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Framework for action on resilient and sustainable health systems in the

WHO European Region, 2025–2030

Building on the legacy of the 2008 Tallinn Charter for Health Systems for Health and Wealth, this

document offers an updated vision for health systems in the WHO European Region. It is based on

the health systems work of the WHO Regional Office for Europe under the European Programme of

Work, 2020-2025, leading up to, and including the outcomes of, a high-level health systems

conference held in Tallinn, Estonia 12-13 December 2023.

Presented here as a ‘Framework for action on resilient and sustainable health systems in the WHO

European Region’, the document identifies eight (8) priority action areas which build on health

system priorities agreed by previous Regional Committees. These areas are brought together in an

overarching manner to reflect a more systems-oriented perspective to address the contemporary

challenges facing health systems in the European Region.

The framework recognizes that health systems are key to the future health and cohesion of our

societies. It introduces in an explicit manner the role of health systems resilience in relation to

broader contextual issues affecting the WHO European Region, including climate change, social

fragmentation, demographic shifts, complex multi-morbidities, a volatile social and economic

landscape, rapid societal digitalization, and the health impacts of conflict. In this challenging

context, health systems must transform to meet the physical and mental health needs of

individuals and populations.

The aim of the proposed framework is captured in the following vision statement: For everyone to

be able to trust that they will receive the right care, at the right time, in the right place, from

the right person, without experiencing financial hardship. High-performing health systems,

available to all people throughout life, and fit for a changing world, is the enactment of this vision.

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BACKGROUND AND RATIONALE

1. In 2008, Member States in the WHO European Region endorsed the Tallinn Charter on Health

Systems for Health and Wealth. Informed by the 1996 Ljubljana Charter on Reforming Health Care in

Europe1, the Tallinn Charter acknowledged that there are differences between health systems in the

Region and sought to coalesce Member States around the shared values of equity, solidarity, and

participation for delivering health services to their populations. These values remain significant today,

as does the Charter’s definition of a health system as “the ensemble of all public and private

organizations, institutions and resources mandated to improve, maintain or restore health [which]

encompass both personal and population services, as well as activities to influence the policies and

actions of other sectors to address social, environmental and economic determinants of health”.

2. The Charter set out a shared vision for health systems and, over the past 15 years, has served

as a touchpoint for action by both the WHO Regional Office for Europe (WHO/Europe) and its Member

States. The interim report2 and the final report on implementation of the Tallinn Charter3 point to a

number of policies and decisions taken by WHO/Europe and the Member States in the context of

enacting the Charter’s commitments.

3. The regional context for health systems has changed dramatically since 2008. Health systems

have not ‘bounced back’ since COVID-19 (Coronavirus disease 2019) pandemic. Further, many

legacy health system challenges remain, including the burden posed by noncommunicable diseases

(NCDs), the unfinished communicable disease agenda, and the cost of access to medicines and

health technologies. Health systems across the Region are now struggling to respond to a series of

additional or worsened crises, many of which are interlinked, as well as emergent trends that require

new policy responses. Among these are:

 growing numbers of patients presenting with progressively complex multi-morbidities, in the

context of an increasingly older population cohort;

 a growing mental health burden, particularly among younger persons (the full impact of which

has yet to be understood);

 a health and care workforce in crisis due to a manifest shortage in both the current and future

context of care in relation to increased needs;

 outdated models of care, in view of changing patient needs and the rapid increase in

technological advances, including the role of artificial intelligence;

 the direct and indirect impacts of the climate emergency on individual and population health,

and the health system’s own contribution to climate change;

 the rise in antimicrobial resistance; and

 crowding out of fiscal space for health due to competing pressures, such as the impact of

conflict, along with a humanitarian and migrant and refugee health crisis.

4. The COVID-19 pandemic did not just affect health systems. It has negatively impacted our

societies, damaging economies and livelihoods, and contributed to a growing lack trust in science

and expert opinion4. The result is a loss of confidence in health systems across the Region – among

1 The Ljubljana Charter on Reforming Health Care in Europe. Copenhagen: WHO Regional Office for Europe; 1996. 2 See: https://who-sandbox.squiz.cloud/__data/assets/pdf_file/0008/147725/wd11E_InterimTallinnCharter_111356.pdf. 3 Implementation of the Tallinn Charter: final Report. 4 European Observatory on Health Systems and Policies & McKee M (editor). Drawing light from the pandemic: a new strategy for health and sustainable development: a review of the evidence. Copenhagen: WHO Regional Office for Europe; 2021.

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individuals, health and care workers, and policy-makers5 – with some countries now backsliding on

UHC and earlier health gains being reversed6.

5. WHO/Europe and the Government of Estonia convened a high-level health systems

conference on 12–13 December 2023 in Tallinn7. The outcome statement8 recognized the need for a

transformational agenda to promote more resilient and sustainable health systems in the Region,

also in support of more equitable and healthy societies. In keeping with the directions set out in the

outcome statement [FORTHCOMING], and as approved via concept-noted (document

EUR/SC31(2)/6) at the second session of the thirty-first Standing Committee of the Regional

Committee9, the current document proposes a framework for action on resilient and sustainable

health systems in the Region for the period 2025–2030.

VISION STATEMENT

6. The vision underpinning the proposed framework for action on health systems is: For

everyone to be able to trust that they will receive the right care, at the right time, in the right

place, from the right person, without experiencing financial hardship. High-performing health

systems, available to all people throughout life, and relevant for a changing world, is the enactment

of this vision.

7. This vision is based on several elements. The first is trust – in health systems, in health

professionals, and in quality services. Second, to ensure quality outcomes care should be

appropriate, person-centred, and delivered in a timely fashion in the right setting as close to

individuals as possible. Third is that this care is delivered by trained, motivated and supported

professionals. Fourth is that no one should have to choose between healthcare or other basic needs.

And fifth is that a transformation in thinking, planning and implementing health systems is required

for this vision to become a reality.

8. While this vision expresses the role of health systems towards serving the health needs

Region’s individuals, its starting-point is that health systems cannot simply be static dispensers of

healthcare services. The myriad challenges outlined earlier necessitate a move away from a purely

clinical, siloed, or reactive view of healthcare delivered by outdated service models and health

professional roles. Health systems are part of national socio-economic fabrics, operating in a context

of constant change and uncertainty, and must be able to fulfil their potential as complex adaptive

systems.10 A transformation in policy and practice to address current and future challenges is thus

needed, including: changing the roles and interfaces of primary health care and hospitals; managing

the health-social care overlap; adopting innovations in practice and technology (e.g., AI, big data, and

genomics, which themselves alone necessitate a shift in health systems thinking); and a wider

recognition of the contribution of well-functioning systems to social cohesion and economic

prosperity.

5 see: https://eurohealthobservatory.who.int/publications/i/trust-the-foundation-of-health-systems 6 Can people afford to pay for health care? Evidence on financial protection in 40 countries in Europe. Copenhagen: WHO Regional Office for Europe; 2023. 7 Tallinn Charter 15th Anniversary Health Systems Conference: Trust and transformation – resilient and sustainable health systems for the future. Copenhagen: WHO Regional Office for Europe; 2008. 8 see: https://iris.who.int/bitstream/handle/10665/375032/TC-15-Health-systems-conference-Tallin-statm-2023-eng.pdf 9 see: https://iris.who.int/bitstream/handle/10665/376480/31s2e00_REP_240051.pdf 10 see: https://iris.who.int/bitstream/handle/10665/44204/9789241563895_eng.pdf

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PRIORITY ACTION AREAS

9. The eight interlinked priority action areas are proposed from a systems-thinking perspective,

seeking to strike a balance between the need to be aspirational versus realistic, and to consolidate

versus itemize.

(a) advancing primary health care (PHC) as the anchor for health systems across the Region

through integrated and patient-centered care models, and rethinking the role of hospitals

and how specialist care is delivered, while ensuring a commitment to public health,

prevention, and quality of care across all settings;

The 2018 Astana Declaration on Primary Health Care11 extended the definition of PHC beyond the

narrow biomedical remit of health services to engage with the wider social determinants of economic

and social development. The COVID-19 pandemic underscored the importance of PHC in addressing

not only physical health needs but also mental and social health determinants. Integrated

multidisciplinary primary health care teams have emerged as better positioned to address current

health and well- being challenges.

The most immediate priorities for PHC across the Region, therefore, are to strengthen collaboration

between public health and primary health care services at the community level, to scale up mental

health services in primary health care, and to more closely integrate with social care. In the area of

NCDs12, increasing capacity at the primary care level to engage in brief lifestyle interventions, provide

personalized and patient-centered advice on behavioural change, manage risk-factors and disease

with affordable effective medicines (referring to specialized care when appropriate), all enable PHC

to play a leading role in increasingly complex NCD management and care. Redefining the model of

care in this way brings dividends not just in terms of health outcomes, but also in cost-savings and

more efficient health systems.

(b) strengthening and expanding community-based interventions, including working closely

and effectively with civil society organizations, the public and underserved groups;

The COVID-19 pandemic underlined the ability of civil society and other community-based

organizations to reach underserved and vulnerable populations, providing an important support to

health authorities across the Region. Such organizations are also well-positioned to provide feedback

on the acceptability of public health measures and policies in general, allowing health authorities to

adapt and improve interventions and health system decision-making. Their importance has been

recognized through a first-ever resolution on social participation during the 77 World Health

Assembly (WHA)13

Social participation is key to ensuring that people have a health system that they trust and regard as

responsive to their needs14. It can help support UHC, as national health policies, strategies and plans

are more likely to be implemented effectively if their development and negotiation is inclusive of all

relevant stakeholders. And it is central to support health system transformation, particularly to

generate trust and to reach vulnerable and underserved groups and communities.

11 Declaration of Astana. Copenhagen: WHO Regional Office for Europe Copenhagen: WHO Regional Office for Europe; 2019. 12 see: https://iris.who.int/bitstream/handle/10665/365318/WHO-EURO-2022-6620-46386-67147-eng.pdf 13 see: https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_ACONF3-en.pdf 14 see: https://iris.who.int/bitstream/handle/10665/375276/9789240085923-eng.pdf

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(c) protecting and promoting the health and well-being of the health and care workforce, and

addressing not just workforce numbers, but also where and how care is delivered and the

quality of care received;

All countries in the European Region face multiple challenges to their health and care workforce, with

a consequent impact on the quality of health service provision. There is a projected shortfall of 4.1

million health and care workers across the Region by 203015.

The delivery of quality health services does not depend just on workforce numbers, but also their

skills and competencies, their incentives and sense of being valued. WHO/Europe’s Framework for

Action on the Health and Care Workforce16 brings together five pillars of action to address the

multitude of health and care workforce challenges facing Member States today. Importantly, it put

the needs of workers at the centre of planning and policy.

Ensuring that the health and care workforce is fit-for-purpose is a pre-requisite for ensuring a high

standard of care and quality services, but it is not sufficient. Quality health services are also a

product of the wider health systems environment. At its simplest, quality of care is the degree to

which health services for individuals and populations increase the likelihood of desired health

outcomes. This involves the provision of services that are effective, safe, and people-centered, and

these services must be timely, equitable, integrated, and efficient17. Context matters, but poor-

quality care leads to adverse outcomes and a lack of trust and confidence in the health system.

While quality improvement efforts continue across the Region, Member States struggle against

persistent gaps in financing, workforce, and healthcare infrastructure. Addressing so-called ‘medical

deserts’ and working to ensure that persons in underserved and rural communities receive quality

care, including through the leveraging of new digital solutions, must be a priority across countries.

The relationship between a strong health and care workforce and good quality care is clear and must

be an area of renewed focus as Member States look to transform their health systems.

(d) investing in high-end health technologies with proven cost–effectiveness, and developing

robust and ethical digital policy and digital governance for equitable and safe access to

new health technologies that support better and more efficient and timely care;

Investing in health technologies and robust digital solutions with proven cost-effectiveness is key to

health system transformation. The Regional Office’s regional report on digital health found that many

countries report technological advancements, especially in data analytics and artificial intelligence,

offering significant opportunities for health-care improvements18. But there is insufficient evaluation

of the impacts (including benefits), especially regarding resource allocation decisions in many

countries. Additionally, new technologies must be accompanied by the development of ethical digital

policies and governance frameworks.

Public funding for digital health programmes is key. Establishing national partnerships between civil

society, the civil service, and private-sector entities could be a useful approach to mobilize resources

and accelerate the acceptance and implementation of digital health strategies and new technologies.

Cultivating leadership competencies, crafting policies that bolster innovation, and supporting the

scaling of evidence-based innovations, are all crucial to promote emerging technologies that have a

15 Health and care workforce in Europe: time to act. Copenhagen: WHO Regional Office for Europe; 2022. 16 Framework for action on the health and care workforce in the WHO European Region 2023–2030. Copenhagen: WHO Regional Office for Europe; 2023. 17 see: https://www.who.int/news-room/fact-sheets/detail/quality-health-services 18 see: https://cdn.who.int/media/docs/librariesprovider2/data-and-evidence/english-ddh-260823_7amcet.pdf

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longer-term sustainable (including environmental considerations) impact on health systems and

patient outcomes,

(e) strengthening health information systems to facilitate data sharing, interoperability, and

real-time information exchange, with the aim of promoting health, preventing disease, and

ensuring the best outcomes;

A strong health information system (HIS) is the backbone of an effective health system and an

important part of health system governance. Its functioning goes well beyond collecting data, and

includes analysis, knowledge-generation, and the active application of evidence into policy and

practice. Member States stand to benefit from improved health information systems. Advanced

techniques that help measure and attribute impacts on NCD mortality, morbidity and risk including

the use of new sources of data (such as the integration with electronic health records) and the

adoption of new techniques such personalized predictive analytics can bring considerable dividends

in terms of health system resource utilization and improved health outcomes.

Based on the last WHO/Europe Health Information Assessment exercise, sharing and interoperability

of data is a strategic policy priority cited by most Member States. Data governance challenges around

lack of resources or complexity of processes for data access for secondary purposes are common to

many countries and need to be tackled as part of new health systems resilience and emergency

preparedness thinking.

(f) financing policy to ensure equitable access to high-quality and cost-effective services,

including medicines and medical products, without compromising the financial stability of

health systems or pushing people into financial hardship, and recognizing the imperative

of addressing unmet needs;

The continuing effects of the COVID-19 pandemic, ongoing global economic uncertainty, and

widening health inequalities (also due to inequitable access to new therapies and technologies)

mean that it is unlikely the European Region will achieve the hoped-for progress around UHC.

WHO/Europe’s 2023 report on the state of financial protection in the European Region finds that too

many people are still struggling to access health care because of out-of-pocket payments for health,

resulting in rising unmet need and catastrophic health spending – particularly so for people with low

incomes.19 Without financial protection, people may be forced to choose between health care and

other basic needs, which can deepen poverty, erode health and well-being, and increase inequalities.

Outpatient medicines (along with medical products and dental care) are the main driver of out-of-

pocket payments in the Region. But wider access to medicines challenges prevail as well, in the form

of shortages of essential medicines, or the unaffordability of many effective, novel, high-cost

medicines and therapies.

Progress in improving UHC and financial protection, along with the need to ensure that people can

access (and afford) life-saving therapies and medicines remain key areas of concern. The proposed

framework supports this focus and emphasizes the need to ensure that people do not experience

financial hardship when accessing health care and the need for closer collaboration in the area of

medicines to ensure health system financial sustainability.

19 Can people afford to pay for health care? Evidence on financial protection in 40 countries in Europe. Copenhagen: WHO Regional Office for Europe; 2023.

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(g) ensuring up-to-date, agile, and evidence-informed health system emergency preparedness

plans that leave no one behind as part of strengthened health systems; and

One of the key health systems lessons from the COVID-19 pandemic was the necessity of ensuring a

health (care) system that can operate in a dual-track mode i.e., providing uninterrupted care and

essential services alongside the capacity to scale up and down as needed in response to

emergencies. Strengthening health systems for health security, with a focus on building a flexible

health and care workforce, and providing new modes of service delivery through a renewed PHC

approach, will be key to addressing challenges across all phases of the emergency management

cycle and developing resilience.

Ensuring that the Region’s health systems develop these capacities requires a coordinated effort

across all levels of governance, involving the harmonization of policies and practices. Legislative and

ethical frameworks must clearly define accountability, enabling effective coordination, collaboration,

funding, and information-sharing. Moreover, these frameworks should empower decision-makers

with the authority and information needed to respond swiftly and effectively to emergencies.

Understanding health systems resilience as more than being able to withstand an emergency or

shock is crucial, as is the use of a resilience testing toolkit for preparedness purposes20. These calls

are at the core of the Regional Office’s proposed new regional strategy and action plan21, which aims

to strengthen health emergency preparedness, response, and resilience in the Region.

PHC services generated real world evidence around the epidemiology of the disease and the nature

and transmission of the virus. A further lesson of the pandemic, therefore, is the need for Member

Sates – and the international community at large – to be better able to act on emerging evidence, in

timely fashion, towards enabling improved clinical and public health practice.

(h) recognizing better health system spending as an investment – in disease prevention,

health promotion, action on social determinants, and sustainable living environments –

and the importance of public financing for health, which reflects the central contribution

of people’s health to wealth and societal cohesion.

COVID-19 underlined the extent to which social inequalities and inequities affect and define

individuals’ health status, and some 600,000 excess deaths in the Region were attributable to low

human development and health system investment22. Addressing the health impacts of social

inequities at policy level involves strategies to tackle economic exclusion – which drives poverty and

in turn poor physical and mental well-being – and governments must work inter-sectorally, including

with health authorities and local communities. At health system level, it underlines the imperative for

PHC and public health to be better integrated in order to address prospective health issues earlier in

individuals’ lives.

The implementation of stronger regulations to protect public health policy and population health from

commercial influences and other negative determinants must be part of the vision for healthier

societies and health systems resilience.

Attending to the impacts of climate change and the need to ensure healthy living environments are

also key to promoting healthier and fairer societies. In the European Region it is estimated that some

20 see: https://iris.who.int/bitstream/handle/10665/376809/9789289059596-eng.pdf 21 see: https://iris.who.int/bitstream/handle/10665/372629/73wd13e-HealthEmergs-230637.pdf 22 see: https://iris.who.int/bitstream/handle/10665/370945/WHO-EURO-2023-7761-47529-69924-eng.pdf

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1.4 million deaths per year are attributable of environmental risk factors,23. Further, with Europe the

quickest warming of the WHO Regions, heat illness and heat-related deaths are rising, challenging

health systems. More environmentally-friendly and sustainable living spaces are crucial and involving

a health (systems) lens in urban planning and in ensuring – through digital solutions as appropriate –

that rural populations are served is required.

Investing in health systems towards promoting healthier and thriving societies and economies,

including addressing environmental risk factors, is part of the economy of well-being vision being

pursued by several Member States.

ALIGNMMENT WITH REGIONAL AND GLOBAL AGENDAS

10. The eight priority action areas set out in this document are not exhaustive. They draw on the

health systems work of the Regional Office since the Pan-European Commission on Health and

Sustainable Development delivered its findings in 202124. They also align with Member State priorities

under ongoing agendas, most of which have been recognized by the Regional Committee over the

same period. For more detail on the eight priority action areas, Member States are invited to consult

the various workstreams across the Regional Office, including the relevant technical and governance

documentation. Most notably, these agendas include: non-communicable diseases25; health in the

well-being economy;26 environment and health;27 primary health care;28 health and care workforce;29

antimicrobial resistance and One Health30; vaccines and immunization;31 behavioural and cultural

insights;32 refugee and migrant health33; health emergencies and preparedness;34 digital health35; and

now, health innovation more broadly [Ref to INNOVATION STRATEGY, FORTHCOMING]. Forthcoming

agendas around healthy ageing and child and adolescent health are also relevant to several of the

priority action areas. These have provided the evidence-base for, and have informed the development

of, the proposed framework.

11. Managing and monitoring change at national level to pursue these priority action areas will be

essential. Member States are encouraged to consult the updated global HSPA framework produced

23 See: https://iris.who.int/bitstream/handle/10665/368160/WHO-EURO-2023-7588-47355-69518-eng.pdf 24 European Observatory on Health Systems and Policies & McKee M (editor). Drawing light from the pandemic: a new strategy for health and sustainable development: a review of the evidence. Copenhagen: WHO Regional Office for Europe; 2021. 25 Reducing noncommunicable disease: a signature roadmap for the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2022. 26 Shifting together to well‑being economies: investing in healthy, fairer, prosperous societies today: outcome statement of the WHO European Regional High-level Forum on Health in the Well-being Economy, 1–2 March 2023 Copenhagen, Denmark. Copenhagen: WHO Regional Office for Europe; 2023. 27 Declaration of the Seventh Ministerial Conference on Environment and Health: Budapest, Hungary 5–7 July 2023. Copenhagen: WHO Regional Office for Europe; 2023. 28 Primary health care policy and practice: implementing for better results: youth-led outcome statement. Copenhagen: WHO Regional Office for Europe; 2023. 29 Framework for action on the health and care workforce in the WHO European Region 2023–2030. Copenhagen: WHO Regional Office for Europe; 2023. 30 Roadmap on antimicrobial resistance for the WHO European Region 2023–2030. Copenhagen: WHO Regional Office for Europe; 2023. 31 European Immunization Agenda 2030. Copenhagen: WHO Regional Office for Europe; 2021. 32 European regional action framework for behavioural and cultural insights for health, 2022-2027. Copenhagen: WHO Regional Office for Europe; 2022. 33 Action plan for refugee and migrant health in the WHO European Region 2023-2030. Copenhagen: WHO Regional Office for Europe; 2023. 34 Health emergency preparedness, response and resilience in the WHO European Region 2024–2029. Copenhagen: WHO Regional Office for Europe; 2023. 35 See: https://iris.who.int/bitstream/handle/10665/360950/72wd05e-DigitalHealth-220529.pdf

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for the Tallinn conference36 and accompanying dashboard of key health system performance

indicators that are tied to policy actions37 to understand where and how transformational

improvements in line with this framework can be made. WHO/Europe and the European Observatory

on Health Systems and Policies will support these efforts as needed.

12. The call for health system transformation under the proposed framework (along with the

priority action areas themselves) is consistent with the overarching goal of the forthcoming GPW14

“to promote, provide and protect health and well-being for all people, everywhere”.38 It builds on the

commitment to leave no one behind under the EPW, and will be central to the forthcoming

programme of work for the Regional Office until 2030.

ACTION BY THE REGIONAL COMMITTEE

13. This proposed framework for action on health systems is submitted to the WHO Regional

Committee for Europe at its 74th session, accompanied by an information document

[FORTHCOMING] and a background document [FORTHCOMING].

14. Member States are asked to support the overall health systems transformation agenda

reflected in this document, re-affirmed in an updated health systems perspective through the eight

priority action areas listed in 11 (a)-(h).

15. Crucial to effective and successful health system transformation, and delivering these eight

priority action areas, is the principle of co-creation. The recognition and implementation of policies

that place people, communities, and health and care workers at the heart of policy design and

delivery is necessary for transformation to become a reality. This is in line with the recently adopted

WHA77 resolution on social participation39. As co-creation is first dependent on trust, trust and

transformation are seen as representing a virtuous cycle. The inverse is a vicious cycle where a lack

of trust will inhibit transformation, and insufficient transformation will foster a lack of trust. The

framework therefore takes trust as a core value, and Member States are encouraged to undertake

actions towards re-building trust in health systems and among stakeholders to accelerate

transformation.

16. WHO/Europe will support Member States to pursue these directions and the priority policy

areas set out in this document. To guide the work of the Secretariat, the Regional Committee is

further invited to provide guidance on the following questions:

 Which of the priority action area(s) are the main priorities for your country?

 Are there additional priority action areas that need to be considered?

 What support should WHO/Europe seek to provide in taking these area(s) forward?

 What opportunities and limitations do you foresee in implementing the action areas?

17. Additionally, Member States are requested to consider the attached Decision

[FORTHCOMING] and to advise on next steps for implementation of the framework for action.

36 see: Health system performance framework: A renewed global framework for policy-making. Copenhagen: WHO Regional Office for Europe; 2023.. 37 see: Assessing health system performance: A proof of concept a HSPA dashboard of key indicators. Copenhagen: WHO Regional Office for Europe; 2023. 38 Draft fourteenth general programme of work. Geneva, World Health Organization; 2024 39 see: https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_ACONF3-en.pdf

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Framework for action on resilient and sustainable health systems in the

WHO European Region, 2025–2030

Building on the legacy of the 2008 Tallinn Charter for Health Systems for Health and Wealth, this

document offers an updated vision for health systems in the WHO European Region. It is based on

the health systems work of the WHO Regional Office for Europe under the European Programme of

Work, 2020-2025, leading up to, and including the outcomes of, a high-level health systems

conference held in Tallinn, Estonia 12-13 December 2023.

Presented here as a ‘Framework for action on resilient and sustainable health systems in the WHO

European Region’, the document identifies eight (8) priority action areas which build on health

system priorities agreed by previous Regional Committees. These areas are brought together in an

overarching manner to reflect a more systems-oriented perspective to address the contemporary

challenges facing health systems in the European Region.

The framework recognizes that health systems are key to the future health and cohesion of our

societies. It introduces in an explicit manner the role of health systems resilience in relation to

broader contextual issues affecting the WHO European Region, including climate change, social

fragmentation, demographic shifts, complex multi-morbidities, a volatile social and economic

landscape, rapid societal digitalization, and the health impacts of conflict. In this challenging

context, health systems must transform to meet the physical and mental health needs of

individuals and populations.

The aim of the proposed framework is captured in the following vision statement: For everyone to

be able to trust that they will receive the right care, at the right time, in the right place, from

the right person, without experiencing financial hardship. High-performing health systems,

available to all people throughout life, and fit for a changing world, is the enactment of this vision.

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BACKGROUND AND RATIONALE

1. In 2008, Member States in the WHO European Region endorsed the Tallinn Charter on Health

Systems for Health and Wealth. Informed by the 1996 Ljubljana Charter on Reforming Health Care in

Europe1, the Tallinn Charter acknowledged that there are differences between health systems in the

Region and sought to coalesce Member States around the shared values of equity, solidarity, and

participation for delivering health services to their populations. These values remain significant today,

as does the Charter’s definition of a health system as “the ensemble of all public and private

organizations, institutions and resources mandated to improve, maintain or restore health [which]

encompass both personal and population services, as well as activities to influence the policies and

actions of other sectors to address social, environmental and economic determinants of health”.

2. The Charter set out a shared vision for health systems and, over the past 15 years, has served

as a touchpoint for action by both the WHO Regional Office for Europe (WHO/Europe) and its Member

States. The interim report2 and the final report on implementation of the Tallinn Charter3 point to a

number of policies and decisions taken by WHO/Europe and the Member States in the context of

enacting the Charter’s commitments.

3. The regional context for health systems has changed dramatically since 2008. Health systems

have not ‘bounced back’ since COVID-19 (Coronavirus disease 2019) pandemic. Further, many

legacy health system challenges remain, including the burden posed by noncommunicable diseases

(NCDs), the unfinished communicable disease agenda, and the cost of access to medicines and

health technologies. Health systems across the Region are now struggling to respond to a series of

additional or worsened crises, many of which are interlinked, as well as emergent trends that require

new policy responses. Among these are:

 growing numbers of patients presenting with progressively complex multi-morbidities, in the

context of an increasingly older population cohort;

 a growing mental health burden, particularly among younger persons (the full impact of which

has yet to be understood);

 a health and care workforce in crisis due to a manifest shortage in both the current and future

context of care in relation to increased needs;

 outdated models of care, in view of changing patient needs and the rapid increase in

technological advances, including the role of artificial intelligence;

 the direct and indirect impacts of the climate emergency on individual and population health,

and the health system’s own contribution to climate change;

 the rise in antimicrobial resistance; and

 crowding out of fiscal space for health due to competing pressures, such as the impact of

conflict, along with a humanitarian and migrant and refugee health crisis.

4. The COVID-19 pandemic did not just affect health systems. It has negatively impacted our

societies, damaging economies and livelihoods, and contributed to a growing lack trust in science

and expert opinion4. The result is a loss of confidence in health systems across the Region – among

1 The Ljubljana Charter on Reforming Health Care in Europe. Copenhagen: WHO Regional Office for Europe; 1996. 2 See: https://who-sandbox.squiz.cloud/__data/assets/pdf_file/0008/147725/wd11E_InterimTallinnCharter_111356.pdf. 3 Implementation of the Tallinn Charter: final Report. 4 European Observatory on Health Systems and Policies & McKee M (editor). Drawing light from the pandemic: a new strategy for health and sustainable development: a review of the evidence. Copenhagen: WHO Regional Office for Europe; 2021.

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individuals, health and care workers, and policy-makers5 – with some countries now backsliding on

UHC and earlier health gains being reversed6.

5. WHO/Europe and the Government of Estonia convened a high-level health systems

conference on 12–13 December 2023 in Tallinn7. The outcome statement8 recognized the need for a

transformational agenda to promote more resilient and sustainable health systems in the Region,

also in support of more equitable and healthy societies. In keeping with the directions set out in the

outcome statement [FORTHCOMING], and as approved via concept-noted (document

EUR/SC31(2)/6) at the second session of the thirty-first Standing Committee of the Regional

Committee9, the current document proposes a framework for action on resilient and sustainable

health systems in the Region for the period 2025–2030.

VISION STATEMENT

6. The vision underpinning the proposed framework for action on health systems is: For

everyone to be able to trust that they will receive the right care, at the right time, in the right

place, from the right person, without experiencing financial hardship. High-performing health

systems, available to all people throughout life, and relevant for a changing world, is the enactment

of this vision.

7. This vision is based on several elements. The first is trust – in health systems, in health

professionals, and in quality services. Second, to ensure quality outcomes care should be

appropriate, person-centred, and delivered in a timely fashion in the right setting as close to

individuals as possible. Third is that this care is delivered by trained, motivated and supported

professionals. Fourth is that no one should have to choose between healthcare or other basic needs.

And fifth is that a transformation in thinking, planning and implementing health systems is required

for this vision to become a reality.

8. While this vision expresses the role of health systems towards serving the health needs

Region’s individuals, its starting-point is that health systems cannot simply be static dispensers of

healthcare services. The myriad challenges outlined earlier necessitate a move away from a purely

clinical, siloed, or reactive view of healthcare delivered by outdated service models and health

professional roles. Health systems are part of national socio-economic fabrics, operating in a context

of constant change and uncertainty, and must be able to fulfil their potential as complex adaptive

systems.10 A transformation in policy and practice to address current and future challenges is thus

needed, including: changing the roles and interfaces of primary health care and hospitals; managing

the health-social care overlap; adopting innovations in practice and technology (e.g., AI, big data, and

genomics, which themselves alone necessitate a shift in health systems thinking); and a wider

recognition of the contribution of well-functioning systems to social cohesion and economic

prosperity.

5 see: https://eurohealthobservatory.who.int/publications/i/trust-the-foundation-of-health-systems 6 Can people afford to pay for health care? Evidence on financial protection in 40 countries in Europe. Copenhagen: WHO Regional Office for Europe; 2023. 7 Tallinn Charter 15th Anniversary Health Systems Conference: Trust and transformation – resilient and sustainable health systems for the future. Copenhagen: WHO Regional Office for Europe; 2008. 8 see: https://iris.who.int/bitstream/handle/10665/375032/TC-15-Health-systems-conference-Tallin-statm-2023-eng.pdf 9 see: https://iris.who.int/bitstream/handle/10665/376480/31s2e00_REP_240051.pdf 10 see: https://iris.who.int/bitstream/handle/10665/44204/9789241563895_eng.pdf

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PRIORITY ACTION AREAS

9. The eight interlinked priority action areas are proposed from a systems-thinking perspective,

seeking to strike a balance between the need to be aspirational versus realistic, and to consolidate

versus itemize.

(a) advancing primary health care (PHC) as the anchor for health systems across the Region

through integrated and patient-centered care models, and rethinking the role of hospitals

and how specialist care is delivered, while ensuring a commitment to public health,

prevention, and quality of care across all settings;

The 2018 Astana Declaration on Primary Health Care11 extended the definition of PHC beyond the

narrow biomedical remit of health services to engage with the wider social determinants of economic

and social development. The COVID-19 pandemic underscored the importance of PHC in addressing

not only physical health needs but also mental and social health determinants. Integrated

multidisciplinary primary health care teams have emerged as better positioned to address current

health and well- being challenges.

The most immediate priorities for PHC across the Region, therefore, are to strengthen collaboration

between public health and primary health care services at the community level, to scale up mental

health services in primary health care, and to more closely integrate with social care. In the area of

NCDs12, increasing capacity at the primary care level to engage in brief lifestyle interventions, provide

personalized and patient-centered advice on behavioural change, manage risk-factors and disease

with affordable effective medicines (referring to specialized care when appropriate), all enable PHC

to play a leading role in increasingly complex NCD management and care. Redefining the model of

care in this way brings dividends not just in terms of health outcomes, but also in cost-savings and

more efficient health systems.

(b) strengthening and expanding community-based interventions, including working closely

and effectively with civil society organizations, the public and underserved groups;

The COVID-19 pandemic underlined the ability of civil society and other community-based

organizations to reach underserved and vulnerable populations, providing an important support to

health authorities across the Region. Such organizations are also well-positioned to provide feedback

on the acceptability of public health measures and policies in general, allowing health authorities to

adapt and improve interventions and health system decision-making. Their importance has been

recognized through a first-ever resolution on social participation during the 77 World Health

Assembly (WHA)13

Social participation is key to ensuring that people have a health system that they trust and regard as

responsive to their needs14. It can help support UHC, as national health policies, strategies and plans

are more likely to be implemented effectively if their development and negotiation is inclusive of all

relevant stakeholders. And it is central to support health system transformation, particularly to

generate trust and to reach vulnerable and underserved groups and communities.

11 Declaration of Astana. Copenhagen: WHO Regional Office for Europe Copenhagen: WHO Regional Office for Europe; 2019. 12 see: https://iris.who.int/bitstream/handle/10665/365318/WHO-EURO-2022-6620-46386-67147-eng.pdf 13 see: https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_ACONF3-en.pdf 14 see: https://iris.who.int/bitstream/handle/10665/375276/9789240085923-eng.pdf

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(c) protecting and promoting the health and well-being of the health and care workforce, and

addressing not just workforce numbers, but also where and how care is delivered and the

quality of care received;

All countries in the European Region face multiple challenges to their health and care workforce, with

a consequent impact on the quality of health service provision. There is a projected shortfall of 4.1

million health and care workers across the Region by 203015.

The delivery of quality health services does not depend just on workforce numbers, but also their

skills and competencies, their incentives and sense of being valued. WHO/Europe’s Framework for

Action on the Health and Care Workforce16 brings together five pillars of action to address the

multitude of health and care workforce challenges facing Member States today. Importantly, it put

the needs of workers at the centre of planning and policy.

Ensuring that the health and care workforce is fit-for-purpose is a pre-requisite for ensuring a high

standard of care and quality services, but it is not sufficient. Quality health services are also a

product of the wider health systems environment. At its simplest, quality of care is the degree to

which health services for individuals and populations increase the likelihood of desired health

outcomes. This involves the provision of services that are effective, safe, and people-centered, and

these services must be timely, equitable, integrated, and efficient17. Context matters, but poor-

quality care leads to adverse outcomes and a lack of trust and confidence in the health system.

While quality improvement efforts continue across the Region, Member States struggle against

persistent gaps in financing, workforce, and healthcare infrastructure. Addressing so-called ‘medical

deserts’ and working to ensure that persons in underserved and rural communities receive quality

care, including through the leveraging of new digital solutions, must be a priority across countries.

The relationship between a strong health and care workforce and good quality care is clear and must

be an area of renewed focus as Member States look to transform their health systems.

(d) investing in high-end health technologies with proven cost–effectiveness, and developing

robust and ethical digital policy and digital governance for equitable and safe access to

new health technologies that support better and more efficient and timely care;

Investing in health technologies and robust digital solutions with proven cost-effectiveness is key to

health system transformation. The Regional Office’s regional report on digital health found that many

countries report technological advancements, especially in data analytics and artificial intelligence,

offering significant opportunities for health-care improvements18. But there is insufficient evaluation

of the impacts (including benefits), especially regarding resource allocation decisions in many

countries. Additionally, new technologies must be accompanied by the development of ethical digital

policies and governance frameworks.

Public funding for digital health programmes is key. Establishing national partnerships between civil

society, the civil service, and private-sector entities could be a useful approach to mobilize resources

and accelerate the acceptance and implementation of digital health strategies and new technologies.

Cultivating leadership competencies, crafting policies that bolster innovation, and supporting the

scaling of evidence-based innovations, are all crucial to promote emerging technologies that have a

15 Health and care workforce in Europe: time to act. Copenhagen: WHO Regional Office for Europe; 2022. 16 Framework for action on the health and care workforce in the WHO European Region 2023–2030. Copenhagen: WHO Regional Office for Europe; 2023. 17 see: https://www.who.int/news-room/fact-sheets/detail/quality-health-services 18 see: https://cdn.who.int/media/docs/librariesprovider2/data-and-evidence/english-ddh-260823_7amcet.pdf

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longer-term sustainable (including environmental considerations) impact on health systems and

patient outcomes,

(e) strengthening health information systems to facilitate data sharing, interoperability, and

real-time information exchange, with the aim of promoting health, preventing disease, and

ensuring the best outcomes;

A strong health information system (HIS) is the backbone of an effective health system and an

important part of health system governance. Its functioning goes well beyond collecting data, and

includes analysis, knowledge-generation, and the active application of evidence into policy and

practice. Member States stand to benefit from improved health information systems. Advanced

techniques that help measure and attribute impacts on NCD mortality, morbidity and risk including

the use of new sources of data (such as the integration with electronic health records) and the

adoption of new techniques such personalized predictive analytics can bring considerable dividends

in terms of health system resource utilization and improved health outcomes.

Based on the last WHO/Europe Health Information Assessment exercise, sharing and interoperability

of data is a strategic policy priority cited by most Member States. Data governance challenges around

lack of resources or complexity of processes for data access for secondary purposes are common to

many countries and need to be tackled as part of new health systems resilience and emergency

preparedness thinking.

(f) financing policy to ensure equitable access to high-quality and cost-effective services,

including medicines and medical products, without compromising the financial stability of

health systems or pushing people into financial hardship, and recognizing the imperative

of addressing unmet needs;

The continuing effects of the COVID-19 pandemic, ongoing global economic uncertainty, and

widening health inequalities (also due to inequitable access to new therapies and technologies)

mean that it is unlikely the European Region will achieve the hoped-for progress around UHC.

WHO/Europe’s 2023 report on the state of financial protection in the European Region finds that too

many people are still struggling to access health care because of out-of-pocket payments for health,

resulting in rising unmet need and catastrophic health spending – particularly so for people with low

incomes.19 Without financial protection, people may be forced to choose between health care and

other basic needs, which can deepen poverty, erode health and well-being, and increase inequalities.

Outpatient medicines (along with medical products and dental care) are the main driver of out-of-

pocket payments in the Region. But wider access to medicines challenges prevail as well, in the form

of shortages of essential medicines, or the unaffordability of many effective, novel, high-cost

medicines and therapies.

Progress in improving UHC and financial protection, along with the need to ensure that people can

access (and afford) life-saving therapies and medicines remain key areas of concern. The proposed

framework supports this focus and emphasizes the need to ensure that people do not experience

financial hardship when accessing health care and the need for closer collaboration in the area of

medicines to ensure health system financial sustainability.

19 Can people afford to pay for health care? Evidence on financial protection in 40 countries in Europe. Copenhagen: WHO Regional Office for Europe; 2023.

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(g) ensuring up-to-date, agile, and evidence-informed health system emergency preparedness

plans that leave no one behind as part of strengthened health systems; and

One of the key health systems lessons from the COVID-19 pandemic was the necessity of ensuring a

health (care) system that can operate in a dual-track mode i.e., providing uninterrupted care and

essential services alongside the capacity to scale up and down as needed in response to

emergencies. Strengthening health systems for health security, with a focus on building a flexible

health and care workforce, and providing new modes of service delivery through a renewed PHC

approach, will be key to addressing challenges across all phases of the emergency management

cycle and developing resilience.

Ensuring that the Region’s health systems develop these capacities requires a coordinated effort

across all levels of governance, involving the harmonization of policies and practices. Legislative and

ethical frameworks must clearly define accountability, enabling effective coordination, collaboration,

funding, and information-sharing. Moreover, these frameworks should empower decision-makers

with the authority and information needed to respond swiftly and effectively to emergencies.

Understanding health systems resilience as more than being able to withstand an emergency or

shock is crucial, as is the use of a resilience testing toolkit for preparedness purposes20. These calls

are at the core of the Regional Office’s proposed new regional strategy and action plan21, which aims

to strengthen health emergency preparedness, response, and resilience in the Region.

PHC services generated real world evidence around the epidemiology of the disease and the nature

and transmission of the virus. A further lesson of the pandemic, therefore, is the need for Member

Sates – and the international community at large – to be better able to act on emerging evidence, in

timely fashion, towards enabling improved clinical and public health practice.

(h) recognizing better health system spending as an investment – in disease prevention,

health promotion, action on social determinants, and sustainable living environments –

and the importance of public financing for health, which reflects the central contribution

of people’s health to wealth and societal cohesion.

COVID-19 underlined the extent to which social inequalities and inequities affect and define

individuals’ health status, and some 600,000 excess deaths in the Region were attributable to low

human development and health system investment22. Addressing the health impacts of social

inequities at policy level involves strategies to tackle economic exclusion – which drives poverty and

in turn poor physical and mental well-being – and governments must work inter-sectorally, including

with health authorities and local communities. At health system level, it underlines the imperative for

PHC and public health to be better integrated in order to address prospective health issues earlier in

individuals’ lives.

The implementation of stronger regulations to protect public health policy and population health from

commercial influences and other negative determinants must be part of the vision for healthier

societies and health systems resilience.

Attending to the impacts of climate change and the need to ensure healthy living environments are

also key to promoting healthier and fairer societies. In the European Region it is estimated that some

20 see: https://iris.who.int/bitstream/handle/10665/376809/9789289059596-eng.pdf 21 see: https://iris.who.int/bitstream/handle/10665/372629/73wd13e-HealthEmergs-230637.pdf 22 see: https://iris.who.int/bitstream/handle/10665/370945/WHO-EURO-2023-7761-47529-69924-eng.pdf

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1.4 million deaths per year are attributable of environmental risk factors,23. Further, with Europe the

quickest warming of the WHO Regions, heat illness and heat-related deaths are rising, challenging

health systems. More environmentally-friendly and sustainable living spaces are crucial and involving

a health (systems) lens in urban planning and in ensuring – through digital solutions as appropriate –

that rural populations are served is required.

Investing in health systems towards promoting healthier and thriving societies and economies,

including addressing environmental risk factors, is part of the economy of well-being vision being

pursued by several Member States.

ALIGNMMENT WITH REGIONAL AND GLOBAL AGENDAS

10. The eight priority action areas set out in this document are not exhaustive. They draw on the

health systems work of the Regional Office since the Pan-European Commission on Health and

Sustainable Development delivered its findings in 202124. They also align with Member State priorities

under ongoing agendas, most of which have been recognized by the Regional Committee over the

same period. For more detail on the eight priority action areas, Member States are invited to consult

the various workstreams across the Regional Office, including the relevant technical and governance

documentation. Most notably, these agendas include: non-communicable diseases25; health in the

well-being economy;26 environment and health;27 primary health care;28 health and care workforce;29

antimicrobial resistance and One Health30; vaccines and immunization;31 behavioural and cultural

insights;32 refugee and migrant health33; health emergencies and preparedness;34 digital health35; and

now, health innovation more broadly [Ref to INNOVATION STRATEGY, FORTHCOMING]. Forthcoming

agendas around healthy ageing and child and adolescent health are also relevant to several of the

priority action areas. These have provided the evidence-base for, and have informed the development

of, the proposed framework.

11. Managing and monitoring change at national level to pursue these priority action areas will be

essential. Member States are encouraged to consult the updated global HSPA framework produced

23 See: https://iris.who.int/bitstream/handle/10665/368160/WHO-EURO-2023-7588-47355-69518-eng.pdf 24 European Observatory on Health Systems and Policies & McKee M (editor). Drawing light from the pandemic: a new strategy for health and sustainable development: a review of the evidence. Copenhagen: WHO Regional Office for Europe; 2021. 25 Reducing noncommunicable disease: a signature roadmap for the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2022. 26 Shifting together to well‑being economies: investing in healthy, fairer, prosperous societies today: outcome statement of the WHO European Regional High-level Forum on Health in the Well-being Economy, 1–2 March 2023 Copenhagen, Denmark. Copenhagen: WHO Regional Office for Europe; 2023. 27 Declaration of the Seventh Ministerial Conference on Environment and Health: Budapest, Hungary 5–7 July 2023. Copenhagen: WHO Regional Office for Europe; 2023. 28 Primary health care policy and practice: implementing for better results: youth-led outcome statement. Copenhagen: WHO Regional Office for Europe; 2023. 29 Framework for action on the health and care workforce in the WHO European Region 2023–2030. Copenhagen: WHO Regional Office for Europe; 2023. 30 Roadmap on antimicrobial resistance for the WHO European Region 2023–2030. Copenhagen: WHO Regional Office for Europe; 2023. 31 European Immunization Agenda 2030. Copenhagen: WHO Regional Office for Europe; 2021. 32 European regional action framework for behavioural and cultural insights for health, 2022-2027. Copenhagen: WHO Regional Office for Europe; 2022. 33 Action plan for refugee and migrant health in the WHO European Region 2023-2030. Copenhagen: WHO Regional Office for Europe; 2023. 34 Health emergency preparedness, response and resilience in the WHO European Region 2024–2029. Copenhagen: WHO Regional Office for Europe; 2023. 35 See: https://iris.who.int/bitstream/handle/10665/360950/72wd05e-DigitalHealth-220529.pdf

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for the Tallinn conference36 and accompanying dashboard of key health system performance

indicators that are tied to policy actions37 to understand where and how transformational

improvements in line with this framework can be made. WHO/Europe and the European Observatory

on Health Systems and Policies will support these efforts as needed.

12. The call for health system transformation under the proposed framework (along with the

priority action areas themselves) is consistent with the overarching goal of the forthcoming GPW14

“to promote, provide and protect health and well-being for all people, everywhere”.38 It builds on the

commitment to leave no one behind under the EPW, and will be central to the forthcoming

programme of work for the Regional Office until 2030.

ACTION BY THE REGIONAL COMMITTEE

13. This proposed framework for action on health systems is submitted to the WHO Regional

Committee for Europe at its 74th session, accompanied by an information document

[FORTHCOMING] and a background document [FORTHCOMING].

14. Member States are asked to support the overall health systems transformation agenda

reflected in this document, re-affirmed in an updated health systems perspective through the eight

priority action areas listed in 11 (a)-(h).

15. Crucial to effective and successful health system transformation, and delivering these eight

priority action areas, is the principle of co-creation. The recognition and implementation of policies

that place people, communities, and health and care workers at the heart of policy design and

delivery is necessary for transformation to become a reality. This is in line with the recently adopted

WHA77 resolution on social participation39. As co-creation is first dependent on trust, trust and

transformation are seen as representing a virtuous cycle. The inverse is a vicious cycle where a lack

of trust will inhibit transformation, and insufficient transformation will foster a lack of trust. The

framework therefore takes trust as a core value, and Member States are encouraged to undertake

actions towards re-building trust in health systems and among stakeholders to accelerate

transformation.

16. WHO/Europe will support Member States to pursue these directions and the priority policy

areas set out in this document. To guide the work of the Secretariat, the Regional Committee is

further invited to provide guidance on the following questions:

 Which of the priority action area(s) are the main priorities for your country?

 Are there additional priority action areas that need to be considered?

 What support should WHO/Europe seek to provide in taking these area(s) forward?

 What opportunities and limitations do you foresee in implementing the action areas?

17. Additionally, Member States are requested to consider the attached Decision

[FORTHCOMING] and to advise on next steps for implementation of the framework for action.

36 see: Health system performance framework: A renewed global framework for policy-making. Copenhagen: WHO Regional Office for Europe; 2023.. 37 see: Assessing health system performance: A proof of concept a HSPA dashboard of key indicators. Copenhagen: WHO Regional Office for Europe; 2023. 38 Draft fourteenth general programme of work. Geneva, World Health Organization; 2024 39 see: https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_ACONF3-en.pdf