Quarterly of the European Observatory on Health Systems and Policies EUROHEALTH European
on Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS Special Issue on Health Systems Strengthening (Ljubljana Charter 1996 – 2016)
❚ Transforming health services ❚ En hancing the health workforce
› 2 Priorities for to meet the health challenges 016 ❚ En suring equitable access to cost- | of the 21st century health systems effective medicines and technology ❚ Moving towards universal ❚ I mproving health information and health coverage and a Europe strengthening health information systems N umber 2 free from impoverishing out- |
in the WHO of-pocket payments European Region Volume 22 ISSN 1356 ISSN Still Steve Production: and Design prior without form any in transmitted or system aretrieval in stored reproduced, copied, be may publication this of part No 2016. Policies and Systems Health on Observatory European of behalf on © WHO &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 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 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 and Europe in debate aconstructive to contribute so and issues policy health on views their express to policymakers and experts researchers, for aforum provides that publication aquarterly is Eurohealth at: Available Guidelines Submission Article Winter Regina and Polunina Tatiana Russian: in correspondence and Translation 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 Holland, Walter 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 [email protected] Palm: Willy ADVISOR EDITORIAL [email protected] 6381 7955 20 +44 McDaid: David Maresso: Anna 6194 7955 20 +44 Merkur: Sherry TEAM EDITORIAL SENIOR Kluge Hans Langins Margrieta EDITORS GUEST http://www.healthobservatory.eu [email protected] Email: 0936 2525 +32 F: 9240 2524 T: +32 Belgium Brussels, 1060 Horta Victor Place (Office Eurostation Policies and Systems Health on Observatory European the of Quarterly EUROHEALTH
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CONTENTS 1
EDITORIAL: INTRODUCING THE 20TH B UILDING PUBLIC HEALTH 2 LJUBLJANA CHARTER ANNIVERSARY 31 LEADERSHIP SKILLS IN THE ISSUE – Zsuzsanna Jakab, Milojka Kolar REPUBLIC OF KAZAKHSTAN – Zhanna Celarc and Jevgeni Ossinovski A. Kalmatayeva, Saltanat A. Mamyrbekova, Gainel. M Ussatayeva and Regina Winter Introduction TRANSFORMING HEALTH PRIORITIES FOR STRENGTHENING 34 PROFESSIONAL EDUCATION AND 4 PEOPLE-CENTRED TRAINING IN MALTA – Maria Cordina HEALTH SYSTEMS – Hans Kluge A DDRESSING HEALTH WORKFORCE 38 OUTFLOW IN HUNGARY THROUGH A Transforming health SCHOLARSHIP PROGRAMME – Edit Eke, services Eszter Kovács, Zoltán Cserháti, Edmond Girasek, Tamás Joó and Miklós Szócska PEOPLE-CENTRED POPULATION 7 HEALTH MANAGEMENT IN GERMANY – Oliver Groene, Helmut Hildebrandt, Ensuring equitable Lourdes Ferrer and .K Viktoria Stein access to cost-
D EVELOPING INTEGRATED HEALTH effective medicines 11 AND SOCIAL CARE MODELS IN and technology SCOTLAND – Toni Dedeu CENTRALIZING PROCUREMENT OF TRANSFORMING THE MODEL OF CARE 42 MEDICINES TO SAVE COSTS FOR 15 FOR TREATING TUBERCULOSIS DENMARK – Dorthe Bartels IN THE REPUBLIC OF ARMENIA – Saro Tsaturyan and Armen Hayrapetyan IMPROVING ACCESS TO ESSENTIAL 45 MEDICINES IN THE REPUBLIC OF MOLDOVA – Zinaida Bezverhni, Vladimir Moving towards Safta, Elena Chitan, Alessandra Ferrario CONTENTS universal health and Jarno Habicht coverage Improving health UNIVERSAL HEALTH COVERAGE 18 AND THE ECONOMIC CRISIS information and health IN EUROPE – Sarah Thomson, Tamás information systems Evetovits and Hans Kluge I MPROVING THE MORTALITY GENERATING EVIDENCE FOR 48 INFORMATION SYSTEM 23 UHC: SYSTEMATIC MONITORING IN PORTUGAL – Cátia Sousa Pinto, OF FINANCIAL PROTECTION IN Robert N. Anderson, Cristiano Marques, EUROPEAN HEALTH SYSTEMS – Sarah Cristiana Maia, Henrique Martins and Thomson, Tamás Evetovits, Jonathan Cylus Maria do Carmo Borralho and Melitta Jakab EVIDENCE-INFORMED 52 POLICY-MAKING IN SLOVENIA Enhancing the health – Mircha Poldrugovac, Tit Albreht, workforce Tanja Kuchenmüller, Marijan Ivanuša, Tatjana Buzeti and Vesna Kerstin Petricˇ
Quarterly of the European Observatory on Health Systems and Policies A PEOPLE-CENTRED SYSTEM EUROHEALTH European on Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS APPROACH IN WALES: PRUDENT THE EUROPEAN OBSERVATORY Special Issue on Health Systems Strengthening (Ljubljana Charter 1996 – 2016) 27 HEALTHCARE – Jean White, Ruth Hussey 55 ON HEALTH SYSTEMS AND POLICIES: and Leighton Phillips KNOWLEDGE BROKERING FOR HEALTH SYSTEMS STRENGTHENING – Suszy Lessof, Josep Figueras and Willy Palm
› ❚ Transforming health services ❚ Enhancing the health workforce Priorities for to meet the health challenges 2016 ❚ Ensuring equitable access to cost- | of the 21st century health systems effective medicines and technology ❚ Moving towards universal ❚ Improving health information and health coverage and a Europe strengthening health information systems Number 2 free from impoverishing out- | of-pocket payments PUBLICATIONS in the WHO European Region Volume 22 © Europhotos | www.dreamstime.com 60
Eurohealth — Vol.22 | No.2 | 2016 2 Editorial
INTRODUCING THE 20TH LJUBLJANA CHARTER ANNIVERSARY ISSUE
By: Zsuzsanna Jakab, Milojka Kolar Celarc and Jevgeni Ossinovski
Zsuzsanna Jakab is WHO Regional Director for Europe; Milojka Kolar Celarc is Minister of Health of the Republic of Slovenia; and Jevgeni Ossinovski is Minister of Health and Labour of the Republic of Estonia.
Introduction burden of non-communicable and about health systems. The Ljubljana communicable diseases, and promoting Charter brought a health systems We are delighted to offer our joint support resilient communities and supportive perspective to health care reform, to this publication, which looks at how environments. emphasizing the importance of smooth Member States across the European linkages between health system functions Region are strengthening their health It is in supporting the Health 2020 policy and health care performance. It focused systems in line with the recently launched priority of strengthening people-centred on the positive role of health within strategic document “Priorities for health health systems and public health that the development of societies, and the systems strengthening in the WHO the charters have made the greatest importance of intersectorality. Universal European Region 2015 – 2020: walking the contribution. Implementation of the access, it was argued, should be assured, talk on people centredness”. 1 The strategic charters has led to important advances alongside sustainable financing and document guides countries on how to in the WHO European Region, giving a continuously striving for quality. The implement the values outlined in two better understanding on how to invest in achievement of these aims was supported health systems charters – the Ljubljana health systems for the benefit of the overall with the establishment of the European Charter on Reforming Health Care in development of societies and establishing Observatory for Health Systems Europe 2 and The Tallinn Charter: Health a mandate to invest in policies that respond and Policies. 5 Systems for Health and Wealth. 3 to the needs of vulnerable groups. The Ljubljana Charter emphasized the In 2012, the European health policy The charters are relevant for all countries, responsibility of governments exercising framework Health 2020 4 was adopted promoting human rights and gender stewardship for the health system through by the WHO Regional Committee. equality, where markets and economic legislation and governance, regulating Health 2020 builds upon both charters, interests may not. Together these health system performance and financing. taking a human rights approach and documents remain of critical importance A national health policy should be emphasizing the importance of solidarity, in guiding Ministers of Health towards the based on values, and aim to shape the equity and participation at the heart strengthening of health systems and public performance of health care. of national health policy development health, which lie at the heart of achieving and decision making. The main goals our goals for population health. Health systems should focus on the role of of Health 2020 are the equitable public health and primary health care, and improvement of health and well-being, integrate disease management, including and improvements in leadership and The charters health promotion, disease prevention, participatory governance for health. The Ljubljana Charter on Reforming treatment and rehabilitation. The Charter The strengthening of people-centred Health Care in Europe of 1996, also emphasized respect for citizens’ health systems and public health is one whose 20th anniversary we are celebrating voice and choice; moving away from of its four policy priorities, alongside this year, was a milestone in thinking acute hospital care to primary health care, a life-course approach, tackling the
Eurohealth incorporating— Vol.22 | NEuroo.2 Observer| 2016 — Vol.22 | No.2 | 2016 Editorial 3
community care, day care, home care and has provided a value-based foundation level political mandate to invest in health informal care; and the coming together of on which to build the health system in systems across the Region and have health and social care. responses to a range of new and existing secured health systems strengthening at challenges for providing better health the top of the agenda in both Member The Tallinn Charter: Health Systems care, building on the themes of improving States and WHO. Now reinforced by for Health and Wealth of 2008 built on health system performance, and promoting Health 2020, many countries in the Region these themes, with the added focus on transparency and accountability, are developing and implementing policies health system-wide performance and particularly when these qualities were informed by these goals. accountability. The Tallinn Charter most needed due to the financial crisis. It emphasizes that health systems should also presented a forward-looking vision, Now more work needs to be done, focusing prioritize financial protection, consider the covering issues such as health system particularly on the role of health systems social determinants of health and actively responsiveness, patient-centeredness and in taking social determinants of health into influence other sectors with Health in All the ability to respond to crises. The values account to reduce inequalities, achieving Policies. of solidarity, equity and participation transformative change and improved also paved the way to Universal Health health outcomes. This is the purpose The Tallinn Charter also emphasizes Coverage (UHC). of the strategic document Priorities for that health systems should guide other health systems strengthening in the WHO sectors to address the social determinants For both Estonia and Slovenia, the main European Region 2015–2020: walking the of health. This approach to consider values of the charters have been integrated talk on people-centredness. the multiple determinants of health into national health planning, focused on in addressing public health was taken the equitable improvement of health and References further in Health 2020, with its focus well-being and the further development of on governance for health across all health care services. Based on these values 1 WHO Regional Office for Europe. Priorities for determinants, and its emphasis on Slovenia has recently launched a reform health systems strengthening in the WHO European Region 2015–2020: walking the talk on people whole-of-government, whole-of-society of its health system to assure patient- centredness. Copenhagen: WHO, 2015. Available at: and Health in All Policies approaches to centredness. The reform aims to improve http://www.euro.who.int/en/about-us/governance/ improvements in health and well-being. the integration of services, including regional-committee-for-europe/65th-session/ public health and social services, along documentation/working-documents/eurrc6513- Another focus of the Tallinn Charter with strengthening primary health care. priorities-for-health-systems-strengthening-in-the- who-european-region-20152020-walking-the-talk- is on financial accountability, and the In Estonia, despite considerable overall on-people-centredness fair and efficient use of resources. budget cuts during the financial crisis, the 2 Vitally, individuals should not become health care budget was largely sustained WHO Regional Office for Europe. Ljubljana charter on health care reform. Copenhagen: WHO, poor due to ill-health. Overall system as the charters helped to guide decision 1996. Available at: http://www.euro.who.int/__data/ financing should meet needs, reduce making to reduce the effects of the crisis. assets/pdf_file/0010/113302/E55363.pdf barriers, protect against financial risk, 3 WHO Regional Office for Europe Tallinn Charter: and be fiscally responsible. Throughout, In both countries, reforms have been Health systems for health and wealth. Copenhagen: care delivery should be integrated and based on evidence and analysis, through WHO, 2008. Available at: http://www.euro.who. coordinated, delivering people-centred wide stakeholder engagement and the int/__data/assets/pdf_file/0008/88613/E91438. care and integrated disease-specific involvement of other sectors. The charters pdf?ua=1 management programs. have helped guide decisions about 4 WHO Regional Office for Europe Health 2020: a investment in the health sector and the use European policy framework supporting action across government and society for health and well-being. The importance of the charters of resources – human, pharmaceutical and technological – particularly during the Copenhagen: WHO, 2013. Available at: http://www. euro.who.int/en/publications/abstracts/health-2020- There are many similarities between the recent financial crisis. Investments have a-european-policy-framework-supporting-action- Ljubljana and Tallinn charters, which been made in expanding the health care across-government-and-society-for-health-and-well- have provided frameworks for progress, services available through primary care being now supported by Health 2020. Both as well as developing health care at the 5 European Observatory on Health Systems and charters emphasize that governments local level, improving cooperation with Policies. Available at: http://www.euro.who.int/en/ have an ultimate responsibility to sustain the social welfare system. Investments about-us/partners/observatory universality in access to timely and have also been made in the training and affordable services of good quality. Such development of the health professional an approach also clearly links with the workforce, as well as improvements in United Nations’ Sustainable Development compensation, working environments Goals (SDGs). and staff morale.
This issue of Eurohealth looks at Across the European Region, Member Member State examples of health systems States have been working towards strengthening as outlined in the strategic implementing the main values of the document. In Estonia, the Tallinn Charter charters, which have provided a high-
Eurohealth incorporating Euro Observer — Vol.22 | No.2 | 2016 4 INTRODUCTION
PRIORITIES FOR STRENGTHENING PEOPLE- CENTRED HEALTH SYSTEMS
By: Hans Kluge
Hans Kluge is Director of the Division of Health Systems and Public Health, WHO Regional Office for Europe, Copenhagen, Denmark: Email: [email protected]
The WHO Regional Office for Europe areas agreed on by all 53 Member responsive and proactive in meeting them. supports Member States in strengthening States, and which find their inspiration It also involves providing the necessary their health systems to become more in the Ljubljana and Tallinn charter tools to empower and engage with people people-centred in order to accelerate commitments to strengthening health and populations as co-producers of health health gain, reduce health inequalities, systems via a value-oriented approach. and health services to ensure better and guarantee financial protection and ensure more equitable access to health. This is an efficient use of societal resources. Priorities for strengthening people particularly important for the vulnerable, The goals of these efforts are entrenched centred health systems whose access to quality services will in Health 2020, the health policy and ultimately determine our success in framework for the WHO European Following the 5th year anniversary of the promoting people-centred health systems Region 1 2 stressing a value-based Tallinn Charter, and a high level meeting that do not leave anyone behind and set us approach to health systems. These values to commemorate the event, 5 the Division on the path to Universal Health Coverage are entrenched in the Ljubljana Charter of Health Systems and Public Health began (UHC) as called for under Health 2020. on reforming health care and the Tallinn a process of consultations with Member Charter on Health Systems, Health and States to map out the key strategic It is clear that strengthening health Wealth 3 4 which were signed by the directions around the development of systems in a manner that places people countries of the WHO European Region people-centred health systems under the at the centre necessarily involves trade- in 1996 and 2008 respectively, and which third pillar of Health 2020. The result was offs, especially in times of economic are central to the health systems work of a strategic document entitled Priorities for hardship. And, while cost savings often the WHO Regional Office. health systems strengthening in the WHO occupy a central focus of governments, European Region 2015 – 2020: walking in Europe we need to ensure political This June, and through this Special Issue the talk on people centredness, 6 which, in and popular support for moving towards of Eurohealth, we are celebrating the 20th turn, was adopted by all Member States UHC remains a health system priority. anniversary of the Ljubljana Charter. during the 65th WHO European Regional This was an important message to come This anniversary offers us an important Committee held in Vilnius, Lithuania out of two meetings convened by the moment to reflect on the legacy of the in 2015. Division of Health Systems and Public Charter and what progress we have made Health on the impact of the Economic in our health systems strengthening The sub-title of the document – walking Crisis on Health and Health Systems activities over the last twenty years. the talk on people centredness – reflects in 2009 and 2013 in Oslo. 7 8 The Division, the importance that the Regional Office in close collaboration with the European In this vein, we have commissioned a attaches to ensuring that health systems Observatory on Health Systems and series of articles from across the Region, in the European Region meet people’s Policies, evaluated the evidence from which reflect specific initiatives or needs and live up to their expectations. across Europe on policy responses to policy options pursued by countries in In our view, this means providing an economic shocks, and set out a series order to strengthen their health systems. opportunity for people to voice their of key messages to guide countries in They correspond to a series of priority needs and contribute to systems which are making the right policy choices in times
Eurohealth — Vol.22 | No.2 | 2016 INTRODUCTION 5
of budgetary pressures; with a focus Figure 1: Priorities for health system strengthening in the European Region on addressing inefficiencies rather 2015 – 2020: walking the talk on people centredness than strictly the balancing of books or cost containment. 9 These resulted in a series of 10 policy lessons 10 which were endorsed via Resolution by all Member States during the 53rd Regional
Committee, held in Izmir, Turkey in information health Boosting September 2013*. Again, our overriding Transforming health health workforce health priority is to develop health systems which services delivery the Enhancing serve the needs of all our populations.
With the endorsement of the ‘walking the talk on people-centredness’ strategic Moving towards universal document, the Regional Office and health coverage Member States have committed to work intensively together over the 2015–2020 period in two priority areas (Figure 1): 1) transforming health services to meet the Managing change and innovation health challenges of the 21st century; 2) moving towards universal health Source: Ref 6 coverage for a Europe free of impoverishing out-of-pocket payments. while designing effective and evidence- b) Foundation 2: ensuring equitable In focusing our efforts in these two informed policies on service delivery and access to cost-effective medicines and main directions, we acknowledge that health financing. technology health needs in the 21st century require c) Foundation 3: improving health the transformation of health services In addition, high-quality health system information and health information away from traditional approaches inputs make it possible to transform health systems. based on disease-specific, reactive and services and away from impoverishing fragmented interventions. Instead, we out-of-pocket payments. The availability, It is clear from the above, that the must move towards health systems with accessibility, acceptability and quality of implementation of these strategic strong primary health care that delivers the health workforce will be central to the directions and underlying foundations comprehensive, integrated and people- transformation of service delivery and to requires leadership for managing change, centered services coordinated with public translating the vision of universal health the willingness and ability to embrace health and multisectoral interventions coverage into improved health services innovations, and an understanding of to improve health outcomes and reduce on the ground. Similarly, ensuring the the need to ensure accountability for inequalities. In parallel to promoting availability of and equitable access to performance as part of good governance; such a transformation of services is a cost-effective medicines and technology in other words, an overall commitment to need to rethink health financing. More is an important input into health systems. change management in the health system. specifically, policy-makers must ensure Finally, health information and research To date, while the literature on specific that individuals can afford the quality that strengthens health systems and reform measures and the evidence of services they require and that health health policy will include strengthening their impact continues to grow, there is system financing has the ability to not only the information content but also little evidence available to guide policy withstand economic or other shocks. the information systems themselves, makers about the process of reform and Indeed, this is key to the promotion of including health information platforms, methods for making a transition. In other resilience in health systems today. To make infrastructure and eHealth. words, while countries can learn how progress in these areas requires whole- to implement a specific intervention or of-society and whole-of-government In this regard, three underpinning policy, there is less understanding on how efforts to embrace intersectoral actions, foundations that will need concerted to shape and reform their systems more support to achieve the two overarching fundamentally. As such, it is often left to directions have been set out in the strategic judgment as to whether, when and how to document as follows: transform. 11 As Figure 1 indicates, this is
* http://www.euro.who.int/en/about-us/governance/ a) Foundation 1: enhancing the health of course the overall impetus for change, regional-committee-for-europe/past-sessions/sixty-third- workforce and it is important that countries work session/documentation/resolutions-and-decisions/eurrc63r5- together towards embracing the change health-systems-in-times-of-global-economic-crises-an- management required. update-of-the-situation-in-the-who-european-region
Eurohealth — Vol.22 | No.2 | 2016 6 INTRODUCTION
WHO support to the Member States and dialogue with provider and patient With these strategic priorities set, this associations. (e.g., expert meeting is a good time for us to take the pulse of In pursuit of these health system for the health system response to the Region in terms of what is happening strengthening directions, the WHO non-communicable diseases work and how these changes are being realized Regional Office for Europe, through the programme¶¶, sub-regional meeting through this Special Issue of Eurohealth. Division of Health Systems and Public on antimicrobial consumption***, The series of articles which follows will Health, is prioritizing its support to the subregional training course for the profile a select number of examples of Member States via a number of activity central Asian republics on public progress currently being made in the lines. These include: health leadership†††, strengthening European Region. • the provision of direct technical the coordination/integration in the assistance to countries (e.g., Review delivery of services in the WHO These articles describe the challenges of pharmaceutical sector reform in European Region‡‡‡, collaboration and opportunities in managing processes Ukraine†, health financing reform in with the European Forum of National for quality and better outcomes through Georgia‡, strengthening the response Nursing and Midwifery Associations effective intersectoral action and regular to ambulatory care sensitive conditions (EFNNMA) §§§). monitoring of performance in order to in Portugal§ and improving midwifery transform services to meet the health education in Uzbekistan¶); The work of the Regional Office and the challenges of the 21st century and move Division has also been bolstered through towards a Europe free of impoverishing • the generation of information and the establishment of a new WHO Centre out-of-pocket payments. evidence (often with the European of Excellence on Primary Health Care Observatory) disseminated via based in Almaty, Kazakhstan. The work As we celebrate the 20th anniversary various media (e.g., On access to of this office, under the guidance of the of the Ljubljana Charter, and reflect on new medicines**, good practices in Division, will be instrumental in assisting how far we have come in health systems strengthening health systems for the countries in the transformation of health strengthening, bolstered by the Tallinn prevention and care of tuberculosis and service delivery. Additionally, change Charter and Health 2020, we hope that drug-resistant tuberculosis††, developing management represents a key area of this Special Issue will provide you with the case for investing in public health‡‡ future work for the Division of Health new insights into how the two priority and good practices in nursing and Systems and Public Health and here we areas and three foundations for health midwifery§§); have set up an important collaboration system strengthening are being enhanced • capacity building and providing an with the Deusto Business School and in the WHO European Region. We still international platform for partnerships Durham University to establish a network have a way to go, but such examples and of high-level policy-makers able to advise stories can provide inspiration to us on the current decision-makers on how to initiate, journey that lies ahead. † http://www.euro.who.int/en/health-topics/Health-systems/ accelerate, sustain or improve large scale health-technologies-and-medicines/country-work ¶¶¶ health system reforms . References ‡ http://www.euro.who.int/en/health-topics/Health-systems/ pages/news/news/2015/07/georgias-health-financing- 1 WHO Regional Office for Europe. Health 2020: a reforms-show-tangible-benefits-for-the-population European policy framework supporting action across ¶¶ http://www.euro.who.int/en/health-topics/Health- government and society for health and well-being. § http://www.euro.who.int/en/health-topics/Health-systems/ systems/pages/news/news/2015/12/third-expert-meeting-in- Copenhagen: WHO, 2010. health-service-delivery/publications/2016/ambulatory-care- the-health-system-strengthening-ncd-work-programme sensitive-conditions-in-portugal-2016 2 WHO Regional Office for Europe. Towards people- *** http://www.euro.who.int/en/health-topics/Health- centred health systems: an innovative approach for ¶ http://www.euro.who.int/en/media-centre/events/ systems/health-technologies-and-medicines/news/ better health outcomes. Copenhagen; WHO, 2013. events/2015/11/workshop-on-improving-midwifery-education- news/2016/02/10-countries-participate-in-subregional- in-uzbekistan consultation-on-antimicrobial-consumption 3 WHO Regional Office for Europe. The Ljubljana Charter on Reforming Health Care. Copenhagen: ** http://www.euro.who.int/en/health-topics/ ††† http://www.euro.who.int/en/health-topics/Health- WHO, 1996. Health-systems/health-technologies-and-medicines/ systems/pages/news/news/2015/06/subregional-training- publications/2015/access-to-new-medicines-in-europe- course-for-the-central-asian-republics-on-public-health- 4 WHO Regional Office for Europe. The Tallinn technical-review-of-policy-initiatives-and-opportunities-for- leadership Charter: health systems for health and wealth. collaboration-and-research-2015 Copenhagen: WHO, 2008. ‡‡‡ http://www.euro.who.int/en/health-topics/Health- †† http://www.euro.who.int/en/health-topics/communicable- systems/health-service-delivery/publications/2014/ 5 WHO Regional Office for Europe. Health systems diseases/tuberculosis/publications/2015/good-practices-in- coordinatedintegrated-health-services-delivery-cihsd.-kick- for health and wealth in the context of Health 2020: strengthening-health-systems-for-the-prevention-and-care-of- off-technical-meeting follow-up to the 2008 Tallinn Charter. Copenhagen: tuberculosis-and-drug-resistant-tuberculosis-2015 WHO, 2014. §§§ http://www.euro.who.int/en/health-topics/Health- ‡‡ http://www.euro.who.int/__data/assets/pdf_ systems/nursing-and-midwifery/news/news/2016/03/ 6 WHO Regional Office for Europe. Priorities for file/0009/278073/Case-Investing-Public-Health.pdf memorandum-of-understanding-between-whoeurope-and- health systems strengthening in the WHO European efnnma Region 2015–2020: walking the talk on people §§ http://www.euro.who.int/en/health-topics/Health- centredness. Copenhagen: WHO, 2015. systems/nursing-and-midwifery/publications/2015/ ¶¶¶ http://www.euro.who.int/en/countries/poland/news/ nurses-and-midwives-a-vital-resource-for-health.-european- news/2016/02/who-expert-meeting-gathers-tailored-policy- compendium-of-good-practices-in-nursing-and-midwifery- advice-from-past-health-ministers-on-large-scale-health- towards-health-2020-goals system-reforms
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7 PEOPLE-CENTRED WHO Regional Office for Europe. Health in times of global economic crisis: implications for the WHO European Region. Copenhagen: WHO, 2009.
8 POPULATION HEALTH WHO Regional Office for Europe. Health systems in times of global economic crisis: an update of the situation in the WHO European Region. Copenhagen: WHO, 2013. MANAGEMENT 9 http://www.euro.who.int/en/about-us/ governance/regional-committee-for-europe/65th- session/documentation/working-documents/ IN GERMANY eurrc6513-priorities-for-health-systems- strengthening-in-the-who-european-region- 20152020-walking-the-talk-on-people-centredness Thomson S, Figueras J, Evetovits T et al. Economic crisis, health systems and health in Europe: impact and implications for policy. Copenhagen: WHO/ By: Oliver Groene, Helmut Hildebrandt, Lourdes Ferrer and K. Viktoria Stein European Observatory on Health Systems and Policies, 2014.
10 WHO Regional Office for Europe. Outcomes document for the high-level meeting on Health systems in times of global economic crisis: an update of the situation in the WHO European Region. Summary: Since 2006 the Gesundes Kinzigtal (GK) model has Copenhagen: WHO, 2013.
11 Smith P. Some reflections on priorities for health demonstrated how a people-centred focus on population health systems strengthening in the WHO European Region. management can lead to significant gains in achieving the Triple Aim Copenhagen: WHO, 2015. of better population health, improved experience of care, and reduced per capita costs. Through a strong management organization, a sophisticated data management system, and a trusting relationship between network partners and the communities, the GK model has been able to provide better outcomes for all partners involved.
Keywords: People-Centred Care, Population Health Management, Integrated Care Outcomes, Germany
Background often impede a continuum of care. Not surprisingly, poorly integrated systems are In Europe, cardiovascular diseases, frequently associated with inefficiencies, cancer, diabetes, obesity, and chronic consumer dissatisfaction, and restricted respiratory diseases account for an access to and poor quality of health estimated 77% of the disease burden care services. 3 as measured by disability-adjusted life years. Between 70% and 80% of health Given the evidence and experience of the care costs in Europe are due to chronic past 15 years, it is now widely accepted disease management. In monetary that in order to achieve a safe, effective, terms, this corresponds to €700 billion patient-centred, timely, efficient, and and this figure is expected to increase equitable health care system, we need substantially in coming years. 1 2 This to overcome the fragmentation of care Oliver Groene is Head of Research represents a major challenge for health and strengthen the focus on population and Development and Helmut systems across Europe and has profound Hildebrandt is Chairman of the health. 4 5 To tackle these challenges, social and economic implications, as Board, OptiMedis AG, Hamburg, the call for a transformation of health Germany; Lourdes Ferrer is patients with chronic conditions often services to strengthen people-centred care Director of Programmes and require treatment and care from different K. Viktoria Stein is Head of the has been taken up by policy makers and practitioners in multiple institutions and Integrated Care Academy at the managers and has led to the adoption of International Foundation for settings over time. However fragmented Integrated Care, Oxford, UK. governance and funding mechanisms, Email: [email protected] misaligned incentives, and vested interests
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population health management and the monitors the implementation of the GK health and care services, managing Triple Aim approach as the underlying model. Based on a dynamic and well population health, achieving system guiding principle. developed data management system, the integration at the management level, and GK model features a continuous learning implementing tailored solutions with the Tackling the challenges of the environment, which also serves to inform involvement of stakeholders. 21st century in Germany further development and innovation of the services and programmes. Strengthening people and The German health system is communities to improve population characterized by federalization, whereby The GK model is based on a population health the ‘Laender’ (federal state) is in charge health management approach, identifying of implementing national health policies. the patients and the community as key The GK model adopted these key Key stakeholders in the operationalization, partners in care. Population health principles and since 2006 has taken delivery and design of health services at management is an integral part of up the role of regional integrator for the regional and local level are the health people-centred care, by using the needs the population of the area. Set up insurance companies and sickness funds, of the people as the prerequisite for the as an accountable care organization of which there are non-for profit and planning of services. These then need to between a network of physicians and private ones, all competing for potential be addressed on two levels. First, these a management company, GK holds insurees. German citizens have (in person- or patient-centred care services long-term contracts with two German principle) free choice between the public, develop individual care plans through non-profit sickness funds to integrate non-profit and private insurances, but they shared decision-making. Secondly, strong health and care services for their insured are obliged by law to be insured (i.e., one community engagement and increased populations in Kinzigtal. Currently, cannot opt-out of the system). As the birth health literacy leads to informed choice they have enrolled approximately place of the Bismarck system, the German and co-design of services. 7 half of the 71,000 inhabitants in their health (insurance) system is a highly programmes. Since 2006, GK has held competitive but also highly regulated ‘virtual accountability’ for the health system. It is characterized by frequent care budget of this population, and since national health reforms, resulting in January 2016, a new contract assigns the constant adjustments but maintaining the GK management company full financial key features of a publicly funded health population health accountability. If the sickness funds system, including: strong stakeholder spend less on health care for this group organizations and decentralized management is than standardized, risk-adjusted costs, governance, clear accountability pathways GK shares the benefits with the sickness and funding structures. an integral part of funds and reinvests the savings into the extension and improvement of the model. In tackling the challenges of people-centred Thus, a shared health savings account the 21st century, a decisive stimulant is created. for change came in 2000 and increased care in 2004, with the introduction of a In order to achieve the Triple Aim, national health reform regulating that The three targets of the Triple Aim the GK model focussed on improving henceforth health insurances and provider model are: 1) better‘‘ population health; population health in the region from the coalitions could offer integrated care 2) improved experience of care; very beginning, and targeted programmes options to patients. The initiative also and 3) reduced per capita costs. The model for people with chronic illness. Thus, a provided seed money for the development was built on substantial evidence from patient-centred care approach is embedded and implementation of integrated care research and practice related to success at three levels: at the structural level by projects. One well-researched – and factors for health care integration. 8 9 10 11 12 including patients in biannually elected successful – example of an integrated This accumulated evidence helped identify patient-advisory boards, and giving care system is the Integrierte Versorgung several necessary components for attaining patients opportunities to contribute to Gesundes Kinzigtal model, referred to the Triple Aim. These are: developing identifying and developing new programs; hereafter as the GK model. The model a clear (regionally defined) reference at the level of intervention, by embedding is designed around the Triple Aim population; external policy constraints a strong focus on shared-decision making approach 6 and based on promoting (such as a total budget limit, assumption of and supported self-management in design a governance model that prioritizes financial responsibility for the population, and development; and at the level of strong stakeholder consensus building or the requirement that all groups should individual doctor-patient interactions, towards achieving population health. be treated equitably); and the presence of by providing patients a comprehensive An independent management organization a regional integrator to take responsibility health-check (including a self-assessment acts as the regional integrator, brings for the three aims. The integrator plays a questionnaire), based on which the together the stakeholders involved in crucial role in establishing partnerships appropriate programmes and services service provision and systematically with individuals and families, redesigning are offered. Patients are also given the
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Figure 1: Achieving the Triple Aim in Gesundes Kinzigtal developed a health-related goal, 45.4% stated they now live a healthier life Participants die (compared to 0.6% stating the contrary 1.4 years later and 54% stating no change, p> 0.001). (78.9 vs 77.5 control) The second is a quasi-experimental study comparing the intervention population to a matched random sample of around 500,000 insurance members from 98.9 % of neighbouring regions. €5.5M surplus enrollees who The financial results have been improvement set an objective assessed in relation to the development for the two sickness agreement with their of the contribution margin described funds in the Kinzigtal physician would above. 14 Routine data analysis has region in 2013 against recommend becoming a member shown a decrease in the overuse of €75M norm costs to their friends or relatives health services for the prescription of anxiolytics, antibiotics for higher respiratory tract infections, non-steroidal anti-rheumatics, non-recommended Source: Authors’ own. prescription for vascular dementia, non-recommended prescription for opportunity to set health-related goals with 38 community organizations like Alzheimer dementia, and an increase in (i.e., doing more exercise, giving up local sports clubs, associations for people the prescription of antiplatelet drugs and smoking, reducing alcohol consumption, with disabilities, dancing and hiking statin (where appropriate) for patients or losing weight), which are then discussed clubs, women’s groups, and kids clubs, with chronic coronary heart disease with the physician and monitored, in addition to closely collaborating with (CHD), prescriptions of statins for patients accompanied by individual support and ten local self-help groups. In cooperation with an acute myocardial infarct (AMI), participation in patient education and with 14 local community councils, GK cardiology referrals for patients diagnosed self-care programmes on an as-needed has designed a wide variety of activities with heart insufficiency. basis. Programmes to support families to engage local inhabitants, strengthen and caregivers complement the services local networks, and incentivize people to offered to the patients. engage in social activities. GK established two walking trails for memory training, 45.4% On the population level, programmes to hiking trails for children and their parents, strengthen health literacy and primary and developed a joint community centre stated they now prevention are offered through the with nurses and housing options in “Healthy Kinzigtal Academy” and lectures development. live a healthier life on health and self-management for a whole variety of diseases and health issues. Improving outcomes for all partners According to routine data, there are still A magazine and TV channel, available involved: demonstrating impact a number of indicators that haven’t yet in 22 GP practices or health centres, shown a significant change, perhaps due inform people about upcoming activities, The impact of all activities is evaluated to insufficient observational time. For two courses, classes and health improvement in terms of implementing the Triple indicators – AMI patients on beta blockers programmes on a continuous basis. Health Aim approach has been supported by and osteoporosis patients with indicated festivals are also held to provide people two independent, scientific evaluation medication – the analysis suggests a with a fun and relaxed setting in which studies. 13 The first involves conducting deterioration.‘‘ Overall, a propensity they can try out different types of physical a biannual random survey with insurees score matched control group suggests an activity. Furthermore, GK developed a regarding their perceived health, increase in life expectancy by 1.4 years, specific employee health management satisfaction, changes in health behaviour, and ten years since inception of the programme targeting small and medium- and health-related quality-of-life and project. 15 Overall costs have developed sized enterprises, which normally would levels of activation. The results of the favourably compared to expected costs, not have the resources to provide such survey demonstrated very high levels with annual savings amounting to programmes in-house. of overall satisfaction: 92.1% state they €5.5 million in 2013. This difference is would recommend joining GK and 19.7% expected to further increase in the coming Another success factor lies in a strong state that, overall, they have lived a years as some of the health programmes network of service providers, many healthier life since joining GK (with 0.4% will start paying off years after the initial of which do not belong to the health stating the contrary and 79.9% stating intervention. The reasons for the observed sector. GK has established cooperation no change). Among insurees who had effects are not yet fully understood and
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further, long-term evaluation is needed to References 11 Groene O, Garcia-Barbero M. Integrated care. A position paper of the WHO European office for assess whether, and to what extent, these 1 Gallinat A. The chronic disease challenge. integrated health care services. Int J Integr Care results can be further enhanced through Pan European Networks: Government 2015(16):42. 2001;1:1-16. improving quality and greater citizen and 2 World Health Organization. Global strategy on 12 Vázquez ML, Vargas I, Unger J-P, et al. Integrated provider engagement. people-centred and integrated health services. Interim health care networks in Latin America: toward Report. Geneva: WHO, 2015. a conceptual framework for analysis. [Revista Conclusions 3 Stange KC. The problem of fragmentation and Panamericana de Salud Pública]. Washington: Pan the need for integrative solutions. Annals of family American Health Organization, 2009;26(4). The GK model demonstrates that a focus medicine 2009;7(2):100 –3. 13 Groene O, Hildebrandt H. Integrated Care in on population health management and 4 Nolte E, McKee M. Integration and chronic care: Germany. In: Amelung V, Stein V, Goodwin N, Balicer providing a continuum of care, including a review. In: Nolte E and McKee M (eds.) Caring for R, Nolte E, Suter E (eds.) Handbook Integrated Care. health promotion and primary prevention, People with Chronic Conditions. A Health System Springer, forthcoming 2016. Perspective. London: European Observatory on can lead to cost-effective solutions, 14 Hildebrandt H, Stunder B, Schulte T. Triple Aim Health Systems and Policies Series, 2008:64-91. while also strengthening communities in Kinzigtal, Germany: Improving population health, and healthier people. The model also 5 Alderwick H, Ham C, Buck D. Population health integrating health care and reducing costs of care underlines the importance of taking systems. Going beyond integrated care. London: – lessons for the UK? Journal of Integrated Care an inter-sectoral approach even when The King’s Fund, 2015. 2012;20:205-22. 15 working at the local and regional level, 6 Berwick DM, Nolan TW, Whittington J. The Schulte T, Pimperl A, Fischer A, Dittmann B, since so many determinants outside the Triple Aim: Care, health and costs. Health Affairs Wendel P, Hildebrandt H. [A quasi-experimental health system influence the health and 2008;27:759-69. cohort study: propensity score matching of participants vs non-participants of the integrated 7 wellbeing of people. Establishing lasting, Ferrer L. Engaging patients, carers and care network GK – secondary data analysis] Eine trusting and respectful relationships with communities for the provision of coordinated/ quasi-experimentelle Kohortenstudie: Propensity and between health service providers, integrated health services: strategies and tools. Score-Matching von Eingeschriebenen vs. Nicht- social and community services, private Working Document. Copenhagen: WHO Regional Eingeschriebenen der Integrierten Versorgung Office for Europe, 2015. enterprises and local councils was another Gesundes Kinzigtal auf Basis von Sekundärdaten, Optimedis Health Data Analytics, 2014. Available at: 8 Conrad DA, Dowling WL. Vertical integration in factor in developing these successful http://optimedis.de/files/Publikationen/Studien- health services: theory and managerial implications. people-centred services. Finally, long- und-Berichte/2014/Mortalitaetsstudie-2014/ Health care management review 1990;15(4):9–22. term and sustainable change can only Mortalitaetsstudie-2014.pdf be achieved with the help of a strong 9 Shortell SM, Jones RH, Rademaker AW. evaluation and monitoring framework Assessing the impact of total quality management and organizational culture on multiple outcomes in order to understand the impact of of care for coronary artery bypass graft surgery the interventions, identify risk factors patients. Medical care 2000;38(2):207–17. early on, and design and improve the 10 Skelton-Green JM, Sunner JS. Integrated services based on evidence and predictive delivery systems: the future for Canadian health care modelling. Looking more closely at health reform? Canadian journal of nursing administration inequalities and strengthening patient- 1997;10(3):90 –111. related outcomes and experience measures are also essential.
Lessons from transforming is compelling. In the context of both new challenges and opportunities, initiatives to transform services delivery across health services delivery: the WHO European Region has emerged. Compendium of initiatives in the This Compendium demonstrates the diversity in activity, WHO European Region describing examples of health services delivery transformations from each Member State in the Region. The initiatives vary greatly in their scope and stages of implementation, from early Copenhagen: WHO Regional Office for Europe, 2016 changes to initiatives at-scale. When taken together, these Available for download at: http://www.euro.who.int/en/ examples offer unique insights for setting-up, implementing and health-topics/Health-systems/health-service-delivery/ sustaining transformations. A summary of 10 lessons learned publications/2016/lessons-from-transforming-health-services- attempts to synthesize key findings and consolidate insights delivery-compendium-of-initiatives-in-the-who-european- derived from experiences. region-2016
In order for health services delivery to accelerate gains in health outcomes it must continuously adapt and evolve according to the changing health landscape. At present, the case for change
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DEVELOPING INTEGRATED HEALTH AND SOCIAL CARE MODELS IN SCOTLAND
By: Toni Dedeu
Summary: Across Europe demographic and epidemiological changes are challenging Member States’ health systems. Scotland is no exception. The Scottish government is integrating health and social services to improve their quality and consistency, thereby improving health outcomes in Scotland. A clear vision, strong political commitment, extensive partnerships, and a health systems approach to integrating services have all enabled integration that promotes strong accountability arrangements, transparent joint planning, and a clear outcomes framework. The government has provided funds to facilitate the reform and has established clear communication mechanisms for managing the transformational change that is needed.
Keywords: Health and Social Care, Integration, Scotland
Introduction A step wise and participatory approach The configuration of Scottish society is changing as are the health and social The transformation has involved several care needs of its communities. Over the phases. The transformation began next ten years, the number of people in in 1999, when 79 local health care Scotland aged over 75 is likely to increase cooperatives were established across by over 25%. Over the same time period, Scotland to bring together health and it is estimated that nearly two-thirds social care practitioners to deliver a of the population will have developed range of primary and community health long-term conditions by the age of 65. services and promote joint working Public services will need to adapt to these with local authorities and the voluntary changes and be reconfigured to respond sector. In 2000, the Joint Futures Group, to these emerging health and social care a collection of senior figures from the Toni Dedeu is the Director of the needs. Since 1999, successive Scottish National Health Service (NHS) and local Agency for Healthcare Quality & Governments have been exploring ways to government, recommended that shared Assessment of Catalonia (AQuAS), Ministry of Health, Government of anticipate and tackle these demographic assessment procedures, information Catalonia, Spain. He was formerly and epidemiological challenges. The result sharing, joint commissioning, and the Director of Research & has been the transformation of health and joint management of services must Knowledge Exchange, Digital Health 1 & Care Institute, Innovation Centre, social care services. be developed throughout the country. University of Edinburgh, Scotland. By 2002, the Community Care and Email: [email protected] Health (Scotland) Act included powers, but not duties, for NHS boards and
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Table 1: A brief history of integration in Scotland body (referred to as an integrated joint board). 5 Both authorities are key to 1999 Seventy-nine Local Health Care Cooperatives (LHCCs) established, bringing ensuring accountability for integration. together GPs and other primary health care professionals in an effort to increase partnership working between the NHS, social work and the voluntary sector. An integrated budget is established by 2002 Community Care and Health (Scotland) Act introduced powers, but not duties, each integration authority to support for NHS boards and councils to work together more effectively. delivery of integrated functions, which 2004 NHS Reform (Scotland) Act required health boards to establish CHPs, replacing must cover adult social care, adult LHCCs. This was a further attempt to bridge gaps between community-based care, community health care, and aspects of such as GPs, and secondary health care, such as hospital services, and between adult hospital care and aim to support health and social care. prevention and improved outcomes. 2005 Building a Health Service Fit for the Future: National Framework for Service Change. This set out a new approach for the NHS that focused on more preventative health Each integration authority (lead agency or care, with a key role for CHPs in shifting the balance of care from acute hospitals to community settings. integrated joint board) establishes locality planning arrangements which engage a 2007 Better Health, Better Care set out the Scottish Government's five-year action plan, giving the NHS lead responsibility for working with partners to move care out of forum for local professional leadership and hospitals and into the community. innovation in service planning. Localities 2010 Reshaping Care for Older People Programme launched by the Scottish Government. correspond to the more recognisable towns It introduced the Change Fund to encourage closer collaboration between NHS and cities of Scotland which can be found boards, councils and the voluntary sector. within settlements (of 500 or more people). 2014 Public Bodies (Joint Working) (Scotland) Act introduced a statutory duty for NHS boards and councils to integrate the planning and delivery of health and Each integration authority puts in place social care services. a strategic commissioning plan for 2016 All integration arrangements set out in the 2014 Act must be in place by functions and budgets under its control. 1 April 2016. The joint strategic commissioning plan will be widely consulted upon with non- Source: Ref 8 statutory partners, patient and service-user representatives, among others.
local authorities to work together more authorities*. Health boards and local Where an integrated joint body is effectively. 3 An overview of reforms authorities are required to establish introduced, a Chief Officer must be is provided in Table 1 but in summary integrated partnership arrangements. The appointed by the integrated partnership they resulted in the 2013 report on purpose of the partnership arrangements to provide a single point of management the Public Bodies (Joint Working) is to establish an integration scheme, for the integrated budget and integrated (Scotland) Bill which proposed to replace an integration authority and ultimately service delivery. For the delegation the 79 local health care cooperatives oversee the implementation of the between partners model, this single with 32 partnership arrangements – one integration of health care and social care point of management falls to the Chief for each area – between the NHS and local in the area. Statutory partners (health Executive of the Lead Agency (i.e., the council care services. boards and local authorities) decide partner to whom functions and resources locally whether to include children’s are delegated). The step wise and participatory health and social care services, criminal transformation has achieved a high level justice, social work and housing support Principles of integration of consensus between key stakeholders services in their integrated partnership and was formalised with the Public Bodies arrangements. There are five key principles promoted by (Joint Working) (Scotland) Act 2014 which the Scottish model for integration. 6 The received Royal Assent on 1 April 2014. 4 Based on how health boards and local principles inspire change in culture and The Act now allows for better anticipatory authorities develop their integrated services to improve outcomes and deliver and preventative care and strengthened partnership arrangements they will these reforms successfully. The integration community-based care and provides a choose different integration authorities. model: respects the rights of service- legislative framework for the integration of Two models exist: a) delegation of users; protects and improves the safety health and social care services in Scotland. functions and resources between health of service-users; improves the quality of boards and local authorities (referred the service; best anticipates needs and Key features of the Public Bodies to as a lead agency); or b) delegation of prevents them from arising; and makes the (Joint Working) (Scotland) Act 2014 functions and resources by health boards best use of the available facilities, people and local authorities to a corporate and other resources. National outcomes for health and wellbeing apply equally to health Integrated services must be integrated boards, local authorities and integration * Integration authorities are the single agency ultimately from the point of view of service-users, accountable for the implementation of a statistical data but also planned and led locally in a way integration project.
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Table 2: Integrated partnership arrangements in Scotland Box 1: Integration Scheme components Project Name Description Community The project aims to provide support for older people (over 65 years), who are • Engagement of stakeholders Links Project, isolated and living in the Midlothian area. It works to enable them to stay connected Midlothian with their local community and maintain or build on existing social networks • Clinical and care governance and opportunities. arrangements Sustaining This initiatives strives to provide practical assistance to tenants through an • Workforce and organizational tenancy, enhanced management service. Run by Muirhouse, it aims to help people maintain sustaining their tenancy, enable them to improve their quality of life, and create the conditions development wellbeing, in which people can address aspects of their health and wellbeing. This initiative • Data sharing Muirhouse illustrates how housing associations – through extra services – can have a positive Housing impact on their tenants’ quality of life, health and wellbeing. • Financial management Association
• Dispute resolution Edinburgh The City of Edinburgh Council and NHS Lothian have been working collaboratively Joint Carers’ with carer organizations and carers themselves to develop a strategic approach to • Local arrangements for the Integration Strategy commission support services for carers. The development of its three year Joint Carers Strategy for 2014 – 2017 included a logic model that promotes consultation Joint Board with carers on priorities and support required. • Local arrangements for operational delivery Source: Ref 7
• Liability arrangements Implementation of integration in Service (IDS). The IDS was convened • Complaints handling Perth & Kinross to directly assist hospital staff to ensure patients preparing for discharge are 5 The recent integration of two services – Source: Ref connected with the Reablement Service. the Reablement Service and hospitals – in The IDS team consists of a Reablement Perth and Kinross is one example of how Coordinator, twelve new Reablement the reform described above is translating that is engaged with the community, Assistants, an occupational therapist into the integration of health and social those who look after service-users, and support assistant and a clerical officer. services. Other examples are provided those who are involved in the provision in Table 2. of health or social care. Furthermore, the Achievements services must take into account the needs The Reablement Service 9 is a social of different service-users; the communities Since the introduction of IDS and by service that was launched in 2010 in Perth in which they live; their dignity; the November 2012, Perth and Kinross to help patients over the age of 65 † regain particular needs of service users as they have successfully reduced the number their independence upon discharge from vary across the country; and the particular of hospital bed days for patients over 65 hospital and return home. The service characteristics and circumstances of by 50%. The ability of hospital staff to offers individuals six weeks of support different service users. 7 directly connect with the Reablement to plan and implement measures that Service though the IDS has also allowed promote independence focusing on the hospital-based social workers to direct Integrated partnership arrangements things they would like to be able to do for non-complex cases to the Reablement themselves. This can include anything Each integrated partnership arrangement Services and redirect hospital social from washing and dressing to preparing (i.e., each of Scotland’s 32 areas) must services to more complicated cases. meals. The amount of care and support propose an Integration Scheme that Direct collaboration between hospital someone receives varies depending on facilitates ten key components, as and Reablement Service staff has individual needs and if individuals cannot presented in Box 1. resulted in improved communication achieve full independence after the six and collaboration. This is in large part week period, on-going care is arranged. Currently, 22 joint integration schemes due to having dedicated clerical staff Until 2010, this service was engaged have been approved by the Cabinet to assume administrative and logistical upon referral by the local authority, Secretary for Health, Wellbeing and Sport communication responsibilities allowing independently from any health care and established across Scotland. Ten joint clinicians to focus on clinical discussions service or provider. integration schemes are still currently and care plans with patients and the undergoing internal review. A number Reablement Service staff. Such a review In 2011, as a means of reducing of policy leaders, financial officers and and redesign of the discharge pathway bureaucracy and accelerating patient solicitors are also involved to ensure that has led to a robust, efficient multi- access to Reablement Service the locality the integration schemes comply with disciplinary approach to assist with introduced the Immediate Discharge legislation. building community capacity, reduced duplication and increased efficiency. † The number of people aged over 65 living in Perth and Direct access to the Reablement Service Kinross is expected to increase by 74% by 2031.
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Figure 1: Quantifying the benefits of the IDS-Reablement Service Box 2: National health and wellbeing outcomes As of September 2014, 4876 bed days saved 1. People are able to look after and ⅓ of hospital patients used the re-ablement service to return to their previous level of independence improve their own health and wellbeing 65% of these patients required reablement services for up to 6 weeks and live in good health for longer. of which 40% required a care package in addition to the 6 weeks of support 2. People, including those with disabilities or long term conditions, or Since April 2012, ward‐based occupational therapists have assumed 806 direct access assessments who are frail, are able to live, as far as reasonably practicable, independently This freed‐up 20% of ward‐based social workers’ workload and at home or in a homely setting in now redirected to other in – hospital demands their community.
Given that each social‐worker‐administered assessment costs £158 per unit, the IDS – 3. People who use health and social reablement service saved the governement a total of £127,348 since 2012 care services have positive experiences or £54,576 per annum of those services, and have their dignity respected. Waiting times for social worker assessments have decreased from 8 to 4 days 4. Health and social care services are centred on helping to maintain or Source: Ref 10 improve the quality of life of people who use those services.
by health workers has reduced the waiting Conclusions 5. Health and social care services time for assessments. See Figure 1 for more contribute to reducing health In March 2013, the Scottish Government quantified gains from this initiative. inequalities. launched its 2020 Vision. The vision aspires to the goal that by 2020 everyone 6. People who provide unpaid care are Monitoring outcomes is able to live longer healthier lives at supported to look after their own health home or in a homely setting. Thanks to and wellbeing, including to reduce any A national framework for measuring the the development of the integrated health negative impact of their caring role on impact of integrated health and social care and social care system in Scotland the their own health and well-being. on the health and wellbeing of individuals foundations for achieving that vision is being developed based on a series of 7. People who use health and social are in place in most Scottish territories. desired outcomes of the Health and Social care services are safe from harm. Interventions ranging from hard regulation Care Integration model. The outcomes to detailed integration schemes, have 8. People who work in health and emphasize quality and consistency of ensured this transformation is tailored to social care services feel engaged with services for individuals, carers, their the specificities of each territory. By 2020, the work they do and are supported to families, and those who work in health Scotland will have a health care system continuously improve the information, and social care. All health boards, local that fully integrates health and social care support, care and treatment they authorities and integration authorities are and focuses on prevention, anticipation provide. jointly responsible and accountable for and supported self-management. Day achieving these outcomes. The desired 9. Resources are used effectively and care treatment will become the norm outcomes are listed in Box 2. Indicators efficiently in the provision of health and where traditionally individuals have been have been developed and linked to social care services. hospitalized. Whatever the setting, care outcomes in consultation with a wide will be provided at the highest standards range of stakeholders across all sectors, 11 of quality and safety, with the person at Source: Ref with significant input from the Convention the centre of all decisions. The focus will of Scottish Local Authorities (COSLA). be on ensuring that people get back to They have also been approved by a References their home or community environments Ministerial Steering Group. The indictors 1 as soon as appropriate, with minimal risk Scottish Government. Resources. Available at: are still being piloted, however, and will of re-admission’. Scotland’s integrated http://www.gov.scot/Topics/Health/Policy/Adult- need to be tested before their usefulness Health-SocialCare-Integration/Material health and social care model, is at the can be assessed both in terms of reporting 2 forefront of transformational change Scottish Government. Communications toolkit: and strategic planning. Integration in Europe. Close monitoring of the A guide to support the local implementation of Health Authorities will then be required to publish and Social Care Integration. Available at: http:// implementation and impact of the Scottish annual performance reports that monitor www.gov.scot/Topics/Health/Policy/Adult-Health- model will be important for scaling up and progress on these indicators along with SocialCare-Integration/Material/CommsToolkit knowledge exchange. any information on the local setting that can help contextualize local performance.
Eurohealth — Vol.22 | No.2 | 2016 Transforming health services 15
3 Joint Improvement Partnership Board. Joint TRANSFORMING THE Improvement Team Scotland. Available at: http:// www.jitscotland.org.uk/about-jit/background/ 4 Scottish Government. Public Bodies (Joint MODEL OF CARE FOR Working) (Scotland) Act 2014. Available at: http:// www.legislation.gov.uk/asp/2014/9/contents/ enacted TREATING 5 Scottish Government. Health and Social Care Integration Narrative. Available at: http://www.gov. scot/Resource/0044/00447596.pdf TUBERCULOSIS IN 6 Scottish Government. Principles of Adult health and social care integration. Available at: http:// www.gov.scot/Topics/Health/Policy/Adult-Health- SocialCare-Integration/Principles THE REPUBLIC OF
7 Scottish Government. Integration of health and social care. Available at: http://www.gov.scot/ Topics/Health/Policy/Adult-Health-SocialCare- ARMENIA Integration
8 Joint Improvement Team. Examples of Practice. Available at: http://www.jitscotland.org.uk/examples- of-practice/ By: Saro Tsaturyan and Armen Hayrapetyan 9 Joint Improvement Team. Reshaping Care for Older People Community Capacity Building / Co- production Case Study: Reablement Service – Perth & Kinross, 2016. Available at: http://www.jitscotland. org.uk/wp-content/uploads/2014/09/Perth-and- Kinross-CCB-CP-Case-Study-Feb-131.pdf
10 Joint Improvement Team. Immediate Discharge Summary: Reforms to treat tuberculosis (TB) patients undertaken Service – Reablement, Perth & Kinross (Update). Available at: http://www.jitscotland.org.uk/example- in Armenia have actively moved away from traditional modalities of of-practice/reablement-service-perth-kinross service delivery, and are rather based on modern service delivery 11 Scottish Government. National Health and Wellbeing Outcomes. Available at: http://www.gov. models informed by evidence-based guidelines, with clearly developed scot/Topics/Health/Policy/Adult-Health-SocialCare- pathways, more appropriate use of resources (human and physical), Integration/Outcomes and revised roles for hospitals. In the context of limited public resources, measures were introduced to change the model of care to deal with the growing burden of multidrug-resistant and extensively drug-resistant forms of TB. These measures included changing the hospitalization and discharge criteria for TB patients and reorganizing TB services while aligning provider payment mechanisms.
Keywords: Tuberculosis, Health Services Delivery, Health Financing, Armenia
Introduction population in 2014 was 45, 2 compared to 62.4 in 2005. 3 TB services, including Although ongoing reforms have resulted outpatient and hospital services for the in large reductions in tuberculosis (TB), entire population, are fully covered by the morbidity and mortality rates over the past Basic Benefits Package (BBP), which is years* TB remains a major public health funded from the public budget. However, Saro Tsaturyan is the Head of the threat in Armenia. The TB incidence the rise in the number of multidrug- State Health Agency, Ministry of rate (including HIV+TB) per 100 000 Health, Yerevan, Armenia; Armen resistant and extensively drug-resistant Hayrapetyan is the Director of the forms (M/XDR) forms of TB poses National Centre for Tuberculosis Control, Abovyan, Armenia. * TB morbidity was 34.7 per 100 000 inhabitants in 2014, serious public health and social challenges Email: [email protected] compared with 62.4 in 2005. The TB mortality rate for the same for the country. period was reduced from 5.2 to 1.6 (1).
Eurohealth — Vol.22 | No.2 | 2016 16 Transforming health services
public potential role of outpatient facilities “fee per case” payments for hospital in diagnosing, treating and preventing services. However, some types of inpatient funding for TB TB. The reorganization that followed services, including the treatment of TB the 2013 reform included all aspects patients prior to 2014, were reimbursed services was of TB services: human resource through a combination of fee per case management; administrative procedures and fee per bed/day mechanisms, such increased and financing mechanisms. that hospitals would receive a fixed fee per case for each discharged patient for Prior to the 2013 TB infrastructure In 2014, new criteria for admission and a pre-defined length of stay. If the actual optimization reform described here, there discharge of patients with TB were length-of-stay was less than the normative were 72 outpatient and 9 inpatient TB implemented in line with the WHO number of days, then the reimbursement care facilities in Armenia, of which 21 recommendations. The introduction of was calculated according to the actual outpatient and 2 inpatient facilities were specific hospitalization and discharge number of bed/days multiplied by the fee located‘‘ in the capital city Yerevan†. More criteria directed clinicians to avoid per day. than 65% of TB patients in Armenia hospitalization except for diagnostic were diagnosed at inpatient TB care purposes or smear negative TB patients. 6 During 2012 – 2013, the National facilities, where around 95% of all TB To further increase the efficiency of the Tuberculosis Control Office, in patients received their intensive course of system, a recommendation was made by collaboration with SHA, conducted a treatment. In 2013, 82% of public funding the Ministry of Health working group to comprehensive evaluation of TB service was allocated for hospital facilities and the close inpatient facilities that were serving delivery and financing in the country. remaining 18% for outpatient services. 4 only a limited number of patients annually Based on the findings, recommendations and to revise the structure of outpatient TB were to modify the financing mechanism An evaluation of the ongoing TB reforms, facilities in Yerevan. 7 for outpatient services from being based conducted by a team of WHO experts purely on per capita calculations and to in 2014, identified both achievements This resulted in the reduction of the introduce financing mechanisms that and existing shortcomings, such as number of outpatient TB facilities in were based on a combination of per the need to emphasize the role of Yerevan from 21 to 9 in 2014 (the number capita and performance based payments. intersectoral cooperation for successful of facilities in the regions remained the For inpatient services recommendations implementation of health sector reforms, same – 51), while their human resources included shifting from the previously to adopt a strategy for the integration of and technical capabilities were further mentioned mix of fee per case and bed/day vertical programmes (including TB) into strengthened. With the support of the approach and introduce a combination of primary health care, development of a Project “Strengthening tuberculosis guaranteed funds for facility maintenance unified health information system and control in Armenia” (funded by a grant (fixed) costs plus remuneration for variable reform of hospital infrastructure. More from the Global Fund), all TB providers costs (drugs, other medicine and food). specific recommendations with regard in Yerevan (i.e., doctors, nurses, lab Measures aimed to implement financial to TB were to improve training of TB technicians) were involved in training incentives for health care providers providers, to increase their awareness opportunities. Premises providing TB to incentivize early interventions, about performance-based incentives services in two Yerevan polyclinics were successfully treat TB cases, reduce the at the primary care level and to ensure also renovated. Three regional-level number of unnecessary hospitalizations more flexibility for the Ministry of inpatient facilities were closed due to and average length of stay, and overall, Health in managing budget allocations by low workloads bringing the total number promote higher productivity and cost consolidating numerous budget programs. 5 of inpatient TB facilities to six – two in effectiveness. While some of those recommendations Yerevan and four in the regions. are not yet fully implemented and need Armenia has had a performance-based further consideration by the Ministry Alignment of financing mechanisms financing (PBF) mechanism for primary of Health and other stakeholders, others to transform TB care care providers in place since 2010. were addressed with specific steps In 2014, two additional indicators related described below. It is important to mention that public to early detection of TB (one for adults funding for TB services (both outpatient and another for children) were added to 8 Transforming the TB model of care and inpatient) was increased during the the existing set of PBF indicators. New same period. In Armenia, the medical financing mechanisms for inpatient TB Prior to 2014 most hospitalized TB services covered by the BBP are funded services were introduced in October, patients did not meet the WHO criteria from the public budget through the State 2014. 9 While 2014 was marked by a for hospitalization, undermining the Health Agency (SHA) of the Ministry of transitional period for the implementation Health which acts as a single purchaser of new financing mechanisms, 2015 saw of services. Prior to the 2013 reform, the first full-scale post-reform reporting † The largest inpatient TB facility in the country, the National Anti-Tuberculosis Dispensary, is geographically located in the payment mechanisms included “per period. Further data comparisons will be Kotayk region, near the capital city Yerevan, and is directly capita” payments for outpatient and drawn between 2013 (the baseline year) managed by the Ministry of Health.
Eurohealth — Vol.22 | No.2 | 2016 Transforming health services 17
Table 1: Financing TB services in Armenia, 2013 – 2015
2013 2015 Number of Funding Number of Funding Number of cases bed/days (AMD millions) Number of cases bed/days (AMD millions) Hospital TB services 6 513 144 582 1 249.9 4 382 99 193 1 425.0 Outpatient TB services n.a. n.a. 270.2 n.a. n.a. 347.6 Total 1 520.1 1 772.6
Source: Database of State Health Agency, Ministry of Health, Armenia. Notes: AMD – Armenian Dram; n.a – data not available. and 2015. During the 2013 – 2015 period, Preliminary findings 6 Ministry of Health of Armenia (2013). Minister total public funding for TB services of Health order N 59-N of October 14, 2013, While assessing the impact of increased by 16.6%. Table 1 shows that “The standard on tuberculosis management in comprehensive reforms will require a the framework of state guaranteed free of charge public funding for outpatient TB services longer term perspective than is currently medical services”. increased by 28.6% while funding for available, initial achievements have Available at: http://moh.am/?section=static_pages/ inpatient TB services increased by 14.0%. index&id=588&subID=819 been encouraging. Continuous annual This is also reflected in the increased 7 monitoring and evaluation of the outcomes Ministry of Health of Armenia (2013). Minister outpatient/inpatient ratio of public funding in order to identify necessary adjustments of Health order N 712-A of March 26, 2013 “On (80% for inpatient services in 2015 establishment of working group for conducting a in a timely manner is ensured through and 20% for outpatient). study in TB cabinets of Yerevan city of the Republic a set of 33 indicators covering inputs, of Armenia”. Yerevan: Ministry of Health. processes and outputs (some indicators 8 Ministry of Health of Armenia (2013). Minister also will be monitored on a quarterly of Health order N 262-A of February 2, 2013 “On basis). First assessment results are approval of the performance based financing manual expected by May 2016 (after this article for primary health care facilities within the framework was sent to press). Overall, the success of of Disease prevention and control project”. Yerevan: improved quality the reform on TB care in Armenia seems Ministry of Health. to have hinged on the clarity of definitions 9 Ministry of Health of Armenia (2013). Minister of care and for models of care and the alignment of of Health order N 2488-A of October 24, 2014 “On the incentives and financing mechanisms approval of contractual budgets and financing norms higher for medical organizations providing state guaranteed to underpin those changes towards a more free of charge medical care and services within the satisfaction sustained transformation. framework of tuberculosis care program”. Yerevan: Ministry of Health. The total number of hospital TB cases References dropped by 32.7% from 2013 to 2015 1 Ministry of Health of Armenia (2015). Health while the number of bed/days was and Healthcare 2015. Statistical Yearbook, National reduced by 31.4%. These changes resulted Institute of Health. Data of the National Centre for ‘‘ Tuberculosis Control of Armenia. Yerevan: Ministry in an increase in the average cost per discharged patient by 69.4%, while total of Health of Armenia. funding of inpatient services increased 2 WHO country data for Armenia: Tuberculosis only by 14% during the same period, as profile. Available at: https://extranet.who.int/sree/ mentioned above. This, in turn, has led Reports?op=Replet&name=%2FWHO_HQ_Reports %2FG2%2FPROD%2FEXT%2FTBCountryProfile&IS to improved quality of care and higher O2=AM&LAN=EN&outtype=html satisfaction of both providers and patients, 3 since TB facilities received additional National Centre for Tuberculosis Control of Armenia. Internal data. resources to invest in improvement of both service delivery and working conditions 4 Ministry of Health of Armenia (2016). Database for their staff. At the National Anti- of State Health Agency. Yerevan: Ministry of Health. https://sha.am/ Tuberculosis Dispensary, which manages approximately 80% of all hospital cases, 5 WHO Regional Office for Europe (2014). Extensive average monthly salaries increased review of tuberculosis prevention, control and care in Armenia 17–25 July 2014. Copenhagen, WHO. by 20 – 25% in 2015 compared to 2013; Available at: http://www.euro.who.int/en/countries/ this represents a 21.5% increase for doctor armenia/publications/extensive-review-of-tb- salaries, and a 26.7% increase for nurses prevention,-care-and-control-services-in-armenia salaries. 3
Eurohealth — Vol.22 | No.2 | 2016 18 Moving towards universal health coverage
UNIVERSAL HEALTH COVERAGE AND THE ECONOMIC CRISIS IN EUROPE
By: Sarah Thomson, Tamás Evetovits and Hans Kluge
Summary: As the concept of universal health coverage (UHC) has gained prominence internationally, some have questioned its relevance for high-income countries, especially for countries that already offer universal (or near-universal) population coverage. This line of questioning is misguided because it limits UHC to population coverage and assumes that past achievements cannot be undone. In the years following the economic crisis, many people in EU member states experienced an erosion of health coverage. Before the crisis, unmet need for health services was falling across the EU, but by 2014 it had once again reached the level of 2007.
Keywords: Economic Crisis, Universal Health Coverage, Health System Performance
What does UHC mean for high- others to follow. Yet few policy makers in income countries? EU member states would claim to be fully satisfied with their country’s progress in UHC means everyone can use effective meeting all three UHC goals. And in the health services when they need them wake of the economic crisis, few would without experiencing financial hardship. 1 2 argue that movement around UHC is Moving towards UHC involves meeting inexorably in one direction. three distinct health system goals: access to needed health services; the provision of services of sufficient quality to be The impact of the crisis on UHC: effective; and financial protection, with theory equity being central to each goal. This An economic shock can undermine in turn requires a focus on all three progress towards UHC through the dimensions of health coverage, as shown following pathways: in the cube in Figure 1 and not looking Sarah Thomson is Senior Health solely at the share of the population that is • failure to address existing gaps in health Financing Specialist and Tamás covered, but also thinking about the range, coverage may add to financial pressure, Evetovits is Head of Office at the WHO Barcelona Office for Health quality and timeliness of covered services especially for households at risk of Systems Strengthening, Division and the presence and magnitude of co- poverty, unemployment and ill health of Health Systems and Public payments people are required to pay when Health. Hans Kluge is Director of • growing unemployment and poverty they use health services (user charges). the Division of Health Systems and may increase people’s need for health Public Health, WHO Regional Office care or lead people to save money by for Europe, Copenhagen, Denmark. During the 20th century, European Union using publicly rather than privately Email: [email protected] (EU) countries led the way in moving financed treatment; increased need for towards UHC, providing a model for
Eurohealth — Vol.22 | No.2 | 2016 Moving towards universal health coverage 19
Figure 1: Three dimensions of health coverage on health fell to such an extent that the level of spending per person in 2013/14 was around the level of 2007/08 in Croatia, Universal coverage of needed services and financial protection Cyprus, Italy, Latvia, Luxembourg, Costs: Slovenia and Spain, and around the how much do level of 2003/04 in Greece, Ireland Include people have to cost‐effective and Portugal. pay out‐of‐ Reduce co‐payments and services pocket? other out‐of‐pocket Between 2008 and 2014, out-of-pocket payments payments per person rose steadily in all except a handful of countries (Croatia, Cyprus, France, Greece and Slovakia, where they were lower in 2014 than Pooled funds Services: Extend to which services they had been in 2008). Out-of-pocket non‐covered are covered, of payments rose as a share of total spending what quality? on health in just over half of all EU Population: who is covered? countries (Figure 3). In several countries heavily affected by reductions in public spending on health, the increase in the Source: Adapted from Ref 1 out-of-pocket share has been large. For Note: In almost every country in the world, the vast majority of pooled funds are considered to be public because they are example, in Ireland, Portugal and Spain, generated through compulsory forms of pre-payment and are not linked to individual risk of ill health. the out-of-pocket share in 2014 was higher than in any year since 1995. In Greece, the out-of-pocket share fell dramatically health care and increased use of publicly Finally, we consider data on two key in 2009, but grew rapidly in 2013 and 2014. financed treatment may put pressure on UHC outcome indicators: unmet need and Changes of this magnitude indicate a publicly financed health services financial protection. substantial shifting of health care costs from governments to households at a • reductions in public spending on health The information we draw on comes from a time when many households were facing and restrictions of health coverage are study on the impact of the crisis on health additional financial pressure. likely to shift health care costs onto and health systems in Europe carried out households, increasing the out-of-pocket jointly by the European Observatory on share of total spending on health and Health Systems and Policies and the WHO leading to financial hardship, access Regional Office for Europe. 3 4 5 The study barriers and unmet need, particularly looked at policy responses to the crisis among vulnerable groups of people. between the end of 2008 and the beginning spending cuts of 2013. Evidence from previous shocks indicates that countercyclical public spending were large on health and other social services Many countries shifted health care during an economic downturn – that costs onto households enough to limit is, public spending that rises as gross Changes in public spending on health domestic product (GDP) is falling – is access and out-of-pocket payments can be important for protecting health and health used as simple proxy indicators of system performance. Relatively vulnerable people lost potentially negative effects on UHC. entitlement to publicly financed health Evidence from previous economic coverage The impact of the crisis on UHC: shocks clearly highlights the importance ‘‘ practice of countercyclical public spending in People who are not entitled to publicly minimising risks to health and health financed health coverage will face To assess the impact of the crisis on system performance. significant barriers to access unless UHC in EU countries, we look first at they are able to buy private insurance. trends in public spending on health and Figure 2 shows how public spending Extending population entitlement is trends in out-of-pocket payments, to see on health has been pro-cyclical – that therefore a critical first step in moving if reductions in public spending shifted is, falling as GDP falls – rather than towards UHC. The decade before the health care costs onto households. We countercyclical in nearly half of all EU crisis saw important changes to population then review health system responses to countries in the years since the crisis, with entitlement in EU countries – for example, the crisis, focusing on changes to the several countries experiencing substantial coverage expansions in Belgium for three dimensions of health coverage. and sustained declines. Public spending self-employed people, in Ireland for older
Eurohealth — Vol.22 | No.2 | 2016 20 Moving towards universal health coverage
Figure 2: Change in public spending on health per person during the crisis, EU28 policy response to this problem varied across countries. Early on in the crisis 70 (2009), Estonia extended health coverage 60 50 to people registered as unemployed for 40 more than nine months, on the condition 30 that they were actively seeking work. As 20 a result, a high share of the long-term 10 unemployed now benefit from improved 0 Change (%) -10 financial protection, although they still do -20 not have publicly financed access to non- -30 emergency secondary care. 5 In contrast, -40 in Greece action to protect unemployed -50 people has been slow and ineffective. 5 Italy Malta
Spain Estimates suggest that around a fifth of the Latvia Ireland France Poland Austria Cyprus Croatia Greece Finland Estonia Belgium Sweden Bulgaria Portugal Slovakia Hungary Slovenia Romania Denmark Lithuania Germany Greek population no longer has entitlement Netherlands Luxembourg to comprehensive health coverage due Czech Republic United Kingdom to unemployment or inability to pay Source: Authors using WHO data on per person public spending on health in national currency units 7 contributions – an alarming situation that 5 Note: Negative changes are between the year before public spending on health fell and the last year in which public spending on has as yet to be resolved. health fell (so for Greece it is between 2009 and 2014, for Ireland between 2008 and 2013 etc). Positive changes are between 2009 and 2014. The crisis has clearly shown the limitations of basing population entitlement on income or employment (often a proxy for Figure 3: Change in the out-of-pocket share of total spending on health during income) and demonstrated the merits of the crisis, EU28 basing entitlement on residence.
7 6 Very few countries selectively de- 5 listed non-cost-effective benefits 4 3 Using health technology assessment 2 (HTA) to identify and de-list (remove from 1 coverage) non-cost-effective services, 0 medicines and patterns of use can save Change(% points) -1 money and enhance efficiency. It would -2 therefore be an appropriate response -3 -4 to fiscal pressure if the infrastructure required were already in place. However, UK Italy Malta Spain Latvia Ireland France Austria Poland HTA was not in fact widely used to inform Cyprus Croatia Finland Greece Estonia Sweden Belgium Bulgaria Portugal Slovakia Hungary Slovenia Romania Denmark Lithuania Germany coverage decisions during the crisis. Only Netherlands Luxembourg four EU countries reported using HTA CzechRepublic for disinvestment, while eleven reported Source: Authors using WHO data 7 restricting benefits on an ad hoc basis.
Note: The change is between 2009 and 2014 for all except Estonia and Romania (2008 and 2014). Data for the Netherlands are not This is a cause for concern, especially internationally comparable because they systematically understate out-of-pocket payments. 8 where countries restricted access to primary care – for example, Romania introduced a cap on the number of covered people and in the Netherlands for richer making it more difficult for households to visits to a general practitioner for the same people previously excluded from publicly qualify for entitlement. Spain restricted condition, initially set at five visits a year financed coverage. access for adult undocumented migrants, in 2010 and further restricted to three but the measures were not implemented visits a year in 2011. During the crisis, six EU countries by all regions and, in 2015, the central reported reductions in population government announced it would partially In some countries, spending cuts were entitlement. Almost all of the reductions reverse the policy. 6 large enough to limit access to needed affected relatively poor households health services. Cuts to hospital budgets (Cyprus, Ireland, Slovenia) and non- Unemployed people are highly vulnerable in Latvia are reported to have pushed citizens (the Czech Republic, Spain). In in countries where entitlement to a up waiting times for elective surgical Cyprus, Ireland and Slovenia, the targeting comprehensive package of publicly funded procedures to such an extent that these of poorer households was the result of health services does not extend beyond services were de facto no longer publicly a change in the means-test threshold, a fixed period of unemployment. The
Eurohealth — Vol.22 | No.2 | 2016 Moving towards universal health coverage 21
Figure 4: Unmet need for health care due to cost, distance or waiting time, 2005 – 2014, EU28
12
10 Unemployed
8 Poorest quintile
2nd quintile % 6 Whole population
4 3rd quintile
4th quintile 2 Richest quintile
0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Source: Authors using data from EU-SILC 9 available from 2005 to 2014.
financed; those who needed them had reported reducing co-payments or trying Across the EU, only data on unmet need to use private hospitals and pay out to strengthen protection against co- are routinely available and disaggregated*. of pocket. 5 payments. Economic adjustment programs These data show how, on average, unmet negotiated with the European Commission need due to cost, distance or waiting Many countries increased co- required a blanket increase in co-payments time had fallen substantially before payments; a few understood the risks in Cyprus, Greece and Portugal, without the crisis began, but has risen steadily selectivity or protection for poorer people. since 2009. In 2014, unmet need for these When faced with fiscal pressure, some In this respect, the programs were not three reasons was back at the level it countries will consider introducing or in line with international evidence or had been in 2007 (Figure 4). As a result, increasing co-payments. This is likely to best practice. over 3 million more people reported unmet undermine access and financial protection need for health care in 2014 than in 2009. unless co-payments are applied with Some countries tried to address fiscal great care, in a highly selective way: (a) pressure through efficiency gains rather targeting non-cost-effective care only; than coverage restrictions. For example, or (b) targeting rich households only. reductions in medicine prices in countries unmet However, option (a) would probably not where co-payments are set as a share of lead to more efficient patterns of use medicine costs have lowered the financial need has risen because people will generally continue to burden on patients and enabled a wider use services and medicines if instructed range of medicines to be publicly financed. in 22 out of to do so by a physician or other health worker; removing non-cost-effective care Impact on UHC outcomes 28 EU member from coverage would be more likely to have the desired effect, if accompanied by Assessing changes in two UHC outcomes states strong signals to care providers. Option (unmet need and financial protection) (b) might succeed in shifting some costs requires data on the use of health Since the onset of the crisis, unmet need onto households without increasing access services, estimates of the incidence of due to cost, distance and waiting time has barriers or financial hardship, but the impoverishing and catastrophic out-of- risen across the whole population in 22 out administrative costs incurred could mean pocket payments, and data on unmet need, of 28‘‘ EU member states and was higher the net revenue gained is small. all disaggregated by income and other in 2014 than in 2009 among the poorest individual characteristics to allow analysis quintile in 21 out of 28 countries. 9 The Twelve EU member states reported of impact on equity. highest rises in unmet need among the introducing new or higher co-payments
in response to the crisis, suggesting many * Through the EU Survey on Income and Living Conditions countries found this to be a relatively easy (EU-SILC) covering the EU28 countries, Iceland, Norway policy lever to employ. Eight countries and Switzerland.
Eurohealth — Vol.22 | No.2 | 2016 22 Moving towards universal health coverage
poorest quintile – a doubling or more, an especially (but not only) among the References
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Cyprus, Finland, France, Greece, in unmet need is driven by changes in 2 WHO Regional Office for Europe. Priorities for Ireland, Italy, Latvia, Luxembourg, the households’ financial status or changes health systems strengthening in the WHO European Netherlands, Poland, Portugal, Spain and in the health system (or both). However, Region 2015–2020: walking the talk on people the United Kingdom. identifying the precise source of the centredness. Copenhagen: WHO, 2015. Available at: increase is probably not as important http://www.euro.who.int/en/about-us/governance/ regional-committee-for-europe/65th-session/ Until recently, financial protection was as understanding that, in any future documentation/working-documents/eurrc6513- not systematically monitored in Europe. downturn, the health system response priorities-for-health-systems-strengthening-in-the- To address this gap, the WHO Regional must be to step up protection for poorer who-european-region-20152020-walking-the-talk- Office for Europe has initiated a study to households as a priority. The fact that so on-people-centredness collect and analyse data on the incidence many countries failed to prevent erosion 3 Thomson S, Figueras J, Evetovits T, et al. of impoverishing and catastrophic out- of health coverage for the most vulnerable Economic crisis, health systems and health in Europe: of-pocket payments across a range of EU people should be a matter of concern to impact and implications for policy. Policy Summary, countries (see the article by Thomson, national and international policy makers Copenhagen: WHO/European Observatory on Health Systems and Policies, 2014. Evetovits, Cylus and Jakab in this issue). in. the EU Preliminary results for countries in which 4 Thomson S, Figueras J, Evetovits T, et al. pre- and post-crisis data are available Third, resilient health systems will take Economic crisis, health systems and health in Europe: impact and implications for policy. Maidenhead: Open indicate an increase in financial hardship steps now to ensure that fiscal pressures University Press, 2015. over time in most countries. do not undermine UHC achievements 5 in the future. This includes establishing Maresso A, Mladovsky P, Thomson S (eds.) (2015). Economic crisis, health systems and mechanisms to enable countercyclical What lessons for the future? health in Europe: country experience. Copenhagen: public funding for the health system; WHO/European Observatory on Health Systems In assessing the effects of the crisis on abolishing links between population and Policies.
UHC, we identify three important lessons entitlement and employment or income, 6 Expert Panel on effective ways of investing in for policy. First, for a robust assessment, to ensure that relatively vulnerable people Health (EXPH), Final Report on Access to Health we need better data on patterns of do not lose entitlement if they become Services in the European Union, May 2016. Available health service use; more internationally unemployed or because a means-test at: http://ec.europa.eu/health/expert_panel/index_ comparable data on unmet need; and threshold is raised; putting in place the en.htm more regular analysis of catastrophic and infrastructure needed to make evidence- 7 WHO. Global health expenditure database [online impoverishing out-of-pocket payments. informed decisions about cost-effective database], 2016. Available at: http://www.who.int/ All of these data, and data on health investment and disinvestment; and health-accounts/ghed/en/ spending trends, need to be made available bringing the design of co-payment policies 8 OECD. OECD iLibrary [online database], 2015. much more quickly than at present. in line with international evidence, so that Available at: http://www.oecd-ilibrary.org/ there is effective protection for the poor 9 Eurostat. EU-SILC data on unmet need, 2016. Second, it is evident that the remarkable and for regular users of health services and Available at: http://ec.europa.eu/eurostat progress EU countries made in meeting a cap on co-payments for everybody. UHC goals in the decade before the crisis has been partly undone as a result of the crisis. We see this in the widespread rise in unmet need across countries,
Good practices in strengthening Available for download at: http://www.euro.who.int/en/ publications/abstracts/good-practices-in-strengthening-health- health systems for the systems-for-the-prevention-and-care-of-tuberculosis-and-drug- prevention and care of resistant-tuberculosis-2015 tuberculosis and drug-resistant To improve the transfer of knowledge and experience among countries and their use of the health-system approach to tuberculosis tackle health problems, the WHO Regional Office for Europe has collected and disseminated good examples of the Edited by: C Acosta, M Dara, M Langins, H Kluge prevention, control and care of TB in the Region. In this second compendium, it presents 45 examples of good practice in Copenhagen: WHO Regional Office for Europe, 2015 strengthening health systems for the prevention and care of TB and drug-resistant TB from 21 countries.
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GENERATING EVIDENCE FOR UHC: SYSTEMATIC MONITORING OF FINANCIAL PROTECTION IN EUROPEAN HEALTH SYSTEMS
By: Sarah Thomson, Tamás Evetovits, Jonathan Cylus and Melitta Jakab
Summary: High-performing health systems protect people from experiencing financial hardship when using needed health services. But what does financial hardship mean, how is it measured and what can policy makers learn through systematic monitoring? These are some of the questions the WHO Regional Office for Europe is addressing in a new study that uses a refined methodology to monitor financial protection across countries in Europe. The study will provide actionable information on a key indicator of universal health coverage (UHC) and an important dimension of health system performance.
Keywords: Financial Protection, Universal Health Coverage, Health System Performance
Why does financial protection matter? food, housing and utilities. In the long run, this could lead to further deprivation and Financial hardship is an outcome of using ill health. health services and having to pay for them ‘out of pocket’ at the point of use*. Health systems that provide strong Out-of-pocket payments are unlikely to financial protection keep out-of-pocket be a problem if they are small and paid payments to a minimum using a by people who are well off. However, combination of strategies. 1 These include even small payments can cause financial adequate and stable public funding for a Sarah Thomson is Senior hardship for poor people and those who broad spectrum of health services; limited Health Financing Specialist and need to pay on an ongoing basis – for Tamás Evetovits is Head of Office at use of co-payments (user charges); efforts example, to cover some or all of the cost the WHO Barcelona Office for Health to ensure equitable and timely access Systems Strengthening, Division of of medicines for chronic conditions. to good quality care delivered at least Health Systems and Public Health, Weak financial protection may prevent Barcelona, Spain; Jonathan Cylus cost; and policies to protect vulnerable households from spending enough on is Research Fellow at the European groups of people. Because outpatient Observatory on Health Systems health care and other basic needs like and Policies, London, United medicines account for a large share of Kingdom; Melitta Jakab is Senior out-of-pocket payments, policies to expand Health Economist at the WHO publicly financed coverage of medicines, Barcelona Office for Health Systems to reduce medicine prices and to ensure Strengthening. * Out-of-pocket payments refer to formal and informal Email: [email protected] payments made by people at the time of using any good or service delivered in the health system.
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cost-effective prescribing, dispensing Figure 1: Public spending on health and out-of-pocket payments in high-income and use of medicines play a vital role in countries in the WHO European Region, 2014 strengthening financial protection. 50 R² = 0.57 Why monitor financial protection in high-income countries? 40 Many people see lack of financial protection as a policy problem mainly 30 affecting health systems in low- and middle-income countries. The assumption 20 is that richer countries provide good financial protection through high levels of 10
public spending on health and universal Out-of-pocket payments (or near-universal) population coverage.
Although it is true that the incidence of as aof % total spending on health 0 financial hardship tends to be higher 0 1 2 3 4 5 6 7 8 9 10 11 in poorer than in richer countries, 2 Public spending on health as a % of GDP inadequate financial protection remains a pertinent issue in high-income countries.
First, there is substantial variation across Source: WHO data. high-income countries in levels of public Note: The figure includes high-income countries in the WHO European Region with populations of more than 100,000 people. spending on health and of out-of-pocket payments, as shown in Figure 1. Across the 34 high-income countries in the The genuinely global relevance of For catastrophic out-of-pocket payments, WHO European Region, public spending financial protection is reflected in the the threshold is a share of a household’s on health ranges from 3.3% to 10.0% of inclusion of universal health coverage in budget or capacity to pay. A simple GDP and out-of-pocket payments range the sustainable development goals (SDGs), approach is to consider out-of-pocket from 6.3% to 48.7% of total spending to which all countries have committed. payments to be catastrophic if they exceed on health. Because financial protection is a core a share of a household’s budget, with health system objective, it should be budget defined as total income or total Second, population coverage alone is not a central component of health system consumption (that is, actual spending, enough to secure financial protection. If performance assessment in rich and poor often regarded as a more stable indicator publicly financed benefits do not include countries alike. of financial status than income, especially a broad range of good quality health in contexts where incomes are irregular or services, or if co-payments are required, How is financial protection measured? partially in kind). some people will experience financial hardship in spite of being covered. Financial protection is commonly More refined approaches define out-of- measured using two indicators associated pocket payments as catastrophic if they Third, policy choices matter. Even high- with the use of health services: so-called exceed a share of capacity to pay – that is, income countries face fiscal constraints ‘impoverishing’ and ‘catastrophic’ out- income or consumption remaining after and must make trade-offs when allocating of-pocket payments. 2 4 5 Both indicators deducting an amount to cover spending resources. They also have people who estimate the number of households in on basic needs. This amount could be are poor or vulnerable in other ways. which out-of-pocket payments for health normative – the same for all households of As a result, failure to spend limited care exceed a pre-defined threshold. equivalent size – or reflect a household’s resources efficiently and to provide actual spending on basic needs. Studies effective protection for vulnerable groups The threshold used to estimate the that account for capacity to pay usually (for example, through exemptions from incidence of impoverishing out-of-pocket focus on food spending, but food may co-payments) is likely to exacerbate payments is a poverty line. Estimates not be a good proxy for basic needs in financial hardship. involve identifying households initially all contexts. above the poverty line (non-poor Finally, policy achievements can be households) who find themselves below In estimating either indicator, it is not undone. People in many EU member the poverty line after making out-of- the absolute amount spent out of pocket states have experienced an erosion of pocket payments (now poor households). that is important, but rather the impact of health coverage due to changes introduced The poverty line can be defined in this spending on a household’s financial during the economic crisis 3 (see the article different ways. status – so the amount relative to a by Thomson, Evetovits and Kluge in household’s proximity to the poverty line this issue). (impoverishing out-of-pocket payments)
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Figure 2: The incidence of impoverishing and catastrophic out-of-pocket payments is a normative amount based on spending for health services in a high-income country on food, rent and utilities among relatively poor households†. 100% No OOPs 90% We present the incidence of impoverishing and catastrophic out-of-pocket payments 80% Figure 2 Not at risk of impoverishment in a single chart ( ). The chart Could also draws attention to other important 70% after OOPs experience groups of people, such as those ‘at risk of catastrophic 60% At risk of impoverishment after impoverishment’ because they come close OOPs OOPs to the basic needs line after making out-of- 50% pocket payments; those who are ‘further
Population impoverished’ because they are living 40% Impoverished after OOPs Always below the basic needs line before incurring experience 30% out-of-pocket payments; and people who catastrophic Further impoverished after 20% OOPs do not incur any out-of-pocket payments OOPs at all, potentially raising questions about 10% the magnitude of unmet need for health Catastrophic OOPs services. 6 Highlighting out-of-pocket 0% spending among already poor people is
Source: Authors’ modelling. particularly valuable for policy makers given the emphasis many health systems Note: Stylised example; OOPs = out-of-pocket payments. place on protecting poorer households.
What can policy makers learn from Figure 3: The distribution of impoverishing and catastrophic out-of-pocket payments monitoring financial protection? across income groups in a high-income country Analysis of financial protection provides 25% policy makers with actionable information on an important dimension of health 20% system performance and a key indicator of universal health coverage. At a national or sub-national level at one point in 15% time, it sheds light on how many people experience financial hardship as a result 10% of out-of-pocket payments (incidence, Figure 2); who these people are and whether some groups are systematically 5% disadvantaged (distribution, Figure 3); and the role of different types of health 0% service in causing financial hardship Poorest 2nd 3rd 4th Richest (drivers, Figure 4) – most datasets quintile quintile allow disaggregation by inpatient care, Source: Authors’ modelling. outpatient care, medicines, medical
Note: Based on data from an EU country; income groups are based on household consumption quintiles. products, diagnostic tests and dental care.
or the amount relative to capacity to pay policy implications and to increase policy When analysis involves more than one (catastrophic out-of-pocket payments). relevance in both high- and middle- year of data, it makes it easier to identify For both indicators, disaggregating income countries. Our approach extends correlations between the incidence, results based on household characteristics the concept of basic needs to spending distribution and drivers of financial (income, age, place of residence and so on) on housing (rent) and utilities (water, hardship, the health system and the socio- is central to the analysis. gas, electricity and heating) as well as economic environment. For example, it spending on food. The poverty line we may be possible to link a change (or the The WHO Regional Office for Europe use – reflecting the costs of basic needs – absence of change) in financial hardship to has recently developed a further refined methodology that adapts these common indicators to address inconsistencies in
measurement, to enhance clarity around † Households between the 25th and 35th percentiles of the household consumption distribution.
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Figure 4: The drivers of impoverishing and catastrophic out-of-pocket payments across countries in the regularity of data across income groups in a high-income country collection and in the level of detail with which household spending on health 100% services is assessed. 90% Inpatient care 80% In the past 15 years, WHO and the World Bank have supported monitoring Outpatient care 70% of financial protection in Europe and Central Asia. However, the analysis has 60% Dental care been limited to a relatively small number 50% Diagnostic tests of countries and at regional level we still 40% lack a comprehensive set of comparable Medical products 30% estimates. This new study initiated by the WHO Regional Office for Europe is the 20% Medicines first to apply the same methodology to 10% a large number of countries from across the whole region, including a significant 0% Poorest 2nd 3rd 4th Richest quintile number of western European countries and quintile EU member states.
Previous multi-country analysis of
Source: Authors’ modelling. financial protection has generated numbers on the incidence of Note: Based on data from an EU country; income groups are based on household consumption quintiles; OOPs = out-of-pocket payments. impoverishing or catastrophic spending on health services without accompanying national analysis. 2 7 8 In contrast, our changes (or the absence of change) in the could not afford to pay for it. In our study study takes a bottom up approach. We health system and in policies beyond the we try and address this by ensuring that have commissioned one or more national health system. each national report includes a discussion experts in over 20 countries to prepare of data on unmet need. Highlighting a comprehensive national assessment of Comparative analysis can generate even people who do not incur any out-of-pocket financial protection. Each national report richer evidence for policy. Preliminary payments also helps to make the issue of will not only generate numbers using at results from ten of the countries in our unmet need more visible, particularly in least two data points, but also provide a study show how financial hardship is health systems that do not exempt people detailed discussion of these numbers in consistently concentrated among the from co-payments, although most datasets the context of health system and broader poorest 40% of the population and mainly do not allow us to say whether these socio-economic developments. National driven by out-of-pocket spending on people experience unmet need or not. experts are using a standard template outpatient medicines, especially among for reporting to facilitate comparison poorer households. Early results also show What does it take to monitor financial across countries. Their reports will that the incidence of financial hardship protection systematically? feed into a regional overview and varies significantly across countries. comparative analysis. While incidence is associated with out- Systematic monitoring of financial of-pocket payments as a share of total protection requires three things: survey What will monitoring financial spending on health, it is also influenced data on household consumption; a protection achieve? by policies to protect vulnerable groups standard approach to monitoring applied of people. Differences in the way in over time and across countries; and a good Systematic monitoring of financial which countries provide people with understanding of national health system protection with in-depth national analysis protection against co-payments appear to and socio-economic contexts. will lead to a better understanding of be important. This finding suggests that the contextual factors and policies that efforts to strengthen financial protection EU member states are required to carry drive financial hardship within and need to focus on policies, not just on levels out household budget surveys at least once across countries. It will allow countries of public spending on health. every five years; some do this annually. to identify ways of improving financial Many non-EU countries in Europe also protection, especially for vulnerable A limitation of all indicators used to carry out regular household budget groups of people. The WHO Regional measure financial protection is that they surveys. This means the statistical data Office for Europe is ready to work with do not capture unmet need due to cost – needed to monitor financial protection are member states to ensure that the evidence that is, instances in which people needed routinely available in almost all countries generated by our study raises awareness of but did not use health care because they in Europe, although there is variation financial hardship and, ultimately, results
Eurohealth — Vol.22 | No.2 | 2016 Enhancing the health workforce 27
in policy changes that strengthen financial A PEOPLE-CENTRED protection. To this end, we seek to facilitate policy dialogue through national and international meetings to share results, SYSTEM APPROACH foster cross-country learning and support evidence-informed policy development. IN WALES: PRUDENT References 1 WHO Regional Office for Europe (2015). HEALTHCARE Priorities for health systems strengthening in the WHO European Region 2015–2020: walking the talk on people centredness. Copenhagen: WHO. Available at: http://www.euro.who.int/en/about-us/ governance/regional-committee-for-europe/65th- session/documentation/working-documents/ By: Jean White, Ruth Hussey and Leighton Phillips eurrc6513-priorities-for-health-systems- strengthening-in-the-who-european-region- 20152020-walking-the-talk-on-people-centredness
2 Xu K, Evans D, Kawabata K, Zeramdini R, Klavus J et al (2003) Household catastrophic health Summary: The Ministry of Health of Wales has introduced the expenditure: a multicountry analysis. The Lancet 362: 111–117. Prudent healthcare policy to transform service delivery towards 3 Thomson S, Figueras J, Evetovits T, Jowett M, empowering people through enhanced health literacy and engagement Mladovsky P, Maresso A, Cylus J, Karanikolos M and Kluge H (2015). Economic crisis, health systems and of patients in clinical decision-making, self-management and care health in Europe: impact and implications for policy, Maidenhead: Open University Press. Available at: planning. Prudent healthcare seeks to minimise interventions and http://www.euro.who.int/en/about-us/partners/ observatory/publications/studies/economic-crisis,- maximise effectiveness. The policy places people at the centre of health-systems-and-health-in-europe.-impact-and- implications-for-policy decision-making working in partnership with patients to co-produce
4 Wagstaff A (2009) Measuring financial protection a course of action with shared responsibility. Particular focus here in health. In Smith P, Mossialos E, Papanicolas I and Leatherman S, eds. Performance measurement has been devoted to the implications for the health workforce, the for health system improvement: experiences, first foundation of “walking the talk on people-centredness”. challenges and prospects. Cambridge: Cambridge University Press.
5 Saksena P, Hsu J, Evans D (2014) Financial risk Keywords: Health Literacy, Engagement, Co-production, People-centred, Wales protection and universal health coverage: evidence and measurement challenges. PLOS Medicine 11(9): e1001701. Introduction of interventions, this is likely to lead to 6 Wagstaff A and Eozenou P (2014) CATA meets more, not less health inequality in society, In the face of increasing demands for IMPOV. A unified approach to measuring financial will be unsustainable over the long term protection in health, Policy Research Working Paper health care, many governments are and will not necessarily achieve improved 6861, Washington DC: The World Bank. considering how best to respond to ensure outcomes. Focusing improvement activity 7 accessible and sustainable health services Xu K, Evans D, Carrin G, Aguilar-Rivera A, solely on access and patient flow is Musgrove P et al (2007). Protecting households that are people-centred and value-based unlikely to ensure the affordable health from catastrophic health spending. Health Affairs 26: but also affordable. These aims are in line improvements that all are seeking. A 972–983. with those set out in the third pillar of greater understanding of demand for 8 World Bank (2012) Health equity and financial the World Health Organization Regional services coupled with redesigned care protection datasheet: Europe and Central Asia, Office for Europe’s overarching policy pathways is now needed. Building on an Washington DC: The World Bank. framework, Health 2020, dedicated to international movement towards using strengthening people-centred health health resources more wisely, Wales systems and public health. As therapeutic has developed a policy that sets out four medicines advance and technologies guiding health care principles ensuring Jean White is Chief Nursing Officer, improve at a rapid pace, there is an a person-centred approach to care that Ruth Hussey (now retired) was inevitable temptation to engage with formerly Chief Medical Officer and utilizes health resources intelligently these developments and thereby increase Leighton Phillips is Deputy Director to secure the desired outcome for for Health Strategy and Policy, the number of medical interventions, individuals. 1 By applying this prudent Welsh Government, Cardiff, Wales. often driven by the public’s expectations. Email: [email protected] policy to health care delivery, a new Without prudence and careful selection
Eurohealth — Vol.22 | No.2 | 2016 28 Enhancing the health workforce
Figure 1: The Prudent Healthcare policy, Wales wide range of resources that explores the principles in the context of health care delivery; as well as a number of conferences and other events providing fora of engagement at regular intervals. All health service organizations are now exploring and testing how these four principles can be used to drive service change and the remodelling of patient pathways.
The action plan for national health services in Wales, ‘Prudent healthcare – Securing Health and Wellbeing for Future Generations’, was published in February 2016. This sets out three priorities to focus collective national action by professionals, the public and public service leaders. The areas chosen for action in this plan are: • reducing unnecessary and inappropriate
Source: Ref 1 tests, treatments and medication and ensuring people are able to make informed decisions about their care; system-wide policy is established that and poor outcomes from the excessive prioritizes activities that add value, use of medical interventions. For • changing the model of outpatients; and contribute to improved patient outcomes example, the Choose Wisely campaigns • public services working together to as well as sustainability. in the US and Canada 3 provide simple improve health care. information which makes clear the The Prudent healthcare policy helps advantages and disadvantages of different Info-graphics are used where possible to implement aspirations outlined in existing tests, treatments and medications, thus help communicate the concept and help legislations and ensures these aspirations enabling patients to make better informed with engagement (Figure 1). are realised and synergised. For example, decisions with their clinicians. The British the Well-being of Future Generations Medical Journal campaign ‘Too much Act (2015) 2 is cross sectoral legislation medicine’ 4 highlights the threat to human focusing on sustainable development with health posed by over-diagnosis and the an emphasis on long term prevention, waste of resources on unnecessary care. co- collaboration, involvement and integration Scotland has also recently advocated the of approaches that are needed to tackle concept of ‘Realistic Medicine’. There production the generational challenges like climate is some evidence that suggests that change, tackling poverty and health around 10% of all health care interventions focusses on inequalities. Consequently, ensuring contribute to some harm to patients, 5 sustainable public services are responsive while an estimated 20% of health service empowering to patient needs, both immediately and for activity has no effect on patient future generations, is a key government outcomes 6 – suggesting this ‘imprudent’ individuals to strategic priority, as this is a powerful use of resources is endemic in current driver to improve the health and well- health systems. actively being of the population. Furthermore, by participate focusing on working with individuals to Principles and actions reach their desired outcome, the Prudent ‘‘ The specific actions within the plan were healthcare policy also ensures that a more The development of the Prudent selected because they touch the lives of integrated and coordinated approach healthcare policy for health services many people and because coordinated across services is delivered. in Wales was initiated by the Bevan action taken at both a national level Commission in 2013. 7 Following and by provider organizations will nationwide discussion, four guiding Part of an international movement have a significant impact on the way principles have been adopted (see left health services are delivered in Wales. In recent years there has been a growing side of Figure 1). A Prudent healthcare For example, the number of outpatient international movement to reduce harm website 1 has been developed with a appointments held in acute secondary care
Eurohealth — Vol.22 | No.2 | 2016 Enhancing the health workforce 29
hospitals each year is roughly equivalent in moderation, eating five or more portions is the rapid expansion of advanced practice to the number of people who live in Wales, of fruit and vegetables a day, taking roles for nurses, midwives, paramedics and 3.1 million. Many of these appointments regular exercise and maintaining a healthy allied health professionals. Practitioners would be more effective if they were held weight) can reduce premature death and can advance their practice through various in health settings closer to the person’s dramatically reduce the prevalence of continuing professional development home or via tele-health. Streamlining conditions such as diabetes, heart disease, activities, either by developing specialist follow-up for people with complex needs dementia and cancer. knowledge, acquiring prescriptive would save time for patients from having authority for medicines and tests and to attend multiple condition-specific Much attention is now focussed on advancing clinical decision-making skills. clinics. Designing services around patient how health professionals can work with For some professions, this advanced needs and life circumstances will both members of the public to ensure that they practice means leading delivery of care, optimize the use of acute hospital facilities have the information needed to make previously the exclusive domain of the and improve the experience for service informed choices. An example of this doctor. This has become a growing and users, particularly for the large portion of is in maternity care, where early access essential practice in health services the population who live in rural areas and to a midwife is seen as essential. In globally. 11 have multiple chronic conditions. Wales, over 80% of women are seen by a midwife by the time they have completed A people-centred approach twelve weeks of pregnancy. All health providers have been asked to organize Putting people at the centre of care care so that women are able to access is widely recognized as an essential local services by ten weeks of pregnancy. renewed component of modern health care. The This ensures earlier access to advice on first Prudent healthcare principle focuses healthy lifestyles, referrals to support configurations on people, particularly in adjusting the services (e.g., smoking-cessation services) power dynamic that currently exists and information on community services and roles of between health professionals and the (e.g., specialized exercise classes and patient so that patients are equal partners social support). Midwives, who already health in making decisions about their treatment. encourage and support women to give A simple illustration of what this means up smoking during pregnancy, are now professionals is that all health professionals should ask equipped with carbon monoxide monitors the patient “What matters to you and to support mother’s understanding of Wales introduced a framework how can we work together to focus on risk from smoking to their own and their for advanced health professionals 12 ‘‘ this?” This discussion on priorities and baby’s health. There is a strong interest in 2010 which is framed around four an honest exploration of advantages and in focusing on the first 1000 days of life core functions: clinical practice, research disadvantages of options may lead to as a means of maximising health service and development, clinical leadership more appropriate clinical pathways for the impact and ensuring these services are and management and education. This patient. 8 universally accessible to ensure all babies framework has been accompanied by have the best start in life. 10 guidance on the safe delegation of tasks This concept of co-production is now by health professionals to other health being applied widely within public Rethinking the roles of health workers workers. The Welsh government has service organizations in Wales. A new and optimizing skill mix now committed to annually investing web portal has been created to offer case in providing education programmes to study examples, demonstrating how Part of the wider implications for the expand this cadre of workers within the collaborative working can materially health workforce in adopting a prudent national health care system. improve the economic, social and approach is renewed configurations and environmental well-being of people and roles of health professionals to deliver A nurse-led prudent service is the communities. 9 care in a timely manner. Pursuing development of leg ulcer clubs in Powys, 13 Prudent healthcare may mean a change a rural part of mid Wales, which typically The principle of co-production focusses to some traditionally held roles and role serves around 3000 leg ulcer patients on empowering individuals to actively adjustments within multidisciplinary annually. Here drop-in clinics have been participate in achieving the outcomes that teams. The ‘prudent’ concept here is set up in non-clinical settings, where matter to them. Practically, this means that activities should be undertaken by patients can show up without appointments engaging with the public specifically about the most appropriate person. This is for advice or other practical issues of their what they can and should do to ensure particularly pertinent in primary care, care, often involving group-based services their own health and well-being and that which is the fundamental building block and activities. Local volunteers have of their families. There is good evidence of a prudent health system. An example also been organized by the local health that the adoption of five healthy lifestyle is the growth of pharmacy posts within service providers to support patients with activities (not smoking, consuming alcohol general practice. A further manifestation transportation and other access issues.
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The community approach helps address Mark Drakeford, Welsh Minister for 7 Bevan Commission website. Available at: http:// social isolation and loneliness, which is Health and Social Services, sums up the www.bevancommission.org/home frequently experienced by patients with urgency and need for reform by saying: 8 Dineen R. Co-producing Prudent healthcare: leg ulcers and has proven to shorten putting people in the picture, 2015. Available at: “Our health services are under pressure; recovery time. It has also been identified http://www.prudenthealthcare.org.uk/coproduction/ the people who work in the health service as a more cost efficient use of community 9 feel that pressure absolutely every day… Good Practice Wales website. Available at: http:// nurse resources. 14 www.goodpractice.wales/ So today in the challenges we face, I believe that the Prudent healthcare 10 WHO Regional Office for Europe. Nurses and Conclusion movement gives us an opportunity to midwives: a vital resource for health. European compendium of good practices in nursing and recreate, reinvent and reimagine that most Prudent healthcare in Wales is in its midwifery towards Health 2020 goals, 2015. important of all our public services for early stages, but it has already caught the Available at: http://www.euro.who.int/en/health- the future…” 14 topics/Health-systems/nursing-and-midwifery/ imagination of those focused on improving publications/2015/nurses-and-midwives-a-vital- the delivery of public services. Its success resource-for-health.-european-compendium-of- is predicated on strong leadership, not References good-practices-in-nursing-and-midwifery-towards- health-2020-goals only at the top of organizations, but 1 Welsh Government. Prudent healthcare web site, also at the clinical professional level. It 2016. Available at: http://gov.wales/topics/health/ 11 National Leadership & Innovation Agency for provides an opportunity to reshape and nhswales/prudent-healthcare/?lang=en Healthcare (Wales) Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in base clinical care pathways on evidence 2 National Assembly for Wales. Well-being of Future Wales, 2010. Available at: http://www.weds.wales. and allows for a greater emphasis on Generations Act, 2015. Available at: http://www. nhs.uk/resources-workforce-modernisation primary and community services which legislation.gov.uk/anaw/2015/2/contents/enacted 12 National Leadership & Innovation Agency for are located closer to the individual. At its 3 ABIM Foundation ‘Choose Wisely’ campaign. Healthcare(Wales) All Wales guidance on delegation, core, Prudent healthcare calls for new Available at: http://www.choosingwisely.org/about- 2010. Available at: http://www.weds.wales.nhs.uk/ us/ relationships between service providers, resources-workforce-modernisation professionals and the public that centre on 4 British Medical Journal ‘Too Much Medicine’ 13 Powys Teaching Health Board leg clubs. Available sharing power and challenging traditional campaign. Available at: http://www.bmj.com/too- at: http://www.powysthb.wales.nhs.uk/leg-clubs practices and roles. People need to be much-medicine 14 Welsh Government. Prudent healthcare – equal partners in securing their health and 5 Vincent C. Adverse events in British hospitals: securing health and well-being of future generations. well-being and must take responsibility preliminary retrospective record review. BMJ Action plan, 2016:22. Available at: http://www. 2001;322:517. for their own health. To do this they prudenthealthcare.org.uk/securing-health-and- need information and support from 6 MacArthur H, Phillips C, Simpson H. wellbeing-for-future-generations/ knowledgeable health workers. Improving Quality Reduces Costs. Cardiff: 1000 Lives Improvement, 2012. Available at: http:// www.1000livesplus.wales.nhs.uk/quality-and-cost/
Economic Crisis, Health critical. This book looks at how health systems in Europe reacted to pressure created by the financial and economic Systems and Health in Europe: crisis that began in 2008. Drawing on the experience of Impact and implications for policy over 45 countries, the authors: • analyse health system responses to the crisis in three policy By: S Thomson, J Figueras, T Evetovits, M Jowett, areas: public funding for the health system; health coverage; P Mladovsky, A Maresso, J Cylus, M Karanikolos and H Kluge and health service planning, purchasing and delivery
Copenhagen: Open University Press, 2015 • assess the impact of these responses on health systems and population health Freely available for download at: http://www.euro.who.int/ en/health-topics/Health-systems/public-health-services/ • identify policies most likely to sustain the performance of publications/2015/the-case-for-investing-in-public-health health systems facing financial pressure
Economic shocks pose a threat to health and health system • explore the political economy of implementing reforms performance by increasing people’s need for health care and in a crisis. making access to care more difficult – a situation compounded The book is essential reading for anyone who wants to by cuts in public spending on health and other social services. understand the choices available to policy-makers – and the But these negative effects can be avoided by timely public implications of failing to protect population health or sustain policy action. While important public policy levers lie outside health system performance – in the face of economic and other the health sector, in the hands of those responsible for fiscal forms of shock. policy and social protection, the health system response is
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BUILDING PUBLIC HEALTH LEADERSHIP SKILLS IN THE REPUBLIC OF KAZAKHSTAN
By: Zhanna A. Kalmatayeva, Saltanat A. Mamyrbekova, Gainel M. Ussatayeva and Regina Winter
Summary: Building capacity to restructure public health services is an important means of transforming health services to meet the health challenges of the 21st century. Several Member States have embarked on restructuring their public health services. The Republic of Kazakhstan is one such example. Its new State Policy for Public Health Development has set the course for reforming the country’s public health services. Implementation of this policy will require well-trained public health professionals. This article describes how the Higher School of Public Health at the al-Farabi Kazakh National University Medical Faculty is leading the way by aligning curricula with contemporary public health needs and career trajectories.
Keywords: Public Health, Health Workforce, Education, Curricula Transformation
Introduction figure prominently as an integral part of the public health system. Moreover, Historically, management and the public health services were financed and organization of public health services in operated in parallel to health care service the Central Asian Republics (CAR) have structures, which remained predominately followed the Sanitary Epidemiological curative and disease-oriented. Advantages (san-epid) Service model, a model that was and disadvantages of the Semashko system concerned more with hygiene, sanitation continue to be the subject of extensive and communicable disease control than discussion in these countries. Zhanna A. Kalmatayeva is Dean, with health promotion and intersectoral Saltanat A. Mamyrbekova is action for health. 1 This has been attributed Vice-Dean of Academic Affairs and Educational Work and to the fact that the very concept of ‘public The State Policy for Public Health Gainel M. Ussatayeva is Vice-Dean health’ has been difficult to translate into Development of Research and Innovation Work national languages. Previously, public and International Collaboration at In order to address its contemporary health was hierarchically organized and al-Farabi Kazakh National University public health challenges, the Republic of the majority of public health services Medical Faculty – Higher School of Kazakhstan recently launched the State Public Health, Kazakhstan; Regina were provided in a context that prioritized Policy for Public Health Development Winter is technical consultant for centralized monitoring, inspection and the Health Systems and Public for 2016–2019. 3 The policy puts forward mandatory sanitary services. 2 Health Health Division at the WHO Regional a transformative and novel vision for Office for Europe. promotion, preventive programmes public health services in the country. Email: [email protected] besides immunization, and to some These now include 1) empowering extent environmental and occupational and educating the population in health health or operational research, did not
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promotion and disease prevention to closely in line with the European Program on health systems strengthening, is still avoid exposure to environmental, dietary of Core Competences for Public Health underdeveloped in CAR countries. This and behavioural risks; 2) improving Professionals which defines a relatively can in part be explained by the historical surveillance of communicable but also wide range of competencies for public and political context of leadership non-communicable diseases, including health professionals. 4 5 6 in some of these countries. Another mental health disorders, road safety and explanation could be that the definition injury prevention; 3) improving inter- Currently, public health education of leadership is translated differently in sectoral communication; 4) strengthening in Kazakhstan is offered at bachelor these languages. For example, the word public health legislation and regulation; degree level, through post-graduate “leadership” alone can be translated in and 5) optimizing long-term disease programmes (master’s and doctoral Russian as “leadership”, “management” modelling to better forecast risks at the degree (PhD) programmes) as well as and “guidance”. This has posed significant regional and national levels. Under this through continuing professional education challenges for the preparation and training new public health policy, the Republic of (CPE) courses to provide supplementary, of public health leaders in CAR countries Kazakhstan is prioritizing the integration advanced and updated training for health at the required quantities and quality. of the aforementioned public health professionals. services with various sectors, primary care The Higher School of Public Health services, and various specialized medical In 2016, the Republic of Kazakhstan’s includes modules on public health research institutions. Implementation and School of Public Health was moved to the leadership and management in all of integration has been planned for both the Al-Farabi Kazakh National University its courses. Every stream –described national and regional level. (www.kaznu.kz) where it joined fifteen below–provides students with the basic departments and 47 institutes and centres*. concepts of public health leadership and At the national level, a network of public Moving the school into the Al-Farabi management as well as applied topics health organizations will perform the Kazakh National University was an on leadership and management that functions of monitoring risk factors for important first step in the transformation depend on specific features of the stream communicable and non-communicable of public health education as it provides (e.g. management in lab diagnostics, or diseases; developing public health policy an opportunity for the school, its faculty leadership in primary health care). and inter-sectoral programmes; conducting and students to interact with a range of public health research; establishing and disciplines, thus improving content and The Higher School of Public Health strengthening public health surveillance organization of the curricula to promote and warning systems; and improving interdisciplinary and intersectoral When the newly named al-Farabi Kazakh quality of, and accessibility to, public collaboration. National University Higher School of health programmes. Public Health initially piloted its new Public health leadership and courses their new content received a very At the regional level, development, management positive response and demand has been planning, implementation and monitoring increasing ever since. The Higher School of communicable and non-communicable One emerging topic of discussion of Public Health provides three streams for disease prevention activities will be among Public Health experts across students: 1) medical and preventative care; conducted in collaboration with primary CAR countries and a topic of discussion 2) public health; and 3) health systems and health care facilities, including screening during a workshop in 2015 with the WHO health care management. and preventive medical examinations. Regional Office for Europe† has been the An important emphasis has been placed perception of leadership in Public Health. Medical and preventative stream on prioritizing the prevention and Contemporary understandings of public Students enrolled in this can take monitoring of the main burden of diseases health leadership based on collaboration courses in three areas: 1) epidemiology in Kazakhstan (cardiovascular diseases, and on horizontal, adaptive structures and hygiene 2) consumers rights, and/ injuries, cancer, tuberculosis, diabetes). involving many actors and many sectors, or 3) laboratory diagnostics and infection as proposed by the WHO Regional control. All these streams represent Office for Europe’s strategic document Introducing a new public health priority areas in public health for curriculum Kazakhstan as much today as they did * The University consists of 15 departments, 8 scientific- during the Soviet period. Today, however, Health workforce training will have a research institutes, 4 institutes, and 35 social-humanitarian the school distinguishes itself by preparing central role in the implementation of the scientific centers. graduates with added content that State Policy for Public Health. In order † The WHO Regional Office for Europe organized a emphasizes the importance of developing to implement the policy, the al-Farabi subregional training course on public health leadership for advanced leadership skills, ability to work Kazakh National University Higher School the central Asian republics on 15–18 June 2015 in Tashkent, in interdisciplinary teams, dealing with of Public Health has launched innovative Uzbekistan. It brought together 30 participants from the four ethical issues, and embracing emotional new courses and programmes to help central Asian republics – Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan – and the Russian Federation. Participants intelligence over and above basic public prepare a public health workforce that is included mid-to-senior-level public health policy-makers, health knowledge and skills. These will all fit for purpose. The school’s curriculum is administrators, public health programme managers and representatives of public health institutions.
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be important skills for graduates as they degrees but also targeting students with References begin to work with the new public health a background in economics, law, history, 1 Rechel B, Richardson E, McKee M. Trends in services in the country. sociology, biology and other specialties. health systems in the former Soviet countries. This will not only benefit the students Copenhagen: WHO Regional Office for Europe The courses will focus not only on basic to learn from diverse perspectives but on behalf of the European Observatory on Health theory of epidemiology and hygiene but can also help to prepare leaders in public Systems and Policies, 2014 will also include biomedical statistics, health to work in other sectors (education, 2 Footman K, Richardson E. Organization and research methods, applied and field-based finance, transportation, social care). governance. In: Trends in health systems in the former epidemiology, health protection, health Soviet countries. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on promotion and prevention of diseases, law Health systems and health care Health Systems and Policies, 2014: 235. bioethics, and management. management 3 The “Densaulyk”, State Program of Healthcare This stream provides students with Development of the Republic of Kazakhstan, The courses on consumer rights protection theory and practice to work in health care 2016 – 2019. Available at: http://www.mzsr.gov.kz/ teach students about international organizations. This is the newest of the 4 practice in consumers rights protection Birt C, Foldspang A. European Core Competences three streams and offers specializations for Public Health Professionals (ECCPHP). ASPHER (i.e., definitions, development, legislation, in strategic management in public health, Publication # 5. Brussels: ASPHER, 2011. Available and various approaches to protecting management of human resources for at: http://aphea.net/docs/research/ECCPHP.pdf consumers rights etc). The courses also health, and a combined specialization in 5 Birt C, Foldspang A. European Core Competences address EurAsEC Regulatory Compliance public health economics, financing and for MPH Education (ECCMPHE). ASPHER Publication in the Republic of Kazakhstan (e.g. law. This stream provides students with # 6. Brussels: ASPHER, 2011. Available at: http:// food safety, toys safety and etc.). This www.aphea.net/docs/research/ECCMPHE1.pdf various leadership and management skills. focus is an important one given the 6 The focus has been on building leadership, Birt C, Foldspang A. ASPHER’s European Public increasing role of requirements and effective communication, social Health Core Competences Programme: Philosophy, technical regulations set by the Eurasian Process, and Vision. ASPHER Publication # 7. marketing, and oral presentation skills. Economic Commission. 7 Brussels: ASPHER, 2011. The stream takes a perspective that leaders 7 learn by doing and that they need to Eurasian Commission. Technical regulations of The third set of courses allows students the Customs Union which came into force. Available develop specific leadership qualities that to focus on lab test errors. In Kazakhstan, at: http://www.eurasiancommission.org/en/act/ are important to maintain organizations’ 2.7% in clinical settings and 12% of lab texnreg/deptexreg/tr/Pages/TRVsily.aspx focus and motivation on specific interests, errors result in inappropriate treatment 8 M. Plebani, The detection and prevention of technical areas and visions for public choices for patients. 8 Courses therefore errors in laboratory medicine. Annals of Clinical health. This is important in a context address unsafe lab practice, and Biochemistry 2010; 47:101-10. where administrators and heads of health clinical practice by nurses, physicians, care institutions cannot always do so given pharmaceutical workers and lab workers. the changing nature of their portfolios. In order to systematically address these errors, courses have been introduced to teach students about bioethics, patients’ Conclusion safety, organizational behaviour, personal As a result of this new approach to public accountability and legislation literacy. The health education, experts across the main emphasis is on improving training Republic of Kazakhstan are increasingly programmes on biosafety, biosecurity, more confident that they are securing patient and sample identification, relevant the country’s capacity to respond to information technologies, and quality its public health needs and implement management systems for laboratories. the new State Policy for Public Health Development for 2016 – 2019. Through Public health stream programmes like those offered at the The public health stream, alongside Al-Farabi Kazakh National University traditional topics, provides students with School of Public Health the country is tools to measure the interactions and effectively equipping itself with a group of relationships between social-behaviours, public health professionals that are fit for the environment, genetics, and biology purpose to take on the health challenges of along with internal and external risks, the 21st century. point and cumulative effects for health. For this stream in particular, the School has decided to expand its student body to be more inclusive of students with diverse backgrounds. This means not only recruiting students with medical science
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TRANSFORMING HEALTH PROFESSIONAL EDUCATION AND TRAINING IN MALTA
By: Maria Cordina
Summary: Enhancing the health workforce will be critical to transforming health services delivery to better respond to the changing needs and realities of the 21st century. This article describes new methods and approaches for facilitating interprofessional education and training during initial, graduate and continuous professional education and training of health professionals in Malta. By embracing the principles of transformative education and training, Malta is moving towards breaking down boundaries across levels of care and settings, thereby developing a health workforce that is fit-for-purpose to address contemporary health challenges.
Keywords: Education, Training, Cooperation, Collaboration, Multidisciplinary Teams, People-centred
Introduction of the individuals, their families, and communities affected. A health workforce The health needs and priorities of that is focused on facilitating this will the 21st century for the World Health be fundamental to improving health Organization (WHO) European Region, outcomes. Transformative models of documented in Health 2020, aim to education and training for the health ‘significantly improve the health and well- workforce will be key to achieving these being of populations, reduce inequalities goals. 2 This is by no means a trivial task. strengthen public health and ensure It demands dramatic shifts in mind-set people-centred health systems that are both among clinicians and academics. universal, equitable, sustainable and Over the past ten years, leaders in Malta of high quality’. 1 The European Region have been embracing transformative has placed non-communicable diseases, education and training in several areas, chronic conditions, multi-morbidity and including the area of safe and effective other conditions requiring long-term use of medicines. management at the top of its European Maria Cordina is Associate health policy agenda. 2 Successful Professor in the Department management leading to positive patient Transformative education and training of Clinical Pharmacology and outcomes of these conditions will require Therapeutics, Faculty of Medicine The goal of transformative education and and Surgery, University of Malta, coordinated and integrated inputs across training is to foster greater alignment Malta. disciplines throughout the individual’s Email: [email protected] between educational and training life course rather than through episodic institutions and health services. 3 management and isolated services. This These goals are also important in securing also calls for more active participation
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the pursuit of Universal Health Coverage Surgery, Dentistry and Health Sciences based on current recommendations. 7 8 9 10 (UHC) and were endorsed by Member are also practitioners in Malta’s state This facilitates the introduction of the States in Resolution WHA66.23 teaching hospitals. The experience and same key and general concepts related Transforming Health Workforce Education insights they possess help to ensure that to safe and effective use of medicines for in Support of Universal Health Coverage. health professional education and training all health professional students. While In response to the Resolution, WHO has is up to date and delivered by academics all health professional students receive convened a technical working group who are skilful and aware of the most education and training on this topic, on Health Workforce Education and current needs of health services and traditionally the focus of this education Assessment Tools ‘to enable countries the patients and populations they serve. and training has varied depending on the to identify and measure their progress A number of these academics are also group of students, e.g. medical students towards developing a transformative involved in professional organizations and tend to focus on prescribing issues, approach to health workforce education unions. In Malta, these teachers have been pharmacy students on dispensing and that will promote and support universal instrumental in introducing modifications identifying errors, and nursing students health coverage’. 4 and new methods of teaching to better focus on administration. This led to a overcome barriers and obstacles faced by situation where the individual health The WHO Regional Office for services. This places them in a strategic professions are not able to fully appreciate Europe’s own Expert Group on Health position to promote necessary changes the entire medicines use process and the Professionals’ Education and Training also to education and training, but also contributions of different professions to recognised that education and training to services. the process. institutions are often disconnected from the needs of health services, especially Interprofessional education when faculty is mainly composed of and training development of academics theoretically oriented academics with minimal One means of transforming health exposure to practice. The working group professional education and training methods that has discussed development programmes is through the introduction of of academics, addressing the evolving interprofessional education and training foster more health care needs, utilizing a variety in both undergraduate and post graduate of approaches to support the selection programmes. 3 Interprofessional education interprofessional of the most suitable methods of health and training and collaborative practice can professional education and training. 5 help to address fragmentation of health learning These methods aim to lessen the ‘theory- care services and the unmet needs of practice gap’ 3 by engaging experienced the system. 6 Interprofessonal education Since 2010, the Department of Clinical clinicians from hospitals and primary and training however, can also be quite Pharmacology introduced new methods care who possess the necessary skills to challenging. A significant amount of that foster more interprofessional teach in initial education and training coordination between academics and learning. This approach‘‘ allows all health institutions and contribute to continuing programme developers from different professional students to continue receiving education and training. professions/disciplines is necessary to uniform and consistent knowledge about implement it. 3 All academics must be the safe and effective use of medicines Bridging the gaps at the University convinced of the need to implement such while also allowing them to gain a better of Malta programmes and must then invest a lot appreciation of the entire medicines use of time in re-designing curricula which process, to identify their place in the The University of Malta is the highest can effectively promote teamwork and process, and to realise how their practice publicly funded health professional team learning. can contribute positively and negatively education and training institution in to the safe and effective use of medicines. Malta. While the university is overseen by Safe and effective use of medicines Students also get the chance to learn, the Ministry of Education, that ministry reflect and improve their skills and work shares close ties with the Ministry of The Department of Clinical Pharmacology in teams well before entering practice, Health and supports the Ministry of and Therapeutics oversees all teaching thereby accelerating their ability to work Health’s goals and objectives: to provide related to pharmacology and therapeutics in teams once they have graduated. It also education and training that is relevant to for health professional students at the promotes the use of a common language population health needs. The university University of Malta. A core group of which enhances effective communication has applied guidance produced by the people in the Department is responsible for between different professions. above-mentioned steering groups. coordinating, overseeing and participating in the teaching of all courses. Teaching The topics addressed are discussed in For example, at the University of Malta is provided by clinical pharmacologists, the context of practice, through both the vast number of academics involved in specialised practicing medics and lectures and tutorials, using examples teaching in the Faculties of Medicine and practicing clinical pharmacists and is and cases from teaching hospitals and
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the community. At times the classes are with each other and appreciate the which are highly prevalent in Malta. These multidisciplinary and at times, due to health-related needs of the community. are approached from different angles logistical restraints, they are taught by This effort has been an important means and would include academic updates and discipline. Even when taught to a single of better positioning students – future practical information, such as efficient discipline of students, discussions on the clinicians – to understand the meaning ways to access patient services and contribution of other professions to the of, and contribute to, a people-centred collaborating with different disciplines to medicines use process are prioritized. health system. achieve the best possible patient outcomes. Explicit efforts are made to also give Methods of decreasing the burden on the students hands on training in clinical system and the patient are also usually settings, both in hospitals and the highly debated. community where they will eventually instill a work. The department has received Towards this end, various professional positive feedback, both from the students culture of organizations organise CPD for their following the courses as well as from professions. It is not unusual for CPD the different faculties. The environment engaging in CPD sessions to be organized jointly by various created has been deemed very constructive associations. CPD sessions organized and the curriculum has been made in students by all professional organizations are dynamic through the interactions sometimes open to undergraduate health of experts from various disciplines, Continuing professional development professional students, as a means of academics and students. introducing them to the concept of CPD. A fit-for-purpose workforce also needs to In addition, professional associations The Department also offers a Master’s be continuously updated with information habitually invite members from other course in Clinical Pharmacology. on emerging new evidence-based practice, professions to address their educational Individuals from different professions are innovative‘‘ technological approaches, sessions. For example, the Malta College encouraged to enrol, which provides a knowledge regarding new treatment of Pharmacy Practice regularly invites very healthy environment for the exchange modalities and various skills. Continuing medical doctors who have specialized in of ideas and methods for increased professional development (CPD), like relevant fields to address management of collaboration. These individuals then university-based education and training, respiratory, cardiovascular and endocrine proceed to act as key leaders in their own can benefit from transformative education conditions; nutritionists to address professions to champion and disseminate and training principles. In Malta, CPD for obesity and provide updates on healthy the principles of interprofessional work for health care professionals is not mandatory eating practices; and psychiatrists and the safe and effective use of medicines. nor is it linked to licensing. It is the psychologists to address management individual professional associations, of mental health. 13 CPD is offered in the Student engagement and participation such as the Malta College of Pharmacy form of in-service training, interactive Practice, the Malta College of Family workshops, seminars, and as a series of The university also actively encourages Doctors, the Malta Association of Hospital talks. Therefore, there has been a very student driven activities that can serve Pharmacists to mention a few, who have interesting and diverse mix of approaches to promote interprofessional learning. undertaken initiatives to provide CPD to and methods to give health professionals Student groups are encouraged to their members. In the absence of a national the opportunity to reflect and improve collaborate across disciplines in integrated accrediting body, the associations are their team practice. public health activities as a means for self-accrediting. Meetings are national and better understanding of each other’s are held in various locations, such as the Conclusion contribution to various conditions. University of Malta, the main public acute In Malta, health professional student hospital, and various private locations. Due to the varying structures that exist organizations are very active and regularly in different countries, there is no single collaborate in a number of initiatives It is important to instil culture of engaging solution to effectively train undergraduate as well as organize joint educational in CPD in students while they are still and postgraduate students to practice seminars. For example, recently student studying at the undergraduate level. This efficiently as a team. Multiple modalities health care associations organised a can increase the probability that they need to be used to produce a health conference entitled, The Multidisciplinary will identify with, master and engage in workforce that is flexible, multi-skilled, Approach to Health Care, with the desirable practices. Various methods of and team-oriented. Academics from aim of promoting communication CPD are in use in Malta. Most importantly, different disciplines could shift from the and teamwork between all health care what is offered should be responsive to the comfort of their traditional approach to professionals. 11 The Maltese health care current and changing health challenges education and training and break down student associations also hosted the first faced by clinicians; 3 for example, the barriers between different professions. World Medicine and Pharmacy Students management of a number of chronic Collaborations between academics from Joint symposium. 12 Here again, they diseases, such as diabetes, cardiovascular the different disciplines has been key to learn from an early stage how to engage disease, and dealing with obesity, all of drawing on the strengths, identify gaps,
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and together build effective programmes 4 Development of a WHO evaluation toolkit for health 9 Clinical Pharmacology in Health Care, Teaching and to deliver a health workforce that is fit-for- workforce education. Available at: http://www.who. Research. World Health Organization, International purpose to successfully transform health int/hrh/education/dev_who_toolkit_eval/en/ Union of Clinical and Basic Pharmacology, Council for International Organization for Medical Sciences. 5 Steinert Y. Staff development. In Dent J, Harden R services and respond to the demanding Geneva: WHO, 2012. Available at: http://www.who. (eds.) A practical Guide for medical teachers. Oxford: needs to the 21st century. int/medicines/areas/quality_safety/safety_efficacy/ Elsevier Ltd, 2009:391-7. OMS-CIOMS-Report-20120913v4.pdf 6 The Framework for Inter professional Education 10 Strand LM, Morley PC, Cipolle RJ, Ramsey References and Collaborative Practice. Health Professions R, Lamsam GD. Drug- related problems their 1 Network Nursing and Midwifery offices within the Health 2020: a European policy framework structure and function. Annals of Pharmacotherapy Department of Human Resources for Health. Geneva: supporting action across government and society for 1990;24:1093-7. health and well-being. Copenhagen: WHO Regional WHO, 2010. Available at: http://www.who.int/hrh/ 11 Office for Europe, 2013. Available at: http://www. nursing_midwifery/en/ Students promote multidisciplinary view of euro.who.int/en/publications/abstracts/health-2020- health care. The Times of Malta, 8 December 2013. 7 Patient Safety Curriculum Guide: Multi-professional a-european-policy-framework-supporting-action- Available at: http://www.timesofmalta.com/articles/ Edition. Geneva: WHO, 2011. Available at: http:// across-government-and-society-for-health-and-well- view/20131208/education/Students-promote- www.who.int/patientsafety/education/curriculum/ being multidisciplinary-view-of-healthcare.498080 en/ 12 2 Priorities for health systems strengthening Health profession students join forces. The Times 8 Frank J, Brien S. The Safety Competencies: in WHO European Region 2015 – 2020: walking of Malta, 23 October 2005, Available at: http:// Enhancing Patient Safety Across the Health the talk on people centeredness. Copenhagen: www.timesofmalta.com/articles/view/20051023/ Professions. Toronto: Canadian Patient Safety WHO Regional Office for Europe, 2015. education/health-professions-students-join- Institute, 2009. Available at: http://www. Available at: http://www.euro.who.int/__data/ forces.74301 patientsafetyinstitute.ca/en/toolsResources/ assets/pdf_file/0003/282963/65wd13e_ safetyCompetencies/Documents/Safety%20 13 The Malta College of Pharmacy Practice. HealthSystemsStrengthening_150494.pdf?ua=1 Competencies.pdf Activities. Available at: http://www.mcppnet.org/ 3 Transforming and scaling up health professionals’ activitiesmain.htm education and training. World Health Organization Guidelines 2013. Geneva: WHO, 2013. Available at: http://whoeducationguidelines. org/sites/default/files/uploads/WHO_ EduGuidelines_20131202_web.pdf
NCD country assessments: Challenges and opportunities for health systems
Available at: http://www.euro.who.int/en/health-topics/Health-systems/health-systems-response-to-ncds
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ADDRESSING HEALTH WORKFORCE OUTFLOW IN HUNGARY THROUGH A SCHOLARSHIP PROGRAMME
By: Edit Eke, Eszter Kovács, Zoltán Cserháti, Edmond Girasek, Tamás Joó and Miklós Szócska
Summary: Evidence-based interventions are key to ensuring a sufficient and sustainable health workforce and thereby ensuring a workforce available for transforming health service delivery. As health professional retention strategies are among the top priorities of the country’s national health policy agenda, Hungary has introduced a scholarship programme for resident doctors. This evidence-informed strategy appears to be reducing the outflow of Hungarian doctors. While evaluation is still pending, the country’s high level commitment to securing a sustainable health workforce is offering new graduates the opportunity to stay and practice in Hungary.
Keywords: Human Resources for Health, International Health Workforce Migration, Retention Policies, HWF Data, Scholarship Programme, Hungary
Introduction Over the past decade, Hungary has become a source country for health professionals Acknowledgments: The authors The impact of health workforce shortages in the European Union (EU). Estimates would like to acknowledge the and health professional mobility on important contributions of Hanna show that a significant proportion of health governments’ abilities to respond to Páva and Zsolt Bélteki. Hanna Páva professionals have migrated to other EU is the Director and Zsolt Bélteki patient and population health needs is countries since Hungary’s accession to is Head of the Department at the high on national, European and global Health Registration and Training the EU (on 1 May 2004). 3 4 Doctors in health policy agendas. Higher wages Center, Budapest, Hungary. particular – who obtained their academic and better working conditions in more medical qualification as “general” medical economically developed countries attract doctors in the Hungarian graduate health qualified health professionals from education system – have expressed Edit Eke is a Consultant; less developed countries. The resulting intentions to leave and work abroad. 5 Eszter Kovács is Assistant shortages of qualified health professionals Professor; Zoltán Cserháti is a Although proxy indicators are available and the rapidly changing dynamics of Consultant; Edmond Girasek is on outflow, precise numbers are hard to Assistant Professor; Tamás Joó is health professional mobility (i.e., changing define, due to difficulties in follow-up a Consultant and Miklós Szócska individual motivations, legal and economic is Director at the Health Services with those who actually have left Hungary. circumstances, working arrangements, Management Training Centre, It is important to understand the potential and policy frameworks) have added a layer Semmelweis University, Budapest, volume and reasons for outflow to secure Hungary. Email: [email protected] of complexity to securing a sustainable a sustainable health workforce and develop health workforce. 1 2 responsive policies.
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Table 1: Age distribution and total numbers of active doctors
Age 2011 2012 2013 2014 –4 2 104 108 94 113 259 – 2 2 050 2 380 2 736 3 096 304 – 3 2 483 2 460 2 455 2 468 359 – 3 2 656 2 762 2 742 2 881 404 – 4 3 036 2 968 2 792 2 820 459 – 4 3 391 3 385 3 353 3 378 504 – 5 3 908 3 872 3 757 3 725 559 – 5 4 276 4 371 4 426 4 318 604 – 6 3 258 3 452 3 603 3 913 659 – 6 2 349 2 535 2 747 2 855 70 – 1 951 2 236 2 749 3 234 Total 29 462 30 529 31 454 32 801
Source: Ref 6
Specific issues and concerns the significant increases in wages in 2012 in health care and participation in training and 2013, Hungary still struggles to courses – must be collected to obtain Since accession to the EU, tensions have compete with higher western EU wages. 6 a renewal. been rising in Hungary over the public health sector budget. Salaries have Since Hungary’s accession to the EU, ENKK also provides publicly available been below those of the EU and Central recruitment has also become easier for annual health workforce status reports to and Eastern Europe averages 7 8 and destination countries through various the government. Between 2012 and 2014, by 2012, salaries had not risen for ten strategies, i.e., direct advertizing. Licenced a national IT project was dedicated years. In 2014, the net salary of doctors and practising doctors, including senior especially to health workforce monitoring working full time in the Hungarian public specialists, have received offers of development. The project was led by health care sector was 310.770 HUF employment from abroad without having ENKK, and its sustainability has been (approximately €1,002) per person per proactively sought such opportunities. supported by this authority, running and month. 8 In 2011, the European Federation The 36/2005 EU directive on mutual updating the health workforce monitoring of Salaried Doctors rated Hungary’s recognition of medical diplomas, 10 system. The system enables data salaries as the second worse in the 27 amended by 55/2013 has further eased linkages in compliance with individual EU countries. 7 In June 2011, Hungary’s the mobility of specialists on a legal and data protection. resident doctors’ monthly take-home pay practical basis. was between HUF 80,000 (€258) and In 2014, based on ENKK data HUF 100,000 (€323). Financial pressures (see Table 1) 21 413, i.e., 65.3% of and austerity measures further strained Centralized monitoring of medical doctors with active licenses were over health workforce expenditures. 9 Despite doctors in Hungary the age of 45, while 1002, i.e., 30.5% In 2004, Hungary established a central were over 60 years old. Young health authorization office – the Health doctors between the ages of 25 to 29, Table 2: Number of all doctors who Registration and Training Center numbering 3096 in total, only accounted applied for a verification certificate (Egészségügyi Nyilvántartási és Képzési for approximately 9.4% of the doctors’ between 2011 and 2014 Központ, ENKK) – to collect, manage workforce. 6 and analyse all health workforce related All applicants data (including graduate and postgraduate Monitoring health workforce outflows (including doctors health workforce specialization training with foreign data, licencing data, etc.). ENKK is also ENKK also issues verification certificates Year nationality) responsible for maintaining and updating to health professionals intending to work 2011 1200 national registers of health professionals abroad. This allows ENKK to monitor the 2012 1108 and overseeing continuing professional age, professional background and preferred 2013 955 development (CPD). In Hungary, renewal destination country of applicants. These of licenses is compulsory every five years data can be used as proxy indicators 2014 948 and the process is regulated. A specified for outflow, albeit with acknowledged number of credits – obtained for practise limitations. This data cannot capture Source: Ref 6
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actual outflow, or confirm how long, if especially outflow among new graduates, 11 at all, the health professional settles to is a top priority of the country’s health Box 1: Scholarships# work in the destination country. Data also policy agenda. This political commitment include foreign nationals who obtain their resulted in concrete efforts to address 1. Markusovszky Lajos Scholarship medical degree in Hungary, but does not the issue in a comprehensive way. Program distinguish outflow of domestic medical One of the interventions implemented Introduced in 2011, this scholarship is doctors in their case. Table 2 shows the to secure the health workforce was a available to all resident doctors who number of applications received by ENKK scholarship programme. are enrolled in their first specialization from 2011 to 2014. training, regardless of speciality. The The scholarship programme scholarship stipulates that graduates Semmelweis University Health Services and implementation must work in the public health care Management Training Centre (HSMTC) system upon completion of the has also played a key role in assessing The programme was introduced in 2011 specialty training. The monthly net sum mobility of the health workforce in with a scholarship for resident doctors. of this scholarship is 100,000 HUF Hungary. Back in 2003, the Centre and In 2012 and 2013, two additional (approx. €320). the Association of Hungarian Resident scholarships were introduced (see Box 1). Doctors (doctors in postgraduate These three scholarships are only available 2. Méhes Károly Scholarship Program specialization training) initiated a survey for resident doctors entering postgraduate Introduced in 2012, this scholarship is for resident doctors. The annual survey training to obtain their first specialization available to paediatric resident doctors. studied the potential and motivations for or who have at least one year remaining Upon completion of the specialization residential doctors to migrate. 5 Based prior to completing their ongoing first training, graduates are appointed to a on these surveys migration potential specialization training*. As compensation, service post in underserved areas in was high, between 60% and 70%, with the recipients must provide the equivalent primary care* practices that have been around 10% (average rate) taking active number of years of service in a specified left vacant for a prolonged period. The steps to realize this intention among health care setting (settings vary monthly net sum of this scholarship respondents. 5 The analysis also identified depending on scholarship) after obtaining is 200,000 HUF (approx. €640). a potential “marginal migration decision the specialization, typically amounting to threshold point” for remuneration. five years of service. All three scholarships 3. Gábor Aurél Scholarship Program According to the analysis, medical award doctors a tax-free net sum for the Introduced in 2013, this scholarship doctors “would not consider migration period of their postgraduate specialist responds to acute shortages in and not take on a second job and/or accept training, in addition to their monthly emergency medicine. The Gábor Aurél informal payment” if salaries for resident salary. The marginal migration decision Scholarship is available to emergency doctors in their first two years, non- threshold point served to determine the medicine resident doctors. Recipients specialists and specialists were increased monetary value of these scholarships. must work at a Hungarian Ambulance to 200,000 HUF (€645 Euro); 300,000 Service assigned post upon completion HUF (€970); and 450,000 HUF (€1450), Based on a recorded decrease in the of the specialization. The monthly net per month, respectively. number of applications for verification sum of it is 200,000 HUF (approx. €640). certificates to work abroad by new graduates, the scholarships have been Migration as a top policy priority Note: important in retaining newly graduated # Resident doctors can apply for more than one 6 Despite these available data, by 2010, no doctors – the main target group. scholarship, but they can only accept one scholarship. comprehensive retention strategy had * Primary care for children is characteristically provided been implemented. This changed when the The entire process (application, by paediatrician specialists in Hungary. State Secretariat for Healthcare declared contracting, payment, monitoring) is that the international mobility of doctors, coordinated and managed by ENKK. Announcements of recipients and rules are scholarships granted for the Markusovszky available on the ENKK website. 12 scholarship alone has increased three fold Table 3: Annual number of Markusovszky since its introduction (see Table 3). scholarships between 2011 and 2013 Results The number of resident doctors applying Number of granted Since the introduction of this programme for postgraduate specialist training is Year scholarships applications have exceeded the amount also monitored annually, together with 2011 584 of awards that the government was able the number of graduating doctors. These to fund, indicating great interest among data allow further observations. Since 2012 486 the target group. The total number of doctors, who apply for the aforementioned 2013 547 scholarship programmes, have to enter Total 1614 * Specialists who enter a new postgraduate resident training postgraduate specialization training, they program to obtain a second or third specialization are not also have to apply for a postgraduate 6 Source: Ref eligible to apply for the scholarship.
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Table 4: Number of applications for subsidized postgraduate training positions compared to the number of graduate doctors annually, 2010 – 2014
2010 2011 2012 2013 2014 Total Graduate doctors with Hungarian citizenship 705 750 905 876 864 4 100 Applications for subsidized resident doctor positions 421 705 712 794 884 3 516 Proportion 60% 94% 79% 91% 102% 86%
Source: Ref 6 training position. Changes in the numbers References 7 European Hospital Doctors’ Salaries, Document: F11-071 EN, 13 September 2011. Available at: http:// of applicants reflect how the scholarship 1 Aszalós Z et al. D042 Report on Mobility Data www.liganet.hu/news/6205/F11-071_EN_European_ programmes influence the number of Final, 2016. Available at: http://healthworkforce.eu/ Hospital_Doctors_Salaries.pdf entries into the postgraduate training wp-content/uploads/2016/03/160127_WP4_D042- program for specialists. Table 4 shows that Report-on-Mobility-Data-Final.pdf 8 ENKK. Statistics on health care sector personnel and wages 2014 [ENKK – OSAP 1626 – Bér- és the number of applications has increased 2 Buchan J, Wismar M, Glinos IA, Bremmer J. (eds.) létszám statisztika, 2014 – Vezeto˝i összefoglaló], Health Professional Mobility in a Changing Europe. since 2011. Budapest, Hungary, 2014. Available in Hungarian Copenhagen: World Health Organization, 2014. at: http://www.enkk.hu/hmr/documents/ Conclusion 3 European Commission. Determining labour beresletszam/2014/teljes/eu_vez.pdf shortages and the need for labour migration from 9 Mladovsky P, Srivastava D, Cylus J, et al. Health third countries in the EU, Hungary, 2015. Available at: The three scholarships seem to have been policy responses to the financial crisis in Europe. http://ec.europa.eu/dgs/home-affairs/what-we-do/ effective in retaining the health workforce Copenhagen: World Health Organization, 2012. networks/european_migration_network/reports/ Available at: http://www.euro.who.int/__data/ and demonstrate the importance of docs/emn-studies/13a_hungary_labour_shortages_ assets/pdf_file/0009/170865/e96643.pdf targeted evidence-based interventions. study_en_may_2015.pdf The scholarship programme appears to 10 European Union. DIRECTIVE 2005/36/EC 4 Kroezen M, Dussault G, Craveiro I et al. OF THE EUROPEAN PARLIAMENT AND OF THE also be shifting the dynamics of health Recruitment and retention of health professionals COUNCIL of 7 September 2005 on the recognition professional migration among young across Europe: A literature review and multiple case of professional qualifications, 2014. Available at: study research. Health Policy 2015;119:1517–28. doctors. While it is too early to draw http://eur-lex.europa.eu/legal-content/EN/TXT/ any solid conclusions – the average 5 Eke E, Girasek E, Szócska M. From melting pot PDF/?uri=CELEX:02005L0036-20140117&from=EN specialization training programme lasts to change lab central Europe: health workforce 11 ENKK. Statistics on Migration [Migrációs migration in Hungary. In Wismar M, Maier CB, for five years – preliminary evaluations Statisztikák]; Statistics of 2015 [2015.évi Glinos IA, Dussault G, Figueras J (eds.) Health point to an increase in available doctors statisztikák], 2015. Available in Hungarian at: professional mobility and health systems: evidence in Hungary and to a decrease in outflow http://www.enkk.hu/hmr/index.php/migracios- from 17 European countries. World Health statisztikak/2015-evi-statisztikak of doctors. Sophisticated evaluation Organization on behalf of the European Observatory criteria for the scholarship programme are on Health Systems and Policies, 2011. 12 NKK.E The Health Registration and Training Office still needed to evaluate the effects of the [Egészségügyi Nyilvántartási és Képzési Központ, 6 ENKK. Annual report on the HRH situation of health ENKK], 2015. Available in Hungarian at: http://www. programme over the long run. care sector 2014. [Beszámoló az egészségügyi ágazati enkk.hu/index.php/hun/ humánero˝forrás 2014.évi helyzetéro˝l az egészségügyi ágazati humánero˝forrás monitoring rendszer alapján]. Budapest, Hungary, 2014. Available in Hungarian at: http://www.enkk.hu/hmr/documents/ beszamolok/HR_beszamolo_2014.pdf
The case for investing in effective, provide value for money and give returns on investment in
THE CASE FOR INVESTING IN PUBLIC HEALTH public health A public health summary report for EPHO 8 both the short and longer terms. This report gives examples of Copenhagen: WHO Regional Office for Europe, 2015 interventions with early returns on investment for health and Assuring sustainable organizational Available for download at: http://www.euro.who.int/en/ structures and financing other sectors. Population-level health-topics/Health-systems/public-health-services/ approaches are estimated to cost publications/2015/the-case-for-investing-in-public-health on average five times less than 1 The case for investing in public health The economic crisis has led to increased demand and reduced individual interventions. Investing resources for health sectors. The trend for increasing health in cost-effective interventions care costs to individuals, the health sector and wider society to reduce costs to the health sector and other sectors can is significant. Public health can be part of the solution to this help create sustainable health systems and economies for challenge. The evidence shows that prevention can be cost- the future.
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CENTRALIZING PROCUREMENT OF MEDICINES TO SAVE COSTS FOR DENMARK
By: Dorthe Bartels
Summary: An important foundation of the WHO Regional Office for Europe’s health systems strengthening strategy is to ensure equitable access to cost-effective medicines and technology. Denmark has taken important measures that have not only helped to save costs but also ensured higher quality and more equitable use of expensive medicines. Two initiatives are central: 1) a centralized structure, in this case a public sector organization–Amgros–that carries out the tendering procedures and bulk purchasing for all hospitals in Denmark; and 2) the Danish Council for the Use of Expensive Hospital Medicines that assesses the clinical costs and benefits of expensive medicines and helps guide the selection of medicines by Amgros and clinicians. By investing in and combining these two processes the Danish government saved approximately €314 million in 2015.
Keywords: Procurement, Medicines, Equitable Access, Amgros, Denmark
Introduction account for 12.6% of the national health budget and 55.6% of these costs are Concerns about containing health costs incurred in hospitals. touch all governments. Pharmaceuticals are among the highest expenses for many governments and their population, Amgros ensures price and supply regardless of who picks up the cost of Amgros* is the pharmaceutical medicines. Meanwhile, they are also procurement service for the five regional vital to improving health outcomes. authorities in Denmark. It is a public- Decreasing costs of pharmaceuticals have sector organization owned by the regions. a direct impact on ensuring that the right Before establishing Amgros, each region medicines reach patients at the right time. handled their own procurement of Ministries of health or their delegated pharmaceuticals; therefore, Amgros was authorities can play an important role established in 1990 to create economies in negotiating prices so that the cost of Dorthe Bartels is Head of of scale and to achieve administrative medicines is decreased, out-of-pocket Procurement, Department of savings by centralizing the procurement Tenders and Logistics, Amgros, payments are reduced and the population of pharmaceuticals. Copenhagen, Denmark. does not experience an onerous financial Email: [email protected] burden. In Denmark, pharmaceuticals * http://www.amgros.dk/en/areas-of-work/tenders-and- procurement/
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Ninety-five percent of Amgros’ business Figure 1: Pharmaceutical turnover in Amgros (million Euros) 2008 – 2015 is pharmaceuticals for Danish hospitals while the remaining 5% of business procures medical devices. The primary AIPPPP task of Amgros is to ensure that Danish public hospitals are always equipped HPPP with the medicines they need at the best SAIP possible price. In so doing, Amgros can adjust tendering according to the current market situation, thereby optimizing competition. In addition to carrying out tendering procedures, Amgros manages registration and coordination of all pharmaceuticals produced in hospital pharmacies in Denmark. Hospital consumption of pharmaceuticals accounts for more than 55% of the market. 1
As a result of this centralized process the Source: Department of Business Analysis, Amgros. five Danish regions saved €314 million Note: PPP – Pharmacy purchasing price; HPPP – Amgros negotiated price. in 2015. 1 Figure 1 shows the difference between the market price of the medicine, also known as the pharmacy purchasing types of tender contracts: framework period of time (a few months). Therefore, price (PPP) and the negotiated price by contracts, fixed volume tender contracts, this means that product availability Amgros after the tender process (HPPP). regional tender contracts and contracts for changes frequently and can potentially The difference between these two values new products (with tailored criteria like place patient safety at risk if the patient represents the savings for the health confidential prices). needs to change “product” frequently. system. Moreover, a recent analysis The number of product changes must by the consultancy KPMG concluded Framework contracts be weighed carefully against potential that Amgros is highly cost-efficient cost savings. Moreover, needs over short Framework contracts are the most in purchasing pharmaceuticals†. 2 The periods cannot always be estimated common form of tender used by Amgros. process of involving an external evaluation very precisely. The amount of required Because treatment guidelines change, company is only one of several continuous medicine can vary depending on the this form of tender allows hospitals the improvement activities that Amgros is number of patients undergoing a certain degree of flexibility they need. The engaged in. In order to remain responsive treatment. Hence, only certain products framework contract gives Amgros the the organization looks at the experiences with very stable consumption patterns right, but not the obligation, to buy the of other countries, and actively engages in are suitable to be negotiated using fixed amount of products included in the various subregional and regional networks, volume tenders, such as Paracetamol. It tender. When special medical reasons or e.g. a Nordic Forum and different should be noted that fixed volume tenders issues regarding patient safety dictate, European networks. appeal more to suppliers of parallel it is possible to use another supplier. imported pharmaceutical products. Through a thorough preparation of Tender structures the tenders and the involvement of all Regional tenders and tenders for relevant parties, including clinicians and During the last few years, Amgros has new products regional representatives, Amgros strives made several changes to their tender to create consensus and support for its Regional tender contracts allow suppliers structures in order to optimize the balance recommendations for treatment. more flexibility as they can bid to supply between negotiating good prices, ensuring either one or all regions, depending on patient safety and safeguarding the Fixed volume tender contracts their ability to deliver. Since 2007, Amgros availability of necessary drugs. The goal is has entered into many region-specific to create favourable conditions that allow Over the past few years, Amgros has tender contracts. However, there has not all potential suppliers – whether big or introduced other types of tenders in order been a trend of more suppliers bidding for small – to participate in the tender process. to create a more dynamic market and to these smaller tenders, most likely because To achieve this Amgros uses four different ensure both small and large suppliers they are more difficult to administer. In have the possibility to bid for tenders. The most cases, one supplier wins the tender in advantage of the fixed volume tender is all regions. † In 2014, KPMG estimated that Amgros could still save to give suppliers the security of selling a an additional €8 – 13 million (or (DKK 60 – 95 million) by certain amount of product. However, these implementing KPMGs recommendations, all of which lie within For new products, Amgros has created contracts typically expire after a short Amgros’ control. In 2014, Amgros’ total annual revenue was a new model of agreement (with new €966 million.
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anatomical therapeutic chemical -ATC- The system was originally received ERP systems also mean that Amgros code). This involves price volume negatively as not respecting physician’s does not have to manage and run stocks agreements whereby prices decrease as autonomy. Over time, however, many of medicines. Hospital pharmacies order volume increase and all discounts are physicians have started to regard the drugs directly from the supplier-once confidential. These agreements can be system as helpful§, and instead now see approved through the tender process- terminated with three months’ notice, the treatment recommendations as a useful through an online ERP system. which can then be used in the case of tool for decision making; the system is parallel imports. also reported to alleviate physicians’ workloads. Assessing expensive medicines billions Prioritizing quality Another important initiative in Denmark of Euros have that has benefited the centralized The RADS council has made it possible procurement work of Amgros is the for Amgros to negotiate better prices. been saved Danish Council for the Use of Expensive While an evaluation of the process to Hospital Medicines (RADS council), assess cost savings from engaging the As a purchaser Amgros is constantly established in 2010. The RADS council RADS council is still pending and will on the lookout for cheaper alternatives consists of representatives from each depend on hospitals’ implementation of to existing medicines that are also of region, the National Health Board, the tool, what is clear is that the RADS equivalent quality. Pharmacists in its the Danish Association of Clinical process has improved quality of treatment tendering unit are employed to scan Pharmacology and the Patients’ in Denmark. 1 Preliminary estimates the market, make decisions about new Association. The Council’s objective is suggest that the RADS council and its products and explore possibilities for to ensure that all patients have access recommendations has given the country substitution‘‘ or parallel import. Suppliers to the best possible treatment no matter €42 million added value at an expense of can benefit from the unique internet- where they live and which hospital they approximately €22 million since 2010. 1 based tendering system, which ensures visit. To achieve this, the RADS council easy workflows, transparency and set up smaller professional councils Prioritizing cost-effective processes equal treatment for everyone submitting consisting of leading experts within the a tender. different specialties. Each professional Over the 25 years that Amgros has council evaluates the clinical benefits existed, billions of Euros have been saved Next steps of expensive medicines that have been for Danish public hospitals. 1 Although selected for evaluation. The evaluation the objective remains the same- to save Amgros will continue to play an important is based on dossiers submitted by the costs in pharmaceutical procurement – role in the centralized procurement industry and an analysis of the literature Amgros has become more than a trading for hospital medicines in Denmark. It of the therapeutic area. RADS uses the company. In addition to ensuring savings, continues to meet the regions’ expectations Grading of Recommendations Assessment Amgros has been able to promote safety and reduces costs by working in close (GRADE) methodology‡. After a thorough and quality of medicines used in hospitals and constructive dialogue with all assessment, the professional council across Denmark and has also engaged in stakeholders. Amgros is driving an publishes recommendations for treatment. research and development activities by efficient business when it comes to buying Amgros uses these recommendations for promoting research collaborations with pharmaceuticals. Centralized procurement treatment to determine which medicines it hospital pharmacies. It also provides has resulted in savings for Denmark and will hold tenders for. The RADS council administrative support to hospital Amgros is now working on becoming a then prepares a priority list showing which pharmacies, allowing them to focus more strategic procurement business partner. generic substances hospitals should choose on patient care and their core tasks. Being a strategic partner means being first, then second and so forth. After the able to forecast market trends but also tender, the recommendation includes the Trading has been made easier for scanning the market for new products and name of products. both suppliers and customers through innovations, known as horizon scanning. Amgros. The specially tailored tender The results of the tender are used and Enterprise Resource Planning (ERP) References to establish a list of medicines that systems support the business processes hospitals should use for the treatment in for hospital pharmacies, hearing clinics 1 Internal data, Department of Business Analysis, question. The winner of the tender and and suppliers. Hospital pharmacies and Amgros. their product is ranked first on the list hearing clinics achieve considerable 2 KPMG. External Analysis of Pharmaceutical which prescribers will then use unless administrative savings by having Amgros Procurement of Amgros. Copenhagen: Denmark, they have a justification not to. It is organize supply, and fully integrating 2014. Available in Danish upon request. important to underline that physicians order management systems. The efficient maintain their prescription authority.
§ This assessment is based on feedback from the RADS ‡ http://www.gradeworkinggroup.org/index.htm Secretary General.
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IMPROVING ACCESS TO ESSENTIAL MEDICINES IN THE REPUBLIC OF MOLDOVA
By: Zinaida Bezverhni, Vladimir Safta, Elena Chitan, Alessandra Ferrario and Jarno Habicht
Summary: The Republic of Moldova is one of the former Soviet Union countries being widely documented as a reformer in terms of successful health financing policy and introducing mandatory health insurance. The benefit package covers the majority of hospital medicines but is limited in how much it covers outpatient pharmaceuticals. Policy responses have sought to increase coverage through higher budget allocations for pharmaceuticals and positive list extensions. However, with low affordability of medicines and limited public budgets, implementing universal health coverage is still facing significant challenges.
Acknowledgements: The authors Keywords: Essential Medicines, Universal Health Coverage, Access, Reimbursement, would like to express their gratitude Moldova to Mircea Buga, former Minister of Health and Svetlana Cotelea, former Deputy Minister of Health for their commitment and involvement in this Introduction several legislative amendments have policy initiative, to Nina Sautenkova, extended benefits to the most vulnerable former Manager of Pharmaceutical Since independence, the Republic of and poorest citizens. 2 The Government Policy in the NIS at WHO Regional Moldova has made significant strides Office for Europe for her valuable vision on future policy developments is towards improving the performance and constructive suggestions during clearly described in the National Health the development of this initiative of its health system through several Policy 2007 – 2021 and the Health System and Haris Hajrulahovic, WHO important health reforms. Implementation Representative in Moldova for his Development Strategy 2008 – 2017. These of family medicine in the late 1990s and advice and assistance during the documents set out three overarching writing of this article. decentralization of both primary and goals for the health system: improved hospital care* significantly improved health, financial risk-protection patients’ access to health services. 1 and responsiveness to changing The introduction of mandatory health Zinaida Bezverhni is a Health population needs. Systems Officer at the WHO Country insurance in 2004 has led to many office in Moldova; Vladimir Safta, positive improvements in financing of is Professor and Elena Chitan, health services. Since 2009 the main The need to make medicines is Assistant Lecturer at the State University of Medicine and focus of health reforms has shifted affordable Pharmacy “Nicolae Testemitanu”, towards universal health coverage with While resource allocations from the Moldova; Alessandra Ferrario the primary health care benefit package insurance fund to medicines have been is a Research Officer at LSE being extended to all citizens irrespective Health, The London School of increasing and the positive list has been of their insurance status. In addition, Economics and Political Science, gradually extended over time, a number UK; and Jarno Habicht is WHO Representative in Kyrgyzstan. of essential out-patient pharmaceuticals Email: [email protected] * The policy initiative was partially supported by the are not included in benefit package in the European Union/WHO joint initiative to support policy dialogue Republic of Moldova. The majority of in- and universal health coverage.
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patient medicines are covered. Medicines Essential Medicines List was mainly driven by higher income and are the main driver of out-of-pocket (OOP) expenditure by households rather than The essential medicines list (EML) is a payments and a key source of catastrophic an actual increase in coverage of the list of medicines deemed necessary to health expenditures and impoverishment reimbursement list. 9 meet priority health care needs of the in most transition countries. Moldova is population. These medicines should be no exception. In 2014, nearly 94% of total available in health systems at all times, New policy initiative expenditures on medicines were borne in adequate amounts, in the appropriate by patients as direct OOP payments. 3 Several policy options can be considered to dosages, with assured quality, and at a The Government has taken steps towards increase coverage for essential medicines. price the individual and the community securing timely and equitable access Depending on its design, a price reduction can afford. 5 Moldova started to implement to medicines by developing and policy can have a wide reaching effect the EML and to promote its rational use implementing national programmes for on medicines affordability, beyond in the public and private health sector in the main non-communicable diseases reimbursed medicines. On the demand the mid-1990s. 6 7 The national list was (NCDs) (diabetes, mental health, cancer, side, the National Health Insurance developed in 2002 and it was intended cardiovascular diseases), communicable Company has set the objective to increase to be regularly updated every two years. diseases (tuberculosis, HIV/AIDS, expenditure on medicines from 4.3% However, the EML has only been revised hepatitis, immunizations), rare diseases, to 10% of its total expenditure in 2017. The three times since its launch. During transplantations, congenital pathology, available budget for medicines has grown these revisions, the number of medicines blood products security and emergency by almost 140% since 2010. 11 Another listed has gradually increased from 506 care. In 2013, access to insulin was objective is to reduce OOP expenditures international non-proprietary names improved by including it in the positive list (not just medicine-related expenditure) (INN) in 2007 to 585 INNs in 2009 of medicines eligible for reimbursement from the baseline of 72% to 65% of total and 650 INNs in 2011. The next revision of (previously insulin was only procured OOP expenditures by 2017. Reducing the EML is expected in 2016. through a separately funded national medicine prices will reduce household programme). While adding it to the expenditure provided consumption does positive list of medicines seemed to Pricing of medicines not increase. Besides regulating ex-factory improve access to antidiabetic treatments prices, it is important to reduce excessive High prices of medicines substantially for patients, the additional cost, due to charges being added to medicines as they affect patient access to medicines, distribution through pharmacies and move through the supply chain. Moldova is especially in low and middle-income insulin now subject to retail mark-ups, had already regulating the maximum levels of countries. The Republic of Moldova a negative impact on the budget. Increased distribution mark-ups, so the next step was introduced its first price control policies expenditure is also likely to have been to introduce a regressive mark-up scheme. in 1995. 8 All levels of medicines prices due to improved access. Considering the This policy option has been widely used have been subject to regulation in a step- growing prevalence of chronic diseases globally in low and middle-income, as well wise manner. Manufacturer prices for all and only partial health coverage, the as high-income countries. 12 13 medicines (including over-the-counter main burden of medicine expenditures medicines, or OTCs) have been fixed remains with patients and their families. 4 Significant variability exists in the using external price referencing, based In this context, efficient use of limited methods for calculating and controlling on a basket including eleven countries. resources, smart selection of medicines the size of mark-ups. A single model The wholesale mark-up has been limited and responsible use of medicines become does not fit all settings. Early in 2015, an to a maximum of 15% of the ex-factory important tools to improve financial initiative to increase financial protection procurement price and the retail mark-up protection and meet population needs. for the population was developed by the to 25% of the wholesaler procurement Parliament and subsequently underwent price. All medicines are subject to 8% intensive rounds of consultation led by the value added tax, which is less than the Ministry of Health with technical support normal VAT rate of 20%. from the World Health Organization. Two main models were considered, one based increase Access to medicines on three price segments (less than 50 lei (€2.40); 51 – 150 lei (€7.20); more Despite all efforts and policy changes, than 151 lei) and the second based on five expenditure on total health expenditure has increased price segments (less than 30 lei (€1.40); over the last ten years, including OOP 31 – 60 lei (€2.90); 61 – 120 lei (€5.70); medicines from expenditure on medicines and medical 121 – 240 lei (€11.5); more than 241 lei). supplies. 9 10 Affordability of partially Other country’s experiences – such as 4.3% to 10% of reimbursed medicines for the treatment the Baltic countries and Romania – were of NCDs has improved since the explored and adapted to the Moldovan total NHIC introduction of the first reimbursement context. A simulation model based on list in 2006 for all income and expenditure expenditure 9 five price segments was designed using ‘‘ quintiles. However, this improvement
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the National Catalogue of manufacturers’ stakeholders will help create transparency efficient generics and antimicrobials, prices†. Mark-ups are regressively defined and accountability of the new amendments and resource generation by improving starting from 15% to 5% for wholesale to legislation. There is a need to develop a public procurement processes are already mark-ups and from 25% to 11% retail. reliable mechanism for monitoring prices included in the country’s newly approved Simulations showed that, if applied, the and sales of medicines in order to assess Action Plan for Pharmaceuticals for 2016. proposed regressive mark-up structure the intended and unintended effects of would lead to a reduction of wholesale price regulations on affordability and References median prices by 6% and retail median access to medicines. Trying to balance prices by 12%. Around 80% of medicines public and private interests without 1 Domente S, Turcanu G, Habicht J, Richardson will experience a price reduction jeopardising access to medicines can be E. Developments in primary care in the Republic of Moldova: essential steps for improving access to from 2% to 10% in the wholesale sector achieved by regulating only priority areas services. Eurohealth 2013; 19(2): 28 – 31. and from 7% to 20% in the retail sector. (e.g. reimbursed medicines) and provide 2 The Government introduced these changes some flexibility in non-priority areas (e.g. Shishkin S, Jowett M. A review of health financing reforms in the Republic of Moldova. WHO Regional in the Summer of 2015 with gradual exempting OTCs from price regulation). Office for Europe, 2012. implementation from October 2015 for 3 wholesalers and April 2016 for retailers. As this initiative covers only a part of Vian T, Feeley F.G. Domente S. Framework for addressing OOP and informal payments for health the procurement and supply management services in the Republic of Moldova. WHO regional chain – namely margins – further efforts Office for Europe, 2014. to improve other areas of relevance to 4 Skarphedinsdottir M, Smith B, Ferrario A, Zues policy improve access to medicines, such as O, et al. Better noncommunicable disease outcomes: selection, financing, supply and rational challenges and opportunities for health systems initiatives were a use of medicines, are needed. – Republic of Moldova country assessment. WHO Regional Office for Europe, 2014. result of intensive Steps forward 5 WHO. Essential medicines and health products. Available at: www.who.int/medicines
inter-sectoral Ensuring long-term sustainability of and 6 Parliament Decision No.1352- XV from access to medicines is one of the greatest 03.10.2002, “Regarding National Medicines Policy.
dialogue challenges for health systems in Europe 7 Ferrario A, Sautenkova N, Bezverhni Z, Seicas R, and worldwide. One of several important Habicht J, Kanavos P, Safta V. An in-depth analysis Lessons learned requirements is an overall review of of pharmaceutical regulation in the Republic of procurement and supply management Moldova. Journal of Pharmaceutical Policy and While international evidence is important processes to bring efficiency into all steps Practice 2014, 7:4. in defining‘‘ the vision and directions of of the supply chain. Clear criteria for 8 Richardson E, Sautenkova N, Bolokhovets G. pharmaceutical policies, contextualized including and excluding medicines and Access to medicines in the former Soviet Union. situation analysis through a participatory medical devices are needed, together with Eurohealth. 2015; 21(2). process in consultation with stakeholders capacity building on health technology 9 WHO. Medicine price, availability, affordability and is crucial for acceptance of new policies. assessment. Decision-makers are price components in the Republic of Moldova. WHO, The policy initiatives described here increasingly faced with difficult choices Regional Office for Europe, 2013. were a result of intensive inter-sectoral due to budget constraints and pressure 10 Ferrario A., Chitan E., Seicas R., et al. Progress dialogue in 2015, including academic from different stakeholders. Health in increasing affordability of medicines for non- partners, health authorities, private sector systems must adapt and be responsive to communicable diseases since the introduction partners and parliamentary officials. Over changing environments, new priorities and of mandatory health insurance in the Republic of Moldova. Health Policy and Planning 2016; February: the short-term regulation of mark-ups, innovations while also managing limited doi: 10.1093/heapol/czv136 p.1–8. will probably lead to reduced medicine financial resources. The pharmaceutical 11 prices. In the medium and long-term, market is highly regulated and particularly National Health Insurance Company Activity Report for 2014. Available at: http://www.cnam. the new regulation on regressive mark- sensitive to the introduction of new policy md/editorDir/file/Rapoarte_activitate/Raport%20 ups may have an effect on the viability measures. Regular monitoring of market activitate%20CNAM%202014_ENG.pdf of some actors in the pharmaceutical data, business intelligence tools and 12 WHO. WHO Guideline on Country Pharmaceutical supply chain and may adversely affect projections of market response have yet Pricing Policies. WHO, 2015. operations in more remote areas. However, to be implemented in Moldova, nor have 13 there is no evidence on the expected and efficient supply management processes. Kanavos P, Schurer W, Vogler S. The Pharmaceutical Distribution Chain in the actual impact to date: incentives and Their implementation will be key to European Union: Structure and Impact on disincentives need to be mapped out and informed policy-making. Extension of Pharmaceutical Prices. EINet, LSE, GOEG, 2011. unexpected effects anticipated to ensure the positive list based on sound selection Available at: http://whocc.goeg.at/Literaturliste/ viability of the supply chain and access to criteria (cost-efficiency, budget impact, Dokumente/FurtherReading/Pharmaceutical%20 medicines in all regional areas. Continued evidence based), awareness campaigns Distribution%20Chain%20in%20the%20EU.pdf open constructive dialogue with all for consumers about responsible use of medicines, with special focus on cost- † Available at: http://www.amed.md/ro/catalogul-national
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IMPROVING THE MORTALITY INFORMATION SYSTEM IN PORTUGAL
By: Cátia Sousa Pinto, Robert N. Anderson, Cristiano Marques, Cristiana Maia, Henrique Martins and Maria do Carmo Borralho
Summary: The inability to invest in and develop mortality information systems has been considered the single most critical failure in health information systems. Health information systems are an integral part of health systems. This includes strengthening not only the information content but also the information systems themselves, health information platforms and infrastructure. In this article, particular focus has been placed on the regional and inter-sectoral
Acknowledgements: The approach to implementation adopted in Portugal. The article shows authors wish to thank those in Portugal who worked on how legal and operational barriers have been overcome and focuses and implemented electronic death certification, including: on the potential of the new system to improve the quality and Fernando Lopes, Rui Garcia, Benilde Barbosa, José Alberto timeliness of mortality statistics. Marques, Joaquim Bodião, Ana Nunes, Alberto Magalhães, Ana Rita Eusébio, Leonor Murjal, Keywords: Electronic Death Certificate, Mortality Information System, Mortality Nelson Pereira, Cristina Cordeiro, Statistics, Mortality Surveillance, Portugal Rui Batista, Pedro Branquinho, José Lima, Sónia Mata, Isabel Almeida, Eugénia Pimpão, as well as Ana Pedroso, for support in the development of legal regulations. Introduction largely unchanged in most countries, The authors are solely responsible mainly due to legal and operational for the perspectives expressed Mortality information is a critical barriers. Transition to electronic mortality in this article. cornerstone of public health surveillance information systems often requires and is at the core of health policy decision changing laws and regulations (e.g., making. Inability to invest in and develop electronic signatures, data protection mortality information systems has Cátia Sousa Pinto is Head of and confidentiality). In addition, for the been considered the single most critical the Mortality Information optimal application of these systems System, Directorate-General failure in health information systems there is a need to invest in ensuring that of Health, Lisbon, Portugal; and there is a recognized urgent need to Robert N Anderson is Chief of the these systems are made user-friendly improve mortality statistics and cause- Mortality Statistics Branch, Centers for health professionals and the range for Disease Control and Prevention, of-death information. 1 2 Even where of professionals outside the health care National Center for Health Statistics, complete coverage has been achieved, sector who will provide information to USA; Cristiano Marques is IT the quality of mortality statistics and project manager, Cristiana Maia the system. is IT product manager, Henrique cause-of-death information remains Martins is President of the suboptimal. 3 Although there have been Electronic registration of death certificates Administration Board, Maria do major developments in information Carmo Borralho is IT project can improve the quality and timeliness technology with the potential to improve manager, Shared Services of the of mortality statistics. 5 There are two Ministry of Health, Lisbon, Portugal. public health information systems, 4 approaches to developing electronic Email: [email protected] mortality data collection has remained
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mortality information systems: 1) death Table 1: E-death certification implementation period in Portugal, by region of certificates are registered electronically the country using information from paper records (e-death registration) or, 2) all institutions E-death certification implementation period involved in the death certification Region Start date End Date process enter information directly into an Center 15 November 2012 15 June 2013 electronic system without relying at all on paper records (e-death certification). The Madeira 18 February 2013 15 October 2013 latter – e-death certification – is a more North 1 March 2013 1 September 2013 efficient means of synchronizing data Algarve 5 June 2013 1 July 2013 from various institutions and ensuring Lisbon and Tagus Valley 5 June 2013 15 November 2013 a more complete and accurate record. Alentejo 10 June 2013 5 September 2013 Azores 1 July 2013 4 November 2013
100% Source: Authors’ own.
Note: E-death certification implementation period for NHS institutions in each Portuguese region. The private health sector was e-death included on 1 January 2014, except in the autonomous region of Azores (on 4 November 2014). certification was
achieved improper cause-of-death certification, The development of the legal framework poor descriptions of cause of death, an to guide the digitisation of death Death Registration and Certification inability to collect and use cause-of- certificates was concluded in 2012 with in Portugal death information from autopsy reports publication of a law and four decrees in available after death certification, and the Portuguese Official Journal 8 9 10 11 12 Mandatory civil registration of deaths in an inability to register multiple causes of and the approval of the Portuguese Data Portugal was instituted in 1911, along with death. This resulted in a high proportion Protection Authority. The new legal the closing of church registries. 6 Until of ill-defined causes of death, or so-called framework requires certification of all ‘‘ 5 now, The Mortality Information System “garbage codes” (> 20%). deaths in Portugal through an electronic in Portugal has been based primarily registry and the electronic transmission on paper-based death certification with To improve timeliness, accuracy and of death certificates for civil registration cause-of-death information registered overall quality of information the purposes. Additionally, it requires that an in accordance with World Health Portuguese DGS implemented electronic integrated electronic system is set up to Organization recommended guidelines. 3 death certification as the basis of the synchronize and link electronic clinical In Portugal, cause-of-death certification mortality information system. 7 and circumstantial information forms, was, and still is, performed by a qualified electronic forensic autopsy reports, and medical doctor and is mandatory for all Development of the electronic electronic clinical autopsies. deaths including foetal deaths (of more mortality information system than 22 weeks of gestational age). Web-based software, SICO (Sistema de Between 2007 and 2013, DGS coordinated Informação dos Certificados de Óbito), A national mortality database was created a joint working group involving the was developed by the Shared Services by combining civil registry information Portuguese Ministries of Health, Justice of the Ministry of Health to support with cause-of-death coding performed and Internal Administration (including the system described above (available manually at the Directorate-General of the Shared Services of Ministry of Health, through https://servicos.min-saude.pt/ Health (DGS) in accordance with the the Institute of Civil Registries, Public sico). This software is accessed by all International Statistical Classification of Prosecution Services, Police Authorities, doctors in Portugal through a high security Diseases and Related Health Problems National Institute of Legal Medicine and password validated by the Portuguese (ICD).This system did not allow for Forensic sciences, National Institute of Medical Association. It is also accessed timely epidemiological surveillance and Medical Emergency and the National by the Public Prosecution Service and depended on paper death certificates being Institute of Statistics) and the National Police Authorities through a high security collected centrally, a process that usually Medical Board. Their aim was to review password provided by the Ministries of took several months, followed by time the legal framework and operational Internal Affairs and Justice. needed to retrieve and code cause of death. procedures for death certification in Another challenge was the accuracy and Portugal and to develop a new legal Upon completion, death certificates completeness of the information obtained framework to guide e-death certification registered by medical doctors are from paper death certificates because of and web-based software to support the forwarded to a central database maintained difficulties with reading handwriting, electronic mortality information system. by the Institute of Civil Registries and
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made available to local civil registry framework for the implementation was health or personal data information that offices. Death certificates for suspected crucial to achieving a coherent force can stigmatize the deceased or their family violent deaths and deaths of uncertain for change, and a multi-organizational as was reported to occur with paper-based cause are first processed by the Public transition to the electronic system. The death certification. Prosecution Service and the Institute of regional approach allowed for institutions Legal Medicine and Forensic Sciences across the country to be prepared From an epidemiologic perspective, in order to allow for a legally required simultaneously for change but also allowed e-death certificates have substantially forensic autopsy before they are forwarded for closer monitoring and support. improved the timeliness of access to to the central database. mortality data. While previously this The pilot phase started in Coimbra information was only available after six Portuguese legislation requires that a University Hospital Centers in months it is now available as soon as the clinical and circumstantial information November 2012. During the one month death is registered. Electronic certification form be completed by the certifying trial phase the software was tested and has also improved the completeness doctor for deaths of unknown cause and adjusted to correct system errors and and quality of data through the use of suspected violent death. Once this form to respond to the end-users’ feedback. automatic form-filling of demographic is registered in SICO it can be made Adjustments mainly included resolving data drawn from the civil registry and available to the Public Prosecution Service difficulties in using the software, based on a national identification number, for investigation. application errors, operational needs not automatic error checking and the use of identified in preliminary testing and web mandatory field features. Corrections Causes of death reported on death service data flow. and amendments can be made directly certificates and registered in SICO are in the database. The need to decipher available to the DGS (Ministry of Health) The national stepwise roll-out started handwritten entries is avoided and the use in real time for mortality surveillance and in December 2012. During this period a of mandatory fields can be used to ensure cause-of-death coding. Once information national training plan was implemented by information that is frequently neglected is is received and coded, it is sent through a core team based at DGS and by regional complete (e.g., pregnancy at time of death, a web service to the National Institute teams (Regional Health Administrations) date of labour and data regarding previous of Statistics. responsible for training. Each region pregnancies and demographic information started using the system on a specific date of the mother for foetal and neonatal SICO also allows for queries to the agreed upon by the Regional Health and deaths). National Medical Emergency Institute Justice Administrations and approved database in all situations where emergency by the Ministry of Health. Table 1 shows care was provided directly prior to the when each region initiated and finalized death of an individual. This information the transition to the new mortality is then made available to the certifying information system. doctor and also for cause-of-death coding operational and performed at DGS. Implementation across the country was completed in December 2013 and 100% epidemiological A secondary but nonetheless important e-death certification was achieved at the function of SICO is to update the National beginning of January 2014. improvements in Health Service (NHS) Users Registry to remove decedents from the health Improved data quality and cause-of- mortality insurance coverage plan. The NHS Users death coding Registry is the national registry of people surveillance insured by the NHS, which is used as The transition to e-death certification in the basis for planning and evaluation of Portugal has resulted in both operational A preliminary analysis of improvements several disease prevention programs and and epidemiological improvements in data quality has‘‘ shown that previously provision of health services. in mortality surveillance, as well as unavailable data has been made available improvements in the quality of data in death certificates (e.g., whether the Implementation collected. From an operational point autopsy was performed; access to the of view, e-death certification allows autopsy report before coding). Also, A strategic multi-step and multi-sectoral for more efficient communication as a substantial amount of duplication of approach, across the country, was taken to participants interact electronically and information from different sources has implement the system. It included a pilot can minimize confidentiality breaches been minimized. Previous data collection phase; training in software use for public with the elimination of paper records of methods required that different entities and private doctors, forensic medical personal information. This improves the of the state register the same information. pathologists, the Public Prosecution legal and administrative process of death Now, for example, doctors do not need to Services and Police Authorities; and a certification. It also ensures that doctors write in the death certificate that a forensic national stepwise rollout. A regional do not have to disclose more sensitive
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autopsy was performed as that information of the system between central, regional 9 Portuguese Official Gazette. Ministry of is already directly available from public and local levels of the Ministry of Health. Internal Administration, Justice and Health. prosecution services. The intersectoral stepwise approach Ordinance no. 329/2012, 22 October 2012. Portuguese Official Gazette 1st series 204. allowed for input from a range of sectors Available at: https://dre.pt/application/dir/ As a result of electronic interoperability (health institutions, public prosecution pdf1sdip/2012/10/20400/0594605947.pdf between health software and civil registry services, police authorities and civil 10 Portuguese Official Gazette. Ministry of software (e.g., between the institutions registry services) that proved to be crucial Internal Administration, Justice and Health. involved in death certification), additional for supporting the transition period in Ordinance no. 330/2012, 22 October 2012. information has been linked with the each region. Portuguese Official Gazette 1st series 204. death certificate and can serve to validate, Available at: https://dre.pt/application/dir/ specify or rectify cause-of-death coding. Implementation of e-death certification pdf1sdip/2012/10/20400/0594705948.pdf In a sample of 40,039 e-death certificates is the first step to improving mortality 11 Portuguese Official Gazette. Ministry of Justice registered in 2013, 16.4% had additional information in Portugal. Next steps and Health. Ordinance nro. 331/2012, 22nd October relevant information available on cause will include: improving electronic error 2012. Portuguese Official Gazette 1st series 204. Available at: https://dre.pt/application/dir/ of death. National emergency forms were checking and alert functions for medical pdf1sdip/2012/10/20400/0594805948.pdf available in 6.9% of all deaths, autopsy certifiers and coding staff; improving the 12 reports and clinical and circumstantial registry of clinical and forensic autopsies; Portuguese Official Gazette. Ministry of Justice and Health. Ordinance nr 334/2012, 23 October information forms in 9.9% of all deaths developing a process for epidemiological 2012. Portuguese Official Gazette 1st series nr (50% of suspected violent deaths and investigation of ill-defined deaths and 205. Available at: https://dre.pt/application/dir/ deaths of unknown cause in the sample deaths of unknown cause with local health pdf1sdip/2012/10/20500/0597605979.pdf used). Clinical and circumstantial authorities; developing an integrated information forms, and autopsy reports, automatic coding functionality; and are especially important for non-natural electronic integration with other relevant deaths as these often provide detail on health information systems. the circumstances of death and nature of injury that can substantially improve References the specificity of cause-of-death coding. Similarly, these may be used to identify 1 Setel PW, Macfarlane SB, Szreter S, et al. on the cause of deaths that are initially behalf of the Monitoring Vital Events (MoVE) writing group. A scandal of invisibility: making certified as unknown. everyone count by counting everyone. The Lancet 2007;370(9598):1569 – 77. A more complete evaluation on the impact 2 Mahapatra P, Shibuya K, Lopez AD, et al. on of this new mortality system on quality of behalf of the Monitoring Vital Events (MoVE) writing cause-of-death coding will be conducted group. Civil Registration Systems and Vital Statistics once a complete year of coded e-death successes and missed opportunities. The Lancet certificates data (2014) is made available. 2007;370(9599):1653 – 63. 3 Mathers CD, Ma Fat D, Inoue M, et al. Counting the dead and what they died from; an assessment of the Conclusions and next steps global status of cause-of-death data. Bulletin of the Transition to electronic, real-time World Health Organization 2005;83(3):171 – 7. mortality information systems in Portugal 4 AbouZahr C, Cleland J, Coullare S, et al. on behalf involved strong core leadership and of the Monitoring Vital Events (MoVE) writing group. inter-jurisdictional cooperation in both The way forward. The Lancet 2007;370(9601): 1791 . – 9 development and implementation from the DGS and the inter-jurisdictional group. 5 Department of Economic and Social Affairs, The experience has also shown that a Statistics Division. Handbook on Civil Registration and Vital Statistics Systems – Computerization. regional approach to implementation is an New York: United Nations, 1998. effective way of transitioning to electronic 6 death certification. The transition in Portuguese Official Gazette. Ministry of Justice. Civil registration code. 18 February 1911. Portuguese Portugal was completed in one year Official Gazette no. 41, year 1911, 653 – 65. and 100% coverage was achieved in two 7 years. These achievements were also due George F. A first note on SICO (Death Certificates Information System): editorial. Revista Portuguesa de to an adequate legislative framework Saúde Pública 2014;32:1 – 2. [in Portuguese] Available that defined a horizontal approach to at: http://www.elsevier.pt/pt/revistas/revista- the functions of the State in the vital portuguesa-saude-publica-323/pdf/90316098/S300/ registration system, good collaboration 8 Portuguese Official Gazette. Law n. 15/2012, 3rd between all ministries involved and April 2012. Portuguese Official Gazette 1st series 67, shared responsibility for implementation 1716 – 8. Available at: https://dre.pt/application/dir/ pdf1sdip/2012/04/06700/0171601718.pdf
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EVIDENCE-INFORMED POLICY- MAKING IN SLOVENIA
By: Mircha Poldrugovac, Tit Albreht, Tanja Kuchenmüller, Marijan Ivanuša, Tatjana Buzeti and Vesna Kerstin Petricˇ
Summary: Health information and research are important foundations for health systems strengthening (HSS). This includes strengthening the information systems themselves such that they are up-to-date, inclusive of all relevant stakeholders and tailored to local contexts. Evidence-informed policy-making (EIP) is a major priority for Slovenia. This article shows how Slovenia applied the principles of EIP to two complementary initiatives contributing to the reform process: 1) a large-scale health system review and 2) an evidence brief for policy on provider payments in primary care. As a result, both are contributing to the transformation of the Slovenian health system.
Keywords: Health Systems Strengthening; Evidence-Informed Policy-Making; Provider Payment; Primary Care; Slovenia
Introduction from the challenges that balancing these two dimensions of high-level policy- Strengthening evidence-informed policy- making present for decision makers. making (EIP) has gained increasing attention across the European region over In 2015, a comprehensive, large-scale, the past few years. On the eve of the 20th evidence-informed health system review anniversary of the Ljubljana Charter was commissioned by the Ministry of Mircha Poldrugovac is a public on Reforming Health Care in Europe, Health to support the development of health medicine specialist and it is important to mention that EIP was Tit Albreht is Head of the Centre a new national health plan in Slovenia. already recognized as a key contributor to for Health Care, National Institute Simultaneously, the Ministry supported of Public Health, Ljubljana, effective reform when Ministers of Health activities to establish a Knowledge Slovenia; Tanja Kuchenmüller is signed the Charter in 1996. To manage a Technical Officer in the Evidence Translation Platform (KTP) to strengthen the reform of health care effectively, and Information for Policy-making the role of systematic evidence in the Charter urged that “…decisions on Unit, Division of Information, important areas not covered by large Evidence, Research and Innovation, [the] development of the health care health system evidence – they tested this World Health Organization Regional system should be based on evidence, Office for Europe, Copenhagen, 1 in the area of primary care. Denmark; Marijan Ivanuša is Head where available.” At the same time, of the World Health Organization the Charter stressed that “governments country office in Slovenia; Tatjana must raise value-related issues for The Slovenian health system review Buzeti is Senior advisor at the public debate…” 1 Although seemingly Minister’s Cabinet, and Vesna At the start of 2015, Slovenia was in Kerstin Petricˇ is Head of the contradictory, decision makers need to need of a new national health plan to Division for Health Promotion and reconcile these two dimensions – the need Prevention of Noncommunicable guide medium- and long-term policy for evidence and the need to consider Diseases at the Ministry of Health, priorities. The previous national health Ljubljana, Slovenia. values – in order to identify policy actions plan had expired at the end of 2013 and Email: [email protected] that promote the health of the population. new austerity measures had been put No country, including Slovenia, is exempt
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in place with the 2012 adoption of the delivery. The drafts of the reports served conducted an EIP situation analysis, Fiscal Balance Act. The Fiscal Balance to guide a series of policy workshops informed by a stakeholder consultation Act influenced as many as 30 legal acts held in autumn 2015. Some of the with the participation of the WHO in different sectors. In addition, the reports addressed issues already high Country Office, the EVIPNet Europe Health Insurance Institute of Slovenia on the policy agenda, i.e., the role of Secretariat at WHO and the Ministry (HIIS), which governs the country’s complementary health insurance, while of Health. This resulted in a proposal to single-fund, compulsory social health others addressed issues requiring more and the Ministry of Health to institutionalize insurance system, had had to significantly immediate attention based on long-term EIP through the establishment of a KTP cut its budgets for hospitals. According forecasts and international experiences, in collaboration with key health system to the HIIS, the unit cost of health i.e., the overreliance on payroll funding of stakeholders. 5 Stakeholders included services reimbursed to health care the compulsory health insurance system. the HIIS, professional associations and providers declined cumulatively by 8.5% The findings of the review were then used chambers, academia and NGOs, in between 2009 and 2013. Despite rising to inform the new national health plan addition to the Ministry of Health and stakeholder pressures for the speedy approved by the Slovenian government the NIPH. development of a reform agenda, the in December 2015. Ministry of Health decided to pursue Primary care in Slovenia the more time-consuming but also more The Minister of Health’s novel and explicit evidence-based approach of a large scale approach towards evidence-informed Primary care is considered a fundamental health systems review. health system reform in Slovenia gained building block of the Slovenian health care national as well as international attention. 2 system. It is currently being challenged To better understand the complexities On the occasion of the presentation of the by an ageing population and an increase of a broad spectrum of health system final reports on the health system review, in multi- and co-morbidities requiring issues, the Ministry of Health engaged the the Minister of Health urged: “The time increased capacity in managing patients technical assistance of the World Health for reflection and strategic planning is and integrating care, particularly for those Organization (WHO) Regional Office for drawing to a close; the next two years with chronic conditions. Despite several Europe and the European Observatory on will be the time for concrete actions in all changes taking place in primary care, a Health Systems and Policies. Together, priority areas.” 3 report in 2013 6 called for clear targets WHO experts, external consultants and to understand the extent of primary care national experts conducted an extensive EVIPNet in Slovenia provider networks in Slovenia. Two factors analysis to inform a new national health were deemed as important to focus on: plan. In order to strengthen the analysis, In order to implement the priorities set out the health workforce (availability), and the the Ministry of Health invited key health in the national health plan, transformation nature of financing (including the extent sector stakeholders–the HIIS, the National and systematic scale-up into practice and method of financing). Institute of Public Health (NIPH), will be required. An institutionalized * professional associations and chambers, knowledge translation platform (KTP) Developing a KTP in Slovenia provider organizations, and patient can help identify policies and a range of representatives. In order to ensure that a possible actions using scientific research As an initial trial to test the KTP, the broader and more intersectoral approach and local experiences in a systematic and Ministry of Health requested the group was achieved, the Ministry of Health comprehensive way. of stakeholders to: 1) prepare an evidence also invited representatives from non- brief for policy (EBP), and 2) organize health sectors, including the Ministry of The Evidence-Informed Policy Network a policy dialogue. Using the EVIPNet Labour, Family, Social Affairs and Equal (EVIPNet) is a WHO-sponsored initiative, methodology, an EBP aims to summarize Opportunities, the Ministry of Finance aiming to build and institutionalize and analyze the evidence while also and the Institute of Macroeconomic national capacities to strengthen EIP providing three policy options for Analysis and Development. These through a systematic, transparent and decision makers to choose from. The stakeholders were involved from the very broad stakeholder approach. In 2012, policy dialogue should ideally follow beginning of the analysis and provided the WHO Regional Office for Europe a process that allows the EBP to be not only evidence, but also diverse views launched EVIPNet Europe and considered among the real-world factors to help address challenges faced by the selected Slovenia as a pilot country influencing the policy-making process. 7 health system. for implementation of the EVIPNet This is achieved by convening a dialogue methodology. 4 Aware of its potential, of the key stakeholders in the policy The health system review explored six in 2014 the Ministry appointed two area in question. Both the EBP and the thematic areas, resulting in six reports: experts from the NIPH to participate in the policy dialogue are fundamental to the Health system expenditure review, pilot project. Throughout 2014, the experts KTP proposed by EVIPNet and have Evaluating health financing, Long-term proven to be successful mechanisms by care, Making sense of complementary which to translate evidence into policy * A knowledge translation platform is a formal organization, health insurance, Purchasing and department or network, focusing on bringing actors together, in a systematic and transparent manner 4 8 payment review and Optimizing service synthesizing explicit and tacit knowledge, and leading elsewhere. networking in knowledge translation. 7
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The EVIPNet country team, which worked The credibility of any document that stakeholders that it needs to maintain on the situation analysis described earlier, synthesises evidence depends on the its integrity and strength. This political a representative of the Ministry of Health consistency of the methods used to support, however, must be matched with and the WHO Country Office decided combine and appraise the evidence, ongoing, appropriate local capacity, that the first EBP should focus on the considering locally specific circumstances financial and non-financial resources payment model for personal physicians and the involvement of stakeholders. It is as well as systematic approaches. (general practitioners or paediatricians)†. clear that both the health system review The EBP would help guide the Ministry and the development of the EVIPNet- References to implement the national health plan. informed KTP effectively involved a broad A team was formed to prepare this range of stakeholders. For both processes 1 WHO. Ljubljana charter on Reforming Health Care specific EBP. The group consisted of these were valuable opportunities to in Europe. Copenhagen: WHO Regional Office for Europe, 1996. Available at: http://www.euro.who. experts and practitioners, including a acquire direct experience and unpublished int/__data/assets/pdf_file/0010/113302/E55363. family medicine specialist, the director of information (or tacit knowledge) that help pdf?ua=1 a health care centre, a community nurse, strengthen the scientific evidence. With 2 MMC RTV SLO. European Commissioner an expert from the providers’ association, such a large group of interests around the impressed by the preparations for healthcare reform. a representative from the HIIS, and the table it is possible to cross check scientific 21 March 2016. Available at: https://www.rtvslo.si/ EVIPNet country team. The process evidence and minimize the monopoly of zdravje/novice/evropski-komisar-navdusen-nad- involved several iterations before the draft one single set of interests or agendas. Both pripravami-na-zdravstveno-reformo/388793 EBP was reviewed by both national and processes required time and continuous 3 Kolar Celar M. Speech by the Minister of Health international experts. The preparation of consultation to address all stakeholders, at the presentation of the analysis of the health care the EBP was then presented and discussed interests and priorities. Both processes system in Slovenia, Brdo pri Kranju, Slovenia on, at the health system review policy dialogue also require continuously clarifying 8 January 2016. Available at: http://www.mz.gov.si/ fileadmin/mz.gov.si/pageuploads/Analiza/8_1_2016/ on primary care held in December 2015. roles and responsibilities among the Uvodni_nagovor_Milojka_Kolar_Celarc.pdf diverse groups of stakeholders to plan for 4 successful implementation. WHO. EVIPNet Europe Strategic Plan. Copenhagen: Lessons learned WHO Regional Office for Europe, 2015. Available at: http://www.euro.who.int/__data/assets/pdf_ Slovenia’s experience with both the Finally, an important lesson learned is that file/0009/291636/EVIPNet-Europe-strategic-plan- health systems review and developing a a strong convening power, such as that 2013-17-en.pdf
KTP using the EVIPNet methodology from the Ministry of Health, is necessary. 5 WHO. Slovenia holds workshop to optimize have been fundamental to equipping the This was particularly evident in the case of evidence-based health policy-making. Copenhagen: government with evidence-based and the health system review where important WHO Regional Office for Europe, 2015. Available at: inclusive decision-making processes that backing from the Ministry of Health http://www.euro.who.int/en/countries/slovenia/ are up-to-date, tailored and relevant to was in place. As the focus shifts towards news/news/2015/02/slovenia-holds-workshop-to- optimize-evidence-based-health-policy-making the local context. Both the processes of implementation of the new national health drafting the health system review reports plan, the Ministry will need to sustain 6 Petricˇ D, Žerdin M. Public network of primary care and the EVIPNet-guided EBP and policy and create additional capacities to ensure providers in the Republic of Slovenia – General and familiy medicine clinics and paediatric clinics at the dialogues should continue to be employed the ongoing, systematic and targeted primary care level. Ljubljana: Ministry of Health, 2013. in the future. use of evidence in policy-making. This Available at: http://www.mz.gov.si/fileadmin/mz.gov. is a primary focus and strength of the si/pageuploads/mreza_na_primarni__sekundarni_ The two approaches to EIP are EVIPNet methodology. in_terciarni_ravni/Mreza_za_ZS_13-11-2013- complementary. While both approaches lektorirano.pdf 7 served to summarize and analyze available Conclusion WHO. EVIPNet Europe starter kit. Copenhagen: evidence and information, the EBP to WHO Regional Office for Europe; in press. be used for informing primary care The two approaches to EIP clearly 8 Ongolo-Zogo P, Lavis JN, Tomson G, reform provides decision makers with responded to different policy-making Sewankambo NK. Initiatives supporting evidence three detailed policy options to choose needs and should be seen along a informed health system policymaking in Cameroon from. The EIP processes used to inform continuum of EIP. Both approaches set and Uganda: a comparative historical case study. BMC health services research 2014;14(1):1. the health system review, on the other out to “synthesize, exchange and apply hand, resulted, with a few exceptions, knowledge by relevant stakeholders to in identifying the broader areas of accelerate the benefits of global and local required action. innovation in strengthening health systems and improving people’s health.” 4 The Slovenian Ministry of Health is clearly committed to engaging EIP processes for health reforms. Without such government † Personal physicians are primary care providers support, evidence-based policy-making (particularly general practitioners) in the public health care system, chosen by insured people (or their guardians) as their initiatives would not attract the attention, first port of call for health related services. They also act as the expertise, or the involvement of gatekeepers to specialist and hospital care.
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THE EUROPEAN OBSERVATORY ON HEALTH SYSTEMS AND POLICIES: KNOWLEDGE BROKERING FOR HEALTH SYSTEMS STRENGTHENING
By: Suszy Lessof, Josep Figueras and Willy Palm
Summary: The European Observatory on Health Systems and Policies (Observatory) is a partnership hosted by the WHO Regional Office for Europe. It emerged from the preparatory work for the Ljubljana Charter and in response to the focus on people centred, quality health systems shaped by values and evidence. Over the last 20 years it has generated and communicated evidence explicitly to inform policy makers, developing a range of innovative approaches to knowledge brokering. The key lessons for bringing evidence into the processes of health systems strengthening revolve around the understanding that knowledge brokering is a dynamic process with three phases: identifying what the evidence need is; pulling together the right evidence; and unpacking and sharing that evidence so that policy makers can use it.
Keywords: Observatory, Health Systems, Health Policy, Knowledge Brokering
The legacy of Ljubljana The Observatory follows from the commitment that all the big decisions The Ljubljana Charter, adopted 20 years on health system development should be ago, was a remarkable achievement. It “based on evidence where available”. 1 Its was rooted in the belief that health cannot founding Partners recognized the lack of be separated from the wider society health systems evidence and, perhaps more or economy and articulated a set of importantly, the significant gap between principles for health system reform, which what academic researchers were producing understood that people’s experiences of and what decision makers needed to shape health systems are central to improving policy. They designed the Observatory to them. It went on to inform the Tallinn Suszy Lessof, Josep Figueras bridge that gap, and to support evidence- Charter and the WHO Regional Office for and Willy Palm are all based at the based policy making through the rigorous European Observatory on Health Europe commitment on walking the talk analysis of the dynamics of health Systems and Policies’, Brussels on people centeredness. hub Belgium. Email: [email protected]. care systems. who.int
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health systems. Table 1 (over the page) Box 1: Observatory Partners at May 2016 matches an example of the Observatory’s recent work with each heading and lists Governments International Academic organizations the knowledge brokering lessons. It organizations demonstrates that knowledge brokering is • Austria • London School of not simply about explaining the evidence. • WHO Regional Office Economics and Political • Belgium It needs to tackle a much broader set of for Europe (host and Science questions around who defines the ‘right’ • Finland Partner) • London School of Hygiene question, where the evidence can be • Ireland • European Commission and Tropical Medicine found, which country comparisons are illuminating, how national context is • Norway • World Bank understood, and who is involved in taking • Slovenia Other organizations a policy agenda forward.
• Sweden • Union nationale des caisses d’assurance Knowledge brokering for health • United Kingdom maladie (UNCAM), systems strengthening: some • Veneto Region France conclusions To support policy makers in strengthening their health systems means managing the Figure 1: Knowledge brokering as the dynamic between evidence and policy dynamic inter-relationship between the three phases of knowledge brokering:
Policy Identifying what the evidence need is: this means working with policy makers, their advisers, experts and academics to Knowledge brokering: Knowledge brokering: pin down what the real policy question transmitting the evidence designing the analysis is. This holds true whether a major study or a policy dialogue is being planned. There needs to be a ‘drilling down’ to Evidence understand the situation that prompts the question; to check that the way the question is described means the same Source: Authors’ own. things to everyone involved; and to ensure that the evidence the team plan to A partnership to broker knowledge Health Systems and Public Health (DSP) assemble will properly and directly speak to understand what policy makers need; to the question. The Observatory brings together different assemble the right evidence; and share it stakeholders – international organizations, in ways that are useful – with all phases governments, and academics (see Box 1) feeding into each in an iterative cycle. who insist that ‘generating evidence’ must be tied to policy relevance. They also place huge emphasis on disseminating Evidence products and the the findings – that is, on packaging lessons learned evidence to and sharing evidence so policy makers A wide range of evidence products have can use it. As advocates of evidence, support policy in evolved to reflect this experience and to they also draw on it so the Observatory bring decision makers and the evidence uses research on knowledge transfer to practice together in ways that work. These include enrich and improve the way it connects published outputs (studies, policy briefs, Pulling together the right evidence: this researchers and policy makers; builds Eurohealth); face to face work (policy does not imply huge amounts of primary trust; signals quality and credibility; dialogues, flagship courses, Summer research; it requires knowledge of what and makes its outputs ‘interpretable’, School) and on-line platforms (see Box 2). has already been done and by whom ‘applicable’ and, above all, accessible. so that existing work is not duplicated The way that these evidence products and existing expertise can be co-opted. The evidence interacts with health systems ‘‘ support policy in practice can best be It means working across boundaries, strengthening through the dynamic of explained through ‘real’ examples. WHO’s so health economists working with knowledge brokering. The Observatory ‘walking the talk’ strategic priorities 2 epidemiologists or Spanish specialists works with decision makers and key provides a framework for strengthening collaborating with Latvian ones. It also counterparts like the WHO Division of
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References
Box 2: Observatory evidence products 1 WHO Regional Office for Europe. The Ljubljana Charter on reforming health care: clause 6.1.2 • HiTs (Health Systems in Transition series): a set of reviews that describe how Copenhagen: WHO, 1996 Available at: http://www. each country’s health system works, using the same structure and terms to euro.who.int/__data/assets/pdf_file/0010/113302/ E55363.pdf support comparison. 2 WHO Regional Office for Europe. Priorities for • HSPM (Health Systems and Policy Monitor): an on-line platform and network health systems strengthening in the WHO European whose members provide health systems news and updates and reflections on Region 2015–2020: walking the talk on people policy developments. centredness. Copenhagen: WHO, 2015 Available at: http://www.euro.who.int/en/about-us/governance/ • Case studies: tailored reviews of how a particular issue is being addressed in different regional-committee-for-europe/65th-session/ countries using a standard questionnaire and a network of national experts. documentation/working-documents/eurrc6513- priorities-for-health-systems-strengthening-in-the- • Analytic studies: detailed explorations of an issue that bring together existing primary who-european-region-20152020-walking-the-talk- research and different disciplines to develop a rounded understanding of current on-people-centredness policy challenges. 3 Slovenia Health System Review Reports. 2015. Available at: http://www.mz.gov.si/si/pogoste_ • Performance studies: looking at a particular domain and how the indicators available can vsebine_za_javnost/analiza_zdravstvenega_sistema/ be used (and misused) in addressing health system performance. 4 Maresso A, Mladovsky P, Thomson S, Sagan A, • HFCM (Health and Financial Crisis Monitor): a web platform and twitter feed that provides Karanikolos M, Richardson E, Cylus J, Evetovits T, updates on emerging evidence on the health system impacts of the financial crisis. Jowett M, Figueras J and Kluge H, (Eds). Economic crisis, health systems and health in Europe: • Policy briefs: concise reviews of evidence around a clearly (and narrowly) defined policy country experience, Copenhagen: WHO/European question with a format that emphasizes key messages and demonstrates the strength of Observatory on Health Systems and Policies, 2015. the evidence underpinning them. Available at: http://www.euro.who.int/__data/ assets/pdf_file/0010/279820/Web-economic-crisis- • Eurohealth: a quarterly journal aimed at both the scientific and the policy-making health-systems-and-health-web.pdf?ua=1 communities which shares syntheses of evidence, news, and debate. 5 Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, Cylus J, Karanikolos M • Health Reform Monitor: an open access series of articles in the journal Health Policy that and Kluge H. Economic crisis, health systems and draws on the HSPM network to discuss reform issues across Europe. health in Europe: impact and implications for policy, Maidenhead: Open University Press, 2015. Available • Policy dialogues: carefully facilitated meetings that allow small groups of senior policy at: http://www.euro.who.int/__data/assets/pdf_ makers to discuss a specific, current policy decision in a confidential environment with file/0008/289610/Economic-Crisis-Health-Systems- key evidence and expert inputs. Health-Europe-Impact-implications-policy.pdf?ua=1
• Presentations: at conferences, meetings and seminars which ensure the Observatory’s 6 Horsley T, Grimshaw T, Campbell C. How to evidence contributes to the wider European public health and health policy debate. create conditions for adapting physicians’ skills to new needs and lifelong learning. Policy Brief 14. • Summer School: an intensive one-week course for policy makers, planners and Copenhagen: WHO/European Observatory on Health practitioners which this year addresses primary care innovation and integration. Systems and Policies, 2010. Available at: http:// www.euro.who.int/en/data-and-evidence/evidence- informed-policy-making/publications/2010/how-to- create-conditions-for-adapting-physicians-skills-to- means transparent and explicit terms of Factors that confer success new-needs-and-lifelong-learning reference, methods and review as well as a 7 Wiskow C, Albreht, de Pietro C. How to create an The Observatory tries to combine these strong focus on context, comparability and attractive and supportive working environment for elements and tools to bring policy makers trends over time. health professionals. Policy Brief 15. Copenhagen: the right evidence at the right point in WHO/European Observatory on Health Systems the decision making cycle, so that they and Policies, 2010. Available at: http://www.euro. Sharing the evidence so that policy can make informed choices. It could not who.int/en/data-and-evidence/evidence-informed- makers can use it: this requires clear, policy-making/publications/2010/how-to-create-an- begin to do so without the extraordinary timely, and understandable messages that attractive-and-supportive-working-environment-for- network of academics, policy makers and are demonstrably trustworthy and backed health-professionals practitioners who contribute to its work; its by high quality evidence and expertise. 8 Greer S, Wismar M, Figueras J (Eds.) staff team who combine academic rigour It means tailoring messages to the issue Strengthening health system governance: better with a commitment to evidence for policy; and the specific audience, and, when policies, stronger performance. Open University its colleagues in DSP; and its Partners who Press, 2015. Available at: http://www.euro. possible, tapping into an entry point – a know what it is like to try to put evidence who.int/__data/assets/pdf_file/0004/307939/ key moment when there is the will to take into practice. Strengthening-health-system-governance-better- evidence on board. It also means engaging policies-stronger-performance.pdf?ua=1 policy makers and ensuring that they feel ownership, creating the momentum for them to follow through.
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Table 1: Evidence products and knowledge brokering lessons
Observatory evidence product Knowledge brokering lessons
Walking the talk: strategic priority 1: Transforming health services • Link with national experts: working closely with the Slovenian Institute of Public Health, Health Insurance Institute, academics, managers and Slovenia – health system review: a comprehensive review in conjunction other stakeholders was central to understanding what was really with WHO Europe’s DSP, assessing expenditure, funding, purchasing, happening and building trust. payment and service delivery including long term care. Experiences and evidence from other European health systems illuminated possible choices • Work across silos: bringing different experts together who could for Slovenia. connect hospitals payment to referral patterns to multi-morbidity turned the analysis from an abstract exercise into something practical. The Review delivered a set of interlinked reports 3 that were welcomed by the Minister and discussed in Parliament. DSP will work with Slovenia to • Tap into political will: it was a Slovenian decision to explore the use the evidence and the ownership created to improve health evidence and to use it. Without (senior) engagement evidence has system performance. little power.
Walking the talk: strategic priority 2: Moving towards universal health • Cultivate extensive academic networks: the case studies were only coverage possible because they drew on the knowledge and insights of dozens of experts across the Region. Financial crisis case studies: these case studies (a response to the pressures of the economic crisis on health systems), were carried out in • Make methods and review transparent: the significant investment in close collaboration with DSP and its Barcelona team. They reviewed in developing a country questionnaire paid dividends in demonstrating detail policy responses in the areas of public funding, health coverage and validity and building trust. health service planning, purchasing and delivery in nine countries. 4 The • Release results early: timeliness is crucial for policy makers and studies provided the evidence for policy dialogues in member states, although the case studies took time to publish they were circulated and demonstrating that securing universal coverage was an appropriate used in policy dialogues, and by DSP, to support practitioners and response in the face of the crisis. They also fed into an overview volume implementation, as soon as they were quality controlled. analysing the policy responses in 47 countries. 5
Walking the talk: foundation 1: Enhancing the health workforce • Write explicit terms of reference: these policy briefs had to fit closely into a wider agenda – they worked because a lot of thought was given to Health workforce policy briefs: Developed to support the Belgian the commissioning process and to ensuring that the evidence collected European Union Presidency, the briefs addressed very specific themes would address the policy need. (workforce needs, skills, audit for quality and work environment) reviewing the evidence and generating evidence-informed policy • Highlight key messages: the policy briefs are structured in the options. 6 7 understanding that decision makers have little time. They offer one page of easy access key messages and a brief summary (all underpinned by a fuller iteration of the evidence). • Use entry points: in this case the Belgian government used the EU Presidency to push forward thinking on workforce issues. Having an opening when policy makers are willing to address an issue makes a real difference to evidence uptake.
Walking the talk: foundation 2: Ensuring equitable access to medicines • Define the question: policy dialogues bring evidence together for and technologies a particular group to meet a particular need. Therefore, getting the question right is imperative. A lot of work went into understanding Central European Policy Dialogue: A policy dialogue in Bratislava on the central Europe context and what would be useful. pricing and reimbursing pharmaceuticals in Central-Europe, bringing together Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, • Bring the right experts together: this policy dialogue involved two Slovakia and Slovenia, and key experts to consider the challenges and leading academics and experts from WHO, the European Commission options. and the OECD. The Observatory facilitator helped line up their different strengths and perspectives to provide the right evidence for the Summer School: the 2014 OBS Venice Summer School was on rethinking participants. pharmaceutical policy and looked at pricing, procurement and innovation. Summer Schools are not policy dialogues but many of the same lessons • Create a safe space for discussion: the dialogue worked because apply to their design and delivery. participants could try out different ideas and ask any questions in a See: http://theobservatorysummerschool.org/ secure and confidential setting.
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Observatory evidence product Knowledge brokering lessons
Walking the talk: foundation 3: Improving health information • Build in comparability: policy makers want to be able to set their national system in a European context and to learn from other countries’ HiTs: give a clear, analytic description of how a country’s health system experiences. HiTs use the same template to ensure ‘read-across’ from is organized and paid for and what it delivers. They detail reform and one to another. policy initiatives and capture the challenges, which helps countries to assess what is happening in their own system and explain it to others. • Address trends over time: a snap shot of what is happening is useful, See: http://www.euro.who.int/en/about-us/partners/observatory/ but a sense of how a picture is evolving over time tells policy makers publications/health-system-reviews-hits much more about the underlying issues and allows them to understand performance evaluations in context. The Health Systems and Policy Monitor: puts HiTs on-line and updates them using a network of leading national experts to capture news and • Update regularly: HSPM network members are an invaluable source of policy developments. See: http://www.hspm.org/mainpage.aspx in-depth knowledge and are able to bring a sense of the changes taking place in real time and with real insight. The Health Reform Monitor: a series of open access articles in Health Policy written by network members. See: http://www.hspm.org/hpj.aspx
Walking the talk: governance: managing change and innovation • Offer practical tools: not all analysis leads directly to something ‘applicable’ but the governance study was able to extract from the Governance study: This Observatory study 8 develops a framework for literature and practice a five- point framework that will allow policy understanding governance and explores how it works in different makers to ‘check’ the health of their system’s governance and focus situations and countries. It concludes that transparency, accountability, efforts to implement change. participation, integrity and capacity are the crucial aspects of health governance. • Identify champions to take ideas forward: the Observatory generates evidence for policy makers but does not support policy development or implementation. The WHO Regional Office for Europe’s Policy and Governance for Health and Well-being programme will make the study’s evidence operational and use it with countries. • Unpack the evidence: the study is rich in detail so the research team are extracting key messages and making them available to different audiences in appropriate formats. They have launched the book, will present at conferences and publish articles to facilitate access.
Israel: Health System quality of hospital care and reduce surgical waiting times, along with Review greater public dissemination of comparative performance data. Due to By: Bruce Rosen, Ruth Waitzberg, the growing reliance on private financing Sherry Merkur with
Health Systems in Transition potentially Copenhagen: World Health Vol. 17 No. 6 2015 deleterious Organization 2015 (on behalf of the effects for Observatory) Israel Health system review equity and Pages: xxv + 212; ISSN 1817-6127 efficiency, action is Freely available for download at: taken to http://tinyurl.com/IsraelHiT2015 Bruce Rosen Ruth Waitzberg expand Sherry Merkur The Israeli health system is considered public quite efficient. At the same time reform financing, initiatives are being taken to tackle improve certain problems: the benefit package is the further expanded to include mental efficiency of the health care and dental care for children; public system and constrain the growth health inequalities are reduced through of the private sector. Finally, major steps a multipronged effort; national projects are being taken to address projected are set up to measure and improve the shortages of physicians and nurses.
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PUBLICATIONS
Health services delivery: European strategic directions Access to new medicines in a concept note for strengthening nursing and Europe: technical review of policy midwifery towards Health initiatives and opportunities for By: J Tello and E Barbazza 2020 goals collaboration and research Copenhagen: WHO Regional Office for Europe, 2015 Copenhagen: WHO Regional Office for Copenhagen: WHO Regional Office for Available for download at: http://www. Europe, 2015 Europe, 2015 euro.who.int/en/health-topics/Health- Available for download at: http://www. Available for download at: http://www. systems/health-service-delivery/ euro.who.int/en/health-topics/Health- euro.who.int/en/health-topics/Health- publications/2015/health-services-delivery- systems/nursing-and-midwifery/ systems/health-technologies-and- a-concept-note-2015 publications/2015/european-strategic- medicines/publications/2015/access-to- This paper takes stock of the developments directions-for-strengthening-nursing-and- new-medicines-in-europe-technical-review- in the literature on health services delivery midwifery-towards-health-2020-goals of-policy-initiatives-and-opportunities-for- and lessons from the firsthand experiences collaboration-and-research-2015 The European strategic directions for of countries, viewing clarity on the strengthening nursing and midwifery This report, with a focus on sustainable performance, processes and system towards Health 2020 goals, the first such access to new medicines, reviews policies dynamics of health services delivery a document produced in the European that affect medicines throughout their prerequisite for Region, was developed as a result of lifecycle (from research and development to the rollout, extensive collaboration with senior nurse disinvestment), examining the current scale-up and and midwife evidence base across Europe. While many Health services delivery: sustainability of a concept note leaders and European reforms. Juan Tello consultation countries have Erica Barbazza Through a with policy Access to not new medicines mixed- in Europe: makers. The technical review of traditionally policy initiatives and methods opportunities for European strategic directions document aims collaboration and research required approach, for strengthening nursing and midwifery towards to guide active evidence from Health 2020 goals Working document Member priority- existing States in setting for frameworks enabling and access to and tools for enhancing medicines, measuring services delivery, country case the March 2015 appraising examples and commissioned papers have contribution of nurses new been reviewed around three key questions: and midwives to achieving the Health 2020 medicines using • what are the outcomes of health goals of improving the health and well- pharmacoeconomics is increasingly seen services delivery? being of populations, reducing health as critical in order to improve efficiency in • How can the health services delivery inequalities, strengthening public health spending while maintaining an appropriate function be defined? And, and ensuring sustainable, people-centred balance between access and cost– • how do other health system functions health systems. effectiveness. enable the conditions for health services Contents: Foreword; Introduction; Health The study features findings delivery? trends and challenges in the Region; from 27 countries and explores different Contents: Preface; About this document; Towards a new era; European strategic ways that health authorities in European Section 1 Performance outcomes for directions for nursing and midwifery; countries are dealing with high spending measuring health services delivery; Implementing and monitoring the on new medicines, including methods such Section 2 Health services delivery; framework; References; Annex 1 Priority as restrictive treatment guidelines, target Section 3 Enabling health system action areas and proposed action lines; levels for use of generics, and limitations conditions for services delivery; Final Annex 2 Enabling mechanisms and on the use of particularly expensive drugs. remarks; Annex 1 Frameworks, tools and proposed action lines. It also outlines possible policy directions strategies reviewed; Glossary of key terms; and choices that may help governments References to reduce high prices when introducing new drugs.
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REGIONAL COMMITTEE FOR EUROPE 65th SESSION Vilnius, Lithuania, 14–17 September 2015
© Humberto Balantzategi Basaguren
© Leah Morantz © WHO © Šarunas Narbutas
© Liva Brizga
© Maria Anghel © Jay Flood-Coleman © Georgi Hristov
© WHO © Teresa Capell Torras © Szymon Chrostowski © Caitriona Cassidy
Priorities for health systems strengthening in the WHO European Region 2015–2020: walking the talk on people centredness
Available at: http://tinyurl.com/healthsystemstrengtheningWorking document