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Safe and nutritious food is a prerequisite for health

WHO Strategic Objective 9: “To improve nutrition, food safety and food security throughout the life-course and in support of public health and sustainable development”.

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A safe and nutritious food supply is essential for good health. The joint FAO/WHO World Declaration on Nutrition from 1992 states that “…access to nutritionally adequate and safe food is a basic individual right”.

Although almost all countries in the European Region have government-approved policies on food safety and nutrition, food safety emergencies and foodborne diseases keep challenging European health systems, even in the most developed countries, and the disease burden associated with poor nutrition continues to grow, particularly as a result of the obesity epidemic.

The food safety and nutrition programmes strive to support the 53 countries of the WHO Regional Office for Europe in their endeavors to strengthen food safety and ensure proper nutrition.

In 2007, the European countries endorsed the WHO European Action Plan on Food and Nutrition Policy 2007–2012. This Action Plan highlights important areas for improvement in both food safety and nutrition. Governments are encouraged to use it as a reference in developing and implementing their own national policies and strategies according to their needs.

Proposed actions include improving nutrition and food safety in the early childhood years, ensuring a safe, healthy and sustainable food supply, providing comprehensive information and education to consumers, integrating actions to address related determinants (such as physical activity, alcohol, water, environment), strengthening nutrition and food safety in the health sector, and monitoring and evaluating progress and outcomes.

The WHO Regional Office for Europe supports the implementation of the Action Plan by promoting political commitment to address food safety- and nutrition-related health and health system challenges; providing technical support for food and nutrition policy development, policy analysis and capacity building in countries; monitoring the public health nutrition and food safety situation; and establishing synergies and integrated action within health systems on related public health issues (such as physical activity promotion, alcohol consumption, noncommunicable and communicable disease prevention, environmental health and water safety).

Introduction

The WHO Regional Office for Europe addresses food safety and nutrition through two programmes:

>> Food SaFety

>> NutritioN (iNcludiNg phySical activity aNd obeSity)

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“Foodborne and nutrition-related diseases represent a significant public health burden and challenge throughout the European Region, affecting all age groups and all socio-economic classes. WHO strives to support European countries in their endeavours to ensure that the food supply is safe and nutritious, for the best of people’s health and the countries’ prosperity.”

Zsuzsanna Jakab, Who regional director for europe

Food safety is challenged by a longer, more complex and globalized food chain than ever before, which makes it more difficult to prevent food contamination even in the most developed countries. Salmonellosis and campylobacteriosis are the most commonly reported foodborne diseases. usage of antibiotics in food animals represents another increasing public health risk. prevention of foodborne disease and effective responses to food safety challenges require holistic, risk-based and timely policies and strategies. Who/europe’s food safety programme supports countries in building capacity to manage these challenges in accordance with the Who european action plan for Food and Nutrition policy 2007–2012 and the Who global strategy for food safety.

Nutrition, physical activity and obesity are closely linked. poor diets and sedentary lifestyles are contributing to an increase of obesity in most countries of the european region, with lower socio-economic groups bearing the biggest burden. in particular, childhood obesity is one of the most serious public health challenges of the 21st century. Who/europe’s nutrition programme supports countries in the development, implementation and evaluation of National action plans based on the european charter on counteracting obesity and the Who european action plan for Food and Nutrition policy 2007–2012. in recent years, over 90% of countries in the european region have developed national policies in the field of nutrition, physical activity and obesity.

Executive Summary

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Food safetyFoodborne diseases cause significant illness and death worldwide through the ingestion or handling of food contaminated by bacteria, viruses, parasites, chemicals and biotoxins. Food safety is hence recognized as an essential public health aspect.

WHO wants food safety to receive more attention. As Dr Margaret Chan, WHO Director-General says: “Governments need to give food safety just as much attention as they devote to the quality and safety of pharmaceutical products. Not everyone needs to take medicine every day, but all people need food each and every day.”

ChallengesToday, the food chain has become longer, more complex and globalized. As a consequence, food contamination is still very common. Globally an estimated 2.2 million people die from food- and waterborne diarrhoeal diseases per year, 1.9 million of whom are children. In industrialized countries, nearly one in three persons per year suffers from a foodborne illness. These figures represent only the tip of the iceberg, as the estimated number of unreported cases is very high. Furthermore, the figures refer to gastrointestinal illness only and do not include disease caused by chemical contamination in the food chain.

Foodborne diseases of zoonotic origin, i.e. transmitted from animals to humans, represent a particular public health burden and challenge. Salmonellosis and campylobacteriosis are the most common, with several hundred thousand cases reported per year in the European Union alone. In some parts of the Region, brucellosis, and the parasitic zoonoses trichinellosis and echinococcosis are also of great concern.

Foodborne viruses are increasingly recognized as a major cause of gastrointestinal illness throughout the Region. Foodborne staphylococcal intoxication is widespread, and in some countries botulism is still a significant threat.

Antibiotic resistance caused in part by usage of antibiotics in food animals is becoming a significant public health problem. Foodborne infections caused by resistant bacteria like Salmonella, Campylobacter or E. coli pose a particular risk to human beings including possible treatment failure, prolonged disease and increased severity of disease, mortality and societal costs. Various chemical hazards also represent a public health risk and food allergies are increasingly recognized as a concern.

The prevention of foodborne disease and the response to food safety challenges requires holistic, risk-based and timely policies and strategies. The food safety programme aims at ensuring that all food is as safe as possible from production to consumption – thus it is essential to adopt a “whole food chain” approach in food safety strategies and measures, which also should include environmental aspects.

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What the WHO Regional Office for Europe is doing

The food safety programme supports countries in building capacity to manage food safety challenges in accordance with the WHO European Action Plan for Food and Nutrition Policy 2007–2012 and the WHO global strategy for food safety. The Action Plan includes a wide range of actions for both policy-makers and health professionals to reduce the incidence of foodborne diseases. It emphasizes that food safety goals should be risk based and tailored to individual country’s needs.

Antibiotic resistance in relation to food safety is a prioritized area. Usage of antibiotics in food animals represents a public health risk, as resistant bacteria, such as Salmonella and Campylobacter, and resistance genes can be spread from animals to humans through the food chain.

Importantly, the food safety programme assists countries in regard to outbreaks of foodborne disease and food safety emergencies, and in building capacity in the following areas:

o developing mechanisms and tools for an intersectoral food safety system with a “whole food chain” approach;

o monitoring contamination of chemical and microbiological hazards, including antibiotic resistance, in the food chain;

o carrying out surveillance of foodborne diseases;o emphasizing hygiene throughout the food chain;o implementing hazard analysis and critical control

points (HACCP) systems in the food industry;o promoting timely and appropriate risk communication

including comprehensive consumer information, by using, for example, the WHO five keys to safer food;

o collaborating on international information sharing on foodborne diseases and food contamination via the International Food Safety Authorities Network (INFOSAN) and International Health Regulations (IHR) network.

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“Noone should become sick from enjoying a meal; however this happens very commonly, throughout the European Region, and no country is spared. The challenges from foodborne disease are further increasing with globalization and growing travelling and trade. To ensure food safety, a ‘health in all policies’ approach is a prerequisite. WHO strives to support European countries, especially in the east, building their food safety capacity on the basis of intersectorial collaboration with a public health focus.”

Zsuzsanna Jakab, Who regional director for europe

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Progress in the Region over the past five years, the food safety programme has contributed to enhancing national capacity in food safety across the region, with special attention being given to the commonwealth of independent States (ciS), the central asian republics and south-eastern european countries (See). More than 1000 professionals from 48 countries have been trained on food safety topics, including issues of increasing concern such as antibiotic resistance. the support provided to Member States through these activities has contributed to improving their procedures and practices at international level, related for example to potential emergencies, outbreaks, and the adoption of standards.

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>>What additional progress can be achieved with more resources? the food safety programme relies mostly on voluntary resources made available to Who. the italian cooperation is funding a food safety project in albania aimed at strengthening food control institutions. codex trust Funds is funding some capacity building activities for countries in south-eastern europe and central asia. uS cdc and institute pasteur are supporting some training courses under the global Foodborne infections Network. the european centres for disease control and prevention (ecdc) and the european Food Safety authority (eFSa) are supporting various capacity building activities.

With more resources, Who/europe could make further progress in the following areas:

> empowering ciS and countries of south-eastern europe and central asia through capacity building to address various food safety issues, for example:

o the establishment of intersectoral food safety systems that encompass the whole food chain, including environmental aspects, and address all types of food safety risks

o the establishment of surveillance systems for the detection of foodborne diseases, microbiological and chemical contamination in the food chain and antibiotic resistance

o food safety risk communicationo the prevention of and response to outbreaks of

foodborne diseases;> raising awareness about antibiotic resistance from a food

safety perspective and supporting countries in taking actions in this area;

> providing support in relation to outbreaks of foodborne disease and food safety emergencies through the international Food Safety authorities Network (iNFoSaN) and international health regulations (ihr).

FOcuS cOuntrieS: the food safety programme works with all Member States with regard to food safety policies and normative work, e.g. relating to codex alimentarius.

Who/europe’s capacity building activities in food safety are concentrated on the ciS, central asian and See countries: albania, armenia, azerbaijan, belarus, bosnia and herzegovina, croatia, georgia, Kazakhstan, Kyrgyzstan, Montenegro, republic of Moldova, romania, russian Federation, Serbia, tajikistan, the former yugoslav republic of Macedonia, turkey, turkmenistan, ukraine, uzbekistan.

Tackling antibiotic resistance from a food safety perspective in Europe http://www.euro.who.int/__data/assets/pdf_file/0005/136454/e94889.pdf (Also available in Russian)

WHO European Action Plan for Food and Nutrition Policy 2007–2012http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/food-safety/publications/pre-2009/who-european-action-plan-for-food-and-nutrition-policy-20072012-2007

WHO Global Strategy for Food Safety: Safer food for better healthhttp://www.who.int/foodsafety/publications/general/global_strategy/en/index.html

Reducing the burden of foodborne disease – How the WHO food safety programme for the European Region supports its Member States (brochure)

Main products

The WHO Regional Office for Europe

The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.

World Health Organization Regional Office for EuropeScherfigsvej 8DK-2100 Copenhagen ØDenmarkTel.: +45 39 17 17 17 Fax: +45 39 17 18 18 E-mail: contact@euro.who.intWeb site: www.euro.who.int

Member States

AlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuania

LuxembourgMaltaMonacoMontenegroNetherlandsNorwayPolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe former Yugoslav Republic of MacedoniaTurkeyTurkmenistanUkraineUnited KingdomUzbekistan

Tackling antibiotic resistance from a food safety perspective in Europe

Tackling antibiotic resistance from a food safety perspective in Europe

Antibiotics have revolutionized the treatment of infectious diseases. But their use and misuse have resulted in the development and spread of antibiotic resistance. This is now a significant health problem: each year in the European Union alone, over 25 000 people die from infections caused by antibiotic-resistant bacteria. Antibiotic resistance is also a food safety problem: antibiotic use in food animals –for treatment, disease prevention or growth promotion – allows resistant bacteria and resistance genes to spread from food animals to humans through the food-chain.

This publication explores the options for prevention and containment of antibiotic resistance in the food-chain through national coordination and international cooperation, including the regulation and reduction of antibiotic use in food animals, training and capacity building, surveillance of resistance trends and antibiotic usage, promotion of knowledge and research, and advocacy and communication to raise awareness of the issues.

This publication is primarily intended for policy-makers and authorities working in the public health, agriculture, food production and veterinary sectors, and offers them ways to take a holistic, intersectoral, multifaceted approach to this growing problem.

WHO EUROPEAN ACTION PLAN FOR FOOD AND NUTRITIONPOLICY 2007-2012

WHO RegiOnal Office fOR euROpe

fOOd safety pROgRammeRegional adviser: Hilde KruseVia francesco crispi 10i-00187 Rome, italytel +39 06 4877 525fax +39 06 4877 599Website: http://www.euro.who.int/foodsafetye-mail: foodsafety@ecr.euro.who.int

the food safety component of the second action plan addresses universal concepts with a focus on imple-mentation of tailored priority actions tackling specific country needs. Within the plan’s six priority areas, food safety support to member states includes a wide range of actions.

1) Supporting a healthy start: care for mothers and children is connected with the use of powdered infant formula (pif) and includes the wide dissemination of the WHO guidelines on safe preparation, storage and handling of pif. prevention of foodborne disease during pregnancy is also critical for the health of the newborn.

2) Ensuring safe, healthy and sustainable food supply: good and safe food, and in adequate quantities for all is supported by the promotion of holistic and intersectoral food safety systems from farm-to-fork with a risk analysis approach; the promotion of hygienic practices throughout the food chain and of Haz-ard analysis and critical control point (Haccp) systems in the food industry; training on Haccp and risk analysis; and assistance in outbreak situations.

3) Providing comprehensive information and education to consumers: know what you eat and how to reduce the risks is undertaken through the dissemination of comprehensive information and education to consumers, such as the WHO five Keys to safer food.

4) Performing integrated actions to address related determinants: don’t forget other risk factors is about ensuring the use of safe water throughout the food chain and reducing the environmental contamination of food by preventing the pollution of air, water and soil.

5) Strengthening nutrition and food safety in the health sector: engage the health professionals, improve the services is related to achieving increased support by health professionals in promoting hygiene throughout the food chain and in ensuring safe food in health facilities.

6) Monitoring, evaluation and research: act on evidence, acquire new knowledge is carried out through training activities to support countries’ efforts. most relevant subjects include surveillance of foodborne disease such as salmonella (e.g. through the global salm-surv network), monitoring systems for micro-biological and chemical hazards in the food chain, total diet studies, antimicrobial resistance, assistance in outbreak situations and evaluation of countries’ food safety systems.

REducingthE buRdEnof foodboRnE diSEaSE

ensuRing fOOd safety tHROugH tHe implementatiOn Of tHe secOnd WHO euROpean actiOn plan fOR fOOd and nutRitiOn pOlicy 2007-2012

the international food Safety authorities network (infoSan) and the international health Regulations (ihR)

infOsan is a global network of national food safety authorities set up to prevent diseases caused by the international spread of contaminated food. infOsan assists member states in dealing with international food safety emergencies due to natural, accidental and intentional contami-nation.

food contamination and foodborne disease events are also part of the scope of the revised international Health Regulations (iHR), an interna-tional instrument legally binding on countries which entered into force on 15 June 2007. certain food safety events require action under the legal provisions included in the iHR.

the national iHR focal points and the infOsan emergency contact points have critical roles in the identification, assessment and management of food safety-related public health events that may have international implications. it is therefore critical that the two parties work in close collaboration.

the requirements of the iHR state that communication between countries and WHO must occur through the national iHR focal points and the WHO iHR contact points. However this does not preclude technical discussions between country food safety officials and WHO’s programme on food safety, including infOsan with regard to food safety events. there will be some food safety events which may not require notification or reporting under iHR, but call for action under infOsan.

the infOsan users guide outlines the criteria used to determine if action is required by infOsan.

Detailed information can be found at http://www.who.int/foodsafety/fs_management/infosan_archives/en/index.html

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Nutrition

Excessive sugar, salt and fat intake, low fruit and vegetable intake and the obesity that results all contribute to a large proportion of noncommunicable diseases, including cardiovascular diseases, cancer and diabetes. These factors not only shorten life expectancy, but also harm the quality of life. No country in the European Region is exempt from the serious consequences of poor nutrition, but lower socio-economic groups are the hardest hit. While developing nations already prioritize access to food, to protect vulnerable populations, governments must also ensure nutrition security.

Challenges Almost 60% of the disease burden in Europe is caused by the seven leading risk factors including high blood cholesterol, low fruit and vegetable intake, overweight and physical inactivity.

Healthy nutrition can help reduce this burden. However, across the Region, the growing intake of foods rich in salt, added sugars and saturated and trans fatty acids leads to unbalanced diets with a high energy density. In some situations, micronutrient deficiencies and moderate malnutrition can threaten child health.

Obesity is already responsible for up to 8% of health costs and up to 13% of deaths in some parts of the Region; and current trends suggest that average levels of body mass index will continue to increase in almost all countries. Adults are not only becoming heavier, but they are passing the problem on to the next generation: children with two obese parents are more than six times as likely to become obese than children with non-obese parents. It is estimated that in some countries of the WHO European Region one in four school-age children is currently overweight or obese. By 2020, at least a third of girls and a fifth of boys will be classified as obese.

Obesity- and overweight-related diseases are more common in poorer countries and populations. People with lower incomes tend to consume more fat, meat and sugar, while those with higher incomes consume more fruit and vegetables.

People with high levels of physical activity are more likely to maintain a healthy weight and are less prone to chronic diseases. Each year, about 1 million people in the WHO European Region die due to the consequences of physical inactivity.

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Overweight is one of the biggest public health challenges of the 21st century: all countries are affected to different extents, but particularly in lower socio-economic groups. The prevalence is increasing and the incidence is also growing or stabilized in some countries (where we have seen comprehensive approaches in place) among children with a double burden of overweight and malnutrition.

Zsuzsanna Jakab, Who regional director for europe

What the WHO Regional Office for Europe is doing

In recent years, over 90% of countries in the European Region have developed national policies in the field of nutrition, obesity and physical activity with a focus on the burden of disease attributable to non-communicable diseases. To be effective, these policies should provide opportunities for greater physical activity and improve the availability and accessibility of healthy foods. They should also encourage the involvement of different government sectors, civil society, the private sector and other stakeholders.

The WHO Regional Office for Europe coordinates international work to implement the actions contained in the European Charter on counteracting obesity, which resulted from the WHO European Ministerial Conference on Counteracting Obesity (Istanbul, 15–17 November 2006), and in the WHO European Action Plan for Food and Nutrition Policy 2007–2012.

WHO supports individual countries in the development, implementation and evaluation of National Action Plans on Nutrition and Physical Activity, paying particular attention to the link between nutrition and inequalities, the role of local governments and primary care, and the identification and promotion of healthy eating and physical activity in different settings.

As part of its support, WHO works with countries and stakeholders to especially reduce sodium intake and improve information dissemination to consumers. It also facilitates countries’ actions to conduct nutritional status evaluations with a specific focus on childhood obesity and the reduction of marketing pressure on children to consume energy-dense, nutrient-poor foods that are high in fat, sugar and salt.

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Progress in the Region europe is diverse and countries are at different stages in responding to the challenge of malnutrition and physical inactivity. evidence from best practice indicates that progress has been achieved through prevention programmes and projects directed at engaging health systems to involve intersectoral and broad societal developments.

one of the region-wide achievements so far has been implementation of the childhood obesity Surveillance initiative. this was launched by Who/europe following approval of the european charter to counteract obesity in 2006 and of the Who european action plan for Food and Nutrition policy 2007–2012, and has already involved more than 50 000 children aged 6-9 years.

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>>What additional progress can we achieve? implementation of the nutrition programme relies on the availability of voluntary resources made available to Who. the Joint Who/european commission project on monitoring progress on improving nutrition and physical activity and preventing obesity is contributing an important proportion of the overall funds of the programme.

More resources would allow Who/europe to fulfill its aims regarding nutrition for the future, including to:

> support countries in scaling up nutrition, obesity and physical activity in their policies for health and other sectors;

> focus on inequalities related with nutrition and physical activity following the establishment of the inequalities and Nutrition action Network;

> assist countries and developing projects in new suggested areas like workplace, municipalities, health sector especially in primary care and finally hiv/tb;

> improve and fine-tune the Who european database on nutrition, obesity and physical activity (Nopa), a joint project with the european commission aiming to develop an integrated web-based database on data, policies and projects;

> develop specific projects on climate change and nutrition in some countries with a focus on children.

FOcuS cOuntrieS: the nutrition, physical activity and obesity programme mainly works at inter-country level, with a focus on the development and implementation of national plans in countries including namely Montenegro, croatia, tajikistan, uzbekistan, Malta, albania, the former yugoslav republic of Macedonia, turkey, and most of the european union Member States. New activities focused on the links between nutrition and other areas like climate change, communicable diseases, primary care, hospitals and inequalities are being developed together with Member States.

· WHO European Action Plan for Food and Nutrition Policy 2007–2012 http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/food-safety/publications/pre-2009/who-european-action-plan-for-food-and-nutrition-policy-20072012-2007

· European Charter to Counteract Obesity 2006 http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/nutrition/publications/pre-2009/european-charter-on-counteracting-obesity-2006

· Nutrition, physical activity and obesity database (NOPA) (under development)

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WHO EUROPEAN ACTION PLAN FOR FOOD AND NUTRITIONPOLICY 2007-2012

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WHO’s European activities in food safety and nutrition are built upon respective global strategies and frameworks, tailored to the specific needs of countries in the Region and in line with the European Food and Nutrition Policy Action Plan. This Plan aims to foster the implementation of comprehensive and intersectoral national plans. Codex Alimentarius food standards, guidelines and related texts provide key references.

In the food safety area specifically, WHO/Europe implements the WHO global strategy for food safety and the Advancing food safety initiatives resolution approved by the World Health Assembly in May 2010.

The policy guidance on antibiotic resistance in relation to food safety is based on the WHO Global Principles for the Containment of Antimicrobial Resistance in Animals Intended for Food.

The core of the European work on nutrition integrates the priorities of the resolution on infant and young child nutrition approved by the World Health Assembly in May 2010; the 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases; and the Global Strategy on Diet, Physical Activity and Health.

Global initiatives and strategic partnerships

WHO global strategic approach tailored to countries’ needs

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Collaboration with stakeholders is at the heart of WHO’s work. The ultimate aim of partnerships is to add value and maximize support to countries, at regional and country level.

Both programmes have long-standing collaborative links with institutions such as the European Commission, The European Food Safety Authority (EFSA), the European Centres for Disease Control and Prevention (ECDC), the Food and Agricultural Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), the World Bank and NGOs. WHO/Europe continues to explore opportunities for new strategic partnerships, based on shared health values and objectives.

Partnerships for safe and nutritious food

To date, key partnerships include: European Commission http://ec.europa.eu/index_en.htm

European Food Safety Authority (EFSA) http://www.efsa.europa.eu

European Centres for Disease Control and Prevention (ECDC) http://www.ecdc.europa.eu

Food and Agricultural Organization http://www.fao.org/

World Organisation for Animal Health (OIE)http://www.oie.int

World Bank http://www.worldbank.org/

Contact information

Food safetyhilde Krusephone +39 06 4877 525e-mail: foodsafety@ecr.euro.who.int

Nutrition, physical activity and obesityJoao bredaphone + 45 3917 1226e-mail: nutrition@euro.who.int

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World Health Organization Regional Office for Europe

Scherfigsvej 8DK-2100 Copenhagen Ø

DenmarkTel.: +45 39 17 17 17Fax: +45 39 17 18 18

Email: contact@euro.who.intWeb site: www.euro.who.int

WHO’s Strategic objectives

With a specific focus on inequalities, social determinants of health and health in all policies, 2020 provides a european platform for achieving the 11 Strategic objectives which frame the work of Who in the european region.

briefings are available in each of the Strategic objective areas:

1. reduce the health, social and economic burden of communicable diseases.

2. combat hiv/aidS, tuberculosis and malaria.

3. prevent and reduce disease, disability and premature death from chronic noncommunicable diseases, mental disorders, violence and injuries and visual impairment.

4. reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence, and improve sexual and reproductive health and promote active and healthy ageing for all individuals.

5. reduce the health consequences of emergencies, disasters, crises and conflicts, and minimize their social and economic impact.

6. promote health and development, and prevent or reduce risk factors for health conditions associated with use of tobacco, alcohol, drugs and other psychoactive substances, unhealthy diets, physical inactivity and unsafe sex.

7. address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches.

8. promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health.

9. improve nutrition, food safety and food security throughout the life-course and in support of public health and sustainable development.

10. improve health services through better governance, financing, staffing and management, informed by reliable and accessible evidence and research.

11. ensure improved access, quality and use of medical products and technologies.

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