Governance for health

Professor Erio Ziglio has been head of the World Health Organisation European Office for Investment for Health and Development in Venice, Italy since 2003. His affection for Scotland is evident.

“Scotland has been very good to me,” he tells Holyrood, referring to his time lecturing and studying at Edinburgh University, where he was awarded his PhD in 1985 from the Department of Social Policy.

However, Professor Ziglio expresses an admiration for Scotland which is professional as well as personal. The WHO’s ‘Health 2020’ policy framework lays out a vision for governance for health, and Ziglio uses Scotland’s interpretation of it as an example when talking to other European countries.

“I can tell you that in my speeches I mention your work,” he says, “I would like to give a word of encouragement to Scotland. Because Scotland is one of the countries we have in Europe where they try to do a number of things that, in our view, are extremely important. First of all, to see the issue of population health, the promotion of health and the reduction of health inequities as an integral part of where Scotland wants to go in the future. It’s an integral part of development. So when we in the WHO advocate for approaching health as a whole of government approach, we can see Scotland is trying to do that. So I would like really to commend that, to encourage that,” he says.

“The other interesting aspect we see is this issue of integration – trying to integrate better, not to have this fragmentation of services like we see in many countries in Europe.”

Dr Ziglio believes coherence between national government strategy and local authority planning is essential, and recognises Scotland has “put these issues on the table, to see what to do.”

The 53 European members states of WHO signed up to Health 2020 in Malta in 2012, a pleasant surprise for Dr Ziglio: “We challenged our 53 countries in Europe and said, ‘well, no matter how you are organised, be it the UK’s organised national health system, the German’s national health insurance, whatever, is it possible that we as Europeans can have an agreement on what these services should produce?’ I have been working in the region for a number of years and I thought, ‘hmm… the countries are going to say no’ – the countries said yes.”

This made Europe the only WHO region which has an agreement on promoting health, reducing health inequalities and strengthening governance for health.

“What I mean by governance is to create the conditions for health. Of course, the NHS has its own responsibility, but the NHS alone, even in a wonderful country like Scotland, I think, won’t have the possibility to reduce health inequities dramatically.”

Figures released recently by Scotland’s chief statistician show that relative inequality in death rates has actually increased since 1997. Inequalities have also widened in heart attack hospital admission rates, among others. Professor Ziglio says the distribution of health is increasingly unequal across Europe, even in countries with traditionally more equal societies, like in Scandinavia: “Very often what happens is that in the health system, we have to deal with the failures of other sectors. For example, if you have a very unequal policy in the area of education, well eventually, then you have this reflected into health inequities, if you have a not very effective housing policy… and so on.

“So we have, basically, two options. One: to do business as usual, to look only within our own sectors, but this is not going to change much. Or you have now to use a kind of jargon: Strengthen the governance for health or create the conditions for health by linking up with other sectors.”

Scotland recognises the challenge, he says: “At least here you have put health inequities, from what I see, as an indicator of the performance of your system, both in terms of the health sector, but also in terms of the Government as a whole. It’s very important. I can tell you there are very, very few countries that have that courage that Scotland has now.”

Governance for health, says Ziglio, “is not just an ideological thing” but an integral part of the development agendas of both national and local governments. It would be impossible to attract investment into a community, he argues “if they have a life expectancy of 25 years old. Because behind that you have not just the problem of health, you have the problem of security, housing, lack of resources, little education.”

Building communities people want to live in is inherent in Health 2020, according to Ziglio: “No one wants to have your own children growing up in a city where poverty is increasing, or where citizen’s rights are not respected, or there is gender inequities.”

He likens it to the immune system. “A good neighbourhood, the levels of solidarity, equality and distribution of social networks, the environment, is all part of our social, city immune system. We have to strengthen that.”

Dr Ziglio commends Scotland’s recognition of community assets as a way of doing this. He gives the late soul singer Ray Charles as an example. In setting up the Ray Charles Foundation, the singer gave Dr Ziglio “a fantastic public health lesson.”

Those who work in health would ask, “where would Ray Charles put his money? Where his problem is, right? Probably into research recreating the ocular tissue or whatever, to prevent blindness. No, he didn’t put his money there. He put his money into the prevention of hearing impediment. That’s a big thing for us.”

Charles himself called his eyes his handicap, but his ears his opportunity.

“When we talk about cities then, I think we have to utilise this wonderful lesson. There are a lot of assets in our city. People, even people who are struggling, have tremendous assets. Just the fact they have the courage somehow to deal with a life that is sometimes not so simple,” says Ziglio.

He also refers to the Renaissance frescoes in Siena’s town hall in his native Italy, painted by Ambrogio Lorenzetti. The Italian town was rebuilt by the quasi-democratic Council of Nine from 1287, who commissioned the paintings to look down on council meetings. The frescoes called Good Governance (Buon Governo) and Bad Governance (Mal Governo) show personifications of the qualities needed for both, and cover the huge room in Siena’s TownHallPalace.

The allegorical depictions are still relevant today, says Ziglio. “They have a vision that the conditions for health are produced by how everything is working. Either we have a society that creates pathogenesis or we create salutogenesis: the conditions for health. Because we are dealing with human resources, with their health, we are dealing with their self-esteem, if they’re feeling adequate.”

People in Scotland, too, are important assets, he says. “I think, if I may say so, you’re also very lucky in the health sector because you have a lot of talent here. For example, if you take your Chief Medical Officer, Sir Harry Burns, he’s a person who understands these issues in a really profound way. And to have at the top of your health authorities, to have people of that calibre? I think that’s something extremely important,” says Ziglio.

“He’s got an international reputation. He’s also one of the few people that in addition to showing the causes of inequities, he’s got some ideas about what you can do about it. To have people of that calibre, I can tell you, there are not so many.”

Amongst all the praise, Scotland is still among the lowest in Europe for life expectancy. Ziglio believes the country’s problems give it credibility when acknowledging them and wanting to do something about them, especially with many European countries having a similar population size.

“I would say, look at Scotland, they had problems: with unemployment, they know what poverty is, they’ve got some downturn, they’ve done things, but at the same time, look what they’re trying to do.”