Refocus public investment on the early years

Most countries spend a greater proportion of public money on older citizens; spending on children tends to focus on children after entry into compulsory education (24,25). Providing universal, comprehensive ECEC services requires investing more resources on the period from conception to school entry (12). This can enhance equity in access to resources, thus reducing health inequities (22). Substantial government investment in this area is needed to secure access to high-quality services for all so that those with a greater need for ECEC services (usually poorer citizens) do not have worse access to services. This can be supported through subsidies to parents (who then purchase provision) or through direct public provision. Without this, the intergenerational transmission of adverse health risks may continue or worsen. At the 2002 European Council in Barcelona, European Union (EU) Member States agreed to ensure provision of full-day formal child care by 2010 for at least 90% of children from age 3 years to compulsory school age and for at least 33% of children under age 3 years (26). However, implementation has been slow, with most countries failing to achieve this target. Whether based on public or private models, transparent mechanisms are needed to ensure equity in provision. Evidence suggests that direct public funding of services brings more effective governmental steering of early years services, with advantages of scale, better national quality, more effective training for educators and more equity in access compared with parent subsidy models (25).

Ensure access to ECEC is proportionate to need

Governments should commit proportionately more resources to groups of children at higher risk of adverse health and development during early childhood. High risk factors are low parental education levels, low income, poverty, parental absence, young mothers, large families, parental mental illness, parental drug and alcohol dependence, social isolation and older siblings with health and development problems (22). It is also important to ensure equitable access to support through high-quality provision in areas with more children in need (Case study 1). Special efforts are needed to include children most at risk of experiencing multiple exclusion processes, particularly those with disabilities, migrants and minority ethnic groups such as Roma (27).

Improve training and working conditions for child care professionals

Strengthening the quality of ECEC is also important for health and requires well-trained staff with sound employment and working conditions. This includes remuneration sufficient to ensure that the best people are attracted and maintained where they are needed most. It also includes regular access to effective training and professional development opportunities to strengthen the skills of ECEC workers (Case study 2) (24,28,119).

In populations with a mixture of public and private ECEC providers, training and professional development for staff varies, with some providers unable to provide regular training or opportunities for improving practice. Action is needed to recruit, retain and strengthen the skills of ECEC staff by ensuring careers are satisfying, well-respected and adequately paid (24). ECEC provision accessed by families with greater needs should be staffed by more highly qualified professionals.

Standards and curricula for ECEC should focus on the holistic developmental needs of children, encompassing emotional development and the development of creativity, self-determination and well-being, alongside classic forms of education such as literacy and numeracy. A growing body of research highlights the importance of “play”: some OECD nations consider this a separate activity, while others include it as a cross-cutting theme (28).

Engage families and communities in ECEC provision

Setting curricula and standards for ECEC should involve children, families and staff to strengthen the democratization of ECEC approaches (24). Enabling local communities to adapt curricula can increase the relevance of ECEC to those communities (28) and might enhance access by improving uptake of the services.

In many countries, ECEC is a shared responsibility between national and local government. A positive consequence of such decentralization has been the integration of ECEC services at local level, along with greater sensitivity to local needs. However, decentralization can also raise challenges: OECD reviews suggests that devolving power and responsibilities may widen differences in access and quality between regions (25). In the devolution process, it is important to ensure that early childhood services form part of a well-conceptualized national policy with a national approach to goal setting, legislation, regulation, financing, staffing criteria and programme standards.

Target ECEC and home visiting programmes

To be effective, ECEC needs to be targeted within the overall framework of a universal system (22). For children requiring stronger early environmental enhancements, targeted, high-quality, intensive early childhood education, parenting support and home visiting programmes should be considered (Case study 3). The most successful programmes place a strong focus on cognitive outcomes, which are more malleable earlier in life. More information on the importance of these approaches for SROI is provided in the linked report on investment for health and well-being (12). Such programmes provide disadvantaged children with an enriched out-of-family environment while also working to raise the quality of the home environment (22). Home visiting improves service uptake by reducing the cost of family travel and allows a trained visitor to assess the home environment and refer to other services. Home visiting programmes can also support parenting skills and reduce the incidence of low birth weight, which correlates strongly with lower cognitive ability (24).

Develop integrated multiservice delivery models for ECEC

Models that integrate support for children across health care, education and social care are becoming more common (20). These services extend beyond the provision of ECEC by taking a cooperative approach with health, education and social care to coordinate support across the full range of children's needs (30). These models offer integrated multidisciplinary services within easy reach of parents and families, usually at community centres or similar settings (Case studies 4 and 5).

Provide income protection, adequate benefits and progressive taxation for families with children

Actions to redistribute income are particularly amenable to multisectoral approaches, with strong crossover between actions to reduce the effects of child poverty, to improve social protection (section 2.3) and to integrate people into the workforce (section 2.2.2). Without effective multisectoral action in these areas, attempts to tackle the negative effects of child poverty will be less effective, with more crossover and waste. The most effective actions (i.e. those with the strongest SROI) combine universal support for all children with targeted policies for the most vulnerable (12,34,123). Universal benefits are distributed to all families with children, often depending on family size. The main advantages of these schemes are that they help to create a favourable environment for families with children, are non-discriminatory and are not reduced when parents get a job. They also recognize that raising a child increases the risk of family poverty.

Targeted benefits support the most vulnerable families (e.g. low income, lone parent, large families and those with disabled children.). Their purpose is to provide income to those most in need, but they can create disincentives for families to take up work or increase their engagement with employment. The effects of narrow targeting of social protection should also be considered to avoid excluding those with high, but not the highest, levels of need.

Providing cash benefits rather than tax concessions tends, on the one hand, to redistribute more income to the poorest children. On the other hand, tax concessions tend to create less distortion in terms of work incentives, with better uptake (35). A range of social protection benefits should be set up to provide adequate income support to households with children, taking into consideration the different costs associated across the age range. These should comprise tax relief or credit, family and child benefits, housing benefits and minimum income schemes aimed at supporting children to live dignified lives (27).

Maximize uptake of benefits

High uptake of targeted benefits should be ensured by facilitating access and outreach to beneficiaries according to level of need. Steps are necessary to avoid stigmatization in benefit delivery and to ensure that benefits are sufficient to address children's needs while minimizing the risk of unintended work disincentives due to reduced total income when taking up work (see section 2.3.4) (27).

Reduce the negative impacts of welfare conditionality

Action should be taken to assess and prevent the negative impacts of conditionality measures and financial sanctions on children. For example, financial sanctions linked to parents’ activation into work and parenting behaviour (such as children's school attendance) may negatively impact children through the loss of household income, thereby increasing their risk of poverty (see section 2.3.4) (27).

Provide cash benefits directly to mothers

There is evidence that payment of a child benefit directly to mothers means that a greater amount will be invested in children. The alternative of salary tax reduction has been shown to be less effective, with less of the benefit spent directly on children (22).

Design integrated policies to help to ease parental transition into employment

Tax, benefits and minimum wage policies should aim to ensure that work provides an adequate income and does not force parents into inadequately paid, insecure or unhealthy employment (124). Redesigning benefits is necessary to ensure that those starting work see genuine increases in take-home pay (27). Measures to keep long-term unemployed parents close to the labour market are useful and may include, for example, supporting participation in voluntary, supported employment or non-commercial (e.g. social economy) activities. Policy-makers can also provide enhanced support for labour market reintegration after parental leave through targeted training measures and job search support, with a specific focus on groups with a higher risk of poverty (e.g. single parents, large families, long-term unemployed). Supporting entrepreneurial skills and self-employment can also be useful (27).

Strengthen family-friendly employment policies

Measures are needed to support parental access to quality employment while maintaining an adequate degree of flexibility (but without turning to insecure contracts) (10,27). These could encompass promoting work patterns and environments that enable all workers to balance work with parenting, including workplace support and flexible working arrangements (27). Measures to further promote gender equity in the labour market and in family responsibility, as well as active fatherhood, include guaranteeing paid parental leave of least six months (31) and supporting the participation of second earners (as well as single parents) in paid work (27). Ensuring access to affordable high-quality child care is an essential component of such policies (see section 2.1.1).

Promote gender equality in employment and education

The position of women in society is associated with the health and survival of children. The interaction of gender inequities with socioeconomic inequities has adverse consequences for children (36). Therefore, improving employment and educational opportunities for women, particularly those from marginalized and excluded groups, has been highlighted in many international policy frameworks as a key factor in breaking the cycle between child poverty and adverse child outcomes, and has positive economic effects, including SROI (12,37,38). The evidence suggests that of all education levels, secondary education has the greatest impact on women's empowerment (39). The education and training of women was also highlighted as an area of concern in the Beijing platform for action (40).

Addressing inequities in workforce participation for women is one of the most effective ways to increase economic growth and improve broader living standards (41). Since most single parent families are led by women, actions to promote women's economic empowerment can help to lift single parents out of poverty and reduce child poverty (42). Although in many European countries there are limited gender inequities in school participation and attainment (43), national averages on girls’ participation and attainment mask the continuing disadvantage of excluded groups (10). For example, there is high gender inequity in educational attainment related to socioeconomic and immigrant status in Europe (10). Gender inequities also arise in the transition from school to work (43). Conditional or unconditional social cash transfers and tuition stipends to women can increase school attendance for girls with low levels of education (44,45). Actions that encourage girls to choose science, technology, engineering and mathematics (fields of study that are underrepresented by women in many countries (46)) and support women in the transition from education into employment can enhance their future employment prospects. Legislation also needs to be in place and enforced to support gender equity in employment.

Support investment in human capital and improvements in infrastructure in disadvantaged areas

The World Economic Forum recommends that countries set investment targets for key areas of human capital formation to promote inclusive growth, including public and private investment in ALMPs, equitable education and gender equality (41). Creating and maintaining infrastructure (public services, transport) is an important investment to support inclusive growth, especially in disadvantaged areas (53). Better-designed and greener energy infrastructure can help to combat energy poverty (12,53) while strengthening sustainable development. Strengthening the monitoring frameworks, regulations and incentive structures in this area is necessary to attract and create such investments. This can be achieved, for example, by developing policies to support access to finance for small and medium-sized enterprises, including through the use of development banks, microfinance and other financial intermediaries (54,126).

Social impact bonds can also be effective in incentivizing private investment for social programmes by offering public sector financial returns if programmes achieve positive social outcomes (54). Public procurement can also be used to improve social, economic and environmental well-being in disadvantaged areas with high unemployment by reserving a percentage of public sector contracts for small to medium-sized enterprises from these areas, ensuring contractors employ people from disadvantaged groups and including working condition standards in tender specifications (55). The public procurement regimen of the EU includes social considerations in procurement, such as compliance with labour standards and “the social integration of disadvantaged persons or members of vulnerable groups among the persons assigned to perform the contract” (56). All public investment policies should ensure that they comply with the United Nations Guiding Principles on Business and Human Rights (57) and core labour standards of the ILO (58).

Create decent health and social sector jobs in disadvantaged areas

The creation and development of decent health and social sector jobs with adequate wages and working conditions (see section 2.2.3), particularly for people from disadvantaged, lower-educated backgrounds, can help to strengthen the health and social care sectors while simultaneously reducing economic and subsequent health inequities, strengthening health in more deprived groups and strengthening the economic infrastructure required for economic opportunity and growth (41). This action requires scaling up the provision of training, skills and education to match health needs; developing women's participation in leadership roles throughout the health and social care sector; and tackling gender concerns in educational training and reform processes (50).

Optimize the health and health inequity impacts of economic strategies

Various forms of impact assessment tools are used in many countries to review how policies across sectors affect health and health inequities (both positively and negatively) and identify areas for improvement (i.e. to optimize positive impacts). These assessments can be carried out quickly to provide feedback within the time constraints of policy-makers or more intensively for larger issues (5,7).

Provide high-quality counselling, case management and job search assistance

Counselling and job search assistance are most effective for the short-term unemployed, particularly as part of high-quality individualized advice packages and combined with a range of potential interventions, including vocational training, job search assistance, social support and courses on motivation (61,62). The OECD found that monitoring and verifying the job search activity of jobseekers can considerably improve re-employment rates (62). Strong public employment services are important in offering vacancy databases and, increasingly, digital services to connect jobseekers with employers. Those aligned with employers’ skill needs are most effective. ALMPs that spend a greater share of funding on public employment services are more effective at reducing unemployment, particularly for low-skilled workers (59). Job search assistance may, however, have limited impact in areas where structural unemployment is high and there is a lack of demand for labour, especially when used in isolation. There are also some questions about the coverage and effectiveness of these services in countries with a high number of informal labour market transactions (63).

Provide subsidies for employers hiring the long-term unemployed

The payment of hiring subsidies to employers can positively impact future employment outcomes if targeted at disadvantaged groups for whom other measures have proved ineffective (62), They can motivate employers to hire people during economic downturns and in the short term, but they may be ineffective in times of economic growth. However, subsidies can have unintended effects if applied incorrectly. For example, programmes that allow employers to choose candidates without explicit criteria can become ineffective and those targeted at large groups of long-term unemployed people may increase overall unemployment as employers reduce hiring among the short-term unemployed. Subsidy programmes should also lead to sustainable quality employment so that the health benefits are maintained.

Provide high-quality training for the most disadvantaged

Evidence indicates that participation in training programmes has a long-term positive impact on employment and earnings (Case study 6) (62). Studies show that both general training and education and specific skills training are effective, with some evidence for greater effects in groups with lower education levels (61,62). Training programmes demonstrate a positive effect on long-term unemployment, even during periods of economic recession when unemployment rates are high, through a bridging effect (i.e. improving the human capital of participants until they gain re-employment). This effect depends, however, on re-establishing long-term job prospects (62). Evidence from the United States indicates that programmes prioritizing job search and including training activities (i.e. mixed programmes) are more effective in the short term than those prioritizing educational activities alone, although long-term effects are similar. To address inequities, the standard programme should be enhanced by a more generous education and training offer for disadvantaged groups (people out of work, at risk of job loss or in informal employment). The most disadvantaged youth may require more intensive programmes with a strong focus on education, work experience and adult mentoring (47). Vocational training for informal workers may be effective in supporting them into the formal economy (64).

Develop high-quality education and training programmes for young people

Vocational education and training programmes for young people should respond to labour market skill deficits by training participants to a level that allows them to secure gainful employment in an area of skills shortage. Approaches combining work-based training and classroom learning are effective in delivering such skills if they provide a good learning experience and a gateway to a good-quality job (Case study 7) (65). Workplace-based programmes, in particular, should actively involve social partners such as labour unions (47) and ensure that young people are not exploited, but instead gain the skills needed for continued employment (12,66).

Support the transition from school to work

Improving education so that all young people gain the transferable skills needed for employment can improve the transition from school to work, thus preventing unemployment and supporting the economy. A combination of career guidance, information about labour market opportunities and good-quality work experience opportunities can support young people to make effective career choices. The school-to-work transition can also be improved by developing high-quality career pathways (41,47,54).

Although many countries in the WHO European Region have limited gender inequality in school participation and attainment, inequalities often arise during the transition from school to work (43). It is, therefore, particularly important that young women receive additional support for this transition, including high-quality career counselling, adult education, internships, apprenticeships and targeted financial support (46).

Develop targeted public works programmes

Public works programmes such as direct employment and job creation schemes are typically targeted at medium- and longer-term unemployed people (61) and can be used to enhance income security and employability (67). They consist of regular direct payments by government or nongovernmental organizations to individuals in exchange for work. In Europe, programmes in Latvia and Greece (129) were initiated in response to the post-2008 financial crises to reduce unemployment, build skills in the workforce and carry out works of social value. Such programmes can support targets across the range of SDGs, for example by temporarily reducing income inequality while supporting environmental sustainability through public works in the green economy. However, drawbacks of public works programmes are that they can be expensive and may not result in long-term job stability because the number of people employed in these programmes is often greater than the market demand for labour (67).

Provide small business support in disadvantaged communities

Programmes supporting the start-up of small businesses (including microfinance initiatives) are effective in reducing unemployment (59,68), although their impacts may be greater for older and better-educated workers (63). Policies such as special taxation gradients for unregistered small and home-based firms should be developed to reduce the size and associated dis-benefits of the informal economy (65).

Support people with chronic illness and disabilities through workplace adjustments and vocational rehabilitation

People with chronic illness and disabilities are more vulnerable to being out of work, with an average disability employment gap across Europe of about 20% (130). Disadvantaged groups are more likely to develop chronic illness and disability, which may cause them to leave the labour market. This increases their risk of poverty and further exacerbates health inequities. Addressing the employment consequences of disability is, therefore, important for tackling health inequities.

Multiple different approaches can be taken to improve employment for disabled workers (69). Many countries have passed legislation to prohibit discrimination against people with disabilities, including those in employment; however, there is little evidence that these laws have improved their employment chances. In contrast, there is evidence that workplace accommodations can improve employment chances for disabled people (131).

Appropriate vocational rehabilitation measures are needed for all categories of people with chronic illness and disabilities, and employment opportunities for disabled people should be promoted (70). Early intervention is likely to be more effective, so support needs to be available as early as possible. A case management approach addressing underlying health problems is likely to be most effective, especially for the most disadvantaged groups in which individuals and families need assistance in several aspects of life (Case study 8). This should coordinate support from employers, health specialists, psychologists, social insurance case workers and other professionals (62). Combining vocational rehabilitation with wage subsidies may also be effective.

Extend representation to more disadvantaged workers

Freedom of association and effective recognition of the right to collective bargaining are fundamental rights outlined in ILO labour standards (73). Increased collective bargaining is associated with reduced incidence of low pay, reduced pay inequalities and improved working conditions (68,747). Promoting the representation of workers at senior corporate level may also help to reduce pay inequalities and improve working conditions (75). Support is needed to create informal workers’ organizations based on relevant shared features such as occupation (e.g. domestic workers, taxi drivers), workplace location (e.g. farmers’ markets, streets) and conditions (e.g. being a migrant worker). These organizations, like labour unions, can strengthen and make politically visible the interests and needs of informal workers (65).

Ensure adequate health and safety legislation

Enacting, maintaining and enforcing adequate health and safety legislation is important for improving working conditions and health (9). The ILO Constitution specifically provides for “the protection of the worker against sickness, disease and injury arising out of his employment” (76). The convention concerning the promotional framework for occupational safety and health (77) requires that countries establish, maintain, progressively develop and periodically review a national system for occupational safety and health, in consultation with the most representative organizations of employers and workers. Occupational health practitioners have an essential role in implementing and strengthening health and safety approaches.

The right of all workers to working conditions that respect their health, safety and dignity is proscribed within the Charter of Fundamental Rights of the EU (78), and EU guidelines for the employment policies of Member States call for quality employment to be ensured in terms of working conditions, including health and safety (79). However, their application varies significantly between EU Member States, leading to variations in workers’ health protection (80).

The existence of increasing numbers of temporary workers, atypical contracts and self-employed workers in the Region raises concerns about the coverage and effectiveness of health and safety provisions (80). To address these concerns, policy-makers could extend coverage to all workers, including those in informal employment, and widen the provision of basic occupational health services to prevent work-related diseases and injuries, especially for more disadvantaged workers.

Enforcement of health and safety standards through independent labour inspectors could be enhanced by, for example, evaluating the performance of national labour inspectorates. Compliance can be improved by strengthening workers’ awareness of required health and safety information and involving workers in compliance monitoring (81). Practical support must be provided to small and medium-sized businesses to support better compliance with health and safety rules without damaging their economic activities. Businesses can benefit from technical assistance and practical tools, such as the Online Interactive Risk Assessment, which is a web-based platform providing risk assessment tools (132).

Promote gender pay equity

Although most European nations now have legislation supporting equal pay and against gender-based discrimination, further actions can be taken to strengthen implementation (82). Some EU Member States have legislation in place for mandatory reporting of gender pay equity plans for companies above a certain size. Others may benefit from introducing similar policies or from strengthening or extending these policies to cover more of the workforce, especially those most in need (82,96).

Extend employment rights

Several ILO conventions contribute to workers’ employment rights. For example, the ILO Termination of Employment Convention, ratified by 10 EU Member States, protects workers’ rights against the termination of employment (83). It guarantees that employment will not be terminated for reasons of discrimination on a range of grounds and provides that workers receive a period of notice, right of appeal and income security, as well as a valid reason and motivation for dismissal. A right to be protected in the event of unjustified dismissal is also enshrined in the EU Charter of Fundamental Rights (Article 30) (84). In particular, self-employed, temporary, part-time and informal workers tend to have weaker statutory benefits and protections in many countries, which may lead to worsening socioeconomic inequities as these forms of work become more common in Europe (85), thus widening health inequities.

Countries can develop legislation to ensure equality of treatment for these non-standard workers by supporting equal treatment by courts and adjudicating bodies, including rights to parental leave, paid annual leave, child care and flexible working hours. Countries should consider the possibility of defining in law the existence of an employment relationship to support the application of employment rights to informal workers (56). Countries can additionally restrict the use of non-standard employment by prohibiting the use of fixed-term contracts for permanent needs, limiting the use of temporary agency work and restricting or prohibiting the use of on-call employment (also known as zero-hours contracts). These measures will particularly benefit women and young people, who are more likely to work in temporary, part-time or informal settings (46,67).

Improve psychosocial working conditions

Addressing psychosocial risks in the workplace can reduce stress-induced physical and mental illnesses such as heart disease, anxiety, depression and musculoskeletal disorders (86). Work–environment differences among workers from different social strata, such as workload, task design, organizational culture, role, level of decision control, in-work relationships and work–life balance, contribute to social gradients in work-related psychological risks (133,134).

The ILO recommends that workplace stress should be treated as an occupational risk and mitigated by implementing risk assessment and management measures, adopting collective and individual preventive and control measures, increasing the coping ability of workers, improving organizational communication, increasing worker participation in decision-making, providing workplace social support systems and strengthening health and safety (87,134).

Establish a minimum living wage

A statutory minimum wage is common globally: most countries in the Region have minimum wage laws, including nations in the Commonwealth of Independent States. The health and health equity benefits of a living wage produce a positive SROI and are mediated through effects such as better mental health and reduced mortality (12).

The ILO recommends that setting a minimum wage should be carefully considered, especially for low- and middle-income countries. The process should be evidence informed and heedful of concerns that statutory minimum wages may reduce employment opportunities. For high-income countries, the evidence suggests that negative effects of minimum wages are minor; for lower-income countries, the evidence is unclear. This evidence gap highlights the importance of monitoring the effects of new policies in this area (88). The overall aim should be to ensure that the minimum wage is sufficient to provide workers with a minimum standard for healthy living based on the current cost of living: minimum wage policies will become less effective if wages are too low to maintain a healthy standard of living or if policies are circumvented (9). Minimum wage legislation can be strengthened by increasing wages in line with inflation, as attempted through indexing in the Russian Federation (88,135). Minimum wage policies should also complement social protection policies (section 2.3) to reduce poverty both in and out of work.

Ensure legal security of tenure for all

Legal frameworks for guaranteeing rights for tenants and protecting against forced evictions that are contrary to the law need to be in place, including for disadvantaged groups such as migrants (101). These frameworks can also include legal minimum periods for rental contracts to enable tenants to have fixed long-term, stable tenancies (102).

Ensure minimum housing standards

Minimum housing standards can be established and enforced to ensure that newly built dwellings are safe, healthy and hazard free (12,103). For existing housing, there should be national and local policies and programmes with defined, prioritized target areas where the worst housing conditions are likely to occur. Although the owner of the dwelling should pay for maintenance and improvement of that dwelling, there is good justification for some form of state subsidy to protect residents when the owner cannot afford the cost of works. There is a risk that minimum housing could become the norm, discouraging further improvements in housing standards. To overcome this, landlords of large housing stock could be required to adopt an improvement scheme for upgrading conditions annually or biannually (104).

Upgrade homes in poorer areas

Existing housing in disadvantaged areas can be improved to ensure access to safe water and sanitation (105), greater energy and water efficiency and improved ventilation and indoor air quality (Case study 13) (106). These changes can bring multiple benefits including reducing the direct health risks of poor housing, increasing disposable income, reducing fuel poverty and mitigating climate change. Local authorities should be equipped with a clear mandate to improve existing housing by including a minimum set of services for households living in private housing stock (107).

Increase the supply of affordable housing

The supply of affordable housing can be expanded through provision of public housing, regulatory measures and market incentives (101). The combination of approaches depends on a careful assessment of local housing markets because policies can have unintended effects on the housing supply. As well as directly providing affordable housing, governments can support community-based, cooperative and non-profit-making rental and owner-occupied housing programmes. Regulations that control rental prices can increase the affordable housing stock in the event of rental market imbalances (102). Such rent controls exist in many European countries including Austria, Germany and Sweden. There is, however, a risk that setting rent controls too low may reduce the supply of rental accommodation as landlords reduce the number of properties they rent when renting becomes less profitable.

Effective sustainable urban planning can support an adequate mixture of housing to ensure sufficient affordable provision (101). This should be a participatory process that integrates sustainable housing with economic, social, recreational and other land uses. Subdivision regulations can encourage mixed land uses, including affordable housing provision, mixing populations of different social and income levels and upgrading infrastructure to meet new housing needs (108).

Increase the affordability of housing

Affordable housing can be ensured by providing subsidies and expanding access to credit. Many EU countries provide direct subsidies for housing costs to people on low incomes. Effective schemes for people living in difficult housing conditions cover running charges and energy costs, especially during winter (102). To extend more credit to people living in poverty, governments can encourage communities to form housing and community development cooperatives by strengthening legal and regulatory frameworks and the institutional basis for credit cooperatives, credit unions, cooperative banks and cooperative insurance enterprises. They can support the establishment of local financial institutions by trade unions; farmers’, women's and consumer organizations; and organizations for people with disabilities (101).

Prevent homelessness and support people at risk of homelessness

Well-timed family counselling to prevent early school-leaving can prevent youth homelessness and associated socially stratified health effects. Early interventions are needed to identify groups most at risk of youth homelessness (e.g. those leaving care, people with mental health problems, families in poverty and some minority groups) (102), including tailored job search assistance, housing support and follow-up. Minority groups, such as Roma, benefit from support to avoid or leave homelessness.

Those experiencing homelessness need access to decent emergency accommodation that is locally available and accessible, matches users’ needs, offers information and other services on the spot and involves users in shelter or accommodation management (102).

Optimize the health impact of climate change mitigation and adaptation strategies

Many measure to mitigate climate change have a high potential for health co-benefits, particularly those promoting energy-efficient buildings and renewable energy; access to safe transport modalities that encourages physical activity and social contact; improved outdoor and indoor air quality; and food choices with a lower carbon footprint (12). However, some mitigation measures could have adverse health effects and worsen health inequities. The potential impacts of climate mitigation measures on health and health inequities should be assessed at all levels and in all sectors, and then adapted to maximize the positive and minimize the negative impacts on outcomes (99,109).

Optimize early warning surveillance and emergency preparedness systems

The extent to which an individual's health is affected by extreme weather events and changes in disease distribution caused by climate change will depend on the resilience and ability of local systems to identify and respond to these events by providing support to those affected (99,109). Preventing adverse health and health equity impacts of these events depends on adequate preparedness and community resilience, particularly for more vulnerable populations. Poorer citizens and excluded groups often suffer disproportionately worse health effects during natural disasters (110).

Preparations should include, for example, effective action plans for heat and health, as outlined in WHO Regional Office for Europe guidance (111), and public health emergency preparedness planning in line with the principles and practices outlined in the WHO International Health Regulations (112) and the Sendai Framework for Disaster Risk Reduction (110). Vital actions include establishing standardized risk-monitoring indicators and emergency response programmes, stockpiling and maintaining emergency materials and supplies and establishing emergency operations centres to coordinate responses (112,113).

Implement public awareness programmes on climate change and health

Public awareness programmes on climate change and health should be developed and implemented to encourage healthy, energy-efficient behaviours in all settings and provide information on opportunities for mitigation and adaptation interventions, with a particular focus on vulnerable groups and subregions. Actions could include developing curricula, communication strategies and advocacy campaigns and activities to improve health-related and climate change-related knowledge, as well as training for health and environment professionals on the health effects of climate change and co-benefits and risks of mitigation and adaptation measures (99,109).

Increase health sector contributions to reducing greenhouse gas emissions

In line with the commitments of WHO European Region Member States through the Parma Declaration on Environment and Health (105), the impact of health policies and infrastructure on climate change should be assessed and adapted to maximize the positive and minimize the negative impacts. This should include strengthening health sector leadership in efficient and sustainable management of health sector supplies, utilities and waste, with the aim of stimulating other sectors to do the same. The health sector could also engage in research and innovation to develop mitigation and adaptation measures, sharing best practice (99,109).

Promote integrated urban planning and transport policies

Integrated policies that promote effective, sustainable urban planning and transport provision by encouraging cleaner, more energy-efficient and healthier modes of transport can have multiple benefits for the local environment, climate change and health. Increasing the use of fuel-efficient and clean public transport and active transport (e.g. walking and cycling) will reduce air pollution, reduce greenhouse gas emissions and promote physical activity, with added public health benefit (12,114).

Implement ambient air quality legislation

Countries should seek to implement and enforce air quality legislation, with the aim of moving closer to WHO recommended levels. Reducing air pollution is a well-established and successful policy area for the EU, which has achieved successful reductions in pollutant emissions through enforcing legal limits to emissions and mitigation controls (Case study 14) (115). Investment in air pollution monitoring and compliance is, however, limited in some countries, and measures could be adapted and applied to achieve positive outcomes in non-EU countries.