Public health is a foundation for social and economic developmentHealth 2020 is a new European public health policy framework. It aims at supporting action across government and society – improving people’s health and life quality, reducing disparities in the area of healthcare, enhancing public health and ensuring a people-centered health system that is equitable, sustainable and of high quality,” Zsuzsanna Jakab, Regional Director of the World Health Organization’s Regional Of-fice for Europe starts her presentation “Health 2020 policy of the WHO/Europe” at the Health Forum in Lithuania.

Zsuzsanna Jakab Regional Director, World Health Organiza-tion’s Regional Office for Europe

Key to economic recovery According to Ms. Jakab, the WHO health policy strategy is evidence-based. The

document elaborates on the importance of the integrated practice in tackling chronic diseases; it lays stress on the in-ternational and interdepartmental col-laboration, the elimination of disparities in healthcare and active promotion of a healthy lifestyle. The strategy sets forth the conditions for

investment in healthcare and expansion of communities that value health. Sec-ond, a good public health is a foundation for social and economic development; it is also a key to economic recovery. What is the benefit of this strategy, you may ask. It gives a vision, priorities and proposals to policy makers of how to ensure the health

of future generations. What is more, the document was drawn up in consideration of the realities that make up the WHO’s European Region. Health 2020 represents two years of in-tensive consulting with the specialists re-sponsible for the health policy across the European Region.

Why Health 2020? A new health policy for 2020 is required be-cause Europe has undergone rapid changes in recent years, and the changes are making an immense influence on health; hence, new ways out of the situation need to be found. Social, economic, demographic and envi-ronmental changes are posing a number of challenges. To achieve positive results both on the international level and in the domes-tic health policy, a consistent and integrated framework is required. “Even though in recent years the WHO’s European Region has implemented a num-ber of improvements in health and they are equally applied everywhere, the most up-to-date research data show that the en-hancement of population health is not even in all countries of the continent. Some show significant disparities, yet in others the situ-ation in the health sector even deteriorates. What is more, when resources are distrib-uted across the region, a unified system enabling the sharing of knowledge and practice brings benefit to everyone,” Ms. Jakab says.Health 2020 strategy is based on the values enshrined in the WHO Constitution and aims at the “highest attainable standard of health” as the underlying human right across Europe. Therefore, we must continu-ously promote the healthcare policy based on values and rights. •

Board Chairman of the Health Forum, Chancellor of the Medical Academy of the Lithuanian Uni-versity of Health Sciences Prof. Dr. Habil. Vilius Grabauskas:

- Health has been the greatest value in the life of the humankind at all times and across all cultures. Lithu-ania is no exception. When we hear the saying “Health is the greatest asset”, no one doubts it, everybody sincerely believes in it. However, as a rule, an individual only thinks about the truth and meaning em-bedded in this belief when our health actually starts to deteriorate. Thus, a question naturally arises whether we accurately perceive the meaning of the famous saying by assigning the responsibility of solving health problems to the health sector and the health specialists working in it. In the meantime, it has long been known that the health system does not cover the healthcare sector alone. By pursuing a healthy life-style, a person must at least live in

such a way as to cause no harm to his or her own health. However, the state has to stretch a helping hand by investing in the creation of a health-friendly social, physical and economic environment, effec-tive functioning of the health sector, which enables early diagnosing of health disorders and their handling to the maximum possible degree. In other words, all sectors of the na-tional social and economic system should play an active role in the

process of health promotion. It is self-evident that the intersec-toral collaboration cannot happen on its own; it should be promoted at all levels. Hence, it is essential to create a mechanism enabling a systematic communication, the search for solutions to health prob-lems and the dissemination of in-formation across all groups of the Lithuanian population. The Health Forum invites all sectors, all profes-sions and all levels of the social and economic system, including politi-cal, to participate in the discussion. The forum operates as a platform helping to expand the creation and development of innovative pro-cesses of health education, disease prevention and healthcare. It is an ongoing dialogue ensuring a broad cooperation in quest of the health policy and strategy trends most ap-propriate to Lithuania. As a result of demographic pro-cesses and population ageing, peo-ple are eventually diagnosed with chronic diseases, which have to be

treated. The problem is even more pressing in Lithuania as the said diseases affect increasingly young-er members of the population. Thus, the more is done to raise awareness and to prevent the disease from oc-curring and to enable an early diag-nosis and effective treatment even in cases where the disease has already progressed, the better results we will achieve. To achieve this aim, invest-ments, cooperation between a pa-tient and a health specialist, infra-structure, diagnostic and treatment equipment, high technologies are needed. However, the situation as it is today should definitely change as only a tiny share of expenditure is dedicated to health education, disease prevention and the ac-tions based on the science of public health – from 1 to 2 percent of the overall national health expenditure as the data available at the Depart-ment of Statistics show. According to the research of the Lithuanian University of Health Sciences, even before a baby is

born, the factors of family and envi-ronment have influence on the new-born’s development. If a mother is reluctant to think about her baby’s future, she smokes and consumes alcohol, lives in the environment harmful to her health, the risk ac-cumulates itself until risk factors entrench themselves and stimulate the appearance of a disease at an older age. It shows that as far as the health system is concerned, it is es-sential to make a thorough evalua-tion of the possibilities for people to be healthy from birth to the old age. It is the goal of the Health Forum to make a clear identification of the problems and to involve not only the health sector but also every other sector in their solving. The structure of this initial opening conference is also targeted at this goal. Whereas the problems related to innovations are broad-ranging and it is not possible to cover all problems in a single event, we tried to classify the information into four major parts. •

Dossier:

• Zsuzsanna Jakab holds a Master’s degree from the Faculty of Humanities, Eötvös Lóránd Univer-sity, Budapest; a postgraduate degree from the University of Political Sciences, Budapest; a diploma in public health from the Nordic School of Public Health, Gothenburg (Sweden) and a postgraduate diploma from the National Institute of Public Admin-istration and Management in Hungary. • From 2010 she took up her duties as Regional Director of the World Trade Organization’s Regional Office for Europe. Before her election as Regional Director, she served as the Founding Director of the European Union’s European Centre for Disease Pre-vention and Control (Stockholm, Sweden). Thanks to her efforts over the period from 2005 to 2010, the centre became an internationally respected centre of excellence in the fight against infectious diseases.

COMMENTARY

No. 1 November 29, 2012, Vilnius

Prof. Sylvie StachenkoProfessor, School of Public Health, University of Alberta (Canada)

- You will deliver a presentation elaborating on inter-sectoral collaboration for the control of chronic non-communicable diseases as one of its major highlights. Why is it important and what is the general Canadian experience in this field?- In contemporary society health is understood as part of our daily life, a life quality indicator. However, health is not evaluated by the diseases and death alone. It is like a crossroad: a place where biological and social factors, an individual and the community, social and economic policy meet. Moreover, it is also a way of self-expression of an individual and a group, a success indicator of the society and its institutions in the creation of wellbeing. Therefore, such a multi-dimensional concept of health has changed its policy strategy. In Canada we achieved that public health is at the top of the list of the govern-ment’s priorities. Special attention is paid to public health in Canada, and it is the matter of concern of not only the ministry of health but also other ministries, non-govern-mental organizations and communities. Health promotion policy covers legislation, financing, social and organiza-tional structures because only a coordinated and efficient health policy can provide equal opportunities of health promotion for all members in the society.

- It is also covered by the Ottawa Charter which is mentioned in your presentation?- The Ottawa Charter was signed in 1986. It laid the foun-dations which we have followed to this day. The Charter is one of the principal instruments for the formation of the public health policy. Health promotion is a far broader subject than healthcare. Politicians must show interest in the issue, realise the influence of their decisions on health and take responsibility for them. Second, people strength-en and maintain health in their daily environment where they study, work and rest. Health is created by taking care of oneself and others, being able to take decisions and taking control of life circumstances, by simultaneously ensuring that the society where a person lives creates ad-equate conditions for every member to seek good health.

- Can you give several Canadian best practice exam-ples which Lithuania could benefit from? - I cannot say that there is a single system which suits all

countries. Probably every country has to find the method that best suits it by taking advantage of the best practice examples of other countries. However, it is obvious that intersectoral collaboration is essential in the formation of health promotion policy. After all, every country, not only Canada and Lithuania, aims for its society to be healthy. Therefore, it is very good that the forum gives us an op-portunity to share experiences. In my presentation I will give three best practice examples which you are free to benefit from but I am not trying to say that you must blindly follow them.

- I have heard that you were one of the initiators push-ing for the recognition of public health as one of the national priorities in Canada. Lithuania declared the next year the Year of Health and Wellness. Perhaps you can give some advice on what we should focus on? - Based on the Canadian experience, I believe that there are two important things you should focus on. First – public health, which has become more visible in several recent years; therefore, it is natural that it draws increas-ingly more attention from politicians and the society it-self. One of its key aims is to attract as large part of the society as possible from kindergarteners, pupils to adults. To achieve this aim, a very solid foundation, as well as the support from politicians and communities, is required. Second – to create firm foundations of public health and to develop infrastructure. It took nearly two decades for Canada to achieve it. •

Prof. Egon JonssonExecutive Director, Institute of Health Eco-nomics (Canada)

- You will give a presentation “Health Technology Assessment: Objectives, Principles, Expecta-tions, Outcomes” at the conference. When and why did the need to as-sess the new technologies arriving in medicine in several aspects emerge? - Such a need emerged some forty years ago, when the first computed tomogra-phy scanners showed up. Back then it was incredibly expensive equipment in the health system costing three to four million dollars. No other equipment had demanded such immense invest-ments until that time. It was a sensa-tion, a breakthrough in medicine, and it is natural that such a breakthrough was desired by everyone: from doc-tors and scientists to media. However, in reality no one could afford it. It was the first time when economists, doc-tors and scientists were addressed. They were asked to assess the impact of the new technology and the benefit it would bring. In earlier times a doctor used to say that some equipment was required and it was bought, but computed tomog-

raphy changed the situation radically. Today some fifty countries worldwide have responsible authorities assessing new technologies. What is more, they

do not only assess medical equipment but also new surgical interventions, new drugs, even new prevention pro-grammes.

- You are a member of one of health technology assessment committees. What is the process of assessment of medical innovations in Canada? - There are three large agencies in Canada and up to ten university facul-ties operating in this field. Naturally, universities are only engaged in re-search activities. Nevertheless, other institutions work on the legal side of

the problem. They attempt to take a broader perspective, i.e., what influ-ence the new technology will have on society. I can tell in greater detail how the sys-tem operates in the region of Alberta, where I work myself. The region’s population is similar to that of Lithua-nia’s, only the area is ten times larger. Several decades ago the Canadian

Dossier:

• Prof. Egon Jonsson is President and CEO of the Institute of Health Economics (Edmonton, Canada). He is also Professor of Health Economics at the University of Alberta and the University of Calgary. • He graduated from Stockholm School of Economics and served as a research associate at Harvard School of Public Health (US). • For 15 years he was Director of the Swedish Council on Health Technol-ogy Assessment and Professor of Economics at the Department of Medi-cine, the Karolinska Institute (Stockholm, Sweden). He later worked for the World Health Organization and significantly contributed to the establish-ment of the Health Evidence Network intended for the health ministries of the countries from the European Region. • From 1990 to 2000 Prof. Jonsson served as the expert of the World Bank on the issues of healthcare services in Latvia and Lithuania.

Dossier:

• Prof. Sylvie Stachenko is Professor at the School of Public Health at the University of Alberta and Visiting Professor at the National School of Public Health in France, as well as a public health expert in the field of health promotion and chronic disease prevention. • She completed her residency in family medicine at the Université de Montréal and earned a Mas-ter’s degree in Epidemiology and Health Services Administration from the Harvard School of Public Health. • She led chronic disease policies in Canada, including cancer, diabetes, cardiovascular diseases and AIDS.• Prior to 2009, Prof. Stachenko was Deputy Chief Public Health Officer at the Public Health Agency of Canada. From 2002 to 2004 she was Director General in the Centre for Chronic Disease Preven-tion and Control in Canada. From 1997 to 2002 Prof. Stachenko served as Director of Health Policy and Services for the WHO’s Regional Office for Europe. •

Dossier:

• Prof. Finn Børlum Kristensen graduated from biomedical stud-ies and received his PhD in epidemiology. He is a primary care physician and specialist in public health. • From 2006 he has been Director of the Coordinating Secretariat of the European Network for Health Technology Assessment (EUnetHTA).• Since 2011 he has been appointed Board Director of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). • Since 1999 he has been Chairman of the EUnetHTA Executive Committee and Professor in health services research and health technology assessment at the University of Southern Denmark.• In 2006–2008 he was a project leader of EUnetHTA (www.eunethta.net). •

Computed tomography made a breakthrough A multi-dimensional concept of health has changed its policy strategy

Health technology assessment: a useful tool in patient protection

Government founded two commit-tees in the region, which assess in-novations and provide recommenda-tions and proposals to the healthcare system. One of the committees is responsible for new drugs only; the other – for technologies, procedures, or even organisational aspects of the healthcare system. I am a member of the latter committee comprising of 12 members. Every second month we gather to meetings to review at least ten new proposals. In fact, it should be noted that the pace of arrival of new technology in medicine is very fast; thus, we now have to consider from 20 to 25 new proposals. One of the key objectives is to deter-mine the advantage of a new technol-ogy over other technologies used be-fore it, what research has been carried out to ground it and, of course, what is the price-efficiency ratio. Once we analyse it, we provide recommenda-tions to the Ministry of Health.

- You had a chance to work with Lithuanian specialists. What health technology assessment prospects do you see in our country? - In my opinion, which, I believe, would be supported by the entire health technology assessment commu-

nity, it is very important that the peo-ple working in this field do not belong to a single public authority because there is no secret that each public sec-tor has its own interests. It must be an absolutely independent body relying on well-founded evidence rather than, for instance, instructions from the government alone – where the lowest price takes the lead irrespective of ef-ficiency and benefit to people. The second important aspect is that the technologies are not only the mat-ter of concern of the ministry of health but also the ministry of education and the ministry of social affairs. I can give prevention programmes as an example. As far as I know, Lithuania, like many other countries, faces problems relat-ed to traumas in road accidents, smok-ing, alcohol and drug abuse. If health technology assessment was applied to these fields, we would see that most of these health problems are determined by a single cause inflicting a number of other problems on a broad scale. Hence, I am convinced that positive results can be achieved once we join our forces; that is why, the body re-sponsible for health technology as-sessment must comprise of the spe-cialists from different fields. •

Prof. Finn Børlum Kristensen Chairman, EUnetHTA (Denmark)

- You are the head of the Eu-ropean Network for Health Technology Assessment. What benefits does the mem-bership offer to the member countries? - The goal of EUnetHTA is to bring together national coordi-nating centres, research insti-tutes and ministries of health and to create an efficient and independent European net-work enabling the exchange in scientific information, which is also costly, as well as to sup-port the healthcare policy. To put it simply, the network en-ables to join the partners from different countries, to share the information, research and data collected and apply them to the medical practice in a specific country.

- EUnetHTA was first launched in Denmark. What inspired the creation of such

a network? - Over the last several de-cades the growth of the use of healthcare technology has been especially rapid. Equip-ment has gotten increasingly more modern, and the fast growth of new technology and knowledge made it impossible to keep pace with the medical progress. What is more, we

faced the necessity to stop the implementation of inefficient healthcare technology until its actual benefit is proven and to prevent the replacement of valuable and efficient diagnos-tic and therapeutic procedures with new uncertified technol-ogy which cannot ensure better results and wastes the finances dedicated to healthcare. Such

IT SHOULD BE NOTED THAT:

The European Network for Health Technology Assessment (EUnetHTA) brings together 25 EU member states, Norway, Iceland, Switzerland and other non-EU member countries, such as the US, Canada, Austra-lia, Israel. •

IT SHOULD BE NOTED THAT:

The basic strategies for health promotion in Canada were set forth in the Ottawa Charter in 1986. The main principles are as follows: health promotion covers all population groups; health promotion is targeted at the determinants of health; health promotion combines various ways and methods; health promotion relies on an ef-fective and specific public role in solving health problems; health promotion is primarily a social and political objective. •

reasons led the Danish health-care institutions to create such a network in collaboration with Danish medicine authorities.

- Can you single out the most important health technology achievements in Denmark? Perhaps you can give some advice for Lithuania?- There are countries which have been applying health tech-nology assessment for as long as several decades. There are also countries which are only making their first steps but that does not mean that their work is inefficient. I would single out two important things de-veloped in Denmark in the sphere of health technology assessment. First, we do not only assess the clinical aspect but also the outcomes to pa-tients. The benefit for a medi-cal institution and how the new technology will pay back are frequently assessed, whereas we try to find the balance and to take into account the needs of patients. Second, we created the tool of health technology assessment for hospitals for them or their subdivisions to be

able to select the most efficient solutions by applying modern technology or interventions in a specific case. This is not my first time in Lithuania; several decades ago I first paid a visit as a consul-tant for primary healthcare of the Ministry of Health. I worked a lot with Professor Vilius Grabauskas and Profes-sor Danguolė Jankauskienė. Regarding health technology assessment, Lithuania could benefit from the successful ex-perience of the neighbouring Poland and the Nordic coun-tries – Finland, Sweden, Den-mark. •

Creating Health for the Year 2020 TodayNovember 29-30, 2012, Radisson Blu Hotel Lietuva, Vilnius

Creating Health for the Year 2020 TodayNovember 29-30, 2012, Radisson Blu Hotel Lietuva, Vilnius

Optimistic Scenario

Patients are monitored remotely

Richard BergströmDirector General, European Federation of Phar-maceutical Industries and Associations

- You present the industry visions of 2020 at the conference. What are they? - Let me present an optimistic sce-nario of the industry of Europe based on research studies in the field of health. Healthcare does not only un-dergo continuous improvement but it is also getting increasingly more ex-pensive. I can see today how innova-tive products rapidly paving their way to medicine are pushing for essential

breakthroughs in healthcare. The role of investments in innovative technol-ogy has become of even greater im-portance in the last decade; however, it does not mean that the currently applied testing or treatment methods are not valuable. In fact, a rapid tech-nological development, personalized medicine techniques have become the central pillar of the pharmaceutical industry. The obtained results provide an opportunity to treat serious diseases and to prolong human life expectancy. Is this not what we are striving for?I understand when they say that the current economic situation imposes a number of limitations. However, it is important to remember that health and economics are tightly linked, and an investment in health is an investment in the future.

- You will present a European-wide vision. Could you also elaborate on Lithuania’s vision? - First of all, Lithuania has a very strong legal base but my advice is to increase participation in clinical trials – it would definitely be beneficial to your healthcare system. I am not trying to offend anyone – however, compared to other European countries, innovative technology is still not easily accessible to Lithuanian patients. For instance, if we compare a patient treated in Belgium with a pa-tient receiving treatment in Lithuania, a Belgian patient will get the most advanced treatment which is not even available in your country. I believe that it is one of the principal problems which you have to solve. I get an impression that the Lithuanian

IT SHOULD BE NOTED THAT:

• The European Federation of Pharmaceutical Industries and Associations (EFPIA) represents the pharmaceutical industry operating in Europe. Through its direct membership of over 32 associations and 35 leading pharmaceutical companies, EFPIA has become an important voice in the EU context.• EFPIA is 2,000 companies com-mitted to researching, develop-ing and bringing to patients top-quality medicines that will improve the quality of life around the world. • The mission of EFPIA is to promote pharmaceutical research and development in Europe. It also seeks to create favourable economic and political conditions enabling the research-based pharmaceutical industry to meet the growing healthcare needs and expectations of patients. •

healthcare system faces the problems of the lacking continuity assurance and poor intersectoral collaboration. For example, closer cooperation among healthcare specialists, politi-cians and the pharmaceutical industry could be a good starting point in solv-ing innovation accessibility issues. Transparency and publicity are the necessary prerequisites for it. •

Dossier:

• Richard Bergström is a member of the Board of the Karolinska Institute ap-pointed by the Swedish Government. He is a pharmacist by training, receiving his Master’s degree from Uppsala University (Sweden). • Since 2011 he has been the Director General of the European Federation of Pharmaceutical Industries and Associations (EFPIA). • Previously he served for nine years as the Director General of the Swedish Association of the Pharmaceutical Industry (LIF). •

Dossier:

• Prof. Friedrich Köhler received medical training at the Humboldt University in Berlin and is a specialist of cardiology. From 1997 to 2003 he was the coordina-tor of a telemedicine project between Germany and the Baltic States sponsored by the German Ministry of Health. • From 2005 to 2011 he was the head of the Consortium “Partnership for the Heart” sponsored by the German Ministry of Economics and Technology. The aim of the project was the development and clinical trial of a new telemonitor-ing system for patients with heart failure. Since 2009 the professor is the head of the Consortium “Health Region of the Future Northern Brandenburg – Fontane”.• Since 2011 he is Professor of the Centre for Cardiovascular Telemedicine at the Charité University Hospital in Berlin. •

Prof. Friedrich KöhlerDirector, Department of Cardiology and Angiol-ogy, Centre for Cardiovascular Telemedicine, Charité University Hospital (Germany)

- You will present an international best practice example of installing innovative technologies at the con-ference. Could you describe it in brief? - The aim of this project is the creation and clinical trial of a new monitor-ing system aimed at the patients with cardiovascular diseases. The results of the project open new possibilities. The patients attributed to the group

of high-risk heart failure patients are subject to repetitive health check-ups in a number of countries. New con-temporary technologies enable their remote monitoring and health control. In my presentation I will present two trends which can be used and applied to practice. First, I will elaborate on a new model and its clinical results. Second, I will give the examples of how to apply the implemented medi-cal innovations properly and generate the largest possible economic ben-efit. Based on my personal ten-year research experience, I will cover any potential dangers and difficulties.

-Can you also apply this model to the patients diagnosed with other chronic diseases?-Cardiovascular diseases are one of the most common causes of hospi-talisation and one of the most com-mon causes of death. Nevertheless, in the future the new model can also be applied to the patients with other chronic diseases – for instance, diabe-tes. The system is an important step forward in general healthcare. Such a method of monitoring is most benefi-cial to patients who are subject to con-stant health monitoring. The system

enables the patient’s monitoring on a daily basis rather than on individual visits to the doctor. The specialist can thus select the method of treatment and correct it, as well as provide the required assistance when requested. It also contributes to saving finances and time, reduces the frequency of patient’s visits to the doctor and en-sures ongoing monitoring. Patients feel safer while a doctor gets an op-portunity to dedicate more time to other patients in need of his/her help.

- Though a number of prevention pro-grammes are being implemented in Lithuania, we cannot yet fully control cardiovascular morbidity. What is the situation in Germany? Perhaps you can give some advice to our specialists? - Many probably think that it is very easy to give advice but I am defi-nitely not the one who would say to Lithuanian specialists: “This is how you are supposed to do, not the other way round”. I cannot do it. As far as I know, you have highly talented spe-cialists of cardiology, true experts in their field, who are not in any way inferior to foreign specialists. They are heard and seen in international conferences; therefore, I believe that it would be even incorrect to give ad-vice to them.

On the other hand, I cannot say that Germany has discovered some mi-raculous way to avoid cardiovascular diseases. This is definitely not the case. Of course, to forestall the diseases, prevention should not be forgotten – to pay attention to risk factors caus-ing heart failures, to promote healthy lifestyle, etc. As for the fact that car-diovascular diseases are to blame for the majority of deaths, they should not only be the primary concern of doctors but also of politicians shaping the health policy. •

Dr. Liudvika Starkienė, Secretary General, Association Health Fo-rum:- One of the principal goals of the Health Forum is better health and a long life of the population. We can only achieve this goal by gathering the forces of different sectors, public authorities and non-governmental organizations. Foreign guests from Belgium, Denmark, Sweden, Italy, Hungary, Switzerland, Germany, Canada and a number of other countries share their experiences and best practice examples at the conference. A number of Lithu-anian specialists will also deliver their presentations; over 500 par-ticipants are expected. The exhibition showcasing the works of patients’ organizations will also be held during the forum. It will be an excellent opportunity to get to know them better. Their representatives are not only ready to show their works but also to tell about their activities and to share their experiences. According to the speakers of the Health Forum, there is an immense gap between the knowledge of healthcare specialists and patients. The successful experience of other EU member states where the ac-tivities of patients’ organizations are deep-rooted shows that such an unfavourable situation can only be changed by patients themselves – opinion leaders capable of attract-ing other patients and communi-cating experience and knowledge to them. Patients’ organizations do a huge, yet often silent work: there-fore, it is important to increase the awareness of the society of their activities, joys and concerns. •

COMMENTARY

Creating Health for the Year 2020 TodayNovember 29-30, 2012, Radisson Blu Hotel Lietuva, Vilnius

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