Dr. Zsofia Pusztai has been resident in Serbia for a year, as the representative of the World Health Organisation. In this interview for CorD, she underlines that it is crucial, and not only when it comes to the region, to work on a new strategy based on the UN Agenda 2030 and the WHO 2020 plan.
– This new plan, a Roadmap to implement the 2030 Agenda, brings the Region’s priorities forward and provides a common direction, highlighting actions that can accelerate and strengthen the capacities of Member States in implementing the Sustainable Development Goals (SDGs). The Roadmap proposes five strategic directions: 1. advancing governance and leadership for health and wellbeing; 2. strengthening health systems for universal health coverage (UHC); 3. preventing disease and addressing health determinants by promoting multi- and intersectoral policies throughout the life-course; 4. establishing healthy places, settings and resilient communities; and 5. leaving no one behind.
Considering the SDG’s universal applicability, their comprehensive and integrated nature, we have only one way of succeeding: by working in partnerships.
Speaking at the gathering, the WHO called for action in the region and pointed to the need to place health as the central theme of development. What does it mean when you say that health is the central theme of development?
– Health is at the core of the 2030 Agenda for Sustainable Development and it is a political choice. It is a precondition, outcome and indicator of progress. In order to achieve our goal, universal health coverage is key to unlocking the full ambition of the SDGs, which is our moral and strategic imperative. Apart from securing strong political commitment, we also need to transform the way we work and place health at the centre of all actions in the area of development; we need to include health in all policies, build consensus around health-related targets and base progress on the principles of the right to health, equity, fairness, universality and solidarity.
Dr Pusztai, you have been the Head of the WHO Country Office in Serbia for a year. To what extent does Serbia implement WHO recommendations relating to the strategic plan, but also bilateral agreements that you reach with each country individually?
– It has been a very intense year indeed, for gaining a lot of insights, meeting many talented experts and expanding partnerships. There is high motivation among many actors; great expertise on the ground and an existing supportive network of Institutes of Public Health. Still, there is a need for an updated National Health Development Plan, with clear strategic priorities aligned with EU accession and the SDGs’ principles, focusing on strengthening the health system and institutional capacity-building. A new Inter-Governmental Working Group on the Implementation of the UN Agenda 2030 has commenced work, which already provides opportunities for our UN family and partners to channel the necessary support. We have been working jointly with health authorities to set up priorities for the coming biennium and a major commitment is placed on strengthening the public health system, to scale up the prevention and control of noncommunicable diseases (NCDs), as a major threat to socio-economic wellbeing, as well as health promotion in different settings, such as schools and local communities.
To what extent are the principles of the right to health, equality, equity, universality and solidarity applied in Serbia?
– The health-related legislative framework in Serbia is in place, as are laws like those governing healthcare or patients’ rights, which all have these concepts embedded in the heart of Serbian legislation. Some improvements and harmonisation with international regulations are ongoing, as part of current reforms. The goal is to achieve full UHC and provide access to affordable, high-quality services, leaving no one behind, while providing patient-centred health services that are close to the client – that also means strengthening primary health care centres. At the same time, UHC alone is not a guarantee of financial protection – as, according to our data, out-of-pocket payments for health make up more than 30 per cent of total spending on health in Serbia, which raises concerns about the strengths of the system in providing protection for patients against the cost of ill health. Medicines are the main driver of catastrophic spending, especially for the poor. We will work jointly with the Ministry of Health to identify more effective health financing policies and address the needs of the most disadvantaged ones.
Considering that Serbia’s healthcare system has had serious financial and personnel problems for many years, even decades, due to medical staff and doctors abandoning the country for economic reasons, to what extent does our system meet WHO’s sustainability criteria and standards at present?
– The health workforce is the beating heart of any health system, its’ everyday heroes, with their dedication, are the cornerstone of UHC. Without them we will not succeed in achieving Agenda 2030 goals. We are currently working with authorities to assess the human resources for health, as there is a clear need for improved HRH data and information systems, and to better understand mobility patterns. A key element of interventions in this area could be encouraging health professionals to cluster together in centres in rural areas, as well as encouraging medical students to experience work in rural areas through scholarships. Measures that have shown positive results in other countries involved a focus on continuous training, extending the competencies of nurses, increasing remuneration and improving working conditions.
Investment in health will not only drive better health outcomes, but also help reduce poverty and inequalities, strengthen economies and foster communities
Bearing in mind that part of the bilateral agreement between the WHO and Serbia relates to immunisation, in your opinion, is the current social debate that has been going on for months with regard to vaccines, and whether or not they are useful or harmful, the result of insufficient education or insufficient awareness of society?
– I would say both. That’s precisely why the WHO insists on educating all segments of society and raising awareness about the critical importance of full immunisation throughout life and at every stage of life. Vaccines have been one of the biggest success stories of modern medicine, with at least 10 million deaths prevented between 2010 and 2015 thanks to vaccinations delivered around the world. We consider the benefits of vaccines a matter of fact, not a matter of opinion. We only can achieve a world free of measles or rubella if 95 per cent of the population are vaccinated, and it is devastating to see that even in developed countries in recent years we lost hundreds of children from preventable, infectious diseases. Let us not forget about the safest, most efficient and cheapest intervention that mankind invented, and we are collaborating with the health authorities on understanding drivers and barriers to immunisation among the population that would support further steps to increase vaccination coverage.
Sustainable development, including for the natural environment, is a topic that is in the focus of all relevant international organisations, including yours. In your opinion, does Serbia, which has yet to open the EU accession negotiation chapter relating to the environment, devote sufficient attention to these topics?
– Serbia has recognised the importance of environmental protection and launched numerous initiatives in recent years, with those in the area of waste management and waste water requiring huge infrastructure investments. In parallel, the WHO has been addressing environmental determinants of health that are directly or indirectly relevant to all SDGs. Many dangerous environmental hazards have been contained, but we should be aware that a significant number of premature deaths is still attributable to environmental risk factors, with air pollution being the silent killer. Moreover, 14 people die every day of diarrhoeal disease, due to inadequate water, sanitation and hygiene. We work jointly with the UN Country Team to advance this area and our office is also providing support to Serbia’s Presidency of the Protocol on Water and Health (2017-2019), as well as assisting in achieving its national goals. A series of important tools have already been developed to systematically address the provision of safely-managed water and sanitation services.
When I first arrived in Serbia I was shocked that smoking is still allowed in most public places and how many young people and women smoke
According to WHO research, after Poland, Bosnia-Herzegovina, Macedonia and Bulgaria, Serbia has the most polluted air in Europe, resulting, directly or indirectly, in the premature deaths of 5,400 people annually. This research has generated a lot of public attention. Is this statistic really troubling?
– We have just finalised research using a new AirQuality tool software that also estimates the air pollution-related disease burden. Such detailed analysis has to date only been carried out in Serbia and the UK. Yes, the statistics are alarming and in that context measures must be taken to prevent such premature deaths and aim towards reducing emissions of all key pollutants. The goal of policies to reduce health effects of air pollution in Serbia should therefore consider interventions to reduce motorised traffic, decrease use of solid fuels for household heating and cooking, and reduce risks associated with industrial sites. It is equally important to improve awareness of all stakeholders, particularly when it comes to communicating risk, but also ensuring sustainable financing of the air quality monitoring system in Serbia.
Awareness of prevention is not yet at a satisfactory level in Serbia. According to your assessment, who should play a decisive role in raising the awareness of society about the importance of prevention – not only for the system as a whole, but for every citizen?
– First, it is certainly a whole-of-government responsibility, especially in that it has elements beyond the health sector, such as citizen empowerment, health literacy, campaigning etc. In fact, this has two dimensions: first is how much effort the government and health sectors put into prevention, but there is also the individual dimension, as each and every citizen has their own responsibility to take care of their own health. For that, more information, communication and access to preventative services are needed, but everyone could do much more. Public health expenditure in Serbia has been steadily increasing in recent years, bringing more resources for the sector than many neighbouring countries, while the budget for tackling some major risk factors has been constantly decreasing, impairing the implementation of activities on NCD prevention. The question rather refers to how efficiently it is spent, where the gaps are and how to tackle the emerging health issues, as high mortality and morbidity rates from chronic NCDs also exert an enormous burden on the economy. More systematic, good quality data collection, better monitoring of service delivery, as well as assessing the performances of providers, are needed to improve the health system. We often say that what gets measured gets done.
To the best of your knowledge, is it possible for prevention to become a common practise in countries that are poor like ours, with average monthly salaries that barely exceed 400 euros?
– For some reason, risky behaviour is still socially acceptable in Serbia, especially if we look at smoking. Based on the current level of adult smoking in Serbia, premature deaths attributable to tobacco consumption are projected to be more than 1.2 million of the almost 2.5 million smokers alive today, which means half of smokers die much earlier than would otherwise be expected. Let me turn your question to how much of a monthly salary is spent on buying tobacco products, which are, by the way, still among the cheapest in Europe, while simple tobacco control policies could see smoking prevalence reduce, with substantial economic gains. Finally, in order to make prevention a common practise you need to start promoting healthy lifestyles from the onset of life, already educating pregnant mothers and continue through early childhood and school-based programmes, all the way to healthy ageing policies. Not starting smoking, avoiding substance abuse, eating more fruits and vegetables or doing sports are not a matter of money, but rather of awareness. You can build a healthier future for all with such complex programmes, and WHO will provide all its support to ensure Serbia reaches its true health potential.