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DRAFT ROADMAP FOR SUPPORTING BETTER HEALTH IN SMALL COUNTRIES OF THE WHO EUROPEAN REGION, 2022–2025  SCI Draft Roadmap Small Countries Initiative: united action for better health 1. Small countries share common characteristics in terms of political context, economic features and constraints in resource capacity. The Small Countries Initiative (SCI), launched by the WHO Regional Office for Europe in 2013, is an active network of countries with populations of two million and less, which jointly addresses common issues unique to these countries. Since 2019, the SCI network has comprised 11 small countries from across the WHO European Region1, six in the European Union (EU) and five non-EU countries. 2. Since its inception, SCI has provided a forum for innovation, sharing experiences in and tailoring solutions to health-policy implementation (1–6). In the past year and more, this has included a focus on the COVID-19 response (7). It has also involved the hosting of SCI high- level meetings, resulting in the development of “soft” joint commitments, the establishment of technical small-country working groups, and the provision of a “path”, illustrating ways to implement policies, strategies and interventions in small countries. 3. Small countries are contributing to achieving the triple billion targets of WHO’s Thirteenth General Programme of Work, 2019–2023 (GPW 13) (one billion more people benefitting from universal health coverage (UHC); one billion more people better protected from health emergencies; and one billion more people enjoying better health and well-being) (8) and the Sustainable Development Goals of the 2030 Agenda (9). They are also committed to the implementation of the European Programme of Work, 2020–2025 (EPW) (10) and its objectives of leaving no one behind and strengthening the leadership of health authorities in the Region. 4. Small countries have been hit hard by the COVID-19 pandemic. It has amplified pre-existing challenges (such as dependency on larger neighbouring countries for trade, access to medicines and vaccines, and the shortage of and strain on health workers); delayed further social and economic development (for example, through the suspension of tourism and restrictions on movement); and put a large burden on domestic resources. In addition, new challenges have emerged relating, for example, to the availability of and access to medicines and vaccines, the distribution of misinformation, the maintenance of public health measures, the detection of variants, and the aggravation of noncommunicable diseases (including childhood and adult obesity, later-stage cancers, disability, etc.) and mental- health problems, the magnitude of which is still unfolding. Objectives of the roadmap 5. Recognizing the lessons learned from the COVID-19 pandemic, and in an effort to pursue agile transformation, innovation and accelerated action, the objectives of this roadmap are to: i. keep health high on key political agendas during the COVID-19 recovery process and beyond; ii. advocate the needs of small countries at the regional and international levels; iii. promote investment in health and well-being that leaves no one behind; 1 Andorra, Cyprus, Estonia, Iceland, Latvia, Luxembourg, Malta, Monaco, Montenegro, San Marino and Slovenia. PAGE 2  SCI Draft Roadmap iv. build a solutions platform for better health and resilient health systems; v. and measure progress. Priority areas for united action 2022-2025 6. The pandemic has highlighted the need for united action in a number of areas that are critical to small countries now and for the near future. With an emphasis on agile transformation, innovation and responsiveness to changing country needs, this forward- looking agenda considers key drivers of change, including the strategic direction of EPW’s core priorities (10). A number of consultations with the countries participating in SCI revealed the following areas as common priorities for joint action. Protecting against health emergencies 7. Sustainable COVID-19 response and recovery The small countries participating in SCI have reiterated the need to strengthen their strained health systems to be able rapidly to transition to sustainable COVID-19 response and recovery with a focus on: (a) developing a multisectoral, medium-term response and recovery plan; (b) promoting/revising/adapting/operationalizing the recommendations of the Pan-European Commission on Health and Sustainable Development (11); and (c) promoting early warning through the One Health approach (12). Moving towards UHC 8. Strengthen primary health care During the pandemic, primary health care (PHC) was crucial in providing information to patients and e-health services, as well as in treating mild and moderate COVID-19 and non-COVID pathologies and protecting hospitals from becoming overburdened. The small countries have stressed the importance of reaffirming political commitment towards PHC, revisiting strategic directions, and closing gaps in the need for essential health services. Proposals to these ends include: (a) the joint elaboration of innovative modalities to bolster alternative PHC-delivery modalities by addressing specific small-country challenges (staff shortages, geography, limited finances, data); and (b) the establishment of hands- on demonstration sites and the documenting of experiences (13). 9. Strengthen the planning and development of human resources for health Situations relating to human resources for health vary among small countries, ranging from diaspora and commuting workforces to workforce shortages. Needs identified include: (a) the ability to forecast critical health-workforce demands in the coming years and retain health-care workers in the long term, as well as promote digital solutions, where needed; and (b) support for the education and development of the health- workforce capacity, which includes ensuring a health workforce well trained in the all- hazards and safety measures required to avoid infection both at the workplace and in households and communities. PAGE 3  SCI Draft Roadmap 10. Strengthen mechanisms to ensure the accessibility, availability and affordability of medicines, vaccines and medical devices Small countries face challenges regarding inclusion in the medicines market, as well as in vaccine procurement (for example, during the pandemic some non-EU countries initially had difficulties in getting vaccines)), vaccine uptake, communication and misinformation. Modalities to support small countries include: (a) promoting small- country participation in the Oslo Medicines Initiative: better access to effective, novel, high-priced medicines (14); (b) bolstering the role of WHO as a liaison between small countries and the pharmaceuticals industry, including the strengthening of voluntary multicountry/ multiarea collaborations; and (c) using political, strategic and technical levies to ensure the effective implementation of the European Immunization Agenda 2030 in the Region (15). 11. Strengthen mental health Lockdowns, social and economic downturn, and limits on movement and social interaction as a result of COVID-19 have caused a rise in mental-health issues associated with personal safety, self-isolation, unemployment, financial worries, and social exclusion. Small countries have expressed a growing need to focus attention on mental health and to: (a) engage in the Mental Health Coalition and the mental-health data platform (16); (b) promote mental well-being throughout the life course; and (c) transform mental-health services. 12. Innovation in digital health In small countries, digital technologies have been essential in addressing COVID-19, complementing health-system efforts in transitioning to safe, inclusive, people-centered health services. Next steps include: (a) sharing lessons learned through digital experiences and digital innovation; (b) ensuring training and capacity development through innovation labs (17); and (c) elaborating integrated real time health-data information systems specific to small countries (18). Promoting health and well-being 13. Rethinking healthy tourism As many small countries are dependent on tourism, COVID-19 brought to the forefront the socioeconomic and health consequences linked to the slowing down of this sector. The preparation of a policy paper and draft resolution on healthy and sustainable tourism for submission to the WHO Regional Committee for Europe in 2023 has been proposed. 14. Revising and reactivating “soft” SCI commitments As a means to achieving long-term health protection and promotion, specific attention will be paid to addressing climate change and the environment (in coordination with the European Environment and Health Task Force and the Working Group on Health in Climate Change), equity and the economy of well-being, and noncommunicable diseases (specifically obesity). Innovation in modalities of cooperation PAGE 4  SCI Draft Roadmap 15. Building on earlier successful cooperation, this roadmap proposes enhanced political, technical and resource cooperation. 16. Political cooperation Supporting health leadership and governance for health . It is suggested that this include: i. annual high-level SCI meetings on specific political and policy areas of joint concern: if needed these high-level meetings could be organized to discuss and agree on joint strategic political input (for example, to make a joint statement on the report of the Pan-European Commission on Health and Sustainable Development (11) through a small-country lens); ii. advocacy of the needs of small countries at the international level through, for example, joint statements; iii. partnerships with the European Union (19), the Western Balkan Initiative (20), Nordic Co-operation (21), and the Central European Initiative (22), among others. 17. Technical cooperation In-country and multicountry technical support related to norms and standards, the exchange of good practices and experiences, and capacity development, for example, through: i. Creation or continuation of technical working groups, such as:  The SCI technical working group to advise on action for resilience against health emergencies, taking small-country specificities into account (23);  The SCI technical working group on human resources for health, with the renewed aim to support small countries in forecasting critical health- workforce demand, needs and operationalizing in the digital world.;  A coalition of technical partners (including WHO collaborating centres, academia, UN agencies, civil society and other partners) to assess and advise on healthy and sustainable tourism and to develop a policy paper and draft resolution on healthy and sustainable tourism for submission to the WHO Regional Committee for Europe in 2023; ii. in-country and multicounty capacity-building and innovation in specific areas of interest, including:  technical development of policy snapshots and summaries, based on needs;  organization of thematic seminars, thematic workshops, and study visits (bilateral and multilateral);  promotion of the active participation of SCI members in WHO summer schools, or virtual and face-to-face capacity-building activities;  promotion of innovation champion countries and the exchange of learning between pilot sites to solve common challenges and generate and test new practice-based solutions; 18. Resource cooperation In-country and multicountry and through the WHO secretariat, ensure: PAGE 5  SCI Draft Roadmap i. increased communication, awareness-raising and outreach through social media, the internet and active weekly communications; ii. the documentation of success and experiences in implementation, focusing on a "know-how" approach (for example, innovation and solutions finding in PHC, or investment in e-health information systems); iii. connectivity to a wider community of strategic partnerships, including active engagement with actors in and beyond small countries (such as those in civil society and academia), and a wide range of creative approaches to achieving solidarity documented at the community, regional and national levels (beyond government-led approaches) that harness community spirit and volunteerism; iv. identification of opportunities for joint efforts to mobilize financial resources for key areas of cooperation and concern in small countries. References2 19. Equity and sustainable development – keeping people at the centre. Sixth high-level meeting of the small countries, San Marino, Republic of San Marino, 31 March–2 April 2019. Copenhagen: WHO Regional Office for Europe; 2019 (https://www.euro.who.int/__data/assets/pdf_file/0010/407791/20190717-h1035-san- marino-report_FINAL.pdf). 20. Working together for better health and well-being for all. Fifth high-level meeting of small countries, Reykjavik, Iceland, 26–27 June 2018. Copenhagen: WHO Regional Office for Europe; 2018 (https://www.euro.who.int/__data/assets/pdf_file/0006/389580/iceland- report-eng.pdf,). 21. Boosting implementation of Health 2020 and the 2030 Agenda: the WHO Small Countries Initiative. Copenhagen: WHO Regional Office for Europe; 2017 (https://www.euro.who.int/__data/assets/pdf_file/0010/347950/malta-20170830-h1000- web.pdf). 22. Meeting report of the third high-level meeting of small countries. Health and sustainable development: the inherent advantages of small countries Monaco, 11–12 October 2016. Copenhagen: WHO Regional Office for Europe; 2016 (https://www.euro.who.int/__data/assets/pdf_file/0020/334271/Meeting-report-of-the- Third-High-level-Meeting-of-Small-Countries-Monaco.pdf). 2 Unless indicated otherwise, all URLs accessed 6 September 2021. PAGE 6  SCI Draft Roadmap 23. Meeting report of the second high-level meeting of small countries. Taking forward Health 2020: small countries at the forefront of whole-of-government approaches to health, Soldeu, Andorra, 2–3 July 2015. Copenhagen: WHO Regional Office for Europe; 2016 24. Meeting report of the first high-level meeting of small countries. Implementing the Health 2020 vision in countries with small populations, San Marino, 3–4 July 2014 (https://www.euro.who.int/__data/assets/pdf_file/0005/259799/Meeting-report-of-the- First-High-level-Meeting-of-Small-Countries.pdf). 25. Seventh high-level meeting of small countries. COVID-19: lessons learned and building forward in small countries. Copenhagen: WHO Regional Office for Europe; 2021 LINK FORTHCOMING 26. Thirteenth General Programme of Work 2019̶̶–2023 [website]. Geneva: World Health Organization; 2021 (https://www.who.int/about/what-we-do/thirteenth-general- programme-of-work-2019–2023). 27. Transforming our world: the 2030 Agenda for Sustainable Development [website]. New York: United Nations; 2021 (https://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E). 28. About the European Programme of Work [website]. Copenhagen: WHO Regional Office for Europe; 2021 (https://www.euro.who.int/en/health-topics/health-policy/european- programme-of-work/about-the-european-programme-of-work). 29. Regional Committee for Europe, 71st session (2021). Seventy-first Regional Committee for Europe: virtual session, 13–15 September 2021. EUR/RC71/8: report on the Pan-European Commission on Health and Sustainable Development – rethinking policy priorities in the light of pandemics. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/343916, accessed 7 September 2021) 30. G7 Health Ministers’ Communique. Published 4 June 2021. In: G7 UK 2021 [website]. London: UK Government; 2021 (https://www.g7uk.org/g7-health-ministers-meeting- communique-oxford-4-june-2021/). 31. Regional Committee for Europe, 71st session. Seventy-first Regional Committee for Europe: virtual session, 13–15 September 2021. EUR/RC71/9: realizing the potential of primary health care: lessons learned from the COVID-19 pandemic and implications for future directions in the WHO European Region. World Health Organization. Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/343168, accessed 7 September 2021). 32. The Oslo Medicines Initiative [website]. Copenhagen: WHO Regional Office for Europe; 2021 (https://www.euro.who.int/en/health-topics/Health-systems/health-technologies- and-medicines/the-oslo-medicines-initiative). 33. Regional Committee for Europe, 71st session. Seventy-first Regional Committee for Europe: virtual session, 13–15 September 2021. EUR/RC71/10: European Immunization Agenda 2030. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/343330, accessed 7 September 2021). 34. Regional Committee for Europe, 71st session. Seventy-first Regional Committee for Europe: virtual session, 13–15 September 2021. EUR/RC71/11: the WHO European Framework for PAGE 7  SCI Draft Roadmap Action on Mental Health 2021–2025 and the new Mental Health Coalition. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/343939, accessed 7 September 2021). 35. Regional Committee for Europe, 71st session. Seventy-first Regional Committee for Europe: virtual session, 13–15 September 2021. EUR/RC71/7: health system transformation in the digital age during the COVID-19 pandemic. World Health Organization. Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/343164, accessed 7 September 2021). 36. Regional Committee for Europe, 71st session. Seventy-first Regional Committee for Europe: virtual session, 13–15 September 2021. EUR/RC71/5: development of the measurement framework for the European Programme of Work, 2020–2025. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/343118, accessed 7 September 2021). 37. Official Website of the European Union. Brussels: European Union; 2021 (https://europa.eu/european-union/index_en, accessed 7 September 2021). 38. Western Balkan Initiative. In: International Institute for Peace [website]. Vienna: International Institute for Peace; 2021 (https://www.iipvienna.com/western-balkan- initiative, accessed 7 September 2021). 39. Nordic Co-operation [website]. Copenhagen: The Nordic Council and the Nordic Council of Ministers; 2021 (https://www.norden.org/en/information/official-nordic-co-operation, accessed 7 September 2021). 40. Central European Initiative: bridging Europe since 1989 [website]. Trieste: CEI-Executive Secretariat; 2019 (https://www.cei.int/about-us, accessed 7 September 2021). 41. Regional Committee for Europe, 71st session. Seventy-first Regional Committee for Europe: virtual session, 13–15 September 2021. EUR/RC71/6 Rev. 1: response to the COVID-19 pandemic: lessons learned to date from the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/343157, accessed 7 September 2021). PAGE 8 Saatja: NIKOLIC, Lazar <[email protected]> Saadetud: 08.09.2021 20:12 Adressaat: MENNE, Bettina Maria (Maria) <[email protected]>; NIKOLIC, Lazar <[email protected]>; NEMER, Leda Eugenia <[email protected]> Koopia: Mme H. Mas Santuré <[email protected]>; SM Info <[email protected]>; <[email protected]>; <[email protected]>; <[email protected]>; <[email protected]>; <[email protected]>; <[email protected]>; <[email protected]>; BRAJOVIC, Mina <[email protected]>; Calleja Neville at Health Policy <[email protected]>; <[email protected]>; <[email protected]>; DA ROLD, Cristina <[email protected]>; Dr J.-C. Schmit <[email protected]>; Dr O. Kalakouta <[email protected]>; Dr R. Goerens <[email protected]>; <[email protected]>; FORCELLINI, Alvise <[email protected]>; <[email protected]>; <[email protected]>; <[email protected]>; karen.vincenti <[email protected]>; KÖHLER, Kristina <[email protected]>; <[email protected]>; M. G. Rinaldi <[email protected]>; M. J. Romagosa Massana <[email protected]>; mirjana.djuranovic <[email protected]>; MITENBERGS, Uldis <[email protected]>; Mr A. Ioannou <[email protected]>; Mr T. Gantar <[email protected]>; Mrs K.-V. Petrič <[email protected]>; Ms A. Knútsdóttir <[email protected]>; Elen Ohov <[email protected]>; natasa.terzic <[email protected]>; RURANE, Aiga <[email protected]> Teema: Draft SCI roadmap for comments and SCI side event programme Sent on behalf of Dr Bettina Menne: Dear SCI Focal Points and speakers at the RC71 side event, Thanks very much for participating in the SCI side event. The aim of this event is to bring together the small countries participating in SCI (and other Member States) to: 1. articulate a forward-looking vision as a bloc of countries and identify the most immediate areas of need and short-term priorities for a fair COVID-19 recovery that leaves no one behind; and 2. reflect on common priorities for the medium term, taking into account national health plans and using the European Programme of Work 20202025, as an overarching umbrella for guiding national policies and activities. To support the discussion at the side event, it is with great pleasure that I share with you the Draft roadmap for supporting better health in small countries of the WHO European Region, 2022-2025 (please see the enclosed file). This is a first draft, based on discussion with each of you and on discussion at the SCI high level meeting on COVID-19. This is a work in progress, which we hope to finalize by the end of October mid November 2021 in close cooperation with you. Please find also attached: * the Draft program of the side event (confidential as some speakers confirmations are still pending). It would be very important for us to have the final list of speakers, by tomorrow, as the zoom connections will need to be set up by the RDO office. As for your interventions, please keep them as short and succinct as you can, more in the form of a panel discussion under the three GPW/EPW pillars, with a focus on what your country really needs operationally speaking and how the SCI can make a difference as an innovation hub. For more information on the Regional Committee in general, please consult the website at: All sessions, including ours, will be broadcast through our WHO EURO website. Please feel free to contact me at any moment in time on: +39 3456316196 Kind regards Bettina Dr Bettina Menne Healthy settings WHO Regional Office for Europe European Office for Investment for Health and Development +39345 6316196; + 390412793851 Ospedale SS. Giovanni e Paolo, Corridoio S. Domenico, 1st fl.6777 Castello30122 Venice, Italy Side event The Small Countries Initiative – lessons learned during the COVID-19 pandemic and priorities for implementing the European Programme of Work, 2020–2025, in small countries Organized by the Secretariat of the Small Countries Initiative, WHO European Office for Investment for Health and Development, Venice, Italy Friday , 1 7 September 2021 , 11-12:30 CEST (virtual) Chair: Ms Chris Brown, Head of Office, WHO European Office for Investment for Health and Development, Venice, Italy Co-chair: Dr Bettina Menne , Coordinator, WHO European Office for Investment for Health and Development, Venice, Italy 11:00 - 11:02 Welcome and technical o pening Opening of the side event – virtual space 11:02 - 11: 15 Setting the Scene Dr Natasha Muscat , Director of the Division of Country Health Policies and Systems, WHO Regional Office for Europe Ms Chris Brown , Head of Office, WHO European Office for Investment for Health and Development , Venice, Italy, (Chair of the meeting) Dr Bettina Menne , Coordinator, Healthy Settings, WHO European Office for Investment for Health and Development, Venice, Italy Presentation: Draft roadmap for supporting better health in small countries of the WHO European Region, 2022 - 2025 11:16 - 11: 35 Protecti ng against health emergencies San Marino: Video address ed by Minister of Health ; Dr Claudio Muccioli , Director of Health Authority, Ministry of Health and Social Security Andorra : Ms Helena Mas Santuré , Secretary of State of Health, Ministry of Health Malta: Dr Neville Calleja, Director, Department for Policy in Health, Health Information and Research , Ministry for Health Interventions from the floor 11:35 - 1 2 : 04 Universal health coverage Montenegro: Ms X, Minister of Health of Montenegro Cyprus: Dr Olga Kalakouta , Chief Medical Officer and Acting Director of Medical and Public Health Servic es, Ministry of Health Estonia: Ms Kersti Esnar , Head of Health Care Resources, Minis try of Social Affairs Slovenia: Dr Andrej Martin Vujkovac , H ealth Attaché , Third Secretary, Permanent Mission of the Republic of Slovenia to the Office of the United Nations and to the Other Intern ational Organizations in Geneva Interventions from the floor 12:05 - 12: 23 Healthier populations Luxembourg: Minister Dr Paulette LENERT, Minister of Health and Delegate Minister of Social Security Monaco : Ms Isabelle Rosabrunetto , Vice-Minister, Director General, Department of External Relations and Cooperation, Ministry of State 12:24 - 12:30 Closing address: Dr Hans Kluge , WHO Regional Director for Europe Document supporting this side event: Small countries initiative (SCI) draft Roadmap