Tessa Richards: Leadership matters—lessons from Lithuania

Tessa RichardsAt this year’s European Health Forum Gastein, the wannabe Davos for health, a call went out for “stronger leadership on health.” Europe needs health ministers who can advocate to protect the health of its citizens as effectively as their counterparts in finance and industry speak up for and guard it’s economic interests. Tweets from the meeting included the following tongue in cheek plea: #EHFG2013 Could the UK borrow the current Lithuanian health minister? Vast improvement on what we’ve got!

It’s not hard to see why Vytenis Povilas Andriukaitis, who has been in post less than a year, has gained a reputation as one of Europe’s foremost leaders on health. Born in a Gulag camp in Siberia, he has long been politically active; he was arrested by the KGB in 1976. His recent book, which warns against “re-framing” Lithuania’s turbulent recent history, has been praised by critics. He is also a doctor, and he worked as a cardiac surgeon between 1975 and 1993.

At meetings he is both outspoken and diplomatic, and has the positive “can do” attitude that characterises surgeons. Over the past months he has successfully helmed the presidency of the EU health council and furthered the debate in Europe on the responses needed to counter austerity. These, he and many other health policy makers have repeatedly underlined, include the need to sustain investment in health systems, improve their efficiency and  effectiveness, protect human rights, and make equitable universal health coverage a reality.

Mr Andriukaitis has also pushed hard on the tricky “health in all policies” front.

In Lithuania he has set up an interministerial group to focus on health issues. “It’s helped,” he told the BMJ at the recent EU presidency meeting in Vilnius, “that two of my fellow ministers, those in education and defence, are also doctors.”

When I asked him at Gastein to outline his country’s biggest problems, he flagged up poorly integrated care, weak primary care, high co-payments, inequalities in access—“the rich get to specialists faster—“inefficiency, and overuse of medical technologies.” “We have lost our holistic approach,” he said.  A review published this week by the European Observatory on Health Systems and Policies reinforces these messages.

But Lithuania has successes to point to as well. Infant mortality has fallen from 16 per 1000 live births in 1971 to 4.3 per 1000 live births. And during Andriukaitis’s tenure as health minister smoking in public places was banned, taxes on alcohol were increased, industry sponsorship of public events stopped, the number of outlets (and times) where alcohol is sold were restricted, and advertising on television was curtailed. A tax on sports drinks has been introduced and regular physical activity and nutritional education in schools has become mandatory. Deaths from road traffic injuries have been reduced, and there is a concerted drive to reduce the gap (over 12 years) in life expectancy between men and women.

Improving health and preventing disease in Europe depends on the EU as well as national action, and influencing legislation in Brussels remains a challenge for health policy experts. In a bravura display of leadership at the Vilnius meeting, Monika Kosinska, secretary general of the European Public Health Alliance (and driving force behind the Declaration agreed there, spelt out why.

The EU, she reminded delegates, was established to rebuild Europe’s tattered economies, prevent further wars, and feed people. Decades on its “siloed” decision making apparatus remains geared to economic protection.

“The political culture in Brussels does not understand that health matters,” she said, not least to countries’ economies. “Europe’s cows still get a subsidy per head well in excess of per capita expenditure on the health of its citizens.” If subsidies to the beef and dairy industry were removed, she argued “we could tackle childhood obesity.”

Public health experts need to convince policy makers in other sectors of the importance of a strong health sector and policies aimed at reducing socio economic inequalities. Several speakers underlined that they have the evidence to do so.

To those who work outside the Eurosphere, the protracted decision making processes in Brussels remain hard to follow despite the fact that its institutions take transparency seriously.

Yet as Kosinska emphasised, it is crucial to identify where, when, and how to counter the forces in Brussels’ corridors that repeatedly sabotage decisions on draft directives aimed at protecting health, such as plain packages for cigarettes. It can be done, she said, pointing to the successful lobbying that blocked proposals for direct to consumer advertising of pharmaceuticals.

Public health may be a relatively new specialty, but it must come of age and get its voice heard, she said.

Tessa Richards, senior editor BMJ.