Quarterly of the European Observatory on Health Systems and Policies EUROHEALTH RESEARCH • DEBATE • POLICY • NEWS
• Identifying the causes of • SELFIE Framework: Integrated
› Measuring inefficiencies in health systems care for multi-morbidity 2017
| efficiency in • The challenges of using cross- • Proportionality test for regulation national comparisons of efficiency of health professions? health care • Big data for public health • Investing in health literacy Number 2
| • Increasing the health budget in Romania Volume 23 1356 ISSN Still Steve Production: and Design permission. prior without form any in transmitted or system aretrieval in stored reproduced, copied, be may publication this of 2017. part No Policies and Systems Health on Observatory European of behalf on © WHO Medicine. &Tropical Hygiene of School London the and Science Political and Economics of School London Funds), Insurance Health of Union National (French UNCAM Bank, World the Commission, European the Italy, of Region Veneto the and Kingdom United the Switzerland, Sweden, Slovenia, Norway, Ireland, Finland, Belgium, Austria, of Governments the Europe, for Office Regional Organization Health World the between apartnership is Policies and Systems Health on Observatory European The consideration. for authors by submitted or editors the by commissioned independently are Articles sponsors. or partners its of any or Policies and Systems Health on Observatory European the of those necessarily not and alone authors in expressed views The beyond. and Europe in debate aconstructive to contribute so and issues policy health on views their express to policymakers and experts researchers, for Eurohealth at: Available Guidelines Submission Article White: Caroline MANAGER SUBSCRIPTIONS North: Jonathan MANAGER PRODUCTION Still: Steve EDITOR DESIGN B. Richard Mossialos, Elias McKee, Martin Lessof, Suszy Palm, Willy Grand, Le Julian 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 Palm: Willy ADVISOR EDITORIAL 6381 7955 20 +44 McDaid: David Maresso: Anna 6194 7955 20 +44 Merkur: Sherry TEAM EDITORIAL SENIOR http://www.healthobservatory.eu Email: 0936 2525 +32 F: 9240 2524 T: +32 Belgium Brussels, 1060 Horta Victor Place 07C020) (Office Eurostation Policies and Systems Health on Observatory European the of Quarterly EUROHEALTH [email protected] [email protected] is a quarterly publication that provides a forum aforum provides that publication aquarterly is Saltman, Sarah Thomson Thomson Sarah Saltman, – [email protected] [email protected] 1030 http://tinyurl.com/eurohealth [email protected] [email protected] [email protected] [email protected] / 40 Hortaplein, Victor Eurohealth Eur opean [email protected] are those of the the of those are [email protected] on Healt
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CONTENTS EUROHEALTH Quarterly of the European Observatory on Health Systems and Policies and Systems Health on Observatory European the of Quarterly health care efficiency in › Measuring • • •
Big fordata public health national comparisons of efficiency The challenges of using cross- inefficiencies ininefficiencies healthsystems the Identifying causes of • • • •
budget in Romania Increasing the health Investing in health literacy of health professions? test for Proportionality regulation Care for Multi-Morbidity SELFIE Framework: Integrated RESEARCH • DEBATE • POLICY • NEWS • POLICY • DEBATE • RESEARCH
Volume 23 | Number 2 | 2017 Shutterstock © Alberto Masnovo CONTENTS 12 16 8 3 34 33 21 2 28 24
THE SELFIE FRAMEWORK SELFIE THE NEW NEW DRAFT EU DIRECTIVE SUBMITS DIRECTIVE EU DRAFT NEW OF on de Miriam Kraus, Markus THE Papanicolas Irene IDENTIFYING Eurohealth EDITORS’ NEW PUBLICATIONS NEW Eurohealth Vlãdescu Cristian Scîntee, Eurohealth TO Fenna LIFE? OF DATAA THE DOES PROMISE HEALTH: DATA BIG PUBLIC FOR Eurohealth TO NEWS TIME TO FOCUS ON BENEFITS BEYOND THE HEALTH SECTOR: HEALTH THE BEYOND BENEFITS ON FOCUS TO TIME
behalf Bont, Roland Bal, Reinhard Busse, Busse, Reinhard Bal, Roland Bont, A INFORM HEALTH
CHALLENGES
PROPORTIONALITY MEASURES
RM
of COMMENT
–
Leijten, Verena Struckmann, Ewout van Ginneken, Thomas Czypionka, Czypionka, Thomas Ginneken, van Ewout Struckmann, Verena Leijten,
the
LITERACY HEALTH
Martyna Giedrojc Giedrojc Martyna THE
SELFIE
CAUSES OF INEFFICIENCIES OF CAUSES TO
OF and Observer Monitor Systems International
INCREASE
POLICY
– consortium. USING Peter C Smith C Peter
Reiss, Apostolos Tsiachristas, Melinde Boland, Antoinette Antoinette Boland, Melinde Tsiachristas, Apostolos Reiss, David McDaid David
TEST and
FOR
– CROSS-NATIONAL COMPARISONS OF EFFICIENCY OF COMPARISONS CROSS-NATIONAL –
and Cristina Hernández-Quevedo Cristina
THE HEALTH BUDGET IN ROMANIA IN BUDGET HEALTH THE
Rita Baeten Rita Irene Papanicolas Papanicolas Irene
Roger Lim Roger INTEGRATED and
and
THE REGULATION THE Policies
Maureen Rutten-van Mölken Rutten-van Maureen Eurohealth
CARE
IN and
HEALTH Observer Euro incorporating
FOR Jonathan Cylus Jonathan
MULTI-MORBIDITY
SYSTEMS
OF
HEALTH
BETTER QUALITY QUALITY BETTER
THE – –
, Jonathan Cylus, Cylus, Jonathan Silvia Gabriela Gabriela Silvia —
PROFESSIONS
EXAMPLE Vol.23
– |
No.2 |
2017 1 1 2
Being able to measure efficiency is one of the cornerstones of assessing the performance of health systems, and can help to achieve several objectives, such as allocating resources in the best possible way to meet population needs and health system goals; maximising value for money in terms of the resources spent; contributing to improving quality of care for health services users; and improving population health outcomes.
Opening the Summer issue, our Observer section and facilitating a dialogue around continuation, features two articles that explore central issues related implementation and financing – this type of care to measuring the performance of health systems. can benefit patients with multi-morbidity. First, Cylus et al. discuss the challenges of identifying the causes of inefficiencies in health systems, which Turning to Health in All policies, an article by entail not only defining but also interpreting health one of our editors, David McDaid, addresses system efficiency metrics. Outlining the main aspects the challenge of implementing effective health of some of these metrics, the authors propose an promotion and protection actions beyond the analytical framework that can operationalise the health sector. Using the example of health literacy,
COMMENT assessment process; they also apply it to an example he explains how focusing on the benefits to the to illustrate what particular metrics can and cannot education sector, rather than health outcomes
tell us. In a complementary article, Papanicolas and per se, can go a long way in promoting investment Cylus look at the significant challenges involved by other crucial sectors to public health goals. in attempting to use international comparisons of various aspects of efficiency. Noting the scarcity Rounding off the section, Baeten provides some of such comparative studies, the authors discuss perspective on the new draft EU Directive which different types of efficiency data, the availability of proposes imposing a proportionality test to the cross-country databases and some of the cross- regulation of professions, including health professions. country studies that have attempted to gauge She argues that legal uncertainty on regulations may aspects of efficiency at the health system level. result from the lack of clarity as to what measure can withstand the test and proposes a different approach. In a bumper International section, we begin with an article looking at how big data may have some With a spotlight on Romania, the Health Systems potential to change the ways in which we receive and Policies section highlights some of the latest treatment and transform health systems. Giedrojc health system strategies being employed under and Lim discuss how our increasing understanding the country’s recently enhanced health budget. of the broad determinants of health, coupled with the daily use of digital technology, has generated We round off with the Monitor section which big data that could ultimately be used to improve features new publications as well as some of wellbeing. However, they argue that despite some the latest health policy news around Europe. good case examples, the use of big data in health is a new science with many obstacles yet to overcome. We hope you enjoy the issue and the summer!
Partners on the European Commission funded Sherry Merkur, Editor project, ‘Sustainable integrated chronic care Anna Maresso, Editor models for multi-morbidity: delivery, financing, David McDaid, Editor and performance’, so called SELFIE, present their framework. They assert that by better understanding integrated care programmes Cite this as: Eurohealth 2017; 23(2). EDITORS’
Eurohealth incorporating Euro Observer — Vol.23 | No.2 | 2017 Eurohealth OBSERVER 3
IDENTIFYING THE CAUSES OF INEFFICIENCIES IN HEALTH SYSTEMS
By: Jonathan Cylus, Irene Papanicolas and Peter C Smith
Summary: Persistent growth in health expenditures coupled with fiscal pressures have led to widespread calls for efficiency improvements. However, identifying the sources of inefficiencies in health systems remains challenging. In this article, we provide an analytic framework to facilitate better understanding and interpretation of common health system efficiency metrics. To demonstrate its potential, we apply the framework to a simple efficiency metric comparing per capita health care expenditure to amenable mortality rates in the EU-28 Member States. This exercise highlights the information each metric can and cannot tell analysts and decision-makers. Going forward, more refined metrics should be developed based on more standardised and detailed cost accounting data and linked datasets and registries.
Keywords: Efficiency, Health System, Efficiency Indicators, Outcomes, Performance
Why is health system individuals are denied access to care. efficiency important? Taking a broader perspective, health system inefficiencies may divert resources The concept of health system efficiency – from other sectors of the economy where as well as the related topics of cost- the resources could be put to good use. effectiveness and value for money – seeks In addition, not only does increased to capture the extent to which the inputs efficiency allow money to be spent more to the health system, in the form of effectively, but the ability to eliminate expenditures, labour, and capital, are used waste also demonstrates good stewardship Jonathan Cylus is Research Fellow to secure valued health system goals. of the health system, which can persuade at the European Observatory on It is one of the most commonly debated Health Systems and Policies and governments and citizens to finance dimensions of health system performance. London School of Economics & universal health coverage. Political Science (LSE), United Kingdom; Irene Papanicolas Inefficiency in any part of the health is Assistant Professor LSE, The pursuit of efficiency is therefore one system leads to a number of undesirable United Kingdom; and Peter C of the central preoccupations of health consequences, including comparatively Smith is Emeritus Professor at policy-makers and managers, and there Imperial College Business School, poorer outcomes for patients. If finite is considerable evidence to suggest that United Kingdom. Email: J.D.Cylus@ health system resources are not used lse.ac.uk inefficiencies exist in all health systems. efficiently it will also mean that some
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Figure 1: The simplistic view of health system production An analytic framework to facilitate interpretation of efficiency indicators
Physical Health care Physical In light of the challenges in measuring Expenditures Outcomes inputs activites outputs efficiency and interpreting analysis, we have developed a simple framework to Source: Authors assist analysts seeking to understand and respond to efficiency concerns. Using this framework, five aspects of any efficiency The World Health Report 2000 pointed to Numerous other issues arise when indicator can be explicitly considered to very large apparent worldwide variations seeking to develop operational models of clarify what precisely is being measured in efficiency at the system level, a finding efficiency in health care, reflecting the and to determine subsequent analysis or replicated by both the Organisation for complexity of the health care production action (see Figure 2): Economic Cooperation and Development process. The production of the majority of (OECD) as well as the European health care outputs rarely conforms to a • the entity to be assessed; 1 2 3 4 Commission. In this article, we production-line type technology, in which • the outputs (or outcomes) review the concept of efficiency and focus a set of clearly identifiable inputs is used to under consideration; on interpretation of metrics, making use produce a standard type of output. Instead, • the inputs under consideration; of a framework to facilitate analysis. the majority of health care is tailor-made to For more detail please see our full volume the specific needs of an individual patient, • the external influences on attainment; on measuring health system efficiency with consequent variations in clinical • the links with the rest of the produced by the European Observatory needs, social circumstances and personal health system. on Health Systems and Policies. 5 preferences. This means that there is often considerable variation amongst patients In the following sections we briefly Understanding production processes in how inputs are consumed and outputs discuss each aspect. in the health system or outcomes are produced. For example, contributions to the care process may Identifying the accountable entity: Efficiency indicators are useful to compare be made by multiple organisations and who is being evaluated? and evaluate production processes. Taking caregivers, an ‘episode’ of care may occur An assessment of efficiency first a simplistic view, efficiency is represented over an extended period of time, and in depends on understanding the boundaries by the ratio of the inputs an organisation different settings, and the responsibilities of the entity under scrutiny. At the consumes in relation to the valued outputs for delivery may vary from place to place finest level, an entity could be a single it produces (see Figure 1). An organisation and over time. treatment, where the goal is to assess consumes a set of physical resources, its cost relative to its expected benefit. referred to as inputs, often measured in At the other extreme, the entity could terms of total expenditures or physical be the entire health system. Most often, inputs like health care personnel or beds; efficiency measurement takes place at it then transforms those inputs into a series an intermediate level, where the actions of valued outputs, such as an episode although the of individuals or groups of practitioners, of care, through a set of discrete health teams, hospitals or other organisations care activities. core idea of within the health system are assessed. Whatever the chosen level, as a general Any specific indicator of efficiency may efficiency is easy principle it is important that any analysis seek to aggregate all inputs into a single reflects an entity for which clear measure of costs, or it may consider only to understand it accountability can be determined. It is also a partial measure of inputs. For example, important that entities being compared labour productivity measures such as often becomes are genuinely comparable and producing ‘patient consultations per physician’ outputs under similar conditions. ignore the many other inputs into the difficult to consultation, and the many outputs other ‘‘ What are the outputs under than patient consultations produced by the operationalise consideration? physician. In effect, such partial measures Two fundamental issues need to be create efficiency ratios using only a subset Therefore, although the core idea of considered with regards to outputs: how of the inputs and outputs represented efficiency is easy to understand in should the outputs of the health care by the arrows in Figure 1. In short, the principle – maximising valued outputs sector be defined and what value should indicator shows only a fragment of the relative to inputs – it often becomes be attached to them? In principle health complete transformation of resources into difficult to operationalise it when applied care outputs should usually be defined desired outcomes (improved health). to real-life situations, particularly at the in terms of the health gains produced. system level. However, the concept of health gain has
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Figure 2: Visualisation of analytic framework or ‘environmental’ determinants of performance. These are influences on the External entity, beyond its control, that reflect the Influences? external environment within which it must operate. For example, population mortality rates are heavily dependent on the demographic structure of the population under consideration and the broader Entity? social determinants of health. Likewise, a community nurse practicing in a remote rural area may appear inefficient when Inputs? Outputs? assessed using a metric such as ‘patient encounters per month’ if local geography limits the number of patients that can be visited.
There is often considerable debate as to what environmental factors are considered ‘controllable’. This will be a key issue for any scrutiny of efficiency and holding Li relevant management to account. The nk m? s to ste wider health sy choice of whether to adjust for such external influences is likely to be heavily dependent on the degree of autonomy Source: Authors enjoyed by management, and whether the purpose of the analysis is short run proved challenging to make operational. as the input the implication is that the and tactical, or longer run and strategic. Recent progress in the use of patient organisations under scrutiny are free to In the short run, almost all input factors reported outcome measures (PROMs) deploy inputs efficiently, taking account of and external constraints may be fixed. offers some prospect of making more relative prices. In practice, some aspects of In the long run, depending on the level secure comparisons, at least of providers the input mix are often beyond the control of autonomy, many may be changeable. delivering a specific treatment 6 and a of the organisation, such as capital stock, In many circumstances it will be number of well-established measurement at least in the short term. appropriate to consider efficiency metrics instruments have been developed that both with and without adjustment for could be used to collect before/after Labour inputs can usually be measured external factors. measures of treatment effects, such as the with some degree of accuracy, often EQ-5D and SF-36. 7 8 disaggregated by skill level. An important Broadly speaking, environmental issue is therefore how much aggregation factors can be taken into account by In practice, however, analysts are often of labour inputs to use before pursuing restricting comparison only to entities limited to examining efficiency by an efficiency analysis. Unless there is operating within a similarly constrained measuring the volume of activities, for a specific interest in the deployment environment; by modelling the constraints example in the form of patients treated, of different labour types, it may be explicitly, using statistical methods operations undertaken, or outpatients seen. appropriate to aggregate into a single such as regression analysis; 9 or by Such measures are manifestly inadequate, measure of labour input, weighting the undertaking risk adjustment to adjust the as they fail to capture variations in the various labour inputs by their relative outcomes achieved to reflect the external effectiveness (or quality) of the health care wages. Additionally, with regard to constraints. 10 delivered. Yet there is often in practice labour inputs, problems may arise if the no alternative to using such incomplete interest is in examining the efficiency of Links with the rest of the measures of activity in lieu of health sub-units within organisations, such as, health system care outcomes. for example, operating theatres within No outputs from a health service hospitals. As the unit of observation within practitioner or organisation can be What are the inputs under the hospital becomes smaller (department, considered in isolation from the rest of consideration? team, surgeon, and patient), it becomes the health system in which they operate. The input side is usually considered increasingly difficult to attribute labour Scrutiny of a health system entity in less problematic than the output side. inputs to that specific unit. isolation, be it a team of surgeons or Physical inputs can often be measured a hospital, may ignore the important more accurately than outputs, or can be What are the external influences? implications of its impact on whole system summarised in the form of a measure of In many contexts, a separate class of efficiency. For example, if a primary costs. However, when considering costs factors affects production – the external
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Figure 3: Amenable mortality and health expenditure per capita, 2013 Moreover, the output considered is
Health expenditure per capita, EUR PPP amenable mortality, which captures 6000 deaths that are considered avoidable in the presence of timely and effective care. This measure is attractive in the sense 5000 LU that it captures a valued health outcome and it is directly influenced by the quality 4000 NL and availability of health care. However DE SE the input is health care expenditure, DK AT IE FR which serves as an imperfect proxy for 3000 BE FI the health system’s many inputs and UK IT especially for the inputs to amenable ES MT 2000 mortality. Additionally, health care PT SI CZ expenditures go towards other outcomes CY EL SK HU PO HR EE LT besides amenable deaths; it is not possible 1000 BG LV to disentangle expenditure on conditions RO amenable to health care from expenditure
0 on other minor conditions, such as glue 0 50 100 150 200 250 300 350 ear. Amenable mortality rates are also Amenable mortality per 100 000 affected by current health expenditure but are also affected by factors such as Source: OECD Health Statistics 2016 and Eurostat. the prevalence of disease, which occur as a result of things like genetics, current care practice is held to account only by mortality rates in the EU-28 Member and long-term health behaviours, and metrics of costs per patient, it might secure States (see Figure 3). Countries towards health care in previous years. No efforts apparently good levels of efficiency by the bottom right of the figure are spending are made to control for these and other inappropriately shifting certain costs low levels on health care but have external influences that undoubtedly (such as emergency cover) onto other very high rates of amenable mortality. play an important role in determining agencies, such as hospitals or ambulance Countries towards the top left have very amenable mortality rates; this is something services. The chosen metric may create low levels of amenable mortality but high that should be done prior to drawing perverse incentives for the practice, and levels of spending. Countries in the bottom any conclusions about which system is may fail to capture its serious negative left are low spenders that secure low levels most efficient. impact on other parts of the health system. of amenable mortality, and thus appear That consequence should in principle be most efficient. Nevertheless, aggregate analyses like this accounted for in any assessment of that can provide interesting information about practice’s efficiency. The framework demonstrates that this how well systems are performing overall conclusion is not so straightforward. The and can highlight unexpected variations accountable entity in this instance is that might not be observed by focusing on an entire health system. One important specific health care processes alone. Yet consideration is that it is not clear that at the same time, these metrics are useful all of the countries included in the only as a starting point before conducting No outputs can analysis are comparable to such an further analysis, since they cannot give extent that their health systems have the any clear indication about where problems be considered in same potential to produce health care might be occurring within the health outputs. In all likelihood the countries system and are susceptible to missing isolation from the are not sufficiently comparable to be information. The location (e.g. provider) considered together given the multitude of where an efficiency issue becomes rest of the differences, including how they organise apparent is not necessarily the area where health services and inherent differences policy-makers should take action if they health system in their populations’ health needs. Some want to make improvements. countries towards the bottom right of the Applying the framework to compare Figure may be operating efficiently given Potential for health system efficiency health system ‘‘efficiency in the their low levels of expenditure. It would be evaluations in the future European Union sensible to restrict the set of countries to those that are most comparable, or to only The interest in health system efficiency To illustrate, we apply the framework to construct the figure for a single country has been heightened by the perception of a crude metric that compares per capita using multiple years of data. high growth in health system expenditure health care expenditure to amenable in most countries and the widespread
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belief that efficiency gains can be made. A general challenge to better information 5 Cylus, J, Papanicolas I, Smith P (eds). Health However, despite being one of the most on efficiency is the lack of agreement system efficiency: How to make measurement matter fundamental health system performance on information standards and protocols. for policy and management. Health Policy Series, 46. Brussels: European Observatory on Health Systems concerns for researchers and policy- Even within countries, there is and Policies, 2016. makers, the measurement of health system considerable variation in interpretation of 6 efficiency in practice is difficult to realise. accountancy rules and the use of patient Smith P, Street A. On the uses of routine patient- reported health outcome data. Health Economics; It has proved challenging to develop robust level information systems. International 2013;22(2):119 – 31. measures of comparative efficiency that comparison is even more problematic, 7 are feasible to collect or estimate, that and there would be major gains if there EuroQol Group. EuroQol: a new facility for the measurement of health-related quality of life. offer consistent insight into comparative could be international agreement on basic Health Policy 1991;16:199–208. health system performance, and that can reporting and information standards, 8 be usable in guiding policy reforms. building on achievements such as Ware J, Sherbourne C. The MOS 36-item Short Form Health Status Survey (SF-36)’. Medical Care 11 EuroDRG and the System of Health 1992;30:473–83. Accounts. 12 9 Jacobs R, Smith P, Street A. Measuring efficiency in health care: analytic techniques and health policy. Measuring the efficiency of health Cambridge: Cambridge University Press, 2006. systems is therefore a challenging but 10 A challenge to worthwhile undertaking. Decision- Iezzoni LI. Risk adjustment for measuring healthcare outcomes (3rd edn). Baltimore: Health makers who rely on inadequate analysis Administration Press, 2003. better information or interpretation of efficiency metrics to 11 implement reforms may inappropriately Busse R, on behalf of the EuroDRG group. Do diagnosis-related groups explain variations on efficiency is target apparently inefficient practices. in hospital costs and length of stay? Analyses For example, an initiative to reduce the from the EuroDRG project for 10 episodes of care the lack of length of hospital inpatient stay may in across 10 European countries. Health Economics some circumstances yield gains in terms 2012;21(Suppl. 2):1 – 5. agreement on of more intensive use of hospital resources. 12 OECD/WHO/Eurostat. A System of Yet in other circumstances this may Health Accounts: 2011 Edition. Paris: information be at the expense of serious additional OECD Publishing, 2011. DOI: http://dx.doi. ‘‘ costs for ambulatory health services, or org/10.1787/9789264116016-en standards and even future readmissions to hospitals. Decision-makers therefore need to assess protocols the balance of such risks when seeking to tackle inefficiency, and make informed There is enormous scope for improvement judgements about how to reform their in measuring efficiency. Conceptually, system. We believe the analytic framework there is much work still to be done in presented here helps to facilitate the creating indicators that conform to the appropriate interpretation of the relevant usual requirements of specificity, validity, efficiency metrics. reliability, timeliness, comparability, and avoidance of perverse incentives. On References the input side, there is a need for more consistent and more detailed costing 1 OECD. Health care systems: Efficiency and of the care given to individual patients. policy settings. Paris: OECD Publishing, 2010. Available at: http://www.oecd-ilibrary.org/ Management accountants have a key social-issues-migration-health/health-care- role to play in this respect. On the output systems_9789264094901-en side, the use of PROMs might offer great 2 Joumard I, André C, Nicq C, Chatal O. Health scope for improved quality measurement. status determinants: lifestyle, environment, health Furthermore, most indicators reflect only care resources and efficiency. Paris: Organisation part of the patient pathway. The increased for Economic Co-operation and Development (OECD use of electronic health records, linked Economics Department Working Paper, no. 627), datasets and registries, capturing entire 2008. patient treatments, offers considerable 3 WHO. World Health Report 2000. Health systems: scope for developing more complete improving performance. Geneva: World Health efficiency metrics, capable of assessing the Organization, 2000. relative merits of alternative approaches 4 European Commission. Comparative efficiency of to care. health systems, corrected for selected lifestyle factors. Final report. Brussels: European Commission, 2015.
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THE CHALLENGES OF USING CROSS-NATIONAL COMPARISONS OF EFFICIENCY TO INFORM HEALTH POLICY
By: Irene Papanicolas and Jonathan Cylus
Summary: Many comparative efficiency metrics focus on scrutinising the operation of specific parts of a single health system. This article reviews the key issues involved in international comparisons of various aspects of efficiency. It examines data sources and analytic techniques used to create comparative indicators, and discusses approaches to interpreting variations. It also highlights key challenges and promising new initiatives, such as the consistent use of international definitions and technical developments, such as data linkages, which hold the potential to enhance work in this area.
Keywords: Efficiency, Indicators, International Comparisons, Health Systems
Introduction policy-makers and researchers have been interested in developing metrics that are As spending, demographic and able to compare health system efficiency technological pressures on health care across countries. 1 2 3 However, despite the continue to rise across health systems, interest surrounding them, internationally the resources to meet these challenges comparable efficiency indicators are Acknowledgment: This article is are limited. This issue has produced a among the most elusive of health system based on an extensive chapter in drive for policy-makers to identify and Cylus, Papanicolas & Smith, Health comparative performance metrics; with correct for inefficiencies in every aspect system efficiency: how to make a 2008 review noting that of all health care measurement matter for policy of health care – its delivery to patients, efficiency studies, only 4% were cross- and management. WHO Europe/ its technology, its business models and European Observatory on Health country analyses. 4 Systems and Policies, 2016. its policies. To monitor and pinpoint the causes of variability, it can be helpful In this article we consider the availability to compare efficiency within, as well of internationally comparative health as across countries. Looking abroad, to system efficiency data, focusing primarily Irene Papanicolas is Assistant comparative data on health systems which on measures of technical efficiency – i.e. Professor at the London School are designed differently, can be useful of Economics & Political Science the effectiveness of a given set of inputs both for benchmarking as well as to try (LSE), UK and Jonathan Cylus is to produce a given set of outputs or Research Fellow at the European to gauge whether different types of health outcomes. 5 Observatory on Health Systems care delivery or policies may be successful and Policies and at LSE, UK. Email: [email protected] at realising efficiency gains or improving health. As a result, for some time many
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Types of efficiency data (e.g. life expectancy or infant mortality) as metrics that relate health expenditure that can be used to compute efficiency data to health outcome data, such as life We have already noted our interest in metrics. In some cases, such as the OECD expectancy or amenable mortality rates. indicators that relate to a given set of health data, the database contains only Some studies even relate such ratios inputs to produce a given set of outputs or a few indicators that capture ratios of to manually constructed production outcomes. We do not consider allocative outputs and inputs, and which might allow possibilities frontiers*, to better assess efficiency or dynamic efficiency as efficiency comparison, such as average efficiency. 6 very few studies and datasets exist that length of hospital stay or curative care collect or compare data on these types occupancy rates. While these measures can illustrate of efficiency across countries. variations across countries, policy- makers and researchers need to consider While our cross-country review includes the assumptions being made when both indicators that relate health system constructing such ratio measures, to inputs (including but not limited to policy best inform their correct interpretation. expenditures, personnel and beds) to Outcomes such as life expectancy or a given set of health system outputs makers need to avoidable mortality will be influenced by (including but not limited to physician a host of factors outside of the health care visits and discharges), or health outcomes, consider the system, making it difficult to conclusively we note that the distinction between health attribute these ratios to differences in outcome-based and health care output- assumptions health system efficiency. While better based indicators is important. Outcome- quality data on health care quality and based approaches tend to be more policy being made health outcomes is becoming available relevant, given that what matters to While such indicators are often used to (through datasets such as the OECD patients and policy-makers is to obtain make direct efficiency comparisons across Health Care Quality Indicators Project), it quality health services that will improve countries, they should be used with caution is still a challenge to find input data that their health; however in practice, output- as the data will also include information can be directly attributable to the quality based indicators are easier to collect and ‘‘ on both potential inefficiencies, as well as indicators collected. more widely available and thus more differences reflecting case-mix of patients commonly used. across countries, as well organisational Cross-country studies of efficiency differences reflecting different treatment at the system level Cross-country databases patterns or settings (for example, definitions of an acute care bed differ Although efficiency indicators are scarce There are few longitudinal, regularly across countries). As the data are not in international health databases, there updated databases that compare health adjusted for these confounding factors, are a number of studies that compare system efficiency across countries. Key one would not be able to make an informed health care efficiency across countries. resources of comparable cross-country statement of whether differences in length- These studies are often cross-sectional data are collected and regularly updated of-stay are due to more efficient practices and not regularly reproduced. One by intergovernmental organisations, or other factors. The case-mix issue can characteristic that sets these studies apart such as the World Health Organization be partially accounted for by focusing on from the databases discussed above is (WHO), Eurostat, and the Organisation for the length-of-stay for specific diagnostic that these studies frequently employ Economic Cooperation and Development categories, though this still cannot adjust analytic frontier methods to calculate (OECD). Member countries typically for variations in case-severity within a efficiency scores. These methodological supply these organisations with their own diagnostic category. approaches can address some of the issues national data, which are then reviewed that otherwise inhibit comparisons, for and harmonised to ensure comparability Occasionally, some expenditure-based example by accounting for multiple inputs across countries and time (OECD/WHO/ data, such as total health spending as to health production and adjusting for Eurostat). Some resources such as the a share of GDP, are used to compare differences in production capabilities System of Health Accounts (SHA), for efficiency across countries. These too at various scales. However, while many example, have made important advances should be interpreted with caution as analytic approaches have been taken, on the input side to ensure that health care they assume that health outcomes are there is no consensus on the “correct” expenditure data are collected under a identical across countries, so that using methodological approach. Many system- common framework and are comparable fewer resources implies greater efficiency. level studies have taken advantage of across countries. Despite the existence of few comparable access to international harmonised efficiency metrics in most international Each of these databases is updated databases, the large number of input annually and covers a wide range of health and output/outcome information allows care inputs (e.g. health care expenditure, researchers and policy-makers to manually physician density or hospital beds), outputs * A curve depicting all maximum output possibilities for calculate simple efficiency indicators, such (e.g. hospital discharges) and outcomes two goods, given a set of inputs consisting of resources and other factors.
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scores appears to be unexplained by health efficiency if the data are detailed enough. system characteristics or other factors. It For example, the McKinsey Health Care Box 1: Critiques of WHO World is unclear how successfully confounders Productivity study examined variations Health Report can be controlled for. Additionally, most in inputs and outcomes for treating breast studies take a very narrow perspective on cancer, lung cancer, gall stones, and Some critiques of the WHO study the outputs of the health system, with the diabetes in the US, UK and Germany. 15 have illustrated that the choice of main products of the health system being parametric and non-parametric life expectancy and infant mortality. It is Other European projects such as the approaches, such as Data noteworthy that there seems to be little HealthBASKET project reviewed the costs Envelopment Analysis (DEA) or consistency across studies in the countries of care for nine European countries. 16 Stochastic Frontier Analysis (SFA) that are found to perform most efficiently, Using ‘case vignettes’ which describe will influence the results of such an despite studies frequently relying on the particular types of patients (i.e. based 3 8 exercise, as well as noting that same datasets. on age, gender and co-morbidities), such models will be sensitive to the study compared and attempted to the assumptions made about how explain variations in costs within and efficiency changes over time, and Cross-country studies of efficiency at the sector and/or disease level between countries. The advantage of the data and methods available to this approach is that specific services model this. Cross-country studies also compare sub- for comparable patients could be costed sectors (often hospitals) using available and compared across countries. The data, or utilise comparative instruments more recent EuroDRG used an episode datasets to compare efficiency, with their such as vignettes or diagnosis related of care approach to compare costs added value generally being the use of groups (DRGs) to analyse similar patients across countries 17 based on the fact that analytic techniques. and similar types of care using micro- most analyses of efficiency are unable level data. At this less aggregated level, to properly control for differences in One of the first large studies to compare because patient characteristics are often case-mix. This study investigated the the efficiency of health systems was more homogenous than population classification variables used by different conducted by WHO to compare health characteristics, variations in outcomes country DRG systems, such as diagnosis, expenditure per capita to life expectancy are likely due to unobserved confounding procedure, patient age, length-of-stay, (adjusted to account for disability), after factors to a lesser degree. There are also death and the level of reimbursement for controlling for educational attainment 7 a number of outputs, such as hospital a selection of similarly defined patients for 191 countries. The models use country- discharges or physician visits, which can based on episodes of care. fixed effects, which take advantage of be assessed that are not possible at the variations within each country over time health system level. Common frontier- to estimate parameters. An efficiency based analytic techniques, DEA and SFA, index was constructed, where the expected are also employed. few level of health, if there was no health care expenditure, is compared to the expected Studies in this area also vary in terms regularly updated level of health if all health systems were of what they compare, and which data as efficient as the best performer. Based they use. Some studies look at efficiency databases on this analysis, only one country, Oman, in hospitals, adjusting for differences in is deemed to be efficient while Zimbabwe case severity and environmental factors. 12 compare health the least efficient. Researchers have also compared efficiency for specific types of care provided within system efficiency The WHO efficiency study and related a hospital, often using DEA models, and study of overall performance in the 2000 performing specific analysis amongst across countries World Health Report 3 have been heavily countries with similar institutional criticised both on methodological and arrangements 13 or access to similar high Another recent project, the European data quality grounds (see Box 1). Similar quality patient data such as registries. 14 Health Care‘‘ Outcomes, Performance and research using DEA methods and panel Efficiency project (EuroHOPE) has made data regression have also been carried Health system efficiency has also important advances in disease-based out by the OECD 9 and the European been explored by examining the costs, efficiency comparisons across countries. 18 Commission 10 as well as by independent resources, outputs and outcomes This study uses linkable patient-level authors using available international associated with treating specific diseases, data, which allows for measurement of data. 11 Yet despite the efforts to account the advantage being that patients treated both outcomes (including follow up) and for other inputs that have an effect for certain diseases are likely to be more the use of health care resources (costs, on health outcomes, such as lifestyle, homogeneous. Additionally, it may be days of care, procedures, and drugs) for education or institutional characteristics, possible to more accurately observe the comparable patient groups. much of the variability in efficiency processes that lead to differences in
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Key progress and remaining education, occupation). Longitudinal 9 Joumard I, André C, Nicq C. Health Care Systems: challenges disease-based studies that take advantage Efficiency and Institutions. OECD Economics of high quality patient-level data allow Department Working Papers, No. 769. Paris: OECD, We find that while there are many 2010. numerous observable non-health- different ways to conceptualise and 10 related confounders to be controlled European Commission. Comparative efficiency calculate efficiency metrics, estimates for when comparing the treatment of of health systems, corrected for lifesyle factors: do not generally lead to definitive Final report. Brussels: European Commission, 2015. specific diseases across countries, conclusions regarding efficient health Available at: http://ec.europa.eu/health/systems_ providing important insight into health systems, providers or practices. Frequently performance_assessment/docs/2015_maceli_ production processes. report_en.pdf collected metrics are simple, compare entire health systems, and are readily 11 Hadad S, Hadad Y, Simon-Tuval T. Determinants available in international databases, but Conclusions of healthcare system’s efficiency in OECD countries. European Journal of Health Economics, 2013;14(2), because of their high level of aggregation, While there has been considerable 253 – 65. doi: 10.1007/s10198-011-0366-3. these metrics are not particularly useful for progress, much work remains before 12 identifying determinants of inefficiency or Varabyova Y, Schreyögg J. International internationally comparable efficiency comparisons of the technical efficiency of the hospital developing appropriate policy responses. metrics should play a formal role in sector: Panel data analysis of OECD countries using Advanced analytical tools are often informing health policy. To ensure that parametric and non-parametric approaches. Health used to construct more sophisticated Policy 2013;112(1–2), 70 – 79. doi: http://dx.doi. international health system efficiency system-level metrics based on data from org/10.1016/j.healthpol.2013.03.003 metrics do not misinform policy decisions, these same international databases; 13 it is essential for continued efforts Steinmann L, Dittrich G, Karmann A, Zweifel P. however, their use of the same, limited Measuring and comparing the (in)efficiency of to enhance data quality, availability datasets raises potential questions of their German and Swiss hospitals. European Journal of and comparability. external validity. Health Economics, 2004;5(3), 216 – 26. doi: 10.1007/ s10198-004-0227-4. Overall, there are few longitudinal, References 14 Linna M, Häkkinen U, Magnussen J. Comparing hospital cost efficiency between Norway and Finland. regularly updated databases that compare 1 Hollingsworth B, Wildman J. The efficiency of Health Policy, 2006;77(3), 268 – 78. health system efficiency across countries. health production: re-estimating the WHO panel data 15 Available data is at an aggregated level, using parametric and non-parametric approaches Garber AM. Comparing health care systems from making it difficult to directly attribute to provide additional information. Health Economics the disease-specific perspective. In OECD (Ed.), 2003;12(6), 493 – 504. doi: 10.1002/hec.751. A Disease-based Comparison of Health Systems: output or outcome data to input data, or What is Best and at What Cost? OECD: Paris, 2006. to properly adjust for confounding factors 2 OECD. Towards High-Performing Health Systems. 16 that might influence efficiency. Despite Paris: OECD, 2004. Busse R, Schreyögg,J, Smith PC. Variability in healthcare treatment costs amongst nine EU 3 the common use of analytic methods such WHO. World Health Report 2000. Geneva: countries – results from the HealthBASKET project. as DEA or SFA in multi-country efficiency WHO, 2000. Health economics, 2008;17(S1), S1-S8. doi: 10.1002/ hec.1330. studies we were not able to identify any 4 Hollingsworth B. The measurement of efficiency regularly-updated longitudinal databases and productivity of health care delivery. Health 17 Busse R & on behalf of the Euro DRG group that employ these tools themselves in Economics, 2008;17(10), 1107 – 28. doi: Doi 10.1002/ (2012). Do diagnosis-related groups explain variation an effort to report efficiency scores that Hec.1391 in hospital costs and length of stay? Analysis from the EURODRG project for 10 episodes of care across account for multiple inputs and outputs, 5 Cylus J, Papanicolas I, Smith P. Health system 10 European countries. Health economics, 2012;21, or that control for factors exogenous to efficiency: how to make measurement matter for 1 – 5. doi: 10.1002/hec.2861. the health system. Current international policy and management. Copenhagen: WHO Europe/ databases are therefore limited to simple European Observatory on Health Systems and 18 Hakkinen U, Iversen T, Peltola M, Seppala TT, Policies, 2016. measures, primarily unadjusted ratios of Malmivaara A, et al. (2013). Health care performance comparison using a disease-based approach: 6 International Monetary Fund. Republic of Slovenia, outputs to inputs, to gauge cross-country The EuroHOPE project. Health Policy, 112(1 – 2), Technical Assistance Report: Establishing a Spending differences in health care efficiency. 100 – 109. doi: DOI 10.1016/j.healthpol.2013.04.013. Review Process. IMF Country Report No. 15/265. Washington DC: IMF, 2015. Cross-country comparisons of providers 7 or sub-sectors allow for more detailed Evans DB, Tandon A, Murray CJ, Lauer JA. Comparative efficiency of national health analysis and are a promising way forward, systems: cross national econometric analysis. but are primarily focused on hospitals, BMJ, 2001; 323(7308), 307 – 310. doi: 10.1136/ with limited analysis of other types of bmj.323.7308.307. care settings. Some of the most important 8 Gravelle H, Jacobs R, Jones AM, Street A. gains have been made by disease-based Comparing the efficiency of national health systems: efficiency studies; these studies capture a sensitivity analysis of the WHO approach. Applied variations in the costs, processes, and Health Economics and Health Policy, 2003;2(3), outcomes associated with treating 141 – 47. particular diseases, and can often be linked to registry data containing non- health based characteristics (e.g. income,
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BIG DATA FOR PUBLIC HEALTH: DOES THE DATA PROMISE A BETTER QUALITY OF LIFE?
By: Martyna Giedrojc and Roger Lim
Summary: Public health in the 21st century brings all stakeholders together in an organised effort to ensure the safe use of their data in a digital world. Big data holds the potential to transform and benefit public health and could lead to improved quality of life. It could open the door for more research and bring effective and tailored treatments for patients. It is no longer only about providing access to health care services and medication, but also about assuring a whole range of other factors, such as a stable social and economic situation, climate, as well as good housing and workplace conditions.
Keywords: Big Data, Public Health, Quality of Life, Privacy, Digital Future
Europe’s digital challenges and public daily lives has led us to generate massive health transformation amounts of data, which in the majority of cases are unstructured. Only recently have The notion of what is considered public we been able to understand and have the health has been changing. Previously, means to use this data for health purposes. it primarily focused on addressing the The current “big data revolution” has need for sanitary conditions and the fight the potential to transform our health against infectious diseases. The next systems and change the way in which we public health revolution was focused receive treatment. Big data could lead on changing individual behaviours to improved quality of life for people by contributing to non-communicable providing them with crucial information diseases and premature death. At present, about their future health and enabling public health is emphasising health as a them to take the necessary steps to prevent key factor of quality of life. It means that the onset of illness and thus stimulate future health moves beyond a focus on behavioural change. As global society is individual behaviour towards recognising becoming more digital, there are many the influence of a very broad range of challenges that need to be solved to ensure determinants on health such as climate, that Europe does not lag behind. Digital social and economic development, culture, technology can enrich public health and Martyna Giedrojc is Policy Officer housing and workplace conditions. 1 for Health Systems, European care provision, thus allowing citizens Public Health Alliance (EPHA), to live longer and enjoy more healthy In line with that, European society has Brussels, Belgium; Roger Lim life years. is Policy Officer at DG SANTE, embraced new technology by transforming Brussels, Belgium. the ways in which we pay, shop, dine and Email: [email protected] travel. The use of digital technology in our
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What kind of data is desirable? account the behavioural aspect of collected mind, feature among the key concerns, data. The major concerns of big data for which could led to social and cultural On the other hand, the notion of sharing society are a decline of universal access segregation. 4 personal data between people, facilities to health care, growing inequalities and and companies for purposes other than patients and health professionals’ exclusion treating the patient has raised many Better use of data for health systems from the product development process, for concerns regarding data privacy. Personal the benefit of business development. The needs of our society are growing and health data has become of great value citizens are becoming more demanding, for organisations and institutions which therefore European health systems need use it for research purposes. The list of The people behind big data to start adjusting to the new situation. companies interested in big data includes The term big data is already well known Concerns about deteriorating health access major pharmaceutical and medical devices and frequently used in scientific, political are well-founded and the quality of health players who use these data to tailor their and corporate discussions at the European care affects public health in general. In health care products to the needs and level. For example, its importance has practice, public health expenditure has demands of patients. In recent years, been acknowledged by the European been decreasing steadily since the onset technology giants have been showing Commission in the “Study on Big Data of the financial crisis and patients’ out of greater interest in providing health care in Public Health, Telemedicine and pocket expenditure has increased. solutions and have become large actors in Health care”: the health care sector. These companies offer solutions for storing data in their “Big Data in Health refers to large clouds and they invest heavily in the routinely or automatically collected development of artificial intelligence (AI) datasets, which are electronically Big for health care. But the digital footprints captured and stored. It is reusable in the of every click leave traces on the Internet: sense of multipurpose data and comprises data could lead every piece of information has a value the fusion and connection of existing and by extension it also has a price on the databases for the purpose of improving to improved health care market. health and health systems performance. It does not refer to data collected for quality of life 3 The health care sector is a data-intensive specific study.” Some countries monitor and measure industry collecting information, such their health systems by using the Health as clinical, genetic, behavioural and The study, prepared by Gesundheit System Performance Assessment (HSPA), environmental data from an array of Osterreich Forschungs – und Planungs a tool to collect information and data to devices including electronic health GmbH and commissioned by Directorate identify areas where health systems need records (EHRs), genome sequencing General Health and Food Safety improvements. The assessment captures machines, patient registries, social (DG SANTE), highlights the need to ‘‘ and takes into account all aspects of networks and smartphone applications communicate a positive picture of big health systems, especially indicators on that monitor health. Gathering this wealth data in health and to encourage people workforce, health information systems, of information by tapping into different to get involved in the discussion. The health determinants and, socio-economic data repositories and being able to Commission has also outlined the next and environmental factors in order analyse it provides immense potential for steps towards a data-driven economy, to have a complete picture of health improving the effectiveness and quality by making sure that all citizens have systems performance. The feasibility of health care for patients, possibilities a sufficient level of digital skills. This and effectiveness of HSPA depends on for disease prevention, by identifying risk includes not only patients, health the existence of extensive comparable factors at population, subpopulation and professionals, academics and medical and reliable data sources, collected on a individual level and improve medicine industries, but the whole of society. consistent basis in each country and the monitoring and patient safety. Big data ability to compare the results amongst for public health purposes could also The use of big data in health is a new as many other countries as possible. The encompass information from Internet science full of promising case examples, EU could focus on improving availability clicks, queries in search engines, social but arguably there are still many obstacles of indicators and making better use of media information, home monitoring, that need to be overcome. While the those data that could be translated into mobile transactions and socioeconomic use of big data for public health holds comparable knowledge. indicators. 2 Such data can be analysed enormous promise, there are numbers of and linked with health data to create new practical and legal hurdles that need to The advent of big data has important datasets for analytical purposes. On the be worked out, such as data privacy and implications on further measuring the one hand, this can foster innovation and citizen’s awareness of its ownership. The accessibility, effectiveness, efficiency create patterns for new insights, but on the lack of transparency, uneven access to and safety of health systems. Healthy other hand it can be an assumption based information and, unfair and discriminatory life years and access to high-quality only on data comparison. This assumption conclusions based on comparisons of health care for those in need should be can be wrong as it does not take into data blocks with no specific questions in
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the principles of every HSPA process. of the human body. To better understand Data translated into quality of life One of the difficulties is that national the course of a disease, researchers need to Big data presents a formidable opportunity governments have the liberty to determine track interactions between multiple genes. and sizeable challenge to the development their own way of applying HSPA, for Big data use in the area of genetics might of digital health. The EU bolsters data- which there is no single accepted template lead to a better understanding to predict driven innovation and growth and in 2014, at the European level yet. 5 This creates specific health outcomes of populations the European Commission launched its challenges for the comparability of in the future. 7 strategy on big data, which, according to indicators between EU Member States. the Vice President for the Digital Single The information for epidemiological Market will bring opportunities to more purposes could be used to plan and Outbreak control in favour of traditional sectors such as health care. 10 epidemiology evaluate future strategies to prevent illness and study the distribution of diseases To obtain a complete picture of data- The process of providing an overview among populations. As can be expected, driven health care, it is crucial to have of the national legislation on electronic only through access to reliable information a regulated and safe free flow of data health records within the EU Member can epidemiologists predict actions and between countries. Reliable data flow States and the introduction of the legal create guidelines for the management also involves cross-border health care, requirements for electronic health records of patients who already have existing where information can be collected, implementation remains one of the most health conditions. 8 With high quality data exchanged or shared. The European important priorities of DG SANTE. 6 sources, tracking disease outbreaks can be Commission DG SANTE has been simpler and faster, but a closer look at the working closely with the eHealth Network, source of the data is needed. 9 established under Article 14 of the Directive on the application of patients’ ensure Business innovation result in better rights in cross-border health care. It has treatment created a voluntary network of national safe use of data authorities responsible for eHealth, whose Big data could open the door for more main activity is to improve eHealth effective and tailored treatments for in a digital world interoperability, allowing data to travel patients. That brings an opportunity for the smoothly between health systems. eHealth Furthermore, on 9 March 2017 the development of new pharmaceuticals that interoperability creates added value by European Commission launched 24 respond to different patients individually, linking up various data repositories in the European Reference Networks (ERN) albeit coming at great financial cost. For EU, which could be tapped into for the covering more than 950 highly specialised example, innovation in the pharmaceutical purpose of research. health care units in 313 hospitals field in view of the digital agenda and within 25 Member States and Norway. eHealth could be a key driver to safeguard In the next few years, the eHealth Its implementation is one of the most the health, well being and lives of Network’s work on big data will focus on important and innovative pan-European European citizens. It is likely to uncover ‘‘ the real importance of public health and cooperation initiatives in health care. unknown links between diseases, which how data could contribute to the quality These ERNs will help facilitate access to can lead to medical recommendations of life for all people living in Europe. diagnosis and treatment by centralising based on new information. Big data can For example, it could be used to create knowledge and experience, medical accelerate the development of new drugs a better understanding of the causes of research and training and resources in the and repurpose existing ones in order to people’s bad eating and drinking habits, area of rare or low prevalence complex tailor them to the needs of patients. It also lifestyle factors and stress, all of which diseases or conditions. The possibility to fosters the creation of new data-focused exert a negative effect on physical and analyse data in medical research plays an businesses and health analytics. mental health. important role in many other disease areas such as cancer or Alzheimers. While it brings a lot of opportunities, big data also raises some important Health in the 21st century ensures The secondary use of data has an concerns about its impact on the rights public health in a digital world enormous potential to better understand and freedoms of people, including their People tend to forget that technology the human genome and allow researchers right to privacy. There is not enough is only a means to an end on the path to sequence and analyse the latter in transparency about the risk of constant to success in achieving better public order to find out individuals’ possible monitoring of people’s daily activities health. In order to make the best use of predisposition to certain conditions–for and about the logic of profiling, which digital technology for health we need instance, cancer or other genetic diseases; could be used for marketing unhealthy to guarantee a whole range of factors. 1 to follow the course of infectious diseases; products and behaviours, or even abused It will not be possible to create effective, and to better grasp the overall resistance by unauthorised persons. accessible and resilient health systems
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and sustainable economies whilst dealing about the bigger picture in which society 7 Buckley J. Big Data Analytics Alters How We with a population that is increasingly understands digital technology, also taking Study the Human Genome, DATAVERSITY 2016. unhealthy. Health, as one of the key into account the socio-behavioural aspects Available at: http://admin.dataversity.net/big-data- analytics-alters-how-we-study-the-human-genome/ preconditions for economic growth, has that influence quality of life. to be strengthened using many measures 8 What is epidemiology? BMJ 2017. Available at: including healthy housing and workplace http://www.bmj.com/about-bmj/resources-readers/ References publications/epidemiology-uninitiated/1-what- conditions and improving lifestyles, as epidemiology well as maintaining good air quality. 11 1 Kickbusch I. In search of the public health paradigm for the 21st century: the political 9 Harford T. Big data: are we making a big mistake? dimensions of public health. Política de saúde 2009. Financial Times 28 March 2014. Available at: https:// www.ft.com/content/21a6e7d8-b479-11e3-a09a- 2 The Use of Big Data in Public Health Policy and 00144feabdc0 Research, the Brussels: European Commission, health 10 2014. Available at: http://ec.europa.eu/health//sites/ The Digital Single Market website, European health/files/ehealth/docs/ev_20141118_co07b_ Commission 2017. Available at: https://ec.europa.eu/ systems need to en.pdf digital-single-market/en/big-data
3 Study on Big Data in Public Health, Telemedicine 11 Tackling Meat Production and Consumption, the start adjusting to and Health care. Luxembourg: Directorate-General European Health Parliament 2016. Available at: http:// for Health and Food Safety Health Programme, 2016. www.healthparliament.eu/documents/10184/0/EHP_ the new situation Available at: https://ec.europa.eu/health/sites/ PAPERS_2016_ClimateChangeAndHealth_SCHERM. health/files/ehealth/docs/bigdata_report_en.pdf pdf/27d853e4-ac5f-4bc7-be34-6642035ff7f0
In the end, public health policy as 4 Kitchin R. Big Data, new epistemologies and such is not something that needs to paradigm shifts. Big Data and Society 2014; April – be implemented only by public health June: 1 – 12 2014. Available at: http://journals. authorities. To advance on health in sagepub.com/doi/full/10.1177/2053951714528481 the 21st century, all stakeholders should 5 Giedrojc M. State of Play on Health System be aware and involved in an organised Performance Assessment. European Public Health ‘‘ Alliance 2016. Available at: https://epha.org/state-of- effort to ensure safe use of data in a play-on-health-system-performance-assessment/ digital world. Big data holds the potential to transform and benefit public health in 6 Overview of the national laws on electronic the future, but it will be no longer only health records in the EU Member States, DG SANTE website 2017. Available at: http://ec.europa. about providing access to health care eu/health/ehealth/projects/nationallaws_ services, institutions and medication, but electronichealthrecords_en.htm
Portugal: health system review Since the financial crisis, health sector reforms in Portugal have been guided by the Memorandum of Understanding that was signed between the Portuguese Government and three By: J Simões, GF Augusto, I Fronteira & international institutions C Hernández-Quevedo (the European Commission, Health Systems in Transition Copenhagen: World Health Organization 2017 Vol. 19 No. 2 2017 the European Central Bank (on behalf of the Observatory) and the International Monetary Fund) in exchange Number of pages: 184 pages; ISSN: 1817-6127 Portugal Health system review for a €78 billion loan. Freely available to download at: http://www.euro.who. Measures were implemented int/__data/assets/pdf_file/0007/337471/HiT-Portugal.pdf?ua=1 to contain costs, improve efficiency and increase While overall health indicators for Portugal have notably regulation. Still, financial Jorge de Almeida Simões improved in recent years, they still hide significant health Gonçalo Figueiredo Augusto sustainability of the Inês Fronteira inequalities, which are mostly related to health determinants, Cristina Hernández-Quevedo Portuguese health system such as child poverty, mental health and quality of life. remains a challenge. Due to cuts in public workers’ Even though the Portuguese National Health Service (NHS) salaries the increasing is universal, comprehensive and almost free at point of delivery, migration of health care there are also inequities in access to health care, mostly workers risks to negatively affect the quality and related to geography, income and health literacy. The so-called accessibility of care. While several reforms are aimed at health subsystems, the special health insurance schemes for improving coordinated care and developing the use of Health particular professions or companies that exist next to the NHS, Technology Assessment, there is still scope for increasing as well as private voluntary health insurance, provide easier efficiency in the health system. access for certain groups.
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THE SELFIE FRAMEWORK FOR INTEGRATED CARE FOR MULTI-MORBIDITY
By: Fenna RM Leijten*, Verena Struckmann*, Ewout van Ginneken, Thomas Czypionka, Markus Kraus, Miriam Reiss, Apostolos Tsiachristas, Melinde Boland, Antoinette de Bont, Roland Bal, Reinhard Busse, and Maureen Rutten-van Mölken, on behalf of the SELFIE consortium.
Summary: There is an increasing prevalence of multi-morbidity, Fenna RM Leijten is Researcher at the Institute of Health Policy and which is associated with lower quality of life and higher expenditures, Management, Erasmus University Rotterdam, the Netherlands; and constitutes a challenge to current, often fragmented, care Verena Struckmann is Researcher at the Department of Health Care provision. Integrated care programmes appear to be a promising Management, Berlin University of Technology, Germany; Ewout solution. However, the dialogue on such programmes needs to be van Ginneken is Hub Coordinator at the European Observatory on streamlined to ensure continuation, wider implementation and Health Systems and Policies, Berlin University of Technology, sustainable financing. The SELFIE framework provides a means to Germany; Thomas Czypionka is Senior Researcher and Head of IHS ensure such a dialogue by structuring relevant concepts of integrated Health Economics and Health Policy Group and Deputy Director at the care for multi-morbidity. The framework can be used to describe, Institute of Institute of Advanced Studies; Markus Kraus is Senior develop, implement and evaluate integrated care programmes for Researcher and Miriam Reiss is Researcher at the Institute of multi-morbidity. Advanced Studies, Vienna, Austria; Apostolos Tsiachristas is Senior Researcher at Erasmus University Keywords: Multi-morbidity, Integrated Care, Sustainable Financing, Rotterdam, the Netherlands and SELFIE Framework at the Health Economics Research Centre, University of Oxford, UK; Introduction Melinde Boland is Researcher, Antoinette de Bont is Professor of Acknowledgement: This project With the rapid increase in the prevalence Sociology of Innovation in Health (SELFIE) has received funding from of multi-morbidity there is a need for Care; and Roland Bal is Professor the European Union’s Horizon 2020 of Healthcare Governance at the research and innovation programme appropriate care provisions. People with Institute of Health Policy and under grant agreement No 634288. multi-morbidity are often confronted Management, Erasmus University The content of this publication with care providers from different Rotterdam, the Netherlands; reflects only the SELFIE group’s Reinhard Busse is Professor and views and the European disciplines, organisations, or even 1 Director of the Department of Commission is not liable for any sectors. Subsequently, individuals with Health Care Management, Berlin use that may be made of the multi-morbidity have been found to have University of Technology, Germany; information contained herein. Maureen Rutten-van Mölken is a lower quality of life and greater health Professor of Economic Evaluations care utilisation. 2 3 Multi-morbidity has of Innovative Health Care for also become a serious challenge for policy Chronic Diseases at the Institute of Health Policy and Management, makers responsible for the organisation, Erasmus University Rotterdam, financing and provision of care. Integrated the Netherlands and Scientific care, defined as coordinated, pro-active, director of the Institute for Medical Technology Assessment (iMTA), person-centred, multidisciplinary care Erasmus University Rotterdam, the provided by well-communicating and Netherlands.*Shared first-author. collaborating providers, can offer the Email: [email protected] solution to providing multi-morbidity care.
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implementation and evaluation thereof. between professionals and organisations Such a framework has been developed and attention to potential treatment SELFIE (Sustainable intEgrated within the Horizon2020 EU-funded interactions. chronic care modeLs for multi- project SELFIE: Sustainable Integrated morbidity: delivery, FInancing, and Chronic Care Models for Multi-Morbidity: At the meso level there should be performancE) is a Horizon2020 Delivery, Financing and Performance. recognition for continuous quality funded EU project that aims to The SELFIE framework for integrated improvement systems, which are a contribute to the improvement of care for multi-morbidity was developed challenge in the case of multiple chronic person-centred care for people through a scoping review of scientific and diseases – appropriate indicators still need with multi-morbidity by proposing grey literature and expert discussions in to be developed. Furthermore, to increase evidence-based, economically eight European countries. Specifically the sustainability of integrated care sustainable, integrated care five types of experts were involved in programmes, organisational and structural programmes that stimulate these discussions: Patients (individuals integration across sectors is beneficial. cooperation across health and with multi-morbidity), Partners (informal This can be realised not only through social care and are supported by caregivers), Professionals, Payers and formal alliances or mergers but also appropriate financing and payment Policy makers (the 5Ps). through informal cooperative agreements. schemes. More specifically, SELFIE aims to: The SELFIE framework structures • Develop a taxonomy of promising relevant concepts to consider in integrated integrated care programmes for care for multi-morbidity into a ‘core’ and holistic persons with multi-morbidity; micro-, meso-, and macro-levels of the six slightly adapted WHO health system • Provide evidence-based advice understanding of components (see Figure 1). 4 Each is on matching financing/payment described below. The framework has been schemes with adequate incentives the individual in extensively described elsewhere. 5 to implement integrated care; his or her • Provide empirical evidence of the The core: the individual with multi- impact of promising integrated care morbidity environment on a wide range of outcomes using Multi-Criteria Decision Analysis; At the core of integrated care for people However, at the macro level policies that with multi-morbidity is the holistic stimulate the integration of care across • Develop implementation and understanding of this individual in his organisations and sectors are needed, change strategies tailored to different or her environment. Attention to the meaning that market regulation that care settings and contexts in Europe, ‘‘ individual’s health, well being, capabilities permits such collaboration needs to be especially Central and Eastern and self-management abilities is needed. in place. Policies that ensure service Europe. The basis for ensuring person-centred availability and access are also important The SELFIE consortium includes and tailored care is a focus on his or her to protect vulnerable groups – such eight organisations in the following needs and preferences. There is also a as people with multi-morbidity, e.g., countries: the Netherlands focus on several ‘environmental’ factors acceptable waiting times and reasonable (coordinator), Austria, Croatia, that interplay with the aforementioned travel times. Germany, Hungary, Norway, Spain, factors: their social network, financial and the UK. www.selfie2020.eu and housing situation, their community Leadership and governance [Grant Agreement No 634288] and the transport and welfare services available to them. A holistic understanding For persons with multi-morbidity different is something that is often made concrete problems often occur simultaneously; thus through a formal assessment at multiple prioritisation, individual care planning Increasingly, integrated care programmes points in an integrated care trajectory. and tailoring are necessary. These for multi-morbidity are being implemented should all occur throughout a process of across Europe. A basic and essential Service delivery shared decision-making between formal starting point, however, is to understand providers, informal caregivers and the these programmes, e.g., what does such At the micro level, service delivery individual with multi-morbidity. a programme consist of, how does it pertains to person-centred, pro-active work, how has it been implemented, and tailored care provision, with attention At the organisational, meso level, is it effective, what can others learn for all that comes out of the holistic integration can be facilitated by supportive from it? In order to have a successful understanding/assessment. It is especially leadership, organisational transparency dialogue on these programmes it is relevant in the case of multi-morbidity and clear accountability. Collaborations important to use a consistent framework that continuity is ensured, which includes that have a culture of shared vision, that aids the description, development, smooth and monitored transitions ambition, and values are more likely
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Figure 1: SELFIE Framework for Integrated Care for Multi-Morbidity
Source: SELFIE Consortium, for more information see 5
to succeed in the long run. Integrated Workforce Professionals with a specialist background care programmes could be supported by can benefit from continuous education and Integrated care for people with multi- performance-based management on all further development to help enhance their morbidity requires teamwork that is levels, dis-incentivising opportunistic skills in managing people with multi- multidisciplinary and, when needed, behaviour. Political commitment at the morbidity, e.g., teamwork, providing truly crosses organisational- and sectoral macro level can also facilitate the success person-centred care, conducting holistic boundaries. Often, however, it is beneficial of integrated care programmes. assessments, creating individualised care to distinguish a core team and a named plans, and navigating the health- and social coordinator that is the central contact point care systems. Professionals also need to for the individual with multi-morbidity. focus attention on the informal caregiver and should organise the necessary support
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for him/her. At the more organisational savings between organisations. For multi- This includes automated notifications level it is also important to systematically morbidity it is essential that there is a risk in information exchange (e.g., notifying consider new professional roles that are adjustment in place to counter adverse primary care upon hospital discharge). arising in the context of integrated care selection and cream-skimming. For Collected data can be used for individual for multi-morbidity, such as physician innovative integrated care programmes risk prediction. Individual and group level assistants, specialised nurse practitioners, organising a basic secured budget may be information can also be used to apply risk or social district support teams that take on an important facilitator to ensuring the stratification. Innovative research methods case management. sustainable commitment of all involved. are needed and being developed that allow such data to be successfully used The above requires educational and Such payment schemes, specifically for to increase the evidence-base of complex workforce planning, whereby new skills multi-morbidity and/or integrated care, integrated care programmes for people are taught early on in the curriculum. need to be embedded in a supportive with multi-morbidity. With an ageing society and an ageing care national or regional system that recognises workforce, there is also a need to create a their necessity and supports the further Issues surrounding data ownership and workforce-demography match, supporting development of innovative schemes. Also protection come to the forefront in ICT, in sustainable employment of care providers at the macro level, attention is needed to all care fields, but perhaps even more so in and informal caregivers, who also need safeguard access and equity for vulnerable multi-morbidity, again due to the different to remain in employment alongside their groups in the payment system, such as organisations and sectors (e.g., health- and caregiving roles for longer. those with multi-morbidity. social care) involved: what information can be shared with what professionals? These Financing Technologies and medical products issues should not hamper the care process. Coverage and reimbursement of integrated Information and communication care programmes or interventions need technology (ICT) can act as a key to be generous enough to ensure equity facilitator in integrated and coordinated smooth in financial access. Attention to out-of- care, although this is not necessarily a pocket costs is also needed when it comes prerequisite. ICT applications relevant at and monitored to financial access; these can take the form the micro level include electronic medical of co-payments, co-insurance, deductibles, records (EMRs) and patient portals. transitions and in some contexts also informal EMRs allow for information exchange payments. On the other end, experiments between professionals, patients, and between with financial incentives to motivate informal caregivers that link information persons with multi-morbidity to partake and thus improve communication. This professionals in integrated care programmes are also is, however, very complex for people arising–for example, providing vouchers with multi-morbidity that deal with and or free gym memberships. Reimbursement different organisations across sectors. should allow professionals to spend E-health tools, telemedicine, and assistive organisations enough time with individuals with multi- technologies also play a role here as they ‘‘ morbidity, whereby multiple issues at hand can allow individuals with multi-morbidity Also at the macro level privacy and data need to be addressed in a holistic manner. to live independently for longer. protection legislation is important to consider. Policies that stimulate research Fragmentation not only occurs in service A shared information system that is can also benefit the status quo. Lastly, delivery, but also through the silo structure accessible by multiple professionals can patient- and informal caregiver-access of financing of care for people with facilitate care processes. A prerequisite to information is especially relevant multi-morbidity. 6 Dominant existing is interoperable, or linked, information for multi-morbidity, as disease-specific payment schemes lack incentives to systems. At the macro level policies information can easily be found online, but stimulate multidisciplinary collaboration that foster technological development information on navigating different fields and actually dis-incentivise addressing and innovation in the field of ICT and within the health- and social care sector patients’ needs. New payment systems are e-health can aid integrated care for multi- (e.g., what is covered in an insurance being introduced to tackle these issues, morbidity. Furthermore, equitable access package) is much more difficult, as well as such as pay-for-coordination and bundled to technological and medical products is information on treatment interactions. payments. The most comprehensive form important. to date is population-based payment, Information and research can also be usually involving the definition of a Information and research used as inputs for monitoring integrated virtual budget that is based on the case care for multi-morbidity with a three mix of the catchment population. When Individual level data, as often pronged: improving population health, actual costs are lower than expected, these automatically collected via ICT, can patient experience, and reducing costs. 7 types of payments also allow for shared effectively be used in the care process. The evidence-base for integrated care
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programmes for multi-morbidity needs comprehensive framework can be applied 3 Hopman P, Heins MJ, Rijken M, Schellevis FG. to be expanded in order to ensure wider in different contexts. Integrated care is Health care utilization of patients with multiple implementation and sustainability of not a noun but rather an active process chronic diseases in The Netherlands: Differences and underlying factors. Eur J Intern Med 8 programmes. that spans across different sectors and 2015;26(3):190 – 6. grows through time – the framework 4 will also grow and change. It can be WHO. Key components of a well functioning health system. Geneva: WHO, 2010. used as a starting point to develop and Curious to see how the framework 5 systematically describe programmes Leijten FRM, Struckmann V, van Ginneken E, has already been used? In the for multi-morbidity (micro-meso), and et al. The SELFIE Framework for Integrated Care SELFIE project, 17 promising for Multi-Morbidity: development and description. their target groups (the core) within their integrated care programmes Health Policy forthcoming. respective contexts (meso-macro). These for multi-morbidity have been 6 descriptions can aid comparison and Struckmann V, Quentin W, Busse R, van extensively described in ‘thick Ginneken E. How to strengthen financing mechanisms understanding that in turn can translate description’ reports. These reports to promote care for people with multimorbidity in into other implementation processes. The are based on document analyses Europe? Policy Brief 24 European Observatory on framework can subsequently be used to Health Systems and Policies, 2017. and interviews with key stakeholders, evaluate programmes. 7 and are structured according to the Berwick DM, Nolan TW, Whittington J. framework. The reports can be found The triple aim: Care, health, and cost. Health Aff 2008;27(3):759 – 69. on the SELFIE website (publications). References 8 de Bruin SR, Versnel N, Lemmens LC, et al. www.selfie2020.eu 1 Barnett K, Mercer SW, Norbury M, Watt G, Comprehensive care programs for patients with Wyke S, Guthrie B. Epidemiology of multimorbidity multiple chronic conditions: A systematic review. and implications for health care, research, and Health Policy 2012;107(2 – 3):108 – 45. medical education: a cross-sectional study. Conclusion The Lancet 2012;380(9836):37 – 43. 2 Fortin M, Bravo G, Hudon C, et al. Relationship This framework structures relevant between multi-morbidity and health-related quality concepts and elements of integrated care of life in patients in primary care. Qual Life Res for multi-morbidity. By grouping these 2006;15(1):83 – 91. into six components and three levels, the
The former Yugoslav Republic of the country after independence reverted to a social health insurance system. Despite the broad benefit package, the Macedonia: health system levels of private health expenditure are still quite high review Health Systems in Transition Vol. 19 No. 3 2017 and satisfaction with health care delivery is very mixed. By: N Milevska Kostova, S Chichevalieva S, NA Ponce, Primary care providers were E van Ginneken & J Winkelmann The former Yugoslav Republic of Macedonia privatised and new private Copenhagen: World Health Organization 2017 Health system review hospitals were allowed to (on behalf of the Observatory) enter the market. The public hospital sector in particular Number of pages: 160 pages; ISSN: 1817-6127 is characterised by
Freely available to download at: http://www.euro.who. Neda Milevska Kostova • Ninez A. Ponce inefficient organisation and Snezhana Chichevalieva• Juliane Winkelmann int/__data/assets/pdf_file/0006/338955/Macedonia-HiT-web. Ewout van Ginneken service delivery. However, pdf?ua=1 significant efficiency gains were achieved through the Since its independence in 1991 population health in the former introduction of a Yugoslav Republic of Macedonia has improved significantly, pioneering health with life expectancy and mortality rates for both adults and information system that has reduced waiting times children reaching similar levels to those seen in ex-socialist EU and led to the better coordination of care. Member States. However, death rates caused by unhealthy More broadly, the impact of professionals moving to other behaviour remain high. countries and to the private sector is being felt. This is also why The country has also made important progress in transitioning future reforms will need to focus on sustainable planning and from a centrally-steered to a more market-based health system. management of human resources, as well as enhancing quality Having inherited a large health care infrastructure, good public and efficiency of care. health services and well-distributed health service coverage,
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TIME TO FOCUS ON BENEFITS BEYOND THE HEALTH SECTOR: THE EXAMPLE OF HEALTH LITERACY
By: David McDaid
Summary: Many actions to promote and protect health may be funded and delivered outside of the health sector. However, these actions may be seen as activities that may deflect valuable resources away from these sectors’ core goals. Thus, while promoting Health in All Policies as a concept is appealing, in practice implementation can be difficult. The importance of looking beyond health outcomes becomes important when making a case for investment in health literacy actions targeted at children and young people. These outcomes and impacts are still too often neglected when arguments are being made for health in all policies.
Keywords: Return on Investment, Cross-sectoral Investment, School-based Health Promotion, Health Literacy, Health in All Policies
Introduction to other sectors from investing in health related actions. This article illustrates this A continuing challenge in health issue by looking at the potential benefits promotion is to facilitate the beyond the health sector of investing in implementation of effective actions actions to foster health literacy in young beyond the health sector. This can be people. These themes have been discussed particularly challenging if the non-health in more detail in a recent policy brief. 1 sector in question is expected to finance and administer the health promoting activity. External sectors may not see The health benefits of good health promotion as a critical objective, health literacy but rather as something that may deflect Good health literacy can be thought of valuable resources away from activities as having the knowledge, confidence that are core to their own sector-specific and skills to seek out, as well as process, goals. Thus, while promoting Health in information to improve and protect health All Policies as a concept is appealing, in from a variety of sources. Too often practice implementation can be difficult. people are not equipped with these skills: David McDaid is Associate One way of overcoming this challenge a survey of nearly 8,000 adults in eight EU Professorial Research Fellow, LSE and facilitating implementation may be Health and Social Care, The London countries found that 47% had inadequate to demonstrate that in addition to impacts School of Economics & Political or problematic levels of health literacy. 2 Science, United Kingdom. on health there are substantial co-benefits Email: [email protected]
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The beneficial impacts of health literacy wellbeing found that these programmes Assessing the economic impacts interventions for health and lifestyles were associated with a significant 11% of co-benefits from health literacy have been well discussed. 3 It appears improvement in academic performance. 6 programmes particularly important to develop health It is also important to assess the economic literacy skills early in life to maximise As well as specific evaluations of the case, including the return on investment, potential benefits. Good childhood health direct impact of programmes that for the funding sector from health literacy literacy has, for instance, been associated strengthen health literacy on educational programmes. Undoubtedly it is a limitation with routinely having a healthier diet, and other non-health outcomes, it that there are few specific examples of and a better understanding and use of is important to look at the indirect the cost effectiveness of health literacy nutritional information on foods and relationship between better health interventions for children. 9 However, drinks. 4 There are also positive impacts behaviours, health status and educational this lack of published evidence on cost on mental health; building resilience outcomes. If health literacy interventions effectiveness or economic impact does in childhood through health literacy successfully influence health behaviours, not mean that nothing can be said about programmes can have a positive impact then it is reasonable to infer that ultimately the economic impacts of health literacy on psychological health and wellbeing some further additional benefits to the programmes. across the life course, as well as reducing education sector might be realised. To the severity of depression and anxiety do this it is feasible to link two different A first step is to ascertain the resources problems experienced in adulthood. 5 sources of information: required to deliver programmes and attach (i) evidence on the effectiveness of health costs to these programmes (see Box 1). literacy programmes in respect of health Even if programmes have been shown to behaviours and health outcomes; and be effective in specific settings, policy helpful makers will want to know what would be (ii) evidence on how changed health the economic cost of delivering the same behaviours or health status impact on to point to intervention (perhaps adapted to take educational outcomes account of differing local circumstances) evidence on the in their local context. For example, if health literacy actions do influence the physical health behaviours association In the case of interventions delivered of children, then it can be helpful to point within the education sector, these costs to evidence on the association between between better may appear modest if interventions are better physical health and educational implemented by teachers as part of the attainment. There is a significant body physical health school curriculum in normal working of evidence indicating that children who hours, but there may be training costs are more physically fit and engage in and educational to consider, as well any economic aerobic exercise in pre-adolescence, have ‘‘ consequences of activities that are improved brain function and are likely to attainment displaced from the school curriculum. have superior cognitive performance and If additional members of school staff or academic achievements compared with Moving beyond health impacts external service providers are needed to children who have low levels of exercise. 7 deliver health literacy programmes, then Nearly all children are educated in schools, The obverse can also be emphasised: poor the costs will be much more substantial. meaning that school is a great setting in physical and psychological health have There may also be costs associated with which to help enhance health literacy. been associated with poor levels of materials or technologies that are used to In many countries, schools or ministries educational achievement. 8 help engage with children, as well as any of education will have the responsibility licensing fees that may have to be paid to for funding school-based health literacy Finally, although not of immediate concern use manualised literacy programmes. It programmes. It is important therefore to to policy makers, it may still be helpful is also important to identify any gaps in convey the benefits of such programmes to note potential generational benefits the current provision of services in order to the education sector. The attention of of improved health literacy. In the very to then be able to estimate the resource policy makers can be drawn to growing long term, better levels of education, due requirements and costs of scaling up evidence of the benefits to cognitive in part to higher levels of health literacy, programme provision, and to determine development and academic achievement will mean better outcomes for future which group or groups from which associated with evidence-based social and generations of parents. Increased health sector(s) would be responsible for paying emotional literacy / learning programmes. literacy in the parents of tomorrow may for these programmes. For example, a major meta-analysis of also have a positive impact on the health school-based programmes delivered to literacy levels of future generations Box 1 also highlights the importance of promote pupils’ social and emotional of children. identifying outcomes and resource impacts that are of direct interest to programme funders. A monetary value can be placed
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modelling techniques can be used to is strengthened when also looking at synthesise existing evidence on long- education-sector specific outcomes and Box 1: Information needed to term effects and benefits and to project impacts. The case is also strengthened for determine the costs and economic a return on investment. This approach has the use of mechanisms to overcome any impacts of delivering school-based been used to influence health promotion financial disincentives to cross-sectoral health literacy programmes interventions in many different country collaboration. These outcomes and contexts. 10 impacts are still too often neglected when • Undertake assessment to identify arguments are being made for Health in the extent to which aspects of health literacy programmes may already be All Policies. delivered within the existing teaching curriculum. References • Estimate resource use, time and costs 1 of implementation, including training. A monetary McDaid D. Investing in health literacy: what do we This should include determining know about the co-benefits to the education sector whether programmes can be delivered of actions targeted at children and young people? by existing school staff (as part of value can be Copenhagen: WHO Regional Office for Europe, 2016. current school day) or alternatively will 2 Sorensen K, Pelikan JM, Rothlin F, et al. Health need additional staff /external input. placed on costs literacy in Europe: comparative results of the • Determine who is responsible for European health literacy survey (HLS-EU). European funding literacy programmes: e.g. avoided by non- Journal of Public Health 2015;25:1053 – 8. education ministry, individual school 3 Kickbusch I, Pelikan J, Apfel F, Tsouros AD (eds.) budget holders, ministry of health, health sectors Health literacy. The solid facts. Copenhagen: WHO local government, etc. Regional Office for Europe, 2013. • In addition to health outcomes, Previous evaluations of return on 4 Cha E, Kim K, Lerner H, et al. Health literacy, identify sources of information on investment can also be cited. This can other outcomes and resource impacts ‘‘ self-efficacy, food label use, and diet in young adults. be illustrated by referring to the ten-year that are of direct interest to programme American Journal of Health Behaviour 2014;38:331 – 9. follow up of the effects of a universal, funders. 5 Roberts J. Improving health literacy to reduce comprehensive, community-based social • Identify resource unit costs to attach to health inequalities. London: Public Health England, changes in resource impacts relevant and emotional health promoting project 2015.
to programme funders. for primary school children and their 6 Durlak J, Weissberg R, Dymnicki A, Taylor R, families in the Canadian Better Beginning • Determine short, mid and long term Schellinger K. The impact of enhancing students’ 11 return on investment to programme Better Futures evaluation. Not only did social and emotional learning: a meta-analysis funders. this evaluation look at health outcomes of school-based universal interventions. Child but it also documented improvements Development 2011;82:405 – 32. in educational performance, as well 7 Donnelly J, Hillman C, Castelli D, et al. Physical as a reduction in the need to repeat activity, fitness, cognitive function, and academic on costs avoided by non-health sectors. school years and use expensive special achievement in children: a systematic review. From a school perspective these might educational needs services. It also Medicine and Science in Sports and Exercise, 2016;48:1197 – 222. include a reduction in costs of classroom documented a decline in contacts with disruption arising from the poor behaviour social welfare services by families. The 8 Rimpelä A, Caan W, Bremberg S, Wiegersma P, of some children. Better behaviour should overall economic analysis demonstrated Wolfe I. Schools and the health of children and young people. In: Wolfe I, McKee M (eds.) European child also reduce the likelihood that teachers that the programme had net benefits of health services and systems: lessons without borders. become stressed and take time off work, €2,599 per family or around €2.50 for Maidenhead: Open University Press, 2013. reducing costs associated with the every €1 spent. Health care costs increased 9 Heijmans M, Rose T, Hofstede J, et al. Study on employment of temporary or permanent but these were more than offset by costs sound evidence for a better understanding of health substitute staff. There will also be savings avoided due to the reduced use both of literacy in the European Union. Brussels: European to the education system if fewer children education and social welfare services. Commission, Directorate-General for Health and have to be educated in costly special Food Safety, 2015. educational settings as a result of a Making it happen 10 McDaid D, Sassi F, Merkur S. Supporting effective reduction in exclusions from mainstream and efficient policies: the role of economic analysis. schools. This short article has argued that it is In McDaid D, Sassi F, Merkur S (eds.) Promoting essential to look beyond health outcomes health, preventing disease: the economic case. Maidenhead: Open University Press, 2015. The return on investment to different and health sector impacts when making sectors, including programme funders, the case for health promoting activities 11 Peters RD, Petrunka K, Khan S, et al. Cost-savings can then be calculated, recognising that that are sometimes funded and certainly analysis of the better beginnings, better futures community-based project for young children and the return on investment is likely to differ delivered outside of the health sector. their families: a 10-year follow-up. Prevention Science over time. It will take time to generate data This has been illustrated using the 2016;17:237 – 47. on the actual return on investment of any example of school-based health literacy programme; in the meantime, economic programmes. The case for investment
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NEW DRAFT EU DIRECTIVE SUBMITS THE REGULATION OF HEALTH PROFESSIONS TO A PROPORTIONALITY TEST
By: Rita Baeten
Summary: With a new draft Directive, the European Commission proposes to apply a general proportionality test on the regulation of professions, including health professions. Member States must prove that the measures they adopt are necessary to achieve a public interest objective, and that the result cannot be achieved by measures which are less restrictive to free movement. The lack of clarity as to what measure can stand this proposed test could lead to substantial legal uncertainty on regulations that can be crucial to preserving high-
PIECE quality health services and universal access to care. Therefore, an
adapted approach for health professions would be advisable.
Keywords: Health Professions, Regulation, Proportionality, EU Directive
Regulated health professions and This is certainly also true for health EU integration professions, where Member States have traditionally tried to protect According to the European Commission, both patients and licensed health care over 6,000 different professions are providers. However, such nationally-set regulated across the European Union conditions can de-facto create barriers (EU), 42% of which are to be situated for professionals coming from another within the health and social services Member State. Indeed, the variation in sector. 1 Regulation can make access to a regulations across the EU potentially profession conditional upon the possession obstructs the fundamental freedom of of a specific professional qualification. It health providers to establish in another can submit the pursuit of that profession to OPINION Member State or temporarily provide certain requirements or standards and can services there. This is why the EU reserve the use of a specific professional established a European regulatory title to those who fulfil all these framework that ensures the mutual conditions. The objective is to reduce the recognition of professional qualifications information asymmetry between service based on either a minimum harmonisation Rita Baeten is Senior Policy providers and consumers and to protect the of training requirements or the Analyst, European Social public from unqualified practitioners. Observatory, Brussels, Belgium. coordination of access conditions and Email: [email protected] licensing rules. Within the boundaries
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EU Directive which introduces a general providers might seek to respectively obligation for Member States to conduct receive and supply more health care Box 1: The Proportionality Principle an ex-ante proportionality assessment of (moral hazard), due to the fact that the any new or any amendments to existing cost is mainly borne by a (public) third The proposal for a proportionality test provisions that are likely to restrict party. For these reasons, health care is a requires Member States, when reviewing existing rules on regulated (health) access to or the pursuit of regulated field with extensive regulation, aimed at professions or introducing new ones: professions (hereafter ‘the proposal for a addressing the important market failures 4 • to assess whether the provisions are proportionality test’, see Box 1). in this sector, ensuring quality and safety necessary to attain a public interest of services delivered to patients, and objective, The type of regulations referred to in the achieving the most cost-effective use of • are suitable for securing the attainment proposal for a proportionality test include: limited public resources. of the objective pursued, and continuous professional development; • do not go beyond what is necessary language knowledge; reserving specific These are all valid reasons to justify to attain that objective. activities for professionals with a public regulation. However, regulation of particular professional title; rules relating health professions can also be subject to to the organisation of the profession, regulatory capture. Regulatory capture is professional ethics and supervision; the phenomenon whereby regulation or set by the so-called Professional compulsory chamber membership, regulatory bodies set up to safeguard the Qualifications Directive (PQD), Member registration or authorisation schemes; public interest may instead be ‘captured’ States can continue to regulate health requirements limiting the number of by the interest groups that dominate professions for as long as the conditions authorisations to practice, or fixing a the sector it is charged with regulating, they impose are non-discriminatory and minimum or a maximum number of to protect specific corporate or private do not unduly infringe on the principles of employees, managers or representatives interests. In other words, health care free movement. In this respect, the Court holding particular professional providers may use regulation to avoid of Justice of the European Union (CJEU) qualifications; and finally territorial competition and sustain their incomes, plays a central role as it interprets EU law restrictions, in particular where the which could result in scarcity of certain and makes sure it is applied in the same profession is regulated in a different necessary services and inefficiencies. way in all EU Member States. In its case manner in different parts of a Member law, the CJEU has made it clear that not State. These kinds of measures are indeed Mutual screening exercise only rules that discriminate against foreign applied in many health systems. trained health professionals can be liable With the last revision of the PQD to restricting free movement but also The importance of regulation in in 2013, a new provision was introduced measures that equally apply to domestic health care (Article 59), obliging Member States professionals and providers from abroad. to list the professions they regulate and Consequently, almost any regulation can Some specific features of the health sector to explain why regulation is necessary. be challenged as a potential obstacle to the require strong regulatory frameworks. As a result during 2015 –16, Member free movement of services. 2 First, in Europe health and access to States carried out a mutual screening health care are generally acknowledged as exercise, entering all regulated professions A proportionality test for the fundamental human rights. To guarantee into an EU Database, with all the regulation of professions these, public intervention and financing regulatory measures implemented for are considered necessary. Second, from each profession notified. They had In January 2017, as part of its Single an economic perspective the health care to examine whether their regulatory Market Strategy, the European sector is characterised by significant requirements were compatible with Commission came up with several externalities and market failures, which the principles of non-discrimination, initiatives to simplify procedures for cross- make it impossible to achieve an efficient necessity and proportionality, and had border service providers and to increase market for health care. Indeed, patients to justify any decisions taken as a result EU scrutiny on regulation in the services generally lack the necessary background of this analysis to maintain or amend sectors. According to the Commission, knowledge to make an informed decision professional regulations. Other Member unnecessarily burdensome and outdated about the care they need and the quality States and stakeholders were invited rules can make it unreasonably difficult and effectiveness of the service(s) they to submit their observations on these for qualified candidates to access jobs receive. Since health care providers may assessments. Furthermore, 12 professions in other Member States. The proposed have interests other than their patients, were chosen as examples of different measures should make it easier for this information asymmetry makes the regulatory approaches, including four professionals to provide services in the relationship very precarious. Health care health professions: physiotherapist, EU, would benefit consumers, jobseekers providers have the unique power to induce psychologist, dental hygienist and optician. and businesses, and would generate demand and to set prices. Furthermore, The Commission has published a sector economic growth across Europe. 3 The since health care in the EU is mainly report on each of these professions, 5 package also includes a proposal for an publicly financed, both patients and health drawing on information communicated
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by the Member States and discussions screening exercise of their regulation Excluding health professions? which took place during a meeting of services (Article 15). The application Whereas previously there were fierce in 2015 on mutual evaluation for each to health services of the initial proposal reactions in both the Council and the sector. These sector reports call on in 2004 – in particular the screening European Parliament, today there Member States to assess in more depth under Article 15 – provoked serious appears to be much less political the necessity and proportionality of controversy. The main criticism was that controversy around the current proposal. specific requirements, most of which have this proposal did not take into account The Competiveness Council gave the subsequently been listed in the proposal the specificity of the health care sector, Commission a mandate to provide an for a proportionality test. where extensive regulation is needed analytical framework for a comprehensive to correct market imperfections and to proportionality assessment of professional The proposal stems from the guarantee universal access to care. It was regulations, and reached a “general Commission’s findings following feared that the implementation of this approach” on the proposal for a this mutual screening exercise. The draft Directive would lead to considerable proportionality test 8 surprisingly fast and Commission considers this draft Directive legal uncertainty for public authorities, without much debate, which will serve as necessary to enforce compliance with the providers and patients. This finally led to a basis to negotiate with the Parliament. proportionality principle as it argues that health services being excluded from the In the European Parliament, the ENVI Member States in the mutual evaluation scope of the Services Directive. (Environment, Public Health and Food exercise repeatedly did not sufficiently Safety) Committee which is the prime demonstrate the proportionality of the In its impact assessment of the current forum for investigating any EU initiative measures imposed on professions. 6 (2017) draft Directive for a proportionality that affects public health, initially even test, the Commission clarifies that this decided not to put it on its agenda. Back to the future: the Services proposal is complementary to the Services Directive and in particular that, in terms Directive However, positions seem to be slowly of scope, the Services Directive “does moving. The ENVI Committee This proportionality test closely recalls not cover the medical professions”. 6 This revoked its initial decision and is now the heated discussions more than ten seems to suggest that this is a new attempt preparing an opinion on the proposal years ago that predated the adoption of the to submit health sector regulation – or for a proportionality test. Together with Services Directive in 2006 (see Box 2). 7 at least the part that deals with health the JURI (Legal Affairs) Committee Under this Directive, Member States were professions – to the same scrutiny, from they are proposing to exclude the health also obliged to engage in a systematic which it was excluded ten years ago.
Box 2: Recalling the controversy over the Services Directive in 2006
This opinion paper shows that the concerns that led to the exclusion
of health services from the Services Directive in 2006 apply in the same No. 18 / April 2017 way to the proposed Directive for a proportionality test on regulation of
professions. It argues that a specific approach for national regulation
on health care professionals would be advisable.
Baeten R. Was the exclusion of health care from the Services Directive
a pyrrhic victory? A proportionality test on regulation of health
professions. OSE Paper Series, Opinion Paper 18, Brussels, OSE, 2017.
Available at: http://www.ose.be/files/publication/OSEPaperSeries/ Was the exclusion of Baeten_2017_OpinionPaper18.pdf health care from the Services Directive a
pyrrhic victory?
A proportionality test on regulation of health professions
Rita Baeten
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professions from the scope of the proposal. The lack of clarity as to the extent to 9 European Parliament. Proportionality test before Meanwhile, several national parliaments which a specific approach for health adoption of new regulation of professions, 2017. have adopted reasoned opinions stating professionals could be justified under Available at: http://www.europarl.europa.eu/oeil/ popups/ficheprocedure.do?lang=en&reference=201 that the draft does not comply with the the proportionality test, could lead to 6/0404(OLP)#tab-0 principle of subsidiarity. In a resolution, substantial legal uncertainty on regulation 10 the German Bundesrat requests an that can be crucial to preserving high- CED, CPME and PGEU. European dentists, doctors and pharmacists conclude: proposed proportionality exemption for health professions or quality health services and universal tests for professional regulation ignore public interest alternatively to take patient protection into access to care. Therefore, an adapted and threaten quality and safety of patient care. better consideration. 9 approach in the application of the free Available at: http://doc.cpme.eu:591/adopted/2017/ movement rules to national regulation of CED_PGEU_CPME_joint_PR_January_2017.pdf So far, the most vigorous stakeholder health professions would be advisable. 11 Hervey T, McHale J. European Union Health Law, reactions to the proposal for a Such a legal clarification should take into Themes and Implications. Cambridge: Cambridge proportionality test have come from the account the role of health professionals in University Press, 2015. EU-level organisations of some key health protecting human life and health and their professionals. In a joint position statement embeddedness in national publicly funded the Standing Committee of European health systems. Doctors (CPME), the Pharmaceutical Group of the European Union (PGEU), References and the Council of European Dentists (CED), are calling for the exclusion of 1 European Commission. Commission staff working health professionals’ regulation from document, A Single Market Strategy for Europe – Analysis and Evidence Accompanying the document any EU-wide proportionality test. Upgrading the Single Market: more opportunities They express concerns about the lack for people and business. SWD (2015)202, of specificity in addressing the overall Brussels, 2015. issue of health profession regulation, and 2 Gekiere W, Baeten R, Palm W. Free movement are convinced that health professions of services in the EU and health care, in Mossialos should be considered distinctly from E, Permanand G, Baeten R, Hervey T. (eds.) Health other professions. They argue that policy Systems Governance in Europe: the role of European decisions relating to the regulation of the Union law and policy. Cambridge University Press, 2010: 461-508. health professions must serve the objective of attaining the best possible quality of 3 European Commission. A services economy that care for every patient and that under no works for Europeans, 2017. Available at: http:// europa.eu/rapid/press-release_IP-17-23_en.htm circumstances should quality of care, access to care or patient safety be put at 4 European Commission, Proposal for a Directive risk by policies driven by other agendas, in of the European Parliament and of the Council on a 10 proportionality test before adoption of new regulation particular economic considerations. of professions, COM (2016) 822, Brussels, 10 January 2017.
Towards an adapted approach for 5 European Commission. Transparency and health professions? mutual evaluation of regulated professions, 2017. Available at: http://ec.europa.eu/growth/single- A general proportionality screening could, market/services/free-movement-professionals/ in principle, help to clarify what objectives transparency-mutual-recognition_nl are really pursued in the regulation of 6 European Commission. Commission staff working health professions, and to distinguish document; impact assessment accompanying the between genuine general interest document: Proposal for a Directive of the European objectives and corporatist interests or Parliament and of the Council on a proportionality test before adoption of new regulation of professions, national protectionist reactions. However, SWD (2016) 463, Brussels, 2017. in the proposal for a proportionality test, as 7 in European law in general, the regulation Directive 2006/123/EC of the European Parliament and of the Council of 12 December 2006 of health professionals, rather than being on services in the internal market, OJ L 376/36–68, seen as a way of protecting patients, or 27 December 2006. inherent to the proper functioning of 8 Council of the European Union. Proposal for national health care systems, is viewed a directive of the European Parliament and of the as an obstacle to the operation of the Council on a proportionality test before adoption of EU market. 11 new regulation of professions – General approach, 2017. Available at: http://data.consilium.europa.eu/ doc/document/ST-9057-2017-REV-1/en/pdf
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NEW MEASURES TO INCREASE THE HEALTH BUDGET IN ROMANIA
By: Silvia Gabriela Scîntee, Cristian Vlãdescu and Cristina Hernández-Quevedo
Summary: Romania’s health system is characterised by low funding and the inefficient use of public resources. There is a weak link between planning decisions and population health needs, due to a lack of appropriate information systems. The new government has increased the budget for health to: retain the health workforce by stopping the immigration of health workers, dedicate more funds to national health programmes, and ensure better access to medicines. It is hoped that the new measures considered by the recently-elected Romanian government will lead to better outcomes and that increased funding will lead to improved performance of the health system.
Keywords: Health Budget, Workforce, Access, National Health Programmes, Romania
Introduction dedicated mainly to improving access to medicines, initiating the building of The new Romanian government, which three regional hospitals and procuring came to power in December 2016, has medical technology for hospitals and increased the budget for health in order vaccines. 2 According to the 2017 budget, to achieve three main objectives on the the Statutory Health Insurance budget health policy agenda: 1 retaining the health administered by the National Health workforce by stopping immigration; Insurance House (NHIH) takes up 77% dedicating more funding to national health of public funds dedicated to health. programmes; and ensuring better access to This is 10.4% higher than the previous Silvia Gabriela Scîntee is Deputy medicines. These efforts are particularly year, with the main increase envisaged General Director at the School relevant for a country characterised by of Public Health, Management for home care (14.49%) and ambulatory an underfunded health system and it is and Professional Development, care (9.89%). 3 These focus areas are Bucharest, Romania; Cristian the first time an increase in health care in keeping with the National Health Vlãdescu is Professor of Public funding is linked to the stated objectives Health and Management at Strategy 2014 –2020 of increasing the of the government. the “Victor Babes” University volume of services provided within of Medicine and Pharmacy in ambulatory and community care settings Timisora and General Director In particular, the budget allocated for and of rationalising the use of hospital at the School of Public Health, health in 2017 increased by 23.5%, Management and Professional services. 4 Development, Bucharest, Romania; compared to the budget in 2016 Cristina Hernández-Quevedo is (from 30.28 to 37.4 billion lei / €6.7 to Romania ranks last among EU Technical Officer at the European €8.3 billion), representing a total health Observatory on Health Systems Member States in terms of total health expenditure of 4.7% of GDP (compared and Policies, LSE Health, London, expenditure (THE) per capita (€PPP 816 United Kingdom. to 4% in 2016). The increased budget is Email: [email protected]
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Figure 1: Health expenditure per capita in the EU (2014)
8000 Government/ compulsory insurance
7000 Private/ voluntary insurance
6000
5000
4000
1. Includes investments. 3000 2. OECD estimate.
2000 3. For Luxembourg, the population data refer only to the total insured 1000 resident population, which is somewhat lower than the 0 total population. 2 2 2 2 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1, 2 EU Italy Spain Latvia Finland Estonia France Sweden Greece Ireland Poland Malta Austria Croatia Cyprus Slovenia Portugal Germany Bulgaria Belgium Hungary Romania Denmark Lithuania Netherlands Luxembourg Czech Republic Slovak Republic United Kingdom
Source: OECD Health Statistics 2016; Eurostat Database; WHO, Global Health Expenditure Database. per capita in 2015) and as a share of for the stewardship of the system and for pregnancy. Out of pocket (OOP) payments GDP (see Figure 1). THE as a share its regulatory framework. District public take the form of direct payments and of GDP has been decreasing steadily health authorities (DPHAs) represent informal payments. The share of OOP since 2010, influenced by the spending the MoH at the local level. Also at payments is the second largest source of cuts implemented to meet the country’s central level, the NHIH administrates revenue for health care spending (20%), fiscal deficit target and the unstable and regulates the SHI system and it is while the contribution of voluntary health political situation. Public expenditure represented at district level by district insurance (VHI) is marginal (0.2%). 5 The on health as a share of total public health insurance houses (DHIHs). 6 share of informal payments is thought expenditure (11.9%) is well below the to be substantial but unknown, although EU average (16.3%), although it has been recent legislative changes, which heavily increasing since 2011. The public sector incriminates both making and taking accounts for the largest part of THE informal payments, could have an impact. (78.9%), in line with the EU average (78.8%). Public sources account for 79% Increasing New measures to increase the of total health financing, converging with collection of funds the EU average. 5 income alone will The 2017 budget increase for health The Romanian health system not stop relies on some recent measures. Since in context February 2017, the national minimum immigration of monthly wage has increased from 1,250 The Romanian health system is a social to 1,450 lei (from €278 to €322), and the health insurance (SHI) system that has health workers average gross monthly wage from 2,815 remained highly centralised despite recent to 3,131 lei (€625 to €696). 7 This follows efforts to decentralise some regulatory Although SHI is compulsory, it covers the trend since the second half of 2015, functions. The national level is responsible only 86% of the ‘‘population. Insured where successive increases of salaries for setting general objectives, while the individuals are entitled to a comprehensive in some public sectors, such as health, district level is responsible for ensuring benefits package while the uninsured are education, social assistance, public service provision. The Ministry of Health entitled to a minimum benefits package, administration, culture (ranging from 10% (MoH) is the central administrative which covers life-threatening emergencies, to 50% depending on the area) have authority in the health sector responsible infectious diseases, and care during been taking place. This latest measure is
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expected to increase SHI contributions, as the share of VHI as a proportion of THE More funds for the national health they are paid as a percentage from gross already increased from 0.2% in 2012 programmes income (5.5% from gross salary and 5.2% to 0.6% in 2014. 9 Current national health programmes are from the employer, or 5.5% for the self- not contributing enough to increasing the employed). Implications for new legislation health status and satisfaction of patients. The preventive component is often weak Previously, the way SHI contributions Retention of health workforce and some important health problems, were calculated had a limit on the total Over the last decade, Romania has faced such as cardio-vascular diseases, are salary base used, set at five times the big waves of workforce emmigration. not included. Moreover, patients have average gross monthly wage. This Although there is a lack of precise data, difficulties accessing treatment offered favoured high earners who earned more the MoH issued over 43,500 certificates of under curative health programmes due to than this. This measure was recently conformity for health professionals in 2016 the fact that drugs can only be disbursed modified to eliminate the upper limit that offer the right to work in another after a complicated authorisation process. 6 for the health contribution calculation EU country. 10 base. According to the prime-minister, The Government Programme around 36,000 people with a monthly To counteract this trend, since 2015, there for 2017 – 2020 includes the introduction income higher than five average have been successive increases in health of a national programme for early gross wages would now pay a surplus workforce salaries. In addition, the new detection of cardio-vascular diseases and of 500 million lei per year (€111 million) government has set new allowances for establishing a dedicated budget for the to SHI. 8 different working conditions: 11 i.e. up treatment of rare diseases. A first step in to 85% of basic salary for those that apply improving existing health programmes is outbreak control measures, those exposed to include patients with advanced fibrosis to microorganisms and those that work under the new treatment (interferon free) Access in burns units; up to 70% for staff in for Hepatitis C. emergency departments, intensive care to medicines is units and psychiatric wards; up to 25% Another measure already taken is the for staff in infectious diseases, new-born simplification of drugs disbursement limited for and maternity wards, laboratories, stroke under the national health programmes. units, neurology and neurosurgery wards; Previously, the process to obtain patients on low and other allowances between 5 – 15% for reimbursement was cumbersome; different personnel categories exposed to however, through a recent government incomes different ergonomic risk factors. These decision, medical specialists are able measures are currently under debate to prescribe specific medicines under On the other hand, some measures have between specialists, particularly those who certain criteria. Patients now have rapid been taken which are expected to have stand to lose out from the new allowances, access to 106 drugs covered by SHI a negative impact on the SHI budget. for example, forensic medicine already that previously needed authorisation. These‘‘ have an alternative aim of raising receive allowances for working conditions These latter measures have raised cost population living standards, such as of 100% of basic salary and under the new concerns as the authorisation process was exempting pensioners with a pension regulation their income will decrease. the main mechanism for cost control of below €444.40 per month from making Moreover, a new law on salaries will come medicines. Since the health programmes contributions and (from 2017) no longer to force by January 2018 that aims to have a dedicated budget but physicians counting some supplementary incomes, increase the average income for doctors to have no prescribing limits, the system such as investments or bank deposits, as the equivalent of 70% of the EU averages. may face the challenge of accumulated part of total income. Overall, the 2017 debts. In response, the NHIH has health insurance budget from contributions Increasing income alone will not stop prepared an online system for validating is estimated to increase by 10.6% emmigration. Besides low salaries, prescriptions based on a set of therapeutic (€5,233.7 million vs. €4,731.5 million the most common reasons for leaving criteria. Through the new system, the in 2016). Besides this increase in the the country include low levels of specialist fills out an electronic form SHI budget, more funds are expected to satisfaction with social status and lack of sent instantly to the DHIH and after the flow into the system from introducing recognition, limited career development confirmation is received, he/she may issue tax deductible health subscriptions for opportunities, and discrepancies between the e-prescription. employees towards VHI, with a value of the level of competencies required and up to €400 per year. 7 While it is not clear working conditions (equipment, access Ensuring better access to medicines whether the share of VHI will increase, the to consumables, drugs and modern Access to medicines is limited for value representing the VHI expenditures diagnostic tests). 6 During 2016, a patients on low incomes by co-payments. is expected to rise with this measure. multiannual plan for human resources Moreover, when a generic medicine According to national health accounts, strategic development was developed, but (covered by health insurance) is not was not officially adopted. available, the patient must pay the full
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price of the available product. Also new Further, thirteen new innovative dissatisfaction, lack of access to quality treatments may not yet be added to the medicines are now covered, with or care by the poor and other vulnerable reimbursement list. without co-payment, mainly for cancer, for groups, and decreasing numbers of conditions and diseases relating to blood medical staff. There is broad agreement and blood-forming, lung diseases, rare within the Romanian community that diseases, rheumatic diseases, and diabetes. investments in human development, and New innovative drugs are included particularly in health and education, after a Health Technology Assessment represent important factors contributing to Romania spends evaluation of new molecules. Measures the acceleration of Romania’s convergence to reduce the price of medicines have and integration with the EU. less on health also been proposed through changes in the pricing methodology, but this has The program of the new government care than most raised opposition from the pharmaceutical includes measures to tackle some of the industry. There may also be the risk problems in the health sector, which aim EU countries of parallel exports if prices were to be to increase the quality and efficiency of reduced, which may further decrease health services delivery and to generate The new government has attempted access to those medicines. better health outcomes, including an to improve access to medicines on important growth in the incomes of one hand by increasing the income of Conclusions medical staff as a method of retention, vulnerable groups,‘‘ and on the other hand together with the overall increase of the by decreasing the cost of medicines and Romania historically has committed health care budget. These changes are increasing their availability. Thus, besides a relatively low share of its GDP to expected to be developed in a financially increasing the national minimum monthly health care. Part of the difference arises sustainable manner, without neglecting wage and minimum monthly pension, it from Romania’s relatively low public the required fiscal consolidation. Whether was decided that pensions under 2,000 expenditures on health and part from low these measures are sufficient to enhance lei (€444) are exempted from income tax private expenditures. Most comparisons the competitiveness of the Romanian (16%) and the health insurance premium suggest that Romania spends less on economy and to reduce inequalities in (5.5%), leaving pensioners with more health care than most EU countries and health and access to health care services resources available for basic needs, in parallel, health outcomes are lagging for the Romanian population, remains including drugs. behind EU standards. Thus, Romania is to be seen. facing several challenges, including user
Romania: health system review remains characterised by under-provision of primary and community care and inappropriate use of inpatient and specialised outpatient care. By: C Vlãdescu, SG Scîntee, V Olsavszky, C Hernández- Reforms have been hampered Quevedo & A Sagan Health Systems in Transition Vol. 18 No. 4 2016 by the relatively low number Copenhagen: World Health Organization 2016 of physicians and nurses, (on behalf of the Observatory) compared to EU averages, Romania Health system review something attributed to the Number of pages: 170 pages; ISSN: 1817-6127 high rates of workers Freely available to download at: http://www.euro.who. emigrating abroad over the int/__data/assets/pdf_file/0017/317240/Hit-Romania.pdf?ua=1 past decade. However, measures introduced to Cristian Vlaˇdescu Silvia Gabriela Scîntee The Romanian population has seen increasing life expectancy Victor Olsavszky counter these shortages Cristina Hernández-Quevedo and declining mortality rates, however both remain among the Anna Sagan do not seem to have made worst in the European Union. Some other troubling trends are a difference. also apparent; for example, although social health insurance Contents: Preface, is compulsory, only 86% of the population is actually covered. Acknowledgements, Those that do have such insurance should have access to Abstract, Executive summary, a comprehensive benefits package, however, the population Introduction, Organisation and governance, Financing, Physical seems dissatisfied with both service delivery and quality. and human resources, Provision of services, Principal health Reform to tackle these and other issues affecting the Romanian reforms, Assessment of the health system, Conclusions, health system has frequently proved ineffective, due in part to Appendices. instability in health governance. Whilst efforts have been made to strengthen the role of primary care, health care provision
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5 10 References OECD Health Statistics 2016. Paris: OECD. Ministry of Health [Ministerul Sa˘na˘ta˘t‚ii] (2016), Available at: http://www.oecd.org/els/health- Nota˘ de fundamentare pentru modificarea s¸i 1 Government of Romania [Guvernul României] systems/health-data.htm completarea Hota˘rârii Guvernului nr. 1028/2014 (2017) Program de guvernare 2017 – 2020. Politici privind aprobarea Strategiei nat‚ionale de sa˘na˘tate în domeniul sa˘na˘tata˘tii [Programme for Government 6 Vlãdescu C, Scîntee SG, Olsavszky V, Hernández- ‚ 2014– 2020 s¸i a Planului de act¸iuni pe perioada 2017 – 2020. Health policies], Bucuresti. Available at: Quevedo C, Sagan A. Romania: Health system review. , 2014– 2020 pentru implementarea Strategiei http://gov.ro/ro/obiective/programul-de-guvernare Health Systems in Transition 2016;18(4):1–170. nat‚ionale [Substantiation note for the amendment 2 7 Government of Romania [Guvernul României] Ministry of Public Finances [Ministerul Finant‚elor of the Government Decision 1028/2014 regarding (2017) Declarat‚ii sust‚inute de ministrul Finant‚elor Publice] (2017) Ministerul finant‚elor publice the National Health Strategy 2014 – 2020 and its Publice, Viorel S‚ tefan [Statement of the Minister of < Acasa˘ < Transparent‚a˘ decizionala˘ < Proiecte acte implementation plan]. Available at: http://www. Public Finances, Viorel S‚ tefan], 31 January 2017. normative – Raport privind situat¸ia macroeconomica˘ ms.ro/wp-content/uploads/2016/10/3.Not%C4%83- Available at: http://gov.ro/ro/print?modul=sedinte pe anul 2017 s¸i proiect¸ia acesteia pe anii 2018 – 2020 fundamentare.pdf
&link=declaratii-sustinute-de-ministrul-finantelor- [Report on the macroeconomic situation for 2017 and 11 Ministry of Health [Ministerul Sa˘na˘ta˘t‚ii] (2017). publice-viorel-stefan-si-ministrul-justitiei-florin- projections for 2018 – 2020]. Available at: http://www. Hota˘râre pentru aprobarea Regulamentului privind iordache-la-finalul-edintei-de-guvern#null mfinante.gov.ro/transparent.html?method=transpare stabilirea locurilor de munca˘, a categoriilor de nta&pagina=acasa&locale=ro 3 CNAS [National Health Insurance House] (2017) personal, ma˘rimea concreta˘ a sporurilor pentru CNAS < Comunicate de presa˘ < Comunicat – CNAS 8 Government of Romania [Guvernul României] condit¸ii de munca˘ precum s¸i condit¸iile de acordare are în 2017 un buget majorat cu 10,42% fat¸a˘ de anul (2017) Guvern < Comunicate s‚i acte s‚edint‚a˘ de a acestora pentru personalul din sistemul sanitar, anterior [The budget of the National Health Insurance govern < Declarat‚ii sust‚inute la începutul s‚edint‚ei de unita˘t‚ile de asistent‚a˘ medico-sociala˘ s‚i unita˘t‚ile de House in 2017 is 10.42% higher compared to 2016], govern 6 Ianuarie 2017 [Statements by Prime Minister asistent‚a˘ sociala˘/servicii sociale cu sau fa˘ra˘ cazare 8 February 2017. Available at: http://www.cnas.ro/ Sorin Mihai Grindeanu at the beginning of the first [Decision for approval of the Regulation regarding post/type/local/cnas-are-in-2017-un-buget-majorat- Cabinet meeting], Bucures,ti. Available at: http://gov. the allowances for working conditions, and the cu-10-42-fata-de-anul-anterior.html ro/ro/guvernul/sedinte-guvern/declaratii-sustinute- conditions for receiving them for the personnel from la-inceputul-edintei-de-guvern health care sector, medico-social units and social care 4 Ministry of Health [Ministerul Sa˘na˘ta˘t‚ii] (2014) units]. Available at: http://www.ms.ro/wp-content/ 9 Strategia Nat‚ionala˘ de Sa˘na˘tate 2014– 2020. Sa˘na˘tate National Institute of Statistics (2016). Sistemul uploads/2017/02/HG-1.pdf pentru prosperitate [National Health Strategy conturilor de sa˘na˘tate în România Anul 2014 [The 2014–2020. Health for wealth] Bucures,ti. Available National Health Accounts: Romania 2014]. Bucures,ti, at: http://www.ms.ro/documente/Anexa%20 Institutul Nat‚ional de Statistica˘. 1%20%20Strategia%20Nationala%20de%20 Sanatate_886_1761.pdf
NALYSIS HEALTH SYSTEMS AND POLICY A
models more applicable; and how to POLICY BRIEF 23 Five new Policy How to improve care for people make implementation more effective. with multimorbidity in Europe?
Mieke Rijken Verena Struckmann Briefs – Integrating Iris van der Heide Anneli Hujala • How to improve care for people Francesco Barbabella Ewout van Ginneken NALYSIS François Schellevis HEALTH SYSTEMS AND POLICY A
RE4EU consortium care for people with with multimorbidity in Europe? On behalf of the ICA
POLICY BRIEF 22 How to strengthen patient- • How to strengthen patient- centredness in caring for people multimorbidity: what No. 23 with multimorbidity in Europe? centredness in caring for people ISSN 1997-8073 Iris van der Heide Sanne P Snoeijs does the evidence Wienke GW Boerma with multimorbidity in Europe? François G Schellevis Mieke P Rijken
RE4EU consortium tell us? • How to strengthen financing On behalf of the ICA NALYSIS mechanisms to promote care for HEALTH SYSTEMS AND POLICY A No. 22 ISSN 1997-8073
POLICY BRIEF 24 Some 50 million Europeans live with people with multimorbidity in Europe? How to strengthen financing mechanisms to promote care for people with multimorbidity in multimorbidity and their numbers are • How can eHealth improve care for Europe? likely to grow. They have complex Verena Struckmann people with multimorbidity in Europe? Wilm Quentin Reinhard Busse ICY ANALYSIS Ewout van Ginneken HEALTH SYSTEMS AND POL nsortium health problems and need ongoing On behalf of the ICARE4EU co • How to support integration to promote POLICY BRIEF 25 care. Policymakers all over Europe are How can eHealth improve care care for people with multimorbidity for people with multimorbidity No. 24 in Europe? alarmed by the challenge this poses to ISSN 1997-8073 in Europe? Francesco Barbabella their health systems and social services, Maria Gabriella Melchiorre Sabrina Quattrini Roberta Papa The concrete lessons they offer on Giovanni Lamura nsortium many have put multimorbidity high on On behalf of the ICARE4EU co multimorbidity care are intended to help their policy agenda. ICY ANALYSIS HEALTH SYSTEMS AND POL
policymakers as they adapt their health No. 25 ISSN 1997-8073 The European Commission has mobilised POLICY BRIEF 26 systems to this pressing challenge. How to support integration to promote care for people with research to help them, including the multimorbidity in Europe? ICARE4EU project which looked at Download them at: http://www.euro.who. Anneli Hujala Helena Taskinen int/en/about-us/partners/observatory/ Sari Rissanen new approaches to integrated care. nsortium On behalf of the ICARE4EU co news/news/2017/04/integrating-care-for- The five policy briefs share the project people-with-multimorbidity-what-does- No. 26 ISSN 1997-8073 findings. They consider: how to improve the-evidence-tell-us the design of integrated care for people with multimorbidity; how to make new
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NEW PUBLICATIONS
Health system efficiency: how to make Targeting innovation in antibiotic drug discovery measurement matter for policy and management and development: the need for a One Health – One Europe – One World Framework Edited by: J Cylus, I Papanicolas and PC Smith
Copenhagen: World Health Organization, 2016 Edited by: MJ Renwick, V Simpkin and E Mossialos
Number of pages: xxii + 242 pages; ISBN: 978 92 890 50 418 Copenhagen: World Health Organization, 2016
Freely available for download: http://www.euro.who.int/__data/ Number of pages: viii + 126 pages; ISBN: 978 92 890 5040 1 assets/pdf_file/0004/324283/Health-System-Efficiency-How- Freely available for download: http://www.euro.who.int/__data/ make-measurement-matter-policy-management.pdf?ua=1 assets/pdf_file/0003/315309/Targeting-innovation-antibiotic-drug- Efficiency is one of the central preoccupations of health policy- d-and-d-2016.pdf?ua=1 makers and managers. Inefficient care can lead to unnecessarily Antimicrobial resistance is a global crisis that threatens public poor outcomes for patients, either in terms of their health, or in health and modern medicine. The discovery and development of their experience of the health system. Further, inefficiency novel antibiotic products are critical components in combating it. anywhere in the system is likely to deny health improvement to Many international, European patients who might have been treated if resources had been used Union and national initiatives better. Improving efficiency is address the scientific, 6 Page 1 Cover_WHO_nr46_Mise en page 1 5/01/17 12:0 46 46 therefore a compelling policy goal, HEALTH SYSTEM EFFICIENCY regulatory and economic Health System Series lth policy-makers and managers, and especially in systems facing Efficiency is one of the central preoccupationsnnecessarily of hea poor outcomes for patients, either nce of the health system. What is more, Policy Health justifiably so. Inefficient care can lead to u deny health improvement to patients who Efficiency barriers to antibiotic innovation. in terms of their health, or in their experie n used better. Improving efficiency is therefore inefficiency anywhere in the system is likely to ms facing serious resource constraints. might have been treated if resources had bee How to make measurement serious resource constraints. Targeting innovation in a compelling policy goal, especially in syste great deal of decision-making, but the routine lacking. The desire for greater efficiency motivates a matter for policy and management rst be able to measure it and must antibiotic drug discovery use of efficiency metrics to guide decisions is severely This study identifies, reviews and useful for policy-makers and managers. To improve efficiency in the health system we mustart fi on efficiency measurement in health therefore ensure that our metrics are relevant the pitfalls and potential associated Edited by In this book the authors explore and development In this book the authors explore the state of the Jonathan Cylus systems and international experts offer insights into and critically assesses these with various measurement techniques. Irene Papanicolas The authors show that nd in principle - maximizing valued outputs Peter C. Smith the state of the art on efficiency operational in real-life situations The need for a One Health – One Europe –
HOW TO MAKE MEASUREMENT MATTER • The core idea of efficiency is easy to understa FOR POLICY AND MANAGEMENT relative to inputs, but is often difficult to make One World Framework initiatives, and provides es in data collection and availability, as well as give valuable insights into how efficiently • There have been numerous advanc s that measurement in health systems innovative methodological approache health care is delivered te the development and interpretation of policy recommendations • Our simple analytical framework can facilita efficiency indicators world to explore how policy-makers and international experts ment to support their work in the past, and The authors use examples from Europe and around the ency measurement in the future. and managers have used efficiency measure for improving the global suggest ways they can make better use of effici t links to a forthcoming study offering et policy relevant efficiency metrics and to offer insights into the pitfalls The study came out of the Observatory’s LSE hub. I. It will be of considerable use to policy- further insights into how to develop and interpr atient representative groups, managers the earlier volumes on performance measurement and European agendas for makers and their advisors, health care regulators, p and researchers. and potential associated Jonathan Cylus, Irene Papanicolas, Peter C. Smith research and development of The editors is Research Fellow, European Observatory on Health Systems and with various measurement Jonathan Cylus Policies, London School of Economics and Political Science. antibiotics. is Assistant Professor of Health Economics, Department of Social Irene Papanicolas Policy, London School of Economics and Political Science. techniques. The authors use Matthew J Renwick, Victoria Simpkin and Elias Mossialos is Emeritus Professor of Health Policy at Imperial College London and Peter C. Smith European Observatory on Health Systems and Policies. te research
9 examples from Europe and A very thorough analysis of the different initiatives to stimula Contents: Foreword;
7 lands
8 and innovation of antibiotics ISBN 9289050418
Health Policy Series No. 46 9 2 Edith Schippers, Minister of Health, Welfare and Sport, The Nether 8 www.healthobservatory.eu 9
0
5 around the world to explore Acknowledgments;
0
4
1 8 how policy-makers and Executive Summary; List of managers have used efficiency abbreviations; List of figures and tables; Objectives, measurement to support their work in the past, and suggest ways Background, Research Methodology, Results, Discussion, they can make better use of efficiency measurement in the future. Conclusions & Recommendations; References, Appendices.
Contents: A framework for thinking about health system efficiency; Measuring and comparing health system outputs; Using registry data to compare health care efficiency; Management accounting and efficiency in health services; Measurement and policy; Cost–effectiveness analysis; Cross-national efficiency comparisons; Efficiency measurement for policy formation and evaluation; Efficiency measurement for management; Conclusions.
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NEWS works for maltreatment prevention and how performance across the full range of this can be implemented at a country level. indicators. Sarah Cook, Director of UNICEF Innocenti called the report “a wake-up- Child maltreatment is a leading cause of call that even in high-income countries inequality and social injustice, with poorer progress does not benefit all children.” and disadvantaged populations at higher International risk. It is estimated that tens of millions of As well as results on income poverty and children and young people in the WHO food insecurity the report notes that neo- EU Semester process: country specific European Region have been affected natal mortality has dramatically fallen in recommendations for health and by sexual, physical or emotional abuse most countries; and rates of adolescent care systems and maltreatment. The consequences suicide, teenage births and drunkenness are grave, with far-reaching effects on are declining. For some indicators – income The European Commission (EC) has children’s physical, mental and social well- inequality, adolescent self-reported mental published the 2017 Country Specific being, yet it is estimated that only 10% of health and obesity – the trends suggest Recommendations (CSRs), the proposals such maltreatment comes to the attention cause for concern in a majority of rich for Member States which are part of of protection agencies. countries. In two out of three countries the EU Semester economic governance studied, the poorest households with process. Health is mentioned in The United Nations Sustainable children are now further behind the average recommendations for 17 countries. Most of Development Goals recognise the than they were in 2008. The rate of obesity these recommendations address the issue importance of intersectoral actions to among 11–15 years old and the rate of of the sustainability of healthcare systems, address this issue, setting the specific adolescents reporting two or more mental along with recommendations on reform. target (16.2) for eradicating violence against health problems a week is also increasing children by 2030. Many actions are only Some of the issues addressed include in the majority of countries. possible through intersectoral collaboration. strengthening community care and primary These include creating safe environments, Overall the Nordic countries, Germany, care (instead of hospital care), disease encouraging better parenting, changing Switzerland, Slovenia and the Netherlands prevention and affordability of care. There norms, making preschool education rank among the ten best performing are also references to informal payments available, implementing and enforcing laws countries, along with the Republic of Korea. and out-of-pocket expenditure. From on child maltreatment, reducing gender Bulgaria, Romania, Turkey, Lithuania, an equity perspective, the reduction of inequality and providing social support. Israel and Hungary are in the bottom ten (income) inequalities, poverty, and social countries, alongside New Zealand, the exclusion, – particularly among disabled The European Child Maltreatment Prevention United States, Mexico and Chile. The and older people, is highlighted together Action Plan is available at: http://tinyurl.com/ UK and Ireland rank poorly in terms of with the importance of improved social y6vu8cw8 child hunger; 34th and 31st respectively, safety nets. in contrast to their overall rankings. 8% The recommendations are available at: of 11–15 years old are obese or overweight Action required to address widening child http://tinyurl.com/ybrdzzgo in Denmark compared with 27% in Malta. health and development inequalities The highest suicide rates in adolescents (more than 10 per 100,000 population) in A new report from the United Nations Nordic and Baltic countries gather to Europe are found in Ireland, Finland and Children’s Fund (UNICEF), covering high discuss intersectoral action to prevent Lithuania. Only 14% of adolescents in income countries has found that one in child maltreatment Germany and Austria report two or more five children lives in relative income poverty mental health issues per week, compared and on average one in eight faces food On June 1 and 2 a workshop was held in with 33% and 37% in Bulgaria and Italy insecurity. The report – Building the Future: Riga, Latvia, on strengthening intersectoral respectively. In general although many Children and the Sustainable Development working to prevent child maltreatment in the countries have seen broad progress in Goals (SDGs) in Rich Countries – is Nordic and Baltic countries. The workshop, a number of indicators, there are still the 14th edition of the Report Card a joint venture of the WHO Regional Office wide gaps between them in other areas. series produced by the UNICEF Office for Europe, the Nordic Council of Ministers National income levels fail to explain all of of Research – Innocenti. It focuses on and the Government of Latvia, focused these differences: for example, Slovenia is the ten SDGs considered most relevant on intersectoral collaboration involving far ahead of much wealthier countries on to child wellbeing and uses comparable the health, welfare, education and justice many indicators, while the United States data sources on 25 indicators specifically sectors. A total of 100 participants from ranks 37th out of 41 countries in the selected to assess the status of children in these sectors, representing 14 countries, summary league table. high-income contexts. A composite league took part in the workshop. Participants table summarises 41 European Union and Based on the results presented in Report were presented with good practices and Organisation for Economic Co-operation Card 14, UNICEF calls for high-income evidence-based experience about what and Development (OECD) countries’ countries to take action in five key areas:
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• Put children at the heart of equitable were transported down corridors in a Health and safety risks at the workplace: and sustainable progress; improving state of undress, while bathing several a joint analysis of three major surveys the well-being of all children today residents at the same time was also a is essential for achieving both equity common practice. Some older people A new report for the European Agency and sustainability. were also faced with verbal or physical for Safety and Health at Work (EU-OSHA) • Leave no child behind; national aggression, lack of medical support such presents the key findings of a joint analysis averages often conceal extreme as dental care, insufficient daily meals and of EU-OSHA’s second European Survey inequalities and the severe disadvantage “prohibitive or hidden costs” for their care. of Enterprises on New and Emerging Risks (ESENER-2), Eurostat’s Labour of groups at the bottom of the scale. The report notes that as long-term care Force Survey (LFS) 2013 ad hoc module • Improve the collection of comparable has become more pervasive, ensuring its on accidents at work and other work- data; in particular on violence against quality has become an ever-pressing issue related health problems, and Eurofound’s children, early childhood development, for local, regional and national policy- Sixth European Working Conditions migration and gender. makers. It argues that it is essential to Survey (EWCS). The aim was to have a monitor residential and home care services • Use the rankings to help tailor policy comprehensive overview of the state of on an ongoing basis to protect human responses to national contexts; no occupational safety and health (OSH) in rights. However the report states that few country does well on all indicators of Europe by bringing together, on the one EU Member States have continuous quality wellbeing for children and all countries hand, the perspectives of establishments monitoring systems, with independent face challenges in achieving at least on risk management and risk awareness, regulators, in which human rights are taken some child-focused SDG targets. and on the other, those of workers on into account. • Honour the commitment to global exposure to risks and OSH outcomes. sustainable development. More information on the project and the report The analysis found that exposures to are available at: http://ennhri.org/Human- The report is available in English, French, risks, as perceived by employees, and Rights-of-Older-Persons-in-Long-Term- Italian and Spanish at: https://www.unicef- particularly to specific environmental, Care irc.org/publications/890/ musculoskeletal and psychosocial risks, appear to be important drivers of the management of OSH. Additionally, where Study: consistent association between New report highlights poor conditions employees have reported mental health depression in youth and risk of violence in Europe’s nursing homes problems, more attention had been paid in Europe to management of psychosocial risk in In 2015, the European Network of National workplaces. The authors recommended Using data from three longitudinal studies Human Rights Institutions (ENNHRI) that more focus be paid to strengthening in England, Finland and the Netherlands, started a project funded by the European employers’ commitment and resources researchers have found a consistent Commission to increase awareness of for the management of all OSH, including association between adolescent depressive the human rights of older persons living musculoskeletal disorders. More could symptoms and an increased risk of in or seeking access to long-term care in also be done to strengthen employee committing violent acts. The study, led by Europe, as well as to develop the capacity participation in the management of OSH as Rongqin Yu at the University of Oxford and of NHRIs to monitor and support human improving formal employee representation published in the Journal of the American rights based policies in this area. As part is strongly associated with better OSH Academy of Child and Adolescent of the project, six members of ENNHRI risk management. National and sectoral Psychiatry, found that there were positive (NHRIs in Belgium, Croatia, Germany, stakeholders could also support the associations between depression and Hungary, Lithuania and Romania) carried development of risk assessment tools. subsequent violent behaviours, even after out intensive monitoring within their taking account of family status and any The report is available at: http://tinyurl.com/ jurisdictions, based on ENNHRI reports past history of violence. The increased yardcf7b on human rights standards for older risk of future violence ranged between 1.7 peoples’ long term care and monitoring and 2.1 times that seen in young people methodologies of NHRIs. They each who did not experience depression. The European Commission opens first drafted national reports, setting out their authors concluded that the study supports investigation into concerns of excessive findings and recommendations. A new the case for better efforts at a population pricing practices in the pharmaceutical report has now been published identifying level for early identification and treatment industry key trends relating to the human rights of of depression. the residents of long term care services. In the EU, national authorities are free Sadly it documents some severe human The open access paper is available at: http:// to adopt pricing rules for medicines rights abuses. dx.doi.org/10.1016/j.jaac.2017.05.016 and to decide on treatments they wish It points out that in many cases older to reimburse under their social security people were admitted to care homes systems. Each country has different without their consent. In addition, some pharmaceutical pricing and reimbursement
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policies, adapted to its own economic depends on a number of factors, including issued with a Conformité Européene (CE) and health needs. The pricing of original the complexity of the case, the extent mark via the Medicines and Healthcare medicines that are protected by patents to which the undertaking concerned Products Regulatory Authority (MHRA) is highly regulated. For off-patent cooperates with the Commission and the and its recognised Notified Bodies (of medicines, Member States may directly exercise of the rights of defence. More which there are five in the UK). In order for influence prices of generic entrants, but information on the investigation will be these bodies to function under the existing also encourage competition to achieve available on the Commission’s competition legislation, they must reside within the EU. lower prices. As a result, prices generally website, in the public case register under Thus the Institution of Mechanical fall significantly when a medicine goes the case number 40394. Engineers (IME) has published a policy off-patent. paper with recommendations on actions to However on May 15 the European be taken to reduce regulatory uncertainty Eight EU countries commit to working Commission announced that it had opened as a result of Brexit. The IME stresses together to secure affordable access a formal investigation into concerns that that ahead of the UK leaving the EU, it to new medicines Aspen Pharma, a global pharmaceutical is imperative that the UK Government company headquartered in South Africa, acts quickly to create a stable regulatory In Malta on May 9 at the Third Roundtable has engaged in excessive pricing of platform from which device manufacturers meeting of EU Health Ministers and some cancer medicines. It is investigating can implement any changes necessary CEOs and Heads of Europe-based whether Aspen has abused a dominant to maintain their access to market. pharmaceutical companies, ministers of market position in breach of EU antitrust They recommend that the government eight Member States – Cyprus, Greece, rules. The investigation concerns Aspen’s negotiates a Med Tech compliancy Ireland, Italy, Malta, Portugal, Romania and pricing practices for niche medicines arrangement with the EU to ensure Spain – signed the Valletta Declaration. The containing the active pharmaceutical continuity in the CE marking process for signatories have agreed to work together to ingredients chlorambucil, melphalan, UK manufacturers. This arrangement they explore possible ways to guarantee access mercaptopurine, tioguanine and busulfan. suggest should be supported by parallel to new medicines for patients. A Technical The medicines in question are used for policies to encourage long-term investment Committee will be established, with the first treating cancer, such as haematologic in the sector with the goal of attracting Med meeting taking place in June in Cyprus. tumours. They are sold with different Tech small and medium sized enterprises to This group will explore possible areas for formulations and under multiple brand the UK through clear support for innovation cooperation including information sharing, names. Aspen acquired these medicines and product development. horizon scanning and possible price after their patent protection had expired. negotiations and joint procurement. They further believe that UK industry The Commission will investigate information and the National Health Service (NHS) After the signing one of the signatories, indicating that Aspen has imposed very must work together to ensure that they Irish Minister of Health Simon Harris said, significant and unjustified price increases retain influence over future European “since coming into office [in May 2016], of up to several hundred percent, so- regulation. This influence could flow from I have seen the challenges our health called ‘price gouging’. The Commission the purchasing power of the NHS but service and, more importantly, patients has information that, for example, to should also be based on more formal post- have experienced in terms of access impose such price increases, Aspen has Brexit arrangements negotiated by the UK to new medicines at an affordable threatened to withdraw the medicines in Government on its behalf. Finally they call price. International collaboration is key question in some Member States and has for UK Research and Innovation to address to addressing this issue. The Valletta actually done so in certain cases. the EU funding shortfall. declaration marks a concrete step forward Aspen’s behaviour may be in breach of the in this regard. Ireland will continue to build The policy paper is available at: EU’s antitrust rules (Article 102 of the Treaty on this and our relationship with other http://tinyurl.com/ybcn9szq on the Functioning of the European Union member states in our efforts to secure (TFEU) and Article 54 of the European affordable access for Irish patients to Economic Area (EEA) Agreement), which innovative medicines.” Additional materials supplied by: forbid the imposition of unfair prices or EuroHealthNet Office unfair trading conditions on customers. The 67 rue de la Loi, B-1040 Brussels investigation covers all of the EEA except Impact of Brexit: Medical Devices Tel: + 32 2 235 03 20 Italy, where the Italian competition authority and CE Marking Fax: + 32 2 235 03 39 already adopted an infringement decision Email: [email protected] against Aspen on 29 September 2016. Medical devices are highly regulated and The Commission notes that the opening of currently the UK legal framework that formal proceedings does not prejudge the governs these devices originates from long- outcome of the investigation. established EU Directives that have taken EU Member States decades to achieve. At There is no legal deadline to complete present, medical devices can be marketed inquiries into anti-competitive conduct. across Europe only once they have been The duration of an antitrust investigation
Eurohealth incorporating Euro Observer — Vol.23 | No.2 | 2017
Health in All Politics — a better future for Europe 4 6 OCTOBER 2017, BAD HOFGASTEIN, AUSTRIA
WHY? Because health matters.
ehfg_inserat_parliament_mag_210x270.indd 3 13.06.17 15:04