jan mos rivm 22 4 2010

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Nederland gezond en wel

Gezond blijvenVoorkomen is beter dan genezen?

Rollen en taken RIVM

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Three themes

1. Role of RIVM in the public domain

2. What is needed?

3. VTV: what do we (think) we know?

Discussion and clarification when needed!

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What may citizens expect from their government?

What is the responsibility of the federal government?

What is the role of state and local authorities?

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Government responsible for public health

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Government responsible for safe environment

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Public health is inherently political …

Politics is the process by which groups of people make decisions.

It is the authoritative allocation of values. Although the term is generally applied to behavior within

governments, politics is observed in all human group interactions, including corporate, academic, and religious institutions.

www.en.wikipedia.org/wiki/Politics

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Public health is inherently political

• Within a governmental framework• Involves complex tradeoffs—one value weighed against another• May need to act before all desirable information is known• Frequently need to involve the public — actions, or at least agreement

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But Public Health Institutes must be non-partisan…

• Decisions based on science, not ideology, financial interests, or ‘self-interest’• Complex tradeoffs — decision making transparent, quantitative modelingDecision analysis should identify and quantify areas of uncertaintyPublic communication, engagement

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Political responsibility

Research & policy support

The ministries have political responsibilities

RIVM: independent scientific responsibility (air quality)

Risk-assessment (RIVM, ECDC)

Risk-management (Government, EU, RIVM)

Clear separation of responsibilities

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Summarizing

• Separation of responsibilities• But the same goal• With different roles and interests

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Role of RIVM in the public domain

The aim of the RIVM is to improve public health and safeguard a healthy environment.

This is achieved by:• Research & knowledge integration• Policy support• National / federal coordination functions • Specific intervention programs (NIP, screening)• Effective communication on health (care) and

environment

RIVM serves the public authorities, the professional and the public

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Three themes

1. Role of RIVM in the public domain

2. What is needed?

3. VTV: what do we (think) we know?

discussion

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National Public Health Institute scientific role

• Selection of important public health question• Define appropriate scientific approachFrequently multi-disciplinary

• Obtain needed data• Participate in decision making, regulations• Implement, with partners, programs• Continue monitoring to evaluate impact

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Public Health Questions: Emerging Infections (Zoonoses)

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Public Health Questions: Problems in the air?

particulate matter electromagnetic fields public threat?

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Public Health Questions: Legionella (environment)

Legionella in cooling-towers

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Public Health Questions: Behaviour, trends and concerns for the future

physical inactivity

excessive alcohol use

severe obesity

Overweight

smoking

stablestableStable

badstablegood

badbadbad

badbadbad

stablegoodgood

youthFemalesMales

Trend

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National Public Health Institute scientific role

• Selection of important public health question• Define appropriate scientific approachFrequently multi-disciplinary

• Obtain needed data• Participate in decision making, regulations• Implement, with partners, programs• Continue monitoring to evaluate impact

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Transform information into wisdom (science)

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Understand risk assessment and communication

power lines

benzene

disasters

legionellanoise

passive smoking

airpollution

Radon

traffic

accidentsalcohol

accidents at home

fat food

lack of physical activityobesity

mobile phone base station

smoking

10-2

10-10

10-9

10-8

10-7

10-6

10-5

10-4

10-3 Risk on premature death

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Priority setting: use transparent criteria

Burden of disease and Cost of illnessInclude TrendsEvaluate effectiveness and efficiency of preventive measures

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DALYs in the Netherlands, 1980 - 2020

0

5000

10000

15000

20000

25000

1980

2000

2010

1980

2000

2020

1980

2000

2020

1980

2000

2020

1980

2000

2020

PM10 long-term

Noise Radon UV Trafficaccidents

DA

LY

s p

er m

illi

on p

eop

le

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Relative burden: 7 infectious diseases in Europe

incidence mortality disease burden

influenza measles HIV-infection campylobacteriosisEHEC-infection salmonellosis tuberculosis

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What is needed?

Good scientific background, credibility

Priority setting requires integrated knowledge based onBiomedical & health scienceHealth systems effectsEffective interventions

Thrive for a strong position to advice:Professionals, Politicians, Citizens

Consumer behavior experience Risk communicationEffective interventions

No formal power – authority needed (central vs local)

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What are the consequences for RIVM?

The Dutch government has redefined its role in public healthOur Institute is under reconstruction (mainly research)!

Additional tasks: better preparedness for outbreak / risk managementPrevention and intervention programs (based on burden of dis)Protect and promote health (alcohol, overweight, etc)

This requires to unify many different tasks of our instituteYou need mental maps

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Conceptual model for the Dutch PHSF

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Develop models to get grip on reality

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Need to develop knowledge-model

‘Sources’ ‘Effects’ ‘Systems’ ‘Intervention

laboratory and field research, modeling

Communication

desk research and (inter)national networks

Chain

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NIPH

owner Customers

Sister institutes

Research centers

citizens

professionals

Budget-holder

Need to develop stake-holder model

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Three themes

1. Role of RIVM in the public domain

2. What is needed?

3. VTV: what do we (think) we know?

discussion

Datum invullen25 maart 2010Titel van de presentatieVan gezond naar beter – VTV 201032

Public health reporting in the Netherlands

Public Health Status and Forecast 2010

Fons van der Lucht & Johan Polder

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General purpose of public health reporting

to provide an overview and analysis of the available data and information in the field of public health, on a regular basis

with explicit identification of any gaps in the information supply

for the:

evaluation of current health policy

preparation of new health policy

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Public health reporting by cVTV/RIVM

PHSF report: every four year (2010)

Thematic reports

Websites (regular updates):Public health CompassPublic health AtlasCosts of illnessEuphix.org

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Conceptual model for the Dutch PHSF

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PHSF in The policy cycle(Anderson and Hussey)

Preparation(agendasetting)

Implementation(programme implementation)

Evaluation Development(policy formulation)

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Preparation(agendasetting)

Implementation(programme implementation)

Evaluation Development(policy formulation)

Min. Health:Policy-document(2006/2007)

Municipalities:Policy-documents(2008/2009)

RIVM: PHSF-report(2010)

Healthcare-inspectorate(2009)

Datum invullen25 maart 2010Titel van de presentatieVan gezond naar beter – VTV 201038

From healthy to better

Public health status and forecast 2010(The fifth PHSF)

Fons van der Lucht & Johan Polder

Issued and offered march 25, 2010

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Life expectancy increases

70

72

74

76

78

80

82

84

86

88

90

1970 1980 1990 2000 2010 2020 2030 2040 2050

women man

life expectancy (years)

Life expectancy 2008Man: 78,3Women: 82,3

Dutch Women not in top of Europe

Sharp increase in last 4 years2 Years

Continuation of increase 2050: 6 years more

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Nadenken over consequenties….

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Large differences in life expectancy within the Netherlands

Lower life expectancy in big cities (e.g. Amsterdam, Rotterdam)

Lower life expectancy in ‘rural’ deprived areas (Limburg, Twente, Groningen, Betuwe)

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Persistent and large health inequalities(healthy)Life expectancy by level of education)

0 20 40 60 80

low

highWOMEN

low

highMAN

le without physical limitations

le with physical limitations

life expectancy (years)

Gap in Life expectancy7.3 years men6.4 years women

Life expectancy without limitations:

14 years

Trends in the gap constant/slight increase

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More disease, but more health

0

10

20

30

40

50

60

70

80

90

1983 1986 1989 1992 1995 1998 2001 2004 2007

life expectancy (le)

le without limitations

le in good (self perceived) health

le without chronic diseases

years, men

0

10

20

30

40

50

60

70

80

90

1983 1986 1989 1992 1995 1998 2001 2004 2007

life expectancy (le)

le without limitations

le in good (self perceived) health

le without chronic diseases

years women

More years, with more chronic diseases

But also in good health (trend will continue)

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Most prevalent diseases

Top 5 of diseases: each disease more dan 600.000 cases

(based on health care registrations)

1. Diabetes2. Arthrosis3. Coronary Heart diseases4. Complaints of neck and

shoulder5. Hearing loss

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Why are there more diagnoses?Medical factors

Increasing Knowledge: Prevention and early detection and treatment

(early detection: cancer and DM; better treatment cataract)

Successes in health care attribute to the increasing number of diagnosis

Social factorsless acceptance of inconvenience or discomfortsLess tolerance for variance in behaviour and healthExtension of the health conceptMedicalisation of daily complaintsHigher demands of our knowledge based economy

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…and why is doesn’t have to mean less health

Health is more than the absence of disease

'feel good' 'do the things

you want to do'

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 or more chronicdiseases

percentage

good (self perceived) health no limitations

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Less smokers, but still 27% smokes

0

20

40

60

80

100

1958 1968 1978 1988 1998 2008

men w omen average

percentage

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Overweight stabilizes at high level

0

10

20

30

40

50

1981 1984 1987 1990 1993 1996 1999 2002 2005 2008

obesity men obesity womenoverweight men overwweight women

percentage

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Priority setting: Tackling the biggest problems?

Smoking causes the highest burden of disease

However:- Many determinants of health still unknown- Lifestyle behaviour is clustering and has a common cause- Living healthy is not easy

- (what’s healthy, personal differences, environmental influences)

The social and physical environment as a starting point?

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Opportunities of preventionHealth protection and disease control (vaccination, screening) have produced

a lot of health gain in the pastMaintainanceExpansion

Health promotion (focused on lifestyle changes) is less succesfullNormative aspects (freedom of choice versus lifestylepolicy)Lacking knowledge (effectiviness of interventions is largely unknown)Institutional aspects (Unclear responsibilities, too many parties)

NB. Still opportunities when we deal with these problems

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The future of healthcare

Large increase in health care costs:Demographic developments Medical technologyLess possibilities for laboursaving innovationsMany employees needed in the health care sector

More health ≠ less health care

More health = more participation

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30% van de economische groei door betere voeding en gezondheid

30% van de economische groei door betere voeding en gezondheid

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Investing in health is necessary

Health is wealth

Health is highly appreciatedHealth is a source of human capital (education and employment)Health is a important condition for societal participation (Quality of the society)

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Investing in health is necessary• To get back in the top of Europe• Prevalence of diseases is increasing, limitations stabilize• Lifestyle is still a threat• Persisting health inequalities

And

• Everybody is needed on the labour market• Or in volunteer work or informal care• Health contributes to welfare and societal well-being

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A future for prevention- Long term:– concerted action, clear targets and a framework for assessment and appraisal: normative debate, investing in knowledge, and organisation of the public health field

- Short term:- Investment on effectiveness

- Priorities- Limitations- Health inequalities- Broadening the lifestyle

perspective (societal problem in stead of an individual)

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Gezondheidsbevordering moet anders

Bij gezondheidsbevordering verder kijken dan gedrag

Aandacht voor fysieke én sociale omgeving

Aandachtspunten voor de korte en lange termijn.

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Toekomst van preventie:Lange termijn Maatschappelijk actieprogramma

Heldere doelen op elk niveau

Afweging in samenhang

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Toekomst van preventie: korte termijn Gericht op de algemene bevolking (universele preventie)

Gericht op hoogrisicogroepen (selectieve preventie)

Gericht op individuen met een verhoogd risico (geïndiceerde preventie)

Gericht op het voorkomen van complicaties (zorggerelateerde preventie)

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Een zorgvolle toekomst

Is de zorg een koekoeksjong…

of…

een kip met gouden eieren?