European Quarterly of the European Observatory on Health Systems and Policies EUROHEALTHon Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS Observatory 20th Anniversary Special Issue
• 20 years of evidence into practice • What's new in health system
› 2018 Observatory reforms • Happy Birthday Observatory |
• Successes and failures of public 20th Anniversary • The role of health systems in the health policy 21st century
Special Issue • Universal coverage and evidence- Number 2
• Evolution of health system performance | based approaches assessment • Reframing the health workforce • EU integration and health policy at
the cross-roads :: Special Issue :: Volume 24 1356 ISSN Still Steve Production: and Design permission. prior without form any in transmitted or system aretrieval in stored reproduced, copied, be may publication this of part No 2018. Policies and Systems Health on Observatory European of behalf on © WHO Medicine. &Tropical Hygiene of School London the and Science Political and Economics of School London Funds), Insurance Health of Union National (French UNCAM Bank, World the Commission, European the Italy, of Region Veneto the and Kingdom United the Switzerland, Sweden, Slovenia, Norway, Ireland, Finland, Belgium, Austria, of Governments the Europe, for Office Regional Organization Health World the between apartnership is Policies and Systems Health on Observatory European The consideration. for authors by submitted or editors the by commissioned independently are Articles sponsors. or partners its of any or Policies and Systems Health on Observatory European the of those necessarily not and alone authors in expressed views The beyond. and Europe in debate aconstructive to contribute so and issues policy health on views their express to policymakers and experts researchers, for Eurohealth at: Available Guidelines Submission Article White: Caroline MANAGER SUBSCRIPTIONS North: Jonathan MANAGER PRODUCTION Still: Steve EDITOR DESIGN B. Richard Mossialos, Elias McKee, Martin Lessof, Suszy Palm, Willy Grand, Le Julian Figueras, Josep Busse, Reinhard Belcher, Paul BOARD ADVISORY EDITORIAL aboutUs/LSEHealth/home.aspx http://www2.lse.ac.uk/LSEHealthAndSocialCare/ 6803 7955 20 +44 F: 6840 7955 20 T: +44 Kingdom United 2AE, WC2A London Street, Houghton Science Political and Economics of School London Health, LSE Mossialos: Elias EDITOR FOUNDING Palm: Willy ADVISOR EDITORIAL 6381 7955 20 +44 McDaid: David Maresso: Anna 6194 7955 20 +44 Merkur: Sherry TEAM EDITORIAL SENIOR http://www.healthobservatory.eu Email: 0936 2525 +32 F: 9240 2524 T: +32 Belgium Brussels, 1060 Horta Victor Place 07C020) (Office Eurostation Policies and Systems Health on Observatory European the of Quarterly EUROHEALTH [email protected] [email protected] is a quarterly publication that provides a forum aforum provides that publication aquarterly is – [email protected] [email protected] 1030 http://tinyurl.com/eurohealth [email protected] [email protected] [email protected] [email protected] / 40 Hortaplein, Victor Eurohealth Saltman, Sarah Thomson Thomson Sarah Saltman, [email protected] are those of the the of those are [email protected]
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CONTENTS EUROHEALTH Quarterly of the European Observatory on Health Systems and Policies and Systems Health on Observatory European the of Quarterly Special 20th Anniversary › Observatory
Issue • • • • •
the EU integration and health policy at assessment Evolution of health system performance 21st The role of health systems in the Happy Observatory Birthday 20 years of evidence into practice
cross-roads
Eur century opean on Healt h Sy stem s andP oli cies Observatory 20th Anniversary Special Issue Special Anniversary 20th Observatory • • • •
Reframing the health workforce based based approaches Universal coverage and evidence- health Successes and failures of public reforms What's new in health system RESEARCH • DEBATE • POLICY • NEWS • POLICY • DEBATE • RESEARCH
policy
:: Special Issue :: Volume 24 | Number 2 | 2018 Philipp Konrad / EyeEm CONTENTS 19 15 12 10 8 45 43 38 34 4 29 28 23 2
EVOLUTION DEVELOPMENTS UNIVERSAL MY HSPM Monitor Eurohealth – CONUNDRUMS and – DECISIONS BASKET BENEFIT IN David FAILURES Wilm WHAT’S Policies and Systems Eurohealth and EU Marina – INSTITUTIONS INTERNATIONAL AND COMPARISONS INTERNATIONAL OF Comments from from Comments REFORM TO LJUBLJANA International Eurohealth PUBLICATIONS AND ACTIVITIES OF OVERVIEW SELECTED FRIENDS AND HA and – LESSONS 10 IN (KEY) 20 Observer Eurohealth INTO EDITORIAL 20 YEARS OF OF YEARS 20 GETTING AND KEEPING PEOPLE HEALTHY: REFLECTING ON THE SUCCESSES AND AND SUCCESSES THE ON REFLECTING HEALTHY: PEOPLE KEEPING AND GETTING THE
YEARS PPY
INTEGRATION Reinhard Busse Reinhard Matthias Reinhard Busse Reinhard FAVOURITE
PRACTICE PRACTICE ROLE Quentin, Erica Richardson, Anne Spranger Anne Richardson, Erica Quentin,
McDaid, Matthias Wismar Matthias McDaid,
COUNTRY Karanikolos
NEW? – – NEW? 20TH
OF OF
DIRECTIONS
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Wismar HEALTH HEALTH OF
ANNIVERSARY
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TALLINN – – TALLINN EVIDENCE – THE Cristina Hernández-Quevedo, Anna Maresso, Sherry Merkur, Sherry Maresso, Anna Hernández-Quevedo, Cristina
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Jo HEALTH Matthias Wismar, Claudia B Maier, Anna Sagan BMaier, Anna Wismar, Claudia Matthias OBS SERVATORYANNIVERSARY 20TH
chard NEWS
IN sep Figueras Figueras sep AND and
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EUROPE’S
Suszy Lessof, Josep Figueras, Martin McKee, Elias Mossialos Elias McKee, Martin Figueras, Josep Lessof, Suszy BOOK COVERAGE SYSTEM
Jonathan Cylus Jonathan – CHANGING CONTEXTS AND ENDURING CHALLENGES – CHALLENGES ENDURING AND CONTEXTS CHANGING –
Saltman Martin McKee, Suszy Lessof Suszy McKee, Martin HEALTH
SYSTEM FROM INTO
OR SYSTEM
@OBSHEALTH! POLICY
Juliane Winkelmann, Dimitra Panteli, Miriam Blümel Miriam Panteli, Dimitra Winkelmann, Juliane and
REFORMS and
PRACTICE:
ACTIVITY
HEALTH THE POLICY
AND THE ROLE OF EVIDENCE-BASED APPROACHES APPROACHES EVIDENCE-BASED OF ROLE THE AND
Martin McKee Martin PERFORMANCE Liisa-Maria Voipio-Pulkki Liisa-Maria
FIRST
IN IN
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EUROPE
AT WORKFORCE:
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YEARS TW SHES AND TWEETS FROM COLLEAGUES COLLEAGUES FROM TWEETS AND SHES
CROSS-ROADS Ewout van Ginneken Ewout van
ENTY YEARS OF EVIDENCE EVIDENCE OF YEARS ENTY
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CENTURY: and
ASSESSMENT: Gemma A Williams, Bernd Rechel, Rechel, Bernd AWilliams, Gemma
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and THE ROAD FROM FROM ROAD THE
Irene AGlinos Irene – – THE ROLES ROLES THE Peter C.Peter
Willy Palm Willy —
Vol.24 Smith, Smith, |
No.2
|
2018 1 2 Eurohealth and policy practice. policy and evidence interface between complex addressvery the and, makers ultimately,policy with to striving with systems, assessing health in experience working our from ofrange reflections a arising Observatory, offers it of the Systems Policies. staff by the and Written Health 20th of issue special This Twentyinto ofevidence practice years
— anniversary of the European Observatory on on European ofObservatory the anniversary
Vol.24 |
No.2 analytical studies – while central – would not not –would central –while studies analytical comparative of rigorous realisation the that clear however, outset, became it very the From countries. other in experiments and experience the from benefit could country one in reform system health where laboratory to anatural as referred often is Europe services, health deliver and systems health their finance and to organise approaches different adopted traditionally have countries Since region. European the across practices best and developments system health from learn and compare assess, systematically to States of Member need to expressed the 1996 aresponse in as Ljubljana in by WHO organised was that systems health on Conference Ministerial European first the at conceived was 1998, in it born was Observatory the While anniversary. our on partners from received wishes and messages some and Observatory of the development the in key milestones the of of some outline an includes also issue This years. twenty past the over work Observatory’s to the central been have that issues policy, all workforce health and coverage health universal policy, health public in reform, system health in key trends some covers it addition, In policies. and systems health on had has integration European that impact the as well as performance, systems health of assessing uses policy and needs growing the systems; health strengthening in played has community international the role the explore issue this in contributions other brokering, knowledge in lessons main ten the highlighting article alead with Beginning |
EDITORIAL 2018 Eurohealth marks the the marks health policy. The first study, formally attributed attributed study, formally first policy. The health European on impact lasting and a significant to was have Observatory the if sufficient be has invested in developing dissemination dissemination developing in invested has Observatory the work, analytical comprehensive its on Building makers. of policy needs specific of principle second the with closely very links understand, they alanguage in and makers to policy Translating trust. and timeliness tailoring, translation, principles: “T” four the as to them refer often We practice. into policy evidence transferring in success Observatory’s the for essential to be proven have key ingredients Four work. Observatory’s of the components defining of the one become has brokering knowledge in) innovation of (and development the this, doing for mechanisms and strategies proven no were there time the at While into practice. put to endeavour complex to arather be out turned implementation policy and evidence between expectations” and needs countries’ individual on depend will application their (…); situation local the to fit mechanisms reform adopting and adjusting is so (…) element essential an is experiences reform argued authors the former the On making. decision into policy evidence bring and countries across transfer policy effective to ensure both need the highlighted Figueras, and by Saltman authored strategies’ current of analysis Reform: Care Observatory, to nascent the “while learning from other countries about about countries other from learning “while Tailoring the evidence in a way that appeals appeals away that in evidence the . On the second, bridging the gap gap the bridging second, the . On the evidence to the evidence the ‘European Health Health ‘European , Eurohealth Observer 3
strategies that make these studies more readily systems reform never ends. The Observatory accessible for policy makers. Through formats is ready for another twenty years of monitoring, such as policy briefs and policy dialogues, the analysing, evaluating and sharing evidence. evidence is summarised and organised around the specific questions that policy makers have and the practical lessons that are drawn from it, taking into account the specific context in which Josep Figueras is they have to operate. Moreoever, the Timeliness Director, European in transferring the evidence – by identifying the Observatory on Health ‘windows of opportunity’ or ‘honeymoons’ for Systems and Policies, decision making – cannot be understated for Brussels, Belgium ensuring policy relevance and uptake. To account for this factor, the Observatory has developed over the years a wide range of mechanisms for face- to-face engagement formats that adapt to the Liisa-Maria Voipio- particular needs of the policy cycle and are put in Pulkki is Chair of the place at short notice in response to policy needs. Observatory’s Steering Committee Trust is the fourth, and perhaps, most important principle underlying Observatory knowledge brokering activities. Gaining the trust of both the policy making and academic communities not only relies on the solidity and quality of our work but also arises from the neutral, non-judgmental Cite this as: Eurohealth 2018; 24(2). stance that the Observatory takes, mindful of the political economy complexities or the role of value trade-offs in addressing health system challenges. Whereas a central tenet of the Observatory is the importance of solid evidence for developing sound policies, it also recognises the limitations of evidence in decision making. This is why we tend to promote the idea of ‘evidence- informed – rather than evidence-based – policy’.
Trust also relates to the composition of the partnership on which the Observatory is built, representing a wide range of international bodies, national governments, health authorities and academic institutions gathered around one main common denominator: to strive for objective, high quality and policy relevant evidence. With a role that is going well beyond that of traditional donors, the Observatory’s Partners take a central role in its governance, leading its strategic directions and actively incorporating its evidence in their respective policy developments.
Both Observatory Partners and staff are very much committed to continuing this work. Judged by its users, knowledge-driven policies in health are more than ever needed and relevant. At the start of the new five year cycle, we have identified a number of areas that will be core to the new strategic work plan. Clearly, there is no lack of topics to explore and health
Eurohealth — Vol.24 | No.2 | 2018 4 Eurohealth Observer
20 YEARS OF EVIDENCE INTO PRACTICE: REFLECTIONS ON THE OBSERVATORY IN 10 (KEY) LESSONS
By: Suszy Lessof, Josep Figueras, Martin McKee, Elias Mossialos and Reinhard Busse
Summary: The Observatory has spent the last twenty years generating evidence and communicating it to policy makers so that they can take better informed health system decisions. Ten key lessons are that: 1. Evidence makes a difference 2. The academic approach has huge strengths 3. Academic analysis needs to be ‘mined’ and ‘refined’ to bring out the policy relevance 4. If you don’t communicate findings clearly no one can use them 5. Personally mediated knowledge brokering has the greatest impact 6. Entry points are key 7. Policy makers want to know (and learn from) what others have done 8. Not everyone understands the same thing 9. Partnership works 10. Knowledge brokering is a cycle that turns evidence into ‘evidence for policy’.
Keywords: Observatory, Knowledge Brokering, Evidence Informed Policy, Policy Learning
A bridge for knowledge transfer right health workforce. The Observatory has contributed to WHO’s thinking In 1998 a mix of organisations, all on Health-in-all-policies, health and committed to better health systems, wealth, and governance. It has supported founded the Observatory. Its mission was European Commission efforts on issues to support evidence informed decision ranging from responding to patient making and to be a ‘bridge’ between and professional mobility, comparing policy makers and research. Over the countries’ health system performance, Suszy Lessof is Director of last twenty years it has worked with to the savings associated with physical Management and Josep Figueras, governments across Europe on a variety of Martin McKee, Elias Mossialos and exercise and improved diets. Over the health systems challenges, such as paying Reinhard Busse are co-directors years the group of Partners has grown, as of the European Observatory on for health care; managing the effects have their expectations. They have shaped Health Systems and Policies. of the financial crisis; or ensuring the Email: [email protected]
Eurohealth — Vol.24 | No.2 | 2018 Eurohealth Observer 5
and reshaped the Observatory’s work to analysis has helped Malta and Austria to strengthen the way it monitors countries; present arguments for European action to Box 1: Research can be shaped to to keep its analysis rigorous and relevant; address market failures and protect small be policy relevant when … and above all to ensure that knowledge member states purchasing high cost items. brokering informs everything it does. So • A structured approach is used what lessons have been learned? 2. The academic approach has huge strengths • Policy makers and academics are involved in framing (and Evidence informed policy is only worth reviewing) the work pursuing if the evidence is robust. This • The policy challenge is made means working with a set of academic explicit Evidence allows imperatives around consistency, replicability and detail. ‘Pure’ research • Existing research is systematically policy makers to may not always apply obviously and captured (and the organisations directly to policy and it rarely gives involved engaged) assess if instant answers to ‘real’ questions, but • Proposals define how what is commissioning only overtly policy ‘known’ intersects with the policy proposals are relevant research would hugely weaken issue and are explicit about what the evidence scene. Work predicated on needs to be extracted, reshaped likely to achieve challenges that are already ‘on the radar’ or amplified to serve policy does not prompt blue skies thinking or makers better their stated aims encourage experts to develop new themes. ‘‘ It will tend to mean there is no stream • Detailed terms of reference guide 1. Evidence makes a difference of analysis waiting to be exploited when contributors issues first emerge. There are of course • Researchers, experts and Health systems are complex. They are limitations to a purely academic treatment stakeholders are given a chance the product of long, often contested of evidence for policy and many analysts to share their thinking with each histories and are embedded in the societies are still interested in methods and results other so that they can respond they serve; expressing preferences and but not the application of their findings. to other perspectives possibilities, past and present; providing However, the Observatory has been cure and care, employment and identity. privileged to work with academics who • There is an iterative process of There is rarely a single ‘best’ way of doing care about policy, are generous in sharing testing, reviewing and revising. things, but evidence uncovers better and their primary research, and who network worse ways of dealing with health systems and think across disciplinary boundaries. issues in different contexts. In-depth and It has learned how important they are and, systematic review of how systems fit hopefully, how to support their work, not it. The Observatory develops and tests together; analysis of the links between least with focused terms of reference, with conceptual frameworks with academic money flows and services, incentives recognition and in dialogue. It has also experts and policy makers to build in and outputs, training and behaviour; and developed and systematised secondary relevance; populates the theoretical mapping of the consequences of change, research strategies to ensure that policy skeleton with the work already being done all generate insights and understandings relevance is captured. to avoid duplication; and commissions new that make for better system design. work to ‘fill in the gaps’. This requires Evidence allows policy makers to assess if 3. Academic analysis needs to be a conscious effort to bring disciplines proposals really are likely to achieve their ‘mined’ and ‘refined’ to bring out the together; to facilitate open discussion stated aims; to think through unintended policy relevance across organisations; and to combine impacts; and to nuance and adjust plans. perspectives. It also involves constant, France, for example, has used comparative Extracting the policy relevant from the deliberate ‘worrying’ about what findings evidence to avoid introducing performance academically rigorous is central to what mean ‘in practice’ and a willingness to payments based on an overly narrow set the Observatory does (see Box 1). It has adapt work as the policy-research dynamic of quality indicators and Switzerland has taken secondary research and meta- throws up the unexpected. stepped back from charging citizens for analytic models and aligned them to using emergency services inappropriately, policy needs. It builds on what researchers 4. If you don’t communicate findings by understanding the blocks to accessing ‘know’ and shapes it to tackle the clearly no one can use them primary care. Evidence also helps to make challenges policy makers face. This means the case for change. Slovenia drew on a that when a policy question presents itself There is a difference between raft of examples to show why public health there is a systematic attempt to seek out communicating analytic findings and makes sense as an integral part of its existing primary research and comparative working directly with policy makers primary care and prevention system while evidence and to extract the lessons from to understand and apply evidence.
Eurohealth — Vol.24 | No.2 | 2018 6 Eurohealth Observer
The Observatory is best known for the the right people together and makes them and evidence highlight the different ways latter, but making the evidence ‘generally’ focus on a single issue at a specific time. of approaching a policy issue and have available is important. It gives those It trades too on the fact that when (suitably been found useful over and over again responsible for drafting, scrutinising and skilled) experts explain the evidence but there is also value in the anecdotal. implementing policy, access to expert they can compress complex information Policy makers consistently find it helpful analysis, even if impact is muted by a into the available ‘attention span’, tackle to hear from their peers on the challenges ‘generic’ presentation. It also signposts questions immediately and generally ‘short they faced and the practical aspects of where, if circumstances allow, they circuit’ the process of assimilation. It is implementation. This reflects somewhat might seek further help. Thirdly it also about trust. A discussion that is well on the trust dimension of knowledge means that findings can contribute to the prepared and, above all, well facilitated brokering. Policy makers have faith in wider debate, not least in the academic creates a safe space that fosters a sense of ‘peers’ who like themselves are in the health policy community, moving ownership, advantages the rational, and position of seeking to introduce a system thinking forward. encourages appropriate reconciliation change and who are judged on whether between competing demands. reform works in practice and not just on whether a policy ‘stands up’ in theory. 6. Entry points are key They do not distrust sound academic analysis but they are looking for the Defining the policy making model as additional insights that come from having Bringing together rational or politically (policy) driven steered a proposal through the political or path dependent gives insights into and cultural complexities of agreement. actual policy how decisions may be reached but real It is also about the reality and the politics decisions in real time are always based on of implementation. Context is of course makers means a complex combination of circumstances. hugely important and no policy makers Windows of opportunity open and imagine that another country’s experience, that priority close depending on the interaction of however similar the challenge, gives a contextual factors and what is feasible blue print for reform in their own specific setting reflects changes. Bringing evidence into the setting. They do though want to know policy cycle effectively – and so that a model which makes sense actually the realities of it helps policy makers reach a better panned out in a many-layered, non- ‘‘ informed decision – depends on having linear environment. key stakeholders access to the right people (i.e. the ones that will influence the decision) at the 8. Not everyone understands the 5. Personally mediated knowledge right moment (i.e. both when they are same thing brokering has the greatest impact receptive to evidence inputs and when there is real scope to adjust or improve a Two decades of knowledge brokering Evidence, and the part it plays in policy policy in the making). Getting a chance have made clear how easy it is to have formulation, is mediated through a mix to put the evidence ‘on the table’ and conversations at cross purposes. This of cognitive, environmental and political to access the right mix of stakeholders reflects the complexity of translating filters. These vary across Europe with is not an easy matter. It can require policy concepts across a host of European some systems being more ideologically opportunism – seizing on the slightest languages, the term ‘policy’ itself is a driven, others giving greater weight to opening and reacting quickly; or networks case in point, with markedly different technocratic inputs and all dealing with – colleagues, contacts and peers who can connotations in different languages. It varying degrees of path dependence and lever access; or trust – the decision makers is also because terms are understood resource constraint. There is also huge already knowing and valuing the evidence differently and practice has evolved diversity in the staging of decision making, providers. These are often connected. differently. The assumption tends to be the types of consultation involved and Certainly the academic credibility of that ‘we all mean the same thing’ by a the role of different levels of government experts and the ‘real’ experience of DRGs but it can mask a diverse set of and stakeholders. Presenting evidence, practitioners create trust and once a track systems and understandings. At the risk ‘in person’ makes a real difference in all record – of providing useful inputs – has of seeming patronising, it is important contexts. Explaining the data and analysis been established then trust is reinforced to define terms carefully. By the same directly to decision makers; giving them and the next entry point is easier to secure. token, it is crucial in assembling the a chance to interrogate the experts; and evidence response to a policy question to creating opportunities for them to talk to 7. Policy makers want to know (and define what that question actually is. It is each other around an ‘objective’, evidence learn from) what others have done surprisingly difficult to define the ‘actual’ driven agenda, all increase the uptake question well. A perceived problem and impact of that evidence. This is, in, A very clear lesson of the last twenty around bed numbers may obscure a more part because of the convening power of a years is the power of hearing someone profound challenge about how and where briefing or policy dialogue which brings else’s experience. Comparative analysis to provide social care. If policy makers
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Figure 1: The knowledge brokering cycle References
1 Lessof S, Figueras J, Evidence for Action: The European Observatory on Health Care Systems. Policy Eurohealth, 1998;4(5): 33 – 35. 2 van de Goora I, Hämäläinenb R, Syed A, Juel Laud C, et al., on behalf of the REPOPA consortium. Knowledge brokering: Knowledge brokering: Determinants of evidence use in public health policy making: Results from a study across six designing the analysis transmitting the evidence EU countries. Available at: https://doi.org/10.1016/j. healthpol.2017.01.003
3 Lavis J, Catallo C and the BRIDGE study Evidence team (eds.). Bridging the worlds of research and policy in European health systems. European Observatory on Health Systems and Policies, 2013 (Observatroy Studies series, 36). Available at: The ‘right’ The ‘right’ The ‘right’ http://www.euro.who.int/en/about-us/partners/ question evidence communication observatory/publications/studies/bridging-the- worlds-of-research-and-policy-in-european-health- systems-2013
4 Evans M. International policy transfer: Between Global and Sovereign and between Global and Local. Source: Adapted from Ref 7. In Stone D, Moloney K (Eds). Oxford Handbook on Global Policy and Transnational Administration. Oxford University Press, 2017.
knew exactly what the question was they 10. Knowledge brokering is a cycle 5 that turns evidence into ‘evidence Oliver Innvar S, Lorenc T, Woodman J, Thomas J. might not need as much help to answer A systematic review of barriers to and facilitators it. The Observatory has learned to work for policy’ of the use of evidence by policymakers. BMC Health iteratively and carefully with them to reach Services Research 2014; 14(2). Available at: https:// The Observatory was set up to be a bridge a clear understanding of where the policy doi.org/10.1186/1472-6963-14-2 between the academics ‘with the evidence’ question comes from and what the real 6 and the policy makers seen to be in need McKee M, Figueras J, Lessof S. Research and evidence need is (and to think through policy: living on the interface. Eurohealth, 2008; of it. It has learned over the last twenty from there who the stakeholders are, what 12(1): 26 – 29. years that the notion of a bridge is far the right expertise is and which country 7 too static and the idea of one-way traffic Lessof S, Figueras J, Palm W. The European examples will have most resonance). Observatory on Health Systems and Policies: is simply wrong. Getting evidence into knowledge brokering for health systems practice is complex and context dependent strengthening. Eurohealth, 2016;22(2):55 – 59. 9. Partnership works and very much a dynamic process. There has to be an active feedback loop shaping The Observatory itself has always research and the way it is communicated depended on partnership. At the most basic and then learning from the interaction level it was set up by a group of countries, with policy makers how to better frame international agencies and universities. the next round of research (see Figure 1). Bringing together actual policy makers The Observatory uses policy makers to like the European Commission and identify priorities and as a key audience countries with international agencies to test work and to understand if the and academic institutions means that messages speak to practitioners. It uses priority setting reflects the realities of academics to set rigorous standards and key stakeholders. But partnership as a key deliver work of quality and worth. As ‘lesson’ extends beyond the structure of the knowledge broker it tries to link both the Observatory itself. When evidence groups and to bridge the gaps between generators and policy makers work them not as a simple, one or even two together collaboratively, and as genuine directional exercise but as part of an active partners, evidence uptake increases. By set of relationships. the same token policy makers sharing experience openly with each other makes evidence not just more accessible but easier to act on.
Eurohealth — Vol.24 | No.2 | 2018 Happy 20th Anniversary @OBSHealth!
Colleagues and friends of the European Observatory express their good wishes and reflect on memorable events.
Paul Belcher Josef Probst @RCPLondon Director-General, Main Association of
Happy 20th anniversary @OBShealth | Proud to be Austrian Social Security Institutions associated with your ‘Eurohealth’ journal throughout Happy Birthday to the young institution this time. with dynamic people and senior knowledge. Thank you for providing objective advice and generating Yves Charpak indispensable know-how. Health systems @YesWeKnow can definitely benefit from the possibility of dialogue and networking between Enjoy the anniversary and be prepared for the next science and policy at European level. 20 years, unknown future in Europe!
Maaike Droogers Dale Huntington @EUPHA @Former Director of Asia-Pacific Observatory EUPHA congratulates OBS for the important High quality, timely analyses produced by and very often innovative and creative work well known academics. that was done in the past 20 years on shedding light on our health systems and the complex dynamics of these systems. Jacqueline Bowman Spreading the word about OBS findings @Third-i contributes to its impact. EUPHA wishes the Observatory another successful 20 years You give the baseline evidence to allow informed and is looking forward to continuing and policy-making. It would also be nice in the future intensifying our collaboration. to include not only a government perspective, but to actively engage users of the health systems and other actors who impact on how Natasha Azzopardi M policies are implemented in reality. @EUPHA @uniofmalta Proud to represent @uniofmalta within Lieven De Raedt @OBShealth – Happy Birthday! We look @health.fgov.be forward to the Malta meeting in October 2019. @ValettaCampus @umhealthscience You are an agenda-setter in health policy with innovative and far-sighted studies. Liisa-Maria Voipio-Pulkki Director General, Finnish Ministry of EU_Health Social Affairs and Health @EU_Health I am so glad and honoured to be a Happy celebration, to many more to come! member of this absolutely great team. Congratulations! In Finnish: Lämpimät onnittelut, Observatorio!
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Centre for Global Chronic Conditions Walter Ricciardi @LSHTM_CGCC @Italian National Institute of Public Health Proud to be part of @OBShealth which is celebrating its 20th anniversary! happy birthday!
Gastein Forum Rifat Atun @GasteinForum @RifatAtun (Harvard University) 20th anniversary!! 20 years of experience!! Congratulations to the Observatory family 20 years of service!! 20 years shaping the for the outstanding work — a remarkable outlook on the future #euhealth policies achievement by a super group of public Congratulations!! Looking forward health leaders. We need the Observatory celebrating with you. #EHFG2018 more than ever in a fast changing Europe.
Hans Kluge Director of the Division of Health Systems Francis Arickx @riziv.fgov.be and Public Health, WHO/Europe The twin-relation between WHO and the Congratulations for your ‘courage’… Observatory is a winner for countries. You Messages are not always simple… provide us with state of the art evidence, which we can then use to formulate policy recommendations to countries and Boris Azais follow up with technical assistance. Warm @borisazais congrats for the 20th anniversary! Best public health crew in Brussels! You help preventing ideology to get in the way of smart policy making. Nima Asgari Director, Asia-Pacific Observatory As the younger observatory that has Stefan Eichwalder been modelled on OBS, I have found Deputy Head of Unit, Austrian Federal the support from OBS fundamental in Ministry of Labour, Social Affairs, Health developing the Asia-Pacific Observatory on and Consumer Protection Health Systems and Policies. I wish you a very happy birthday.
Thank you for the input and assistance you provide in a timely and reliable way, that Petronille Bogaert contributes in making better (informed) @Sciensano.be health policy. Congrats. You help to make health information easy to use and Thank you for establishing a trusted understandable. Clear recommendable platform for discussion and exchange (also outcomes. Strengthen the use of health among us partners of the Observatory). information in use with policy makers.
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SELECTED HIGHLIGHTS FROM THE FIRST 20 YEARS
1998 2001 2004 The founding partners sign the The OBS provides evidence support to The study Health Policy and EU agreement creating the “European the Belgian EU Presidency exploring Enlargement is published to coincide Observatory on Health Care Systems” the impact of EU law on health and support the accession of the 10 new systems. Member States of the EU The first annual Baltic Policy Dialogue 1999 takes place in Lithuania The official launch of the Observatory 2002 takes place in London at the OBS becomes the new editing partner international meeting ‘Evidence into for Eurohealth 2005 Action’ hosted by the London School Funding health care: options for Two major new studies are published of Hygiene and Tropical Medicine Europe, wins the EHMA Baxter Award – Social health insurance systems in Critical challenges for health care Western Europe and Purchasing to reform in Europe wins the prestigious improve health systems performance EHMA Baxter Award 2003 The first Summer School takes place in The name changes to the European Dubrovnik (1999 – 2002) Observatory on Health Systems and 2006 Policie; the Secretariat moves from OBS provides health evidence support Copenhagen to Brussels to the Finnish EU Presidency on Health in All Policies 2000 A range of meetings engaging with Since the launch already 23 country senior policy advisors develop into HiT profiles are published. the “Policy Dialogues” program, a particular brand of knowledge transfer 2007 A series expert panels on cross-border health care are organised to support the European Commission to develop a new Community framework The annual Summer School is re- started, taking place every year on the island of San Servolo, Venice A third OBS book, Mental health policy and practice across Europe, wins the Baxter Award 2008 OBS celebrates its 10th anniversary . It receives the World Bank prize for its contribution to knowledge and learning With the Health Evidence Network, OBS produces nine policy briefs for
Dr Jo Asvall, WHO Regional Director at the official OBS launch (1999) the WHO Ministerial Conference on Health Systems for Health and Wealth in Tallinn
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OBS supports the Slovenian EU The open-access Health Reform OBS provides evidence support to the Presidency on its health priority of Monitor series starts in the journal Austrian EU Presidency on access to cancer policies Health Policy medicines
The work begun 20 years ago 2009 2014 continues … OBS leads the EC (FP7) BRIDGE The European Commission invites research project to map current OBS, along with WHO and OECD, to knowledge brokering practices for join the Expert Group on HSPA health policy-making in Europe With WHO, OBS provides support to OBS supports the Czech and Swedish Ireland on its decision making on the EU Presidencies with evidence on financial crisis their health priorities respectively Current OBS Partners of financial sustainability and (with date of joining) antibiotic research 2015 WHO / Europe (1998) A new programme of work on health OBS supports the European World Bank (1998) system performance assessment Commission with implementation of (HSPA) is launched the European Reference Networks Government of Norway (1998) (ERNs) The London School of Economics 2010 OBS and WHO conduct a and Political Science (1998) comprehensive review of the Slovenian The London School of Hygiene The network of National Lead health system to support national & Tropical Medicine (1998) Institutions (NLIs) is founded, later to reforms become the Health Systems and Policy Government of Sweden (2002) Monitor (HSPM) network Government of Belgium (2003) 2016 OBS supports the Belgian EU Government of Finland (2004) Presidency with four policy briefs on With WHO, OBS assesses the the health workforce performance of the Portuguese health Veneto Region of Italy (2004) system in the post-crisis recovery Government of Slovenia (2006) period Government of Ireland (2009) 2011 OBS leads an international expert The results of the Health Professionals panel to pre-review proposed health European Commission (2009) mobility in the EU (PROMeTHEUS) and social care reforms in Finland French National Union of Health study are presented under the Insurance Funds (UNCAM) (2009) Hungarian EU Presidency Government of Austria (2013) Eurohealth and EuroObsever merge to 2017 become the OBS’s quarterly journal OBS supports the Maltese EU Government of the United Kingdom Presidency with two policy briefs on (2013) voluntary cross border collaboration Government of Switzerland (2016) 2012 OBS collaborates on the TO-REACH OBS staff provide inputs to the EC’s consortium for the development of Expert Panel on Effective Ways of a joint European health systems and For a more detailed historical Investing in Health services research programme overview on OBS activities and OBS and OECD jointly produce the publications, read our brochure: 2013 European Commission’s State of Celebrating the 20th anniversary Health in the EU country profiles of the European Observatory on The results of the cross-country review Health Systems and Policies (2018) of health system responses to the or watch our video Making sense economic crisis are presented at the 2018 of the evidence (2018). WHO High-Level Meeting in Norway OBS celebrates its 20th Anniversary www.healthobservatory.eu The Health Systems and Policies OBS collaborates with WHO/EURO https://bit.ly/2PvetDe Monitor (HSPM) and Health & on the High-level meeting on Health https://bit.ly/2NYW40N Financial Crisis Monitor (HFCM) web Systems for Prosperity and Solidarity – platforms are launched Leaving no-one behind
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THE ROLE OF THE HEALTH SYSTEM IN THE 21ST CENTURY: THE ROAD FROM LJUBLJANA TO TALLINN
By: Martin McKee, Suszy Lessof and Josep Figueras
Summary: For 20 years the European Observatory has been part of an intensive dialogue about what health systems are for. The goals of health systems have developed from improving health, responding to expectations and financial protection, to promoting economic growth and, ultimately, to social inclusiveness and solidarity. This article describes this evolving thinking, showing how ideas have moved forward at a series of major European conferences.
Keywords: Health Systems, Inclusiveness, Investment, Innovation, European Observatory
What is a health system for? life-threatening illness, had little choice if they wanted to survive. The problem This is a simple question, but without was that those who had the greatest health a simple answer. The most obvious is needs were typically those least able to that it should prevent and treat illness. pay. Those who were old and poor are A person feels ill, they seek help from a most likely to fall ill. Recognising this health professional, and hopefully they fundamental problem, the modern health are given a diagnosis, offered treatment, system acts as a means of redistribution. and recover. For most of recorded history Those who can afford it pay for those that that was it. All that changed was that cannot. Often they are the same people, as the probability of making an accurate those who are healthy and in work pay in, diagnosis or providing effective treatment in the expectation that the funds will be progressively increased. Yet by the middle there when they are old and poor. In this of the twentieth century, it became clear way, health systems took on another role, Martin McKee is Co-Director, that health systems, or at least those that of financial protection. European Observatory on Health that were appropriately designed, could Systems and Policies and do much more. They could prevent Professor of European Health But there is more. Once, there was an Policy at the London School of those unfortunate enough to become ill expectation that those engaging with Hygiene and Tropical Medicine, from facing catastrophic expenditure. 1 UK; Suszy Lessof is Director of those in authority were expected to be Modern medicine may have improved Management and Josep Figureas deferential. In health care, this meant that the probability of survival from an ever is Director at the European “the doctor always knows what is best”. Observatory on Health Systems and expanding range of conditions but they did Patients were expected to do what they Policies, Belgium. Email: Martin. so at a cost. And, unlike typical consumer [email protected] were told and, if it was thought that they goods, the patient, at least those with a
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needed treatment, they should simply rapidly increasing body of research, some some of the worst affected countries began accept it. In most countries those days undertaken by those working for or with to invest, both in their wider economies have long gone and decisions on treatment the Observatory. 8 It presented evidence and their health systems. Some adopted are reached following discussions between on how health systems improved health, 9 industrial strategies in which life sciences patient and health professional. Health but also how better health reduced the featured prominently. 13 However, by systems gained another goal, to respond to need for health care. Economic growth now it was clear that health systems the expectations of their users. created more money for health care, but had other goals, support for economic health systems, if linked to therapeutic and growth and, by improving the health of These three goals of a health system were technological innovation, could promote the population, contributing to a more first brought together formally in 2000, economic growth. Healthier people productive workforce. Crucially, the gains in the World Health Report. 2 Each of are more productive and remain in the from better health came not only to those the world’s health systems was scored labour force longer, thereby contributing in the workforce but also to those who on health outcomes, responsiveness, to economic growth, 10 while stronger might have to leave the workforce to care and fairness of financing. For the first economies enable people to make healthier for sick relatives. two, both overall progress and equity choices, at least if the resources are shared were assessed. The resulting scores were equitably and governments put in place Prosperity and solidarity inevitably controversial, not least because appropriate regulatory frameworks for of the necessity to estimate a very large harmful products, such as tobacco or Ten years later, health ministers came number of missing data points. However, junk food. These ideas were incorporated together again in Tallinn. They were there the process did stimulate a major research into the 2008 Tallinn Charter, to which to take stock of what had happened in initiative, the Global Burden of Disease the World Health Organization (WHO) the previous decade. But they were also programme, which has transformed Regional Office for Europe Member States looking ahead, to where health systems our understanding of the health of the committed. 11 were going in the 21st century. At the world’s population. 3 It has highlighted conference – entitled “Health Systems for what was previously the hidden burden of Prosperity and Solidarity: Leaving no-one non-communicable disease and injuries behind”– a new model was proposed, in low and middle income countries. It health with new goals for the health system. has also added to our understanding of These drew on, but extended what had the scale of impoverishment attributable systems need to gone before. Once again, the Observatory to health care where health systems are played a key role, working with our weak. This evidence also contributed to respond to the colleagues in WHO. The model centred recognition of the importance of health on 3 I’s: Include, Invest, and Innovate. system strengthening, especially as part expectations of of what by then were the growing number The need for inclusion was highlighted of global health system initiatives. 4 This their users by new analyses from WHO’s Barcelona report changed the way that health systems Office for Health System Strengthening, were viewed. The Observatory had Unfortunately, a few months after the showing that even in health systems contributed to the text that accompanied Charter was endorsed, the world changed. that, on paper, have achieved universal scores, in particular using work done A series of events culminated in the coverage, many people still face large for the 1997 Ljubljana conference on global financial crisis. Governments out-of-pocket payments or even, in some 5 6 ‘‘ health systems, that was, in effect, the gave vast sums of money to the large cases, catastrophic expenditure, while midwife of the Observatory. A particular financial institutions, many of which other research by those linked to the contribution, that has endured in the had created the crisis, to protect them Observatory, most notably in association discourse on health systems, is the concept against insolvency. To pay for this, with the European Commission, has of stewardship, 7 in which governments many implemented deep cuts to public sought to measure and understand trends have a responsibility to anticipate the spending. In some countries, the austerity and patterns in unmet need for care. 14 All future and ensure that their health systems programmes hit health systems hard. The is not well in many countries but health remain fit for purpose. The three main ideas set out in Tallinn were tested, not by systems can do much to improve things, goals of a health system are now widely the hoped for programme of investment if they are enabled to by governments by accepted. But it soon became clear that but by disinvestment. Instead of mutually promoting models that include everyone health systems do even more. reinforcing gains in health, health systems, on their territory, including migrants. and wealth, some countries went into a Fortunately, after some retrenchment Health systems, health, and wealth vicious downward spiral, with worsening during the economic crises, certain health, weaker health systems, and countries are bringing vulnerable groups The 2008 Tallinn Conference, in which economic decline. 12 In some, what had back into the system, 15 but there is still the Observatory played a leading role, been steadily declining mortality began to much to do and many problems lie ahead. presented a new framework for thinking increase in some areas and at some ages. about health systems. 8 This built on a After what was effectively a lost decade,
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The case for investment in health systems how the work that the Observatory has 14 Expert panel on effective ways of investing in was made at the 2008 Tallinn conference done helps them to do it better. This health. Benchmarking access to healthcare in the EU. and again at another that marked its contribution is different. To go back to the Brussels: European Commission, 2018. fifth anniversary. The evidence is now beginning, it asks a simple question. What 15 Legido-Quigley H, Pajin L, Fanjul G, Urdaneta E, stronger than ever. However, this will are health systems for? As it shows, the McKee M. Spain shows that a humane response not be easy, requiring a mature debate answer is far from simple. It has evolved to migrant health is possible in Europe. The Lancet Public Health. 2018. DOI: https://doi.org/10.1016/ between health and finance ministers. over time. And working with others, the S2468-2667(18)30133-6 These were presented graphically at Observatory has contributed substantially 16 the 2018 conference in an imaginative to the understanding of that evolution. World Health Organization. An additional funding request 2018. Available at: https://www.youtube. and informative film in which a former com/watch?v=ceeS9ncv1hM state secretary from the Netherlands who References has held both positions participated in negotiations with himself. 16 1 Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. The Lancet 2003;362(9378):111 – 7. Health 2 World Health Organization. World Health Report 2000: health systems: improving performance. systems are part Geneva: World Health Organization, 2000. 3 Institute for Health Metrics and Evaluation. Global Burden of Disease (GBD): IHME, 2018. Available at: of the glue that http://www.healthdata.org/gbd binds society 4 Balabanova D, McKee M, Mills A, Walt G, Haines A. What can global health institutions do to help strengthen health systems in low income together countries? Health Research, Policy and Systems 2010;8:22.
The third imperative is innovation, in 5 World Health Organization. The Ljubljana medicines, technology, and models of Charter on Reforming Health Care 1996. Available care, including those that take account of at: http://www.euro.who.int/__data/assets/pdf_ the enormous advances in information file/0010/113302/E55363.pdf?ua ‘‘ 6 technology. Looking further ahead there Saltman RB, Figueras J. European health care is artificial intelligence. Yet, just because reform: analysis of current strategies. Copenhagen: something is new, it does not mean it is World Health Organization, 1997. something that should be adopted. Too 7 Saltman RB, Ferroussier-Davis O. The concept many new medicines offer no benefits over of stewardship in health policy. Bulletin of the World what already exists. Too many seemingly Health Organization 2000;78(6):732 – 9. clever ideas, in areas such as telemedicine, 8 McKee M, Suhrcke M, Nolte E, et al. Health fail to live up to their potential. So the systems, health, and wealth: a European perspective. challenge facing health systems is how The Lancet 2009;373(9660):349 – 51. to identify the good ideas and implement 9 Nolte E, McKee M. Does health care save lives? them at scale, while avoiding the seduction Avoidable mortality revisited. London: The Nuffield of the bad ones. Trust, 2004. 10 Suhrcke M, McKee M, Stuckler D, Sauto Arce R, The final message from Tallinn in 2018 Tsolova S, Mortensen J. The contribution of health was that these three I’s must be brought to the economy in the European Union. Public Health together, for prosperity, as set out ten 2006;120(11):994 – 1001. years earlier, but also for solidarity. Health 11 World Health Organization. The Tallinn Charter: systems are part of the glue that binds health systems for health and wealth. Copenhagen: society together. And this means that they WHO Regional Office for Europe, 2008. are a political statement of our mutual 12 Reeves A, McKee M, Basu S, Stuckler D. interdependence. As European societies The political economy of austerity and healthcare: become more diverse, the importance of cross-national analysis of expenditure changes in 27 European nations 1995 – 2011. Health Policy this role cannot be underestimated. 2014;115(1):1 – 8.
13 The Observatory has spent 20 years Rawlins MD. The UK's Life Sciences Strategy: opportunities for clinical pharmacology. British thinking about health systems. Much of the Journal of Clinical Pharmacology. 2018; Jun 19. rest of this special edition of Eurohealth doi: 10.1111/bcp.13629. is about how they work and, importantly,
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EVOLUTION OF HEALTH SYSTEM PERFORMANCE ASSESSMENT: THE ROLES OF INTERNATIONAL COMPARISONS AND INTERNATIONAL INSTITUTIONS
By: Peter C. Smith, Marina Karanikolos and Jonathan Cylus
Summary: Health system performance assessment (HSPA) has become increasingly important nationally and internationally as a way to evaluate whether and to what degree health systems achieve their goals and to hold decision-makers to account. A core challenge remains how to best integrate HSPA in policy processes and to use the findings to contribute meaningfully to health system improvement and health policy development. In this article we review the evolution of HSPA over the past two decades, discuss some of the conceptual and methodological challenges and consider in particular the roles of international comparisons and international institutions.
Keywords: Performance, International Comparisons, Accountability, Health Policy, Peter C. Smith is Emeritus Professor of Health Policy, Measurement Imperial College Business School and Professor of Global Health Economics, University of York, UK; Marina Karanikolos The evolution of HSPA and reviewing the achievement of high- is Research Fellow, European level health system goals based on health Health system performance assessment Observatory on Health Systems system strategies”. 4 The key objectives of (HSPA) is becoming a central instrument and Policies, London School of HSPA are: Hygiene & Tropical Medicine, UK; in the governance of modern health Jonathan Cylus is Economist/ systems. 1 The notion of the health – To set out the goals and priorities for Research Fellow and London Hub Coordinator, European Observatory system was first given serious attention a health system; on Health Systems and Policies, nearly 20 years ago in the World Health – To act as a focus for policymaking London School of Economics and Report 2000 2 and further developed Political Science, UK. and coordinating actions within the in the World Health Organization Email: [email protected] health system; (WHO) report Everybody’s business: Parts of this text are adapted from strengthening health systems to improve – To measure progress towards previously published material: health outcomes. 3 It defined the health achievement of goals; Smith P. Peer Review in Social system as “… all the activities whose Protection and Social Inclusion: – To act as a basis for comparison with primary purpose is to promote, restore Health System Performance other health systems; Assessment. Brussels: European or maintain health.” WHO then defined Commission, 2014. HSPA as “a country-specific process of monitoring, evaluating, communicating
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– To promote transparency and to citizens’ preferences; the financial accountability to citizens and other protection offered by the health system; Box 1: Key features of HSPA legitimate stakeholders for the way that and the productivity, or value-for-money, money has been spent. of the health system. Furthermore, all HSPA is regular, systematic and HSPA efforts make reference to the issue transparent. Reporting mechanisms HSPA was given a further stimulus of fairness, or equity, in how attainment are defined beforehand and cover in the WHO European Region by the of its goals is distributed across different the whole assessment. It is not signing of the “Tallinn Charter on Health population groups. bound in time by a reform agenda Systems for Health and Wealth” in 2008. or national health plan end-point, The 53 Ministers of Health from the although it might be revised at European region made a commitment “to regular intervals to better reflect promote transparency and be accountable emerging priorities and to set for health systems performance to achieve appropriate targets. measurable results”. HSPA is seen as to be relevant, an important mechanism for fulfilling HSPA is comprehensive and that commitment. comparisons balanced in scope, covers the whole health system and is not limited to What information is included in require in-depth specific programmes, objectives or an HSPA? levels of care. The performance of knowledge of the system as a whole is more than As envisaged by WHO, HSPA is primarily the sum of the performance of each a country-specific process for which there health systems of its constituents. is no single accepted template, although HSPA is analytical and uses there are many generally accepted There is less consensus on how to complementary sources of principles of best practice in developing a incorporate health system functions into 4 ‘‘ information to assess performance. specific HSPA. Some of these include: HSPA. These might include: service Performance indicators are delivery; workforce; information – HSPA should focus on the health supported in their interpretation resources; medical products, vaccines and system as a whole, including health by policy analysis, complementary technologies; financing; and governance. promotion and public health as well as information (qualitative assessments) Such functions are the fundamental health services; and reference points: trends over building blocks of any health system, and time, local, regional or international – Health systems goals should be how they are deployed can have a major comparisons or comparisons to expressed in terms of outcomes such as influence on health system outcomes. standards, targets or benchmarks. improved health and reduced exposure However, they are often difficult to to financial risk, rather than processes compare across different types of health In meeting these criteria, HSPA such as workforce size or numbers system, and a focus on functions can needs to be transparent and of treatments; sometimes inhibit progress towards new promote the accountability of the ways of promoting the ultimate goals of health system steward. – Wherever feasible, progress should be the health system, such as a shift away quantified using reliable metrics and from treatment towards prevention of Source: 5 associated analytic techniques; disease. It is for this reason that HSPA – HSPA should be a regular process, should focus primarily on outcomes. embedded in all aspects of Assessment of functions may nevertheless to otherwise support cross-country health policymaking; be an important diagnostic tool for performance comparisons as an important understanding reasons for progress (or element of HSPA. These include work – The exact form of HSPA should be a lack of progress) towards health system by the European Observatory on Health matter of choice for individual systems, goals. Box 1 summarises the key features Systems and Policies, as well as the although its effectiveness is likely to be of HSPA, as envisaged by WHO. 5 Commonwealth Fund, Organisation for maximised by the adoption of metrics Economic Co-operation and Development and methods that enjoy widespread (OECD), European Commission, and the international use. The role of international comparisons in HSPA Institute of Health Metrics and Evaluation among others. Despite differences in how objectives are HSPA is seen as a national competency expressed and measured, there is almost due to the need to focus on country- International comparisons benefit national universal agreement that any HSPA specific goals and maintain relevance HSPA efforts in a number of ways, for should reflect health system goals. These within different institutional settings. example by providing the opportunity include the improvement in health that However, there have been many for cross-country learning in terms of the can be attributed to the health system as a international efforts to conduct or conducting of HSPA itself, as well as for whole; the health system’s responsiveness
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indicator benchmarking. However, there for policy. 7 While there is general Systems in Transition series – as well as by remain a number of challenges to take agreement on the definition of amenable the OECD in its survey of health system full advantage of the potential offered by deaths, namely those that could be avoided institutional characteristics are beginning international performance comparisons. through timely and effective health care, to show how this can be achieved. These include the persistent interest in measures of preventable mortality range using international comparisons to rank from those which include just three causes The role of the international health systems, the comparability of data of death (lung cancer, liver disease and community in strengthening HSPA and concepts across countries, as well road traffic deaths) to others which are as the difficulties in interpreting cross- more widely defined. In particular, the Considerable progress has been made in country findings. definition of preventable mortality used institutionalising HSPA in many countries. by Eurostat 8 includes the three previously Yet while HSPA should be designed at The problem with rankings mentioned causes, but also includes deaths country level to ensure acceptability and from ischaemic heart disease, influenza, relevance, there is also a clear role at It is not surprising that there is great diabetes, breast and cervical cancer – European or international level. A good interest in seeking to rank health conditions that are also included in the example is the recent collaborative work systems, especially given that the World measure of amenable mortality. Such between the European Observatory on Health Report 2000 has largely been the differences matter because an important Health Systems and Policies, the OECD, inspiration for much of the appetite for reason for seeking to distinguish between and the European Commission to produce performance assessment and comparison. amenable and preventable mortality is to the State of Health in the EU profiles, However, determining that one health establish broad lines of accountability: providing policymakers, interest groups, system is ‘better’ than another is rarely identifiable effective interventions and and health practitioners with factual, a clear, evidence-based and transparent health care providers in the first case; comparative data and insights into health process. One of the most controversial and wider policy measures that stretch and health systems in EU countries. 10 examples is the Euro Health Consumer beyond the health system, requiring the Likewise, the European Commission’s Index (EHCI), which ranks health systems involvement of other sectors, such as legal Expert Group on HSPA established in 2014 annually based on an arbitrary selection measures around road safety or a smoking provides a useful forum for Member States of indicators which are then given ban, in the second. 8 Counting some causes and other international stakeholders to arbitrary scores. 6 For example, amongst of death as both preventable and amenable discuss good and bad practices, as well as its flaws as a comparative health system provides little concrete information in more generally share their experiences. assessment tool, the EHCI implicitly terms of what is being assessed, who values shorter waiting times more than it is accountable, and what can be done values survival – something that is hard to about it. imagine reflects the preferences of health care consumers. primary Interpreting cross-country findings In reality though, any health system To be relevant, comparisons require not purposes of ranking based on a single or composite only good data quality and conceptual measure will be unable to fully capture agreement as described above, but also HSPA: promoting differences in cross-country preferences in-depth knowledge of health systems. and other unobserved factors that explain Identifying the reasons for observed accountability performance. In general, it is hard to variations is challenging even within advocate the use of composite measures of a single health system, let alone across and supporting performance and the associated rankings countries. For example, the indicator of health systems, other than as a device to ‘average length of stay for a specific policy draw attention to the HSPA initiative. condition’ has little meaning without adjustment for patients’ profile, which development The challenges of comparability is often not available across countries. ‘‘ In considering the future of HSPA and Moreover, while it may indicate more Although much progress has been how the international community can help efficient resource use in the short run, made, there remain questions over the to maximise its potential, we consider in the long-run discharging patients comparability of apparently similar two of the primary purposes of HSPA: early may, without appropriate follow- concepts used by different research promoting accountability and supporting up care, lead to more complications, institutions. For example, avoidable policy development. slower recovery and, ultimately worse mortality, one of the key health outcomes and higher costs. 9 Therefore, outcomes indicators in HSPA – has been Promoting accountability is important so any HSPA requires supporting information conceptualised in a number of different that citizens, parliamentarians and other on contextual factors in order to offer ways, which can have obvious effects on stakeholders can check that policymakers, information on the reasons for the the indicator’s comparability as well as institutions and providers are progressing observed outcomes. Work by the European important implications for its usefulness towards their shared objectives. In Observatory – including the Health
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doing so, HSPA also serves to maintain identify priorities for improvement and 4 WHO/Europe. Pathways to health system the solidarity that underpins societal provide policy guidance as part of the performance assessment: a manual to conducting willingness to support universal health European Semester. health system performance assessment at national or sub-national level. Copenhagen: World Health coverage, since people are able to verify Organization Regional Office for Europe, 2012. that their health system is delivering on Where do we go from here? 5 its promises and achieving goals. One WHO/Europe. The European health report 2009. Health and health systems. Copenhagen: World of the ways to ensure accountability is HSPA is an important mechanism to Health Organization Regional Office for Europe, 2009. through frequent reporting. However, the ensure effective, accountable health p. 141. timeliness of data availability remains systems. There is a clear role for 6 Cylus J, Nolte E, Figueras J, McKee M. What, variable. For example, international international comparisons and the if anything, does the EuroHealth Consumer Index mortality data are published with at international community more broadly in actually tell us? BMJ Blogs, 9 February 2016. least a two-year lag. International facilitating and supporting national level Available at: http://blogs.bmj.com/bmj/2016/02/09/ organisations, such as the WHO, OECD analysis. International organisations, such what-if-anything-does-the-eurohealth-consumer- and the European Commission can help as the WHO, the European Commission index-actually-tell-us/ by supporting data harmonisation and and OECD can provide not only valuable 7 Karanikolos M, Nolte E. Interpreting health streamlined collection processes. This and much needed information, but also systems performance indicators – more complex is already the case, for example with the assist in harmonisation of data collection than it looks? Lancet Public Health 2018. Available at: 11 http://www.thelancet.com/pdfs/journals/lanpub/ System of National Health Accounts. and concepts, assist in highlighting PIIS2468-2667(18)30076-8.pdf Improving access to administrative data specific issues and common priorities, 8 and creating better linkages across as well as facilitate knowledge exchange Eurostat. Amenable and preventable deaths statistics, 2017. Available at: http://ec.europa.eu/ providers and registries is of great use in through international expert groups and eurostat/statistics-explained/index.php/Amenable_ improving timeliness. other forums for sharing experience. and_preventable_deaths_statistics
9 Cylus J, Papanicolas I, Smith P. How to make Supporting policy development is the References sense of health system efficiency comparisons? other key purpose of conducting an HSPA. Policy Brief 27. Copenhagen: WHO Regional Office 1 Countries like Portugal have explicitly Papanicolas I, Smith P (eds.) Health system for Europe, 2017. Available at: http://www.euro.who. used HSPA to inform their National performance comparison: an agenda for policy, int/__data/assets/pdf_file/0005/362912/policy- information and research. Maidenhead: Open brief-27-eng.pdf?ua=1 Health Plan. However, this is not the case University Press, 2013. everywhere, making it difficult to know 10 European Commission. State of Health in the EU, 2 the extent to which HSPA feeds into policy WHO. The World Health Report 2000. Health 2017. Available at: https://ec.europa.eu/health/state/ systems: improving performance. Geneva: World country_profiles_en development. International organisations Health Organization, 2000. like the European Union can play an 11 OECD. A System of Health Accounts 2011: 3 important role in linking performance WHO. Everybody’s business: strengthening health Revised edition, 2017. http://www.oecd.org/els/ systems to improve health outcomes. Geneva: World assessment to policy. For example, there health-systems/a-system-of-health-accounts-2011- Health Organization, 2007. 9789264270985-en.htm are ongoing efforts by the Commission to use HSPA data as a screening tool to
How to make sense of health • There is no single metric or set of indicators that will give the complete picture of health system efficiency in a country. system efficiency comparisons? • The real causes of any identified inefficiencies need to be carefully identified and analysed to inform good By: J Cylus, I Papanicolas, PC Smith policymaking. Policy Brief 27 (2017): 28 pages • More nuanced Freely available to download at: http://www.euro.who. indicators require more int/__data/assets/pdf_file/0005/362912/policy-brief-27-eng. HEALTH SYSTEMS AND POLICY ANALYSIS standardised and pdf?ua=1 detailed cost accounting POLICY BRIEF 27 data and linked datasets How to make sense of health Improving health system efficiency is a compelling policy goal, system efficiency comparisons? and registries. especially in systems facing serious resource constraints. • This policy brief gives However, in order to improve efficiency we must know how a useful framework to properly measure it. This policy brief proposes an analytic Jonathan Cylus for understanding framework for understanding and interpreting many of the most Irene Papanicolas Peter C Smith and interpreting the common health care efficiency indicators. Key messages are: healthcare efficiency • The inexorable growth in health expenditure has led to a metrics that are widely
No. 27 widespread demand for efficiency improvements. ISSN 1997-8065 used.
Eurohealth — Vol.24 | No.2 | 2018 Eurohealth International 19
EU INTEGRATION AND HEALTH POLICY AT THE CROSS-ROADS
By: Willy Palm and Matthias Wismar
Summary: With the European Union trying to find new breath after Brexit and other political crises, the discussion about its role in the field of health may be open to fundamental change. In this context it is good to remind ourselves of how the role of the EU in health matters has grown and matured over the years.
Keywords: European Union, EU Health Policy, Internal Market, Fiscal Governance, Cross-border Cooperation
Twenty years since “Kohll decision, however, that patients would be and Decker” able to seek health care in another Member State without prior approval from their It was more or less around the time that national payer organisation, was seen in the European Observatory was established many European capitals as a potential in 1998 when two rulings by the European threat to the national welfare state, one of Court of Justice (ECJ) created some quite the last standing strongholds of national vigorous political reactions in the health discretionary power. Member States were sector. The Kohll and Decker cases, concerned that the economic rules of EU concerning two Luxembourg citizens integration may supersede and undermine who were denied reimbursement by their the social construction underpinning sickness fund for elective health services national health systems. But at the same they had obtained in neighbouring time, these rulings also gave an impetus to Germany and Belgium, fundamentally discussing the actual role of the European dealt with the question of whether Union in health. 2 European internal market rules also apply to health care. The ECJs decision that statutory health systems indeed Health as an EU objective also have to respect the principle of free Since the very start of the EU integration movement of services, came as a surprise process, public health has played a role to many national health policymakers. as one of the three quarantine criteria They believed that, based on the famous on the grounds of which free movement subsidiarity principle, all decisions relating of persons, goods or services can be to their health and social protection restricted. However, it was only in 1985, systems could remain exclusively as a with the launch of the first action national competence. programme on cancer, that the EU’s health portfolio really started to develop (for an Willy Palm is Senior Advisor Even if today the data on it are still both overview of the historical process, also and Matthias Wismar is Senior patchy and diverse, the mobility of patients Health Policy Analyst, European see Box 1). After the inclusion of a proper was always bound to remain a rather Observatory on Health Systems and public health article in the Maastricht Policies, Brussels, Belgium. small phenomenon, except perhaps for Treaty, which opened the door for the EU Email: [email protected] some border regions, holiday destinations to take action directly aimed at improving and migrant communities. 1 The Court’s
Eurohealth — Vol.24 | No.2 | 2018 20 Eurohealth International
Figure 1: Health within the EU’s agenda for growth and jobs Health caught within the broader EU agenda Social cohesion To really understand the interplay between health and EU integration the broader influence from other EU policy areas cannot be ignored. As mentioned, this already became clear through the Kohll Europe 2020 and Decker rulings in 1998, but also in the subsequent political debate on the so- called “Bolkestein” Directive on services in the internal market, which required Health Member States to screen all national regulations to see which measures may unjustifiably hamper free movement of services. The deregulatory effect of such an approach on a tightly regulated area like health care, prompted a lot of criticism and concern that this would undermine Internal market Fiscal governance health system objectives and eventually led to the exclusion of health services from the Directive’s scope in 2006. Source: Authors’ own. Ironically, we currently see similar rules and mechanisms reappearing in a new health, it took various health crises and health systems to become more effective, draft Directive proposing a proportionality subsequent revisions in the Amsterdam accessible and resilient. The European test for the adoption of new regulation and Lisbon treaties, for the EU health Commission’s health-specific Directorate of professions. 4 mandate to mature. 3 General, which was established in 1999 and coordinates all these activities, has The financial crisis that some ten years Today, the protection and improvement achieved a great deal in making Member ago hit Member States’ economies and of human health is inscribed as a firm States cooperate, coordinate their policies, fiscal space is another good example commitment and objective of the EU. share experiences, exchange best practice of how other EU policies, in this case Nonetheless, the legal competences and develop benchmarks. However, in the mechanism of fiscal governance attributed to achieving this goal remain financial terms the Health Programme (introduced to secure the stability of essentially limited to supporting, only represents a fraction of less the euro and to coordinate economic coordinating or supplementing the actions than 0.1% of the EUs total budget. policies across the EU) indirectly of Member States. Yet, even within this influence national health policies and restricted mandate, the EU has managed systems. The more or less binding policy over time to develop a broad array of recommendations on reforming national activities and measures. They range from health systems, coming through the combined efforts in health research and Economic Adjustment Programmes the development of guidelines for breast EU health policy or the European Semester, have only cancer screening to binding rules ensuring increased the EUs impact on health. 5 It the quality and safety of blood products, is captured shows that EU health policy is captured tissues and organs. Following the adoption within the trinity dimensions of economic in 2007 of an integrated health strategy within the trinity integration, fiscal sustainability and social (“Together for health”) a multi-annual cohesion (see Figure 1) 6 , around which health programme the current version, dimensions of the Commission’s European 2020 strategy called “Health for Growth”, directs and for growth and jobs is developed. It also funds all EU activities to promote health economic provides proof of the “constitutional and protect citizens against cross-border asymmetry” in the EU, which makes the health threats (cf. the establishment of integration, fiscal EU better equipped at integrating markets the European Centre for Disease Control ‘‘ than promoting social protection. 7 Indeed, and Prevention). It also facilitates access sustainability and “hard law” regulation stemming from to better and safer health care and the traditional EU policy domains would increases health systems sustainability. social cohesion easily seem to outweigh the “soft law” Member States have gradually accepted instruments on which EU health policy that the European Commission would is built (coordination mechanisms, joint set up a framework for strengthening actions, projects, grants).
Eurohealth — Vol.24 | No.2 | 2018 Eurohealth International 21
Box 1: Some milestones in the development of EU health policy
1965: First European pharmaceutical legislation following the Thalidomide crisis
1971: Regulation on the coordination of social security systems, including entitlements to cross-border health care
1975: First Doctors’ Directive ensuring the mutual recognition of medical diplomas
1987: Launch of the ‘Europe against cancer’ programme
1992: First public health article in the Maastricht Treaty
1993: Communication on the Framework for Action in the Field of Public Health
1995: European Medicines Evaluation Agency (EMEA)
1998: ECJ rulings on Kohll and Decker
1999: DG Health and Consumers (SANCO)
2000: Charter of Fundamental Rights of the EU, including the right to health care (article 35)
2002: European Food Safety Authority (EFSA)
2003: Start of the first EU Health Programme (2003 – 2007)
2004: European Centre for Disease Prevention and Control (ECDC)
2005: Executive Agency for the Public Health Programme
2006: Council Conclusions on Common values and principles in European Union Health Systems
2007: White Paper “Together for Health”
2009: Communication on “Solidarity in Health: reducing health inequalities in the EU”
2011: Directive on the application of patients’ rights in cross-border health care
2013: Social Investment Package for Growth and Cohesion
2014: Communication on effective, accessible and resilient health systems
2016: Start of the first cycle of State of Health in the EU
2017: European Pillar of Social Rights
Sources: Authors
Health focus lost in implementation? regulation of endocrine disruptors, the Financial Framework 2021 – 2027), the Because EU health policy often has positioning of health in international trade Health programme is integrated into a developed in a fragmented and reactive agreements, the labelling of food products, new single, comprehensive instrument, way, but also due to the fact that it is alcohol pricing, the imposition of austerity together with the European Social Fund, determined by other EU policies, it is measures affecting health, pharmaceutical the Youth Employment Initiative, the sometimes difficult to really see the regulation and tobacco control measures. Fund for European Aid to the Most progress and achievements that have Deprived and the Employment and Social been made. 8 In some cases EU policy There is also growing concern that under Innovation programme. in health matters may even seem the current political constellation and paradoxical or contradictory, especially following Brexit, from the so-called #EU4HEALTH when other interests or policy objectives five “Juncker scenarios”, which are take precedence over health goals and described in the White Paper on the The possible disappearance of a self- other Commission Directorates take the future of Europe, the option of “doing standing health-specific programme and lead. Over the years health advocates less more efficiently” would be chosen as the integration of EU health policy into have occasionally criticised the European the new mantra. As a result health may a broader EU social investment agenda institutions for their sometimes lukewarm be removed from the thematic portfolio. are likely to be interpreted as a step support of the health mandate on issues In the Commission’s proposed new backwards. However, the health focus like the licensing of glyphosate, the EU budget for the future (Multiannual cannot so easily be abandoned.
Eurohealth — Vol.24 | No.2 | 2018 22 Eurohealth International
First of all, the UK’s vote to leave subsidiarity principle: identifying the References
the European Union and the ensuing policy level that is best placed to address 1 Wismar M, Palm W, Figueras J, Ernst K, Van difficult discussions on finding practical specific challenges. Ginneken E (eds.) Cross-border Health Care in the solutions to separate from the existing EU European Union. Copenhagen: European Observatory regulatory and policy frameworks, have Moreover, as the social dimension is on Health Systems and Policies, 2011. Available at: clearly demonstrated how interconnected becoming ever more critical for the EU’s http://www.euro.who.int/en/about-us/partners/ observatory/publications/studies/cross-border- EU Member States’ health systems and “survival”, its contribution to protecting health-care-in-the-european-union.-mapping-and- policies have become. Brexit not only and improving the health and well-being analysing-practices-and-policies-2011 affects the position of nearly 150,000 of its citizens will have to be part of this 2 Mossialos E, McKee M (Eds.) EU Law and the health and social care workers in the UK new narrative. The European institutions Social Character of Health Care. Brussels: PIE Lang, coming from other EU Member States, all together have just proclaimed the 2002. or the coverage of health care treatment European Pillar of Social Rights, which 3 Rosenkötter N, Clemens T, Sorensen K, Brand H. of EU citizens in the UK and UK citizens establishes a set of 20 principles and Twentieth anniversary of the European Union health living or staying in the EU. It also impacts rights to ensure equal access to the labour mandate: taking stock of perceived achievements, on any EU-based health regulation more market, create fair working conditions failures and missed opportunities – a qualitative generally, as well as on EU-based funding and secure social protection and inclusion. study. BMC Public Health 2013;13:1074. or cooperation in health research or other This pillar explicitly endorses the right 4 Baeten R. New draft EU Directive submits fields. Disentangling all that will cost a lot to health and social care. The EU also regulation of health professions to proportionality of effort and money, but more importantly, strongly committed to the UN's 2030 test. Eurohealth 2017;23(2):24 – 7. it also risks to negatively impact on Agenda on sustainable development, 5 Baeten R, Vanhercke B. Inside the black box: the public health if it would lead to lowering which includes the goal of ensuring EU’s economic surveillance of national healthcare standards, growing staff shortages, healthy lives and promoting well-being for systems, Comparative European Politics 2017;15:478. restricting coverage or decreasing all at all ages. https://doi.org/10.1057/cep.2016.10 health budgets. 9 6 Brand H, Palm W. Health and European integration: part of the problem or part of the Health in all EU Policies solution? Eurohealth 2014;20(3):5 – 7.
To deliver on these commitments, the 7 Mossialos E, Permanand G, Baeten R, Hervey T. strong links with, and the embedment Health Systems Governance in Europe: The Role of of health regulation in other EU policies EU Law and Policy. Cambridge: Cambridge University Press, 2010. No policy level can actually be a value added. The Treaty on the Functioning of the European 8 Greer SL, Fahy N, Elliott HA, Wismar M, Jarman H, or entity can Union, which states that “a high level Palm W. Everything you always wanted to know about European Union health policies but were afraid physical and mental health protection to ask. European Observatory on Health Systems claim exclusivity shall be ensured in the definition and and Policies), 2014. Available at: http://www.euro. implementation of all Community policies who.int/__data/assets/pdf_file/0008/259955/ over health and activities” (Article 168 TFEU), Everything-you-always-wanted-to-know-about- provides a strong mandate for pursuing a European-Union-health-policies-but-were-afraid-to- ask.pdf?ua=1 But also the remaining Member States Health in All Policies approach. 10 Through would have more to lose than to win various mechanisms, like interservice 9 Fahy N, Hervey T, Greer S, et al. How will from withdrawing from a common consultation within the Commission or Brexit affect health and health services in the UK? Evaluating three possible scenarios. The Lancet 2017; health agenda. As shown by previous the involvement of the Public Health ‘‘ 390:2110 – 18. health crises and recent and ongoing Committee in the European Parliament 10 initiatives like the European Reference in discussing legislative proposals, health Azzopardi-Muscat N, Czabanowska K, Tamsma N, Turnbull A. What is the future of Public Health Policy Networks, joint procurement of medical concerns can be brought to the EU table within the European Union? European Journal of countermeasures, the EUs One Health when preparing policies and legislation Public Health 2017;27(5):792–93.
Action Plan against Anti-Microbial in fields like agriculture, internal market, 11 11 Greer S, Harvey T, Mackenbach J, Resistance, as well as collaboration environment or education. Irrespective McKee M. Health law and policy in the European in Health Technology Assessment, of where the locus for health will be in the Union. The Lancet 2013; 381:1135 – 44. many health threats and challenges that future configuration of EU institutions, countries are facing can only be dealt this should be the starting point for an with effectively through cooperation integrated EU health policy, making every and solidarity. Some of these areas of EU Commissioner a Health Commissioner. cross-border cooperation have now been institutionalised in the Directive on the application of patients’ rights in cross- border health care. No policy level or entity can claim exclusivity over health. That is also the true meaning of the
Eurohealth — Vol.24 | No.2 | 2018 Eurohealth Systems and Policies 23
20 YEARS OF HEALTH SYSTEM REFORMS IN EUROPE: WHAT’S NEW?
By: Cristina Hernández-Quevedo, Anna Maresso, Sherry Merkur, Wilm Quentin, Erica Richardson, Anne Spranger and Ewout van Ginneken
Summary: Reforming health systems is crucial to keeping them fit for purpose and able to meet the needs of the populations they serve. While reforms 20 years ago were focused mostly on improving efficiency, in many countries they are now concentrated on improving quality, strengthening primary care services and promoting integrated care. Several examples are used to illustrate the shift in focus, including in the areas of payment mechanisms, primary care and hospitals. Looking forward, European countries still have the same goals i.e. to ensure the sustainability, efficiency and quality of their health systems. But they face rising challenges, which include overcoming system fragmentation, addressing multimorbidity and effectively using an ever-growing supply of data.
Keywords: Health Systems, Reform Trends, Quality, Primary Care, Integrated Care
How has the focus of health system Owing to the Observatory’s varied work reform changed? across Europe, some observations can be drawn. Overall, there has been a growing Cristina Hernández-Quevedo is For the last 20 years, the European recognition of the benefits of adopting a Research Fellow; Sherry Merkur Observatory on Health Systems and is Research Fellow, European health system perspective when tackling Policies has been providing evidence Observatory on Health Systems reforms. That is, since reforms in one area and Policies, London School to support national and international have implications for other parts of the of Economics and Political policy making processes by monitoring Science, UK; Anna Maresso is health system as a whole, policymakers and analysing health systems across Country Monitoring Co-ordinator, are increasingly aware of the need to Europe. Several tools have been used Wilm Quentin is a Senior Research formulate plans that go beyond singular Fellow, Anne Spranger is Research for this purpose, including the Health in policy changes. Furthermore, across Fellow; Ewout van Ginneken is Hub Transition (HiT) series, analytical studies Coordinator, European Observatory Europe there has been a clear shift in the and policy briefs and, more recently, the on Health Systems and Policies, focus of reforms: some changes are in step Berlin University of Technology, Health Systems and Policy Monitor online with national political developments or Germany; Erica Richardson platform (HSPM) * and the Country Health is Research Fellow, European changing environments (e.g. the financial Profiles (the latter jointly with the OECD). Observatory on Health Systems and crisis), while others reflect changing Policies, London School of Hygiene & Tropical Medicine, UK. Email: priorities, such as considerations in health [email protected] * These resources are freely available from: www. care financing or the need to ensure equity healthobservatory.eu
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in tandem with efficiency objectives. This Technology Assessment to aid decision- renewed focus on equity can also be linked making in reimbursement decisions for Box 1: Universal Health Coverage to international organisations, such as pharmaceuticals and other technologies the World Health Organization (WHO), were part of these efforts to improve cost- Achieving UHC means that everyone that have long championed the goals containment and achieve greater value is covered, the type and number of of achieving universal health coverage for money. services are appropriate to reflect the (UHC) and addressing the socio-economic population’s needs, and people are determinants of ill health (Box 1; see also Since then, the rising burden of chronic protected from financial risk through the article by Winkelmann et al. in this illness, and in particular the rapid increase adequate public funding (protecting issue). in the number of people with multiple against high co-payments and other health problems (multimorbidity), along private out-of-pocket spending). Another factor shaping the agenda of with the ageing of the population have Strong political momentum for UHC health reforms in European Union (EU) emerged as tangible health system is endorsed by the 2015 decision countries is the need for Member States challenges that need attention. In of the United Nations General to comply with EU legislation. Member response, there has been a growing Assembly to adopt health as one of States have undertaken reforms in areas acknowledgement of the importance of its 17 sustainable development goals such as setting limits on the working prevention and health promotion, having a (SDGs) and UHC is health target hours of doctors and ensuring that the strong primary care system with integrated SDG 3.8. 5 In celebrating its 70th reimbursement of health services are in services, and improving the quality of anniversary, WHO has spearheaded line with the directive on cross-border services. 4 Moreover, rising multimorbidity several initiatives to achieve UHC care 1 (see also the article by Palm and will necessitate a shift from disease including “Health for All” and the Wismar, in this issue). In addition, since focused health systems to patient-centred “UHC 2030 International Health the onset of the economic crisis some health systems, but European countries Partnership”. The latter is a joint countries, such as Cyprus, Greece, are generally still at the beginning of this initiative by national governments, Latvia and Portugal, have pursued transformation. Being able to monitor international organisations and quite substantial reforms as part of the health systems’ performance so that they civil society determined to achieve conditions specified within Economic meet their stipulated goals and priorities UHC by 2030. Adjustment Programmes tied to has also emerged as an important financial assistance from international objective, although much work still needs lenders. Such conditions may focus on to be done in designing feasible and containing costs and introducing greater appropriate performance metrics (see the for general practitioner services on the efficiencies. 2 In non-EU countries article by Smith et al. in this issue). basis of a combination of capitation and and particularly Former Soviet Union fee-for-service. In hospital care, most (FSU) countries, transnational actors, Health reform trends over time European countries have refined their including WHO and the World Bank, payment systems by introducing a variant or bilateral actors such as USAID, play In this section we provide a broad of DRGs, which is used to determine at a major role through assisting countries description of some health reform trends least part of the hospital budget. This to devise reform plans and by lending or that illustrate the shift in focus. means that payment depends on the providing aid. diagnoses of patients treated and on the Payment mechanisms procedures performed. Nevertheless, global budgets continue to play an Moving from improving efficiency to Over the past 20 years, almost all important role, for example, as a base tackling new challenges countries have reformed (and re- payment independent from DRGs or as reformed) their payment systems for Broadly speaking, policies in the a limit to the total amount that hospitals primary care, specialist ambulatory care, late 1990s were focused on improving can receive on the basis of DRG-based and hospital care. In line with overall efficiency, often strengthening case payments. Furthermore, with the trends, the main objective in earlier years competition or using market liberalisation increasing availability of information was to increase efficiency in service as a tool to increase the effective use on quality of care, the focus of payment provision. Often existing payment of resources. Policymakers faced reform has shifted towards the use of this mechanisms (e.g. capitation payments) pressures to achieve better control over information in “pay for quality” (P4Q) or were combined with other elements expenditure and/or greater productivity “pay for performance” (P4P) initiatives. (e.g. fee-for-service payments) in order and efficiency, while still maintaining However, the size of incentives related to overcome the negative incentives universal access to care and improving to quality of care remains limited (e.g. related to more simple forms of provider the distribution of services. 3 Changes usually 5 – 15% for primary care, and less payment. These reforms have resulted to payment mechanisms, such as the than 5% for hospital care). 6 Too often, in different – but increasingly quite development of Diagnosis-Related- countries brand their payment scheme similar – forms of blended payments Group (DRG-) based payment systems, P4P, although in fact it is still focused systems across countries. In ambulatory and the increased adoption of Health on production and efficiency increases care, most countries in Europe now pay
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instead of quality metrics. Furthermore, than ‘manage’ chronic conditions. They presupposes that patients have somewhere given the rather inconclusive evidence are, therefore, not efficiently organised safe and supportive to go to, which about the effectiveness of P4Q 7 and to respond to the changing needs and requires continuity with other parts of the continuing debates about the reliability preferences of users, in particular, those health and care system. of quality information, it remains to be with multiple chronic conditions. In seen whether the growth of P4Q initiatives response, countries have been looking Long-term care will continue. at ways to strengthen the coordination Over the last 20 years, countries have between primary care, secondary care and increasingly developed the public other-level services for the chronically provision of long-term care (LTC) (due ill. Among several country examples to the ageing population, co-morbidities that include Germany and the United rising among older people, and the need to Kingdom, we can add Denmark, which provide assistance with daily activities), in recent years has launched a national multimorbidity will although the pace of changes has been strategy on chronic disease management largely determined by budget constraints. and developed a generic model for chronic necessitate a There is a high level of heterogeneity disease management programmes together across Europe in the size, organisation with the regions and municipalities. shift from and financing of such services, with countries placing different emphasis Hospitals disease focused on the resources dedicated to providing Historically, hospital care has been at the institutional care in nursing homes, formal to patient- very centre of health service delivery. care within the home and community However hospitals have been faced with settings, or providing cash benefits to centred health many challenges which have changed eligible recipients to purchase the care ‘‘ enormously in recent decades. The factors that they need. An example of a country systems involved are extremely complex and with a very comprehensive LTC system interlinked but broadly include changes in is the Netherlands, but concerns about Primary care technology (diagnostics and treatments), its sustainability led to recent reforms While the gatekeeping role of primary changes in patients (who are older, frailer which have sought to control spending by care providers is often cited as the and often more socially isolated), changes keeping people in their homes longer and main characteristic of a strong primary in staffing (a move towards specialists giving municipalities a stronger role in care system, additional conditions also and multidisciplinary teams), and the coordination of non-residential care. contribute to the strength of primary care changes in the models of care (involving One thing that has not drastically changed such as the lack of barriers to access, networks and integrated pathways). 9 over this period is the strong reliance on closeness of primary care services to Furthermore, hospitals continue to have a informal care by family members and communities, a patient-centred approach, concentration of medical and diagnostic other carers, who continue to provide the and continuity of care. 8 Over the last expertise, while at the same time striving bulk of care for older people. 10 decade, the delivery of primary care to provide integrated care for chronic has moved increasingly from a system patients, involving transfer to care in Quality of care of solo gatekeepers to multidisciplinary the community and the home as well as Most health reforms in Europe over the health centres. There has also been managing patient expectations. These last two decades have claimed to aim at greater emphasis all over Europe on profound sets of changes have led to improving the quality of care, but they managing chronic care conditions within many reforms. have often been vague about what that the primary care setting, For example, actually means. There is an emerging multidisciplinary primary care units Over the past 20 years, hospital reforms consensus that quality of care is the degree are the core element of primary care in many European countries have to which health services for individuals both in Spain and Portugal, providing focused on reducing the overall number and populations are effective, safe, and better integrated primary care for local of hospital beds and concentrating people-centred. 11 Efforts to improve populations. Recent reforms in Estonia are highly specialised care. Furthermore, quality of care around the turn of the aiming to achieve this as well. the emergence of patient safety on the century were still mostly focused on policy agenda, which overlaps to some assuring the quality of health system Primary care also has a substantial role extent with the concept of quality of care, inputs or structures, e.g. by defining in managing chronic conditions. In fact, a reflects the need for hospitals to put in standards for buildings, professional higher use of health services and related place appropriate procedures and new training, continuous education and costs due to the increase in multimorbidity organisational structures. The move in technologies. Since then, efforts have are among the key concerns currently hospital funding towards DRG-based shifted to improving health care processes faced by policymakers in Europe. 4 Most payment systems incentivises hospitals to and outcomes and this remnains an open of these health care systems have been increase efficiency with the consequence agenda given the difficulty in measuring designed to ‘treat’ acute episodes, rather of reducing length of stay. The latter
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for ensuring that deep, systemic reform stays on track (see Box 2). Without such Box 2: Strategies for reform: Kyrgyzstan and the Republic of Moldova consensus, there is a risk that a cycle develops with each new government The Moldovan National Health Policy (2007 – 2021) provides a systemic approach reforming the health system by unpicking to improving the health of the population and outlines the overall priorities for the the work of those previously in power health system. The importance of cross-party support for health strategies came to along ideological lines. Such a treadmill of the fore during extended periods of political uncertainly in the country such as from reform, where changes are announced but April 2009 to March 2012 when political stalemate meant there was no functioning with insufficient consensus, can impede government. This shared political support meant that necessary reforms could successful implementation. Concrete plans still progress. for reforms can be hindered by a lack of The first Kyrgyz health programme (Manas, 1996 – 2006) laid the foundations for stakeholder commitment, un-coordinated the rebuilding of the health system following independence from the USSR and actions and/or badly designed incentives. extreme economic hardship. The achievements of the first strategy in laying the Thus, strong leadership and operational foundations for a sustainable and equitable health system were consolidated in the planning are needed to keep reforms on second programme (Manas Taalimi, 2006 – 2010). Notably, these plans have had track. Subsequently, evaluation of reforms the support of the medical community as well as politicians and donors. is crucial to building a knowledge base and maintaining support. 15 Evaluations also Along with broad stakeholder support, both strategies took a longer-term allow policymakers to learn from reforms perspective – beyond a single political cycle – acknowledging that bold reforms that did not work well or had unintended to the way health services are financed, organised and provided take time to consequences and to address shortcomings implement. Both strategies also emphasise how implementation should be with remedial action. monitored and evaluated to ensure they deliver on agreed priorities.
Sources: 12 13 reform
health outcomes and of attributing change However, insufficient resources can limit initiatives should to a particular intervention or provider. In a system’s capacity to reform in times of addition, countries have been increasingly fiscal constraint. Firstly, lacking policy start with an interested in collecting patient-reported and managerial capacity to effectively experience measures (PREMs) as well run a reform will blunt implementation assessment of as patient reported outcome measures efforts. This factor is often overlooked but (PROMs), as a means to improve health any reform initiatives should start with an available policy system quality. Nevertheless, as a result of assessment of available policy capacity. the increasing availability of information– Secondly, successful reforms also need capacity due to the expansion of information and to use existing capacity efficiently and communication technology (ICT) in health if necessary to build capacity in the Where might reforms be going next? systems and health care organisations– health system, particularly in the health ‘‘ The emerging patterns of health system there is a continuously growing potential workforce. If health services need to be reforms point to common challenges for using this information in order provided in a different way, then health facing policymakers across Europe, to measure and improve health care workers need the necessary training as well as common difficulties in the processes and outcomes. to implement the required changes. implementation of reforms. Looking Similarly, health financing reforms are forward, these challenges include ensuring underpinned by capacity building in health What does it take to successfully the sustainability, efficiency and quality of care management at the provider level. reform a health system? their health systems. The successful introduction of active There are several factors that can facilitate purchasing mechanisms, for example, also The trends suggest that there will be a or limit the successful reform of a health relies on good data, so it is necessary to continued focus on reforms that aim to system which can be captured under two strengthen IT capacity in parallel. guide patients more fluidly through the main categories: capacity constraints and health system, including enabling primary political will. Political will, vision and leadership: The care systems to manage patients with importance of a clear vision and political long term chronic conditions and to better Capacity constraints: As mentioned will to strengthen the health system should co-ordinate or integrate health services for above, sometimes the spur for health not be underestimated. 14 A ‘roadmap’ everyone. This implies that countries need system reform has been some form of with cross-party support and buy-in from to shift their health systems away from a external economic shock and policies a wide range of stakeholders (including disease-focused provision of health care seek to contain health care spending. health workers) can be a powerful tool
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to a patient-centered approach that looks References 10 Mor V, Leone T, Maresso A (eds.) Regulating long-term care quality: An international comparison. at the patient’s (multiple) needs and his or 1 Greer SL, Fahy N, Elliott HA, Wismar M, Jarman H, Cambridge: Cambridge University Press, 2014. her environment (ie. taking a holistic view) Palm W. Everything you always wanted to know and away from fragmented delivery in about European Union health policies but were afraid 11 WHO. Handbook for national quality policy and several subsystems with separate funding to ask. Copenhagen: World Health Organization strategy: a practical approach for developing policy sources (e.g. social care, acute care). (acting as the host organization for, and secretariat and strategy to improve quality of care. Geneva: of, the European Observatory on Health Systems World Health Organization, 2018. Although it is early days, many countries and Policies), 2014. Available at: http://www.euro. 12 Balabanova D, McKee M, Mills A (eds.) ‘Good are piloting and exploring population- who.int/__data/assets/pdf_file/0008/259955/ health at low cost’ 25 years on. What makes a based integrated care programmes which Everything-you-always-wanted-to-know-about- successful health system? London: London School of European-Union-health-policies-but-were-afraid-to- have the potential to combine the benefits Hygiene and Tropical Medicine, 2011. of a patient-centred approach with ask.pdf?ua=1 13 Turcanu G, Domente S, Buga M, Richardson E. payment reform, and by doing so, facilitate 2 Thomson S, Figueras J, Evetovits T, et al. Republic of Moldova: health system review. Health Economic crisis, health systems and health in Europe. better cooperation and integration. An Systems in Transition 2012:14(7):1–151. ever-growing ambition is to harness the Impact and implications for policy. Maidenhead: Open University Press, 2015. Available at: http://www. 14 potential of information systems and Rechel B, Richardson E, McKee M. Trends in euro.who.int/__data/assets/pdf_file/0008/289610/ health systems in the former Soviet countries. patient data as enablers of this patient- Economic-Crisis-Health-Systems-Health-Europe- Copenhagen: World Health Organization (acting centred vision and to facilitate the sharing Impact-implications-policy.pdf?ua=1 as the host organization for, and secretariat of, the European Observatory on Health Systems and of decision-making between patients, 3 Saltman R, Figueras J. European Health care Policies), 2014. caregivers and doctors. Coupled with more Reform. Analysis of current strategies. European emphasis on prevention and addressing the Series, no. 72. Copenhagen: WHO Regional Office 15 Kutzin J, Cashin C, Jakab M. Implementing social-economic determinants of health, for Europe, 1997. Available at: http://www.euro.who. health financing reform: Lessons from countries in policies and new technologies will also int/en/about-us/partners/observatory/publications/ transition. Copenhagen: World Health Organization studies/european-health-care-reform.-analysis-of- aim to identify and target potential health (acting as the host organization for, and secretariat current-strategies-1997 of, the European Observatory on Health Systems and problems further upstream by fostering 4 Policies), 2010. healthier populations to begin with. Nolte E, Knai C, Saltman RB. Assessing chronic disease management in European health systems: 16 Jacab M, Palm W, Figueras J, Kluge H et al., concepts and approaches. Copenhagen: World Health systems respond to NCDs: the opportunities Such developments would reinforce other Health Organization (acting as the host organization and challenges of leapfrogging. Eurohealth health system strengthening initiatives that for, and secretariat of, the European Observatory 2018;24(1): 3 – 7. bolster sustainability, such as creating a on Health Systems and Policies), 2014. Available health workforce that is resilient to future at: http://www.euro.who.int/__data/assets/ pdf_file/0009/270729/Assessing-chronic-disease- challenges and investing strategically to management-in-European-health-systems.pdf?ua=1 provide access to health services that are 5 proven, safe and cost-effective. Reforms World Health Organization and the International HiT Health System Bank for Reconstruction and Development; The World are also likely to look to innovation to Bank. Tracking universal health coverage: 2017 global Reviews potentially maximise gains and capitalise monitoring report, 2017. Available at: http://pubdocs. on experiences elsewhere. This could worldbank.org/en/193371513169798347/2017- HiT health system reviews are involve examples of leap-frogging 16 over global-monitoring-report.pdf country-based reports that provide inferior or less efficient technologies 6 Eckhardt, H, Smith P, Quentin W. Pay for Quality. a detailed description and analysis or adopting more innovative delivery In: Busse R et al. (eds.) Improving Quality of Care in of a country's health system and structures to accelerate improvements in Europe: A systematic overview of quality strategies. of reform and policy initiatives in disease management or health outcomes. Copenhagen: World Health Organization (acting as the host organization for, and secretariat of, progress or under development. the European Observatory on Health Systems and All of this is in keeping with the enduring Policies). Forthcoming. Download them free at: challenges that have underpinned health http://www.euro.who.int/en/ 7 Milstein R, Schreyoegg J. Pay for performance system reform trends over the last few in the inpatient sector: A review of 34 P4P about-us/partners/observatory/ decades: to design and implement changes programs in 14 OECD countries. Health Policy publications/health-system- that the health system can afford while at 2016;120(10):1125 – 40. reviews-hits the same time delivering high quality care 8 Kringos DS, Boerma WGW, Hutchinson A, to the people who need to use its services. Saltman RB. Building primary care in a changing 1 06/06/2018 16:03 61468 Greece_covers_9.6mm_spine.pdf Health Systems in Transition Europe. Copenhagen: World Health Organization Vol. 19 No. 5 2017 Vol. 19 No. 5 2017 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems
and Policies), 2015. Available at: http://www.euro. Health Systems in Transition: Greece who.int/__data/assets/pdf_file/0018/271170/
BuildingPrimaryCareChangingEurope.pdf
9 Greece McKee M, Merkur S, Edwards N, Nolte E (eds.) Health system review
The changing role of the hospital in European health Charalampos Economou Daphne Kaitelidou Marina Karanikolos systems in the 21st century. Cambridge: Cambridge Anna Maresso HO Regional s and Policies is a partnership, hosted by the orway,W Slovenia, ssion; the The European Observatory on Health Systemvernments of Austria, Belgium, Finland, Ireland, N University Press; forthcoming. he Veneto Region of Italy; the European Commiof Economics Office for Europe, which includes the Go of Health Insurance Funds); the London Schooln Observatory Sweden, Switzerland, the United Kingdom and t niversity World Bank; UNCAM (French National Unionol of Hygiene & Tropical Medicine. The Europea ndon (at LSE and LSHTM) and at the Technical U and Political Science; and the London Scho has a secretariat in Brussels and it has hubs in Lo pproach that of Berlin. initiatives and policies, produced using a standardized a
e facts, figures and analysis and highlight reform HiTs are in-depth profiles of health systems allows comparison across countries. They provid in progress.
ISSN 1817-6127
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Reform directions – changing contexts and enduring challenges
Two seminal studies marked the launch of the Observatory in 1998. They basically laid out the groundwork for developing a systematic approach to describing and assessing the development and reform of health systems in Europe.
Both publications – European health care reform. Analysis of current strategies (1997) and Critical challenges for health care reform in Europe (1998) were the result of the preparatory work for the 1996 WHO Conference in European Health Care Reforms, held in Ljubljana and helped to shape the recommendations made in the Ljubljana Charter, which was approved by the Member States.
We asked one of the editors and co-founders of the Structurally, a substantial number of country health Observatory, Richard Saltman, Professor of Health systems have undergone major organisational Policy and Management at the Rollins School of reforms, re-arranging formal reporting, managerial Public Health, Emory University, USA, whether the and governance relationships. Governance has been context of health system reforms has fundamentally both decentralised to institutional level (various types changed over these last twenty years and if the of self-governing hospitals) while centralised more challenges described back then have been met. in national political bodies (e.g. Norway, Denmark, Ireland, Netherlands, Germany, also Czech) especially Professor Saltman: Well, from a clinical perspective, for financing issues. Management has become stronger many practical dimensions of day-to-day medical care at hospital level, supported by IT and, at the executive have indeed changed as the international standard of level, often by boards of trustees. clinical care has evolved, although the rate and degree of change varies across systems. Patient-wise, there has On the financial level, securing sufficient funding been substantial improvement in patient choice across still remains the biggest challenge, especially in tax- tax-funded health systems, and, equally as important, funded health systems. Since the economic recovery a strong shift across Europe in favour of patient control in Europe following the financial crisis has been weak over their clinical care. for nearly a decade, even with recent improvement, a next recession may be difficult for nearly all publicly There have been efforts to strengthen primary care, for financed health systems. example in Denmark (extra payment to manage certain chronic elderly patients) and in Sweden (shifting 50% Lastly, politically, and perhaps underscoring many of of primary care physicians and visits to a private sector these other points, the policy tension between public and GP model). In Central Europe and Former Soviet private never goes away in European health policy. Republics primary care has established deeper, mostly private sector, roots. Managing chronically ill elderly has become a central focus, along with finding better ways to collaborate with social sector actors.
Clearly, IT has altered patient pathways for some chronic conditions, although it can sometimes also become a barrier to effective primary care as GPs spend visit time reporting on the keyboard rather than examining the patient. While there has been considerable clinical innovation, there remains much to do, particularly in tax-funded health systems. The rapid developments in genome-based personal medicine will test existing European health systems going forward.
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GETTING AND KEEPING PEOPLE HEALTHY: REFLECTING ON THE SUCCESSES AND FAILURES OF PUBLIC HEALTH POLICY IN EUROPE
By: Gemma A Williams, Bernd Rechel, David McDaid, Matthias Wismar and Martin McKee
Summary: Public health policies in Europe have achieved much success in the past 20 years, reducing the burden of communicable and non-communicable diseases (NCDs) and thus contributing to rising life expectancy. This article explores some of the successful health promotion and disease prevention policies that have been implemented across the region, focusing specifically on those that aim to combat NCDs. We identify policy gaps and contemplate why some countries have been able to implement effective polices while others have not. We offer concluding remarks on how the public health community can respond to meet new and emerging public health challenges.
Gemma A Williams is Research Officer, European Observatory Keywords: Public Health Policies, Non-Communicable Diseases, Tobacco Control, on Health Systems and Polices, London School of Economics and Alcohol Control, Obesity Political Science, UK; Bernd Rechel is Research Officer, European Observatory on Health Systems and Polices, London School of Shifting priorities over the last the greatest gains were from improving Hygiene & Tropical Medicine, 20 years UK; David McDaid is Associate sanitary conditions and tackling infectious diseases. The last 20 years have, however, Professorial Research Fellow, People across Europe are living longer Department of Health Policy, seen a shift in priorities, with public and healthier lives than ever before. Life London School of Economics health becoming increasingly focused and Political Science, UK; expectancy and healthy life expectancy on combatting the growing challenge Matthias Wismar is Senior have, at least until recently, steadily risen, Health Policy Analyst, European of NCDs, which now account for while rates of communicable diseases Observatory on Health Systems approximately 77% of the disease burden and Policies, Brussels, Belgium; and major non-communicable diseases and 80% of health care costs in Europe. 1 2 Martin McKee is Co-Director, (NCDs) such as cardiovascular diseases European Observatory on Health and preventable cancers have seen Systems and Polices and Professor Public health has a critical role to play of European Public Health, London overall declines. 1 Although the exact in combatting NCDs. Much of the School of Hygiene & Tropical contribution is difficult to quantify, much disease burden can be prevented or Medicine, UK. of this success is due to implementation Email: [email protected] delayed by reducing exposure to a few of effective public health policies. Once,
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immediate hazards, such as enforcement of drink driving limits, and measures in Box 1: Selected European policies and strategies that support comprehensive some major cities to enhance opportunities approaches to health promotion and prevention for physical activity by investing in cycling and walking infrastructure. More recently, The Vienna Declaration on Public Health adopted in 2016 reaffirms the region’s there has been growing recognition of commitment to the Ottawa Charter, but also embraces new commitments to meet the potential for campaigns that directly new and emerging threats to public health. 3 These commitments include enhanced target corporations manufacturing these use of information systems; greater advocacy for health; monitoring the effects of products, exposing the tactics they use to Health in All Polices; and creating a highly qualified public health workforce. undermine healthy public policies. The European Health 2020 policy framework defines priority areas for action and outlines strategies that rely on joint action across government and society to improve health, reduce health inequalities and ensure the health of future generations. 4 Priory areas include, but are not limited to, investing in health through many a life-course approach and tackling the disease burden of non-communicable and communicable diseases. countries The Health in All Policies approach was adopted in 2006 with the aim of enhancing adopting collaboration across sectors in recognition that health and health inequalities are determined by many factors outside of the health sector. 5 It advocates for impacts multifaceted on health to be considered in policy making from other sectors. The European Treaties require a high level of health to be assured in all EU policies. responses that New opportunities for public health and the advancement of the Health in All Policies approach are presented by the European Pillar of Social Rights, a joint cross multiple proclamation from the European Parliament, European Council and European Commission. The Pillar provides a framework for improving equal opportunities and sectors access to the labour market, fair working conditions and inclusion by supporting ‘‘ policies and activities that promote ‘a high level of employment, the guarantee Over the past two decades, these of adequate social protection, the fight against social exclusion and a high multifaceted policy approaches have level of education, training and protection of human health’. 6 The Pillar creates contributed to a steady decline in alcohol opportunities for multi-sectoral collaboration and actions that are necessary to consumption, smoking prevalence and tackle the social determinants of health (see Box 2). related harms across the European Union (EU) and to a slight stabilisation in the rate The European NCD strategy promotes a comprehensive and integrated approach of increase of obesity prevalence in some to tackling NCDs. It advocates for integrated intersectoral action on risk factors and countries. 1 As highlighted by research their underlying determinants, with efforts to refocus health system actions towards from the European Observatory on Health improved prevention and control. 2 The NCD strategy is supported by a number Systems and Policies on the ‘Economic of complementary strategies on individual risk factors in areas including food and case for prevention’, these policies overall nutrition, physical activity, smoking cessation policies and tobacco and alcohol have also been shown to be cost-effective control both at the European and national levels. and in some cases cost saving. 7
Public health policies have also played major risk factors, namely tobacco, tackling exposure to leading risk factors a key role in reducing cancer incidence alcohol, unhealthy diets, and sedentary through action on price, availability, and mortality by targeting both primary lifestyles, while secondary prevention, and marketing. Examples of ‘best buys’ prevention (reducing exposure to risk such as organised screening for early include taxation, initially applied to factors) and secondary prevention through detection of cancer, also contributes. In tobacco and alcohol and now successfully screening for early detection. The majority the past 20 years, Europe’s governments to sugar-sweetened beverages; advertising of countries have implemented have scaled up their efforts to implement restrictions on alcohol, tobacco and population-based screening programmes appropriate measures to combat NCDs, unhealthy food and drinks; and regulations for breast, cervical and colorectal with many countries adopting multifaceted on availability and accessibility – for cancers in the past 20 years, spurred by responses that cross multiple sectors example, through minimum ages, smoking recommendations from the European (see Box 1). bans, bans on trans fats, restrictions on Council in 2003 on best practices in fast food outlets and licensing restrictions early cancer detection. 8 A recent review 1 Successes in public health policy on retail monopolies for alcohol sales. of progress found that 25 EU Member States now have population-based The most successful policies have been These policies have been accompanied breast cancer screening programmes, those implemented at a population level, by actions in all countries to reduce more 22 have population-based cervical cancer
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screening programmes, and 23 have or are planning to implement population-based 8 Box 2: Tackling health inequalities colorectal screening.
Substantial inequalities in health and life expectancy persist across and within Public health policy gaps EU countries. Health varies by many modifiable factors, including socioeconomic status, employment, and ethnicity, with these factors often clustering. Compared to Despite much progress, many policy gaps more affluent individuals, people with a lower socioeconomic status are more likely remain that are preventing progress in to have poorer mental and physical health, including a higher prevalence and earlier tackling poor health and its determinants. onset of chronic conditions. They are more likely to smoke, be obese and drink One of the most pressing issues remains excess alcohol, but less likely to attend routine cancer screening services. This the development of effective health and evidence has given rise to the concept of the social determinants of health. intersectoral policies to tackle health inequalities (see Box 2). A number of strategies at the European (see Box 1) and national levels have been implemented in the past decade to address health inequalities. These ideally Alcohol adopt the principles of Health in All Policies, establish health equity as a political priority and take a life-course perspective. However, these policies often fail to When considering the main risk factors, tackle the fundamental cause of health inequalities, namely the unequal distribution a discord remains between the strength of resources and power in society, or the transmission of poverty and ill health of alcohol control policies and the scale between generations. of alcohol use and related harms. Alcohol consumption and the burden of alcohol- It is important that policies acknowledge that health inequalities have causes related diseases and mortality remains beyond the direct influence of health sectors and require intersectoral actions higher in Europe than in any other to spur necessary transformations in social and economic development that region, yet many effective alcohol control will improve the health of the most vulnerable to the levels of the most affluent strategies have been opposed strongly by in society. the alcohol industry, preventing or limiting In the past 20 years, intersectoral actions from different sectors such as sport, their implementation. Affordability is transport, finance, agriculture or education and industry representatives, the media, one of the most important drivers of and non-governmental organisations have contributed significantly to improving the consumption, but minimum alcohol efficiency, effectiveness and cost-effectiveness of many public health interventions unit prices have only been introduced and to reducing health inequalities. Successful examples include smoking bans in in Scotland very recently and many public areas, voluntary reformulation of salt content in food, taxes on alcohol and countries have failed to adjust taxes for cigarettes, and expansion of facilities encouraging physical activity. Nevertheless, inflation in recent years, increasing the greater intersectoral collaboration is needed to create healthy environments that relative affordability of alcohol over time. make healthy living easier, in particular for those with low socioeconomic status Additionally, mandatory labelling of alcohol is not required in the EU while a number of countries lack alcohol strategies or national action plans, key components people. Although these have attracted while few countries have introduced of a comprehensive strategy to reduce some support from health professionals, mandatory front-of-package labelling alcohol consumption. mainly in England, elsewhere there are to help consumers easily understand the growing concerns about evidence that they nutritional content of food. Promoting Tobacco encourage adolescent smoking and reduce cycling as part of daily commutes rather than help quitting. represents a cost-effective way to Tobacco is one area where there has been increase physical activity levels among considerable success, despite the strenuous Obesity the working-age population, yet outside efforts of tobacco companies. However, of some major cities in Western Europe, there is still considerable scope to raise Existing policies are currently insufficient investment in cycling infrastructure prices markedly and not all countries have to stem the alarming rise in obesity remains low. 6 yet kept up with the leaders who have prevalence, which has more than doubled banned smoking in public places, imposed since 2000. In terms of best buy policies, Cancer screening pictorial health warnings, prohibited less than one-third of EU Member States point of sales displays and enforced have introduced taxes on sugar-sweetened Further policy efforts are needed to reduce plain packaging. Inevitably, the tobacco beverages, taken action to ban trans fats inequalities in access to cancer screening. industry is fighting back. Recognising or introduced mandatory reformulation Population-based screening programmes the importance of encouraging and of salt content in food. 1 Regulations on are absent in Bulgaria, Greece, and maintaining nicotine for its business the advertising of unhealthy foods and Slovakia, while uptake of screening model, it is now heavily promoting drinks to children are missing in many varies markedly, ranging from 6.2% a range of nicotine delivery devices, countries and generally only apply to to 83.5% across countries, compared to several targeted particularly at young broadcast media, ignoring social media, the EU average of 60.2%. Furthermore,
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significant inequalities in uptake remain Routine surveillance of NCDs and related quantities of rapidly collected, complex between social groups, reflecting a need risk factors are not available in some data–will improve understanding and for cancer screening policies to address countries, making it difficult to develop monitoring of current and emerging the barriers preventing people with low country-specific, evidence-based health health threats and can be used to inform socioeconomic status from accessing policies. Many countries also lack an appropriate responses. However, this is screening programmes. appropriately qualified public health threatened by revelations of the misuse of workforce and the governance structures data for commercial and political purposes that are necessary to enact and enforce and there is a need to rebuild public trust. 3 legislation. Importantly, investment in it is public health remains low throughout To adopt and implement effective public the EU, with preventative care generally health policies it will be necessary to make essential that accounting for an average of only 3% of better use of intersectoral governance health budgets, 1 and with some countries mechanism such as cabinet committees cost-effective experiencing a major reduction in and secretariats, parliamentary spending following the recent global committees, interdepartmental public health economic crisis. committees and units, mega-ministries and mergers, joint budgeting, delegated strategies are The way ahead for public health policy financing, and public, stakeholder and industry engagement. 10 implemented Public health policies over the last 20 years have contributed substantially to reducing Meeting future public health challenges and enforced in the burden of disease in Europe. However, can only be achieved by adopting ‘‘ although good progress in the region has a whole-of-society and whole-of- all countries been made overall, a number of proven, government approach. The engagement cost-effective policies have not been and action of individuals, civil society, Many factors have influenced the introduced or have only been partially researchers, public health professionals, success and failure of public implemented in many countries. These and government and industry stakeholders health policy policy gaps are undercutting health are fundamental to ensure the successful improvements and contributing to development, implementation and Some countries in Europe have been persistent health inequalities. enforcement of effective public health and more successful at adopting effective intersectoral policies. As recognised by public health polices than others. Yet, Moving forward, it is essential that the Vienna Declaration, it is important why is this the case? In recent years, there cost-effective public health strategies are that these actors are actively encouraged has been increasing recognition that the implemented and enforced in all countries. to engage with public health issues and political and commercial determinants This will help create conditions that that governments, industry and civil of health present major obstacles to the make it easier for people to live healthy society are held to account for any health- implementation and effectiveness of public lifestyles and will lay the foundation harming actions. health policies. 9 In particular, better for public health to respond to growing understanding of the role of manufacturers and new threats posed by issues such as Lastly, responding effectively to future in opposing healthy public policies has antimicrobial resistance, climate change health challenges in Europe will not given rise to a new area of study, the and emerging and re-emerging infectious be possible without renewed focus and ‘commercial or corporate determinants diseases. It is important that the equity investment in public health. Across the of health’. Powerful corporations can effects of any policy are considered to region, public health is not prioritised shape the dominant narrative, such as ensure they do not disproportionately or incentivised, despite evidence that the trade-off between individual rights disadvantage the least well-off and investing in effective prevention strategies and government action. They also exacerbate health inequalities. can provide a greater return on investment seek to capture the regulatory process, and generally represents better value for emphasising largely ineffective voluntary To improve future public health responses, money than treatment of disease at later agreements rather than legislation. Politics it is also important that all countries stages. There is thus a strong economic also matters: a lack of political will to develop a highly motivated and skilled case to be made for greater public health address a public health issue is likely to public health workforce that can meet action, and public health professionals translate into a lack of action. emerging threats, advocate for public must advocate for public health to capture health, and build intersectoral partnerships a larger share of health budgets. Finally, even if a public health issue has to tackle health inequalities. Enhanced been established as a political priority, use of health information systems for some countries may lack the necessary surveillance of infectious diseases and resources and infrastructure for the NCDs, and related risk factors, combined implementation of effective policies. with growing availability of big data – vast
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Organization and financing of explains the training and employment of the public health workforce; and analyses existing frameworks for quality and public health services in Europe: performance assessment. Country reports The study reveals a wide range of experience and variation across Europe and clearly illustrates two fundamentally different Edited by: B Rechel, A Maresso, A Sagan, et al. approaches to public health services: integration with curative health services (as in Slovenia or Sweden) or organization and Copenhagen: World Health Organization (acting as the host provision through a separate parallel structure (Republic of organization for and secretariat of, the European Observatory Moldova). The case studies explore the context that explain on Health Systems and Policies) 2018. this divergence and its implications. Number of pages: xi + 133 pages This study is the result of close collaboration between the Freely available to download at: http://www.euro.who. European Observatory on Health Systems and Policies and int/__data/assets/pdf_file/0011/370946/public-health-services. the WHO Regional Office for
pdf?ua=1 49 49 Europe, Division of Health OBS_49_A4_new_color_WHO_A4 18/04/18 12:59 Page 1
ORGANIZATION AND FINANCING OF PUBLIC HEALTH SERVICES IN EUROPE
Organization and Series ey are, or what Systems and Public Health. of nine countries, detailing
What are “public health services”? Countries across Europe understand whatnd th train and employ financing of public Policy Health they should include, differently. This study describes the experiences, the Netherlands, Slovenia, the ways they have opted to organize and finance public health services a current practice that What are “public health services”? Countriestheir public health workforce. It acrosscovers England, France, Germany,Europe ealthItaly capacities and services. health services It accompanies two other Sweden, Poland and the Republic of Moldova, and aims to give insightsth into services and the context will support decision-makers in their efforts to strengthen public h sources of public in Europe Each country chapter captures the historical background of public healment of the public health understand what they are, or what they should include, ssessment. The study Observatory publications in which they operate; sets out the main organizational structures; assesses the health financing and how it is allocated; explains the training and employand clearly illustrates two Country reports ith curative health workforce; and analyses existing frameworks for quality and performance a te parallel reveals a wide range of experience and variation across Europe differently. This study describes the experiences fundamentally different approaches to publicof health nine services: integration t explain w this divergence Edited by: Organization and financing services (as in Slovenia or Sweden) or organization and provision through a separa Bernd Rechel structure (Republic of Moldova). The case studies explore the context tha tory on Health Systems Anna Maresso and its implications. lth Systems and Public Health. countries, detailing the ways they haveThis studyopted is the result of close to collaboration organize between the European Observa and Anna Sagan of public health services in Organization and financing of public health and Policies and the WHO Regional Office for Europe, Division of Hea Cristina Hernández-Quevedo It accompanies two other Observatory publications (both forthcoming). and The role of public health organizations in addressing public health problems services in Europe Gemma Williams finance public health services and trainin Europe: and the case of obesity,employ alcohol and antimicrobial their resistance public Erica Richardson Europe and The role of icies, Elke Jakubowski The editors bservatory on Health Systems and Pol is Research Officer at the European O s. Ellen Nolte Bernd Rechel giene & Tropical Medicine. health workforce. It covers England, France,based at the London School Germany, of Hy bservatory Italy,on Health Systems and Policiecies, public health organizations is Research Officer at the European O Anna Maresso bservatory on Health Systems and Poli is Research Officer at the European O Anna Sagan Economics and Political Science. bservatory on Health Science. the Netherlands, Slovenia, Sweden, Polandbased at the London andSchool of is Research the Officer atRepublic the European O in addressing public health Cristina Hernández-Quevedo ondon School of Economics and Political Systems and Policies, based at the L Observatory on Health Systems and is Research Officer at the European Gemma Williams ol of Economics and Political Science. ervatory on Health Systems and of Moldova, and aims to give insights into Policies, basedcurrent at the London Scho practice that problems in Europe: the is Research Officer at the European Obs Erica Richardson Hygiene & Tropical Medicine. Policies, based at the London School of egy at the Division of Healthn. Systems is Senior Advisor for Policy and Strat lth Elke Jakubowski l Office for Europe, based in Copenhage will support decision-makers in their effortsand Public Health to for the WHOstrengthen Regiona ubs of the European Observatorypublic on Hea case of obesity, alcohol Ellen Nolteis Hub coordinator for the London H health capacities and services. Systems and Policies. and antimicrobial Health Policy Series Series No. 49
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Each country chapter captures the historical background of 7
0 5 forthcoming). public health services and the context in which they operate; sets out the main organizational structures; assesses the sources of public health financing and how it is allocated;
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UNIVERSAL HEALTH COVERAGE AND THE ROLE OF EVIDENCE-BASED APPROACHES IN BENEFIT BASKET DECISIONS
By: Juliane Winkelmann, Dimitra Panteli, Miriam Blümel and Reinhard Busse
Summary: The extension of universal health coverage along its three dimensions – population coverage, benefit coverage and financial protection – has dominated health policy agendas in recent years. However, decisions on the benefits covered by publicly financed schemes have only recently received increased attention, being supported by evidence-based approaches such as health technology assessment (HTA) to ensure quality and “value for money” of care. Yet, new developments in the area of high-cost speciality medicines have highlighted the limitations of HTA in guiding the optimal allocation of finite resources, posing a challenge to “universality” of coverage and requiring increased efforts towards aligned HTA in Europe.
Keywords: Universal Health Coverage, Health Basket, Innovations, Pharmaceuticals, Health Technology Assessment
Introduction of health coverage, encompassing a mandatory public and a voluntary All health care systems are confronted private component. with the question of which treatments and pharmaceuticals to pay for publicly The rationale behind covering certain as resources for health are limited, thus Juliane Winkelmann is Research benefits while excluding others varies competing with other sectors within the Fellow; Dimitra Panteli is Research between jurisdictions, reflecting both Fellow; Miriam Blümel is Research public budget. Despite health needs and societal norms and system characteristics. Fellow at the Department of desires, it is not possible for a health Health Care Management, Berlin Public benefit “baskets” or packages system to afford to pay for all available University of Technology, Germany. are usually defined more broadly at the Reinhard Busse is Co-Director of health care benefits for everyone, even legislative level with a stipulation of the the European Observatory on Health under universal coverage aspirations. areas of care to be covered. They are Systems and Policies and Professor Therefore, trade-offs arise in coverage and Head of the Department then regulated more concretely, centrally decisions when priorities have to be set for Health Care Management, or regionally and usually within each Berlin University of Technology, between different benefits and cost- area of care, resulting in more or less Berlin, Germany. Email: juliane. sharing levels as well as the population [email protected] explicit benefit baskets. Especially in the groups covered. As a consequence, most realm of coverage decisions for health countries opt for two-tiered models
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Figure 1: The three dimensions of universal health coverage population coverage and financial protection. While both dimensions offer little scope for policy variation if the fundamental values of universality and Total health expenditure Height: solidarity are not to be contradicted, the What range of services covered by publicly proportion financed schemes constitutes a playing of the costs 8 is covered? field in health policy for decision-making.
Indeed, there is a lot of variation in the level of explicitness and the approaches Cost sharing Other services countries use to define their priorities and benefit packages. They range from very detailed (positive) lists of all goods and services available through statutory coverage to a vaguely formulated and Public expenditure implicit benefit package with reference to Uninsured broad categories of services (e.g. primary on health Depth: 4 7 9 Which benefits care, pharmaceuticals). For example, are covered? UK legislation defines very broad categories of health care services, Breadth: Who is insured? considering services necessary within ‘reasonable limits’, while leaving providers with the possibility to establish positive Source: 7 lists. 6 8 At the same time, an institution tasked with identifying necessary, technologies, evidence-based approaches demonstrating their commitment to appropriate and cost-effective care, the have been increasingly employed to ensure achieving health care for all. Today it is National Institute for Health and Care quality and efficiency of care, or “value one of the most prominent global health Excellence (NICE) provides very clear for money”, in the composition of the policies, most notably retained in the guidance on whether a new medicine benefit package. Sustainable Development Goals (SDGs) should be made available to NHS patients in 2015. The UHC concept encompasses who meet particular criteria. 8 Health In recent years, benefit baskets in many three dimensions: coverage for everyone benefit baskets can also be defined European countries have been expanded (breadth), type and number of needed negatively by excluding certain benefits. by costly innovations in medicines health services covered (depth) and For example, Italy and Spain use positive and devices leading to rising health the proportion of total health service and negative lists and have a structured expenditures. In a context of already costs that are publicly funded and not and detailed minimum benefit baskets that constrained health budgets, formal subject to cost sharing (height), also can be further adapted by regional health structures to support evidence-based referred to as financial risk protection, authorities. 3 9 Israel is probably the only decision-making in a multitude of and is best reflected in the UHC cube country in the world with one detailed list countries have been established to identify (see Figure 1). The UHC cube was first of all benefits across all sectors covered (non-) cost-effective services. At the same conceived in mid-2000 2 3 and was further under the National Health Insurance Act; time, the fundamental values of universal developed for the framework behind the the list is updated once a year. 10 health coverage (UHC) and solidarity have European Observatory’s Health Systems come under threat; this became evident in Transition reports. 4 It was most Over the last two decades, there has been particularly during the economic crisis prominently used in the World Health a general trend to make positive lists more when countries had to decide between Reports 2008 and 2010 5 6 and has since explicit, both in tax-funded countries restricting the number of people covered become known as the coverage cube. (where benefits were previously left to the (most visibly in Greece), the services Today, it is used worldwide to illustrate discretion of providers) as well as those included the benefit basket (see Box 1) and UHC and supports related analyses. with Social Health Insurance (where lists the extent of the cost to be borne privately used to be merely fee schedules), and to for services in the benefit basket. 1 expand the range of services in the benefit Defining the health benefit basket is 3 7 still challenging baskets. However, the opposite can Achieving UHC along the also be observed, in particular during ‘coverage cube’ Despite the importance of the range the economic crisis when services were of benefits covered, the focus in the removed from the benefits package In the last 20 years, UHC has substantially discussion on UHC to date has been (see Box 1). gained importance with governments dominated by the two dimensions of
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(most commonly following an application to existing alternatives. 16 17 However, they for inclusion in the benefit basket by the do require evaluation and investment of Box 1: UHC and the economic crisis manufacturer or a request by relevant HTA-related resources. decision-makers), scientific evidence In response to budget pressures is collected and evaluated (evidence New medicines based on novel during the economic crisis, many assessment) and subsequently appraised mechanisms, such as gene and cell countries redefined benefit baskets in context (evidence appraisal). therapies, have started entering the and some tried to remove non-cost- market with extremely high price effective services from coverage. These formal assessment mechanisms tags (e.g. Novartis´ immunocellular In a study jointly carried out by the are most frequently in place for therapy against leukaemia was priced European Observatory and the WHO pharmaceuticals. In Europe, at $475 000 per infusion for the US Regional Office for Europe in 2014, pharmaceuticals have historically market). Viewed against a backdrop of 15 European Union countries represented one of the largest expenditure a per capita pharmaceutical expenditure reported trying to restrict or redefine items in health care spending with of US$ PPP 553 (OECD country average the publicly financed benefit basket costs predominantly being covered in 2015 14 ), it becomes clear that health between 2008 and 2013. Of these, by statutory funds. 14 To bring a new systems will be unable to bear such costs only four countries incorporated medicine to market, demonstration of in a routine manner as part of the benefit HTA in decision-making while eleven safety and clinical “efficacy” are usually package. A new discussion on the effect countries restricted benefits on an sufficient. These are demonstrated within of these medicines on the “universality” ad hoc basis. Disinvestment mostly randomised controlled trials, with selected of coverage in European health systems is involved medicines, followed by cash patients (e.g. excluding multimorbid warranted. Indeed, the Dutch Presidency benefits for temporary sickness leave ones) and using placebo as control. It of the European Council in 2016 placed and dental care, but also primary is the role of the subsequent HTA to the spotlight on the imbalances in the care visits (e.g. a cap was introduced determine whether – at least in principle current system of development, pricing on the number of general practice – the therapeutic benefit is meaningful to and reimbursement of medicines and visits covered in Romania) and patients compared to alternatives in real raised questions about its sustainability preventive services (the Netherlands world conditions – and therefore whether, for Europe and Europeans. and Bulgaria). 1 11 12 to what extent and/or at what price new medicines will be covered publicly. To Looking forward ensure that they are subsequently used The importance of HTA for coverage appropriately is mainly the domain of Decision-makers are increasingly decisions has grown clinical guidelines. 15 confronted with difficult coverage decisions due to budget constraints and Tools supporting evidence-based decision- new and costly health technologies. making are increasingly incorporated Expensive innovations have big Over the last two decades numerous in formal decision-making structures, implications for coverage decisions techniques have been applied to guide as mentioned above, especially in the New developments in the output portfolio the decision-making process and to direct realm of coverage decisions for health of the pharmaceutical industry have the optimal allocation of finite resources. technologies (i.e. pharmaceuticals, medical highlighted the limitations of traditional The desire to maximise the value for devices, procedures or interventions). HTA-based systems in guiding the optimal money of health services and to ensure The concept of technology assessment as allocation of finite resources. The market the long-term sustainability of access to a policy-informing tool to guide decision- entry of breakthrough therapies with technologies, have been met by increased making for coverage in health care was large target populations and steep price use of evidence-based approaches. In first introduced in the United States tags (such as the pharmaceuticals against this context, the application of HTA has in 1975. The evaluation model of the Hepatitis C in 2014) served as a wake- received increased attention in health Office of Technology Assessment (OTA) up call for policymakers, who were policy in most European countries and included elements of safety, effectiveness suddenly confronted with unmanageable will continue to play an important role, and cost, as well as socioeconomic and budget impacts and a lack of suitable thus requiring enhanced collaboration ethical implications of adopting (new) management levers. The number of and knowledge exchange. Indeed, the technologies in health care. It was new high-cost specialty medicines and European Commission has been promoting subsequently adapted by national health so-called “niche-busters” (aimed at very related research and collaborative activities technology assessment programmes in a narrowly defined patient sub-populations) for more than 15 years, culminating in number of European countries. 13 has increased substantially over the last the establishment of an HTA network in two decades. At the same time, evidence Directive 2011/24/EU. The scientific and The exact scope and configuration of HTA suggests that a substantial majority of technical cooperation of the network has are country-specific and heterogeneous. these new pharmaceuticals do not provide been the responsibility of the EUnet HTA However, HTA is generally applied substantial patient benefit gains compared Joint Actions. following marketing authorisation. After selection of the technologies to evaluate
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A further promising step towards 3 Schreyögg J, Stargardt T, Velasco-Garrido M, 11 Thomson S, Evetovits E, Kluge H. Universal aligned and centralised HTA in the EU Busse R. Defining the “Health Benefit Basket” in nine health coverage and the economic crisis in Europe. was made on 31 January 2018 when European countries. Evidence from the European Eurohealth 2016;22(2):18 – 22. Union Health BASKET Project. European Journal 12 Thomson S. Changes to health coverage. In the European Commission issued a Health Economics 2005;6(Suppl. 1):2–10. proposal for regulation building on the Thomson S, Figueras J, Evetovits T, et al. (eds.) 4 exeprience of EU Member States in the Rechel B, Thomson S, van Ginneken E. Health Economic Crisis, Health Systems and Health Systems in Transition: template for authors. in Europe. Impact and implications for policy. area of HTA and related collaboration Copenhagen: WHO Regional Office for Europe, Maidenhead: Open University Press, 2015. and mandating joint assessments of on behalf of the European Observatory on Health 13 Velasco-Garrido M, Børlum Kristensen F, clinical elements (effectiveness and Systems and Policies, 2010. Palmhøj Nielsen C, Busse R (eds.) Health technology safety) of new medicines and certain new 5 World Health Organization. World Health Report: assessment and health policy-making in Europe – medical devices. Although the proposal primary health care – no more than ever. Geneva: Current status, challenges and potential. Copenhagen: has been criticised for various reasons World Health Organization, 2008. WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and (e.g. manufacturers are not mandated to 6 World Health Organization. World Health Report: Policies, 2008. provide full trial data but are afforded health systems financing: the path to universal the possibility to comment on assessment coverage. Geneva: World Health Organization, 2010. 14 OECD. Health at a Glance 2017. OECD Indicators. Paris: OECD Publishing, 2017. Available at: http:// drafts and specify which information is 7 Busse R, Schlette S. Focus on Prevention, Health dx.doi.org/10.1787/health_glance-2017-en not to be made publicly available), more and Ageing and Human Resources. Gütersloh: Verlag collaboration in the evaluation of new Bertelsmann Stiftung, 2007. 15 Legido-Quigley H, Panteli D, Car J, McKee M, Busse R. Clinical guidelines for chronic conditions medicines is a welcome concept on the 8 Smith P, Chalkidou K. Should Countries Set an in the European Union. Copenhagen: World Health path to ensuring that new technologies Explicit Health Benefits Package? The Case of the Organization, on behalf of the European Observatory English National Health Service. Value in Health with true patient benefit are identified on Health Systems and Policies, 2013. early and evaluated for inclusion in the 2017;20(1):60 – 6. 16 Salas-Vega S, Iliopoulos O, benefit basket at affordable costs. 9 Auraaen A, Fujisawa R, de Lagasnerie G, Paris V, Mossialos E. Assessment of overall survival, quality et al. How OECD health systems define the range of life, and safety benefits associated with new cancer of good and services to be financed collectively. medicines. JAMA Oncology 2017;3(3):382 – 90. References OECD Health Working Papers, No. 90. Paris: OECD Publishing, 2016. 17 Davis C,Huseyin N, Evrim G, Elita P, Ashlyn P, 1 Thomson S, Figueras J, Evetovits T, et al. Ajay A. Availability of evidence of benefits on overall Economic crisis, health systems and health in Europe: 10 Brammli-Greenberg S, Waitzberg R, Medina- survival and quality of life of cancer drugs approved impact and implications for policy. Policy Summary, Artom T, Adijes-Toren A. Low-budget policy tool by European Medicines Agency: retrospective Copenhagen: WHO/European Observatory on Health to empower Israeli insureds to demand their cohort study of drug approvals 2009 – 13. BMJ Systems and Policies, 2014. rights in the healthcare system. Health Policy 2017;359:j4530. 2014;118(3):279 – 84. 2 Busse R, Schreyögg J, Velasco- Garrido M. HealthBASKET: Synthesis Report. Brussels: EHMA, 2006.
Related Observatory publications:
Economic crisis, health systems Clinical guidelines for chronic Health technology assessment and health and health in Europe: impact and conditions in the European Union (2013) policy-making in Europe – Current implications for policy (2014) https://goo.gl/Fh4kCj status, challenges and potential (2008) https://goo.gl/vB5Wp8 https://goo.gl/zNu1gj
on Health Systems and Policies Series European Observatory
Economic Crisis,Europe Health Systems and Health in Impact and implications for policy stem threat to health and health sy nd Economic shocks pose a eople’s need for health care anded performance by increasing p difficult – a situation compourvices. making access to care moreon health and other socialy public se HealthSystems Economic Crisis, by cuts in public spendingcts can be avoided by timel tside But these negative effe ant public policy levers lieor ou fiscal Health EconomicCrisis, policy action. While importands of those responsible f is and the health sector, in the h the health system response Health Systems policy and social protection, critical. ted to w health systems in Europe reac at began in in Europe This book looks at ho nancial and economic crisistries, th the Health Europe pressure created by the fi xperience of over 45 coun in 2008. Drawing on the e olicy and authors: ponses to the crisis in three p rage; Impact and implications for policy • analyse health system resr the health system; health cove areas: public funding fo purchasing and delivery nd and health service planning, sponses on health systems a Thomson,Figueras, Evetovits,Jowett, Mladovsky, Maresso, • assess the impact of these re Cylus, Karanikolos, Kluge population health of ely to sustain the performance • identify policies most lik ncial pressure health systems facing fina in a omy of implementing reforms • explore the political econ crisis for anyone who wants to d the The book is essential readingilable to policy-makers – anr sustain Written by understand the choices avaprotect population health oic and other implications of failing toance – in the face of econom Sarah Thomson, health system perform Josep Figueras forms of shock. pe and the WHO Regional Office for Euro Josep Tamás Evetovits Sarah Thomson ics and Political Science. London School of Econom ealth Systems and Policies. rope. Matthew Matthew Jowett Figueras European Observatory on H WHO Regional Office for EuEuropean Tamás Evetovits Philipa Mladovsky London Philipa Mladovsky Jowett WHO (Geneva). Systems and PoliciesAnna and theMaresso Anna Maresso Observatory on Health litical Science. . Jonathan School of Economics and PoHealth Systems and Policies Jonathan Cylus lth Systems and Policies. European Observatory on alth Systems European Observatory on Hea Marina Karanikolos Cylus European Observatory on He ope. Marina Karanikolos WHO Regional Office for Eur Hans Kluge Hans Kluge and Policies.
Eurohealth — Vol.24 | No.2 | 2018 38 Eurohealth Systems and Policies
DEVELOPMENTS IN EUROPE’S HEALTH WORKFORCE: ADDRESSING THE CONUNDRUMS
By: Matthias Wismar, Claudia B Maier, Anna Sagan and Irene A Glinos
Summary: The health workforce makes a key contribution to the performance and sustainability of health systems. There is no adequate care without an adequate health workforce and the models of care are changing profoundly to address changing patient needs. To adapt to these changes the health workforce will need to continue to grow; nurses and other health professions will need to assume new and more sophisticated tasks and roles; and more investment in the health workforce is needed. But at the same time, the recruitment of health workers has limits, we have a looming nursing crisis and realigning investment with sustainability is difficult. To improve health system performance and sustainability it is important to understand and address these conundrums.
Keywords: Health Systems, Health Workforce, Performance, Sustainability, Investment
Expectations and conundrums • Investment in the health workforce needs to be made but this may The health workforce is one of the main undermine health system sustainability contributors – if not the most important one – to health system performance and In this article we address these sustainability in Europe. Although size conundrums by presenting the and composition of the health workforce characteristics of Europe’s health may vary widely between countries the workforce and showing why it is challenges it is facing are similar. These important. We will also analyse the three Matthias Wismar is Senior Health challenges pose real conundrums: Policy Analyst and Irene A Glinos conundrums in more detail, explore what is Health Systems Analyst at the • The health workforce is expected to has been done over the last two decades European Observatory on Health grow further in the future, but the pool and what more could be done. Systems and Policies, Belgium; Claudia B Maier is Research of potential health workers is shrinking Fellow, Department of Health Care Management, Berlin University • Nurses are expected to assume new What is the European health of Technology, Germany; and tasks and roles, but we don’t have workforce? Anna Sagan is Research Fellow, enough of them and we are losing The health workforce is the largest European Observatory on Health too many Systems and Policies, London segment of the European labour market. School of Economics and Political In the European Union (EU) it amounts Science, UK. Email: [email protected] to 18.6 million workers which is 8.5%
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Figure 1: Doctor and nurse densities in European Union countries in long-term care, social care or public health and health promotion; but also social workers, and increasingly fire Practising nurses per 1 000 population, 2015 (or nearest year) fighters, police officers, housing officers 20 Doctors Low Doctors High and volunteers are tasked with health Nurses High Nurses High awareness, for example conducting ‘safe- DK and-well’ visits, detecting symptoms of neglect, loneliness, depression 15 FI and diseases. DE
IE LU NL Why is the health BE SE 10 workforce important? EU: 8.4 SI FR EU AT Financing the health workforce requires UK MT LT HU CZ EE a lot of money. A study published by the RO IT PT HR World Health Organization (WHO) has 5 PL LV ES BG estimated that expenditure on the health SK CY EL workforce as share of total expenditure on health is 73.4% in the WHO European Doctors Low Doctors High 7 Nurses Low EU: 3.6 Nurses Low Region. Even in a high technology 0 1 2 3 4 5 6 7 environment, like the hospital, it is
Practising doctors per 1 000 population, 2015 (or nearest year) estimated that two thirds of all expenditure is related to the health workforce.
Source: OECD data of the total workforce. 1 It is bigger than professions under the directive on the nearly the automotive and hospitality industry recognition of professional qualifications workforces, among others. (2005/36/EC). This includes medical 75% of all health doctors, dentists, nurses, midwives and The health workforce has grown over the pharmacists. But variations in curricula expenditure last two decades. This growth was more development and acquired knowledge and pronounced for medical doctors than skills remain. Moreover, new roles are goes on the for nurses and was stronger in the older being continuously created, further adding EU member states. The financial and to these variations. Currently seventeen health workforce economic crisis has affected growth in EU countries have introduced or are in the some countries 2 but overall the growth process of introducing nurses in advanced Producing an adequate health workforce pattern has been stable. The health roles. Finland, Ireland, the Netherlands requires planning and forecasting, workforce is much more than just doctors, and the United Kingdom have introduced curricula development, adaptation of nurses and pharmacists. For example advanced practice nursing roles with training‘‘ facilities and continuous medical the 2016 Federal Health Reporting extensive task shifting between doctors and professional development. This for Germany lists 50 distinct health and nurses while in thirteen countries is challenging given the sheer size of professions (without specialisations) in the task shifting is more limited. But the health workforce, the multitude of hospital, long-term care or ambulatory even within each of the groups there are professions involved and the constantly settings. 3 variations regarding the assigned tasks. 4 changing models of care. Another example of these variations was The composition of the health workforce the stalled attempt to establish a common In health care delivery, it is absolutely varies from country to country. As shown European training framework for health essential that the right number of in Figure 1, some countries have a high care assistants, despite a common core health workers, with the right skills and doctor and nurse density, while others are set of learning outcomes identified by qualifications are in the right place. If not, low on both. Other countries are high on researchers, because of different training waiting lists will emerge or patients will doctors and low on nurses and vice-versa. and regulatory requirements. 5 not have access to services that are in the health care basket. Patients afflicted with The health workforce in Europe is diverse The health workforce goes beyond health chronic diseases will face discontinuity in despite common legal frameworks. In systems. There are plenty of professions their treatment. It goes without saying that the European Economic Area (EEA) which either have a partial role in health the health workforce has a critical impact countries, there are some commonalities or need to have some health awareness. 6 on the quality and safety of services, in training for the so called regulated This is particularly the case for professions medical outcomes and patient experience.
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doctors can keep pace. Second, and this concerns all health professions, in the EU Box 1: WHO and the global/European health workforce the share of children and young people in its population has been decreasing In WHO and the United Nation system, the health workforce has increasingly continuously over recent years. The pool received a lot of analytical and political attention. WHO published in 2006 a from which we can train and recruit landmark report – World Health Report – Working together for health – focusing future health workers is shrinking, though thematically on the health workforce. In 2010 the Member States adopted projections suggest that we will need the WHO Global Code of Practice on the International Recruitment of Health more. Third, the new generation of health Personnel in which member states agreed not to recruit health workers from workers is apparently not following the countries confronted with shortages of health workers. The UN Secretary General working patterns of its predecessors. The established a High-Level Commission which, together with WHO, OECD and feminisation of the medical profession ILO, has produced a Five-Year Action Plan for Health Employment and Inclusive is advancing. The nursing profession is Economic Growth 2017 – 2021. In 2017, the WHO Regional Office for Europe already almost entirely female: 90% of published The toolkit for a sustainable health workforce in the WHO European nurses in the United Kingdom’s NHS are Region. The toolbox is framed around four strategic objectives: education women. This requires more opportunities and performance, planning and investment, capacity-building, and analysis to reconcile family and work. In many and monitoring. countries doctors tend to work fewer hours than previous generations, they tend to work part time and have less appetite The governance of the health workforce with regard to funding, training, service for taking on entrepreneurial risks or is critical for health system reforms. delivery, outcomes and governance it investing in an office-based setting. As many countries are constantly is crucial to get its future development striving to improve the performance and right. But this is, unfortunately, not Investment and sustainability sustainability of their health systems, they straightforward; instead, it poses three The second conundrum is on looming are planning health system reforms. But conundrums. and current nursing shortages and the the implementation of patient-centred expansion of the role that nurses play in health system reforms, the adaptation of health systems. Many countries are trying innovations, new patient pathways and to strengthen primary health care through models of care will not work without the the increased employment of nurses. health workforce. The introduction of new Slovenia, for example, has added half a tasks, the redistribution of existing tasks, 17 European full-time equivalent nurse to each general the increased need for coordination and practice to focus on prevention and health for more team work (like, for example, in countries are promotion, a service included in the health palliative teams, chronic disease teams and care basked but sometimes neglected by mental health care teams) require changes introducing medical doctors. Other countries add in the health workforce; changes with nurses in order to take on non-medical regard to the numbers, the proportions, the advanced roles tasks from medical doctors, for example skills and eventually also the professional wound dressing. Germany has recently ethics of health workers. Health workforce for nursing given nurses and medical assistants changes can trigger so-called ripple additional training to do time-consuming effects: changes in the health workforce Growth and demography home visits in lieu of medical doctors. As require changes in regulation and scope of The first conundrum‘‘ is posed by health already mentioned seventeen European practice, adaptation of payment systems, workforce growth and demography. countries are introducing advanced roles changes in medical education and changes The majority of experts predict that the for nurses to unburden medical doctors in governance structures. 8 This is a health workforce would need to grow in from standardised medical tasks so that challenging task because in most countries order to meet future care needs. This is doctors can focus on the more complicated responsibilities for those changes sit at unsurprising since demographic changes cases. The evidence overwhelmingly different political-administrative levels and the rise in chronic diseases and multi- shows that nurses conduct simple and and are not necessarily within the remit of morbidities demand more services. There standardised medical task as safely the ministry of health. They are also often are, however, three emerging questions all and as well as medical doctors. 9 These associated with strong vested interests linked to demography. First, an accelerated developments all seem to make perfect of stakeholders. exit of medical doctors from the health sense if there wasn’t a looming nursing workforce is expected. Many European crisis. There is some, but limited, evidence Health workforce conundrums countries that expanded medical training that suggests that enabling nurses to work capacities in the 1970s are now facing in advanced roles and improve their career Given the great importance of the health a wave or retirees. This is calling into opportunities may attract more students workforce and the challenges it poses question whether the replacement by new into nursing, yet the evidence to date is
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development and policy on an evidence practice-specific and needs-based base. European research and policy training plans are among the policy Box 2: Health workforce research 16 action on the health workforce has options. agenda been intensified over the course of EU • Public health workforce training and enlargement in 2004. Further to this, 1) to develop frameworks that align education lags behind. Large gaps initiated by Belgium and supported health systems/governance and are apparent in both the numbers of by other member states, the European health workforce policy/planning professionals trained and the kind of Council adopted Conclusions on the training that exists. There are policy 2) to explore the effects of changing health workforce giving the European options that help to address a much skill mixes and competencies Commission a mandate to act in this wider public health workforce than across sectors and occupational policy area. The action plan for the EU today and to fill deficits with regard groups Health Workforce became part of the EU to information, prevention, social and high level policy on a job-rich recovery. 3) to map how education and health regulatory issues. International agencies like WHO have workforce governance can be also ensured that health workforce • Health professional mobility is of better integrated issues remain high on the policy agenda high importance in the EU, including 4) to analyse the impact of health (see Box 1). Against this backdrop, major the EEA. Ireland, Norway, Sweden, workforce mobility on health areas of research and action have evolved: Switzerland and the United Kingdom systems have more than 20% foreign trained • Health workforce forecasting and doctors in their health workforce. 17 5) to optimise the use of planning is a necessity since health Mobility has been growing with EU international/EU, national and systems are undergoing profound enlargements. It has changed directions regional health workforce data and changes. It needs to start from the and magnitude with the economic monitoring changing needs of patients and health and financial crisis. The system, 6) to build capacity for policy professionals and the evolving models while not broken could benefit from implementation of care. 12 Some countries, such as the some changes to improve the trade- Netherlands, are using an integrated, offs between efficiency and equity, multi-professional workforce planning between EU labour markets and health approach, taking account of skill-mix systems, between sending and receiving primarily from the United States. 10 In changes to better project the future countries and between employers the EU, the European Commission had health workforce needs. 13 and the health workers. 18 Mobility forecast a shortage of 590 000 nurses and cross-border collaboration in the • Recruitment and retention is key to in 2020. 11 This crisis is more evident health workforce is essential, especially avoid underserved rural and remote in social and long-term care, but it also for smaller countries or in highly and over-crowded urban areas. In affects health care. It is a particular issue specialised care. 19 addition, an early exit from the health for hospitals with high staff turnover. workforce needs to be avoided. There • Skill-mix innovations are essential are educational, financial, professional when improving the performance of Shortages and expansion and personal and regulatory instruments health systems. A common strategy The third conundrum is the one on which can address the mal-distribution is to unburden medical doctors from investing in the health workforce to ensure of health workers. 14 There are also non-medical or routine medical tasks by its expansion while at the same time policy options for retention in the assigning advanced practice nurses and securing the financial sustainability of hospital sector. 15 other specialised nurses, pharmacists or the health system as a whole. Investment other professionals with advanced roles. • Continuous professional development might be a good idea in terms of Complex patient pathways also require is crucial since the knowledge and performance if this improves access, more coordination skills and more team skills acquired at the end of formal comprehensiveness of care, continuity of working skills. 20 undergraduate and postgraduate care, quality, safety, the patient experience professional medical education are • To further advance those and other and medical outcomes. But in terms of a insufficient to sustain competence and pressing issues the health workforce health system’s financial sustainability performance over a career. Physicians, research community has published a it might be a challenge that is difficult dentists, nurses, midwives and other research agenda (see Box 2). 21 to master. How can we ask for more health professions are expected to investment if it undermines a health effectively engage in lifelong learning Outlook system’s capacity to pay for it long-term? strategies. Increased accountability, There are no easy solutions to these compulsory engagement, enhanced conundrums. But several additional factors What has been done so far? quality and rigour of programme, may play a role in solving them. Among In Europe, a lot has been done over the these, there is the profound change in last 20 years to put health workforce labour markets that we are expecting in
Eurohealth — Vol.24 | No.2 | 2018 42 Eurohealth Systems and Policies
the near future. Developments in artificial 6 Bjegovic-Mikanovic V, Czabanowska K, Flahault A, 17 Wismar M, Maier CB, Glinos IA, Dussault G, intelligence, self-driving vehicles and Otok R, Shortell S, Wisbaum W, Laaser U. Addressing Figueras J. Health professional mobility and health robotics are deemed to change the demand needs in the public health workforce in Europe. systems. Evidence from 17 European countries. Copenhagen, European Observatory on Health European Observatory on Health Systems and for certain professions. This does not need Systems and Policies, 2014. Available at: http://www. Policies, 2011. Available at: http://www.euro.who. to result in structural unemployment as euro.who.int/__data/assets/pdf_file/0003/248304/ int/__data/assets/pdf_file/0017/152324/Health- the health system is likely to absorb more Addressing-needs-in-the-public-health-workforce-in- Professional-Mobility-Health-Systems.pdf?ua=1 Europe.pdf?ua=1 workers. It is, however, more of a mid- 18 Glinos I, Wismar M, Buchan J, Rakovac I. How term solution as retraining today’s lorry 7 Hernandez P, Dräger S, Evans DB, Tan-Torres can countries address the efficiency and equity drivers and accountants to become nurses Edejer T and Dal Poz MR. Measuring expenditure implications of health professional mobility in and other health professions would pose for the health workforce: evidence and challenges. Europe?. European Observatory on Health Systems challenges on all sides. World Health Organization, Geneva, 2006. and Policies, 2011. Available at: http://www.euro. who.int/__data/assets/pdf_file/0008/287666/OBS_ 8 Kachur EK, Krajic K. Structures and trends in PB18_How-can-countries-address-the-efficiency- health profession education in Europe. In Dubois C, Second, the investment in the health and-equity-implications-of-health-professional- Nolte E, McKee M (eds). Human Resources for Health workforce and particularly in nurses mobility-in-Europe.pdf?ua=1 in Europe. European Observatory on Health Systems and other health professions may trigger and Policies, 2006. Available at: http://www.euro. 19 Kroezen M, Buchan J, Dussault G, Glinos IA, positive recruitment and retention who.int/__data/assets/pdf_file/0006/98403/ Wismar M. How can structured cooperation between effects as well as positive effects for E87923.pdf?ua=1 countries address health workforce challenges related to highly specialized health care?: Improving access economic growth. Income levels, career 9 Laurant M, van der Biezen M, Wijers N, to services through voluntary cooperation in the EU. pathways and working conditions that are Watananirun K, Kontopantelis E, van Vught AJ. European Observatory on Health Systems and Nurses as substitutes for doctors in primary care. compatible with family life and conducive Policies, 2016. Available at: http://www.euro.who. Cochrane Database of Systematic Reviews, 2018;(7). to individual work-live-balance choices int/__data/assets/pdf_file/0008/331991/PB20. will matter. These investments may be 10 Maier CB, Aiken LH. Expanding clinical roles for pdf?ua=1 nurses to realign the global health workforce with perfectly in line with improvements in 20 Wismar M et al. eds. Skill-mix innovations in population needs: a commentary. Israel Journal of performance. It may also help to build up primary and chronic care. Mobilizing Patients, peers Health Policy Research; 2016;5:21. consumer power in a part of the working professionals. European Observatory on Health population which is at the moment, 11 European Commission. Communication from the Systems and Policies, Forthcoming. European Commission to the European Parliament, especially in comparison with the US, not 21 Kuhlmann E, Batenburg R, Wismar M, Dussault G, the Council, the European Economic and Social well paid. Above all, it will be essential Maier CB, Glinos IA, Azzopardi-Muscat N, Bond C, Committee, the Committee of the Regions. Towards a Burau V, Correia T, Groenewegen PP. A call for that we have the economic models, as job-rich recovery (COM(2012) 173 final). Strasbourg, action to establish a research agenda for building a well as the policies and politics in place 18/04/2012. future health workforce in Europe. Health Research to achieve this transition. 12 Dussault G, Buchan J, Sermeus W, Padaiga Z. Policy and Systems, 2018; 16(1):52. Available at: Assessing future health workforce needs. European https://health-policy-systems.biomedcentral.com/ References Observatory on Health Systems and Policies, 2010. articles/10.1186/s12961-018-0333-x Available at: http://www.euro.who.int/__data/ 1 European Commission. State of Health in the EU. assets/pdf_file/0019/124417/e94295.pdf?ua=1 Companion Report 2017. Luxembourg, 2017. Available 13 Maier CB, Batenburg R, Birch S, Zander B, at: https://ec.europa.eu/health/sites/health/files/ Elliott R, Busse R. Health workforce planning: which state/docs/2017_companion_en.pdf countries include Nurse Practitioners and Physician 2 Dussault G, Buchan J. The economic crisis in the Assistants and to what effect?. Health Policy, 2018 EU: impact on health workforce mobility. In Buchan J, Aug 11. Available at: https://doi.org/10.1016/j. Wismar M, Glinos IA and Bremner J (eds.) Health healthpol.2018.07.016 professional mobility in a changing Europe. European 14 Kroezen M, Dussault G, Craveiro I, Dieleman M, Observatory on Health Systems and Policies, 2014. et al. Recruitment and retention of health Available at: http://www.euro.who.int/en/about- professionals across Europe: a literature review us/partners/observatory/publications/studies/ and multiple case study research. Health Policy, health-professional-mobility-in-a-changing-europe.- 2015;119(12):1517 – 28. new-dynamics,-mobile-individuals-and-diverse- responses-2014 15 Wiskow C, Albreht T, De Pietro C. How to create an attractive and supportive working environment for 3 Gesundheitsberichterstattung (GBE) des Bundes health professionals. European Observatory on Health [Federal Health Reporting]. Available at: http://www. Systems and Policies, 2010. Available at: http://www. gbe-bund.de/oowa921-install/servlet/oowa/aw92/ euro.who.int/__data/assets/pdf_file/0018/124416/ WS0100/_XWD_PROC?_XWD_104/20/XWD_CUBE. e94293.pdf?ua=1 DRILL/_XWD_132/D.489/44440 16 Horsley T, Grimshaw J, Campbell C. How to create 4 Maier CB, Aiken LH. Task shifting from physicians conditions for adapting physicians’ skills to new needs to nurses in primary care in 39 countries: a cross- and lifelong learning. European Observatory on Health country comparative study. European Journal of Systems and Policies, 2010. Available at: http://www. Public Health, 2016; 26(6):927 – 34. euro.who.int/__data/assets/pdf_file/0005/75434/ 5 Kroezen M, Schäfer W, Sermeus W, Hansen J, E93412.pdf?ua=1 Batenburg R. Healthcare assistants in EU Member States: an overview. Health Policy, 2018. Available at: https://doi.org/10.1016/j.healthpol.2018.07.004]
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HSPM includes providing comments on changes aged 65 and over during 2018, and for in legislation and actions. Additionally, children up to 18 years old during 2019. the Council can establish working groups This step will conclude reforms concerning COUNTRY to handle specific questions such as dental care for children, which started those affecting patients with a particular back in 2010 with the inclusion of dental diagnosis. care for children up to 8 years old in the NEWS health basket. Since then, dental care has been gradually expanded for children Denmark: Revised psychiatric care up to 10 years old (in 2011), 12 years old pathways (2012), 14 years old (2016) and 16 years old (2018). The most costly group for The Observatory’s Health Systems Psychiatric care pathways were revised, dental care are older people; therefore, and Policy Monitor platform provides in September 2017, after a few years the funding for this group will be provided systematic descriptions of country of monitoring clinical use and patient gradually. health systems and features up- experiences. The aim of psychiatric to-date information on ongoing care pathways, which were originally health reforms and policies. See the implemented by the Danish regions Lithuania: Continued expansion of individual country pages for these in 2013, was to offer standardised high- eHealth services news items and more: quality treatment for patients with similar http://www.hspm.org mental health problems in all psychiatric A turning point for eHealth services in departments. Twenty pathways have Lithuania occurred in 2017 as the use of been defined aiming to strengthen the ePrescriptions and other electronic medical quality of psychiatric care and increase the services expanded rapidly. By March 2018, quality of life and average life expectancy 429 providers had entered into data Compiled by Sherry Merkur based among psychiatric patients. The pathways transfer agreements, and a further 121 on 2018 reform logs. will be revised further if significant new had expressed their willingness. Since evidence emerges. March 2018, all records of the following must be managed electronically: outpatient Croatia: Establishment of a national fund visits, hospitalisations, ePrescriptions, birth for very expensive drugs France: New national prevention plan and death certificates and drivers’ health check-ups. Survey data from the Ministry In December 2017, the Croatian The new prevention plan covers all of Health shows that 38% of all health care government decided to establish a special population groups. For young children, key providers supply data to the central eHealth state budget account where private objectives include general practitioners system (ESPBI IS), issue ePrescriptions and donations can be made to finance very prescribing physical activity and information medical certificates, while 46% are still in expensive drugs that are not covered by campaigns on endocrine disruptors. For the preparatory phase. the Croatian Health Insurance Fund. The adolescents, measures mainly target funds will be spent transparently on strictly risky sexual behaviours and addictions by defined drugs for the treatment of rare and/ providing free condoms and easing access The Netherlands: New Act on organ or serious diseases. A special commission to outpatient clinics. For adults, measures donation appointed by the Minister of Health will include extensive coverage of smoking evaluate, for each individual patient, the cessation treatments, better treatment Starting in 2020, people who do not medical indications for the use of drugs and for hepatitis C outside of hospitals, and actively express their choice in the Organ will recommend and approve the purchase organised screening for cervical cancer. Donation Registry will be registered of drugs. For disabled and older people, objectives as having no objection against organ include improving regular follow-ups and donation; however, next of kin will have dental care in nursing homes. Additional the option to object to donation. All Dutch Czech Republic: Re-establishment of the efforts involve educating the general citizens will receive a letter at the age Patient Council population in first-aid, improved medicines of 18, in which they are asked to register labelling and pharmacists administering their choice; also, in 2020 all citizens In October 2017, the Czech Minister of vaccines. who are not yet registered will receive Health appointed 24 members to a re- this letter. If they fail to respond, they will established Patient Council (Order No. be registered as having no objection. 15/2017). The members were carefully Israel: Further expansion of dental care Despite controversy, the Act was passed selected so that different types of patients’ coverage by Parliament in September 2016 and the needs were equally represented. The Senate in February 2018, both by a very Council is meant to serve as a mediator The Ministry of Health budget (2018-19) narrow majority. between patients’ needs and the Ministry of will fund the expansion of the health basket Health and has a four year mandate, which to include dental care for older people
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Norway: Financing of specialist health fund the NHS. Data show a reduction Spain: Persistent growth of care to be revised of around 5% in the purchase of these pharmaceutical care beverages from 2016 to 2017. In 2016, In March, the Royal Commission on 63% of beverages had more than 80g of Total pharmaceutical expenditure in resource allocation to the Regional Health sugar per litre, but since reinforcement of Spain increased 3.1% in 2017 compared Authorities (RHAs) was appointed to the law (2017) the percentage decreased to 2016, reaching an overall bill of €21.7 advise the government on a new model to 38% while the percentage of beverages billion. From this total, about half was of financing for specialist health care. with 5 to 8g of added sugar increased spent on outpatient prescriptions, 30% Currently, the four RHAs are financed from 6% to 28%. This suggests a positive on in-hospital medicines and 21% on by a combination of block grants (based impact of this policy in the reduction of the over-the-counter drugs. Notably, drugs on population size, demographics and amount of sugar added to soft drinks. prescribed in outpatient premises cost) and activity-based funding (based experienced a 2.5% increase (from 2016 on diagnosis related groups). The RHAs to 2017), continuing a steady upward trend are free to decide how to allocate funding Romania: Implementation of the since 2014. Nonetheless, the amount to hospitals within their respective European Drug Verification System spent on outpatient prescriptions in 2017 regions. In its assessment and proposals, (EDVS) was still below that in 2009 or 2010. In the Commission will take into account turn, hospital pharmaceutical expenditure the overall responsibility of the RHAs to According to EU legislation, EDVS increased 3.3%, while over-the-counter provide specialist care for their respective should be fully operational across spending increased 4.3% in the same populations as well as their obligations the EU from 9 February 2019. In period. Average prices for pharmaceuticals regarding research and education of health February 2018, implementation of EDVS rose 1.82% in 2017 compared to 2016, personnel, but activity-based funding will was officially launched in Romania with while the number of prescriptions increased not be assessed. The findings are expected the establishment of the Organisation for by 0.77%. in November 2019. the Serialisation of Medicines in Romania (OSMR). It is an NGO with the specific task of implementing Directive 2011/62/EU on Sweden: New decision-making process Poland: Mobile dental clinics to help preventing the entry of falsified medicinal for national concentration of highly improve oral health in children products into the legal supply chain. It will specialised care provide a verification platform for Romania, In 2017, the Minister of Health connected to a European hub, through This new process was adopted into the purchased 16 mobile dental clinics which pharmacies and other stakeholders Healthcare Act in July 2018. The law (‘dentobuses’), one for each county will be able to verify the authenticity defines the concept of national highly (voivodeship). Dentobuses have fully of medicinal products. Producers of specialised care as publicly funded health equipped treatment rooms, including medicines will be obliged to place a unique care that needs to be concentrated in one x-ray machines, and are meant to provide identifier and an anti-tampering device or a small number of delivery units rather dental care to children in smaller towns, on each pack of medicine to allow their than in each health care region in order which do not have dental clinics at schools identification and authentication. to maintain quality, patient safety and or in the area. The funds to purchase an effective use of resources. The new dentobuses came from the state and are process allows for concentration of more part of a special budget dedicated to Slovenia: Preparation of a new public services and to an increased number of specific solutions for improving the quality health strategy based on EPHO delivery units with consideration given to and accessibility of health care services. whether the care is complex or rare and Dentobuses will be made available free-of- The Slovenian Ministry of Health, together whether it requires a certain minimum charge to dental care providers contracted with WHO/Europe and the National Institute volume, multidisciplinary competence, or by the National Health Fund (NHF). Costs of of Public Health (NIJZ) have prepared a large investments. dental services will be covered by the NHF new public health strategy for Slovenia and maintenance and running costs will be based on a comprehensive assessment of met by the providers. the ten essential public health operations (EPHOs). After previous unsuccessful attempts to develop a national public health Portugal: New tax on soft drinks national strategy, the Ministry of Health decided to mobilise and involve a wide In February 2017, the government extended range of public health professionals and the existing tax on alcoholic beverages to other stakeholders in assessing public all drinks with added sugar or sweeteners. health, including the use of the WHO online This policy aims to encourage reduced tool for the assessment of the EPHOs. consumption through higher prices; reduce The process started in September 2017, the amount of added sugar in the products; with a draft strategy produced in 2018. and to use the tax revenue to partially
Eurohealth — Vol.24 | No.2 | 2018 Monitor 45
MY FAVOURITE OBS BOOK OR ACTIVITY
Hans Kluge Director of the Division of Health Systems and Public Health, WHO/Europe ‘The 2013 Observatory study: “Successes and failures of health policy in Europe. Four Fred Lafeber decades of divergent trends and converging @Ministry of Health, the Netherlands challenges”, is a landmark publication as Congratulations and keep up the good it provides a wide-ranging assessment of work! My favourite is summer school 2011 the performance of healthy public policies, on ageing. showing us what works to improve health systems and in what circumstances’.
Melitta Jakab @WHO Barcelona Office for Health Andre Peralta Santos Systems Strengthening @University of Washington Happy Bday @OBShealth The European The HiTs are a flagship product, but my health policy landscape wouldn't be the favourite activity are the policy dialogues. same without you! My favourite is the
Ungureanu, Marius-Ionut Eurohealth issue on leapfrogging health Babes-Bolyai University, Cluj-Napoca, RO systems responses to noncommunicable Marius Ungureanu diseases. @Cluj School of Public Health, Romania
Happy anniversary, @OBShealth! Great Dr. Marius Ungureanu is an Associated Researcher at the Babe?-Bolyai University in Cluj-Napoca, Romania. In 2016 he served as Secretary of State in the Romanian Ministry of Health. Dr. Ungureanuresources, has extensive experience in public health but and health systems even research, with a specialgreater people! Grateful focus on health workforce and health policy issues. He has been trained as a Medical Doctor and Dimitrios Florinis holds a PhD in Public Health & Healthcare Management.
(lastfor updated 29.08.2017)all your work, my favourite though is @DGSANTE the policy brief on efficiency & equity of Two books that inspired me for my PhD #healthworkforce mobility. Keep up the and in my professional life: “Health Policy good job! and European Union Enlargement” (2004) and “Health Systems Governance in Europe: The Role of EU Law and Policy” Luigi Bertinato (2010). They both present the challenges @Italian National Institute of Public Health and opportunities in EU health policy and show that in health there are no borders. The Venice summer school: a way to close Continue the work and inspire future the gap between scientists and health generations of policy makers! workers involved in front line activities
Eduardo Pisani Stefan Buttigieg MD @UCB Biopharma @health20malta Eurohealth has been a great tool to share My favourite: Malta HIT 2017 with valuable information across the health @natasha_azzmus @nevillecalleja community. @SherryMerkur OUR MISSION: • strengthening health systems • promoting evidence-based policy making • bridging the gap between health research and policy making
OUR APPROACH: • informing policy makers • sharing international evidence and experience • building partnerships
OUR FUNCTIONS: • monitoring country health systems • analysing trends and health policy developments • assessing health systems performance • engaging with policy makers
Health Policy – special issue
• Special issue on the Occasion of the 20th OBS anniversary.
• Collection of cross-country comparative articles (partly Open Access provided by OBS, partly others)
• Editorial by Reinhard Busse and Ewout van Ginneken on the Observatory and on comparative Research in Europe
• Table showing 40 cross-country comparisons published in Health Policy since 2014 including topics and countries covered.