Comment

www.thelancet.com Vol 381 March 30, 2013 1075

The WHO European region includes 53 member states of enormous diversity, with a total population of around 750 million people, and stretches from Greenland to the Bering Strait. During the past two decades, most European countries have made impressive progress in population health.1 This progress has, however, been uneven, and the health divide across the European region is unacceptably large. Mean life expectancy at birth in the WHO European region was more than 72 years for men and around 80 years for women in 2010. Yet overall life expectancy varies from 69 years in Russia to 82 years in Switzerland, with huge variations within some countries.2 The noteworthy heterogeneity of health progress in the European population could result from intrinsic diff erences in resources for health care (including support for basic measures such as control of tobacco and hypertension), in willingness to take action, or in negative eff ects of political divisions. Public health experts argue that conditions that improve population health have to be shaped in the policy arena to suit national and regional circumstances. If so, what measures are available to policy makers in Europe to increase the success of public health policies in the face of the fi nancial crisis and ageing populations?

The WHO Regional Offi ce for Europe has published Health 2020 (its new health policy strategy) and an accompanying European Action Plan.3,4 Both documents have been endorsed by the 53 member states, giving WHO a mandate to ensure progress and hold member states to account. Through an extensive process of consultation among the countries, overarching targets have been established in the three foci of Health 2020—namely, reducing the burden of disease and risk factors, improving health and wellbeing, and improving governance and systems for health. To achieve these common strategic goals, WHO has developed regional Health 2020 targets.5,6

The Lancet Series on Health in Europe7–13 not only examines the health status of European citizens, but also includes a comparative analysis of the eff ectiveness of European health policy over the past decades. It quantitatively assesses the health eff ects of diff erent social and economic European Union (EU) policies and the associations between health, health systems, and EU law. The Series also discusses possible explanations for the remarkably low life expectancy in the Com mon wealth

of Independent States (and the related quality of health care). Migrants’ diffi culties in accessing health services are analysed, as are the challenges for welfare systems in helping people to stay active and healthy in old age and the eff ects of the fi nancial crisis and austerity in Europe on health, with a look to the future. In times of economic downturn, people who are disadvantaged are more aff ected than are others, so tackling the social determinants of health should be a priority at all levels of governance in WHO.14

Going back to the question about the need for policy makers to increase the success of public health policies and reduce failures, I believe that what is needed now is leadership, and capacity to implement practical solutions that can make a diff erence. Policy makers need to be guided on what sort of policy changes actually lead to tangible health improvements,15 and one of the key messages of this Series is that identifi cation of the determinants of successes and failures of diff erent EU health policies can guide policy makers to achieve optimum results.7 The framework of Health 2020 off ers eff ective policy and practice interventions, giving politicians and policy makers the opportunity to improve health and wellbeing and health equity.16

Health in Europe—policies for progressPublished OnlineMarch 27, 2013http://dx.doi.org/10.1016/S0140-6736(13)60356-6

See Series pages 1125, 1135, and 1145

See Online/Serieshttp://dx.doi.org/10.1016/S0140-6736(12)62085-6,http://dx.doi.org/10.1016/S0140-6736(12)62086-8,http://dx.doi.org/10.1016/S0140-6736(12)62087-X, andhttp://dx.doi.org/10.1016/S0140-6736(13)60102-6

Comment

1076 www.thelancet.com Vol 381 March 30, 2013

Sustaining a growing ageing population across the European region through integrated health policies that put citizens at the centre of the health-care process can achieve improvements in the health and wellbeing of citizens in coming decades.

Walter RicciardiDepartment of Public Health, Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 1-00168 Rome, Italywricciardi@rm.unicatt.it

I declare that I have no confl icts of interest.

1 Mackenbach J, McKee M. Successes and failures of health policy in Europe: four decades of divergent trends and converging challenges. Milton Keynes: Open University Press, 2013.

2 WHO. European health for all database. http://www.euro.who.int/hfadb (accessed Feb 14, 2013).

3 WHO. Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen: World Health Organization Regional Offi ce for Europe, 2012.

4 WHO. European action plan for strengthening public health capacities and services. Copenhagen: World Health Organization Regional Offi ce for Europe, 2012.

5 McCarthy M. Targets for health in Europe: the debate continues. Eur J Public Health 2012; 22: 455–56.

6 WHO. The European health report 2012: charting the way to well-being. Copenhagen: World Health Organization Regional Offi ce for Europe, 2013.

A proliferation of complex challenges to development, such as political confl ict, economic austerity, and environ mental degradation, all demand attention, but should not defl ect from recognising that good health is central to advancing global prosperity. Development is about improving people’s lives. A population cannot progress if it is burdened with ill-health. Good health is the foundation on which communities and nations can and do fl ourish. A healthy, educated population is one of the major engines of development—and one of its most universally valued outcomes. Whatever framework for development is agreed upon for the post-2015 era, people must be at the centre. Ultimately, we must be able to measure our success through indicators that help us understand the diff erence we have made in people’s lives.

Looking back to 2000, when 189 countries adopted the Millennium Declaration, which set the principles and commitments for the Millennium Development Goals (MDGs), it was not known if such a framework would work. Although the MDG framework is not perfect, its contribution to the results in global health is tangible. Fewer children are dying: the number

of children younger than 5 years who die each year has been reduced by more than 40% since 1990.1 Fewer children are underweight: the percentage of underweight children under the age of 5 years in developing countries is estimated to have dropped from 25% in 1990 to 17% in 2011.2 Fewer people are contracting HIV: worldwide the number of people acquiring HIV infection in 2011 was 20% lower than in 2001, and an unprecedented 8 million people in low-income and middle-income countries are on life-saving antiretroviral treatment.3 And fewer women die in childbirth each year: maternal mortality has been reduced by almost half from 1990 to 2010.4

A healthy population is a prerequisite for development. 1 extra year’s increase in average life expectancy can increase gross domestic product by 4%.5 Some of the best buys in improving global welfare are through investments in health, such as expanding access to immunisation. Healthy individuals are more productive, earn more, save more, invest more, and work longer. Unhealthy people carry a high cost for themselves and for their countries. For example, malaria, which greatly contributes to the disease burden

A healthy perspective: the post-2015 development agendaPublished Online

March 25, 2013http://dx.doi.org/10.1016/

S0140-6736(13)60722-9

7 Mackenbach JP, Karanikolos M, McKee M. The unequal health of Europeans: successes and failures of policies. Lancet 2013; published online March 27. http://dx.doi.org/10.1016/S0140-6736(12)62082-0.

8 Greer SL, Hervey TK, Mackenbach JP, McKee M. Health law and policy in the European Union. Lancet 2013; published online March 27. http://dx.doi.org/10.1016/S0140-6736(12)62083-2.

9 Rechel B, Roberts B, Richardson E, et al. Health and health systems in the Commonwealth of Independent States. Lancet 2013; published online March 27. http://dx.doi.org/10.1016/S0140-6736(12)62084-4.

10 Wolfe I, Thompson M, Gill P, et al. Health services for children in western Europe. Lancet 2013; published online March 27. http://dx.doi.org/10.1016/S0140-6736(12)62085-6.

11 Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. Lancet 2013; published online March 27. http://dx.doi.org/10.1016/S0140-6736(12)62086-8.

12 Rechel B, Grundy E, Robine J-M, et al. Ageing in the European Union. Lancet 2013; published online March 27. http://dx.doi.org/10.1016/S0140-6736(12)62087-X.

13 Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013; published online March 27. http://dx.doi.org/10.1016/S0140-6736(13)60102-6.

14 Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P, on behalf of the Consortium for the European Review of Social Determinants of Health and the Health Divide. WHO European review of social determinants of health and the health divide. Lancet 2012; 380: 1011–29.

15 Guest C, Ricciardi W, Kawachi I, Lang I. Oxford handbook of public health practice, 3rd edn. Oxford: Oxford University Press, 2013.

16 Jakab Z. Promoting health and reducing health inequities in Europe. Lancet 2012; 380: 951–53.