported technically in addressing ID, co‐funded by TUR and the EU. These ‘Houses of hope’have in turn been evaluated, and have demonstrated significantly improved quality of life and opportunities for their residents. Good practice from around Europe has been used for education and dissemination, culminating in an international conference. Experiences and materials are being used as a good example across the Region specifically for Moldova and CAR countries. Evt. Supportive documentation for Outcome achievement: Need assessments of institutions and houses of hope, training modules and conference procedures available from mental health programme. N:\DNP\MNH\3.Country Work\Turkey\Turkey 2013\021013 Report on Assesment of Houses of Hope.doc General narrative on deliverable (Output) 1) Report on achieved progress and need assessments available for Turkey and Moldova. 2) Seminars held in Turkey and Moldova. Links to supportive documentation for deliverables N:\DNP\MNH\3.Country Work\Turkey\Turkey 2013\021013 Report on Assesment of Houses of Hope.doc

Challenges: The main challenge for both WHO and country was the instability of staffing at the Ministries, resulting in changes of policy and delayed decision making. The country struggled because of a shortage of competent health staff for the large number of new services. An additional challenge for WHO was the increased expectation of the Ministry of Health, beyond the original objectives. WHO had difficulties implementing due to the short time tables required for increasingly complex and large scale training programmes. Lessons learned: The evaluation cycle, starting with a need assessment that produced a new strategy, implementation and again evaluation proved very effective. International expertise in consultation with the member State inspired confidence in our competence. Direct training was less effective due to a combination of language and capacity issues, and was replaced by a train the trainer model with leading

78 universities. Plans for 2014‐2015: Activities related to Intellectual disabilities (under Euro Regionaloutcome 40: Member States offer good care systems to improve the health and social inclusion of people with intellectual disabilities throughout the lifespan) will be linked to Global Outcome 2.2. Increased access to services for MNH & substance use disorders (Global Output 2.2.2 Mental health promotion, prevention, treatment and recovery services improved through advocacy, better guidance and tools on integrated mental health services). We will implement large scale training and disseminate the technology across the Region. In other countries we will support deinstitutionalization strategies and establishment of small scale homes, and train staff.

Outcome 42 Assessment (OPO)

SO.03.001 Member States increase capacities and resources to address the OSER Achievement burden of violence and injuries Fully 5 Partially Not‐achieved Not‐reported Total 5 Outcome responsible: Dr Dinesh Sethi General narrative on Outcome achievement: MS having increases capacities and resources to address the burden of injuries and violence during 2012‐2013. This is evidenced by nore countries having a budget and focal point to work in the area and a greater number of health professionals trained

Contribution to public health impact: Increased capacities of health systems to work in a multisectoral way and greater policy priority being given to these areas with increasing number of MS developing national policies and programming. There has been a reduction in the burden of injuries in the Region.

Evt. Examples of outstanding Outcome achievements in one or two countries: • EST: government task force on injury prevention established and unit with budget focusing on injury prevention • UZB: 6000 doctors have received trained using TEACH‐VIP Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/health‐ topics/disease‐prevention/violence‐and‐injuries/news/news/2013/04/decade‐of‐action‐and‐road‐safety‐ platform‐launched‐in‐turkey

General narrative on deliverable (Output): 1. Activities linked to the Decade of Action for Road Safety with technical support provided to countries for developing national road safety policy and advocating for higher priority. Policy workshops based on the results of the global status report survey held in CZH, MKD, LTU, ALB, KGZ, RUS, TUR, TJK, KAZ with advocacy for pedestrian road safety week 2. National policy dialogues to develop policy for child injury prevention held in BLR and EST 3) Capacity building workshops held for SEE and European health ministry focal points for injury surveillance and for SEE and Baltics for adverse childhood experiences prevention and alcohol and violence prevention. Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/disease‐prevention/violence‐and‐ injuries/news/news/2013/10/injury‐prevention‐spotlighted‐in‐tajikistan Challenges: Mobilising resources have been a major issue as well as mobilising the health sector; the latter is being overcome by building capacity.

Lessons learned: Building capacity is critical

Plans for 2014‐2015: Child injury prevention is linked to deliverable 2.3.2. Continue to invest in capacity and to advocate for prevention

Outcome 43 Assessment (OPO)

SO.03.006 Member States improve and offer care and rehabilitation for injured OSER Achievement and disabled people proportionately to need Fully 1 Partially Not‐achieved Not‐reported Total 1 Outcome responsible: Dr Dinesh Sethi General narrative on Outcome achievement: Countries have been encouraged to use evidence informed trauma and rehabilitation care through the dissemination of reports. It has been reported that the reports have been valuable in changing practice in Tajikistan and Macedonia.

Contribution to public health impact: Increased capacity and advocacy for equitable access to and provision of care and rehabilitation for injured and disabled people will lead to improved well‐being for the concerned and contribute to health and productivity in the society.

Evt. Examples of outstanding Outcome achievements in one or two countries:

TJK: improved rehabilitation services for victims of polio and disability services. Uptake of trauma services guide. Capacity‐building activities for government rehabilitation centres working with children and adults with disabilities have also begun. Since October 2013, WHO has supplied the rehabilitation centres with an internationally trained physiotherapist and started on‐the‐job capacity building for the staff (doctors, nurses and therapists). National workshops on rehabilitation management for various disabling conditions took place in December 2013. In addition, WHO has started a situation analysis on physical rehabilitation and mobility devices in Tajikistan. The Ministry of Health prepared a position paper on better health for people with disabilities, which covers a six‐year period and was launched on the International Day of Persons with Disabilities, 3 December 2013 Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/health‐topics/disease‐prevention/violence‐and‐ injuries/news/news/2013/11/better‐services‐for‐people‐with‐disabilities‐in‐tajikistan

General narrative on deliverable (Output): 1) Reports on improving trauma care and rehabilitation disseminated. 2) Training workshops held using TEACH‐VIP curriculum with an emphasis on improved equity and access to trauma care held in AZB, BLR, UZB, TJK, KAZ. 3) Assessments of disability conducted in MKD, TJK. 4) Advocacy for disability with the launch of the World report on disability‐ workshops with policy dialogues held in several countries including ITA, MKD, ALB, MDA, UNK, SWE 5) Regional consultation held for global action plan on disability. Contribution to global action plan on disability for next WHA.

MKD: survey of disability conducted and policy dialogue held.

Links to supportive documentation for deliverables http://www.who.int/disabilities/actionplan/en/

Challenges: There was a shortage of resources.

Lessons learned: Focus on equity should continue

Plans for 2014‐2015: This will be linked to deliverable 2.4.1 next biennium.

Outcome 44 Assessment (OPO)

SO.03.004 Member States progressively adopt and adapt evidence‐ OSER Achievement based interventions for primary and secondary prevention of Fully 6 NCDs within their primary health care systems Partially Not‐achieved Not‐reported Total 6 Outcome responsible: Ms Frederiek Mantingh General narrative on Outcome achievement: Member States have progressively adopt and adapt evidence‐based interventions for primary and secondary prevention of NCDs within their primary health care systems through capacity building, assessments, and implementation of guidelines, protocols and risk assessment tools.

Contribution to public health impact: In the area of cardiometabolic risk assessment and management, evidence shows that early identification and modification of cardio‐metabolic risk factors is an effective intervention to prevent the development of hyperglycemia, type 2 diabetes mellitus, hypertension and hyperlipidemia. Emphasis should be placed on overall assessment of a number of risk factors, rather than on a strategy aimed at a single disease or single risk factor. This important public health intervention is at the core of the Package of Essential NCD interventions for primary health care which was implemented in several countries. In the area of cancer‐control the focus of the work was on early detection. Where resources and health systems are limited, and where the majority of the cancers amenable to early detection are diagnosed in late stages, the establishment of an early diagnosis programme may be the most feasible strategy to reduce the proportion of patients presenting with late stage cancer (“downstaging”) and to improve survival rates. Therefore, the early detection of cancer programmes were being strengthened in the member states.

Evt. Examples of outstanding Outcome achievements in one or two countries: Tajikistan has implemented the assessment on health system strengthening for NCDs and also started implementation of the recommendations through identification of core technologies and medicines, implementation of risk prediction tools, and improving the protocols required for implementation of set of essential NCD interventions.

Evt. Supportive documentation for Outcome achievement: The assessment guide will be published early 2014. The specific results of Tajikistan have not been published. For more general overview or achievements in NCD please see progress report of implementation of the European NCD Action Plan which includes primary and secondary prevention of NCDs. Prevention and control of noncommunicable diseases in the European Region: a progress report. WHO Regional Office for Europe. 2013. http://www.euro.who.int/en/health‐topics/noncommunicable‐ diseases/cancer/publications/2013/prevention‐and‐control‐of‐noncommunicable‐diseases‐in‐the‐ european‐region‐a‐progress‐report

General narrative on deliverable (Output): Action research projects with a view of documenting the effects of interventions are being implemented through the joined project with the Division of Health Systems. In this project country assessments of health system challenges and opportunities for better NCD outcomes are

83 implemented in Turkey, Tajikistan, Hungary, Republic of Moldova, and Kyrgyzstan. The assessment guide and country reports will be published early 2014.

In addition, evidence based interventions for primary and secondary prevention of NCDs have been implemented through workshops on implementing the Package of Essential NCD interventions for primary health care in Tajikistan and Uzbekistan.

An intercountry meeting was organized on the contribution of strengthening primary care for the prevention and control of NCDs, and a sub‐regional meeting was organized on strengthening public health services for improved NCD prevention and control.

Links to supportive documentation for deliverables: The assessment guide on health system challenges and opportunities for better NCD outcomes and the related country reports will be published early 2014.

Package of essential noncommunicable disease interventions for primary health care in low‐ resource settings: http://www.who.int/cardiovascular_diseases/publications/pen2010/en/

Challenges: Due to the high amount of actions in countries, some countries choose to give other action areas priority, or merge deliverables. Therefore in some countries the NCD part of the BCA was not (fully) delivered. A challenge at the secretariat to deliver the Outputs is the low amount of human resources which led to less focussed and in depth support than we would wish for.

Lessons learned: It is good to organize intensive support to a country. When in a country multiple areas are being assessed at the same time, as was done through the project on health system for NCD assessments, changes are more receptive to sustain. Also, this leads to clear results and shows the impact WHO can have in a country.

Plans for 2014‐2015: Work in this area will be continued through EURO Outcome 9, Output 2.1.1 on the adoption , implementation and evaluation of a priority list of evidence‐based actions for prevention and control for NCDs consistent with the Global and European NCD Action Plans, and EURO Outcome 41, Output 2.1.1 on the development and implementation of European regional guidance for cardio‐metabolic risk assessment and management. In the coming biennium a new group of countries will be chosen for intensive assessment of health system challenges in line with the work implemented past biennium. A few countries in this group will remain the same, as it is also important to intensive support the implementation of the recommendations coming out of an assessment.

Outcome 45 Assessment (OPO)

SO.03.004 Member States develop and progressively implement European OSER Achievement Regional Guidance for cardio‐metabolic risk assessment and Fully 3 management Partially Not‐achieved 1 Not‐reported Total 4 Outcome responsible: Ms Frederiek Mantingh General narrative on Outcome achievement: Several member States have developed and progressively implement guidance for cardiometabolic risk assessment and management. The capacity of member states to develop and implement guidance was strengthened through for example training on the Package of Essential NCD interventions for primary care which includes risk prediction charts and standard protocols, or assessments of the health systems for NCDs followed by recommendations.

Contribution to public health impact: Evidence shows that early identification and modification of cardio‐metabolic risk factors is an effective intervention to prevent the development of hyperglycemia, type 2 diabetes mellitus, hypertension and hyperlipidemia. Emphasis should be placed on overall assessment of a number of risk factors, rather than on a strategy aimed at a single disease or single risk factor.

Evt. Examples of outstanding Outcome achievements in one or two countries: Ukraine has strengthened their national NCD plan by working on the plan intensively with support of WHO. The plan is adopted during the biennium and implementation has started. Activities of the plan related to cardiometabolic risk assessment are raising public awareness, assessment for cardiometabolic determinants using Coronary Risk Prediction Charts, and recommendations to patients. After the successful adoption of the NCD plan, work has started on a plan in the area of salt, a major risk factor for cardiovascular diseases. Also this plan is highly valued by the nationals.

Evt. Supportive documentation for Outcome achievement: The plans of Ukraine have not been published and are not public accessible, but can be received through the technical programme or country office. News item on the way of working can be viewed at: http://www.euro.who.int/en/countries/ukraine/sections/news/2012/08/new‐hands‐on‐approach‐to‐ policy‐making‐ukraine‐develops‐national‐plan‐at‐whoeurope.

For a more general overview of achievements in this area: Prevention and control of noncommunicable diseases in the European Region: a progress report. WHO Regional Office for Europe. 2013. http://www.euro.who.int/en/health‐topics/noncommunicable‐ diseases/cancer/publications/2013/prevention‐and‐control‐of‐noncommunicable‐diseases‐in‐the‐ european‐region‐a‐progress‐report

General narrative on deliverable (Output) In January 2012, the WHO organized a regional meeting on strengthening primary care contribution to the prevention and control of NCDs. At this meeting a European review of guidance on cardiometabolic risk assessment was presented and several tools were discussed. In June 2012, a policy dialogue on public health services strengthening for improved NCD prevention and control was organized for the CIS

85 countries. During this meeting, countries presented their case studies and best practices.

Links to supportive documentation on deliverables Report of the meeting on strengthening primary care contribution to the prevention and control of NCDs and related documents are accessible through: http://www.euro.who.int/en/health‐topics/Health‐ systems/primary‐health‐care/publications/2012/who‐regional‐office‐for‐europe‐meeting‐on‐ strengthening‐primary‐care‐contribution‐to‐the‐prevention‐and‐control‐of‐non‐communicable‐diseases

Summary of the meeting on strengthening public health services for improved NCD prevention and control is accessible through: http://www.euro.who.int/en/health‐topics/noncommunicable‐ diseases/sections/news/2012/7/newly‐independent‐states‐aim‐to‐reduce‐noncommunicable‐diseases. Meeting report can be shared through technical unit.

Challenges: The challenge was to meet the requests of the countries while the post of technical officer cardiovascular diseases and diabetes was vacant. Therefore, the regional office had limited technical capacity to support member states and was dependent on consultants and collaborating centres.

Lessons learned: The Package of Essential NCD interventions for primary health care, a product developed by Headquarters, is highly valued by the member states that have implemented it. And even though the target group for the package is low‐resource countries, we have learned through the biennium that also high resource countries could highly benefit from the materials of the package.

Plans for 2014‐2015: Work in this area will be continued through EURO Outcome 9, Output 2.1.1 on the adoption , implementation and evaluation of a priority list of evidence‐based actions for prevention and control for NCDs consistent with the Global and European NCD Action Plans, and EURO Outcome 41, Output 2.1.1 on the development and implementation of European regional guidance for cardio‐metabolic risk assessment and management. The post of technical officer on cardiovascular diseases and diabetes is foreseen to be fulfilled during 2014 to strengthen the capacity of the regional office. One of the tasks of this technical officer is the alignment of the Package of Essential NCD interventions to European high‐resource settings.

Outcome 46 Assessment (OPO)

SO.03.004 Member States develop and implement national cancer control OSER Achievement programmes with an emphasis on the early detection of breast, Fully 7 cervical and colorectal cancers developed Partially Not‐achieved 5 Not‐reported Total 12 Outcome responsible: Ms Frederiek Mantingh General narrative on Outcome achievement: Member States have developed and implemented national cancer control programmes with an emphasis on early detection through assessment missions and implementation of the recommendations, intensive consultant missions, and national workshops. Contribution to public health impact: Where resources and health systems are limited, and where the majority of the cancers amenable to early detection are diagnosed in late stages, the establishment of an early diagnosis programme may be the most feasible strategy to reduce the proportion of patients presenting with late stage cancer (“downstaging”) and to improve survival rates. Improved survival rates leads to lower premature mortality.

Evt. Examples of outstanding Outcome achievements in one or two countries: Kazakhstan has reviewed the national policy and programme documents related to cervical cancer screening and has reviewed the organization of the national screening programme for cervical cancer and its key components. Recommendations to Ministry of Health were provided in the area of quality management of screening and the roles of each level of the health system. It is expected that the improved cervical cancer screening programme will decrease mortality from cervical cancer, will decrease the number of cervical cancer detected in advanced stages, and will decrease the incidence of cancer and increase detection of pe‐cancerous lesions and provide them with optimal treatment.

Evt. Supportive documentation for Outcome achievement: The report of the assessment and recommendations is not published but can be received through the Technical Unit or the Country Office.

For a more general overview on progress in counties in the area of early detection of cancer: Prevention and control of noncommunicable diseases in the European Region: a progress report. WHO Regional Office for Europe. 2013. http://www.euro.who.int/en/health‐topics/noncommunicable‐ diseases/cancer/publications/2013/prevention‐and‐control‐of‐noncommunicable‐diseases‐in‐the‐ european‐region‐a‐progress‐report

General narrative on deliverable (Output) The European review of guidance is being postponed awaiting international agreement regarding the controversies around the early detection of breast cancer and agreement on guidance taking into account the new technologies for the early detection of cervical cancer. While the guidance is pending, WHO has supported assessment (and follow‐up) missions as part of the collaboration with the International Atomic Energy Agency. The following countries were supported through this programme: Armenia, Montenegro, Republic of Moldova, Romania, and Tajikistan. In addition, WHO supported the preparation of a palliative care plan in Ukraine, the Walking the Cure event in Turkey, a conference on the role of primary care in cancer prevention in Latvia, and assessments in collaboration with IARC and a consultant in respectively Belarus and Kazakhstan.

Links to supportive documentation for deliverables The reports of the assessment missions as part of the collaboration with the International Atomic Energy Agency (the imPACT missions) are not published. However, the reports and the recommendations per letter to the Minister, can be received through the Technical Unit and Country Offices.

Summaries of the activities can be viewed through news items at: http://www.euro.who.int/en/countries/turkey/news/news/2012/11/turkey‐on‐the‐move‐to‐reduce‐ breast‐cancer; http://cancer.iaea.org/impact.asp

Challenges: The challenge was to meet the requests of the countries while the post of technical officer cancer was vacant. Therefore, the regional office had limited technical capacity to support member states and was dependent on consultants and partners.

Lessons learned: For the first time, follow‐up missions to imPACT missions in collaboration with the International Atomic Energy Agency were organized. This was a pilot project for the European Region developed by both agencies. These follow‐up missions supported the selected countries intensively with implementation of 1 or 2 recommendations of the imPACT assessment missions. The selected countries highly valued this approach, and it is important to continue with this initiative to show results and inspire other regions.

Plans for 2014‐2015: Work in this area will be continued through EURO Outcome 9, Output 2.1.1 on development of national multisectoral policies and plans, and 2.1.2 on including NCDs in development agendas. The post of technical officer on cancer is foreseen to be fulfilled during 2014 to strengthen the capacity of the regional office. One of the tasks of this technical officer is the collaboration with the International Atomic Energy Agency on the imPACT missions and follow‐up of the recommendations of the assessments. Also, it is important to prepare regional guidance taking into account the international movement.

Outcome 47 Assessment (OPO)

SO.04.006 Member States competent in developing, implementing and monitoring OSER Achievement adolescent health programmes using a whole‐of‐society perspective Fully 5 Partially 1 Not‐achieved 1 Not‐reported Total 7 Outcome responsible: Mrs Vivian Birgitte Barnekow General narrative on Outcome achievement: Member states have linked their adolescent health policy analysis and development to the general CAH strategy development (see outcome 11 (KPO). Four countries have had a focus on adolescent health (ARM, KGZ, TJK, UZB)

Contribution to public health impact: The use of Health Behaviour in School‐aged Children survey data to develop whole‐of‐society approaches is increasing, as the data is being used for evidence based CAH policy development to improve the health and well‐being of children and adolescents .

Evt. Examples of outstanding Outcome achievements in one or two countries: • Moldova has done an assessment of its school health services which has lead to a re‐orientation of the curriculum for school nurses as well as to providing in service training to school professionals having served in the field for several years. A set of case studies showing the implementation of the re‐oriented school health services have been developed. The model is expected to be used in several other countries in the coming biennium, if technical capacity is available

• Latvia has conducted the Health Behaviour in School‐aged Children survey for several cycles, and in this biennium MoH requested that data was used to analyse health and well‐being for children as well as to inform development of comprehensive CAH policy.

Evt. Supportive documentation for Outcome achievement: 4th Health promoting School conference website: http://schools4health.dk/

General narrative on deliverable (Output) European assessment of the quality and resources of school health services has led to the development of a set of proposed standards for these services and suggested competences for school health professional.

Schools for Health in Europe network,. Tailored capacity building has been provided to members from the Eastern part of the Region. WHO was co‐sponsoring the 4th International conference on Health Promoting Schools – equity, education and health where the latest research on HPS effectiveness was presented. Links to supportive documentation for deliverables http://www.who.int/maternal_child_adolescent/news_events/news/2012/lancet_adolescent_health/en/in dex.html

Challenges: There was an over‐planning mainly due to expectation of successful resource mobilization – however adolescent health seems not to be attractive to donors. Further, the technical officer for adolescent health was laterally transferred to HQ mid‐2012, so the proposed achievements were only partly reached.

Lessons learned: The successful parts are described above. In some cases it was possible to make use of NPOs from more developed countries in ADH for those countries that were starting out, but with the growing portfolio of NPOs in countries this is a source which cannot be used frequently. Plans for 2014‐2015: Adolescent health will mainly be addressed though the renewed CAH strategy.

Main focus will continue to be on school health services with support from WHO CC. A growing number of countries are requesting support for revising their school health services.

Collaboration with Schools for Health in Europe will continue.

The Health Behaviour in School‐aged Children survey is also included in category 3 work for the coming biennium (presently covered in SO 3.) The next survey cycle will be finished in summer 2014, and the next international report is planned for autumn 2015.

Outcome 48 Assessment (OPO)

SO.04.005 Member states equipped to implement evidence‐based OSER Achievement interventions for child health and development Fully 4 Partially Not‐achieved Not‐reported Total 4 Outcome responsible: Dr Aigul Kuttumuratova General narrative on Outcome achievement: MSs (ALB, MDA and UZB) are equipped to implement evidence‐based interventions for child health and development (guidelines updated, new child health protocols developed, national policies update has been informed by evidence from several assessments using WHO tools (quality of paediatric hospital care, Child rights in hospitals, existing supervision system)

Contribution to public health impact: Introduction of updated guidelines, assessments of quality of primary and hospital care and rights in child services also from the family prospective have contributed to developing national actions plans, improved quality of care, review of national CAH strategies, upgraded family and community participation

Evt. Examples of outstanding Outcome achievements in one or two countries: • Uzbekistan– Based on the WHO technical consultation and review of the current supervision of MCH services, the national policy for integrated supportive supervisory system developed and package of the tools drafted. • Moldova: Based on the results of paediatric hospital care assessment the country is equipped to develop an evidence‐based action plan. Set of recommendations for improving policy framework related to CH have been informed by situation analysis of existing supervision in CH services on agreement with key stakeholders.

Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/countries/republic‐of‐moldova/news/news/2012/09/republic‐of‐moldova‐ improves‐supervisory‐system‐in‐mother‐and‐child‐health‐care Assessment reports on paediatric hospital care, child rights in hospitals and supportive supervision in child health services available in CAH program http://www.euro.who.int/en/countries/uzbekistan/areas‐of‐work/maternal‐and‐child‐health Technical reports on supportive supervision, policy document and tools on supportive supervision in MCH services available in CAH program General narrative on deliverable (Output): Technical support provided to 14 countries in evidence‐based review of practices, adaptation and development of guidelines and tools for delivery quality care for children and incorporating child health interventions in health systems approach to meet MDG 4. MDA, TJK and KGZ were supported in assessment of child rights in hospitals.

Kyrgyzstan and Tajikistan‐ Assessment of child rights in 21 paediatric hospitals in both countries conducted using the adapted tools for different stakeholder’s groups. Report with the findings and recommendations with specific actions for improvement developed. Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/Life‐stages/child‐and‐adolescent‐ health/news/news/2014/03/assessment‐of‐childrens‐rights‐in‐the‐hospitals‐of‐tajikistan

Assessment report of child rights in hospitals in English and Russian available in CAH programme and are expected to be published on the WHO web site soon.

Challenges: No major challenges.

Lessons learned: Pulling up additional funds in MDA and UZB has enabled closing the funding gap and full implementation of the workplan. Technical staff presence in the country offices, interdivisional collaboration and strong engagement of national counterparts contributed to enhanced synergy and achievement of the outcome. Plans for 2014‐2015: Integration plans for holistic approaches to improving child health, including pneumonia and diarrhoea control. Work on promoting child rights approach in health services and improving QoC at all levels will be expanded.

Outcome 49 Assessment (OPO)

SO.04.002 Research capacity strengthened in Member States and new evidence OSER Achievement on sexual and reproductive health available Fully 2 Partially Not‐achieved Not‐reported Total 2 Outcome responsible: Dr Gunta Lazdane General narrative on Outcome achievement: In close collaboration with HRP/RHR WHO HQ evaluation of the impact of operational research trainings carried out in the WHO European Region 2008‐2012 was done and discussed during the multi‐country meeting in Kaunas, Lithuania. Recommendations for further assistance to countries of eastern and central Europe in strengthening research capacity in RMNCAH are developed and an article submitted for publication. Research capacity has been strengthened in 16 countries of eastern and central Europe.

Contribution to public health impact: Outcomes of the operational research carried out in countries are assisting policy makers to take the evidence‐based actions in improving reproductive, maternal, newborn, child and adolescent health. In 2012‐13 focus on WHO supported operations research projects are on improving access and quality of safe abortion in the RF and Kyrgyzstan Final results are expected for 2015. Evt. Examples of outstanding Outcome achievements in one or two countries: • Lithuania: Investment in Human Reproductive Health Research (HRHR) Center in Lithuanian University of Health Sciences has resulted in establishment of a Center and group of experts that are assisting countries of eastern and central Europe in research capacity strengthening.

Evt. Supportive documentation for Outcome achievement: The article: ”Introduction of operational research in reproductive health in Easternand Central Europe: a case report of collaboration between World Health Organization and Lithuanian University of Health Sciences” is in print (http://medicina.kmu.lt/)

The report of the WHO meeting “Capacity building in operational research in reproductive health in countries of Eastern and Central Europe” is being edited and will be available on http://www.euro.who.int/en/health‐topics/Life‐stages/sexual‐and‐reproductive‐ health/activities/operations‐research in January 2014.

General narrative on deliverable (Output): Scientific Research Institute of Obstetrics, Gynecology and Perinatology (SIOGP) of the Ministry of Health in Dushanbe, Tajikistan received WHO assistance in development and submission of the Long‐term Institutional Development grant (LID grant) for research capacity building in reproductive health. SIOGP is the first health institution in the WHO European Region that has received LID grant. Human Reproductive Health Research (HRHR) Center, Lithuanian University of Health Sciences has been involved in implementation of research capacity building in SIOGP and finalization of the research project proposal in maternal and newborn health. Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/Life‐stages/sexual‐and‐reproductive‐ health/activities/operations‐research Challenges: Turn‐over of policy makers in the countries of eastern and central Europe result in lack of interests and support in operational/implementation research studies.

The counterpart in RHR WHO HQ changed several times during the biennium that resulted in difficulties in

93 achieving this OPO including assistance to Tajikistan in LID grant development.

Lessons learned: Limited understanding of implementation research in RMNCAH by policy makers. Better use of innovative approaches and modern technologies for the training workshops and follow up of the projects is necessary. Plans for 2014‐2015: (1) Organization of the meeting for policy makers in explaining the importance of implementation research in improving RMNCAH. (2) Developing the web training module in operations research in RMNCAH.

Outcome 50 Assessment (OPO)

SO.04.007 Member States have adapted and implemented tools for accelerating OSER Achievement progress in achieving universal access to sexual and reproductive Fully 5 health Partially Not‐achieved Not‐reported Total 5 Outcome responsible: Dr Gunta Lazdane General narrative on Outcome achievement: Skills and knowledge in family planning and provision of safe abortion services of the primary health care providers improved regionally and in particular in Kyrgyzstan, Republic of Moldova, Tajikistan and Ukraine. MS have adapted and adopted WHO guidelines.

Contribution to public health impact: Improving of prevention and management of unintended pregnancies, maternal and perinatal health, elimination of sexual violence against women has resulted in progress in decreasing maternal and perinatal morbidity and mortality in the Region. The rate of abortion per 1000 births in the European Region has decreased from 2000 to 2011 for a half. Maternal deaths per 100000 live births have decreased from 19.06 in 2000 to 11.53 in 2011, perinatal deaths per 1000 births – from 12.11 in 2000 to 10.11 in 2011. In some countries mortality rate has increased due to better reporting. Evt. Examples of outstanding Outcome achievements in one or two countries: • Decreasing of unsafe abortion rate and maternal morbidity due to unsafe abortion in Ukraine and in the Republic of Moldova. • Improvement of family planning in Kyrgyzstan due to comprehensive approach from strategic assessment, integration of quality family planning services in primary health care, improvement of health literacy of youth and improvement of quality of antenatal and postpartum care.

Evt. Supportive documentation for Outcome achievement: Impact of implementation of the tools in improving sexual and reproductive health regionally and in countries (including Ukraine, Kyrgyzstan and others) is published in 5 issues of the European Magazine for Sexual and Reproductive Health “Entre Nous” http://www.euro.who.int/en/health‐topics/Life‐stages/sexual‐and‐ reproductive‐health/publications published by WHO/Europe and UNFPA RO EECA. General narrative on deliverable (Output): Assisting countries in capacity building of the health care providers in delivering high quality family planning and safe abortion services, in developing the scaling up strategies and sustainability of initiatives. Links to documentation for deliverables Success stories and analysis of barriers are published in the European Magazine for Sexual and Reproductive Health “Entre Nous” http://www.euro.who.int/en/health‐topics/Life‐stages/sexual‐and‐ reproductive‐health/publications – 5 issues of “Entre Nous” in English and Russian in 2012‐13.

Challenges: Sexual health despite being an important part of human well‐being is often neglected in many countries due to sensitive character and traditions. Lessons learned: Collaboration with other sectors and human rights approach is to be strengthened in improving sexual and reproductive health in the WHO European Region. Violation of human rights including reproductive rights especially of vulnerable groups has resulted in increase of ill‐health in these population groups. Plans for 2014‐2015: To ensure joint efforts of programmes in assisting countries in understanding of importance of decreasing inequalities in sexual and reproductive health, human rights principles and inter‐ sectorial collaboration.

Outcome 51 Assessment (OPO)

SO.05.007 In times of acute and chronic crises, response and recovery actions (incl. OSER Achievement health cluster coordination) mobilized and integrated into the multi‐ Fully 4 sector emergency response strategies of affected MS Partially Not‐achieved Not‐reported Total 4 Outcome responsible: Dr Gerald Rockenschaub General narrative on Outcome achievement: During the biennium two humanitarian health coordination mechanisms were active and coordinated by WHO, without formal activation of the humanitarian cluster approach; Tajikistan and southern Turkey (being affected by refugees displaced by the crisis in the Syrian Arab Republic). In southern Turkey a field presence was established in October 2013 with two technical teams supporting the health response in Turkey and working with NGO partners on health information management and coordinating humanitarian health action. WHO is coordinating humanitarian health interventions with health partners, monitoring the health of Syrians refugees in camps and in urban settings, supporting the response to the polio outbreak in Syria and supporting the Ministry of Health and local authorities through information sharing and technical assistance to monitor and control infectious diseases. Post crisis transition activities in Kosovo have been phased out and fully integrated into overall efforts to strengthen the health system capacity in general and the national response capacity to emergencies in particular. A post crisis recovery project was completed and capacity building efforts finalized, engaging health authorities and other sectors like the Ministry of Emergencies. Contribution to public health impact: Through targeted WHO interventions health ministries and NGOs were supported to respond to specific public health aspects in natural disasters and conflicts. Capacity building initiatives supported the establishment of standardized communicable disease surveillance and early warning mechanisms, to strengthen emergency medical services systems and joint trainings, exercises and drills with the Ministries of Emergencies and other sectors helped to test and improve multi‐ sector crisis management systems. With health being more prominent and better represented within the multi‐sector response strategies the health response to future emergencies will be more effective. Evt. Examples of outstanding Outcome achievements in one or two countries: • Turkey: In close collaboration with the MoH and AFAD the health of Syrians living temporarily in Turkey is well monitored and health service provision is well organized by national authorities for the displaced Syrians and the host population despite the massive burden that the increasing number of Syrians fleeing the crisis is placing on the national health care system. • Tajikistan: Since almost a decade WHO is organizing joint capacity building with the MoH and the Ministry of Emergency Situations, which are now well connected and undertake joint response activities during earthquake or flood events. The emergency medical services system, including the system of first responders was strengthened and mass casualty trainings took place in all the regions where the medical and logistical capacities of both ministries were effectively joined. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐response/country‐ work/tajikistan http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐response/country‐ work/turkey http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐response/country‐ work/serbia/kosovo‐in‐accordance‐with‐security‐council‐resolution‐1244‐1999

General narrative on deliverable (Output): In Turkey WHO is coordinating in close collaboration with the

MoH the activities of NGOs to monitor medical services to Syrians and to avoid duplication and gaps in health care. Regular joint monitoring missions of WHO together with national health authorities were conducted engaging UN partners to document and ensure that Syrians as well as the host population continue to receive high quality services . WHO has organized trainings, provided technical advice and mobilized supplies to monitor and control infectious diseases, particularly to contain the recent polio outbreak in Syria and to avoid its spread into Turkey. National vaccination campaigns were supported.

In Tajikistan WHO projects to strengthen emergency medical services and mass casualty management were finalized which enabled the MoH and the Ministry of Emergency Situations to more effectively cope with emergencies; joint trainings and exercises were conducted and lead to the development of joint action plans and more effective use of available logistics.

In Kosovo a project on emergency medical services systems strengthened the multisecoral cooperation through training, technical advice and supply of medical equipment to MoH and to emergency services.

Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐ topics/emergencies/disaster‐preparedness‐and‐response/news/news/2012/12/united‐nations‐mission‐ visits‐camps‐for‐syrian‐people‐in‐turkey The reports of the projects in TJK and KOS are not on the web. Challenges: WHO’s coordination activities to support NGO partners to improve health conditions in opposition –held parts of northern Syria have to be negotiated on a case by case basis, requiring extensive negotiations with a variety of stakeholders and partners. WHO is not directly involved in cross border activities in northern Syria but monitors the public health situation through information sharing band analysis in collaboration with a variety of health partners.

Lessons learned: Response and recovery actions should be backed up by bi‐or multilateral developmental efforts and agreements to develop sustainable national plans to strengthen health system emergency preparedness. Plans for 2014‐2015: To further train and strengthen WHO staff and staff from partners through jointly organized surge trainings to expand the regional expert roster as surge for future crisis response operations as laid out in the Emergency Response Framework ERF and to improve the response capacity for infectious disease outbreaks and to strengthen the health care services for Syrians living in southern Turkey. In TJK and KOS to continue with capacity building in MoH and between MoH and Ministries of Emergencies and Interior and other key partners in emergency response and recovery.

The planned GDO for preparedness for humanitarian and health emergencies in Turkey will strengthen the Regional Office’s capacity to assist Member States in prevention, preparedness, risk management and capacity‐building for humanitarian and health emergencies and support mobilizing surge capacity for future response operations.

Outcome 52 Assessment (OPO)

SO.05.001 MS are better equipped to establish effective partnership mechanisms OSER Achievement for collaboration and capacity development in health emergency and Fully 9 disaster risk management Partially Not‐achieved Not‐reported Total 9 Outcome responsible: Dr Gerald Rockenschaub General narrative on Outcome achievement: MS are now better equipped to prepare, update and implement mechanisms for collaboration and capacity development with particular focus on public health events including public health emergencies during high visibility mass gatherings. WHO informed and provided MS with lessons learned and legacy for planning and implementation of public health activities during high‐level mass gathering events. As result, WHO was advising MoHs how to set up special surveillance systems, collect and analyse specific data, prepare health facilities and provide health promotion and advice to the travellers, guests and host population. According to the national situation and requirements the receiving countries implemented it and were well prepared for emergencies. No major outbreaks our mass casualty events happened during these mass gathering events. Contribution to public health impact: A well prepared health system is better able to manage outbreaks or other forms of emergencies during mass gathering events without jeopardizing the health care needs of the host population and to keep improved public health systems available for their population after the event (legacy). Legacy includes improved surveillance systems, updated laboratory capacities, expansion of emergency medicines through new equipment and training of personnel, which has happened in all the countries under the BCA. Evt. Examples of outstanding Outcome achievements in one or two countries: • UEFA EURO‐2012 football tournament, where WHO was present to actively support the MoH of Poland and Ukraine before and during the tournament and where legacy of the event contributed to an improved public health system in both countries. As a result the surveillance system of both countries was harmonized, laboratory capacities modernized and expanded and new equipment was introduced to health facilities designated for the tournament. Health decision makers attended public health trainings organized by WHO. • Azerbaijan was hosting the Eurovision song contest in 2012 and requested support from WHO, which led also to improved public health capacities and a new request was issued from the MoH to WHO to assist in the preparation for the Athletic Games in 2015, where an assessment mission by WHO experts was undertaken in Oct 2013. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐ response/news/news/2012/02/2012‐uefa‐european‐football‐championship‐health‐advice http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐ response/publications/2012/frequently‐asked‐questions‐faq‐euro‐2012 http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐ response/news/news/2011/10/who‐supports‐public‐health‐preparedness‐for‐euro‐2012‐in‐poland‐and‐ ukraine

General narrative on deliverable (Output): MS were provided with recommendations, through comprehensive health system assessments, on how to improve their generic health system crisis management capacities with particular emphasis on the management of mass gathering events. Health

98 promotion recommendations and health advise to travellers, visitors and to the host population were provided to the host countries and distributed widely through travel agencies. Public health legacy was documented and analysed. Training on managing public health and emergency management was provided to 75 health care decision makers of 18 MS. Key hospitals and mass gathering designated hospitals were assessed regarding their resilience to disasters. The hospital checklist for emergencies was applied to strengthen capacities in those hospitals.

Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐ response/publications/2010/assessment‐of‐health‐systems‐crisis‐preparedness‐poland http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐ response/publications/2010/assessment‐of‐health‐systems‐crisis‐preparedness‐ukraine http://www.euro.who.int/en/health‐topics/emergencies/disaster‐preparedness‐and‐ response/publications/2011/hospital‐emergency‐response‐checklist

Challenges: MoHs require enhanced capacities to ensure sustainable implementation of the recommendations and to translate them into changing policies towards more effective cooperation and coordination with other sectors, for example the Ministries of Emergencies, Civil Defence and other stakeholders.

Lessons learned: To further reinforce surge capacity development Ministries of Health should enhance efforts to strengthen multi‐sectorial cooperation in emergency risk management and preparedness planning and to adopt good practice and lessons learnt from other countries. The Ministries of Emergencies and civil defence are in many countries important partners for a closer collaboration; WHO has in that context organized several joint trainings, which provided in several countries an opportunity for further strengthening the collaboration between MoHs and Ministries of Emergencies. Plans for 2014‐2015: The cooperation between MoH and Ministry of Emergencies should be further strengthened through joint actions like trainings and drills and the integration into preparedness and response activities. The regional network has been established and is further expanding, partnering countries with fewer resources with countries with ample experience and expertise to facilitate sharing of good practice and development of interoperable emergency plans.

Outcome 53 Assessment (OPO)

SO.06.006 Gender responsive evidence‐based policies and interventions OSER Achievement promoting safer sex and tackling the social and individual Fully 1 consequences of unsafe sex adapted and implemented Partially Not‐achieved Not‐reported Total 1 Outcome responsible: Dr Gunta Lazdane General narrative on Outcome achievement: Guidance for Implementation of the Standards for Sexuality Education in Europe” (2013) and Standards for Sexuality Education in Europe (2010) triggered development and revision of sexuality education in Estonia, Finland, Germany, Netherlands, Switzerland, Kyrgyzstan, Turkmenistan. It is good example of collaboration of the education and health sectors.

Contribution to public health impact: Increase of knowledge and skills related to sexuality, impact on sexual behavior including decrease of sexual violence, decrease of unintended pregnancies and STIs in countries where sexuality education has been implemented. Evt. Examples of outstanding Outcome achievements in one or two countries: Estonia – increase in condom use and contraception, decrease of abortion, HIV and syphilis rate parallel to development of school based sexuality education and access to youth friendly health services. Germany – increase in condom use and decrease of abortion rate in young people parallel to introduction and improvement of sexuality education.

Evt. Supportive documentation for Outcome achievement: Study “Youth sexuality” carried out in Germany every 4 years has proved the positive health impact of sexuality education http://www.english.forschung.sexualaufklaerung.de/4121.html Experience in Estonia on the role of sexuality education and youth‐friendly services on improvement of youth sexual health published in peer review magazine: Eur J Contr and RHC, 2012; 17; 351‐362 General narrative on deliverable (Output): Guidance on Implementation of Sexuality Education Standards was launched and promoted. “Standards for Sexuality Education in Europe: A framework for policy makers, educational and health authorities and specialists”(Standards) developed by BZgA and WHO/Europe in 2010 are translated and available in 10 languages of the WHO European Region. Overview of the progress of implementation of Standards is monitored. BZgA, WHO Collaborating Centre in Cologne has actively coordinated the process with financial support of the German government. An international expert group involved in the process includes academia, representatives of UN organizations and international NGOs. Links to supportive documentation for deliverables “Guidance on Implementation of Sexuality Education Standards” http://www.bzga‐ whocc.de/?uid=01a65030038feecd775305b3943c39e5&id=home

Challenges: Sexual health and sexuality education are delicate issues and strongly based on personal norms and values. Despite the fact that Sexuality education standards are based on human rights, there is resistance towards holistic and more positive view on sexuality education especially from the more religious groups. In 2013 there have been several requests (mainly from Spain and Poland) to DG and RD to withdraw Standards for Sexuality Education in Europe from the web. The needs of sexuality education for disabled have not been addressed in sexuality education standards. Lessons learned: No funds were allocated for this OPO, but good progress achieved thanks to the collaboration with BZgA, WHO Collaborating Centre in Cologne, Germany.

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Plans for 2014‐2015: Development of a fact sheet on the impact of sexuality education in Europe and “Frequent asked questions” in collaboration with BZgA and the international expert group. Development of web project on sexual health for vulnerable migrants in collaboration with BZgA and IPPF European network.

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Outcome 55 Assessment (OPO)

SO.06.004 Member States have implemented drug dependence treatment OSER Achievement including opioid substitution therapy based on WHO guidance. Fully 6 Partially Not‐achieved 1 Not‐reported Total 7 Outcome responsible: Dr Lars Moller General narrative on Outcome achievement: In the European action plan for HIV 2012‐2015 it is recommended that 40% of all opioid users receive opioid substitution therapy (OST)5. The majority of Member States in western and central Europe provide OST in the treatment of opioid dependence but in the eastern part of the region there are a number of countries where such treatment is not permitted. WHO has facilitated pilot programmes in Kazakhstan, Kyrgyzstan and Uzbekistan during the last 8 years, but progress is slow. However, an increasing number of countries is now supporting the use of OST in prisons. Contribution to public health impact: Injecting drug use is a major risk factor for hepatitis C and HIV in the European region and OST is the most effective treatment for decrease the spread of these diseases. The delay in introducing effective OST treatment is part of the explanation for the slow progress in reducing the incidence of these blood born diseases.

Evt. Examples of outstanding Outcome achievements in one or two countries: Kazakhstan, Serbia and Republic of Moldova are in the process of expanding and improving the OST treatment service and EURO is continuing providing guidance for this positive development. Evt. Supportive documentation for Outcome achievement: The Secretariat has collected information on substance use treatment an information system has been established with the data collected, see summary: http://www.who.int/substance_abuse/activities/msbatlasexecsum.pdf

General narrative on deliverable (Output): The Regional Office has only got limited resources for giving guidance on drug dependence in 2012/2013 and is focused on giving guidance for Member States requesting assistance. Five Member States received guidance during the period.

Links to supportive documentation for deliverables Resources for the prevention and treatment of substance use disorders http://www.who.int/gho/substance_abuse/en/index.html

Challenges: There are a number of Member States without offering OST to drug dependent opioid users and there is a continued need to collect evidence and to give guidance on how to establish effective systems for OST. Only two countries asked for guidance on drug dependence treatment in 2012/2013 and in Ukraine there were not allocated any funds for the activities and the task had to be sunset.

Lessons learned: The Regional Office has limited resources on substance abuse treatment and focus has been on alcohol treatment. It is an important area and still injecting drug is an important risk factor for the high incidence of Hepatitis C and HIV. Member States in the EU is assisted by the European Monitoring

5 (http://www.euro.who.int/__data/assets/pdf_file/0011/153875/e95953.pdf)

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Centre on Drugs and Drug Dependence and a number of countries outside the EU is provided with assistance by the Council of Europe and UNODC. Still there is a need for WHO to assist in the harm reduction and OST.

Plans for 2014‐2015: Only a few Member States have asked for assistance in 2014‐2015 and all activities will be focused on assisting Member States. Through HQ EURO will collect information to update the ATLAS database on drug dependence and treatment.

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Outcome 56 Assessment (OPO)

SO.06.004 Member States have implemented comprehensive health OSER Achievement interventions within their prison system. Fully 4 Partially Not‐achieved Not‐reported Total 4 Outcome responsible: Dr Lars Moller General narrative on Outcome achievement: There has been little direct country work initiated by WHO (see examples below). However, countries have been directly involved in the publication of a joint WHO‐UNODC recommendation for a transfer and the integration of prison health services from the jurisdiction of prison authorities into the jurisdiction of health ministries (see link below: WHO, UNODC, 2013. Good Governance for Prison Health in the 21st century. A policy brief on the organization of prison health.) Further, best practices in the fields of drugs, mental health and communicable diseases have been exchanged at two network meetings (44 MS compose the network) organized by WHO secretariat in October 2012 and October 2013. Contribution to public health impact: There are two compelling reasons for providing health care in prisons. First, among prisoners, there is a very high prevalence of serious and often life‐threatening conditions Sooner or later most prisoners will return to the community and may carry with them new diseases and untreated conditions. The other reason is society’s commitment to equity and social justice. The mentioned publication on prison health governance, the country examples below, and the mentioned network meetings have the potential to contribute to health systems strengthening, to reduce the burden of health problems in poor communities and to contribute to health equity. Evt. Examples of outstanding Outcome achievements in one or two countries: Serbia: SRB has implemented OST in all prisons. However, there are practical problems that prevent full coverage: a lack of coordination between the MoJ and the MoH and the regionalisation of OST centres that define access to OST. A joint meeting by SRB, WHO, UNODC, Council of Europe in December 2013 has highlighted these issues. A follow up is scheduled for 2014. Kosova: in Kosova the responsibility for the health of prisoners has been legally and practically transferred from MoJ to MoH in summer 2013. This makes Kosova to be one of the first entities in Europe to implement a 2013 joint WHO‐UNODC recommendation. At a meeting in December 2014 in Prishtina, MoH, MoJ, WHO and UNDP have discussed further practical steps of integration of prison health into the jurisdiction of MoH (training for staff, development of protocols and standards). This work will continue in 2014. Financial help is sought from the Swiss Development Agency and WHO is facilitating the respective contacts. Evt. Supportive documentation for Outcome achievement: Kosovo: See health law of Kosovo attached as pdf (approved by Parliament in July 2013: http://www.kuvendikosoves.org/common/docs/ligjet/Law%20on%20Health.pdf General narrative on deliverable (Output) 2012‐2013 output portfolio: 1. Give guidance to MS on prison health issues with focus on illicit drugs, mental health, and communicable diseases 2. Facilitate the role of the public health system to take responsibility of prison health and secure close links to the civil system. 3. Annual meetings with Member States and international partners to exchange best practice 4. Relevant publications on prison health issues including an update of the prison health guide and on prison

104 health stewardship

Guidance to MS: seethe two publications listed below. Additional guidance will be given by the second edition of the WHO prison health guide in May 2014. It has been in the process of edition in 2013. Strengthening of MoH’s role in prison health: This was a central topic in the Kosova and Serbia meetings . The contract with the Collaborating Centre at the UK Department of Health could be extended (2012‐ 2017). As it is the Department of Health that is responsible for prison health in the UK their knowledge is important in order to consult other MS considering a transfer to MoH. Links to supportive documentation for deliverables Good governance for prison health in the 21st century. A policy brief on the organization of prison health (http://www.euro.who.int/__data/assets/pdf_file/0017/231506/Good‐governance‐for‐prison‐health‐in‐ the‐21st‐century.pdf)

Alcohol problems in the criminal justice system: an opportunity for intervention (English and Russian) (http://www.euro.who.int/__data/assets/pdf_file/0006/181068/e96751‐ver‐ 2.pdf) and (http://www.euro.who.int/__data/assets/pdf_file/0007/187081/e96751r.pdf).

Challenges: For the Secretariat: Currently the Secretariat’s staff consists of 80% technical officer, 10% programme management, 30% administrative assistance. The technical officer is seconded by CH. The secondment ends in August 2014. Almost all funding of the programme is covered by CH in 2012‐2014. There are no assessed contributions (regular budget) in the programme. Therefore the continuation of the programme after August 2014 remains very critical. In order to give evidence based support to MS better data is needed on the levels of epidemiology, policy and prison health economy. The challenges are huge here and close collaboration with other international organizations in the field (such as EMCDDA, ECDC, UNODC, CoE, research institutions) is as crucial as funding. For MS: Prison health is for the majority of countries in our region still under the responsibility of the Ministry of Justice or MoI, and it is a challenge to keep the Ministry of Health involved and interested in the area. Lessons learned: The network run by the Secretariat is exclusive an important as a good way of linking the different actors in a country on prison health. Data collection with the limited resources of the Secretariat is only possible with additional funding and close collaboration with other international organizations. There are many other international actors in the field of prison health. Their mandates, roles and responsibilities have to be evaluated in order to sharpen and clarify the profile of the WHO Health in Prisons Programme with its very limited resources. This programme should use synergies, be complementary, and focus on the main public health challenges of prison health. Plans for 2014‐2015: WHO is looking for funds to continue the programme in 2014‐2015 after the funding from the Swiss Government expires in June 2014. In May 2014 a Steering Group meeting will be organized and back to back a launch event for the new prison guide is planned at the premises of the Council of Europe.

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Outcome 57 Assessment (OPO)

SO.06.005 Member States have strengthened the capacity of their health OSER Achievement workforce with a focus in the Primary Health Care sector in the areas Fully 5 of diet and physical activity to deliver evidence based interventions Partially according to the European Charter on Counteracting Obesity, the Food Not‐achieved and Nutrition Policy Action Plan and the Action Plan for the Not‐reported implementation of the European Strategy on Noncommunicable Total 5 Diseases. Outcome responsible: Dr Joao Breda General narrative on Outcome achievement: MS have strengthened the capacity of their health workforce in the field of nutrition notably by enhanced training and curricula development. MS have produced with the secretariat a report on nutrition in primary health care which highlights progress and gaps in health professional’s competencies in the area. This outcome was based on capacity building and on evidence generation in favour of PHC interventions in the field of nutrition. The report focusing on cost effectiveness of nutrition and physical activity related interventions in the PHC setting, together with a contribution to the discussions of the Conference celebrating the 30 years of the Alma‐Ata Declaration and the advice provided to Member States on workforce development in the area of nutrition have contributed to public health impact.

Contribution to public health impact: Improving the health sector capacity in the area of nutrition and PA is linked with relevant health gains. Evt. Examples of outstanding Outcome achievements in one or two countries: Strengthening management of acute malnutrition in Tajikistan. A round of training on integrated management of acute malnutrition was held in Kurgan‐tube, Tajikistan. The 5‐day training workshop for 30 paediatricians from primary health care and paediatric wards of 10 central district hospitals in the Khatlon region was a follow‐up of an earlier 5‐day workshop on treatment challenges and enigmas of severe acute malnutrition. This round of training focused on improving referral systems with active case findings, as well as improving the capacity of health care providers to prevent acute malnutrition, manage cases with moderate and severe acute malnutrition without complications, and prevent relapse through follow‐up care. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/countries/tajikistan/news/news/2013/12/strengthening‐management‐of‐ acute‐malnutrition‐in‐tajikistan

General narrative on deliverable (Output): A report on nutrition and physical activity in PHC was produced. This report was focused on effectiveness of nutrition and physical activity related interventions in the PHC setting. Furthermore a contribution to the discussions of the Conference celebrating the 30 years of the Alma‐Ata Declaration on PHC was made. Advice provided to Member States on workforce development in the area of nutrition and physical activity.

Tajikistan: a project based on the use of mobile phones to promote surveillance of children nutritional status in areas with high prevalence of malnutrition by Primary Health Care staff was developed and will be implemented during the course of next biennium. The initiative reflects collaboration in the country between UN agencies and NGOs. Its major ingredient is innovation in the way support and training is provided to health professionals.

Links to supportive documentation for deliverables Report “Nutrition in primary health care in the WHO European Region” is in its pre‐final format and will be

106 published during the course of 2014.

Challenges: Resources to implement activities under this outcome particularly at country level were scarce but in spite of that a good collaboration between the three levels of the organization: CO, RO and HQ made implementation possible.

Lessons learned: Collaboration between research Institutions, NGOs in the field of nutrition and UN agencies under WHO Regional Office for Europe leadership showed to be a formula for success and high visibility particularly in some countries. The establishment of such joint‐ventures has facilitated overcoming limitations in resources.

Plans for 2014‐2015: Addressing the challenges particularly those related with resource scarcity and taking into account lessons learned notably the need for stronger collaboration with other UN agencies and other partners. Publication of the final report on Nutrition and PA in Primary Care as a WHO product and wide dissemination. Further development of the Tajikistan NUTm‐health Project and exporting it to other Member States.

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Outcome 58 Assessment (OPO)

SO.06.003 Ratification of the WHO FCTC by the remaining countries OSER Achievement Fully 2 Partially Not‐achieved Not‐reported Total 2 Outcome responsible: Ms Kristina Mauer‐Stender General narrative on Outcome achievement: Three Member states (Tajikistan, Uzbekistan and Czech Republic ) became new Parties to the WHO FCTC in 2012‐2013, making WHO European Region the Region with highest number of Parties, i.e.,50. Three countries, Andorra, Monaco and Switzerland, remain to become Party. Contribution to public health impact: Adoption of the WHO FCTC and its implementation create a moment at country level for strengthened tobacco control policies and their implementation in view to decrease mortality and morbidity related to tobacco use.

Evt. Examples of outstanding Outcome achievements in one or two countries: Tajikistan and Uzbekistan, besides recently becoming Party to the WHO FCTC, have adopted strong tobacco control laws in line with the Treaty and started their implementation. Tajikistan: as a result of the ratification, two major surveys have been conducted, a household survey together with WB and a youth survey, GYTS, with the aim to establish the national baseline to monitor the implementation of the WHO FCTC. National Tobacco Control Strategy and Action Plan are ready for adoption. Revision of the tobacco control law has been prepared to align the national legislation fully with the WHO FCTC. Uzbekistan: as a result of the ratification, a tobacco control was adopted partly in line with the WHO FCTC. Analysis on its implementation is being prepared to feed into the revision of the existing law to align it with the requirements of the Treaty.

Evt. Supportive documentation for Outcome achievement: “Reference / link to documents, reports, publications, etc.” Parties to the WHO Framework Convention on Tobacco Control http://www.who.int/fctc/signatories_parties/en/

General narrative on deliverable (Output): Policy tools prepared to assist countries in implementing key articles in the WHO FCTC such as ban on advertising, taxation, health warnings and smoke‐free public places. Assessment reports on existing policies and their alignment to the WHO FCTC has been prepared for Tajikistan (available in Russian). Assessment report on the existing policies and their implementation is being finalized for Uzbekistan. Political support to encourage ratification by countries has been provided by RD during her high‐level country visits as well as meetings with countries at various occasions. In the case of Tajikistan and Uzbekistan ratifications, political support from RD has been one of the key factors for country actions. Technical advise has been delivered in various formats. One of the examples is the legal database at the request and funding of Switzerland, non‐Party to the WHO FCTC.

Links to supportive documentation for deliverables

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Policy tools: http://www.euro.who.int/en/health‐topics/disease‐ prevention/tobacco/publications/2012/tobacco‐control‐in‐practice Technical support: http://www.euro.who.int/en/health‐topics/disease‐prevention/tobacco/policy/the‐ tobacco‐control‐database‐for‐the‐who‐european‐region Challenges: Country related challenges: multiple health priorities of countries; limited national awareness on tobacco control and its benefits to health of population at country level; heavy influence and lobby on policy makers from tobacco industry EURO related challenges: limited human capacity at WHO Regional and Country Offices to react very quickly at country requests for advise and technical assistance, to do active and continuous follow‐up

Lessons learned: highest importance of political support from WHO Regional Office at the level of RD; important need to follow‐up with countries on ongoing basis with advice and support provided in order to ensure actions and change

Plans for 2014‐2015: In order to ensure that 3 remaining countries become Parties to the WHO FCTC, high‐level political support and encouragement in various formats is needed. Technical discussions should be permanent to keep the issue on the national agenda and support provided by EURO as needed.

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Outcome 59 Assessment (OPO)

SO.06.003 Member states have established or strengthened national surveillance OSER Achievement systems of tobacco consumption and exposure to tobacco smoke built on Fully 25 sustainability, standardization and comparability across countries and use Partially data for policy making in line with the WHO FCTC. Not‐achieved Not‐reported Total 25 Outcome responsible: Ms Kristina Mauer‐Stender

General narrative on Outcome achievement: Member States have strengthened national surveillance systems through the Global Adult Tobacco Survey (GATS) in Greece, Kazakhstan and Turkey, the Tobacco Questions for Surveys in Almaty (Kazakhstan), Croatia, Czech Republic, Turkmenistan and Uzbekistan, and the Global Youth Tobacco Survey (GYTS) completed in 9 countries and at final preparations in 13 countries.

Contribution to public health impact: The achievements build evidence to the extent of the problem and/or effectiveness of implementation of policies in line with WHO FCTC, creating momentum to further strengthen policies and tackle burden of tobacco and NCDs. The results of the above surveys will be published in 2014. Evt. Examples of outstanding Outcome achievements in one or two countries:

Turkey has established a very strong and solid tobacco surveillance system and is the first country in Region to establish GATS as core element of its system by repeating the survey and matching necessary funds from the national budget.

Czech Republic has strengthened its national surveillance system and built sustainability into it by identifying a cost‐effective alternate to the costly GATS survey and integrating the full TQS questions (subset of GATS questions) into its existing CINDI questionnaire. Evt. Supportive documentation for Outcome achievement:

Turkey repeat GATS: http://www.who.int/tobacco/surveillance/survey/gats/turkey/en/index.html

General narrative on deliverable (Output): Tobacco control database was launched 31 May 2013. Architecture for second phase of database finalized, with expanded database to be launched October 2014. Links to supportive documentation for deliverables Tobacco control database: http://data.euro.who.int/tobacco/

Challenges: Financial constraints in countries make it challenging for them to match funds to the GYTS and build sustainability to the surveillance system.

Financial constraints at Secretariat have delayed organizing timely GYTS Analysis & Data Dissemination Workshops to supply countries with real‐time data to strengthen policy dialogues. Lessons learned: GATS – Engagement missions for new countries should be considered as an essential element for success. GYTS – Discussions for future plans with countries should be initiated as soon as possible to allow them time to include national funding into their budgets for the survey year.

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Database – Extensive costing estimates should be formulated before discussions with Donor. Plans for 2014‐2015: Support countries in strengthening surveillance systems, through the completion of GATS in Kazakhstan, the integration of TQS into the EHIS survey in Croatia (at minimum) and the completion of the GYTS in 13 countries.

Engagement mission to be planned in 2015 for repeat GATS countries (lesson learned).

Support countries in using data for policy making by holding timely GYTS Analysis Workshop, expanding the intent of the workshop to include strong focus on data dissemination (lesson learned).

Second phase of database to be initiated after extensive costing estimates (lesson learned), and to be launched by October 2014, linking TOB with NCDs.

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Outcome 60 Assessment (OPO)

SO.06.004 Member States have established national alcohol surveillance systems OSER Achievement that are built on sustainability, standardization and comparability Fully 1 across Member States and use data for the European Information Partially System on Alcohol and Health. Not‐achieved Not‐reported Total 1 Outcome responsible: Dr Lars Moller General narrative on Outcome achievement: The European Information System on alcohol and health is part of a global information system but EURO has included a number of European specific indicators to follow the implementation of the European action plan to reduce the harmful use of alcohol 2012‐2020. In 2012 all 53 Member States in the region were invited to respond to a survey including 200 indicators on alcohol consumption, harm and the policy responses. All MS replied to the survey and the data was used to update the information system as well as for a new European status report which was published in June 2013. At network meetings in 2012 and 2013 most of the MS were represented and special sessions were used for training in using the online data entry system as well as using the system for data analysis. Contribution to public health impact: The information system, the reports and other publications has been an important tool for EURO in working with countries and the information has been used in countries by journalists and policy makers. The huge activity level on alcohol policy changes in Member States, as reported under Outcome 13 is probably linked to new information which also gives comparable results between countries.

Evt. Examples of outstanding Outcome achievements in one or two countries: EURO has a 100% participating by all countries in the European information system for alcohol and health. This is due to a very large and intensive communication between EURO and Member States as well as for specific training sessions at the annual focal point meetings in 2012 and 2013. Evt. Supportive documentation for Outcome achievement: Data on policy achievements were collected in all 53 Member States in 2011 and 2012 and data are available in the European Information System on alcohol and health European Information System on Alcohol and Health (EISAH) (http://apps.who.int/gho/data/view.main‐euro?showonly=GISAH) General narrative on deliverable (Output): All Member States of the European Region have contributed with data for the European Information System for Alcohol and Health latest in 2012. Country representatives have met in 2012 and 2013 and discussed problems, challenges and ways of using the system. Countries have received training in data entry as well as analysing data. Data has further been used for two status report in 2012 and 2013.

Links to supportive documentation for deliverables 1. European Information System on Alcohol and Health (EISAH) (http://apps.who.int/gho/data/view.main‐euro?showonly=GISAH) Challenges: Collection of data from all Member States is a time consuming process involving training, intensive contact with MS and long processes with data cleaning and reporting. It is also adding a burden to MS and therefore in the future data collection will only take part every four years. In between smaller surveys will be performed with a few of the key indicators on alcohol and health. Lessons learned: Data on alcohol consumption, harm and the policy response are extremely important to facilitate policy changes on alcohol in Member States and the work will continue.

Member States are not willing to provide information annually and for the future it has been decided to collect all relevant information every four years and in between the surveys WHO will collect information

112 on 32 key indicators which can be used for drafting country profiles and to be used for a scoring system. Plans for 2014‐2015: There is a continued need to provide evidence based guidance to MS and it is essential to have access to recent data on a number of key indicators. Therefore a small data collection will take place in 2014 as well as collecting data for a new timeline database on policy changes in Member States. A publication on alcohol scoring will be published in connection to the Regional Committee together with new alcohol profiles by country. The information system will be further developed and WHO will develop guidance on using the system.

Future work is needed to ensure good data quality and a good system for collecting data. It is the hope that the good collaboration with the EC will continue from 2014 and WHO has been working with the EC on a new direct grant to support future activities on the alcohol information system.

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Outcome 61 Assessment (OPO)

SO.06.001 Multisectoral health and wellbeing strategies and plans developed and OSER Achievement capacity for health promotion and health equity strengthened at the Fully 2 local level in Member States in line with Health 2020 principles and Partially approaches. Completion of Phase V of the Healthy Cities Programme. Not‐achieved Not‐reported Total 2 Outcome responsible: Dr Agis Tsouros General narrative on Outcome achievement: Phase V (2008‐2013) of healthy cities was completed with an overall assessment showing a high level of engagement, political commitment and a wealth of practical experience on addressing inequalities, inter‐sectoral action, healthy ageing and health urban planning. Healthy Cities was recognised as the strategic vehicle for delivering Health 2020 at the local level. Belfast, Udine, Bursa, Stavropol, Lodz, Cardiff are examples of cities with impressive records in implementing the Phase V goals. The Czech, the Russian, The Turkish, the Norwegian national healthy cities networks/associations are vibrant examples of very active and effective networks supporting the goals of healthy cities.

Contribution to public health impact: Cities have developed a wide range of innovative practices on tackling inequalities and addressing the social determinants of health including action on disadvantaged communities; older people, deprived neighbourhoods through health urban planning projects; and living conditions. The in depth Phase V evaluation is underway and will be completed at the end of 2014. Evt. Examples of outstanding Outcome achievements in one or two countries:

Evt. Supportive documentation for Outcome achievement:

General narrative on deliverable (Output)

Links to supportive documentation for deliverables Addressing the Social Determinants in the Urban context; Governance for Health in the 21st Century (studies I and II).

Challenges: The huge demand for support and potential for innovation and the small capacity in the Office to respond fully to this challenge.

Lessons learned: The increasing recognition of the key role of local governments in health development The importance of developing capacity for leadership and facilitating change including inter sectoral action and citizens involvement.

Plans for 2014‐2015: 1. Complete designations to and start up implementation of Phase VI 2. Completion of Phase V evaluation 3. Organizing of 2014 Open Healthy Cities conference.

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Outcome 62 Assessment (OPO)

SO.07.002 Improved capacity and uptake [by Member States] for governance OSER Achievement for action on the social determinants of health and health inequities Fully 28 within the Health 2020 Policy Framework and consistent to WHA Partially 1 62.14 Not‐achieved 2 Not‐reported Total 31 Outcome responsible: Ms Christine Brown General narrative on Outcome achievement: Policy support tools and round table dialogues have supported ministries of health and the public health community to make the case and to implement health equity priorities in public policies, development plans and in national and sub‐regional investment frameworks 11 member states have reviewed and are strengthening cross sectoral strategies on the social determinants of health equity Health for Inclusive Growth in the Western Balkans. Objectives and indicators to improve health as a way to achieve inclusive growth targets were formally adopted by Health and Economic ministers from 7 countries under the Western Balkan Growth Strategy, SEE2020. This is the first time that improving health by addressing social determinants and reducing health inequities has been formally included as a key area and as an indicator for economic growth in the western Balkans. Contribution to public health impact: Unemployment, geographic variation in health and social protection systems and in infrastructure for growth and development continue to be some of the main determinants of health and health inequities across the Region. Evidence synthesis reports and country capacity building have been used by member states to i) agree common approaches to reduce inequities across public policies ii) Strengthen governance instruments for intersectoral cooperation on health and employment, linked to national inclusive growth strategies iii) review legal and program mechanisms so as to increase equity impact of health and social protection systems. e.g as exemplified by strengthening health contracting for equity in Poland. Evt. Examples of outstanding Outcome achievements in one or two countries:

• Slovak Republic. A partnership has been established between regional authorities, the private sector and the health community to implement a bottom up approach to employment for populations experience exclusion. The partnership is an innovative approach in working across sectors and stakeholders to reduce social inequities in health.

Evt. Supportive documentation for Outcome achievement: http://www.slideshare.net/marekkmet/bosakova‐ luciaabottomupapproachtoemploymentisbn9788097147518http://seehnsec.blogspot.it/2013/11/just‐ endorsed‐south‐east‐europe‐2020.html

General narrative on deliverable (Output):

1. Normative Guidance & Analytical Tools Checklist to support assessment of governance capacity in for intersectoral action on the social determinants of health and health equity 2. Evidence Synthesis/ Policy Briefs Regional synthesis Report of why policies and interventions to reduce inequities in health succeed or

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fail. ‐ Report Governance for Health Equity in the European Region Capacity Building 3. Learning Exchange Platform on the social determinants of health

Links to supportive documentation for deliverables http://www.euro.who.int/en/publications/abstracts/governance‐for‐health‐equity‐in‐the‐who‐european‐region Challenges: There is increasing convergence of interest among non health sector agencies on the importance of social determinants in reducing inequities and promoting inclusive growth. These offer strong potential as policy entry points to reduce social inequities in health. However know how and capacity on how to integrate health into development agendas across government remain fragile, despite high levels of interest from the health community

There are infrastructure challenges at country and secretariat level that are also holding back progress to reduce health inequities as part of broader government development agendas. The main ones include lack of disaggregated data that would enable better identification of specific policy measures and indicators of progress. There is also no specific current program of work in the secretariat that is offering MS support specifically on how to integrating health into development agendas. Lessons learned: • An analysis of reasons for lower than anticipated level of action and impact on the social determinants and health inequities in 2013 has highlighted the need for new instruments tools and more tailored guidance on integrating health into development agendas linked to social cohesion inclusive growth and rural regeneration. • Training events are not enough to address the ‘implementation gaps’ identified by member states on cross sectoral approaches to health and reducing inequities. New ways to increase capacity and improve delivery in real‐time have been tried and these show more promise. Workshops, on the job mentoring structured learning exchange on policy implementation and use of demonstration sites are the main techniques being combined into capacity building programs to accelerate uptake and application in practice.

Plans for 2014‐2015: • Scale up capacity support to build health and equity measures into national development plans and investment frameworks. Establish a new regional office program on health and development Scale up capacity support to member states to strengthen partnership models of policy design, implementation and review of public policies and in governance of social determinants and the reduction of health inequities. • Increase capacity and commitment of health and non‐health sectors to take forward the findings from the EURO and EU Health Inequality reviews through a regional‐wide Platform for learning exchange and problem solving in reducing inequities by addressing social determinants.

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Outcome 63 Assessment (OPO)

SO.07.003 Member States systematically use analyses of social & economic OSER Achievement determinants and health inequalities to inform the development, Fully 7 implementation, monitoring and evaluation of health policies & Partially programmes. Not‐achieved 7 Not‐reported Total 14 Outcome responsible: Dr Erio Ziglio

General narrative on Outcome achievement: Activities carried out under this outcome strengthened capacity in 7 Member States (EST, ITA, HUN, POL, SVN, SPA, SWE to produce/revise health profiles and health plans taking into account, where available, disaggregated data on health inequities, both at national and subnational level. Improved capacity to analyse individual and contextual data with socioeconomic disaggregation has led to more targeted policies and interventions.

The work achieved under this Outcome in 2012‐13 has enabled 8 Member States to present evidence in a systematic manner thereby providing the health sector with the necessary arguments to present to decision‐makers for policy changes, programme implementation and even allocation of financial resources to support these activities. Contribution to public health impact: The work carried out under this Outcome has enabled 7 Member States and Regions to collect and analyse data on social and economic determinants. This has allowed a more thorough analysis of the population’s needs and identification of vulnerable groups and will lead to the development of more targeted policies. Where socio‐economic indicators were not routinely collected, work under this outcome helped raising awareness on the importance of collecting such information to achieve more complete epidemiological profiles. Evt. Examples of outstanding Outcome achievements in one or two countries: • Sweden: Vastra Gotland incorporated SDH/HI indicators in their regional health/development plan. Under the WHO Regions for Health Network, Vastra Gotland is producing a report on the process – which is the same in different regional and national settings ‐ to incorporate indicators on SDH/HI in regional/national plans. • Estonia: Ongoing work to strengthen routine monitoring & analysis of SD and Health Equity including a) a review of indicators and targets for health equity and b) an appraisal of different options for integrating health equity measures into i) national government social inclusion strategy and ii) municipal planning and reporting systems. Estonia published two reports on equity and social determinants based on analyses of disaggregated data (from HSBC survey and other national sources) ‐ one on dietary habits of children and young people, and one on alcohol related harm. Evt. Supportive documentation for Outcome achievement: Together towards social responsibility: Action Plan for Health Equity in Vastra Gotaland, Equity Action, RETHI, Region Vastra Gotaland: November 2012, http://www.vgregion.se/jamlikhalsavast

Case study on socially determined inequities in alcohol consumption patterns in Estonia, 2013: WHO Regional office for Europe and Tervise Arengu Institute http://www.euro.who.int/en/countries/estonia/publications3/case‐study‐on‐socially‐determined‐ inequities‐in‐alcohol‐consumption‐patterns‐in‐estonia

Dietary habits of adolescents in Estonia: Equity and social determinants, 2013: National Institute for health Development, Tallinn, Estonia and WHO Regional Office for Europe

117 http://www.euro.who.int/en/countries/estonia/publications3/dietary‐habits‐of‐adolescents‐in‐estonia‐ equity‐and‐social‐determinants

General narrative on deliverable (Output): In line with the recommendations from the WHO Commission on Social Determinants of Health, the foundation of any technical assistance must be the ability of Member States to record, measure, monitor and analyze data disaggregated by social and economic factors and sex. In the WHO European Region, work with countries and work with health programmes commenced to incorporate this work back in 2006 and the momentum has been sustained and been strengthened. We have worked at inter‐country level (RHN, EC project), multi‐country level (San Marino project) and directly with 7 Member states (also at sub‐national level) to produce or revise health profiles, health plans which are designed to inform policy‐makers and address health inequalities. In addition, in partnership with the European Commission – DG SANCO and the European Agency for Health and Consumers we have produced 5 policy briefs on actions to reduce inequities in tobacco, alcohol, obesity, unintentional injury, and how to take an overarching approach to addressing health inequities which incorporate data on SDH/HI. As well, the Division of Evidence, Information and Innovation to produce a health equity atlas which will be reported under Outcome 80 but is nonetheless important to mention also in connection with Outcome 63.

Links to supportive documentation for deliverables Health and Environment ‐ Communicating the risks, English version http://www.euro.who.int/__data/assets/pdf_file/0011/233759/e96930.pdf Health and Environment ‐ Communicating the risks, Russian Version http://www.euro.who.int/__data/assets/pdf_file/0005/235076/e96930r.pdf About the PUBs above: http://www.euro.who.int/en/about‐us/networks/regions‐for‐health‐network‐ rhn/publications/2013/health‐and‐environment‐communicating‐the‐risks RHN in Cardiff http://www.euro.who.int/en/about‐us/networks/regions‐for‐health‐network‐ rhn/sections/news/2013/10/the‐regions‐for‐health‐network‐meets‐in‐cardiff RHN workplan http://www.euro.who.int/en/about‐us/networks/regions‐for‐health‐network‐rhn/workplan2 RHN Video: http://www.youtube.com/watch?feature=player_embedded&v=Xb97mOsgNos The Regions for Health Network: Göteborg Manifesto, in English, Italian and Swedish http://www.euro.who.int/en/about‐us/networks/regions‐for‐health‐network‐rhn/publications/2012/the‐ regions‐for‐health‐network‐goteborg‐manifesto Reducing health inequalities in small countries: WHO/Europe signs agreement with San Marino, 01‐08‐ 2012 http://www.euro.who.int/en/countries/san‐marino/sections/news/2012/08/reducing‐health‐inequalities‐ in‐small‐countries‐whoeurope‐signs‐agreement‐with‐san‐marino Montenegro collaborates with other small countries to implement Health 2020, 23‐04‐2013 http://www.euro.who.int/en/countries/san‐marino/sections/news/2013/04/montenegro‐collaborates‐ with‐other‐small‐countries‐to‐implement‐health‐2020 Challenges: ‐ Great variety across the WHO European Region in terms of collected indicators, systems of classification, reliability of information. Diversity in the collected information makes it difficult to conduct cross‐national comparisons. ‐ Ownership of data: informative flows on socioeconomic variables are often outside the domain of Ministry of Health. Also in countries where such boundaries are not a problem, it is technically challenging

118 to link socio‐economic sources with health data sources at the individual level. ‐ Changes on informative flows often require normative steps, infrastructural and organizational changes, and strengthened capacity on data collection and analysis. ‐the country‐specific OSERs which were NOT ACHIEVED was caused by the departure in June 2012 of the Resp Officer (Sarah Simpson). The work was reprogrammed once her replacement was recruited (Dec 2012) and focus was put on other countries Lessons learned: ‐ Recognizing the need of disaggregated data on SDH/HI is only the first step of a long process. Results can only be expected over several biennia. ‐ Collaboration with other sectors such as education (university curricula), justice, finance, labor is essential and should aim at have an updated set of core data accessible to policy developers and decision makers. ‐ There is the need of homogeneity in terms of standards for data collection, definition and analysis. ‐ Supranational events or recommendations (such as the endorsement of Health 2020) can provide the political momentum to better use –or collect‐ indicators on SDH/HI

Plans for 2014‐2015: ‐ Dissemination of successful processes and practices to incorporate SDH/HI indicators in health/development regional and national plan. ‐ Sustained support to Member States to revise health/development plans taking into account disaggregated socio‐economic indicators. ‐ Analysis of the process which leads to incorporation of SDH/HI indicators in health/development policies; identification of enabling and disabling factors; identification of successful cases; dissemination of these cases; mentoring programs between “benchmark countries/regions” and countries/regions which leg behind.

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Outcome 64 Assessment (OPO)

SO.07.005 Greater capacity and commitment in Member States to apply a OSER Achievement gender approach in the development and implementation of Fully 4 health policies and programmes, as per WHA Resolution 60.25. Partially Not‐achieved 3 Not‐reported Total 7 Outcome responsible: Dr Isabel Yordi Aguirre

General narrative on Outcome achievement: This outcome has a cross cutting nature so most of the work towards increasing country capacity and commitment was done through mainstreaming gender in WHO technical work and increasing capacity of staff. The commitment of MS can be measured by the endorsement of Health which has gender fully integrated into the policy and the evidence together with the human rights and the reduction of inequities. Contribution to public health impact: WHO is committed to gender equality as a human rights issue and as a social determinant of health. This outcome works on mainstreaming gender across the organization. Consequences of gender inequalities have serious impact on public health. For example: violence against women and avoidable mortality due to risk behaviour led by gender norms. The interlink between gender, education and socioeconomic status may increase the public health impact of NCDs if not addressed properly. Evt. Examples of outstanding Outcome achievements in one or two countries: • “Tajikistan: Gender assessment of the National health Strategy was done and it guided the identification of capacity building needs for the next biennium. This work will continue in this biennium. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/health‐ topics/health‐determinants/gender/news/news/2013/03/slovenian‐journal‐of‐public‐health‐releases‐ issue‐on‐health‐inequalities‐among‐women General narrative on deliverable (Output): The main focus in this biennium was the integration of gender issues in Health 2020 process and documents. This was achieved by emphasizing a coherent approach to gender, human rights and equity following the directions of the WHO Reform. This has been done by integrating capacity building efforts (training of NPOs in 2013 and 2013), by supporting the development of accountability mechanism led by HQs (Office Wide Action Plan developed with in depth contributions from EURO) and by providing technical advice to countries and WHO programmes such as the integration of gender in the NCDs action plan, the Ageing action plan or the integrate health care initiative.

The capacity building efforts translated into country work such as the gender assessment of National Health Strategy in Tajikistan or the support of the CO to the MoH in Moldova to adapt the guidelines on violence for the health sector.

Intercountry: Conference on Eliminating Violence Against women, Vienna 25‐26 November 2013 will guide the development and revision of protocols to address violence against women in the health services. Links to supportive documentation for deliverables Gender and health: Eurohealth 18 (2) 2012 http://www.euro.who.int/en/health‐topics/health‐determinants/gender/publications/2012/gender‐and‐ health,‐eurohealth‐182,‐2012

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Challenges: Mechanisms to support the integration of gender throughout our assistance to countries are not yet in place. From evidence to accountability, countries are not yet fully equipped to mainstream gender in the health sector which is far behind other sectors, such as education or social affairs. The collection and use of relevant data is still a main challenge. OSERs in 3 countries were not achieved due to the involvement of the technical officer in the work of the Health 2020 secretariat which together with the lack of funding meant that activities in these countries were put on hold. Lessons learned: It is a good strategy to integrate the mainstreaming of gender and rights under an equity umbrella. However, the integration of these approaches should not mean the invisibility of the specific need of addressing gender inequalities and specific capacity building when needed. Work with technical divisions needs to be combined with a top down approach that enforces accountability mechanisms for mainstreaming. Ownership by technical division needs to include allocation of financial and human resources. Plans for 2014‐2015: Ensuring better integration with human rights under the equity umbrella. Promoting better mainstreaming within WHO through accountability mechanisms and capacity building. This will require major effort in monitoring uptake by technical programmes and country offices that show results in MS of capacity building and technical support provided inside the organization. Strengthening country support to address gender and rights in Health 2020 implementation. New human resources for the Health 2020 implementation will allow the gender adviser to strengthen this area of work in this biennium.

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Outcome 65 Assessment (OPO)

SO.07.004 Greater capacity and commitment in Member States to apply a OSER Achievement human rights‐based approach in the development and Fully 4 implementation of health policies, plans and programmes, including Partially a specific focus on populations experiencing poverty and social Not‐achieved Not‐reported exclusion. Total 4 Outcome responsible: Ms Åsa Nihlén General narrative on Outcome achievement: The main focus and achievement in 2012‐13 has been the integration of human rights perspectives and approaches in the European Health Policy Framework for Health and Well‐being – Health 2020. The Health 2020 policy framework has been endorsed by all 53 Member States in the Regional Committee for Europe, and human rights approaches forms an integral part of its implementation.

Contribution to public health impact: Discrimination and other human rights violations have enormous public health consequences. However, public health impact is a secondary purpose in working towards this outcome. Human rights promotion and protection is at the core of the UN mandate and WHO support to countries therefore need to be founded in a human rights based approach to health.

Evt. Examples of outstanding Outcome achievements in one or two countries:

Evt. Supportive documentation for Outcome achievement:

General narrative on deliverable (Output): The main focus and achievement in 2012‐13 has been the integration of human rights perspectives and approaches in the European Health Policy Framework for Health and Well‐being – Health 2020.

WHO Europe has in 2012‐13 contributed to important developments for human rights protection and promotion in Member States. Much of the work implemented in country offices is indeed contributing to this outcome directly or indirectly. WHO country office staff are also increasingly contributing to different human rights treaty review mechanisms, and in 2012‐13 two EURO Member States (Azerbaijan and Tajikistan) were visited by the UN Special Rapporteur on the Right to Health. Links to supportive documentation for deliverables

Challenges: WHO Europe has in 2012‐13 contributed to important developments for human rights protection and promotion in Member States. This work is many times part of WHO health diplomacy efforts and therefore rarely reported on to the public. It appears as invisible, but this is also its strength. This is a challenge from both a reporting and resource mobilisation perspective.

Lessons learned: It is important that human rights perspectives are not presented as an “add on” to WHO regular work, but instead at the core of the WHO mandate. It is important that general capacity is built with staff so that this is acknowledged and implemented. However, it is still crucial that specific human rights expertise is available within WHO to support technical teams, but also for communication and health diplomacy efforts. Plans for 2014‐2015: In the next biennium, work will focus on implementing the Health 2020 framework both through the development of national health policies and through reviewing and adapting existing ones. Emphasising human rights perspectives for greater health equity is an important component in this work.

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In 2014‐15, gender, equity and rights will function as a common programmatic area (PB 3.3) for these cross‐ cutting issues.

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Outcome 66 Assessment (OPO)

SO.08.001 Evidence‐based strategies and WHO norms and guidelines OSER Achievement addressing main environmental health risk factors (air and water Fully 7 pollution, noise, chemicals) adopted in the MS Partially Not‐achieved 1 Not‐reported Total 8 Outcome responsible: Dr Elizabet Paunovic

General narrative on Outcome achievement: Member States in the European Region adopted strategies and WHO norms and guidelines to address main environmental health risks. This was achieved mainly through the development of National plans for the elimination of asbestos‐related diseases, by applying WHO/ILO methodology; through the ratification of Water and Health Protocol; through ratification of the Convention on Long‐ Range Transboundary Air Pollution. The activities have been performed through the active involvement of WHO and joint work with Member States in providing technical support in the mentioned areas, under the above stated mechanisms and by providing capacity building trainings and by performing in country missions through BCA implementation. Contribution to public health impact: About 19 million people across the European Region still do not have access to adequately protected drinking‐water (a so‐called “improved” source), and about 100 million people do not have access to piped water on premises. Although access has increased in general, this progress masks significant disparities within and between countries, between urban and rural areas as well as between high‐ and low‐income groups. For example, in the Caucasus and central Asia, 22% of the rural population lives in homes without access to improved drinking‐water sources, as opposed to only 4% of urban dwellers. Even more significant, 71% of the rural population lacks access to piped water on premises whereas only 16% of town and city residents are similarly disadvantaged. Notably, for some countries in the European Region access to piped water on premises is decreasing. Evidence shows that air pollution at current levels in European cities is responsible for a significant burden of deaths, hospital admissions and exacerbation of symptoms, especially for cardiorespiratory disease. Exposure to air pollutants is largely beyond individuals’ control and requires action by public authorities at the national, regional and even international levels. While the hazardous properties of many common pollutants are still under intensive research, evidence‐ based policies demonstrate that health protection is possible and effective. For example, phasing out leaded petrol decreases blood lead levels in children and reduces their risk for impaired neurobehavioural development. Controlling air pollution, both indoor and outdoor, can significantly prevent diseases. Evt. Examples of outstanding Outcome achievements in one or two countries: Georgia, a signatory of the Water Protocol, identified the increase in access to safe water as a specific priority need of the country and submitted a proposal to address this need to the Protocol project facilitation mechanism (PFM), which helps mainstreaming international support for national action. Within this mechanism, Germany, a party to the Protocol, agreed to provide technical and financial support to a project piloting the introduction of water safety plans in two Georgian districts through its Federal Environment Agency. WHO/Europe provides technical assistance and coordination of project activities with both countries through the PFM. Upon successful completion of this project, Georgian authorities are able to carry out further assessment and improvement programmes, aiming to extend these activities over the whole country in a consistent way.

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Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/health‐topics/environment‐and‐health/water‐and‐sanitation/country‐ work/georgia‐preventing‐water‐related‐diseases‐by‐increasing‐access‐to‐safe‐water

General narrative on deliverable (Output) –Air quality activities completed; noise activities ongoing (revision of WHO guidelines for community noise for the European Region. WHO project “Review of health aspects of air pollution – REVIHAAP”6, implemented to support revision of air quality policies of European Union in 2013, has reviewed the evidence on health aspects of air pollutants published since the last update of the AQG to include new evidence for PM2.5, PM10, ozone, NO2 and SO2. In Albania the action plan for the improvement of the air quality was revised. Activities regarding the indoor air quality were also successfully conducted.

Joint work with UN Kosovo Team Human Security Project “Building a better future for citizens of Fushë Kosovë/Kosovo Polje and Obiliq/Obilić: Participation, Protection, and multi‐ethnic Partnership for Improved Education, Health and Sustainable Livelihoods” provided a two policy advsing freports, as the basis for further evidence‐based policy making.

New IT platform and database launched. Russian version of ENHIS interface and indicators factsheets launched. Detailed methodologies of new indicators have been developed.An SQL relational database for school survey‐based indicators has been developed. Data collection and analysis for new indicators are in progress. Successful completion of several publications, including a genral one on Contamin Sites and Health (English and Russian); Risk Communication (English and Russian); and a special issue of a scientific journal is being finalised. –

Nanotechnology and human health: Scientific evidence and risk governance. Report of the WHO expert meeting 10‐11 December 2012, The WHO Regional Office for Europe undertook a critical assessment of the current state of knowledge and the key evidence on the possible health implications of nanomaterials, with a view to identify options for risk assessment and policy formulation, and convened an expert meeting to address the issue.

Current evidence is not conclusive. As complexity and uncertainty are large, risk assessment is challenging, and formulation of evidence‐based policies and regulations elusive. Innovative models and frameworks for risk assessment and risk governance are being developed and applied to organize the available evidence on biological and health effects of nanomaterials in ways to inform policy.

Harmonized data collection activities performed and produced environmental exposure data that is comparable both within a country and at international level. Links to supportive documentation for deliverables

http://www.euro.who.int/en/data‐and‐evidence/environment‐and‐health‐information‐system‐enhis http://www.euro.who.int/__data/assets/pdf_file/0006/189051/Health‐effects‐of‐particulate‐matter‐final‐ Eng.pdf http://www.euro.who.int/__data/assets/pdf_file/0018/140355/e94968.pdf Challenges: During the development of evidence based norms and strategies on main environmental health

6 Review of health aspects of air pollution – REVIHAAP Project. Technical report. WHO 2013 http://www.euro.who.int/__data/assets/pdf_file/0004/193108/REVIHAAP‐Final‐technical‐report‐final‐version.pdf

125 risks, in some areas with well developed corpus of scientific evidences, WHO faced with the lack of human resources for coordination of complex processes of systematic scientific literature review required to be performed during the development of WHO guiding documents (e.g. revision of Noise guidelines for Europe). This has caused some delays in delivering this Output. From the Member States point of view, the challenge of intersectorial cooperation, especially in integral uptake of the whole set of ENHIS indicators appeared challenging in some of the member states. Lessons learned: Having in mind very successful implementation of both air quality related projects which have been based on producing questions on health impacts relevant for policy makers, it will be used as the proven well structured methodological approach in similar undertakings. Similar approach will be applied for the revision of Noise guidelines for Europe as an effective model for the use of resources. This will be the way to overcome lack of human resources by applying good methodological model.

Plans for 2014‐2015: Deployment of additional monitoring stations in relevant areas that adequately represent urban population exposure. Development and maintenance of databases to track levels and trends as well as health data. Awareness raising, capacity building and training of local authorities and experts in air quality monitoring and health risk assessment.

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Outcome 67 Assessment (OPO)

SO8.002 Inequalities in environmental health risks identified and addressed OSER Achievement by national policies/actions Fully 2 Partially Not‐achieved Not‐reported Total 2 Outcome responsible: Dr Elizabet Paunovic General narrative on Outcome achievement: Member States in the WHO European Region identified inequalities in environmental health risks based upon the methodology provided by WHO given in the baseline Report. Environmental health risks became the part of the national strategies and policies in different sectorial policy documents, especially through the implementation of health 2020 strategy at the national level. Contribution to public health impact: As the particular impact of addressing environmental health inequalities in national policies and appropriate actions would be, after a longer period of time of implemented actions (at least one decade) would be lower level of injuries in children in less developed and poor countries; lower exposure to traffic air pollution and though lowering the risk of the children from less affluent families; It is expected that the number of children age 1‐4 years that are dying each year because of the use of solid fuel at home would be lower. Evt. Examples of outstanding Outcome achievements in one or two countries: Environmental health inequalities in Malta, 2013: This report presents the first national assessment of the magnitude and distribution of environmental health inequalities in the Maltese Islands, in line with national commitments made at the Fifth Ministerial Conference on Environment and Health in Parma, Italy in 2010 and the implementation of Health 2020, adopted in Malta in 2012. The assessment report is based on a set of 14 core inequality indicators related to housing, injuries and the environment developed by the WHO Regional Office for Europe. National data has provided a good snapshot of the current distribution of environmental risk factors, indicating that environmental health inequalities are a reality in Malta. However, further detailed information is still needed to enable in‐depth assessments of the distribution of environmental exposures and outcomes and more reliable identification of the most vulnerable population groups. Evt. Supportive documentation for Outcome achievement:

Lancet editorial on WHO activities : http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673612602918.pdf

Published 2013 by: Department for Health Regulation, Ministry for Health, Malta Authored by: Ministry for Health, Malta / WHO Regional Office for Europe https://ehealth.gov.mt/HealthPortal/public_health/environmental‐ health/policy_coord_unit/seminars_publications.aspx Download at: https://ehealth.gov.mt/download.aspx?id=9923 General narrative on deliverable (Output) –” Environmental health inequalities in Europe: Assessment report, WHO/Europe, 2012: The unequal distribution of people’s exposure to – and potentially of disease resulting from – environmental conditions is strongly related to a range of socio demographic determinants. WHO Regional Office for Europe has carried out a baseline assessment of the magnitude of environmental health inequality in the European Region based on a core set of 14 inequality indicators. The main findings indicate that socioeconomic and demographic inequalities in risk exposure are present in all countries, though they vary from country to country. The report reviews inequalities related to housing, injuries, and

127 the environment, identifies gaps in evidence that still need to be filled, and suggests priority action to be taken at both the sub regional and the national level, bearing in mind those national variations

Promoting networking and action on healthy and equitable environments for physical activity (PHAN) project implemented during 2010‐ 2013, supported actions involving different sectors, such as transport, urban planning, education, tourism, sport and leisure that provide environmental conditions facilitating physical activity through all settings of daily life. PHAN placed a particular focus on children and socio‐ economically disadvantaged groups. Products include evidence‐based guidance, tools, examples of good practices and platforms for networking on physical activity promotion to support Members States. This project was co‐funded by the European Union in the framework of the Health Programme 2008‐2013.The main products of the Project are: Developed guidance on effective promotion of physical activity among youth in their everyday life, with the engagement of youth representatives. Strengthening exchange on use of tools for integrating physical activity into city planning and into economic assessments Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/environment‐and‐health/pages/social‐inequalities‐in‐ environment‐and‐health/publications‐on‐environment‐and‐health‐in‐the‐european‐region/environmental‐ health‐inequalities‐in‐europe.‐assessment‐report http://www.euro.who.int/en/health‐topics/disease‐prevention/physical‐activity/activities/promoting‐ networking‐and‐action‐on‐healthy‐and‐equitable‐environments‐for‐physical‐activity‐phan

Challenges: Irrespective of developmental status, environmental inequalities can be found in any country for which data are available. Despite lack of the systematic data collection on environmental inequalities (there are mostly data available from epidemiological studies, social inequalities in environmental risk must be considered a public health issue for each country and the whole Region. Systematic data collection at the national level on environmental health inequalities is one of the existing challenges. What concerns challenges for delivering the outputs, they are mainly related to the need for horizontal and topics wide approach between different technical areas of expertise within WHO, which is posing a challenge in terms of good coordination between different units. Lessons learned: Although the evidence base on social inequalities and environmental risk is fragmented and data are often available for few countries only, it indicates that inequalities are a major challenge for environmental health policies. By analyzing the existing data, in WHO Baseline report, it was confirmed that people living in adverse socioeconomic conditions in Europe can suffer twice as much from multiple and cumulative environmental exposures as their wealthier neighbours, or even more. So, the intervention in environmental health, taking into account socioeconomic conditions can improve health status of the population, and vice versa. Not taking into account socio economic status in environmental health interventions, migh result in less successful outcomes. Similarly, inequalities in exposure to environmental threats have been identified for vulnerable groups such as children and elderly people, low‐education households, unemployed persons, and migrants and ethnic groups. Only little evidence is available indicating that in some circumstances, well‐off and advantaged social groups are more at risk. The main interventions, though, in environmental health should take into account vulnerability of some of the above mentioned groups in particular in order to be successful. Plans for 2014‐2015: Analyses and the systematic review of data collected at the national level, as it was realized that there is the lack of systematic data collection at the national level, will be performed and supported. As in the previous period baseline report was developed, in the coming period the impacts of the applied interventions to decrease environment and health inequalities will be performed in order to support identified gaps (lack of systematic data at the national level ).

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Outcome 68 Assessment (OPO)

SO.08.003 Capacities, tools and resources enhanced in Member States for OSER Achievement addressing environmental health security and emerging risks Fully 11 Partially Not‐achieved 1 Not‐reported Total 12 Outcome responsible: Dr Elizabet Paunovic

General narrative on Outcome achievement: Member States have reported a progress in the development and application of capacities, tools and resources, which resulted in the enhancement of their overall capacities to address environmental health security and emerging risks. The improved response to current emerging challenges in the environmental health is achieved in 8 countries from central and eastern Europe (Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia). The main area of improvement and enhancement is environmental health risk assessment. These 8 Member States are now able to perform proper health impact assessments, environmental impact assessments and strategic environmental assessments of projects, plans, programmes or policies, to analyse the interactions between the environment and health and to integrate health into environmental assessments.

Contribution to public health impact: Public health impact is reflected through better integration of health in environmental assessments and policies through the use of health impact assessments; improved national capacity on health impact assessment and developed methods and tools for health impact assessment (as one of public health operations). By performing essential public health operations in environmental health overall public health will be impacted by better identification of environmental health risks and by the prevention of the potential new risks when the new technologies are applied. The fields of application are very diverse, with transport being the most extensively explored. Evt. Examples of outstanding Outcome achievements in one or two countries:

Estonia strengthened its capacity for environmental health risk assessment. The first step was to perform a gap analysis, followed by training. Capcity has been strengthened in: implementation of Health Impact Assessment (HIA); further integration of health in environmental assessments (EA); and use of methods for quantitative risk assessment in local assessments. One result was a national methodology for the integration of health in environmental assessment and how to use information on existing EA in health impact assessment.

The “Environment and Health Performance Review” is a tool developed as the joint activity Environment and health performance review is the tool developed by Member States. In Belarus the review identified the most important environment and health problems, evaluated the public health impact of environmental exposures and reviewed the policy and institutional framework taking into account the institutional set‐up, the policy setting and legal framework, the degree and structural functioning of intersectoral collaboration and the available tools for action. Belarus will report (in the Mid‐term review report in 2014 ) which policies were developed by implementing this tool. Evt. Supportive documentation for Outcome achievement:

Estonia: http://www.euro.who.int/en/health‐topics/environment‐and‐health/health‐impact‐ assessment/publications/2013/strengthening‐health‐in‐environmental‐assessments‐in‐estonia.‐gap‐

129 analysis‐and‐way‐forward

Belarus: http://www.euro.who.int/__data/assets/pdf_file/0004/152329/e95817.pdf General narrative on deliverable (Output): Strategic environmental assessment (SEA): the SEA Protocol ‐ facilitates the identification and prevention of a project’s possible environmental effects right from the start, and enables environmental objectives to be considered on a par with socioeconomic ones. WHO/Europe ensured that provisions for including health aspects in environmental assessments were made in the United Nations Economic Commission for Europe (UNECE) Strategic Environmental Assessment (SEA) Protocol, and assists its Member States in implementing the Protocol. This Protocol is a means of integrating environmental and health concerns into the decision‐making process. By requiring parties to evaluate the environmental and health consequences of their draft plans and programmes, as well as to consult with health authorities in the SEA process, it marks a step ahead of the European Union SEA Directive, to which it is closely related. The SEA Protocol was signed in 2003 by 35 European countries and entered into force in 2010.

Nanotechnology and human health: Scientific evidence and risk governance. WHO expert meeting 10–11 December 2012, Bonn, Germany.

A workshop was organized in Trento, Italy 16 April 2013 to enable participants to share experience in the management and communication of environmental risks. Links to supportive documentation for deliverables

Link to nanotechnology and health report from the expert meeting: http://www.euro.who.int/en/health‐topics/environment‐and‐health/health‐impact‐ assessment/publications/2013/nanotechnology‐and‐human‐health‐scientific‐evidence‐and‐risk‐ governance.‐report‐of‐the‐who‐expert‐meeting‐1011‐december‐2012,‐bonn,‐germany

Report on management and communication of environmental risks http://www.euro.who.int/__data/assets/pdf_file/0011/233759/e96930.pdf

EH health Impact assessment in Latvia http://www.euro.who.int/en/health‐topics/environment‐and‐health/health‐impact‐ assessment/publications/2012/strengthening‐the‐implementation‐of‐health‐impact‐assessment‐in‐latvia http://www.euro.who.int/en/health‐topics/environment‐and‐health/occupational‐ health/publications/2013/the‐human‐and‐financial‐burden‐of‐asbestos‐in‐the‐who‐european‐region

“Using impact assessment in environment and health ‐ a framework” http://www.euro.who.int/__data/assets/pdf_file/0007/190537/e96852‐final.pdf

Challenges: Existing gaps in capacity and knowledge at the Member States level for performing environment and health performance review and environmental health impact assessment is a challenge Lack of human resources to perform trainings and provide other support is the challenge from WHO side as the needs in these two areas are very high across the region. . This is why WHO is applying sub regional approach and works with several member states with common level of challenges. Lessons learned: The subregional approach in performing environmental health impact assessment trainings appeared to be very good approach. Providing technical support of the application of the tool

130 called Environment and health performance review at MS level would be more efficient if we train sub regionally MS representatives to implement this tool as well, as we are already doing for environmental health impact assessment. Plans for 2014‐2015: More training workshops on both above mentioned tools will be performed by applying sub regional approach as this proved as the efficient way of work which saves resources.

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Outcome 69 Assessment (OPO)

SO.08.003 Intersectoral approaches to addressing environmental determinants OSER Achievement of health implemented in Member States ( e.g. in transport, built Fully 7 environment, workplaces) Partially 1 Not‐achieved Not‐reported Total 8 Outcome responsible: Ms Francesca Racioppi General narrative on Outcome achievement: Capacities were strengthened in Member States to implement intersectoral approaches and health impact assessment to address challenges related to water and sanitation, occupational health, transport and environment, industrially contaminated areas, with a focus on ALB, KAZ, KGZ, LVA, MDA. Contribution to public health impact: Supported Member States in reducing the health effects of exposures in industrially contaminated areas and work settings, as well as of lack of water‐related diseases. Evt. Examples of outstanding Outcome achievements in one or two countries: • Kyrgyzstan: Increased capacities for implementing Water Safety Plans and introduced the Water safety Plans Assessment Tool to operators of centralized water supplies, with emphasis on needs in rural areas. • Kazakhstan: Increased capacities to use health impact assessment to address the health effects of exposures in industrially contaminated areas and to develop supportive policy frameworks in sectors that impact on health. Evt. Supportive documentation for Outcome achievement: • Publication on Water safety Plans Assessment Tool used to support activities in Kyrgyzstan http://www.euro.who.int/en/health‐topics/environment‐and‐health/water‐and‐ sanitation/publications/2014/water‐safety‐plan‐a‐field‐guide‐to‐improving‐drinking‐water‐ safety‐in‐small‐communities

• Adoption of water targets through a joint order of the Minister of Health and the Minister of Agriculture and Melioration in Kyrgyzstan of 26 June 2013

• Publication on “Using impact assessment in environment and health: a framework. Capacity Building in Environment and Health (CBEH) project” used to support activities in Kazakhstan http://www.euro.who.int/en/health‐topics/environment‐and‐health/health‐impact‐ assessment/publications/2013/using‐impact‐assessment‐in‐environment‐and‐health‐a‐ framework

General narrative on deliverable (Output): Main deliverables included capacity building events, training material, tools and publications for “whole of government” approaches to health impact assessment, notably in industrially contaminated areas, development of water safety plans, intersectoral approaches for transport, environment and health, including quantification of the health benefits of physical activity through cycling and walking. Two EU‐funded projects were successfully completed and a new one negotiated Member States were supported in achieving MDG 7 on water and sanitation. Links to supportive documentation for deliverables

• Young and physically active: a blueprint for making physical activity appealing to youth http://www.euro.who.int/en/health‐topics/Life‐stages/child‐and‐adolescent‐

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health/publications/2012/young‐and‐physically‐active‐a‐blueprint‐for‐making‐physical‐activity‐ appealing‐to‐youth • Physical activity promotion in socially disadvantaged groups: principles for action. Policy summary http://www.euro.who.int/en/health‐topics/environment‐and‐health/Transport‐and‐ health/publications/2013/physical‐activity‐promotion‐in‐socially‐disadvantaged‐groups‐ principles‐for‐action.‐policy‐summary • Health economic assessment tools (HEAT) for walking and for cycling. Methodology and user guide. Economic assessment of transport infrastructure and policies http://www.euro.who.int/en/health‐topics/environment‐and‐health/Transport‐and‐ health/publications/2011/health‐economic‐assessment‐tools‐heat‐for‐walking‐and‐for‐cycling.‐ methodology‐and‐user‐guide • Contaminated sites and health: report of two WHO workshops (Syracuse, Italy, 18 November 2011; Catania, Italy, 21–22 June 2012. http://www.euro.who.int/__data/assets/pdf_file/0003/186240/e96843.pdf • Using impact assessment in environment and health: a framework. Capacity Building in Environment and Health (CBEH) project. http://www.euro.who.int/__data/assets/pdf_file/0007/190537/e96852‐final.pdf. • Continuous training in environment and health. Capacity Building in Environment and Health (CBEH) project. http://www.euro.who.int/__data/assets/pdf_file/0003/191802/Continuous‐ training‐in‐environment‐and‐health.pdf. • Strengthening the implementation of health impact assessment in Latvia. http://www.euro.who.int/document/e96481.pdf Challenges: To ensure sustained and predictable resources to focus the technical work on supporting member states in delivering on their commitments on environment and health. Lessons learned Important to maintain a strong network of technical and political partners, based on the production of good products; as funds mobilization efforts are very resource intensive, cost‐benefit analysis is useful. Plans for 2014‐2015: Activities to be continued in 2014‐15 under Category 3.5.1 (country support) and 3.5.2 (technical support at the inter‐country level), making an effort to diversify and expand the sources of funding and continue to build on and expand the network of supportive partners.

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Outcome 70 Assessment (OPO)

SO.08.006 Prevention of health effects of climate change and other global OSER Achievement changes and extreme events enhanced and sustainable public health Fully 13 measures and green developments promoted in Member States Partially Not‐achieved Not‐reported Total 13 Outcome responsible: Dr Bettina Maria Menne

General narrative on Outcome achievement: WHO/assisted European Member States in implementation the Parma Commitment to Act on climate change and health. Twenty – two European Member States assessed the health impacts of climate change, elaborated evidence to inform national decision making, and five countries engaged successfully in mainstreaming health into national climate change related policy developments. Contribution to public health impact: Heat health action plans in eighteen European Member States reduced deaths compared to deviations from the average expected. Measures to reduce greenhouse gas emissions in the transport and energy sector contributed to reducing respiratory and cardiovascular diseases. Evt. Examples of outstanding Outcome achievements in one or two countries: • Kyrgyzstan: the government identified health as one of the five priority areas for adaptation investment. A special sectoral programme on climate change and health is established. The ultimate aim is to reduce mortality and disease related to climate change risks. A large promotional program on renewable energy for the health sector is now been funded by multiple agencies and increases access to services. • Russian Federation: The strategy for adaptation to climate change impacts on the population’s health in the Arkhangelsk Region and Nenets Autonomous District of the Russian Federation, has been developed and governmentally approved. • The former Yugoslav Republic of Macedonia developed national health adaptation strategy and action plans, monitors implementation process, equipped hospitals with renewable energy, contributed to preventing the health effects of heat on workers health.

Evt. Supportive documentation for Outcome achievement: 1. WHO Regional Office for Europe (2013). Protecting health from climate change: A seven‐country initiative. topics/environment‐and‐health/Climate‐change/publications/2013/protecting‐health‐ from‐climate‐change‐a‐seven‐country‐initiative 2. Ministry of Healthcare and Social Development of the Arkhangelsk Region and the Northern State Medical University (2012). Strategy for adaptation to climate change impacts on the population’s health in the Arkhangelsk Region and Nenets Autonomous District of the Russian Federation. Arkhangelsk, Russia. 88 pages. ISBN 978‐5‐94789‐509‐4. http://toplotnibranovi.mk/en/downloads/publications/Russia_Strategy_March_2012.pdf 3. WHO Regional Office for Europe and Ministry of Health of the former Yugoslav Republic of Macedonia (2012). Climate change health adaptation strategy and action plan of the former Yugoslav Republic of Macedonia. Copenhagen, WHO Regional Office for Europe. http://www.euro.who.int/__data/assets/pdf_file/0018/144171/e95094.pdf General narrative on deliverable (Output) Evidence, methods, tools, information and technical support through capacity development was provided

134 to European Member States for identifying, preventing and tackling public health problems resulting from climate change.

Links to supportive documentation for deliverables Governance: 1. WHO Regional Office for Europe (2012). Establishment of a working group on climate change and its impact on health (HIC) of the European Environment and Health Task Force (EHTF) – meeting report. Copenhagen. http://www.euro.who.int/en/health‐topics/environment‐and‐health/Climate‐ change/publications/2013/establishment‐of‐a‐working‐group‐on‐climate‐change‐and‐its‐impact‐on‐health‐ hic‐of‐the‐european‐environment‐and‐health‐task‐force‐ehtf 2. WHO Regional Office for Europe (2012). Climate change and health: lessons learnt in the WHO European Region – meeting report. Copenhagen. http://www.euro.who.int/en/health‐topics/environment‐and‐ health/Climate‐change/publications/2013/climate‐change‐and‐health‐lessons‐learnt‐in‐the‐who‐ european‐region

3. WHO/Europe contribution to the EU adaptation strategy package: http://ec.europa.eu/clima/policies/adaptation/what/documentation_en.htm

4. WHO/Europe contribution to Commission Staff Working Paper. http://ec.europa.eu/clima/policies/adaptation/what/docs/swd_2013_136_en.pdf

5. At the meetings of the parties of the United Nations Framework Convention on Climate Change (UNFCCC) in Germany and Poland (COP19), the WHO Regional Office for Europe contributed to loss and damage, national adaptation strategies, and hosted side‐events at the conferences. http://www.euro.who.int/en/health‐ topics/environment‐and‐health/Climate‐change/news/news/2013/11/health‐on‐agenda‐at‐cop19‐climate‐ change‐conference

Capacity development in countries and published results (not mentioned above): 4. Ministry of Health and Social Development of the Arkhangelsk Region and Northern State University. (2012). Assessment of health vulnerability and adaptation to climate change in the Arkhangelsk Region and Nenetsk autonomous district of the Russian Federation. Arkhangelsk, Russia. 80 pages. http://toplotnibranovi.mk/en/downloads/publications/VA_RUS_final_March_2012.pdf

5. Ministry of Health, Albania, (2012) Protecting health from climate change in Albania. Vulnerability assessment report (English). http://www.klima.developingcorner.com/images/stories/publikime/protecting_from_change.pdf

6. Public Health England (2012). Health effects of climate change in the UK, 2012. http://www.hpa.org.uk/hecc2012 7. Ministry of Health Republic of Albania (2012). Protecting health from climate change in Albania. Tirana. http://toplotnibranovi.mk/en/downloads/publications/Albanian_Climate_change_and_health_strategy.pdf 8. WHO Regional Office for Europe and Ministry of Health Republic of Kazakhstan (2013). Protecting health from climate change in Kazakhstan. Copenhagen, WHO Regional Office for Europe. http://toplotnibranovi.mk/en/downloads/publications/Republic_of_Kazakhstan_Protecting_Health_from_Cli mate_change_en.pdf 9. Turkey: national draft action plan. http://cevresagligi.thsk.saglik.gov.tr/Dosya/Iklim_degisikligi.pdf

Technical Tools and evidence:

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1. WHO Regional Office for Europe (2013). Climate change and health: a toolkit to estimate health and adaptation costs. Copenhagen. http://www.euro.who.int/en/health‐topics/environment‐and‐ health/Climate‐change/publications/2013/climate‐change‐and‐health‐a‐tool‐to‐estimate‐health‐and‐ adaptation‐costs 2. WHO Regional Office for Europe (2013). Infectious diseases in a changing climate. Kopenhagen. http://www.euro.who.int/en/health‐topics/environment‐and‐health/Climate‐ change/publications/2013/infectious‐diseases‐in‐a‐changing‐climate 3. WHO Regional Office for Europe (2013). Floods in the WHO European Region: health effects and their prevention. http://www.euro.who.int/en/health‐topics/environment‐and‐health/Climate‐ change/publications/2013/floods‐in‐the‐who‐european‐region‐health‐effects‐and‐their‐prevention 4. WHO Regional Office for Europe (2013). Greening health systems. http://www.euro.who.int/en/health‐ topics/environment‐and‐health/Climate‐change/publications/2013/greening‐health‐systems.‐ report 5. Heat health action plans and their evaluation (18 European countries), in: Bittner et al.(2013). Are European countries prepared for the next big heat‐wave? Eur J Public Health. 2013 Oct 6http://www.ncbi.nlm.nih.gov/pubmed/24097031 6. Protecting health from climate change: vulnerability and adaptation assessment. Europe contribution http://www.who.int/globalchange/publications/vulnerability‐adaptation/en/ 7. Contribution to Health in the Green economy. http://www.who.int/hia/green_economy/en/index.html 8. Atlas on health an climate change. Europe contribution. http://www.who.int/globalchange/publications/atlas/report/en/index.html 9. Contribution to the Intergovernmental Panel of Climate Change report on extreme events. http://www.ipcc.ch/pdf/special‐reports/srex/SREX_Full_Report.pdf 10. WHO/Europe coordinated health chapter in: EEA (2012). Climate Change Impacts and vulnerability in Europe, 2012. http://www.eea.europa.eu//publications/climate‐impacts‐and‐vulnerability‐2012 11. Leone et al (2013) A time series study on the effects of heat on mortality and evaluation of heterogeneity into European and Eastern‐Southern Mediterranean cities: results of EU CIRCE project. Enviro.Health, 2013 Jul 3; 12:55. doi: 10.1186/1476‐069X‐12‐55. 12. Analitis et al (2014) Environ Effects of heat waves on mortality: effect modification and confounding by air pollutants. Epidemiology. 2014 Jan;25(1):15‐22. doi: 10.1097/EDE.0b013e31828ac01b. 13. Gribrovski et al (2012) No association between temperature and deaths from cardiovascular and cerebrovascular diseases during the cold season in Astana, Kazakhstan‐‐the second coldest capital in the world. Int J Circumpolar Health. 2012;71. doi: 10.3402/ijch.v71i0.19769. Epub 2012 Dec 17.

Information platform: 14. WHO Euro website. http://www.euro.who.int/en/health‐topics/environment‐and‐health/Climate‐ change

15. WHO/Europe contribution to the EU – Climate adapt website. http://climate‐adapt.eea.europa.eu/

Challenges: None

Lessons learned: The implementation of the Parma Commitment to Act was either in those countries were multi‐sectoral committees were established with a focus on health, strong linkages with the science community available and a wealth of knowledge as well as the public health workforce well trained. Plans for 2014‐2015: Future emphasis will be on reducing mortality from extreme weather events and climate change related risks; as well as stronger investment into knowledge generation on environmental benefits of health sector action as well as sustainable development across departments.

136

Outcome 71 Assessment (OPO)

SO.09.005 Strengthened systems for surveillance, prevention and control of OSER Achievement foodborne diseases and food hazards in the MS Fully 10 Partially Not‐achieved Not‐reported Total 10 Outcome responsible: Dr Hilde Kruse General narrative on Outcome achievement: The systems for surveillance, prevention and control of foodborne diseases in Albania, Croatia, Kazakhstan, Kyrgyzstan, Romania, Serbia, Tajikistan, Turkmenistan, and Uzbekistan have been strengthened, with a particular focus on mechanisms for intersectoral collaboration, cooperation and information sharing and the importance of a whole‐food‐chain approach.

Evt. Examples of outstanding Outcome achievements in one or two countries: Albania: Through the project “Strengthening food control institutions in Albania”, that was successfully completed in 2013, and parallel BCA activities, Albania strengthened the food safety system. A clear example is that Albania aligned their shellfish production with European Commission safety requirements. Furthermore, intersectoral (public health, agriculture/veterinary sectors) collaboration in the food safety area has been strengthened by providing platforms for intersectoral communication and network and joint work. Tajikistan: WHO supported the development of draft national food safety strategy (2014‐2020) and the development of communication materials for the prevention of botulism.

Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/countries/tajikistan/areas‐of‐work/preventing‐botulism‐in‐tajikistan http://www.euro.who.int/en/countries/albania/areas‐of‐work/strengthening‐food‐control‐institutions‐in‐ albania

General narrative on deliverable (Output) – National and sub‐regional workshops, trainings and meetings have been held on integrated surveillance, prevention and control of foodborne diseases, food safety risk communication, and AMR from a food safety perspective.

Links to supportive documentation for deliverables http://www.euro.who.int/en/countries/albania/news/news/2013/06/albania‐aligns‐with‐european‐ commission‐standards‐on‐safe‐production‐of‐shellfish http://www.euro.who.int/en/countries/albania/news/news/2013/06/balkan‐countries‐improve‐ knowledge‐of‐international‐food‐standards‐setting.‐zagreb,‐croatia,‐4‐6‐june‐ 2013http://www.euro.who.int/en/countries/turkmenistan/sections/news/2013/10/integrated‐foodborne‐ infections‐surveillance‐training‐in‐turkmenistan

Challenges: A major challenge for both WHO’s ability to deliver on food safety as well as the MS’s ability for uptake is to ensure good collaboration, cooperation and communication between the health and the agriculture/veterinary sectors, which is crucial for cost‐effective prevention and control of foodborne

137 diseases. Lessons learned: To ensure adequate intersectoral collaboration, it is important to also involve the agriculture/veterinary sectors in capacity building activities on food safety. Partnership between FAO and WHO can help achieve this. Plans for 2014‐2015: Continue the good food safety capacity building that has taken place in SEE countries and CAR during the last biennium, and also engage in Ukraine and Turkey. Joint activities with FAO are envisaged and more intersectoral approaches are planned for.

138

Outcome 72 Assessment (OPO)

SO.09.003 Member States develop, implement and evaluate intersectoral OSER Achievement strategies for the substantial reduction of under‐nutrition concurring Fully 1 for the progressive elimination of stunting in the Region Partially Not‐achieved Not‐reported Total 1 Outcome responsible: Dr Joao Breda General narrative on Outcome achievement: Several Member States have developed, implemented and evaluate intersectoral nutrition strategies, notably those concurring to the reduction of malnutrition in the Region. In countries of the Region where malnutrition is significant coordination mechanism involving International organization (FAO, UNICEF, and WFP) and National authorities have been established. MS produced together with the secretariat for the first time an update on salt and iodine status and policy developments in the Region. Contribution to public health impact: Tools that have been developed to facilitate implementation and evaluation of novel and innovative nutrition policies resulted in changes that are expected to bring public health gains and reduce the burden of disease associated with nutrition. Evt. Examples of outstanding Outcome achievements in one or two countries: • Uzbekistan: identified priority actions for tackling childhood obesity and implemented a joint UNICEF/WHO project on improvement of complementary feeding of children. • Tajikistan: draft National guidelines on breastfeeding and complementary feeding to promote appropriate growth and prevent later NCDs were prepared. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/countries/uzbekistan/sections/news/2012/11/uzbekistan‐identifies‐priority‐ actions‐for‐tackling‐childhood‐ obesityhttp://www.euro.who.int/__data/assets/pdf_file/0009/186462/Mapping‐salt‐reduction‐initiatives‐ in‐the‐WHO‐European‐Region.pdf General narrative on deliverable (Output) Intersectoral coordination mechanisms for nutrition and food security are in place and functional with WHO engagement and leadership notably in Uzbekistan, Tajikistan and Albania. Set of draft implementation indicators to evaluate nutrition policies was developed (Nut‐PAT). Support was provided to scientific and policy outputs for the MS Nutrition Action Networks, notably ESAN and MKT food to children. Capacity building for the health workforce and recommendations for breastfeeding, complimentary feeding and infant nutrition were delivered. The ESAN (European Salt Action Network) involves already 27 Member States and is recognized as a very important tool for implementation providing a forum for exchange and guidance for adhering countries. The Network held a very successful meeting in Turkey. The Action Network Reducing Marketing Food to Children: involves 23 Member States and is recognized as a very important tool for implementation providing a forum for exchange and guidance for adhering countries having been very important for the adoption of the “WHO Set of Recommendations” adopted in 2010. The Network held very successful meetings in Denmark and Turkey. A briefing paper on obesity and inequalities was produced jointly with PCR. Links to supportive documentation for deliverables A briefing paper on obesity and inequalities was produced jointly with PCR (in press). http://www.euro.who.int/en/countries/uzbekistan/sections/news/2012/11/uzbekistan‐identifies‐priority‐ actions‐for‐tackling‐childhood‐

139 obesityhttp://www.euro.who.int/__data/assets/pdf_file/0009/186462/Mapping‐salt‐reduction‐initiatives‐ in‐the‐WHO‐European‐Region.pdf

Challenges: Reduced visibility of the problem of malnutrition in countries of WHO Region where undernutrition is still an unresolved issue problem creates lack of attention and interest from potential donors and ODA countries and make it very difficult to capture resources and foster collaboration. Reduced level of funding for further development of tools to evaluate implementation and impact of nutrition actions was a problem. Looking for support to the work of the Action Networks turned out to be a difficult task notably to find hosting countries and to support countries particularly from the Eastern part of the Region. Lessons learned: Working with Networks of Member States with a stake in certain areas of Nutrition policy proved to be a very effective means to move agendas at National and International level and facilitated the outcome achievement. Funding and country support to the Action Networks is a difficult task and requires proactive engagement with MS and understanding of their priorities and emerging opportunities. Plans for 2014‐2015: Given the challenges of reduced funding they will be addressed mainly by using tools and approaches whereby MS can work together in the context of Action Networks where full development of the appraisal tools is expected. Further meetings and policy briefs production as a result of the work of the Action Networks. These tools will fit very nicely the objectives of category II for the next biennium.

140

Outcome 73 Assessment (OPO)

SO.10.003 Member States have strengthened their institutional capacity to OSER Achievement coordinate donor assistance and promote integrated systemic Fully 4 approaches to health systems strengthening Partially Not‐achieved Not‐reported Total 4 Outcome responsible: Dr Maria Skarphedinsdottir General narrative on Outcome achievement: MOH in Moldova, Kyrgyzstan and Tajikistan all convened and led annual reviews of their national health policy with participation of a wide range of stakeholders. In Moldova a mapping of external ODA support was published. In Kyrgyzstan MoH developed a new monitoring framework for all partners around implementation of the NHP. MoH in UZE developed and got approval for applications for 17m GAVI HSS funding and in KGZ MoH was approved for 4.5m USD GAVI HSS grant. Contribution to public health impact: Harmonization and alignment of all efforts around NHP is critical to development of integrated approaches to health system strengthening and to the success of health reforms Evt. Examples of outstanding Outcome achievements in one or two countries: • Tajikistan –MoH developed a monitoring framework for the sector agreed with all sector partners. MoH organized a joint annual reviews on NHP progress attended by all Ministry divisions, Regions, development partners and civil society. • Moldova‐ MoH convened for the second time a National health forum on NHP progress with participation of all districts and other sectors Evt. Supportive documentation for Outcome achievement: Moldova: http://www.euro.who.int/en/countries/republic‐of‐moldova/news/news/2013/12/broad‐ platform‐for‐strategic‐health‐reform‐in‐the‐republic‐of‐moldova Tajikistan: http://www.euro.who.int/en/countries/tajikistan/news/news/2013/09/tajikistan‐revises‐ monitoring‐and‐evaluation‐indicators‐for‐national‐health‐strategy

General narrative on deliverable (Output): WHO supported MoH in MDA, KGZ and TJK in coordinating partners around MS comprehensive national plans in conducting joint annual reviews, development of monitoring frameworks and in implementing these plans. Policy papers were produced of different aspects of reforms and support given to policy dialogues and joint reviews of direction of reforms. WHO also worked with MoH to help access GAVI and GF resources, organized regional meetings on immunization and HS, gave input to GF policy papers and KGZ and UZE with WHO assistance developed and were approved for new GAVI HSS proposals of 4.5m and 17m USD respectively. Links to supportive documentation for deliverables Moldova: http://www.euro.who.int/en/countries/republic‐of‐moldova/publications2/monitoring‐official‐ development‐assistance‐to‐the‐health‐sector‐in‐the‐republic‐of‐moldova‐2011‐report

Kyrgyzstan: http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Results___Evidence/JA NS_Lessons/Kyryz%20Republic%20JANS%20lessons%20learned%202012.pdf

Challenges: Delivery of this output is highly dependent on the capacity of the country office to engage in policy development/dialogue on overall health reforms supported by the RO. Operational models of some partners are not geared towards optimal harmonization and alignment around comprehensive GVT lead policy implementation. Coordination with other sectors continues to be challenging. Lessons learned: In countries with strong country office WHO with RO support can help mobilize significant

141 resources for member states through support to national policy development and implementation and play a catalytic role in harmonizing partner input around government plans. Overall this contributes to strengthening the health system capacity for better delivery of health outcomes. Plans for 2014‐2015: Overall support will continue along the same lines, special focus will be place in GAVI graduation countries in collaboration with VPI. Specific outputs planned include a review of coordination in MDA including coordination in other sectors and EC accession coordination for 2014, continued support to JARs and HF and to policy dialogues around different technical aspects of NHP. Continued support to countries on GAVI and GF health system windows.

142

Outcome 74 Assessment (OPO)

SO.10.001 Member States have strengthened their institutional capacity to (1) OSER Achievement gather and (2) assess evidence, and (3) formulate, (4) implement and Fully 10 (5) evaluate, evidence‐ informed policies to improve the performance Partially 1 of primary health care services, with a particular focus on the Not‐achieved 1 Not‐reported prevention and management of non‐communicable diseases. Total 12 Outcome responsible: Ms Christine Beerepoot General narrative on Outcome achievement: Member states have strengthened PHC by drawing on the health systems functions, such as governance, financing and resource generation, as well as the characteristics of all primary care: accessibility, comprehensiveness, coordination and continuity. As enshrined in the conference statement that took place in November 2013 in Almaty to commemorate the 35 Anniversary of the endorsement of primary health care approach, MS recognized the need to reinvigorate and raise the prestige of PHC based on new evidence, shared experiences and lessons learnt in the various countries. Contribution to public health impact: Strong primary care is associated with good population health status and low health costs, increased patient satisfaction, lower hospitalisation, less use of specialists and emergency care and less risk of overtreatment, added to the need for reducing prevalence of NCDs. Primary health care can play a pivotal role to this purpose. Evt. Examples of outstanding Outcome achievements in one or two countries: • Moldova has reviewed and identified, among other priorities, the need for: human resources planning and management for PHC; more emphasis on inter sectoral work and integration in community; continuous development of informational systems at providers’ level; revision and improvement of performance indicators; increased access to subsidized medicines at PHC level; review of opportunities for co‐payments to control unjustified demand. These conclusions and recommendations will serve as the basis for further policy actions and investments at country level. • Slovakia has in a WHO supported meeting between general practitioners and the MOH identified a need to revise the norms for a minimum network and adopt standard diagnostic and therapeutic guidelines for GPs aimed at high quality and effectiveness of care in this segment of the health system. The fact that more than half of all GPs in Slovakia are older than 50 years is an urgent issue to resolve by increasing motivation and improving working conditions. The meeting concluded with a discussion between GPs and the Ministry of Health on how to make the best use of the findings. Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/countries/republic‐of‐moldova/news/news/2013/03/policy‐dialogue‐on‐health‐service‐delivery‐in‐the‐republic‐of‐ moldova‐from‐evidence‐to‐practice http://www.euro.who.int/en/health‐topics/Health‐systems/primary‐health‐care/publications/2012/evaluation‐of‐the‐structure‐and‐provision‐of‐ primary‐care‐in‐the‐republic‐of‐moldova http://who.sk/images/stories/Sprava_neoficialny%20preklad.pdf www.phc35.kz. General narrative on deliverable: WHO has contributed to the technical organization of the International Anniversary conference marking 35 years of the Declaration of Alma‐Ata on PHC and the development of a first draft of the paper on revitalized PHC. A multi country study on Ambulatory Care Sensitive conditions was launched in few countries and will help to better overcome the barriers that impede treatment of certain conditions at primary care level. WHO supported MS in platforms and technical meetings to develop and improve PHC including implementing the Primary Care Evaluation Tool (PCET). A benchmark report (10 countries) on the PCET, the Horizontal analysis, is being developed in collaboration with NIVEL.

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WHO participated to numerous events and networks to align the work of WHO with developments in other settings, such as OECD, NDPPH, European Forum for PHC, WONCA and the International Hospital Federation. The WHO Regional Committee for Europe RC64 has approved the establishment of a Centre for Primary Health Care and Health Services Delivery, hosted in Almaty by the Government of the Republic of Kazakhstan. Technical assistance was provided to AND, BLR, EST, GRE, KAZ, KOS, MDA, SVK, TJK, TUR, UZB.

Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/Health‐systems/primary‐health‐care/news/news/2013/11/celebrating‐35‐years‐of‐commitment‐to‐ primary‐health‐care‐in‐the‐who‐european‐region http://www.euro.who.int/en/health‐topics/Health‐systems/primary‐health‐care/news/news/2013/08/european‐forum‐for‐primary‐care‐ conference‐balancing‐primary‐and‐secondary‐care‐provision‐for‐more‐integration‐and‐better‐health‐outcomes http://www.euro.who.int/en/health‐topics/Health‐systems/health‐service‐delivery/news/news/2013/10/framework‐for‐action‐towards‐ coordinatedintegrated‐health‐services‐delivery‐cihsd‐launched http://www.euro.who.int/__data/assets/pdf_file/0005/231692/e96929.pdf

Challenges: Need to define tools for improving coordination of providers, integration of services and implementing models of care that are people centred. Understanding the barriers that impede scaling up quality services specially to reach vulnerable populations. Lessons learned: PHC needs to take into account the full concept of people‐centred health care services, coordination, integration and continuity of care, revised role of hospitals, coordination, organization and management of health providers, patient management and disease management, life course, chronicity including palliative, among other relevant aspects that challenge scale up universal health coverage interventions by Ms. Plans for 2014‐2015: Establishment and start up of the new WHO Centre for PHC to better support the increasing needs of MS. Further development of the work on Coordinated/Integrated care and ambulatory care sensitive conditions.

144

Outcome 75 Assessment (OPO)

SO.10.011 Member States have improved their reporting on national health OSER Achievement accounts (NHA) and strengthened their capacity to generate evidence on Fully 4 resource flows, the costs and effects of interventions, equity in the Partially Not‐achieved finance and receipt of health services, and the extent and distribution of Not‐reported catastrophic and impoverishing levels of health spending. Total 4 Outcome responsible: Mrs Melitta Zsuzsanna Jakab General narrative on Outcome achievement: Member States have improved their reporting of health expenditures by adopting the new standard (SHA 2011) and institutionalising new reporting standards (Hungary, Moldova, Kyrgyzstan, etc). Several MSs excel at using health financing tracking data to inform policy decisions on budget allocation and priority setting (e.g. Estonia, Kyrgyzstan, Moldova) Contribution to public health impact: Better expenditure tracking allows improved priority setting and more equitable and efficient resource allocation of resources in order to move towards universal health coverage and improve health outcomes and their distribution as evidenced in several MSs (Moldova, Ireland, and Kyrgyzstan). Evt. Examples of outstanding Outcome achievements in one or two countries: • Moldova. NHA is becoming institutionalized and the country has conducted a range of other health financing analysis including on financial protection and transparency (informal payments). • Georgia. NHA published annually in an institutionalized manner and results feed policy dialogue. Analysis conducted to track financial protection. This has contributed to intensified policy response to expand coverage. Evt. Supportive documentation for Outcome achievement:

Health Financing Paper documents institutionalization efforts for better health expenditure reporting and NHA network efforts to facilitate this http://www.euro.who.int/en/health‐topics/Health‐systems/health‐systems‐ financing/publications2/2012/20111‐behind‐the‐estimates‐of‐out‐of‐pocket‐spending‐on‐health‐in‐the‐ former‐soviet‐union

General narrative on deliverable (Output) EURO participated in an inter‐agency effort to improve the norms and tools for health expenditure tracking and reporting (System of Health Accounts or SHA). Regional training events were carried out. Tailored support was provided to Member States to introduce and solidify new tools. Regional expenditure analysis was carried out. Links to supportive documentation for deliverables

Inter‐agency technical workshop of health financing framework under SHA 2011 (France) http://www.euro.who.int/en/health‐topics/Health‐systems/health‐systems‐ financing/news/news/2012/11/technical‐workshop‐on‐the‐implementation‐of‐the‐health‐financing‐ framework‐under‐sha‐2011

Sub‐regional workshop on expenditure tracking (Kyrgyzstan) http://www.euro.who.int/en/health‐topics/Health‐systems/health‐systems‐financing/activities/national‐ health‐accounts‐estimates‐of‐national‐health‐expenditures/training‐workshop‐on‐the‐system‐of‐health‐ accounts‐2011‐and‐tracking‐of‐rmnch‐expenditures

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Challenges: Health expenditure data validity remains a major issue in several MSs and quality improvement requires more effort. In addition, greater use and analytical work drawing on health expenditure data could have greater impact on policy decisions. Institutionalization and capacity remain major issues in selected MSs. Lessons learned: Health expenditure tracking and analysis of financial protection and equity has been a powerful instrument to build political support for universal health coverage in several Member States where sufficient investments in this direction were made. Plans for 2014‐2015: Continued inter‐country analytical work on health financing trends, financial protection and equity, and support to selected countries in capacity building, institutionalization, and policy follow‐up.

146

Outcome 76 Assessment (OPO)

SO.10.012 Member States have strengthened their capacity to gather and assess OSER Achievement evidence, and formulate, implement and evaluate, evidence‐informed Fully 7 health system financing policies to improve and sustain financial risk Partially protection, equity in finance and the distribution of resources and Not‐achieved services, access to care, efficiency, and transparency. Not‐reported Total 7 Outcome responsible: Mr Tamas Evetovits General narrative on Outcome achievement: Member States have strengthened their capacity in health financing policy demonstrated by greater use of health evidence in policy decisions, and thorough evaluation on their impact to improve and sustain financial risk protection, equity, access and transparency. Strengthened capacity achieved through training courses, on‐the‐job training, country to country exchange, etc. Contribution to public health impact: Strengthened capacities in countries to ensure equitable and efficient use of resources in a transparent manner for improved financial protection and access with increased spending on cost‐effective public health services. These improvements lead to improved health outcomes and their more equitable distribution. Evt. Examples of outstanding Outcome achievements in one or two countries: • Kyrgyzstan. Continued to adjust and fine‐tune health financing arrangement to improve financial protection and equity while balancing a tight budget with a continued structural deficit. • Hungary. Financial protection analysis and report created demand for regular monitoring, process has been institutionalized and fully integrated into MOH work plan and structures with adequate national resources. Evt. Supportive documentation for Outcome achievement:

Kyrgyzstan policy monitoring and impact analysis: http://www.hpac.kg/ http://densooluk.med.kg/en/

Hungary: Ministerial Decree issued by Hungarian MOH and printed in the official bulletin of the Government and available upon request (in Hungarian only). Report documenting process is currently under editing and will be available at: http://www.euro.who.int/en/countries/hungary. General narrative on deliverable (Output): Highly successful delivery of four training courses by the Barcelona office attended by more than 200 policy makers and experts from 24 countries. Capacity building in countries through support to health financing policy analysis units, sector monitoring efforts, analytical work and reporting on financial risk protection, equity, efficiency and transparency.

Links to supportive documentation for deliverables

Barcelona course on health financing: http://www.euro.who.int/en/health‐topics/Health‐systems/health‐systems‐financing/activities/learning‐ opportunities‐and‐training‐courses/barcelona‐course‐on‐health‐financing

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Flagship course on health systems w/ a focus on NCDs: http://www.euro.who.int/en/health‐topics/Health‐systems/health‐systems‐ financing/news/news/2012/10/flagship‐course‐on‐health‐system‐strengthening‐focus‐on‐ noncommunicable‐diseases

Challenges: Sustaining the impact of country level capacity building is a challenge when funding is at risk after project completion therefore institutionalization is of vital importance. Lessons learned: State of the art training courses are effective means for building capacity and supporting country level policy dialogue. Plans for 2014‐2015: Continued delivery of annual training courses on health financing with a focus on universal health coverage and on health system strengthening with a focus on NCDs. Intensive capacity building in selected countries.

148

Outcome 77 Assessment (OPO)

SO.10.008 Member States have strengthened their knowledge base on the health OSER Achievement workforce at the country, regional and international levels. Fully 18 Partially Not‐achieved Not‐reported Total 18 Outcome responsible: Dr Galina Perfilieva General narrative on Outcome achievement: Member States have strengthened their information and knowledge base on health workforce. In the review period 46 countries (out of 53 in the region) have reported validated statistics on human resources for health (employment and education) to the Joint data base (WHO Europe, OECD and Eurostat). A sub‐ regional Observatory on HRH established for South‐Eastern Europe Health Network Countries (10 countries) hosted by the Republic of Moldova. 21 countries in the region have committed working on EU Joint Action on health workforce planning and forecasting. Contribution to public health impact: Effective policy‐making to respond to health workforce challenges requires solid information, reliable research and a firm knowledge base. Robust and reliable HRH databases in countries allow proper analysis and planning of the workforce. Supporting countries in strengthening their capacity contributes to effective policy making and improving the performance of health systems. Evt. Examples of outstanding Outcome achievements in one or two countries: • Republic of Moldova: Increased technical capacity in the country to assess, monitor and plan strategically human resources for health through the improved information system, research and series of training courses, study visits and policy dialogues with national stakeholders. Established national and sub‐regional (SEEHN) Observatory on HRH for information sharing and supporting decision making. (The outcome was made possible due to the EU funded project “Better managing mobility/migration of health professionals in the Republic of Moldova” managed by WHO Europe. • Hungary: Established National Observatory on HRH with a network of country stakeholders; improved information and knowledge base on HRH through consolidated efforts of all national actors; established a roster of HRH experts and stakeholders; convened a policy dialogue for consensus building on the Joint Action at national level; established a web‐based communication platform on HRH issues. Evt. Supportive documentation for Outcome achievement: http://seehrhobs.blogspot.com/ http://www.medici‐in.md/home

General narrative on deliverable (Output): • Technical consultations on HRH data collection and validation; • WHO guidelines on HRH information systems and Observatories; • Capacity building workshops and training packages; • Recommendations on HRH issues to MSs and partners • Roster of experts, networks of national focal points, institutions; • Publications. Links to supportive documentation for deliverables http//www.euro.who.int/en/health‐topics/Health‐systems/health‐workforce/publications2

Challenges: Limited human and financial resources in the programme; Statistical data on HRH remains a challenge for

149 all MSs due to many sources of HRH data in countries and lack of coordination of information flows; introduction of the new variables and definitions for Joint Data collection (OECD, Eurostat, WHO Europe), discrepancies between the Global Atlas on HRH and Joint Data collection in terms of indicators. Lack of consensus on min data set for monitoring HRH migration flows between international partners. Lessons learned: In spite of high promotion of countries in the region regularly reporting health workforce statistics, the quality of data varies considerably. Further inter‐divisional cooperation on HRH statistics with DIR, collaboration with Eurostat and OECD is required. Progress has been achieved in harmonizing HRH indicators, definitions and procedures in all European countries and establishing Joint Data base for OECD, Eurostat and WHO Europe. Inconsistency remains between the Joint Data Base and the Global Atlas on HRH. Efforts have been made to establish national Observatories on HRH using modalities and experience from other WHO regions. The progress on this is limited in a few countries; a promotion of good experience will be required. The case of Moldova in developing HRH information system and training the staff dealing with this system can be learned and followed by other countries.

Plans for 2014‐2015: Responding to the above challenges and lessons learned, the Regional Office will continue working with all relevant partners to improve the information and knowledge base on human resources for health at national, regional and international levels. A particular focus will be on health workforce migration flows and building consensus with partners on the minimum data set to monitor these flows. Further research will be conducted to generate evidence to support decision and policy‐making in Member States.

Further efforts will be made to harmonize HRH indicators and definitions with the WHO Global Atlas on HRH.

150

Outcome 78 Assessment (OPO)

SO.10.009 Member States have strengthened their capacity to monitor and OSER Achievement analyse health workforce dynamics, and to formulate, implement and Fully 16 evaluate evidence‐ informed health workforce policies, strategies, and Partially 1 plans. Not‐achieved Not‐reported Total 17 Outcome responsible: Dr Galina Perfilieva General narrative on Outcome achievement: There are no countries in the European region with critical health workforce shortages, but ensuring an appropriate, trained and sustainable workforce is clearly one of key challenges for European health policy makers now and in the future. In the review period the awareness about the health workforce issues has increased in Member States, national capacity to monitor and analyse health workforce dynamic strengthened. 42 countries (out of 53 in the region) have established designated national authorities (DNAs) responsible for monitoring and reporting information on health personnel migration and the implementation of the WHO Code of Practice. 36 countries had submitted their reports to the WHO Secretariat. Information on countries’ experiences in development, implementation and evaluation of health workforce policies, strategies and plans was shared and discussed at various regional, sub‐regional and country events.

Contribution to public health impact: One of the most important inputs in strengthening health systems is health workforce policies. The effectiveness of health systems and the quality of health services depend on the availability, affordability, accessibility and quality of health workers to the population health needs. Strengthening national capacity to deal with health workforce issues ensures that countries can build their health workforce in support of achieving health outcomes. Evt. Examples of outstanding Outcome achievements in one or two countries: Republic of Moldova: Increased country capacity to address challenges of health professionals’ mobility/migration, recruitment, retention and performance, based on evidence generated from series of research studies conducted in the Republic of Moldova and destination countries for Moldovan migrant health workers. Consensus was achieved between all national stakeholders on the draft generic bilateral agreement to regulate circular migration and international recruitment of Moldovan health professionals and to reduce brain drain/waste. The Moldovan experience was shared and promoted across the region and beyond. Evt. Supportive documentation for Outcome achievement: http://www.medici‐in.md/home http://ms.gov.md/stiri/ministerul‐sanatatii‐si‐biroul‐organizatiei‐mondiale‐sanatatii‐republica‐moldova‐ lanseaza General narrative on deliverable (Output): • WHO Europe – led network of DNAs • Regional strategy and tools, for the implementation of the WHO Code; • Multi‐stakeholders policy dialogues; • Consultative meetings on health professions education in support of Health 2020 • WHO Regional meeting of Chief Nursing Officers • Draft Strategic Directions for Strengthening Nursing and Midwifery Services towards Health 2020; • Manual for developing country case studies of good nursing and midwifery practice; • Publications.

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Links to supportive documentation for deliverables http://www.euro.who.int/en/health‐topics/Health‐systems/health‐workforce/publications2/2013/who‐ policy‐dialogue‐on‐international‐health‐workforce‐mobility‐and‐recruitment‐challenges‐technical‐report http://www.euro.who.int/en/health‐topics/Health‐systems/health‐ workforce/publications2/2012/roadmap‐implementing‐the‐who‐global‐code‐of‐practice‐in‐the‐ european‐region http://www.euro.who.int/en/health‐topics/Health‐systems/health‐ workforce/publications2/2012/toolkit‐for‐country‐health‐workforce‐strengthening http://www.euro.who.int/en/health‐topics/Health‐systems/health‐ workforce/publications2/2012/implementing‐the‐who‐global‐code‐of‐practice‐on‐international‐ recruitment‐of‐health‐personnel‐in‐the‐european‐region‐draft Challenges: Limited human and financial resources in the programme; HRH – complex, many stakeholders involved with different interests, inter‐and cross‐sectoral approach required; weak country capacities to address HRH issues, limited number of experts in the respective area of HRH, most of experts with a narrow focus (education, migration, policy, performance, etc). Lessons learned: Due to demographic and epidemiological changes in Member States (ageing and noncommunicable diseases) the demand for health care services/health workers increased. The impact of the financial crisis varied across the region. Country capacity to deal with HRH issues has increased in the past years, but still remains weak and unevenly distributed. In spite of the importance of HRH and their impact on health system performance, Member States demonstrated different levels of political commitments to address HRH challenges. Dealing with multiple stakeholders on HRH at national level was recognized and reported by DNAs as the biggest problem, due to different interests and objectives of stakeholders (private and public sectors, governmental organizations and NGOs, etc.). Close collaboration with international partners contributed to achieving common objectives and maximizing efficient use of limited resources. Plans for 2014‐2015: WHO will continue monitoring the progress on the implementation of the WHO Global Code of Practice (WHA resolutions) and support Member States in the process (to the extent possible). This work will be done in cooperation with national focal points, DNAs and all relevant partners through technical consultations, policy dialogues and information sharing and exchange. Facilitation of dialogue between stakeholders and work across sectors is planned for 2014‐2015. Compendium of support materials and countries case studies of good practices will be developed. A particular focus will be on strengthening nursing and midwifery services in Member States, as well as transforming health professional education and training in support of Health 2020 and UHC in the European region.

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Outcome 79 Assessment (OPO)

SO.10.013 Member States have enhanced the quality and safety of OSER Achievement health care services, through an integrated approach that Fully 9 focuses on the patient, the provider and the service Partially 1 Not‐achieved Not‐reported Total 10 Outcome responsible: Dr Valentina Hafner General narrative on Outcome achievement: Adherence to Clean care and World Blood Donor day events in Member States across the region came as a result of advocacy and support to institutionalization of safety interventions in health care. Four countries participated in a taxonomy review for research on patient participation in reducing health care related risks initiating further work on patient engagement Multi stakeholder partnership continued through shared best practices and awareness‐raising in blood and transplant services and patient safety. Four countries analysed existing reporting mechanisms developing national networks of stakeholders, coordinating results within OECD and EU PASQ (EU joint action for patient safety follow up) and two of these countries applied for national piloting of the minimal information model for patient safety, expected to harmonize reporting requirements. Contribution to public health impact: Blood and transplant services are important public health issues, with direct epidemiological impact (blood borne pathogens and nosocomial infections), close links to education to healthy life style (donor criteria), and prevention of chronic conditions leading to organ impairment. Information and screening for risk factors for infectious diseases reduced service safety risks related to transmission of HIV, hepatitis and emerging/imported malaria and West Nile virus, feeding into rapid alert and surveillance mechanisms at national and sub‐regional level Evt. Examples of outstanding Outcome achievements in one or two countries: • Poland – signature of the Clean care pledge, and national scale implementation of safe surgery checklist. Following wide implementation of the safe surgery checklist in Polish hospitals, the tool was adapted to 9 surgical specialties, piloted and agreed for scale up at national level in December 2013. Work was done in collaboration with the WHOCC for quality of care Krakow • Slovakia – national patient safety network established drawing from three rounds of evaluating reporting mechanisms for patient safety at country level. Work was based on evaluating the costs of adverse events in Slovakian hospitals and policy and organizational changes subsequent to successive dedicated BCAs Evt. Supportive documentation for Outcome achievement: http://www.euro.who.int/en/countries/poland/sections/news/2013/10/poland‐hosts‐multicounty‐ workshop‐on‐patient‐safety General narrative on deliverable (Output) Work focused on supporting health service reform and institutionalization of integrated quality and safety interventions in health care. A taxonomy review for integrated people centred health service delivery was completed in 2012 and research on patient participation in reducing health care related risks in 2013. Multi stakeholder partnership continued through shared best practices and awareness‐raising in blood and transplant services and patient safety. Particular emphasis was given to reporting and monitoring risks in health care for tailoring standardized safety interventions. Links to supportive documentation for deliverables http://www.euro.who.int/en/publications/abstracts/exploring‐patient‐participation‐in‐reducing‐health‐ care‐related‐safety‐risks http://www.euro.who.int/en/countries/slovakia/news/news/2013/02/advancing‐patient‐safety‐in‐

153 slovakia

Challenges: Limited financial and human resources Lessons learned: Wide consultation processes and multi stakeholder/partner coordination are important to ensure regional and national adherence to guidelines. Work with WHOCCs and expert networks was a success factor in advancing implementation, by complementing the existing technical and administrative capacity of the programme. WHOCC Krakow proved instrumental in implementing agreed BCA work on a national basis, in close collaboration with Country Office and technical unit. Plans for 2014‐2015: Blood and transplant services have not been considered as such regional priorities for the biennium. Work will continue to provide input in the process of health systems strengthening through integrated interventions for health promotion, disease prevention and quality and safety of care (i.e. policy advice and capacity building in quality and safety management), in close collaboration with HQ, EU and OECD, WHOCCs and expert networks.

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Outcome 80 Assessment (OPO)

SO.10.005 Member States utilize the information and analytical products OSER Achievement provided by EURO to Member States for planning, monitoring and Fully 7 evaluation of health situation and inequalities at country level Partially Not‐achieved Not‐reported Total 7 Outcome responsible: Dr Enrique Gerardo Loyola Elizondo

General narrative on Outcome achievement: Member States are using a number of information and analysis products, including the European Health Report to compare their heath situation and trends, particularly as it relates to the Health 2020 policy targets and indicators. HFA databases are used as references for comparisons of health indicators but also as examples to set up national indicators data presentation systems.

Contribution to public health impact: HFA databases continue to be essential for health information comparisons in European Member States’ monitoring and health situation assessments. This allows them to determine health inequalities and how they are doing over time, how do they fare compared to neighbouring or other countries and what health determinants and risk factors make them different that could be addressed to improve the health inequalities situation. Following the examples prepared by WHO is a mean to promote national capacity development. WHO health information products are highly regarded and used for public health monitoring and reporting at both regional and national levels, while helping to meeting monitoring mandates of WHO Member States. Availability of products in Russian language adds value to these products.

Evt. Examples of outstanding Outcome achievements in one or two countries: • Several Member States are taking a leading role with assessments of health inequalities. A major challenge is linking different data sources to allow the stratification of socioeconomic groups and their health situation. Lithuania prepared a national report setting an example that this is possible even in settings without fully integrated systems. Strong commitment, institutional collaboration and innovative thinking made this possible. • Member States follow the WHO approach and tools to produce their own HFA‐based health indicators systems. Recently, the Czech Republic, Italy, Lithuania, Serbia and Spain have produced subnational level indicators systems with DPS

Evt. Supportive documentation for Outcome achievement: Over 30 Member States are using the HFA model for developing their own databases and analysis tools. In addition, several Member States use the HFA data to compare their situation with other countries and/or subregions. Some examples from the Czech Republic on mortality and mental health may be found at http://www. Uzis.cz/en/catalogue/deaths, http://www.uzis.cz/en/fast‐information/demographic‐situation‐czech‐ republic‐2012 http://www.uzis.cz/en/category/tematicke‐rady/who‐data Although Scotland is part of the UK it has also used HFA data and tools to prepare their own system to allow for their comparative health analyses. http://www.scotpho.org.uk/comparative‐health/scotland‐ and‐european‐hfa‐database

General narrative on deliverable (Output): Increased number of health information analyses and products. Based on biannually updated HFA family of databases, the European Health Report 2012 was

155 produced as an important input for priority and target setting of Health 2020 policy. Atlases of health inequalities are updated with additional functionalities to monitor change and used for specific topics (e.g. health and ageing, on cardiovascular diseases and injuries and poisonings). The addition of a German JPO staff, additional training and the use of electronic tools are catalytic factors.

Links to supportive documentation for deliverables

Following the development of the European Health Report 2012: charting the way to well‐being. http://www.euro.who.int/en/data‐and‐evidence/european‐health‐report‐2012, several Member Statesare preparing their monitoring framework for Health 2020 indicators and using EURO data for comparisons, for example Turkey in their Ministry of Health strategic plan 2013‐2017. http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/stratejikplaning.pdf In addition, the Atlas of Health Inequalities. http://www.euro.who.int/en/data‐and‐evidence/equity‐in‐ health‐project/interactive‐atlases has motivated countries to develop their own Atlases systems. One example from the UK has been developed for its regions. http://www.apho.org.uk/resource/item.aspx?RID=127334

Challenges: Improving quality of some health information systems and their outputs in several Member States, when resources are limited. Further understanding of the implications and working together with other technical units of WHO is necessary to increase and enhance health information products.

Lessons learned: Establishing the Autumn School has allowed to involve Member States in capacity building, including the availability and use of WHO health information products (e.g. HFA, European Health Reports, Highlights of Health, among others). This should lead to increased use of those products and development of national ones. Collaborating with other international partner organizations (e.g. OECD and EC) to improve harmonization of definitions, improvement of data and metadata and reducing the burden of collection on Member States, increases the efficiency and synergy of the work and outcomes. The addition of a German JPO staff, additional training of Member States’ professionals and the availability and use of electronic tools are catalytic factors.

Plans for 2014‐2015: In order to increase uptake of EURO health information by Member States, consideration has been given for preparation of new high quality health information products (e.g. European Health Statistics and the country Highlights of Health and Wellbeing) to monitor progress of Health 2020 targets indicators, that will be directly linked to their national efforts. Expand the cooperation of international organizations to other collections.

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Outcome 81 Assessment (OPO)

SO.10.007 Member States utilize knowledge management methods and tools OSER Achievement for the collection, storage and dissemination of their information Fully 1 Partially 1 Not‐achieved Not‐reported Total 2 Outcome responsible: Dr Enrique Gerardo Loyola Elizondo General narrative on Outcome achievement: Progress in reaching the outcome was made by assisting Member States to strengthen their capacity to collect and analyse data and to increase the level of interoperability of communication between systems at the national level ‐ hence improving the quality of Health Information and its ability to be utilized in policy formulation. Contribution to public health impact: Improvements to the quality of health information in Member States was made in two ways. By improving the quality and interactions of health information systems and by establishing facilities for information sharing among different healthcare professionals. This allows citizens to be better informed and increase interaction with the health system to enhance their knowledge of health. Evt. Examples of outstanding Outcome achievements in one or two countries: • The Republic of Moldova made important progress towards the development of a national eHealth strategy. As a result of this process, the Ministry of Health will have a clearly defined roadmap to improve governance and maximize synergies of efforts in the country. • Estonia has become a leader of eHealth, as reflected in the Tallinn Conference on Health, Health systems and Wealth, where experiences were shared with Member States. With limited resources they “leaped‐frogged” with innovation uptake and systems development, having citizens at the centre of their strategy. Evt. Supportive documentation for Outcome achievement: “Reference / link to documents, reports, publications, etc.” http://www.slideshare.net/alexandrurosioru/ehealth‐strategy‐of‐republic‐of‐moldova http://www.euro.who.int/__data/assets/pdf_file/0014/232511/Abstract‐Parallel‐Session‐D‐Using‐ eHealth‐to‐improve‐health‐systems‐performance.pdf http://www.telemed.no/index.php?cat=7398

General narrative on deliverable (Output): Increasing demand for guidance on eHealth strategy development by Member States required additional HMA efforts however resources were limited for this area. Through partnerships with international organizations, WHO Collaborating Centres and WHO/HQ, a contribution was made towards achieving this outcome. Direct technical support to countries on implementation of eHealth solutions was carried out and guidance and tools for development of eHealth strategies and interoperability of systems were promoted and disseminated.

Links to supportive documentation for deliverables

Directory of eHealth Policies http://www.who.int/goe/policies/countries/en/index.html

WHO Press Release, Moldova eHealth Strategy Development http://www.euro.who.int/en/countries/republic‐of‐moldova/news/news/2013/06/moving‐toward‐a‐

157 comprehensive‐ehealth‐strategy‐in‐the‐republic‐of‐moldova

Challenges: Limited resources at WHO and difficulty in identifying and engaging the relevant national stakeholders, including the private sector with its strong influences, in a field that needs to be better coordinated among international agencies aiming to improve information systems for the health of citizens. Lessons learned: Ensure that Member States have a unified understanding of the rationale for national eHealth strategy development. e.g. The Moldovan government is modernizing its functions through ICT, creating conditions to improve efficiency while centring focus on citizens, having an eHealth strategy as first step. Joint contributions of international organizations, the NOR WHO Collaborating Centre on eHealth and WHO provided funding and technical resources to achieve this goal which was the crucial factor in achieving success. Plans for 2014‐2015: Working to implement WHA Resolution 66.24 for eHealth in the European Region and to develop the eHealth agenda, specifically through the development of national eHealth strategies, provision of technical guidance to implement interoperability standards and providing assistance to Member States for implementation of major eHealth initiatives (e.g. Electronic Health Records). Support from the WHO NOR Collaborating Centre will be stepped up to support this implementation.

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Outcome 82 Assessment (OPO)

SO.10.005 Member States will use OSER Achievement (i) Evidence on their own and other health systems. Fully 18 (ii) Thematic and comparative evidence on key themes. Partially (iii) Evidence on comparative performance. Not‐achieved 1 (iv) Ongoing evidence updates and dissemination tools to mobilize and “translate” evidence to their own context; to assess and evaluate policy Not‐reported options; to support better decision making, and to strengthen reform Total 19 processes Outcome responsible: Ms Suszy Lessof General narrative on Outcome achievement: MS are increasingly proactive in using evidence and setting policy choices in the context of others’ experience. They use HiTs to understand health systems (Belarus, Latvia, Malta) and the analysis generated to inform policy debate (primary care Austria; hospital financing BIH; influencing health behaviours Sweden) and call on knowledge brokering (dialogues, briefings) to support decision making. Contribution to public health impact: MS are using evidence in responding to financial crisis and other challenges (governance, public health). Health policy makers have mobilized data and comparative analysis in debates with other sectors to support steps that ameliorate the adverse effects of crisis (e.g. targeting benefits at low income groups France, Ireland, Moldova, increasing taxes on alcohol, promoting exercise, screening, Belgium, Bosnia and Herzegovina, Hungary) and to promote reforms which protect public health (resisting cuts Cyprus, Hungary, Ireland, Lithuania). It is not of course possible to attribute policy decisions to any single evidence intervention but MS are demonstrably consulting evidence (Observatory and WHO) as part of their decision‐making.

Evt. Examples of outstanding Outcome achievements in one or two countries: • Estonia has promoted the notion of evidence for decision making, hosting the Tallinn conference and championing a focus on evidence and governance. In practice decision makers have actively called for and used evidence; convening a mini‐seminar on strategic purchasing of healthcare services within and across borders, including reviewing the implications of the EU cross‐border care Directive; facilitating a sub‐regional dialogue on the evidence on free movement, cross‐border care and professional mobility. Decision makers have incorporated reviews of comparative experience in formulating national approaches (including on purchasing, improving quality and health system performance) although again policy consequences cannot be traced to particular evidence interventions. Estonia has also joined the HSPM on‐line monitoring initiative. • Slovenia has actively called for and used evidence to support work on health strategy, primary prevention, financing, and public health. It instigated a series of policy dialogues to marshal evidence, external expertise and comparative analysis and integrated it into the development of its public health strategy and in formulating health financing reform. Slovenia also took part in the central European policy dialogue series; sent professionals to the Observatory Summer School to increase their capacity to apply evidence; and participated in HSPM on‐line monitoring. Its policy decisions are of course informed by many elements but health decision makers consistently include evidence in their deliberations. Evt. Supportive documentation for Outcome achievement: • Translation of the Estonian HiT into Estonian Lai T, Habicht T, Kahur K, Reinap M, Kiivet R, van Ginneken E. Estonia: health system review. Health Systems in Transition, 2013; 15(6):1–196 • 10th Baltic policy dialogue 28‐9.11.13; Free movement in health care – a sub‐regional approach to cross border care and health professional mobility

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• Policy dialogue 11.09.13 Reforming health financing in Slovenia options and challenges • Consensus conference: 13.09.13 Public health in Slovenia Action plan 2014‐2015 General narrative on deliverable (Output):

Links to supportive documentation for deliverables Country monitoring HiTS : All country profiles are substantive documents authored by national experts with Observatory technical support and editing and external review. For full details of each see http://www.euro.who.int/en/about‐us/partners/observatory/health‐systems‐in‐transition‐hit‐series 2013 (Volume 15): • Armenia: health system review. Richardson E. • Austria: health system review. Hofmarcher MM, Quentin W • Belarus: health system review. Richardson E, Malakhova I, Novik I, Famenka A. • Canada: Health system review. Marchildon G • Estonia: health system review. Lai T, Habicht T, Kahur K, Reinap M, Kiivet R, van Ginneken E. • Lithuania: health system review. Murauskiene L, Janoniene R, Veniute M, van Ginneken E, Karanikolos M. • United States of America: health system review. Rice T, Rosenau P, Unruh LY, Barnes AJ, Saltman RB, van Gineken E. 2012 (Volume 14) • Bulgaria health system review. Dimova A, Rohova M, Moutafova E, Atanasova E, Koeva S, Panteli D, van Ginneken E • Cyprus health system review. Theodorou M, Charalambous C, Petrou C, Cylus J. • Denmark health system review. Olejaz M, Juul Nielsen A, Rudkjøbing A, Okkels Birk H, Krasnik A, Hernández‐Quevedo C. • Kazakhkstan health system review. Katsaga A, Kulzhanov M, Karanikolos M, Rechel B. • Latvia: Health system review. Mitenbergs U, Taube M, Misins J, Mikitis E, Martinsons A, Rurane A, Quentin W • Republic of Moldova health system review. Turcanu G, Domente S, Buga M, Richardson E. • Sweden health system review. Anell A, Glenngård AH, Merkur S. • United Kingdom (Northern Ireland): Health system review. O'Neill C, McGregor P, Merkur S • United Kingdom (Scotland): Health system review. Steel D, Cylus J. • United Kingdom (Wales): Health system review. Longley M, Riley N, Davies P, Hernandez‐Quevedo C. • Veneto Region, Italy. Health system review. Toniolo F, Mantoan D, Maresso A. The Health Systems and Policy Monitor: The Observatory has established a new on‐line monitoring function with 18 countries currently updating their country profile ’live’. The updates are by the the HSPM network of national expert instututions and are supported by Observatory techncial staff. All pages are available through http://www.hspm.org/mainpage.aspx Belgium; France; Israel; Italy; Netherlands; Spain; Denmark; Hungary; Poland; Portugal; Slovenia; Sweden; UK; Bulgaria; Canada; Estonia; Ireland; Lithuania

Analysis Studies: The Observatory produces thematic volumes, case studies and comparative analysis by working with extensive networks of academics and practitioners. Selected examples only include • Mackenbach JP, McKee M. (eds) Successes and failures of health policy in Europe. Four decades of divergent trends and converging challenges Open University Press Buckingham 2013 http://www.euro.who.int/en/about‐ us/partners/observatory/studies/successes‐and‐failures‐of‐health‐policy‐in‐europe.‐four‐decades‐of‐divergent‐trends‐and‐ converging‐challenges • Jakubowski E and Saltman R (eds) The changing national role in health system governance. A case‐based study of 11 European countries and Australia World Health Organization and European Observatory on Health Systems and Policies 2013 http://www.euro.who.int/en/about‐us/partners/observatory/studies/changing‐national‐role‐in‐health‐system‐governance‐ the.‐a‐case‐based‐study‐of‐11‐european‐countries‐and‐australia • Leppo K, Ollila E, Peña S, Wismar M, Cook S (eds) Health in All Policies ‐ Seizing opportunities, implementing policies Copenhagen, World Health Organization and European Observatory on Health Systems and Policies http://www.euro.who.int/en/about‐us/partners/observatory/studies/health‐in‐all‐policies‐seizing‐opportunities,‐ implementing‐policies • Palm, W., Glinos, I., Rechel, B., Garel, P., Busse, R., Figueras, J., editors 2013: Building European Reference Networks in Health Care. Exploring concepts and national practices in the European Union, Copenhagen, World Health Organization and European Observatory on Health Systems and Policies http://www.euro.who.int/en/about‐

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us/partners/observatory/studies/health‐system‐performance‐comparison.‐an‐agenda‐for‐policy,‐information‐and‐research • Martin‐Moreno JM, Albreht T, Radoš Krnel S Boosting innovation and cooperation in European cancer control Copenhagen, World Health Organization and European Observatory on Health Systems and Policies 2013 http://www.euro.who.int/__data/assets/pdf_file/0014/235211/Boosting‐Innovation‐and‐Cooperation‐in‐European‐Cancer‐ Control.pdf • Glinos I and Wismar W (eds) Hospitals and borders. Seven case studies on cross‐border collaboration and health system interactions World Health Organization and European Observatory on Health Systems and Policies 2013 http://www.euro.who.int/en/about‐us/partners/observatory/studies/hospitals‐and‐borders.‐seven‐case‐studies‐on‐cross‐ border‐collaboration‐and‐health‐system‐interactions • Legido‐Quigley H, Panteli D, Car J, McKee M and Busse R (eds) Clinical guidelines for chronic conditions in the European Union World Health Organization and European Observatory on Health Systems and Policies 2013 http://www.euro.who.int/en/about‐us/partners/observatory/studies/clinical‐guidelines‐for‐chronic‐conditions‐in‐the‐ european‐union • Intersectoral governance for health in all policies. Structures, actions and experiences (2012) McQueen, Wismar, Lin, Jones and Davies (eds) http://www.euro.who.int/__data/assets/pdf_file/0005/171707/Intersectoral‐governance‐for‐health‐in‐all‐policies.pdf

Summaries, briefs and articles: There is a joint policy brief series with DSP that makes succinct and focussed evidence available while articles are used to reach different audiences and to inform health policy debate. Selected examples only include • Thomson S, J Figueras, T Evetovits, M Jowett, P Mladovsky, A Maresso, M Karanikolos, J Cylus, M McKee, M Jakab and H Kluge (2013), Health, health systems and economic crisis in Europe, Policy summary 10, Copenhagen: WHO/Europe and European Observatory on Health Systems and Policies. • Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, Mackenbach JP, McKee M. Financial crisis,austerity, and health in Europe. Lancet 2013: 381: 1323–31 • Merkur S, Sassi F, McDaid D (2013), Promoting health, preventing disease: is there an economic case? Policy Summary 6. Copenhagen, World Health Organization Regional Office for Europe http://www.euro.who.int/en/about‐ us/partners/observatory/policy‐briefs‐and‐summaries/promoting‐health,‐preventing‐disease‐is‐there‐an‐economic‐case • F Sassi and D McDaid (eds.) The Economics of Public Health and Health Promotion. OECD & European Observatory on Health Systems and Policies (forthcoming) • Mackenbach JP, Karanikolos M, McKee M. Health policy in Europe: factors critical for success. BMJ 2013: 2013;346:f533 • Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. Lancet 2013: 381: 1235–45

Performance The focus is not on measurement but the consequences (use and misuse) of measurement for policy decisions. There are domain reports ongoing, articles and • Smith PC, I Papanicolas and J Figueras (eds.) Health system performance comparison: an agenda for policy, information and research. Buckingham, Open University Press. http://www.euro.who.int/en/about‐us/partners/observatory/studies/health‐ system‐performance‐comparison.‐an‐agenda‐for‐policy,‐information‐and‐research Challenges: While Health Ministries seek to take evidence informed decisions, there are still barriers in making the policy case to Finance Ministries and to overcoming pressures for short term fixes that ignore lasting public health impacts. Lessons learned: Policy makers need clear, accessible evidence underpinned by credible expertise and trusting relationships, that is, above all, timely. Reacting rapidly may therefore be more effective than pushing for evidence to be included in a nationally owned process. Plans for 2014‐2015: OBS (which in 2014‐2015 is outside the WHO Programme budget) will refocus its combination of country monitoring, analysis, performance assessment and knowledge brokering to make the evidence it generates more timely and accessible. Analysis will be generated to address the most pressing policy priorities with an emphasis on tailoring how evidence is shared so that it can help policy makers take the best possible decisions in their specific contexts.

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Outcome 86 Assessment (OPO)

SO.11.002 Member States have improved capacity in regulation and quality OSER Achievement assurance for medical products (medicines, vaccines, blood products) Fully 11 and technologies Partially Not‐achieved Not‐reported Total 11 Outcome responsible: Ms Hanne Bak Pedersen General narrative on Outcome achievement 25 countries have improved their capacity in regulation and quality assurance for medical products.

18 products, manufactured by 6 companies in the European Region, were prequalified by the WHO PQ of medicines programme in 2013. One of them is anti‐TB product cycloserine produced in the Russian Federation. The Prequalification Collaborative Procedure was launched and serves to facilitate and accelerate national registration of products which WHO Prequalification of Medicines Programme has already assessed and prequalified. Three countries in the Region (KGZ, GEO and UKR) applied for participation in Collaborative procedure between the World Health Organization Prequalification of Medicines Programme and national medicines regulatory authorities in the assessment and accelerated national registration of WHO‐prequalified pharmaceutical products. Ukraine has amended existing regulation and provided exemption of fees for the fast track registration of these medicines.

Contribution to public health impact: Capacity development in regulation and quality assurance for medical product is an important element to safeguard patient safety as well as to ensure efficacy of medical products. Evt. Examples of outstanding Outcome achievements in one or two countries: Progress on capacity development in regulation and quality assurance for medical products (medicines, vaccines, blood products) and technologies have been very good in Azerbaijan, Belarus, Kazakhstan, the Russian federation and Ukraine.

Evt. Supportive documentation for Outcome achievement:

General narrative on deliverable (Output) Regulatory technical support continues to be important and HTP engage both at country specific level as well as with regional initiatives for convergence in regulation. Direct support to National Regulatory Authorities (NRAs) upon request has been provided when funding has been available to undertake the work. Participation in international, regional consultations as well as specific country support to strengthen regulation and oversight. Engagement in SSFFC and PQP activities.

In the WHO Pre‐qualification area a Joint UNICEF, UNFPA, WHO meeting was held at the UN‐City, Copenhagen in September 2013 with participation from 31 countries. This event provided a forum at which medicines and diagnostics manufacturers, quality, safety and efficacy experts, procurement agencies, and international donors working in public health, came together to focus on production and supply of quality essential medicines and priority diagnostics.

Assessment of medicines regulatory situation was performed in Georgia. The report was submitted to the Ministry of Labour, Health and Social Affairs.

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Links to supportive documentation for deliverables HTP annual report 2012: http://www.euro.who.int/en/health‐topics/Health‐ systems/medicines/publications2/2012/health‐technologies‐and‐pharmaceuticals‐annual‐report‐2012

WHO prequalification programme http://www.who.int/topics/prequalification/en/ Challenges: Limited HR and financial resources at the Secretariat has limited opportunities for direct country follow up. Some MS still requires substantial technical support to meet international requirements in the medical product regulation area. Lessons learned: Regulation of medical products varies across European countries and quality is still an issue to be mindful about. Regulatory convergence is desirable and WHO will continue to support countries in moving ahead in this area. Plans for 2014‐2015: Support to countries on regulatory systems development and continue engagement in WHO PQP activities. Provide assistance to the SSFFC MS Mechanism as relevant. Support to strengthen countries medical product quality monitoring including capacity to carry out audits. Engagement in WHO expert Committees as relevant including for AMR, EML.

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Outcome 87 Assessment (OPO)

SO.11.003 Member states have improved capacity and developed policies for OSER Achievement the rational use of medical products (medicines, vaccines, blood Fully 14 products) and technologies Partially Not‐achieved Not‐reported Total 14 Outcome responsible: Ms Hanne Bak Pedersen General narrative on Outcome achievement: 18 MS have improved capacity and developed policies for the rational use of medical products (medicines, vaccines, blood products) and technologies. Awareness raised on AMR. 14 non‐EU countries have undertaken drug utilisation studies of use antibiotics and developed pilot systems for monitoring antibiotic consumption. This pilot surveillance system needs further consolidation but provides a tool to develop quality indicators of antibiotic use and to assess the impact of policy and regulatory actions. Collection of valid, representative, comparable data on systemic antimicrobial use in these countries was undertaken and a cross country analysis made. To share the findings a peer reviewed publication is in preparation. Essential medicines list reviewed in 5 countries. Contribution to public health impact: Rational use of medicines is critical for the individual as well as for public health. Resistance to antibiotics is a major public‐health problem and antibiotic use is being increasingly recognised as the main selective pressure driving this resistance. Assessment of outpatient use of antibiotics and the association with resistance is key evidence required for appropriate policy action at country level. Evt. Examples of outstanding Outcome achievements in one or two countries: Turkey has further developed their pharmaceutical sector to support rational use medical products (medicines, vaccines, blood products) and technologies. Montenegro –blood service reform with completed update of legal framework, communication strategy for donor promotion drawing from social survey, training in quality standards and management Evt. Supportive documentation for Outcome achievement http://www.euro.who.int/en/countries/montenegro/sections/news/2013/11/meeting‐on‐blood‐ transfusion‐in‐montenegro General narrative on deliverable (Output) Policies for medical products are an important branch of a national health policy for every country. It deals with the development, provision and use of medications, medical devices and vaccines within a health care system. WHO Europe participated actively in policy dialogues of rational use including for antimicrobials with various countries in the European region. 3 sub‐regional consultations were held one of this a joint consultation with the European Observatory. 12 countries have been trained in strategies and systems for rational use of medical products, including on selection and cost‐containment, through 3 study tours and a number of individual country workshops.

Links to supportive documentation for deliverables HTP annual report 2012: http://www.euro.who.int/__data/assets/pdf_file/0007/185893/Health‐ Technologies‐and‐Pharmaceuticals‐final8.pdf Challenges: Limited HR and financial resources for the Secretariat limits responses to country requests. Particular focus is required for sustaining and expanding efforts in the AMR area as well as enhancing the prescribing

164 of low cost generics in line with WHO guidance. Lessons learned: Supporting countries in creating evidence for policy and decision making as well as supporting capacity, mechanisms and tools for monitoring and follow up has been efficient towards improving rational use of medical products.

Plans for 2014‐2015: Continuing work on AMR. Strengthening collaboration and technical support to countries on management of introduction of new high prices medical products.

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