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Saatja: GALMOND, Elena <[email protected]> Saadetud: 12.04.2023 20:11 Adressaat: <"Peep Peterson">; <"Triin Uusberg">; <"Elen Ohov"> Koopia: <"Elen Ohov">; <"Triin Uusberg">; <"SM Info">; Ms K. Saarsalu- Layachi <[email protected]>; <[email protected]>; Kaisa.Mitt-Alvarez <[email protected]>; <[email protected]>; <[email protected]>; KÖHLER, Kristina <[email protected]>; CHAOUALI, Mafaten <[email protected]> Teema: Nomination letter for the WHO European Regional Meeting on Hospitals, 5–7 June 2023, Baku, Azerbaijan Please see the attached correspondence sent from the World Health Organization, Regional Office for Europe. One or more attachments may be included. Kind regards, Elena Galmond Programme Assistant Health Workforce and Service Delivery WHO Regional Office for Europe Marmorvej 51 2100 Copenhagen Denmark Tel. &#43;45 45 33 66 79 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTÉ REGIONAL OFFICE FOR EUROPE BUREAU RÉGIONAL DE L'EUROPE WELTGESUNDHEITSORGANISATION ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ REGIONALBÜRO FÜR EUROPA ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО WHO Europe Regional Meeting on Hospitals Fit-for purpose hospitals: Prioritizing Quality and Sustainability to meet the demands of Modern Healthcare Baku, Azerbaijan June 5-7, 2023 30/03/23 Original: English Concept Note Introduction Hospitals play a crucial role in the healthcare system, yet many are struggling to keep up with the changing demands made on them and are confronting policy makers with a particularly difficult set of strategic challenges. This concept note sets out an approach to understanding and addressing the key challenges in the hospital sector, supporting the decision makers who confront these and the development of a programme of concerted action that stakeholders in this area need to take to do this. It is essential that we develop a shared vision for hospitals that are fit for purpose today and in the future to meet the current and future needs of the healthcare system and to make the case for change for why this is necessary. Achieving this change will require actions across multiple areas: The first agenda is reflecting on the current crisis, exacerbated by the COVID, and is about empowering and learning for the future, or what we refer to as "healing” hospitals. This includes creating an environment that supports continuous learning and innovation within the hospital and empowers health professionals to take ownership of the care they provide and addressing issues such as burnout and promoting the health and well-being of hospital staff. The second is improving the way that hospitals currently operate through restructuring and strengthening. Some of this will be about a focus on ensuring that existing processes and systems are fit for purpose and operating effectively. This may also include investing in new technologies, improving infrastructure, reducing pressure on staff, and dealing with the inefficient use of resources. The third agenda is strategic change or transformation of systems, processes and even whole hospitals, where they need to do new things. This could involve expanding the services offered, adopting new models of care and integrated care networks, as well as using new technologies and digital solutions. In order to ensure that hospitals meet their needs now and, in the future, strategic shifts in planning, policy, and management are necessary. This includes redesigning the process and models of care, improving the incentives and enablers for change such as health financing, professionalization of management, and digitalization, as well as addressing the institutional design of hospitals. It also will require hospitals to work in new ways to support primary care in delivering new approaches to population health. This requires a collaborative effort between decision makers, healthcare  Concept note Page 2 professionals, and the community as well as with international organizations and agencies to develop this shared vision for the future of hospitals and implement changes that will support the healthcare system in meeting the evolving needs of the population. Furthermore, it is important to recognize that change is not only about policies and strategies, but also about addressing the sociological barriers to change, such as power dynamics and institutional logics. The COVID-19 pandemic has highlighted the need for change and presented opportunities for collaboration and investment and we should work on suggesting concrete next steps and prioritization for achieving change. This concept note sets out an agenda for a high-level meeting to be held in Baku in June 2023 that will explore these issues and develop concrete proposals for action. This approach will build on the insights from the WHO Europe high-level expert meeting on “hospitals of the future”, held in Brussels 21-22 April 2022, policy development by other parts of WHO and a process of engagement that will take place in the run up to the meeting. This will consider the issues facing hospitals across the region but with a particular focus on the EECA countries where they are the most pressing. Objectives Hospitals will continue to have an important role, but this will need to evolve, and this will require well managed changes at national, regional and hospital levels. To support this, the meeting will bring a range of stake holders and experts together to: • Develop the case for change in hospitals and a shared understanding of the issues they face. • Set out a positive vision for the role of hospitals as part of a modern and sustainable health system and which includes strengthened relationships with primary care and the provision of new functions such as telemedicine, preventative care, population health management, etc. • Identify the steps required to achieve this and understand the obstacles to change and the challenges in managing it. • Share expertise and intelligence and provide ideas and evidence to support decision makers. • Identify concrete actions for countries to advance their goals for “healing”, improving and transforming hospitals in the healthcare system and the priorities for coordinated actions across the region where appropriate. • Develop a group of supporters and form communities of practice with mechanisms for sharing knowledge and experience and to jointly work to develop solutions and products, and advocate for change. This will provide the basis for a mandate for an intensified level of support for the development of hospitals from WHO Europe. It will also pave the way towards the WHO Tallinn meeting on health systems scheduled in 2023 having as a key principle the importance of trust building in health systems. An urgent need for change The expert meeting in Brussels and other work by WHO Europe have explored the challenges and opportunities faced by hospitals which are creating a threat to their sustainability and ability to carry out what is needed by health systems.  Concept note Page 3 Hospitals will need to change to respond to new and higher levels of demand from growing numbers of older and more complex patients. They will need to adapt to embrace the opportunities of digital technology which remain under-exploited in healthcare. Many hospitals will be doing this with buildings and equipment that are not fit for purpose and shortages of key staff as the global problems with the health workforce continue to grow. This will be exacerbated by problems of professional burnout being experienced in many countries. This was highlighted by the impact of the pandemic, which also pointed to a more general need to develop more resilience to deal with future crises but also the rewards from new types of collaboration. COVID crisis has also underscored that better hospital responsiveness relies on creating a trustful dynamic resulting from considering the balanced perspective of people, staff, payers, and health authorities. Rural and remote areas have additional challenges in terms of viability and their ability to recruit and retain key staff. There remains a strong imperative to improve systems for ensuring quality and safety and to improve operational efficiency more generally. This is an issue because policy makers and payers will be reluctant to see the hospital sector grow and there will be tight controls on funding in many systems that will put increased pressure on hospitals to become more efficient and to demonstrate their wider value to the economy. This pressure is intensified by the view amongst many policy makers that hospitals are inefficient and in a number of countries by restricted fiscal space. As large and publicly visible organizations they will have to adapt to become more environmentally sustainable, minimizing their impact on the environment including on the carbon footprint. These pressures are challenging enough but they are likely to become more intense over time and they compounded by some significant weaknesses in the capacity and capability of management and governance systems to support this change in many countries. Finally, ambitions to create primary care-oriented health systems will be difficult to achieve without changes in how hospitals relate to other part of the system. This includes the share of the budget hospitals consume and the support they provide to other providers and primary care. What is the vision for hospitals? The growing pressures mean that it is important to articulate a clear vision about the role of hospitals and this will be the initial focus of the meeting building on previous work by WHO. This vision will be consistent with the aim of creating a Primary Health Care oriented health systems to support achieving Universal Health Coverage. Hospitals in the region are quite diverse and the nature of the approaches that are required will vary but there are common aspects of a future vision that are shared across systems. The starting point for this vision includes the following ideas: • Hospitals need to become increasingly integrated, and people oriented. This means that they will look beyond their walls to partner with local communities to create a culture of health and well-being. They also have to be part of the broader agenda on the contribution of health services to the economic and social development of countries. • The model will be increasingly decentralised, made possible by technology and better ways of working with primary care to improve accessibility and help to provide high-quality,  Concept note Page 4 patient-centred care, with special attention to the underserved, the aged and the chronically ill, acknowledging a strong social responsibility of public hospitals. • Hospitals will be networked between each other to optimise patient pathways and make the best use of scarce expertise. • The opportunities of digital technology will be fully exploited. • Care will be provided in buildings that promote patient health, staff well-being and high quality and safe care. • Hospitals will recognise the importance of staff in achieving this new vision particularly in the context of the pandemic and global shortages of key staff. They will therefore focus on their welfare and ensure that they are empowered and supported by teamwork and continuous learning. • Hospitals will be a hub for innovation, expertise, research and education supporting the wider system around them. They will also be important parts of their local economies as ‘anchor institutions’ • Management and leadership will be enhanced through the development of increased capacity and the adoption of processes and approaches that will boost organizational performance. Well-developed management and governance will promote quality, safety and continuous improvement and the connection of the hospital to wider healthcare and other local systems. Making hospitals fit for purpose There are a number of interlinked responses to these challenges that will be required to achieve the shared vision for hospitals. These will need to operate at all levels of the system from the clinical front line to national policy frameworks. Some of these will be about a focus on ensuring that existing processes and systems are fit for purpose, well designed and operating effectively – doing things better (transactional change). Others will be about new processes and new models of delivery that combine staff, technology and systems in novel ways – doing different things (transformational change). In addition, post-pandemic and in response the pressures of the pandemic there is work to do, to address the trauma that this has caused to create a stable basis for future progress (heal the system). We need input from stakeholders at the meeting to explore and prioritise these areas. There is a division between approaches that operate at the system and policy level and those that are more targeted at the operational, local system or hospital level but there is some overlap between them. Policy/system level changes Policy makers have a range of levers available to directly affect the health system and support a move to delivering the vision or at least to create a favourable environment and policies that support changes at the local level. All the levers for policy/ system level can support the healing, improving and transforming agenda and each is a possible opportunity for intervention that will be shaped according to the immediate priority (healing), the mid term perspective (improving) and longer- term goals (transforming).  Concept note Page 5 There are four major areas for action: Improving how hospitals are managed. This can be through policies to improve internal accountability and performance management, regulation, the development of autonomy and other governance changes, the development of information policy and systems, investments in leadership, workforce strategy, policy on quality and safety standards etc. Enabling high performance. This could include aligning contracting, payment and accountability for key outcomes, policy to support electronic health records, systematic quality assurance including accreditation, regulation, workforce policies and the development of feedback mechanisms and benchmarking approaches, etc. Change the shape of the hospital system. This includes master planning of the hospital system, capital investment to support change, the design of payment mechanisms, the public-private mix, the setting of standards to drive changes in care delivery, or policy to facilitate integrated care, etc. Broader public policy: This may also be relevant to reshaping the hospitals role as well as the requirements placed on them, for example, policy and standards on environmental sustainability, transport policy, public service reform, spatial planning and development, political decentralisation, etc. All these contribute to a better recognition of the societal role of the hospital and the contribution of health workers. Organizational level changes Many of the changes need to take place at the level of individual hospitals or local health systems. Such changes require that decisions can be made at this level and that strong accountability on results is in place. Interventions at organizational level can also help with the healing, improvement and transformation agenda. Having these three agendas in mind will provide longer term evolution as well as bringing more immediate and tangible results for patients, health professionals as well as for payers and health authorities. Change in this area will include: Improvements in organizational design to create favourable conditions for high performance. For example, this includes new ways to ensure the effective participation of the population and patient groups in key decisions which will be critical for the integration of hospitals in their communities. Interventions enabling performance supported by highly developed management capacity and capability and a well-established service oriented organizational culture sensitive to sustainable development. Information systems supporting evidence-based decision making, increased responsiveness and performance assessment and management will be a key part of this. Methods for process design supported by appropriate organisational structure, delegation and proper administration, supply chain, human resources management practices and systems, staff welfare, people responsive care, etc . Ensuring that work in this area is integrated with primary care and other parts of local health systems will also be important here. Mastering these advanced practices and tools will boost operational performance and create a sound basis for further transformation.  Concept note Page 6 Managing change Making major changes to the role or functioning of hospitals is difficult and many attempts at rationalisation and major structural changes fail. The development of change management capability will be a critical driver for achieving better fit for purpose hospitals and this will be the common thread for this meeting. Understanding the reasons for these difficulties and why strategies been successful or failed will be important. This will help to inform the development of policies and plans and in providing support to countries that want to embark on process of reorienting their hospitals to be part of a population health system. The critical challenge for driving change in the hospital sector lies in its complexity and atomicity. For this reason, having a national policy describing the vision on role and position of hospitals supported by clear mission for the hospitals with well described objectives to achieve will be important for setting the grounds for changing hospitals to make them better fit for purpose. A high level of alignment between the adopted interventions at system and organizational level within the healing-improving-transforming agenda will be a condition for success especially if this consistency is kept over time. Although flexibility to adapt to the evolution of situation is required, the stability of the broad objectives should not be compromised. This requires a high level of consensus to be achieved between the population, health professionals and politicians of all stripes. Specific attention will also need to be given to creating a favourable environment for dialogue and a good alignment between the major partners of the international community that contribute to shaping the policies and supporting country development. Conclusions The desired endpoint of the work over the next few months is the creation of a coalition of organisations with a shared vision for the hospital and a narrative about the need for change. It will also be desirable that this coalition agrees on the change agenda supported by a framework describing possible levers for interventions. This will form the basis for the development of products and materials to support member states and inform decision making by policy makers, development agencies and banks and other key stakeholders. Developing this will need to be an inclusive process of coproduction and a range of activities will be put in place leading up to the meeting in Baku in June.  Concept note Page 7 Appendix Insights from Brussels and analysis of EECA issues Hospital governance and leadership Countries in the EECA part of the region have particular challenges related to the governance and leadership of hospitals. In addition to the opportunities to improve the efficiency of care delivery and the effective use of resources there are several areas where improvements can be made. In a number of countries attempts have been made to make hospitals more autonomous often with ownership being vested in different levels of local, city or regional government. This raises questions about the capability of these bodies to act as effective stewards of hospitals or to provide the right level of strategic leadership. The need for hospitals to be part of wider networks has been recognised in some places but developing effective networks is difficult given the current configuration of hospitals. The absence of a clear strategic vision for the role of hospitals or about the results that the system is expected to produce in many countries means that there is relatively weak accountability and opportunities for improvement are not exploited. The quality of hospital management is also an issue. EECA Counties have not had a strong tradition of professional hospital management, and this is an obstacle to some of the areas for improvement identified elsewhere in this concept note. In addition to shortages of skills the politicisation of hospital director posts in a number of systems creates an unhelpful dynamic when difficult decisions need to be taken. Hospital investment Often underestimated and poorly funded, hospital capital investment is often Achille’s heel for the transformation of the hospital sector. Different strategies have been adopted from stronger mobilization of private sector to priority health programs for responding to investment needs. In all cases the strategic dimension of capital investment and its role on creating possible acceleration of transformation of the organization and the location of health services have not been well addressed. Most EECA countries require major investment to replace or upgrade their hospitals and/or need to rationalize the network of hospitals. Many hospitals have layout, and the space provided for functions, internal flexibility, engineering (such as lifts, medical gases) and other aspects of the design mean that adapting them to be suitable for modern medicine is often impossible or very expensive. There is also significant overcapacity and duplication persisting in many countries. This means that hospital investment often requires the closure or repurposing of many existing hospitals which is politically difficult. The management of change and the configuration of the hospital network is sometimes complicated by different levels of government owning different types of hospital within the same areas and local political considerations also tend to complicate making and create resistance to change. There are successful examples of large-scale master planning or strategic change exercises, for example in Denmark, Hungary and Estonia, but these required a degree of ceding of control by local owners. There is more to do to create successful  Concept note Page 8 methods for changing the shape of the hospital network. This requires also a new approach on health service delivery planning considering more the specificities of territories and their population in regard to the critical lines of healthcare services needed and to the epidemiological and demographic situation. Privatization of public hospitals is not the response to the challenges of hospital investments. The example of Private Funded Investment (PFI) in the UK and other attempts of Public Private Partnerships in other western European countries have not been up to their promises. In Georgia hospitals have been largely privatised and some countries also have private ownership of some specialist providers which creates a similar set of issues about coordination and the development of a rational hospital network that can integrate with primary care services and other hospitals. In the public sector a particular attention is also required for parallel hospital systems (Universities, National Railway, Military, Public companies, etc) which also creates some issues for planning when they are out of the scope of the responsibility of the Ministry in charge of public health. The processes and criteria for making investment decisions need to be strengthened to ensure a more evidence-based approach and to help future-proof investment. This should be done at two levels: the facility itself and the hospital sector as part of health service delivery system serving a population on a defined territory. For both, the investment should never be considered just modernizing the facilities but rather as a powerful tool for transforming the internal hospital organization and its role in the health delivery system. In addition, nowadays with the climate change commitments, there is a systematic need to improve the environmental sustainability of proposed new hospital development and dealing with the poor environmental performance of many existing buildings. Hospital financing One of the themes discussed in the Brussels meeting was the need for new approaches to payment systems in which a blend of different payment methods and other policy instruments are used. DRG payment models are only one element in a mix of more complex measures and work is required to develop mixed methods that can deliver health system objectives. The major challenge is to better align the expected outputs from hospitals to an adequate payment system. The shortcomings from the existing payment systems are well described: they are not providing the expected incentives for efficiency and quality improvement and a significant portion of hospital activities are not covered properly by the existing funding system. In addition, in some countries the underfunding of routine activities opens the door for corruption. At the same time the poorly designed funding system of public hospitals is responsible for waste while at the same time the units face frequent shortage of basic resources needed to operate properly. Beyond the hospital financing, the financial management and the accounting system are both often performing poorly. Part of this results from the institutional set up, governance and management models mentioned previously but also from the rigidity of rules that are driving the public sector with no exception for the public hospitals. Some EECA countries have been adopting DRG based payment systems through importing approaches from other countries but there are a number of supporting changes in the hospital sector that are required to make this effective. These include improved costing systems for hospitals that allow the development of meaningful estimates of resource use and internal budget management systems.  Concept note Page 9 There is a global trend to recognize that hospitals need blended payment system for financing their activities but for such systems to be effective, beyond the technical aspects related to each of them, it will be necessary to better identify all the functions that hospitals are performing and what is the cost of them. Quality of care and patient safety Quality of care and patient safety has focused a lot of attention in the hospitals with an important movement towards systematic accreditation and certification. Countries have adopted very different approaches from mandatory accreditation by public or private organization to incentive for voluntary accreditation and no accreditation at all. Countries like Denmark have challenged the benefits of a national accreditation scheme. The application of accreditation, external review and other more formal regulatory processes are also often under-developed. They tend to focus on structure rather than processes and tend to lack meaningful enforcement mechanisms. Many countries have also adopted patient safety indicators with full public disclosure as an incentive for continuous improvement. Last, the quality of care and patient safety is also evolving as a major priority for hospitals with the judicialization of health care. The collective responsibility of the hospital is often brough to court when patients face adverse events regardless of personal malpractice but with an emphasis given to process failure. EECA countries have more to do to ensure that there are reliable systems in hospitals to apply best practice in quality of care and safety, use up to date guidelines and implement processes for quality review and improvement. There is also a need to significantly improve the collection of data on key quality and safety indicators for hospitals. In addition, the incident reporting system that is the cornerstone for building patient safety face often strong resistance from health workers and poor support by the health authorities shy in pushing forward the needed cultural shift required for its implementation. A greater focus on quality and safety could improve outcomes for patients, reduce avoidable harm and help improve the confidence of the public in hospital services. This will require the development of capability within hospitals in terms of staff and systems as well as major changes in policy frameworks and regulatory machinery. Integrated care In all countries, integrated care is still a wishful objective. When social care is also considered the situation is even worse. It must be acknowledged that efforts have been made in the last decade for better coordination of care both within the public sector among levels of care and between public and private sector. But it must be recognized that coordination and integration of care is a complex issue that will require some systemic transformation and the leverage of a core tool that is the ubiquitous patient own electronic health record. In all countries, there are still high levels of admission to hospital for ambulatory care sensitive conditions as well as for rehospitalization that could be avoided. In EECA countries this situation is exacerbated by a systemic under-developed primary care and the improper incentives in some systems. There is also an often-unhelpful lack of connection between hospital specialists, narrow specialists working in polyclinics and primary care. The referral systems to support primary care  Concept note Page 10 and access to specialists for advice are poorly developed which creates problems with coordination and the over-use of hospitals for some services. The availability of home care, rehabilitation and palliative care combined with internal processes in hospitals contributes to relatively longer lengths of stay. This is also to relate with the very poor articulation between health and social care. In the EECA countries most often the absence of proper response to post-acute care is resulting from the in heritage of the Soviet Union health care model and lack of anticipation of the ageing population. Closer integration between hospitals and primary and outpatient care could therefore make a significant contribution to both efficiency and the effectiveness of population health management. This will need to consider: Improving referral processes and making these more evidence based and systematic as well as more properly supported by an adequate payment system. Creating systems for hospital specialists to better support primary care in the management of common NCDs. Establishing systems for information exchange and shared records and ways to identify high risk patients more effectively. Investing in health workforce development All parts of the region have problems relating to the supply, distribution and skills of the workforce and often a lack of flexibility including limited scope for developing skills mix. Rural and remote regions have a particular problem and will require new care models, the use of technology and a different type of workforce to deal with these issues. Hospitals in the EECA countries do not have access to a nursing workforce with advanced skills and capability to work in more autonomous ways. Regulatory rules, salaries and educational institutions all need to adapt to create the environment for the development of the workforce in nursing and other non-medical clinical disciplines. Although there has been a lot of focus on the challenge of health workforce shortage, the attention has been on collective interventions related to training, to retention and to skill mix. However, the role of public hospitals that are most often the first employer of health workforce and their role in training and expanding it has been underestimated. Part of the challenges at hospital level are related to the institutional framework, the governance and management model which can play a significant role in reducing the attrition of the health workforce. WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTÉ WELTGESUNDHEITSORGANISATION ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ Date: 12 April 2023 REGIONAL OFFICE FOR EUROPE BUREAU RÉGIONAL DE L’EUROPE Mr Peep Peterson REGIONALBÜRO FÜR EUROPA Minister of Health and Labour ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО Ministry of Social Affairs Head office: Suur-Ameerika 1 UN City, Marmorvej 51, 10129 Tallinn DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00; Fax: +45 45 33 70 01 Estonia Email: [email protected] Website: https://www.who.int/europe Our reference: Your reference: Notre référence: Votre référence: Unser Zeichen: Ihr Zeichen: См. наш номер: На Ваш номер: Dear Sir, Request for nomination of representative(s) for the WHO European Regional Meeting on Hospitals, 5–7 June 2023, Baku, Azerbaijan I have the honour to request your nomination of representative(s) for the WHO European Regional Meeting on Hospitals, jointly hosted by the Ministry of Health of the Republic of Azerbaijan, taking place in Baku on 5–7 June 2023. This crucial meeting will bring together a diverse group of stakeholders and experts and aims to address strategic challenges faced by hospitals, developing a shared vision for hospitals' transformation and building on insights from the WHO European high-level expert meeting on rethinking the future of hospitals in the WHO European Region that was held in April 2022. To ensure effective representation at the meeting, we would be honoured if you would consider nominating two representatives from your country, as follows, to attend the meeting and contribute to the discussions and development of proposals for action: • one representative with knowledge and experience in hospital management responsibilities; and • one representative with national or regional responsibilities and experience in hospital planning. We would be grateful if you would share the contact details (name, functional title and email address) of the nominated representatives by 28 April 2023 via email to Dr Mafaten Chaouali [email protected], copying Ms Elena Galmond [email protected]. We look forward to receiving your nominations. Yours very truly, Dr Hans Henri P. Kluge Regional Director UN City, Marmorvej 51 Tel.: +45 45 33 70 00 Email: [email protected] DK-2100 Copenhagen Ø Fax: +45 45 33 70 01 Website: https://www.who.int/europe Denmark Encls: Concept note Copy for information to: Ms Elen Ohov, Adviser, European Union Affairs and International Co-operation Department, Ministry of Social Affairs, Suur-Ameerika 1, 10122 Tallinn, Estonia Ms Triin Uusberg, Head, European Union Affairs and International Co-operation Department, Ministry of Social Affairs, Suur-Ameerika 1, 10129 Tallinn, Estonia H.E. Ms Katrin Saarsalu-Layachi, Ambassador Extraordinary and Plenipotentiary, Permanent Representative, Permanent Mission of the Republic of Estonia to the United Nations Office and other international organizations in Geneva, Chemin du Petit-Saconnex 28A, CH-1209 Genève, Switzerland H.E. Mr William Mart Laanemäe, Ambassador Extraordinary and Plenipotentiary, Embassy of the Republic of Estonia, Frederiksgade 19, 4th floor, 1265 Copenhagen K, Denmark Ms Kristina Köhler, Liaison Officer, WHO Country Office, Estonia, Paldiski Road 81, 10617 Tallinn, Estonia –2–