Evaluation of the European strategy for Health for All by the year 2000

239

Health Policy, 6 (1986) 239-269 Elsevier HPE 00101

Evaluation of the European strategy Health for All by the Year 2000

for

J.E. Asvall, J.-P. Jardell and A. Nanda WHO Regional Office for Europe, Copenhagen, Denmark Accepted 30 May 1986

Summary For the first time ever, Europe has a concrete, comprehensive and forward-looking health policy framework. Forming part of the worMwide movement for Health for All HFA) by the Year 2oo0, the European regional HFA strategy, embodied in 38 spe4fic targets*, has been developed by the 22 Member States of the WHO European Region. Completed in lggg, the first evaluatlon of overall progress in implementing this new health policy** has shown that the regional targets may be ambitious but they are viable and realistic. Certain countries have already achieved some of the targets, but even in theee countries efforts are still needed to improve equity among social groups. Performance in key areas such as orientation towards prfmary health care and the provision of safe water and adequate sanitary facilities, although improving, is still not at the levels hoped for and these remain priority hems. Even more serious difficulties are apparent in other areas such as healthy MestYles and the quality of care. The quality of the information available, even in an area as developed as Europe, also leaves much to be deslred. The gaps and weaknesses identified must be tackled urgently lf the goal of HFA is to be achieved, but there are encouraging signs that the HFA movement in Europe has now really started. evaluation; HFA 2ooO; Europe

* Targets for Health for All. Copenhagen, WHO Regional Office for Europe, 1985. ** Seventh Report on the World Health Situation, Vol. 5 (in preparation). Address for correspondence: Dr. J.E. Asvall, Regional Director for Europe, World Health Organization, 8 Scherligsvej, DK-2100 Copenhagen 0, Denmark. 0168~8510/86/$03.50 0 1986 Elsevier Science Publishers B.V. (Biomedical Division)

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Introduction At the Thirtieth World Health Assembly in May 1977, WHO Member States decided that the main social target of governments and WHO in the coming decades should be to attain for all the citizens of the world by the year 2000 “a level of health which will permit them to lead a socially and economically productive life” [l]. This historic resolution launched the worldwide HFA movement, which has progressed rapidly at national, regional and global levels, with Member States both individually and collectively developing strategies for attaining HFA. The global strategy for HFA by the year 2000 was adopted at the Thirty-fourth World Health Assembly in May 1981 [2]. To support the global strategy, the regional offices of WHO formulated strategies more directly relevant to the health problems and health systems of their areas. In Europe, an extensive analysis involving experts from all Member States led to the identification of some of the major health problems. It also identified the main strategic options available to attack the root causes of ill health and the deficiencies of the health care system. This resulted in the regional HFA strategy that the European Member States endorsed in 1980. The regional strategy outlined four main areas of concern: lifestyles and health, risk factors affecting health, a reorientation of the health care system and, finally, the political, management, technological, manpower, research and other support necessary to bring about the desired changes in the first three areas. Calling for a basic change in countries’ health policies, the strategy urged that much higher priority be given to health promotion and disease prevention; that not merely the health services but all sectors with an impact on health should take positive steps to maintain and improve it; that much more stress should be laid on the role that individuals, families and communities can play in health development; and that primary health care should be the major approach used to make these changes. In pledging themselves for the first time ever to a common regional health policy, Member States also recognized that history is full of good intentions that never led to practical change because they were not sufficiently concrete. Therefore, to move from philosophy to action and after extensive analysis and debate, 38 specific regional targets were adopted in 1984 [3] to support the implementation of the strategy. Described as “a blend of today’s realities and tomorrow’s dreams”, these targets indicate levels of improvement that could realistically be attained all over Europe if countries have the political will and managerial capability to make the changes proposed by the strategy. Simultaneously, regional indicators were provisionally adopted by Member States to be used to monitor their own progress towards the 38 targets. By agreeing to undertake regular monitoring and evaluation, Member States have ensured that their pledge will not remain a mere pious wish but will be followed by concrete action. Furthermore, they have decided to forward their national reports to the WHO Regional Committee for Europe for collective discussion on the overall progress towards their agreed strategy. This cooperative process will provide all countries with information and feedback on health trends and intervention

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and should make it easier to reach rational decisions on changes needed in policies and strategies at all levels. The lirst major evaluation of progress in implementing the regional strategy was completed in 1985. It was distinguished by the active participation of all 33 Member States, which seriously evaluated their own national progress towards the goal of HFA. The national reports formed the basis for the regional evaluation that was discussed at the thirty-fifth session of the Regional Committee in Amsterdam in September 1985. The regional evaluation, along with evaluations by country, will be published in 1986 as Vol. 5 of the Seventh Report on the World Health Situation. *

Framework of the evaluation The 38 European regional targets are a deliberate attempt by European Member States to change the course of their health development. The first 12 targets cover, in terms of health outcomes, four main objectives as the keys to the attainment of HFA in Europe: equity in health: reducing the present inequalities in health status and health services among countries and among groups within countries; adding years to life: reducing premature deaths, thereby increasing life expectancy; adding health to life: reducing disease and disability; adding Zifeto years: promoting conditions to help people use their existing capabilities fully, to lead a socially and economically productive life. The remaining targets (13-38) deal with the specific activities required in lifestyles, the environment and the health services, and with the support measures needed to bring about these changes. The regional evaluation is structured in line with the above. It starts by assessing progress in improving health (health outcomes). It then examines the changes and development that have taken place that could and should bring about such improvements. These fall into two groups. The first group comprises factors that relate to lifestyles and the environment and, while not directly under the control of the health sector, have an important influence on health outcomes. The second group consists of factors that the health sector can directly tackle. Finally, the evaluation relates the progress achieved to the changes that have taken place in the influencing factors; it summarizes the results, and it considers the effectiveness of the actions taken. Some influencing factors such as peace, social justice, political will and public support are fundamental to the attainment of HFA. Therefore, progress in these prerequisites for health is dealt with first.

* Evaluation of the Strategy for Health for All by the Year 2ooO: Seventh Report on the World Health Situation, Vol. 5. Copenhagen, WHO Regional Office for Europe (to be publishedin 1986).

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The methods used In the absence of any practical starting-point from which to begin an assessment, progress towards the attainment of HRA and the regional targets has been gauged using historical trends. In general, this has been done by measuring the overall percentage change between a ‘historical year’ (usually around 1970) and a ‘latest available year’ (usually around 1980). The percentage change is intended to show the direction and magnitude of the trends. In the case of nonquantitative indicators, the evaluation is based on the number of countries that have taken a particular type of action or introduced a particular type of service. The regional evaluation is concerned with the progress of the Region as a whole towards the goal of HFA and with the collective performance of all Member States in their efforts to attain the regional targets, which are themselves expressed as weighted regional averages. A comparison of the performance of one country or group of countries with the performance of another is not the objective. Where appropriate, the trends in individual countries have been used to illustrate or highlight particular health problems or achievements.

The results Prerequisites for health

Without peace and social justice, without enough food and water, without education and decent housing and without providing each and every person with a useful role in society and an adequate income, there can be no health for the people, no real growth and no social development. The health sector must intensify its efforts to identify and present the consequences for health of social deprivation so that priorities in overall national development take into account the need to strengthen these aspects. Changes in demographic characteristics with the rapid aging of the population, especially the very old, continue to create an increasing demand for health and social services. Unemployment, particularly long-term unemployment, is a phenomenon whose effects on health are just beginning to be recognized. Inequality continues to be a major problem. At the same time, there is intense strain on financial resources, with increased demands for savings on health services, which are inevitably highly labour-intensive. These trends will continue to alter the fabric of society and to affect the resources allocated to the health services. HFA strategies must increasingly be directed to the needs of vulnerable groups, prominent among whom are the elderly and the unemployed. Experience suggests that, in countries where there has been a real attempt to formulate HFA policies and strategies, it has encouraged greater intersectoral coordination for health, and established a more effective information and evaluation system that will provide an essential basis for the future assessment and development of policies.

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Patterns and trends in health status

If HFA is to be achieved in Europe by the year 2000, two basic goals must be reached. One is to reduce health inequalities and the other is to strengthen health through health promotion, as well as by reducing disease and its consequences. Equity in health

The first target of the regional strategy is to reduce by 25% differences in health status between countries and between groups within countries. An assessment of equity between countries has been based on the dispersion of country values of the 12 mortality-related regional indicators of health status. Six of the 12 indicators show widening differences between countries. A significant assessment of equity between groups was not possible for the Region as a whole, because such data were available for only a few countries. However, studies in some countries, such as Denmark, Finland, France and the United Kingdom, show wide differences in health status between socioeconomic groups. Where trends have been analysed, although the absolute levels have improved, the differences between groups have not in general decreased; in some cases, an increasing trend is emerging. These differences continue to exist despite significant increases in health expenditure and in the provision of public health services. The issue of equity is raised more often in the debate on health policies and in the current economic situation often arouses controversy. This makes it critically important for countries to commit themselves to reducing health-related inequalities in their territories and to continue cooperating internationally to assist the least developed nations in their task of achieving HFA. Adding years to life

The Region as a whole continues to show improvement in achieving this objective. This is reflected in the regional trends in life expectancy at birth (Fig. 1). Life expectancy summarizes the age pattern of mortality in a single indicator. By the early 198Os,six countries had already reached the regional target of 75 years, and most countries of the Region are likely to reach it by the year 2000. The difference between male and female life expectancy at birth has widened, however, with only four countries showing a decrease. Furthermore, increased life expectancy to date is largely attributable to a decline in infant mortality, followed by the fact that people aged over 65 years are on average living longer. The greatest potential for significant increases in life expectancy lies in reducing mortality in the age group 35-64 years. Measures to this effect - mainly related to lifestyles are the highest priority for continued improvement in the future. There have been significant improvements in infant mortality (Table 1). Around 1982, 26 out of 32 countries had achieved a rate below the regional target of 20 deaths per 1000 live births; only 12 were below that level in 1970. Although the

Global tar et (60 years3

1

Llte expectancy at blrtn {years) 0

around1971

m

around1982

Fig. 1: Frequency distribution of life expectancy at birth for males and females combined (around 1971 and around 1982) (31 countries of Europe representing 99.99% of the regional population). Table 1 Infant mortality rate per 1000 live births Regional average

No. of countries” with an infant mortality rate in the range:

Total No.

O-19

20-39

40-59

>120

;iuntries

Around 1970

49.1%

;:2.1%)

;:2.3%)

;6.8%)

;6.7%)

Ti7.9%)

Around 1982

26 (49.5%)

0

36.4%

?9.8%)

iO.3%)

32 (67.9%)

Year

66-79

w-99

KS119

0

0

0

0

2 0 (8.2%)

B The proportion of the total population involved is shown in parentheses.

dispersion between countries has decreased markedly, the range between countries and between social groups within countries remains unacceptably wide. The regional average maternal mortality rate for 27 countries (60% of the regional population) was nearly halved between the early 1970s and 1980s; 22 countries reached the regional target of less than 15 maternal deaths per 100000 live births. Mortality from abortions only showed a marginal decrease, however, and by around 1982 accounted for nearly half of maternal deaths. Elimination of maternal deaths from abortions would in itself ensure the attainment of the regional target in 26 out of the 27 countries. Diseases of the circulatory system (target 9), cancers (target 10) and injuries, including homicide, accidental poisoning (target 11) and suicide (target 12), constitute the three leading causes of death. Even relatively small changes in these cause-specific mortality indicators would have an appreciable impact on the ob-

245

jective of adding years to life. The overall changes from around 1972 to around 1981 (Fig. 2) show decreasing trends in deaths from diseases of the circulatory system and from accidents; however, mortality due to all cancers and suicide increased. Trends in particular age and sex groups vary considerably for all the disease categories. In most cases, the rates for females are more encouraging than those for males. Malignant neoplasms and cardiovascular diseases have some common risk factors such as smoking and nutritional patterns. Smoking in particular is known to be a contributing factor to several cancers, especially lung cancer, which has the highest rates of increase of all the cancers considered. The increase in suicide, especially among young adults, suggests that more attention should be paid to economic, social and cultural factors. Concerted efforts and an integrated approach in the prevention of these causes of death are therefore necessary if the regional targets concerned with reducing premature deaths, and thereby increasing life expectancy, are to be achieved.

Target

Disease category

Cardiovascular diseases lschaemic heart disease

I I

Cerebrovascular disease All malignant neoplasms Lung cancer

t I I I I I I

cancer

Suicide 10 (-

)

Overall

percentage

change

15

20

(+I

Fig. 2. Overall percentage change from around 1972 to around 1981 in the European average age-adjusted mortality rates per 1OOGQO population (25-27 countries representing approximately 55-66% of the regional population).

246

Adding health to life Progress towards the objective of reducing disease and disability has been assessed by considering the diseases that can be eliminated and those in which attributable disability could be reduced; information on the incidence or prevalence of disability as such was seldom reported. It is estimated, however, that about 20% of disability is due to noncommunicable somatic diseases, 15% to accidents, 15% to psychiatric disorders, alcoholism and drug abuse, 10% to congenital anomalies and 7% to mental retardation. The proportion of people having difficulties in coping with their day-to-day lives increases with age. The highest priority should be given to the primary prevention of the most common disabling conditions such as cardiovascular diseases, accidents, cancer, mental disorders and occupational diseases. A special effort is needed to achieve target 5 concerning the elimination of specific diseases. Although progress in the reduction of infectious diseases such as diphtheria, acute poliomyelitis and tetanus, particularly neonatal tetanus, is encouraging, the situation for measles and pertussis is less satisfactory. Information on the incidence of congenital rubella is incomplete, although by 1984 eight countries were known to be carrying out routine rubella vaccinations. With the exception of Morocco and Turkey, malaria is not of local origin in the Region, Notifications of nonindigenous malaria more than doubled between 1970 and 1981. The number of cases in Morocco has considerably decreased, but a resurgence of the disease has occurred in Turkey. Information on communicable diseases such as influenza, infectious intestinal diseases and viral hepatitis is unreliable, and reporting is variable and often incomplete. Notifications of tuberculosis show a uniform decline in almost all countries, whereas the incidence of gonorrhoea and primary syphilis has increased since the 1970s. The appearance of new diseases such as legionellosis and the acquired immune deficiency syndrome (AIDS) emphasizes the importance of improved epidemiological surveillance and control systems for rapid detection, vigorous research in order to develop effective vaccines, specific measures to protect highly exposed groups and education programmes aimed at the role of individual behaviour in the prevention of communicable diseases. Adding years to life Progress towards the objective of adding years to life, with a consequential increase in the elderly population, has resulted in an increase in the numbers of the handicapped and in the prevalence of chronic disease and disabilities. This emphasizes the need to view health as a much more positive condition than a mere reduction in disease and premature death. The lack of adequate indicators and of a clear historical picture has made it difficult to assess progress in this field. The degree to which the needs of the elderly and the handicapped are met varies, sometimes greatly, from country to country and within individual countries.

241

The major tasks ahead are to provide for the needs of chronically ill psychiatric patients and elderly patients, especially those with mental disabilities, for continuing care, and to measure and assess the effectiveness of current legislation. A special effort is also needed to change the basic attitude of society towards disabled people.

Influencing factors Lifestyles

The lifestyle-related targets and indicators have been considered in two groups: those dealing with the health-enhancing or health-damaging effects of lifestyle-related factors and those concerned with the means of influencing or affecting changes in behaviour, such as health education and promotion, legislation and social support. Measuring trends in these individually at regional level is difficult, given the available data. Assessing the impact and success or failure of efforts to positively influence lifestyle-related behaviour is even more difficult. Behavioural trends

Between 1976 and 1983, cigarette consumption increased slightly. This increase was confirmed by consumption data for 1979 and 1982, although 11 out of 26 countries recorded a decline. Five of these are achieving a rate of decrease that, if it continues, will lead to a 50% reduction by the year 2000. In some central and north European countries, smokers are now no longer a majority of the adult population, although those who continue to smoke are smoking more cigarettes than before. Furthermore, trends in smoking by women, adolescents and the socio-economic gradient in smoking are a cause of considerable concern. The consumption of alcohol decreased by 7% between 1970 and 1983 (Fig. 3). Ten out of 29 countries showed a decline, mainly those with previously high levels. The overall picture is more complex, however, since several countries show a sharp increase until the mid-197Os, followed by a stabilization or decline. Patterns of drinking have also considerably changed, with a marked increase in consumption by women and young people. Data on drug abuse are limited. However, in the western European countries of the Region, the indications are that illicit drug trafficking and drug abuse (especially by the younger age groups) are becoming increasingly and alarmingly prevalent. The licit use of psychotropic drugs is also of concern, and efforts have been made to change physicians’ prescribing habits in some Member States. Violent social behaviour is an emerging trend of extreme concern. Mortality rates due to homicide and deliberate injury increased by about 20% from around 1972 to around 1981, with only seven out of 15 countries recording a decline. Child abuse, wife-beating, sexual abuse and rape, and their consequences, are arousing increasing concern in many Member States.

248

TimetrendsinEurope (27countriesa)

14

13 7i 512 u ill B v) .;10 -I 9

0

1970

1971

1972

1973

1974 1975

1976 1977 Year

1978

1979

1980

1981

1982

,9;13

Fig. 3. Alcohol consumption per capita aged 15 years and over. BData for two other countries, although available for some years, was not available for all years between 1970 and 1983.

In the field of nutrition, the amount of fat in our diet shows an increase between 1970 and 1982, with some stabilization in recent years. Only four countries show a decrease, however, and 17 countries (14 in 1970) now have a fat intake exceeding the recommended level of 35% [4]. The quality of maternal nutrition and prenatal surveillance is reflected in the fact that few newborn babies in the Region have a birth weight less than or equal to 2500 g. The variations among countries show both the improvements that are possible and the effects such improvements would have on reducing perinatal deaths (Fig. 4). Available information on breastfeeding shows that in recent years women have returned to this practice in some countries. Physical inactivity is a risk factor for coronary heart disease, and it is widely believed that exercise is beneficial for mental health and relaxation. The balance between work and leisure and between different types of work is changing, however, and trends towards labour-saving technology have resulted in a tendency for work to involve less activity. This emphasizes the need for concerted programmes to promote physical recreation, exercise and physical fitness. Factors influencing

lifestyles

Through their choice of lifestyle, people can promote their health or damage it, but their environment and financial means limit their ability to choose healthy ways

249 Birthweight less than 2500 g

mortality

w

FIN

m

DEN

_

NOR

B

NET

m

DEU

_

FRA

m

AUT

m

BEL

-

DDR

POL ISR CZE ITA YUG MAT HUN I

I

I1

25

20

15

t

I1

10

5

Perinatal mortality per 1000 live births

0

0

I

I

,

1

,

1

2

4

6

8

10

12

Percentage of newborn with a birthweight less than 2500 g

Fig. 4. Perinatal mortality and birth weight for selected countries, around 1979.

to live. The targets and indicators considered here are concerned with making healthy lifestyles easier to choose. The public in the countries of the Region has many ways to gain access to information and to express its views on proposed policies and existing practices. These range from a system based on a principle of self-management by consumers and providers in every sector of society, including health care, to small groups with a personal focus that endeavour to influence public policy in their particular areas of concern. In spite of the desire of individuals to be involved and the existence of formal and informal mutual-aid groups, very few countries have developed policies and progranunes to make rational use of the capacities of families and extended social networks for promoting health-enhancing lifestyles. A strong and effective social

250

support system, designed to assist individuals and vulnerable groups in their particular situations, will strengthen the basic capacities of these people to make choices and to cope with stressful situations. The Region has a long tradition of health education designed to influence unhealthy lifestyles. Most Member States have campaigns to prevent motor vehicle traffic accidents, smoking, alcoholism and drug abuse. Other areas of interest include household accidents, mental health, oral health and family planning. The recent trend towards active support for health-enhancing behaviour, as distinct from the avoidance of risk factors, has focused on increased physical activity, balanced nutrition and the promotion of breastfeeding. Legislation related to health promotion has increased [5]. For example, legislation on alcohol and tobacco may aim at changing the supply or drinking and smoking practices. Among the former, tax increases as a fiscal measure have had equivocal results, although there is evidence that a real price increase can have an effect. Among the latter, measures against advertising are the main control methods used. Twelve countries of the Region have so far imposed a total (or effectively total) ban on all forms of cigarette promotion [6], and health warnings on cigarette packets have been enforced in 15 countries since 1971, when they were first introduced in the Region. Data on the results of health education and legislation are in most cases not definite enough for the effectiveness of the programmes to be assessed. Hopeful trends are discernible in some countries where a combination of legislation with rationally designed and sustained health promotion campaigns would seem to promise the greatest effect. Environmental health During the last 15 years, environmental health has become a very important issue in health promotion. Changes brought about by over-rapid industrialization and uncontrolled urbanization have resulted only too often in progressive deterioration in the environment and disruption of the ecological balance. The control of environmental conditions is therefore a crucial element of health care. Quantitative measures of environmental pollution at regional level are scarce, and the emphasis here is on trends in legislative coverage and machinery to monitor, reduce or prevent environmental and occupational health risks. Environmental health policies. All governments have some form of legislation in most of the key areas, but responsibility frequently lies with different ministries and is often divided further, more than one ministry being responsible for different aspects of the same subject, such as water supply and water quality. Some Member States are attempting to rationalize and amalgamate some of these responsibilities under one authority. The systems employed may differ, but how the work is coordinated is immaterial as long as it is effective. Although most Member States have some mechanism for informing the public about specific environmental health hazards, in general, countrywide systems for

251

systematically and actively informing the public on a regular basis do not exist. Some Member States rely on the media, while others are setting up statistical systems as prerequisites for active programmes. Some national systems do exist; although not comprehensive, they systematically attempt to inform all exposed groups. Some Member States have specific regulations on the control of transfrontier pollution. It is recognized that national efforts can achieve little by themselves, and most see national and international cooperation and agreements as the main means of control. The topic of greatest interest is the control of hazardous waste, and air and water pollution. Monitoring, assessment and control. Most Member States have comprehensive regulations governing some of the key areas of environmental health, such as food safety, but at present no Member State seems to have such provisions in all the target areas. The areas of greatest recent interest are water, air, hazardous waste and radiation. Clear, quantifiable standards and targets at national level have been set in some countries to aid monitoring, assessment and control in conjunction with international monitoring exercises. There is evidence of a growing concern for protection against dangerous consumer goods, and much legislation in this area has recently been introduced. Environmental pollution The regional strategy singled out four main areas of concern: water, air, food and hazardous waste. Water pollution. Strict regulations cover the quality of piped water, the type of water supply prevailing in most countries. In a few countries, the piped supply is supplemented by other sources of water, and in parts of the Region the availability of water is still a major problem. In the Region as a whole, the proportion of the population covered by appropriate water supplies is 92%, and 20 countries are above that level. Only 66% of the regional population have adequate sanitary facilities, however, and nine countries are below this level (Table 2). Table 2 Proportion of population with access to safe water and with adequate sanitary facilities Year

Regional No. of countries0 with a value in the range: average

O-19%

20-39% 40-59% 60-79%

Around 1983

91.9%

0

0

2 (3.7%)

Adequate Around sanitation 1981

66.2%

1 (5.7%)

0

6 (45.7%) t.s%)

Safe water

;17.9%)

Total No.

809%

100%

tUtties

;;7.9%)

;:9.2%)

&.8%)

t:O.9%)

T9.41)

;;7.4%)

a The proportion of the total regional population involved is shown in parentheses.

252

In some countries, present evidence strongly suggests that the targets of the International Drinking Water Supply and Sanitation Decade, which require that by 1990 all people should be provided with a continuous supply of safe drinking-water and appropriate means of sanitation, will not be met on time. Much greater total effort and commitment are needed throughout the remaining years of the Decade, with better multisectoral coordination and improved information. Concern about the increased risk of pollution to rivers, lakes and coastal areas is growing, and action in these areas, through increased international collaboration and agreements, is needed. Air pollution continues to be of major concern to Member States. Along with increased industrialization, urbanization and mechanization of transport, some Member States have developed sophisticated and extensive monitoring systems and in general the same pollutants (sulfur dioxide, nitrogen oxides, ozone and carbon monoxide) are measured, nitrogen oxide having only recently aroused general interest. Some of these national monitoring systems also form part of the regional (CEC, EMEP) and global (UNEP/GEMS) monitoring networks. Countries have also intensified their regulations to control air pollution. Several governments have agreed on concerted action through the Convention on Longrange Transboundary Air Pollution. Emissions from the incineration of waste of highly toxic substances and the presence of polychlorinated biphenyls (PCBs) in breastmilk have recently aroused concern. Air pollution.

Food safety. Food safety is perhaps the area the most amenable to national control and systems employed vary. In recent years, interest has increased in the datemarking of food, a practice that is spreading. Monitoring food additives is also receiving increased attention. Recent events in some parts of the Region show that food safety is an area of great public concern. A continuous effort is needed to improve routine surveillance and to provide a well trained inspectorate to back up existing legislation. Hazardous waste. The generation of increasingly large quantities of hazardous waste, its transport and disposal, and the occurrence of a number of major accidents in recent years have resulted in great public and administrative concern. This is reflected in the rapid evolution of national regulations and legislation in this area and the interest of international agencies. Most countries in which legislation exists require special permits for the storage, treatment and disposal of hazardous waste. Regulations on the export and import of waste vary and are generally unilateral. Dumping hazardous waste at sea is subject to a number of different conventions. The Oslo and Helsinki Conventions apply to specific seas (the North Atlantic, the Baltic and the Mediterranean), while the London Convention applies to all the world’s oceans.

253

Living and working environments

Despite great improvements during the last three decades, the housing situation is far from satisfactory in the European Region. Although some Member States have updated existing building legislation and guidelines, in general these lag behind known health requirements. Occupational health records exist in most countries of the Region, but do not always keep abreast of rapidly changing work-related disorders. Definitions are not standardized among the various countries, and this makes it impossible to perform any regional analysis. In the majority of cases, legislation was first adopted many years ago, primarily to provide compensation for industrial injuries. The recent trend is towards updated legislation more closely related to occupational health risks and their prevention. Environmental management should aim not only at safeguarding health from the potential adverse effects of biological, chemical and physical factors, but also at enhancing the quality of life by providing people with conditions that can have substantial positive effects on health and wellbeing. These targets will be achieved only if governments regard environmental health as an indissoluble part of socioeconomic development.

Change and development in health care systems Faced with the challenge of an increasing demand, finite resources and changing patterns of needs and expectations, Member States of the Region adopted primary health care as a cornerstone of the regional strategy and the major approach to bring about the changes sought by the strategy. Support for primary health care should come from all levels of authority and be backed by effective legislation, regulations and plans.

Measurement of the situation and trends Although fraught with problems of definition and standardization, the percentage of the gross national product spent on health is a crude indicator of commitment to health care. Nineteen out of 26 countries reported spending more than 5% (the global target), and the regional average around 1983 was 5.5%. Richer countries on the whole tend to spend more of their income on health without necessarily obtaining commensurate health benefits (Fig. 5). The question of an op timal level of expenditure on health is far from settled, and so is the importance in national allocation of cure, rehabilitation, prevention and promotion. Defining what is meant by health expenditure, and measuring it precisely, involves major problems of methods and interpretation. Information to enable the direct measurement of the reorientation of the health care system towards primary health care is generally unavailable; 16 countries pro-

. .

1

0

I

I

2000

I

I

4000

I

I1

I1

6000 GDP

8000

I

10000

I1

1

12000

I

14000

percapita (US)

Fig. 5. Gross domestic product per capita compared to percentage of gross domestic product spent on health, around 1980/1981(29 countries of Europe representing 99.4% of the regional population), with suitable adjustments between GNP, GDP and the net material product in use for centrally planned economies.

vided information for one year on the percentage of health expenditure devoted to local health care, and this ranged from 10% to 50%. Data recently published by the Organisation for Economic Co-operation and Development [7], however, allow trends in the percentage of the total expenditure spent on institutional medical care to be analysed. Trends in this proxy indicator show that there has been little shift from institutional care towards primary health care. On average, the ratio of health personnel to population increased consistently. This increase is most marked in the case of physicians (there is already a problem of ‘over-availability’ in several European countries) and is very small in the case of midwives. There is a trend towards longer training and increasing specialization for the health professions. The available data are rarely broken down between primary health care and other services; hence here also the proportion of personnel allocated to primary health care or trends therein cannot yet be established. However, manpower plans that take into account the primary health care approach are being developed in several countries. Between 1973 and 1982, there was a slight increase in the hospital bed/population ratio in 30 countries. The gap between the extreme values increased over the period, and countries that already had ratios below the average were often those that showed a decrease, while increases occurred in countries that were already well equipped. Information from 25 countries (representing 82% of the regional population) shows that primary health care is available to 100% of the population in all countries except one (95%), although this is a fairly general statement. Some countries

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mention that coverage is still not complete for all sectors of the population and some still have difficulties with the infrastructure. However, this is not sufficient to assess whether the primary health care system provides a wide range of healthpromotive, curative, rehabilitative and supportive services to meet the basic needs of the population or whether it gives special attention to high-risk, vulnerable, underserved individuals and groups. As an illustration, immunization shows an effective (above 80%) level of prevention in most countries for most of the diseases considered. Measles, with a regional average coverage of 70%, is the main exception; the range between countries is large, and this is reflected in the level of measles incidence. Clearly, variations in policy for all diseases affect the value of this indicator. Satisfactory historical data are not available and trends over time cannot be assessed.

Situation and trends in factors influencing health care systems Important and at times radical changes have been made in the health care systems of several countries in the Region. The associated legislation in virtually all cases gives prominence to primary health care. This varies from detailed legislation specific to primary health care to more general legislation embracing the whole of the health service but emphasizing local health care. Several countries have emphasized that any increases in health personnel will essentially be among the providers of primary health care. The need to motivate and familiarize all health personnel with the primary health care approach, to overcome their opposition or mistrust and ensure coordinated training to maximize the use of human resources has been recognized in several cases. Although some training institutions have developed programmes to align training with the changing role of health personnel, in many countries the need for primary health care is not linked with the production of the appropriate health personnel. HFA strategies rely heavily on action in sectors other than health and, as mentioned earlier, where real attempts to formulate and evaluate I-IF’Astrategies have been made, they have resulted in greater intersectoral coordination for health. Regarded by the countries concerned as a positive development, this should be brought home to the mass media and thus to the general public. In some countries, the political and administrative structure lends itself more readily to local community involvement. The trend is towards decentralization with greater involvement of the community, although in the initial stages the technical problems of organizing primary health care tend to take precedence over informed community participation. Effective community involvement requires new attitudes and motivation in consumers, providers, officials and politicians. Established programmes for systematically evaluating the quality of care, especially in terms of consumer acceptability, are seldom available at national level, although a number of countries are considering legislation to this effect. Except in the case of new drugs, the impact of health technology and its consequences for the organization and delivery of health care are generally not evaluated or as-

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sessed in countries. In addition, whereas technical effectiveness and safety are considered in the evaluations that are done, the impact on health status and patient satisfaction are not. Research is still mainly construed as biomedical, although several research institutions have specifically geared their projects to HFA strategies. In general, there is no national coordination and, as a large proportion of available funds is still tied up in projects already in progress, it will take some time before reorientation is achieved. The WHO European Advisory Committee on Medical Research is developing a plan for research to support the HFA strategy. Timely and relevant information for health management has been stressed by several countries. In some cases, specific information units have been set up, while in others intricate and complex networks exist in which health or health-related concerns have a part. In many countries, data banks on health and social services are being developed to allow the general user to extract data more easily and to reveal more clearly the links between health and social support.

Summary assessment It is striking to note the overwhelming readiness of the countries in 1985 to make for themselves an extensive evaluation of their progress towards HPA, five years after the Member States of the Region took the dramatic step of agreeing to a common health policy and only one year after the regional targets were endorsed. The quality and comprehensiveness of many of the national evaluations indicate that the doubt and scepticism existing before 1980 have given way to commitment and confidence in the regional strategy, reflecting its practical relevance to Member States. The evaluation has shown that the regional targets are both viable and realistic, Many countries of the Region have already, or will have by the year 2oo0, achieved many of the targets. Although the outlook appears reasonably good for the Region as a whole, closer and more detailed examination reveals great differences. In general, progress towards equity in health has been poor. Major differences still exist between populations in many of the target areas, and striking differences persist between countries at similar levels of development. The achievement of social equity is an essential prerequisite for health for the 820 million people of the European Region and is a crucial issue in resource allocation and in social and economic policy, Equity cannot be achieved without strong political leadership and support. In contrast, trends in the health status indicators are more satisfactory, with ischaemic heart disease, some cancers and suicides the main exceptions. Progress towards the objective of adding years to life, as reflected by trends in the overall indicator on life expectancy, has been due mainly to a reduction in infant mortality, followed by the fact that people aged over 65 years are living longer on average. The achievement of this regional target will largely depend on the successful reduction of premature deaths in the age group 35-64 years.

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Although some, and at times significant, progress has been made towards the other main objectives of adding health to life and life to years, much remains to be done. In particular, the gaps in basic information and the lack of assessment of the effectiveness of policies need to be tackled. The reduction of premature deaths will require vigorous attention to lifestyles. In these areas, progress is also poor. Regional targets such as reductions of 50% in tobacco consumption and 25% in alcohol consumption will be achieved only if Member States take stronger and more concerted action. Several countries have taken encouraging and positive action through health education, legislation and other methods to make healthy lifestyles the easier lifestyles to choose. All Member States need to sustain and intensify such efforts, drawing on the experience of the countries that have made progress in these areas. Significant improvements in lifestyle also require social and welfare support, still a weak point in several countries at both central and local levels. Although the commitment of the Member States is apparent in their adoption of a common health policy and in the quality of many of the national evaluation reports received, only in some countries have detailed national HFA strategies been formulated. At present, political decisions at the highest level, confirmed in all sectors, are needed. The provision of information to the public and their involvement in HFA policies is very slight, and information systems concerning the needs of the HFA strategies need strong support. The organization of primary health care varies widely within the Region. In some countries, well coordinated teams form the established and recognized first point of contact with the official health system. In others, people may gain access to health care through general practitioners, specialists or nurses, all working alone. Many countries see the decentralization of health matters as a criterion for primary health care. While there can be little doubt that some progress has already been made, there is no doubt that much more needs to be done. All too often the hospital is still considered as the basis of the health system, with major responsibility for the entire range of health care. In several countries, although a great deal of thought has been given to defining the functions and responsibilities of the health care sector, less attention has been paid to implementing the changes called for and to integrating the activities of the primary, secondary and tertiary levels into a coherent whole. In many countries, people belonging to particular social groups or living in particular geographical areas are still without good access to primary health care services, while in other instances preventive and rehabilitative services are less generally available than curative services. The challenge facing Member States, many of whom started with a historical imbalance in favour of hospital-based curative sciences, is how to achieve a shift towards primary health care in a situation of financial stringency. The attitude of the health professions is decisive in this regard. Unless measures are taken to reorient the work of health personnel, with their consent and full support, and, at the same time, to keep the public more fully informed to encourage individual participation, the achievement of this task will be at risk.

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Conclusions The 1985evaluation of the European regional HFA strategy has shown that in general the main objectives of the strategy can be achieved. The priority given by the regional strategy to lifestyles, environmental risk factors, and the reorientation of the health care system itself has been confirmed. The influence of individual lifestyle-related factors on the potential for improvement in the objective of adding life to years has been strongly emphasized. Smoking, alcoholism, long-term unemployment and poor social and environmental conditions tend to affect the groups of people on whose physical and mental health they have the most vicious and cumulative impact. The incipient threat that our youth may become one of these risk groups is a major concern of our times. Action is urgently needed if we are to achieve the goal of HFA.

References 1 Alma-Ata 1978: Primary Health Care (“Health for All” Series, No. l), World Health Organization, Geneva, 1978. 2 Global Strategy for Health for All by the Year 2000 (“Health for All” Series, No. 3), World Health Organization, Geneva, 1981. 3 Targets for Health for All. Copenhagen, WHO Regional Office for Europe, 1985. 4 Prevention of coronary heart disease: report of a WHO Expert Committee, WHO Technical Report Series, No. 678, 1982. 5 Leenen, H.J.J. et al., Trends in Health Legislation in Europe. Masson, Paris, 1986. 6 Roemer, R., Legislative Action to Combat the World Smoking Epidemic, World Health Organization, Geneva, 1982. 7 Measuring Health Care, 196&1983: Expenditure, Costs’and Performance. Organisation for Economic Co-operation and Development, Paris, 1985.