Health In All Policies Prospects And Potentials - European Commission

ContributorsFor those contributors based at STAKES (The National Research andDevelopment Centre for Welfare and Health), the address is P.O. Box 220,Helsinki, FIN-00531, Finland.Franz Baro Professor of Psychiatry, Collaborating Centre on Health andPsychosocial and Psychobiological Factors, Rue de l’Autonomie 4, 1070Brussels, BelgiumJulia Blau MSc, Research Officer, European Observatory on Health Systemsand Policies, WHO European Centre for Health Policy, Rue de l’Autonomie4, 1070 Brussels, BelgiumˆˆˆMojca Gabrijelcic Blenkus MD, Specialist in Public Health, Head of theDepartment for Health Promotion, Institute of Public Health of theRepublic of Slovenia, Trubarjeva 2, 1000 Ljubljana, SloveniaKonrade von Bremen MD, MHEM, Senior Researcher, Institute of HealthEconomics and Management, University of Lausanne, César Roux 19,1005 Lausanne, SwitzerlandLiselotte Schäfer Elinder PhD, Director, Associate Professor, Department ofHealth Behaviour, Swedish National Institute of Public Health,S-103 52 Stockholm, SwedenEva Elliott, Senior Research Fellow, The Cardiff Institute of Society,Health and Ethics, 53 Park Place, Cardiff CF23 3AT, UKKelly Ernst MPH, Research Officer, European Observatory on HealthSystems and Policies, WHO European Centre for Health Policy,Rue de l’Autonomie 4, 1070 Brussels, BelgiumRainer Fehr MPH, PhD, LÖGD (Landesinstitut für den ÖffentlichenGesundheitsdienst NRW), Institute of Public Health, North RhineWestphalia, Westerfeldstrasse 35–37, D-33613 Bielefeld, GermanyAlison Golby PhD, Research Associate, The Cardiff Institute of Society,Health and Ethics, 53 Park Place, Cardiff CF23 3AT, UKGabriel Gulis PhD, Associate Professor, Unit of Health, University ofSouthern Denmark, Niels Bohrsvej 9–10, 6700 Esbjerg, DenmarkRiitta-Maija Hämäläinen PhD, Researcher, Finnish Institute ofOccupational Health, Topeliuksenkatu 41a A, FIN-00250 Helsinki, Finland

x ContributorsLoes van Herten PhD, Team Manager, TNO Quality of Life, P.O. Box2215, CE 2301 Leiden, The NetherlandsJorma Järvisalo DMedSci, Research Professor, Health Policy andInternational Development, Social Insurance Institution, Peltolantie 3,FIN-20720 Turku, FinlandPekka Jousilahti MD, PhD, Research Professor, National Public HealthInstitute, Department of Epidemiology and Health Promotion,Mannerheimintie 166, FIN-00300, Helsinki, Finland, and School of PublicHealth, Tampere, FinlandThomas Karlsson MSc, Researcher, Alcohol and Drug Research, STAKESTapani Kauppinen MSc, Project Manager, STAKESJohn Kemm, Director, The West Midlands Public Health Observatory,Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UKMeri Koivusalo MD, DMedSci, Senior Researcher, STAKESEero Lahtinen MD, PhD, Ministerial Adviser, Ministry of Social Affairs andHealth, P.O. Box 33, FIN-00023 Government, Helsinki, FinlandTeresa Lavin MPH, Public Health Development Officer, The Institute ofPublic Health in Ireland, 5th Floor, Bishop’s Square, Redmond’s Hill,Dublin 2, IrelandKimmo Leppo, Director-General, Ministry of Social Affairs and Health,P.O. Box 33, FIN-00023 Government, Helsinki, FinlandKari Lindström, Director, Centre of Expertise, Finnish Institute ofOccupational Health, Topeliuksenkatu 41a A, FIN-00250 Helsinki, FinlandKaren Lock MD, Clinical Research Fellow, London School of Hygiene andTropical Medicine, Keppel Street, London WC1E 7HT, UKPia Mäkelä PhD, Senior Researcher, Alcohol and Drug Research, STAKESMarco Martuzzi PhD, Scientific Officer, World Health Organization,European Centre for Environment and Health, Via F. Crispi 10,00187 Rome, ItalyOdile Mekel MPH, LÖGD (Landesinstitut für den ÖffentlichenGesundheitsdienst NRW), Institute of Public Health, North RhineWestphalia, Westerfeldstrasse 35–37, D-33613 Bielefeld, GermanyTapani Melkas, Director, Ministry of Social Affairs and Health,P.O. Box 33, FIN-00023 Government, Helsinki, Finland

Contributors xiKirsi Nelimarkka MSc, Researcher, STAKESEeva Ollila MD, DMedSci, Senior Researcher, STAKESEsa Österberg MSc, Senior Researcher, Alcohol and Drug Research, STAKESKerttu Perttilä PhD, Development Manager, STAKESAnna Ritsatakis PhD, 14 Tsangaris Street, Melissia 151 27, GreeceNina Scagnetti, Institute of Public Health of the Republic of Slovenia,Trubarjeva 2, 1000 Ljubljana, SloveniaMarita Sihto DSocSci, Senior Researcher, STAKESMartin Sprenger MPH, Medical University of Graz, Schubertstrasse 22/6,8010 Graz, AustriaTimo Ståhl PhD, Senior Researcher, STAKESIngrid Stegeman, Project Officer, EuroHealthNet, Rue Philippe le Bon 12,1000 Brussels, BelgiumˆˆMarius Stricka, Researcher, Kaunas University of Medicine, A. Mickeviciausg. 9, 50009 Kaunas, LithuaniaChristoffer Tigerstedt PhD, Senior Researcher, Alcohol and Drug Research,STAKESIsmo Tuominen LLM, Ministerial Adviser, Ministry of Social Affairs andHealth, P.O. Box 33, FIN-00023 Government, FinlandRudolf Welteke MD, LÖGD (Landesinstitut für den ÖffentlichenGesundheitsdienst NRW), Institute of Public Health, North RhineWestphalia, Westerfeldstrasse 35–37, D-33613 Bielefeld, GermanyGareth Williams, Professor, School of Social Sciences, Glamorgan Building,King Edward IV Avenue, Cardiff University, Cardiff CF10 3WT, UKMatthias Wismar PhD, Health Policy Analyst, European Observatory onHealth Systems and Policies, WHO European Centre for Health Policy,Rue de l’Autonomie 4, 1070 Brussels, Belgium

ForewordEnsuring a high level of human health protection in all Community activitiesis a central part of our responsibilities. This has been a constant themethroughout the development of the Community. Even before the specific publichealth article was introduced, health was integrated into other areas of policysuch as agriculture and free movement, and the Single European Act stipulatedthat a high level of health protection should be taken as a basis for completingthe internal market.A great deal has therefore been achieved towards the aim of Health in AllPolicies (HiAP). Within the Commission we have established coordinationmechanisms to ensure that the health dimension is integrated into activities ofall Commission services. We have also developed detailed methodologies forhealth impact assessment (HIA), in particular through projects under the publichealth programme. Together with work on impact assessment in other specificareas such as the environment, these methodologies have laid the foundationsfor the integrated approach to HIA now used throughout the Commission.More can still be done; for example, we are working with Member States todevelop a specific methodology for assessing the impact of proposals on healthsystems. Nevertheless, the Commission’s integrated approach to HIA is animportant achievement, bringing together consideration of the full range ofpotential economic, environmental and social impacts in a single mechanism.Beyond these technical developments there is also growing recognition of theimportance of health for the overall objectives of the Community. Health is akey foundation stone of the overall Lisbon strategy of growth, competitiveness andsustainable development. A healthy economy depends on a healthy population.

xiv ForewordWithout this, employers lose worker productivity and citizens are deprived ofpotential length and quality of life. This is doubly important as the Europeanpopulation ages in the coming decades. The impact of this demographic ageingwill crucially depend on our ability to keep our citizens healthy and activethroughout their longer lives. We are adding years to life, but we must also addhealthy life to years.A wide range of policies can help to influence this, ranging from employmentand social protection strategies to the food we eat and how much we walkrather than drive. European policies and rules shape many of these areas, andthis underlines how vital it is to ensure the integration of health protectioninto all policies and actions.This is not just work for the Commission. After all, although we produce theproposals for Community action and the HIA that accompanies them, it isthen up to the Parliament and Council to decide on them. Ensuring theintegration of health protection into Community policies therefore alsodepends on the members of the European Parliament and the Member Statesin the Council.Moreover, even if all best efforts are taken to integrate the health dimensioninto Community measures, health is a complex topic, and it is simply notalways possible to anticipate all the impacts of new measures. Initial HIAsmust therefore be accompanied by constant monitoring and evaluation inpractice. At European level, we already have the important overall key indicatorof Healthy Life-Years. But more research and statistical work is needed todevelop more detailed indicators for particular areas and outcomes to ensurethat the integration of health into all policies is not simply a one-off exercise,but a constant activity guiding our actions for the future.I welcome this publication as part of the Finnish presidency and hope it willlead to greater awareness of the importance of HiAP and to future progress.Robert MadelinDirector-GeneralHealth and Consumer ProtectionEuropean CommissionBrusselsJune 2006

PrefaceHealth in All Policies (HiAP) – the main health theme of the Finnish EuropeanUnion (EU) Presidency in 2006 – is a natural continuation of Finland’s longterm horizontal health policy. While the health sector has gradually increasedits cooperation with other government sectors, industry and nongovernmentalorganizations in the past four decades, other sectors have increasingly takenhealth and the well-being of citizens into account in their policies. The keyfactor enabling such a development has been that health and well-being areshared values across the societal sectors.The Finnish population is now healthier than ever, the health of the elderly isconstantly improving, the increased years of life are predominantly healthyyears, and we have also been able to prevent major diseases. These outcomesare not only based on advancing preventive and curative health care services,but, in particular, on the creation of and support for healthy living conditionsand ways of life. In concrete terms, this has meant increasing the opportunitiesfor healthy choices, not only health education.Our contribution to the EU public health policy can also be considered asquite consistent. In 1999, during the first Finnish EU Presidency, a Councilresolution was adopted “on ensuring health protection in all Communitypolicies and activities” on Finland’s proposal. Now, seven years later, it is veryencouraging to see how the EU public health discourse has changed towardswhat was suggested and how some of the activities anticipated have beenimplemented – most importantly, the impact assessments of the Commission’sinitiatives. Even more positive, however, is to notice that our understanding ofthe matter itself has improved.

xvi PrefaceDespite its solid background in science, HiAP is a politically challenging strategythat requires deliberate efforts to be promoted. This is why we persistently wantto draw attention to it. Determinants of health, their surveillance and relatedmethodological issues are demanding questions that most naturally, practicallyand effectively are developed in a European collaboration, not by any singleMember State acting alone. The EU Public Health Programme project, ofwhich this book is one of the outputs, is an excellent example of worthwhileand productive collaboration between Member States, strongly supported by theEU Commission and the European Regional Office of the World HealthOrganization.Major diseases – both “old” and emerging – are challenges to public health.A systematic response is considerably facilitated by the fact that the risk factorsare mainly the same. Instead of seeing major diseases as a challenge to thehealth sector only, HiAP highlights the fact that the risk factors of majordiseases, or the determinants of health, are modified by measures that are oftenmanaged by other government sectors as well as by other actors in society.Broader societal health determinants – above all, education, employment andthe environment – influence the distribution of risk factors among populationgroups, thereby resulting in health inequalities. Focusing on HiAP may shift theemphasis slightly from individual lifestyles and single diseases to societal factorsand actions that shape our everyday living environments. It does not, however,imply that any other public health approaches, for example health educationor disease prevention are undermined or treated as less important.Effective and systematic action for the improvement of population health,using genuinely all available measures in all policy fields, is an opening for anew phase of public health. As the EU has the unique mandate to act forhealth across all policy sectors and as we in Europe have all the other necessarymeans, I would like to see Europe as the world leader in such a modernapproach. Whether Europe will achieve this position depends on all of us.Dr Liisa HyssäläMinister of Health and Social ServicesHelsinkiFinlandJuly 2006

IntroductionMatthias Wismar, Eero Lahtinen, Timo Ståhl, Eeva Ollila, Kimmo LeppoThe countries of the European Union (EU) have achieved historicallyunprecedented levels of health and wealth. In recent decades life expectancyhas grown substantially. People now live longer and are in better health than20 years ago. Simultaneously the wealth of the EU countries has grownsteadily since 1980. However, wealth and health inequalities between andwithin countries have largely remained or even grown.Health and wealth are related. The link is especially strong at lower levels ofaffluence. It has been shown that better health boosts rates of economicgrowth,1 while countries with weak conditions for health have a hard timeachieving sustained growth.2 For high-income countries, gross domesticproduct and life expectancy correlate less strongly at national levels. However,for high-income countries, it has been demonstrated that good healthcontributes positively to the economy while poor health can have substantialnegative effects. It is noteworthy that greater socioeconomic inequality insociety is associated with poorer average health.3–5Health and well-being are undoubtedly major societal objectives in their ownright, and these objectives are not limited to the contribution of health to theeconomy. In the EU health systems are seen to form a central part of socialprotection, as well as providing an important contribution to social cohesionand social justice. In the development of their health policies the Europeancountries share the values of universality, access to good care, equity andsolidarity.6 The same values have also been guiding the development of theHealth for All Policy of the World Health Organization (WHO). Recently, theMember States of the European Region of WHO endorsed an update of the

xviii IntroductionEuropean Health for All policy, which places health in the framework ofhuman rights, stressing the common European values of equity, solidarity andparticipation.7Because of the solid evidence that health can be influenced by policies of othersectors, and that health has, in turn, important effects on the realization of thegoals of other sectors, such as economic wealth, this book proposes Health inAll Policies (HiAP) as a strategy to help strengthen this link between healthand other policies. Health in All Policies addresses the effects on health acrossall policies such as agriculture, education, the environment, fiscal policies,housing, and transport. It seeks to improve health and at the same timecontribute to the well-being and the wealth of the nations through structures,mechanisms and actions planned and managed mainly by sectors other thanhealth. Thus HiAP is not confined to the health sector and to the public healthcommunity, but is a complementary strategy with a high potential towardsimproving a population’s health, with health determinants as the bridgebetween policies and health outcomes. Regarding the overall contribution ofhealth both to the social capital and to the economy, it is hoped that Healthin All Policies: Prospects and potentials will attract readers from across all societalsectors.For Europe, it is vital to further strengthen the link between health and otherpolicies. It cannot be taken for granted that the positive developments of thepast will last into the future. Through the looming obesity crisis,8 the expectedrise in chronic diseases and the cognitive decline associated with ageing,European societies provide examples of the challenges lying before us.In parallel, concerns regarding the prospects of European economies have beengrowing in recent years. The European Council has addressed these concernsby agreeing on new strategic goals for the EU to strengthen employment,economic reform and social cohesion as a part of a knowledge-based economy.This strategy, endorsed by the Council in 2000 and better known as theLisbon Agenda, addresses some of Europe’s economic weaknesses. Amongthem are the low employment rate characterized by insufficient participationin the labour market by women and older workers, and long-term structuralunemployment and marked regional unemployment imbalances that remainendemic in parts of the EU. The Lisbon Agenda is seen as a response to thechallenges posed by globalization and the need for European economies tomaintain a competitive edge in a rapidly changing globalized world.9The Lisbon Agenda refers to the need to modernize the European socialmodel, social protection and promoting social inclusion. The essential role ofhealth, however, is not reflected properly in reality although health plays animportant role in addressing the challenges highlighted by the Lisbon Agenda,

Introduction xixand this role is even more important regarding demographic development inEurope. The proportion of the population beyond retirement age is growing,so creating a further downturn in the employment rate. The remainingworkforce is ageing, and the proportion of older workers is increasing, puttingeven more emphasis on appropriate and effective strategies to integrate olderworkers into the labour market. Declining populations and dwindling labourmarket participation could result in shrinking economies unless there are gainsin productivity and income. Again, this could put pressure on the Europeansocial model in terms of financial sustainability, undermining social cohesion.This book is linked to the Lisbon Agenda by assuming that better health andwell-being can contribute to a rise in productivity and add productive lifeyears. Healthier populations will have more years of healthy life expectancyand a reduced number of years suffering from chronic diseases. Improving apopulation’s health will reduce the foregone national income from sickness.In this regard, better health is one way of addressing the economic challengesof Europe. It may help to support the financial sustainability of the Europeansocial model and it may help to strengthen social cohesion. To this end, thecontributions in this book are exploring the prospects and potential of HiAPto improve population health.The wealth and health of Europe have been growingThe wealth of the nations, measured in GDP purchasing power parities percapita, (GDP PPP per capita) has grown steadily since 1980 for the EU-15countries. A similar trend is observable for the ten Member States that joinedthe EU in 2004.Both the EU-15 and EU-10 averages show a considerable growth in lifeexpectancy since 1980. Some countries, such as Sweden, have already reacheda level above 80 years of age.Despite these positive trends, inequalities between countries in health andwealth have remained. The gap in the wealth of the nations between the EU15

Ministry of Social Affairs and Health Health Department Finland kirjaamo.stm@stm.fi The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the Finnish Ministry of Social Affairs and Health, the European Commission, or the European Observatory on Health Systems and Policies or any of its .