Public Health Education in Montenegro

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WP1. ANALYSIS AND ROADMAPING: PUBLIC HEALTH EDUCATION IN MONTENEGRO

DELIVERABLE 1.1 ‘Analysis of EU practice for public health’

Published on:11/07/2017

Authors:

Prof. Dr. John Mantas, Health Info Lab, Dept. Of Public Health, University of Athens, Greece Katia Kolokathi, Health Info Lab,Dept. Of Public Health, University of Athens, Greece

Prof. Dr Ramo Sendelj, University of Donja Gorica, Montenegro Prof. Dr Milica Vukotic, University of Donja Gorica,Montenegro Prof. Dr Maja Drakic Grgur, University of Donja Gorica, Montenegro Assist.Prof.Dr Ivana Ognjanovic, University of Donja Gorica, Montenegro Boris Bastijancic,University of Donja Gorica, Montenegro

Prof. Dr. Elske Ammenwerth, UMIT, Austria

Prof. Dr Róza Ádany, DSc, Faculty of Public Health, University of Debrecen, Hungary Prof. Dr. Orsolya Varga, Faculty of Public Health, University of Debrecen, Hungary

Doc. dr. Anđela Jakšić Stojanović, Mediterranean University, Montenegro Doc. dr. Danilo Ćupić, Mediterranean University,Montenegro Prof. dr Jelena Žugić,Mediterranean University,Montenegro Doc. dr Dragica Žugić, Mediterranean University, Montenegro

Prof. Dr. Petra Knaup, Inst. of Med Biometry and Informatics, University of Heidelberg Max Seitz,Inst. of Med Biometry and Informatics, University of Heidelberg, Germany

Prof. drGoran Nikolic, Faculty of Medicine, University of Montenegro, Montenegro

Prof.dr Dragan Đurić, Institute of Modern Technology, Montenegro Bojana Tošić, Institute of Modern Technology, Montenegro

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

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Table of Contents WP1 Task 1.1 Analysis of EU practice for public health Deliverable 1.1

Contents 1. Introduction ...... 5 1.1. Definitions ...... 5 1.2. Historical Aspects ...... 7 2. Relevant Organizations and Institutions ...... 11 2.1. International Institutional Response ...... 11 2.2. Regional Organizations...... 15 2.3. National Organizations ...... 18 3. International Public Health Strategies, Best Practices, and Frameworks ...... 18 3.1. EU practices ...... 18 4. Public Health of EU Countries ...... 37 4.1. Austria ...... 37 4.2. Belgium ...... 45 4.3. Bulgaria ...... 53 4.4. Croatia ...... 58 4.5. Cyprus ...... 64 4.6. Czech Republic ...... 81 4.7. Denmark ...... 86 4.8. Estonia ...... 93 4.9. Finland ...... 98 4.10. France…………………………………………………………………………………………………………....104 4.11. Germany………………………………………………………………………………………………………...109 4.12. Greece…………………………………………………………………………………………………………….116 4.13. Hungary………………………………………………………………...…………...………………...………143 4.14. Ireland………………………………………………………………………...………………………………...145 4.15. Italy………………………………………………………………………………………………………………..149 4.16. Latvia……………………………………………………………………………………………………………...170 4.17. Lithuania………………………………………………………………………………………………………...178 4.18. Luxemburg……………………………………………………………………………...…………...………..186 4.19. Malta………………………………………………………………………………………………………….....192

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4.20. Netherlands……………………………………………………………………………………………………197 4.21. Poland…………………………………………………………………………………………………………….203 4.22. Portugal………………………………………………………………………………………………………….209 4.23. Romania………………………………………………………………………………………………………….232 4.24. Slovakia…………………………………………………………………………………………………………..238 4.25. Slovenia………………………………………………………………………………………………………....244 4.26. Spain……………………………………………………………………………………………………………….251 4.27. Sweden…………………………………………………………………………………………………...……..257 4.28. United Kingdom……………………………………………………………………………………………..263 5. Public Health Best Practices of other Countries ...... 268 5.1. Australia ...... 268 5.2. Canada ...... 274 5.3. Japan ...... 281 5.4. USA ...... 288 6. Conclusions ...... 293 References ...... 296

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1. Introduction

This report provides an overview of public health practices in EU and other countries. The report commences with definitions of the domain of public health and proceeds with brief historical aspects of public health. Furthermore, it collects country descriptions on the basis of demographics, health indicators, healthcare system organisations, informatics applications, health economics. These country descriptions will provide the way to compare and collect best practices in assisting the authorities of Montenegro to select and compare practices in EU and elsewhere with their own practices in Public Health. 1.1. Definitions

Public health refers to "the science and art of preventing disease, prolonging life and promoting human health through organized efforts and informed choices of society, organizations, public and private, communities and individuals."

Public health incorporates the interdisciplinary approaches of epidemiology, biostatistics and health services. Environmental health, community health, behavioral health, health economics, public policy, mental health and occupational safety and health are other important subfields. The focus of public health intervention is to improve health and quality of life through prevention and treatment of disease and other physical and mental health conditions. This is done through surveillance of cases and health indicators, and through promotion of healthy behaviors. Examples of common public health measures include promotion of hand washing, breastfeeding, delivery of vaccinations, suicide prevention and distribution of condoms to control the spread of sexually transmitted diseases.

The focus of a public health intervention is to prevent and manage diseases, injuries and other health conditions through surveillance of cases and the promotion of healthy behaviors, communities and environments. Many diseases are preventable through simple, nonmedical methods. For example, research has shown that the simple act of hand washing with soap can prevent many contagious diseases. In other cases, treating a disease or controlling a pathogen can be vital to preventing its spread to others, either during an outbreak of infectious disease or through contamination of food or water supplies. Public

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health communications programs, vaccination programs and distribution of condoms are examples of common public health measures. Measures such as these have contributed greatly to the health of populations and increases in life expectancy. The World Health Organization (WHO) identifies core functions of public health programs including: providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping a research agenda and stimulating the generation, translation and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; monitoring the health situation and assessing health trends. In particular, public health surveillance programs can: serve as an early warning system for impending public health emergencies; document the impact of an intervention, or track progress towards specified goals; and monitor and clarify the epidemiology of health problems, allow priorities to be set, and inform health policy and strategies as well as diagnose, investigate, and monitor health problems and health hazards of the community. 1.2. Historical Aspects

Public health has early roots in antiquity. From the beginnings of human civilization, it was recognized that polluted water and lack of proper waste disposal spread communicable diseases (theory of miasma). Early religions attempted to regulate behavior that specifically related to health, from types of food eaten, to regulating certain indulgent behaviors, such as drinking alcohol or sexual relations. Leaders were responsible for the health of their subjects to ensure social stability, prosperity, and maintain order. By Roman times, it was well understood that proper diversion of human waste was a necessary tenet of public health in urban areas. The ancient Chinese medical doctors developed the practice of variolation following a smallpox epidemic around 1000 BC. An individual without the disease could gain some measure of immunity against it by inhaling the dried crusts that formed around lesions of infected individuals. Also, children were protected by inoculating a scratch on their forearms with the pus from a lesion. In 1485 the Republic of Venice established a Permanent Court of supervisors of health with special attention to the prevention of the spread of epidemics in the territory from abroad. The three supervisors were initially appointed by the Venetian Senate. In 1537 it was

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assumed by the Grand Council, and in 1556 added two judges, with the task of control, on behalf of the Republic, the efforts of the supervisors.

However, according to Michel Foucault, the plague model of governmentality was later controverted by the cholera model. A Cholera pandemic devastated Europe between 1829 and 1851, and was first fought by the use of what Foucault called "social medicine", which focused on flux, circulation of air, location of cemeteries, etc. All those concerns, born of the miasma theory of disease, were mixed with urbanistic concerns for the management of populations, which Foucault designated as the concept of "biopower". The German conceptualized this in the Polizeiwissenschaft ("Police science").

The 18th century saw rapid growth in voluntary hospitals in England. The latter part of the century brought the establishment of the basic pattern of improvements in public health over the next two centuries: a social evil was identified, private philanthropists brought attention to it, and changing public opinion led to government action. The practice of vaccination became prevalent in the 1800s, following the pioneering work of Edward Jenner in treating smallpox. James Lind's discovery of the causes of scurvy amongst sailors and its mitigation via the introduction of fruit on lengthy voyages was published in 1754 and led to the adoption of this idea by the Royal Navy.Efforts were also made to promulgate health matters to the broader public; in 1752 the British physician Sir John Pringle published Observations on the Diseases of the Army in Camp and Garrison, in which he advocated for the importance of adequate ventilation in the military barracks and the provision of latrines for the soldiers. With the onset of the Industrial Revolution, living standards amongst the working population began to worsen, with cramped and unsanitary urban conditions. In the first four decades of the 19th century alone, London's population doubled and even greater growth rates were recorded in the new industrial towns, such as Leeds and Manchester. This rapid urbanisation exacerbated the spread of disease in the large conurbations that built up around the workhouses and factories. These settlements were cramped and primitive with no organized sanitation. Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants. Unavailable housing led to the rapid growth of slums and the per capita death rate began to rise alarmingly, almost doubling in Birmingham and Liverpool. Thomas Malthus warned of the dangers of overpopulation in 1798. His ideas, as well as those of Jeremy Bentham, became very influential in government circles in the early years of the 19th century.

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Epidemiology The science of epidemiology was founded by John Snow's identification of a polluted public water well as the source of an 1854 cholera outbreak in London. Dr. Snow believed in the germ theory of disease as opposed to the prevailing miasma theory. He first publicized his theory in an essay, On the Mode of Communication of Cholera, in 1849, followed by a more detailed treatise in 1855 incorporating the results of his investigation of the role of the water supply in the Soho epidemic of 1854. By talking to local residents (with the help of Reverend Henry Whitehead), he identified the source of the outbreak as the public water pump on Broad Street (now Broadwick Street). Although Snow's chemical and microscope examination of a water sample from the Broad Street pump did not conclusively prove its danger, his studies of the pattern of the disease were convincing enough to persuade the local council to disable the well pump by removing its handle. Snow later used a dot map to illustrate the cluster of cholera cases around the pump. He also used statistics to illustrate the connection between the quality of the water source and cholera cases. He showed that the Southwark and Vauxhall Waterworks Company was taking water from sewage-polluted sections of the Thames and delivering the water to homes, leading to an increased incidence of cholera. Snow's study was a major event in the history of public health and geography. It is regarded as the founding event of the science of epidemiology. Disease control With the pioneering work in bacteriology of French chemist Louis Pasteur and German scientist Robert Koch, methods for isolating the bacteria responsible for a given disease and vaccines for remedy were developed at the turn of the 20th century. British physician Ronald Ross identified the mosquito as the carrier of malaria and laid the foundations for combating the disease.Joseph Lister revolutionized surgery by the introduction of antiseptic surgery to eliminate infection. French epidemiologist Paul-Louis Simond proved that plague was carried by fleas on the back of rats, and Cuban scientist Carlos J. Finlay and U.S. Americans Walter Reed and James Carroll demonstrated that mosquitoes carry the virus responsible for yellow fever.

With onset of the epidemiological transition and as the prevalence of infectious diseases decreased through the 20th century, public health began to put more focus on chronic

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diseases such as cancer and heart disease. Previous efforts in many developed countries had already led to dramatic reductions in the infant mortality rate using preventative methods. In Britain, the infant mortality rate fell from over 15% in 1870 to 7% by 1930. 2. Relevant Organizations and Institutions 2.1. International Institutional Response

2.1.1. American Public Health Association (APHA)

The American Public Health Association works to advance the health of all people and all communities. As the nation’s leading public health organization, APHA strengthens the impact of public health professionals and provides a science-based voice in policy debates too often driven by emotion, ideology or financial interests. APHA is at the forefront of efforts to advance prevention, reduce health disparities and promote wellness.

2.1.2. The International Association of National Public Health Institutes (IANPHI)

The International Association of National Public Health Institutes links and strengthens the government agencies responsible for public health. IANPHI improves the world’s health by leveraging the experience and expertise of its member institutes to build robust public health systems. IANPHI’s unique focus on national public health institutes has led to measureable improvements in capacity including outbreak surveillance and response for Ebola, Zika, and other urgent threats that require swift, comprehensive public health cooperation across borders.

2.1.3. World Bank

Strengthening health systems is at the center of the World Bank’s global strategy for health, nutrition, and population. The World Bank doesn’t focus on one disease or condition; but looks at health as a whole: what is preventing people from being healthy, how we can change this, and what impact it will have on development. World Bank Group provides financing, state-of-the-art analysis, and policy advice to help countries expand access to quality, affordable health care; protects people from falling into poverty or worsening poverty due to illness; and promotes investments in all sectors that form the foundation of healthy societies.

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2.1.4. United Nations (UN)

The United Nations, since its inception, has been actively involved in promoting and protecting good health worldwide. Leading that effort within the UN system is the World Health Organization (WHO), whose constitution came into force on 7 April 1948. It would be misleading to suggest that the entire work of the UN system in support of global health rests with the WHO. On the contrary, many members of the UN family are engaged in this critical task. Many health-related matters are addressed directly by the General Assembly and the Economic and Social Council, as well as through the efforts of the Joint United Nations Programme on HIV/AIDS (UNAIDS); the work of the United Nations Population Fund (UNFPA) in support of reproductive, adolescent and maternal health; and the health- related activities of the United Nations Children’s Fund (UNICEF).

2.1.5. World Health Organization (WHO)

There are more than 7000 people are working in 150 country offices, in 6 regional offices and at the headquarters in Geneva. The primary role of the WHO is to direct and coordinate international health within the United Nations’ system. The main areas of work are: Health systems, Promoting health through the life-course, Noncommunicable diseases, Communicable diseases, Corporate services, Preparedness, surveillance and response.

2.1.6. OECD

The mission of the Organisation for Economic Co-operation and Development (OECD) is to promote policies that will improve the economic and social well-being of people around the world. OECD's work is based on continued monitoring of events in member countries as well as outside OECD area, and includes regular projections of short and medium-term economic developments. The OECD Health Database offers the most comprehensive source of comparable statistics on health and health systems across OECD countries.

2.1.7. International Red Cross and Red Crescent Movement

The International Red Cross and Red Crescent Movement is a global humanitarian network of 80 million people that helps those facing disaster, conflict and health and social problems. It consists of the International Committee of the Red Cross, the International Federation of Red Cross and Red Crescent Societies and the 190 National Red Cross and Red Crescent Societies.

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2.1.8. Medecins Sans Frontieres (MSF)

Médecins Sans Frontières is a private, international association. The association is made up mainly of doctors and health sector workers and is also open to all other professions which might help in achieving its aims.

2.1.9. Bill & Melinda Gates Foundation

The Bill & Melinda Gates Foundation works to help all people lead healthy, productive lives. In developing countries, it focuses on improving people's health and giving them the chance to lift themselves out of hunger and extreme poverty. In the United States, it seeks to ensure that all people—especially those with the fewest resources—have access to the opportunities they need to succeed in school and life. The Bill & Melinda Gates Foundation invests about $1.2 billion a year in global health initiatives.

2.1.10. The Open Society Foundations

The Foundation works to build vibrant and tolerant societies whose governments are accountable and open to the participation of all people. It helps to shape public policies that assure greater fairness in political, legal, and economic systems and safeguard fundamental rights. The Foundations supports initiatives to advance justice, education, public health, and independent media.

2.1.11. The Rockefeller Foundation

For more than a century, The Rockefeller Foundation has been dedicated to a single mission: promoting the well-being of humanity throughout the world. A featured topic of the Foundation is the health. Working to advance universal health coverage and foster more resilient and equitable health systems – all to enable people to lead healthier lives. 2.2. Regional Organizations

2.2.1. WHO Regional Committee for Europe

WHO is the authority responsible for public health within the United Nations system. The WHO Regional Office for Europe (WHO/Europe) is one of WHO’s six regional offices around the world. It serves the WHO European Region, which comprises 53 countries, covering a vast geographical region from the Atlantic to the Pacific oceans. WHO/Europe staff are

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public health, scientific and technical experts, based in the main office in Copenhagen, Denmark, in 3 technical centres and in country offices in 29 Member States.

2.2.2. EC Health and Food Safety

In order to support Member States in their evidence-based policy making, European Commission's Directorate for public health and risk assessment provides information on policies and decisions taken at European, national and international level to protect Europeans' health by enabling them to make healthy choices and live healthier lives.

2.2.3. Eurobarometers

The Standard Eurobarometer was established in 1974 by the European Commission. Each survey consists of approximately 1000 face-to-face interviews per country. Reports are published twice yearly. Health policy, safety, quality of services are often addressed by Eurobarometer studies. Special Eurobarometer reports are based on in-depth thematic studies carried out for various services of the European Commission or other EU Institutions and integrated in the Standard Eurobarometer's polling waves. Flash Eurobarometers are ad hoc thematic telephone interviews conducted at the request of any service of the European Commission. Flash surveys enable the Commission to obtain results relatively quickly and to focus on specific target groups, as and when required. The qualitative studies investigate in-depth the motivations, feelings and reactions of selected social groups towards a given subject or concept, by listening to and analysing their way of expressing themselves in discussion groups or with non-directive interviews.

2.2.4. Eurostat

Eurostat is the statistical office of the European Union situated in Luxembourg. Its mission is to provide high quality statistics for Europe. Providing the European Union with statistics at European level that enable comparisons between countries and regions is a key task. Democratic societies do not function properly without a solid basis of reliable and objective statistics.

2.2.5. European Environment Agency (EEA)

The European Environment Agency (EEA) is an agency of the European Union which provides sound, independent information on the environment and also on health. The EEA's mandate is: 1, to help the Community and member countries make informed

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decisions about improving the environment, integrating environmental considerations into economic policies and moving towards sustainability and 2,to coordinate the European environment information and observation network.

2.2.6. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) was established in 1993. Inaugurated in Lisbon in 1995, it is one of the EU’s decentralised agencies. The EMCDDA exists to provide the EU and its Member States with a factual overview of European drug problems and a solid evidence base to support the drugs debate. Today it offers policymakers the data they need for drawing up informed drug laws and strategies. It also helps professionals and practitioners working in the field pinpoint best practice and new areas of research.

2.2.7. European Centre for Disease Prevention and Control (ECDC)

The European Centre for Disease Prevention and Control (ECDC) was established in 2005. It is an EU agency aimed at strengthening Europe's defences against infectious diseases. It is seated in Stockholm, Sweden. Within the field of its mission, the Centre shall: (a) search for, collect, collate, evaluate and disseminate relevant scientific and technical data; (b) provide scientific opinions and scientific and technical assistance including training; (c) provide timely information to the Commission, the Member States, Community agencies and international organisations active within the field of public health; (d) coordinate the European networking of bodies operating in the fields within the Centres mission, including networks arising from public health activities supported by the Commission and operating the dedicated surveillance networks; and (e) exchange information, expertise and best practices, and facilitate the development and implementation of joint actions. 2.3. National Organizations

2.3.1. ISPOR

Founded in 1995 as an international multidisciplinary professional membership society, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) advances the policy, science, and practice of pharmacoeconomics (health economics) and outcomes research (the scientific discipline that evaluates the effect of health care

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interventions on patient well-being including clinical, economic, and patient-centered outcomes). The ISPOR has provided a good collection national authorities of public health.

Detailed list of public health services of each European country is below. 3. International Public Health Strategies, Best Practices, and Frameworks 3.1. EU Practices

Nowadays all European governments face crucial decisions that will affect the health and well-being of their populations. Economic and social crises combined with environmental threats as well as major shifts in geopolitics, patterns of disease, demography and migration pose profound challenges to health and threaten the capacity of governments to fulfil their responsibilities for their people’s health and well-being. The way forward is unclear, and today’s political and economic models may undergo profound transformation that is unknown now.

Health 20201 is a joint commitment by the WHO Regional Office for Europe and the 53 European Member States to a new common policy framework. The proposed vision for Health2020 is consistent both with the concept of health as a human right and with a reductionin current health inequalities. Health 2020 is also consistent with existing commitments endorsed by Member States, including the United Nations Millennium Declaration2 and Millennium Development Goals3, which embrace a vision of a world in which countries work in partnership for the betterment of everyone, especially the most disadvantaged people. The Vision for Health 2020: A WHO European Region in which all people are enabled and supported in achieving their full health potential and well-being and in which countries, individually and jointly, work towards reducing inequities in health within the Region and beyond.

1 Health 2020 policy framework and strategy. http://www.euro.who.int/__data/assets/pdf_file/0011/199532/Health2020-Long.pdf 2 United Nations Millennium Declaration. http://www.un.org/millennium/declaration/ares552e.pdf 3Millennium Development Goals. http://www.who.int/topics/millennium_development_goals/en/ | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

A vision relates to a high ideal. It needs to be translated into an achievable Health 2020’s shared goals as: To significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure sustainable people- centred health systems that areuniversal, equitable, sustainable and of high quality.

Health 2020 recognizes the diversity of countries across the European Region. It reaches out to many different people, within and outside of government, to provide inspiration and direction on how better to address the complex health challenges of the 21st century. The framework confirms the values of Health for All and – supported by the evidence provided in the accompanying documents – identifies two key strategic directions with four policy priority action areas. It builds on the experiences gained from previous Health for All policies to guide both Member States and the WHO Regional Office for Europe. Health 2020 recognizes that successful governments will achieve real improvements inhealth and well-being if they work across government to integrate action in two main strategic objectives:  Improving health for all and reducing health inequalities  Improving leadership and participatory governance for health

The Health 2020 policy framework proposes four priority areas for policy action:  Investing in health through a life-course approach and empowering people  Tackling Europe’s major health challenges of non communicable and communicable diseases  Strengthening people-centred health systems, public health capacity and emergencypreparedness, surveillance and response  Creating resilient communities and supportive environments

Health 2020 is organized in three parts:  Renewing the commitment to health and well-being – the context and drivers  Applying evidence-based strategies that work and the key stakeholders  Enhancing effective implementation – requirements, pathways and continuous learning

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Renewing the commitment to health and well-being – the context and drivers

Health 2020 is based on values enshrined in the WHO Constitution, namely the highest attainable standard of health and health as a human right. The Constitution expresses these values in this form:”The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.” Importantly, the right to health means that governments are required to create conditions in which everyone can be as healthy as possible4. Such actions range from ensuring the availability, affordability and accessibility of health services to taking public health measures for healthy and safe working conditions, adequate housing and nutritious food and other conditions for protecting and promoting health. Citizens, in turn, need to understand the value of their health and contribute actively to creating better health in society at large. This is increasingly recognized as key to protecting public health and integral to a governance approach. The specific values of Health 2020 are full recognition and application of the human right to health, solidarity, fairness and sustainability. These values incorporate several others that are important within the European Region: universality, equity, the right to participate in decision-making, dignity, autonomy, non- discrimination, transparency and accountability.

The determinants of health are complex and include biological, psychological, social and environmental dimensions. All the determinants interact, influencing both individual exposure to advantage or disadvantage and the vulnerability and resilience of people, groups and communities. Because these determinants are not equally distributed, this leads to the health inequities seen across the European Region: the health divide between countries and the social gradient between people, communities and areas within countries.

The past three decades within the European Region have witnessed tumultuous political and social change, but “health for all” and the importance of primary health care approaches have remained as key guiding values and principles for the development of health in the Region. Health 2020 builds on that experience, detailing ways to orchestrate setting priorities around common health and well-being targets and outcomes, and

4The right to health. Geneva, Office of the United Nations High Commissioner for Human Rights, 2008 (http://www.ohchr.org/Documents/Publications/Factsheet31.pdf). | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

catalysing action not only by health ministries but also by heads of government, as well as other sectors and stakeholders.

Despite the real health improvements across the European Region, the challenge that health poses to governments is greater than ever. People have come to expect protection from health risks – such as unhealthy environments or products – as well as access to high- quality health care throughout the life-course. Nevertheless, the financial pressures on health and welfare systems make it ever harder to respond. In many countries, the health share of government budgets is larger than ever before, and health care costs have grown faster than gross national product (GNP). Any health reform must contend with deeply entrenched economic and political interests, as well as with social and cultural processes. Getting the balance right for health is a difficult task that health ministers cannot resolve on their own particularly in the face of economic crisis. The right policies and technologies can contain the upward curve of health care costs.

Health 2020 addresses the economic and funding aspects of health and health systems. Social progress and stability have been achieved most successfully in countries that ensure the availability of services promoting good health and education, and of effective social safety nets, through strong public services and sustainable public finances. Failure to achieve these goal scan be reflected in a decline in societies’ social capital of civic institutions and social networks.

Applying evidence-based strategies that work and the key stakeholders

Health 2020 includes headline, overarching regional targets which will be supported by appropriate indicators and reported as regional averages. It is intended that these targets will be both quantitative and qualitative where appropriate and “smart”: (specific, measurable, achievable, relevant and time-bound). Each will represent real potential progress across the processes, outputs and outcomes of the Health 2020 policy framework.

The targets are elaborated in three main areas, which support the two strategic objectives and four policy priorities that underpin Health 2020. These three main areas are:

 burden of disease and risk factors

 healthy people, well-being and determinants

 processes, governance and health systems.

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The Health 2020 policy framework proposes four common areas for policy action based on the categories for priority-setting and programmes in WHO agreed by Member States at the global level and aligned to address the special requirements and experiences of the European Region. These also build on relevant WHO strategies and action plans at the regional and global levels.

 Investing in health through a life-course approach and empowering people.

 Tackling Europe’s major disease burdens of noncommunicable and communicable diseases.

 Strengthening people-centred health systems, public health capacity, and emergency preparedness surveillance and response.

 Creating resilient communities and supportive environments. Addressing political, social, economic and institutional environments is vital for advancing the health of the population. Intersectoral policies are both necessary and indispensable. Whole-of-government responsibility for health requires that the entire government at all levels of responsibility fundamentally considers effects on health in developing all regulatory and social and economic policies5.

The Commission on Social Determinants of Health6set out three main principles for action:

 Improve the conditions of daily life – the circumstances in which people are born, grow, live, work and age.

 Tackle the inequitable distribution of power, money and resources – the structural drivers of the conditions of daily life – globally, nationally and locally.

 Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health and raise public awareness about the social determinants of health.

5Interim second report of the social determinants of health and the health divide in theWHO European Region. Copenhagen, WHO Regional Office for Europe, 2011 (http://www.euro.who.int/data/assets/pdf_file/0010/148375/id5E_2ndRepSocialDetjh.pdf). 6Commission on Social Determinants of Health. Closing the gap in a generation: healthequity through action on the social determinants of health. Final report of theCommission on Social Determinants of Health. Geneva, World Health Organization,2008 (http://www.who.int/social_determinants/resources/gkn_lee_al.pdf). | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Health 2020 focuses on a set of effective integrated strategies and interventions to address major health challenges across the Region related to both noncommunicable and communicable diseases. Both areas require a combination of determined public health action and health care system interventions. The effectiveness of these is underpinned by actions on equity, the social determinants of health, empowerment and supportive environments. In particular, a combination of approaches is required to successfully address the high burden of noncommunicable diseases in the Region. Although the challenges are significant, there is a growing body of evidence about what works to improve individuals’ and communities’ health and well-being. With so many different influences on health, this means that understanding of, and insights into, what works is spread inpractice across a diverse range of academic and professional disciplines. In the health sector in particular, approaches and learning are often strongly informed by a biophysical and medical sciences perspective. Although this is clearly of huge importance, it is limiting and unidimensional in isolation. As a result, there has been a growing appreciation of the need to better integrate learning from other sectors, especially contributions from the wide range of social and behavioural sciences.

Health 2020 reconfirms the commitment of WHO and its Member States to ensure universal coverage, including access to high-quality and affordable care and medicines. It is vital to promote long-term sustainability and resilience to financial cycles, to contain supply driven cost increases and to eliminate wasteful spending. Health technology assessment and quality assurance mechanisms are critically important for health system transparency and accountability and are an integral part of a patient safety culture. In order to revitalize public health and transform service delivery, the education and training of health professionals needs to be rethought so as to improve the alignment between educational and health system priorities and the population’s health needs. To support this transformation of service delivery towards an evidence-informed culture with strong coordination across sectors and levels of care, education and training need to reflect several specific factors: producing a more flexible multi skilled workforce to meet the challenges of changing epidemiology; joint working with other sectors on the social determinants of health; supporting team-based delivery of care; equipping personnel with improved skills; supporting patient empowerment, learning new approaches to consultation; and building leaders’capabilities at all levels in various organizations to support these changes. The ability to update their knowledge and competencies and to respond to new health challenges is a prerequisite forthe health professionals of the future; this should be supported by ready access to lifelong learning opportunities. | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Good governance strengthens health systems by improving performance, accountability and transparency. A cornerstone of health system governance in the 21st century is to make health policies more evidence-informed, intersectoral and participatory, and to transform leadership accordingly. Most health policies have been developed using top- down approaches. However, in a whole-of-government environment, horizontal relationships across the whole of government need to be encouraged. Greater participation of citizens and civil society would enhance the orientation of new national health plans and strategies towards citizens and the users of health services and would articulate social values. Enhancing effective implementation – requirements, pathways and continuous learning

In taking Health 2020 forward, countries will not only face different contexts and starting- points but will also need to have the capacity to adapt to both anticipated and unanticipated conditions under which policies must be implemented. Member States will choose different approaches and align their actions and choices on their particular political, social, epidemiological and economic realities, their capacity for developing and implementing policy, and their respective histories and cultures. Member States are encouraged to analyse and critically appraise where they stand in relation to the Health2020 policy framework and whether their policy instruments, legislative, organizational, humane source and fiscal situations and measures support or impede the implementation of Health2020. This includes an appreciation of system complexity, capacity, performance and dynamics. Health 2020 sets out the present, emerging and future issues that need to be addressed, but it also highlights the fact that policy-makers are challenged to accommodate unforeseen issues as well as changes in context that will have an impact on policy goals. Continuous analysis and policy adjustments will be necessary, as will the readiness to terminate policies that are no longer relevant or effective.

In such a complex environment, seven approaches have been suggested to support policy making:

 Integrated and forward-looking analysis.

 Multi stakeholder deliberation.

 Automatic policy adjustment.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

 Enabling self-organization and social networking.

 Decentralization of decision-making.

 Promoting variation.

 Formal policy review and continuous learning. Government and Health ministers have a vital role to play here. Their strong leadership is key for all the actions necessary to advance health, including: developing and implementing national and sub national health strategies focused on improving health and well-being; advocating for and achieving effective intersectoral working for health; engaging the active participation of all stakeholders; delivering high-quality and effective core public health functions and health care services; and defining and monitoring standards of performance within a framework of transparent accountability. Whole-of-society and whole-of-government responsibilities for health will be driven by a high degree of political commitment, enlightened public administration and societal support. Making this responsibility meaningful and functional requires concrete intersectoral governance structures that can facilitate the requisite action, with the aim of including, where appropriate, health in all policies, sectors and settings. These intersectoral governance structures are equally relevant for governments, parliaments, administrations, the public, stakeholders and industry.

II The Global Strategy of the U.S. Department of Health and Human Services

The increasing interconnectedness of our world requires that the Department of Health and Human Services (HHS)7 engage globally to fulfill its mission of protecting and promoting the health, safety, and well-being of Americans. While HHS carries out the majority of its work within US borders, US scientists, epidemiologists, and policy experts work with governments, research institutions and multilateral organizations across the globe toward achieving this mission. The Department’s efforts also provide the opportunity for HHS to share technical expertise, exchange best practices, and collaborate on science, public health, and policy efforts that contribute to a healthier, safer world. HHS’s global humanservices work encompasses the cross-cultural educational, social, and economic

7Department of Health and Human Services.www.hhs.gov | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

support activities that promote health, well-being, safety, and resilience ofindividuals and communities across the globe.

This Global Strategy of the Department of Health and Human Services (Global Strategy)8 describes the approaches that will guide HHS’s global efforts to prevent disease andimpairment, prolong life, and promote health and well-being. The Global Strategy (2015-2019)

The Global Strategy derives from both the HHS mission to protect and promote the health and well-being of the American people and the HHS Strategic Plan (FY 2014-2018), which emphasizes making investments where they will reach the most people, building effectively on the efforts of US partners, and leading to the biggest gains in health and well-being for the American people. It highlights HHS’s role as a key contributor to this international work through broad national interests and Administration priorities, such as the National Security Strategy9, National Health Security Strategy (2015-2018)10, the Global Health Security Agenda11 and the core principles guiding U.S. government global efforts to protect and improve the lives of mothers, women, children, and families. The Global Strategy comprises three fundamental goals and 10 key objectives that contribute to achieving HHS’s global vision of a healthier, safer world. The three goals of the Global Strategy are deeply interrelated. None can be achieved in isolation from the others. HHS’s three strategic goals for global engagement reflect mission to protect and promote Americans’ health, well-being, and security, while contributing the Department’s unique assets that can improve health and well-being around the world. HHS’s engagement with a range of experts, resources, and talent internationally helps the Department make better-informed decisions about our own investments, prioritize our actions, and ultimately improves outcomes for people at home and abroad.

Goal 1: Protect and Promote the Health and Well-Being of Americans through Global Action

8Global Strategy of the Department of Health and Human Services. www.hhs.gov/sites/default/files/hhs-global-strategy.pdf 9National Security Strategy. www.state.gov/documents/organization/63562.pdf 10National Health Security Strategy (2015-2018). https://www.phe.gov/Preparedness/planning/authority/nhss/Documents/nhss-ip.pdf 11Global Health Security Agenda. https://www.ghsagenda.org/ | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

HHS’s mission requires global action to ensure the health, safety, and well-being of Americans. This mission drives the Department’s work, from research on the genesis of disease and development of cures to efforts to protect the food supply, ensuring the safety and efficacy of therapeutics, policies, and programs to improve the quality of service provision, and assuring that the needs of vulnerable populations are met.

Goal 2: Improve Global Health and Well-Being by Providing International Leadership and Technical Expertise in Science, Policy, Programs, and Practice Maximizing health and well-being is an international priority, and U.S. skills, knowledge, leadership, and experience can guide effective collaborative action. HHS’s unmatched expertise in biomedical and implementation science research, public health, regulatory science, strengthening the health workforce, program management, and health and human services policy can advance global health and well-being and help partners develop, implement, and utilize policies and practices proven to work. Goal 3: Advance United States Interests in International Diplomacy, Development, and Security through Global Action

The global community increasingly recognizes that health engagement is a necessary component of international diplomacy, development, and security. HHS established the position of Assistant Secretary for Global Affairs to assure top-level engagement with international partners, and the Department of State established the position of U.S. Special Representative for Global Health Diplomacy to advance U.S. global health-related interests worldwide. The 10 objectives of the Global Strategy build on core strengths and expertise embodied within HHS and contribute to the achievement of the Strategy’s three goals. Objective 1: Prevent and Treat Infectious Diseases and Other Health Threats

Work with global partners to enhance health security and prevent the introduction, transmission, and spread of infectious diseases, and reduce the emergence and spread of antimicrobial resistance and other health threats, within and across borders. Key Priorities:

• Use bilateral and multilateral partnerships to support the development of sustainable capacities among partner governments and international

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

agencies to address both public health emergencies and day-to-day public health and human service needs

• Facilitate development, use, and evaluation of vaccines and other prevention strategies such as clean water and controlling insects that can transmit disease, focusing on achieving global disease reduction goals.

• Support database and information technology infrastructure with global access and common portals for disease surveillance and monitoring purposes, including measures for early warning systems.

• Ensure effective risk and crisis communication by coordinating with global partners to disseminate public information and emergency notification, especially to at-risk populations and stakeholders.

Objective 2: Enhance Global Capabilities to Detect and Report Health Events Strengthen global surveillance to detect, track, identify, control, and prevent diseases and address health concerns that may affect, indirectly or directly, the health security of the U.S. population. Key priorities:

• Support countries and multilateral organizations to strengthen surveillance systems, addressing current gaps and ensuring interoperability of systems.

• Assist with improving workforce and laboratory capacity to support diagnosis for disease surveillance.

• Provide leadership and technical expertise, often through bilateral and multilateral engagement with ministries of health.

• Develop and evaluate innovative surveillance, information management, and communication strategies. Objective 3: Prepare for and Respond to Public Health Emergencies

Mobilize and support an immediate health sector response to international outbreaks and public health emergencies.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Key Priorities:

• Support the development of sustainable response capacities and international coordination mechanisms for addressing public health emergencies consistent with the IHR.

• Provide technical expertise and share mechanisms for investigating disease outbreaks and identifying their cause.

• Collaborate with international partners to identify best practices and develop standard indicators and guidelines for responding to natural and human- made disasters.

• Develop policy frameworks, agreements, and operational plans to facilitate HHS decision-making.

• Provide technical assistance to aid countries, communities, and individuals in addressing outbreaks and recovering from the effects of natural and human- made disasters.

Objective 4: Increase the Safety and Integrity of Global Manufacturing and Supply Chains Enhance regulatory systems and global manufacturing and supply chains to ensure the safety of medical products, food, and feed that enter into the United States. Key Priorities:

• Identify key risks in the global manufacturing and supply chain and implement strategies to mitigate them in cooperation with other governments and international agencies.

• Strengthen strategic regulatory partnerships to promote a safer, higher quality global supply of medical products, food, and feed.

Objective 5: Strengthen International Standards through Multilateral and Bilateral Engagement

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Provideleadershipto establish, strengthen,andimplementscience-based international health and safety standards and support multilateral efforts to improve policies, programs, and practice for global health and well-being. Key Priorities:

• Ensure an appropriate leadership role for the United States in the development of science-based norms and standards, particularly within WHO and other multilateral bodies.

• Strengthen existing multilateral relationships and develop new strategic alliances to maximize the achievement of our global goals and objectives. Objective 6: Address the Changing Global Patterns of Death, Illness, and Impairment Related to Aging Populations Encourage global action to address individuals’ health and well-being needs throughout their lifespans, taking into account how demographic changes are affecting the major current and emerging contributors to global death, aging, and illness. Key Priorities:

• Promote the development, implementation, evaluation, dissemination, and exchange of cost-effective policies, strategies, and interventions.

• Promote the integration of effective public health policies and trade policies.

• Strengthen health and human services systems’ capacities to address multiple NCDs and promote health for all by fostering evidence-based interdisciplinary practices.

• Engage across disciplines such as education, transportation, and economic agencies to address the drivers of health inequity across the lifespan. Objective 7: Catalyze Research Globally to Improve Health and Well-being Catalyze biomedical, public health, and social welfare research and innovation globally to promote the discovery, development, delivery, and evaluation of new interventions that improve health and well-being across national borders.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Key Priorities:

• Address research priorities that are linked to scientific opportunity, innovative platforms, public health and human services needs, and the evolving burden of disease.

• Support the rapid translation of research results into new or improved preventive, diagnostic treatment, habilitative and rehabilitative products, platforms and processes.

• Encourage research that identifies pathways of the spread of infectious disease and other health threats, and address the growing problem of antimicrobial resistance. Objective 8: Strengthen Global Health and Human Services Systems by Identifying and Exchanging Best Practices

Increase the exchange of best practices and strategies to improve services with a focus on strengthening of our global health and human services systems.

Key Priorities:

• Support collaborative health and human service system strengthening activities, including workforce development.

• Promote the global exchange of best practices and lessons learned to ensure that evidence supports decisions.

• Address the underproduction and retention of health and human services professionals in developing countries.

Objective 9: Support the Integration of Global Health and Development Efforts to Improve Well-being and Raise Living Standards Support the integration of U.S. government agency expertise to overcome global health challenges that threaten lives at home and around the world by addressing the social determinants of health.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Key Priorities:

• Contribute to the achievement of U.S. government goals and principles in the areas of HIV/ AIDS, malaria, tuberculosis, neglected tropical disease, maternal and child health.

• Support the integration of public health services for prevention and control of key diseases such as HIV/AIDS and vaccine-preventable diseases with other priority health interventions.

• Through research, programs, and policy.

Objective 10: Advance Health Diplomacy

Within the broader context of U.S. foreign policy, engage in health and well-being issues with diplomatic partners, whether individual countries or international organizations, and strengthen peer-to-peer technical, public health, and scientific relationships.

Key Priorities:

• Assign health attachés to selected U.S. embassies for international cooperation, ensuring that opportunities to achieve political, security and health objectives are maximized.

• Establish a corps of rotational staff ready for international deployment and provide specialized support units and training for all employees.

• Strengthen diplomatic knowledge, negotiation skills, and understanding of development principles for HHS field staff and technical experts. 4. Public Health of EU Countries 4.1. Austria

4.1.1. Demographics of Austria

Austria is a federally administered parliamentary republic in Central Europe. It is landlocked state of approximately 84 000 km2. Austria has 8.5 million inhabitants (2013),

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

of whom 51.2% were women. Since the year 2000, the population has increased by 4.7%. A population increase of almost 4%, to 8.71 million inhabitants, is predicted by 2020.

These are general information of Austria: Gross national income per capita (PPP Int $) (2015): 43.840

Life expectancy (2015): 82 years

Hospital beds per 100.000 (2014): 759

Physicians per 100.000 (2015): 515 % of population aged 65+ years (2014): 18%

Life expectancy at birth m/f (2015): 79/84 years

Total expenditure on health as % of GDP (2014): 11% Internet users: 81%

4.1.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The Austrian health-care system has been shaped in its development since the mid- nineteenth century by three important institutional characteristics: (1) the constitutional make-up of the state with health-care competences being shared between the federal level and the regional level (“Länder”); (2) a high degree of delegation of responsibility to self- governing bodies; and (3) a mixed model of financing, where the state and social health insurance contribute almost equal shares. Provision of the population with health-care facilities and governance of the health-care system are seen as largely the job of the state. The health-care system is 75% financed by social insurance contributions and from taxation, while almost 25% comes from private sources (user charges and direct payments; private health insurance; non-profit-making organizations). Health care facilities are offered by state, private non-profit-making and private organizations, as well as individuals operating independently. The Federal Constitutional Law stipulates that responsibility for regulation of most areas of the health-care system lies primarily with the federal government. However, the most

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

important exception to this rule is the hospital sector, for which only the basic requirements are defined at the federal level, while the Länder are in charge of the specifics of legislation and implementation; and the Länder have to ensure the availability of sufficient hospital capacity for inpatient care.

In the ambulatory and rehabilitation sectors, as well as in the field of medication, health care is organized through negotiations between the 22 social security institutions or the Federation of Austrian Social Security Institutions on the one hand, and the chambers of physicians and pharmacy boards (which are organized as public law bodies), and the statutory professional associations of midwives and other health-care professions on the other. This cooperation works within a legally defined framework to safeguard care and the financing of care. In the social security system membership in a health insurance fund is determined automatically as a result of legislation. Individuals do not have the opportunity to choose their insurer. However patients benefit from the principle of free choice when selecting between different providers. They can freely choose their physician and even an important portion of care provided by non-contracted physicians is reimbursed by social health insurers. Patients also can choose freely between public hospitals.

4.1.3. Public Health Indicators

Since 1980 life expectancy at birth has risen by eight years. Circulatory illnesses and cancer are the most common causes of death and together are responsible for more than two- thirds of deaths. Age-standardized mortality rates for circulatory illnesses, particularly ischemic heart disease and cerebrovascular accidents (strokes), have fallen more than 40% since 1995. In 2010, just under 70% of all Austrians assessed their own state of health as “very good” or “good”. Infant mortality in Austria is at 3.9 per 1000 live births, just above the EU15 average (3.6 per 1000 live births). Mortality rates for common diseases have fallen significantly in recent years. In some cases, they are also noticeably below the OECD average. Age-standardized five-year survival rate for breast cancer was below the OECD average over the period 2004–2009. The implementation of the breast cancer screening programme, planned for 2013 is thought to be an important step towards improving survival rates. In contrast to breast cancer, the probability of surviving bowel cancer for five years in Austria is significantly higher than the OECD average.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

The cardiac mortality rate in the 30-day period following hospitalization was cut in half between 2000 and 2009, when it was at 5.7%. However, it remained above the average of 16 OECD countries. The 30-day-in-hospital mortality rate from ischemic stroke was already significantly below the OECD average in 2000 and has continued to fall. In 2009, it was at 3.1%.

Vaccination rates among the Austrian public are relatively low compared to other countries. Although the 2012 vaccination concept took important steps to broaden vaccination cover, particularly for children and elderly people, the incidence of certain complex infectious diseases, such as hepatitis B is comparatively high.

4.1.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

There has been a clear increase in the use of electronic media in Austria in recent years. In 2011, more than 75% of households had Internet access. In the past few years great efforts have been made to build and expand information systems in the health-care system with the principal aim of increasing transparency. A series of national guidelines on the systematic documentation of services and costs, particularly in inpatient care, were recently issued or refined. Another important step was the Health Care Telematics Act, passed in 2005 as part of the health-care reforms at the time.

While the current level of ICT provision in the Austrian health-care system is generally good, there are individual areas that require improvement. In particular, the ambulatory sector is still marked by a high degree of heterogeneity in the use of ICT. In hospitals, the use of relatively standardized ICT systems is already standard practice. The hospital information system, the radiology information system, as well as the digital imaging archive are well established.

A series of national expert systems, indices, registries and information platforms, such as the public Health Portal, exist. This Health Portal was developed to offer an accessible service with quality-assured information on health matters and health-care provision for patients, and went online at the start of 2010. Other expert systems include the DIAG (Documentation and Information System for Health Care Analyses) Extranet, the Austrian Clinical Information System with the Regional Health Information System extension option, the e-database of addictive substances, monitoring and licensing of medication, the quality

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

platform, the Epidemiological Reporting System for infectious diseases connected to TESSy (the European Surveillance System) and the consumer information system VIS.

All insured persons in Austria have an e-card (which is also valid as a European Health Insurance Card). The e-card is only used for identification purposes and does not contain any medical data.

In 2005, the Ministry of Health issued the Healthcare Reform Act that involved the introduction of a lifelong electronic health record (“ELGA”) in Austria. ELGA is an abbreviation for electronic health records (“Elektronische Gesundheitsakte”) in German. ELGA is an information system which provides patients, doctors, hospitals, care facilities and pharmacies with easy access to health records. Health records such as medical reports on a person are created at various health facilities. ELGA networks this data and makes it available electronically via a link. ELGA intends to save time, provide users with a better overview and prevent multiple examinations of the same kind being carried out. Patients can print your own medical test results on ELGA and view, print or save an overview of the medication (e-medication). In this way, the ELGA system should make a valuable contribution towards increasing patient safety.

The core applications planned within ELGA are e-results, e-physician’s letters (hospital discharge notices), living wills and eMedikation. In 2011, a pilot project on eMedikation was carried out in three test regions. In 2013, ELGA put the ELGA patient portal into operation – at that time without any documents contained yet. However, patients were already able to configure some functions of their own ELGA records. For example, they could exclude individual health service providers or medications, or they could cancel their ELGA registration altogether (“opt out”). In 2015, ELGA services started with the discharge letters from hospitals in two regions (Vienna and Styria). Nationwide roll-out of ELGA started in 2016.

4.1.5. Expenditure, Economics, Management

Total health expenditure in Austria in 2010 was greater than the EU15 average, at approximately 11% of GDP (EU15 average is 10.6%). The proportion of public health expenditure (taxes and social insurance contributions) within total expenditure was 77.5%, which is slightly above the EU15 average (77.3%).

In 2010, social insurance funds were the most important source of finance, accounting for approximately 52% (€13.3 billion) of current health expenditure and 0.7% (€28.9 million)

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of current long-term care expenditure. The Federation, Länder and local authorities covered approximately 24% (€6.1 billion) of expenditure on health and 81% (€3.6 billion) of expenditure on long-term care. Private health insurance funds financed approximately 4.7% of current expenditure in total, predominantly through supplementary insurance schemes, which principally cover services in hospitals (“hotel services” and freedom to choose a hospital physician). Private households contributed almost 17% of current expenditure through out-of-pocket payments. Low-income individuals or individuals with chronic illnesses are exempted from prescription fees and other user charges.

In 2010, spending on inpatient care accounted for just under 43% of total current health expenditure, which is considerably higher than on average in OECD countries. These include inpatient (including day-clinic) costs for hospitals as well as inpatient costs for rehabilitation clinics, care homes and spa facilities. Of total current health expenditure, 26% went towards ambulatory care and 17% was spent on pharmaceuticals and medical products.

4.1.6. Challenges and Future Perspectives

The history and structure of the Austrian health-care system has been shaped by both the federal structure of the state and a tradition of delegating responsibilities to self-governing stakeholders. This coexists on the one hand with a decentralized planning and governance, adjusted to local norms and preferences. On the other hand, this leads to the fragmentation of responsibilities and frequently results in inadequate coordination. For this reason, efforts have been made for several years to achieve more joint planning, governance and financing of the health-care system at the federal and regional level. There is room for improvement throughout the Austrian health-care system. In contrast to life expectancy, which has risen continually, the number of healthy life years in Austria was more than two years below the EU average in 2010. One disadvantage of open access to all levels of care is that it is often difficult for patients to find the care most appropriate to their condition, illness profile and personal requirements within the maze of options. The balance between inpatient and ambulatory care is poor, as is the balance between various levels of ambulatory care and preventive measures, acute inpatient care and aftercare, and between physicians and other health-care professions. The inpatient sector is over- represented in comparison to the ambulatory sector. The costs of the health-care system in Austria are high. One of the Austrian health-care system’s key weaknesses is in prevention

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of illness. For this reason, for several years, key goals within Austrian health-care policy have been the reduction of capacity in the inpatient sector, better coordination between different levels of care, and balancing the health-care system and long-term care provision. The application of e-health infrastructure holds great potential for greater continuity between service providers. This is a field in which Austria is relatively advanced compared to other countries. April 2011 saw the launch of the e-medication project, the first trial implementation of ELGAs. In 2016, nationwide launch of ELGA started as a modern and safe infrastructure. 4.2. Belgium

4.2.1. Demographics of Belgium

Belgium is a federal parliamentary democracy under a constitutional monarch. Belgium has one of the highest population densities in Europe. Its 11,1 Millions inhabitants live in a total land area of 30 528 km2. Belgium has three official languages: Dutch, French and German. Dutch is spoken by around 59% of the population, French by around 40% and German by less than 1%. These are general information of Belgium:

Gross national income per capita (PPP Int $) (2015): 40.280 Hospital beds per 100.000 (2015): 619

Physicians per 100.000 (2014): 297 % of population aged 65+ years (2013): 18%

Life expectancy at birth m/f (2015): 78/83 years

Total expenditure on health as % of GDP (2014): 11%

Internet users: 82%

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

4.2.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The Belgian health system is based on the principle of social insurance characterized by solidarity between the rich and poor, healthy and sick people and with no selection of risk. The organization of health services allows for therapeutic freedom for physicians, freedom of choice for patients and remuneration based on fee-for-service payments. Almost the whole population (> 99%) is covered for a very broad benefits package. The services that are covered by compulsory health insurance are described in the nationally established fee schedule (more than 8000 services). Services not included in the fee schedule are not reimbursable. Financing is based on progressive direct taxation, proportional social security contributions related to income and alternative financing related to the consumption of goods and services (value added tax). Approximately 20% of the total health care expenditures are paid by the patients through official co-payments, supplements and non- reimbursed medical acts, drugs and devices. Co-payments are the same for everyone except for people with preferential reimbursement status.

Decision-making in the Belgian health system relies on negotiations between several stakeholders. General policy matters concerning health insurance and the public health budget are decided by representatives of the government and the sickness funds, but also by representatives of employers, salaried employees and self-employed workers. An important part of the health system is also regulated by national conventions and agreements between representatives of health care providers and sickness funds. In Belgium, responsibilities for health policy are shared between the federal level and the federated entities (regions and communities). The federal level is responsible for the regulation and financing of compulsory health insurance; the determination of accreditation criteria (that is, minimum standards for the running of hospital services); the financing of hospital budgets and heavy medical equipment (e.g. CT and MRI scanners); legislation covering different professional qualifications; and the registration of pharmaceuticals and their price control. At the level of federated entities (regions and communities), governments are responsible for health promotion and prevention; maternity and child health services; different aspects of elderly care, home care, coordination and collaboration in primary health care and palliative care; the implementation of accreditation standards and the determination of additional accreditation criteria; and the financing of hospital investment. To facilitate cooperation | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

between the federal level and governments of regions and communities, interministerial conferences are regularly organized.

Social security contributions and subsidies from the federal government are the main funding sources for the compulsory health insurance system. In 2009, social contributions accounted for 66%, state subsidies for 10%, alternative financing (mainly from indirect tax revenues) for 14%, and allocated and diverse receipts (special contributions of social security, solidarity contributions and contributions by employers for early retirement) for 10% of the compulsory health insurance. Social security contributions are related to income (rates set by law) and are independent of risk.

Health care is provided by public health services, independent ambulatory care professionals, independent pharmacists, hospitals and specific facilities for the elderly. Hospital care is provided by either private non-profit-making or public hospitals. Most medical specialists work independently in hospitals or in private practices on an ambulatory basis. General practitioners (GPs) provide ambulatory or primary care. Dentists and pharmacists also generally work independently.

4.2.3. Public Health Indicators

Life expectancy at birth is 82.6 years for females and 77.1 years for males. Since 1980, life expectancy has increased on average by three months per year. Infant mortality, which represents the ratio of the number of child deaths under one year of age per 1000 live births, has declined between 1980 and 2007 from 12.1 to 4. Between 1980 and 2005, neonatal mortality decreased from 7.5 to 2.3 deaths per 1000 live births and postneonatal mortality decreased from 4.5 to 1.4 deaths per 1000 live births. No national data on the causes of death after 2004 are currently available. The main causes of death in Belgium in 2004 were cardiovascular disorders, neoplasms and disorders of the respiratory system. In 2008, more than one quarter (27.6%) of the population reported having at least one long-term illness, disorder or disabling condition. Since the 1980s, the number of daily smokers has decreased substantially from 40.5% in 1980 to 20.0% in 2008.Vaccination coverage of children in Belgium increased and was above 90% for all vaccines in 2007. The coverage of breast and cervical cancer screening has also increased since 2000, but this increase was moderate compared to other European countries.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

4.2.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

In 2009, 67% of Belgian households had access to the Internet in their place of Residence.

In Belgium, a great deal of detailed data is collected on health and health care. However, significant challenges remain which make it difficult to report reliable data internationally, including a lack of reporting data in the correct manner, and the need to use international classifications and concepts in data collection. Furthermore, additional challenges remain, including: a lack of a unique patient identification between all available databases; a lack of data concerning voluntary health insurance (VHI); difficulties with diagnosis and treatment data as far as validity is concerned, in particular for co-morbidity and complications; a lack of data concerning extramural health care; only moderately useful data concerning psychiatry and very limited data concerning homes for the elderly and nursing homes; a lack of data concerning technology used in health care; and a lack of data concerning non- reimbursed payments.

In 2009, 131 databases containing different types of health-related information were found in Belgium. The actors involved in collecting these data, as well as obligations to provide information, vary from one database to another. For example, the FPS Health, Food Chain Safety and Environment collects, reports and analyses data provided by hospitals, including Minimal Clinical Data, Minimal Nursing Data, Minimal Psychiatric Data, Hospital Billing Data and Mobile Urgency Group Data. These data are mainly collected as tools for the measurement of hospital needs for public financing, and evaluation of the effectiveness and quality of hospital care. MCD registration for hospitalized patients includes relevant clinical data (e.g. primary and secondary diagnosis) and demographic characteristics of patients. The MND registration includes information on a whole series of nursing activities, including the numbers of nurses per care unit, their qualifications and some diagnostic elements. The MPD contains socioeconomic characteristics of the patient, diagnosis and pre-admission problems, treatment data, and diagnosis and residual problems at discharge. The HBD are based on the billing data for hospitalized patients sent by hospitals to the health insurance companies for NIHDI reimbursement. To uniquely identify a patient, two types of eCards are in use in Belgium. So far, the insurance status of a person has been documented by a social security (or "SIS”) card issued since 1998 by the national sick funds at a person’s birth. It will be phased out as the new national eID Card becomes available more broadly. Social security and health insurance status verification will take place using this card bearing a unique identification | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

number. This multi-purpose eID card has a pin-protected chip with cryptographic functions and is used for enabling access to public eServices (libraries, museum, etc.), for tax purposes and for signing eDocuments. It will not carry any other than administrative information. Rather, specific patient data, e.g. emergency data, clinical information or the insurance status, will be made accessible on secured central servers via the Belgian eHealth Platform, with the eID card serving as key.

Since 2008, the eHealth-platform, a shared EHR system, provides a series of so-called ‘basic services’ which can be used by all actors in the healthcare sector and which can be integrated into the various eHealth solutions offered by information and communications technology providers. Special legal frameworks for this exist that does not require the consent of the patient for the setting up of the EHR (but sometimes for sharing). The Belgium eHealth-platform consists essentially of two layers: a Metahub and a Hub. The Metahub consists of a first layer of information available on the level of the eHealth- platform itself which refers to the regional or local network (the “hub”) where further data for a given patient can be found. The Hub is a second layer of information where one is referred to the actual location of the data, for example the local hospital.

The eHealth-platform has a strict user and access management system and checks in authentic sources whether or not a health professional is registered. Additionally the healthcare professional has to provide evidence of a therapeutic relationship with the patient from whom he requests to access health-related data; the evidence of the therapeutic relationship can be provided by various means. Insurance companies are also not allowed to have access to or to receive a copy of the EHR.

If the secondary use of health data is not possible without the identification of patients, an authorization is needed from the Sector Committee for Social Security and Health. In any case, such secondary use will only be possible after prior informed consent of the patient.

4.2.5. Expenditure, Economics, Management

Total health expenditure as a percentage of GDP in Belgium was 11% in 2014. With this percentage of GDP, Belgium ranked third among the EU Member States. The growth in health expenditure in Belgium is similar to that in other western European countries and can be explained by several factors, such as the increasing number of elderly people, higher expectations, growth in real GDP and increasing implementation of new technology in the health care sector.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Curative care services represent almost half (46.5%) of total health expenditure, while prevention and public health services represent around 4% of total health expenditure (in 2007). The main share of total health expenditure (71.3% in 2006) is publicly funded (by taxes and social security contributions), mostly through reimbursement taking place within the compulsory health insurance (67.3%). Federated and local governments represent a modest share in health spending with 1.5% and 2.0%, respectively. Out-of-pocket payments and VHI represent 23.3% and 5.1%, respectively (in 2006). Among out-of-pocket payments, official co-payments were estimated to be around €1771 billion in 2006, that is, around 5.7% of total health expenditure. The compulsory health insurance is managed by the NIHDI which gives a prospective budget to the sickness funds to finance the health care costs of their members. In the past, sickness funds’ expenditures were systematically reimbursed; but since 1995, they have been held financially accountable for a proportion of any discrepancy between their actual spending and their normative risk-adjusted health expenditures.

4.2.6. Challenges and Future Perspectives

Belgium currently enjoys qualitatively good health care. Patients have the freedom to choose their sickness fund, health care provider and health care institution. Waiting lists are not considered to be a problem in Belgian hospitals as they are in other European countries. The compulsory health insurance offers general coverage of health risks and guarantees wide access to care. Moreover, for more vulnerable population groups, several measures have been put in place to ensure their access to high-quality care. Several factors will continue to put pressure on health expenditure, such as the evolution of medical technology and drug innovations, increasing population expectations for new and rapidly available treatments, financial remuneration of health care providers and an ageing population, consequently providing a need for structural changes in the Belgian health system. The challenge for the future of the Belgian health system will be to ensure the efficiency and performance of the health system at a sustainable cost. Public authorities will have to continue to promote the objectives of accessibility, quality and sustainability. The reforms that will be carried out in the coming years will probably build further on previous achievements and recent reforms.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

4.3. Bulgaria

The population of Bulgaria in 2015 was 7,186,893. With a total area of 111,002 square kilometers, the country has a population density of 64 people per square kilometer. The capital, Sofia, is also the largest city with an estimated population of 1.26 million people. Seventy-three percent of Bulgaria's population lives in urban regions, with 1/6 of the population residing in the Sofia area. Approximately 85% of the population is Bulgarian, with other major ethnic groups being Turkish (8.8%), Roma (4.9%) and about 40 small minority groups totaling 0.7%. Bulgarian is the official language of the country, and it is the native language for over 85% of the country's residents. Bulgaria is a secular country, however, its constitution names Orthodox Christianity as a traditional religion and one that was followed by almost 60% of the population. While Bulgaria has a universal healthcare system, the poor quality of health facilities and the lack of medical personnel such as nurses is cause for many residents to seek medical treatment in other countries. Life expectancy for females in Bulgaria is 78 years, while the number drops to just 71.1 for males.

Bulgaria experienced a decline in population from the official figures from 2011 to estimates taken in 2015. In 2011, it was noted that Bulgaria was experiencing a "demographic crisis." This has been attributed to declines that began in the 1990s following an economic collapse. As many as one million people left the country by 2005 because of this. The country also has a low fertility rate of 1.43, with a birth rate that's one of the lowest in the world. Emmigration, low birth rates, and a high death rate are all contributing factors to the declining population in this country.

Bulgarian healthcare is universal and state funded through the National Health Insurance Fund. Bulgaria spends around 4.2% of its GDP on healthcare and has around 1.8 doctors per 1,000 people, which is above the EU average.

The private healthcare sector however, sits in stark contrast to the overall picture. Many doctors and dentists turned private with the introduction of the free market following the fall of communism, leading to a glut of private practices. This meant that clinics had to invest in better technology and provide better staff training and service in order to gain a

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

competitive edge in a crowded market. At the same time, a low wage economy forced them to keep their prices down.

The establishment of the National Health Insurance Fund and a basic benefits package defined the services covered by the public sector and earmarked the revenue collection for health care allowing for more sustainability of the health care budget.

Privatization is another important feature of the Bulgarian health system. The Health Care Establishments Act outlined procedures for the privatization of both state and municipality medical establishments. Private practice was legalized in 1991 and has since expanded significantly, and in 1992 ownership of most health care facilities was devolved to locally elected municipalities. Health care is financed from compulsory and voluntary health insurance (VHI) contributions, taxes, and formal and informal cost-sharing. One of the key principles of reform was the transition from general taxation budget financing to financing based on the health insurance principle.

Despite a reduction in the number of beds during the reforms, Bulgaria has a much higher ratio of hospital beds to population than many countries in the WHO European Region, and the average length of stay (8.2 days in 2004) is lower than in most countries in the WHO European Region. Hospital care in Bulgaria is provided by public and private health facilities divided into multidisciplinary and specialized facilities. The structural health care reform took three key directions: restructuring the health financing system based on compulsory health insurance, reorganizing primary health care and rationalizing outpatient and inpatient facilities. Public health services are organized by the Ministry of Health and its 28 regional health centres and are financed centrally. In 1999, the system of public health was restructured and took on additional functions related to public health protection and promotion run by 28 regional inspectorates of public health protection and inspection (RIPHPIs). The public health network also includes 28 national centers for emergency care, the National Centre for Radiobiology and Radiation Protection, the National Centre of Health Informatization and the National Centre of Public Health.

The Ministry of Health funds university hospitals, specialized health institutions at national and regional levels, the public health system.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Inpatient care is financed from three sources: government budgets, municipal budgets and health insurance. The NHIF pays only to contracted hospitals per case or clinical pathway consisting of a number of diagnoses, with fixed prices. Hospitals which have not contracted with the NHIF continue to be paid by the municipalities or by the State. Hospitals also receive additional revenue from compulsory co-payments and fees for those services that are not covered by the basic benefits package of health insurance. Fee-for-service can be paid out-of-pocket as well as through VHI. Physicians working in the inpatient sector are salaried. Providers of outpatient care are contracted with the NHIF and are paid by fee-for- service. Until 2004 patient rights were defined in the National Framework Contract, which outlined the aspects of health care access and equity and the right of patients to make informed decisions. Further developments of patient rights were made with the introduction of the 2004 Health Act, which came into force in January 2005.

The SMC acts as a consultative body on health policy, hospital networks, national demographic problems, medical education and postgraduate medical training. The Council determines the main priorities of national health policy and medical aspects of demographic problems in the country. The SMC is chaired by the Minister of Health and meets at least four times a year, providing opinions about draft laws and the legislative regulations of the Ministry of Health, and advising on financial and investment policy, implementation of medical technologies and human resources planning and qualifications. The SMC also suggests the criteria for quality assessment of diagnostic and preventive activities. The National Centre of Health Informatics comes under the remit of the Ministry of Health and aims to provide the country with data related to health care and informational support for health care management. The Centre collects routine data such as registered cases by disease, prevalence of disability, births, abortions and fertility rates, hospitalization rates by age, data on health establishments and hospital-related indicators by type of facility and data on health professionals and health facilities by region. The Centre is in charge of disseminating that information, which it does through an annual public health statistics publication, published with the Ministry of Health, along with data from the National Statistical Institute. The Centre also provides pre-print preparation of information and prepares special analyses on the problems within the health system. Data from the National Centre of Health Informatics are also submitted to international organizations for comparative health analysis.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

The network of 28 RIPHPIs covers the entire country, being a centrally managed, well- structured network financed by the Ministry of Health. Public health protection and inspection is also supported by three national centres of the Ministry of Health: the National Centre for Public Health Protection, the National Centre for Infectious and Parasitic Diseases and the National Council on Narcotics Drugs, whose responsibilities and functions are regulated by the 2004 Health Act. The National Centre for Radiobiology and Radiation Protection also belongs to this network of inspectorates. The principal functions of public health protection and inspection are detailed here:

 state sanitary control (public places, products, food and drinking water);

 anti-epidemic control, including the monitoring of infectious and parasitic diseases;

 health promotion and integrated prevention;

 laboratory testing of environmental factors and the assessment of their impact on population;

 inspecting noise in urbanized areas and public places;

 radiology and radiation protection;

 providing consultations and expertise to state, municipal and other bodies on public health protection;

 elaborating and implementing national and regional programmes for public health protection;

 providing postgraduate training for institutions and NGOs on public health protection 4.4. Croatia

Croatia population is about to 4.25 million in 2015. Croatia has a population density of 76 people per square kilometer. The capital and largest city, Zagreb, has city population of 790,000. The next largest city is Split, with only 178,000 people, 90.4% of the population is Croats. This makes Croatia the most ethnically homogeneous of the 6 countries of former Yugoslavia. Other groups include Serbs (4.4%), Bosnians, Italians, Germans, Czechs,

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Romani and Hungarians. More than 86% of the population is Roman Catholic. The second- most common religion is Eastern Orthodoxy at 4%. Croatia is in demographic crisis and losing people each year. Its fertility rate is just 1.5 children per woman, one of the world's lowest, and its death rate has exceeded the birth rate since 1991. Natural growth is negative. Croatia is now ranked as the 14th fastest shrinking country in the world. It's predicted that Croatia's population will shrink to 3.1 million by 2050, after reaching its peak of 4.7 million in 1991. Croatia’s social health insurance system is based on the principles of solidarity and reciprocity, by which citizens are expected to contribute according to their ability to pay and receive basic health care services according to their needs. The steward of the health system is the Ministry of Health, which is responsible for health policy, planning and evaluation, public health programs, and the regulation of capital investments in health care providers in public ownership. The Croatian Health Insurance Fund (CHIF), established in 1993, is the sole insurer in the mandatory health insurance (MHI) system, which provides universal health insurance coverage to the whole population. As the main purchaser of health services, the CHIF plays a key role in the definition of basic health services covered under statutory insurance, the establishment of performance standards, and price setting for services covered under the MHI scheme. The CHIF is also responsible for the payment of sick leave compensation, maternity benefits and other allowances. In addition, it is the main provider of complementary voluntary health insurance (VHI) covering user charges (termed supplemental insurance in Croatia). Although there was a general shift towards privatization in the early 1990s, the State actually increased its control of the health sector during that time. The majority of primary care physicians’ practices have been privatized, and the remaining ones were left under county ownership. Tertiary health care facilities are owned by the State while the counties own the secondary health care facilities. “Concessions” were introduced in 2009; these are public–private partnerships (PPPs) whereby county governments organize tenders for the provision of specific primary health care services. This allowed the counties to play a more active role in the organization, coordination and management of primary health care, with the aim of better tailoring it to local needs. Information relevant to the health sector is collected and processed by a number of national and special registries. Overall, there are more than 60 registers in the health care system. However, these registers are neither linked nor standardized, and a large number of health reports are still produced by manual data processing.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

There is no central web site or other central source that provides general health system information, but web sites and helplines of the Ministry of Health, the CHIF and the majority of hospitals and other health care institutions provide key information related to publicly funded health care services and rights, including some technical information, such as information on waiting times and available treatments.

Patient rights were already laid down in the Health Care Act of 1993 and almost identically continued in the 2004 Act on Protection of Patients’ Rights and its amendments. However, it seems that, due to political and legal as well as cultural and social reasons, this legislation has still not had a significant effect on the status of patients in the Croatian health care system. Croatia’s EU accession on 1 July 2013 required harmonization of the regulatory framework governing the health care sector with the relevant EU legislation, including coordination of the social security systems between Croatia and other EU Member States. In 2012, Croatia spent 6.8% of its GDP on health, a share that was smaller than in most western European countries of the WHO European Region.

In 2012, there were 76 hospital institutions and treatment centers in Croatia. The majority of these were owned either by the State or by the counties, with only nine hospitals and five sanatoriums privately owned.

The use of information technology (IT) in health care is increasing, at both primary and secondary care levels. Since 2001, Croatia has been developing health information system, with its aims being interoperability between the IT systems of health care providers, the CHIF and public health bodies, and the provision of real-time data on each patient and provider. Although integration of IT in primary health care has been completed, 80% of hospitals still have independent IT systems that are not fully integrated into the national hospital information systems. The number of physicians per 100 000 inhabitants increased from around 212 in 1990 to 299.4 in 2011, but this is still substantially lower than the EU27 average of 346. There is a perceived shortage of physicians, especially in family medicine, and shortages are also observed in rural areas and on the islands. The number of nurses per 100 000 inhabitants in Croatia in 2011 was 579, well below the EU average of 836, and the ratio of nurses to physicians, at approximately 2:1 in Croatia, was lower than the same ratio in the EU15 (2.3:1).

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Established in 1993, the CHIF is the single purchaser of health care services provided within the MHI scheme. It may also offer supplemental VHI to persons insured under the MHI scheme (see Section 3.5). The CHIF also plays a key role in the definition of the basic benefits basket covered under the statutory insurance scheme, the establishment of performance standards andin price setting for services covered under the MHI scheme. The CHIF is also responsible for the distribution of sick leave compensation, maternity benefits and other allowances as regulated by the Mandatory Health Insurance. The Croatian National Institute of Public Health (CNIPH) was established in 1923. Its main activities include: provision of statistical research on health and health care services; maintaining public health registers; monitoring and analysis of the epidemiological situation; provision, organization and conduct of preventive and counter-epidemic measures; planning and control of disinfection and pest control measures; planning, control and evaluation of the implementation of compulsory immunizations; provision of microbiological activities of national interest; testing and control of the safety of drinking water, waste water, food and common use objects; and other public health activities requested by the Ministry of Health. The CNIPH operates through a central office in Zagreb and county institutes of public health with their hygiene and epidemiology branch offices in the municipalities. It consists of several departments, including those of Epidemiology, Public Health, Microbiology, Environmental Health, Health Promotion, and Medical Informatics and Biostatistics. Croatia has statutory professional chambers for a number of medical professions. The chambers are responsible for professional registration and the maintenance of professional standards. All university-educated health professionals and nurses must have membership in one of the chambers. The chambers also provide professional opinions on a variety of issues and advice on the licensing of private practices and the opening and closing of health institutions. The rights of citizens as patients were already guaranteed in the Health Care Act of 1993, soon after the Republic of Croatia gained independence in 1990. The Act provided for a set of rights, including the right to seek protection for patients who considered that their rights had been violated – they could request protective measures from the health care provider and, if unsatisfied with the measures taken, turn to a relevant professional chamber, the Minister of Health or a competent court. Provisions relating to the rights and duties of citizens as patients in the Act on the Protection of Patients’ Rights of 2004 are almost identical with those of the 1993.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

The provision of public health services is organized through a network of public health institutes: one national institute (CNIPH), owned by the Ministry of Health, and 21 county institutes, owned by the counties. The activities of the county institutes are coordinated and supervised by the CNIPH. The CNIPH is responsible for the collection, analysis and publication of public health statistics (e.g. information on disease incidence or mortality) and epidemiological data, and for health promotion and health education at the national level. It also maintains a number of public health registers, such as the Croatian Cancer Register, Croatian Register for Psychoses and Register of Suicides, Register of HIV/AIDS, Register of Health Care Workers and others. CNIPH’s Department of Epidemiology is the center for disease control and prevention in Croatia. It maintains the central information system for reporting and monitoring the incidence of infectious diseases, and proposes and supervises the implementation of key preventive and anti-epidemic measures by various actors in the health care system, from family doctors to clinical hospitals, including specially trained and equipped epidemiology service units within the county institutes of public health. The Department also supervises compulsory immunizations and pest control; monitors environmental pollution and waste management; sets standards; and tests food and drinking water safety.

The county public health institutes provide services (for their respective populations) in the following areas: epidemiology and quarantine of communicable diseases; epidemiology of noncommunicable diseases; water, food and air safety services; immunizations (including overseeing the compulsory immunization programs); mental health care (prevention and out-of-hospital treatment of addictions); sanitation; health statistics; and health promotion. 4.5. Cyprus

4.5.1. Demographics of Cyprus

Cyprus, a European Union (EU) and Eurozone country, is an island republic covering an area of 9250 sq km in the eastern Mediterranean Sea with a population of 838 897 in the government-controlled area in 2011. Cyprus is the third largest Mediterranean island after Sicily and Sardinia, and is located 60 km south of Turkey and 300 km north of Egypt. Situated at the intersection of important transport and communication routes linking Europe to the Middle East and Asia, it has historically been influenced culturally and economically by its geographical location. Approximately 70.2% of the population resides in urban areas. Cyprus has been a divided island since 1974. Thus, the government of the

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Republic of Cyprus has no access to information concerning the northern part of the island. Consequently, all figures and discussions in this report refer to those areas of the Republic of Cyprus in which the government of the Republic of Cyprus exercises effective control. In 2011, Cyprus’s total population was 838 897. Of the total population, 78.6% are Cypriot citizens, with the remaining population comprising Europeans (13.4%) and third-country nationals (8.0%). Also, according to Eurostat data available in 2012, the crude death rate (ratio of the number of events to the average population in a given year) was 6.5 per 1000 inhabitants in 2009, which was the lowest rate in the EU27. Cyprus exhibits the typical demographic characteristics of an ageing country with a declining rate of population growth: a declining proportion of the population is aged less than 15 years and an increasing proportion of the population aged over 65 years. Although in comparison with other EU countries the population in Cyprus is relatively young, there has been a steady increase in the over-65 population.

Table 4.5.1.1. General Information of Cyprus

General Information of Cyprus Gross national income per capita (PPP Int $) (2015): 28.830 Life expectancy (2015): 82 years Hospital beds per 100.000 (2014): 4,46 Physicians per 100.000 (2014): 338 % of population aged 65+ years (2014): 15 % Life expectancy at birth m/f (2013): 80 / 85 years Total expenditure on health as % of GDP (2014): 7,4 % Internet users: 61 % Source: Data and Statistics of Cyprus (WHO)

4.5.2. Healthcare System and Public Health Structure, Organisation, and Legislation

Public health care services are directly controlled by the Ministry of Health. Ministry of Health is responsible for ensuring access to health services for all beneficiaries. Τhe resource allocation, management, decision making, budgeting and the preparation of relevant legislation are exclusively the responsibility of the Ministry of Health. The ministry is also responsible for inspecting, regulating and licensing private hospitals and polyclinics.

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More specific, the health system consists of two parallel delivery systems: a public one and a separate private one. The public system is highly centralized and almost everything regarding planning, organization, administration and regulation is the responsibility of the Ministry of Health. It is exclusively financed by the state budget, with services provided through a network of hospitals and health centers directly controlled by the Ministry of Health. Public providers have the status of civil servants and are salaried employees. The private system is financed mostly by out-of-pocket (OOP) payments and to some degree by voluntary health insurance (VHI). It largely consists of independent providers and facilities are often physician-owned or private companies in which doctors are usually shareholders. Other minor health care delivery sub-systems include the Workers’ Union schemes, which mostly provide primary care services, and the schemes offered by semi-state organizations such as the Cyprus Telecommunication Authority (ATHK) and the Electricity Authority of Cyprus (AHK). Other public health programmes are administered by a number of other ministries and agencies, such as the Ministry of Education and Culture, the Ministry of Agriculture, the police, and several nongovernmental organizations (NGOs).

The current legal basis for entitlement to public services is Cypriot or EU citizenship and having earned below a certain level of annual income. Some groups including civil servants, soldiers and students receive care free of charge, while other citizens suffering from specific illnesses such as multiple sclerosis, Alzheimer’s, thalassaemia, myopathy, cystic fibrosis, diabetes and cancer also receive all or some health services free of charge, regardless of income. Non EU nationals – immigrants living and working legally on the island – are one segment of the population that generally purchases private health insurance, as it is a requirement of entering and working in Cyprus. The health services provided include primary care, specialist services, diagnostic tests, paramedical services, emergency services, hospital care, pharmaceutical care, dental care, rehabilitation and home care. The fact that the public system does not provide universal coverage and approximately 17% of Cypriots must pay out of pocket to access the public health system, or must purchase health care from the private sector, demonstrates that the health system does not guarantee financial protection for the entire population. Vulnerable groups including third country nationals, illegal immigrants, asylum seekers, refugees, prisoners and Greek Cypriots not living in the government-controlled area often have difficulty accessing health care services.

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4.5.3. Public Health Indicators

Life expectancy at birth is 77.9 years for males and 82.4 years for females, which is among the highest in the EU.

In Cyprus, apart from limited data available on morbidity and mortality, there is a lack of epidemiological studies on population health.

According to the Ministry of Health, the leading causes of mortality are diseases of the circulatory system, followed by neoplasms, diseases of the respiratory system, endocrine, nutritional and metabolic diseases, and external causes of injury and poisoning. The Ministry of Health implements prevention and health promotion programmes, including successful vaccination and thalassaemia prevention programmes. In particular, by increasing awareness among the general population, by screening carriers and by providing genetic counselling and prenatal diagnoses, new cases of children suffering from thalassaemia have almost been eliminated in Cyprus. Apart from the Ministry of Health, other ministries (e.g. Labour and Social Insurance, Agriculture, Natural Resources and Environment, Education and Culture, Commerce, Industry and Tourism, Interior) and agencies independently or in collaboration with the Ministry of Health and/or other public organizations or NGOs (e.g. consumer associations, police, fire service) plan and implement public health programmes for food safety, school health services, lifestyle and health education, environmental policies and road safety. Also, for the period 2004 – 2008, the most frequent cancers for men were prostate (27.6% of all sites), colorectal (12.3%), trachea, bronchus and lung (11.7%) and bladder (8.4%). Among women the most frequent cancers were breast cancer (34.9% of all sites), colorectal (11.4%), uterus (6.0%) and thyroid (5.9%) (Ministry of Health, 2012b). Data from the National Cancer Registry, show an average incidence of 400 female breast cancer cases per year. This corresponds to an age-standardized incidence rate for breast cancer of 73 per 100 000population. Cyprus is in need of comprehensive, tailored and targeted campaigns aimed at prevention and early diagnosis of breast cancer. Major risk factors such as smoking and alcohol consumption, risky driving and other unhealthy lifestyles may have serious negative impacts on health status in the future. More than 30% of the population aged over 15 years smokes, 34.4% is overweight and 14.8% is obese. Particularly alarming are data on childhood obesity. Results from a cross-sectional study conducted during the period from October 1999 to June 2000 in Cyprus showed that the prevalence of obesity in children 6 –17 years old was 10.3% among males and 9.1%

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among females; an additional 16.9% of males and 13.1% of females were defined as overweight.

According to the European Health Interview Survey 2008 published in 2010, 79.6% of the population aged 15 years and over considers their health status as good or very good, 15.2% consider their health status to be fair and 5.1% bad or very bad.

In Cyprus, the most frequent longstanding health problems are hypertension, lower back disorders or other chronic back defects, hyperlipidaemia (including hypercholesterolaemia) allergies, neck disorders or other chronic neck defects, severe headaches, asthma, ulcers and diabetes. Cyprus has been almost free of many common infectious and parasitic diseases and has achieved significant progress in communicable disease control compared to the average rate of EU27. Cyprus has a low prevalence of HIV infections, with an estimated prevalence rate of 0.1% (adult population 20 – 64 years). According to data from the Ministry of Health, 681 people have been infected between 1986 and 2010.

4.5.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine eHealth is the use of information and communication technologies (ICT) for health. It is recognised as one of the most rapidly growing areas in health today. More specific, eHealth is defined as the use of electronic means to deliver information, resources and services related to health. Covers a wide range of tools aimed at improving prevention, diagnosis, treatment, monitoring and management of health and lifestyle. Electronic health (e-Health) includes online collaboration between patients and health service providers, the exchange of data between different health organizations and communication between patients or health providers. It also includes networks of health information, electronic health records (59% have a national EHR system, and 69% of those have legislation on its use), mobile health, telemedicine services, systems for monitoring and supporting patients. In general, eHealth can put information in the right place at the right time, providing more services to a wider population and in a personalized manner. eHealth plays a vital role in promoting universal health coverage in a variety of ways. For instance, it helps provide services to remote populations and underserved communities

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through telehealth (national policies or strategies address telehealth in 62% of Member States) or mHealth (government-sponsored mHealth programmes are in place in 49% of Member States, but only 7% have carried out evaluations of these programmes). It facilitates the training of the health workforce through the use of eLearning, and makes education more widely accessible especially for those who are isolated. It enhances patient diagnosis and treatment by providing accurate and timely patient information through electronic health records. Through the strategic use of ICT, it improves the operations and financial efficiency of health care systems. eHealth helps to modernize national health information systems and services.

Member States in Europe are under increasing pressure to ensure that national health systems meet the demand for the delivery of high quality, readily available services in spite of zero-growth or decreasing health budgets. Recent advances in mobile technologies, improvements in broadband coverage and the growing acceptance of tele-health and mobile health (m-health) solutions are providing new and attractive options for health care delivery. As a result, many governments are investing in e-health as a means for reforming health systems and for ensuring equitable and affordable access to health care.

Since 2010 the Global Observatory for eHealth (GOe) has been creating and updating an online directory of eHealth-related national policies and strategies from Member States. It includes national eHealth policies or strategies and plans, and national telehealth policies have also been added to broaden the coverage. This resource is designed to support the development of eHealth strategies by governments through easy access to existing policy and strategy documents worldwide. In addition, it gives an indication of which countries have existing national strategies, and where additional resources might be best allocated to aid in the policy development process. The Department of Electronic Communication (DEC) with the guidance of the Advisory Committee for Information Society has developed a comprehensive plan (for the period 2012-2020) for the development of information society in Cyprus and the uptake of ICT entitled “Digital Strategy for Cyprus”, that was approved by the Council of Ministers of Cyprus on 8 February 2012. The digital strategy is in line with the objectives and actions proposed in the Digital Agenda for Europe, one of the flagships of the strategy “Europe 2020”. The strategy promotes the use of ICT in all sectors of the economy and society. The Digital Strategy for Cyprus helps Cyprus to overcome the crisis and promotes economical growth, increase of the competiveness of the private sector and modernization of the public sector.

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The "Digital Strategy for Cyprus" includes objectives, measures and actions. Specifically, in electronic health sector:

Table 4.5.4.1. Measures in eHealth

Measures in eHealth Action 1: Install and operate in all hospitals the Integrated Health Care Information System that covers the key elements of the hospital procedures in order to control both quality of service to patients and hospital cost, in all public hospitals. With the Integrated Health Care Information System the Ministry of Health will achieve the standardization of hospital procedures at all public hospitals (the public hospitals will work the same way). Action 2: Install and operate the drug management system in all hospitals. Action 3: Create regional health networks to exchange information between all health care providers. Action 4: Create an Internet portal to provide private physicians access to patients’ electronic health records. Action 5:Design and implement an Ambient Assisted Living (AAL) program. Introduce an AAL program on a pilot basis by choosing a group of elder people that lives in a remote area. Depending on the results of the pilot project the AAL program will be expanded. Action 6: Use Telemedicine. Source: Digital Strategy for Cyprus, 2012 eHealth activities in Cyprus are in the very early stages. Work on standardization has begun, to help create the infrastructure required for electronic health records, as well as eRecords management and data sharing (electronic prescriptions). In multiple areas of e-health, funding is most important barrier to implementing e-health programmes. In 2015, Cyprus participated in the third global survey on eHealth. This survey was conducted by the WHO Global Observatory for eHealth (GOe) has a special focus – the use of eHealth in support of universal health coverage. It presents data collected on 125 WHO Member States. The survey was undertaken between April and August 2015 and represents the most current information on the use of eHealth in these countries. A total of 125 WHO Member States, representing a 64% response rate, completed the survey, which

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is the highest response rate for any GOe survey to date. The scope of the survey was broad; survey questions covered diverse areas of eHealth, from electronic information systems to social media, to policy issues and legal frameworks. The data are grouped by eight eHealth themes. Each grouping is intended to give the reader an overview of the eHealth landscape in individual countries in 2015 for each particular theme. More specific in Cyprus:

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Table 4.5.4.2. WHO Global Observatory for eHealth

eHealth Foundations National Policies or Strategies Country Year adopted response National universal health coverage - N/A policy or strategy National eHealth Yes 2013 policy or strategy National health information No N/A system (HIS) policy or strategy National telehealth policy No N/A or strategy Funding Sources for eHealth Country Funding source

response % Public funding Yes >75% Private or commercial No Zero funding Donor/non-public Yes <25% funding Public-private No Zero partenerships

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eHealth Capacity Building Country Proportion response Health sciences students-Pre- Yes 25-50% service training in eHealth Health professionals-In- Yes <25% service training in eHealth Source: Atlas of eHealth country profiles-WHO, 2016 Table 4.5.4.2 includes a selection of indicators on eHealth-related policies or strategies, funding, and capacity building. Data are reported by the individual “country response” (yes, no or don’t know), and “year adopted” for the particular indicator in the case of national policies/strategies. The former represent the level of planning and action around the use of eHealth in the country’s health system. As above, the answers are expressed as “country response”; it has an additional measurement for the level of funding: no funding, low <25%, medium <50%, high <75% and very high >75%. Also, eHealth capacity building is another significant indicator as it shows whether students or professionals are receiving training in preparation for their exposure to eHealth in clinical settings. The “proportion” of students receiving training is expressed in the same was as for the funding sources above: no funding, low <25%, medium <50%, high <75% and very high >75%. Telehealth is probably one of the most well-known and best established of all eHealth services. This section (Table 4.5.4.3) reports on the operations of three of the most common telehealth programmes and what level of the health system they are operating at as well as the type of programme.

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Table 4.5.4.3. WHO Global Observatory for eHealth

Telehealth Telehealth Programmes Country Overview

Health system level Programme type

Teleradiology Regional* Pilot***

Telepsychiatry Local** Pilot***

Remote patient monitoring Regional* Pilot*** Source: Atlas of eHealth country profiles-WHO, 2016

* Regional level:health entities in countries in the same geographic region ** Local level: health posts, health centres providing basic level of care

*** Pilot: testing and evaluating a programme

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Table 4.5.4.4.WHO Global Observatory for eHealth

Electronic Health Records (EHRs) EHR Country Overview Country response National EHR system Yes Legislation governing the use of the national EHR Yes system Health facilities with Use EHR EHR Primary care facilities (e.g. clinics and health Yes care centers) Secondary care facilities (e.g. hospitals, No emergency care) Tertiary care facilities (e.g. specialized care, No referral from primary/secondary care) Other electronic Country response systems Laboratory information Yes systems Pathology information No systems Pharmacy information No systems PACS Yes Automatic vaccination No alerting system Source: Atlas of eHealth country profiles-WHO, 2016

This section (Table 4.5.4.4) provides an overview of the state of adoption of Electronic Health Records (EHRs) in the country. It identifies whether the country has introduced a

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national EHR system and if there is legislation governing its use. It identifies at what level of the health system the EHRs are being used (primary, secondary or tertiary). At this point we conclude that the development of the national EHR is strongly dependent on the national standardisation of health on the level of services, systems, information, coding and terminology systems.

Also, Table 4.5.4.4shows other electronic systems that the EHR system is linked to.

The scope of the application of eLearning for pre-service education of health sciences students as well as in-service training for health professionals is covered in the Table 4.5.4.5. The faculties or professions which can benefit from eLearning techniques for training are identified along with the “country response” as well as the “global yes response”.

Table 4.5.4.5. WHO Global Observatory for eHealth

Use of eLearning in Health Sciences eLearning Programmes Country Overview Health sciences Country response Global “yes” response students – Pre-service Medicine N/A 58% Dentistry N/A 39% Public health N/A 50% Nursing & midwifery N/A 47% Pharmacy N/A 38% Biomedical/Life sciences N/A 42% Health professionals – Country response Global “yes” response In-service Medicine Yes 58% Dentistry No 30% Public health No 47% Nursing & midwifery Yes 46% Pharmacy No 31% Biomedical/Life sciences No 34% Source: Atlas of eHealth country profiles-WHO, 2016

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4.5.5. Expenditure, Economics, Management

Total health expenditure (% GDP): 7.4 Despite its relatively strong economy, Cyprus devotes a low share of its financial resources to health care. According to National Health Accounts data, total health care expenditures (THE) in Cyprus in 2010 accounted for 6.0% of GDP, with 41.5% of health care expenditures government funded and 58.5% privately funded. The health expenditure share of total government expenditure (5.3%) is the lowest of all EU countries, that reveals that the health sector is a low priority for the government. This may be due to the absence of universal coverage (83% of the population has the right of access to the public health system free of charge, while the rest of the population must pay to use public services), the relatively young population, limited spending on medical research and the favorable climate and environmental conditions. The health system in Cyprus is financed mainly through the state budget, Out of Pocket (OOP) payments, and to a small extent by Voluntary Health Insurance (VHI). In total in 2010, 41.5% of health expenditure was from the state budget, 48.8% from OOP payments, and 5.5% from VHI. Public hospitals and health centers, which are decentralized units of the Ministry of Health, have no administrative, operational or financial autonomy. Although the Ministry of Health provides an annual budget for every public hospital, in practice only a small part of it is administered by the hospital since most payments are made centrally by the Ministry of Health. Accession to the EU led to many reforms in the health system, particularly in terms of policy, regulation and the provision of services. Major challenges include reducing the rising costs of health care, addressing inequalities in access to health care services and improving the quality of services and financing of the health system. Reforms in these areas will help to maintain the progress achieved in controlling communicable diseases, to reduce the incidence of chronic diseases and to maintain the environment in a way that safeguards quality of life. Health priorities set by the EU are always adopted and financed by the Ministry of Health. For example, priorities for combating chronic and communicable diseases, which have been priorities for the EU, have also been adopted as priorities for Cyprus’s health policy. Public participation in priority setting and resource allocation is very limited, although in

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instances in which the Ministry of Health is developing action plans for combating particular diseases or other major public health problems, the Ministry of Health usually consults with interested groups and other stakeholders.

4.5.6. Challenges and Future Perspectives

The general mission of the health system is to safeguard population health and provide high quality health services. The current health system does not provide universal coverage. Approximately 17% of Cypriots must pay out of pocket to access the public health system, or must purchase health care from the private sector. Major health system issues include the fragmentation of services, inadequate coordination between the public and the private sector and a lack of equity in financing. Other problems that have been identified include the uncontrolled deployment and use of high-cost medical technology in the private sector, long waiting times in the public sector, uninsured illegal immigrants and other shortages or inefficiencies in fields of care including rehabilitation, long-term care and palliative care. Cyprus is trying to move to a comprehensive system of universal coverage with better benefits, more effective financing mechanisms, cooperation between the public and private sectors, and reorganization and computerization of all public hospitals. To this end, a new health insurance system has been planned, although it is uncertain as to when this system will ultimately be implemented. The General Health Insurance System (GHIS) is designed to provide universal coverage within a comprehensive health system. To enable the success of the new system, a number of steps must be taken. For example, while computerization has begun in two public hospitals, IT should be improved and expanded where there is no comprehensive health data collection mechanism. The design of adequate payment mechanisms and associated incentives for doctors and hospitals will largely depend on the existence of quality data. Additionally, there is an issue of affordability since patients in many cases bear the cost of care. The affordability issue is evident not only from several Eurobarometer surveys but also by high private expenditure as a percentage of total health expenditure. Also, Cyprus exhibits the typical demographic characteristics of an ageing country with a declining rate of population growth. This has prompted the government to introduce policies targeted at older people such as the development of primary care centres, chronic disease management programmes and other community services.

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Moreover, in the last few years there has been a notable increase in the unemployment rate in Cyprus. The increase in unemployment could have an impact on cardiovascular diseases, mental health and disease prevention, consistent with a number of studies. Concluding, despite shortcomings, inefficiencies and the relatively low expenditure as a percentage of GDP, the health system in Cyprus produces very positive results according to many performance measures. Basic health indicators, such as high life expectancy at birth, low infant mortality rate and low incidence of communicable diseases rank Cyprus fairly high in EU and international comparisons. Likewise, according to many surveys, patient satisfaction is fairly high and care in the public sector is perceived to be of high quality. Major changes associated with the new GHIS are expected to enhance the quality of services, further improve health outcomes and ensure that all Cypriots benefit from health care provision. 4.6. Czech Republic

4.6.1. Demographics of Czech Republic

The Czech Republic is a parliamentary representative democratic republic landlocked country situated in central Europe, with a population of 10.5 million, of which 50.8% were female. In 2011, 94% of the population were ethnic Czechs or Moravians. These are general information of Czech Republic:

Gross national income per capita (PPP Int $) (2015): 25.530

Hospital beds per 100.000 (2014): 646 Physicians per 100.000 (2013): 369

% of population aged 65+ years (2014): 18%

Life expectancy at birth m/f (2014): 76/82 years

Total expenditure on health as % of GDP (2014): 7% Internet users: 75%

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4.6.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The Czech Republic has a system of statutory health insurance (SHI) based on compulsory membership of a health insurance fund, of which there were seven in 2014. The funds are quasi-public, self-governing bodies that act as payers and purchasers of care.

The Ministry of Health’s chief responsibilities include setting the health-care policy agenda, supervising the health system and preparing health legislation. The 14 regional authorities (kraje) and the health insurance funds play an important role in ensuring the accessibility of health care, the former by registering health-care providers, the latter by contracting them. Czech residents may freely choose their health insurance fund and health-care providers. The health insurance funds must accept all applicants; risk selection is not permitted (though there is risk equalization between the funds, see below). Population coverage is virtually universal, and the range and depth of benefits available to insured individuals are broad. Approximately 95% of primary care services are provided by physicians working in private practice, usually as sole practitioners. Primary care physicians do not play a true gatekeeping role; patients are free to obtain care directly from a specialist and frequently do so. Secondary care services in the Czech Republic are offered by a range of providers, including private practice specialists, health centres, polyclinics, hospitals and specialized inpatient facilities. Almost all pharmacies in the Czech Republic are run as private enterprises.

4.6.3. Public Health Indicators

Life expectancy in the Czech Republic at birth is increasing, having reached 75.1 years for men and 81.3 years for women in 2012; these are well above the averages for EU13 Member States of 72.1 years for men and 79.9 years for women, but still below the EU15 averages of 78.8 years for men and 84.1 years for women in 2011. The rate of infant mortality in 2012 was among the lowest in the world: 2.6 deaths per 1000 live births, compared to an EU average of 4 in 2011.

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Diseases of the circulatory system are the most frequent causes of death, followed by malignant neoplasms, respiratory diseases and external causes. Risk factors for circulatory system disease, such as a relatively high rate of alcohol consumption and persistently high smoking rates, have been worrisome. Additionally, there are strikingly high smoking and alcohol consumption rates amongst teenagers compared to other OECD countries.

Vaccination coverage in the Czech Republic is high, with vaccination rates above 98% in all relevant immunization categories except influenza in 2012.

4.6.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

In 2013 internet access was more widespread among Czech enterprises (96.3% of companies had internet access) than Czech private households (67% with home internet access)

Almost every health-care provider in the Czech Republic uses a computerized information system to charge the health insurance funds for goods and services provided. Due to their structure (and also to legal considerations), however, these data are largely unsuitable for uses other than reimbursement, such as health economic analysis or disease management. Data for health policy and research purposes are collected, instead, by the Czech Institute of Health Information and Statistics. All health-care providers are required to send data reports to the ÚZIS on an annual or semi-annual basis. The reports include service volumes, basic economic data and also information about available human and physical resources. In general, the use of information and communications technology (ICT) is underdeveloped in the Czech Republic; for instance plans to implement national e-health capacities have not been realized. In 2012 the Ministry of Health announced a plan to implement a national e- Health system setting up data standards in Czech health care (to achieve so-called “Economical and Effective Electronic Healthcare”) and enabling providers to share data as well as providing aggregated data for policy-making. However, the necessary EU funding has been denied as yet. The health insurance funds tried to develop their own eHealth capabilities, but so far the majority of projects have failed to reach a significant share of the population

There are other fragmented eHealth initiatives in the Czech Republic, such as individual projects that allow physicians in the Czech Republic to share information about patients through electronic medical records. One example is the Internet Access to Patient Health

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Care Information (IZIP) project. The VZP stopped it due to low utilization among the population and financial issues.

4.6.5. Expenditure, Economics, Management

Following a rapid increase in the early 1990s, total health expenditure in the Czech Republic as a share of GDP has remained relatively low (7.7%) compared to the EU average of 9.6% in 2012. Health expenditure from public sources as a share of total health expenditure remains relatively high at just under 85% (the EU average is 75.9%), with the balance made up through out-of-pocket expenditures (private insurance plays only a marginal role). Since 2007 hospitals have been paid for inpatient care using a combination of a diagnosis- related group (DRG) system, individual contracts and global budgets. Since 2009 hospital outpatient care has been reimbursed using a capped fee-for-service scheme. GPs in private practice are paid using a combination of capitation and a fee-for-service payment system, the latter being applied mostly for preventive care. Non-hospital ambulatory care specialists (e.g. self-employed physicians or dentists) are paid using a capped fee-for- service scheme. In 2012, 50.9% of the health insurance funds’ expenditure was devoted to hospital inpatient and outpatient care. Expenditure on ambulatory care has slightly risen since 2005 to 26.1% in 2012.

4.6.6. Challenges and Future Perspectives

Since the early 1990s the Czech health system has undergone various reforms and transformations and in several areas it performs well in international comparisons. The population enjoys virtually universal coverage and a broad range of benefits, and some important health indicators are better than the EU averages (such as mortality due to respiratory disease) or even among the best in the world (in terms of infant mortality, for example). On the other hand, the standardized death rates for diseases of the circulatory system and malignant neoplasms are well above the EU28 average. The same applies to a range of health-care utilization rates, such as outpatient contacts and average length of stay in acute care hospitals, both of which are high. In short, there is substantial potential in the Czech Republic for efficiency gains and improved health outcomes.

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4.7. Denmark

4.7.1. Demographics of Denmark

The Kingdom of Denmark is a parliamentary constitutional monarchy located in the north of Central Europe (Scandinavia). Geographically Denmark consists of more than 400 islands and an estimated area of about 43,000 km². With 5.7 million inhabitants (2016) Denmark has a high population density of 132/km². General information about Denmark:

Gross national income per capita (PPP Int $) (2016): 44,460

Hospital beds per 100,000 (2016): 350 Physicians per 100,000 (2015): 349

% of population aged 65+ years (2012): 18 %

Life expectancy at birth m / f (2016): 78.6 / 82.5 years

Total expenditure on health as % of GDP (2014): 11 % Internet users: 93 %

4.7.2. Healthcare System and Public Health Structure, Organization, and Legislation

The whole population in Denmark with permanent residency is covered by the public health care system. The health system can be characterized as fairly decentralized, with responsibility for primary and secondary care located at local levels. However, a process of (re)centralization has been taking place, which lowered the number of regions from 14 to 5 regions and of municipalities from 275 to 98. Access to a wide range of health services is largely free of charge for all residents. The health system is organized according to three administrative levels: state, region and local. Planning and regulation take place at both state and local level. The state holds the overall regulatory and supervisory functions as well as fiscal functions, but it is also

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increasingly taking responsibility for more specific planning activities such as quality monitoring and planning of the distribution of medical specialties at the hospital level.

The five regions are, among other things, responsible for hospitals as well as for self- employed health care professionals. The municipalities are responsible for disease prevention and health promotion. In recent years, the development of a more coordinated health system has attracted considerable attention. Regulation takes place through, among other things, national and regional guidelines, licensing systems for health professionals and national quality monitoring systems. A series of laws and initiatives has been introduced since the 1990s to strengthen patient rights, including national laws on patient choice as well as the establishment of an independent governmental institution responsible for complaints procedures.

4.7.3. Public Health Indicators

The demographic development is similar to other western European countries, with an increasing proportion of older people and a low birth rate. Life expectancy at birth has risen on average (male and female) between 1980 (74.1 years) and 2016 (80.55 years) by 6.45 years. Major health issues are chronic and lifestyle diseases, as well as diseases that accompany relatively long lifespans. The three main causes of death are cancer, heart disease and other circulatory diseases. In recent decades, there has been an increase in the number of people who report suffering from long-standing illness and chronic disease. However, the number of people considering their health to be good or very good is generally high compared with most EU countries. Risk factors of importance are obesity, tobacco, physical inactivity and alcohol, among others.

 The occurrence of obesity has increased in the last years, as it has in other European countries. A recent regional study indicated that it may be as high as 16 % of the population.

 The use of tobacco has decreased since the end of the 1990s, to around 20 % of the population being daily smokers in 2010. This is lower than OECD and EU15 averages.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

 Alcohol consumption is high in Denmark; in 2008, the average consumption per inhabitant over the age of 15 years was 10.9 litres of pure alcohol. This is similar to the EU15 average (10.8 litres) but higher than the OECD average and the average for other Nordic countries.

In recent decades, deaths from heart disease have declined remarkably. Denmark has a national children’s vaccination program that covers vaccinations against diphtheria, tetanus, pertussis, polio, Hib infection, pneumococcal disease, MMR and diseases caused by the human papilloma virus. In 2008, 89 % of Danish children were vaccinated against measles; this is a smaller figure than the OECD average or the EU15 average. The rate of influenza vaccinations among older people (above the age of 65) is also below OECD and EU15 averages, at 53.7 % in 2006. The vaccination for diphtheria, tetanus and pertussis is given as part of a vaccination package that also includes vaccination against polio and Hib. The vaccination rate for this particular vaccination is around 90 % and has not changed substantially during recent decades.

Quality of care for acute exacerbations of chronic conditions, as expressed in in-hospital mortality rates (deaths within 30 days of admission) following acute myocardial infarction, haemorrhagic stroke and ischaemic stroke, are outcome measures for the quality of acute care.

 The in-hospital mortality rate for acute myocardial infarction was 2.9 % in 2007.

 The in-hospital mortality rate for haemorrhagic stroke was 16.7 % in Denmark in 2007.

 The in-hospital mortality rate for ischaemic stroke was 3.1 % in Denmark in 2007.

4.7.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

In recent years, access to the Internet has generally increased. In 2010, 89 % of the population had access to the Internet from home, compared with 46 % in 2000. The Internet is used increasingly in searching for health information and for contacting GPs or other health professionals. In 2008, around one third of the population had used the Internet to search for health information within a three-month period. By 2010, that number had doubled.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Denmark has established an E-Health Portal (Sundhed.dk) in 2003. The portal allows patients to access waiting list information, schedule appointments at the primary care doctor, review laboratory test results, access medication lists/profiles, e-mail their primary care doctor and renew prescriptions. Several of the options are also available to providers. Patients log in via unique personal signatures and health professionals via their professional digital log in. All views are logged and unjustified use is a privacy violation and can be punished as such. There has been a large increase in the use of the portal, from 78,000 unique monthly entries in 2004 to 258,000 in 2008.

Current use of IT in Primary Care:

Full and functional electronic health record coverage of the health care sector is not expected at any time in the near future. Integrated information systems and electronic health records have been major priorities in the health IT strategies since the late 1990s. All primary care doctors have and use electronic medical records. Since 2004, primary care doctors have been mandated to use computers and a system for electronic medical records and communication.

In 2010, 90 % of all clinical communication between primary and secondary care was exchanged electronically.

Current use of IT in Secondary Care:

Within hospitals, IT systems are used to register patient data such as patient files, patient administrative systems, laboratory systems, blood bank systems and diagnostic imaging and booking systems. More than 10 different systems, however, are in use across the five different regions. These systems differ from the ones used by primary care doctors.

Health IT Strategies:

Focus is now on creating a common electronic health record system within each of the five regions rather than establishing a common system for Denmark. By the end of 2013, however, all hospitals in the regions must be able to communicate through a national platform, the e-Journal, in order to share relevant information about patients.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

4.7.5. Expenditure, Economics, Management

The health care expenditure is slightly higher than the average for EU15 countries. Denmark spent the equivalent of USD 4,553 per person on health in 2013, compared with an OECD average of USD 3,453. Health care expenditure as a share of total government expenditure has also been fairly stable, falling from 26 % in 1990 to 24–25 % in 2000, followed by a rise to 27 % in 2008. Publicly financed health care: Public expenditures in 2013 accounted for 84 percent of total health spending, representing 10.4 percent of GDP in 2013. All registered Danish residents (coverage of 100 %) are automatically entitled to publicly financed health care, which is largely free at the point of use. In addition, around 27 % of the population have private health insurance, which usually tops up their national healthcare needs and provides cover for dentistry and expenses for medicines. Health care is financed mainly through a national health tax, set at 8 percent of taxable income. Revenues are allocated to regions and municipalities, mostly as block grants, with amounts adjusted for demographic and social differences; these grants finance 77 percent of regional activities. A minor portion of state funding for regional and municipal services is activity-based or tied to specific priority areas, usually defined in the annual economic agreements between national government and the municipalities or regions. The remaining 20 percent of financing for regional services comes from municipal activity- based payments, which are financed through a combination of local taxes and block grants.

4.7.6. Challenges and Future Perspectives

Generally, the organization of the Danish health system can be described as relatively decentralized, with specific health care activities being carried out at the local and regional level. However, during recent years, there has been an increasing focus on national centralized governance, and intersectoral coordination has been developed. The reforms and policies since the early 2000s have, therefore included both (re-)centralizing and decentralizing elements. A recurrent characteristic of recent initiatives is the establishment of greater units within the system providing health care. Recent years have also seen the introduction of more activity-based financing in the public health system, which is combined with more traditional global budgeting in an effort to provide incentives to increase production as well as to stay within the budget; however, incentives promoting higher activity do not necessarily promote higher productivity as well.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

The Danish health status is generally good, with decreases in many mortality and morbidity rates over the last 10–20 years. However, Denmark is still lagging behind in some areas compared with the other Nordic countries, for example with regard to life expectancy. However, improvements have been seen in recent years, as mentioned above, and nationwide initiatives to monitor the quality of health care (such as the DDKM) have been established.

The most recent health system changes, including the major structural reform of 2007, provide a great learning potential. It is still not clear, however, if a more decentralized or a more centralized structure is preferable. What is clear from the latest major reform is that any major structural reform may bring about a transition period where little is actually done, as organizations, employers and employees spend time positioning them according to the new reform and await more concrete decisions on implementation. With their E-Health Portal (Sundhed.dk) Denmark enables access of health care data for a large proportion of the population. Anyhow remain some challenges in the interconnection of the public health systems (e.g. Institution of a uniform electronic health record system). 4.8. Estonia

4.8.1. Demographics of Estonia

Estonia is a country on the east coast of the Baltic Sea with a population of 1.3 million. The Estonian population is ageing. Cardiovascular diseases and cancers are leading causes of mortality and morbidity, with musculoskeletal diseases and mental health problems becoming gradually more important.

General information about Estonia: Gross national income per capita (PPP Int $) (2015): 24,230

Hospital beds per 100,000 (2015): 540 Physicians per 100,000 (2015): 324

% of population aged 65+ years (2011): 19 %

Life expectancy at birth m / f (2015): 73 / 82 years

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Total expenditure on health as % of GDP (2014): 6.4 % Internet users: 79 %

4.8.2. Healthcare System and Public Health Structure, Organization and Legislation

The regulatory framework of the Estonian health system is laid down in five major pieces of legislation: The Health Insurance Act, the Health Services Organization Act, the Public Health Act, the Medicinal Products Act and the Law of Obligations Act.

The Estonian health care system is mainly publicly funded through solidarity-based mandatory health insurance contributions in the form of an earmarked social payroll tax, which amounts to about two-thirds of total health care expenditure. The Ministry of Social Affairs is responsible for financing emergency care for uninsured people, as well as for ambulance services and public health programs. The main purchaser of health care services for insured people is the ‘Estonian Health Insurance Fonds’ (EHIF). The health insurance system covers about 95 % of the population.

The Estonian health system is based on compulsory, solidarity-based insurance and universal access to health services made available by providers that operate under private law. Stewardship (planning and regulation) and supervision as well as health policy development are the duties of the Ministry of Social Affairs and its agencies. The financing of health care is mainly organized through the independent EHIF. The Ministry of Social Affairs and its agencies are responsible for the financing and management of public health and ambulance services financed by the state budget. Local municipalities have a minor, rather voluntary, role in organizing and financing health services. The Estonian health system has developed with the strong participation of professional organizations.

4.8.3. Public Health Indicators

The economic situation and overall well-being have improved over the years but there are still inequalities in health and service utilization. In 2012, Estonians were living longer than ever before, and over the years a steady improvement in life expectancy has been observed. While regional differences in life expectancy have declined, the gender gap in life expectancy is still about 10 years in favour of women.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Many other health indicators are also improving, including infant mortality. In 2015 the infant mortaliy rate which is defined as the number of infants dying before reaching one year of age, per 1,000 live births, was only 2,3. Another problem is increasing obesity rates in most population groups. Intercountry comparable overweight and obesity estimates from 2008 (1) show that 53.7 % of the adult population (> 20 years old) in Estonia were overweight and 20.6 % were obese. The prevalence of overweight was higher among men (59.0 %) than women (49.4 %). The proportion of men and women that were obese was 20.9 % and 20.4 %, respectively. Adulthood obesity prevalence forecasts (2010–2030) predict that in 2020, 27 % of men and 20 % of women will be obese. By 2030, the model predicts that 35 % of men and 22 % of women will be obese. The majority of the current avoidable disease burden is concentrated among the working- age population and is caused by various risk factors, such as smoking and alcohol consumption. A reduction in avoidable mortality in the period 2000–2010 indicates a strong health system contribution to life expectancy gains over the years through preventive and treatment actions, while data for cardiovascular diseases, cancers and injuries indicate that there is still room for improvement.

4.8.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

Eurostat (European Commission, 2013b) data show that 68 % of households in Estonia had Internet access in 2010, which is close to the EU27 average (70 %) and considerably higher than in 2006 (46 %). While in most EU27countries, the proportion of users of the Internet has reached 85–93 % in all age groups, in Estonia only 65 % of those aged 55–74 were using the Internet in 2010.

From an information technology perspective, the Estonian health care landscape is quite diverse. Over the years, most providers of health care services deployed their own information systems and, consequently, these are not mutually compatible and cannot exchange information.

To combat these information technology problems, the Ministry of Social Affairs initiated in 2005 the development of four e-health projects: electronic health records, digital images,

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

digital registration and digital prescription. It was expected that the implementation of these four projects would create a unified national health information system that would be linked with other public information systems and registers while using the existing public information technology solutions. The system was scheduled to become operational by 2009, but only the digital prescription project, was launched in 2010. By 2012, several components of the electronic health records were functional, but because of technical problems with compatibility and some resistance from staff, not every health provider is submitting the data as expected. As a result, the system does not contain sufficient information on every patient and does not allow easy access and use at every location.

4.8.5. Expenditure, Economics, Management

Estonia spent 5.9 % of its GDP on health in 2011. Health care is largely publicly financed. Since 1992, earmarked payroll taxes have been the main source of health care financing. Other public sources of health care financing include the state and municipal budgets, accounting for approximately 9.3 % and 1.4 %, respectively, of total health care expenditure in 2010. The public share of health care spending has declined from 89.8 % in 1995 to 79.3 % in 2011. Private expenditure constitutes approximately 20 % of all health expenditure, mostly in the form of co-payments for medicines and dental care. This share has fallen during the economic crisis, partly because OOP payments fell in line with spending in the economy but also because of increased generic prescribing. The private spending share of EHIF’s (Estonian Health Insurance Fonds) reimbursed medicines decreased from 38.8 % in 2008 to 33.0 % in 2012.

From a European perspective, the level of health expenditure as a share of GDP in Estonia has been rather low over time, with small variations reflecting changes in the economic environment. Health care expenditure in purchasing power parity per capita has increased from a low of US$ 522 in 2000 to US$ 1190 in 2011. In 2010, the per capita spending was slightly below the average for the 12 countries that joined the EU in 2004 and 2007 along with Estonia (EU12). Furthermore, public spending on health in Estonia is higher than all EU averages.

4.8.6. Challenges and Future Perspectives

The challenges are diverse and include financial sustainability, ensuring an adequate workforce, accountability of different health system stakeholders, OOP levels for lower-

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

income groups, optimizing the hospital network, strengthening primary and patient- centred care, as well as better integration of social and health care.

There is a need to enhance provider activity evaluation and monitoring tools across the health system to improve quality and health outcomes. Investments in the e-health system play a critical role here through better exchange of information and increasing accountability. The future challenge remains how to implement public health measures within and outside the core health system in order to improve population health. 4.9. Finland

4.9.1. Demographics of Finland

Finland numbers 5.498.211 people, with the following age structure: 37,9 % of inhabitants are aged between 25 and 54 years; 20,66 % are older than 65 years; 16,42% are below 14 years old; 13,42% are in the range between 55 and 64 years; and 11,6% of population is from 15 to 24 years old. At birth, there are 1.05 males per female in Finland. This ratio decreases to 0.97 males per female for all ages. The birth and death rate are at approximately the same level and amounts – 11 births and 10 deaths per 1.000 people. Finland has a population growth rate of 0.37% which is 0.84% lower than average in the world. The life expectancy is 81 years. The average population density is 17 inhabitants per square kilometre. 84% of the population is living in an urban area. Finland's GDP per capita is 42.311 $, while GNI per capita is 46.550 $. Since Finland's GNI is higher than its GDP, this suggests that Finland has more foreign investments abroad than countries investing within its borders.

4.9.2. Healthcare System and Public Health Care Structure, Organisation and Legislation

The healthcare system in Finland is highly decentralized, with three different health care systems in Finland which receive public funding: municipal health care, private health care and occupational health care, as well as much smaller private sector. Finland puts an effort to enhance health promotion and prevention of disease for the few last decades.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Primary health care services are -the responsibility of municipalities and are generally provided through local health centres (terveysasemat). Each municipality has a health centre, with the exception of some small municipalities, which may share resources with a neighbouring municipality. The health centres provide residents with physician, dental, laboratory and radiographic services. The municipalities own and operate almost all of the hospitals. Primary health services provided by municipalities are defined in the Primary Health Care Act. Secondary care is provided by the municipalities through district hospitals (sairaalat) where more specialist care is available. Secondary care is provided by regional hospitals. Finland also has a network of five university teaching hospitals which makes up the tertiary level. These contain the most advanced medical equipment and facilities in the country. These are funded by the municipalities, but national government meets the cost of medical training. These hospitals are located in the major cities of Helsinki, Turku, Tampere, Kuopio, and Oulu. All these five cities have a medical faculty. Patients who use private-sector services pay the entire cost of the service to the provider, after which they can apply for reimbursement from Kansaneläkelaitos/Folkpensionsanstalten (Kela/FPA) under the Health Insurance Act. The authority body for organization and management of Finland’s healthcare system is Ministry of Social Affairs and Health. The Ministry directs and guides the development and policies of social protection, social welfare and health care. Due to the decentralized public administration, municipalities decide themselves how the local services are provided. In Finland, the state's responsibility to promote welfare, health and security is rooted in the Constitution. This enshrines the right of everyone to income and to care, if they are unable to manage adequately. (The Constitution of Finland 731/1999). The duties of municipal authorities throughout Finland to arrange social and health care are stipulated by laws on social and health care planning and the central government transfers to local government. The law on social welfare stipulates the services that municipalities must produce. (Social Welfare Act 1301/2014). The law on the status and rights of social care clients includes issues of data security.

Special legislation covers: child welfare, child day care, the treatment of substance abusers, the special care of people with intellectual disabilities, disability services, informal care support, family care, rehabilitation, older people. (Child Welfare Act 417/2007; Family

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Carer Act 312/1992; Act on Supporting the Functional Capacity of the Older Population and on Social and Health Services for Older Persons).

There are laws also dealing with ascertaining paternity, child maintenance and security, child care and implementing rights of access, adoption counselling, and family conciliation matters. (Adoption Act 153/1985, Marriage Act 234/1929, Social Welfare Act 1301/2014).

Laws on health care, primary health care and specialized medical care cover health services. (Health Care Act 1326/2010; Primary Health Care Act 66/1972; Act on Specialized Medical Care 1062/1989).

There are separate laws on occupational health care, mental health services and the prevention and treatment of infectious diseases, and the status and rights of patients. (Occupational Health Care Act 1383/2001, Mental Health Act 1116/1990, Communicable Diseases Act 786/1986, Act on the Status and Rights of Patients 785/1992). Legislation also covers the professional standards of social and health care personnel. (Act on Qualification Requirements for Social Welfare Professionals 272/2005; Act on Health Care Professionals 559/1994).

4.9.3. Public Health Indicators

In Finland the 9,4% of GDP yearly is invested and spent in healthcare system. Euro health consumer index placed Finland in 8th position in its 2016 survey, but as a leader in value-for-money healthcare. World Bank Indictors of Finnish public healthcare shows that on 1000 people there are: 5,5 hospital beds, 2,9 physicians, 10,86 nurses and midwifes. Per 100 000 births Maternal mortality ratio is 4, while mortality rate under 5 years old is 3 (per 1000 live births). Life expectancy is 81 years. The cause of death data shows that mortality amenable to healthcare is 82.5 per 100,000; Mortality after surgery is 2.0%; Hospital acquired C-difficile 30 day mortality is 14%. The average proportional 5 year cancer survival is 49.3%. Postoperative pulmonary embolism or deep vein thrombosis is 680 per 100 000 discharges. Foreign body left in during procedure is 3,4 per 100 000 discharges. Age-adjusted 30 day In-hospital case- fatality rate following Acute myocardial infarction (per 100 patients) is 4,8.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Mammography Screening, percentage of women aged 50-69 screened, 2000-2009. is 84.4%. Percentage of participants ‘fairly satisfied’ or ‘very satisfied’ with their healthcare is 66%. Average length of stay for acute myocardial infarction is 8.8 days. Average length of stay for normal delivery is 3.1 days.

4.9.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

The National Electronic Health Records (EHRs) is introduced in 2007 by Government. Core data elements of electronic health record have been defined through a consensus-based approach. The main elements are the patient identification information, the provider's identification information, care episode, risk factors, health patterns, vital signs, health problems and diagnosis, nursing minimum data set, surgical procedures, tests and examinations, information about medication, preventive measures, medical statements, functional status, technical aids, living will, tissue donor will, discharge summary, follow-up care plan and consent information.

EHR is obligated to use in all healthcare facilities – primary, secondary and tertiary. Finland healthcare system use electronic information systems for laboratories, pathology, pharmacy and PACS. From ICT-assisted functions in Finland, there are electronic medical billing systems, supply chain management information system and human resources for health information system. Finland has established the following tele-health programs: teleradiology at regional level and telepsychiatry at regional and national level. At local level, the teledermatology, telepathology and remote patient monitoring is in pilot phase.

4.9.5. Expenditure, Economics, Management

Government of Finland spent about 10% of total expenditure on healthcare per year.

Health care in Finland is mainly provided on the basis of residence and is primarily financed with general tax revenues.It is also funded by patient fees. The maximum fees municipalities can charge are stipulated in the Act and Decree on Social and Health Care Client Fees. Municipalities fund the health centers on the primary care level and regional hospitals on secondary care level. National Health Insurance (NHI) is based on compulsory | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

fees and it is used to fund private healthcare, occupational healthcare, outpatient drugs and sickness allowance. Regional and university hospitals are financed by federations of participating municipalities. The authority body for organization and management of Finland’s healthcare system is Ministry of Social Affairs and Health. The Ministry directs and guides the development and policies of social protection, social welfare and health care.

4.9.6. Challenges and Future Perspectives

Lower fertility rates and an aging population, due to increased life-expectancy, brings new challenges to the Finnish health care system. As there will be fewer people to pay for health and social care, many of the aging population can be predicted to be effected. It is estimated that the old age dependency ratio in Finland will be the highest of all EU countries in 2025. 4.10. France

4.10.1. Demographics of France

According to the official data of Institut National de la Statistique et des Études Économiques, the population of France officially reached 67 million in March 2017. The population density is 121.5 people per km2. An average annual grow rate is +0,6%. The data from 2016 shows that crude birth rate per 1000 was 11,5 and crude death rate per 1000 was 8,9. At birth, there are 1.05 males per female in France. This ratio decreases to 0.96 males per female for all ages. The life expectancy is 82.4 years. The fertility rate is about 1,9 %, while infant mortality rate is 3,7 per 1000. 79% of the population is living in an urban area.

France's GDP per capita is 36.205,60$ and GNI per capita is 40.540,00$. It is clear that France has more foreign investments abroad than countries investing within its borders.

4.10.2. Healthcare System and Public Health Care Structure, Organisation and Legislation

The French health care system is generally recognised as offering one of the best, services of public health care in the world. The health care system in France is made up of a fully-

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

integrated network of public hospitals, private hospitals, doctors and other medical service providers. It is a universal service providing health care for every citizen, irrespective of wealth, age or social status. The structure of French heath care system is consisting of primary health care providers, special health care providers, hospitals and accident and emergency service providers.

Primary health care is provided by a network of 23,000 general practitioners (French: médecins généralistes). Most GPs are self-employed professionals, and work either on their own, or in group practices. Citizens are free to choose the GP they want, as their personal doctor. Citizens may also consult any other GP they wish, but only the personal doctor with whom they are registered is authorised to refer patients to a specialist or to another health care provider - nurse, physiotherapist, etc - for further care under the health care system. In most cases, patients have to pay a flat rate fee for any visit to a general practitioner. The cost in 2017 is 23 € per visit, unchanged for 4 years, irrespective of the time taken, but is higher for visits to surgeries open at night or at weekends, and for home visits. Most of the cost will then be automatically reimbursed to the patient by his state-run health insurance provider, leaving the patient with between zero and 6 Euros to pay for a standard trip to the doctor, depending on the type of health care insurance he has and the age or medical condition of the patient. Accident and emergency A&E services (French: les urgences) are part of the national heath care system. All cities and large towns have a service know as the SAMU, which is the emergency ambulance service situated. Specialist health care is provided by thousands of specialists in all branches of medicine, in towns and cities throughout France. Specialists charge higher fees than general practitioners, but again there are official rates agreed with the National Health Service, which form the basis on which patients are reimbursed. A large number of specialists apply tariffs that are higher than the official rates; in such cases, patients will either be reimbursed according to the standard rate, or else at a higher rate, if their health insurance provider provides for this. Visits to specialists in France are only reimbursed by the health care system at the full rate if the patient has been referred to the specialist by his own GP. Citizens may also visit any specialist they want, without getting referred by their own GP; but if they do so, the cost of their specialist visit will only be paid back at the basic GP visit rate, however much they paid.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

The main exception to this is for dentists: dental care is covered by the health service, but has its own tariffs and reimbursement rates. The most basic dental work - fillings, extractions etc. - is carried out and paid for under much the same conditions as other specialist health care treatment. Other more complex operations are also reimbursed, but at lower rates.

At pharmacies, the pay-and-get-reimbursed principle is applying; the patient pays only the part of the cost that is not taken care of by the state health care system. There are two sorts of hospitals in France; generally speaking, these are known as hôpitaux when they are state run, and cliniques when they are privately run. Most private cliniques are state approved, and can therefore work for the National Health Service. Many specialists work in both state run hospitals and in private clinics: since they are self- employed professionals, they can sell their services to whatever hospital or clinic will pay them. Both GPs and specialists can refer patients for hospital treatment if it is deemed necessary; and within the framework of the health service, they can send them for treatment in either a state-run hospital or a private clinic, whichever they consider to be best for the purpose, or to provide the fastest service.

Regulation of the health care system in France is conducted by the statutory health insurance funds and the state, which consists of the parliament, the government and ministries. The health care system is coordinated centrally by the Ministry of health, and administered by the actors in the service, hospitals, clinics, doctors, other health care providers, pharmacies, ambulance companies, etc.

4.10.3. Public Health Indicators

France is investing 11,5% of GDP in health care system. According to official data of European Health Consumer Index from 2016, France is positioned at 11th place. France has dropped out of the top 10 after reducing formerly liberal access to specialist services around 2009. France has long had the lowest heart disease mortality in Europe, and was the first country (1988), where CVD was no longer the biggest cause of death. Also, France was at first place in the recently published Euro Heart Index 2016. There are 1 general practitioners per 2600 inhabitants, 3,19 physicians per 1000 inhabitants and 6,4 beds per 1000 inhabitants.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Maternal mortality rate is 8 deaths per 100 000 live births. Per 100 000 people, 0.8 died due to tuberculosis, while the incidence of tuberculosis is 8.2 people per 100 000. Tobacco smoking rates remain high in France with statistics indicating 32% of men and 26% of women smoke daily.

4.10.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

In France, the “Hôpital numérique 2012–2017” program was implemented as part of a strategic plan to modernize health information technology (HIT), including the promotion of widespread electronic healthcare records (EHR) use.

Daily emergency telemedicine is performed by SAMU (Accident and Emergency) Regulator Physicians in France.

4.10.5. Expenditure, Economics, Management

The French health care system is funded in part by obligatory health contributions levied on all salaries, and paid by employers, employees and the self-employed; in part by central government funding; and in part by users who normally have to pay a small fraction of the cost of most acts of health care that they receive. The transfer of funds through the system between patients and health care providers is ensured by the National Health Service, the "Sécurité sociale", and often subcontracted to complementary health insurance funds known as Mutuelles. The system is highly computerised, since the introduction over ten years ago of a health insurance smartcard known as the Carte Vitale.

The job of bringing in the obligatory health insurance contributions owed by employers, employees and the self-employed is undertaken by an organisation known as the URSSAF.

4.10.6. Challenges and Future Perspectives

Like health insurance schemes everywhere, the French state health insurance program has difficulty making ends meet, and relies increasingly on top-ups from the general budget of the state. An ageing population and the explosion of health care costs due to increasing

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

expectations and the development of expensive new processes and medicines, have put enormous strains on the system. The rates of reimbursement have been reduced in recent years, and some contributions increased. In short, almost everyone in the Europe knows that France has one of the best health services in the world, if not the best, and one that is the envy of many other countries. New solutions will be needed in the years to come to make sure that the system continues to provide this high level of service; but there is more or less total consensus in France that whatever the cost may be, it will be worth it. The France called for action to reduce adult smoking rates to 15% by 2025. 4.11. Germany

4.11.1. Demographics of Germany

The Federal Republic of Germany is situated in central Europe and covers an area of approximately 357,000 km2. In 2015, Germany had approximately 80.6 million inhabitants. Among them are 7.2 million inhabitants without German citizenship (8.8 % of total population; 6.4 % on EU average): around 2.4 million residents (33 %) are citizens of an EU Member State; another 1.2 million (17 %) come from other parts of Europe and 1.4 million (20 %) are non-European. In both the west and the east, the share of the population below 15 years of age, for example, decreased from 24.5 % in 1970 to 13.8 % in 2010. Between 1970 and 2011, the share of those 65 years of age or older increased from 13.9 % to 20.7 %. Finally, the share of population 80 years of age or older increased to 5.3 % in 2011 and is expected to increase to 14 % by 2060. General information about Germany:

Gross national income per capita (PPP Int $) (2015): 49,090 Hospital beds per 100,000 (2009): 830

Physicians per 100,000 (2009): 348

% of population aged 65+ years (2015): 21 %

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Life expectancy at birth m / f (2015): 79 / 83 years Total expenditure on health as % of GDP (2014): 11.3 %

Internet users (2009): 79 %

4.11.2. Healthcare System and Public Health Structure, Organization and Legislation

Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by competing, not-for-profit, nongovernmental health insurance funds (124 as of January 2015) in the statutory health insurance (SHI) system, or by substitutive private health insurance (PHI). States own most university hospitals, while municipalities play a role in public health activities, and own about half of hospital beds. However, the various levels of government have virtually no role in the direct financing or delivery of health care. A large degree of regulation is delegated to self-governing associations of the sickness funds and the provider associations, which together constitute the most important body, the Federal Joint Committee. Publicly financed health insurance: Coverage is universal for all legal residents. All employed citizens (and other groups such as pensioners) earning less than EUR54,900 (USD69,760) per year as of 2015 are mandatorily covered by SHI, and their nonearning dependents are covered free of charge. Individuals whose gross wages exceed the threshold and the previously SHI-insured self-employed can remain in the publicly financed scheme on a voluntary basis (and 75 % do) or purchase substitutive PHI, which also covers civil servants. About 86 percent of the population receive their primary coverage through SHI and 11 percent through substitutive PHI. Private health insurance: In 2014, 8.8 million people were covered through substitutive private health insurance. There were 42 substitutive PHI companies in June 2015 (of which 24 were for-profit) covering the two groups exempt from SHI (civil servants, whose health care costs are partly refunded by their employer, and the self-employed) and those who have chosen to opt out of SHI. All of the PHI-insured pay a risk-related premium, with separate premiums for dependents; risk is assessed only upon entry, and contracts are based on lifetime underwriting. Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

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PHI also plays a mixed complementary and supplementary role, covering minor benefits not covered by SHI, access to better amenities, and some copayments (e. g., for dental care). Federal government determines provider fees in substitutive, complementary, and supplementary PHI through a specific fee schedule. There are no government subsidies for complementary and supplementary PHI.

4.11.3. Public Health Indicators

In terms of infant mortality, Germany, with 3.4 deaths per 1,000 live births in 2010, was significantly better than the ‘OECD’ average of 4.1 and slightly better than the ‘EU15’ average of 3.6. Germany scores comparatively well in the medical care of patients who have suffered a stroke. In 2011, Germany had a relative low case-fatality rate (6.7 % within 30 days after admission) for adults aged 45 and over hospitalized following an ischaemic stroke. Although 10 countries had lower rates, Germany was, according to the report, below the ‘OECD’average of 8.5 %. In contrast, when looking at the hospital mortality rates within 30 days after admission for an acute myocardial infarction, the results for Germany are sobering. The age- and gender- standardized rate was 8.9 %, thus significantly above the OECD average of 7.9 %. The relative survival rates over a five-year period (2006–2011) of cancer show that only in the case of cervical cancer (64.5 %) was the rate in Germany below the ‘OECD average (66.0 %). Survival rates in breast cancer (85.0 %) and colorectal cancer (64.3 %) were above the OECD average of 84.2 % and 61.3 %, respectively. Germany is not leading among ‘OECD’ countries to the extent that its health service avoids the occurrence of disease through preventive measures. With a breast cancer screening rate of 54.3 % for women aged between 50 and 69 years, Germany lies well below the ‘OECD’average of 61.5 %. The age-standardized mortality rate for breast cancer (30.0 per 100 000 women) is above the ‘OECD’ average (26.3). The mortality rates for colorectal cancer (24.0 per 100,000 population) and cervical cancer (3.0 per 100,000 women) are, however, below the ‘OECD’ average of 25.0 and 3.7, respectively. Looking at Germany’s position among the comparable countries, it has the highest rate of breast cancer mortality and it ranks in the middle of the list for colorectal cancer and cervical cancer.

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4.11.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

Use of Internet: Private use of the Internet by those aged 10 years and over was at 58 % in 2004 and increased to 71 % by 2008. In 2008, the usage rate varied slightly among the sexes (76 % of men and 66 % of women stated that they were using the Internet) but varied significantly with age: 95 % of the population aged 10–24 years used the Internet, 87 % aged 25–54 years and merely 36 % of those over 55 years. Information and communication technologies in the health care sector are ascribed increasing importance with regard to efficient utilization of resources, improvement of service quality and an increased patient orientation. Within the framework of the action plan “eEurope” for the promotion of the development of the information society in the EU, the initiative “eHealth” was started in 2004 for the health sector. In this context, the EU Member States are required to develop international standards for the exchange of health data.

The electronic health card (eGK) contains administrative data for billing purposes. These include name, address, date of birth, sex, insurance number, insurance status and cost- sharing status. From the technical point of view, the eGK is designed in a manner that will allow medical data to be stored in future expansion stages, such as emergency data (e. g. allergies, drug intolerances) as well as references to patient health care directives and organ donation declarations. In future, it may, for instance, also be possible to store drug documentation, vaccination documentation or an electronic patient file. While the storage of administrative data is mandatory, patients can voluntarily decide on the management of their personal medical data.

In 2006, 95 % of all family physicians in Germany used computers in their practices, which was above the EU15 average of 77 %. In addition, 26 % of practices had their own websites and 48 % used electronic patient files for their internal work. In 2007 99 % of family physicians in Germany had a computer in their practice (EU average 87 %) and 85 % even had computers in their consultation rooms (EU 78 %). In Germany, 59 % had Internet access (EU 69 %), but only 40 % had a broadband connection.

4.11.5. Expenditure, Economics, Management

Germany spends a substantial amount of its wealth on health care. According to the Federal Statistical Office, which provides the latest available data on health expenditure, total

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health expenditure was €300.4 billion in 2012, of which 73 percent was public and 58 percent was SHI spending. This corresponds to 11.4 % of GDP. Total health expenditure as a share of GDP recorded the highest increase between 2008 and 2009 (from 10.7 % to 11.7 %), which can be explained by the strong rising of health care expenditure and simultaneously decreasing GDP.

According to WHO, which has lower estimates for health care expenditure, Germany ranked at the fifth place (11.1 % of GDP) among European countries in 2011, just behind the Netherlands (12.0 %), France (11.6 %), the Republic of Moldova (11.4 %), and Denmark (11.2 %), and followed by Switzerland, Austria and Belgium. The EU15average was 10.3 % and new EU Member States 6.9 %. In terms of per capita health expenditure measured in US$ purchasing power parity, Germany’s expenditure in 2011 (US$ 4,371) was higher than the EU15 average of US$ 3,717, but much smaller than those of Luxembourg, Monaco, Norway, Switzerland and the Netherlands – and just behind Denmark and Austria. Germany ranked eighth among all western European countries.

General tax–financed federal spending on “insurance-extraneous” benefits provided by SHI (e. g., coverage for children) amounted to about 4.4 percent of total expenditure in 2014 and 2015. In 2013, all forms of PHI accounted for 9.2 percent of total health expenditure.

4.11.6. Challenges and Future Perspectives

The German health care system shows areas in need of improvement when compared with other countries. This is demonstrated by the low satisfaction figures with the health system in general; respondents see a need for major reform more often than in many other countries. If the outcomes of individual illnesses are analyzed, an important area is quality of care. In spite of all the reforms that have taken place, Germany is rarely placed among the top OECD or EU15 countries, but usually around average, and sometimes even low.

During reform measures, more emphasis could, therefore, be placed on the improvement in quality of medical services. Although much is already being done for the measurement and securing of quality, which is, for instance, shown by the quality indicators in the inpatient sector, a sustainable improvement has not resulted overall and is probably counteracted by the significantly increasing number of cases in some areas, which give rise to the suspicion that there may be an inadequate provision of services and thus a lack of contribution to the improvement of results. In addition to the publicly discussed safeguarding of health care in

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rural areas, overcapacities that become apparent in international comparisons should be given increased attention.

In addition, the division into SHI and PHI remains one of the largest challenges for the German health care system – as risk pools differ and different financing, access and provision lead to inequalities. Reform measures that hamper the inflow of ‘good risks’ into the PHI system (and which have in the meantime been taken back again) and which at the same time facilitate the inflow of ‘bad risks’ through the basic tariff, as well as the increase of tax-based funding, are merely the first steps on the way towards fair competition between the health insurance systems and, ultimately, towards a sound and sustainable health system for the entire population based on solidarity. 4.12. Greece

4.12.1. Demographics of Greece

Greece is located in south-eastern Europe, on the southern end of the Balkan peninsula and covers an area of 131 957 km2. It has about 15 000 km of coastline (Aegean Sea, Ionian Sea and Mediterranean Sea) and a land boundary with Albania, Bulgaria, the former Yugoslav Republic of Macedonia to the north and Turkey to the east, totaling 1180 km. About 80% of the country is mountainous or hilly. According to estimates from the National Statistical Service of Greece (NSSG), the population of the country in 2008 was approximately 11.2 million. In absolute figures, this represents a 27.8% increase since 1970, an 11.4% increase since the early 1990s and a 2.5% increase since the last census in 2001. Population density is 84.5 per km2, yet the population is unevenly distributed, with far more people living in the mainland, particularly the area of greater Athens. More specifically, 61.4% of the population lives in urban areas and 34.3% in the area of greater Athens. The age distribution of the population has changed substantially since 1970. A shift among the age groups has occurred, revealing a decrease in the 0–14-year-old age group of 10.3% and an increase in the 65 years and over age group of 7.6%. In addition, the proportion of very old people (over 80) increased to 3.9%. As a consequence, in 2008 the Greek population aged 65 and over corresponded to 27.7% of the working age population. This figure was the third highest in the EU27 after Italy (30.4%) and Germany (30.0%).

Based on NSSG population projections, it is expected that the Greek population will increase by 240 000 inhabitants until the year 2020, after which the population will start to decline gradually as net migration will no longer outweigh natural decline. The 2001

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census had a total of 762 191 registrants who are normally resident and without Greek citizenship, constituting approximately 7% of the total population. The majority of this group are Albanians (56%) and mainly of working age (80%). However, according to Migration Policy Institute estimates the immigrant population in 2004 stood at around 1.15 million or 10.4% of the total population. Given the lack of sufficient and reliable data, it is difficult to provide the number of legal immigrants in Greece. It could be argued that about 61% are legal, considering that, by October 2004, some 700 000 residence permits had been issued.

Table 4.12.1.1. General Information of Greece

General Information of Greece Gross national income per capita (PPP Int $) (2015): 25.630 Life expectancy (2015): 81 years Hospital beds per 100.000 (2014): 420 Physicians per 100.000 (2014): 625 % of population aged 65+ years (2013): 20 % Life expectancy at birth m/f (2012): 78 / 84 years Total expenditure on health as % of GDP (2014): 9,8 % Internet users: 56 % Source:Data and Statistics of Greece (WHO)

4.12.2. Healthcare System and Public Health Structure, Organisation, and Legislation

Following the OECD classification (OECD 1992), it could be argued that the Greek health care system is a mixture of the public integrated, public contract and public reimbursement systems, incorporating principles of different organizational patterns. The existence of different subsystems and organizational models, combined with a lack of mechanisms for coordination, results in fragmentation and overlaps in care, and creates significant difficulties in the management of the system as well as in the planning and implementation of national health policy. The Greek health care system comprises elements from both the public and private sectors. In relation to the public sector, elements of the Bismarck and the Beveridge models coexist. Social insurance funds continue to play a significant role in the provision and financing of

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health care, especially ambulatory services, and follow two patterns. The first includes funds which have their own medical facilities and cover all the primary health care needs of their insured population. Under this arrangement medical professionals are paid a salary. The second pattern of provision concerns funds which do not own any medical facilities directly but enter into contracts with medical practitioners who are compensated via a defined fee-for-service on a retrospective basis. The level of compensation is subject to approval by the Ministries of Health and Social Solidarity, of Finance and Economics, and of Employment and Social Protection. A variation of this pattern occurs where insured people choose whatever professional they wish to consult and pay the current price on the medical market for the service received; they are then reimbursed a prescribed amount from their sickness fund. This amount is also determined by the three ministries mentioned. The social insurance system in Greece comprises a large number of funds and a wide variety of schemes under the jurisdiction of the Ministry of Employment and Social Protection (formerly the Ministry of Labour and Social Protection), and assignment to one of them depends on the occupation of the insured. There are about 30 different social insurance organizations which provide coverage against the risk of illness. Most of them are administered as public entities and operate under state control. Each insurance institution is subject to different legislation and, in many cases; there are also differences in contribution rates, coverage, benefits and the conditions for granting these benefits, resulting in inequalities in access to and financing of services. According to the provisions of the social insurance law passed in July 2010 (Law 3863/2010), the social insurance funds will need to be merged into only three funds. The National Health System (ESY) is financed by the state budget via direct and indirect tax revenues and provides for emergency pre-hospital, primary and inpatient health care through rural surgeries, health centres and public hospitals, which are reimbursed on a per diem basis. Doctors working in public hospitals and health centres are full-time employees who are not allowed to engage in private practice and are paid a salary. The private sector includes profit-making hospitals, diagnostic centres and independent practices, financed mainly from out-of-pocket payments and, to a lesser extent, by private health insurance (PHI). Besides indemnity insurance for health professionals, the latter can take either the form of preferred provider networks or integrated insurers and providers’ schemes. A large part of the private sector, as mentioned above, contracts with social health insurance/sickness funds to provide mainly primary care, and is financed on a fee- for-service basis according to predetermined agreed prices. | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Private health insurance (PHI) in Greece plays a relatively minor role in the overall health system, since it offers coverage to no more than 12% of the population. It primarily takes the form of supplementary, profit-making schemes providing cover for faster access, better quality of services and increased consumer choice. In addition, a significant portion of specialist care is offered by physicians in private practice, who are either contracted by various social insurance funds or paid directly by the patient on a private basis. Rehabilitation services (physiotherapists etc.) and services for the elderly (geriatric homes) are predominantly offered by the private sector. The private sector does not have any direct involvement in the planning, financing and regulation of the public system. The health care system remained fully dependent on the central government, even for settling bureaucratic minutiae, forming an additional administrative burden for the health ministry. The government, through the Ministry of Health and Social Solidarity, is responsible for ensuring the general objectives and fundamental principles of the National Health System (ESY), such as free and equitable access to quality health services for every citizen. For this reason, the Ministry makes decisions on health policy issues and the overall planning and implementation of the national health strategy. The Ministry sets priorities at a national level, defines the extent of funding for proposed activities and allocates relevant resources, proposes changes in the legislative framework and undertakes the implementation of the laws and of any reform. It is also responsible for health care professionals and coordinates the hiring of new health care personnel, subject to approval by the Ministerial Cabinet. Nowadays, among to the core function of the Ministry is the regulation of the private sector, while social health insurance remains under the authority of the Ministry of Employment and Social Protection.

In addition, various bodies participate in the governance and regulation of the public health care system for example Central Health Council (KESY), National Public Health Council (ESYDY), Health Sector Coordination Body (SOTY) etc.

The Ministry also oversees a number of organizations and institutions including the Centre for the Control and Prevention of Diseases (KEELPNO), the National Drug Organization (EOF), the Institute of Medicinal Research and Technology (IFET), the Research Centre for Biological Materials (EKEVYL), the National Transplant Organization (EOM) and the National School of Public Health (ESDY).

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Apart from the Ministry of Health and Social Solidarity, a number of other ministries have responsibilities, which are linked in one way or another to the public health care system.

The reform acts of 2001 and 2003 (Law 2889/2001 on the Regional Structure of Health Care Services and Law 3106/2003 on the Regional Structure of Welfare Services) initiated an explicit, formal process of structuring PeSYPs and devolved political and operational authority to them. The ministry of health would maintain a strategic planning role at a national level as well as a coordinating role across PeSYPs. According to the provisions of the two Laws, 17 PeSYPs were established, responsible for the coordination of activities and the effective organization, operation and management of all health and welfare units.

The change in government resulted in the abolition of the previous legislation and the enactment of Law 3329/2005. The PeSYPs were renamed Health Region Administrations (DYPEs) and in 2006 their number was reduced to seven.

In 2014 legislation was issued in an attempt to extend coverage to all uninsured Greek citizens and legal residents. However, the uninsured could claim free inpatient healthcare only if they could prove that they could not afford it and other bureaucratic procedures created barriers to access. In addition, the uninsured were still required to pay the same copayments for pharmaceuticals as the insured population, with negative effects for those in difficult economic situations. The free cover includes clinical and diagnostic tests, hospital treatment, prenatal care, rehabilitation, transfer abroad for specialist treatment and the handing out of medicines and other consumables. Any individual earning less than EUR 2,400 per year will not have to pay anything for medicines or health care. This threshold rises for families, depending on the number of children they have. The National Health Services Organization (EOPYY), will be responsible for covering the cost of the free medical care. Legislation introduced in the 2000s has changed the organizational structure of the health care system, establishing regional health authorities which, theoretically, have responsibility for the coordination of regional activities and the effective organization and management of all health care units, the financial accounting system and the information management system. In practice, however, they have no powers regarding capital investment or paying providers, which remain under the control of the Ministry of Health and Social Solidarity.

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The Ministry of Health is still the main policy-making authority, responsible for setting priorities at the national level, determining the funding for proposed activities and allocating relevant resources.

4.12.3. Public Health Indicators

During the last 38 years, the Greek population has gained 6.3 years in life expectancy, with women showing slightly more gain than men (6.5 years and 6.2 years respectively). In 2007, Greece ranked 15th for life expectancy among OECD countries and was registered above the OECD average (OECD 2009). Women continue to have higher life expectancy than men, with 82.5 years compared to 77.8 years for men. Potential Years of Life Lost (PYLL) is a summary measure of premature mortality providing an explicit way of weighting deaths occurring before the age of 70, which are, a priori, preventable. In Greece, premature mortality was reduced by 43.2% during the period 1980–2007. A major factor contributing to this decrease has been the downward trend in infant mortality. In addition, the probability of dying before the age of 5 years has been substantially reduced. These data reflect the fact that the establishment of the National Health System (ESY) probably had a positive effect on health outcomes. As a consequence of this progress, Greece is ranked ninth among OECD countries (OECD 2007a). An interesting feature is that about 28% of PYLL can be attributed to external causes, 24.5% to malignant neoplasms and 19.8% to diseases of the circulatory system (OECD 2009). These figures indicate that the preventive public health policies must focus on the driving, drinking, eating and smoking habits of the population. Since the beginning of the 1990s, diseases of the circulatory system have been the leading causes of death. In 2008, 43.5% of total deaths in Greece were due to cardiovascular diseases. Among the OECD countries, Greece has the fifth highest standardized mortality ratio for diseases of the circulatory system after Slovakia (485.4), Hungary (476.2), Czech Republic (396.4) and Poland (363.0) (OECD 2009). The second major cause of death is cancer. Malignant neoplasms account for 26.4% of mortality. On the other hand, tuberculosis cases have dropped significantly and have stabilized at a low level. Deaths from accidents have also been decreasing steadily although they remain the primary source of premature mortality.

The promotion of healthy habits around alcohol, food and tobacco consumption is a good indicator to assess the impact of preventive policies in controlling diseases effectively. Among OECD countries for which there are available data, Greece records the highest

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tobacco consumption; it ranked fifth in terms of calorie intake per capita after the United States, Portugal, Ireland and Italy; and is 17th in terms of annual alcohol consumption (OECD 2007a). Although the dietary habits of a large part of the Greek population resemble the Mediterranean diet, which is characterized by a high intake of cereals, vegetables, fruits and olive oil, and low intake of meat, poultry and saturated fatty acids, there is a significant fraction of the population (younger age groups) adopting the Western-type diet or a diet with a high consumption of sweets, according to study which conducted in 2003.

4.12.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine eHealth plays a vital role in promoting universal health coverage in a variety of ways. For instance, it helps provide services to remote populations and underserved communities through telehealth or mHealth. It facilitates the training of the health workforce through the use of eLearning, and makes education more widely accessible especially for those who are isolated. It enhances diagnosis and treatment by providing accurate and timely patient information through electronic health records. And through the strategic use of ICT, it improves the operations and financial efficiency of health care systems. The National eHealth Strategy was made public in June 2006. Although efforts for the introduction of ICT in healthcare settings had begun already in the mid-'80s, the results up to now have not yet reached the desired magnitude. There have been positive experiences concerning the potential benefits to patients, health care professionals and the healthcare system at large, but healthcare ICT solutions have not yet become an integral part of healthcare practices. The main actor in defining eHealth policy in Greece is the Ministry of Health and Social Solidarity (YYKA), General Secretariat for Public Health. Other ministries that affect national eHealth policy are:

 The Ministry of Economy and Finance, that provides overall funding for government activities, as well as supports the National Health System expenses. The Information Society Operational Programme, that funds measures related to the deployment and promotion of eHealth, is also operating under the Ministry of Economy and Finance.

 The Ministry of Employment and Social Protection, particularly through the mechanisms for reimbursement of health services

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 The Ministry of the Interior that has the primary responsibility for issues related to identification, and

 the Ministry of Justice that is responsible for matters of data protection, security and confidentiality.

The Greek Ministry of Health referenced the European framework of priorities for the development of eHealth actions and a summary of the proposed strategy and completion of the institutional framework in this area has been produced. The strategy envisions the transition to the Information /Knowledge Society through new organisational structures, national infrastructures for e-government and the design and development of new methods of service provision to citizens. At the same time, the necessary support will be offered to healthcare professionals so that continuity of care and patient safety can be guaranteed, and the required tools will be made available to citizens as well. The aim is to facilitate the transition of the healthcare system to one characterized by sustainability, citizen-centred orientation and adaptability, through a Programme of focused and interconnected Actions. For example, in the development actions are including the development of basic infrastructures, electronic services and standards, as well as actions of project administration and management. The core infrastructure is the National Health Information System and which will interact with its environment through the (citizens') health card and the professional card. A requirement is the preceding development of the basic body of healthcare-relevant standards. Around the NHIS a number of citizen services will be developed, aimed at improving accessibility, simplifying procedures and enforcing communication with both the doctor and the healthcare system. In parallel, services for healthcare professionals will be developed, which will offer support in medical decision making and in executing daily work tasks. For the success of the Programme, co-ordination, comprehensive guidance and daily management are required. The biggest challenge facing eHealth deployment and development in Greece so far was the immaturity of the regulatory framework as a result of which funding processes have been delayed, although funds would be available. In 2015, Greece participated in the third global survey on eHealth. This survey was conducted by the WHO Global Observatory for eHealth (GOe) has a special focus – the use of eHealth in support of universal health coverage. It presents data collected on 125 WHO Member States. The survey was undertaken between April and August 2015 and represents the most current information on the use of eHealth in these countries. A total of 125 WHO Member States, representing a 64% response rate, completed the survey, which

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Table 4.12.4.1. WHO Global Observatory for eHealth

eHealth Foundations National policies or strategies Country Year adopted response National universal health coverage Yes 2015 policy or strategy National eHealth Yes 2013 policy or strategy National health information Yes 2015 system (HIS) policy or strategy National telehealth policy No N/A or strategy Funding Sources for eHealth Country Funding source

response % Public funding Yes >75% Private or commercial Yes <25% funding Donor/non-public - funding Public-private Yes <25% partenerships eHealth Capacity Building

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Country Proportion response Health sciences students-Pre- Yes 25-50% service training in eHealth Health professionals-In- Yes 25-50% service training in eHealth Source: Atlas of eHealth country profiles-WHO, 2016 Table 4.12.4.1 includes a selection of indicators on eHealth-related policies or strategies, funding, and capacity building. Data are reported by the individual “country response” (yes, no or don’t know), and “year adopted” for the particular indicator in the case of national policies/strategies. The former represent the level of planning and action around the use of eHealth in the country’s health system. As above, the answers are expressed as “country response”; it has an additional measurement for the level of funding: no funding, low <25%, medium <50%, high <75% and very high >75%. Also, eHealth capacity building is another significant indicator as it shows whether students or professionals are receiving training in preparation for their exposure to eHealth in clinical settings. The “proportion” of students receiving training is expressed in the same was as for the funding sources above: no funding, low <25%, medium <50%, high <75% and very high >75%.

Table 4.12.4.2.WHO Global Observatory for eHealth

Electronic Health Records (EHRs) EHR Country Overview Country response National EHR system No Health facilities with Use EHR EHR Primary care facilities (e.g. clinics and health N/A care centers) Secondary care facilities N/A

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(e.g. hospitals, emergency care) Tertiary care facilities (e.g. specialized care, N/A referral from primary/secondary care)

Other electronic Country response systems Laboratory information N/A systems Pathology information N/A systems Pharmacy information N/A systems PACS N/A Automatic vaccination N/A alerting system ICT-assisted functions Country response Electronic medical billing Yes systems Supply chain management information Yes systems Human resources for health information No systems Source: Atlas of eHealth country profiles-WHO, 2016

This section (Table 4.12.4.2) provides an overview of the state of adoption of Electronic Health Records (EHRs) in the country. It identifies whether the country has introduced a national EHR system and if there is legislation governing its use. It identifies at what level of the health system the EHRs are being used (primary, secondary or tertiary). At this point we conclude that the development of the national EHR is strongly dependent on the national standardisation of health on the level of services, systems, information, coding, and terminology systems.

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It is worth mentioning that Greece has used ICT to look at ways of improving health care for the Roma community in the municipality of Trikala. Roma populations in Greece often have limited access to specialized health care services. In 2009 the municipality of Trikala, which has a Roma community of about 1000, set up a pilot project to improve the population’s access to health care through telemonitoring and the use of electronic medical records (Electronic medical records are in-house electronic versions of the traditional paper charts used in clinic care, whereas EHRs include additional information about the broader spectrum of health from all clinicians involved in an individual’s care and can be shared electronically with other authorized clinicians.). The pilot project was under the supervision of the Greek Ministry of Health, in cooperation with hospitals in Trikala and Karditsa. The project enabled specialist doctors in Trikala’s general hospital to interpret the information and provide local doctors with diagnostic advice, integrating services between primary and secondary care. In addition, 70 volunteer Roma patients were given electronic medical record smart cards, which enabled doctors to access their health records during hospital consultations. Only authorized parties can access this information, using a personal identification number. Upon completion of the project, it was recognized by the Ministry of Health and the Council of Europe as an example of good practice.

Also, Table 4.12.4.2 shows other electronic systems that the EHR system is linked to. Finally, it lists ICT-assisted systems.

The scope of the application of eLearning for pre-service education of health sciences students as well as in-service training for health professionals is covered in this section (Table 4.12.4.3). The faculties or professions which can benefit from eLearning techniques for training are identified along with the “country response” as well as the “global yes response”.

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Table 4.12.4.3.WHO Global Observatory for eHealth

Use of eLearning in Health Sciences eLearning Programmes Country Overview Health sciences Country response Global “yes” response students – Pre-service Medicine Yes 58% Dentistry Yes 39% Public health Yes 50% Nursing & midwifery Yes 47% Pharmacy Yes 38% Biomedical/Life sciences Yes 42% Health professionals – Country response Global “yes” response In-service Medicine Yes 58% Dentistry Yes 30% Public health Yes 47% Nursing & midwifery Yes 46% Pharmacy Yes 31% Biomedical/Life sciences Yes 34% Source: Atlas of eHealth country profiles-WHO, 2016 This section (Table 4.12.4.4) reports the use of social media by individuals and communities. Each response has a corresponding “country response” and “global yes response”.

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Table 4.12.4.4. WHO Global Observatory for eHealth

Social Media Individuals and communities – Country Global “yes” use of social response response media Learn about Yes 79% health issues Help decide what health services to Yes 56% use Provide feedback to health facilities Yes 62% or health professionals Run community- based health Yes 62% campaigns Participate in community-based Yes 59% health forums Source: Atlas of eHealth country profiles-WHO, 2016 The National Medications Organisation (EOF) has implemented a bar coding system of medications since the 1st of January 2005. As of summer 2006 there will be additional batch coding for the purposes of pharmaco-vigilance follow-up. In August 2006 the launch of a pilot e-prescription project was announced, implemented by OPAD (Organisation for Health Care Provision to Public Servants) and utilizing the bar coding system of the National Medications Organisation. In Greece, the need for a national Health Portal for citizens has been recognized. The citizen portal is aimed to function as the gateway for their communication and interaction with the healthcare system. The portal accept citizens' claims, offer information and assist them in navigating the healthcare service system. Electronic services offer to citizens through the portal, such as information on health issues - particularly prevention and healthy lifestyles- communication with family physicians, booking, viewing of laboratory test results etc.

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In order to provide a constantly updated repository of valid and reliable health information, substantiated on best available scientific evidence, strategic alliances will be necessary both nationally (e.g. with medical schools), as well as internationally (e.g. for shared content development and/or endorsement and translation).

The National Health Portal through which services are provided to citizens should be distinguished from the Ministry's own portal, through which services will be provided on matters of public administration (e.g. job applications, calls for tender, communication with Regional Healthcare Authorities, Prefectures, other Ministries etc). Nowadays, all institutions of the Ministry of Health and Social Solidarity have their own website, accessible by all citizens, in Greek as well as in English. The same applies for health insurance organizations. In Greece telemedicine is a significant priority, due to the need to provide healthcare services to inhabitants of islands and remote areas, but also to the tourists visiting the country. Another application area is that of home care, with the aim of improving the quality of life particularly of chronic patients, as well as achieving substantial cost savings through avoidance of repeated hospitalizations. There have been several successful pilot experiences, but telemedicine services have not as yet been integrated in the standard service panel of the National Health System.

A major obstacle is the absence of a general organisational and legal framework which will clarify tasks, responsibilities, but also reimbursement principles for these services.

Many of the presently running projects were launched without prior agreements on standardisation and interoperability issues, reflecting the fragmented and undisciplined nature of the health IT market. The new strategy and its actions aim to remedy this situation. Standardization activities in health will proceed in collaboration between the Central Health Council and the National Standardisation Organisation (ELOT).

Since a few years, a quite active HL7 affiliate has been set up in Greece. Their focus is on technical interoperability and it has been proposed that they could be the body appointed to run interoperability labs, following the example of the Interoperability Lab set up by HL7 and IHE at HIMSS in San Diego.

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4.12.5. Expenditure, Economics, Management

On March 2016 the Hellenic Statistical Authority published the latest available data on health expenditure. According to these data, health expenditure in Greece saw an unprecedented fall from EUR 23.2 billion to EUR 14.7 billion during 2009-2014, or by 36.6% within six years. As a consequence, total health expenditure in Greece, as a percentage of Gross Domestic Product (GDP) decreased from 9.8% of GDP in 2009 to 8.3% of GDP in 2014. It is remarkable that the public share of total health expenditure as a percentage of GDP dropped from 6.8% in 2009 to 4.95% in 2014, well below the 6% dictated by the Memoranda of Understanding signed by Greece and its international lenders. These cuts were driven by a reduction in public health spending and especially social security (social health insurance) funds' spending on health.

The health care system in Greece is financed by a mix of public and private resources. Public statutory financing is based on social insurance and tax. The primary source of revenue for the social insurance funds is the contributions of employees and employers (including state contributions as an employer). The state budget, via direct and indirect tax revenues, is responsible for covering administration expenditures, funding health centres and rural surgeries, providing subsidies to public hospitals and insurance funds, investing in capital stock and funding medical education. The third important source of health care financing is private expenses, taking the form mainly of out-of-pocket payments for services not covered by social insurance, payments for services covered by social insurance but bought outside the system for reasons related to time, cost and quality, co-payments and various payments made unethically for reasons such as bypassing waiting lists or ensuring more attention on the part of the doctor. Private expenses also can take the form of private insurance schemes, which are, however, of limited importance. A significant characteristic of the mixed financial resources of the Greek health care system is the very high percentage of private expenses. Out-of-pocket expenditure accounts for 37.6% of total health expenditure and private insurance accounts for 2.1%, calling into question the social character of the health care system. The tax system contributes 29.1% of total health expenditure while health insurance accounts for 31.2%. The problem of high private expenditure by citizens is further aggravated by the fact that the redistributive effect of the tax system is regressive due to evasion practices and the hidden economy. Overall, fairness in health care financing is not achieved, with health expenditure disproportionately burdening the lower socioeconomic strata.

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Payments to health care providers are retrospective, including salaries for ESY personnel, fee-for-service payments for providers contracted with public social health insurance funds and per diems for public hospitals. These methods of provider reimbursement are not related to their performance, resulting in less efficient use of health resources compared to prospective methods of payment.

The fact that doctors’ payments are not related to their performance is an incentive to minimize the effort devoted to institutional practice and to spend time in private practice, whether permitted or not. Greece is one of the very few OECD countries that have not adopted the OECD system of health accounts. As a result, the quality and the coverage of the data are very poor. For example, there are no official statistics on the breakdown of public and private aggregate expenditure between the various types of care. In addition, the revisions of GDP result in changes of the shares of total, public and private expenditure as a percentage of GDP. The proportion of total health expenditure is above the average of 9.0% in OECD countries and ranks Greece among the ten highest health spenders of the OECD group. Greece spends more on health than Scandinavian countries (Finland spends 8.2% of GDP, Norway 8.9%, Sweden 9.1%), other Mediterranean countries (Italy spends 8.7% and Spain 8.5%), and countries such as Luxembourg (7.3%) and the United Kingdom (8.4%). Furthermore, it seems that Greece has one of the largest shares of private health expenditure among OECD countries, given that it constitutes 39.7% of total health expenditure. This share ranks Greece as the fifth highest private spender on health after Mexico (54.8%), the United States (54.6%), the Republic of Korea (45.1%) and Switzerland (40.7%). The percentage of GDP that Greece allocates for public health expenditure (5.8%) is one of the lowest among OECD countries after Mexico (2.7%), the Republic of Korea (3.5%), Poland (4.6%), Slovakia (5.2%) and Hungary (5.2%) (OECD 2009).

The Memorandum of Understanding (MoU) required major cuts to hospital and pharmaceutical expenditure. Public hospital sector expenditure decreased from €7.2 billion in 2009 to €6.6 billion in 2012, through major savings in hospital supplies and through MoU conditions stipulating cuts to health personnel salaries and benefits. Large reductions in drug spending have also occurred as a result of a series of government measures aimed at reducing the price of pharmaceuticals, as well as reductions in volumes as costs have been shifted to households.

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The general approach of cost containment measures has taken the form of horizontal cuts rather than a more sophisticated and strategic approach targeting resource allocation. The breakdown of government spending by sector (inpatient services, outpatient services, pharmaceuticals etc.), is almost the same proportionally (except for pharmaceuticals), both at the start (2009) and during the crisis (2012), indicating that cuts were made across the board in order to achieve the targets set under the MoU and without an effort to support services that may prove more efficient in the long term. Besides political pressure to adhere to the short timeframes stipulated in the MoU to implement steep spending reductions, this approach may also be attributed to information constraints. It was not until 2012 that Greece adopted the OECD System of Health Accounts. Until then, limited or no official data were available on the breakdown of health expenditure by type of health care services, by financing agent and by provider. Law 3863/2010 (New Social Insurance System) foresaw the separation of health funds from the administration of pensions, the merger of health funds to simplify the overly fragmented system, bringing all health-related activities under the Ministry of Health and the establishment of the Health Benefit Coordination Council. The aim of the Council was to establish criteria and contract terms between social insurance funds and healthcare providers to achieve reductions in spending, and to initiate joint purchasing of medical goods and services in order to achieve expenditure reductions through price-volume agreements. A year later Law 3918/2011 introduced a major restructuring of the health system. More specifically, the health sectors of all major social insurance funds (IKA - covering employees and workers in the private sector; OGA -farmers; OAEE -self-employed professionals; and OPAD -public sector employees) formed a single healthcare insurance organization (the National Organization for Healthcare Services Provision (EOPYY)) which henceforth acted as a unique buyer of medicines and healthcare services for all those insured, thus acquiring higher bargaining power against suppliers. EOPYY also became the country’s main new body tasked with managing and providing primary care. However, EOPYY soon faced serious problems due to under-financing caused by thecurrent economic crisis as well as personnel shortages and staffing imbalances. Its activities were also hampered by the failure to create an integrated primary healthcare network, and the absence of gatekeeping in the health system. As a result, an alternative operational framework for EOPYY was proposed, in which it would function primarily as an insurer while its primary care units would be integrated with those already existing within the National Health Service. | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

EOPYY has now been transformed solely into a health services purchaser. Taxation, social insurance, out-of-pocket payments and PHI are the sources of finance of the Greek health care sector. Private funding, constituted mainly by out-of-pocket payments, records the largest share of revenues, while the shares of taxation and social health insurance are almost equal.

Out-of-pocket payments represent a high percentage of health expenditure in Greece, accounting for more than half of total health expenditure. The figure depicts formal cost- sharing arrangements, direct payments and informal payments, with the latter two representing the highest proportion of out-of-pocket payments among EU countries. An extensive black economy and informal payments are common features of the Greek health sector. They can be attributed, among other causes, to the lack of a rational pricing and remuneration policy within the health care system. The unethical transactions mainly concern the provision of hospital services and payments to physicians, primarily surgeons, so that patients can bypass waiting lists or ensure better quality of service and more attention from doctors.

4.12.6. Challenges and Future Perspectives

Based on the principle that health is a public good and the state has a responsibility to deliver care, the aim of the National Health System was to ensure equal access to high- quality services for all citizens. Towards this end, it tried to address the growing health care needs of the population, primarily through the establishment of publicly owned and operated infrastructure. The strategic target of structuring a unified health care sector has proved a controversial topic and a politically difficult process. Despite the fact that the system succeeded in improving the health status of the population, structural inefficiencies concerning the organization, financing and delivery of health services remained and increased over the years. A comprehensive and universal health care system has not yet been established, with several quite differently organized and regulated subsystems operating due to the failure to propose and implement a coherent set of reforms with sufficient public and political support. The health system still functions within an outmoded organizational culture dominated by clinical medicine and hospital services, without the support of an adequate planning unit or adequate accessible information on health status, utilization of health services, or health costs, and without being progressive and proactive in addressing the health needs of the population through actions in public

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health and primary health care. As a result, the Greek health care system suffers from inefficiencies which can be summarized as follows:

 a high degree of centralization in decision-making and administrative processes;

 ineffective managerial structures which lack information management systems and, in many cases, are staffed by inappropriate and unqualified personnel, without adequate managerial skills;

 lack of planning and coordination, and limited managerial and administrative capacity;

 unequal and inefficient allocation of human and economic resources, based on historical and political criteria and regional disparities, due to the absence of pooling of health resources, a lack of coordination among the large number of payers, an absence of adequate financial management and accounting systems, and a lack of monitoring processes;

 fragmentation of coverage and an absence of a referral system based on GPs or group practice to support primary health care development and to act as a gatekeeper, meaning that there is no continuity of care and no control of interregional patient flows;

 inequalities in access to services derived from differences in social health insurance coverage, high out-of-pocket payments and uneven regional distribution of human resources and health infrastructure;

 underdevelopment of needs assessment and priority-setting mechanisms;

 regressive funding mechanisms due to the existence of high private spending, under-the-table payments, widespread tax evasion, a high proportion of indirect taxation and social security contribution evasion;

 an anachronistic retrospective reimbursement system according to which providers’ payments are not related to their performance, resulting in the absence of incentives to improve efficiency and quality; and

 an absence of a health technology assessment system, quality assurance and economic evaluation processes, leading to an excess of heavy medical equipment.

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In this context, the need for more determined reforms to improve the efficiency of the Greek health care system is recognized by academic and political thinking and has also been highlighted by international organizations. These developments must be seen in the light of a continuous transition phase that Greece entered at the beginning of the new century. Social insurance benefits and the state budget contribution are of great social concern and the focus of continuous debate. The reform of the social care system, the taxation system and the education system are the subject of passionate and rigorous social debate, giving the impression of a never-ending reform perspective. 4.13. Hungary

4.13.1. History

The main actors responsible for providing or financing health services are defined in Act CLIV of 1997 on Health (1997/20). The most important of these are the National Assembly, the central government, the State Secretariat for Healthcare (within the Ministry of National Resources). In 2010 the government created the Ministry of National Resources by merging the five ministries previously responsible for social, family and youth affairs; health care; education; culture; and sport (2010/7). These former ministries have since been reclassified as State Secretariats, each of which is led by a Minister of State. The aim of this change was to reduce the cost of public administration and create effective platforms for intersectoral cooperation.

4.13.2. State Secretariat for Healthcare

Within the Ministry of National Resources, the State Secretariat for Healthcare is responsible for preparing legislation related to the direction of health care provision at the national level and at institutions of higher education, and for regulating national public health care tasks at the national level. The State Secretariat for Healthcare shares responsibility with the Ministry for National Economy and the Ministry of Interior for health care financing. The main functions of State Secretariat for Healthcare are health policy formulation, coordination and regulation.

4.13.3. National Public Health and Medical Officer Service

The National Public Health and Medical Officer Service (NPHMOS) was formed in 1991 on the basis of the State Supervisory Agency for Public Hygiene and Infectious Diseases and

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headed by the National Chief Medical Officer, who was appointed by the Minister of State for Health. In January 2016 the Hungarian government announced the operational reorganization and centralization of certain background institutions of the Ministry of National Resources with the intention of reducing bureaucracy. The reorganization included NPHMOS as well in 2017. The institution has been integrated into the Ministry of National Resources, together with the National Centre for Patients' Rights and Documentation and the National Health Insurance Fund Administration. Not the departments of the NPHMOS but the Government Offices perform major tasks on public health function as defined in specific legislations. In accordance with legal regulations the Chief Medical Officer exercises limited professional management rights over NPHMOS today. The Government Offices of the capital city and of the counties coordinate and facilitate regional execution of governmental public health tasks such as food and nutritional health, environmental and settlement health. The Government Offices of the capital city and of the counties consist of several units led directly by the Administrative Government Commissioner, and they are structured in district and sub regional offices.

4.13.4. National Healthcare Service Centre

As part of the ongoing reorganization of public administration, the National Institute for Health Development was integrated into the Ministry of Human Resources in 2017. Certain tasks and responsibilities of the institute is transferred to the National Healthcare Service Centre (ÁEEK) as well, including the provision of special health services and the implementation of EU funded projects. Additionally, a large number of smaller background institutions, such as the Institute for Emergency Healthcare Supply Management, the Hungarian National Blood Transfusion Service, the National Institute for Health Development and the National Centre of Epidemiology were integrated into the National Healthcare Service Centre. The National Healthcare Service Centre is a public institution to govern more than 100 public hospitals and integrated outpatient centres owned by Hungarian State and to support the implementation of health care reform in Hungary. Hospitals maintained by the National Healthcare Service Centre cover the majority (cca 80%) of Hungarian inpatient capacities.

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4.14. Ireland

4.14.1. Demographics of the Republic of Ireland

The Republic of Ireland is an independent country making up the majority of the island of Ireland, situated to the north-west of Europe. Its population is 4.6 Mio., with an average age of the population is 35.6 years of age and 49.97% of the population are female. These are general information of Ireland:

Gross national income per capita (PPP Int $) (2012): 35.090 Hospital beds per 100.000 (2014): 260

Physicians per 100.000 (2015): 282

% of population aged 65+ years (2013): 12% Life expectancy at birth m/f (2014): 79/83 years

Total expenditure on health as % of GDP (2014): 8% Internet users: 79%

4.14.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The Irish health care system is predominantly tax funded, although about half the population also has voluntary health insurance (VHI). Around one third of the population can access public services free of charge; the remainder has to make some contribution towards the cost of services utilized.

The State has long played a major role in the provision of services and in the regulation and setting of standards for the health care system. The Department of Health and Children (DoHC), under the direction of the Minister of Health and Children, together with Ministers of State, has strategic responsibility for health and personal social services. The Health Service Executive (HES) provides many health care services directly, but the voluntary sector, including organizations linked with the Church, have and will continue to play an important role in the delivery of health and personal social care services, ranging

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from running hospitals to small community-based projects. HSE is the largest employer in the State with more than 65 000 staff in direct employment and a further 35 000 employed by voluntary hospitals and bodies that are funded by the HSE.

4.14.3. Public Health Indicators

The health status of the Irish population has steadily improved since 1970, although only as recently as 2002 it still had one of the poorer sets of health outcome indicators in the EU15. Disability-adjusted life expectancy in 2002 was estimated at just 69.8 years, the joint second lowest in the EU15. Maternal deaths are low; in 2005, 3.28 deaths per 100 000 live births were recorded. Data from the Health Service Executive (HSE) indicate that circulatory diseases remain the leading cause of death, followed by cancer. These two categories alone accounted for 62% of all deaths in 2005. Of all cancers, lung cancer is most common (21%), followed by colorectal cancer (12%) and breast cancer (8%).

The age-standardized death rate from female breast cancer in 2006 was 29.8 per 100 000 females. This was one of the highest rates in Europe.

Although deaths from all respiratory diseases have fallen from 129.15 per 100 000 population in 1995 to 83.19 per 100 000 in 2006, this rate remains the highest among the EU Member States.

By 2006 only 24.7% of men and women over the age of 15 reported being regular or occasional smokers, compared with rates of 32% and 31%, respectively, in 1998.

4.14.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

ICT plays an increasingly important role in Irish society. ICT also has an important role to play in the health system, as part of the National Health Information Strategy. The National Patient Treatment Register can be accessed electronically by health service professionals and patients to ascertain length of waiting times for different elective procedures. GPs can then use this to help their patients obtain treatment as quickly as possible, by matching them with hospitals with spare capacity.

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There are also plans to develop an electronic health record system and extend the use of ICT across the system, although some of these have been subject to problems and delay. An interim report of the Committee on the Future of Health care states in 2017 that an electronic health record is a critical enabler for the delivery of integrated care across settings.

4.14.5. Expenditure, Economics, Management

The Irish health care system remains predominantly tax funded. A total of 78.3% of all health expenditure, both public and private, was raised from taxation, including pay- related social insurance (PRSI) and other sources of government income, such as excise duties, in 2006 (OECD, 2008a). The remaining components of total health expenditure are from private sources, in particular out-of-pocket household expenditure on GP visits, pharmaceuticals and public/private hospital stays, as well as payments to private health insurance providers.

4.14.6. Challenges and Future Perspectives

Ireland has undergone major economic and social transition since the turn of the millennium. It has been a “star performer” in terms of economic progress in the industrialized world and has reversed decades of net outward migration, while retaining one of the youngest and most highly educated populations in Europe. There have also been positive changes for the health of the population: average life expectancy has increased by more than 5 years within just 15 years, while Ireland led the way in Europe on the introduction of legislation to ban smoking in the workplace. In many ways, developments within the health care system have mirrored these rapid and significant transitions. The health care system can be characterized by a constant process of review and implementation of staged initiatives since the turn of the millennium. This process has culminated in major structural changes – made possible due to the economic growth that Ireland has enjoyed in recent years – impacting on both the organization and orientation of the health care system. The aim is to make the system more primary care driven and supported by improved access to specialist, acute and long-stay services.

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4.15. Italy

4.15.1. Demographics of Italy

With a population of almost 61 million (2012), Italy is the sixth most populous country in Europe. The country is made up of 20 regions, which are extremely varied, differing in size, population and levels of economic development. Since the early 1990s, considerable powers, particularly in health-care financing and delivery, have been devolved to this level of government. The regions are subdivided into provinces made up of municipalities (comuni). Italy has about 8100 municipalities, which range in size from small villages to large cities such as Rome. A range of indicators shows that the health of the population has improved over the last decades. Average life expectancy reached 79.4 years for men and 84.5 years for women in 2011, the second highest in Europe (compared with 77.4 years for men and 83.1 years for women for the EU as a whole). These results can be attributed to multiple factors such as improved standards of living, more widespread education, better-quality health care and increased access to health services. However, there is still a substantial gender difference in life expectancy. Moreover, the population growth rate is very low (0.3% in 2012), one of the lowest in the EU, and immigration is the source of most of this growth. At the end of 2010, foreign nationals accounted for 7.5% of the Italian population. The number of legal documented (regular) immigrants showed an increasing trend. Italy is a parliamentary republic in Southern Europe.The country covers 301 340 km2 and extends from the north where it borders France, Switzerland, Austria and Slovenia to the south where it includes the Mediterranean islands of Sardinia and Sicily and a cluster of other smaller islands.

About 77% of the country is mountainous or hilly and 23% is forested. Population density on average is 206.4 inhabitants per km2 and most of the population clusters around metropolitan areas and along the coasts (urban population accounts for 69% of total population). The structure of the population changed significantly between 1980 and 2012 owing to marked declines in fertility rates and increases in life expectancy at birth.

Italy has an open economy and is a founding member of the EU. It is also a member of major multilateral economic organizations such as the Group of Seven Industrialized

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Countries (G-7), the Group of Eight (G-8), OECD, the World Trade Organization and the International Monetary Fund (IMF). In 2012, according to IMF data, Italy was the ninth largest economy in the world and the fifth largest in Europe in terms of nominal gross domestic product (GDP). Its annual GDP (in current prices) accounts for 12.1% of the EU’s total GDP. Nevertheless, per capita income (measured in current international $PPP) is 33.8% lower than in the United States and nearly 20% lower than the average among EU countries.

Table 4.15.1.1. General Information of Italy General Information of Italy Gross national income per capita (PPP Int $) (2013): 34.100 Life expectancy (2015): 83 years Hospital beds per 100.000 (2013): 331 Physicians per 100.000 (2014): 388 % of population aged 65+ years (2012): 21 % Life expectancy at birth m/f (2012): 80 / 85 years Total expenditure on health as % of GDP (2015): 9,1 % Internet users: 58 % Source:Data and Statistics of Italy (WHO)

4.15.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The National Health Service (NHS) was established in 1978. Italy’s health-care system is an organized National Health Service (Servizio Sanitario Nazionale, SSN) that provides universal coverage largely free of charge at the point of delivery. The system is organized into three levels: national, regional and local. At national level, the Ministry of Health (supported by several specialized agencies) sets the fundamental principles and goals of the health system, determines the core benefit package of health services guaranteed across the country and allocates national funds to the regions. The national level has exclusive authority in determining the core benefit package (livelli essenziali di assistenza – LEA), that must be guaranteed throughout the country free or with cost sharing, using the resources collected through general taxation. The delivery of LEA is organized into three levels: public health; community health medicine and primary care; and hospital care. A specific National Commission for the definition and updating of

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the LEA is requested to follow three criteria: efficacy, appropriateness and consistency with the functions and goals of the SSN.

Regions have exclusive authority in execution-level planning and delivery of health care, as well as health protection and health-related disciplines such as labour safety, organization of professions, food safety and scientific research. Pursuant to the 2001 reform of the Italian constitution, the national level and the regions have become the main instrument for planning and organization of public health care in Italy. In fact, different regions have made different choices on how to use their increasing autonomy. For instance, Tuscany decided to keep the system heavily centralized, with most hospitals remaining under ASL control and only a handful becoming AOs (hospital enterprise-public hospital/aziende ospedaliere). At the other extreme, Lombardy opted in 1998 for a fully fledged experiment in which all hospital and specialist services are delivered by AOs or private providers. The region’s main hospitals were converted to AOs, free to negotiate financing terms with ASLs – although controlled on the quality of services provided – and citizens were given full freedom of choice between ASLs, hospitals and even social care services. At local level, geographically based local health authorities (Aziende Sanitarie Locali, ASLs) deliver public health, community health services and primary care directly, and secondary and specialist care directly or through either public hospitals or accredited private providers. Local health unitsserves geographical areas with average populations of about 300 000. Finally, patient empowerment and patient rights are not specified by a single law but are present in several pieces of legislation, starting with the Italian Constitution and the founding law of the national health system. Over the last 20 years, several tools have been introduced for public participation at all levels but no systematic strategy exists and implementation varies across the country, as does the satisfaction of citizens with the quality of health care.

4.15.3. Public Health Indicators

Notwithstanding the important results gained in health status, geographical differences remain in terms of health conditions and lifestyles, as well as in the supply and quality of services. Southern regions still score lower in life expectancy, lifestyles, access to care and quality of services. Moreover, many concerns are being raised on the sustainability of the system as Italy is undergoing an economic and financial crisis, which requires cost containment and resources reallocation policies. These measures are expected to have a marked impact on health care in the years to come, possibly generating inequalities in

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

access to care, sharpening existing differences in the quality of care among regions and affecting the most vulnerable groups of the population.

The main diseases affecting the population of Italy are circulatory diseases, malignant tumours and respiratory diseases, while smoking and rising obesity levels, particularly among young people, are major health challenges.

Over the last 30 years (between 1980 and 2010) mortality has decreased by 53%. The highest contribution to this large reduction is due to the falling incidence in cardiovascular diseases, with a decrease for both men (127.00 vs 109.41 per 10 000) and women (77.05 vs 69.31 per 10 000) in the period 2002–2009. Cancer has emerged as the most frequent cause of death for people under 64, followed by circulatory diseases. While breast cancer is still the most common cancer among women in Italy (42%), breast cancer mortality trends showed a decreasing rate between 1989 (38.59 per 100 000) and 2010 (23.62 per 100 000). Also, Italy has low infant and neonatal mortality rates, with a significant decrease over the last 40 years compared with other European countries. In 2011, more than one-third of the adult population (35.8%) was overweight, while 1 out of 10 (10%) was obese, with a higher prevalence registered in the southern regions. At national level, 2011 data seem to be stable compared to 2010. Moreover, the proportion of overweight or obese people increases proportionally with age, before declining slightly among the elderly.

The proportion of smokers among the population aged 15 and over was 22.3% in 2011. In 2003, before the approval of Law 3/2003 to ban smoking in public spaces, the prevalence rate was 23.8%. Smoking cigarettes was found to be more common in young adults, particularly in the 25–34 age group and more prevalent among men (28.7%) than women (16.7%). Data for non-smokers and former smokers are inversely distributed among the two genders. Thus, there is a higher prevalence of non-smokers in females (65.1%) than in males (39.4%), while the percentage of former smokers among men is almost double (30.5%) that of women (16.7%). In terms of alcohol consumption, prevalence rates for those drinking a standard number of units per week show a significant gap between genders (11.53% for men vs 2.72% for women aged over 15 who consume alcohol more than once a week) and geographical differences (lower values in the south and Italy’s islands).

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The reduction or elimination of the burden of vaccine-preventable diseases is considered a priority of the public health service. The routine immunization programme includes diphtheria, tetanus (DT) and poliovirus (oral poliovirus vaccine – OPV) vaccinations, which have been mandatory by law since the early 1960s for all newborns under 24 months. The hepatitis B vaccine was added in 1991, introducing universal vaccination of infants and children (up to 12 years of age). Vaccinations against pertussis, measles, mumps, rubella, Haemophilus influenzae type b (Hib), meningococcal C and pneumococcal meningitis, chickenpox and human papillomavirus (HPV) are non-mandatory vaccinations but are recommended by the Ministry of Health. Compulsory and recommended vaccinations are included in the benefit package and are provided free of charge for all Italian and foreign children living in the country.

4.15.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

One of the goals of the Digital Agenda for Europe 2020 is to provide European citizens with secure online access to their medical records by 2015 and widespread telemedicine services by 2020 (European Commission 2010). This is a real change of perspective that gives top priority to the needs and demands of citizens, the primary aim being better health and quality of life in general. Electronic applications can support health personnel in making diagnoses, collecting non- invasive images, preparing for surgery, etc. doctors, nurses and technicians could immediately have access anywhere to images contained in patient’s medical records simply with an Internet connection. A 2006 study on the economic impact of e-health shows that investment in ICT increases health personnel productivity and health service quality. If e- health is implemented effectively, the value of such benefits increases over time and exceeds investment cost significantly. It would improve “health workplaces”, make them more efficient, and spread working relationships among professionals. This would mean better and faster diagnoses, treatment and care, considerably reducing the risk off error. The spread of digital information would allow “virtuous networks” to be created (potentially of a global dimension), not only among health professionals but also among institutions, hospitals, health research centers, and public and private health institutions. The exchange of information, experience, and staff can make a positive contribution to health research, management, implementation of health policies, use of human resources, and management of central and/or local health systems.

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Furthermore, e-health can make health institutions more productive and less expensive through lower service costs, better prevention, de-hospitalization and optimization of the hospitals’ network. Constantly updated computerized health instruments and information systems are of fundamental importance for the continuous and complete monitoring of healthcare costs. The administration of efficient health and clinical services needs, and will increasingly need, more computerized systems to store and analyse data. Health authorities may benefit from direct access to large amounts of comparable health data, which would allow for expenditure analysis, cost-benefit evaluations, and impact assessments. All in all, computerized procedures would enable health authorities to improve processes by speeding up organizational procedures, increasing efficiency in the management of work phases, spreading responsibilities and reducing errors. This would produce better quality and faster services. e-health strategies in Italy are in line with European guidelines, in which ICT is a tool not only for better diagnoses and treatments, but also for simplified and easy access to universal services. Italy took an important step in this direction with the 2012 e-Government Plan presented in January 2008, with the aim of simplifying and digitizing primary health services by 2012 (digital prescriptions and medical certificates, online booking systems), creating the necessary infrastructure for the provision of services closer to the needs of citizens, improving service cost-quality and eliminating waste and inefficiency. In 2008 the Ministry of Health established a working group to develop online health, setting guidelines to harmonize the e-health solutions adopted locally. Thegovernment plan includes substantial investments, in particular to create a GPs’network, digitized prescriptions, dematerialization, electronic health records (EHR) and online booking systems.

The situation of e-health statistics in Italy is similar to that of most European countries: e- health data are currently produced and managed by administrative, management and clinical information subsystems, which are the responsibility of a variety of local centers. More specific, in Italy, the collection, processing and dissemination of data relevant to the statutory health-care system and to citizens’ health status fall within the mandate of the Ministry of Health’s General Directorate of Health-care Statistics (Statistics Office). Local health authorities (LHA) collect data and send them to regions, which in turn, forward them to the Office.

Specific data flows originate locally, from general practitioners (GP) and LHA departments. The surveillance data flow for infectious diseases, the SIMI (Sistema Informativo Malattie

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Infettive), collects notifications filed by doctors on cases of 47 infectious diseases. Each LHA forwards them to the Regional Public Health Agency, which warns the Ministry of Health and the National Health Council; these can notify international organizations (EU, WHO). An annual Epidemiological Bulletin collects the data by month and by location. A similar data flow exists for occupational hazards and work-related accidents.

One of the most important databases is the national database on hospitalizations (Sistema Informativo Ospedaliero – SIO). This database is based on the Hospital Discharge Form (Scheda di Dimissione Ospedaliera – SDO), introduced in 1991, that reports all details of each hospitalization in secondary care structures, classifying diseases based on the most recent revision of the International Classification of Diseases and listing the services provided to patients. Other notable data flows are the information system on accidents and emergencies (Sistema Informativo Emergenza Sanitaria – SIES); the Register of Delivery Certificates (Certificato di Assistenza al Parto – CeDAP), which collects details on every birth in all regions (since 2008); and the data on organ donations and transplants collected by the National Centre for Transplants. General demographic statistics with relevance to health, such as general mortality, child mortality and mortality of live births, are produced by the National Institute of Statistics (Istituto Nazionale di Statistica – ISTAT), which supports all ministries and central government agencies. Financial and organizational data are also collected and analysed by the State General Accountant (Ragioneria Generale dello Stato).

Over the last few decades, several steps have been taken to coordinate local, regional and national information systems. The Health-care Information System (Sistema Informativo Sanitario – SIS) was established in 1984 within the Ministry of Health to coordinate and manage SSN data flows. Since 2001, a centralized national information system for storage and management of health and health-care-related data, the New Health Care Information System (Nuovo Sistema Informativo Sanitario – NSIS), has been under development. Common and interoperable languages have already been developed for its subcomponents (pharmaceutical distribution database; monitoring of care networks; information system on mental health; observatory of public investments in health care; national information system on addictions; traceability of pharmaceuticals; emergency and urgency; home care; residential and semi-residential care; hospital drug consumption; information system for the monitoring of health care errors).

Finally, in 2015, Italy participated in the third global survey on eHealth. This survey was conducted by the WHO Global Observatory for eHealth (GOe) has a special focus – the use

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of eHealth in support of universal health coverage. It presents data collected on 125 WHO Member States. The survey was undertaken between April and August 2015 and represents the most current information on the use of eHealth in these countries. A total of 125 WHO Member States, representing a 64% response rate, completed the survey, which is the highest response rate for any GOe survey to date. The scope of the survey was broad; survey questions covered diverse areas of eHealth, from electronic information systems to social media, to policy issues and legal frameworks. The data are grouped by eight eHealth themes. Each grouping is intended to give the reader an overview of the eHealth landscape in individual countries in 2015 for each particular theme. More specific in Italy: Table 4.15.4.1 includes a selection of indicators on eHealth-related policies or strategies, funding, and capacity building. Data are reported by the individual “country response” (yes, no or don’t know), and “year adopted” for the particular indicator in the case of national policies/strategies. The former represent the level of planning and action around the use of eHealth in the country’s health system. As above, the answers are expressed as “country response”; it has an additional measurement for the level of funding: no funding, low <25%, medium <50%, high <75% and very high >75%. Also, eHealth capacity building is another significant indicator as it shows whether students or professionals are receiving training in preparation for their exposure to eHealth in clinical settings. The “proportion” of students receiving training is expressed in the same was as for the funding sources above: no funding, low <25%, medium <50%, high <75% and very high >75%.

Table 4.15.4.1. WHO Global Observatory for eHealth

eHealth Foundations National policies or strategies Country Year adopted response National universal health coverage Yes 1978 policy or strategy National eHealth Yes 2006 policy or strategy National health information Yes 2001 system (HIS) policy or strategy | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

National telehealth policy Yes 2014 or strategy Funding Sources for eHealth Country Funding source

response % Public funding Yes >75% Private or commercial Yes <25% funding Donor/non-public Yes <25% funding Public-private Yes <25% partenerships eHealth Capacity Building Country Proportion response Health sciences students-Pre- Yes <25% service training in eHealth Health professionals-In- Yes 50-75% service training in eHealth Source: Atlas of eHealth country profiles-WHO, 2016

Recent data show that in 2010 the regions with the most digital health services were Lombardy, Emilia Romagna and the autonomous province of Trento. In this section (Table 4.15.4.2) provides an overview of the state of adoption of Electronic Health Records (EHRs) in the country. It identifies whether the country has introduced a national EHR system and if there is legislation governing its use. It identifies at what level of the health system the EHRs are being used (primary, secondary or tertiary). At this point we conclude that the development of the national EHR is strongly dependent on the

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national standardisation of health on the level of services, systems, information, coding and terminology systems.

Table 4.15.4.2.WHO Global Observatory for eHealth

Electronic Health Records (EHRs) EHR Country Overview Country response National EHR system Yes Legislation governing the Yes use of the national EHR Health facilities with Use EHR EHR Primary care facilities (e.g. clinics and health Yes care centers) Secondary care facilities (e.g. hospitals, Yes emergency care) Tertiary care facilities (e.g. specialized care, Yes referral from primary/secondary care)

Other electronic Country response systems Laboratory information Yes systems Pathology information No systems Pharmacy information Yes systems PACS Yes Automatic vaccination No alerting system ICT-assisted functions Country response

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Electronic medical billing No systems Supply chain management information Yes systems Human resources for health information Yes systems Source: Atlas of eHealth country profiles-WHO, 2016

It further identifies other electronic systems that the EHR system is linked to. Finally, it lists ICT-assisted systems. It should be noted acase of e-health excellence in Italy is the children's hospital “Bambino Gesù”, whose project "Hospital in a Click" includes all major innovative e-health experiences. Through the website, specialist examinations can be booked or cancelled, medical records consulted, payments made, or other types of diagnostic tests carried out. In addition, through the "Carta della salute" (health card) (an electronic card), children’s’ medical record, diagnoses, and medical reports contained in the EHR may be consulted at any time. The scope of the application of eLearning for pre-service education of health sciences students as well as in-service training for health professionals is covered in this section (Table 4.15.4.3). The faculties or professions which can benefit from eLearning techniques for training are identified along with the “country response” as well as the “global yes response”.

Table 4.15.4.3.WHO Global Observatory for eHealth

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Pharmacy Yes 38% Biomedical/Life sciences Yes 42% Health professionals – Country response Global “yes” response In-service Medicine Yes 58% Dentistry Yes 30% Public health No 47% Nursing & midwifery Yes 46% Pharmacy Yes 31% Biomedical/Life sciences Yes 34% Source: Atlas of eHealth country profiles-WHO, 2016

This section (Table 4.15.4.4) reports the use of social media by individuals and communities. Each response has a corresponding “country response” and “global yes response”. Table 4.15.4.4. WHO Global Observatory for eHealth

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health forums Source: Atlas of eHealth country profiles-WHO, 2016

According to a recent study by the Ministry of Health and La Sapienza University of Roma (2010) a significant number of people consult the Internet in case of health problems: percentages are greater for young people and those with a high level of education. Direct access to authoritative, personalized and immediately usable health information is a key element of patient empowerment, i.e. the process in which patients are endowed with knowledge and know-how the enable them (in whole or in part) to determine their own health status. This is part of a process in which health professionals can become, at the discretion of the patient, facilitators who work within a relationship of equality and not just an authority. An analysis of Internet searches, health forums and the use of social networks for health purposes can help health service providers understand the extent of the demand for health services by citizens, thus allowing them to implement policies geared to the specific needs of patients without using up additional resources. The full implementation of e-health is a challenge for Italy and, more generally, for Europe as a whole: what is needed is commitment from central and local health authorities, a common national strategy supported by appropriate legislation and, generally, a new cultural approach to innovation and technology.

4.15.5. Expenditure, Economics, Management

Healthy life expectancy at birth (2012): 73 years. In Italy, as in most OECD countries, health expenditure has steadily increased over time, making its containment a major issue for governments. However, it is noteworthy that public health-care expenditure remained virtually unchanged between 2010 and 2012 (with a +1.1% average yearly change). The recent history of health-care expenditure is marked by attempts to place stricter control over regions’ health spending after a few regions incurred considerable deficits. To address this financial failure, the government introduced a special regime for overspending regions that requires the adoption and implementation of formal regional ‘financial recovery plans’ (Piani di Rientro). Since 2007, ten out of the twenty-one regional health systems have adopted these plans, which include actions to address the structural determinants of costs.

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The overall effect of this regime has been a decrease in the yearly level of overspending. In 2012, the total deficit of the public health-care sector was €1.04 billion.

Total health expenditure (public and private) exceeded €140 billion in 2012(9.2% of GDP), growing at a yearly average 5 of 4.7% from 2000 to 2009 and by only 0.9% from 2009 to 2012. Since 2000, total health-care expenditure has increased by 1.3 percentage points of GDP (from 7.7% in 2000 to 9% in 2010), mainly because the public component has experienced rates of increase that are substantially higher than GDP. Only in the last years (2010–2012) has the increase in public health-care expenditure been radically contained; thus, the ratio of total health-care expenditure to GDP has been stabilized.

In 2012, the country’s health spending (9.2%) was almost on a par with the EU average (9.6%). (WHO) It is important to highlight that since the early 1990s Italian GDP has grown substantially less compared to the rest of Europe. Consequently, important increases in the share of GDP for health care were driven by moderate increases in absolute spending.

Per capita health expenditure among countries in the European Region shown that Italy positioned itself at $US 3040 PPP in 2012, below the EU average of $US 3346 PPP. In 2012, €112.6 billion in public funding was made available for health care. Overall public expenditure on health was €113.6 billion, with a modest growth rate of 0.8% compared to the previous year. In 2010 and 2011 the level of private expenditure rose more than that of public expenditure (1% and 1.3% in public expenditure vs 1.9% and 2.2% in private expenditure). These changes may reflect two contrasting forces: on the one hand, the economic crisis has reduced households’ disposable income and, thus, demand for private health care; on the other, because of cost-containment policies in the public sector, patients may be forced to pay higher co-payments or to go fully private due to longer waiting times or other forms of implicit and explicit rationing. In this respect, it is interesting to note the emergence of low- cost initiatives in the private sector (e.g. for dental and eye care), which are mainly provided in the form of discounted services. During 2007–2009, the central government had increased its efforts to contain costs, especially through policies aimed at increasing the efficiency of public spending. The main strategy was to make regions more accountable in their provision of the benefit package by keeping within financial constraints.

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More recently, more stringent cost-containment measures have been introduced, including the requirement to reduce the number of hospital beds (to 3.7 beds per 1000 population versus 4 previously), promoting lower hospital admissions (by increasing the use of appropriateness criteria to avoid unnecessary admissions) and also reducing the average length of stay. In addition, in response to the financial crisis and the stricter public budget imperatives of the European Commission and the European Central Bank, the national government cut central transfers to regions and local governments for disability, childhood, migrants and other welfare policies. The 2012 ‘Spending Review’ (Decree Law n. 95/2012), the ‘Stability Law’ (Legge di Stabilità, Law n. 228/2012) and the ‘Decreto Salva Italia’ (Decree Law n. 201/2011) reduced total public health financing by €900 million in 2012, €1.8 billion in 2013 and a further €2 billion in 2014. This reduction in central funding was compensated for primarily by higher co-payments and cost-saving measures to reduce pharmaceutical expenditures.

Cost-containment measures also targeted the expenditure side: the government decreased outsourcing expenditures to accredited private providers by 0.5% in 2012, 1% in 2013 and 2% in 2014 (compared to the 2011 level). The budget for regions’ pharmaceutical spending, introduced in the late 1990s to force regions to implement effective cost- containment initiatives was also revised, reducing the budget cap that is in place by 0.2% from 13.3% in 2011 to 13.1% in 2012 and 11.35% in 2013 on drugs used in non-hospital settings (patient co-payments are excluded from the budget cap). A budget cap for medical devices expenditure was also introduced: 4.8% of regional budgets in 2013 and 4.4% in 2014. Moreover, for 2012 the government imposed a 5% reduction in the value of purchasing contracts for medical goods and services signed by public health organizations (including medical devices but excluding pharmaceuticals). The measure places great emphasis on homogenizing the prices of medical goods and services across the country, allowing public ASLs and AOs to roll over or withdraw contracts if large price differences exist for the same good/service (difference >20% of the reference price) among regional health systems. Finally, a main feature of the health-care system is regional variation in the distribution of health-care expenditure and in the supply and utilization of services.

4.15.6. Challenges and Future Perspectives

In 2000 WHO ranked the Italian health-care system very highly due to high attainment scores in all the dimensions considered, namely health of the population, equity of finance | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

and sensitivity to patients’ expectations (WHO, 2000). These attainments were achieved with expenditure levels that were significantly lower than in many other affluent countries. The last 15 years have not been easy for Italy as the economy has been stagnant, public debt has risen and political institutions have shown structural deficiencies. But despite this rather unfavourable general scenario, the SSN is still universal, funded by general taxation, with limited co-payments and provides free access to primary care, specialized care and a variety of other public health and preventive services. Reforms have been recurrent, and despite the very difficult times for the country, the SSN appears to be rather healthy and is sufficiently valued by citizens, even though more scepticism has been manifested since the start of the economic, financial and fiscal crisis.

In the last five years the SSN has been targeted by a number of policies aimed at containing or even reducing health expenditure without reducing the provision of health services to patients. To a certain extent, these policies have been effective as expenditure is now under strict control and industrial relations within the SSN have not worsened. However, citizens’ perception of the quality of services has declined slightly. Overall, the SSN is clearly strained due to the long period of cost cutbacks and there are clear signals that the economic crisis has worsened some health outcome indicators and increased demand for a variety of services. With some very specific exceptions (e.g. lower number of traffic and work injuries), the crisis has generated a double burden for the health-care system: it has increased demand for health care and at the same time has reduced available resources due to fiscal constraints. Given current financial constraints, waiting times are on the rise and continuity of care and intermediate care for chronic diseases is increasingly difficult to ensure. While so far the SSN has been able to cope with the crisis, it is unlikely that it can keep on offering the present level of services if resources are reduced further. While efficiency improvements are always possible, it is unlikely that further cuts can be made without reducing the quantity and quality of care provided to patients.

The future of the health-care system mainly depends on the future of the country’s economy. If Italy overcomes the structural crisis and starts growing, cost-containment measures can be relaxed and the SSN can receive enough resources to meet the expectations of high quality and universal coverage. Overall, compared to other European countries, the SSN is already rather parsimonious; thus, longer periods of hard cost- containment policies may harm the delivery system and may induce popular calls for change.

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4.16. Latvia

4.16.1. Demographics of Latvia

The Republic of Latvia is a sparsely populated country in north-eastern Europe with about 2.1 million inhabitants, according to the 2011 Census. It is one of the Baltic countries (consisting of Estonia, Lithuania, and Latvia) and forms part of the eastern border of the European Union (EU). Riga – the capital – is the largest city, with about 700 000 inhabitants. Population density in 2010 was 36.1 people per square kilometre, which was one of the lowest in the EU, and over 68% of the population lived in urban areas. There are more than 170 nationalities in Latvia, with the two largest being Latvians, accounting for 62% of the population, and Russians, accounting for 27%. At the beginning of 2011 Latvia had an estimated population of 2.2 million, with slightly more women than men. Educational levels in Latvia are rising. Almost two-thirds (64.1%) of people with higher education are women. This are general information of Latvia:

Gross national income per capita (PPP international $, 2013)-22 Unemployment rate: 9.8% (Dec 2016)

Life expectancy: 74.19 years (2014) Population growth rate: -0.8% annual change (2015)

Life expectancy at birth m/f (years, 2015)-70/79

Probability of dying between 15 and 60 years m/f (per 1 000 population, 2015)-226/82 Total expenditure on health per capita (Intl $, 2014)-940

Total expenditure on health as % of GDP (2014)-5,9

4.16.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The Latvian statutory health care system is based on general tax-financed health care provision, with a purchaser–provider split and a mix of public and private providers.

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Resources are raised mainly through general taxation by the central government although OOP payments remain important. Money flows from the Ministry of Finance through the Treasury to the NHS, a state-run organization under the Ministry of Health, which acts as the central statutory purchasing organization. Health reforms in the early 1990s abolished the inherited highly centralized Semashko system and focused on decentralization of health care delivery, administration and financing. The aim was to create a social health insurance type system, and providers were either fully or partially privatized. Different ownership structures characterize health care provision in Latvia. Smaller hospitals and some bigger regional hospitals are usually owned by municipalities, while larger tertiary hospitals (university hospitals) and specialized (monoprofile) hospitals (e.g. psychiatric hospitals) are owned by the state. Most primary care physicians have the legal status of an independent professional, which is a specific form of entrepreneurship existing only for primary care physicians.

This has led to: (1) the development of a more centralized system with state functions consolidated in fewer institutions; (2) the establishment of one central institution for purchasing health care (the NHS); and (3) a health care delivery system with a strong focus on primary care (and substantially fewer hospitals). The central government raises resources for the statutory health care system through general taxation. Parliament approves the budget of the NHS and money is transferred from the Ministry of Finance via the Treasury to the NHS. The NHS is a state-run organization under the control of the Ministry of Health, which contracts and pays health care providers. Providers contracting with the NHS may be public or private: they tend to be predominantly private in the case of primary care; predominantly public in the case of secondary care, with ownership concentrated mainly at the local government level; and exclusively public in the case of tertiary care, with ownership concentrated at the state (national) level. The Ministry of Health is the central government institution responsible for planning and regulation of the health system. The Ministry of Health elaborates health policy and organizes and supervises its implementation. It is in command of public health activities and coordinates health promotion and disease prevention activities of local governments. As part of the reorganization of the health care system between 2007 and 2011, numerous state institutions were closed down or incorporated into other agencies, including, amongst others: the State Pharmaceutical Inspectorate, the State Medicine Pricing and Reimbursement Agency, the PHA, the CHE, the Mental Health Agency, the Narcology State Agency, the Health Promotion Agency, the Centre of HIV/AIDS, the State Centre of Medical Professional Education, the State Agency of Health Statistics and Medical | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Technologies, the Infectology Centre of Latvia, and the State Agency of Tuberculosis and Pulmonary Diseases. Yet, five more important institutions remain.

Public health services in Latvia are provided by the government and financed mainly by the national budget. In addition, municipalities implement and finance local programmes, while the NHS pays for some services provided by GPs (such as immunizations). Two national institutions are responsible for public health activities in Latvia: the Ministry of Health and the CDPC. The Ministry of Health is the most important national authority responsible for the coordination of health promotion and disease-prevention activities of local governments and it supervises the CDPC. The CDPC, which was founded in 2012, is a budgetary organization of the Ministry of Health and is the main institution for infectious and non-infectious disease control The Latvian health system is regulated through a mix of legislative (laws, regulations), administrative (licences, permissions) and market mechanisms (contractual relationships). In general, the parliament passes laws such as the “Medical Treatment Law” (Government of Latvia, 1997), which sets the framework for regulation of providers, pharmaceuticals and medical devices, while more specific regulations for each of these fields are defined by the Ministry of Health and approved by the Cabinet of Ministers. Regulatory functions (standard setting, monitoring, enforcement) are predominantly concentrated in the hands of the central government, i.e. the parliament and the Ministry of Health and its agencies: the NHS with its five territorial branches, the HI, the SAM, the CDPC, the SEMS, the Centre for Forensic Medical Examination, the State Blood Donor Centre, and the Latvian Sports Medicine Agency. In addition, some regulatory functions in the area of education and accreditation of physicians have been delegated to the Latvian Medical Association. Municipalities no longer have a regulatory function in the health system.

4.16.3. Public Health Indicators

Life expectancy at birth has increased by three years in Latvia since 2000. The main causes of death in Latvia are diseases of the circulatory system, malignant neoplasms and external causes. Life expectancy at birth has been increasing in all EU countries. The same is true for Latvia, where average life expectancy at birth has increased by almost five years since 1980, albeit with a substantial discrepancy between men and women. In Latvia, it was only 57 years for females and 54 for males. An analysis of the causes of mortality in Latvia, shows that, similar to many other European countries, the main causes of death are

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

diseases of the circulatory system. In fact, they account for more than half of all deaths in Latvia. Malignant neoplasms (cancer) have been the second most common cause of mortality in the last couple of decades, both for males and for females. Malignant neoplasms (cancer) have been the second most common cause of mortality in the last couple of decades, both for males and for females. As in all other European countries, infectious diseases do not cause high mortality in Latvia. However, mortality from HIV/AIDS in Latvia is the third highest in Europe after Portugal and Estonia, and it has seen a strong and continuous increase since 2000. Vaccination coverage in Latvia has traditionally been very high. However, immunization data show that coverage has decreased since 2008 and is now below the EU average for a number of vaccines and also below WHO’s general target of 95%. There are three population-based screening programmes in Latvia: one is for neonates, to detect congenital phenylketonuria and hypothyroidism; another is a screening programme for pregnant women; and the third is a cancer-screening programme (breast, colorectal and cervical cancer), which was launched in 2009. All three are financed by the NHS.

The Public Health Strategy 2011–2017 places a strong emphasis on an intersectoral approach to health. The active participation of the other ministries and municipalities in the development of the strategy indicates that there is political support for such an approach, which should involve HIA of all policies. The new strategy, among other goals, aims at increasing healthy life expectancy by two years and decreasing by 20 per cent potential years of life lost – both of which will require a strong focus on prevention and treatment of cardiovascular diseases. Finally, public health has received relatively limited resources in Latvia despite the fact that the country suffers from a high burden of preventable lifestyle-related diseases.

4.16.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

Latvia has a well-developed legal framework for the collection of health statistical information. The responsibilities of different institutions, such as the Central Statistical Bureau (CSB), the CDPC and the NHS are clearly defined by the 1997 “Law on National Statistics” and the 2006 “Regulations on the National Programme of Statistical Information”. These regulations determine responsibilities for the preparation of statistical information and the conditions for users for obtaining health-related data.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

In order to utilize a new medical technology, a health care institution is required to provide a package of documents including: a technical description of the new technology; a summary of published studies documenting the effectiveness of the technology; the qualifications of the medical practitioners who will use the technology; a description of the space within the treatment institution in which the technology will be used; the costs of the new technology; and a justification of the use of resources to purchase it. These documents are usually prepared by medical professionals who are interested in the development of their profession and the introduction of new methods. Ideally, information about cost– effectiveness is also considered but reliable information (even about effectiveness) is often not available. Every new technology is then assessed by the Unit of Health Economics, Technology and Clinical Guidelines within the NHS with regard to safety aspects (risks and potential side- effects), potential impact and efficiency, an assessment of the influence of the technology on the patient’s health and quality of life, professional ethics, as well as the economic justification of its use. About 50 to 60 evaluations of new technologies are conducted each year according to a methodology that is specified in the above-mentioned regulations. A positive assessment is a prerequisite for the introduction of a new technology in Latvia.

4.16.5. Expenditure, Economics, Management

The following table shows main two indicators of expenditure in a period from 2000 to 2014.

Table 4.16.5.1.

2000 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09 ’10 ’11 ’12 ’13 ’14 Total health 6 6 6 6 7 6 7 7 7 7 7 6 6 6 6 expenditure % GDP THE per 196 216 252 301 397 456 613 915 1019 817 739 827 827 869 921 capita in US$

High centralization, vertical management and large hospitals were typical features of the health care system in the Soviet Union. Reforms in Latvia in the early 1990s were dominated by efforts to decentralize the inherited Soviet health care system. Powers were devolved to local governments and some providers were privatized as they were seen to be inefficient. As a result of the devolution and privatization process, access of the population

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

to services as well as the quality of care became highly variable across Latvia, with richer areas covering more and better services than specified by the minimum service package. Coordination between districts was insufficient and local authorities attempted to keep as much health care spending as possible within their territories and often opted for duplication of services even if they were available in neighbouring areas.

4.16.6. Challenges and Future Perspectives

Latvia’s Public Health Strategy 2011–2017 represents an important reference point for the development of Latvia’s health system. It marks a departure in approach from the previous system due to the development of integrated approaches to prevention and treatment and involving public health as well as primary, secondary, tertiary and emergency health services. Strategies in specific areas include improvements in mother and child health, non- infectious disease prevention and infectious disease control, ensuring a healthy and safe environment as well as effective management of the health care system. The newly created CDPC (under the Ministry of Health) plays a key role in monitoring and evaluating progress towards the agreed targets. The current government has announced the following objectives to be pursued in the area of health during its time in office: to increase public expenditure on health, to improve the functioning of the health care system through long- term and coherent financial planning, to implement human resource development activities, including a new salary policy and to implement the e-health system. 4.17. Lithuania

4.17.1. Demographics of Lithuania

The Republic of Lithuania is situated on the east coast of the Baltic Sea and has a population of 3 million. Since the declaration of Lithuania’s independence from the USSR in March 1990, there have been a series of reforms of the national economy. In 2003, the birth rate changed from declining to increasing, reaching 11.3 live births per 1000 population in 2011, when 34 400 babies were born. Since 2000, the average age of women giving birth has increased from 26.6 to 28.6 years, while that of first-time mothers has increased from 23.9 to 26.7 years. Ethnic Lithuanians account for 84% of the population, about 6.6% are Polish, 5.8% are Russian and 1.2% are Belarusian. The main religion is Roman Catholic. Lithuania is a parliamentary republic. The country is governed by a single-chamber parliament (Seimas), elected for a four-year term, and a president elected for five years.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

This are general information of Latvia: Gross national income per capita (PPP international $, 2013)-24

Unemployment rate: 8.1% (Dec 2016)

Life expectancy: 73.97 years (2014) Population growth rate: -0.8% annual change (2015)

Life expectancy at birth m/f (years, 2015)- 68/79 Probability of dying between 15 and 60 years m/f (per 1 000 population, 2015) - 244/87

Total expenditure on health per capita (Intl $, 2014) 1,718 Total expenditure on health as % of GDP (2014) 6.5

4.17.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The EU Survey of Income and Living Conditions (European Commission, 2013) for adults in 2011 showed that 52% of males and 41% of females in Lithuania rated their health as good and very good (EU27: 71% of males and 65% of females), while 14% of males and 22% of females rated their health as bad or very bad (EU27 average 8% of males and 11% of females). The survey indicated that 28% of the population had a long-standing illness or health problem (compared with 32% in the EU27), and 23% had some form of long-term health limitation (compared with 26% in the EU27). It showed similar results for self- perceived health, with better health being associated with higher education, being economically active and having higher household income. The same survey showed that among the most frequently reported health problems were severe headache (33%), chronic anxiety or depression (23%) and allergy (20%). In relation to medically confirmed diagnoses, the most prevalent were arterial hypertension (22%) and rheumatoid arthritis (10%); 5% of the population suffered from chronic bronchitis, migraines or headaches, stomach ulcer, or anxiety and depression. The Health System Law 1994 (Parliament of the Republic of Lithuania, 1994) described the structure and the main principles of the national health system. The health system consists of governance institutions (the government, ministries and municipalities, as well as other

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

specialist governance and control bodies), providers of health-care services, and health system resources and services. The Ministry of Health has been a major player in health system regulation through setting standards and requirements, licensing and approving capital investments. Outside the ministry, the number of regulatory agencies declined between 2008 and 2012 as a result of government policy to reduce bureaucracy and related costs.Privatization of the health sector has been limited, particularly in inpatient care. The private sector plays a substantial role in dental care, cosmetic surgery, psychotherapy, some outpatient specialties and primary care. Since 2008, the NHIF has increasingly been contracting private providers for specialist outpatient care. Strategic planning and programme budgeting in the health sector take place mainly through three-year strategic plans (currently 2013–2015) and annual plans. Reporting on implementation of plans takes place on an annual basis. The plans are directly linked with the budget allocation of corresponding institutions. The Ministry of Health produces policy declarations and legal acts and establishes a general framework on scope, conditions and requirements for the service provision, as well as on the network of health-care institutions.

Systematic application of HTA in the country has been delayed until the present time. Since the start of 2013, two three-year projects financed from the EU Social Fund and aiming to develop a strategy for HTA in Lithuania have been under implementation. The policy agenda is set by the Lithuanian Parliament (Seimas) through legislative changes and by the government through the state government programmes. The ministries develop strategic programmes and plans, with specified priorities and ways of programme implementation. To date, programme evaluation has been the most fragile area: regular (mostly annual) institutional reporting of public authorities focuses mainly on financial accountability and often lacks more comprehensive and analytical evaluation. The state itself plays many roles within the health system, including that of legislator (parliament), regulator (government and the Ministry of Health), contributor to the Compulsory Health Insurance Fund (Ministry of Finance) and owner of health-care facilities (Ministry of Health, Ministry of Defence, Ministry of the Interior, Ministry of Justice). In addition to ensuring the implementation of the state health programmes, the Government of Lithuania is responsible for intersectoral collaboration and drafting legislation.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

4.17.3. Public Health Indicators

Life expectancy at birth has been fluctuating greatly since the early 1990s with improvements seen in the most recent years. Mortality rates from ischaemic heart disease, suicides and alcohol-related causes were the highest in the EU. The leading causes of death were circulatory diseases, malignant neoplasms and external causes. Steady improvements have been made in infant mortality, particularly neonatal mortality, since the early 2000s and mortality from road traffic accidents in the past few years.

The public health system in Lithuania consists of 10 public health centres, subordinated to the Ministry of Health, and a number of specialized agencies with specific functions (radiation protection, emergency situations, health education and disease prevention, communicable disease control, mental health, health surveillance, and public health research and training). At the local level, municipal public health bureaus carry out public health monitoring, health promotion and disease prevention. The principal guidelines for the public health service have been outlined in the Health System Law (1994), Lithuanian Health Programme (1998–2010) and the National Public Health Strategy (2006–2013). Public health bureaus are set a broad mission, with goals and priorities to promote public health and well-being at the local level. They aim at strengthening the public health planning role of local government by including evidence, community consultation and evaluation. Therefore, development of the bureaus has provided a mean by which local governments, in partnership with the service providers, other stakeholders and the community within the municipality, can plan and implement public health services and programmes. At the primary health-care level, some public health functions, such as health promotion, primary prevention and immunization, are carried out by GPs. They, along with other medical specialists and dentists, implement national screening programmes financed by the NHIF. Women aged 25–60 years are offered cervical cancer screening every three years, and those aged 50–69 years are offered breast cancer screening every two years. Men aged 50–75 years (and over 45 for those at risk) are eligible for prostate cancer checks every two years. In addition, biannual colorectal cancer screening is available for adults aged 50–75 years; annual screening for those with high cardiovascular risk is available to men aged 40–55 years and women aged 50–65 years, and a dental programme that provides for teeth coating is offered to children aged 6–14 years. These programmes are opportunistic rather than population based. Recently, the NHIF cited evidence that describes most of these programmes as efficient.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

4.17.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

Health data in Lithuania are mainly collected by the public agencies subordinated to the Ministry of Health: the Health Information Centre, currently a unit within the Institute of Hygiene, and the NHIF. Health-care institutions provide data on health status, service utilization and resources. The Ministry of Health governs a few information systems, including the e-health services and information exchange system, the pharmaceutical control system, the health-care institutions licensing system, the communicable diseases system, the radiation safety system, and a system for financial management and health insurance (SVEIDRA) administered by the NHIF. Since the Government of Lithuania approved the fourth stage of the health system reform, all health care institutions are encouraged to join the eHealth system network. The system allows to build a patient record and fill in medical information, produce e-prescriptions. The Ministry of Health encourages the use and spread of the eHealth, provides technical supports and notes that the funding of €7 million was provided to municipal institutions for their information systems installation and upgrading. Survey data shows that currently there are more than 200 primary care centres, outpatient clinics and hospitals which use the eHealth, covering 1,3 million residents and over 700 thousand patient contacts so far. It is planned that from the March of 2018 the use of eHealth will become mandatory for all public healthcare institutions.

Lithuanian National Electronic Health System (NESS) nas been launched by the Ministry of Health on 1st June 2015. It is expected that the e-health system will improve efficiency and quality of healthcare and ensure data exchange between various institutions. The NESS consists of a central e-health information system and its subsystems – electronic prescription, medical images, as well as patient information systems of healthcare service providers. Patients will be able to set privacy settings with regards to certain conditions, and make information accessible only for specific health professionals. Currently only medical records of collaborating providers are included, and the mandatory full use of the e-health system for all healthcare institutions is expected from 2018. The development of NESS took more than a decade, due to legal considerations. The project costed 28 million euros and was financed from the EU structural funds.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

4.17.5. Expenditure, Economics, Management

The following table shows main two indicators of expenditure in a period from 2000 to 2014.

Table 4.17.5.1.

2000 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09 ’10 ’11 ’12 ’13 ’14 Total health 6 6 6 6 6 6 6 6 7 8 7 7 7 7 7 expenditure % GDP THE per 211 219 264 352 378 454 570 753 977 877 829 968 940 1020 1063 capita in US$

There was substantial privatization of state assets in Lithuania in the 1990s. Until the 2000s, there were no consistent attempts to privatize health-care providers. Later, private GP development was enhanced by investments and by contracts with the NHIF. The biggest impact of privatization has been seen in the outpatient sector. There have been a few instances when former units of public polyclinics were converted into private providers. The Parliament of Lithuania has recently approved the 2016 budget for the Compulsory Health Insurance Fund (CHIF), which is the largest source of health care financing. This year’s budget consists of €1.44 billion, with revenues comprised of compulsory health insurance contributions (€995 million), contributions and allocations from the state budget (€423 million) and other revenues (about €20 million). It is expected that in 2016 CHIF budget expenditure for health care services will be about €1 billion, for medicines and medical devices – €281 million, for medical rehabilitation and spa treatment – over €44 million, for health programs and other costs – €75 million euros, for administrative health insurance functions – €21 million. There has been a growth of 4.1% (or €56 million) in funding compared to previous year. Increased budget will help to provide more treatment services for patients and increase provider payments for health care services by 4%. Also more people will be able to participate in various health programs, including prevention, which now receive increasing attention and 8% increase in funding.

4.17.6. Challenges and Future Perspectives

A policy document, Lithuania’s Health System Development Dimensions 2011–2020, was adopted in 2011 and defined the main directions for health system development until 2020 (Parliament of the Republic of Lithuania, 2011a). The document is intended to provide | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

consistency to the future development of the system and make it more efficient and competitive. The key areas of focus are health improvement and disease prevention; expansion of the health-care service market through fair competition; increasing transparency, cost–effectiveness and rational use of resources; and ensuring evidence- based care and access to safe and quality services. The Health System Development Dimensions document suggests three stages of future development: (1) structural changes, including reduction in the numbers of hospitals, hospital beds and physicians; (2) the introduction of budgetary ceilings for health-care providers; and (3) increase in cost- sharing through VHI, legalizing co-payments and introduction of fair competition and effective management principles in health care. The new government, which came to power after the elections in November 2016, has set improvements in population health and healthcare as one of its key priorities. The Government programme recognises that meaningful improvements in life expectancy and healthy life years can only be achieved through intersectoral policies aimed at minimising the role of risk factors, in addition to measures aimed at improving mental health and increasing health care quality and effectiveness. 4.18. Luxemburg

4.18.1. Demographics of Luxembourg

Luxembourg is one of the founding states of the European Union, surrounded by Beligum, France and Germany. With an area of 2,586 square kilometres (998 sq mi), Luxemburg is one of the smallest sovereign states in Europe. Although it is one of the smallest countries in the EU, at the same time it is one of the richest. “The most important sectors of Luxembourg’s economy in 2015 were the financial and insurance activities (28.4 %), wholesale and retail trade, transport, accommodation and food services (16.6 %) and public administration, defence, education, human health and social work activities (15.6 %).”12 It mostly does trade with Germany, France and Beligum, when it comes to export, while the main import partners are Belgium, Germany and China. As one of the smallest countries in the EU, it has population of 562,958 inhabitants (according to census in 2015) at the territory of 2,586 km2. This is 0,1% of population of the EU. GDP is 52,112 billion Euros. In political terms, Luxembourg is a parliamentary constitutional monarchy, which has been a member of Schengen Area since 1995, and Eurozone since 1999.

12http://europa.eu/european-union/about-eu/countries/member-countries/luxembourg_en | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Ethnic groups in Luxembourg are rather diverse: Luxembourger 54.1%, Portuguese 16.4%, French 7%, Italian 3.5%, Belgian 3.3%, German 2.3%, British 1.1%, other 12.3%. Population growth rate is positive (2,05%), which ranks in the place 47 in the world. Life expectancy is 82,3 years – for men it is 79,8 years and women 84,9 years. Luxembourg spends 6,6% of its GDP on health care, putting it on the place number 82 in the world rankings. According to the Fact Book of the CIA, there are 2,9 physicians per 1,000 inhabitants and 5,4 beds per 1,000 of inhabitants. As a representative democracy with a constitutional monarch, it is headed by a Grand Duke, Henri, Grand Duke of Luxembourg, and is the world's only remaining grand duchy. Luxembourg is a developed country, with an advanced economy and the world's highest GDP (PPP) per capita, according to the United Nations in 2014. Its capital, Luxembourg City, is, together with Brussels and Strasbourg, one of the three official capitals of the European Union and the seat of the European Court of Justice.

4.18.2. Healthcare System and Public Health Structure, Organisation, and Legislation

Luxembourg is considered to have one of the best health care systems in Europe which are funded by state. It is based on three crucial principles: “compulsory health insurance, free choice of provider for patients and compulsory provider compliance with the fixed set of fees for services”13 Under this system, majority of general practice treatments, as well as laboratory tests and expenses related to pregnancy, rehabilitation, prescriptions and hospitalization are covered by the state system. A patient pays for the expenses and then asks for reimbursement, which is covered from 80 to 100 per cent. This does not include vulnerable groups which are paid for their medical expenses: students, unemployed and children up to age of 27. “Luxembourg's healthcare system is mainly publicly financed through social health insurance. All employees contribute on average 5.44 percent of gross income (with a maximum contribution of 6,225 euro) to the Caisse de Maladie, which is deducted directly from their salaries and half of which, is paid by the employer.”14

When it comes to private healthcare, it is used as additional means for those areas not approved by the state as essential, by 75% of population, although 99% of population is

13https://healthmanagement.org/c/hospital/issuearticle/overview-of-the-healthcare-system-in-luxembourg 14 https://healthmanagement.org/c/hospital/issuearticle/overview-of-the-healthcare-system-in-luxembourg | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

covered by the state. All hospitals are public, and available event to those who do not have insurance.

The system is split between prevention and treatment, in terms of both provision and financing. For the most part, preventive services are the responsibility of the Ministry of Health; interventions are provided by a few public services and by private practitioners and non-profit associations paid from the Ministry budget. Curative treatment is a shared responsibility of the Ministry of Health and the Ministry of Social Security. The former supervises the organization of health services and subsidises the hospital sector, while thelatter is responsible for the sickness insurance system.

Ministries other than Health and Social Security involved in health-related areas include:

• the Ministry of Environment as regards air and water pollution, waste, noise pollution;

• the Ministry of Family Welfare as regards homes for elderly people including nursing care, home aid services, services for the handicapped;

• the Ministry of Labour as regards safety at work;

• the Ministry of Housing as regards housing projects and subsidies for individual homes;

• the Ministry of Education as regards training of some health professionals and health education in schools;

 the Ministry of Transport as regards traffic safety;

• the Ministry of Justice as regards policy on illegal drug use. The Minister of Health defines and implements health policy, prepares legislation, ensures the implementation of laws and regulations on health and healthservices and authorizes, supervises and funds public and private health institutions and services. The Minister is supported in these duties by several services within the Ministry of Health, dealing with human resources, financing, legislation and coordination.

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The heads of these services and the Director General of Health (who is the head of the Directorate of Health – see below) are members of a small body which advises the Minister, called the bureau Ministériel. General legislation on the organization of the health and social sectors, and various specific laws on institutions and organizations working in the healthsector, require representatives of the Ministry of Health in various interdisciplinary committees and boards. Examples of bodies with such Ministry of Health representation would be: committees within, or run by other government departments and private associations; boards of organizations such as hospitals or the Luxembourg Red Cross; committees overseeing contracted-out health and social sector work. The Directorate of Health also reports to the Minister of Health, as the executive administration for public health in Luxembourg. It has its own responsibilities, such as to study the overall health situation in the country, to advise public authorities on public health matters, to oversee the implementation of laws and regulations on public health, to take immediate measures to protect public health in the face of any threat and to contribute to health policy on the national and international level.

4.18.3. Public Health Indicators

Life expectancy at birth in Luxembourg in 1997 was 74.24 years for men and 80.52 for women. Life expectancy for the whole population in 1995 (77.41 years) was almost equal to the EU average (77.44 years) and well above the WHO European Region average (72.46 years). Infant mortality saw a slight increase over the two years to 1997 (5.1 per 1000 live births), but, as in most of the European Region, is decreasing over the longer term (from 7.09 per 1000 live births in 1990 and 8.28 in 1985). The population is ageing and, of the (approximately) 420 000 population, only 200 000 are economically active. The leading causes of death in Luxembourg in 1998 were diseases of the circulatory system (cardiovascular and cerebrovascular disease) followed by cancer, respiratory diseases and external causes (accidents and suicides).

4.18.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

The Luxembourg government, in October 2006, launched the eHealth Action Plan, which later led to the creation of the eHealth Agency and a platform for sharing and exchanging health data.

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According to the provisions of Article 60ter and 60quater of the Social Security Code, the main role of the eHealth Agency is to ensure better use of information in the health and medico-social sectors, Ensure better coordinated patient care. It is called upon to achieve this through the establishment

• A platform for sharing and exchanging data in the field of health, including the Shared Care Package (DSP)?

• Of a Health Information Systems Master Plan (SDSI) defining a national strategy for interoperability of health information systems so that different health systems can interact smoothly. https://www.esante.lu/portal/fr/agence-esante/notre-histoire- nos-missions,139,106.html There is also Gecamed which is an open source Electronic Health Record system developed in Luxembourg in 2007. It is the first EHR system in Luxembourg to achieve interoperability with the health records management system used by eSanté, the country’s national eHealth agency.

The open source EHR is ideal to transfer knowledge to other EHR developing companies in Luxembourg and it allows users to be on the technological forefront for EHR interoperability.

4.18.5. Expenditure, Economics, Management

Health care services are financed by the statutory health insurance system which covers 99% of the population. The exceptions who are not covered are civil servants and employees of European and international institutions (who have their own health insurance funds) and any unemployed person who is receiving neither unemployment benefit nor a public pension. The compulsory health insurance is managed and provided by the Union of Sickness Funds and nine individual agencies to which people are allocated on the basis of their professional occupation. The health insurance has three sources of finance; contributions from the state (a maximum of 40% of the total), from employers (about 30% of the total) and from insured individuals (about 30%). Contributions are collected centrally for all branches of social security by the Common Centre of Social Security and are allocated to the Union of Sickness Funds.

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Luxembourg’s health care expenditure as a share of GDP is far below the western European average, and the lowest amongst its immediate neighbours Belgium, France and Germany; however Luxembourg’s expenditure per capita on health care seems to be one of the highest in Europe. This apparent contradiction has two explanations. Firstly, per capita expenditure figures based on the resident population can be misleading since a significant minority (about 25%) of Luxembourg’s insured workers are commuters coming from the neighbouring countries. Secondly, Luxembourg’s per capita GDP is one of the highest in the EU.

4.18.6. Challenges and Future Perspectives

Generally, the main internal challenge facing the Luxembourg health system in future is the need to take on board the modern tools of evaluation and costcontainment and tailor them to complement the principal characteristics of the current system. More specifically, key areas which will require hard work and attention over the next few years will be the new long-term-care insurance system (and other changes in social care), and the administration of the pharmaceutical reimbursement system. 4.19. Malta

4.19.1. Demographics of Malta

Malta is a Southern European island country consisting of an archipelago in the Mediterranean Sea. It lies 80 km south of Italy, 284 km east of Tunisia, and 333 km north of Libya. Malta is one of the smallest countries in the world and one of the most densely populated at the same time. It comprises five islands in the Central Mediterranean Sea in the territory of 315 km2, with the population of 429,344 inhabitants (according to data from 2015), which is 0,1% of the total population of the EU.

The capital of Malta is Valletta, which at 0.8 km2, is the smallest national capital in the European Union by area. Political system of Malta is parliamentary republic. It has a GDP of 8,796 billion Euros and it became a member of the Eurozone in 2008. It joined the EU in the largest enlargement in 2004, while it became a part of the Schengen Area in 2007.

“The most important sectors of Malta’s economy in 2015 were wholesale and retail trade, transport, accommodation and food services (22.6 %), public administration, defence,

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education, human health and social work activities (18.8 %) and professional, scientific and technical activities; administrative and support service activities (12.5 %).“15 It mostly exports to Germany, France and Hong Kong; while majority of their imports come from Italy, the Netherlands and the UK.

Ethnic group living in Malta are called Maltese. Population has a positive growth rate: 0,26%, with life expectancy of 80,4 years for the population in general, while 78 years for men and 82,8 years for women.

4.19.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The Ministry for Health has been responsible for both regulation and provision of health services in what has hitherto been mostly an integrated public system of health services organization and delivery, though a substantial shift towards greater private sector involvement is under way. The private sector already carries out a significant amount of activity in the ambulatory and primary care sectors. Its role in the hospital sector is set to increase, with responsibility for management of three hospitals being granted to a private sector provider in the form of a 30-year concession. The government will continue to remain responsible for the funding of the care provided, and those publicly funded health care services will remain free of charge at the point of use to all those entitled. This is an innovative development for the Maltese health system, although similar arrangements have been in place for several years in the long-term care system. As a result, the Ministry for Health’s role will shift from being a direct provider of services to ensuring standards of care through its regulatory function. The 2013 Health Act replaced the Department of Health (Constitution) Ordinance. The Act creates a basic framework for the public component of the health system. In essence, it seeks to regulate the entitlement and quality of health care services and providers, and to consolidate and reformthe government structures and entities responsible for health. To this end, the Act establishes three directorates: the Directorate for Policy in Health, the Directorate for Health-Care Services and the Directorate for Health Regulation. In addition, the Act also aims to empower patient rights and safety, and provides for the enactment of a Charter for Patient Rights and Responsibilities. The Act clearly defines the roles of the three directorates. In addition to the three directorates described in the Health Act, there are three bodies that play an important regulatory and advisory role. These include the Health

15http://europa.eu/european-union/about-eu/countries/member-countries/malta_en | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Policy and Strategy Board, the Council of Health and the Advisory Committee on Healthcare Benefits.

4.19.3. Public Health Indicators

The population is ageing rapidly. The proportion of the population consisting of persons aged 0–14 years has continued to decline and stands at 14.4%, whilst the proportion of persons aged 65 and over has increased from 16.3% in 2011 to 19.2% in 2015 (World Bank, 2016). While the crude death rate has been relatively stable over the past 20 years (7.7 per 1000 persons in 2014), there has been a decline in the fertility rate from 2.0 births per woman in 1991 to 1.38 in 2014. The crude birth rate stood at 9.8 per 1000 in 2014 (World Bank, 2016). The old age dependency ratio, which stood at 19.3% in 2005, rose to 27.6% in 2015 (Eurostat, 2016a). Projections depict a rapidly ageing population with the ratio estimated to reach 32.7% in 2020, thereby exceeding the EU average. This ratio is expected to climb steadily and reach 40.5% (EU average 39.0%) by 2030 (Eurostat, 2016a).

4.19.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

Since the early 1990s there has been steady growth in the use of IT throughout the health system, and this is most evident in public secondary care. In particular, the implementation of the Health-Care Information System in 1997 and the first phase of the Integrated Health Information System in 2007 led to noticeable penetration of IT infrastructure and applications throughout public hospitals and health centres. Public hospitals and health centres have been operating an integrated appointment booking system since 1998. This has recently been integrated into the myHealth portal. In 2006 an eHealth Portal was launched. This facilitates access to specific health-related e- services, such as online referral to hospital, health information and information about government health services. In 2012 the myHealth system was launched which allows patients and the doctors they choose to gain direct access to their electronic patient record through the Internet, providing the first IT link between the private family doctor community and the public sector. Uptake of the myHealth system increased considerably in 2016 following the introduction of a paper-based consent form and improvements in the user experience of the sign-up process, which practically facilitated uptake by patients and physicians alike. This resulted in a 681% increase in July 2016 (13,090) compared to

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September 2015 (1,674) in the total number of patients who subscribed to the myHealth system and have been accepted by their respective doctors.

The development of health information systems at hospital level took a significant leap forward with the opening of MDH in 2007. Systems introduced include a radiology information system, a picture archiving and communication system, an integrated laboratory information system, and an order communication system. Since 2007 a number of additional systems have been introduced to cater for the increased demands within the health care systems, such as the Centralized Theatre Management System, Cardiovascular Information System (CVIS) and Online Surgical Register. In 2013 the old Patient Administration System was migrated to a new system known as the Clinical Patient Administration System (CPAS), which also acts as an electronic appointment booking system and is used nationwide through the health care system as a patient master index. In 2016 a Clinical Decision Support System, known as UpToDate, was implemented at MDH and SAMOC. On a national level, in 2015 a Digital Health Portal was launched (http://digitalhealth.gov.mt ) which intends to consolidate all online resources related to eHealth, such as the recently launched electronic Patient Referral Form, fast-track colorectal clinic referral form (authorized to trained GPs) and a number of paper-based forms which are used on a regular basis.

The nationwide deployment of the e-ID card that stores electronic identification data is well under way in mid-2016. This will allow secure identification and authentication of patients and health professionals, and hence facilitate authorization of online access to personal health data.

4.19.5. Expenditure, Economics, Management

Total health expenditure as a percentage of GDP was 9.75% in 2014, which is slightly higher than the EU average of 9.45%. Public spending was only 69.2% of total health expenditure (compared to 76.2% for the EU as a whole), but government spending on health care is increasing strongly, with an 11.4% increase in the current health budget for 2017, and this follows a 12.5% increase for 2016. Out-of-pocket payments made up 94% of the roughly 30% of health care expenditure that is privately funded. EU funding has also played a significant role in the health sector in recent years, providing €29m of infrastructure investment in health care (3.4% of the total EU structural funds allocated to Malta for the period 2007–2013).

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4.19.6. Challenges and Future Perspectives

Overall, the Maltese health system has registered remarkable progress and this is evidenced by the improvements in preventable and amenable mortality, as well as the generally low levels of unmet need. The main outstanding challenges for the coming period include: adapting the health system to an increasingly diverse population; increasing health system capacity to copewith a growing population; implementing a redistribution of resources and activity from hospital to primary care; ensuring access to innovative expensive medicines whilst concurrently tackling the need to continue identifying efficiency improvements; and addressing the issue of medium-term financial ustainability associated with steep demographic ageing. 4.20. The Netherlands

4.20.1. Demographics of Netherlands

The Netherlands is a parliamentary constitutional monarchy in the north of Central Europe. With about 41,542 km² and 19,925,000 (2015) habitants the Netherlands is a small but densely populated country. One fifth of the population has a foreign background. Important demographic trends are ageing, decreasing growth of the population and urbanization. Life expectancy and mortality rates are favourable, but among OECD countries, the Netherlands has ceded its top ranking in this respect. Malignant neoplasms and diseases of the circulatory system are, by far, the main causes of death. General information about the Netherlands:

Gross national income per capita (PPP Int $) (2015): 43,210

Hospital beds per 100,000 (2015): 470

Physicians per 100,000 (2015): 315

% of population aged 65+ years (2011): 16 % Life expectancy at birth m / f (2015): 80 / 84 years

Total expenditure on health as % of GDP (2014): 12.9 %

Internet users: 93 %

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4.20.2. Healthcare System and Public Health Structure, Organization and Legislation

Publicly financed health insurance:

All residents (and nonresidents who pay Dutch income tax) are mandated to purchase statutory health insurance from private insurers. People who conscientiously object to insurance, as well as active members of the armed forces (who are covered by the Ministry of Defense), are exempt. Insurers are required to accept all applicants, and enrollees have the right to change their insurer each year. Insurers are expected to engage in strategic purchasing, and contracted providers are expected to compete on both quality and cost. The insurance market is dominated by the four largest insurer conglomerates, which account for 90 percent of all enrollees. Currently, there is a ban on the distribution of profits to shareholders. Private (voluntary) health insurance: In addition to statutory coverage, most of the population (84 %) purchases a mixture of complementary voluntary insurance covering benefits such as dental care, alternative medicine, physiotherapy, spectacles and lenses, contraceptives, and the full cost of copayments for medicines (excess costs above the limit for equivalent drugs—an incentive for using generics). Premiums for voluntary insurance are not regulated; insurers are allowed to screen applicants based on risk factors and offer both statutory and voluntary benefits. Nearly all of the insured purchase their voluntary benefits from the same (mostly nonprofit) insurer that provides their statutory health insurance. People with voluntary coverage do not receive faster access to any type of care, nor do they have increased choice of specialist or hospital. In 2013, voluntary insurance accounted for 7.6 percent of total health spending. 4.20.3. Public Health Indicators

Partly because of health care improvements and the ageing population, the prevalence rates of most types of chronic illnesses increased in the past decade. That growth is expected to continue. Early detection and improved treatment of diseases imply that people live longer with their illnesses. Although the number of chronically ill people has risen, the number of people with activity limitations has been relatively stable. The

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majority (65 %) of people with chronic illnesses do not feel unhealthy and only 21 % experience limitations.

The infant vaccination rate through the National Vaccination Program is around 95 %. The percentage of children up to the age of 4 years visiting child health clinics is very high (from 99 % for children in their first life year to 85 % for children aged 4 years old. In the Netherlands 18.5 % of adults report being daily smokers. The obesity rate is 11.8 % (BMI > 30).

4.20.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

Use of Internet: Between 2005 and 2014 the proportion of households with Internet access rose from 78 % to 96 %. In the same period the percentage of people using the Internet every day has increased from 68 % to 90 %. In 2014 over three-quarters of Internet users aged 65 to 75 were daily users of the Internet; in 2005 this was 43 %.

ICT use by Patients and Care Providers: Doctors in the Netherlands are doing well in international comparisons when it comes to the use of electronic health care records and health care information exchange. All GPs (General Practitioner) in the Netherlands use an electronic GP information system to record medical data about their patients. The information system is used to manage the care process and for administration purposes. The introduction of the EVS (Electronic Prescription System) has improved the quality of prescriptions and the use of electronic medical records and has resulted in a reduction of expenditure on medicines. E-Health Policy Development:

In 2013 the Netherlands agreed upon a National Implementation Agenda for eHealth which resulted in the eHealth Governance Covenant 2014 – 2019. Among care recipients and informal caregivers, a growing need for eHealth applications appeared and more physicians acknowledged the benefits of eHealth. However, the use of online services among health care users was stagnating; still relatively few people seem to be aware of the online possibilities that their GP and other care providers offer.

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4.20.5. Expenditure, Economics, Management

According to WHO, the Dutch health system is among the most expensive in Europe, but it is also in the top five best valued systems in Europe and 91 % of insured evaluate the health care system as good.

In 2013, the Netherlands spent 12 percent of GDP on health care, and 78 percent of curative health care services were publicly financed. The health insurance for adults is paid for 50 % by a community-rated premium and the other 50 % via an income-dependent premium. Statutory health insurance is financed under the Health Insurance Act, through a nationally defined, income-related contribution, a government grant for the insured below age 18, and community-rated premiums set by each insurer (everyone with the same insurer pays the same premium, regardless of age or health status). Contributions are collected centrally and issued among insurers in accordance with a risk-adjusted capitation formula that considers age, gender, labor force status, region, and health risk (based mostly on past drug and hospital utilization).

Government health spending was €77.8 billion in 2014 or 29 % of the total public budget, up from 25.5 % in 2012, which corresponds with an average growth of 7 % per year. Netherlands spent the equivalent of USD 5,601 per person on health in 2013.

4.20.6. Challenges and Future Perspectives

The Dutch health care system has not lacked decisiveness over the past decade – a trait that continues to be needed for troubleshooting and maintenance. Indeed, the freshly implemented long-term care reform will have to overcome its growing pains to realize the transition to less publicly provided care and more self-reliance on the part of the citizens. This needs to be achieved jointly by municipalities and the citizens. A particular point of attention is how the new governance arrangements and responsibilities in long-term care, particularly those of municipalities and health insurers, will fit together, without pushing away care to each other. The position of the 2006 reform is much more stable, but fine-tuning is still needed and solutions need to be found where current market-based solutions are not yet effective. Yet friction seems to be growing between competition as the driver of the health care system and reforms that demand cooperation and integration among actors. Specialization among hospitals, substitution between secondary and primary care, integration within

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primary care and between primary care and social care, and seamlessly provided long- term care organized by municipalities are all examples of changes that require harmony and mutual trust. It may prove challenging to create these conditions in a system where competition is the ruling principle. 4.21. Poland

4.21.1. Demographics of Poland

The Republic of Poland is the largest country in central and Eastern Europe in both population (38.1 million) and area (312,685 km²). In 2009, 61 % of the total population lived in urban areas. Warsaw, the capital, has a population of 1.7 million. In terms of ethnicity, language and religion, Poland is more homogeneous than most countries in the region. Poles make up 97.5 % of the population, with Belarusian, German, Lithuanian and Ukrainian minorities accounting for the remainder. In 2004, the number of births fell below that of deaths, resulting in negative natural population growth, as in many other EU countries. Because of the population decline, it is estimated that by 2050 there will be 31.9 million inhabitants in Poland, or 6.2 million less than in 2009. The proportion of people over the age of 65 years, which was 13 % of the total population in 2009, is projected to increase to 37.9 % by 2025. General information of Poland:

Gross national income per capita (PPP Int $) (2015): 22,300 Hospital beds per 100,000 (2014): 670

Physicians per 100,000 (2015): 222 % of population aged 65+ years (2015): 16 %

Life expectancy at birth m / f (2015): 74 / 81 years

Total expenditure on health as % of GDP (2014): 6.7 % Internet users: 65 %

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4.21.2. Healthcare System and Public Health Structure, Organization, and Legislation

Poland has a good standard of compulsory state funded healthcare. Healthcare in Poland is available to all citizens and registered long-term residents. The Ministry of Health is in overall charge of policy and regulation of the healthcare system and the National Health Fund (NHF) aided by its regional branches manages the healthcare insurance scheme. Private healthcare is also available in the country and many citizens choose this to avoid the long waits imposed by the state system. The state healthcare system is funded in two ways - through government budgets to healthcare and through compulsory individual contributions to the state healthcare insurance scheme. It is not possible to opt out of the scheme, despite being a low-income earner or part of a vulnerable group; their contributions are deducted from their benefits, however, the amount of each person’s contribution does vary according to income and status.

Employers must register their employees with the health insurance fund when a new employee starts work. Employees pay around 8.5 percent of gross salary to the NHF and this is deducted directly from each person’s salary. Dependant family members are covered by the contributions paid by employed family members. If you are self-employed, your contribution rate will be determined by the amount you earn, but you will have to get additional insurance to cover members of your family. Foreigners immigrating to Poland without jobs must produce proof of private health insurance in order to obtain their residence permit. All other groups must register themselves with their local branch of the NHF.

The state fund covers most medical services including treatment by GPs and specialists, diagnostic examinations, hospitalization, emergency care, prescription medicine and surgical appliances, pregnancy and childbirth and rehabilitation.

4.21.3. Public Health Indicators

In 2008, the potential years of life lost for all deaths occurring in people under the age of 70 in Poland amounted to 3,127 per 100,000 women and 7,801 per 100,000 men. These

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figures were substantially higher than in all other European OECD countries except Hungary, Slovakia and Estonia.

Infant mortality rate in Poland – 5.6 per 1,000 births in 2009 – was the highest among European OECD countries (together with Hungary), but it is important to note that this represents dramatic progress since 1989, when the rate was 19.1.

Childhood vaccinations (against measles; diphtheria tetanus and pertussis; hepatitis B, etc.) and the very high immunization ratio among children (98–99 %) places Poland at the top of OECD rankings.

The in-hospital case-fatality rates within 30 days after admission for acute myocardial infarction reduced meaningfully and quickly from 6.5 in 2003 to 5.7 in 2005 and 4.5 in 2007, falling below the OECD average (4.9).

The rate of diabetes among the adult population was higher in Poland than in the EU, and although cancer survival rates have increased in recent years, they are still low compared with other OECD countries. The Polish health care sector also needs to make more efforts towards health gains in other areas, particularly in relation to alcohol consumption, obesity among children and adults, and the high numbers of injuries and mental disorders. 4.21.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

According to a 2009 population survey, 55.1 % of Polish households had a computer and 50.9 % had access to the Internet. The share of people using the Internet was higher for the younger age groups: 86.8 % of the 16–24 year olds and 73.7 % of the 25–34 year olds used the Internet. According to Eurostat data in 2010, approximately 25 % of Poles aged 16–74 used the Internet to seek health-related information. This share has risen dramatically over the last few years but is still substantially lower than the EU27 average of 34 % in the same year. In primary care, computers are mainly used for patient registration and administrative purposes but not during medical consultations – neither the physician nor the patient has access to electronic data (such as patient records). Although computers are used in the majority of health care units in Poland, usage in single-physician medical practices and middle-sized ambulatories is low, and medical documentation is still maintained in paper form.

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The use of IT in secondary care still seems to be much less advanced than in Western Europe. The use of e-health in Poland is very low, but some initiatives in this area have been piloted. Currently (2006), there is redundancy of collected data, inconsistency of data between registers and no linkages between various databases. Medical IT and communication technology systems are usually developed separately by individual health care units, and compatibility and coordination are low. According to the 2011 Act on the Information System in Health Care all medical institutions in Poland must, by August 1, 2014 collect, process and retrieve medical data in an electronic form. The goal is to achieve a complete transition to electronic documentation that “follows” the patient wherever he or she goes and gives health care providers access to patient’s up-to-date medical information (state of health, referrals, purchased drugs, etc.). This is also in line with the EU action plan aimed at gathering, processing and sharing of information about the health status and other related information. All documentation processed by the health care institutions will have to be collected and processed digitally according to certain standards and in compliance with the 1997 Law on Personal Data Protection and other regulations that safeguard the security of sensitive information.

4.21.5. Expenditure, Economics, Management

The GDP devoted to health increased during 1995–2009 by only 1.9 percentage points, from 5.5 % to 7.4 % of GDP. Adjusted for purchasing power, health care expenditure per capita increased three and a half-fold from PPP US$ 409.6 in 1995 to PPP US$ 1,394.3 in 2009. Both at the beginning and towards the end of this period, around 72 % of the expenditure came from public sources, while this share was slightly lower in the 2000– 2005 period. Despite these increases, Poland was among the EU countries with the lowest health expenditure per capita measured in US dollars PPP in 2008, with only Bulgaria, Latvia and Romania ranking lower among EU Member States. The comparatively low level of per capita health spending in Poland is not only a consequence of lower GDP but also of the relatively low share of GDP devoted to health, a situation which Poland shares with a number of eastern European countries.

Approximately 70 % of health care expenditure in Poland is covered from public sources. Over 83.5 % of this expenditure can be attributed to the universal health insurance,

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and NFZ expenditure accounted for over 91 % of public expenditure on individual health care in 2008. Even in the early 1990s, the share of public resources in health care financing clearly started to decrease, and private sources reached 30 % of total health expenditure in a short period of time. This share, however, has shown a slowly decreasing trend since 2000.

4.21.6. Challenges and Future Perspectives

Limited financing seems to be the biggest barrier in achieving accessible and good quality of health care services and in improving patient satisfaction with the system. Significant efforts have been made to improve the health care information system, but the goals are far from being achieved and innovative solutions have been piloted on a very small scale. A reliable health information system should improve management and planning of human resources and infrastructure, minimize waste of financial resources, improve quality of care for patients and aid policy-making. Future strategy in the area of e-health is outlined in a recent CSIOZ study introducing the “e-Health Poland” strategy (2011). Its key goals include digitalizing medical registers and strengthening their legal basis (some have out-dated or no legal basis); achieving interoperability of information systems; improving accessibility to information systems for the public administration, physicians and patients; reducing the cost of data collection and processing; and implementing the EU Directive on Patient Rights in Cross-border Health Care. The strategy was supported by legislation proposed by the Ministry of Health and adopted in April 2011. The Law sets out the organization and operation of an information system in health care, with the goal of reducing information gaps in the sector. An improved health care information system should facilitate optimal policy decisions in the future and lead to improved performance of the Polish health care sector. 4.22. Portugal

4.22.1. Demographics of Portugal

Portugal is part of the Iberian Peninsula in the south-west of Europe. The archipelagos of the Azores (nine islands) and Madeira (two main islands and a natural reserve of two uninhabited islands) in the Atlantic Ocean are also part of Portugal. The mainland is 91 900 km² (960 km north to south and 220 km east to west), with 832 km of Atlantic coastline and a 1215 km inland border with Spain. According to the latest estimates, the total

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resident population of Portugal is 10.6 million. Population density is now 116.08 per square kilometre.

Since the late 1990s, legal and illegal immigration from Brazil and central and Eastern Europe, together with the more traditional immigration from Africa has raised new problems and challenges for the Portuguese health care system. According to current laws, immigrants have the same access to health care as Portuguese nationals.Since 2001 (Ministry of Health, Despacho 25360/2001), the services of the NHS cannot refuse treatment based on nationality, illegal immigrant status or lack of financial means to pay for care. Thus immigrants can demand care and expect to be treated. Under the current legal framework, and considering that Portugal’s NHS is funded by general taxation, and that it provides universal health insurance coverage of residents, access by immigrants to health care appears to be wider than in other European countries. Despite the formal equality of access of immigrants relative to nationals, there may exist informal and/or socioeconomic barriers, in particular for undocumented immigrants. Some of these barriers relate to a lack of knowledge of the health care system, language barriers and discrimination by health professionals.

According to 2008 estimates, the legal immigrant population represents 4.1% of the resident Portuguese population (INE/SEF-MAI, 2009). The majority of immigrants (52%) live in the Lisbon area. About 78% of immigrants are in the economically active age group (15–64 years of age). The number of immigrants from eastern European countries has increased since the mid 1990s. The number of births has been declining steadily since 1970 (20.8 live births per 1000 population). In 1990, the crude birth rate for Portugal was 11.7 live births per 1000 population, which was below the average of the EU15 – of 12.02 – for the first time since 1970 (WHO Regional Office for Europe, 2010). By 2008 the number of births per 1000 population declined to 9.8.

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Table 4.22.1.1. General Information of Portugal General Information of Portugal Gross national income per capita (PPP Int $) (2015): 25.360 Life expectancy (2015): 81 years Hospital beds per 100.000 (2014): 332 Physicians per 100.000 (2014): 443 % of population aged 65+ years (2013): 20 % Life expectancy at birth m/f (2013): 78 / 84 years Total expenditure on health as % of GDP (2014): 9,7 % Internet users: 64 % Source: Data and Statistics of Portugal (WHO)

4.22.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The current Portuguese National Health Service (NHS) was established in 1979. Its creation was in line with the principle of every citizen’s right to health, embodied in the new democratic constitution (1976). Existing district and central hospitals as well as other health facilities, previously operated by the social welfare system and religious charities, were brought together under “a universal, comprehensive and free-of-charge National Health Service”. The 1979 law establishing the NHS laid down the principles of centralized control but decentralized management. A number of changes were introduced to the NHS since its creation, namely the introduction of user charges. However, to assure all citizens would have access to health care regardless of their economic and social background; exemptions were also created at the same time. Despite the development of a publicly financed and provided health system, some features of the previous system remain unchanged, namely the health subsystems, which continue to cover a variety of public (civil servants) and private (e.g. banking and insurance companies, postal service, etc.) employees. Although the NHS incorporated most of the health facilities operating in Portugal, private provision has always been available, namely in clinics, laboratory tests, imaging, renal dialysis, rehabilitation and pharmaceutical products.

Following the creation of the NHS, Portuguese health policy went through several periods, from the development of an alternative to the public service (early 1980s), to the promotion of market mechanisms (mid-1990s), and the introduction of a number of policies that drifted away from the market-driven health care provision (late 1990s). By the

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beginning of the twenty-first century, the NHS became a mixed system, based on the interaction between the public and the private sectors, integrating primary, secondary and long-term care. Reforms were enacted aimed to combine the universal coverage provided by the NHS and the promotion of efficiency.

Decades after the inception of the NHS in Portugal, the historical remnants of the pre- existing social welfare system still persist in the form of health insurance schemes for which membership is based on professional or occupational category. These are often referred to as health subsystems (subsistemas de saúde). Today the Portuguese health care system is characterized by three coexisting, overlapping systems: the universal NHS; special public and private insurance schemes for certain professions (health subsystems), covering about a quarter of the population; and private VHI, with estimates of coverage ranging from 10% to 20% of the population.In 2005, a number of subsystems operating in the public sector were integrated into the main subsystem, the ADSE (Assistência à Doença dos Servidores do Estado), for civil servants. Until 2013, the Ministry of Finance controlled the ADSE, which was mandatory for all civil servants until 2009. Since 2009, civil servants may easily opt out from ADSE. In 2015, ADSE was transferred to the Ministry of Health (Decree-Law No. 152/2015, of 7 August 2015). However, in 2017, ADSE was converted into a public institute with special regimen and participated management (Decree-Law No. 7/2017, of 9 January 2017), and it was renamed Institute for Protection and Assistance in Illness (Instituto de Protecção e Assistência na Doença). ADSE is now under the indirect administration of both the Ministry of Health and the Ministry of Finance. Planning and regulation take place largely at the central level in the Ministry of Health and its institutions. The high commissariat for health is responsible for the design, implementation and evaluation of the National Health Plan (the National Health Plan 2011– 2016 is currently in development). The management of the NHS takes place at the regional level. In each of the five regions, a health administration board that is accountable to the Ministry of Health is responsible for strategic management of population health, supervision and control of hospitals, management of primary care/NHS primary care centres, and implementation of national health policy objectives. They are also responsible for contracting services with hospitals and private sector providers for NHS patients. Although in theory the regional health Administrations (RHA) have financial responsibilities, these are limited to primary care since hospital budgets are defined and allocated centrally. All hospitals belonging to the NHS are in the public sector, under the Ministry of Health jurisdiction. Private health care providers mainly fulfil a supplementary | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

role to the NHS rather than providing a global alternative to it. Currently, the private sector mainly provides diagnostic, therapeutic and dental services, as well as some ambulatory consultations, rehabilitation and hospitalization. The health care delivery system in Portugal consists of a network of public and private health care providers; each of them is connected to the Ministry of Health and to the patients in its own way. Most of the population is entitled to choose between two health care insurers (or can use both): NHS and VHI. Part of the population, approximately 20– 25%, is also covered by a health subsystem; therefore, individuals with this coverage have a third option for the choice of care. Coverage by a health subsystem is compulsory for certain beneficiaries, as it is occupation-based health insurance. Health care providers can be either public or private, with different agreements with respect to their financing flows, ranging from historically based budgets to purely prospective payments. OOP payments make up a significant portion of the financial flows.

The central government, through the Ministry of Health, is responsible for developing health policy and overseeing and evaluating its implementation. Core function of the Ministry of Health is the regulation, planning and management of the NHS. It is also responsible for the regulation, auditing and inspection of private health services providers, whether they are integrated into the NHS or not. The policy-making process takes place within government offices with little or no information being released publicly. Enactment of government rulings often goes to institutional partners for consultation, though no public account of draft legislation and comments and opinions expressed about it are available. Usually, there is no detailed evaluation plan or ex-post assessment of policy measures. The implementation of the policies is a task for the RHAs. The Ministry of Health performs some assessment and audit, as well as the Court of Auditors and the General Inspectorate of Health-related Activities (IGAS), but the process of policy evaluation is far from systematic.

Many of the planning, regulation and management functions are in the hands of the Minister of Health. The Secretaries of State have responsibility for the first level of coordination, under delegation of the Minister of Health. The Ministry of Health is made up of several institutions: some of them under direct government (Estado) administration; some integrated under indirect government administration; some having public enterprise status; an HRA and a consultative body. The

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Health Regulatory Agency (HRA) is formally independent in its actions and decisions, though its budget comes mostly from the Ministry of Health.

As the NHS does not have its own central independent administration, the Ministry of Health carries out most of the planning, regulation and management functions. The main aspects of the NHS are centralized in the Central Administration of the Health System (ACSS). There are central, regional and sector planning bodies. Central planning for health is mainly carried out by the Directorate-General of Health (DGH), based on plans submitted by the RHA boards. The High Commissioner for Health (GPEARI) has authority over the RHAs. Consequently, a general framework within the National Health Plan has been created to avoid regions pursuing national policies at their own pace, as has happened in the past. A formal national health strategy and health care policy with quantified objectives and targets were defined for the first time in 1998, for the period 1998–2002. A revised version of this policy document was produced in 1999 involving a broader range of social partners and stakeholders. It was made public by the Ministry of Health under the title Health: a commitment. In fact, this structuring tool was a true commitment of the administration to the citizens. In 2002, the GPEARI produced a national report on health gains revising the achievements and pitfalls of the strategy for the period 1998–2002 (DGH, 2002). A new National Health Plan has been designed and implemented throughout the country since 2004 (DGH, 2004). It comprises strategic guidelines and objectives with relation to a minimum set of health system activities to be put into effect by the Ministry of Health.

4.22.3. Public Health Indicators

The report Primary health care – now more than ever (WHO & ACS, 2008) classifies Portugal as one of the top five countries in the world (the others are Chile, Malaysia, Thailand and Oman) that have made remarkable progress in reducing mortality rates. In Portugal, the mortality rate declined more than 0.8% since 1975. This trend reflects both improved access to an expanding health care network, thanks to continued political commitment, and economic growth, which made it possible to invest large amounts in the health care sector.

Portuguese life expectancy at birth doubled during the 20th century, both in women (40.0 years in 1920 to 79.7 years in 2000) and in men (35.8 years in 1920 to 72.6 years in 2000). In 2008, average life expectancy at birth in Portugal was 78.2 years, while the EU15 average was 80.4 years (WHO Regional Office for Europe, 2010). There is a significant

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difference between estimates of life expectancy for men and for women in Portugal: the 2008 figures were 81.4 years for women and 74.9 years for men. As it will be made clear below, men usually die younger due to cerebrovascular diseases, ischaemic heart conditions, traffic accidents and malignant neoplasms.

Child health has improved since the early 1960s: the indicators of child health are currently near the average European level. The infant mortality rate decreased fivefold between 1970 and 1990, and decreased from 10.9 per 1000 in 1990 to 3.3 per 1000 in 2008, below the EU15 average (3.84 per 1000 live births in 2007). The perinatal mortality rate dropped from 3810 deaths in 1980 to 746 in the year 2000 and further to 418 in 2008. From 1990 to 2008 the neonatal mortality rate decreased from 804 to 216 deaths. Although there has been a positive evolution of infant mortality indicators, there are still some regional disparities. Improvements in the health status of the Portuguese population are associated with increases in human, material and financial resources devoted to health care, as well as to a general improvement in socioeconomic conditions. Despite the overall improvement in living standards, there are inequalities among the regions and between social classes. These disparities are evident in the variation of some health indicators. For example, the average for crude malignant neoplasm mortality rates over the period 1999–2003 ranged between 1.9 per 1000 in the North region and 3.4 in lower Alentejo. Over the same period, the rates of infant mortality were 4.6 per 1000 in the Lisbon region and 6.9 in the Alentejo region. There are also disparities in the supply ratio of physicians (6.0 per 1000 in Lisbon and Oporto, whereas in lower Alentejo the 2004 figure was only 1.6) and nurses (6.0 per 1000 in Lisbon and Oporto, while in lower Alentejo in 2004 there were 2.4 nurses per 1000 inhabitants) to population (INE, 2004, 2005). Furthermore, the latest National Health Survey shows that the highest level of self-reported health status is found in the Lisbon and the Algarve regions, with the lowest found in the Centre and Alentejo regions. The leading causes of death are shown in, and the standardized mortality rates in 2005– 2008 are shown. Since the mid 1980s, the main causes of death have been cardiovascular and cerebrovascular diseases and malignant neoplasms. These are likely to remain the main causes of death of the Portuguese population for the coming decades, according to the Directorate-General of Health (DGH) study (DGH, 2002). One should not underestimate the extremely high level of undefined causes of death, suggesting there might be weaknesses in data collection. A project is currently under way at DGH to address and improve reporting on causes of death. Diseases of the circulatory system, together with malignant neoplasms, accounted for over 50% of deaths in 2008, according to the latest figures provided by the | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

National Statistics Institute (INE, Instituto Nacional de Estatística). The mortality rate of these diseases has been above the EU27 average over recent decades. In contrast, Portugal has one of the lowest mortality rates from cardiac ischaemic disease in the EU. The most frequent fatal tumours in 2008 were lung tumours, among both men and women.

Another important indicator of health status is “avoidable mortality”. According to 2005 data, men die from avoidable causes much more than women do, essentially due to cerebrovascular disease and malignant neoplasms. Avoidable deaths decreased during recent decades, especially in the Centre region. A large share of premature mortality among men comes from traffic accidents (Ministry of Internal Affairs & Road Safety Authority, 2009). The mortality rate associated with motor vehicle accidents was 5.1 per 100 000 population in 2001, the highest in the EU15. Excessive speed, dangerous manoeuvres and high blood alcohol levels are the main causes of this problem and have been targeted with specific legislation and law-enforcement measures. Nonetheless, the number of avoidable deaths is still high, especially in the south of the country. Overall, over the last decades, Portuguese health indicators became more and more positive because it attributes this fact to two major factors: the promotion of healthy living conditions; and the increase in health care access and quality. These factors are most likely due to the evolution of the primary and long-term care networks, as well as the recent enforcement of the National Health Plan.

4.22.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

In 2015, 71% of the families in Portugal had a computer. Moreover, 70.2% of the families had access to the Internet, of which 98% were broadband connections (INE, 2016a).

The ACSS (Central Administration of the Health System) is the service at the Ministry of Health responsible, in a centralized manner, for the study, guidance, assessment and implementation of IT, and for financial management of the NHS. Established in 2007, one of the main goals of ACSS was to develop an information system and the infrastructure needed to support it. Additionally, it also aims to effectively and rationally manage available economic and financial resources. The ACSS made available to all citizens a fair amount of information on hospitals, primary care centres and other NHS institutions and projects.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

The brand new website of the NHS, launched in February 2016, provides important information on a regular basis, such as waiting list of patients registered for surgery, waiting times for emergency visits at NHS hospitals or outpatient consultations both at NHS hospitals and primary care units, and performance indicators for the Ministry of Health. Additionally, the new website offers the possibility of booking a visit at NHS primary care units and inserting personal medical information – for example immunization records, allergies, medications. Over time, the ACSS produced several IT software applications for registration and analysis of health unit activities. Additionally, the ACSS manages the database of hospital admissions. There have been occasional attempts to implement electronic medical records, but this approach has not yet been widely disseminated. A study placed Portugal close to the European average in terms of its eHealth profile (European Union, 2013). Overall, regarding eHealth deployment indicators between 2010 and 2012, Portugal shows a negative growth of –4%, whereas the European average grew 3% over the 2-year period. The report identified that the greatest gains since 2010 in Portugal have been achieved in “Broadband > 50 Mbp”, “Exchange of laboratory results with external providers” and “Single and unified wireless”, which delivered 31%, 28% and 25% growth, respectively. However, “Single Electronic Patient Record shared by all departments” and “Integrated system for eReferral” had negative growth, at –28% and – 40%, respectively (European Union, 2013). The think tank “eHealth in Portugal: Vision 2020” was an initiative of SPMS, which aimed to create a forum for reflection and debate about the Portuguese eHealth Strategy for the period 2016–2020, based on the methodology of the WHO “National eHealth Strategy Toolkit”. Regarding the benefits for the Portuguese health system that could be achieved through eHealth, participants put special emphasis on those related to improving access to health care; providing information to enhance the quality and safety of care; contributing to the efficiency of the system; and increasing knowledge on population health (SPMS, 2015).

In 2015, Portugal participated in the third global survey on eHealth. This survey was conducted by the WHO Global Observatory for eHealth (GOe) has a special focus – the use of eHealth in support of universal health coverage. It presents data collected on 125 WHO Member States. The survey was undertaken between April and August 2015 and represents the most current information on the use of eHealth in these countries. A total of 125 WHO Member States, representing a 64% response rate, completed the survey, which is the highest response rate for any GOe survey to date. The scope of the survey was broad; survey questions covered diverse areas of eHealth, from electronic information systems to | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

social media, to policy issues and legal frameworks. The data are grouped by eight eHealth themes. Each grouping is intended to give the reader an overview of the eHealth landscape in individual countries in 2015 for each particular theme. More specific in Portugal: Table 4.22.4.1. WHO Global Observatory for eHealth

eHealth Foundations National policies or strategies Country Year adopted response National universal health coverage Yes 1979 policy or strategy National eHealth No N/A policy or strategy National health information Yes 2013 system (HIS) policy or strategy National telehealth policy Yes 2013 or strategy Funding Sources for eHealth Country Funding source

response % Public funding Yes 50-75% Private or commercial Yes <25% funding Donor/non-public Yes <25% funding Public-private No Zero partnerships eHealth Capacity Building Country Proportion response Health sciences Yes <25%

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students-Pre- service training in eHealth Health professionals-In- Yes <25% service training in eHealth Source: Atlas of eHealth country profiles-WHO, 2016

Table 4.22.4.1 includes a selection of indicators on eHealth-related policies or strategies, funding, and capacity building. Data are reported by the individual “country response” (yes, no or don’t know), and “year adopted” for the particular indicator in the case of national policies/strategies. The former represent the level of planning and action around the use of eHealth in the country’s health system. As above, the answers are expressed as “country response”; it has an additional measurement for the level of funding: no funding, low <25%, medium <50%, high <75% and very high >75%. Also, eHealth capacity building is another significant indicator as it shows whether students or professionals are receiving training in preparation for their exposure to eHealth in clinical settings. The “proportion” of students receiving training is expressed in the same was as for the funding sources above: no funding, low <25%, medium <50%, high <75% and very high >75%.

Telehealth is probably one of the most well-known and best established of all eHealth services. This section (Table 4.22.4.2) reports on the operations of fourof the most common telehealth programmes and what level of the health system they are operating at as well as the type of programme.

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Table 4.22.4.2. WHO Global Observatory for eHealth

Telehealth Telehealth Programmes Country Overview

Health system level Programme type

Teleradiology National* Established***

Teledermatology National* Established***

Telepathology Regional** Established***

Remote patient monitoring National* Pilot**** Source: Atlas of eHealth country profiles-WHO, 2016

* National level: referral hospitals, laboratories and health institutes (mainly public, but also private). **Regional level: health entities in countries in the same geographic region.

*** Established:an ongoing programme that has been conducted for a minimum of 2 years and is planned to continue.

**** Pilot: testing and evaluating a programme.

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Table 4.22.4.3.WHO Global Observatory for eHealth

Electronic Health Records (EHRs) EHR Country Overview Country response National EHR system Yes Legislation governing the use of the national EHR Yes system Health facilities with Use EHR EHR Primary care facilities (e.g. clinics and health Yes care centers) Secondary care facilities (e.g. hospitals, Yes emergency care) Tertiary care facilities (e.g. specialized care, Yes referral from primary/secondary care) Other electronic Country response systems Laboratory information Yes systems Pathology information No systems Pharmacy information Yes systems PACS No Automatic vaccination No alerting system ICT-assisted functions Country response Electronic medical billing Yes systems Supply chain Yes

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management information systems Human resources for health information No systems Source: Atlas of eHealth country profiles-WHO, 2016 This section (Table 4.22.4.3) provides an overview of the state of adoption of Electronic Health Records (EHRs) in the country. It identifies whether the country has introduced a national EHR system and if there is legislation governing its use. It identifies at what level of the health system the EHRs are being used (primary, secondary or tertiary). At this point we conclude that the development of the national EHR is strongly dependent on the national standardisation of health on the level of services, systems, information, coding and terminology systems. It further identifies other electronic systems that the EHR system is linked to. Finally, it lists ICT-assisted systems.

The scope of the application of eLearning for pre-service education of health sciences students as well as in-service training for health professionals is covered in this section (Table 4.22.4.4). The faculties or professions which can benefit from eLearning techniques for training are identified along with the “country response” as well as the “global yes response”.

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Table 4.22.4.4.WHO Global Observatory for eHealth

Use of eLearning in Health Sciences eLearning Programmes Country Overview Health sciences Country response Global “yes” response students – Pre-service Medicine Yes 58% Dentistry Yes 39% Public health Yes 50% Nursing & midwifery Yes 47% Pharmacy Yes 38% Biomedical/Life sciences Yes 42% Health professionals – Country response Global “yes” response In-service Medicine No 58% Dentistry No 30% Public health No 47% Nursing & midwifery No 46% Pharmacy No 31% Biomedical/Life sciences No 34% Source: Atlas of eHealth country profiles-WHO, 2016 This section (Table 4.22.4.5) reports the use of social media by individuals and communities. Each response has a corresponding “country response” and “global yes response”.

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Table 4.22.4.5. WHO Global Observatory for eHealth

Source: Atlas of eHealth country profiles-WHO, 2016

4.22.5. Expenditure, Economics, Management

Total health expenditure in Portugal has risen steadily from 7.5% of GDP in 1995 to 10.4% of GDP in 2010, above the EU average of 9.8% in 2010. The economic recession and the austerity measures required by the Economic and Financial Adjustment Programme in 2011 reversed this trend, with total health expenditure decreasing to 9.5% of GDP in 2014. The economic crisis in Portugal led to changes in total health expenditure. The reduction of the GDP by 5.4% between 2010 and 2013 was accompanied by a 12.4% decrease of the total health expenditure in the same period (INE, 2016a). Thus, analysing total health expenditure as a share of the GDP, Portugal was above the EU average in 2010, but in line with the EU average in 2014.

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Austerity in Europe also led to the decrease of total health expenditure in countries like Spain, the United Kingdom or Italy, but that reduction was sharper in Portugal and Latvia. Despite being among the top spenders on health care as a percentage of GDP, even after the Economic and Financial Adjustment Programme, Portugal spent US$ 2689.9 per capita (purchasing power parity) in 2014, which is below the EU average of US$ 3379 (purchasing power parity).

Between 2010 and 2014, there was a significant decrease in general government health expenditure in Portugal (–9.7%). Measuring general government health expenditure as a share of general government expenditure, Portugal is below the EU average.

Since 2010, the amount spent on health care has decreased in both absolute and relative terms, after a strong growth pattern observed in the previous years. The Economic and Financial Adjustment Programme required public expenditure for health to be cut, while some part of those cuts targeted the private sector. In the European context, public sources of spending as a percentage of total health expenditure in Portugal (64.7%) are among the lowest in the EU, where the average is 76.0%.

Data on health expenditure by health sector, for example, primary care, inpatient care and dental care, are not available. Most private health expenditure is accounted for by out-of-pocket (OOP) spending, in the form of co-payments and direct payments made by citizens for pharmaceuticals, examinations and outpatient consultations. OOP payments in Portugal are estimated to be among the highest in the EU, accounting for 27.6% of total health expenditure in 2015 (INE, 2016f). Health care financing in Portugal is overall slightly regressive due to the high share of OOP payments along with a heavy reliance on indirect taxes. Indirect taxes on goods and services accounted for 42.3% of total government revenue in 2015, whereas the EU average is 34.7% (INE, 2016e).

4.22.6. Challenges and Future Perspectives

The Portuguese health system has been under the political spotlight for several years. Since the early 1990s, there has been a considerable increase in total expenditure on health care, driven mainly by the growth of public health care spending. Despite improvements in the health of the population, a growing concern about spending levels and an increasing

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awareness that a fair amount of waste in terms of utilization of resources exists have motivated many policy measures.

All policy measures that have been adopted constitute attempts to improve the current health system. No radical change has been proposed by the successive governments, or by the parties represented in the Parliament. Of course, some of the policy measures aim at more ambitious goals than others. Some aim at long-term impact, while others focus on short-term effects. Although costs have been an important driver for some of the government interventions, other measures have actually been taken without a careful and detailed analysis of cost implications. There is no broad area in the health system that has seen no change at all: primary care, hospital care, long-term care, the pharmaceutical market, PPPs, regulation, human resources, and new investments in capacity have all been affected, to a different extent, by recent policy measures. In terms of the health of the population, the National Health Plan is a major landmark, as a guide for public action aimed at obtaining health gains for the population. The National Health Plan covers the period 2004–2010 and implementation is well under way, with the next Plan covering the period 2011–2016 is being developed. Four years after the design of the National Health Plan 2004–2010, the Ministry of Health and WHO began the process of auditing and evaluating the progress of the National Health Plan. This work led to recommendations for the process of developing the new National Health Plan 2011–2016:

 strategic use of the support gained because of the National Health Plan 2004–2010, aiming at obtaining health gains;

 balance between objectives, priorities and measurable goals to strengthen the health system;

 planning on the areas of health inequalities, sustainability of the NHS, human resources, quality and equity;

 reinforcing the ability of RHAs to deal with local authorities, as well as regional-level health care planning; and

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 strengthening of the relations between ministries, as well as of the ability to evaluate the health impact of government policies.

The National Health Plan 2011–2016 aims to define itself as the continuation of the 2004– 2010 Plan, by:

 keeping the same values as the previous National Health Plan: social justice, universality, equity, solidarity;

 giving continuity to some of the goals and programmes, as well as monitoring outcomes;

 identifying structural axes on which to focus: access, quality, citizenship, healthy policies across ministries;

 specifying the instruments and implementation mechanisms and careful monitoring of the Plan; and

 developing partnerships with the RHAs, giving further importance to the planning and regional implementation of the National Health Plan 2011–2016. Since the mid 1990s, hospital care has also received attention from policy-makers. A general movement towards performance-based payments and explicit contracting within the public sector is very clear. A major impetus for this movement can be traced back to the 2002 set of policies. Even if some gains, in terms of cost savings, have been achieved, this did not change the overall trend of increased hospital spending. As for professionals, the number of hospital nurses has continued to grow and the number of physicians has stabilized in recent years. Pressures for building new hospitals and for new equipment are likely to remain. The main challenges in this area are reducing the waste of resources without harming quality of care, and redefining hospitals’ role in the health system in line with recent developments in primary care and in long-term care. Hospital expenditure seems to be evolving rapidly as news of growing debts of hospitals to the pharmaceutical industry has been reported. This resumes a trend of a decade ago towards hidden deficits that had appeared to be absent in the past five years. Pharmaceutical innovation has been pointed to as the main reason; although no clear account of the causes of such debts exists at this point in time.

For many of the reforms, the two main points to be considered are: (a) they mostly aim at improving efficiency of the health system, namely public provision; and (b) the jury is still

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out as to their effects, as they are too recent for a fair appraisal to be made. The legal changes that have occurred have not yet materialized in changes in the health system. As has happened in the past, there is the risk that many of them may not translate into actual changes, and that unanticipated effects may emerge. This may be true for long-term care in particular. Although an initial increase in costs may occur, it is expected that the substitution of acute care beds by recovery beds and palliative care introduced into the long-term care network will help to drive down cost increases. Could resistance to reducing hospital beds undermine this objective? There is no clear answer at the moment. Similar observations can also be made with regard to primary care changes. For most of the ongoing reforms, the jury is still out, as mentioned above. Challenges remain, namely in implementation. Nonetheless, a better health system and improved health for the population are potential gains.

4.23. Romania

4.23.1. Demographics of Romania

 The current population of Romania is 19,259,346 as of Tuesday, May 2, 2017, based on the latest United Nations estimates16.

 The total land area is 230,080 km2, the population density is 84 per Km2.

 Romania population is equivalent to 0.26% of the total world population.

 Romania ranks number 59 in the list of countries (and dependencies) by population.

 Ethnic groups: Romanian 83.4%; Hungarian 6.1%; Roma 3.1%; Ukrainian 0.3%; German 0.2%; other 0.7%, unspecified 6.1%.

 61.3 % of the population is urban.

 Life expectancy at birth: total population: 75.1 years; male: 71.7 years; female: 78.8 years.

 Age structure: 0-14 years: 14.4%; 15-24 years: 10.76%; 25-54 years: 45.97%; 55-64 years: 12.8%; 65 years and over: 16.07%.

16 Comapare: http://www.worldometers.info/world-population/slovakia-population/ and https://www.cia.gov/library/publications/the-world-factbook/geos/lo.html | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

 The median age in Romania is 42.5 years.

 Population growth rate: -0.32%.

4.23.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The national social health insurance system covers all Romanian citizens and provides a comprehensive benefits package. The Romanian health system is organized at two main levels, national and district, mirroring the administrative division of the country, with the national level responsible for setting general objectives and the district level responsible for ensuring service provision according to the rules set at the central level. The system remains highly centralized, with the Ministry of Health being the central administrative authority in the health sector responsible for the stewardship of the system and for its regulatory framework. The Ministry of Health also exerts indirect control over some functions that have been recently decentralized to other institutions and that are only just beginning to assert regulatory functions, such as the National Authority for Quality Management in Health Care. District public health authorities (DPHAs) represent the Ministry of Health at the local level. The other key actor at the central level is the National Health Insurance House (NHIH), which administrates and regulates the social health insurance system. This organizational structure has been in place since 1999, having replaced the Semashko model. The NHIH is also represented at district levelby district health insurance houses (DHIHs) The key legal act regulating the organization and functioning of health care providers is the Law 95/2006. Quality of care is one of the weaker points of health care regulation. It is not regulated by any specific act and is one area for which secondary legislation is only just being developed.17. But there are two strategic documents: The National Development Plan 2014–2020 and The National Sustainable Development Strategy 2013–2020–2030.

17 Cristian Vladescu, Silvia Gabriela Scîntee, Victor Olsavszky, Cristina Hernández-Quevedo, Anna Sagan, Romania Health system review, Health Systems in Transition, Vol. 18 No. 4 2016 (Europian observatory on helth system and policies- a partnership Hosted by WHO) | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

4.23.3. Public Health Indicators

As being member of EU, Romania is making assesmnt of public healht indicators at national level, thus making them comparable to other EU member states:

 Life expectancy at birth has increased steadily over recent decades, by some five years since 1995, to 75.1 years in 2014, while remaining lower compared to other EU countries, which have an average of 80.9 years (Eurostat, 2016). Women live on average longer (78.7 years) than men (71.6 years). At 7.1 years in 2014, the gender gap for life expectancy at birth in Romania is higher than the EU average (5.5 years) (Eurostat, 2016). Furthermore, National Institute of Publih Health of Romaina (http://www.insp.gov.ro/index.php) conducts more comprehensive research on assesing and analysing public health indictors, such as:

 ‘National Report on the State of Health of the Romanian Population’18- analyses of the health indicators of the Romanian population and its determinants on the basis of indicators collected by INSP-CNSISP, public health units (Ministry of Health, Local Administration, Romanian Academy) and indicators of ECHI community.

 ‘MONITORING INEQUALITIES IN HEALTH STATUS OF THE POPULATION OF ROMANIA IN 2013’19- description and analyses in geographic, demographic, socio-economic and environmental inequalities, health outcomes (various indicators, life expectancy, mortality or morbidity), access inequalities.

 National health reports of childern and youth20, as well as thematic reports related to specific aspects of childern and youth health: ‘Assessment by morbidity cronce hospitalization collectivities children and young people’21,‘Evaluation of physical development and health based on medical

18http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/11/SSPR-2016-2.pdf 19http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/11/INEGALITATI-2014.pdf 20http://insp.gov.ro/sites/cnepss/wp-content/uploads/2017/03/Raport-scolara-2016-1.pdf 21http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/12/BILANT-SINTEZA-2015.pdf

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

examinations of children and young people balance collectives urban and rural schools’22, ‘Risk youth behaviors YRBSS - 2014’23, etc.

4.23.4. Medical Informatics, Information Systems, Informatics Applications, Telemedicine

The National Health Insurance HouseNHIH24 has developed three important projects related to e-health. Two are financed with EU funds – e-Prescription (implemented in 2012) and Electronic Health Record (implemented in 2014), and one is self-funded – the e-Health Card (introduced in May 2015). The card is the only means of obtaining medical consultations and prescriptions through the national health insurance system, with the exception of emergency medical services. All these systems are integrated into the existing centralized Sole Integrated Information System (SIUI), in use in all counties of Romania. The National Health Insurance House (NHIH) manages the Integrated Unique Informatics System which collects information on over 26 thousands health service providers, and on 21 million insured persons. This data includes medical information on patients, economic information on providers and on the administration. There are also numerous smaller information databases connected with the national health programs or with different clinical activities (for example NSPH-MPD: collecting patient-level clinical data from hospitals). There’s still no coherent policy in field of health information, which makes the communication between the systems minimal. In addition, data collected are not comparable. There are plans to integrate information systems by the NHIH and Ministry of health.

The telemedicine system in Romania is still under developemnt. What makes the Romanian telemedicine system special is the fact that it is a nationalsystem based on a communictaion backbone run by a governmental agency, the Special Telecommunications Service. In the recent years, many patients from Romaina choose Second Opinion consultations by telemedicine25. On the other side, the prehospital telemedicine system was completed in 2009 with an inter-hospital telemedicine system. Based at the emergency

22http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/12/Comportamente-cu-risc-la-tineri-YRBSS-2014.pdf 23http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/12/Comportamente-cu-risc-la-tineri-YRBSS-2014.pdf 24https://www.export.gov/article?id=Romania-Healthcare-and-Medical-Equipment 25https://books.google.me/books?id=diolDAAAQBAJ&pg=PR5&lpg=PR5&dq=telemedicine+center+romania&sourc e=bl&ots=j6n6ZRgLz6&sig=gvysE3lmiyVzVJNiUgkMtpUgbDo&hl=en&sa=X&ved=0ahUKEwib49KLjtLTAhXME5oKHfL wAsYQ6AEIRzAE#v=onepage&q=telemedicine%20center%20romania&f=false | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

departments of 41 hospitals in the central region of Romina, the inter-hospital telemedicine system was meant to facilitate decision making and support non-emergency physcisians on duty in small emergency rooms. That is a reason why Raed Arafat (the president of the foundation for SMURD-Romaina emergency rescue service) declared that “Romaina is the first country in Europe, if not in the world, in what concerns telemedicine, in percent 85 ambulances being enabled with tablets that transmit video images and medical information” and that “there are 1200-1400 ambulances of type B that are able to transmit data from the field”.

4.23.5. Expenditure, Economics, Management

Table 4.23.5.1.

2012 2013 2014 2015 2016 GDP (constant 2010 US$, million) 170,861 176,895 182,337 189,016 170,861 GDP growth (annual %) 0.64% 3.53% 3.08% 3.66% 0.64% GDP per capita (constant 2010 8,518 8,852 9,159 9,539 8,518 US$) Health expenditure, total (% of .. .. GDP) 5.48% 5.60% 5.57% Health expenditure per capita, .. .. PPP 1005 1070 1079 Health expenditure, private (% of .. .. total health expenditure) 19.73% 19.22% 19.60% Health expenditure, public (% of .. .. total health expenditure) 80.27% 80.78% 80.40% Out-of-pocket health expenditure (% of total expenditure on .. .. health) 19.14% 18.66% 18.87%

The Romanian health system is organized at two main levels, national and district, similar to the administrative organization of the country, with the national level responsible for setting general objectives and the district level responsible for ensuring service provision according to the rules set at the central level. The system remains highly centralized, with the Ministry of Health being the central administrative authority in the health sector

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

responsible for the stewardship of the system and for its regulatory framework. The Ministry of Health also exerts indirect control over some functions that have been recently decentralized to other institutions and that are only just beginning to assert regulatory functions, such as the National Authority for Quality Management in Health Care. District public health authorities (DPHAs) represent the Ministry of Health at the local level. The other key actor at the central level is the National Health Insurance House (NHIH), which administrates and regulates the social health insurance system. This organizational structure has been in place since 1999. The NHIH is also represented at district level by district health insurance houses (DHIHs).A ‘Framework Contract’ lays down the definition of the statutory benefits package and contains information on the terms under which patients can obtain services, provider payment mechanisms, the relationship between providers and the DHIHs, terms of contracts (for example, quality criteria for providers),providers’ rights and obligations, and transposition of EU regulations with relevance to health care provision. It is adopted every two years and forms the basis for individual contracts between the DHIHs and health service providers.26 4.24. Slovakia

4.24.1. Demographics of Slovakia

 The current population of Slovakia is 5,431,706 as of Tuesday, May 2, 2017, based on the latest United Nations estimates27.

 The total land area is 48,091 Km2, the population density is 113 per Km2.

 Slovakia population is equivalent to 0.07% of the total world population.

 Slovakia ranks number 118 in the list of countries (and dependencies) by population.

 Ethnic groups: Slovak 80.7%, Hungarian 8.5%, Roma 2%, other and unspecified 8.8%.

26Vlãdescu C, Scîntee SG, Olsavszky V, Hernández-Quevedo C, Sagan A. Romania: Health system review. Health Systems in Transition, 2016; 18(4):1–170. pp xviii, available at: http://www.healthobservatory.eu 27Comapare: http://www.worldometers.info/world-population/slovakia-population/ and https://www.cia.gov/library/publications/the-world-factbook/geos/lo.html

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

 53.7 % of the population is urban.

 Life expectancy at birth: total population: 77.1 years; male: 73.5 years; female: 80.9 years.

 Age structure: 0-14 years: 15.14%; 15-24 years: 11.32% ; 25-54 years: 45.13% ; 55-64 years: 13.52%; 65 years and over: 14.88%..

 The median age in Slovakia is 39.5 years.

 Population growth rate: 0.01%.

4.24.2. Healthcare System and Public Health Structure, Organisation, and Legislation

Each employed citizen has to pay so-called “healthcare contributions”. People who earn more pay more, those who earn less pay less, but all receive the same healthcare. The healthcare contributions are mandatory and are paid to the health insurance company (HIC) of the employee’s choice. Health insurance for the unemployed people, children, retired people, women on the maternity leave is paid by the state. The most important components of the healthcare system in the Slovak Republic are:HSA - The Healthcare Surveillance Authority, SIDC-State Institute for Drug Control, SNAS - Slovak National Accreditation Service, PHA - Public Health Authority of the Slovak Republic, NRC - National Reference Center(s) for the particular diseases, ZP - Health Insurance Company, LF UK - Faculty of Medicine of the Comenius University, JLF UK - Jessenius Faculty of Medicine of the Comenius University, LF UPJŠ - Faculty of Medicine of P. J. Šafárik University, LF SZU - Faculty of Medicine of the Slovak Medical University, SAS - Slovak Academy of Sciences, SO SR - Statistical Office of the Slovak Republic, NHIC - National Health Information Center, SNARS - Slovak National Antimicrobial Resistance Surveillance System, EPIS - Epidemiological Information System, SMC - Slovak Medical Chamber, SkMA - Slovak Medical Association, SLeK - Slovak Chamber of Pharmacists, SKIZP - Slovak Chamber of Other Healthcare Professionals28. The basic legislation related to the healthcare: Health care act (Act No 576/2004); Act on Extent (Act No 577/2004); Act on providers (Act No 578/2004); Act on emergency

28Marko Kapalla, Dagmar Kapallová, Ladislav Turecký, EPMA J. 2010 Dec; 1(4): 549–561. | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

ambulance service (Act No 579/2004); Act on health insurance (Act No 580/2004); Act on helth insurance companies (Act No 581/2004); Act on drugs and medical aids (Act No 140/1998).

4.24.3. Public Health Indicators

WHO Forum in December 2015 highlited that “Slovakia will focus in the next 2 years (2016-2017) on assessing the national public health situation, building capacity and introducing new norms and standards for running public campaigns. This was agreed upon in a recent meeting between the national authorities and WHO in Bratislava”29 The key reason could also be found in “Slovakia tops Visegrad Four (Czech Republic, Hungary, Poland, Slovakia) in health-care expenditures, lacks respective indicators”30, thus proving that Slovakia lacks with additional analyses and colection of public health indicators at national level. However, Slovakia is also a of EU, Romania is making assesment of public health indicators at national level, thus making them comparable to other EU member states: “Although indicators of population health status of the population are improving, Slovakia is lagging behind neighbouring countries and the EU-28 average. In 2014 life expectancy reached 73.3 years for Slovak men and 80.5 years for Slovak women (lower than the EU-28 averages of 78.1 years for men and 83.6 years for women). Diseases of the circulatory system are the most frequent cause of death in Slovakia, accounting for half of all deaths in Slovakia in 2014.”31

4.24.4. Medical Informatics, Information Systems, Informatics Applications, Telemedicine

As explained on the website of Slovakia’s eHealth32, this country is developing national eHealth program which is supporting all forms of healthcare (professional healthcare, public health, individual level of healthcare, community level of healthcare). They clearly

29http://www.euro.who.int/en/countries/slovakia/news/news/2015/12/slovakia-to-focus-on-public-health- capacity-building-in-next-2-years 30https://spectator.sme.sk/c/20226145/slovakia-tops-v4-in-health-care-expenditures-lacks-respective- indicators.html 31http://www.euro.who.int/__data/assets/pdf_file/0011/325784/HiT-Slovakia.pdf?ua=1 32http://www.ezdravotnictvo.sk | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

stated that “The position of the Slovak Republic in the EU is not satisfactory in terms of successful implementation of eHealth. The backwardness of the Slovak Republic in comparison with other developed countries concerning eHealth activities is estimated to be 7-10 years.”33

 eHealth in Slovakia is planned to be realized in the form of services, products and tools, and several phases are already completed, as follows:

 First eHealth applications were employed in 2015: Central provision of public health relevant information, electronic booking mainly of laboratory treatment and vaccination, electronic prescription and medication processes and provision of patient’s health information (in the form of electronic health record)

 Basic electronic Helalht services: National Health Portal with basic information; Citizen Health eBook, ePrescription, eMedication, eAllocation; creating conditions for integration of healthcare providers information systems (IS HCP) with national eHealth solution, verifying integration with IS HCP during pilot operation.

 Extension of Functionality and Services: data consolidation of medicine and knowledge database; provision of administration and data updating of medicine and knowledge database; expansion of mechanisms for the protection of personal data of a specific category with expanded functionality and range of electronic health services; new functionalities of electronic health services. Slovakia’s National Health IS (NHIS) has 3 levels of IT in health service: Local level (healthcare providers-pharmacies, laboratories, hospitals, emergency rescue services…), Health insurance companies and National level. The use of NHIS services by health professionals and citizens is voluntary by December 31, 2016. As of January 1, 2017, the use is mandatory and valid for all insurees. The creation of patient summary is mandatory by June 30, 2017.

Furthermore, The Slovak Arthroplasty Register34 (SAR) was established by the Ministry of Health of the Slovak Republic (Law no. 576/2004 Coll. on health care, services concerned with offering health care and on the change and completion of certain laws). It is a medical information system, which carries out the collection of precisely defined data on each

33http://www.ezdravotnictvo.sk/en/eHealth_Programme/Pages/default.aspx 34http://sar.mfn.sk/the-slovak-arthroplasty-register.348.html | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

implant of an artificial joint replacement carried out on individual sites in the Slovak Republic, and then evaluates them.

4.24.5. Expenditure, Economics, Management

Table 4.24.5.1.

2012 2013 2014 2015 2016 GDP (constant 2010 US$, million) 93,555 94,949 97,390 101,121 93,555 GDP growth (annual %) 1.66% 1.49% 2.57% 3.83% 1.66% GDP per capita (constant 2010 17,301 17,540 17,973 18,644 17,301 US$) Health expenditure, total (% of 8.15% 8.00% 8.05% .. .. GDP) Health expenditure per capita, 2065 2080 2179 .. .. PPP Health expenditure, private (% of 30.28% 27.69% 27.49% .. .. total health expenditure) Health expenditure, public (% of 69.72% 72.31% 72.51% .. .. total health expenditure) Out-of-pocket health expenditure (% of total expenditure on 22.37% 22.69% 22.54% .. .. health)

The health care system in Slovakia is based on universal coverage, compulsory health insurance, a basic benefit package and a competitive insurance model with selective contracting of health care providers by health insurers, and flexible pricing of health services. After fulfilling certain explicit criteria, there are no barriers to entry to health care provision and health insurance markets. Health care is provided to insured free at the point of delivery (apart from some co-payments, described below) through benefits-in-kind and paid by health insurers.

The Ministry of Health defines the minimum benefit package, the provider network, minimum quality criteria for providers and maximum waiting lists for patients. Furthermore, the MoH owns and operates the largest health care providers, including four

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

university hospitals, eight faculty hospitals, highly specialized institutions and almost all psychiatric hospitals and sanatoria, and the Ministry is the only shareholder in the largest health insurance company, the General Health Insurance Company (GHIC). Three health insurance companies compete for clients based on the quality and variety of their contracted services. Health insurance companies are obliged to ensure accessible health care regulated by law, by contracting a sufficient network of providers as determined by the Ministry of Health. The Health Care Surveillance Authority (HCSA) is responsible for surveillance over the health insurance, health care provision and health care purchasing markets. Since 2005 all health insurance companies are joint stock companies, that is, they were transformed from (public) health insurance funds to health insurance companies. In 2016 there is one state-owned health insurer (with roughly 65% of the market share) and two privately owned health insurers.35 4.25. Slovenia

Slovenia's population is 2.1 million. The country has a population density of 101 people per square kilometer. This is one of the lowest population densities in Europe. Most people are concentrated in the Central Slovenian statistical region, which includes the capital and largest city, Ljubljana. Ljubljana has a population of 275,000, which is the only city with a population of more than 100,000. About 65 to 79% of the population lives in urban areas. 83% of the population is Slovenes, followed by Serbs (2%), Croats (2%), Bosnians (1%) and other groups. The official language is Slovene, which is spoken by 92% of the Slovenian population. This makes Slovenia one of the most homogenous countries in EU in terms of speakers of the predominant mother tongue. Many people in Slovenia speak a variant of Serbo-Croatian as their native language. Most are immigrants who moved to the country from other former Yugoslav republics between the 1960's and 80's and their descendants. About 12% of Slovenians were born abroad, and there are 100,000 non-EU citizens in the country, which represents 5% of the total population. Most come from Bosnia-Herzegovina, along with Serbia, Croatia, Kosovo and Macedonia. The steward of the health system in Slovenia is the Ministry of Health. The organizational structure within the health system is advanced and comprises numerous actors, including

35 Smatana M, Pažitný P, Kandilaki D, Laktišová M, Sedláková D, Palušková M, van Ginneken E, Spranger A (2016). Slovakia: Health system review. Health Systems in Transition, 2016; 18(6):1–210, pp.xxii, available at: http://www.healthobservatory.eu

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

various agencies under the Ministry of Health (such as the Health Inspectorate); public independent bodies (such as the Health Insurance Institute of Slovenia (HIIS), Institute of Public Health of the Republic of Slovenia (IPH-RS)); (publicly owned) hospitals and primary care centres, as well as private providers of health services; and various nongovernmental organizations (NGOs) and professional associations. Experts from the Ministry of Health fulfil a role of supervision and control within the system, which has been gradually decentralized to different stakeholders. Fundamental reforms aiming to build up a modern health system were carried out in 1992. These consisted mainly of the introduction of compulsory health insurance; an approval process for private practice in the field of health care; introduction of co-payments for health care services; and a (re- )introduction of professional associations (such as the Medical Chamber and the Pharmaceutical Chamber). These major reforms were followed by a period of implementation and further adjustments of the health system. Recent reforms included, amongst others, the introduction of the diagnosis-related group (DRG) system for payment of hospital services; development and implementation of patient pathways toenhance quality of treatment; and introduction of a risk-equalization scheme for providers of complementary voluntary health insurance (VHI). Long waiting times, especially for dental services and some specialized services and surgeries remain a problem still to be solved within the Slovene health care system.

Since 1992 Slovenia has had a Bismarckian type of a social insurance system based on a single insurer for statutory health insurance, which is fully regulated by national legislation and administered by the HIIS. This insurance is universal and based on a clear employment status or on a legally defined dependency status (such as minors, unemployed spouses, registered unemployed people and individuals without source of income). Experts from the Ministry of Health have a supervisory and controlling role within a system, which has been gradually decentralized through a number of tasks being assigned to different stakeholders. Since 1992, the previously exclusively publicly financed system has been transformed into a mixed system where private sources of funding have become significant, reaching 27.8% in 2006 (Statistical Office of the Republic of Slovenia 2009). This has been achieved by financing some expenditure from co-payments and complementary insurance. Co-payments have never become fully effective incentives for lowering utilization, as most of the adult population took out complementary insurance, which accounted for a 13.8% share of total health expenditure in 2006 (Statistical Office of the Republic of Slovenia 2009).

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Some of the previous tasks for which the State was responsible have been assigned to professional associations, called zbornice (professional chambers), which control qualifi cations, specialty training and continuous education. Another important feature of today’s health system in Slovenia is the growing share of private providers, especially in primary and specialist health care. This has led to increasingly complex contracting arrangements, as privatization is associated with fragmentation in provision. Most of the care delivery is still carried out by state-owned (hospitals, most of outpatient specialist care and tertiary care) and municipality-owned providers (primary health care centers), who collectively employ more than 75% of the total health workforce (IPH-RS 2006b). Only for dental services does the share of private providers exceed 50%, with 12% of all providers working exclusively for out-of-pocket (OOP) payments.

At the end of 2006 there were 29 hospitals in Slovenia, which are almost all publicly owned.

The numbers of physicians in Slovenia increased steadily from 199 per 100 000 in 1990 to 237 per 100 000 in 2006. However, Slovenia still has a significantly smaller number of physicians per capita than most EU and central and eastern European (CEE) countries.

As in other central and eastern European (CEE) countries, the main demographic characteristics in Slovenia are a low birth rate, a low fertility rate and a low rate of population growth. Hence, Slovenia’s population is ageing. The crude birth rate decreased from 15.7 per 1000 population in 1980 to 9.0 in 2005 and has increased slightly since then to 9.8 in 2007 Slovenia had one of the lowest fertility rates of all EU Member States in 2006. The total fertility rate of 1.4 in 2007 was far below the replacement level. In 2007 Slovenia’s crude death rate was 9.2 per 1000 population (WHO Regional Office for Europe 2009b). According to Eurostat future projections, in the baseline scenario the population is expected to decrease to 1.9 million by 2050, that is, by 4.8% Slovenia is therefore facing an advanced phase of demographic transition, which will relatively soon reflect itself in changing patterns of morbidity and mortality at the population level. Since the early 1990s the elderly population has increased by more than 50%, which raises concerns over the incidence of chronic diseases and their social implications. This is all the more relevant because the elderly population (aged 65 years and over) is estimated to increase by more than 67% from 300 000 in 2004 to 503 000 in 2030.

The National Board of Health is an advisory body to the Government and is responsible for retaining health as an agenda matter of consideration in governmental and parliamentary procedures. As defined by the Health Care and Health Insurance Act of 1992, the Board’s

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

role is to support health policy by monitoring the effects of the social and physical environment on health; it evaluates the development of plans and legislative drafts from a population-based perspective. For this purpose, the Board cooperates with administrative bodies and coordinates work relating to health issues that need to be addressed. The function of the Board has come under review owing to the need to clarify its accountability. The Board is a coordinating body for multispectral investment in health and it coordinates all governmental activities that affect public health, including determining tax policy, defense and food policy, as well as defining sports and cultural programs, introducing new technologies, road traffic safety and the protection of health at work. However, it only has an advisory role, that is, it can only point to problems, but has no decision-making power. The task of the Ministry of Health is to prepare legislation for health care and health protection, and to ensure regulation and supervision of the implementation of legislation. The activities of the Ministry of Health relate to health and health financing matters at the primary, secondary and tertiary levels. Furthermore, the Ministry monitors public health, prepares and implements health promotion programs and ensures conditions for people’s health education. It also supervises the production, trade and supply of medicines and medicinal products, as well as the manufacture of and trade in illicit drugs. The Health Insurance Institute of Slovenia (HIIS) was created as a public non-profit-making entity rigorously supervised by the State and bound by statute to provide compulsory health insurance for the population. The HIIS is governed by an Assembly, made up of representatives of employers and the insured population, who independently administer the activities of the Institute. The Director is nominated by the Assembly and appointed with the agreement of Parliament. The priorities of the HIIS must be coordinated with those of the State in representing the interests of insured individuals. The HIIS has 55 branch offices altogether; 10 at the regional level and 45 at the local level. The regional branches also have regional councils,yet their function is more of an advisory nature and they cannot decide on issues relating to health insurance. However, the 10 regional HIIS branches are responsible for contracting with providers. Both the Medical Chamber, responsible for medical doctors and dentists, and the Pharmaceutical Chamber were abolished in 1945 and then re-established in 1992. The chambers have supervisory and administrative functions; both are responsible for specialization, licensing, the development and issuing of a code of medical ethics, and supervision over professional practice. Membership of the chambers is compulsory for practicing professionals. The Medical Chamber has become an influential body that has taken over responsibilities that were traditionally within the scope of the Ministry of | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Health. The Nursing Chamber was established in 1992. There are also proposals to establish other new health professional chambers.

Health care in Slovenia is oriented towards improved health and a better quality of life. Constant improvements in the quality of health care are in line with the interests and rights of patients. Patient rights are a topic which has been under discussion ever since the health care legislation in effect at the time of writing was adopted. This subject was not transparent, which led to many problems in managing patients’ rights, in terms of procedures to be undertaken and orientation through the system. Despite the above-mentioned technical advances, the development and introduction of IT in health care remains a difficult task and for a long time the penetration of IT in this sector has been low. Especially in hospitals, the level of IT development was found to be insufficient, through various analytical consultancies (World Bank Mission of 1997, the Health Sector Management Project 1999–2004, Expert Panel for IT at the Clinical Centre in Ljubljana in 2004) as the investments dedicated to IT were often below 0.5% (final accounting reports by the Association of Public Providers of Health Care). There was a lack of a clear national strategy on IT development in health care and, consequently, the process has significantly increased differences among individual providers. In addition, there was little coordination of the activities related to software development, except in those applications related to health insurance. In 1992 there were two divergent concepts proposed in the preparation of the reforms to the organization and delivery of health care and of other health services. Public health, on the one hand, was seen as too extensive a service, and should be completely restructured. In practical terms this would mean a complete dismantling of the IPH-RS and merging its various services with other institutions – health statistics and reporting to be incorporated into the Statistical Office; medical microbiology laboratories into the Medical Faculty in Ljubljana; sanitary chemistry and sanitary microbiology into the Health Inspectorate; imports and distribution of vaccines would be made a commercial service; and the rest would become a department of the Ministry of Health. The other option, which defended the classical setting of public health, prevailed. This meant that the public health infrastructure would not be changed – the IPH-RS, as well as the nine regional institutes of public health, were maintained. The terminology was standardized by law, as were the services that the regional institutes were to deliver. This implied that a more structured reform of the public health infrastructure would be postponed.

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4.26. Spain

The population of Spain was last recorded in 2012 as 46.6 million people. This is a significant figure since the total population back in 1960 was 30.5 million as reported by Eurostat - a 52% increase over the last half-century. The 2016 estimate is 48,146,134. The population growth rate experienced a drastic rise.

Spain’s life expectancy is the highest in Europe, surpassing even the likes of Australia, US, Canada and Norway. Life expectancy is 79.6 for males and 85.6 for females, which averages to a total life expectancy of 82.6. This places the Kingdom of Spain at rank 5 in World Life Expectancy, according to a WHO report published in 2013. The life expectancy at birth gives the number of years an infant would live if the prevailing mortality conditions at the time of birth were to stay the same all throughout his or her lifetime. Spain has the 3rd lowest level of lives lost in the world. Some attribute this to the Mediterranean diet, while others say it’s because the country is performing well against causes of death such as various types of cancer.

Population density is about 91.4 people per square kilometer. The population density is lower than that of most other Western European Countries. With the exception of Madrid, the capital of Spain, the populous regions in the Kingdom of Spain are along the coastline of the country. The birth rate rose from 9.10 births per 1000 people to 10.9 over a period of ten years from 1996 to 2006. The birth rate in 2016 is estimated to be 9.6.

The Kingdom of Spain currently has no official religion. This is despite the fact that over 90% of the population prefer to identify themselves as Catholic. The central government in Spain assumes responsibility for certain strategic areas, including: general coordination and basic health legislation; financing of the system, and regulating the financial aspects of social security; definition of a benefits package guaranteed by the NHS; international health; pharmaceutical policy; undergraduate education and postgraduate medical training; civil service-related human resources policies. Although the Ministry of Health and Consumer Affairs plays the most significant role in determining the parameters of health policy, it increasing lyshares its policy formulation authority with regional governments. In addition, many financial matters, as well as the definition of

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benefits, still require the approval of the social security system and/or the Ministry of Economy and Finance, while most of the issues related to personnel are dealt with by the Ministry of Public Administration. The 1986 General Health Care Act pays specific attention to the public health system users’ rights, including: respect for the users’ personality, human dignity and intimacy; information about the health services accessible to them; confidentiality; warning about the usage of prognostic, diagnostic and therapeutic processes as well as written authorization to undergo any tests; assignment to a particular doctor; participation in health activities; existence of complaint and suggestion procedures; and provision of the necessary drugs and health products to promote, preserve or re-establish his/her health status. Hospitals in the National Health System are funded through a global budget, set against individual spending headings. Traditionally, hospital expenditure was retrospectively reimbursed on a routine basis, with no prior negotiation between the third-party payer (INSALUD or regional health services) and providers, and no formal evaluation. Since the early 1990s, however, some regional health services (mainly through pilot tests) have changed the way in which hospital budgets are allocated. The Catalan Government pioneered these reforms and other managerial and organizational innovations introduced during the decade, partly as a result of the prevalence of a hospital sector dominated 61 Health systems in transition Spain by private non-profit-making providers, which gave higher priority to sound contracting practices. The situation regarding health information systems in Spain is fairly paradoxical. Individual Health Cards in the form of smart cards are well established throughout Spain and there is plenty of legislation in place governing freedom of information, protecting the rights of patients and ensuring professionals’ access to, and sharing of, information. However, there is not one single card model. Currently, seven card models coexist; one for the 10 regions previously managed by INSALUD plus the Canary Islands and six other models corresponding to the other six autonomous regions. Each member of the covered population holds a card, and this is the day-to-day key to accessing the health care system. A technical platform has therefore been developed to be shared by all regions. This consensus initiative is intended to avoid not only duplications in treatment of the covered population but also discrepancies over whether individual inhabitants are covered. It also helps to manage financing issues and inter territorial budget transfers in case of health care services provided to residents of other Acs.

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Information technologies within the health system have improved substantially in recent years in Spain, albeit in a rather uncoordinated manner. Insufficient regulations in the General Health Care Act regarding medical records led to a proliferation of regional rules that in turn gave way to a heterogeneous mix of clinical information and documentation systems. As already explained), before the passing of the 41/2002 Act, only Basque Country had approved a specific decree to regulate the use of medical records, in 1986. Other autonomous regions include this issue in their health laws/acts, albeit with different degrees of development. The Individual Health Card was seen as a useful instrument to this end, through its legal validity throughout the entire NHS, but it has suffered from the above-mentioned drawback of lack of compatibility. Currently the NHS directly employs around 420 000 people of which 80% work in specialized health care. There were 4.6 qualified doctors per 1000 inhabitants. The Spanish Ministry of Health and Consumer Affairs is in charge of the overall health care system, policy design and evaluation. Responsibilities for public health have been passed over to a large extent to the autonomous communities from the state (see Chapter 2 on organizational structure and Chapter 4 on regulation). Some core areas of public health have remained the exclusive responsibility of the state, including external relations, the management of the Nutrition Alert Network, and the Environmental Surveillance Network. The state also retains a coordinating role over regional public health functions, which it exercises through the Inter territorial Council of the NHS, conditional upon a voluntary regional endorsement. In the field of public health, devolution from the central administration was completed by1986 but the transfer of powers to local governments may have slowed down the process somewhat. The integration of all responsibilities regarding public health into a single level of government has led to the coordination and management of epidemiological surveillance at regional level. In parallel, an extensive, reformed public primary care network with operational duties in public health has been developed. In Spain public health services are integrated within PHC. The bulk of preventive medicine and health promotion is integrated with primary health care and carried out by general practitioners and practice nurses as part of their normal workload (see also Section 6.3 on PHC). During the 1980s and 1990s a series of specific programs – supported by books and other training materials – was produced by the national and regional authorities for PHC professionals, targeting population groups (from maternal and child health care to care of the elderly) and specific illnesses (e.g. hypertension, etc.) with the intention of providing a broad public health scope to the regular PHC activities.

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Some ACs went through a quick reorganization of decentralized services, and several inspectorates on health issues, previously dispersed among different sectors (health, agriculture, industry, environment, etc.), were soon integrated. However, some other regions kept their former organizational structure with the only exception being food safety inspection services which were always integrated within the public health services (a requirement of the European Directive in force at the time). This reorganization has been extremely important and has improved the inspection of food production and food retail premises and the promotion of competence of inspectors (previously, there were fundamental risks regarding the independence of the inspection authority, since many inspectors had economic links with the industries they audited). In most cases environmental issues have also been concentrated in specific environmental services departments, which have been much developed since the 1990s. Overall, substantial improvements in public health have been achieved, even if effective organizational integration has not occurred sometimes, owing to the fragmentation of public health responsibilities among different departments of the regional administrations. Some problems of coordination have also been identified regarding the decentralized governmental structure and the weak enforcing capacity of the Inter territorial Council of the NHS. In addition, it is important to take into account that the Spanish NHS is clinically oriented, rather than prevention oriented. The issue of inequalities in health is an interesting feature of the Spanish public health situation. Spain has produced a number of policy statements (see sections on organizational overview and on planning and health information management) emphasizing unambiguous safeguarding of the principle of equity in health. However, beyond non-contributory social subsidies, the impact of poverty on health is mainly addressed through emphasizing access to health services (PHC) and there have been few differentiated targeted initiatives to identify and tackle equity-related issues (there are, for example, no explicit means-related exemptions related to co- payments for pharmaceuticals, other than that of being a pensioner). Some ACs went through a quick reorganization of decentralized services, and several inspectorates on health issues, previously dispersed among different sectors (health, agriculture, industry, environment, etc.), were soon integrated. However, some other regions kept their former organizational structure (Segura, Villalbí et al. 1999), with the only exception being food safety inspection services which were always integrated within the public health services (a requirement of the European Directive in force at the time). This reorganization has been extremely important and has improved the inspection of food production and food retail premises and the promotion of competence of inspectors (previously, there were fundamental risks regarding the independence of the inspection authority, since many inspectors had economic links with the industries they audited). In most cases

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environmental issues have also been concentrated in specific environmental services departments, which have been much developed since the 1990s.

Overall, substantial improvements in public health have been achieved, even if effective organizational integration has not occurred sometimes, owing to the fragmentation of public health responsibilities among different departments of the regional administrations. Some problems of coordination have also been identified regarding the decentralized governmental structure and the weak enforcing capacity of the Inter territorial Council of the NHS. In addition, it is important to take into account that the Spanish NHS is clinically oriented, rather than prevention oriented. The issue of inequalities in health is an interesting feature of the Spanish public health situation. Spain has produced a number of policy statements (see sections on organizational overview and on planning and health information management) emphasizing unambiguous safeguarding of the principle of equity in health. However, beyond non-contributory social subsidies, the impact of poverty on health is mainly addressed through emphasizing access to health services (PHC) and there have been few differentiated targeted initiatives to identify and tackle equity-related issues (there are, for example, no explicit means-related exemptions related to co- payments for pharmaceuticals, other than that of being a pensioner). 4.27. Sweden

4.27.1. Demographics of Sweden

Sweden is a monarchy with a parliamentary form of government. The size of the population is about 9.4 million inhabitants and more than 80 % of the populationlives in urban areas. On average, there are 20 inhabitants per square km of land, with a high concentration of people living in the coastal regions and in the south of the country. The population growth rate was 0.79 % in 2010 due to a positive net birth rate (115,641 born and 90,487 deceased) and a net migration flow (98,801 immigrants and 48,853 emigrants). The fertility rate has increased during the past 10 years and was 1.98 births per woman the same year. Sweden has one of the world’s oldest populations, with more than 20 % of the population being 65 years or older (2015) and more than 5 % being 85 years or older.

General information about Sweden: Gross national income per capita (PPP Int $) (2015): 44,760

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Hospital beds per 100,000 (2015): 280 Physicians per 100,000 (2015): 393

% of population aged 65+ years (2016): 20 %

Life expectancy at birth m / f (2015): 81 / 84 years Total expenditure on health as % of GDP (2014): 9.7 %

Internet users: 94 %

4.27.2. Healthcare System and Public Health Structure, Organization and Legislation

The Swedish health care system is a socially responsible system with an explicit public commitment to ensure the health of all citizens. Three basic principles are intended to apply to all health care in Sweden. The principle of human dignity means that all human beings have an equal entitlement to dignity, and should have the same rights, regardless of their status in the community. The principle of need and solidarity means that those in greatest need take precedence in medical care. The principle of cost–effectiveness means that when a choice has to be made between different health care options, there should be a reasonable relationship between the costs and the effects, measured in terms of improved health and quality of life. All three levels of Swedish government are involved in the health care system. At the national level, the Ministry of Health and Social Affairs is responsible for overall health and health care policy, working in concert with eight national government agencies. At the regional level, 12 county councils and nine regional bodies (regions) are responsible for financing and delivering health services to their citizens. At the local level, 290 municipalities are responsible care of the elderly and the disabled. The local and regional authorities are represented by the Swedish Association of Local Authorities and Regions (SALAR). Three basic principles apply to all health care in Sweden:

Human dignity: All human beings have an equal entitlement to dignity and have the same rights regardless of their status in the community.

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Need and solidarity: Those in greatest need take precedence in being treated. Cost-effectiveness: When a choice has to be made, there should be a reasonable balance between the costs and the benefits of health care, measuring cost in relationship to improved health and quality of life.

Publicly financed health care: Health expenditures represented 11 percent of GDP in 2013. About 84 percent of this spending was publicly financed, with county councils’ expenditures amounting to 57 percent, municipalities’ to 25 percent, and the central government’s to almost 2 percent. The county councils and the municipalities levy proportional income taxes on their populations to help cover health care services. In 2013, 68 percent of county councils’ total revenues came from local taxes and 18 percent from subsidies and national government grants financed by national income taxes and indirect taxes. General government grants are designed to reallocate some resources among municipalities and county councils. Targeted government grants finance specific initiatives, such as reducing waiting times. In 2013, about 90 percent of county councils’ total spending was on health care.

Coverage is universal and automatic. The 1982 Health and Medical Services Act states that the health system must cover all legal residents. Emergency coverage is provided to all patients from European Union / European Economic Area countries and to patients from nine other countries with which Sweden has bilateral agreements. Asylum-seeking and undocumented children have the right to health care services, as do children who are permanent residents. Adult asylum seekers have the right to receive care that cannot be deferred (e.g., maternity care). Undocumented adults have the right to receive nonsubsidized immediate care.

Private health insurance: Private health insurance, in the form of supplementary coverage, accounts for less than 1 percent of expenditures. Associated mainly with occupational health services, it is purchased primarily to ensure quick access to an ambulatory care specialist and to avoid waiting lists for elective treatment. Insurers are for-profit. In 2015, 614,000 individuals had private insurance, accounting for roughly 10 percent of all employed individuals aged 15 to 74 years.

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4.27.3. Public Health Indicators

Life expectancy in Sweden is among the highest in the world. Diseases of the circulatory system are the leading cause of mortality, accounting for about 40 % of all deaths in 2009. The second largest cause of death is cancer.

Men have higher mortality rates in lifestyle-related diseases, such as diseases of the circulatory system but also deaths due to traumas and accidents, alcohol and suicide. Women have higher mortality rates in cancer than men in ages up to 60 years of age, explained partly by the rate of breast cancer. Deaths due to mental illness and diseases of the nervous system have increased during the past 20 years in both men and women. Overall, the relative five-year survival rates for men with cancer have increased from about 50 % in 1990–1994 to almost 70 % in 2005–2009. For women, an increase from 60 % to 80 % can be noted over the same period.

The vaccination coverage rate for measles, mumps and rubella for children born in 2007 was 96.5 % in January 2010. This level of coverage is considered high by international standards.

Total mortality within 28 days following stroke decreased from 26 % in 1994 to 22 % in 2008.

4.27.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

Access to, and use of computers and the Internet is high amongst the Swedish population. More than 90 % of the population had access to the Internet in their home in 2010.

Regarding health information, all county councils and most hospitals and primary care facilities have web pages where information (publicly and privately provided) about health care services can be found. Several different IT systems operate in the Swedish health care sector. Generally, both the quality of such systems and their levels of use in hospitals and primary health care facilities are high. Usually patients’ records are kept electronically. More than 90 % of primary care providers use electronic patient records for diagnostic data. Also, the use of e-prescriptions is becoming increasingly common and in 2009 more than half of all Swedish prescriptions were e-prescriptions.

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It is up to every hospital to select and procure its own preferred IT system. In several county councils, efforts are made towards harmonizing patients’ records across all hospitals in the county. There are also ongoing projects at the national level, aimed at integrating (and making compatible) the various information systems used, with the purpose of increasing the security and effectiveness within the systems.

4.27.5. Expenditure, Economics, Management

Health care expenditure as a share of GDP was 9.9 % in Sweden in 2009. Sweden’s health care expenditure (US$ PPP) per capita was 3,423 in 2009, which was slightly higher than the EU average (2,877). Health care is regarded as a public responsibility and is largely tax-financed in Sweden. About 80 % of all expenditures on health are public expenditures and about 17 % are private expenditures, predominantly user charges. Both the county councils and the municipalities levy proportional income taxes on the population to cover the services that they provide.

There are user charges for health care visits in both primary and specialist care in the form of flat-rate payments. The national ceiling, regulated by law, for those payments means that an individual will never pay more than €122 for health care visits within a period of 12 months. About 80 % of all expenditures on health are public expenditures, with county councils’ expenditures amount to about 70 %, municipalities’ to about 8 % and the central government’s to about 2 % of all health expenditures in 2009. Total expenditures on health amounted to €34 billion in 2009, including expenditures for dental care and all care produced by the county councils and the municipalities and all pharmaceuticals.

4.27.6. Challenges and Future Perspectives

Several recent and currently discussed initiatives are guided by an emerging performance paradigm in the governance and management of health care. Key words related to the current and expected future trend are national quality registers, public comparison of quality and efficiency across local authorities and providers, value for money invested in health care, health outcomes and benefits from the patient perspective, process orientation and coordinated delivery of services.

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Future developments within the Swedish health care sector can be expected to include the implementation of already initiated reforms. Although the attention is more on cost control, cost–effectiveness and quality of care in the overall governance of health care, it is not evident that this has had any major impact on development of services so far. The introduction of choice and privatization in primary care is still a new reform in several county councils and the outcome for patients is uncertain.

An emerging question is the long-run financing of health care services. The prognosis shows increased demand because of rapid changes in demography with an increase in the proportion of older people in the next 10–15 years. The same prognosis also means a funding problem since the workforce is not likely to increase. There is, however, no political support for any major changes in the financing of health care. 4.28. United Kingdom

4.28.1. Demographics of United Kingdom

The United Kingdom, located off the north-west coast of the European mainland, comprises the three nations of Great Britain (England, Scotland and Wales) and Northern Ireland. It has a population of around 64 million, mostly concentrated in urban areas. The United Kingdom is a constitutional monarchy with a parliamentary system. These are general information of the United Kingdom:

Gross national income per capita (PPP Int $) (2013): 35.760

Hospital beds per 100.000 (2014): 274 Physicians per 100.000 (2015): 281

% of population aged 65+ years (2013): 17%

Life expectancy at birth m/f (2014): 79/83 years

Total expenditure on health as % of GDP (2014): 9% Internet users: 87%

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4.28.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The United Kingdom’s health care system is largely funded by taxes and is mostly free at the point of access. Legal residents of the United Kingdom may use the services of the National Health Service (NHS), and they are also free to purchase private health insurance if they wish. Health care in the United Kingdom is mainly a devolved matter, meaning that Scotland, Wales and Northern Ireland make their own decisions about the way in which health services are organized. The United Kingdom government allocates a budget for health care in England, and allocates block grants to Scotland, Wales and Northern Ireland which in turn decide their own policies for health care. The health ministers of Scotland, Wales and Northern Ireland are responsible for public health and health services in their nation. NHS (National Health Service) England is an executive non-departmental body; it has a wide range of statutory duties and is accountable to the Secretary of State and the public. It oversees the delivery of NHS services and is responsible for the contracting and purchasing of primary care health services, as well as some nationally based functions previously undertaken by the Department of Health.

4.28.3. Public Health Indicators

Average life expectancy at birth in the United Kingdom increased from 73.7 to 81 years between 1980 and 2013. Similar to other high-income countries, the main causes of death in the United Kingdom are circulatory diseases (ischemic heart diseases and cerebrovascular diseases); malignant neoplasms (most commonly lung, colorectal, breast and cervical cancer); and respiratory diseases. Deaths from respiratory and circulatory diseases, as well as from cancer, have fallen since 1990. Although tobacco use has fallen, tobacco remains the leading health risk factor, contributing to poor performance for some cancer and chronic obstructive pulmonary disease (COPD). Alcohol consumption and high blood pressure, as well as overweight and obesity, are other important health risk factors.

Reductions in cardiovascular mortality rates are in part due to improvements in acute cardiovascular care. Acute myocardial infarction mortality rates (30 days after admission to hospital using hospital admissions data) have fallen in recent years, reaching 7.6 per 100 admissions aged 45 and over in 2013.

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The infant mortality rate has nearly halved since 1990, from 7.9 deaths per 1000 births in 1990 to 3.5 in 2015.

4.28.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

The proportion of households in Great Britain with access to the Internet rose from 55% in 2005 to 84% in 2014 (ONS, 2014a); in 2014 92% of the United Kingdom population were Internet users. Providers of care in England collect data to feed back to the Department of Health. Data are often used for financial planning purposes, such as for Payment by Results (PbR) in England and for Quality and Outcomes Framework programmes across the United Kingdom. The English NPfIT (National Programme for Health IT) was abandoned in 2013 after being plagued by accusations of being inefficient and not cost-effective – it went considerably over budget, costing €13.3 billion, and failed to deliver on what had been promised.

Some parts of the programme remain, and other programmes have been introduced as well. These include Summary Care Records, in which patient information is stored to allow emergency and out-of-hours staff faster access to clinical data; Choose and Book, an online booking system for appointments; the Electronic Prescription Service (EPS); NHSmail for internal mail; Picture Archiving and Communications Systems (PACS) to store and transmit patient imaging; and a GP payment system. These information-sharing services are known collectively as Spine Services. NHS Choices, introduced in 2008, is a website supporting patient health care by providing information on local NHS services and serving as a portal to Choose and Book.

4.28.5. Expenditure, Economics, Management

Health expenditure as a share of GDP grew from 6.9% in 2000 to 9.4% in 2010. Health services are mainly funded through general taxation, with the remainder coming from private medical insurance and out-of-pocket payments. In 2013 out-of-pocket payments comprised 9.3% of total health expenditure while private medical insurance made up 2.8%, with less than 5% coming from other forms of private expenditure

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Most services are provided free of charge at the point of use, but there are some that can involve cost-sharing (such as dental care and pharmaceuticals) or direct payments (such as most social care). Only England has prescription drug charges.

4.28.6. Challenges and Future Perspectives

Although the emphasis among analysts in the United Kingdom has been on how much the health systems of England, Scotland, Wales and Northern Ireland have diverged since political devolution in 1997, their health systems still have much in common. Their shared primary objective remains to provide high-quality health care to everyone that is free at the point of service, and increasingly one of their main goals has been to better integrate health and social care. From the outside, the health systems in the United Kingdom function as a single whole; and most importantly, from the perspective of patients, the health systems of the United Kingdom are accessed in fundamentally the same way. Overall, the health systems function remarkably well given their relatively low levels of funding – less money is spent on health as a percentage of GDP than in comparable affluent EU nations. Nevertheless, important health disparities remain between socioeconomic groups despite the existence of advanced health systems that guarantee access to care for all. All of the United Kingdom faces many of the same challenges going forward, including how to cope with the needs of an ageing population, how to manage populations with poor health behaviours and associated chronic conditions, how to meet patient expectations of access to the latest available medicines and technologies, and how to adapt a system that has limited resources to expand its workforce and infrastructural capacity so it can rise to these challenges. 5. Public Health Best Practices of other Countries 5.1. Australia

5.1.1. Demographics of Australia

Australian population is almost 23 million (22 992 654). 41,55% of population is aged between 25 and 54; 17,84% is in the range from 0 to 14 years; 15,82% inhabitants are older than 65; 12,96% is between 15 and 24 years; and 11,82% is 55-64. The median age of population is 38.6. The population growth rate is 1,06%. There are 12.1 births and 7.2

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deaths per 1000 inhabitants. 89,4% of population is living in the urban area. An average population density is 3,2 persons per square kilometer of total land area.

The last two decades Australia had continuous growth, low unemployment, contained inflation, very low public debt, and a strong and stable financial system. The services sector is the largest part of the Australian economy, accounting for about 70% of GDP and 75% of jobs. The GDP per capita is 65.400,00 $. The real GDP grow rate is 2,5% yearly.

5.1.2. Healthcare System and Public Health Care Structure, Organisation and Legislation

Australia's health-care system is a multi-faceted web of public and private providers, settings, participants and supporting mechanisms. Health providers include medical practitioners, nurses, allied and other health professionals, hospitals, clinics and government and non-government agencies. These providers deliver a plethora of services across many levels, from public health and preventive services in the community, to primary health care, emergency health services, hospital-based treatment, and rehabilitation and palliative care. Public sector health services are provided by all levels of government: local, state, territory and the Australian Government. Private sector health service providers include private hospitals, medical practices and pharmacies. There are three types of Health Care in Australia: primary, secondary and hospitals (tertiary).

In Australia, primary health care is typically a person's first point of contact with the health system and is most often provided outside the hospital system (Government of Western Australia Department of Health 2013). A person does not routinely need a referral for this level of care, which includes services provided by general medical and dental practitioners, nurses, Indigenous health workers, pharmacists and other allied health professionals such as physiotherapists, dieticians and chiropractors. Primary health care is delivered in a variety of settings, including general practices, Aboriginal and Community Controlled Health Services, community health centres and allied health services, as well as within the community, and may incorporate activities such as public health promotion and prevention.

The primary healthcare system does not operate in isolation. It is part of a larger system involving other services and sectors – secondary healthcare system. Secondary care is

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medical care provided by a specialist or facility upon referral by a primary care physician. It includes services provided by hospitals and specialist medical practices.

Hospital emergency departments are a critical component of hospitals and the health system. They provide care for patients who have an urgent need for medical or surgical care, and in some cases also provide care for patients returning for further care, or patients waiting to be admitted. Hospital services are provided by both public and private hospitals. State and territory governments license or register private hospitals, and each state and territory has legislation relevant to the operation of public hospitals. State and territory governments are also largely responsible for health-relevant industry regulations such as for the sale and supply of alcohol and tobacco products. The Australian Government's regulatory roles include overseeing the safety and quality of pharmaceutical and therapeutic goods and appliances, managing international quarantine arrangements, ensuring an adequate and safe supply of blood products, and regulating the private health insurance industry.

A National Registration and Accreditation Scheme (NRAS) for health practitioners started on 1 July 2010. The NRAS has been established by state and territory governments to: protect the public by ensuring that only suitably trained and qualified practitioners are registered; facilitate workforce mobility across Australia; enable the continuous development of a flexible, responsive and sustainable Australian health workforce.

5.1.3. Public Health Indicators

Australian Government distributed approximately 9,5% of GDP on healthcare expenditures per year.

There are 3,27 physicians; 10,65 nurses and midwife; and 3,9 hospital beds per 1000 inhabitants.

There were 1,345 hospitals in Australia in 2013 and total hospitalizations rose by 4.6% to almost 9.3 million in 2013. Maternal mortality rate is 6 deaths per 100 000 live births, while infant mortality rate is 4 per 1000 live births.

In Australia lives about 26.900 people with HIV/AIDS, and yearly app 200 of them died.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

5.1.4. Informatics Applications, Medical Informatics, Information Systems, Telemedicine

The National Electronic Health Records (EHRs), known as The My Health Record, was launched on 1 July 2012 by Government. A My Health Record is a secure online summary of an individual’s health information. The My Health Record System Operator is the Secretary of the Department of Health. The My Health Record system is supported by a robust legislative framework that includes governance arrangements, privacy and security framework and a registration regime. The legislation is available at ComLaw (Personally Controlled Electronic Health Records Act 2012; Personally Controlled Electronic Health Records Regulation 2012; PCEHR Rules 2012; PCEHR (Participation Agreements) Rules 2012; PCEHR (Assisted Registration) Rules 2012)

EHR is obligated to use in all healthcare facilities – primary, secondary and tertiary. Australian healthcare system use electronic information systems only for pharmacies, but not for laboratories, pathology, automatic vaccine alert system and PACS. From ICT-assisted functions in Australia, there are electronic medical billing systems and supply chain management information system. Australia has established the telepsychiatry program at national level, and the teleradiology is piloting at national level.

5.1.5. Expenditure, Economics, Management

There are 4 broad areas of health spending in Australia: hospitals, primary health care, other recurrent expenditure, and capital expenditure. In 2015, the largest component of health spending was for hospital services 48,9 % of total health expenditure), delivered by both public and private providers. Primary health care accounts for almost as much health spending as hospital services, accounting for 44,9 % of total health expenditure in 2015. Australia's health care system is funded and administered by several levels of government (national, state/territory and local) and is supported by private health insurance arrangements. Australia’s national public health insurance scheme, Medicare, is funded and administered by the Australian Government and consists of three health care components – medical services (including visits to general practitioners (GPs) and other medical

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

practitioners), prescription pharmaceuticals and hospital treatment as a public patient (the latter is jointly funded by the Australian and state/territory governments). Medicare is presently nominally funded by an income tax surcharge, known as the Medicare levy, which is currently 2% of a person's taxable income. An exemption applies to low income earners, with different thresholds applying to singles, families, seniors and pensioners, with a phasing-in range. Since 2015–16, the exemptions applied to taxable incomes below $21,335, or $33,738 for seniors and pensioners. The phasing-in range is for taxable incomes between $21,335 and $26,668, or $33,738 and $42,172 for seniors and pensioners. The amount paid by the federal government includes: patient health costs based on the Medicare benefits schedule. Typically, Medicare covers 75% of general practitioner, 85% of specialist and 100% of public in-hospital costs. Overall coordination of the public health system is the responsibility of all Australian health ministers, that is, the Commonwealth and state and territory ministers. Managing the individual Commonwealth, and state and territory health systems is the responsibility of the relevant health minister and health department in each jurisdiction. The health ministers are collectively referred to as the Standing Council on Health, which has a supplementary coordination role. Membership of the council also includes the Commonwealth Minister for Veterans' Affairs and the New Zealand Health Minister. The Standing Council comes under the auspices of the Council of Australian Governments (COAG), which is the peak intergovernmental forum in Australia.

5.1.6. Challenges and Future Perspectives

There is concern that this ageing of the population will put unsustainable pressure on public spending, with particular concerns about rising health costs and the ability of the health system to serve the increasing numbers of older people needing care. However, the majority of Australians consider themselves to be in good health, and manages to live independently—with or without community-based supports—until their final days. As older Australians retire, the labor force will shrink. The result will be less tax revenue to pay for the health services the graying population will need. Even with the government’s current plan to increase the retirement age to 70, Australia’s labor participation is expected to continue to fall.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

5.2. Canada

5.2.1. Demographics of Canada

 The current population of Canada is 36,567,998 as of Monday, May 1, 2017, based on the latest United Nations estimates.36

 The total land area is 9,071,595 Km2, The population density is 4 per Km2.

 Canada population is equivalent to 0.49% of the total world population.

 Canada ranks number 38 in the list of countries (and dependencies) by population.

 Ethnic groups: Canadian 32.2%, English 19.8%, French 15.5%, Scottish 14.4%, Irish 13.8%, German 9.8%, Italian 4.5%, Chinese 4.5%, North American Indian 4.2%, other 50.9%

 82.1 % of the population is urban.

 Life expectancy at birth: total population 81.9 years; male: 79.2 years; female: 84.6 years (2016 est.)

 Age structure:0-14 years: 15.44%; 15-24 years: 12.12%; 25-54 years: 40.32% ; 55-64 years: 13.94%; 65 years and over: 18.18%,

 The median age in Canada is 40.8 years.

 Population growth rate: 0.74%.

5.2.2. Healthcare System and Public Health Structure, Organisation, and Legislation

Canada's health care system is a group of socialized health insurance plans that provides coverage to all Canadian citizens. Under the health care system, individual citizens are

36 Compare: http://www.worldometers.info/world-population/canada-population/ and https://www.cia.gov/library/publications/the-world-factbook/geos/ca.html | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

provided preventative care and medical treatments from primary care physicians as well as access to hospitals, dental surgery and additional medical services.37

The Canada Health Act is federal legislation that puts in place conditions by which individual provinces and territories in Canada may receive funding for health care services. Provincial and territorial health care insurance plans must meet the standards described in the Canada Health Act. These standards include:

 public administration

 comprehensiveness

 universality

 portability

 accessibility. The Minister of Health is responsible for maintaining and improving the health of Canadians. This is supported by the Health Portfolio which comprises Health Canada (Federal department), the Public Health Agency of Canada, the Canadian Institutes of Health Research, the Patented Medicine Prices Review Board and the Canadian Food Inspection Agency38.

5.2.3. Public Health Indicators

Public health indicators are collected are measured by different agencies and institutes in Canada, such as:

 Public Health Agency of Canada, developed framework39 on the burden of chronic diseases and associated determinants. The Framework includes a core set of indicators and specific measures which are grouped into six core domains: Social and environmental determinants, early life/childhood risk and protective factors, behavioural risk and protective factors, risk conditions, disease prevention practices, and health outcomes/status.

37http://www.canadian-healthcare.org/ 38http://www.hc-sc.gc.ca/index-eng.php

39http://infobase.phac-aspc.gc.ca/cdiif/ | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

 Statistics Canada and the Canadian Institute for Health Information developed Health indicators framework40 which includes 80 indicators measuring health status, non-medical determinants of health, health system performance and community and health system characteristics.

 In 2003, health ministers signed the First Ministers’ Accord on Health Care Renewal, which stated each jurisdiction would report regularly on its health programs and services, health system performance, health outcomes and health status. Thus, Health Indicators41provide information on health care across the country and allow governments and Canadians to compare data, track changes, see progress and identify areas for improvement within the health care system.

 Pan Canadian Public Health Networkof individuals across Canada from many sectors and levels of government developed Indicators of health inequalities42 aimed to identify pan-Canadian indicators that can be used to measure and report on inequalities in health and in key determinants of health in Canada.

 Aboriginal Affairs and Northern Development Canada developed the community well-being (CWB) index43 as a means of examining the well-being of individual Canadian communities, which includes among others indicators of socioeconomic well-being, including education, labour force activity, income and housing, etc.

 CanadianInstitute for Health Information created repository of health indicators44, whichcovers 60 health system performance topics including health promotion, access, quality, spending, outcomes, and disease prevention.

 The Federation of Canadian Municipalities’ Quality of life reporting system45 report series highlights trends in 27 municipalities and urban regions that account for more than half of Canada’s population, and includes many of Canada’s largest urban and suburban centres.

40http://www.statcan.gc.ca/pub/82-221-x/2013001/hifw-eng.htm 41http://www.hc-sc.gc.ca/hcs-sss/indicat/index-eng.php 42http://www.phn-rsp.ca/pubs/ihi-idps/pdf/Indicators-of-Health-Inequalities-Report-PHPEG-Feb-2010-EN.pdf 43http://www.aadnc-aandc.gc.ca/eng/1100100016579/1100100016580 44https://www.cihi.ca/en/health-system-performance/performance-reporting/indicator-library 45http://www.fcm.ca/home/programs/quality-of-life-reporting-system.htm | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

5.2.4. Medical Informatics, Information Systems, Informatics Applications, Telemedicine

The Government of Canada has been making investments in the area of eHealth since the 1997 Federal Budget, including federal commitments towards First Ministers Agreements (September 2000 and 2003).

Nowdays, the use of IT in health care in Canada can be summarized as folows46:

 Electronic health record (EHR) data is now available for 93.8 per cent of Canadians47. It is considered as a secure and private lifetime record of and individual health. A majority (more than 257,000) of health system professionals (doctors, nurses, pharmacists, other clinicians and administrators) are now using EHRs. Key program level components of the EHR include Registries, Infrastructure, Laboratory Systems, Imaging Systems, Drug Systems, Interoperable EHR, Telehealth, Public Heath Surveillance, and Innovation and Adoption. This system improves decision-making process, which is leading to more effective diagnosis and treatment, increased efficiency and improved access to services.48.

 Canada is still at the stage of adopting Electronic medical record (EMR) as an office-based system that enables a health care professional, such as a family doctor, to record the information gathered during a patient’s visit (e.g. weight, blood pressure and symptoms, etc.). A unified EMR solution for Canada cannot be achieved until the interoperability of EMR offerings for hospitals, pharmacies, and clinics is addressed49.

 Clinical applications. While most hospitals in Canada have implemented core clinical applications (e.g. ADT, RIS, LIS, etc), the advanced clinical applications like CPOE and eMAR systems are in the early stages of implementation.

 Clinical and Related Administrative Systems. More than 579 Canadian hospitals have digitized most aspects of the core clinical and administrative processes.

46http://www.ictc-ctic.ca/wp-content/uploads/2012/06/ICTC_eHealthSitAnalysis_EN_04-09.pdf 47https://www.infoway-inforoute.ca/en/what-we-do/progress-in-canada 48https://www.infoway-inforoute.ca/en/component/edocman/3098-annual-report-2015-2016/view- document?Itemid=101 49https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677946/ | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Core clinical systems include Laboratory and Pharmacy systems, PACS, Radiology Information Systems, and Order Communications.

 Laboratory. In 2009, over 600 Canadian hospitals claim to have some type of Laboratory Information System installed.

 Pharmacy/Drug Information Systems. Over 400 Canadian hospitals report an instance of Pharmacy Information Systems. Provincial Drug Information Systems are still in planning and development, and early implementation stages throughout Canada.

 Diagnostic Imaging (DI). Nearly all hospitals with over 100 beds across the country have an installation of Radiology Information System and many also have PACS.

 Telehealth is used for a wide range of services, from cancer and stroke care to mental health. Every province and territory is now using telehealth to bring care closer to Canadians in their communities, and even within their homes so they don’t have to travel great distances and incur personal expenses to see primary care providers or specialists.

 Consumer Health Solutions. Several ongoing health demostration projects, that enable consumers to do a number of things online: view their own health information such as lab results, schedule appointments, and consult with their health care providers using secure messaging.

 IT Installations in Regional Care. Canada also launched it’s first region-wide integrated EHR. Since 1989, every province has developed a regionalization strategy, though each one has taken a somewhat different approach to this task. Projects common among regions and provinces include: The implementation of a secure provincial EHR; Supporting the use of EMRs by physicians; Expanding telehealth services to improve access to care in rural areas; and Expanding public access to health information and health services through web-based applications.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

5.2.5. Expenditure, Economics, Management50

Table 5.2.5.1.

2012 2013 2014 2015 2016 GDP (constant 2010 US$, 1,693,133 1,735,038 1,779,547 1,796,304 1,693,133 million) GDP growth (annual %) 1.75% 2.48% 2.57% 0.94% 1.75% GDP per capita (constant 48,722 49,353 50,065 50,108 48,722 2010 US$) Health expenditure, total (% 10.78% 10.67% 10.45% .. .. of GDP) Health expenditure per 4585 4623 4641 .. .. capita, PPP Health expenditure, private (% of total health 29.02% 28.97% 29.07% .. .. expenditure) Health expenditure, public (% of total health 70.98% 71.03% 70.93% .. .. expenditure) Out-of-pocket health expenditure (% of total 13.74% 13.64% 13.60% .. .. expenditure on health)

Canadian health system is dominantly financed through general tax revenues at three levels – federal, provincial and territorial governments. Canada has a predominantly publicly financed health system with approximately70% of health expenditures financed through public funds fromall three levels of government. Almost all revenues for public health spending come from the general tax revenues of all three level of government. Significant amount of these revenues is used to provide universal medicare – medically necessary hospital and physician services that are free at the point of service for residents

50Source: GDP data: World Bank national accounts data, and OECD National Accounts data files, http://databank.worldbank.org/ Health expenditures data: World Health Organization Global Health Expenditure database (see http://apps.who.int/nha/database for the most recent updates) | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

in all provinces and territories. The remaining amount is used to subsidize other types of health care including long-term care and prescription drugs. While the provinces raise the majority of funds through own-source revenues, they also receive less than a quarter of their health financing from The Canada Health Transfer, an annual cash transfer from the federal government. The provinces and territories are responsible for administering their own tax-funded and universal hospital and medicare plans. Medically necessary hospital, diagnostic and physician services are free at the point of service for all provincial and territorial residents.51 5.3. Japan

5.3.1. Demographics ofJapan

 The current population of Japan is 126,092,264 as of Sunday, April 30, 2017, based on the latest UN estimates.

 The total land area is 364,571 Km2, the population density is 346 per Km2.

 Japan population is equivalent to 1.68% of the total world population.

 Japan ranks number 11 in the list of countries (and dependencies) by population.

 Ethnic groups: Japanese 98.5%, Koreans 0.5%, Chinese 0.4%, other 0.6%.

 94.5 % of the population is urban.

 Life expectancy at birth: total population: 85 years (male: 81.7 y; female: 88.5 y).

 Age structure: 0-14 years: 12.97% ; 15-24 years: 9.67% ; 25-54 years: 37.68%; 55- 64 years: 12.4%; 65 years and over: 27.28%.

 The median age in Japan is 46.9 years (male: 45.6 years; female: 48.3 years).

 Population growth rate: -0.19%.

51 Gregory P. Marchildon. Canada: Health system review. Health Systems in Transition, 2013; 15(1): 1 – 179. | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

5.3.2. Healthcare System and Public Health Structure, Organisation, and Legislation

The health care delivery system in Japan has three pillars that cover all people impartially; universal health insurance coverage, a framework for health care delivery cantered on the Medical Care Act (Act No. 205 of July 30, 1948), and public health administration and service. “Free access” is a major characteristic in the health care delivery system in Japan; private facilities can open hospitals or clinics if they satisfy the criteria in the Medical Care Act, patients can choose their desired medical institution, and doctors can choose to work in the private or public systems. Both public and private sectors provide the same health care services at the same costs. Annual health checks (kenshin) are provided free to just about everyone in Japan. There is no 'family doctor' system. People over the age of 40 are required to pay Long-term Care Insurance (Long-Term Care Insurance Act (Act No. 123 of 1997)). The Medical Care Plan is the national health strategy to establish a system to provide high quality and appropriate medical care. There are at least five Prefectural Health Care Plans based on the national plans; Health Promotion Plan, Medical Care Plan, Insured Long-term Care Service Plan, Basic Plan to Promote Cancer Control, and the Medical Expenditure Optimizing Plan. The Health Insurance Act (1922) and The National Health Insurance Act (1938) established a health insurance system that covered the entire population by 1961. The Community Health Act (1997) promoted regional health care. Healthy Japan 21 (2000) supported by a new Health Promotion Law (2002) established a national health promotion program to reduce non-communicable diseases.

The law also stipulates the National Health and Nutritional Survey and encourages both central and local governments to monitor the prevalence of lifestyle related diseases for effective health promotion. A range of other legislation influences health services, including the Mental Health Act, Maternal and Child Health Act, Child Welfare Act, Labor Standards Act, School Health Law, and the industrial Safety and Health Act.

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Traditional medicine is regulated in the same way as conventional medicine and relevant laws are applied52.

Ministry of Health, Labour and Welfare is responsible for helping Japanese maintain and improve their health. National Institute of Public Health was established on April 1st, 2002, integrating The Institute of Public Health, National Institute of Health Services Management and a part of the Department of Oral Science in National Institute of Infectious Disease. The mission of the new organization is to carry out education and training of the personnel engaging in the works of public health, environmental hygiene and social welfare, and to conduct research in these areas53. It is a member of International association of national public health institutes.

5.3.3. Public Health Indicators

Several surveys and analyses are conducting at national level in Japan, aimed on measuring and collecting health indicators, such as:

 Japan’s National Health and Nutrition Survey (NHNS) is the oldest of all national health examination surveys currently conducted in the world54. It uses a stratified two-stage cluster sample design to obtain a nationally representative sample of the non-institutionalized Japanese population. The NHNS has three component surveys: the dietary intake survey, the lifestyle survey (covering eating, drinking, smoking, sleeping, exercise and dental care habits), and the physical examination (measuring the height, weight, abdominal circumference, and blood pressure of participants). Survey interviewers are mainly dietitians and registered dietitians for the dietary intake survey, and medical doctors, public health nurses and clinical laboratory technologists perform the physical examination.

 Currently, the oldest electronically available data in Japan are death and stillbirth records for 1972 (Statistics and Information Department, Ministry of Health, Labour and Welfare, personal communication). These surveys provide information about a wide range of health indicators in depth, including fertility,

52 Health Service Delivery Profile, Japan 2012, Compiled in collaboration between WHO and Ministry of Health, Labour and Welfare, Japan 53https://www.niph.go.jp/index_en.html 54https://academic.oup.com/ije/article/44/6/1842/2572514/Data-Resource-Profile-The-Japan-National-Health | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

mortality, morbidity, health service utilization, and health risks and behaviors, in Japan55.

5.3.4. Medical Informatics, Information Systems, Informatics Applications, Telemedicine

 Electronic Health Records (EHR). The prevalence of electronic medical record in Japan varies according to the size of the hospital which is 62.5% in major hospitals, 21.7% in medium, 9.1% in small size hospitals, and 16.5% in clinics56. Regional medical information network: Concept of regional medical information coopertaion system relies on EHR (used by clinics, hospitals, physcisians, pharmacies, labs), Personal Health Record (PHR) enabling individuals to access their health records, all concented through PI/RL (“Patent Index”/”Record Locator”) software- these tools guide data requests through the netwotk to relevant information about the correct patient.

 Computerized Physician Order Entry (CPOE) system is extensively used by emergency healthcare service providers, hospitals, nurses, and office-based physicians. It plays a significant role in reducing errors related to handwriting and has an efficient role in point of care treatment. The pharmaceutical industry is growing at a very fast pace in emerging economies, additionaly to Japan, also in China and India, which in-turn is driving the market for Computerized Physician Order Entry systems.

 The “My Number” system57 provided all Japanese citizens with a Social Security/tax identification number, but the system currently is used only for immunization records and health check information in relation to healthcare and treatment. Other health information has been kept separate from “My Number” due to privacy concerns.

 Japanese Telemedicine and Robotics stand out as application areas – but it is in Medical Informatics the most interesting changes as well as greatest impact on the health care system takes place. Japan is in an ideal position to use

55https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773486/ 56https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3212745/ 57http://trade.gov/topmarkets/pdf/Health_IT_Japan.pdf | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

telemedicine and remote monitoring for two reasons58: 1) it has the technological infrastructure and sophistication to support and rapidly implement it, and 2) more than 20% of Japan’s population is over the age of 65, and this percentage is expected to rapidly increase. In providing home care for this population, telemedicine and remote monitoring capabilities will be increasingly important. To exemplify, KOHOEN is a social welfare organization in Japan. One of its primary missions is to improve and provide community-level care, and to promote team-based care among doctors, nurses, pharmacists, and care managers. It equips care teams and patients with remote care tools, which in turn help older individuals live at home and maintain independence. One tool KOHOEN uses is a tablet solution (an Intel atom processer powered android- based ASUS fonepad) for a 24-hour visiting nurse and attendant service.

 Anyway, there are numerous reports about eHealth on the Japanese market being colored by spectacular examples of futuristic technology. Alongside with robotics and telecommunications as Japan’s strengths, comes telemedicine and robot care. Japan is world’s leader59 in creating industrial robots, which is clearly applying to the health care. This area is growing fast in Japan with m any projects such as investigation of emotional interaction between older people and animal-shaped robots, robotic surgery, companion robotics etc.

5.3.5. Expenditure, Economics, Management

58https://itpeernetwork.intel.com/international-telehealth-trends-insights-from-japan/ 59https://www.tillvaxtanalys.se/download/18.201965214d8715afd13c7fe/1432668283111/Rapport_2010_08.pdf | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Table 5.3.5.1.

2012 2013 2014 2015 2016 GDP (constant 2010 US$, 5,778,635 5,894,236 5,914,021 5,986,138 5,778,635 million) GDP growth (annual %) 1.50% 2.00% 0.34% 1.22% 1.50% GDP per capita (constant 45,301 46,288 46,519 47,150 45,301 2010 US$) Health expenditure, total (% 10.17% 10.25% 10.23% .. .. of GDP) Health expenditure per 3622 3713 3727 .. .. capita, PPP Health expenditure, private (% of total health 17.30% 16.78% 16.41% .. .. expenditure) Health expenditure, public (% of total health 82.70% 83.22% 83.59% .. .. expenditure) Out-of-pocket health expenditure (% of total 13.88% 13.89% 13.91% .. .. expenditure on health)

Japan’s statutory health insurance system is administered by a multitude of insurers: the government (from October 2008, a quasi-governmental body, the Japan Health Insurance Association) for employees of small to medium-sized firms and their dependents, 1584 Society-managed Health Insurance funds for employees of large firms and their dependents, 76 Mutual Aid Society (MAS) funds for government employees and dependents, 1835 municipal National Health Insurance funds for the self-employed, retired and unemployed, and 166 National Health Insurance Society funds for some occupational groups such as doctors and lawyers, each with different premium contribution rates.60 In Japan, everyone has public health insurance. People’s health and lives are protected by the universal health insurance system that we casually benefit from through having

60 Source: Tatara K, Okamoto E. Japan: Health system review. Health Systems in Transition, 2009; 11(5): 1–164. pp xvi. | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

established a society in which everyone can receive high quality medical services at a certain burden regardless of their income or type of work. The health insurance systems that workers subscribe to include Health Insurance managed by the Health Insurance Society, which consists of the employees of enterprises, and the Japan Health Insurance Association-managed Health Insurance, which diversifies the risk using subscriptions from all the workers of small- and medium-sized enterprises. In addition, National Health Insurance is a health insurance system that is operated by municipalities, etc. and to which people who do not have any other insurance plan subscribe to. Furthermore, people aged 75 or older subscribe to thelate-stage medical care system for the elderly. As described above, everyone is covered by some form of public insurance system and thus can receive necessary medical services at low cost by paying certain insurance premiums and co- payments (10% to 30%) at reception desks. In addition, “free access,” which means that everyone can receive medical services at any medical institution nationwide, is also a characteristic of the Japanese health insurance system.61 5.4. USA

5.4.1. History

The Public Health Service Act is a United States federal law enacted in 1944, which clearly established the federal government's quarantine authority for the first time. It gave the United States Public Health Service responsibility for preventing the introduction, transmission and spread of communicable diseases from foreign countries into the United States. The Public Health Service Act of 1944 also structured the United States Public Health Service, founded in 1798, as the primary division of the U.S. Department of Health, Education and Welfare (which was established in 1953), which later became the United States Department of Health and Human Services in 1979–1980 (when the Education agencies were separated into their own U.S. Department of Education). The Office of the Surgeon General was created in 1871.

5.4.2. Agencies

The Public Health Service comprises all Agency Divisions of Health and Human Services and the Commissioned Corps.

61 MHLW. Health and Medical Services. http://www.mhlw.go.jp/english/policy/health-medical/health- insurance/index.html | PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

Agencies that are components of the Public Health Service The following Staff Offices report directly to the Secretary:

 Office of the Assistant Secretary for Preparedness and Response (ASPR)

 Office of Global Affairs (OGA) The following Operating Divisions report directly to the Secretary:

 Agency for Healthcare Research and Quality (AHRQ)

 Agency for Toxic Substances and Disease Registry (ATSDR)

 Centers for Disease Control and Prevention (CDC)

 Food and Drug Administration (FDA)

 Health Resources and Services Administration (HRSA)

 Indian Health Service (IHS)

 National Institutes of Health (NIH)

 Substance Abuse and Mental Health Services Administration (SAMHSA) However public health system is a wider term, public health systems in the US are commonly defined as “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.” This concept ensures that all entities’ contributions to the health and well-being of the community or state are recognized in assessing the provision of public health services. The public health system includes:

 Public health agencies at state and local levels

 Healthcare providers

 Public safety agencies

 Human service and charity organizations

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro

 Education and youth development organizations

 Recreation and arts-related organizations

 Economic and philanthropic organizations

 Environmental agencies and organizations

5.4.3. Activity Areas

The Core Public Health Functions Steering Committee developed the framework for the Essential Services in 1994. The committee included representatives from US Public Health Service agencies and other major public health organizations. The 10 Essential Public Health Services describe the public health activities that all communities should undertake:

 Monitor health status to identify and solve community health problems

 Diagnose and investigate health problems and health hazards in the community

 Inform, educate, and empower people about health issues

 Mobilize community partnerships and action to identify and solve health problems

 Develop policies and plans that support individual and community health efforts

 Enforce laws and regulations that protect health and ensure safety

 Link people to needed personal health services and assure the provision of health care when otherwise unavailable

 Assure competent public and personal health care workforce

 Evaluate effectiveness, accessibility, and quality of personal and population-based health services

 Research for new insights and innovative solutions to health problems

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5.4.4. Best Practices

Public health programs, interventions, and policies that have been evaluated, shown to be successful, and have the potential to be adapted and transformed by others working in the same field. Selection of best practices from the array of implemented programs is one way of generating such practice-based evidence. A best practice is firstly defined as an intervention that has shown evidence of effectiveness in a particular setting and is likely to be replicable to other situations. Regardless of the area of public health, interventions should be evaluated by their context, process and outcomes. A best practice should hence meet most, if not all, of eight identified evaluation criteria: relevance, community participation, stakeholder collaboration, ethical soundness, replicability, effectiveness, efficiency and sustainability as suggested by Eileen Ng and Pierpaolo de Colombani.

5.4.5. Relevant Best Practice Databases from the US

1, The Community Tool Box is a free, online resource for those working to build healthier communities and bring about social change. It offers thousands of pages of tips and tools for taking action in communities. The Community Tool Box is a public service of the Work Group for Community Health and Development at the University of Kansas. The Work Group also provides a variety of services including technical assistance and training and participatory evaluation of community-based efforts. 2, CDC Community Health Improvement Navigator Database of Interventions (Centers for Disease Control and Prevention) – Database of interventions that work in four action areas for the greatest impact on community health: socioeconomic factors, physical environment, health behaviors, and clinical care. 3, Center of Excellence for Training and Research Translation (University of North Carolina at Chapel Hill) – Interventions and strategies on preventing and controlling obesity, heart disease and stroke, and other chronic diseases through nutrition and physical activity.

4, Model Practice Database (National Association of County and City Health Officials) – Collection of projects from around the United States highlighting successful public health projects. 5, National Registry of Evidence-Based Programs and Practices (NREPP) (Substance Abuse and Mental Health Services Administration) – Searchable online registry of interventions

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supporting mental health promotion, substance abuse prevention, and mental health and substance abuse treatment.

6, Promising Practices Network (RAND Corporation) – Collection of summaries of successful projects, programs and practices addressing the needs of children and youth.

7, Research-tested Intervention Programs (RTIPs) (National Cancer Institute) – Searchable database of cancer control interventions and program materials that have been shown to be effective, published in a peer-reviewed journal, and reviewed by a panel of experts in the field.

8, Stories in Public Health (Association of State and Territorial Health Officials) – Collection of stories that highlight promising and useful practices and implementation strategies developed by state and territorial health agencies.

9, Canadian Best Practices Portal (Public Health Agency of Canada) – Compendium of community interventions related to chronic disease prevention and health promotion that have been evaluated, shown to be successful, and have the potential to be adapted and replicated by other health practitioners working in similar fields. 6. Conclusions

This report provided an overview of public health practices in EU and other countries. The first chapter of the report gave the definitions and the historical aspects of public health. The follow up chapter explain the definition the duties of the healthcare organizations related to public health. The EU practices in public health are regulated through the authorities of the European Commission with close collaboration with the twenty eight ministries of health of the member states. Recent developments in the EU strategies require evidence based process to be applied in old decision making procedures in health care. In addition, the healthcare systems should be able to take it in to account stakeholders views and options in developing the public health strategies. The application of eHealth is becoming a requirement in the functionality of health care to achieve public health quality standards. The EU has issued and implemented the health 2020 policy and proposed for common areas for policy action: empowering people, tackling major diseases strengthening people-centered health system creating supporting communities.

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Health 2020 reconfirms the commitment of and its Member states to ensure universal coverage. Health technology assessment and quality assurance mechanism are critically important for health system transparency and accountability. Providing a comparison of public health status across its of the member states one can extract the following conclusions

All EU member states follow the regulations of the international health organizations and the European Commission recommendations on public health. The healthcare systems may differ across the EU but they follow the same scope and objectives. The legislation is harmonized across the various levels of regional and state implementation of healthcare. The challenges in in public issues are similar across Europe. The ageing of population is one critical factor but other issues affect recently the public especially across the periphery of EU, such as immigration and poverty due to the recent economic crisis. The European Commission and the related Member States are trying to tackle these issues but it seems that more coordinated effort is required not only in actions but also in economic support. Since the periphery, and not only, of the EU is suffering by both economic crisis and immigration the public status of those countries affected may jeopardize the whole European public status, since public health issues can easily cross borders. The application of eHealth in the healthcare system will affect in a very positive way the management and administration of the healthcare services across Europe, hence, as a consequence will improve the public health status in the long run. Furthermore, by increasing the accountability eHealth will minimize the health related costs as it was evident in the member states wherever e-prescription was applied. The eHealth applications provide the tools and the means to survey the diseases across the continent and alert the health when increase of frequency of incidents arises. In addition, prevention may found in eHealth a powerful assistant to empower the healthcare professionals, educate the citizens and assist the public health authorities to meet its objectives.

Regarding the mobility of citizens across the Member States the application of eHealth and the European Community legislation minimizes risks on public health as public health promotion and awareness of public issues are much easier understood, disseminated, and implemented.

The European Union has reached a level of understanding of the public health issues by exchanging information and experiences of best practices among the member states. New candidate countries may well take advantage of these accumulated experiences of the EU

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member states as described in this report and by avoiding the any mistakes of the past at those countries look at the future in public health in their own countries complementing their activities by taking up the best practices in European Union, when they wish to apply new legislation, improve healthcare management and health economics, and finally when eHealth becomes the means for improving the quality of public for the benefit of the citizens.

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References Relevant Organizations and Institutions

International Institutional Response https://www.apha.org/about-apha/our-mission http://www.ianphi.org/whoweare/index.html http://www.worldbank.org/en/topic/health http://www.un.org/en/sections/issues-depth/health/ https://www.unicef.org/ http://www.unaids.org/ http://www.unfpa.org/ http://www.who.int/about/en/ http://www.oecd.org/health/ https://www.icrc.org/en/who-we-are/movement http://www.msf.org/en/msf-charter-and-principles http://www.gatesfoundation.org/ https://www.opensocietyfoundations.org/about/mission-values https://www.rockefellerfoundation.org/our-work/topics/advance-health/ Regional Organizations http://www.euro.who.int/en/about-us http://ec.europa.eu/health/state/summary_en http://ec.europa.eu/commfrontoffice/publicopinion/index.cfm/General/index

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http://ec.europa.eu/eurostat/about/overview https://www.eea.europa.eu/about-us http://www.emcdda.europa.eu/about http://ecdc.europa.eu/en/aboutus/what-we-do/Pages/Mission.aspx National Organizations https://www.ispor.org/HTARoadMaps/HealthAuthorityEurope.asp

International Public Health Strategies, Best Practices, and Frameworks

EU Practices

Health 2020 policy framework and strategy. http://www.euro.who.int/__data/assets/pdf_file/0011/199532/Health2020-Long.pdf

United Nations Millennium Declaration. http://www.un.org/millennium/declaration/ares552e.pdf Millennium Development Goals. http://www.who.int/topics/millennium_development_goals/en/ The right to health. Geneva, Office of the United Nations High Commissioner for Human Rights, 2008http://www.ohchr.org/Documents/Publications/Factsheet31.pdf Interim second report of the social determinants of health and the health divide in theWHO European Region. Copenhagen, WHO Regional Office for Europe, 2011http://www.euro.who.int/data/assets/pdf_file/0010/148375/id5E_2ndRepSocialDet jh.pdf Commission on Social Determinants of Health. Closing the gap in a generation: healthequity through action on the social determinants of health. Final report of theCommission on Social Determinants of Health. Geneva, World Health Organization,2008http://www.who.int/social_determinants/resources/gkn_lee_al.pdf Department of Health and Human Services.www.hhs.gov

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Global Strategy of the Department of Health and Human Services. www.hhs.gov/sites/default/files/hhs-global-strategy.pdf National Security Strategy.www.state.gov/documents/organization/63562.pdf National Health Security Strategy (2015-2018). https://www.phe.gov/Preparedness/planning/authority/nhss/Documents/nhss-ip.pdf Global Health Security Agenda.https://www.ghsagenda.org/ Public Health of EU Countries

Austria

European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Austria: http://www.hspm.org/countries/austria08012013/countrypage.aspx Austrian Ministry of Health and Women’s Affair. ELGA – electronic health records. http://www.bmgf.gv.at/home/EN/Health_care_services/ELGA/ World Health Organization Europe: Data and statistics of Austria. http://www.euro.who.int/en/countries/austria/data-and-statistics World Health Organization: Statistics. Austria. http://www.who.int/gho/countries/aut.pdf?ua=1

World Health Organization Europe. Global Observatory for eHealth. 2015 survey. eHealth country profile Austria. http://www.who.int/goe/publications/atlas/2015/aut.pdf?ua=1

Belgium

European Commission. European countries on their journey towards national eHealth infrastructures eHealth Strategies. eHealth Strategies report. 2011. http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=2920 European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Belgium: http://www.hspm.org/countries/belgium25062012/countrypage.aspx

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Overview of the national laws on electronic health records in the EU Member States and their interaction with the provision of cross-border eHealth services. 2014. http://ec.europa.eu/health//sites/health/files/ehealth/docs/laws_report_recommendatio ns_en.pdf

World Health Organization Europe: Data and statistics of Belgium. http://www.euro.who.int/en/countries/belgium/data-and-statistics World Health Organization Europe. Global Observatory for eHealth. 2015 survey. eHealth country profile Belgium. http://www.who.int/goe/publications/atlas/2015/bel.pdf?ua=1 Cyprus http://www.hspm.org/countries/cyprus30042014/countrypage.aspx http://www.who.int/goe/policies/en/ http://www.who.int/goe/survey/2015survey/en/ http://www.who.int/goe/policies/countries/en/ http://www.who.int/goe/en/ http://www.who.int/goe/publications/atlas/en/ http://www.who.int/goe/publications/atlas_2015/en/ http://www.moh.gov.cy/moh/cbh/cbh.nsf/page20_en/page20_en?OpenDocument http://www.who.int/goe/publications/atlas/cyp.pdf?ua=1 http://www.who.int/goe/policies/countries/cyp/en/ http://www.moh.gov.cy/moh/cbh/cbh.nsf/page20_en/page20_en?OpenDocument http://www.who.int/goe/publications/en/ http://www.mcw.gov.cy/mcw/dec/digital_cyprus/ict.nsf/3700071379D1C658C2257A6F 00376A80/$file/Digital%20Strategy%20for%20Cyprus-Executive%20summary.pdf http://apps.who.int/iris/bitstream/10665/204523/1/9789241565219_eng.pdf?ua=1

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http://www.euro.who.int/en/health-topics/Health-systems/e-health/e-health-readmore http://www.euro.who.int/en/health-topics/Health-systems/e-health/data-and-statistics http://www.euro.who.int/en/health-topics/Health-systems/e-health/publications http://www.euro.who.int/__data/assets/pdf_file/0013/303322/fact-sheet-status-of- ehealth-in-who-european-region.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/204523/1/9789241565219_eng.pdf?ua=1#p1 08 http://www.euro.who.int/en/countries/cyprus/data-and-statistics http://www.who.int/goe/publications/atlas/2015/cyp.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0017/174041/Health-Systems-in- Transition_Cyprus_Health-system-review.pdf?ua=1 http://www.euro.who.int/en/about-us/partners/observatory/publications/health- system-reviews-hits/full-list-of-country-hits/cyprus-hit-2012 http://apps.who.int/iris/bitstream/10665/204523/1/9789241565219_eng.pdf?ua=1 Czech Republic

European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Czech Republic: http://www.euro.who.int/__data/assets/pdf_file/0005/280706/Czech-HiT.pdf?ua=1 Overview of the national laws on electronic health records in the EU Member States and their interaction with the provision of cross-border eHealth services. 2014. http://ec.europa.eu/health//sites/health/files/ehealth/docs/laws_report_recommendatio ns_en.pdf World Health Organization Europe: Data and statistics of Czech Republic. http://www.euro.who.int/en/countries/czech-republic/data-and-statistics

World Health Organization Europe. Global Observatory for eHealth. 2015 survey. eHealth country profile Czech Republic. http://www.who.int/goe/publications/atlas/2015/cze.pdf?ua=1

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Denmark

The official website of Denmark. Most recent statistics: http://denmark.dk/en/quick- facts/facts World Health Organization: Statistics of Denmark: http://www.who.int/goe/publications/atlas/2015/dnk.pdf?ua=1 European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Denmark: http://www.hspm.org/countries/denmark27012013/countrypage.aspx OECD Health Statistics 2015. How does health spending in Denmark compare: https://www.oecd.org/els/health-systems/Country-Note-DENMARK-OECD-Health- Statistics-2015.pdf Article about the health care in Denmark: http://www.denverpost.com/2009/09/03/health-care-in-denmark/

Healthcare in Denmark: http://www.europe-cities.com/destinations/denmark/health/ International Health Care System Profiles: http://international.commonwealthfund.org/countries/denmark/ Estonia

World Health Organization: Statistics of Estonia: http://www.who.int/countries/est/en/ http://www.who.int/goe/publications/atlas/2015/est.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0007/243295/Estonia-WHO-Country- Profile.pdf European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Estonia: http://www.hspm.org/countries/estonia05112013/countrypage.aspx The World Bank – Popoulation ages 65 and above (% of total):

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http://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS Trading Economics – Moratlity rate, infant (per 1,000 live births): http://www.tradingeconomics.com/country-list/antenatal-care-any-skilled-personnel- percent-of-women-with-a-birth-q4-wb-data.html Germany

World Health Organization: Statistics of Germany: http://www.who.int/countries/deu/en/ http://www.who.int/goe/publications/atlas/2009/deu.pdf?ua=1

European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Germany: http://www.hspm.org/countries/germany28082014/countrypage.aspx

International Health Care System Profiles: http://international.commonwealthfund.org/countries/germany/

The world bank – Population ages 65 and above (% of total) http://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS

Greece http://www.hspm.org/countries/greece09062014/countrypage.aspx http://www.hspm.org/countries/greece09062014/livinghit.aspx?Section=1.1%20Geogra phy%20and%20sociodemography&Type=Section http://www.hspm.org/countries/greece09062014/livinghit.aspx?Section=2.1%20Overvie w%20of%20the%20health%20system&Type=Section http://www.euro.who.int/en/countries/greece/data-and-statistics http://apps.who.int/iris/bitstream/10665/204523/1/9789241565219_eng.pdf?ua=1#p1 08

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http://www.euro.who.int/__data/assets/pdf_file/0004/130729/e94660.pdf?ua=1 http://ehealth-strategies.eu/database/documents/Greece_eHealth- ERA_country_report.pdf http://apps.who.int/iris/bitstream/10665/204523/1/9789241565219_eng.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0012/302331/From-Innovation-to- Implementation-eHealth-Report-EU.pdf?ua=1 Hungary http://www.hspm.org/countries/hungary25062012/countrypage.aspx https://www.antsz.hu/en/about_us http://www.hspm.org/countries/hungary25062012/countrypage.aspx http://www.healthpowerhouse.com/en/news/euro-health-consumer-index-2015/ http://www.hspm.org/countries/hungary25062012/livinghit.aspx?Section=6.2%20Futur e%20developments&Type=Section Ireland

Committee on the Future of Health Care. Second Interim Report. 2017. http://www.oireachtas.ie/parliament/media/committees/futureofhealthcare/Second- Interim-Report-of-the-Committee-on-the-Future-of-Healthcare-200117.pdf

European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Ireland: http://www.hspm.org/countries/ireland18092013/countrypage.aspx

World Health Organization Europe: Data and statistics of Ireland. http://www.euro.who.int/en/countries/ireland/data-and-statistics World Health Organization Europe. Global Observatory for eHealth. 2015 survey. eHealth country profile Ireland. http://www.who.int/goe/publications/atlas/2015/irl.pdf?ua=1 Italy

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http://www.hspm.org/countries/italy25062012/livinghit.aspx?Section=2.2%20Historical %20background&Type=Section http://www.euro.who.int/en/countries/italy/data-and-statistics http://www.euro.who.int/__data/assets/pdf_file/0003/263253/HiT-Italy.pdf?ua=1 http://www.who.int/gho/countries/en/ http://www.who.int/gho/countries/ita.pdf http://www.who.int/gho/countries/ita.pdf?ua=1 http://www.who.int/goe/publications/atlas/2015/ita.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/204523/1/9789241565219_eng.pdf?ua=1#p1 77 http://www.who.int/gho/countries/ita/country_profiles/en/ http://www.euro.who.int/__data/assets/pdf_file/0012/103215/E88550.pdf?ua=1 http://www.attivitaproduttive.gov.it/images/stories/comunicazioni/Staff_CapoDipartime nto/Div.I/e_health_Italy.pdf http://www.euro.who.int/__data/assets/pdf_file/0003/263253/HiT-Italy.pdf?ua=1 Latvia http://www.euro.who.int/__data/assets/pdf_file/0009/332883/Latvia-Hit.pdf?ua=1 http://www.hspm.org/countries/latvia08052014/countrypage.aspx http://apps.who.int/gho/data/node.country.country-LVA https://eupha.org/public-health-association-of-latvia Lithuania

LR Parliament (2016) The 17th Government Programme https://www.e- tar.lt/portal/lt/legalAct/ed6be240c12511e6bcd2d69186780352

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The Government of the Republic of Lithuania (2016) https://e- seimas.lrs.lt/portal/legalAct/lt/TAP/3ed26560babd11e6a3e9de0fc8d85cd8 http://sam.lrv.lt/lt/naujienos/e-sveikatos-ir-jos-sistemu-naudojimas-priklauso-nuo- savivaldybiu-ir-gydymo-istaigu-administraciju

Lithuanian Health Insurance Fund (2015) http://www.vlk.lt/naujienos/Puslapiai/Seimas- patvirtino-2016-m.-PSDF-biud%C5%BEet%C4%85.aspx http://www.hspm.org/countries/lithuania14112013/countrypage.aspx Luxemburg

Kerr, Elizabeth (1999). Health Care Systems in Transition – Luxembourg. European Observatory on Health Care Systems. http://www.euro.who.int/__data/assets/pdf_file/0007/95128/E67498.pdf http://europa.eu/european-union/about-eu/countries/member- countries/luxembourg_en https://healthmanagement.org/c/hospital/issuearticle/overview-of-the-healthcare- system-in-luxembourg https://healthmanagement.org/c/hospital/issuearticle/overview-of-the-healthcare- system-in-luxembourg https://www.esante.lu/portal/fr/agence-esante/la-plateforme-esante-et-ses- services,394,425.html https://www.esante.lu/portal/fr/agence-esante/notre-histoire-nos- missions,139,106.html Malta

Azzopardi-Muscat, N., Buttigieg, S., Calleja. N. & Merkur, S. (2017). Malta - Health System Review. Health Systems in Transition, Vol. 19 No. 1 2017 http://www.euro.who.int/__data/assets/pdf_file/0009/332883/Malta-Hit.pdf?ua=1 http://europa.eu/european-union/about-eu/countries/member-countries/malta_en

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Netherlands

World Health Organization: Statistics of Netherlands: http://www.who.int/countries/nld/en/ http://www.who.int/goe/publications/atlas/2015/nld.pdf?ua=1

European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Netherlands:http://www.hspm.org/countries/netherlands25062012/countrypage.aspx International Health Care System Profiles: http://international.commonwealthfund.org/countries/netherlands/ OECD – The Netherlands: https://www.oecd.org/els/health-systems/Netherlands-OECD- EC-Good-Time-in-Old-Age.pdf Poland

WHO: http://www.who.int/countries/pol/en/ http://www.who.int/goe/publications/atlas/2015/pol.pdf?ua=1 Country Economy – Poland – Life expectancy at birth: http://countryeconomy.com/demography/life-expectancy/poland European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Poland: http://www.hspm.org/countries/poland27012013/countrypage.aspx Healthcare in Poland: http://www.europe-cities.com/destinations/poland/health/ Portugal http://www.who.int/goe/publications/atlas/prt.pdf?ua=1 http://www.who.int/goe/publications/atlas/2015/en/#P http://www.who.int/goe/publications/atlas/2015/prt.pdf?ua=1

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http://www.euro.who.int/en/countries/portugal/data-and-statistics http://www.euro.who.int/__data/assets/pdf_file/0007/337471/HiT-Portugal.pdf?ua=1 http://www.hspm.org/countries/portugal25062012/livinghit.aspx?Section=2.1%20Overv iew%20of%20the%20health%20system&Type=Section Romania http://www.worldometers.info/world-population/slovakia-population/ https://www.cia.gov/library/publications/the-world-factbook/geos/lo.html Cristian Vladescu, Silvia Gabriela Scîntee, Victor Olsavszky, Cristina Hernández-Quevedo, Anna Sagan, Romania Health system review, Health Systems in Transition, Vol. 18 No. 4 2016 (Europian observatory on helth system and policies- a partnership Hosted by WHO) http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/11/SSPR-2016-2.pdf http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/11/INEGALITATI-2014.pdf http://insp.gov.ro/sites/cnepss/wp-content/uploads/2017/03/Raport-scolara-2016- 1.pdf http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/12/BILANT-SINTEZA- 2015.pdf http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/12/Comportamente-cu-risc- la-tineri-YRBSS-2014.pdf http://insp.gov.ro/sites/cnepss/wp-content/uploads/2014/12/Comportamente-cu-risc- la-tineri-YRBSS-2014.pdf https://www.export.gov/article?id=Romania-Healthcare-and-Medical-Equipment https://books.google.me/books?id=diolDAAAQBAJ&pg=PR5&lpg=PR5&dq=telemedicine+c enter+romania&source=bl&ots=j6n6ZRgLz6&sig=gvysE3lmiyVzVJNiUgkMtpUgbDo&hl=en &sa=X&ved=0ahUKEwib49KLjtLTAhXME5oKHfLwAsYQ6AEIRzAE#v=onepage&q=telemed icine%20center%20romania&f=false Slovakia

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Vlãdescu C, Scîntee SG, Olsavszky V, Hernández-Quevedo C, Sagan A. Romania: Health system review. Health Systems in Transition, 2016; 18(4):1–170. pp xviii, available at: http://www.healthobservatory.eu http://www.worldometers.info/world-population/slovakia-population/ https://www.cia.gov/library/publications/the-world-factbook/geos/lo.html

Marko Kapalla, Dagmar Kapallová, Ladislav Turecký, EPMA J. 2010 Dec; 1(4): 549–561. http://www.euro.who.int/en/countries/slovakia/news/news/2015/12/slovakia-to-focus- on-public-health-capacity-building-in-next-2-years https://spectator.sme.sk/c/20226145/slovakia-tops-v4-in-health-care-expenditures- lacks-respective-indicators.html http://www.euro.who.int/__data/assets/pdf_file/0011/325784/HiT-Slovakia.pdf?ua=1 http://www.ezdravotnictvo.sk http://www.ezdravotnictvo.sk/en/eHealth_Programme/Pages/default.aspx http://sar.mfn.sk/the-slovak-arthroplasty-register.348.html

Slovenia

Smatana M, Pažitný P, Kandilaki D, Laktišová M, Sedláková D, Palušková M, van Ginneken E, Spranger A (2016). Slovakia: Health system review. Health Systems in Transition, 2016; 18(6):1–210, pp.xxii, available at: http://www.healthobservatory.eu Sweden

World Health Organization: Statistics of Sweden:http://www.who.int/countries/swe/en/ http://www.who.int/goe/publications/atlas/2015/swe.pdf?ua=1 European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of Sweden:http://www.hspm.org/countries/sweden25022013/countrypage.aspx

International Health Care System Profiles:http://international.commonwealthfund.org/countries/sweden/

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OECD Data – Sweden: https://data.oecd.org/sweden.htm The world bank - Population ages 65 and above: http://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS Index mundi – Sweden Demographics Profile 2016:http://www.indexmundi.com/sweden/demographics_profile.html

United Kingdom

European Observatory on Health Systems and Policies. The Health System and Policy Monitor. Health Systems in Transition (HiT) profile of United Kingdom: www.hspm.org/countries/england11032013/livinghit.aspx World Health Organization Europe: Data and statistics of United Kingdom of Great Britain and Northerin Ireland. http://www.euro.who.int/en/countries/united-kingdom-of-great- britain-and-northern-ireland/data-and-statistics World Health Organization: Statistics. United Kingdom. http://www.who.int/countries/gbr/en/ World Health Organization Europe. Global Observatory for eHealth. 2015 survey. eHealth country profile United Kingdom of Great Britain and Northern Ireland. http://www.who.int/goe/publications/atlas/2015/gbr.pdf?ua=1

Public Health Best Practices of other Countries Canada http://www.worldometers.info/world-population/canada-population/ https://www.cia.gov/library/publications/the-world-factbook/geos/ca.html http://www.canadian-healthcare.org/ http://www.hc-sc.gc.ca/index-eng.php http://infobase.phac-aspc.gc.ca/cdiif/ http://www.statcan.gc.ca/pub/82-221-x/2013001/hifw-eng.htm

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http://www.hc-sc.gc.ca/hcs-sss/indicat/index-eng.php http://www.phn-rsp.ca/pubs/ihi-idps/pdf/Indicators-of-Health-Inequalities-Report- PHPEG-Feb-2010-EN.pdf http://www.aadnc-aandc.gc.ca/eng/1100100016579/1100100016580 https://www.cihi.ca/en/health-system-performance/performance-reporting/indicator- library http://www.fcm.ca/home/programs/quality-of-life-reporting-system.htm http://www.ictc-ctic.ca/wp-content/uploads/2012/06/ICTC_eHealthSitAnalysis_EN_04- 09.pdf https://www.infoway-inforoute.ca/en/what-we-do/progress-in-canada https://www.infoway-inforoute.ca/en/component/edocman/3098-annual-report-2015- 2016/view-document?Itemid=101 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677946/ https://www.infoway-inforoute.ca/en/component/edocman/3098-annual-report-2015- 2016/view-document?Itemid=101 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677946/ GDP data: World Bank national accounts data, and OECD National Accounts data files, http://databank.worldbank.org/ Health expenditures data: World Health Organization Global Health Expenditure database (see http://apps.who.int/nha/database for the most recent updates)

Gregory P. Marchildon. Canada: Health system review. Health Systems in Transition, 2013; 15(1): 1 – 179. Japan

Health Service Delivery Profile, Japan 2012, Compiled in collaboration between WHO and Ministry of Health, Labour and Welfare, Japan

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https://www.niph.go.jp/index_en.html https://academic.oup.com/ije/article/44/6/1842/2572514/Data-Resource-Profile-The- Japan-National-Health https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773486/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3212745/ http://trade.gov/topmarkets/pdf/Health_IT_Japan.pdf https://itpeernetwork.intel.com/international-telehealth-trends-insights-from-japan/ https://www.tillvaxtanalys.se/download/18.201965214d8715afd13c7fe/143266828311 1/Rapport_2010_08.pdf Tatara K, Okamoto E. Japan: Health system review. Health Systems in Transition, 2009; 11(5): 1–164. pp xvi. USA

MHLW. Health and Medical Services. http://www.mhlw.go.jp/english/policy/health- medical/health-insurance/index.html https://www.cdc.gov/nphpsp/essentialservices.html https://www.cdc.gov/stltpublichealth/publichealthservices/pdf/usph101.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4693338/ http://ctb.ku.edu/en/about-the-tool-box http://www.cdc.gov/chinav/database/index.html http://www.centertrt.org/?new http://archived.naccho.org/topics/modelpractices/database/ http://nrepp.samhsa.gov/landing.aspx http://www.promisingpractices.net/default.asp

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https://rtips.cancer.gov/rtips/index.do http://www.astho.org/stories/ http://cbpp-pcpe.phac-aspc.gc.ca/

| PROJECT COORDINATOR: University of Donja Gorica European Commission Erasmus+ Project: 573997-EPP-1-2016-1-ME-EPPKA2-CBHE-JP | Donja Gorica, 81 000 Podgorica, Montenegro