The real challenge for Health 2020 is what happens to it following its endorse-ment by Member States. Endorseendorse-ments of earlier strategies like Health for All did not result in major advances in public health and while having such reminders of the needs and challenges that confront public health from time to time does no harm, producing such reports needs to add value rather than consume it. Other-wise they are of symbolic value only and short-lived. Part of the problem doubt-less lies in the very nature of WHO and the way it is funded and conducts its business (Hawkes 2011).
WHO is acutely aware of the charge that it produces worthy strategies and policy frameworks with laudable values and aims but that it cannot compel any Member State to do anything about them. It is also aware of the high expectations that have been generated around Health 2020 and the need to adopt a different ap-proach from anything that has appeared in the past. At the same time, given that Health 2020 is the RD’s flagship policy initiative and will be her legacy, its en-dorsement merely marks the end of the beginning. The real work to ensure that the policy framework gains traction in practice has only just got underway and will dominate much of WHO’s work programme over the next few years.
In a note on implementing Health 2020 which Member States approved at the time of its launch, WHO mentions the need for the policy framework to reach wider audiences to be successful. It accepts it cannot manage the implementation task alone and will need to prioritise its efforts given the resources available to it.
Among the initiatives on which WHO intends to lead are the following:
develop a series of seminars and/or Masterclasses
develop a core package of resources, services and training materials
develop internet-based interactive platforms, including crowd sourcing approaches
optimise the use of existing networks (eg those related to Healthy Cities, Regions for Health, Health-Promoting Schools, Health-Promoting Hospi-tals and so on)
hold country-level consultations with key stakeholders
create new collaborating centres to support new thinking and leading-edge work in developing guidance for policy-makers and practitioners.
Ideally, to make a real difference WHO would like to create a social movement for improving health across Europe that would involve many networks, interests and partners. Certainly in a new digital age of social media such ambition is not
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unachievable but for WHO it entails a quite different way of working and one for which its own internal bureaucratic and governance structures are probably not best adapted.
European Action Plan (EAP)
A significant part of making a difference and enabling Health 2020 to achieve at least a degree of implementation will fall to the EAP, noted earlier. The Plan’s overall vision is to support the delivery of Health 2020 and as far as possible it has been aligned with the policy framework. The EAP is structured around 10 integrative avenues for action which reflect practical steps to be taken by Member States as well as by WHO and its partners to advance and strengthen public health capacities and services and implement the 10 essential public health operations (EPHOs) that also form a core part of the Plan. The avenues parallel the EPHOs and provide the means for their implementation. They cover all facets of the pub-lic health function although not all may be equally developed in all countries.
They are:
surveillance of population health and well-being
monitoring and response to health hazards and emergencies
health protection including environmental and occupational health, food safety and others
health promotion, including action to address social determinants and health inequity
disease prevention including early detection of illness
assuring governance for health and well-being
assuring a sufficient and competent public health workforce
assuring sustainable and organisational structures and financing
advocacy, communication and social mobilization for health
advancing public health research to inform policy and practice.
Many of the avenues cover familiar and well-trodden ground in public health, especially those focused on population surveillance, health protection, promotion and prevention. These components form the bedrock of a public health system (Griffiths, Jewell & Donnelly 2005). But others reflect more contemporary con-cerns and understanding of the public health function and what needs to change to enable it to confront the complex, cross-cutting issues that face it whether result-ing from climate change or growresult-ing inequalities. For instance, the need for a new approach to governance is acknowledged as well as equipping the public health workforce with skills in leadership and political astuteness alongside traditional
competencies that include epidemiology and analytical skills. There is also a need for having well-developed skills in communication and political advocacy and, finally, being able to access and use evidence is a topic of growing importance in the practice of public health. Often the issue is not so much a lack of evidence about what works, although that remains an issue, but an inability to apply or use it in practice (Rushmer, Steven & Hunter 2011). The growing interest in notions of knowledge transfer, exchange and brokerage needs to be reflected in how those working in public health relate to evidence and how its value to them can be har-nessed and maximised. Indeed, the move increasingly is to favour a co-production model where researchers and practitioners are encouraged to work alongside each other to produce knowledge and evidence that best meets the needs of those seek-ing to brseek-ing about change.
An assessment
It is too early to pass judgement on the success or otherwise of Health 2020 or the EAP accompanying it. What both documents do, however, plus the other accom-panying reviews referred to earlier, is provide a wealth of practical advice and pointers to allow policy-makers to take action to meet the public health challenges and reduce inequalities should they so decide. Health 2020 has collected in one place, and made accessible, the latest evidence on health and how it can be im-proved and sustained. This includes practical and evidence-based guidance, pre-viously lacking, on what interventions merit investment or disinvestment. In or-der to persuade and convince hard-nosed managers and finance directors of how investing in public health can provide benefits in respect of the return on that in-vestment, having information of this kind can really advance the agenda. Public health practitioners are often viewed as ‘pink and fluffy’ and lacking in business acumen. Making the business case for investing in health has not been seen as a priority. But that seems likely to change when resources are tight and when pres-sures on health care services resulting from lifestyles choices are forcing policy-makers to consider ways of easing them.
Of course, none of this will remove the play of politics from the decision process and whether countries are prepared to take strong collective action, using the taxation and regulatory powers available to them, or whether they wish to focus on individual lifestyle behaviour change using ‘nudge’ type incentives will be up to them. Such decisions may at best be evidence-informed but will probably not be evidence-based (Ovretveit 2007). But having sound evidence on what works will help shape the debate and allow public scrutiny and discussion of the options available. If Health 2020 does no more than provide a platform for that civic
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versation to occur it will have achieved something new, important and be an ad-vance on what has gone before it. If nothing else, it will expose government deci-sions, and even possible inaction if that is what happens. Foot-dragging and fail-ure will be seen for what it is and has always been, namely, a political problem concerned with power, the distribution of resources, and social justice (Scambler 2012). Whether any of this will prove sufficient to ensure public action on the part of hostile or incompetent governments remains to be seen but at the very least the issues will be out in the open and on the public agenda.
However, tougher sanctions may be required too if there is to be effective action that is up to the challenge. Through its much applauded work on tobacco control and the passage of the Framework Convention on Tobacco Control, WHO has shown itself able to exercise some real muscle when confronted by powerful vest-ed interests in the shape of the tobacco lobby (WHO 2003). The experience offers important lessons that apply to other public health issues, notably, obesity where similarly powerful vested interests in the shape of the food and drink corporate interests need to be confronted. Sadly, governments in Europe under pressure from these powerful corporate interests to keep their distance have been reluctant to confront them in the bold way shown over tobacco. Consequently, the learning that could be applied to this and other public policy sectors has been thwarted.
At the root of all the major issues in public health lies politics. We ignore politics at our peril. But until we acknowledge and accept this truism, any attempt to find lasting solutions that work as distinct from fiddling at the margins is doomed to failure. Health 2020 can only succeed if the political will exists.
Conclusion
The impact of Health 2020 will be determined by the extent to which govern-ments of different political persuasions show real as opposed to rhetorical com-mitment to the notion of a whole of government, whole of society, cross policy approach to the practice of health. This will be the key test of the new policy framework that will set it apart from its predecessors. Health 2020 is evidence of the determination of WHO to go beyond a grand statement of intent and to inform and support government action. There has been a shift from analysis to engaging in the messy and difficult world of implementation and delivery. In some respects the values of solidarity and universalism espoused in Health 2020 are out of kilter with the times as governments across Europe struggle to contain public spending and stimulate private sector growth. But political landscapes are subject to rapid and sudden shifts that are not wholly predictable as we have witnessed in Greece,
The Netherlands, France, and Italy. This is not to suggest that neoliberalism has run its course but a few economists are starting to call for a new political econo-my that will replace neoliberalism with a public service ethos that puts greater value on the community as a whole (Mooney 2012). If a shift in political ideology is stirring across Europe then just possibly Health 2020 will catch the tide and its ambition may be realized however inauspicious the circumstances surrounding it may appear to be at the present time. Should that day come, then WHO needs to be ready to seize the moment. That means moving away for its reliance on tradi-tional skills and expertise such as epidemiology and data analysis and embracing new skills in implementation and policy science, knowledge exchange and trans-fer. Above all it means a deeper understanding of how to bring about transforma-tional change in complex systems. The next year or so will demonstrate just how far WHO has been able to bring about that shift and offer the prospect of Health 2020 having a significant impact on the public health challenges facing its Mem-ber States.
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JOHTAMINEN
"Jos tekosi inspiroi muita unelmoimaan enemmän, oppimaan enemmän, tekemään enemmän ja olemaan enemmän, olet johtaja."
- John Quincy Adams